Validation of an electronic frailty index with electronic health records: eFRAGICAP index.

OBJECTIVE: To create an electronic frailty index (eFRAGICAP) using electronic health records (EHR) in Catalunya (Spain) and assess its predictive validity with a two-year follow-up of the outcomes: homecare need, institutionalization and mortality in the elderly. Additionally, to assess its concurrent validity compared to other standardized measures: the Clinical Frailty Scale (CFS) and the Risk Instrument for Screening in the Community (RISC). METHODS: The eFRAGICAP was based on the electronic frailty index (eFI) developed in United Kingdom, and includes 36 deficits identified through clinical diagnoses, prescriptions, physical examinations, and questionnaires registered in the EHR of primary health care centres (PHC). All subjects > 65 assigned to a PHC in Barcelona on 1st January, 2016 were included. Subjects were classified according to their eFRAGICAP index as: fit, mild, moderate or severe frailty. Predictive validity was assessed comparing results with the following outcomes: institutionalization, homecare need, and mortality at 24 months. Concurrent validation of the eFRAGICAP was performed with a sample of subjects (n = 333) drawn from the global cohort and the CFS and RISC. Discrimination and calibration measures for the outcomes of institutionalization, homecare need, and mortality and frailty scales were calculated. RESULTS: 253,684 subjects had their eFRAGICAP index calculated. Mean age was 76.3 years (59.5% women). Of these, 41.1% were classified as fit, and 32.2% as presenting mild, 18.7% moderate, and 7.9% severe frailty. The mean age of the subjects included in the validation subsample (n = 333) was 79.9 years (57.7% women). Of these, 12.6% were classified as fit, and 31.5% presented mild, 39.6% moderate, and 16.2% severe frailty. Regarding the outcome analyses, the eFRAGICAP was good in the detection of subjects who were institutionalized, required homecare assistance, or died at 24 months (c-statistic of 0.841, 0.853, and 0.803, respectively). eFRAGICAP was also good in the detection of frail subjects compared to the CFS (AUC 0.821) and the RISC (AUC 0.848). CONCLUSION: The eFRAGICAP has a good discriminative capacity to identify frail subjects compared to other frailty scales and predictive outcomes.

The impact of frailty on admission to home care services and nursing homes: eight-year follow-up of a community-dwelling, older adult, Spanish cohort.

BACKGROUND: Frailty in older adults is a common multidimensional clinical entity, a state of vulnerability to stressors that increases the risk of adverse outcomes such as functional decline, institutionalization or death. The aim of this study is to identify the factors that anticipate the future inclusion of community-dwelling individuals aged ≥70 years in home care programmes (HC) and nursing homes (NH), and to develop the corresponding prediction models. METHODS: A prospective cohort study was conducted in 23 primary healthcare centers located in Catalonia, Spain, with an eight-year follow-up (2005-2013). The cohort was made up of 616 individuals. Data collection included a baseline multidimensional assessment carried out by primary health care professionals. Outcome variables were collected during follow-up by consulting electronic healthcare records, and the Central Registry of Catalonia for mortality. A prognostic index for a HC and NH at 8 years was estimated for each patient. Death prior to these events was considered a competing risk event, and Fine-Gray regression models were used. RESULTS: At baseline, mean age was 76.4 years and 55.5% were women. During follow-up, 19.2% entered a HC program, 8.2% a NH, and 15.4% died without presenting an event. Of those who entered a NH, 31.5% had previously been in a HC program. Multivariate models for a HC and NH showed that the risk of a HC entry was associated with older age, dependence on the Instrumental Activities of Daily Living, and slow gait measured by Timed-up-and-go test. An increased risk of being admitted to a NH was associated with older age, dependence on the Instrumental Activities of Daily Living, number of prescriptions, and the presence of social risk. CONCLUSIONS: Prognostic models based on comprehensive geriatric assessments can predict the need for the commencement of HC and NH admission in community-dwelling older adults. Our findings underline the necessity to measure functional capacity, mobility, number of prescriptions, and social aspects of older adults in primary healthcare centers. In such a setting they can be offered longitudinal holistic assessments so as to benefit from preventive actions in order to remain independent in the community for as long as possible.

