ABSTRACT BACKGROUND: Neck circumference (NC) is a useful anthropometric measure for predicting obstructive sleep apnea (OSA). Ethnicity and sex also influence obesity phenotypes. NC cut-offs for defining OSA have not been established for the Latin American population. OBJECTIVES: To evaluate NC, waist circumference (WC), and body mass index (BMI) as predictors of OSA in the Colombian population and to determine optimal cut-off points. DESIGN AND SETTING: Diagnostic tests were conducted at the Javeriana University, Bogota. METHODS: Adults from three cities in Colombia were included. NC, WC, and BMI were measured, and a polysomnogram provided the reference standard. The discrimination capacity and best cut-off points for diagnosing OSA were calculated. RESULTS: 964 patients were included (57.7% men; median age, 58 years) and 43.4% had OSA. The discrimination capacity of NC was similar for men and women (area under curve, AUC 0.63 versus 0.66, P = 0.39) but better for women under 60 years old (AUC 0.69 versus 0.57, P < 0.05). WC had better discrimination capacity for women (AUC 0.69 versus 0.57, P < 0.001). There were no significant differences in BMI. Optimal NC cut-off points were 36.5 cm for women (sensitivity [S]: 71.7%, specificity [E]: 55.3%) and 41 cm for men (S: 56%, E: 62%); and for WC, 97 cm for women (S: 65%, E: 69%) and 99 cm for men (S: 53%, E: 58%). CONCLUSIONS: NC and WC have moderate discrimination capacities for diagnosing OSA. The cut-off values suggest differences between Latin- and North American as well as Asian populations.

ABSTRACT Objective: To identify risk factors for nonresponse to prone positioning in mechanically ventilated patients with COVID-19-associated severe acute respiratory distress syndrome and refractory hypoxemia in a tertiary care hospital in Colombia. Methods: Observational study based on a retrospective cohort of mechanically ventilated patients with severe acute respiratory distress syndrome due to SARS-CoV-2 who underwent prone positioning due to refractory hypoxemia. The study considered an improvement ≥ 20% in the PaO2/FiO2 ratio after the first cycle of 16 hours in the prone position to be a ‘response’. Nonresponding patients were considered cases, and responding patients were controls. We controlled for clinical, laboratory, and radiological variables. Results: A total of 724 patients were included (58.67 ± 12.37 years, 67.7% males). Of those, 21.9% were nonresponders. Mortality was 54.1% for nonresponders and 31.3% for responders (p < 0.001). Variables associated with nonresponse were time from the start of mechanical ventilation to pronation (OR 1.23; 95%CI 1.10 - 1.41); preintubation PaO2/FiO2 ratio (OR 0.62; 95%CI 0.40 - 0.96); preprone PaO2/FiO2 ratio (OR 1.88. 95%CI 1.22 - 2.94); and radiologic multilobe consolidation (OR 2.12; 95%CI 1.33 - 3.33) or mixed pattern (OR 1.72; 95%CI 1.07 - 2.85) compared with a ground-glass pattern. Conclusion: This study identified factors associated with nonresponse to prone positioning in patients with refractory hypoxemia and acute respiratory distress syndrome due to SARS-CoV-2 receiving mechanical ventilation. Recognizing such factors helps identify candidates for other rescue strategies, including more extensive prone positioning or extracorporeal membrane oxygenation. Further studies are needed to assess the consistency of these findings in populations with acute respiratory distress syndrome of other etiologies.

