Emergency presentation of colorectal patients in Spain.

BACKGROUND: Colorectal cancer (CRC) is the leading cause of cancer deaths in Europe. Survival is poorer in patients admitted to hospitals through the emergency department than in electively admitted patients. Knowledge of factors associated with a cancer diagnosis through presentation at an emergency department may reduce the likelihood of an emergency diagnosis. This study evaluated factors influencing the diagnosis of CRC in the emergency department. METHODS AND FINDINGS: This is a cross-sectional study in 5 Spanish regions; subjects were incident cases of CRC diagnosed in 9 public hospitals, between 2006 and 2008. Data were obtained from patient interviews and primary care and hospital clinical records. We found that approximately 40% of CRC patients first contacted a hospital for CRC through an emergency service. Women were more likely than men to be emergency presenters. The type of symptom associated with emergency presentation differed between patients with colon cancer and those with rectal cancer, in that the frequency of "alarm symptoms" was significantly lower in colon than in rectal cancer patients who initially presented to emergency services. Soon after symptom onset, some patients went to a hospital emergency service, whereas others contacted their GP. Lack of contact with a GP for CRC-related symptoms was consistently related to emergency presentation. Among patients who contacted a GP, a higher number of consultations for CRC symptoms and any referral to outpatient consultations reduced the likelihood of emergency presentation. All diagnostic time intervals were shorter in emergency presenters than in elective patients. CONCLUSIONS: Emergency presenters are not a uniform category and can be divided into categories according to their symptoms, help seeking behavior trajectory and interaction with their GPs. Time constraints for testing and delays in obtaining outpatient appointments led patients to visit a hospital service either on their own or after referral by their GP.

Predictive factors of satisfaction and quality of life after immediate breast reconstruction using the BREAST-Q©.

AIMS AND OBJECTIVES: To analyse quality of life and satisfaction after immediate breast reconstruction due to cancer and its determining factors. BACKGROUND: Studying breast reconstruction is important because of its frequency and variability. In addition to the surgical results, it is necessary to analyse the quality of life and patient satisfaction using a specific tool. DESIGN METHODS: An ambispective design was used (n = 101; α = 0.05; precision = 10%), studying anthropometric, sociocultural data, Fagerström test and the BREAST-Q© questionnaire. A logistic regression analysis was performed to identify variables associated with quality of life and satisfaction. RESULTS: Mean age of the patients on diagnosis was 44.87 ± 8.5 years. Forty-one of the patients were carried out a skin-sparing mastectomy (42.7%). Immediate reconstruction was performed with implant in 73 (74.5%). The domains on the BREAST-Q© for quality of life with the lowest scores were physical well-being chest (74) and sexual well-being (61.5). The satisfaction domain with the lowest score was with the breast (59). The variables associated with the worst quality of life in the physical well-being chest domain were the skin-sparing mastectomy (OR, 4.2; 95% confidence interval (CI), 1.2-14.1) and lymphedema (OR, 12.9; 95% CI, 1.0-159.9). Antibody treatment was associated with a worse score on the psychosocial well-being domain (OR, 4.25; 95% CI, 1.0-18.0) and sexual well-being domain (OR, 7.34; 95% CI, 0.9-54.6). Satisfaction was associated with nicotine dependence on the breast and outcome scale. The higher the dependence on nicotine, the greater the dissatisfaction with the breasts (OR, 2.41; 95% CI, 1.1-5.3) and with the result (OR, 2.45; 95% CI, 1.0-5.9). CONCLUSIONS: The type of treatment and lymphedema modify the patients' quality of life. Nicotine dependence is associated with lower satisfaction with the breast and with the outcome. RELEVANCE TO CLINICAL PRACTICE: This study suggests the need for multidisciplinary attention during the first year of adjuvant treatment despite the benefits of immediate reconstruction. It shows the need for preoperative assessment of the level of nicotine dependence, anxiety and depression of smoking patients before preoperative counselling.

A complexity scale for clinical trials from the perspective of a pharmacy service.