Family caregiver mistreatment of the elderly: prevalence of risk and associated factors.

BACKGROUND: The detection of elder mistreatment is emerging as a public health priority; however, abusive behaviors exercised by caregivers are little known and rarely detected among primary health care professionals. This study aims to estimate the prevalence of risk of abuse against community-residing elderly with moderate to severe dependency whose caregivers are relatives. In addition, we aim to describe the association between such a risk and socio-demographic variables, cognitive and dependency state of the victim, and the scale of the caregiver's anxiety, depression, and burden. METHODS: Cross-sectional study developed in 72 Primary Health Care teams from Barcelona, Spain. Participants were caregivers and their dependent care recipients (N = 829). Home interviews included the Caregiver Abuse Screen (CASE); self-reported abuse from care recipient; activities of daily living and cognitive state of the care recipient; anxiety and depression in caregivers and Caregiver Burden Scale. The relationship prior to the dependency, positive aspects of caregiving, and social support for the caregiver were also assessed. Multivariate analysis was performed using logistic regression with risk of abuse as dependent variable. RESULTS: Caregivers were mainly women (82.8%) with a mean age of 63.3 years. Caregivers and care recipients lived in the same household in 87.4% of cases, and 86.6% had enjoyed a good previous relationship. Care recipients were women (65.6%), with a mean age of 84.2 years, and 64.2% had moderate to severe cognitive impairment. CASE demonstrated a prevalence of 33.4% (95% CI: 30.3-36.7) of abuse risk by the caregiver. Logistic regression showed as statistically significant: caregiver burden (OR = 2.75; 95% CI: 1.74-4.33), caregiver anxiety (OR = 2.06; 95% CI: 1.40-3.02), caregiver perception of aggressive behavior in the care recipient (OR = 7.24; 95% CI: 4.99-10.51), and a bad previous relationship (OR = 4.66; 95% CI: 1.25-17.4). CONCLUSIONS: Prevalence of risk of abuse is high among family caregivers. Our study has found risk factors in family caregivers that are preventable to an extent, namely: anxiety and feelings of burden. It is essential to become aware of these risk factors and their causes to intervene and help primary as well secondary prevention.

Community programmes for coronary heart disease in Spanish primary care.

OBJECTIVE: To explore the added value of community-orientated programmes aimed at enhancing healthy lifestyles associated with the key components of cardiovascular risk management (CVRM) in coronary heart disease (CHD) patients. METHODS: Observational study in Spain, including 36 practices, 36 health professionals, and 722 CHD patients (mean (SD) age 72 (11.73)). Our predictor variable of interest was reported deliveries from primary care practices (PCPs) concerning community-orientated programmes such as physical exercise and smoking cessation groups. Data were obtained through structured questionnaires administered to PCP health professionals. Our CVRM outcome measures were as follows: recorded risk factors, drug prescriptions, and intermediate patient outcomes (blood pressure levels, low-density lipoprotein cholesterol, and body mass index). RESULTS: Thirty practices delivered community programmes: most delivered one [17 (47.2%) practices] or two [11 (30.5%) practices]. These educational programmes aimed to encourage enhanced healthy lifestyles through group counselling sessions, mailed print material, and one-to-one counselling. In PCPs delivering community programmes, more patients received antihypertensives (89.7%), antiplatelet therapy (80.5%), and statins (70.8%) than those PCPs without programmes, although there were no statistically significant differences between them. CONCLUSIONS: No evidence was found for the added value of community-orientated CVRM programmes that could help health professionals refine criteria when including CHD patients in preventive programmes.

Effectiveness of a primary care based multifactorial intervention to improve frailty parameters in the elderly: a randomised clinical trial: rationale and study design.

