Carotid angioplasty in diabetic patients carriers of critical carotid stenosis. Experience in a hospital in Mexico; results and six-month follow-up / Angioplastia carotídea en pacientes diabéticos portadores de estenosis carotídea crítica. Experiencia en un hospital en México; resultados y seguimiento a seis meses

Abstract: Objective: To evaluate the impact of diabetic status on outcome of patients undergoing carotid artery stenting (CAS). Background: Diabetes has been demonstrated to be a strong predictor of adverse outcome in patients undergoing coronary revascularization. Its significance in predicting outcome of patients undergoing carotid interventions has not been ascertained. Methods: This research is an observational, retrospective, comparative, descriptive study. Results: 279/341 patients/lesions were evaluated for carotid stenosis undergoing stenting. Non-diabetics versus diabetics were compared. Of the diabetic group, 59.5% were men, mostly hypertensive and with hypercholesterolemia. More than 40% of both groups had a prior percutaneous coronary intervention (PCI), 68.2% were asymptomatic and a half was high risk, greater comorbidity in the diabetic group with an EuroSCORE > 3, 46 vs 21.4% p = 0.000. No statistically significant difference was found in terms of major adverse cardiovascular events (MACE) at 30 days and accumulated six months in the non-diabetic group (non-DM) versus the diabetic (DM): nine patients (5.4%) versus eight (4.8%), p = 0.756 OR, 95% CI 0.857 (0.322-2.27) and 14 (8.3%) versus nine (5.3%), p = 0.249 OR, 95% CI 0.604 (0254-1435), respectively. Diabetic patients treated with carotid stent who underwent cardiovascular surgery showed a higher intrahospitalary mortality (4.6 vs 0.6%, p = 0.02). There was a higher rate of restenosis (1.9 vs 0%, p = 0.077) in non-diabetic patients. An increased incidence of TIA (transient ischemic attack) was observed in diabetic patients (8.7 vs 3.6%, p = 0.05). Conclusion: Diabetics undergoing CAS are more likely to have associated co-morbidities. However despite this handicap, their short term outcome after CAS is similar to that of non diabetics. Endovascular treatment of carotid stenosis may be a good alternative to surgical treatment.(AU)

Resumen: Objetivo: Evaluar el impacto del estado diabético sobre el resultado de los pacientes que se someten a la colocación de stents en la arteria carótida (CAS). Antecedentes: Se ha demostrado que la diabetes es un fuerte predictor de resultados adversos en pacientes sometidos a revascularización coronaria. No se ha determinado su importancia para predecir el resultado de los pacientes que se someten a intervenciones carotídeas. Métodos: Esta investigación es un estudio observacional, retrospectivo, comparativo y descriptivo. Resultados: Se evaluaron 279/341 pacientes/lesiones para la estenosis carotídea sometida a colocación de stents. Se compararon los no diabéticos versus los diabéticos. Del grupo diabético, 59.5% fueron hombres, la mayoría hipertensos y con hipercolesterolemia. Más del 40% de ambos grupos tuvieron una intervención coronaria percutánea (ICP) previa, el 68.2% fueron asintomáticos y la mitad de ellos de alto riesgo, mayor comorbilidad en el grupo diabético con un EuroSCORE > 3, 46 vs 21.4% p = 0.000. No se encontraron diferencias estadísticamente significativas en cuanto a los eventos cardiovasculares adversos mayores (MACE) a los 30 días y acumulados a los seis meses en el grupo no diabético (no DM) versus diabético (DM): nueve pacientes (5.4%) versus ocho (4.8%), p = 0.756 OR; IC 95%: 0.857 (0.322-2.27) y 14 (8.3%) versus nueve (5.3%), p = 0.249 OR; IC 95%: 0.604 (0254-1435), respectivamente. Los pacientes diabéticos tratados con endoprótesis carotídea sometidos a cirugía cardiovascular mostraron una mortalidad intrahospitalaria mayor (4.6 vs 0.6%, p = 0.02). Hubo una mayor tasa de reestenosis (1.9 vs 0%, p = 0.077) en pacientes no diabéticos. Se observó una mayor incidencia de AIT (ataque isquémico transitorio) en pacientes diabéticos (8.7 vs 3.6%, p = 0.05). Conclusión: Los diabéticos que se someten a la CAS son más propensos a tener comorbilidades asociadas. Sin embargo, a pesar de esta desventaja, su resultado a corto plazo después del CAS es similar al de los no diabéticos. El tratamiento endovascular de la estenosis carotídea puede ser una buena alternativa al tratamiento quirúrgico.(AU)