OBJECTIVE: To establish a method for evaluating the complexity of clinical trials (CTs) from the perspective of a pharmacy service (PS) and to analyse the complexity of CTs carried out in a tertiary level hospital. METHODS: An observational, prevalence and retrospective study was carried out in a Spanish tertiary level hospital during the period 2008-2013. A scale of complexity was developed, whose internal consistency was determined by Cronbach's alpha. The study involved five steps: an analysis of the activities involved, score allocation to the activities, identification of CTs started in the study period, data collection and assessment of the complexity. Three complexity levels were determined: low, medium and high. The variables calculated were mean overall complexity, mean complexity per medical specialty, per pathology, per phase of CT, per initiation year and percentage of CTs by complexity level. RESULTS: Cronbach's alpha of the scale of complexity was 0.738. The two most influential items were dose preparation and number of professionals involved. 55.0% of CTs were in the medium level of complexity and 12.1% of CTs were in the high level. The mean complexity of CTs studied was 13.3±4.7 (median 12, range 6-32). Statistically significant differences were found in the complexity values between CTs of different medical specialties, pathologies, phase and dose preparation in the PS (p<0.001). CONCLUSIONS: The scale designed to evaluate the complexity of CTs had internal consistency. More than half of the CTs are in the medium level if complexity. The largest number of CTs with a high level of complexity were in rheumatology and oncology.

Validity of the Edinburgh claudication questionnaire for diagnosis of peripheral artery disease in patients with type 2 diabetes. / Validez del cuestionario de Edimburgo para el diagnóstico de arteriopatía periférica en pacientes con diabetes mellitus tipo 2.

OBJECTIVE: To assess the prevalence of peripheral artery disease and the validity of clinical signs for its diagnosis in patients with type 2 diabetes. METHODS: Setting: Health center (Mariñamansa,Orense). PERIOD: January 2011-January 2013. INCLUSION CRITERIA: Patients with type 2 diabetes, informed consent. MEASUREMENTS: Age, sex, diabetes duration, body mass index, Charlson index, blood pressure, ankle-brachial index (ABI), cholesterol levels, smoking. Cardiovascular risk (UKPDS). Edinburgh Claudication Questionnaire. SAMPLE SIZE: n=323 (± 5.5% accuracy, 95% confidence). STATISTICAL ANALYSIS: multivariate logistic regression analysis. Sensitivity, specificity, predictive values, and agreement were estimated. Informed consent and ethics committee approval were obtained (2010/278). RESULTS: Mean patient age was 71.56±12.73 years, and mean diabetes duration 12.38±9.96 years. Symptoms of intermittent claudication were reported by 26,4% of patients, ABI was normal (0.9-1.1) in 37.2% of patients, less than 0.9 in 26,5%, and higher than 1.10 in 36.2% of patients. The kappa index of agreement of peripheral artery disease according to the Edinburgh Claudication Questionnaire and the ankle-brachial index was 0.33). The questionnaire showed a sensitivity of 50.7% for predicting the diagnosis of peripheral artery disease (ABI <0.9) with a specificity of 82.6%, with positive and negative predictive values of 48.6% and 83.8% respectively. CONCLUSIONS: One-fourth of patients with type 2 diabetes had peripheral artery disease. There was a low level of agreement between the evaluation of symptoms of intermittent claudication and the results of the ankle-brachial index. Presence or absence of symptoms of claudication did not allow for confirming or ruling out peripheral artery disease.

Negative Pressure Wound Therapy for a Complicated Abdominal Laparotomy in Neonatal Necrotizing Enterocolitis: A Case Report.

Necrotizing enterocolitis (NEC) is the most common surgical emergency in neonatal intensive care units, and patients who require surgery have high mortality and morbidity rates. The utility of negative pressure in the management of adults with complicated abdominal wounds has been documented, but there are few reports describing the use of negative pressure wound therapy (NPWT) in children or following neonatal surgery. The case of a 6 day old, 5-weeks premature neonate with NEC is presented. An exploratory midline laparotomy was performed on day 3 of life owing to rectal bleeding and abdominal distension that did not respond to gastric decompression, bowel rest, and intravenous antibiotics. Ten (10) cm of necrosis in the distal ileum were noted and resected; in addition, an ileostomy was performed, and a Penrose drain was left in the surgical site. On postoperative day 5, the laparotomy dehisced. Continuous NPWT (50 mm Hg) was initiated and changed owing to patient tolerance to intermittent therapy (5 minutes on, 30 seconds off) at 80 mm Hg. By postoperative day 11, granulation tissue formation was complete. No surgical procedures were required for the complete closure of the abdominal wall, and no adverse reactions were noted. The baby was discharged from the hospital on postop day 15. In this patient, the use of negative pressure was found to be safe and facilitated management of a complicated abdominal wound in the presence of a stoma and the formation of healthy granulation tissue. Additional research is needed to help clinicians provide optimal, evidence-based care for dehisced wounds in this vulnerable population.

