Prevalence and incidence of heart failure in type 2 diabetes patients: results from a nationwide prospective cohort-the DIABET-IC study.

BACKGROUND: Type 2 diabetes (T2D) patients have an increased risk of heart failure (HF). There are limited data on the association between HF and T2D in specific healthcare settings. This study sought to analyse the prevalence and incidence of HF in a contemporary cohort of T2D patients attending cardiology and endocrinology outpatient clinics. METHODS: We conducted an observational multicentre prospective study (DIABET-IC) that enrolled patients with a T2D diagnosis attending cardiology and endocrinology outpatient clinics in 30 centres in Spain between 2018 and 2019. The prevalence at the start of the study and the incidence of HF after a 3 year follow-up were calculated. HF was defined as the presence of typical symptoms and either: a) LVEF < 40%; or b) LVEF ≥ 40% with elevated natriuretic peptides and echocardiographic abnormalities. RESULTS: A total of 1249 T2D patients were included in the present analysis (67.6 ± 10.1 years, 31.7% female). HF was present in 490 participants at baseline (prevalence 39.2%), 150 (30.6%) of whom had a preserved ejection fraction. The presence of adverse social determinants and chronic conditions such as chronic kidney disease and atherosclerotic cardiovascular disease were more frequent in HF patients. During the study period, there were 58 new diagnoses of HF (incidence 7.6%) among those without baseline HF. The incidence rate was 3.0 per 100 person-years. Independent predictors of incident HF were smoking, left ventricular ejection fraction, NT-ProBNP, history of tachyarrhythmia and treatment with pioglitazone, oral anticoagulants, or diuretics. Despite an average suboptimal glycaemic control, the use of antidiabetic drugs with cardiovascular benefits was low (30.4% for sodium-glucose cotransporter-2 inhibitors and 12.5% for glucagon-like peptide-1 receptor agonists). CONCLUSIONS: In this contemporary cohort of T2D patients attending cardiology and endocrinology outpatient clinics, the prevalence and incidence of HF were high, comorbidities were frequent, and the use of antidiabetic agents with cardiovascular benefit was low. Outpatient care seems to be a unique opportunity for a comprehensive T2D approach that encompasses HF prevention, diagnosis, and treatment.

Implementation of a Teledermatology Electronic Consultation Program to Improve the Care of Patients with Inflammatory Bowel Disease.

Introduction: Skin lesions are a common extraintestinal manifestation associated with inflammatory bowel disease (IBD), although they may also appear as a complication of IBD treatment. Prompt referral to the dermatologist can be very helpful in practice. Teledermatology complements the traditional in-person health care modality, improving access to dermatological care. Objective: To evaluate the impact of a store-and-forward teledermatology electronic consultation (e-consult) program on the care of IBD patients. Methods: A retrospective study assessing the outcomes of our teledermatology program over its first 2 years of implementation. Results: A total of 39 consultations involving 33 patients (69.2% women, mean age 39.6 years [12-63]) were conducted. The mean number of teleconsultations was 2.8 per month in the initial implementation stage: 33 consultations were carried out in patients with Crohn's disease and 6 in ulcerative colitis. Only 18% of the patients had an active flare-up. The most frequent reason for the e-consult was paradoxical psoriasiform lesions (n = 13, 33.3%), commonly related with anti-tumor necrosis factor agents (70% of the patients) and hidradenitis suppurativa (n = 4, 10.3%). Resolution was achieved in 87% of patients, with a mean waiting time of 4.7 days (0-14). Almost all patients (97%) were satisfied with our program, and considered the referral through the program to be appropriate (92%). Best valued features were the reduced waiting time and the coordinated approach between the two departments involved. Conclusions: Dermatology e-consult is an efficient and useful means of optimizing IBD patient care.

Incidence and Prognosis of Colorectal Cancer After Heart Transplantation: Data From the Spanish Post-Heart Transplant Tumor Registry.

In this observational and multicenter study, that included all patients who underwent a heart transplantation (HT) in Spain from 1984 to 2018, we analyzed the incidence, management, and prognosis of colorectal cancer (CRC) after HT. Of 6,244 patients with a HT and a median follow-up of 8.8 years since the procedure, 116 CRC cases (11.5% of noncutaneous solid cancers other than lymphoma registered) were diagnosed, mainly adenocarcinomas, after a mean of 9.3 years post-HT. The incidence of CRC increased with age at HT from 56.6 per 100,000 person-years among under 45 year olds to 436.4 per 100,000 person-years among over 64 year olds. The incidence rates for age-at-diagnosis groups were significantly greater than those estimated for the general Spanish population. Curative surgery, performed for 62 of 74 operable tumors, increased the probability of patient survival since a diagnosis of CRC, from 31.6% to 75.7% at 2 years, and from 15.8% to 48.6% at 5 years, compared to patients with inoperable tumors. Our results suggest that the incidence of CRC among HT patients is greater than in the general population, increasing with age at HT.

Early and late onset cardiotoxicity following anthracycline-based chemotherapy in breast cancer patients: Incidence and predictors.

