[Relationship between thyroid function changes with work-/night-shifts and history of thyroid pathology among health personnel].

BACKGROUND: The study aim was to analyze the relationship between functional thyroid pathology and the exposure to work shifts / night shifts, and describe the most prevalent thyroid disorders based on the type of shift. METHODOLOGY: Cross-sectional study performed in the emergency department of a hospital in Almeria (Spain). Relationships between thyroxine and thyrotropin levels (TSH) and work shifts, professional category and history of thyroid pathology were analyzed. RESULTS: The study included 133 workers; 80.5% female, average age was 46.11 years (38 - 65), and 52% were part of the nursing staff; thyroid disorders were more frequent in female participants. Most participants (81.2%) had rotating shifts schedules and 11.3% night shifts (12.1% female and 7.7% male). Thyroid alterations were found in 27% of the participants (usually elevated TSH levels and normal thyroxine levels), particularly in those doing night shifts (61.1%). TSH alterations were more frequent in individuals doing night shifts than in rotating shifts (53.3 vs 13.0%; p<0.001). Individuals working night shifts had mean TSH values in the normal range, although significantly higher than the individuals in the rest of the shifts; thyroxine levels were found to be similar. No thyroid disorders were found in day shift participants. Night shift and a history of thyroid pathology were independent predictors of thyroid disorders. CONCLUSIONS: Night shift schedules and history of thyroid disorders are more frequent in female, both related to the presence of thyroid disorders, indicating the need to include the evaluation of these disorders in health surveillance programs and analyze gender differences.

External Validation of SAFE Score to Predict Atrial Fibrillation Diagnosis after Ischemic Stroke: A Retrospective Multicenter Study.

Introduction: The screening for atrial fibrillation (AF) scale (SAFE score) was recently developed to provide a prediction of the diagnosis of AF after an ischemic stroke. It includes 7 items: age ≥ 65 years, bronchopathy, thyroid disease, cortical location of stroke, intracranial large vessel occlusion, NT-ProBNP ≥250 pg/mL, and left atrial enlargement. In the internal validation, a good performance was obtained, with an AUC = 0.88 (95% CI 0.84-0.91) and sensitivity and specificity of 83% and 80%, respectively, for scores ≥ 5. The aim of this study is the external validation of the SAFE score in a multicenter cohort. Methods: A retrospective multicenter study, including consecutive patients with ischemic stroke or transient ischemic attack between 2020 and 2022 with at least 24 hours of cardiac monitoring. Patients with previous AF or AF diagnosed on admission ECG were excluded. Results: Overall, 395 patients were recruited for analysis. The SAFE score obtained an AUC = 0.822 (95% CI 0.778-0.866) with a sensitivity of 87.2%, a specificity of 65.4%, a positive predictive value of 44.1%, and a negative predictive value of 94.3% for a SAFE score ≥ 5, with no significant gender differences. Calibration analysis in the external cohort showed an absence of significant differences between the observed values and those predicted by the model (Hosmer-Lemeshow's test 0.089). Conclusions: The SAFE score showed adequate discriminative ability and calibration, so its external validation is justified. Further validations in other external cohorts or specific subpopulations of stroke patients might be required.

Epidemiological Situation of High-Prevalence Non-Communicable Diseases in Spain: A Systematic Review.

High-prevalence non-communicable diseases (HNCDs) are an ongoing global public health problem, posing a risk to the continuity of the 2030 Agenda for Sustainable Development. The aim of this study is to describe the current situation in Spain regarding certain HNCDs, namely, ischaemic heart disease, type 2 diabetes mellitus and colorectal cancer, including their prevalence and incidence in recent years. A systematic review was conducted between October 2022 and February 2023 using the MEDLINE, ProQuest and Scopus databases. After an exhaustive search, a total of thirty-four articles were included, comprising fourteen articles on colorectal cancer, seven on ischaemic heart disease and thirteen on diabetes mellitus type 2. The main topics included risk factors, lifestyles, mortality and incidence, the importance of screening and patient empowerment. On analysing each disease, it can be gleaned that risk factors and lifestyle impact the incidence, prevalence and mortality of the diseases studied. In addition, responsible human behaviour, associated with lifestyle factors, is related to the occurrence of these three diseases.