BACKGROUND: Frailty is a highly prevalent condition in old age leading to vulnerability and greater risk of adverse health outcomes and disability. Detecting and tackling frailty at an early stage can prevent disability. The purpose of this study is to evaluate the effectiveness of a multifactorial intervention program to modify frailty parameters, muscle strength, and physical and cognitive performance in people aged 65 years or more. It also assesses changes from baseline in falls, hospitalizations, nutritional risk, disability, institutionalization, and home-care. METHODS/DESIGN: The current study is a randomised single-blind, parallel-group clinical trial, with a one and a half year follow-up, conducted in eight Primary Health Care Centres located in the city of Barcelona. Inclusion criteria are to be aged 65 years or older with positive frailty screening, timed get-up-and-go test between 10 to 30 seconds, and Cognition Mini-Exam (MEC-35) of Lobo greater than or equal to 18. A total of 352 patients have been equally divided into two groups: intervention and control. Sample size calculated to detect a 0.5 unit difference in the Short Physical Performance Battery (Common SD: 1.42, 20% lost to follow-up). In the intervention group three different actions on frailty dimensions: rehabilitative therapy plus intake of hyperproteic nutritional shakes, memory workshop, and medication review are applied to sets of 16 patients. Participants in both intervention and control groups receive recommendations on nutrition, healthy lifestyles, and home risks.Evaluations are blinded and conducted at 0, 3, and 18 months. Intention to treat analyses will be performed. Multivariate analysis will be carried out to assess time changes of dependent variables. DISCUSSION: It is expected that this study will provide evidence of the effectiveness of a multidisciplinary intervention on delaying the progression from frailty to disability in the elderly. It will help improve the individual's quality of life and also reduce the rates of falls, hospital admissions, and institutionalizations, thus making the health care system more efficient. This preventive intervention can be adapted to diverse settings and be routinely included in Primary Care Centres as a Preventive Health Programme. TRIAL REGISTRATION: ClinicalTrials.gov PRS: NCT01969526. Date of registration: 10/21/2013.

Investigating silent strokes in hypertensives: a magnetic resonance imaging study (ISSYS): rationale and protocol design.

BACKGROUND: Silent brain infarcts are detected by neuroimaging in up to 20% of asymptomatic patients based on population studies. They are five times more frequent than stroke in general population, and increase significantly both with advancing age and hypertension. Moreover, they are independently associated with the risk of future stroke and cognitive decline.Despite these numbers and the clinical consequences of silent brain infarcts, their prevalence in Mediterranean populations is not well known and their role as predictors of future cerebrovascular and cardiovascular events in hypertensive remains to be determined.ISSYS (Investigating Silent Strokes in Hypertensives: a magnetic resonance imaging study) is an observational cross-sectional and longitudinal study aimed to: 1- determine the prevalence of silent cerebrovascular infarcts in a large cohort of 1000 hypertensives and to study their associated factors and 2-to study their relationship with the risk of future stroke and cognitive decline. METHODS/DESIGN: Cohort study in a randomly selected sample of 1000 participants, hypertensive aged 50 to 70 years old, with no history of previous stroke or dementia.On baseline all participants will undergo a brain MRI to determine the presence of brain infarcts and other cerebrovascular lesions (brain microbleeds, white matter changes and enlarged perivascular spaces) and will be also tested to determine other than brain organ damage (heart-left ventricular hypertrophy, kidney-urine albumin to creatinine ratio, vessels-pulse wave velocity, ankle brachial index), in order to establish the contribution of other subclinical conditions to the risk of further vascular events. Several sub-studies assessing the role of 24 hour ambulatory BP monitoring and plasma or genetic biomarkers will be performed.Follow-up will last for at least 3 years, to assess the rate of further stroke/transient ischemic attack, other cardiovascular events and cognitive decline, and their predictors. DISCUSSION: Improving the knowledge on the frequency and determinants of these lesions in our setting might help in the future to optimize treatments or establish new preventive strategies to minimize clinical and socioeconomic consequences of stroke and cognitive decline.

The effectiveness of a health promotion with group intervention by clinical trial. Study protocol.