INTRODUCTION: Cardiotoxicity represents a major limitation for the use of anthracyclines or trastuzumab in breast cancer patients. Data on longitudinal studies about early and late onset cardiotoxicity in this group of patients is scarce. The objective of the present study was to assess predictors of early and late onset cardiotoxicity in patients with breast cancer treated with A. METHODS: 100 consecutive patients receiving anthracycline-based chemotherapy (CHT) to treat breast cancer were included in this prospective study. All patients underwent evaluation at baseline, at the end of CHT, 3 months after the end of CHT and 1 and 4 years after the beginning of CHT. Clinical data, systolic and diastolic echo parameters and cardiac biomarkers including high sensitivity Troponin T (TnT), N-terminal pro-brain natriuretic peptide (NT-proBNP) and Heart-type fatty acid binding protein (H-FABP) were assessed. RESULTS: Mean doxorubicin dose was 243 mg/m2. Mean follow-up was 51.8 ± 8.2 months. At one-year incidence of anthracycline related-cardiotoxicity (AR-CT) was 4% and at the end of follow-up was 18% (15 patients asymptomatic left ventricular systolic dysfunction, 1 patients heart failure and 2 patients a sudden cardiac death). Forty-nine patients developed diastolic dysfunction (DD) during first year. In the univariate analysis DD during first year was the only parameter associated with AR-CT (Table 1). In the logistic regression model DD was independently related with the development of AR-CT, with an odds ratio value of 7.5 (95% CI 1.59-35.3). CONCLUSIONS: Incidence of late-onset cardiotoxicity is high but mostly subclinical. Diastolic dysfunction early after chemotherapy is a strong predictor of anthracycline cardiotoxicity.

Cancer in patients with heart failure: Incidence, risk factors and prognostic impact.

AIMS: To assess the incidence of cancer diagnosis and cancer-related mortality in patients with heart failure (HF). METHODS: Observational study based in a prospective cohort of patients with HF referred to a specialized Spanish clinic between 2010 and 2019. The observed incidence of malignancies (excluding non-melanoma skin cancer) was compared to that expected for the general Spanish population according to the Global Cancer Observatory. RESULTS: We studied 1909 consecutive patients with HF. Over a median follow-up of 4.07 years, 165 new cases of malignancy were diagnosed. Observed age-standardized incidence rates of cancer were 861 (95% CI 618.4-2159.4) cases per 100,000 patients-years in men and 728.5 (95% CI 451.1-4308.7) cases per 100,000 patients-years in women; while age-standardized incidence rates of cancer expected for the general Spanish population were 479.4 cases per 100,000 patients-years in men (risk ratio = 1.80) and 295.5 cases per 100,000 patients-years in women (risk ratio = 2.46). Both a history of pre-existing malignancy at baseline and the development of new malignancies during follow-up were associated with reduced survival. Observed age-standardized cancer-related mortality was 344.1 (95% CI 202.1-1675) deaths per 100,000 patient-years in men and 217.0 (95% CI 32.8-3949.3) deaths per 100,000 patient-years in women; while age-standardized cancer-related mortality expected for the general Spanish population was 201.4 deaths per 100,000 patients-years in men (risk ratio = 1.71) and 96.2 deaths per 100,000 patients-years in women (risk ratio = 2.26). CONCLUSION: Patients with HF showed higher incidence rates of cancer diagnosis and cancer-related mortality than those expected for the general population.

Malignancy following heart transplantation: differences in incidence and prognosis between sexes - a multicenter cohort study.

Male patients are at increased risk for developing malignancy postheart transplantation (HT); however, real incidence and prognosis in both genders remain unknown. The aim of this study was to assess differences in incidence and mortality related to malignancy between genders in a large cohort of HT patients. Incidence and mortality rates were calculated for all tumors, skin cancers (SCs), lymphoma, and nonskin solid cancers (NSSCs) as well as survival since first diagnosis of neoplasia. 5865 patients (81.6% male) were included. Total incidence rates for all tumors, SCs, and NSSCs were lower in females [all tumors: 25.7 vs. 44.8 per 1000 person-years; rate ratio (RR) 0.68, (0.60-0.78), P < 0.001]. Mortality rates were also lower in females for all tumors [94.0 (77.3-114.3) vs. 129.6 (120.9-138.9) per 1000 person-years; RR 0.76, (0.62-0.94), P = 0.01] and for NSSCs [125.0 (95.2-164.0) vs 234.7 (214.0-257.5) per 1000 person-years; RR 0.60 (0.44-0.80), P = 0.001], albeit not for SCs or lymphoma. Female sex was associated with a better survival after diagnosis of malignancy [log-rank p test = 0.0037; HR 0.74 (0.60-0.91), P = 0.004]. In conclusion, incidence of malignancies post-HT is higher in males than in females, especially for SCs and NSSCs. Prognosis after cancer diagnosis is also worse in males.

Direct Anticoagulants Versus Vitamin K Antagonists in Patients Aged 80 Years or Older With Atrial Fibrillation in a "Real-world" Nationwide Registry: Insights From the FANTASIIA Study.

OBJECTIVE: To describe major events at follow up in octogenarian patients with atrial fibrillation (AF) according to anticoagulant treatment: direct oral anticoagulants (DOACs) versus vitamin K antagonists (VKAs). METHODS: A total of 578 anticoagulated patients aged ≥80 years with AF were included in a prospective, observational, multicenter study. Basal features, embolic events (stroke and systemic embolism), severe bleedings, and all-cause mortality at follow up were investigated according to the anticoagulant treatment received. RESULTS: Mean age was 84.0 ± 3.4 years, 56% were women. Direct oral anticoagulants were prescribed to 123 (21.3%) patients. Compared with 455 (78.7%) patients treated with VKAs, those treated with DOACs presented a lower frequency of permanent AF (52.9% vs 61.6%, P = .01), cancer history (4.9% vs 10.9%, P = .046), renal failure (21.1% vs 32.2%, P = .02), and left ventricular dysfunction (2.4% vs 8.0%, P = .03); and higher frequency of previous stroke (26.0% vs 16.6%, P = .02) and previous major bleeding (8.1% vs 3.6%, P = .03). There were no significant differences in Charlson, CHA2DS2VASc, nor HAS-BLED scores. At 3-year follow up, rates of embolic events, severe bleedings, and all-cause death (per 100 patients-year) were similar in both groups (DOACs vs VKAs): 0.34 vs 1.35 (P = .15), 3.45 vs 4.41 (P = .48), and 8.2 vs 11.0 (P = .18), respectively, without significant differences after multivariate analysis (hazard ratio [HR]: 0.25, 95% confidence interval [CI]: 0.03-1.93, P = .19; HR: 0.88, 95% CI: 0.44-1.76, P = .72 and HR: 0.84, 95% CI: 0.53-1.33, P = .46, respectively). CONCLUSION: In this "real-world" registry, the differences in major events rates in octogenarians with AF were not statistically significant in those treated with DOACs versus VKAs.