External Validation and Recalibration of a Mortality Prediction Model for Patients with Ischaemic Stroke.

BACKGROUND: Stroke is a highly prevalent disease that can provoke severe disability. We evaluate a predictive model based on the Minimum Basic Data Set (MBDS) compiled by the Spain Health Ministry, obtained for the period 2008-2012 for patients with ischaemic stroke in Spain, to establish the model's validity and to optimise its calibration. The MBDS is the main clinical-administrative database for hospitalisations recorded in Spain, and to our knowledge, no predictive models for stroke mortality have previously been developed using this resource. The main study aim is to perform an external validation and recalibration of the coefficients of this predictive model with respect to a chronologically later cohort. MATERIAL AND METHODS: External validation (testing the model on a different cohort to assess its performance) and recalibration (validation with optimisation of model coefficients) were performed using the MBDS for patients admitted for ischaemic stroke in the period 2016-2018. A cohort study was designed, in which a recalibrated model was obtained by applying the variables of the original model without their coefficients. The variables from the original model were then applied to the subsequent cohort, together with the coefficients from the initial model. The areas under the curve (AUC) of the recalibration and the external validation procedure were compared. RESULTS: The recalibrated model produced an AUC of 0.743 and was composed of the following variables: age (odds ratio, OR:1.073), female sex (OR:1.143), ischaemic heart disease (OR:1.192), hypertension (OR:0.719), atrial fibrillation (OR:1.414), hyperlipidaemia (OR:0.652), heart failure (OR:2.133) and posterior circulation stroke (OR: 0.755). External validation produced an AUC of 0.726. CONCLUSIONS: The recalibrated clinical model thus obtained presented moderate-high discriminant ability and was generalisable to predict death for patients with ischaemic stroke. Rigorous external validation slightly decreased the AUC but confirmed the validity of the baseline model for the chronologically later cohort.

Osteopathic Manual Therapy for Infant Colic: A Randomised Clinical Trial.

BACKGROUND: Infant colic is a multifactorial syndrome for which various therapeutic strategies have been proposed. In this study, we evaluate the effectiveness of osteopathic manual therapy in treating symptoms related to infant colic. METHOD: A prospective, randomised, blinded clinical trial was conducted of patients diagnosed with infant colic. The treatment group were given osteopathic manual therapy, and their parents received two sessions of counselling. The control group received no such therapy, but their parents attended the same counselling sessions. The non-parametric Mann-Whitney U test was applied to determine whether there were significant differences between the groups for the numerical variables considered. For the qualitative variables, Fisher's exact test was used. The threshold assumed for statistical significance was 0.05. RESULTS: A total of 42 babies were assigned to each group. Those in the experimental group presented less severe infant colic with a trend towards statistical significance after the first session (p = 0.09). In sucking, excretion, eructation and gas there were no significant differences between the groups. Crying was a statistically significant dimension both after the first intervention (p = 0.03) and two weeks after (p = 0.04). Regurgitation values were significantly lower in the experimental group during the three weeks of follow-up (p = 0.05). Values for sleep were lower in the experimental group, but the differences were not statistically significant. In both groups, colic severity decreased over time, with no side effects. CONCLUSIONS: Treatment with osteopathic manual therapy alleviates the symptoms of infant colic and could be recommended for this purpose from the onset of the condition.

Socio-economic inequalities in lung cancer mortality in Spain: a nation-wide study using area-based deprivation.

