Profile of the Patient Who Refuses to Participate in the Expert Patients Program.

The Expert Patients Program (EPP), an educational intervention for chronic diseases aimed at nonprofessionals, has high nonparticipation and dropout rates. We used quantitative and qualitative methods to identify the prevalence of and reasons for nonparticipation in 100 patients with acute myocardial infarction and 69 with stroke. We confirmed a high prevalence of refusal, identifying three groups based on degree of participation: patients who refused to attend (51%), patients who attended and then dropped out (10%), and patients who attended (39%). Patients who refused to participate or dropped out were mainly women and former/current smokers with a better-than-average physical condition. In addition, they were invited to participate in the EPP long after their cardiovascular event. We found that the degree of participation depended upon the patient's individual and social context and the professional profile of the recruiter. Therefore, tailored strategic interventions should be designed for each type of participation.

Dose-response association of physical activity with acute myocardial infarction: do amount and intensity matter?

OBJECTIVE: The aims of this study were to analyze the dose-response association between leisure time physical activity (PA) practice and myocardial infarction (MI), considering not only the total amount but also the amount of PA at different levels of intensity, and to determine whether these associations were modified by age. METHOD: In a population-based age- and sex-matched case-control study, all first acute MI patients aged 25 to 74 years were prospectively registered in four Spanish hospitals between 2002 and 2004. Controls were randomly selected from population-based samples recruited during the same period of time. The Minnesota PA questionnaire was administered to assess total energy expenditure in PA and in light-, moderate-, and high-intensity PA. RESULTS: Finally, 1339 cases and 1339 controls were included. The association between PA and MI likelihood was non-linear, with significantly lower MI odds at low practice levels (≥ 500 MET·min/week), lowest odds around 1500 MET·min/week, and a plateau thereafter. Light- (in subjects older than 64 years), moderate-, and high-intensity PA produced similar benefits. CONCLUSION: Most of the population could reduce their likelihood of MI by engaging in PA at a moderate level of intensity or, in individuals older than 64 years, at a light level of intensity.

The Psychological Impact on Relatives of Critically Ill Patients: The Influence of Visiting Hours.

OBJECTIVES: To identify the psychologic impact of admission to the ICU on the relatives of critically ill patients, the influence of coping, and the factors involved. DESIGN: We performed a cohort study with repeated measures evaluation using descriptive and comparative bivariate and multivariate analyses. SETTINGS: An adult ICU of a third-level complexity hospital. PATIENTS: The family members of patients (maximum of three per patient) staying longer than 3 days. INTERVENTIONS: Not applicable. MEASUREMENTS AND MAIN RESULTS: Psychologic impact was assessed using two subgroups of psychologic distress: anxiety (by the State-Trait Anxiety Inventory) and depression (by the Beck Depression Inventory). Satisfaction and coping were assessed by the Critical Care Family Needs Inventory and the Brief Coping Orientations to Problems Experienced Inventory, respectively. We included 104 family members; psychologic distress was high at admission (72% had anxiety, 45% had depression, and 42% had both) but decreased at discharge (34% had anxiety, 23% had depression, and 21% had both). The risk factors related to psychologic impact were severity (anxiety: Acute Physiology and Chronic Health Evaluation score ≥ 18 points: relative risk [RR], 2; 95% CI, 1-4; p = 0.03), invasive mechanical ventilation (anxiety: RR, 1.9; 95% CI, 1-3.6; p = 0.04), recent psychotropic medication use by relatives (depression: RR, 1.6; 95% CI, 1-2.9; p = 0.05), a restrictive visiting policy (anxiety: RR, 5.7; 95% CI, 2-10.4; p = 0.002), no emotion-focused coping strategy (anxiety: strategy < 11 points, RR, 6.1; 95% CI, 1.2-52; p = 0.01), and functional impairment (depression: Barthel index ≤ 60 points, RR, 7.4; 95% CI, 1.7-26.3; p = 0.01). CONCLUSIONS: The psychologic impact from admission to the ICU on family members is high. Visiting hours is the main modifiable factor to reduce the impact.

High-flow nasal oxygen reduces endotracheal intubation: a randomized clinical trial.