Incidence of cardiovascular events and associated risk factors in kidney transplant patients: a competing risks survival analysis.

BACKGROUND: The high prevalence of cardiovascular risk factors among the renal transplant population accounts for increased mortality. The aim of this study is to determine the incidence of cardiovascular events and factors associated with cardiovascular events in these patients. METHODS: An observational ambispective follow-up study of renal transplant recipients (n = 2029) in the health district of A Coruña (Spain) during the period 1981-2011 was completed. Competing risk survival analysis methods were applied to estimate the cumulative incidence of developing cardiovascular events over time and to identify which characteristics were associated with the risk of these events. Post-transplant cardiovascular events are defined as the presence of myocardial infarction, invasive coronary artery therapy, cerebral vascular events, new-onset angina, congestive heart failure, rhythm disturbances, peripheral vascular disease and cardiovascular disease and death. The cause of death was identified through the medical history and death certificate using ICD9 (390-459, except: 427.5, 435, 446, 459.0). RESULTS: The mean age of patients at the time of transplantation was 47.0 ± 14.2 years; 62% were male. 16.5% had suffered some cardiovascular disease prior to transplantation and 9.7% had suffered a cardiovascular event. The mean follow-up period for the patients with cardiovascular event was 3.5 ± 4.3 years. Applying competing risk methodology, it was observed that the accumulated incidence of the event was 5.0% one year after transplantation, 8.1% after five years, and 11.9% after ten years. After applying multivariate models, the variables with an independent effect for predicting cardiovascular events are: male sex, age of recipient, previous cardiovascular disorders, pre-transplant smoking and post-transplant diabetes. CONCLUSIONS: This study makes it possible to determine in kidney transplant patients, taking into account competitive events, the incidence of post-transplant cardiovascular events and the risk factors of these events. Modifiable risk factors are identified, owing to which, changes in said factors would have a bearing of the incidence of events.

Time to diagnosis and stage of symptomatic colorectal cancer determined by three different sources of information: A population based retrospective study.

BACKGROUND: Survival rates from colorectal cancer (CRC) are highly variable in Europe. This variability could potentially be explained by differences in healthcare system delays in diagnosis. However, even when such delays are reduced, the relationship of the diagnostic interval (time from presentation with symptoms to diagnosis) with outcome is uncertain. METHODS: A total of 795 patients with CRC from 5 regions of Spain were retrospectively examined in this population-based multicenter study. Consecutive incident cases of CRC were identified from pathology services. The total diagnostic interval (TDI) was defined as the time from the first presentation with symptoms to diagnosis based on 3 different sources of information: (i) patient-recorded data (PR-TDI) by interview, (ii) hospital-recorded data (HR-TDI), and (iii) general practitioner-recorded data (GPR-TDI). Concordance correlation coefficients (CCCs) were used to estimate the agreement of 3 different TDIs. The TDIs of patients with different stages of CRC were also compared using the Kruskal-Wallis test. RESULTS: The median TDI was 131days based on patient interview data, 91days based on HR data, and 111days based on GPR data. Overall, the agreement of these TDIs was poor (CCCPRvsHR=0.399, CCCPRvsGPR=0.518, CCCHRvsGPR=0.383). Univariate analysis indicated that the TDI was greater in those with less advanced CRC for all 3 methods of calculation, but this association was only statistically significant for the HR-TDI (p=0.021). CONCLUSION: There is no evidence that patients with more advanced CRC have longer TDIs. In fact, we found an inverse relationship between the TDI and CRC stage, an example of the "waiting time paradox". This association may likely be due to the presence of unmeasured confounders as the stage when symptoms appear or the tumour aggressiveness.

