No / To build an early warning score (EWS) based exclusively on routinely undertaken laboratory tests that might provide early discrimination of in-hospital death and could be easily implemented on paper. Using a database of combined haematology and biochemistry results for 86,472 discharged adult patients for whom the admission specialty was Medicine, we used decision tree (DT) analysis to generate a laboratory decision tree early warning score (LDT-EWS) for each gender. LDT-EWS was developed for a single set (n=3496) (Q1) and validated in 22 other discrete sets each of three months long (Q2, Q3...Q23) (total n=82,976; range of n=3428 to 4093) by testing its ability to discriminate in-hospital death using the area under the receiver-operating characteristic (AUROC) curve. The data generated slightly different models for male and female patients. The ranges of AUROC values (95% CI) for LDT-EWS with in-hospital death as the outcome for the validation sets Q2-Q23 were: 0.755 (0.727-0.783) (Q16) to 0.801 (0.776-0.826) [all patients combined, n=82,976]; 0.744 (0.704-0.784, Q16) to 0.824 (0.792-0.856, Q2) [39,591 males]; and 0.742 (0.707-0.777, Q10) to 0.826 (0.796-0.856, Q12) [43,385 females]. CONCLUSIONS: This study provides evidence that the results of commonly measured laboratory tests collected soon after hospital admission can be represented in a simple, paper-based EWS (LDT-EWS) to discriminate in-hospital mortality. We hypothesise that, with appropriate modification, it might be possible to extend the use of LDT-EWS throughout the patient's hospital stay.

CONTEXTE La syphilis est une maladie ré-émergente depuis 2000. Son traitement est simple, mais son diagnostic est complexe. La technique d’amplification génique de Treponema pallidum (Tp-PCR) existe depuis 1990 mais le CDC l’a incluse dans sa définition de cas en janvier 2014. OBJECTIFS 1) Evaluer la performance diagnostique de la Tp-PCR à différents stades cliniques et milieux biologiques. 2) Mesurer la sensibilité, spécificité et les valeurs prédictives de la Tp-PCR en fonction de 3 groupes de référence dans des ulcères récents. 3) Comparer les performances des 2 principales cibles de Tp-PCR.MATÉRIEL ET MÉTHODES Premièrement, une revue systématique et méta-analyse des études publiées depuis 1990 ont été menées. Ensuite une étude multicentrique prospective a été conduite dans 5 villes européennes pendant 2 ans chez des patients avec un ulcère oro-génital. Tous ont reçu le test de référence local et 2 Tp-PCRs dans l’ulcère (gène tpp47 vs. polA). Les valeurs de sensibilité, spécificité et valeurs prédictives de la Tp-PCR ont été calculées comparativement au fond noir (FN), à la sérologie et à un gold standard amélioré. La concordance des 2 cibles a été évaluée par un coefficient kappa.RÉSULTATS PRINCIPAUX La méta-analyse conclut que la Tp-PCR a une meilleure performance dans les ulcères récents. L’étude clinique montre que la Tp-PCR décrit une meilleure performance comparativement au gold standard amélioré et a même une meilleure sensibilité que le FN. Les 2 cibles ont la même valeur diagnostique et une concordance quasi parfaite. CONCLUSIONS La Tp-PCR ciblant tpp47 ou polA est cliniquement utile pour diagnostiquer une syphilis primaire et pourrait même remplacer le FN sous certaines conditions. / BACKGROUND Syphilis has re-emerged in at-risk populations since 2000. Although the treatment of syphilis is simple, its diagnosis remains challenging. Treponema pallidum Polymerase Chain Reaction (Tp-PCR) has been used in the diagnosis of syphilis since 1990 but it is included in the case definition of the CDC since January 2014. OBJECTIVES 1) To assess the accuracy of Tp-PCR in various biological specimens and syphilis stages. 2) To measure its diagnostic performance (sensitivity, specificity and predictive values) in ulcers from early syphilis compared to three groups of reference. 3) To compare the accuracy of the two most currently used targets: tpp47 and polA genes.METHODS We conducted a systematic review and meta-analysis of all studies published from 1990. We implemented a multicentre, prospective, observational study in 5 European cities between 09/2011 and 09/2013 among patients with an oral or genital ulcer suggestive of syphilis. All patients were tested with traditional reference tests plus 2 Tp-PCRs (tpp47 and polA). We estimated the sensitivity, specificity and predictive values of Tp-PCR compared to darkfield microscopy (DFM), serology and an enhanced gold standard. We used the kappa coefficient to assess the agreement between the 2 targets.MAIN RESULTST p-PCR had the best accuracy in ulcers from early syphilis. Tp-PCR performed better when compared to the enhanced gold standard and had a higher sensitivity than DFM. The 2 Tp-PCRs had a similar accuracy and an almost perfect agreement.CONCLUSIONS Tp-PCR targeting either tpp47 or polA is clinically useful to confirm an early syphilis in smears and could even replace DFM under specific conditions.