BACKGROUND: The benefits of high-flow nasal cannula (HFNC) as primary intervention in patients with acute hypoxemic respiratory failure (AHRF) are still a matter in debate. Our objective was to compare HFNC therapy versus conventional oxygen therapy (COT) in the prevention of endotracheal intubation in this group of patients. METHODS: An open-label, controlled and single-centre clinical trial was conducted in patients with severe AHRF, defined by a PaO2/FIO2 ratio ⩽200, to compare HFNC with a control group (CG) treated by COT delivered through a face mask, with the need to perform intubation as the primary outcome. The secondary outcomes included tolerance of the HFNC device and to look for the predictive factors for intubation in these patients. RESULTS: A total of 46 patients were included (22 in the COT group and 24 in the HFNC group) 48% of whom needed intubation: 63% in the COT group and 33% in the HFNC group, with significant differences both in intention to treat [χ2 = 4.2; p = 0.04, relative risk (RR) = 0.5; confidence interval (CI) 95%: 0.3-1.0] and also in treatment analysis (χ2 = 4.7; p = 0.03; RR = 0.5; IC 95%: 0.3-0.9) We obtained a number needed to treat (NNT) = 3 patients treated to avoid an intubation. Intubation occurred significantly later in the HFNC group. Estimated PaO2/FIO2, respiratory rate and dyspnea were significantly better in the HFNC group. Patients treated with HFNC who required intubation presented significant worsening after the first 8 h, as compared with non-intubated HFNC group patients. Mortality was 22% with no differences. The HFNC group patients were hospitalized for almost half of the time in the intensive care unit (ICU) and in the ward, with significantly less hospital length of stay. A total of 14 patients in the HFNC group (58%) complained of excessive heat and 17% of noise; 3 patients did not tolerate HFNC. CONCLUSION: Patients with severe acute hypoxemic respiratory failure who tolerate HFNC present a significantly lower need for endotracheal intubation compared with conventional oxygen therapy. CLINICAL TRIAL REGISTER: EUDRA CT number: 2012-001671-36The reviews of this paper are available via the supplemental material section.

Potential EEG biomarkers of sedation doses in intensive care patients unveiled by using a machine learning approach.

OBJECTIVE: Sedation of neurocritically ill patients is one of the most challenging situation in ICUs. Quantitative knowledge on the sedation effect on brain activity in that complex scenario could help to uncover new markers for sedation assessment. Hence, we aim to evaluate the existence of changes of diverse EEG-derived measures in deeply-sedated (RASS-Richmond agitation-sedation scale -4 and -5) neurocritically ill patients, and also whether sedation doses are related with those eventual changes. APPROACH: We performed an observational prospective cohort study in the intensive care unit of the Hospital de la Princesa. Twenty-six adult patients suffered from traumatic brain injury and subarachnoid hemorrhage were included in the present study. Long-term continuous electroencephalographic (EEG) recordings (2141 h) and hourly annotated information were used to determine the relationship between intravenous sedation infusion doses and network and spectral EEG measures. To do that, two different strategies were followed: assessment of the statistical dependence between both variables using the Spearman correlation rank and by performing an automatic classification method based on a machine learning algorithm. MAIN RESULTS: More than 60% of patients presented a correlation greater than 0.5 in at least one of the calculated EEG measures with the sedation dose. The automatic classification method presented an accuracy of 84.3% in discriminating between different sedation doses. In both cases the nodes' degree was the most relevant measurement. SIGNIFICANCE: The results presented here provide evidences of brain activity changes during deep sedation linked to sedation doses. Particularly, the capability of network EEG-derived measures in discriminating between different sedation doses could be the framework for the development of accurate methods for sedation levels assessment.

Evaluation of diffuse large B-cell lymphoma patients with 64-slice multidetector computed tomography versus 18FDG positron emission tomography/computed tomography in initial staging and restaging after treatment. / Evaluación de la estadificación inicial y la respuesta final al tratamiento de los pacientes con linfoma difuso de célula grande B con la tomografía computarizada de 64 detectores frente a la 18FDG tomografía por emisión de positrones/tomografía computarizada.