BACKGROUND: Lung cancer is the main cause of cancer mortality worldwide and in Spain. Several previous studies have documented socio-economic inequalities in lung cancer mortality but these have focused on specific provinces or cities. The goal of this study was to describe lung cancer mortality in Spain by sex as a function of socio-economic deprivation. METHODS: We analysed all registered deaths from lung cancer during the period 2011-2017 in Spain. Mortality data was obtained from the National Institute of Statistics, and socio-economic level was measured with the small-area deprivation index developed by the Spanish Society of Epidemiology, with the census tract of residence at the time of death as the unit of analysis. We computed crude and age-standardized rates per 100,000 inhabitants by sex, deprivation quintile, and type of municipality (rural, semi-rural, urban) considering the 2013 European standard population (ASR-E). We further calculated ASR-E ratios between the most deprived (Q5) and the least deprived (Q1) areas and mapped census tract smoothed standardized lung cancer mortality ratios by sex. RESULTS: We observed 148,425 lung cancer deaths (80.7% in men), with 73.5 deaths per 100,000 men and 17.1 deaths per 100,000 women. Deaths from lung cancer in men were five times more frequent than in women (ASR-E ratio = 5.3). Women residing in the least deprived areas had higher mortality from lung cancer (ASR-E = 22.2), compared to women residing in the most deprived areas (ASR-E = 13.2), with a clear gradient among the quintiles of deprivation. For men, this pattern was reversed, with the highest mortality occurring in areas of lower socio-economic level (ASR-E = 99.0 in Q5 vs. ASR-E = 86.6 in Q1). These socio-economic inequalities remained fairly stable over time and across urban and rural areas. CONCLUSIONS: Socio-economic status is strongly related to lung cancer mortality, showing opposite patterns in men and women, such that mortality is highest in women residing in the least deprived areas and men residing in the most deprived areas. Systematic surveillance of lung cancer mortality by socio-economic status may facilitate the assessment of public health interventions aimed at mitigating cancer inequalities in Spain.

Structural Model of Biomedical and Contextual Factors Predicting In-Hospital Mortality due to Heart Failure.

Background: Among the clinical predictors of a heart failure (HF) prognosis, different personal factors have been established in previous research, mainly age, gender, anemia, renal insufficiency and diabetes, as well as mediators (pulmonary embolism, hypertension, chronic obstructive pulmonary disease (COPD), arrhythmias and dyslipidemia). We do not know the role played by contextual and individual factors in the prediction of in-hospital mortality. Methods: The present study has added hospital and management factors (year, type of hospital, length of stay, number of diagnoses and procedures, and readmissions) in predicting exitus to establish a structural predictive model. The project was approved by the Ethics Committee of the province of Almeria. Results: A total of 529,606 subjects participated, through databases of the Spanish National Health System. A predictive model was constructed using correlation analysis (SPSS 24.0) and structural equation models (SEM) analysis (AMOS 20.0) that met the appropriate statistical values (chi-square, usually fit indices and the root-mean-square error approximation) which met the criteria of statistical significance. Individual factors, such as age, gender and chronic obstructive pulmonary disease, were found to positively predict mortality risk. Isolated contextual factors (hospitals with a greater number of beds, especially, and also the number of procedures performed, which negatively predicted the risk of death. Conclusions: It was, therefore, possible to introduce contextual variables to explain the behavior of mortality in patients with HF. The size or level of large hospital complexes, as well as procedural effort, are key contextual variables in estimating the risk of mortality in HF.

Stroke in Young Adults in Spain: Epidemiology and Risk Factors by Age.

INTRODUCTION: Recent research has highlighted an increased incidence of ischemic stroke (IS) in young adults, along with a higher percentage of vascular risk factors at younger ages. This study aimed to estimate the in-hospital incidence of IS and associated comorbidities by sex and age group in Spain. METHODS: A retrospective analysis of the Spain Nationwide Inpatient Sample database from 2016 to 2019 was conducted, which included adult patients with IS. In-hospital incidence and mortality rates were estimated, and a descriptive analysis of the main comorbidities was performed, stratified by sex and age groups. RESULTS: A total of 186,487 patients were included, with a median age of 77 (IQR 66-85) years and 53.3% were male. Of these, 9162 (5%) were aged between 18 and 50 years. The estimated incidence of IS in adults younger than 50 years ranged from 11.9 to 13.5 per 100,000 inhabitants during the study period, with a higher incidence in men. The overall in-hospital mortality was 12.6%. Young adults with IS had a higher prevalence of most vascular risk factors compared to the general Spanish population, with a specific distribution according to sex and age. CONCLUSIONS: This study provides estimates of the incidence of IS and the prevalence of vascular risk factors and comorbidities associated with IS in Spain, stratified by sex and age, using a national registry of hospital admissions. These findings should be considered in terms of both primary and secondary prevention strategies.

