To investigate the association between the clinical evaluation and self-perception of deglutition with the motor disability scale in patients with Multiple Sclerosis.It is a cross-sectional, prospective study that was conducted with individuals with Multiple Sclerosis treated by the Neuroimmunology outpatient clinic of a hospital in southern Brazil. We reviewed the electronic medical records of patients to extract the score from the last Expanded Disability Status Scale. After the analysis of the inclusion criteria, and in clinical consultation, two protocols were applied: one of self-perception for the risk of dysphagia, through the Brazilian equivalence instrument of the Eating Assessment Tool; and the clinical evaluation of swallowing, with food, through the scale Gugging Swallowing Screen. The data were analyzed through tables, descriptive statistics and the tests: Fisher's Exact Association Test and Chi-square Test to assess the association between the results of the applied scales. We considered a maximum significance level of 5% (p <0.05).It was possible to observe that there was a significant association between the scores of the Gugging Swallowing Screen scales with the Expanded Disability Status Scale of the patients. In addition, there was also a relation between the results of both protocols with the Expanded Disability Status Scale.The patients with Multiple Sclerosis in this study presented oropharyngeal dysphagia, what was confirmed by the association between the clinical evaluation of swallowing and the results of the instrument of self-perception of swallowing and the motor disability scale. Within this group, there is Multiple Sclerosis (MS) which is a chronic neurological disease in which the individual's immune system degrades the myelin sheath causing damage - resulting from immune-mediated inflammation, demyelination and consequent axonal damage, neuronal loss and gliosis that lead to impairment of sensory and motor functions . The etiology of MS is not completely known, but it is believed to be multifactorial, with the influence of genetic and environmental factors contributing to the onset of the disease .Demyelinating diseases constitute a group of pathologies in which damage to the myelin sheath occurs generally by affecting different areas of the central nervous system (CNS) ,5. The prevalence of MS found in studies carried out in Brazil ranged from 1.36/100,000 inhabitants in Recife (northwest region) to 27.2/100,000 inhabitants in the city of Santa Maria, Rio Grande do Sul (southern region) .From an epidemiological point of view, MS generally affects Caucasians, young adults, from the second decade of life, and it is twice as frequent in women as in men. The estimated number of people with MS worldwide increased from 2.1 million in 2008 to 2.3 million in 2013 ; primarily progressive, characterized by progressive and cumulative neurological damage since the onset of the disease, without periods of specific relapses; and, secondarily progressive, which consists of an association between the other two manifestations, where after a relapsing-remitting period, the disease enters a phase in which there is clinical deterioration ,8.There are three distinct forms of MS manifestation, namely: relapsing-remitting, which is characterized by outbreaks of symptoms followed by total or partial remission, being the most frequent form .Pharmacological treatment aims to prevent the progression of the disease and modify its natural history. Until 2017, the Clinical Protocol and Therapeutic Guidelines for Multiple Sclerosis (CPTG) subdivided the drugs into first (beta-interferons and glatiramer), second  and third lines . As of 2018, a new CPTG was created, which added teriflunomide in the first line and dimethyl fumarate in the second line, in addition to moving natalizumab to the third line in the treatment of MS .MS is characterized by a variable combination of neurological symptoms such as: chronic pain, fatigue, visual, sensory, motor, coordination, balance, speech and/or swallowing changes, sphincter dysfunction and depression. Deficits caused by disease progression can undergo total or partial remission and, over time, all patients tend to show progressive neurological restrictions . It is estimated that the incidence of dysphagia in patients with MS varies from 33 to 43%, and that it occurs more frequently in individuals who are at a more advanced stage, but it also manifests itself in patients with a lower level of impairment. In these patients, dysphagia can manifest as oral dysfunctions, fatigue during feeding, presence of stasis, penetration and/or aspiration . According to the literature, it is possible to observe the appearance of dysphagia in individuals with mild impairment on the Expanded Disability Status Scale (score <4) and the symptom intensifies when there is a greater impairment according to the scale, as there is an increase in disabilities functional, also affecting the dynamics of swallowing, but there are still few studies that correlate the EDSS scale score with the onset of oropharyngeal dysphagia ,12.Oropharyngeal dysphagia is a symptom that can be identified in MS, which is characterized by the difficulty of swallowing in carrying the bolus from the oral cavity to the stomach. This disorder often results in damage to the individual's nutritional, pulmonary, food and social pleasure aspects In this context, the aim of this study is to investigate the association between clinical assessment and self-perceived swallowing with the motor disability scale in patients with Multiple Sclerosis.The present research was approved by the Ethics and Research Committee of the proposing health institution under opinion number 2.021.922. This is a prospective cross-sectional study carried out through the collection of clinical data from patients diagnosed with Multiple Sclerosis treated at the Neuro-immunology clinic of a hospital in southern Brazil.The inclusion criteria for this study were:Being over 18 years-old;Multiple Sclerosis Diagnosis;Being monitored and treated by the Neuro-immunology Service;.Using first or second-line medication for the treatment of Multiple Sclerosis, in accordance with the Ministry of Health ordinance in force until the year 2017 Agreement and assignment of the Informed Consent Form;The exclusion criteria were:Another disease associated with Multiple Sclerosis;A contraindication for oral feeding;.Using third-line medications for the treatment of Multiple Sclerosis in accordance with the Ministry of Health ordinance in force until the year 2017 Initially, the sample consisted of 51 patients diagnosed with MS evaluated between April 2017 and August 2018. After verifying the inclusion and exclusion criteria, three of these individuals were removed from the sample, two for not agreeing with the Informed Consent Form and one for having a discarded diagnosis of MS, totaling 48 study participants. The average age was 43 years-old, and out of these 34 (70.8%) are female. They presented disease diagnosis time of approximately nine years of disease course . It was First, a review of the electronic medical records of the patients and the appointment schedule of the Neuro-immunology Service was carried out. Thus, data such as age, sex, diagnosis, MRI result, time of diagnosis, proposed treatment (medication), comorbidities and score of the last Expanded Disability Status Scale (EDSS) were collected, this data was updated according to the consultation of the patient with the Neuro-immunology service, that is, the vast majority of patients were evaluated on the same day and some varied in a maximum of 60 days until they were submitted to direct swallowing assessment.After this first phase of identification, patients from the Neuro-immunology Service who met the inclusion criteria were invited to participate in an interview and in a speech therapy assessment at the clinic. Initially, the Informed Consent Form was presented for the use of data collected exclusively for the research, and based on its agreement, the research continued..The researcher applied the Brazilian equivalence protocol of Eating Assessment Tool (EAT-10) to later compare the reported complaints with the results of the clinical evaluation of swallowing. After filling out the EAT-10, the clinical evaluation of swallowing was performed using the Gugging Swallowing Screen (GUSS) scale ,14.The Expanded Disability Status Scale is a method to quantify disabilities that occur during the evolution of Multiple Sclerosis over time and is also a way to monitor changes in the levels of these disabilities. It has twenty items with scores ranging from zero to 10, with a score that increases by half a point according to the degree of impairment of the patient, with the cutoff: score > four showing clinical worsening of the disease ,16.The instrument of Brazilian equivalence of the EAT-10 is a self-assessment to identify the risk of dysphagia. This protocol consists of 10 simple questions, and provides information about functionality, emotional impact and physical symptoms that a problem with swallowing can cause in an individual's life. Each item is rated on a scale from zero (no problem) to four (severe problem). The total score is the sum of all answers, ranging from zero to 40 points. The cutoff point defined as the limit between “pass” and “failure” in feeding screening is three, with a higher risk for oropharyngeal dysphagia being above this value .Consisting of seven items, the GUSS scale aims to assess the capacity and degree of swallowing problems, as well as to identify adequate guidance on nutrition and/or additional investigations. The results predicted by this scale classify swallowing as: normal, mild dysphagia, moderate dysphagia or severe dysphagia The evaluations consisted of the offer of the three food consistencies provided for by GUSS, namely: pasty , liquid (water) and solid (loaf bread), accompanied by cervical auscultation with the aid of stethoscope (Litmann® Classic II Pediatric) for the evaluation of signs suggestive of laryngeal penetration and/or tracheal aspiration. After completing the protocols, the results were discussed with the medical team responsible for the cases, and presented to the patients and their caregivers, with guidance on the signs and symptoms of dysphagia, and when it was necessary, the appropriate referrals to speech therapy were carried out or for additional exams.At the end of collection, all data were organized in a spreadsheet on Excel software version 16.0 and analyzed through tables, descriptive statistics and statistical tests: Fisher's Exact Association Test and Chi-square test to assess the association between the results of the scales applied. The results were considered significant at a maximum significance level of 