Molecular changes in the nucleus accumbens and prefrontal cortex associated with the locomotor sensitization induced by coca paste seized samples.

RATIONALE: In previous studies, we have demonstrated that seized samples of a smokable form of cocaine, also known as coca paste (CP), induced behavioral sensitization in rats. Interestingly, this effect was accelerated and enhanced when the samples were adulterated with caffeine. While the cocaine phenomenon is associated with persistent functional and structural alterations in the prefrontal cortex (PFC) and nucleus accumbens (NAc), the molecular mechanisms underlying the CP sensitization and the influence of caffeine remains still unknown. OBJECTIVE: We examined the gene expression in NAc and mPFC after the expression caffeine-adulterated and non-adulterated CP locomotor sensitization. METHODS: The locomotor sensitization was established in C57BL/6 mice, repeatedly treated with a CP-seized sample adulterated with caffeine (CP-2) and a non-adulterated one (CP-1). We then assessed the mRNA expression of receptor subunits of the dopaminergic and glutamatergic systems in the medial PFC (mPFC) and NAc. Other molecular markers (e.g., adenosinergic, endocannabinoid receptor subunits, and synaptic plasticity-associated genes) were also analyzed. RESULTS: Only CP-2-treated mice expressed locomotor sensitization. This phenomenon was associated with increased Drd1a, Gria1, Cnr1, and Syn mRNA expression levels in the NAc. Drd3 mRNA expression levels were only significantly increased in mPFC of CP-2-treated group. CONCLUSIONS: Our results demonstrated that caffeine actively collaborates in the induction of the molecular changes underlying CP sensitization. The present study provides new knowledge on the impact of active adulterants to understand the early dependence induced by CP consumption.

The Harvey-Bradshaw Index Adapted to a Mobile Application Compared with In-Clinic Assessment: The MediCrohn Study.

Objectives: Mobile apps are useful tools in e-health and self-management strategies in disease monitoring. We evaluated the Harvey-Bradshaw index (HBI) mobile app self-administered by the patient to see if its results agreed with HBI in-clinic assessed by a physician. Methods: Patients were enrolled in a 4-month prospective study with clinical assessments at months 1 and 4. Patients completed mobile app HBI and within 48 h, HBI was performed by a physician (gold standard). HBI scores characterized Crohn's disease (CD) as remission <5 or active ≥5. We determined agreement per item and total HBI score and intraclass correlation coefficients (ICCs). Bland-Altman plot was performed. HBI changes in disease activity from month 1 to month 4 were determined. Results: A total of 219 patients were enrolled. All scheduled assessments (385 pairs of the HBI questionnaire) showed a high percentage of agreement for remission/activity (92.4%, κ = 0.796), positive predictive value (PPV) for remission of 98.2%, and negative predictive value of 76.7%. High agreement was also found at month 1 (93.15%, κ = 0.82) and month 4 (91.5%, κ = 0.75). Bland-Altman plot was more uniform when the HBI mean values were <5 (remission). ICC values were 0.82, 0.897, and 0.879 in all scheduled assessments, 1 and 4 months, respectively. Conclusions: We found a high percentage of agreement between patients' self-administered mobile app HBI and in-clinic physician assessment to detect CD activity with a remarkably high PPV for remission. The mobile app HBI might allow a strict control of inflammation by remote monitoring and flexible follow-up of CD patients. Reduction of sanitary costs could be possible.

Reference Values for the Adolescent/Adult Sensory Profile in Spain.

IMPORTANCE: In Spain, only one culturally adapted assessment tool is available for children between ages 3 and 11 yr. There are no assessments of adolescent and adult sensory processing, and no normative data. OBJECTIVE: To obtain reference values for the Adolescent/Adult Sensory Profile (AASP) in Spain for adolescents (aged 11-17) and adults (aged 18-64 and ≥65). DESIGN: A multivariate analysis of variance was used to compare specific mean values (-2, -1, +1, and +2 standard deviation [SD]) by age group, gender, geographic area, education level, and employment status. PARTICIPANTS: We randomly recruited 787 participants (55.8% female) aged 11 yr or older (mean age = 32.1, SD = 21.1) in Spain. We excluded those with a diagnosis of depression, chronic disease (e.g., diabetes, cancer, neurological disease), or cognitive disability and those who used medication that could affect the central nervous system. RESULTS: Quadrant mean (SD) scores ranged from 29.3 (6.6) for low registration to 49.1 (8.3) for sensory seeking, with significant differences by age group (p < .001) in all quadrants. Significant differences were also found for scores in different quadrants by gender, geographic area, education level, and employment status. Although statistically significant, the differences between scores were not clinically relevant; the mean scores fell within the typical range for sensory processing. CONCLUSIONS AND RELEVANCE: We offer reference values for the cultural adaptation to Spain of the AASP and recommend its use for the typically developing Spanish population ages 11 and older. WHAT THIS ARTICLE ADDS: We provide normative data for the AASP for three age groups of the Spanish population: adolescents, adults, and older adults.