BACKGROUND: The promotion of health and the interventions in community health continue to be one of the pending subjects of our health system. The most prevalent health problems (cardiovascular diseases, cancer, diabetes...) are for the most part related to life habits. We propose a holistic and integral approach as the best option for tackling behavior and its determinants. The research team has elaborated the necessary educational material to realize group teaching, which we call "Health Workshops". The goal of the present study is to evaluate the effectiveness of these Health Workshops in the following terms: Health Related Quality of Life (HRQOL), incorporate and maintain a balanced diet, do physical activity regularly, maintain risk factors such as tension, weight, cholesterol within normal limits and diminish cardiovascular risk. METHODS/DESIGN: Controlled and random clinical testing, comparing a group of persons who have participated in the Health Workshops with a control group of similar characteristics who have not participated in the Health Workshops.Field of study: the research is being done in Health Centers of the city of Barcelona, Spain. POPULATION STUDIED: The group is composed of 108 persons that are actually doing the Health Workshops, and 108 that are not and form the control group. They are assigned at random to one group or the other. DATA ANALYSIS: With Student's t-distribution test to compare the differences between numerical variables or their non parametric equivalent if the variable does not comply with the criteria of normality. (Kolmogorov-Smirnof test). Chi-square test to compare the differences between categorical variables and the Logistic Regression Model to analyze different meaningful variables by dichotomous analysis related to the intervention. DISCUSSION: The Health Workshop proposed in the present study constitutes an innovative approach in health promotion, placing the emphasis on the person's self responsibility for his/her own health.The rhythm of a weekly session during 8 weeks with recommended activities to put into practice, as well as the support of the group is an opportunity to incorporate healthy habits and make a commitment to self-care. The sheets handed out are a Health Manual that can always be consulted after the workshop ends. TRIAL REGISTRATION: Clinical Trials.gov Identifier: NCT01440738.

Risk of Parkinson's disease in a gout Mediterranean population: A case-control study.

INTRODUCTION: High levels of serum urate has been associated to a neuroprotective effect in Parkinson's disease (PD) as an antioxidant agent. However, the relation between gout and PD remains contradictory. OBJECTIVE: To study if the neuroprotective effect of serum urate is maintained in patients with gout in a large urban Mediterranean population. METHODS: Primary care based matched case-control study, carried out using an electronic health record database from the public primary care health system of Barcelona. The database contains anonymous data from 1,520,934 patients. All patients, over 40 years old, with a new diagnostic record of PD, or a new prescription of dopaminergic drugs were included (incident cases). We randomly selected four controls for each case, matched by gender and age, with the frequency matching approach. Retrospective data of PD risk factors were also collected for each individual. A multivariate logistic regression model was used to evaluate the association of gout and PD, adjusted by the presence of other risk factors. RESULTS: A new PD diagnosis was found in 17,629 individuals (incident diagnosis rate of 2.2 per 1000 individuals). Multivariate logistic regression model showed for gout: aOR=0.83 (0.76-0.91). When stratified by age, aOR for those under 75years was 0.99 (0.85-1.16) and 75 or over OR=0.77 (0.70-0.86). Dyslipidemia, hypertension and diabetes mellitus were associated with an increased risk of PD. Tobacco consumption was protective. CONCLUSION: Our study, the first one made in a Mediterranean population, shows a PD protective effect of gout in both men and women over 75years old.

Integrated primary and geriatric care for frail older adults in the community: Implementation of a complex intervention into real life.

BACKGROUND: Frailty is highly prevalent in older persons and associated with negative health-related events and costs. Despite successful clinical trials, translation of evidence into implementation of dedicated programs has been scarce. This is probably due to funding limitations and lack of generalizability of rigid schemes adopted in controlled studies. We propose a guidance to implement complex interventions against frailty in the community, and describe the design and early findings of the +AGIL Barcelona program. METHODS: A guidance "decalogue" resulted from an experts' panel prioritization of recommendations by international independent bodies. On this basis, we reorganized existing primary care, geriatrics and community-based resources to implement our program, which includes a screening, a multi-component intervention modulated on the comprehensive geriatric assessment and integrated follow-up plus continuity through community-based resources. The pre-post impact of the program on physical function, as well as on clinical endpoints, person-center outcomes and costs will be assessed. RESULTS: Integrated care, multi-component, person-centered strategies to empower the final users in a flexible and adaptable way should be promoted after raising awareness and potentially convey long term investments. In 22 months, 185 participants (mean age ±â€¯SD = 81.6 ±â€¯5.7 years, 72% women) joined the program. Although independent in the activities of daily living, participants showed clear indicators of frailty (Short Physical Performance Battery = 7.1 ±â€¯2.5; gait speed = 0.69 ±â€¯0.2 m/s). CONCLUSIONS: +AGIL Barcelona may represent a unique model to manage frailty in older community-dwellers, translating evidence into pragmatic clinical practice. Further research will clarify the effects of this intervention.