RESUMO Objetivo: Identificar fatores de risco em pacientes submetidos à ventilação mecânica devido à síndrome do desconforto respiratório agudo grave associada à COVID-19 e hipoxemia refratária irresponsivos ao decúbito ventral em um hospital terciário na Colômbia. Métodos: Estudo observacional baseado em coorte retrospectiva de pacientes submetidos à ventilação mecânica devido à síndrome do desconforto respiratório agudo grave associada ao SARS-CoV-2 em decúbito ventral devido à hipoxemia refratária. O estudo considerou resposta a melhora ≥ 20% na relação entre pressão parcial de oxigênio e fração inspirada de oxigênio após o primeiro ciclo de 16 horas em decúbito ventral. Os pacientes irresponsivos foram considerados casos, e os responsivos foram considerados controles. Controlamos as variáveis clínicas, laboratoriais e radiológicas. Resultados: Foram incluídos 724 pacientes (58,67 ± 12,37 anos, 67,7% do sexo masculino). Destes, 21,9% eram pacientes irresponsivos. A mortalidade foi de 54,1% nos irresponsivos e de 31,3% nos responsivos (p < 0,001). As variáveis associadas à ausência de resposta foram tempo do início da ventilação mecânica até o decúbito ventral (RC de 1,23; IC95% 1,10 - 1,41); relação entre pressão parcial de oxigênio e fração inspirada de oxigênio pré-intubação (RC de 0,62; IC95% 0,40 - 0,96); relação entre pressão parcial de oxigênio e fração inspirada de oxigênio anterior ao decúbito ventral (RC de 1,88; IC95% 1,22 - 2,94); e consolidação radiológica de múltiplos lobos (RC de 2,12; IC95% 1,33 - 3,33) ou padrão misto (RC de 1,72; IC95% 1,07 - 2,85) em comparação com um padrão em vidro fosco. Conclusão: Este estudo identificou fatores associados à ausência de resposta ao decúbito ventral em pacientes com hipoxemia refratária e síndrome do desconforto respiratório agudo devido ao SARS-CoV-2 em ventilação mecânica. O reconhecimento desses fatores ajuda a identificar os candidatos a outras estratégias de resgate, incluindo decúbito ventral mais prolongado ou oxigenação por membrana extracorpórea. São necessários novos estudos para avaliar a consistência desses achados em populações com síndrome do desconforto respiratório agudo por causa de outras etiologias.

RESUMO Contexto Este artigo tem como objetivo determinar fatores associados à dificuldade de canulação biliar que sejam identificáveis antes dos procedimentos. Métodos Trata-se de um estudo de caso-controle dentro de uma coorte histórica em pacientes adultos submetidos a colangiopancreatografia retrógrada endoscópica (CPRE) de 2015 a 2019 no Hospital Universitário San Ignacio, em Bogotá, Colômbia. Avaliou-se as associações entre variáveis que poderiam ser identificadas antes ou no início dos procedimentos e a probabilidade de difícil canulação biliar (DCB). Essas associações foram avaliadas por meio de análise bivariada e multivariada. O estudo utilizou critérios para DCB definidos pela Sociedade Europeia de Endoscopia Gastrointestinal. Resultados Foram analisados 498 CPRE em 376 pacientes. De todos os procedimentos, 144 (29%) preencheram critérios para DCB. A análise multivariada mostrou associação entre a DCB e o ambiente hospitalar de atenção aguda (OR:2,92; CI 95% 1,70-5,01; P<0,001), papila redundante (OR:7,26; CI95% 3,38-15,61; P<0,001), ou papila peridiverticular (OR:2,45; CI95% 1,38-4,36; P=0,002). Não foi encontrada associação entre a DCB e a experiência do endoscopista, dos níveis de bilirrubina ou da dilatação do trato biliar. Conclusão A DCB é um evento frequente. Alterações na papila e CPRE realizadas no ambiente hospitalar de cuidados agudos são os principais fatores associados a DCB. Essas informações podem ser úteis para prever a DCB e estabelecer estratégias de saúde e administrativas para reduzir suas implicações.

ABSTRACT Background This paper aims to determine factors associated with difficult biliary cannulation (DBC) that are identifiable before procedures. Methods This is a nested case-control study within a historical cohort in adult patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) from 2015-2019 in the Hospital Universitario San Ignacio, Colombia. This study assessed the associations among variables that could be identified before or at the beginning of procedures and the probability of DBC. These associations were evaluated through a bivariate and multivariate analysis. The study used criteria for DBC defined by the European Society of Gastrointestinal Endoscopy. Results A total of 498 ERCP performed in 376 patients were analyzed. Of all procedures, 144 (29%) fulfilled criteria for DBC. The multivariate analysis showed an association between DBC and the acute care hospital setting (OR:2.92; CI95% 1.70-5.01; P<0.001), redundant papilla (OR:7.26; CI95% 3.38-15.61; P<0.001), or peridiverticular papilla (OR:2.45; CI95% 1.38-4.36; P=0.002). No association was found between DBC and endoscopist’s experience, bilirubin levels, or dilation of the biliary tract. Conclusion The DBC is a frequent event. Alterations in the papilla and ERCP performed in the acute care hospital setting are the principal factors associated with DBC. This information might be useful to predict DBC and establish healthcare and administrative strategies to reduce its implications.