5% (p<0.05) and the software used for this analysis was SPSS version 22.0.It was found that most patients (56.3%) had a score on the EDSS scale of up to four points, evidencing a mild motor impairment . ThroughThe time since diagnosis of the disease between 11 and 15 years was associated with a greater impairment in the scale of motor disability - EDSS, as well as the results of the EAT-10 and GUSS demonstrate that they are directly proportional to the EDSS. That is, the lower the EDSS the lower the EAT-10 score, and the lower the chances of patients presenting dysphagia according to the clinical assessment of swallowing .In this sample, 29 (60.4%) of the patients had mild dysphagia . ThroughIn ,3,8. Patients with MS have progressive neurological deficits, with changes in the motor and sensory systems, and with a potential functional impact on swallowing. Dysphagia is more related to the duration of the disease, as evidenced in this study, and can lead to several complications such as: bronchoaspiration pneumonia, dehydration and malnutrition, worsening the quality of life of these patients, and sometimes progressing to death ,18.The profile of patients found in this sample is in line with the findings in the literature, which report that the number of patients diagnosed with MS was higher in females, as well as the most frequent type of MS was relapsing-remitting . It is also understood that dysphagia is more common in patients with more severe conditions of the disease, although the EDSS scale scores demonstrate that some of the individuals in this sample had mild impairment in swallowing with EDSS scores up to four . However, it is expected that with the progression of MS patients present even greater risks for dysphagia due to their motor and/or sensory impairment . Tarameshlu et al. identified in their study that patients with dysphagia had significantly higher EDSS scores than non-dysphagic patients. Furthermore, they also observed that the duration of the disease was significantly longer in the group of dysphagic patients .It is known that the EDSS is an instrument that quantifies the disabilities that occur during the evolution of MS over time and it is estimated that the longer the time since diagnosis of the disease, the higher its score, as identified in this research ,19. Although there are not enough subsidies to indicate that the type of drug has an influence on dysphagia, it was observed that the evolution of the disease in relation to the time of diagnosis and the EDSS scale scores above the cutoff point showed a relationship with the change. of swallowing.First-line drugs are used in patients with early-stage MS and less active disease, that is, with fewer functional disabilities. Second and third-line medications are used in individuals with more aggressive disease progression, and who have already failed with the first therapeutic strategy In this sample, the number of patients with MS who reported symptoms suggestive of swallowing disorders was significant, considering their self-perception through the application of the EAT-10 questionnaire. It indicated that there is interference in the results by the treatment and also by the form of presentation of the disease, suggesting that patients medicated with a first-line drug would have fewer complaints of swallowing, due to the initial stage of the disease and, consequently, lower EDSS. Likewise, individuals with relapsing-remitting MS had fewer complaints than patients with primarily progressive MS.,16. The EAT-10 is an useful instrument to detect the existence of dysphagia and monitor an individual's response to treatment . This questionnaire proved to be useful as a means of screening for dysphagia, as almost half of the patients with MS in this sample reported signs suggestive of swallowing disorders as a result of the questionnaire, which is associated with the level of dysphagia identified by the GUSS. In a previous study, the presence of oropharyngeal dysphagia was identified in 90% of patients evaluated with MS. Dysphagia severity was related to the clinical form of the disease, and it was found that severe dysphagia was more present in the primarily progressive and secondarily progressive forms, and mild and moderate dysphagia was more found in the relapsing-remitting form . These data corroborate the results of the GUSS and EAT-10 scales of this study, which show that more than half of the individuals in this sample have mild oropharyngeal dysphagia, as well as relapsing-remitting MS.There are other self-perception protocols adopted to identify dysphagia in patients with neurodegenerative diseases, in particular, the DYMUS for people with Multiple Sclerosis. However, this is an instrument that is limited to questions related to the act of swallowing, and not to the social and psychological impacts of these individuals caused by a swallowing disorder The study had limitations to assert about the interference of the proposed treatment in relation to the risk of dysphagia, due to the heterogeneity of the groups and the different motor impairments of the patients evidenced by the EDSS scale. The other results are consistent with the findings in the literature, and it is possible to state that the self-perception of the risk of dysphagia in individuals with MS demonstrated by the EAT-10 is related to the findings of the clinical evaluation of swallowing carried out using the GUSS. Further research with homogeneous groups is also suggested for more reliable results in relation to the type of MS, the severity of dysphagia and the treatment of MS and its influence on swallowing disorders.It can be said that there was an association between the findings of the clinical evaluation, the self-perception of swallowing instrument and the scale of motor disability in patients with MS. . Dentro deste grupo, há a Esclerose Múltipla (EM) que se trata de uma doença neurológica crônica em que o sistema imunológico do indivíduo degrada a bainha de mielina causando lesões - resultantes de uma inflamação imunomediada, desmielinização e consequente, dano axonal, perda neuronal e gliose que levam a comprometimentos das funções sensitivas e motoras . A etiologia da EM ainda não é completamente conhecida, mas acredita-se que seja multifatorial com influência de fatores genéticos e ambientais contribuindo para o desencadeamento da doença .As doenças desmielinizantes constituem um grupo de patologias nas quais ocorre lesão da bainha de mielina, em geral afetando diferentes áreas do sistema nervoso central (SNC) ,5. As prevalências de EM encontradas em estudos realizados no Brasil variaram de 1,36 / 100.000 habitantes em Recife (região noroeste) a 27,2 / 100.000 habitantes na cidade de Santa Maria, Rio Grande do Sul (região sul).Do ponto de vista epidemiológico, a EM geralmente acomete caucasianos, adultos jovens, a partir da segunda década de vida, e é duas vezes mais frequente em mulheres do que em homens. O número estimado de pessoas com EM no mundo aumentou de 2,1 milhões em 2008 para 2,3 milhões em 2013 ; primariamente progressiva, caracterizada por lesão neurológica progressiva e cumulativa desde o início da doença, sem períodos de surtos específicos; e, secundariamente progressiva que consiste em uma associação entre as outras duas manifestações, onde após um período surto-remissão, a doença entra em uma fase em que há deterioração clínica ,8.Existem três formas distintas de manifestação da EM sendo elas: remitente-recorrente ou surto-remissão, que caracteriza-se por surtos de sintomas seguidos de remissão total ou parcial deles, sendo a forma mais frequente .O tratamento farmacológico visa impedir a progressão da doença e modificar a história natural dela. Até o ano de 2017, o Protocolo Clínico e Diretrizes Terapêuticas da Esclerose Múltipla (PCDT) subdividia as drogas em primeira (betainterferonas e glatirâmer), segunda  e terceira linhas . A partir de 2018, foi criado um novo PCDT, que acrescentou a teriflunomida na primeira linha e fumarato de dimetila na segunda linha, além de passar o natalizumabe para terceira linha no tratamento da EM .A EM caracteriza-se por uma combinação variável de sintomas neurológicos como: dor crônica, fadiga, alterações visuais, sensitivas, motoras, na coordenação, no equilíbrio, na fala e/ou na deglutição, disfunção esfincteriana e depressão. Os déficits ocasionados pela progressão da doença podem sofrer remissão total ou parcial e, com o decorrer do tempo, todos os pacientes tendem a mostrar restrições neurológicas progressivas . Estima-se que a incidência de disfagia em pacientes com de EM varia de 33 a 43% e que ocorre com mais frequência em indivíduos que se encontram num estágio mais avançado, porém também pode se manifestar em pacientes com menor nível de comprometimento. Nestes pacientes a disfagia pode surtir com disfunções orais, fadiga durante a alimentação, presença de estase, penetração e/ou aspiração . De acordo com a literatura, pode-se observar o aparecimento da disfagia em indivíduos que apresentam comprometimento leve na Expanded Desability Status Scale (EDSS: escore <4) e como um sintoma intensificado quando há um comprometimento maior segundo a escala, já que existe um aumento das incapacidades funcionais, repercutindo também na dinâmica da deglutição .A disfagia orofaríngea é um sintoma possível de ser identificado na EM e se caracteriza pela dificuldade de deglutição na condução do bolo alimentar da cavidade oral até o estômago. Este distúrbio frequentemente resulta em prejuízos aos aspectos nutricionais, pulmonar, prazer alimentar e social do indivíduo -12. Esta relação pode tornar-se uma aliada da equipe multiprofissional no processo de acompanhamento e prevenção de complicações pela evolução da doença. Neste contexto, o objetivo do presente estudo é investigar a associação entre a avaliação clínica, a avaliação de autopercepção da deglutição e a escala de incapacidade motora em pacientes com Esclerose Múltipla.Atualmente, poucos estudos correlacionam escalas motoras, como a EDSS, com a disfagia ou com seu grau de gravidade em pacientes com EM A presente pesquisa foi aprovada pelo Comitê de Ética e Pesquisa da instituição de saúde proponente através do parecer de número 2.021.922. Trata-se de um estudo transversal prospectivo realizado a partir da coleta de dados clínicos de pacientes com diagnóstico de Esclerose Múltipla atendidos no ambulatório de Neuroimunologia de um hospital do sul do Brasil.Os critérios de inclusão para esse estudo foram:Idade acima de 18 anos;Diagnóstico de Esclerose Múltipla;Estar sendo acompanhado e tratado pelo Serviço de Neuroimunologia;.Fazer uso de medicamento de primeira ou segunda linhas para tratamento de Esclerose Múltipla, de acordo com a portaria do Ministério da Saúde vigente até o ano de 2017 Ter concordado e assinado o Termo de