Effects of a Primary Care-Based Multifactorial Intervention on Physical and Cognitive Function in Frail, Elderly Individuals: A Randomized Controlled Trial.

Background: Detecting and managing frailty at early stages can prevent disability and other adverse outcomes. The study aim was to evaluate whether a multifactorial intervention program could modify physical and cognitive frailty parameters in elderly individuals. Methods: We conducted a multicenter, randomized, single-blind, parallel-group trial in community-living prefrail/frail elderly individuals in Barcelona. A total of 352 patients, aged ≥65 years old with positive frailty screening, was randomized into two groups to receive a 12-week multidisciplinary intervention or usual care, with concealed allocation. The intervention consisted of: exercise training, intake of hyperproteic nutritional shakes, memory training, and medication review. Main outcome assessments with multivariate analysis were conducted at 3 and 18 months. Results: A total of 347 participants (98.6%) completed the study, mean age 77.3 years, 89 prefrail subjects (25.3%), and 75.3% female (n = 265). Eighteen-month assessments were performed in 76% of the sample. After 3 and 18 months, adjusted means difference between-groups showed significant improvements for the intervention group in all comparisons: Short Physical Performance Battery score improved 1.58 and 1.36 points (p < .001), handgrip strength 2.84 and 2.49 kg (p < .001), functional reach 4.3 and 4.52 cm (p < .001), and number of prescriptions decreased 1.39 and 1.09 (p < .001), respectively. Neurocognitive battery also showed significant improvements across all dimensions at 3 and 18 months. Conclusions: A physical, nutritional, neurocognitive, and pharmacological multifaceted intervention was effective in reversing frailty measures both at short-term and 18 months. Lasting benefits of a multi-intervention program among frail elderly individuals encourage its prioritization.

Gender differences in health-related quality of life among the elderly: the role of objective functional capacity and chronic conditions.

Although worse Health-Related Quality of Life (HRQL) among women has been widely described, it remains unclear whether this is due to differential reporting patterns, or whether there is a real difference in health status. The objective of this study was to evaluate to what extent gender differences in HRQL among the elderly might be explained by differences in performance-based functional capacity and chronic conditions, using the conceptual model of health outcomes as proposed by Wilson and Cleary. Data are from a cross-sectional home survey of 872 surviving individuals from an elderly cohort representative of Barcelona's general population. Complete valid data for these analyses were obtained from 62% of the subjects (n = 544). The evaluation included the Nottingham Health Profile (NHP), a generic measure of HRQL; three performance-based functional capacity tests (balance, chair-stand, and walking tests); and a standardized list of self-reported chronic conditions. A series of multiple linear regression models were built with the total NHP score as the dependent variable, with gender, socio-demographic information, performance-based functional capacity and chronic conditions included sequentially, as independent variables. Women (65.4%) showed worse results than men on HRQL (mean of NHP total score 28.3 vs 16.7, p < 0.001) and functional capacity (mean of summary score 7.1 vs 8.3, p < 0.001). Functional capacity, arthritis, back pain, diabetes, and depression were significantly associated to the NHP total score in the final regression model, which explained 42% of the variance. Raw differences by gender in the total NHP score were 11.5 points (p < 0.001), but decreased to a non-significant 3.2 points (p = 0.18) after adjusting for all the other variables. In conclusion, our data suggest that worse reported HRQL in elderly women is mainly due to a higher prevalence of disability and chronic conditions.

Dementia Rating Scale-2 normative data for middle-and older-aged Castilian speaking Spaniards.