Variability between Clarke's angle and Chippaux-Smirak index for the diagnosis of flat feet / Variabilidad entre el ángulo de Clarke y el índice de Chippaux- Smirak para el diagnóstico de pie plano

Abstract Background: The measurements used in diagnosing biomechanical pathologies vary greatly. The aim of this study was to determine the concordance between Clarke's angle and Chippaux-Smirak index, and to determine the validity of Clarke's angle using the Chippaux-Smirak index as a reference. Methods: Observational study in a random population sample (n= 1,002) in A Coruña (Spain). After informed patient consent and ethical review approval, a study was conducted of anthropometric variables, Charlson comorbidity score, and podiatric examination (Clarke's angle and Chippaux-Smirak index). Descriptive analysis and multivariate logistic regression were performed. Results: The prevalence of flat feet, using a podoscope, was 19.0% for the left foot and 18.9% for the right foot, increasing with age. The prevalence of flat feet according to the Chippaux-Smirak index or Clarke's angle increases significantly, reaching 62.0% and 29.7% respectively. The concordance (kappa I) between the indices according to age groups varied between 0.25-0.33 (left foot) and 0.21-0.30 (right foot). The intraclass correlation coefficient (ICC) between the Chippaux-Smirak index and Clarke's angle was -0.445 (left foot) and -0.424 (right foot). After adjusting for age, body mass index (BMI), comorbidity score and gender, the only variable with an independent effect to predict discordance was the BMI (OR= 0.969; 95% CI: 0.940-0.998). Conclusion: There is little concordance between the indices studied for the purpose of diagnosing foot arch pathologies. In turn, Clarke's angle has a limited sensitivity in diagnosing flat feet, using the Chippaux-Smirak index as a reference. This discordance decreases with higher BMI values.

Resumen Introducción: Existe una gran variabilidad en las mediciones para el diagnóstico de la patología biomecánica. El objetivo de este estudio fue determinar la concordancia entre el ángulo de Clarke y el índice de Chippaux-Smirak, para determinar la validez del ángulo de Clarke utilizando como referencia el índice de Chippaux-Smirak. Métodos: Se realizó un estudio observacional en una muestra aleatoriamente seleccionada (n= 1,002) en A Coruña (España). Tras el consentimiento informado del paciente y la aprobación del comité de ética, se estudiaron variables, antropométricas, índice de comorbilidad de Charlson y un examen podológico (ángulo de Clarke, índice de Chippaux-Smirak). Se realizó un estudio descriptivo y un análisis multivariado de regresión logística. Resultados: La prevalencia de pie plano utilizando el podoscopio fue de 19.0% (pie izquierdo) y 18.9% (pie derecho), incrementándose con la edad. La prevalencia de pie plano según el índice Chippaux-Smirak o el ángulo de Clarke se incrementan considerablemente llegando a 62.0% y 29.7%. La concordancia (kappa I) entre los índices según grupos de edad oscila entre 0.25-0.33 (pie izquierdo) y 0.21-0.30 (pie derecho). El coeficiente de correlación intraclase (CCI) entre el índice de Chippaux-Smirak y el ángulo de Clarke es -0.445 (pie izquierdo) y 0.424 (pie derecho). Tras ajustar por edad, índice de masa corporal (IMC), score de comorbilidad y sexo la única variable con un efecto independiente para predecir discordancia es el IMC (OR= 0.969; IC 95%: 0.940-0.998). Conclusiones: La concordancia entre los índices estudiados para el diagnóstico de la patología del arco plantar es reducida. Existe a su vez una reducida sensibilidad del ángulo de Clarke para el diagnóstico de pie plano, utilizando como referencia el índice de Chippaux-Smirak. Esta discordancia disminuye con valores más altos de IMC.

Effect of diagnostic delay on survival in patients with colorectal cancer: a retrospective cohort study.