<p>Povratak na posao nakon operacije lumbalne diskus hernije determinisan je funkcionalnim stanjem, prisustvom i stepenom tegoba od strane lumbosakralne kičme, zahtevima na radnom mestu bolesnika ali i psihosocijalnim faktorima, koji pri oceni radne sposobnosti zaposlnih zahtevaju individualni pristup. Grupa pacijenata koja se neće vratiti na posao može biti identifikovana putem prognostičkog modela. Cilj ove studije je definisanje prognostičkog modela za povratak na posao bolesnika operisanih zbog lumbalne diskus hernije kao i identifikacija najznačajnijih faktora rizika odgovornih za lo&scaron; ishod operativnog lečenja, posmatrano kroz prizmu povratka na posao. Istraživanje je prospektivna studija koja je obuhvatila ukupno 200 ispitanika, koji su operisani zbog lumbalne diskus hernije na jednom nivou i praćeni su u vremenskom period do 12 meseci nakon operativnog lečenja. U statističku ananlizu je u&scaron;lo 153 bolesnika, koji su ispunili kriterijume selekcije ispitanika studije. Nakon određivanja značaja posmatranih biolo&scaron;kih, profesionalnih i psihosocijalnih faktora rizika za povratak na posao, kreirani su i evaluirani prognostički modeli bazirani na svim i na odabranim atributima desetostrukom kros-validacijom: stablo odlučivanja (DT), model vi&scaron;eslojnih perceptrona (MLP) i model potpornih vektora (SVM). Za predviđanje povratka na posao najveću tačnost, specifičnost i senzitivnost za odabrane atribute postiže model potpornih - podržavajućih vektora (SVM). Najbolju intuitivnu i praktičnu vrednost za predviđanje povratka na posao pruža model stabla odluka (DT). Identifikacijom najznačajnijih faktora rizika za nepovoljan ishod povratka na posao omogućeno je preventivno delovanje na iste, u cilju smanjenja broja pacijenata sa umanjenjem radne sposobnosti i invaliditeta.</p> / <p>Return to work after lumbar discectomy is determinated by functional status, presence and degree of discomfort in the lumbosacral spine, the requirements in the workplace of patients and psychosocial factors that in the assessment of working capabilities require an individual approach. Groups of patients which don&rsquo;t return to work after surgery could be identified by predictive model. The aim of this study is to define prognostic model to return to work patients after lumbar discectomy, as well as the identification major risk factors responsible for the poor outcome of operative treatment viewed through the prism of returning to work. This prospective study included a total of 200 patients, who underwent surgery for lumbar disc herniation on one level and were followed up in period of 12 months following surgery. The statistical analysis included 153 patients who fulfilled all selection criteria of the study subjects. After determining significance of the observed biological, professional and psychosocial risk factors for return to work, prognostic models were designed and evaluated based on all and selected attributes by tenfold cross-validation: decision tree (DT) model of multilayer perception (MLP) model and support vector (SVM). For the prediction of return to work best accuracy, specificity and sensitivity for selected attributes, is achieved by supporting vector model (SVM). The decision tree model (DT) provides the best intuitive and practical value for predicting return to work. By identifying the most important risk factors for adverse outcome for return to work it is made possible for preventive actions, to reduce the number of patients with reduced work ability and disability.</p>

<p>Uvod: Stratifikacija rizika je postala integralna komponenta savremenog pristupa tretmanu u kliničkoj praksi. Danas se u dijagnostici i lečenju akutnog infarkta miokarda (AIM) koriste različiti skorovi rizika kao prognostički instrumenti za kratkoročan i dugoročan ishod bolesti. Nužni proceduralni procesi, u toku primarne perkutane koronarne intervencije (pPKI), kao i saznanja o distribuciji i vrstama lezija koronarnih arterija su od velikog značaja, te se preporučuje finalna evaluacija rizika neposredno nakon izvr&scaron;ene pPKI. Metode istraživanja podataka omogućavaju pronalaženje skrivenih obrazaca u podacima, otkrivanje njihovih uzročno-posledičnih veza I odnosa, te razvoj savremenih prediktivnih modela. Cilj: Kreiranje i testiranje jednostavnog, praktičnog i u svakodnevnoj praksi upotrebljivog prediktivnog modela za procenu intra-hospitalnog ishoda lečenja pacijenata obolelih od AIM sa ST-elevacijom (STEMI) lečenih pPKI. Metode: Istraživanje je unicentrična, retrospektivna, ali I prospektivna studija. U retrospektivnu studiju je uključeno 1495 pacijenta sa STEMI koji su lečeni na Klinici za kardiologiju Instituta za kardiovaskularne bolesti Vojvodine (IKVBV) kod kojih je u cilju rekanalizacije infarktne arterije izvr&scaron;ena pPKI, u periodu od decembra 2008. godine do decembra 2011. godine. Svaki pacijent je inicijalno predstavljen sa 629 obeležja sadržanih u postojećem IKVBV informacionom sistemu, koja čine demografske karakteristike, podaci iz anamneze i kliničkog nalaza, parametri biohemijskih analiza krvi priprijemu, parametri ehokardiografskog pregleda, angiografski i