OBJECTIVES: The Dementia Rating Scale-2 (DRS-2) is frequently used as a dementia screening tool in clinical and research settings in Spain. The present study describes DRS-2 Total and subscale scores in community-dwelling Spaniards, aged 50-71, and provides normative data for its use in Castilian Spanish-speaking individuals. METHODS: The sample consisted of 798 individuals who participated in an observational study on essential hypertension. Mean age was 62.8 years (SD = 5.4), mean education was 8.6 years (SD = 3.4) with 47.9% females. Almost all of them were receiving blood pressure-lowering drugs (93%) and most of them had fairly well-managed blood pressure control (M systolic/diastolic blood pressure = 142.3/77.0 ± 16.0/9.2 mm Hg). We applied a previously described method of data normalization from the Mayo's Older Americans Normative Studies to obtain the Castilian Spanish DRS-2 norms. RESULTS: Worse performance on Total and subscale scores was associated with older age (p < .05) and fewer years of education (p < .001). Women obtained lower raw Total scores than men (131.68 ± 7.2 vs. 133.10 ± 6.90, p < .005), but had fewer years of education (7.96 ± 3.33 vs. 9.17 ± 3.45, p < .001). This gender difference disappeared after correcting for age and years of education. Total and subscale scores are presented adjusted by age, and normative data are shown for Total scores adjusted by age and years of education. CONCLUSIONS: These norms are useful for studying cognitive status and cognitive decline in research and clinical settings in Castilian Spanish-speaking populations.

Risk prediction in the community: A systematic review of case-finding instruments that predict adverse healthcare outcomes in community-dwelling older adults.

Few case-finding instruments are available to community healthcare professionals. This review aims to identify short, valid instruments that detect older community-dwellers risk of four adverse outcomes: hospitalisation, functional-decline, institutionalisation and death. Data sources included PubMed and the Cochrane library. Data on outcome measures, patient and instrument characteristics, and trial quality (using the Quality In Prognosis Studies [QUIPS] tool), were double-extracted for derivation-validation studies in community-dwelling older adults (>50 years). Forty-six publications, representing 23 unique instruments, were included. Only five were externally validated. Mean patient age range was 64.2-84.6 years. Most instruments n=18, (78%) were derived in North America from secondary analysis of survey data. The majority n=12, (52%), measured more than one outcome with hospitalisation and the Probability of Repeated Admission score the most studied outcome and instrument respectively. All instruments incorporated multiple predictors. Activities of daily living n=16, (70%), was included most often. Accuracy varied according to instruments and outcomes; area under the curve of 0.60-0.73 for hospitalisation, 0.63-0.78 for functional decline, 0.70-0.74 for institutionalisation and 0.56-0.82 for death. The QUIPS tool showed that 5/23 instruments had low potential for bias across all domains. This review highlights the present need to develop short, reliable, valid instruments to case-find older adults at risk in the community.

Which Part of a Short, Global Risk Assessment, the Risk Instrument for Screening in the Community, Predicts Adverse Healthcare Outcomes?

The Risk Instrument for Screening in the Community (RISC) is a short, global risk assessment to identify community-dwelling older adults' one-year risk of institutionalisation, hospitalisation, and death. We investigated the contribution that the three components of the RISC (concern, its severity, and the ability of the caregiver network to manage concern) make to the accuracy of the instrument, across its three domains (mental state, activities of daily living (ADL), and medical state), by comparing their accuracy to other assessment instruments in the prospective Community Assessment of Risk and Treatment Strategies study. RISC scores were available for 782 patients. Across all three domains each subtest more accurately predicted institutionalisation compared to hospitalisation or death. The caregiver network's ability to manage ADL more accurately predicted institutionalisation (AUC 0.68) compared to hospitalisation (AUC 0.57, P = 0.01) or death (AUC 0.59, P = 0.046), comparing favourably with the Barthel Index (AUC 0.67). The severity of ADL (AUC 0.63), medical state (AUC 0.62), Clinical Frailty Scale (AUC 0.67), and Charlson Comorbidity Index (AUC 0.66) scores had similar accuracy in predicting mortality. Risk of hospitalisation was difficult to predict. Thus, each component, and particularly the caregiver network, had reasonable accuracy in predicting institutionalisation. No subtest or assessment instrument accurately predicted risk of hospitalisation.

Models for preclinical studies in aging-related disorders: One is not for all.