Consentimento Livre e Esclarecido;Os critérios de exclusão foram:Ter outra doença associada a Esclerose Múltipla;Ter contraindicação de alimentação por via oral;.Utilizar medicações de terceira linha para tratamento de Esclerose Múltipla, de acordo com a portaria do Ministério da Saúde vigente até o ano de 2017 Inicialmente a amostra foi composta por 51 pacientes diagnosticados com EM avaliados entre o período de abril de 2017 até agosto de 2018. Após verificar os critérios de inclusão e exclusão, três desses indivíduos foram retirados da amostra, dois por não concordarem com o Termo de Consentimento Livre e Esclarecido e um por ter diagnóstico de EM descartado, totalizando 48 participantes do estudo. A média de idade foi de 43 anos sendo que destes 34  eram do sexo feminino. Em relação ao tempo de diagnóstico da doença, observou uma média de aproximadamente nove anos de curso da doença . VerificExpanded Disability Status Scale (EDSS). Este dado era atualizado de acordo com a consulta do paciente no serviço de Neuroimulogia. A grande maioria dos pacientes foram avaliados no mesmo dia da avaliação direta de deglutição. Não havendo esta possibilidade, o escore utilizado era o da última consulta do mês de inclusão do paciente em nosso estudo.Realizou-se, primeiramente, revisão dos prontuários eletrônicos dos pacientes e da agenda dos atendimentos do Serviço de Neuroimunologia. Dessa forma, foram coletados dados como idade, sexo, diagnóstico, resultado da RM, tempo de diagnóstico, tratamento proposto (medicação), comorbidades e o escore da Após esta primeira fase de identificação, os pacientes do Serviço de Neuroimunologia que se enquadraram nos critérios de inclusão, foram convidados a participar de uma entrevista e de uma avaliação fonoaudiológica no ambulatório. Foi apresentado, inicialmente, o Termo de Consentimento Livre e Esclarecido para utilização dos dados coletados exclusivamente para a pesquisa, e a partir da concordância do mesmo, prosseguia-se a pesquisa.Eating Assessment Tool (EAT-10) para posterior comparação das queixas relatadas com os resultados da avaliação clínica da deglutição. Após o preenchimento da EAT-10, realizava-se a avaliação clínica da deglutição através da escala Gugging Swallowing Screen (GUSS) .Foi aplicado, pela pesquisadora, o protocolo de equivalência brasileira do Expanded Disability Status Scale trata-se de um método quantificador de incapacidades ocorridas durante a evolução da Esclerose Múltipla ao longo do tempo e também é uma forma de monitorar mudanças nos níveis destas incapacidades. Possui vinte itens com escores que variam de zero a 10, com pontuação que aumenta meio ponto conforme o grau de prejuízo do paciente tendo como corte: escore maior que quatro evidenciando piora clínica da doença ,14.A ,16.Já o instrumento de equivalência brasileira do EAT-10 trata-se de uma autoavaliação de identificação do risco de disfagia. Esse protocolo é composto por 10 perguntas simples, e fornece informações sobre a funcionalidade, o impacto emocional e sintomas físicos que um problema de deglutição pode acarretar na vida de um indivíduo. Cada item é classificado em uma escala de zero (sem problema) a quatro (problema grave). A pontuação total é a soma de todas as respostas, variando de zero a 40 pontos. O ponto de corte definido como limite entre “passa” e “falha” na triagem da alimentação é de três, sendo acima desse valor, um risco maior para disfagia orofaríngea .Composta por sete itens, a escala GUSS tem como objetivo avaliar a capacidade e grau dos problemas de deglutição, bem como identificar a orientação adequada sobre nutrição e/ou investigações adicionais. Os resultados previstos por essa escala, classificam a deglutição em: normal, disfagia leve, disfagia moderada ou disfagia grave As avaliações consistiam na oferta das três consistências alimentares previstas pela GUSS, sendo essas: pastosa , líquida (água) e sólida macia (pão de forma), acompanhadas da ausculta cervical com auxílio de estetoscópio (Litmann® Classic II Pediatric) para a avaliação de sinais sugestivos de penetração laríngea e/ou aspiração traqueal. Após a finalização do preenchimento dos protocolos, os resultados foram discutidos com a equipe médica responsável pelos casos e apresentados aos pacientes e seus acompanhantes, sendo realizadas orientações acerca dos sinais e sintomas de disfagia, e quando necessário, foram realizados os devidos encaminhamentos para terapia fonoaudiológica ou para exames complementares.Ao final da coleta, todos os dados foram organizados em uma planilha através do software Excel versão 16.0 e analisados através de tabelas, estatísticas descritivas e pelos testes estatísticos: Teste de Associação Exato de Fisher e Teste Qui-quadrado para avaliar a associação entre os resultados das escalas aplicadas. Os resultados foram considerados significativos a um nível de significância máximo de 5%  e o software utilizado para esta análise foi o SPSS versão 22.0.Constatou-se a maioria dos pacientes , apresentaram escore da escala EDSS de até quatro pontos, evidenciando um comprometimento motor leve . AtravésO tempo de diagnóstico da doença entre 11 e 15 anos esteve associado com um comprometimento maior na escala de incapacidade motora - EDSS, assim como os resultados da EAT-10 e da GUSS demonstram ser grandezas diretamente proporcionais a EDSS. Ou seja, quanto menor a EDSS menor o escore da EAT-10 e menores as possibilidades de os pacientes apresentarem disfagia de acordo com a avaliação clínica de deglutição .Nesta amostra, 29  dos pacientes apresentaram disfagia leve . AtravésNa ,3,8. Pacientes com EM apresentam déficits neurológicos progressivos, com modificações nos sistemas motores e sensitivos, e com potencial impacto funcional sobre a deglutição. A disfagia está mais relacionada ao tempo de duração da doença, como evidenciada no presente estudo, e pode levar a várias complicações como: pneumonia broncoaspirativa, desidratação e desnutrição, piorando a qualidade de vida desses pacientes, e por vezes evoluindo ao óbito ,18.O perfil de pacientes encontrados nesta amostra vai ao encontro dos achados da literatura, os quais referem que o número de pacientes com diagnóstico de EM mostrou-se maior em indivíduos do sexo feminino, assim como, o tipo de EM mais frequente foi de surto-remissão . Compreende-se ainda, que a disfagia é mais comum em pacientes com quadros mais graves da doença, apesar dos escores da escala EDSS demonstrarem que alguns dos indivíduos dessa amostra apresentaram comprometimento leve na deglutição com escores da EDSS até quatro . Tarameshlu et al. identificaram em seu estudo que pacientes com disfagia apresentaram escores EDSS significativamente maiores do que em pacientes não disfágicos. Além disso, também observaram que a duração da doença foi significativamente maior no grupo de pacientes com disfagia . Por ser uma doença com progressão, pacientes com EM podem apresentar riscos ainda maiores para disfagia devido ao seu comprometimento motor e/ou sensitivo -20.Sabe-se que a EDSS é um instrumento que quantifica as incapacidades ocorridas durante a evolução da EM ao longo do tempo e estima-se que quanto maior o tempo de diagnóstico da doença, maior será a sua pontuação, assim como identificado na presente pesquisa ,19. Apesar de não haver subsídios suficientes para indicar que o tipo de fármaco tem influência sobre a disfagia, observou-se que a evolução da doença em relação ao tempo de diagnóstico e aos escores da escala EDSS superiores ao ponto de corte, mostraram relação com a alteração de deglutição.Os fármacos de primeira linha são utilizados em pacientes que apresentam EM no seu estágio inicial e possuem a doença menos ativa, ou seja, com menores incapacidades funcionais. Já as medicações de segunda e terceira linhas são usadas em indivíduos com progressão mais agressiva da doença, e que já falharam com a primeira estratégia terapêutica Nesta amostra, foi significativo o número de pacientes com EM que referiram sintomas sugestivos de alterações de deglutição, considerando a autopercepção destes por meio da aplicação do questionário EAT-10. O mesmo indicou sofrer interferência nos seus resultados pelo tratamento e também pela forma de apresentação da doença, sugerindo que pacientes medicados com fármaco de primeira linha teriam menos queixas de deglutição, em virtude do estágio inicial da doença e, consequentemente, menor EDSS. Da mesma maneira que, indivíduos com EM do tipo surto-remissão apresentaram menos queixas do que os pacientes com EM primariamente progressiva.,16. O EAT-10 é um instrumento útil para detectar a existência de disfagia e monitorizar a resposta de um indivíduo ao tratamento . Este questionário mostrou-se útil como forma de triagem para a disfagia, pois quase metade dos pacientes com EM desta amostra relatou sinais sugestivos de distúrbios de deglutição como resultado do questionário, o que está associado ao nível de disfagia identificado pela GUSS. Em um estudo anterior, foi identificada a presença de disfagia orofaríngea em 90% dos pacientes avaliados com EM. A gravidade da disfagia foi relacionada com a forma clínica da doença, sendo constatado que a disfagia grave estava mais presente nas formas primariamente progressiva e secundariamente progressiva, e a disfagia leve e moderada foi mais encontrada na forma recorrente remitente . Dados estes que corroboram com os resultados da escala GUSS e EAT-10 deste estudo, os quais evidenciam que mais da metade dos indivíduos desta amostra apresenta disfagia orofaríngea de grau leve, bem como, EM do tipo surto-remissão.Existem outros protocolos de autopercepção adotados para identificar disfagia em pacientes com doenças neurodegenerativas, em especial, o DYMUS para pessoas com Esclerose Múltipla. Porém, este é um instrumento que se limita a perguntas referentes ao ato de engolir, e não aos impactos sociais e psicológicos desses indivíduos causados por um transtorno de deglutição O estudo apresentou limitações para afirmar sobre a interferência do tratamento proposto em relação ao risco de disfagia, devido à heterogeneidade dos grupos e dos diferentes comprometimentos motores dos pacientes evidenciados pela escala EDSS. Os demais resultados são condizentes com os achados da literatura, sendo possível afirmar que a autopercepção para o risco de disfagia dos indivíduos com EM demonstrada pelo EAT-10, se relaciona com os achados da avaliação clínica da deglutição feita através da GUSS. Sugere-se, ainda, futuras pesquisas com grupos homogêneos para resultados mais fidedignos em relação ao tipo de EM, a gravidade da disfagia e ao tratamento da EM e sua influência com os distúrbios de deglutição.Pode-se afirmar que houve associação entre os achados da avaliação clínica, do instrumento de autopercepção da deglutição e da escala de incapacidade motora em pacientes com EM.