Estimated stroke risk, yield, and number needed to screen for atrial fibrillation detected through single time screening: a multicountry patient-level meta-analysis of 141,220 screened individuals.

BACKGROUND: The precise age distribution and calculated stroke risk of screen-detected atrial fibrillation (AF) is not known. Therefore, it is not possible to determine the number needed to screen (NNS) to identify one treatable new AF case (NNS-Rx) (i.e., Class-1 oral anticoagulation [OAC] treatment recommendation) in each age stratum. If the NNS-Rx is known for each age stratum, precise cost-effectiveness and sensitivity simulations can be performed based on the age distribution of the population/region to be screened. Such calculations are required by national authorities and organisations responsible for health system budgets to determine the best age cutoffs for screening programs and decide whether programs of screening should be funded. Therefore, we aimed to determine the exact yield and calculated stroke-risk profile of screen-detected AF and NNS-Rx in 5-year age strata. METHODS AND FINDINGS: A systematic review of Medline, Pubmed, and Embase was performed (January 2007 to February 2018), and AF-SCREEN international collaboration members were contacted to identify additional studies. Twenty-four eligible studies were identified that performed a single time point screen for AF in a general ambulant population, including people ≥65 years. Authors from eligible studies were invited to collaborate and share patient-level data. Statistical analysis was performed using random effects logistic regression for AF detection rate, and Poisson regression modelling for CHA2DS2-VASc scores. Nineteen studies (14 countries from a mix of low- to middle- and high-income countries) collaborated, with 141,220 participants screened and 1,539 new AF cases. Pooled yield of screening was greater in males across all age strata. The age/sex-adjusted detection rate for screen-detected AF in ≥65-year-olds was 1.44% (95% CI, 1.13%-1.82%) and 0.41% (95% CI, 0.31%-0.53%) for <65-year-olds. New AF detection rate increased progressively with age from 0.34% (<60 years) to 2.73% (≥85 years). Neither the choice of screening methodology or device, the geographical region, nor the screening setting influenced the detection rate of AF. Mean CHA2DS2-VASc scores (n = 1,369) increased with age from 1.1 (<60 years) to 3.9 (≥85 years); 72% of ≥65 years had ≥1 additional stroke risk factor other than age/sex. All new AF ≥75 years and 66% between 65 and 74 years had a Class-1 OAC recommendation. The NNS-Rx is 83 for ≥65 years, 926 for 60-64 years; and 1,089 for <60 years. The main limitation of this study is there are insufficient data on sociodemographic variables of the populations and possible ascertainment biases to explain the variance in the samples. CONCLUSIONS: People with screen-detected AF are at elevated calculated stroke risk: above age 65, the majority have a Class-1 OAC recommendation for stroke prevention, and >70% have ≥1 additional stroke risk factor other than age/sex. Our data, based on the largest number of screen-detected AF collected to date, show the precise relationship between yield and estimated stroke risk profile with age, and strong dependence for NNS-RX on the age distribution of the population to be screened: essential information for precise cost-effectiveness calculations.

Venoarterial extracorporeal membrane oxygenation with or without simultaneous intra-aortic balloon pump support as a direct bridge to heart transplantation: results from a nationwide Spanish registry.

OBJECTIVES: To investigate the potential clinical benefit of an intra-aortic balloon pump (IABP) in patients supported with venoarterial extracorporeal membrane oxygenation (VA-ECMO) as a bridge to heart transplantation (HT). METHODS: We studied 169 patients who were listed for urgent HT under VA-ECMO support at 16 Spanish institutions from 2010 to 2015. The clinical outcomes of patients under simultaneous IABP support (n = 73) were compared to a control group of patients without IABP support (n = 96). RESULTS: There were no statistically significant differences between the IABP and control groups with regard to the cumulative rates of transplantation (71.2% vs 81.2%, P = 0.17), death during VA-ECMO support (20.6% vs 14.6%, P = 0.31), transition to a different mechanical circulatory support device (5.5% vs 5.2%, P = 0.94) or weaning from VA-ECMO support due to recovery (2.7% vs 0%, P = 0.10). There was a higher incidence of bleeding events in the IABP group (45.2% vs 25%, P = 0.006; adjusted odds ratio 2.18, 95% confidence interval 1.02-4.67). In-hospital postoperative mortality after HT was 34.6% in the IABP group and 32.5% in the control group (P = 0.80). One-year survival after listing for urgent HT was 53.3% in the IABP group and 52.2% in the control group (log rank P = 0.75). Multivariate adjustment for potential confounders did not change this result (adjusted hazard ratio 0.94, 95% confidence interval 0.56-1.58). CONCLUSIONS: In our study, simultaneous IABP therapy in transplant candidates under VA-ECMO support did not significantly reduce morbidity or mortality.

[Structure of primary healthcare units for treating persons with diabetes: Cycles I and II of the Brazilian National Program to Improve Access and Quality]. / Estrutura das unidades básicas de saúde para atenção às pessoas com diabetes: Ciclos I e II do Programa Nacional de Melhoria do Acesso e da Qualidade.