proceduralni detalji i &scaron;ifre prijemnih dijagnoza. U svrhu istraživanja podataka kori&scaron;ćeno je programsko re&scaron;enje otvorenog koda Weka. Tokom evaluacije različitih algoritama izabran je algoritam koji daje najbolje rezultate po tačnosti predikcije i ROC parametru. U sklopu retrospektivnog dela izvr&scaron;ena je validacija prediktivnog modela&nbsp; desetostrukom unakrsnom validacijom na celom skupu podataka. Prospektivnom studijom je na uzorku od 400 pacijenata sa STEMI lečenih pPKI u toku 2015. godine izvr&scaron;ena dodatna validacija razvijenog prediktivnog modela. Za iste pacijente je izračunavat i GRACE skor rizika, te je upoređena njegova, i prediktivna moć razvijenog modela. Rezultati: Alternativno stablo odluke (ADTree) izdvojen je kao algoritam sa najboljim performansama u odnosu na ostale evaluirane algoritme. Cost sensitive klasifikacija je kori&scaron;ćena kao dodatna metodologija da bi se pojačala tačnost. ADTree stablo odluke izdvojilo je osam ključnih parametara koji najvi&scaron;e utiču na ishod intra-hospitalnog lečenja: sistolni krvni pritisak pri prijemu, ejekciona frakcija leve komore, udarni volumen leve komore, troponin, kreatinin fosfokinaza, ukupni bilirubin, T talas i<br />rezultat intervencije. Performanse razvijenog modela su: tačnost predikcije je 93.17%, ROC 0.94. Razvijeni model je na prospektivnoj validaciji zadržao performanse: tačnost predikcije 90.75%, ROC 0.93. &Scaron;iroko kori&scaron;ćeni GRACE skor je na prospektivnom skupu postigao ROC=0.86, &scaron;to pokazuje da je razvijeni prediktivni model superiorniji u odnosu na njega. Zaključak: Razvijeni prediktivni model je jednostavan i pouzdan. Njegova implementacija u svakodnevnu kliničku praksu, omogućila bi kliničarima da izdvoje visokorizične pacijente, nakon reperfuzionog tretmana, a potom kod njih intenziviraju tretman i kliničko praćenje, a sa ciljem smanjenja incidence intra-hospitalnih komplikacija i povećanja njihovog preživljavanja.</p> / <p>Introduction: Risk stratification has become an integral component of modern treatment in clinical practice. Today, the diagnosis and treatment of acute myocardial infarction (AMI) use different risk scores as a prognostic instruments for short-term and long-term outcome of the disease. The necessary procedural processes during primary percutaneous coronary intervention (pPCI) as well as knowledge about the distribution and types of lesions in coronary arteries are of great importance, and a final risk evaluation is recommended directly after the pPCI. Methods of data mining allow finding hidden patterns in data, disclosure of their causal connections and relationships, and the development of modern predictive models. Aim: To create and test a simple, practical and usable predictive model in daily practice for the&nbsp; assessment of intrahospital treatment outcome of patients with AMI with STsegment elevation (STEMI) treated with pPCI. Methods: Presented research is unicentric, retrospective but also prospective study. Retrospective study included 1495 patients with STEMI who were admitted to the Clinics of cardiology of the Institute of Cardiovascular Diseases Vojvodina (IKVBV). For the purpose of recanalization of the infarct artery, pPCI has been performed to these patients during the period from December 2008 to December 2011. Each patient was initially described with 629 attributes from the existing information system of IKVBV. Those attributes consist of demographic characteristics, data from history and clinical findings, biochemical parameters of blood tests on admission, the echocardiographic parameters, angiographic and procedural details and admission diagnosis codes. For model development, an open source software solution Weka was used. During the evaluation of different algorithms, algorithm that gives the best results in terms of accuracy and ROC parameter was chosen. As part of the retrospective study, in order to assess the models performance, ten-fold cross-validation on the entire data set was used. A prospective study, on a sample of 400 patients with STEMI, treated with pPCI in 2015, performed additional validation of the developed predictive model. GRACE risk score was calculated for the prospective study patients and comparison with the developed model has been performed. Results: Alternative decision tree (ADTree) was isolated as an algorithm with the best performance in relation to other algorithms evaluated. Cost sensitive classification was used as an additional methodology to enhance accuracy. ADTree selected eight key parameters that most influence the outcome of intra-hospital treatment: systolic blood pressure on admission, left ventricular ejection fraction, stroke volume of the left ventricle, troponin, creatine phosphokinase, total bilirubin, T wave and the result of the intervention. The performance of the developed model are: the accuracy of the prediction is 93.17%, ROC 0.94. The developed model kept its performance in prospective validation: accuracy of prediction 90.75%, ROC 0.93. Widely used GRACE score achieved ROC = 0.86 in the prospective study patients, indicating that developed predictive model is superior to him. Conclusion: Developed predictive model is simple and reliable. Its implementation in everyday clinical practice, would allow clinicians to distinguish high-risk patients after reperfusion treatment, and then for them to intensify treatment and clinical follow-up, with an aim of reducing the incidence of intra-hospital complications and increase their survival.</p>