RESUMO Objetivo: Determinar a concordância da classificação do risco de mortalidade por meio do uso dos escores Pediatric Index of Mortality (PIM) 2 e 3. Métodos: Avaliação de uma coorte retrospectiva pela análise dos pacientes admitidos à unidade de terapia intensiva pediátrica entre abril de 2016 e dezembro de 2018. Calculamos o risco de mortalidade por meio do PIM 2 e do 3. Realizaram-se análises para determinar a concordância entre a classificação de risco obtida com ambas as escalas pela utilização do cálculo do Kappa não ponderado e linearmente ponderado. Resultados: Incluímos 722 pacientes, sendo que 66,6% destes tinham uma condição crônica. A mortalidade global foi de 3,7%. O coeficiente Kappa de concordância para classificação dos pacientes, segundo o risco com o PIM 2 e o 3, foi moderado: 0,48 (IC95% 0,43 - 0,53). Após ponderação linear, a concordância foi substancial: 0,64 (IC95% 0,59 - 0,69). Para pacientes de cirurgia cardíaca, a concordância para a classificação de risco foi regular: 0,30 (IC95% 0,21 - 0,39); após ponderação linear, a concordância foi apenas moderada: 0,49 (IC95% 0,39 - 0,59). O PIM 3 acusou um risco mais baixo do que o PIM 2 em 44,8% dos pacientes desse subgrupo. Conclusão: Nosso estudo comprova que o PIM 2 e o 3 não são clinicamente equivalentes e não devem ser usadas de forma intercambiável para avaliação da qualidade em diferentes unidades de terapia intensiva. Devem ser conduzidos estudos de validação antes que se utilizem os PIM 2 e 3 em situações específicas.

ABSTRACT Objective: To determine the concordance of mortality risk classification through the use of the Pediatric Index of Mortality (PIM) 2 and 3. Methods: Through a retrospective cohort, we evaluated patients admitted to the pediatric intensive care unit between April 2016 and December 2018. We calculated the mortality risk with the PIM 2 and 3. Analyses were carried out to determine the concordance between the risk classification obtained with both scales using unweighted and linearly weighted kappa. Results: A total of 722 subjects were included, and 66.6% had a chronic condition. The overall mortality was 3.7%. The global kappa concordance coefficient for classifying patients according to risk with the PIM 2 and 3 was moderate at 0.48 (95%CI 0.43 - 0.53). After linear weighting, concordance was substantial at 0.64 (95%CI 0.59 - 0.69). For cardiac surgery patients, concordance for risk classification was fair at 0.30 (95%CI 0.21 - 0.39), and after linear weighting, concordance was only moderate at 0.49 (95%CI 0.39 - 0.59). The PIM 3 assigned a lower risk than the PIM 2 in 44.8% of patients in this subgroup. Conclusion: Our study proves that the PIM 2 and 3 are not clinically equivalent and should not be used interchangeably for quality evaluation across pediatric intensive care units. Validation studies must be performed before using the PIM 2 or PIM 3 in specific settings.

Resumen Objetivo: La linfopenia se ha propuesto como un potencial factor asociado al riesgo de infecciones bacterianas nosocomiales (infección urinaria y neumonía), pero la magnitud y relevancia de este factor no ha sido evaluada formalmente. El objetivo de este estudio es determinar si existe asociación entre linfopenia e infecciones nosocomiales en ancianos hospitalizados en una institución de salud en Bogotá, Colombia. Métodos: Estudio de casos y controles, incluyendo personas mayores de 65 años hospitalizadas en el Hospital Universitario San Ignacio entre junio de 2016 y diciembre de 2017. Se consideraron casos aquellos con diagnóstico de infección nosocomial (neumonía, infección de vías urinarias, bacteriemia, infección de tejidos blandos) y se compararon con controles sin infección emparejados por edad y sexo. Se evaluó la asociación entre linfopenia e infección nosocomial mediante análisis bivariado y multivariado controlando por las variables de confusión. Resultados: Se incluyeron un total de 198 pacientes (99 casos y 99 controles). La prevalencia de linfopenia fue de 34.8%, sin encontrarse diferencia entre los dos grupos (p=0.88). La infección nosocomial se asoció a mayor incidencia de mortalidad (29.3 vs 10.1%, p>0.001) y mayor duración de estancia hospitalaria (Mediana 18 vs 9 días, p<0.01). Se encontró asociación entre infección nosocomial con enfermedad cardiovascular (OR = 2.87; IC 95% 1.37-6.00) y antecedente de cáncer (OR = 6.00; IC 95% 1.28-29.78), sin embargo, no hubo asociación con linfopenia (OR = 1.27; IC 95% 0.61-2.65). Conclusiones: Este estudio sugiere que no existe asociación entre linfopenia y el desarrollo de infecciones nosocomiales en pacientes ancianos.