The objective was to describe the necessary structure for treating diabetes patients in the primary healthcare system, as evaluated in Cycles I and II of the Brazilian National Program for the Improvement of Access and Quality (PMAQ) in 2012 and 2014, according to the municipalities' characteristics. A descriptive study was used to assess primary care units whose teams participated in Cycles I and II of the PMAQ in 2012 and 2014. The study used variables from Module I of the external evaluation of the PMAQ that addresses the primary care units' structure. Materials (150kg scale, sphygmomanometer, adult stethoscope, tape measure, blood glucose monitor, monofilament packs, ophthalmoscope, and capillary blood glucose strips); medicines (NPH and regular insulin, glyburide, and metformin); and physical space (clinical consultation room, pharmacy, reception/waiting room, and meeting room). All the medicines and the reception/waiting room increased by more than 10p.p. from 2012 to 2014. The prevalence rates for adequate structure of materials, medicines, and physical space in the primary care units were higher in 2014. Adequate structure increased as follows: for materials, from 3.9% to 7.8%, for medicines, from 31.3% to 49.9%, for physical space, from 15.3% to 23.3%. Municipalities with more than 300,000 inhabitants, higher Human Development Index (HDI), and lower coverage of the Family Health Strategy (FHS) showed higher prevalence rates for adequate primary care units. Units that adhered to Cycles I and II of the PMAQ showed improvement in their structures. However, there was a low prevalence of primary care units with adequate structures, besides differences in the services' structure according to population size, HDI, and FHS coverage.

O objetivo foi descrever a estrutura necessária à atenção às pessoas com diabetes, usuárias da rede de atenção primária à saúde, avaliada nos Ciclos I e II do Programa Nacional de Melhoria do Acesso e da Qualidade (PMAQ) no Brasil, 2012 e 2014, considerando-se as características dos municípios. Utilizando-se um estudo descritivo foram avaliadas as unidades básicas de saúde (UBS) cujas equipes participaram dos Ciclos I e II do PMAQ, em 2012 e 2014. Utilizaram-se variáveis do Módulo I da avaliação externa do PMAQ que aborda a estrutura das UBS. Materiais (balança de 150kg, esfigmomanômetro, estetoscópio adulto, fita métrica, glicosímetro, kit de monofilamentos, oftalmoscópio e tiras de glicemia capilar); medicamentos (insulina NPH e regular, glibenclamida e metformina) e espaço físico (consultório clínico, farmácia, recepção, sala de acolhimento e de reunião). Todos os medicamentos avaliados e a sala de acolhimento apresentaram um aumento de mais de 10p.p. de 2012 para 2014. As prevalências de estrutura adequada de materiais, medicamentos e física nas UBS foram maiores em 2014. A estrutura adequada de materiais passou de 3,9% para 7,8%, de medicamentos de 31,3% para 49,9% e física de 15,3% para 23,3%. Os municípios com mais de 300 mil habitantes, melhor Índice de Desenvolvimento Humano (IDH) e menor cobertura de Estratégia Saúde da Família (ESF) registraram maiores prevalências de UBS adequadas. As unidades que aderiram aos Ciclos I e II do PMAQ obtiveram melhoria em suas estruturas. Entretanto, foi encontrada baixa prevalência de UBS com estrutura adequada, além de diferenças na estrutura dos serviços, de acordo com o porte populacional, IDH e cobertura de ESF.

El objetivo fue describir la estructura necesaria para la atención a las personas con diabetes, usuarias de la red de atención primaria en salud, evaluada en los Ciclos I y II del Programa Nacional de Mejoría del Acceso y de la Calidad (PMAQ) en Brasil, 2012 y 2014, considerándose las características de los municipios. Utilizándose un estudio descriptivo se evaluaron las unidades básicas de salud (UBS), cuyos equipos participaron en los Ciclos I y II del PMAQ, en 2012 y 2014. Se utilizaron variables del Módulo I de evaluación externa del PMAQ que aborda la estructura de las UBS. Materiales (peso de 150kg, esfigmomanómetro, estetoscopio adulto, cinta métrica, glucómetro, kit de monofilamentos, oftalmoscopio y tiras de glucemia capilar); medicamentos (insulina NPH y regular, glibenclamida y metformina) y espacio físico (consultorio clínico, farmacia, recepción, sala de acogida y reunión). Todos los medicamentos evaluados y la sala de acogida presentaron un aumento de más de 10p.p. de 2012 a 2014. Las prevalencias sobre estructura adecuada de materiales, medicamentos y física en las UBS fueron mayores en 2014. La estructura adecuada de materiales pasó de 3,9% a 7,8%, de medicamentos de 31,3% a 49,9% y física de 15,3% a 23,3%. Los municipios con más de 300.000 habitantes, mejor Índice de Desarrollo Humano (IDH) y menor cobertura de Estrategia Salud de la Familia (ESF), registraron mayores prevalencias de UBS adecuadas. Las unidades que se adhirieron a los Ciclos I y II del PMAQ obtuvieron una mejoría en sus estructuras. No obstante, se encontró una baja prevalencia de UBS con estructura adecuada, además de las diferencias en la estructura de los servicios, de acuerdo con la dimensión poblacional, IDH y cobertura de ESF.

Relation of quality of anticoagulation control with different management systems among patients with atrial fibrillation: Data from FANTASIIA Registry.

BACKGROUND: Anticoagulation control in patients with atrial fibrillation (AF) has a multidisciplinary approach although is usually managed by general practitioners (GP) or haematologists. The aim of our study was to assess the quality of anticoagulation control with vitamin K antagonists (VKAs) in relation to the responsible specialist in a "real-world" AF population. METHODS: We consecutively enrolled VKA anticoagulated patients included in the FANTASIIA Registry from 2013 to 2015. We analysed demographical, clinical characteristics and the quality of anticoagulation control according to the specialist responsible (ie GPs or haematologists). RESULTS: Data on 1584 patients were included (42.5% females, mean age 74.0 ± 9.4 years): 977 (61.7%) patients were controlled by GPs and 607 (38.3%) by haematologists. Patients managed by GPs had higher previous heart disease (53.2% vs 43.3%, P < .001), heart failure (32.9% vs 26.5%, P < .008) and dilated cardiomyopathy (15.2% vs 8.7%, P < .001) with better renal function (69.3 ± 24.7 vs 63.1 ± 21.4 mL/min, P < .001) compared to patients managed by haematologists. There was no difference between groups in the type of AF, CHA2 DS2 -VASc or HAS-BLED scores, but patients with electrical cardioversion were more prevalent in GP group. The overall mean time in therapeutic range (TTR) assessed by Rosendaal method was 61.5 ± 24.9%; 52.6% of patients had TTR<65% and 60% of patients had TTR<70%. TTR was significantly lower in patients controlled by haematologists than by GPs (63 ± 24.4 vs 59.2 ± 25.6, P < .005). CONCLUSIONS: About 60% of AF patients anticoagulated with VKAs had poor anticoagulation control (ie TTR<70%), and their management was only slightly better than when it is managed by general practitioners.