<p>UVOD: Karcinom kolona (KK) je velik javnozdravstveni problem usled visoke incidence i stope mortaliteta. Kod KK je stadijum bolesti najvažniji pojedinačni nezavisni faktor prognoze. U prisustvu nepovoljnih prognostičkih parametara, u koje spadaju visok histolo&scaron;ki gradus, ileus, limfo-vaskularna i perineuralna invazija, nakon potencijalno kurativne operacije se kod pacijenata u stadijumu II indikuje primena adjuvantne hemioterapije koja ima pozitivan uticaj na ukupno preživljavanje i na produženje perioda bez bolesti. Međutim, relapsi bolesti nastaju kod nekih bolesnika bez negativnih prognostičkih faktora, &scaron;to ukazuje na moguće postojanje drugih tkivnih faktora lo&scaron;e prognoze. U novije vreme se sve veća pažnja posvećuje fenomenu tumorskog pupljenja koje predstavlja pojavu tumorskih pupoljaka (TP), odnosno oligocelularnih grupa tumorskih ćelija koje se na invazivnom frontu tumora odvajaju od glavne tumorske mase. Ove tumorske ćelije poprimaju fenotip mezenhimnih ćelija i stiču sposobnost ameboidnog kretanja kroz ekstracelularni matriks, uz pomoć citoplazmatskih podija koje se na dvodimenzionalnim histolo&scaron;kim rezovima vizualizuju kao citoplazmatski pseudofragmenti (CPF). Značaj gustine TP i CPF je jo&scaron; uvek nedovoljno ispitan, ali postoje indicije da se radi o moćnom prediktoru biolo&scaron;kog pona&scaron;anja tumora. CILJ: Cilj je bio da se ispita zavisnost dužine perioda bez relapsa, veličine primarnog tumora, gustine peritumorske limfocitne infiltracije i konfiguracije tumorske margine od gustine TP i CPF kod bolesnika sa KK u stadijumu II. METODOLOGIJA: Istraživanjem je obuhvaćeno 114 bolesnika operisanih od KK u stadijumu II na Institutu za onkologiju Vojvodine, bez nepovoljnih prognostičkih faktora i bez indikacija za primenu adjuvantne hemioterapije. Mikroskopskom analizom rutinskih histolo&scaron;kih i imunohistohemijskih preparata utvrđivana je gustina TP i CPF, koja je zatim korelirana sa vremenom pojave relapsa, veličinom primarnog tumora, gustinom peritumorske limfocitne infiltracije i konfiguracijom tumorske margine. REZULTATI: Velika gustina TP i/ili CPF nađena je kod 45 tumora (39,5%). U ovoj grupi se relaps dogodio kod 26 bolesnika (57,8%). U grupi bolesnika sa malom gustinom TP/CPF relaps je registrovan u 4 slučaja (5,8%). Poređenje krivih preživljavanja pokazalo je da je verovatnoća relapsa značajno veća ako se u tumoru nalazi velika gustina TP/CPF (p&lt;0,0001). Tumori sa velikom gustinom TP/CPF su imali najveći prečnik koji je varirao u rasponu od 25 do 100 mm, dok su tumori sa malom gustinom TP/CPF bili najvećeg prečnika od 20 do 110 mm (p=0,6744). Intenzitet peritumorskog limfoidnog odgovora je bio velik kod 13 tumora sa velikom gustinom TP/CPF (28,9%) i kod 17 tumora sa malom gustinom TP/CPF (24,6%), p=0,7747. Konfiguracija tumorske margine je bila infiltrativna u svim tumorima sa velikom gustinom TP/CPF, kao i kod 42 tumora sa malom gustinom TP/CPF (60,9%). ZAKLJUČAK: Velika gustina TP/CPF je nezavisan tkivni indikator lo&scaron;e prognoze kod bolesnika sa KK u stadijumu II, koji je ne korelira ni sa veličinom primarnog tumora ni sa intenzitetom peritumorskog limfoidnog odgovora. Velika gustina TP/CPF nije kompatibilna sa ekspanzivnom konfiguracijom tumorske margine, ali infiltrativna konfiguracija tumorske margine nije prediktor velike gustine TP/CPF.</p> / <p>INTRODUCTION: Colonic carcinoma (CC) is a serious public health problem due to its high incidence and mortality rate. Stage is the single most important independent prognosticator in patients with CC. In the presence of indicators of poor prognosis, including high histologic grade, ileus, lympho-vascular invasion and perineural invasion, there is a need for adjuvant chemotherapy after a potentially curative operation in patients with stage II CC, because the therapy improves both overall survival and disease-free survival. However, some patients with no documented poor prognostic factors suffer recurrences, which indicates that there may be some other tissue features that confer poor prognosis. In the recent publications there is an increasing interest in the phenomenon of tumor budding, a term assigned to the presence of small groups of discohesive tumor cells at the invasive front of the tumor &ndash; tumor buds (TB&#39;s). These cells acquire mesenchymal phenotype and gain the ability to migrate through the extracellular matrix by means of cytoplasmic extrusions which are visible on the two-dimensional immunohistologic sections and are called cytoplasmic pseudofragments (CPF&#39;s). Significance of density of TB&#39;s and CPF&#39;s is still to be evaluated, but the pool of evidence suggests that this is a powerful predictor of biologic behaviour of CC. AIM: The aim of this study