BACKGROUND: Disparate and contradictory results make studies necessary to investigate in more depth the relationship between diagnostic delay and survival in colorectal cancer (CRC) patients. The aim of this study is to analyse the relationship between the interval from first symptom to diagnosis (SDI) and survival in CRC. METHODS: Retrospective study of n = 942 CRC patients. SDI was calculated as the time from the diagnosis of cancer and the first symptoms of CRC. Cox regression was used to estimate five-year mortality hazard ratios as a function of SDI, adjusting for age and gender. SDI was modelled according to SDI quartiles and as a continuous variable using penalized splines. RESULTS: Median SDI was 3.4 months. SDI was not associated with stage at diagnosis (Stage I = 3.6 months, Stage II-III = 3.4, Stage IV = 3.2; p = 0.728). Shorter SDIs corresponded to patients with abdominal pain (2.8 months), and longer SDIs to patients with muchorrhage (5.2 months) and rectal tenesmus (4.4 months). Adjusting for age and gender, in rectum cancers, patients within the first SDI quartile had lower survival (p = 0.003), while in colon cancer no significant differences were found (p = 0.282). These results do not change after adjusting for TNM stage. The splines regression analysis revealed that, for rectum cancer, 5-year mortality progressively increases for SDIs lower than the median (3.7 months) and decreases as the delay increases until approximately 8 months. In colon cancer, no significant relationship was found between SDI and survival. CONCLUSIONS: Short diagnostic intervals are significantly associated with higher mortality in rectal but not in colon cancers, even though a borderline significant effect is also observed in colon cancer. Longer diagnostic intervals seemed not to be associated with poorer survival. Other factors than diagnostic delay should be taken into account to explain this "waiting-time paradox".

A randomized clinical trial to determine the effectiveness of CO-oximetry and anti-smoking brief advice in a cohort of kidney transplant patients who smoke: study protocol for a randomized controlled trial.

BACKGROUND: The cardiovascular risk in renal transplant patients is increased in patients who continue to smoke after transplantation. The aim of the study is to measure the effectiveness of exhaled carbon monoxide (CO) measurement plus brief advisory sessions, in comparison to brief advice, to reduce smoking exposure and smoking behavior in kidney transplant recipients who smoke. The effectiveness will be measured by: (1) abandonment of smoking, (2) increase in motivation to stop smoking, and (3) reduction in the number of cigarettes smoked per day. DESIGN: a randomized, controlled, open clinical trial with blinded evaluation. SCOPE: A Coruña Hospital (Spain), reference to renal transplantation in the period 2012-2015. INCLUSION CRITERIA: renal transplant patients who smoke in the precontemplation, contemplation or preparation stages according to the Prochaska and DiClemente's Stages of Change model, and who give their consent to participate. EXCLUSION CRITERIA: smokers attempting to stop smoking, patients with terminal illness or mental disability that prevents them from participating. RANDOMIZATION: patients will be randomized to the control group (brief advisory session) or the intervention group (brief advisory session plus measuring exhaled CO). The sample target size is n = 112, with 56 patients in each group. Allowing for up to 10 % loss to follow-up, this would provide 80 % power to detect a 13 % difference in attempting to give up smoking outcomes at a two-tailed significance level of 5 %. MEASUREMENTS: sociodemographic characteristics, cardiovascular risk factors, treatment, rejection episodes, infections, self-reported smoking habit, drug use, level of dependence (the Fagerström test), stage of change (Prochaska and DiClemente's Stages of Change model), and motivation to giving up smoking (the Richmond test). RESPONSE: the effectiveness will be evaluated every 3, 6, 9 and 12 months as: pattern of tobacco use (self-reported tobacco use), smoking cessation rates, carbon monoxide (CO) levels in exhaled air measured by CO-oximetry, urinary cotinine tests, nicotine dependence (Fagerström test), motivational stages of change (Prochaska and DiClemente's stages) and motivation to stop smoking (the Richmond test). ANALYSIS: descriptive statistics and linear/logistic multiple regression models will be performed. Clinical relevance will be measured as relative risk reduction, absolute risk reduction and the number needed to treat. ETHICS: informed consent of the patients and Ethical Review Board was obtained (code 2011/061). DISCUSSION: Tobacco is a modifiable risk factor that increase the risk of morbidity and mortality in kidney transplant recipients. If effectiveness of CO-oximetry is confirmed to reduce tobacco exposure, we would have an intervention that is easy to use, low cost and with great implications about cardiovascular risk prevention in these patients. TRIAL REGISTRATION: Current Controlled Trials ISRCTN16615772 . EudraCT number: 2015-002009-12.