Social inequalities in care for the elderly with diabetes in Brazil / Desigualdades sociales en la atención de las personas mayores con diabetes en Brasil / Desigualdades sociais na atenção a idosos com diabetes no Brasil

ABSTRACT Objective. To measure the prevalence of various care services offered to the elderly with diabetes mellitus in Brazil, and to assess the social inequalities in these services. Methods. This cross-sectional, population-based study was carried out in 2013. The care services offered were evaluated in terms of the following eight indicators: recommendations to lower carbohydrates, to measure blood glucose, and to examine the feet; requests made for blood tests, for glycated hemoglobin tests, and for glycemic curve tests; and whether service users had had their eyes or feet examined in the previous year. We used the slope index of inequality and the concentration index to assess the inequalities among wealth quintiles. Results. A total of 1 685 elderly persons with diabetes were evaluated. Overall, 41.7% of them had had their eyes examined in the preceding year, 35.4% had had their feet examined in the preceding year, and 10.9% had been offered all eight of the care services. The largest absolute differences (in percentage points) between the first (poorest) and fifth (richest) wealth quintiles in terms of the care services that were offered to the users were for: a recommendation to measure blood glucose (25.8), a glycated hemoglobin test request (27.4), a glycemic curve test request (31.9), having the eyes examined in the preceding year (29.3), and having the feet examined in the preceding year (27.0). Conclusion. There were notable inequalities in the prevalences of the care services. In the future, measurement of blood glucose and examination of the feet should be emphasized, especially for elderly persons in a lower socioeconomic level.

RESUMEN Objetivo. Medir la prevalencia de los diversos servicios de atención que se ofrecen a las personas mayores con diabetes mellitus en Brasil y evaluar las desigualdades sociales en dichos servicios. Métodos. Este estudio transversal y basado en la población se llevó a cabo en el 2013. Los servicios de atención que se ofrecen se evaluaron en cuanto a los siguientes ocho indicadores: recomendaciones para reducir los carbohidratos, medir la glucemia y revisarse los pies; solicitudes de análisis de sangre, pruebas de glucohemoglobina y pruebas de la curva de glucemia; y si a los usuarios de los servicios les habían examinado los ojos o los pies en el último año. Usamos el índice de pendiente de la desigualdad y el índice de concentración para evaluar las desigualdades entre los quintiles de riqueza. Resultados. Se evaluó en total a 1.685 personas mayores con diabetes. En términos generales, en el último año les habían examinado los ojos a 41,7% de ellos, en el último año les habían examinado los pies a 35,4% y les habían ofrecido los ocho servicios de atención a 10,9%. Las mayores diferencias absolutas en puntos porcentuales entre el primer quintil de riqueza (los más pobres) y el quinto (los más ricos) en cuanto a los servicios de atención ofrecidos a los usuarios se encontraron en la recomendación de medir la glucemia (25,8), la solicitud de pruebas de glucohemoglobina (27,4), la solicitud de pruebas de curvas de glucemia (31,9), el examen de los ojos en el último año (29,3) y el examen de los pies en el último año (27,0). Conclusiones. Hubo notables desigualdades en la prevalencia de los servicios de atención. En el futuro, debe hacerse énfasis en la medición de la glucemia y el examen de los pies, especialmente en las personas mayores de un nivel socioeconómico bajo.

RESUMO Objetivo. Medir a prevalência de vários serviços de atenção oferecidos a idosos portadores de diabetes mellitus no Brasil e avaliar desigualdades sociais nestes serviços. Métodos. Estudo transversal, de caráter populacional, realizado em 2013. Os serviços de atenção oferecidos foram avaliados quanto aos oito indicadores a seguir: recomendação de diminuir o consumo de carboidratos, medir a glicemia e examinar os pés; pedido de exames de sangue, hemoglobina glicada e curva glicêmica; e realização de exame dos olhos ou pés nos usuários do serviço durante o ano anterior. Foram utilizados o índice absoluto de desigualdade e o índice de concentração para avaliar as desigualdades entre quintis de renda. Resultados. Foram avaliados 1.685 idosos com diabetes. Destes, 41,7% haviam sido submetidos a exame dos olhos no ano anterior, 35,4% a exame dos pés, e a 10,9% haviam sido oferecidos todos os oito serviços de atenção. As maiores diferenças absolutas (em pontos percentuais) entre o primeiro (mais pobre) e quinto (mais rico) quintis de renda foram constatadas para os seguintes serviços de atenção: recomendação de medir a glicemia (25,8), pedido de exame de hemoglobina glicada (27,4), pedido de exame de curva glicêmica (31,9), exame de olhos no ano anterior (29,3) e exame dos pés no ano anterior (27,0). Conclusão. Foram constatadas desigualdades notáveis na prevalência dos serviços de atenção. Futuramente, deve-se dar ênfase à medição da glicemia e do exame dos pés, principalmente em idosos de nível socioeconômico mais baixo.