was to determine the influence of density of TB&#39;s and CPF&#39;s on the risk of recurrence in patients with stage II CC. This research also attempted to establish whether there is a correlation between the density of TB&#39;s and CPF&#39;s and several other morphologic features such as tumor diameter, peritumoral lymphocytic response and the configuration of the tumor margin. METHODS: 114 patients with stage II CC were enrolled in the study. All the patients received surgery at the Institute of Oncology in Sremska Kamenica and no patient had indication for adjuvant chemotherapy. Microscopic analysis of routine histologic and immunohistochemical slides was performed to establish the density of TB&#39;s and CPF&#39;s, to estimate the intensity of the peritumoral lymphocytic response and to determine the configuration of the tumor margin. RESULTS: High density of TB&#39;s and/or CPF&#39;s was found in 45 tumors (39.5%). In this group recurrence occured in 26 patients (57.8%). In the group of patients with low density of TB/CPF in the tumor tissue 4 patients relapsed (5.8%). Comparison of survival curves showed that the probability of recurrence was significantly greater if the density of TB/CPF&#39;s was high (p&lt;0.0001). Tumors with high density of TB/CPF&#39;s ranged from 25 to 100 mm in greatest diameter, while those with low density measured from 20 to 110 mm (p=0.6744). Intensity of peritumoral lymphocytic response was high in 13 tumors with high density of TB/CPF&#39;s (28.9%) and in 17 tumors with low density of TB/CPF&#39;s (24.6%), p=0.7747. All tumors with high density of TB/CPF&#39;s and 42 tumors with low density of TB/CPF&#39;s (60.9%) had infiltrative configuration of tumor margin. CONCLUSION: High density of TB/CPF&#39;s is an independent indicator of poor prognosis in patients with stage II CC and it correlates neither with tumor diameter nor with intensity of peritumoral lymphocytic response. High density of TB/CPF&#39;s is not compatible with the expansive configuration of tumor margin, but the infiltrative configuration of tumor margin is not a predictor of high density of TB/CPF&#39;s.</p>

La pharmaco-résistance est une complication évolutive fréquente de l'épisode dépressif majeur. La rTMS est une technique de stimulation cérébrale innovante dont l'efficacité antidépressive est maintenant établie.Le premier objectif de notre travail de thèse a été de caractériser les substrats fonctionnels de la dépression pharmaco-résistante à l'aide de la technique TEMP, afin d'identifier des patterns d'anomalies cérébrales qui leur sont propres. Dans un second temps, et sur la base des travaux existant sur les mécanismes d'action de la rTMS, nous avons étudié la valeur prédictive de marqueurs fonctionnels en neuro-imagerie TEMP et par EEG. Enfin, nous avons relié l'effet cérébral de la rTMS révélé par la neuro-imagerie fonctionnelle à son efficacité antidépressive, et de façon plus globale à la qualité de vie, comme recommandé actuellement.Nos résultats montrent l'existence d'un pattern de perfusion cérébrale commun aux patients pharmaco-résistants quel que soit le type de dépression, impliquant les régions fronto-temporales et le cervelet. L'étude TEMP de la perfusion cérébrale et de l'activité cérébrale en l'EEG dans sa bande alpha semble pouvoir prédire de façon satisfaisante, avant traitement, l'amélioration clinique individuelle des patients dépressifs pharmaco-résistants traités par rTMS. L'efficacité antidépressive de la rTMS apparait équivalente quel que soit le côté stimulé, entrainant des modifications de perfusion cérébrale comparables. Enfin, nos résultats ont permis d'identifier des régions cérébrales dysfonctionnelles distinctes et confirment l'interet d'une approche complémentaire de la dépression, par l'évaluation de la qualité de vie. / Treatment-resistance is a common outcome of a major depressive episode. Repetitive transcranial magnetic stimulation has been put forward as a new technique to treat this debilitating illness. The first objective of our thesis was to characterize the functional substrates of treatment-resistant depression (TRD) using SPECT technique, in order to identify specific patterns of brain abnormalities. In a second part, based on existing work on the antidepressant mechanisms of rTMS, we investigated the predictive value of two neurofunctional biomarkers: SPECT and EEG. Finally, we studied brain SPECT perfusion changes underlying therapeutic efficiency and improvement of quality of life, as currently recommended. Our results showed the existence of a common pattern of brain perfusion in treatment-resistant patients involving the fronto-temporal regions and the cerebellum, regardless the type of depression. At baseline, SPECT brain perfusion and alpha EEG band power could predict individual clinical improvement in TRD-patients treated with rTMS. Regardless the stimulated side, the antidepressant efficacy of rTMS consisted in similar changes in cerebral perfusion. Finally, our results have identified distinct dysfunctional brain regions and confirm the interest of a complementary approach to depression, by assessing quality of life.