BACKGROUND AND OBJECTIVES: To prospectively compare the accuracy in initial staging and end-of-treatment restaging of diffuse large B-cell lymphoma (DLBCL) between 64-slice multidetector computed tomography (64MDCT) and 18FDG positron emission tomography/computed tomography (18FGD PET/CT) with intravenous contrast injection. MATERIAL AND METHODS: Randomised and blind controlled clinical multicentric trial that included biopsy-proven DLBCL patients. Seventy-two patients from five different hospitals in the region of Madrid, Spain, were enrolled in the study between January 2012 and June 2015. Thirty-six were randomly allocated to 18FDG PET/TC and the other 36 to 64MDCT for initial staging and end-of-treatment restaging. A nuclear medicine physician and a radiologist independently analysed 18FDG PET/TC images and reached an agreement post-hoc. 64MDCT images were separately evaluated by a different radiologist. Every set of images was compared to the reference standard that included clinical data, complementary tests and follow-up. The study was approved by participating centres' ethics committees and written informed consent was obtained from all the participants. RESULTS: A good agreement was observed between both diagnostic techniques and the reference standard in initial staging [18FDG PET/CT (k=0.5) and 64MDCT (k=0.6)], although only the 18FDG PET/TC showed a good agreement with the reference standard for the end-of-treatment restaging (k=0.7). CONCLUSION: In DLBCL, both 18FDG PET/TC and 64MDCT have shown good agreement with the reference standard in initial staging. Nevertheless, 18FDG PET/CT has shown to be superior to 64MDCT in end-of-treatment response assessment.

Identifying causal relationships between EEG activity and intracranial pressure changes in neurocritical care patients.

OBJECTIVE: To explore and assess the relationship between electroencephalography (EEG) activity and intracranial pressure (ICP) in patients suffering from traumatic brain injury (TBI) and subarachnoid hemorrhage (SAH) during their stay in an intensive care unit. APPROACH: We performed an observational prospective cohort study of adult patients suffering from TBI or SAH. Continuous EEG-ECG was performed during ICP monitoring. In every patient, variables derived from the EEG were calculated and the Granger causality (GC) methodology was employed to assess whether, and in which direction, there is any relationship between EEG and ICP. MAIN RESULTS: One-thousand fifty-five hours of continuous multimodal monitoring were analyzed in 21 patients using the GC test. During 37.88% of the analyzed time, significant GC statistic was found in the direction from the EEG activity to the ICP, with typical lags of 25-50 s between them. When recordings were adjusted by sedation-perfusion and/or bolus-and handling, these percentages hardly changed. SIGNIFICANCE: Long-lasting, continuous and simultaneous EEG and ICP recordings from TBI and SAH patients provide highly rich and useful information, which has allowed for uncovering a strong relationship between both signals. The use of this relationship could lead to developing a medical device to measure ICP in a non-invasive way.

[Analysis with the propensity score of the association between likelihood of treatment and event of interest in observational studies. An example with myocardial reperfusion]. / Análisis de la asociación entre un tratamiento y un acontecimiento de interés en estudios observacionales utilizando la probabilidad de recibir el tratamiento (Propensity Score). Un ejemplo con la reperfusión miocárdica.

INTRODUCTION AND OBJECTIVES: Analysis of the effect of treatment in observational studies is complex due to differences between treated and nontreated patients. Calculating the probability of receiving treatment conditioned on relevant covariates (propensity score [PS]) has been proposed as a method to control for these differences. We report an application of PS to assess the association between reperfusion treatment and 28-day case fatality in patients with acute myocardial infarction (AMI). METHOD: We describe the procedure used to calculate PS for receiving reperfusion treatment, and different strategies to analyze the association between PS and case fatality with regression modeling and matching. Data were from a population-based registry of 6307 patients with AMI in Spain during 1997-98. RESULTS: The PS for reperfusion was calculated in 5622 patients. In the multivariate analysis, reperfusion was associated with lower case fatality (OR = 0.59; 95% confidence interval [95% CI]: 0.46-0.77). When PS was included as a covariate, this association became non- significant (OR = 0.76; 95% CI: 0.57-1.01). In the subgroup of matched patients with a similar PS (n = 3138), treatment was not associated with case fatality (OR = 0.95; 95% CI: 0.72-1.26). When the influence of cases with missing data on PS was controlled for, reperfusion treatment was associated with lower fatality (OR = 0.66; 95% CI: 0.55-0.80). CONCLUSIONS: Calculating propensity score is a method that controls for differences between treated and nontreated patients. This score has limitations when matching is incomplete and when data are missing. Results of the present example suggest that reperfusion treatment reduces AMI case fatality.