Estrutura das unidades básicas de saúde para atenção às pessoas com diabetes: Ciclos I e II do Programa Nacional de Melhoria do Acesso e da Qualidade / Structure of primary healthcare units for treating persons with diabetes: Cycles I and II of the Brazilian National Program to Improve Access and Quality / Estructura de las unidades básicas de salud para la atención a personas con diabetes: Ciclos I y II del Programa Nacional de Mejora al Acceso y Calidad

Resumo: O objetivo foi descrever a estrutura necessária à atenção às pessoas com diabetes, usuárias da rede de atenção primária à saúde, avaliada nos Ciclos I e II do Programa Nacional de Melhoria do Acesso e da Qualidade (PMAQ) no Brasil, 2012 e 2014, considerando-se as características dos municípios. Utilizando-se um estudo descritivo foram avaliadas as unidades básicas de saúde (UBS) cujas equipes participaram dos Ciclos I e II do PMAQ, em 2012 e 2014. Utilizaram-se variáveis do Módulo I da avaliação externa do PMAQ que aborda a estrutura das UBS. Materiais (balança de 150kg, esfigmomanômetro, estetoscópio adulto, fita métrica, glicosímetro, kit de monofilamentos, oftalmoscópio e tiras de glicemia capilar); medicamentos (insulina NPH e regular, glibenclamida e metformina) e espaço físico (consultório clínico, farmácia, recepção, sala de acolhimento e de reunião). Todos os medicamentos avaliados e a sala de acolhimento apresentaram um aumento de mais de 10p.p. de 2012 para 2014. As prevalências de estrutura adequada de materiais, medicamentos e física nas UBS foram maiores em 2014. A estrutura adequada de materiais passou de 3,9% para 7,8%, de medicamentos de 31,3% para 49,9% e física de 15,3% para 23,3%. Os municípios com mais de 300 mil habitantes, melhor Índice de Desenvolvimento Humano (IDH) e menor cobertura de Estratégia Saúde da Família (ESF) registraram maiores prevalências de UBS adequadas. As unidades que aderiram aos Ciclos I e II do PMAQ obtiveram melhoria em suas estruturas. Entretanto, foi encontrada baixa prevalência de UBS com estrutura adequada, além de diferenças na estrutura dos serviços, de acordo com o porte populacional, IDH e cobertura de ESF.

Abtstract: The objective was to describe the necessary structure for treating diabetes patients in the primary healthcare system, as evaluated in Cycles I and II of the Brazilian National Program for the Improvement of Access and Quality (PMAQ) in 2012 and 2014, according to the municipalities' characteristics. A descriptive study was used to assess primary care units whose teams participated in Cycles I and II of the PMAQ in 2012 and 2014. The study used variables from Module I of the external evaluation of the PMAQ that addresses the primary care units' structure. Materials (150kg scale, sphygmomanometer, adult stethoscope, tape measure, blood glucose monitor, monofilament packs, ophthalmoscope, and capillary blood glucose strips); medicines (NPH and regular insulin, glyburide, and metformin); and physical space (clinical consultation room, pharmacy, reception/waiting room, and meeting room). All the medicines and the reception/waiting room increased by more than 10p.p. from 2012 to 2014. The prevalence rates for adequate structure of materials, medicines, and physical space in the primary care units were higher in 2014. Adequate structure increased as follows: for materials, from 3.9% to 7.8%, for medicines, from 31.3% to 49.9%, for physical space, from 15.3% to 23.3%. Municipalities with more than 300,000 inhabitants, higher Human Development Index (HDI), and lower coverage of the Family Health Strategy (FHS) showed higher prevalence rates for adequate primary care units. Units that adhered to Cycles I and II of the PMAQ showed improvement in their structures. However, there was a low prevalence of primary care units with adequate structures, besides differences in the services' structure according to population size, HDI, and FHS coverage.

El objetivo fue describir la estructura necesaria para la atención a las personas con diabetes, usuarias de la red de atención primaria en salud, evaluada en los Ciclos I y II del Programa Nacional de Mejoría del Acceso y de la Calidad (PMAQ) en Brasil, 2012 y 2014, considerándose las características de los municipios. Utilizándose un estudio descriptivo se evaluaron las unidades básicas de salud (UBS), cuyos equipos participaron en los Ciclos I y II del PMAQ, en 2012 y 2014. Se utilizaron variables del Módulo I de evaluación externa del PMAQ que aborda la estructura de las UBS. Materiales (peso de 150kg, esfigmomanómetro, estetoscopio adulto, cinta métrica, glucómetro, kit de monofilamentos, oftalmoscopio y tiras de glucemia capilar); medicamentos (insulina NPH y regular, glibenclamida y metformina) y espacio físico (consultorio clínico, farmacia, recepción, sala de acogida y reunión). Todos los medicamentos evaluados y la sala de acogida presentaron un aumento de más de 10p.p. de 2012 a 2014. Las prevalencias sobre estructura adecuada de materiales, medicamentos y física en las UBS fueron mayores en 2014. La estructura adecuada de materiales pasó de 3,9% a 7,8%, de medicamentos de 31,3% a 49,9% y física de 15,3% a 23,3%. Los municipios con más de 300.000 habitantes, mejor Índice de Desarrollo Humano (IDH) y menor cobertura de Estrategia Salud de la Familia (ESF), registraron mayores prevalencias de UBS adecuadas. Las unidades que se adhirieron a los Ciclos I y II del PMAQ obtuvieron una mejoría en sus estructuras. No obstante, se encontró una baja prevalencia de UBS con estructura adecuada, además de las diferencias en la estructura de los servicios, de acuerdo con la dimensión poblacional, IDH y cobertura de ESF.

Cocaine and Caffeine Effects on the Conditioned Place Preference Test: Concomitant Changes on Early Genes within the Mouse Prefrontal Cortex and Nucleus Accumbens.