Venous thromboembolism is an entity that encompasses both deep vein thrombosis and pulmonary thromboembolism. Although protocols for the diagnosis of these diseases are well defined, there is evidence of inappropriate use of diagnostic resources.To define the epidemiological profiles of patients admitted to the emergency department with suspected deep vein thrombosis, to determine rates of inappropriate ordering of D-dimer assays and color venous Doppler echocardiography of the lower limbs, and to identify whether these requests followed the recommendations contained in the 2015 Brazilian Society of Angiology and Vascular Surgery guidelines.We conducted a cross-sectional observational study that retrospectively evaluated 168 patients with suspected deep vein thrombosis for whom D-dimer assays were requested. The most common risk factors were measured and the pretest probability was calculated with the Wells score. The epidemiological profile of these patients and the rates of inappropriate D-dimer testing were assessed using descriptive statistics.The D-dimer requests were inadequate in 55 (32.7%) patients. Venous color Doppler ultrasound was used to examine the lower limbs of 14 (8.3%) of the patients with a low probability according to the Wells score and a negative D-dimer result. No additional diagnostic methods were used in 19 (11.3%) of those with a low probability according to the Wells score and a high D-dimer result. There was unnecessary use of CDUS in 35 (20.8%) cases. The overall rate of inappropriate workup was 53.5%.Differences were found between clinical practice and the recommendations for diagnostic evaluation of patients with suspected deep vein thrombosis, with inappropriate use of diagnostic tests. Therefore, a combination of clinical findings with risk factors grouped in a prediction system and use of supplementary tests is the best way of making a diagnosis.,Use of tests for D-dimer (DD), a product of degradation of fibrin that originates during the occurrence of thrombotic events, and use of color Doppler ultrasonography (CDUS) of the veins of the lower limbs both play a central role in investigation of suspected DVT cases.5,Serum DD levels increase significantly in a series of diseases, with age, and during physiological situations such as pregnancy, making them a marker with high sensitivity but low specificity, and a high negative predictive value for VTE.8However, diagnosis by imaging is necessary to confirm a diagnosis of DVT. In this situation, CDUS is the diagnostic method of choice, with 96% sensitivity and specificity exceeding 98%, depending on the region examined.In 2012, in the United States, the American Board of Internal Medicine (ABIM) launched a campaign called Choosing Wisely International. This initiative invokes the “less is more” paradigm, urging physicians not to conduct unnecessary tests.-Recent studies have revealed inappropriate use of diagnostic resources for assessment of VTE, particularly so in the few Brazilian studies that have investigated the issue.12The present study is therefore designed to generate additional data on diagnostic management of DVT, identifying possible mismatches in the investigation of these patients and indirectly highlighting the possible economic impact of inappropriate use of diagnostic resources.Therefore, the principal objectives of this study were to evaluate the clinical and epidemiological profile of patients with suspected DVT seen at a tertiary hospital in Santa Catarina, Brazil, to calculate the rate of inappropriate requests for DD tests and CDUS examinations, and to determine whether DVT investigations were conducted in accordance with the recommendations set out in the 2015 Brazilian Society of Angiology and Vascular Surgery (SBACV) DVT diagnosis and treatment guidelines.This was a cross-sectional observational study that analyzed requests for DD tests for patients with suspected DVT at the emergency department of the Hospital Governador Celso Ramos , from January to December of 2018. Open Epi software was used to perform the sample size calculation.Variables were collected using a research protocol developed by the researchers.Data provided by the institution’s laboratory were used to identify all patients for whom a DD assay was ordered. Their medical records were then analyzed.The following inclusion criteria were adopted: (1) age greater than or equal to 18 years; (2) patients with signs and symptoms suggestive of DVT, such as pain, edema, cyanosis, clubbing of calves, dilatation of the superficial vein system, or compatible changes in the limb involved observed during physical examination; and (3) just one DD assay from each patient seen in emergency was included in the analysis.The exclusion criteria were as follows: (1) clinical variables missing that are needed to calculate probability with the Wells score (WS); (2) suspected DVT in inpatients; and (3) patients who had been seen by the research investigators in the course of their clinical care work.2); cancer diagnosis during the previous 6 months; chronic venous disease; prior DVT; orthopedic procedures such as hip or knee joint replacement or knee arthroscopy; immobility, defined as suppression of joint movements, whether because of neurological or musculoskeletal reasons or because of a surgical procedure; trauma during the previous month; use of oral contraceptives or hormone replacement therapy; pregnancy; puerperium; genetic or hereditary thrombophilias; and family history of VTE.Major risk factors for DVT were recorded, as follows: age greater than 65 years; obesity  were considered normal. For patients over the age of 50 years, the cutoff for normality was found by multiplying the patient’s age by 10.19Definitive diagnoses of DVT were confirmed using the CDUS reports available in patients’ medical records.In turn, requests for CDUS examinations were considered justified when patients had a low WS probability of events but DD over the 500 ngFEU/mL cutoff point, or had moderate or high probability according to their WS.,Diagnostic strategies were considered inappropriate if: (1) DD was ordered as initial test in patients with moderate or high probability according to the WS, in whom its use is questionable; (2) CDUS was requested in patients with low probability according to the WS and a negative DD result; or (3) diagnosis was not supplemented with CDUS in patients with moderate or high pre-test probability or low pre-test probability and DD result over the cutoff point mentioned above.9The study was approved by the institution’s Research Ethics Committee, consolidated opinion number 3.383.755.Data were tabulated and analyzed using SPSS 16.0. Continuous variables were expressed as measures of central tendency and dispersion, and categorical variables were expressed as frequencies and percentages. Descriptive analyses were performed with calculation of a 95% confidence interval (CI) for each point estimated.As illustrated in The mean of age of the patients was 53 years, with a standard deviation of ± 17.6 years. The most prevalent signs and symptoms in the patients with suspected DVT were pain, in 125 patients (74.4%), and edema, in 118 patients (70.2%). Additional characteristics are listed in A total of 27 patients (16.1%) had a diagnosis of DVT confirmed by CDUS and the most common risk factor among patients with suspected DVT was age over 65 years, as shown in The prevalence of DVT increased significantly in line with pre-test DVT probability according to the WS . Figure It was found that DD was ordered for 55 patients  with suspected DVT, even though they had a moderate or high probability of DVT according to the WS. Moreover, in 14 cases  of patients with low probability CDUS was requested regardless of a DD result below the cutoff, while CDUS was not used to confirm or rule out the diagnosis in 19 patients  who had low probability according to the WS but elevated DD results. In just two cases , one with moderate and the other with high probability according to the WS, CDUS was not requested, as illustrated in As such, CDUS was requested inappropriately in 35 cases . Overall, 90 cases  had inappropriate diagnostic management.-3,In the present study, there was a higher prevalence of male patients, in contrast with the results of other studies in which the prevalence of female patients was higher.21,With regard to signs and symptoms, the literature confirms the findings of the present study, demonstrating that the complaints most frequently reported by patients with suspected and confirmed diagnosis of DVT are pain and asymmetrical edema of the lower limbs.17,A diagnosis of DVT was confirmed in 16.1% of cases, a similar rate to those observed in other studies that have assessed individuals with suspected DVT.26With respect to the primary objective of this study, it is important to be clear that the pre-test probability scores were designed and validated to increase diagnostic efficiency when investigating certain diseases. As such, Wells et al. demonstrated and validated use of the WS followed by DD testing for initial assessment of patients with suspected VTE.In our study, in 32.7% of cases, DD tests were ordered when there was a moderate or high probability of DVT according to the WS. In comparison, a single center study found higher rates of DD requests in patients with a probable DVT diagnosis, with 52.7% of inappropriate test orders.A prospective study designed to validate diagnostic algorithms for pulmonary thromboembolism (PTE) observed that 92 of the 930 (9.9%) patients analyzed were not tested as recommended by the protocol. Of these, 5% exhibited PTE or DVT during the months of follow-up.As such, the main utility of this study was to demonstrate inconsistencies in diagnostic investigation of patients with suspected DVT, suggesting that the recommendations set out in guidelines are not being correctly followed in clinical practice.Cabana et al.The present study was not designed to conduct this type of assessment, but, as shown by the results observed, there is a clear need for better educational support to increase physicians’ knowledge about the current recommendations for management of DVT and to improve their understanding of the probability systems to support decision-making and rational use of supplementary examinations and tests.A flow diagram illustrating selection for this study shows that DD assays were also ordered for patients with presentations related to etiologies other than DVT. This study therefore also reveals possible unnecessary use of this assay in other diagnostic scenarios, probably involving increased expenditure for the Unified Health System (SUS - Sistema Único de Saúde). Together with other available evidence, this underscores the need for further studies, preferably prospective national registries, to better analyze these issues related to diagnosis and management of VTE.This study has some limitations. The absence of a clinical protocol for VTE management at the hospital studied makes it difficult to determine the reasons why DD assays were ordered and why CDUS was not requested for patients for whom it was indicated.The low quality of medical records meant that it was not possible to reliably determine the diagnoses of many of the patients in whom DVT was probably ruled out. In an emergency setting, having ruled out the probability of DVT, the physicians chose non-specific diagnostic hypotheses such as pains and/or edema without definitive etiology, followed by discharge of the patient with guidance. Since follow-up was not possible, this study does not have the power to determine what happened afterwards. In view of this, we decided to adapt the research protocol and define these patients’ diagnosis as “diagnosis of undefined etiology”.Moreover, because of the wide range of variation, it was necessary to employ the variable “other diagnoses” to group patients given diagnoses of other conditions that are part of the differential diagnosis of DVT or which could predispose to DVT, such as lymphedema, arthritis, ruptured Baker cyst, pain and edema related to orthopedic trauma (four cases), sickle cell crisis, decompensated liver disease, decompensated heart failure (two cases), and muscle distension (three cases).The absence of a record of WS on the majority of patient records meant that the WS had to be calculated retrospectively, which could result in measurement bias, since the variable in the score that indicates a need to hypothesize “diagnoses more or less probable than DVT” is dependent on the investigator’s judgment. The sample was selected based on data on requests for DD assay and it is therefore possible that patients who were only investigated using imaging exams have been