N-Terminal Pro-Brain Natriuretic Peptide Levels Are Associated with Post-Stroke In-Hospital Complications.

Previous studies have shown the relationship between N-terminal pro-brain natriuretic peptide (NT-proBNP) with stroke mortality and functional outcome after an acute ischemic stroke (AIS). Knowledge of its association with systemic and neurological in-hospital complications is scarce. Our objective is to analyze this. We performed an observational, retrospective study that included consecutive AIS patients during a 1-year period (2020). A multivariate analysis was performed to identify if NT-proBNP levels were independently associated with in-hospital complications. 308 patients were included, of whom 96 (31.1%) developed systemic and 62 (20.12%) neurological in-hospital complications. Patients with any complication (39.3%) showed higher NT-proBNP levels than those without (median (IQR): 864 (2556) vs. 142 (623) pg/dL, p < 0.001). The receiver operating characteristic curve (ROC) pointed to 326 pg/dL of NT-proBNP as the optimal cutoff level for developing in-hospital systemic complications (63.6% sensitivity and 64.7% specificity for any complication; 66.7% and 62.7% for systemic; and 62.9% and 57.7% for neurological complications). Multivariate analyses showed that NT-proBNP > 326 pg/dL was associated with systemic complications (OR 2.336, 95% CI: 1.259-4.335), adjusted for confounders. This did not reach statistical significance for neurological complications. NT-proBNP could be a predictor of in-hospital systemic complications in AIS patients. Further studies are needed.

Development of a Score to Predict the Paroxysmal Atrial Fibrillation in Stroke Patients: The Screening for Atrial Fibrillation Scale.

Background and Purpose: An individual selection of ischemic stroke patients at higher risk of atrial fibrillation (AF) might increase the diagnostic yield of prolonged cardiac monitoring and render it cost-effective. Methods: The clinical, laboratory, and brain/cardiac imaging characteristics of consecutive ischemic stroke patients without documented AF were recorded. All patients underwent at least 72 h of cardiac monitoring unless AF was diagnosed before, transthoracic echocardiogram, blood biomarkers, and intracranial vessels imaging. A predictive grading was developed by logistic regression analysis, the screening for atrial fibrillation scale (SAFE). Results: A total of 460 stroke patients were analyzed to develop the SAFE scale, a 7-items score (possible total score 0-10): age ≥ 65 years (2 points); history of chronic obstructive pulmonary disease or obstructive sleep apnea (1 point); thyroid disease (1 point); NT-proBNP ≥ 250 pg/ml (2 points); left atrial enlargement (2 points); cortical topography of stroke, including hemispheric or cerebellar cortex (1 point); and intracranial large vessel occlusion (1 point). A score = 5 identified patients with paroxysmal AF with a sensitivity of 83% and a specificity of 80%. Conclusion: Screening for atrial fibrillation scale (SAFE) is a novel and simple strategy for selecting ischemic stroke patients at higher risk of having AF who can benefit from a more thorough etiological evaluation. External validation of SAFE in a multicenter study, with a larger number of patients, is warranted.

User Perception of New E-Health Challenges: Implications for the Care Process.