Caffeine is the world's most popular psychostimulant and is frequently used as an active adulterant in many illicit drugs including cocaine. Previous studies have shown that caffeine can potentiate the stimulant effects of cocaine and cocaine-induced drug seeking behavior. However, little is known about the effects of this drug combination on reward-related learning, a key process in the maintenance of addiction and vulnerability to relapse. The goal of the present study was thus to determine caffeine and cocaine combined effects on the Conditioned Place Preference (CPP) test and to determine potential differential mRNA expression in the Nucleus Accumbens (NAc) and medial prefrontal cortex (mPFC) of immediate-early genes (IEGs) as well as dopamine and adenosine receptor subunits. Mice were treated with caffeine (5 mg/kg, CAF), cocaine (10 mg/kg, COC), or their combination (caffeine 5 mg/kg + cocaine 10 mg/kg, CAF-COC) and trained in the CPP test or treated with repeated injections inside the home cage. NAc and mPFC tissues were dissected immediately after the CPP test, after a single conditioning session or following psychostimulant injection in the home cage for mRNA expression analysis. CAF-COC induced a marked change of preference to the drug conditioned side of the CPP and a significant increase in locomotion compared to COC. Gene expression analysis after CPP test revealed specific up-regulation in the CAF-COC group of Drd1a, cFos, and FosB in the NAc, and cFos, Egr1, and Npas4 in the mPFC. Importantly, none of these changes were observed when animals received same treatments in their home cage. With a single conditioning session, we found similar effects in both CAF and CAF-COC groups: increased Drd1a and decreased cFos in the NAc, and increased expression of Drd1a and Drd2, in the mPFC. Interestingly, we found that cFos and Npas4 gene expression were increased only in the mPFC of the CAF-COC. Our study provides evidence that caffeine acting as an adulterant could potentiate reward-associated memories elicited by cocaine. This is associated with specific changes in IEGs expression that were observed almost exclusively in mice that received the combination of both psychostimulants in the context of CPP memory encoding and retrieval. Our results highlight the potential relevance of caffeine in the maintenance of cocaine addiction which might be mediated by modifying neural plasticity mechanisms that strengthen learning of the association between drug and environment.

Indexed left atrial size predicts all-cause and cardiovascular mortality in patients undergoing aortic valve surgery.

OBJECTIVES: The enlargement of the left atrium has been identified as a marker of chronically increased left ventricular filling pressure and left ventricular diastolic dysfunction. This study aims to evaluate the association of indexed left atrial diameter with stroke, cardiovascular mortality, the combined event, and all-cause mortality in patients who underwent aortic valve surgery. METHODS: Indexed left atrial diameter was measured in 2011 adult patients (mean age, 70.9 ± 10.8 years; 58.7% were men) who underwent aortic valve surgery between January 2008 and March 2016. RESULTS: On the basis of the criteria of the American Society of Echocardiography, indexed left atrial diameter was normal in 64% of patients, mildly enlarged in 12.4% of patients, moderately enlarged in 9.2% of patients, and severely enlarged in 14.3% of patients. Over a mean follow-up period of 3.2 ± 2.1 years, there were 334 deaths and 97 strokes. Cardiovascular mortality survival at 5 years among patients with normal, mild, moderate, and severe left atrial enlargement was 91.6%, 86.8%, 77.9%, and 77.4%, respectively (P < .001). After covariable adjustment, Cox regression analysis showed indexed left atrial diameter as an independent predictor of all-cause mortality (hazard ratio per 1-cm/m2 increment, 1.545; 95% confidence interval, 1.252-1.906, P < .001), cardiovascular death (hazard ratio per 1-cm/m2 increment, 1.971; 95% confidence interval, 1.541-2.520; P < .001), and the combined event (hazard ratio per 1-cm/m2 increment, 1.673; 95% confidence interval, 1.321-2.119; P < .001). CONCLUSIONS: Indexed left atrial diameter is a strong predictor of long-term outcomes in patients with aortic valve diseases who undergo surgery.

Long-Term Outcomes and Durability of the Mitroflow Aortic Bioprosthesis.

BACKGROUND: This study aims to determine the incidence and causes of structural valve deterioration (SVD) among all models of Mitroflow bioprostheses (A12/LX/DL), as well as to define their long-term clinical and hemodynamic performance. METHODS AND RESULTS: We retrospectively reviewed a series of 1023 patients who underwent aortic valve replacement with Mitroflow bioprostheses between 2001 and 2014. A small aortic root was found in 22.4% of patients. There were two cases of severe patient-prosthesis mismatch. Only 31 patients developed SVD. The rate of incidence was 8.1 cases per 1000 patient-years. Cumulative incidence of SVD was 1.4% and 3% at five and 10 years, respectively. Freedom from SVD was 97.4% and 88.2% at five and 10 years, respectively. Anticalcification phospholipid reduction treatment (PRT) for model DL was a protective factor for SVD. Multivariable analysis confirmed age <70 years and use of 19 mm valve as independent predictors of SVD. Cumulative survival was 76.6% at five years and 42.3% at 10 years (mean follow-up 3.8 ± 3.1 years). In multivariable analysis, neither the use of small aortic prosthesis (p = 0.18) nor the occurrence of SVD (p = 0.85) was found to be independent predictors of long-term survival. CONCLUSIONS: Mitroflow valves demonstrate an acceptable rate of SVD and satisfactory long-term hemodynamic performance, particularly in patients with small aortic roots, age >70 years, and cases with severe left ventricular hypertrophy. PRT might contribute to improved long-term durability. doi: 10.1111/jocs.12726 (J Card Surg 2016;31:264-273).