Impact of gender on short- and long-term morbidity and mortality after carotid stent angioplasty in a third-level hospital in Mexico / Impacto del género en la morbilidad y la mortalidad a corto y largo plazo después de la angioplastia carotídea en un hospital de tercer nivel en México

Objective: To describe gender differences in adult patients undergoing carotid angioplasty and its relation to morbidity and mortality at 30 days and 6 months. Material and methods: An observational study from the WHO database comprehending all patients underwent carotid angioplasty in the Department of Hemodynamics Coronary and Peripheral Artery Intervention, Cardiology Hospital 34, IMSS, Monterrey, was conducted in order to ASSESS the differences between genders and their relationship to primary end points within 30 days after the intervention, which were defined as the presence of death related to the procedure, major cerebrovascular event, or myocardial infarction. Results: 279/341 patients/lesions were included for analysis. Within baseline characteristics, women had significantly higher prevalence of type 2 diabetes mellitus (61.4 versus 45.4%, p = 0.006), prior renal angioplasty (21.9 versus 11.5%, p = 0.015), right carotid condition (65.8 versus 53.7%, p = 0.03), prior stroke (20.2 versus 34.4%, p = 0.007) and higher EuroSCORE (3.13 ± 1.72 versus 2.4 ± 1.26, p < 0.001). The masculine gender was only associated with smoking (69.2 versus 35.1%, p < 0.001). In univariate analysis, the female gender was associated with major fatal and non-fatal stroke (4.4 versus 0.9%, p = 0.031). According to symptomatology and subgroups, we found a significant association between women with asymptomatic Increased risk of major cardiovascular events when compared to asymptomatic diseases (9.5 versus 1.4%, p = 0.004). Conclusions: In our center, women who underwent carotid angioplasty present more comorbidities and higher risk in comparison with the male gender. However, these differences do not impact on most adverse cardiovascular events (MACVE) at 30 days. In the subgroup of asymptomatic patients, the risk of major cardiovascular events is significantly higher in the female gender.

Objetivo: Describir las diferencias de género en pacientes adultos sometidos a angioplastia carotídea y su relación con la morbimortalidad a 30 días y seis meses. Material y métodos: Estudio observacional de la base de datos que comprende los casos sometidos a angioplastia carotídea en el Departamento de Hemodinámica e Intervención Coronaria Periférica del Hospital de Cardiología No. 34, IMSS, Monterrey. Se analizaron las diferencias entre géneros y su relación con los puntos finales primarios dentro de los 30 días posteriores a la intervención, los cuales fueron definidos como la presencia de muerte relacionada con procedimiento, evento vascular cerebral o infarto agudo de miocardio. Resultados: Se incluyeron 279/341 pacientes/lesiones. Dentro de las características basales se encontró que las mujeres presentaban una mayor prevalencia de diabetes mellitus tipo 2 (61.4 versus 45.4%, p = 0.006), angioplastia renal previa (21.9 versus 11.5%, p = 0.015), afección de carótida derecha (65.8 versus 53.7%, p = 0.03), evento vascular cerebral (EVC) previo (34.4 versus 20.2%, p = 0.007) y EuroSCORE más alto (3.13 ± 1.72 versus 2.4 ± 1.26, p < 0.001). El género masculino sólo se asoció con mayor tabaquismo (69.2 versus 35.1%, p < 0.001). En el análisis univariado, el género femenino se asoció significativamente con EVC (fatal y no fatal) (4.4 versus 0.9%, p = 0.031). Al dividir en subgrupos de acuerdo con la sintomatología, se encontró una fuerte asociación entre las mujeres asintomáticas con más elevado riesgo de eventos cardiovasculares mayores en comparación con el grupo masculino asintomático (9.5 versus 1.4%, p = 0.004). Conclusiones: En nuestro centro, las mujeres sometidas a angioplastia carotídea presentan más comorbilidades y se encuentran en un riesgo mayor en comparación con el género masculino. Sin embargo, estas diferencias no impactan en la incidencia de eventos adversos cardiovasculares mayores (EACVM) a 30 días. En el subgrupo de pacientes asintomáticos el riesgo de eventos cardiovasculares mayores es significativamente más alto en el género femenino.

Borderline intellectual functioning: consensus and good practice guidelines.