[Hospital resources and myocardial infarction case fatality. The IBERICA study]. / Recursos hospitalarios y letalidad por infarto de miocardio. Estudio IBERICA.

INTRODUCTION AND OBJECTIVES: To determine the proportion of patients with myocardial infarction (MI) not admitted to a coronary care unit (CCU), the variables associated with admission into a CCU, and whether admission to a CCU, and the availability of coronary angiography in the same hospital, were associated with 28-day case fatality. PATIENTS AND METHOD: Population-based registry of MI in patients 25 to 74 years of age, admitted during 1996-1998. Demographic and clinical characteristics were recorded, as well as management, clinical course and survival after 28 days. Hospitals were classified according to the availability of a CCU and catheterization laboratory (advanced hospital), CCU only (intermediate hospital) or neither (basic hospital). Admission to the CCU was also recorded. RESULTS: In all, 9046 cases of MI were recorded; in 11.3% the patient was not admitted to a CCU. Age, smoking (OR=1.33; 95% CI, 1.08-1.64), non-Q MI (OR=0.62; 95% CI, 0.49-0.78) or undetermined location of MI (OR=0.34; 95% CI, 0.23-0.50), Killip 4 score on admission (OR=0.63; 95% CI, 0.40-1.00) and delay in arrival at the hospital >6 h were associated with CCU admission. Patients admitted to a CCU showed a lower case fatality in the first 24 h (4.2% vs 23.5%), which was independent of comorbidity, severity and treatment. The 24-hour survivors admitted to a basic hospital had higher case fatality (17.3% vs 7.8%) than other groups, which was related to differences in treatment. CONCLUSIONS: CCU admission is associated with a lower case fatality in the first 24 h. Admission to a basic hospital is associated with a higher 28-day case fatality even in patients who survive 24 h.

[Profile of the patient with inadequate follow-up and control of cardiovascular risk factors after suffering an acute myocardial infarction]. / Perfil del paciente con seguimiento y control inadecuados de los factores de riesgo cardiovascular después de presentar un infarto agudo de miocardio.

OBJECTIVE: To draw up a profile of patients with inadequate follow-up and control of cardiovascular risk factors (CVRF) after acute myocardial infarction (AMI). DESIGN: Cohort study. SETTING: Primary care in Albacete, province of Castilla-La Mancha, Spain. PARTICIPANTS: AMI cases who survived at 28 days and recorded in the IBERICAAlbacete register. MAIN MEASUREMENTS: A structured survey of patients, families or family doctors to find out about the follow-up and control of CVRFs (arterial hypertension [AHT], hypercholesterolaemia, diabetes, smoking habits, and obesity), as well as education level, work situation and return to work. Inadequate follow-up is defined as when the recommended visits are not made, and inadequate control, when adequate levels are no obtained or they smoked. A descriptive, bivariate, and multivariate comparative analysis was performed. The association was measured using relative risk (RR), and the population estimation with the 95% confidence intervals (95% CI). RESULTS: The sample included 21% females, 46% hypertensives, 35% with hypercholesterolaemia, 32% diabetics, 36% obeses, and 39% active smokers, with a mean age of 61 years. There was a 9% loss in follow-up, and 576 patients had a CVRF: 31% with inadequate follow-up (95% CI, 28-36) and 46% with inadequate control (95% CI, 41-51). The profile of a patient with inadequate follow-up was young, unemployed, with university education, smoker, obese and without AHT; that of an inadequately controlled patient was, a smoker, diabetic and unemployed. CONCLUSIONS: There was inadequate follow-up of long term CVRFs in 31% of AMI patients, and 46% with inadequate control, there being characteristics in AMI that identify them.