Objetivo: Verificar a acurácia do Test of Infant Motor Performance (TIMP) e da ultrassonografia de crânio (USC) no diagnóstico neurológico precoce após os 10 meses de idade corrigida em recém-nascidos pré-termo (RNPT) Metodologia: Amostra não aleatória constituída por 59 RNPT (idade gestacional ao nascimento 32 semanas ou peso ao nascimento 1500 gramas) seguidos em média até os 12 meses de idade corrigida. Os resultados da USC foram agrupados em 3 intervalos: 1) de 0 a 15 dias, 2) de 16 a 30 dias e 3) de 31 a 45 dias. Os achados da USC foram classificados em normal e anormal (anormalidades moderada e grave). O TIMP foi aplicado mensalmente, do primeiro retorno após a alta hospitalar até o 4° mês de idade corrigida. As avaliações foram agrupadas em 5 intervalos, correspondentes às avaliações antes do termo, 1°, 2°, 3° e 4° meses de idade corrigida. Os resultados do TIMP foram classificados em normal (média e média baixa) ou anormal (abaixo da média e muito abaixo da média). A avaliação neurológica foi realizada em média aos 12 meses de idade corrigida, e usada como padrão-ouro. Foram calculados os valores de sensibilidade, especificidade e valores preditivos positivos (VPP) e negativos (VPN) para o TIMP e para a USC neonatal. Resultados: A paralisia cerebral foi diagnosticada em 6 crianças. Observamos que a USC apresentou alta sensibilidade (> 70%) assim como altos VPN (>88%) em todos os intervalos. Para a USC, especificidade e VPP foram baixos em todos os intervalos. A sensibilidade do TIMP foi baixa, exceto para o intervalo 0, e os VPP foram baixos em todas as idades. A escala TIMP apresentou alta especificidade (75%, 85%) no 3° e 4° meses e altos VPN (> 77%) em todos os intervalos. Conclusão: Concluímos que os RNPT com pontuação normal no 3° e 4° meses do TIMP tem grandes chances de não desenvolver PC enquanto que RNPT com anormalidades graves e persistentes à USC tem maiores chances de um prognóstico neurológico anormal / Objective: Calculate the accuracy of the Test of Infant Motor Performance (TIMP) and the cranial ultrasonography (CUS) in the neurological outcome after 10 months of corrected age of preterm infants. Methods: Non-random sample of 59 preterm newborn infants (gestational age 32weeks or birth weight1500g) were followed up to a mean of 12 months corrected age. CUS results were grouped into 3 periods: 1) from 0 to 15 days; 2) from 16 to 30 days, and 3) from 31 to 45 days of life. CUS findings were rated into two groups: normal and abnormal (moderate and severe abnormalities). TIMP was applied monthly, from the first outpatient visit after hospital discharge until four months corrected age. The evaluations were grouped into five intervals, corresponding to the assessments performed before term age, 1st, 2nd, 3rd and 4th month of corrected age. TIMP results were ranked as normal (average, low average) or abnormal (below average and far below average). A full neurological examination was performed at a mean of 12 months of corrected age, and used as gold standard. The sensitivity, specificity, positive predictive (PPV) and negative predictive (NPV) values for TIMP and CUS were calculated. Results: Cerebral palsy was diagnosed in six infants. We observed that CUS had a high sensitivity (> 70%) in all intervals as well as high NPV (>88%). For CUS, specificity and PPV were low in all intervals. TIMP sensitivity was low, except for interval 0, and PPV were low at all ages. TIMP scale showed high specificity in the 3rd and 4th month (75%, 85%) and high NPV (> 77%) at all ages. Conclusions: We conclude that preterm infants with normal score at the 3rd and 4th months of TIMP are likely to develop normally while infants with severe and persistent abnormalities in the CUS examinations are more likely to have an abnormal neurological outcome

IGF-1 e IGFBP-3 são medidas indiretas da secreção de GH e ferramentas úteis na avaliação do eixo GH/IGF-1. No diagnóstico de deficiência de GH (DGH) estes peptídeos são avaliados pela idade cronológica. Nosso estudo avaliou a capacidade discriminativa desses peptídeos na identificação de pacientes com DGH e comparou a performance dos escores de desvio padrão do IGF-1 e do IGFBP-3 avaliados para idade cronológica (escore-ZIC), idade óssea (escore-ZIO) e estadio puberal (escore-ZIP) no diagnóstico de DGH. Trata-se de um estudo retrospectivo, transversal, com levantamento de dados de prontuário de pacientes pediátricos com distúrbios de crescimento acompanhados em nosso serviço. Os pacientes foram classificados como DGH ou suficientes de GH (não-DGH). O IGF-1 e o IGFBP-3 foram dosados pelo ensaio quimioluminescência - IMMULITE® e foram calculados o escore-ZIC, escore-ZIO e escore-ZIP. Foram avaliados 50 pacientes classificados como DGH e 187 como