omitted from the sample.Despite these limitations and despite the study having been conducted at a single center, affiliated to the SUS, the data reported here are similar to and replicated by other evidence available in the literature.There was a predominance of males among the patients with suspected DVT admitted to emergency. Pain and edema were the most frequent signs and symptoms among patients with a diagnostic suspicion of DVT.The most common risk factor for DVT among these patients was age over 65 years. It was observed from the results obtained that there are divergences between clinical practice and the recommendations for diagnostic assessment of patients with suspected DVT, due to inappropriate use of diagnostic tests and examinations. ,Dados provenientes de registros americanos estimam que a incidência de tromboembolismo venoso (TEV) tem se mantido constante ao longo do tempo, com uma taxa de 0,7 a 1,4 casos por 1.000 pessoas-ano2O diagnóstico clínico da TVP é um desafio, visto que os sinais e sintomas clássicos nem sempre são observados. Assim, a associação dos achados clínicos com fatores de risco agrupados a um sistema de predição e uso de exames complementares constitui a melhor forma de realização do diagnóstico,Dessa forma, o uso de D-dímero (DD), um produto da degradação da fibrina originado durante a ocorrência de eventos trombóticos, e do eco-Doppler colorido (EDC) venoso de membros inferiores assume papel central na investigação de casos suspeitos de TVP5,Os níveis séricos de DD aumentam significativamente em uma série de doenças, com a idade e em situações fisiológicas como a gravidez, sendo, portanto, um marcador de alta sensibilidade e baixa especificidade, com alto valor preditivo negativo para TEV8Todavia, o diagnóstico por imagem é necessário para o diagnóstico de TVP. Nessa situação, o EDC é o método de escolha para diagnóstico, com sensibilidade de 96% e especificidade superior a 98%, a depender da região examinadaNo ano de 2012, nos Estados Unidos (EUA), o American Board of Internal Medicine (ABIM) lançou uma campanha denominada Choosing Wisely International. Essa iniciativa vai de encontro ao paradigma do “menos é mais”, orientada a não realização de condutas e testes desnecessários-Estudos recentes têm apontado para o uso inadequado de recursos diagnósticos na avaliação de TEV, com destaques para alguns poucos estudos nacionais que avaliaram a questão12Nesse sentido, esta pesquisa pretende gerar mais dados a respeito do manejo diagnóstico da TVP, apontando para possíveis incongruências na avaliação desses pacientes e dando ênfase de forma indireta para o possível impacto econômico no uso inadequado dos recursos diagnósticos.Dessa forma, os principais objetivos deste estudo foram avaliar o perfil clínico e epidemiológico dos pacientes com suspeita de TVP, verificar a taxa de inadequação na solicitação de DD e EDC e definir se a investigação de TVP esteve de acordo com as recomendações propostas pela diretriz de diagnóstico e tratamento de TVP da Sociedade Brasileira de Angiologia e Cirurgia Vascular (SBACV) de 2015 em um hospital terciário em Santa Catarinasoftware Open Epi para cálculo amostralTratou-se de um estudo observacional transversal que avaliou as solicitações de DD em pacientes com suspeita de TVP na emergência do Hospital Governador Celso Ramos , de janeiro a dezembro de 2018. Foi utilizado o As variáveis foram coletadas por meio de protocolo de pesquisa elaborado pelos pesquisadores.A partir dos dados fornecidos pelo laboratório da instituição, identificaram-se todos os pacientes para os quais foram solicitados DD; posteriormente, os prontuários foram analisados.Foram definidos como critérios de inclusão os seguintes: (1) idade maior ou igual a 18 anos; (2) pacientes com sinais e sintomas sugestivos de TVP, como dor, edema, cianose, empastamento de panturrilhas, dilatação do sistema venoso superficial ou alterações compatíveis no membro acometido durante o exame físico; e (3) inclusão de apenas um exame de DD por paciente avaliado na emergência.Os critérios de exclusão determinados foram: (1) ausência de variáveis clínicas necessárias para o cálculo da probabilidade através do escore de Wells (EW); (2) suspeita de TVP em pacientes internados; e (3) pacientes que foram avaliados pelos investigadores da pesquisa durante trabalho assistencial.2), diagnóstico de neoplasia nos últimos 6 meses, doença venosa crônica, TVP prévia, procedimentos ortopédicos como artroplastia de quadril ou joelho ou artroscopia de joelho, imobilidade definida pela supressão dos movimentos articulares, seja por causas neurológicas, musculoesqueléticas ou devido a procedimento cirúrgico, trauma no último mês, uso de contraceptivos orais ou terapia de reposição hormonal, gravidez, puerpério, trombofilias genéticas ou hereditárias e história familiar de TEVMensurou-se o registro dos principais fatores de risco para TVP, que foram: idade maior que 65 anos, obesidade . Em pacientes acima dos 50 anos de idade, o valor limite para a normalidade foi encontrado multiplicando a idade por 1019Os diagnósticos definitivos de TVP foram confirmados por meio de laudo de EDC disponível em prontuário.Quanto às solicitações de EDC, foram consideradas corretas as indicações em pacientes com baixa probabilidade de eventos e DD acima do ponto de corte de 500 ngFEU/mL ou em contexto de moderada ou alta probabilidade no EW.,Foram consideradas inadequadas as estratégias diagnósticas em que houve: (1) solicitação de DD como exame inicial em situação de moderada ou alta probabilidade no EW, em que seu uso é questionável; (2) uso de EDC em situação de baixa probabilidade no EW e DD negativo; (3) não complementação diagnóstica com EDC em pacientes com probabilidade pré-teste moderada ou alta ou probabilidade pré-teste baixa e DD acima do ponto de corte mencionado9O estudo foi aprovado pelo Comitê de Ética e Pesquisa da instituição, sob parecer consubstanciado número 3.383.755.A análise e tabulação de dados foi realizada por meio do programa SPSS 16.0. As variáveis contínuas foram descritas como medidas de tendência central e dispersão, e as variáveis categóricas foram apresentadas como frequências e porcentagens. A análise descritiva foi realizada calculando-se o intervalo de confiança (IC) de 95% para cada ponto estimado.Conforme demonstrado na A média de idade dos pacientes foi de 53 anos, com desvio-padrão de ± 17,6 anos. Os sintomas e sinais mais prevalentes em pacientes com suspeita de TVP foram dor em 125 pacientes  e edema em 118 pacientes . As demais características estão descritas na O diagnóstico de TVP confirmado por EDC foi realizado em 27 pacientes , sendo que o fator de risco mais evidenciado nos pacientes com suspeita de TVP foi idade acima de 65 anos, conforme disposto respectivamente nas A prevalência de TVP aumentou significativamente conforme a probabilidade no EW . Na FiguConstatou-se que, em 55 dos pacientes  com suspeita de TVP, a solicitação de DD foi realizada, apesar da moderada ou alta probabilidade no EW. Nos indivíduos com baixa probabilidade e DD abaixo do ponto do corte, houve solicitação de EDC em 14 casos , enquanto em 19 pacientes  que se apresentaram com baixa probabilidade no EW e DD elevado, não houve complementação com EDC para definição diagnóstica. Em apenas dois casos , um de moderada e outro de alta probabilidade no EW, não houve complementação com EDC, conforme demonstrado na O uso de EDC foi inadequado em 35 casos . A taxa global de inadequação foi de 90 casos .-3,No presente estudo, verificou-se uma maior prevalência de indivíduos do sexo masculino, divergentes de outros em que houve maior prevalência de pacientes do sexo feminino21,Quanto aos sinais e sintomas, a literatura confirma os presentes achados ao demonstrar que as queixas mais frequentemente relatadas em pacientes com suspeita diagnóstica e TVP confirmados são dor e edema assimétricos de membros inferiores17,O diagnóstico de TVP foi realizado em 16,1% dos casos, taxa semelhante à encontrada em estudos que avaliaram indivíduos com suspeita de TVP26Quanto ao principal objetivo desta pesquisa, é importante mencionar que os escores de probabilidade pré-teste foram desenhados e validados para aumentar a eficiência diagnóstica na avaliação de determinadas doenças. Nessa perspectiva, Wells et al. demonstraram e validaram o EW seguido do uso de DD para avaliação inicial de pacientes com suspeita de TEVEm nosso estudo, em 32,7% dos casos, as solicitações de DD foram realizadas diante de TVP com moderada ou alta probabilidade no EW. Em comparação, um estudo unicêntrico constatou taxas mais altas de solicitações em pacientes com provável diagnóstico dessa doença, com 52,7% de pedidos inadequadosEm um estudo prospectivo delineado para validar algoritmos diagnósticos para tromboembolismo pulmonar (TEP), 92 dos 930  pacientes avaliados não foram testados conforme sugerido pelo protocolo. Desses, nos meses de seguimento, 5% apresentaram TEP ou TVPSendo assim, a principal utilidade desta pesquisa foi demonstrar haver incongruências na investigação diagnóstica dos pacientes com suspeita de TVP, sugerindo que, na prática clínica, as recomendações propostas pelas diretrizes não são adequadamente seguidas.Cabana et al.A presente casuística não objetivou fazer esse tipo de avaliação, porém, de acordo com os resultados observados, fica clara a necessidade de maior suporte educacional para ampliar o conhecimento dos médicos sobre as recomendações vigentes no manejo da TVP, bem como maior entendimento dos sistemas de probabilidade para tomada de decisão e uso racional de exames complementares.Conforme fluxograma de triagem do estudo, constatamos que houve solicitação de DD em pacientes com alterações relacionadas a outras etiologias que não TVP. Portanto, o presente estudo também apontou para um possível uso desnecessário desse exame em outros cenários diagnósticos, com provável aumento de custos para o Sistema Único de Saúde (SUS). Isso reforça, junto de outras evidências disponíveis, a necessidade de mais estudos, de preferência registros prospectivos nacionais, para melhor avaliar essas questões referentes ao diagnóstico e manejo do TEV.Este estudo apresentou algumas limitações. A ausência de um protocolo clínico de abordagem para TEV no hospital avaliado dificultou a percepção do motivo por que os DD foram solicitados, bem como a compreensão da ausência da solicitação de EDC nos pacientes com indicação.A baixa qualidade dos prontuários não permitiu avaliar com fidelidade o diagnóstico de muitos pacientes em que a TVP foi provavelmente excluída. Em um cenário de emergência, descartado a probabilidade de TVP, os médicos optaram por hipóteses diagnósticas pouco especificas como dores e/ou edema sem etiologia definida, com a posterior alta e orientação do paciente. Devido à impossibilidade de realizar o seguimento, a presente pesquisa não teve poder para definir o que ocorreu posteriormente. Em vista disso, optamos por adaptar o protocolo e definir o diagnóstico desses pacientes como “diagnósticos de etiologia não definida”.Além de que, por sua ampla variedade, foi necessário utilizar a variável “outros diagnósticos” para agrupar pacientes que receberam diagnóstico de outras condições que fazem diagnóstico diferencial ou que podem predispor TVP, como linfedema, artrite, cisto de Baker roto, dor e edema relacionados a trauma ortopédico (quatro casos), crise falciforme, hepatopatia descompensada, insuficiência cardíaca descompensada (dois casos) e distensão muscular (três casos).A ausência do registro do EW na maioria dos prontuários fez com que fosse necessário o seu cálculo de forma retrospectiva, o que pode resultar em viés de aferição, pois a variável que indica a necessidade de hipotetizar os “diagnósticos mais ou menos prováveis que TVP” no respectivo escore depende da interpretação do investigador. Essa amostra foi baseada nos dados de solicitação de DD; devido a isso, é possível que pacientes que tenham sido avaliados apenas com exame de imagem não tenham sido incluídos nessa casuística.A despeito disso e de o estudo ter sido realizado em um único centro, vinculado ao SUS, os dados aqui mencionados foram semelhantes e replicados por outras evidências disponíveis na literatura.Nos pacientes com suspeita de TVP admitidos à emergência, houve uma maior prevalência de pacientes do sexo masculino. Dor e edema foram os sintomas e sinais mais frequentes nos pacientes com suspeita diagnóstica de TVP.O fator de risco para TVP mais evidenciado nesses pacientes foi a idade acima de 65 anos. Constatou-se, por meio dos resultados obtidos, haver divergências entre a prática clínica e as recomendações propostas para avaliação diagnóstica dos pacientes com suspeita de TVP, devido ao uso inadequado de testes diagnósticos.