Characteristics and pattern of recurrence after curative surgery in oesophageal cancer.

BACKGROUND AND AIM: Recurrence in oesophageal cancer continues to remain high after curative surgery. The aim of this study was to determine the presence of recurrence after curative surgery during follow-up, and the associated variables. METHODS: A retrospective and prospective follow-up study in patients with an anatomical-pathological diagnosis of oesophageal cancer who underwent curative surgery (n = 57) in the health district of A Coruña (Spain) during the period 2003-2008. The calculation of recurrence-free survival was made using a competing risks survival analysis. RESULTS: Out of the 57 patients included in the study, 87.7% were men with a mean age of 61.4 ± 10.3 years. The median follow-up period was 18.5 months, during which 28 recurrences were detected (50.9%). Patients with dysphagia on diagnosis of the disease, as well as patients in stages III-IV, have a higher probability of recurrence during the follow-up period. The median disease-free interval was 8.5 months. After one year of follow up, 57.1% of the recurrences were diagnosed and 82.1% after 2 years of followup. The median post-recurrence survival rate was 4.7 months. After adjusting for a multivariate regression model, the variable with an independent effect for predicting recurrence is the TNM classification (HR = 8.49). CONCLUSIONS: The majority of the recurrences will be developed during the 2 years after surgery, with a very poor prognosis. The predictor variable for recurrence is the TMN classification.

Cost-effectiveness analysis of preoperative treatment of acromegaly with somatostatin analogue on surgical outcome.

CONTEXT: There is no uniform standard of care for acromegaly. Due to the high costs involved, steps must be taken to ensure the cost-effective delivery of treatment. OBJECTIVE: Taking the results of an earlier meta-analysis as a starting point, this study aims to determine whether treatment with long-acting somatostatin analogue (SSA) prior to surgery improves the cost-effectiveness of the treatment of acromegaly. METHODS: The results are presented as an Incremental Cost Effectiveness Ratio (ICER) immediately after surgery, for the following year and over the next four decades. The cure rates percentage (95% CI) for the three randomized prospective controlled trials were 44.4% (34.2-54.7) and 18.2% (10.1-26.3) for preoperative treated and untreated patients respectively. The cost of pharmacological treatments was based on the number of units prescribed, dose and length of treatment. RESULTS: The mean (95% CI) ICER immediately after surgery was €17,548 (12,007-33,250). In terms of the postoperative SSA treatment, the ICER changes from positive to negative before two years after surgery. One decade after surgery the ICER per patient/year was €-9973 (-18,798; -6752) for postoperative SSA treatment and €-31,733 (-59,812; -21,483) in the case of postoperative pegvisomant treatment. CONCLUSIONS: In centres without optimal surgical results, preoperative treatment of GH-secreting pituitary macroadenomas with SSA not only shows a significant improvement in the surgical results, but is also highly cost-effective, with an ICER per patient/year one decade after surgery, of between €-9973 (-18,798; -6752) and €-31,733 (-59,812; -21,483) for SSA and pegvisomant respectively.

Factores pronósticos en adultos hospitalizados por neumonía causada por Legionella pneumophila / Prognostic factors in adult patients hospitalized for pneumonia caused by Legionella pneumophila

Introduction: Legionellosis is a multisystem bacterial disease, which causes pneumonia with high mortality in patients with comorbidity and admitted in intensive care units (ICU). Objective: Determine predictors of mortality or ICU admission. Methods: Retrospective follow-up of patients diagnosed with Legionella pneumophila pneumonia in Complexo Hospitalario Universitario de A Coruña. Period 2000-2013 (n = 240). Analysis of multivariate logistic regression was performed. Results: Mean age was 57.2 ± 15.4 years old, 88.3% were male. Average score of comorbidity (Charlson score) was 2.3 ± 2.3. There was a clear seasonal variation. Predominant symptoms were fever (92.5%), dry cough (38.1%) and dyspnea (33.9%). Creatinine clearance was lower than 60 mL/min/1.73 m² in 29.7% and sodium < 135 mEq/l in 58.3%. Admission to ICU rate was 16.3% and 10.8% needs mechanical ventilation. Inhospital mortality rate was 4.6%, rising to 23.1% in patients admitted to ICU. Variables associated to predict ICU admission were age (OR = 0.96), liver disease (OR = 7.13), dyspnea (OR = 4.33), delirium (OR = 5.86) and high levels of lactatedehydrogenase (OR = 1.002). Variables associated with inhospital mortality were Charlson index (OR = 1.70), mechanical ventilation (OR = 31.44) and high levels of lactatedehydrogenase (OR = 1.002). Discussion: Younger patients with liver disease, dyspnea and confusion are more likely to be admitted to ICU. Comorbidity, mechanical ventilation and elevated LDH levels are associated with higher mortality rate.