não-DGH. Os escores-ZIC, escores-ZIO e escores-ZIP do IGF-1 e do IGFBP-3 foram significativamente menores no grupo DGH em comparação com o grupo não-DGH (p < 0,001). O escore-ZIC do IGF-1 apresentou desempenho discriminativo superior ao escore-ZIC do IGFBP-3 na identificação de pacientes com DGH [área sob a curva ROC (AUC) 0,877 e 0,766, respectivamente, p = 0,001], em que o IGF-1 apresentou melhor sensibilidade (92% vs 45,2%) e o IGFBP-3 melhor especificidade (93,8% vs 69%). Entretanto, o valor preditivo positivo, considerando uma prevalência estimada de DGH de 2% entre crianças com baixa estatura, foi de 5,7% para o escore-ZIC do IGF-1 e de 13,1% para o do IGFBP-3, com valores preditivos negativos semelhantes. O escore-ZIO do IGF-1 demonstrou melhor desempenho discriminativo que o escore-ZIC sem atingir significância estatística (AUCs de 0,902 e 0,877, respectivamente, p=0,29). Mas essa superioridade não foi observada com o escore-ZIO do IGFBP-3. Nos pacientes em idade pré-púbere, não houve diferença estatisticamente significante entre o desempenho do escore-ZIC e escore-ZIO das concentrações séricas do IGF-1 e do IGFBP-3. Já nos pacientes em idade puberal houve uma melhora significativa da especificidade dos escore-ZIO e escore-ZIP do IGF-1 em relação ao escore-ZIC (de 65,6% para 92,7% e 98,4%), apesar da redução da sensibilidade (de 91,3% para 72,2% e 63,6%, respectivamente). Além disso, os valores preditivos positivos (VPP) do escore-ZIO e do escore-ZIP apresentaram uma melhora significativa em relação ao escore-ZIC do IGF-1 (16,8%, 44,8% e 5,1%, respectivamente), sem prejuízo nos valores preditivos negativos. A avaliação combinada de IGF-1 e IGFBP-3 em comparação com o escore-Z do IGF-1 isolado apresentou melhor sensibilidade (de 92% para 94,4%) quando somente um escore-Z desses peptídeos está baixo e melhor especificidade (de 69% para 95,7%) quando os escores-Z de ambos os peptídeos estão baixos / IGF-1 and IGFBP-3 are an indirect measure of the GH secretion and are a useful tool in the evaluation of the GH/IGF-1 axis. These peptides are usually evaluated according to the chronological age in the diagnosis of GH deficiency (GHD). Our study evaluated the diagnostic value of IGF-1 and IGFBP-3 in the diagnosis of GHD and compared their performance assessed by chronological age, bone age and pubertal status. This is a retrospective, cross-sectional study; data of pediatric patients with growth disorders evaluated in our tertiary outpatient clinic were retrieved from medical records. The patients were classified as GHD or GH sufficient (non-GHD). The IGF-1 and IGFBP-3 were measured by a chemiluminescent immunometric assay (IMMULITE®) and these values were transformed into standard deviation scores according to chronological age (SDSCA), bone age (SDS-BA) and pubertal status (SDS-PS). 50 patients were classified as GHD and 187 patients as non-GHD. The IGF-1 and IGFBP-3 SDSCA, SDS-BA and SDS-PS were significantly lower in the GHD group in comparison to the non-GHD group (p < 0.001). The IGF-1 SDS-CA had a superior discriminatory performance than the IGFBP-3 SDS-CA in the diagnosis of GHD [area under the ROC curve (AUC) 0.877 and 0.766, respectively, p = 0.001]. The IGF-1 SDS-CA had a higher sensitivity (92% vs 45.2%) and the IGFBP-3 SDSCA had a higher specificity (93.8% vs 69%). However, the predictive value of a positive result, considering an estimated GHD prevalence of 2% among children with short stature was 5.7% for the IGF-1 SDS-CA and 13.1% for the IGFBP-3 SDS-CA, with similar predictive values of a negative result. The IGF-1 SDS-BA had a better discriminatory performance than the IGF-1 SDS-CA, though not statistically significant (AUCs 0.902 and 0.877, respectively, p=0.29). There was no difference in the performance of the IGFBP-3 SDS-CA and SDS-BA. The diagnostic value of the IGF-1 and IGFBP-3 SDS-CA and SDS-BA of patients of pre-pubertal age was similar. On the other hand, in patients of pubertal age, there was a significant improvement of the specificity of the IGF-1 SDS-BA and SDSPS in comparison to the IGF-1 SDS-CA (from 65.5% to 92.7% and 98,4%), albeit the decay on the sensitivity (from 91.3% to 72.2% and 63.6%, respectively). Furthermore, the positive predictive values of the IGF-1 SDS-BA and SDS-PS were higher than the IGF-1 SDS-CA (16.8%, 44.8% and 5.1%, respectively), with similar negative predictive values. The evaluation of IGF-1 and IGFBP-3 assessed simultaneously in comparison to IGF-1 had a better sensitivity (from 92% to 94.4%) when either one of these peptides is low, and a better specificity (from 69 to 95.7%) when both the peptides are low