Establishing new models of health care and new forms of professional health-patient communication are lines of development in the field of health care. The onset of the COVID-19 pandemic has accelerated the evolution of information systems and communication platforms to guarantee continuity of care and compliance with social distancing measures. Our objective in this article was, firstly, to know the expectations of patients treated in the healthcare processes "cervical cancer" and "pregnancy, childbirth and puerperium" regarding online access to their clinical history and follow-up in the care process. Secondly, we analyzed times involved in the cervical cancer process to find points of improvement in waiting times when digital tools were used for communication with the patient. A descriptive cross-sectional study was carried out on 120 women included in any of the aforementioned processes using a hetero-administered questionnaire. The analysis of times was carried out using the Business Intelligence tool Biwer Analytics®. Patients showed interest in knowing their results before the appointment with the doctor and would avoid appointments with their doctor if the right conditions were met. Most recognized that this action would relieve their restlessness and anxiety. They were highly interested in receiving recommendations to improve their health status. It was estimated that there was room for improvement in the times involved in the care process, which could be shortened by 34.48 days if communication of results were through digital information access technologies. This would favor the optimization of time, resources and user perception.

Predictive Model and Mortality Risk Score during Admission for Ischaemic Stroke with Conservative Treatment.

BACKGROUND: Stroke is the second cause of mortality worldwide and the first in women. The aim of this study is to develop a predictive model to estimate the risk of mortality in the admission of patients who have not received reperfusion treatment. METHODS: A retrospective cohort study was conducted of a clinical-administrative database, reflecting all cases of non-reperfused ischaemic stroke admitted to Spanish hospitals during the period 2008-2012. A predictive model based on logistic regression was developed on a training cohort and later validated by the "hold-out" method. Complementary machine learning techniques were also explored. RESULTS: The resulting model had the following nine variables, all readily obtainable during initial care. Age (OR 1.069), female sex (OR 1.202), readmission (OR 2.008), hypertension (OR 0.726), diabetes (OR 1.105), atrial fibrillation (OR 1.537), dyslipidaemia (0.638), heart failure (OR 1.518) and neurological symptoms suggestive of posterior fossa involvement (OR 2.639). The predictability was moderate (AUC 0.742, 95% CI: 0.737-0.747), with good visual calibration; Pearson's chi-square test revealed non-significant calibration. An easily consulted risk score was prepared. CONCLUSIONS: It is possible to create a predictive model of mortality for patients with ischaemic stroke from which important advances can be made towards optimising the quality and efficiency of care. The model results are available within a few minutes of admission and would provide a valuable complementary resource for the neurologist.

[Evaluation of treatment with intra-articular injections in osteoarticular pathology of the shoulder in primary care]. / Evaluación del tratamiento con infiltraciones intraarticulares en la patología osteoarticular del hombro en atención primaria.

MAIN OBJECTIVE: To evaluate the clinical response at 24weeks after injection, measured as pain relief and functional recovery, in painful shoulder syndrome (PSS) in primary care (PC). DESIGN: Longitudinal case series with injection treatment in the scapulohumeral joint, describing functionality and pain evolution before and at 24weeks post injection. LOCATION: Non-urban primary care centres. PARTICIPANTS: Patients with osteoarticular shoulder pathology susceptible to injection, failure of pharmacological treatment and rating on the visual analogue scale (VAS) ≥4 or constant score (CS) ≤70. INTERVENTIONS: Intra-articular injection of corticosteroid and local anaesthetic into the scapulohumeral joint, describing its evolution at 1, 4, 12 and 24weeks post injection. MAIN MEASUREMENTS: Infiltration response according to EVA before and after, CS before and after, number of infiltrations, side effects, temporary inability to work (TIL). RESULTS: Sixty-six patients receiving injection, mean age 51.1years (SD 14.7), 57.6% were women and 63.3% were injection in the right shoulder. A 22.7% required TIL and were discharged with a median of 14days (range 7-56days). They required an injection (80.3%) and the most frequent injection pathology was rotator cuff tendinitis (90.9%). They suffered mild side effects (9.4%). We found a decrease in pain from severe to mild and a functional improvement from poor to good. The variables: being retired (OR: 37.82, P=.001) and having an EVA score prior to injection >8 (OR: 15.67, P=.055, almost significant) were associated with poor response. CONCLUSIONS: Intra-articular administration of corticosteroids in PSS reduces pain and provides functional improvement after the first week after injection, and is maintained in the long term. This allows a quick recovery to work after an injection at two weeks reducing recovery time by 50%, with few side effects.