Aedes spp. and Culex spp. Both of these are involved in the transmission of arboviruses. Here, we provide novel data for the geographical distribution of 2,383 specimens in the Culicidae family. We also report the percentage of houses infested with these vectors, and Shannon and Simpson diversity indices in three municipalities located in Cauca, Colombia. This dataset is relevant for research on vector-borne diseases because Aedes spp. can transmit arboviruses such as dengue, Zika and chikungunya, and Culex spp. is a well-known vector of West Nile virus and Venezuelan equine encephalitis.The Culicidae family has two of the most important disease vector genus:  Aedes spp. y Culex sp. (Diptera: Nematocera). Además, se reporta el porcentaje de infestación domiciliaria en el área urbana de tres municipios del departamento del Cauca (Colombia). Este conjunto de datos es de relevancia en salud pública teniendo en cuenta que Aedes spp. es capaz de transmitir arbovirus como el dengue, el Zika y el chikungunya, y Culex sp. es un conocido vector del virus del Nilo Occidental y de la encefalitis equina venezolana.Aquí proporcionamos nuevos datos inéditos sobre la distribución de 2.383 ejemplares pertenecientes a los géneros  In 2019, countries in the Americas recorded more than 2.7 million cases of dengue – the highest in history – including 22,127 severe cases and 1,206 deaths reported in October 2019 .Arboviruses like dengue, chikungunya, yellow fever and – more recently – Zika, are expanding, with more cases and fatalities, making them a concern for public health at the international level Aedes aegypti (Linnaeus), Aedes albopictus (Skuse) and Culex quinquefasciatus (Say). These belong to the Culicidae family (Diptera: Nematocera), which comprises about 3200 recognized species. Tropical rainforests, where fauna is more diverse but less well surveyed than temperate regions, probably house many more as-yet undiscovered species . The Ae. aegypti mosquito is a predominantly domestic species, usually infesting natural or artificial containers in or around dwellings. The female feeds on human or domestic animal blood . Owing to its close relationship with humans, it is essentially an urban mosquito. In Colombia, it has been recorded at altitudes ranging from 0–2302 m above sea level  and has also been reported in rural areas .The main mosquitoes involved in the transmission of vector-borne disease are Ae. aegypti females restrict their hematophagous habits to daylight hours, with the peak of biting activity at dawn and shortly before dusk. Diurnal activity has also been recorded in the male, where they copulate and feed on sugary substances. , 9. Under optimal conditions of food availability and adequate oviposition sites, the average dispersion of a female Aedes spp. mosquito is estimated to be between 50 and 100 m, which limits its visits to two or three dwellings during its adult life , 10. However, fed females have been recorded to disperse as far as 800 m in 6 days .Ae. albopictus (Skuse) is more commonly found in forested regions and in open spaces with abundant vegetation, typical of suburban or rural areas. They can be found in environments with extensive vegetation, such as bamboo stumps, tree cavities, plant axils (bromeliads) and water reservoirs in rock crevices as natural breeding sites . When cohabiting with Ae. aegypti in urban areas, it can thrive in artificial reservoirs like flower vases, tires and cans . However, although Ae. albopictus is anthropophilic, the hematophagous behavior of mosquito populations may depend on the availability of alternative food sources  .The mosquito Culex quinquefasciatus (Say) is considered a highly anthropophilic species, which is associated with both urban and rural human habitats in Colombia . Its biting activity occurs mostly nocturnally, but it remains indoors during the day , 16. It is distributed across Colombia at elevations ranging from 0–3000 m above sea level (masl) . Together with Ae. aegypti, the immature stages of Cx. quinquefasciatus also develop in structures serving as drains and catch-basins for stormwater located in streets and avenues .Finally, Here we describe and quantify data associated with Culicidae adult mosquitoes (Diptera: Nematocera) collected with Prokopack aspirators in urban households in three municipalities with a high incidence of dengue in the department of Cauca (southwestern Colombia).Data from the 2383 specimens (529 occurrences) reported here from the Culicidae family are novel unpublished data from the Cauca department, located in the Pacific region of Colombia. The data were collected in 2021 by a multidisciplinary team made up of environmental health technicians, geographic and environmental engineers, and professionals with extensive experience in medical entomology.The mosquitoes were collected in three municipalities in the department of Cauca, an area of study chosen for its endemic–epidemic behavior for dengue disease. The event is characterized by focal endemics, variable transmission scenarios and temporal, seasonal and cyclical patterns in at-risk populations.These municipalities are also part of an ongoing research project, which aims to determine the relationship between environmental, biological, and sociodemographic factors influencing the increase in the burden of dengue and its spatial variation, using geographic information systems in the construction of risk maps.These data are valuable to the scientific community because they show the spatial location of specimen collection, allowing authorities to take action in those neighborhoods where mosquitoes have a higher percentage of house infestation. In addition, by being identified and geo-referenced, they allow various analyses concerning other entomological and environmental variables.® 10.8 software (SCR_011081). To detect hot spots, the incidence rates of dengue per 10,000 inhabitants from 2014–2018 were calculated from cases reported to the Sistema Nacional de Vigilancia en Salud Pública , and the population statistics of the projection system reported by the National Administrative Department of Statistics in Colombia.The collection of species belonging to the Culicidae family was done in the municipalities of Piamonte, Patía, and Miranda. These localities were chosen because they present a high risk of dengue according to incidence rate global cluster analysis , performed using the High-Low Clustering  analysis in the ArcGISAfterwards, sampling was delimited to a neighborhood scale by Kernel density analysis  of dengue cases reported between 2015 and 2019 in the urban area of each municipality. The sample size was calculated through the estimated dengue prevalence (10.5%) in the municipality.n = 180 houses) for the first case, and seven neighborhoods (n = 335 houses) for the second. Finally, in Miranda, six neighborhoods (n = 420 houses) from four clusters with a higher-than-expected prevalence of the disease were sampled.In total, 935 houses and 17 neighborhoods were visited during 2021. In Piamonte and Patía, three dengue clusters were identified, therefore three neighborhoods were sampled  platform ASF Data Search Vertex , which holds the global Digital Elevation Model (DEM) at a resolution of 12.5 m. Each vial was assigned a code corresponding to the house in which its specimens were collected. This code was associated with a sociodemographic survey applied to the same house using the application ArcGISAe. aegypti (n = 572), Ae. albopictus (n = 36) and Cx. quinquefasciatus (n = 1775) were collected in 529 of 935 houses located in Cauca, Colombia. Table A total of 2383 individuals corresponding to three species of the Culicidae family, Ae. aegypti and Cx. quinquefasciatus per house is shown as the percentage of total screened houses in Figure Ae. aegypti individuals were found, and the highest number of adults collected in a single house was 60. In Miranda, more than 10 individuals were found in four houses, and the highest number of adults in a single house was 20. Lastly, Piamonte presented the lowest number of adults per house, and the highest number in a single house was seven.The number of adult . The average diversity index for the three municipalities ranged from 0.27 to 0.66 for the Shannon index, and from 0.12 to 0.41 for the Simpson index. Both indices were highest in Patía and lowest in Piamonte. Graphically, location diversity can be better visualized using the Margalef index. For Miranda, the sample is very diverse, while for the other groups, a sample of diverse characteristics is observed. In general, these values are not high, being in the range of 0.28 to 0.35. , followed by Cx. quinquefasciatus (0.0953), and least values were recorded in Ae. albopictus (0.0275). The dominance index of all mosquitoes sampled at three different municipalities was estimated (Table Cx. quinquefasciatus (0.5548) followed by Ae. aegypti (0.0576) and least in Ae. albopictus (0.0002). These results are similar to those of other previous studies . The highest diversity index was recorded for tus 0.095, and leaAedes includes the dengue-transmitting species Ae. aegypti and Ae. albopictus, while the Culex category includes the species Cx. quinquefasciatus, which is also involved in the transmission of arbovirosis.Figure  In all the mosquito catches, previously designed e-formats designed in Survey123 (ESRI) were used to record field collection information and household geographic coordinates. Expert entomologists advised taxonomical identification. Dataset records were confirmed and verified individually.Aedes spp. and Cx. quinquefasciatus were collected with the sampling method used (Prokopack aspirators). For future studies, complementary sampling methods or monitoring techniques should be used for adult mosquitoes .Only Before a specimen is deposited in the collection, collection curators from the Entomology Group review the information associated with the specimen; that is, the locality, geographical coordinates, sex, stage of development, and taxonomy. The minimum information required to include a specimen in the collection is related to the standard Darwin Core and is the same as the minimum information required for publication in the Global Biodiversity Information Facility (GBIF).The database and vector distribution map provide a novel resource for understanding the abundance and behavior of mosquito-borne diseases for the entomology and vector-borne diseases community. To improve the accessibility and usability of these data, they have been included in the GBIF.Ae. aegypti and Ae. albopictus database may also be helpful for similar projects elsewhere. We suggest to others to make their data similarly available.These data will be useful for museums setting up similar displays, and the data may be used for other research purposes such as predictive models and species geographic distributions. The  , 2. En las Américas, el 2019 fue el año con el mayor número de casos de dengue de la historia con más de 2,7 millones, incluyendo 22.127 casos graves y 1.206 muertes reportadas .Las arbovirosis como el dengue, el chikungunya, la fiebre amarilla y más recientemente el Zika, se están expandiendo en el mundo, situación que se convierte en una preocupación para la salud pública a nivel internacional Aedes aegypti (Linnaeus), Aedes albopictus (Skuse) y Culex quinquefasciatus (Say), las cuales hacen parte de la familia Culicidae (Diptera: Nematocera). Esta