O momento ideal para a extubação de crianças graves é ainda difícil de ser avaliado. A razão entre espaço morto e volume corrente (Vd/Vt), como valor preditiva de extubação bem sucedida, já foi testada em adultos e crianças. O objetivo deste trabalho foi avaliar a eficácia do Vd/Vt, como preditivo do sucesso da extubação, em crianças de uma UTI pediátrica geral. Após aplicação dos critérios de inclusão e exclusão, testou-se o Vd/Vt em 86 pacientes extubados num período de 16 meses. Nos estudos estatísticos o índice Vd/Vt médio não discriminou os grupos de falha e sucesso na extubação nas análises uni e multivariada. O valor do índice, com corte em 0,65, foi limitado na sensibilidade e especificidade e mediano na razão de verossimilhança. O estudo sugere que o índice Vd/Vt, pode ser considerado como complementar aos dados de avaliação clínica no momento da extubação. / The ideal moment for extubation of critically ill children is still difficult to determine. The dead-space : tidal volume ratio (Vd/Vt) has been tested as predictor of extubation failure in adults and children. The purpose of this study was to evaluate the efficacy of the Vd/Vt as a predictor of the success of extubation in children admitted to a pediatric intensive care unit. After the inclusion and exclusion criteria, 86 patients were studied during 16 months. The statistical study revealed that the mean Vd/Vt was not able to discriminate between failure and success of extubation in the multivariate analysis. The utility of the Vd/Vt was limited, in terms of sensibility and specificity, using a cutoff of 0,65, but was medially satisfactory in the likelihood ratio. This study suggests that the Vd/Vt can only be considered as complementary to the routine clinical evaluation prior to extubation.

Introduction – La place des tests de diagnostic rapide (TDR) et des règles de décision cliniques (RDC) pour le diagnostic des pharyngites à streptocoque du groupe A (SGA) chez l’enfant varie selon les recommandations internationales en raison de doutes sur la stabilité des performances diagnostiques du TDR et d’une validation insuffisante des RDC. Méthodes – Dans une étude prospective multicentrique (n=17) ambulatoire réalisée au sein du réseau clinique pédiatrique ACTIV de 2009 à 2011, 1776 enfants avec pharyngite ou sains ont été soumis à des prélèvements de gorge pour réaliser un TDR et une mise en culture (test de référence). Nous avons étudié l’effet indépendant de variables liées aux patients et aux médecins sur les performances diagnostiques du TDR, exploré systématiquement les faux-Positifs (FP) du TDR et réalisé une validation externe et une comparaison des RDC existantes. Résultats – La sensibilité du TDR (en moyenne 87%) variait selon la présentation clinique (âge, signes cliniques), l’inoculum bactérien et le phénomène de portage (paramètres aussi liés entre eux), et selon des variables liées aux médecins (dont le type d’activité clinique). La valeur prédictive négative du TDR était élevée (autour de 90%) et stable. Les FP du TDR étaient positifs pour le SGA en PCR. Aucune RDC n’était satisfaisante en termes de calibration et de discrimination. Conclusion – Le TDR est suffisant pour le diagnostic de pharyngite à SGA si les cliniciens évaluent leurs propres performances et les améliorent si besoin. Aucune RDC ne peut être recommandée en pratique clinique en pédiatrie. / Background – The roles of rapid antigen detection tests (RADT) and clinical prediction rules (CPR) for the diagnosis of group A streptococcus (GAS) in children with pharyngitis vary across international clinical guidelines. This might be related to unstable diagnostic accuracy of RADTs and insufficient validation of CPRs. Methods – In a prospective multicenter (n=17) office-Based study that took place in France within the ACTIV network between 2009 and 2011, 1776 children with pharyngitis or healthy controls underwent throat swabs to perform a RADT and a throat culture (reference standard). We assessed the independent effect of patient- and physician-Level characteristics on the accuracy of a RADT, systematically re-Analyzed RADT false-Positive results, and externally validated and compared existing CPRs. Results – RADT sensitivity (overall 87%) varied according to clinical signs and symptoms, bacterial inoculum size and GAS throat carriage (factors also related to each other), and according to physician-Level characteristics (including type of clinical practice). RADT negative predictive value was high (about 90%) and stable. RADT false-Positives were positive for GAS when using a new PCR technique. No CPR had sufficient performances regarding calibration and discrimination. Conclusions – RADTs are sufficient for diagnosing GAS pharyngitis if clinicians accept diagnostic accuracy monitoring and adequate training when needed. No CPR can be recommended for use in pediatrics.