Glycemic index, glycemic load, and risk of coronary heart disease: a pan-European cohort study.

BACKGROUND: High carbohydrate intake raises blood triglycerides, glucose, and insulin; reduces HDLs; and may increase risk of coronary heart disease (CHD). Epidemiological studies indicate that high dietary glycemic index (GI) and glycemic load (GL) are associated with increased CHD risk. OBJECTIVES: The aim of this study was to determine whether dietary GI, GL, and available carbohydrates are associated with CHD risk in both sexes. METHODS: This large prospective study-the European Prospective Investigation into Cancer and Nutrition-consisted of 338,325 participants who completed a dietary questionnaire. HRs with 95% CIs for a CHD event, in relation to intake of GI, GL, and carbohydrates, were estimated using covariate-adjusted Cox proportional hazard models. RESULTS: After 12.8 y (median), 6378 participants had experienced a CHD event. High GL was associated with greater CHD risk [HR 1.16 (95% CI: 1.02, 1.31) highest vs. lowest quintile, p-trend 0.035; HR 1.18 (95% CI: 1.07, 1.29) per 50 g/day of GL intake]. The association between GL and CHD risk was evident in subjects with BMI (in kg/m2) ≥25 [HR: 1.22 (95% CI: 1.11, 1.35) per 50 g/d] but not in those with BMI <25 [HR: 1.09 (95% CI: 0.98, 1.22) per 50 g/d) (P-interaction = 0.022). The GL-CHD association did not differ between men [HR: 1.19 (95% CI: 1.08, 1.30) per 50 g/d] and women [HR: 1.22 (95% CI: 1.07, 1.40) per 50 g/d] (test for interaction not significant). GI was associated with CHD risk only in the continuous model [HR: 1.04 (95% CI: 1.00, 1.08) per 5 units/d]. High available carbohydrate was associated with greater CHD risk [HR: 1.11 (95% CI: 1.03, 1.18) per 50 g/d]. High sugar intake was associated with greater CHD risk [HR: 1.09 (95% CI: 1.02, 1.17) per 50 g/d]. CONCLUSIONS: This large pan-European study provides robust additional support for the hypothesis that a diet that induces a high glucose response is associated with greater CHD risk.

Predictive Model of the Risk of In-Hospital Mortality in Colorectal Cancer Surgery, Based on the Minimum Basic Data Set.

BACKGROUND: Various models have been proposed to predict mortality rates for hospital patients undergoing colorectal cancer surgery. However, none have been developed in Spain using clinical administrative databases and none are based exclusively on the variables available upon admission. Our study aim is to detect factors associated with in-hospital mortality in patients undergoing surgery for colorectal cancer and, on this basis, to generate a predictive mortality score. METHODS: A population cohort for analysis was obtained as all hospital admissions for colorectal cancer during the period 2008-2014, according to the Spanish Minimum Basic Data Set. The main measure was actual and expected mortality after the application of the considered mathematical model. A logistic regression model and a mortality score were created, and internal validation was performed. RESULTS: 115,841 hospitalization episodes were studied. Of these, 80% were included in the training set. The variables associated with in-hospital mortality were age (OR: 1.06, 95%CI: 1.05-1.06), urgent admission (OR: 4.68, 95% CI: 4.36-5.02), pulmonary disease (OR: 1.43, 95%CI: 1.28-1.60), stroke (OR: 1.87, 95%CI: 1.53-2.29) and renal insufficiency (OR: 7.26, 95%CI: 6.65-7.94). The level of discrimination (area under the curve) was 0.83. CONCLUSIONS: This mortality model is the first to be based on administrative clinical databases and hospitalization episodes. The model achieves a moderate-high level of discrimination.