familia cuenta con 3.200 especies reconocidas, y es probable que exista un buen número de especies por descubrir, principalmente en las selvas tropicales, donde se concentra una mayor biodiversidad .Las principales especies de mosquitos implicadas en la transmisión de arbovirosis son Ae. aegypti, es una especie predominantemente doméstica, que de manera general infesta criaderos naturales o artificiales en las viviendas o sus alrededores. La hembra se alimenta de sangre humana o de animales domésticos . Debido a su estrecha relación con el hombre, es esencialmente un mosquito urbano. En Colombia, se ha registrado en un rango altitudinal va de los 0 a los 2.302 m s.n.m.  y se ha reportado también en áreas rurales .El mosquito Ae. aegypti restringen sus hábitos hematófagos a horas diurnas. Sus picos de mayor actividad se encuentran en el amanecer y un poco antes del crepúsculo vespertino, aunque puede picar a cualquier hora del día. El hábito diurno también ha sido registrado en el macho, tiempo en el que copulan y se alimentan de sustancias azucaradas , 9. En condiciones óptimas de disponibilidad de alimento y zonas de oviposición adecuadas, la dispersión media de una hembra de Aedes spp. se estima entre 50 y 100 m, lo que limita sus visitas a 2 o 3 viviendas durante su vida adulta , 10, aunque se han registrado hembras alimentadas con capacidad para dispersarse hasta 800 m en 6 días .Las hembras de Ae. aegypti, el mosquito Ae. albopictus (Skuse) se encuentra con mayor frecuencia en regiones forestales y en espacios abiertos con abundante vegetación, propios de zonas suburbanas o rurales. Pueden encontrarse en ambientes con extensa vegetación, aprovechando como criaderos naturales los tocones de bambú, cavidades de árboles, axilas de plantas (bromelias) y depósitos de agua en grietas de las rocas . Cuando cohabita con el Ae. aegypti en la zona urbana, puede desarrollarse muy bien en depósitos artificiales como floreros, llantas y latas . Aunque Ae. albopictus es antropofílico, el comportamiento hematófago de las poblaciones de esta especie de mosquito puede depender de la disponibilidad de las fuentes alternativas de alimentación  .A diferencia de Culex quinquefasciatus (Say), es considerada una especie acentuadamente antropofílica y que se encuentra asociada con mayor frecuencia al hábitat humano tanto urbano como rural en Colombia . Su actividad de picadura se asocia mayormente a hábitos nocturnos, sin embargo, permanece durante el día en el interior de la vivienda , 16. Se distribuye por todo el territorio nacional en alturas que van desde los 0 hasta los 3.000 m s.n.m . Junto con Ae. aegypti, los estadios inmaduros de esta especie también se desarrollan en estructuras que sirven de desagües y sumideros de aguas lluvias ubicados en calles y avenidas .Finalmente, El siguiente artículo de datos contiene la descripción y cuantificación de los mosquitos adultos del género Culicidae (Diptera: Nematocera) recolectados con aspiradores Prokopack en viviendas del área urbana de tres municipios con alta incidencia de dengue en el departamento del Cauca (Suroeste Colombia).Los 2.383 especímenes (529 ocurrencias) de la familia Culicidae en este conjunto de datos son registros inéditos para el departamento del Cauca, Colombia. Los datos fueron obtenidos en el año 2021 por un equipo multidisciplinario conformado por ingenieros geógrafos y ambientales, así como profesionales y técnicos con amplia experiencia en entomología médica.Los mosquitos fueron recolectados en tres municipios del Cauca, departamento seleccionado por presentar un comportamiento endemo-epidémico para el dengue, es decir, presentación de endemias focalizadas, escenarios variables de transmisión y patrones temporales, estacionales y cíclicos en poblaciones de riesgo.Los municipios integran el área de estudio de un proyecto de investigación que pretende establecer la relación entre los factores ambientales, biológicos y sociodemográficos que influyen en el aumento de la carga de dengue y su variación espacial; por medio del uso de los sistemas de información geográfica en la construcción de mapas de riesgo.La información presentada es de utilidad para las autoridades sanitarias, ya que en cada municipio se muestran los barrios donde se concentró una mayor densidad de mosquitos. Por otra parte, la georeferenciación de las capturas permitirá realizar nuevos análisis asociando otras variables entomológicas y ambientales.® 10.8 (SCR_011081). Posteriormente, se delimitó el muestreo a nivel de barrio con el análisis de densidad de Kernel  con los casos de dengue registrados entre el 2015 y el 2019 en el área urbana de cada municipio.La recolección de mosquitos adultos de la familia Culicidae, se llevó a cabo en los municipios de Piamonte, Patía y Miranda, seleccionados por presentar un alto riesgo de dengue, de acuerdo con el análisis global de clúster de la variable tasa de incidencia por cada 10.000 habitantes en el departamento del Cauca, análisis para el cual se utilizó la técnica High-Low Clustering  en el software ArcGISn = 180 viviendas) y siete barrios en el segundo (n = 335 viviendas). Finalmente, en el municipio de Miranda se muestrearon seis barrios de cuatro conglomerados (n = 420 viviendas) con incidencia de la enfermedad más alta que la esperada.En total, se muestrearon 935 viviendas en 17 barrios de los tres municipios durante el año 2021. En el municipio de Piamonte y Patía se identificaron tres conglomerados para la transmisión del dengue, por lo cual se muestrearon tres barrios en el primer municipio  Global a una resolución de 12,5 metros. A los mosquitos de cada vivienda se les asignó un código el cuál fue asociado con la encuesta sociodemográfica realizada mediante la aplicación ArcGISAedes aegypti (n = 572), Aedes albopictus (n = 36) y Culex quinquefasciatus (n = 1.775). La Tabla Un total de 2.383 mosquitos de la familia Culicidae fueron recolectados en las viviendas inlcuidas en el muestreo: Ae. aegypti, la Figura Ae. aegypti. Cabe destacar que en tres casas de Patía, más de 15 Ae. aegypti y el mayor número de adultos colectados en una sola casa fue de 60. En Miranda se encontraron más de 10 individuos en cuatro casas y el mayor número de adultos en una sola casa fue de 20. Por último, Piamonte presentó el número más bajo de adultos por casa, y el número más alto en una sola casa fue siete.Centrándonos en el vector . El índice de diversidad promedio para los tres municipios osciló entre 0,27 y 0,66 para el índice de Shannon y entre 0,12 y 0,41 para el índice de Simpson. Ambos índices fueron más altos en Patía y más bajos en Piamonte. Gráficamente, la diversidad de ubicaciones se puede visualizar mejor utilizando el índice de Margalef. Para Miranda la muestra es muy diversa, mientras que para los demás grupos se observa una muestra de características diversas. La Figura Como medida de la heterogeneidad de la comunidad, se utilizaron los índices de diversidad de Shannon y Simpson  En todas las capturas de mosquitos se utilizaron formatos electrónicos previamente diseñados en Survey123 (ESRI) para registrar la información de la recolección en el campo y las coordenadas geográficas de las viviendas. Expertos entomólogos realizaron la identificación taxonómica. Los registros del conjunto de datos fueron verificados y confirmados uno por uno.Ae. aegypti , seguido de Cx. quinquefasciatus (0.0953), y los valores más bajos se registraron en Ae. albopictus (0.0275). Se estimó el índice de dominancia de todos los mosquitos muestreados en tres municipios diferentes (Cuadro 3); los valores más altos se registraron en Cx. quinquefasciatus  seguido de Ae. aegypti (0.0576) y menos en Ae. albopictus . Estos resultados son similares a los de otros estudios previos .El mayor índice de diversidad se registró para Ae. aegypti y Ae. albopictus, mientras que la categoría Culex incluye la especie Cx. quinquefasciatus, que también está implicado en la transmisión de arbovirosis.La Figura Cx. quinquedasciatus fueron recolectados con el método de muestreo utilizado (aspiradores Prokopack). Para estudios futuros, se deben utilizar métodos de muestreo complementarios o técnicas de monitoreo para mosquitos adultos . Antes de depositar un espécimen en la colección, los curadores de la colección del Grupo de Entomología revisan la información asociada con el espécimen; es decir, la localidad, coordenadas geográficas, sexo, etapa de desarrollo y taxonomía. La información mínima requerida para incluir un espécimen en la colección está relacionada con el Darwin Core estándar y es la misma que la información mínima requerida para la publicación en el Global Biodiversity Information Facility (GBIF). Sólo Aedes spp. y El conjunto de datos de mosquitos aquí presentado, así como la información resumida en la tabla y las figuras constituyen un recurso valioso para las autoridades de salud encargadas de la vigilancia entomológica y control de arbovirosis en la Región y específicamente en el departamento del Cauca.Ae. aegypti y Ae. albopictus base de datos albopictus también puede ser útil para proyectos similares en otros lugares. Sugerimos a otros que hagan que sus datos estén disponibles de manera similar.La base de datos puede ser usada por la comunidad científica interesada en el estudio de las enfermedades transmitidas por vectores en la construcción de modelos de predicción de la distribución de las especies transmisoras de arbovirosis. Para mejorar la accesibilidad y la posibilidad de re-uso de la información, los datos fueron incluidos en la plataforma del Global Biodiversity Information Facility. El  Upload additional filesDRR-202202-04/form/GigaByte_Review_DRR_202202_04_Arbovirus_CJA_08Mar2022.pdfReviewer name and names of any other individual's who aided in reviewer Chris ArmitDo you understand and agree to our policy of having open and named reviews, and having your review included with the published papers. YesIs the language of sufficient quality?NoPlease add additional comments on language quality to clarify if needed
The GBIF Dataset page and the Metadata are in Spanish, and so I cannot determine the quality of the language in these resources.Are all data available and do they match the descriptions in the paper? YesAdditional CommentsAre the data and metadata consistent with relevant minimum information or reporting standards? See GigaDB checklists for examples <a href="http://gigadb.org/site/guide" target="_blank">http://gigadb.org/site/guide</a>YesAdditional CommentsIs the data acquisition clear, complete and methodologically sound?YesAdditional CommentsIs there sufficient detail in the methods and data-processing steps to allow reproduction?YesAdditional CommentsIs there sufficient data validation and statistical analyses of data quality? YesAdditional CommentsIs the validation suitable for this type of data?YesAdditional CommentsIs there sufficient information for others to reuse this dataset or integrate it with other data?YesAdditional CommentsAny Additional Overall Comments to the AuthorThis Data Release manuscript describes the occurrence of mosquitoes in Colombia. The dataset is in Spanish, and the Metadata consists of 529 Geographic Locations and include the different Latitude / Longitude coordinates where Sampling was accomplished. These Geographic Locations relate to the Colombian municipalities of: 1) Patia; 2) Miranda, and; 3) Piamonte, which are all based in Cauca which is a Department in Southwestern Colombia.