[Association between paraoxonase-1 and paraoxonase-2 polymorphisms and the risk of acute myocardial infarction]. / Asociación de los polimorfismos de la paraoxonasa 1 y la paraoxonasa 2 con el riesgo de infarto agudo de miocardio.

INTRODUCTION AND OBJECTIVES: Two particular polymorphisms, namely PON1-192 and PON2-311, in the genes encoding the antioxidant enzymes paraoxonase-1 (PON1) and paraoxonase-2 (PON2) have been associated with an increased risk of acute myocardial infarction (AMI). However, previous findings have been contradictory. The aim of this study was to investigate the association between the PON1-192 and PON2-311 polymorphisms and their interaction on AMI risk. METHODS: This case-control study involved 746 consecutive AMI patients and 1796 control subjects without cardiovascular disease, who were randomly selected from the same population from which the patients came. All participants were recruited between 1999 and 2000 from four Spanish autonomous regions. All were assessed for the presence of PON1-192 and PON2-311 and for classical cardiovascular risk factors. Multivariate analysis was carried out using logistic regression modeling. RESULTS: The odds ratios (OR) of AMI for patients with the PON1-192 QQ and PON2-311 SS genotypes (who comprised 50% and 66% of the population, respectively) were 1.26 (95% confidence interval [CI], 1.02-1.55) and 1.25 (95% CI, 1.04-1.50), respectively, compared with R and C allele carriers. Moreover, in patients with both QQ and SS genotypes, the adjusted OR of AMI increased to 1.41 (95% CI, 1.13-1.76). CONCLUSIONS: Our results indicate that the PON1-192 and PON2-311 polymorphisms were independent risk factors of AMI in our population.

[Effect of cardiovascular risk factors on long-term morbidity and mortality following acute myocardial infarction]. / Efecto de los factores de riesgo cardiovascular sobre la morbimortalidad a largo plazo después de un infarto agudo de miocardio.

INTRODUCTION AND OBJECTIVES: Generally, cardiovascular risk factors are poorly controlled after myocardial infarction. The objective of this study was to determine the effect of these risk factors on long-term morbidity and mortality in patients experiencing a myocardial infarction. METHODS: In total, 655 acute myocardial infarction survivors recorded in the IBERICA database for the Spanish province of Albacete were followed up. Provincial healthcare center databases and the regional death registry were consulted, and semistructured interviews were carried out. Bivariate and multivariate descriptive and comparative statistical analyses were performed. RESULTS: The median follow-up period was 5.5 years. At the end of the study, 74% of patients had hypertension or hypercholesterolemia, 39% had diabetes, 36% were obese, 13% smoked, and 1% were alcoholics. Overall, 48% of patients experienced a cardiovascular event. Uncontrolled hypercholesterolemia was found to be a risk factor for angina (odds ratio [OR]=2.4, 95% confidence interval [CI], 1.1-5.1), and uncontrolled diabetes was a risk factor for reinfarction (OR=3.5, 95% CI, 1.6-7.6) and stroke (OR=10.6, 95% CI, 3.6-31.2), both of which occurred earlier in patients with uncontrolled diabetes. In total, 115 (18%) patients died, with more than 50% of deaths being due to cardiovascular causes. Uncontrolled hypertension and diabetes were the most important risk factors for both overall and early mortality, whereas controlled hypercholesterolemia appeared to be a protective factor. CONCLUSIONS: The prevalence of cardiovascular risk factors in patients who have experienced a myocardial infarction is very high. Control of these risk factors influences both cardiovascular events and long-term mortality.

Smoking and myocardial infarction case-fatality: hospital and population approach.