Abstract Objective: Lymphopenia has been proposed as a potential factor associated with the risk of nosocomial bacterial infections (urinary tract infection and pneumonia), but the magnitude and relevance of this factor has not been formally evaluated. Objective is to determine the association between lymphopenia and nosocomial infections in elderly hospitalized in a health institution in Bogotá, Colombia. Methods: Case-control study, including people over 65 hospitalized in the University Hospital San Ignacio - Bogotá, during the period between June 2016 and December 2017. Cases with a diagnosis of nosocomial infection (pneumonia, urinary tract infection, bacteraemia, soft tissue infection) were considered and compared with controls without infection matched by age and sex. The association between lymphopenia and nosocomial infection was evaluated by bivariate and multivariate analysis, controlling for confounding variables. Results: A total of 198 patients (99 cases and 99 controls) were included. The prevalence of lymphopenia was 34.8%, with no difference between the two groups (p = 0.88). Nosocomial infection was associated with a higher incidence of mortality (29.3 vs. 10.1%, p> 0.001) and a longer duration of hospital stay (Median 18 vs. 9 days, p< 0.001). An association was found between nosocomial infection with cardiovascular disease (OR = 2.87; 95% CI 1.37-6.00) and a history of cancer (OR = 6.19; 95% CI 1.28-29.78), however, there was no association with lymphopenia (OR = 1.27 ; 95% CI 0.61-2.65). Conclusions: This study suggests that there is no association between lymphopenia and the development of nosocomial infections in elderly patients.

Resumen Objetivo: La implementación de las guías de práctica clínica está limitada por la falta de herramientas que faciliten los procesos de auditoría y retroalimentación a los profesionales de salud. Este estudio evalúa la herramienta automatizada (EXEMED), diseñada para valorar la adherencia a las guías de práctica clínica a partir de la información consignada en las historias clínicas electrónicas. Métodos: En un grupo de 35 pacientes hospitalizados entre enero y marzo de 2016 se evaluó la adherencia a cinco recomendaciones contenidas en las guías de práctica clínica de falla cardiaca del Hospital Universitario San Ignacio. Se utilizó la herramienta automatizada EXEMED y se evaluó la validez de la misma comparando los resultados con la valoración realizada por una junta médica independiente. Se determinó concordancia entre los dos métodos usando el coeficiente kappa. Resultados: La adherencia a las diferentes recomendaciones osciló entre 0% para la determinación del perímetro abdominal al ingreso, hasta 97% para el uso de betabloqueadores al egreso. La proporción de acuerdo entre los dos métodos de evaluación estuvo por encima del 90% para todas las recomendaciones. El kappa para las diferentes recomendaciones fue de 0,78 (IC 95% 0,62-0,95) y 0,64 (0,48-0,80). El tiempo de evaluación se redujo de veinte a dos minutos por paciente con el uso de la herramienta EXEMED. Conclusiones: EXEMED es una herramienta válida y eficiente en la evaluación de la adherencia a las guías de práctica clínica. Se requieren nuevos estudios para evaluar el impacto de su uso asociado a retroalimentación a los clínicos, en la evolución a largo plazo de los pacientes con falla cardiaca.

Abstract Objective: The implementation of clinical practice guidelines is limited due to the lack of tools to carry out audits and provide feedback to the health professionals. In this study, an evaluation is performed using the automated (EXEMED) tool in order to assess the adherence to clinical practice guidelines from the information entered in the electronic health records. Methods: The adherence to 5 recommendations contained in the heart failure clinical practice guidelines was evaluated in a group of 35 patients admitted to the Hospital Universitario San Ignacio between January 2016 and March 2016. The automated EXEMED tool was used to assess this, by comparing the results obtained with the evaluation carried out by an independent medical committee. The kappa coefficient was used to determine the agreement between the two methods. Results: The adherence to the different recommendations varied between 0%, for the determination of the abdominal circumference, up to 97%, for the use of beta-blockers at discharge. Percentage agreement between the two evaluation methods was above 90% for all the recommendations. The kappa for the different recommendations was 0.78 (95% CI; 0.62-0.95) and 0.64 (0.48-0.80). The evaluation time was reduced from 20 minutes to 2 minutes with the use of the EXEMED tool. Conclusions: EXEMED is a valid and effective tool in the evaluation of adherence to clinical practice guidelines. Further studies are required to assess the impact of its used associated with feedback to the clinicians, in the long-term outcomes of patients with heart failure.