The GBIF Metadata with Latitude / Longitude coordinates was included in the Darwin Core DwC package “occurrence.txt” file. As a reviewer, I performed a spot check of 10 Samples, and I can confirm that the Latitude / Longitude coordinates for these 10 Samples refer to the aforementioned locations. There are a total of 3 mosquito species referred to in the Metadata – Aedes albopictus, Aedes aegypti, Culex quinquefasciatus – which is consistent with the manuscript. In addition, the manuscript states the following:

• “A total of 2,383 individuals corresponding to three species of the Culicidae family: Ae. Aegypti (n=572), Ae. albopictus (n=36) and Cx. quinquefasciatus ”

The values in the GBIF Dataset are in agreement with this statement. Furthermore, the manuscript refers to 529 occurrences, and so GBIF Metadata is also consistent with this.

The major issues with this Dataset are as follows:

1. The GBIF Dataset is in Spanish.

2. The License is: CC-BY-NC 4.0

3. The DOI redirects to the IPT webpage rather than the GBIF Dataset page

• https://doi.org/10.15472/dxbowv

4. There is a link in the IPT Dataset that I am not authorised to access:

• https://ipt.biodiversidad.co/cr-sib/resource.do?r=01300_ins-dipteroscauca_20220128

RecommendationMinor Revision Reviewer name and names of any other individual's who aided in reviewer Nils TjadenDo you understand and agree to our policy of having open and named reviews, and having your review included with the published papers. YesIs the language of sufficient quality?YesPlease add additional comments on language quality to clarify if needed
Are all data available and do they match the descriptions in the paper? YesAdditional Commentsavailable on GBIF, which is exactly the right place for itAre the data and metadata consistent with relevant minimum information or reporting standards? See GigaDB checklists for examples <a href="http://gigadb.org/site/guide" target="_blank">http://gigadb.org/site/guide</a>YesAdditional Commentsfollows GBIF metadata standards, which appear to be in line with what GigaDB expectsIs the data acquisition clear, complete and methodologically sound?NoAdditional CommentsSelection of study sites could be clearer: Where did the incidence data come from? Where did the case numbers for the neighborhoods come from? Were all houses in a selected neighborhood visited or just a selection? Were all visited houses accessible to sampling?Is there sufficient detail in the methods and data-processing steps to allow reproduction?YesAdditional CommentsThis is pretty much unprocessed, raw data.Is there sufficient data validation and statistical analyses of data quality? YesAdditional CommentsReally not much to validate here. Locations seem to be located where they are supposed to be, and apparently all records were double-checked individually. It's already been through the GBIF system too.

In terms of (explorative) statistics, I was wondering why Figure 2 was limited to one of 3 species.Is the validation suitable for this type of data?YesAdditional CommentsIs there sufficient information for others to reuse this dataset or integrate it with other data?YesAdditional CommentsAny Additional Overall Comments to the AuthorDear Authors,
Thanks not only for sharing this data set but also for making it CC-0!

Some minor points:

Reference #1 does not appear to suitable to support the claim made in the first sentence of the introduction, at least not on its own. The sentence is about global patterns of several diseases, the cited paper by Ye & Moreno is about dengue in Colombia only. Maybe it was supposed to go with the following sentence? In any case, there must be a suitable review or WHO report you could cite instead.

First sentence of second paragraph of introduction: 1) "y" -> "and" 2) there appears to be a "which" missing before "consists of about 3,200 recognized species".

Figure 1 is not referenced in the main manuscript text.

Figure 3, upper left corner: some text has been cut off (suppose "sri" should be "Esri"?)RecommendationMinor Revision Upload additional filesDRR-202202-04/form/Main text (1).docxReviewer name and names of any other individual's who aided in reviewer Dr. P. Senthamarai SelvanDo you understand and agree to our policy of having open and named reviews, and having your review included with the published papers. YesIs the language of sufficient quality?YesPlease add additional comments on language quality to clarify if needed
In the introduction part try to avoid too many split in paragraph. And also minimize the paragraph with coherence. Are all data available and do they match the descriptions in the paper? YesAdditional CommentsAre the data and metadata consistent with relevant minimum information or reporting standards? See GigaDB checklists for examples <a href="http://gigadb.org/site/guide" target="_blank">http://gigadb.org/site/guide</a>YesAdditional CommentsIs the data acquisition clear, complete and methodologically sound?NoAdditional CommentsAuthors should use statistical tools for representing data.Is there sufficient detail in the methods and data-processing steps to allow reproduction?NoAdditional CommentsAuthors have taken extra care to process the identification of Culicidae, but still, there is a chance for escape while identification. How they will manage. Is there sufficient data validation and statistical analyses of data quality? NoAdditional CommentsThe authors were not used sufficient statistical tools to interpret the data. They proved numerically but not statistically. Ref: 10.1016/j.actatropica.2016.03.029Is the validation suitable for this type of data?NoAdditional CommentsAuthors should use indices for this study. Try to use the House index, Container index and Breteau index.
Refer: Senthamarai Selvan and Jebanesan, Indian Journal of Natural Products and Resources Vol. 7(3), September 2016, pp. 234-239Is there sufficient information for others to reuse this dataset or integrate it with other data?YesAdditional CommentsI appreciate the investigators for getting such meaningful data.Any Additional Overall Comments to the AuthorAuthors should explain, other species while collecting the mentioned vectors viz., Aedes aegypti, Aedes albopictus and Culex quinquefasciatus. As per the statement, the authors collected only those three species, but there is a high chance for the collection of other species also. Why the authors are not considering/mentioned on other species.RecommendationMajor Revision Comments to the AuthorPlease await the proofs for both the English and Spanish versions