Effects of Levels of Self-Regulation and Regulatory Teaching on Strategies for Coping With Academic Stress in Undergraduate Students.

The SRL vs. ERL TheoryTM predicts that regulation-related factors in the student and in the context combine to determine the student's levels in emotional variables, stress, and coping strategies. The objective of the present research was to test this prediction in the aspect of coping strategies. Our hypothesis posed that students' level of self-regulation (low-medium-high), in combination with the level of regulation promoted in teaching (low-medium-high), would determine the type of strategies students used to cope with academic stress; the interaction of these levels would focus coping strategies either toward emotions or toward the problem. A total of 944 university students completed validated questionnaires on self-regulation, regulatory teaching, and coping strategies, using an online tool. ANOVAs and MANOVAs (3 × 1; 3 × 3; 5 × 1) were carried out, in a quasi-experimental design by selection. Level of self-regulation and level of regulatory teaching both had a significant effect on the type of coping strategies used. The most important finding was that the combined level of self-regulation and external regulation, on a five-level scale or heuristic, predicted the type of coping strategies that were used. In conclusion, the fact that this combination can predict type of coping strategies used by the student lends empirical support to the initial theory. Implications for the teaching-learning process at university and for students' emotional health are discussed.

Structural Equation Model (SEM) of Stroke Mortality in Spanish Inpatient Hospital Settings: The Role of Individual and Contextual Factors.

Introduction: Traditionally, predictive models of in-hospital mortality in ischemic stroke have focused on individual patient variables, to the neglect of in-hospital contextual variables. In addition, frequently used scores are betters predictors of risk of sequelae than mortality, and, to date, the use of structural equations in elaborating such measures has only been anecdotal. Aims: The aim of this paper was to analyze the joint predictive weight of the following: (1) individual factors (age, gender, obesity, and epilepsy) on the mediating factors (arrhythmias, dyslipidemia, hypertension), and ultimately death (exitus); (2) contextual in-hospital factors (year and existence of a stroke unit) on the mediating factors (number of diagnoses, procedures and length of stay, and re-admission), as determinants of death; and (3) certain factors in predicting others. Material and Methods: Retrospective cohort study through observational analysis of all hospital stays of Diagnosis Related Group (DRG) 14, non-lysed ischemic stroke, during the time period 2008-2012. The sample consisted of a total of 186,245 hospital stays, taken from the Minimum Basic Data Set (MBDS) upon discharge from Spanish hospitals. MANOVAs were carried out to establish the linear effect of certain variables on others. These formed the basis for building the Structural Equation Model (SEM), with the corresponding parameters and restrictive indicators. Results: A consistent model of causal predictive relationships between the postulated variables was obtained. One of the most interesting effects was the predictive value of contextual variables on individual variables, especially the indirect effect of the existence of stroke units on reducing number of procedures, readmission and in-hospital mortality. Conclusion: Contextual variables, and specifically the availability of stroke units, made a positive impact on individual variables that affect prognosis and mortality in ischemic stroke. Moreover, it is feasible to determine this impact through the use of structural equation methodology. We analyze the methodological and clinical implications of this type of study for hospital policies.

Influence of psychological variables in morbidly obese patients undergoing bariatric surgery after 24 months of evolution. / Influencia de variables psicológicas en pacientes obesos mórbidos operados con cirugía bariátrica tras 24 meses de evolución.