INTRODUCTION: The Borderline Intellectual Functioning (BIF) is conceptualized as the frontier that delimits "normal" intellectual functioning from intellectual disability (IQ 71-85). In spite of its magnitude, its prevalence cannot be quantified and its diagnosis has not yet been defined. OBJECTIVES: To elaborate a conceptual framework and to establish consensus guidelines. METHOD: A mixed qualitative methodology, including frame analysis and nominal groups techniques, was used. The literature was extensively reviewed in evidence based medical databases, scientific publications, and the grey literature. This information was studied and a framing document was prepared. RESULTS: Scientific publications covering BIF are scarce. The term that yields a bigger number of results is "Borderline Intelligence". The Working Group detected a number of areas in which consensus was needed and wrote a consensus document covering the conclusions of the experts and the framing document. CONCLUSIONS: It is a priority to reach an international consensus about the BIF construct and its operative criteria, as well as to develop specific tools for screening and diagnosis. It is also necessary to define criteria that enable its incidence and prevalence. To know what interventions are the most efficient, and what are the needs of this population, is vital to implement an integral model of care centred on the individual.

From treatment adherence to advanced shared decision making: new professional strategies and attitudes in mental health care.

Treatment adherence is related to "self-regulation" of prescribed drugs. Patients organise their drug intake around their own priorities, which may be very different from prescribers' priorities, since most of the patients value their personal concerns and/or their social roles more than the benefits of a prescribed treatment. A gap exists between patients' and professionals' views. This gap is mainly related to patients' health beliefs and physicians' attitudes. A number of strategies can help professionals overcome gaps between their treatment options for depression and schizophrenia and the "real world" alternatives shared by the lay public, patients, their relatives, and political stakeholders. These strategies include integrated care and recovery, family engagement, and the development of a mutualistic patient/physician relationship with the adoption of advance directives and appropriate guidelines that incorporate the patient's choices. The effective implementation of these combined strategies within the person-centred care model empowers patients to collaborate with mental health professionals and their families in making complex health care choices. Barriers to this process include factors affecting the control, contact and communication facets of the patient/physician relationship.

The role of ethical banks in health care policy and financing in Spain.

OBJECTIVES: Ethical, social, or civic banks, constitute a secondary source of financing, which is particularly relevant in Southern and Central Europe. However there is no information on the scientific literature on this source of health care financing. METHOD: We review the characteristics of saving banks in Spain and illustrate the contribution of one institution "Obra Social Caixa Catalunya" (OS-CC) to the health care financing in Spain. RESULTS: Savings bank health care funding was equivalent to 3 percent of the public health expenditure for 2008. The programs developed by OS-CC illustrate the complex role of savings banks in health financing, provision, training, and policy, particularly in the fields of integrated care and innovation. CONCLUSIONS: Financing is a basic tool for health policy. However, the role of social banking in the development of integrated care networks has been largely disregarded, in spite of its significant contribution to complementary health and social care in Southern and Central Europe. Decision makers both at the public health agencies and at the social welfare departments of savings banks should become aware of the policy implications and impact of savings bank activities in the long-term care system.

Development and spatial representation of synthetic indexes of outpatient mental health care in Andalusia (Spain).

INTRODUCTION: There is a need to develop composite indicators to monitor mental health care in countries such as Spain, where there is wide variability of care systems in 17 different regions. The aim of this study is to generate and to test the usability of synthetic indexes in Andalusia (Southern Spain). METHOD: Seven mental health indicators were selected by expert opinion from a previous list of simple indicators used to compare mental health care systems across Spain (Psicost-74). A Geographical Information Systems (GIS) was used to delineate 71 sectors based on the catchment areas of the mental health centers in Andalusia. Synthetic indexes were obtained through linear combinations of simple indicators via Principal Components Analysis (PCA), using activity data from the Mental Health Information System of Andalusia (SISMA). Maps of these indexes were drawn for 71 catchment areas. RESULTS: Two synthetic indexes were obtained and showed high consistency in the PCA. The Care Load Index (component 1) related to population size and total outpatient care provided within the area. The Case Load Index (component 2) related to assisted morbidity in relation to the population size. The care load index was higher in populated urban areas, whereas the case load was higher in rural areas. DISCUSSION: Care and case load indexes show a different pattern in urban and rural areas. This may be related to a different underlying model of care related to the degree of urbanisation. Geographical Information Systems (GIS) improved recognition and assessment of the spatial phenomena related to the mental health care system, and support policy decision making process in mental health.