Preclinical studies are essentially based on animal models of a particular disease. The primary purpose of preclinical efficacy studies is to support generalization of treatment-effect relationships to human subjects. Researchers aim to demonstrate a causal relationship between an investigational agent and a disease-related phenotype in such models. Numerous factors can muddle reliable inferences about such cause-effect relationships, including biased outcome assessment due to experimenter expectations. For instance, responses in a particular inbred mouse might be specific to the strain, limiting generalizability. Selecting well-justified and widely acknowledged model systems represents the best start in designing preclinical studies, especially to overcome any potential bias related to the model itself. This is particularly true in the research that focuses on aging, which carries unique challenges, mainly attributable to the fact that our already long lifespan makes designing experiments that use people as subjects extremely difficult and largely impractical.

Prevalence and associated factors of silent brain infarcts in a Mediterranean cohort of hypertensives.

Silent brain infarcts (SBIs) are detected by neuroimaging in approximately 20% of elderly patients in population-based studies. Limited evidence is available for hypertensives at low cardiovascular risk countries. Investigating Silent Strokes in Hypertensives: a Magnetic Resonance Imaging Study (ISSYS) is aimed to assess the prevalence and risk factors of SBIs in a hypertensive Mediterranean population. This is a cohort study in randomly selected hypertensives, aged 50 to 70 years old, and free of clinical stroke and dementia. On baseline, all participants underwent a brain magnetic resonance imaging to assess prevalence and location of silent infarcts, and data on vascular risk factors, comorbidities, and the presence of subclinical cardiorenal damage (left ventricular hypertrophy and microalbuminuria) were collected. Multivariate analyses were performed to determine SBIs associated factors. A total of 976 patients (49.4% men, mean age 64 years) were enrolled, and 163 SBIs were detected in 99 participants (prevalence 10.1%; 95% CI, 8.4%-12.2%), most of them (64.4%) located in the basal ganglia and subcortical white matter. After adjustment, besides age and sex, microalbuminuria and increasing total cardiovascular risk (assessed by the Framingham-calibrated for Spanish population risk function) were independently associated with SBIs. Male sex increased the odds of having SBIs in 2.5 as compared with females. Our results highlight the importance of considering both global risk assessment and sex differences in hypertension and may be useful to design future preventive interventions of stroke and dementia.

[Primary care asthma treatment: Are we following international consensus (GINA 2002)?]. / Tratamiento del asma en atención primaria: 'lo hacemos según el consenso internacional (GINA 2002)?

OBJECTIVE: To check whether treatment of asthma patients at our centre coincides with international criteria (GINA 2002). DESIGN: Transversal, descriptive study. SETTING: Urban primary care team. PARTICIPANTS: Asthma patients over 14 years old. MAIN MEASUREMENTS: Review of clinical histories (CH) and analysis of the last prescription between November 2002 and May 2003. RESULTS: We reviewed 436 CH, of which 395 made up the study group. 71.4% (SD, 66.9-75.8) were women. Average age was 51.4 (SD, 49.2-53.6). Classification of asthma as function of gravity was: intermittent (IA): 30% (25.7-34.3); light persistent (LPA): 24.8% (20.7-28.8); moderate persistent (MPA): 30.7% (26.4-35.1); serious persistent (SPA): 5.05% (3.19-7.54). Unclassified: 9.4% (6.83-12.5). Correct treatment: IA, 69.5% (61.6-77.4); LPA, 22.2% (14.4-30.1); MPA, 46.2% (7.8-54.7); SPA, 72.7% (49.8-89.3). The most common cause of incorrect treatment in all kinds of asthma was the use of international criteria (IC) at inadequate doses: IA, 47.5% (31.5-63.9); LPA, 73.8% (63.1-82.8); MPA, 38.9% (27.6-51.1); SPA, 33.3% (4.3-77.7). The scant use of B2CD.AD was noticeable: IA, 47.5% (31.5-63.9); LPA, 85.7% (76.4-92.4); MPA, 86.7% (74.3-92.1); SPA, 66.7% (22.3-95.7). The most commonly used active principles were salbutamol, salmeterol, budesonide, and montelukast. On overall measurement of good treatment, we found that 48.9% (n = 193) of patients had a correct prescription. CONCLUSIONS: In primary care, light forms of asthma are most commonly monitored. We found low concordance with the GINA 2002 directives. IC are widely used, but often at incorrect doses. We insist on the importance of classifying asthma according to its gravity in order to prescribe the right treatment.