BACKGROUND: Bariatric surgery is considered a more effective means of achieving weight loss than non-surgical options in morbid obesity. Rates of failure or relapse range from 20 to 30%. The study aims to analyse the influence of psychological variables (self-esteem, social support, coping strategies and personality) in the maintenance of weight loss after bariatric surgery. METHODS: A cohort study was conducted involving 64 patients undergoing bariatric surgery for 24 months. At the end of the follow-up period, patients were divided into 2sub-cohorts classified as successes or failures. Success or favorable development was considered when the value of percent excess weight loss was 50 or higher. RESULTS: No statistically significant differences were observed between the 2groups in any variable studied. All patients had high self-esteem (87,3 those who failed and 88,1 those who are successful) and social support (90,2 and 90,9). Patients who succeed presented higher scores for cognitive restructuring (57,1) and were more introverted (47,1), while those who failed scored more highly in desiderative thinking (65,7) and were more prone to aggression (50,7) and neuroticism (51,7). CONCLUSIONS: High self-esteem and social support does not guarantee successful treatment. The groups differed in how they coped with obesity but the data obtained do not justify the weight evolution. In the absence of psychopathology, personality trait variability between patients is insufficient to predict the results.

[Description of clinical pathological concordance and patient satisfaction in minor surgery in a Primary Care centre]. / Descripción de la concordancia clinicopatológica y satisfacción del paciente en la cirugía menor en un centro de atención primaria.

AIM: To describe the minor surgery (MS) characteristics in a Primary Care (PC) centre, and to evaluate the clinical pathological concordance and patient satisfaction. DESIGN: Descriptive and retrospective study. SETTING: Primary Care, urban health care centre, Almería, Spain. PARTICIPANTS: The population were the patients belonging to urban Primary Health Care centre, referred by their family physicians or paediatricians for the performing of MS during year 2013, and who consented to the intervention. A sample of 223 patients was obtained. MAIN MEASUREMENTS: Variables analysed were: sex, age, locations of the lesions, type of intervention, clinical diagnosis, histopathology diagnosis, complications, and patient satisfaction. The data were extracted from the medical history, the histopathology reports, and by using a satisfaction questionnaire completed by post or telephone by the patients. RESULTS: The population consisted of 53.8% males, and had a mean age of 51.12 years (SD 19.02). The location of the most intervened lesions was in the head (35.4%). Electro-surgery was the most used procedure (62.8%), with only 16.9% of the lesions being biopsied, of which the most frequent was fibroids (32.3%). The clinical pathological concordance was >80% and the Kappa index was 0.783 (P<.001). The complications presented were low. The patient's satisfaction was high. CONCLUSIONS: Although a simple MS technique like electro-surgery has become more extensive, MS in PC remains safe and satisfactory for the user.

Serotonin syndrome probably triggered by a morphine-phenelzine interaction.

Serotonin syndrome is a potentially life-threatening condition caused by excessive central and peripheral stimulation of serotonin brainstem receptors, usually triggered by inadvertent interactions between agents with serotonergic activity. Evidence supporting an association between nonserotonergic opiates, such as oxycodone or morphine, and serotonin syndrome is very limited and even contradictory. In this case report, we describe a patient who developed serotonergic-adverse effects likely precipitated by an interaction between morphine and phenelzine. A 57-year-old woman presented to the emergency department with complaints of increasing visual hallucinations, restlessness, photophobia, dizziness, neck stiffness, occipital headache, confusion, sweating, tachycardia, and nausea over the previous week. On admission, her blood pressure was 185/65 mm Hg, and clonus was noted in the lower extremities. The patient was hospitalized 10 days earlier for cellulitis of the left breast secondary to a left mastectomy 5 months earlier, and a short course of oral morphine was prescribed for pain control. Her routine medications consisted of aspirin, atorvastatin, bisoprolol, clopidogrel, gabapentin, omeprazole, phenelzine, and ramipril. Supportive measures were initiated on admission. Phenelzine and morphine were discontinued immediately, leading to a progressive resolution of symptoms over the next 48 hours. Phenelzine was restarted on discharge without further complications. Use of the Drug Interaction Probability Scale indicated a probable relationship (score of 6) between the patient's development of serotonin syndrome and the combination of morphine and phenelzine. The mechanism underlying this interaction, however, remains unclear and warrants further investigation. Clinicians should carefully weigh the risk and benefits of initiating morphine in patients taking monoamine oxidase inhibitors or any other serotonin-enhancing drugs.