BACKGROUND: Smoking is a risk factor for coronary heart disease, but it has been associated with better short-term prognosis in hospitalized patients with acute myocardial infarction. The aims of this study were to determine the association between smoking and myocardial infarction 28-day case-fatality in hospitalized patients and at the population level; and, whether smokers presenting with fatal myocardial infarction are more likely to die before reaching a hospital. DESIGN AND METHODS: Population-based myocardial infarction registry, carried out in 1997-1998 in seven regions of Spain, used standardized methods to find and analyze suspected myocardial infarction patients (10 654 patients; 7796 hospitalized). Four categories of smoking status were defined: never-smokers, former smokers for more than 1 year, former smokers for less than 1 year, and current smokers. RESULTS: The main end-point was 28-day case-fatality, found to be 20.1, 17.1, 15.6, and 8.9%, in the four smoking status categories, respectively, for hospitalized patients; and 37.4, 33.0, 24.5, and 23.2%, respectively, at population level. Hospitalized current smokers had lower age, sex, and comorbidity-adjusted 28-day case-fatality than never-smokers (odds ratio=0.71; 95% confidence interval: 0.56-0.90). This association held at population level (odds ratio=0.68; 95% confidence interval: 0.60-0.76), in which former smoking was also associated with lower case-fatality. In fatal cases, recent former smokers presented a lower risk of out-of-hospital death than never-smokers (odds ratio=0.47; 95% confidence interval: 0.29-0.77), whereas current smoking was marginally associated with out-of-hospital death (odds ratio=1.22; 95% confidence interval: 0.99-1.50). CONCLUSIONS: Current smoking is associated with lower 28-day case-fatality in hospitalized myocardial infarction patients. This association held at population level. Among fatal cases, smoking is associated with higher and recent former smoking with lower risk of dying out-of-hospital.

Public perception of stroke in Spain.

BACKGROUND AND PURPOSE: Stroke is one of the leading causes of death and disability in western countries. Improving attention to stroke demands better public information about the illness. The aim of the present study was to determine the current knowledge of stroke among the Spanish population. METHODS: We conducted a population-based telephone interview in Spain. A total of 3,000 respondents were selected at random following a systematic procedure aimed at filling the sex/age community quotas. RESULTS: A total of 16,016 telephone calls were made. Three thousand respondents were eligible and 2,884 completed the telephone interview. Only 4.5% of respondents knew the term stroke, 1,719 (59.6%) participants were able to mention at least one stroke risk factor, and only 940 (32.6%) could mention at least one stroke sign without prompting. Most respondents considered stroke to be a severe and dangerous illness that can be treated, but less than half of the respondents went immediately to a hospital when faced with a stroke event. Suitable stroke knowledge was only achieved by 302 (10.5%) respondents. Those who had home-based occupations and no previous stroke experience were less likely to have suitable stroke knowledge. CONCLUSIONS: This study confirms that our community is still unfamiliar with stroke. Wide population-based educational programs are needed to increase public knowledge of stroke. Our results indicate that people with home-based occupations should be the main target of our education campaigns.

Regional variability in population acute myocardial infarction cumulative incidence and mortality rates in Spain 1997 and 1998.

BACKGROUND: Myocardial infarction (MI) incidence and mortality display a high geographic variation. AIMS: The objective of the present study was to analyze MI mortality, cumulative incidence rate variability in seven regions of Spain from 1997 to 1998. METHODS AND RESULTS: Standardized methods were used to identify, find, register, and classify MI cases that were classified as definite, possible, insufficient-data MI, and non-MI. The total population of the seven monitored regions was 7,364,682 inhabitants. Of the 11,256 cases fulfilling eligibility criteria to investigate, 10,660 were selected to calculate MI rates: 6554 (61.5%) non-fatal definite MI, 1179 (11.1%) fatal definite MI, 1859 (17.4%) fatal possible MI, 1068 (10.0%) fatal cases with insufficient data. The IBERICA 25-74 years age-standardized cumulative incidence rates for men and women, were 207 (range: 175-252) and 45 (range: 36-65) per 100,000, respectively. The age-standardized mortality rates for men and women, were 73 (range: 62-94) and 20 (range: 13-29) per 100,000, respectively. Age-standardized case-fatality was 31.4 and 24.2% in men aged 25-74 and 35-64 years, respectively, and 32.7 and 27.0%, respectively, in women. CONCLUSIONS: MI cumulative incidence and mortality rates are low compared with other industrialized countries but, vary considerably among regions in a Mediterranean country like Spain.