Introducción: La legionelosis es una enfermedad bacteriana multisistémica, causante de neumonías con mortalidad elevada en pacientes con comorbilidad e ingresos en Unidad de Cuidados Intensivos (UCI). Objetivo: Determinar factores pronósticos de mortalidad o ingreso en UCI. Material y Métodos: Estudio de seguimiento retrospectivo de pacientes diagnosticados de neumonía por Legionella pneumophila en Complexo Hospitalario Universitario de A Coruña (España). Período 2000-2013 (n = 240), con análisis de regresión logística multivariada. Resultados: La edad media fue 57,2 ± 15,4 años, 88,3% fueron hombres. La puntuación media de comorbilidad (score Charlson) fue 2,3 ± 2,3. Existe clara estacionalidad. La clínica predominante fue fiebre (92,5%), tos seca (38,1%) y disnea (33,9%). El 29,7% presentó aclaramiento de creatinina < 60 mL/min/1,73 m² y el 58,3% sodio < 135 mEq/l. Un 16,3% ingresó en UCI, precisando ventilación mecánica invasiva el 10,8%. La mortalidad global fue 4,6% y de 23,1% en ingresados en UCI. Variables asociadas para predecir ingreso en UCI fueron menor edad (OR = 0,96), hepatopatía (OR = 7,13), disnea (OR = 4,33), síndrome confusional (OR = 5,86) y lactato deshidrogenasa elevada (OR = 1,002). Las variables asociadas a mortalidad intrahospitalaria fueron índice de Charlson (OR = 1,70), ventilación mecánica invasiva (OR = 31,44) y cifras elevadas de lactato deshidrogenasa (OR = 1,002). Discusión: Pacientes jóvenes, con hepatopatía, disnea o confusión tienen más probabilidad de ingresar en UCI. Comorbilidad, ventilación mecánica y lactato deshidrogenasa elevada se asocian a mortalidad.

Clinical-pathological characteristics and prognosis of a cohort of oesophageal cancer patients: a competing risks survival analysis.

BACKGROUND: To determine the clinical course, follow-up strategies, and survival of oesophageal cancer patients using a competing risks survival analysis. METHODS: We conducted a retrospective and prospective follow-up study. The study included 180 patients with a pathological diagnosis of oesophageal cancer in A Coruña, Spain, between 2003 and 2008. The Kaplan-Meier methodology and competing risks survival analysis were used to calculate the specific survival rate. The study was approved by the Ethics Review Board (code 2011/372, CEIC Galicia). RESULTS: The specific survival rate at the first, third, and fifth years was 40.2%, 18.1%, and 12.4%, respectively. Using the Kaplan-Meier methodology, the survival rate was slightly higher after the third year of follow-up. In the multivariate analysis, poor prognosis factors were female sex (hazard ratio [HR] 1.94; 95% confidence interval [CI], 1.24-3.03), Charlson's comorbidity index (HR 1.17; 95% CI, 1.02-1.33), and stage IV tumours (HR 1.70; 95% CI, 1.11-2.59). The probability of dying decreased with surgical and oncological treatment (chemotherapy and/or radiotherapy) (HR 0.23; 95% CI, 0.12-0.45). The number of hospital consultations per year during the follow-up period, from diagnosis to the appearance of a new event (local recurrences, newly appeared metastasis, and newly appeared neoplasias) did not affect the probability of survival (HR 1.03; 95% CI, 0.92-1.15). CONCLUSIONS: The Kaplan-Meier methodology overestimates the survival rate in comparison to competing risks analysis. The variables associated with a poor prognosis are female sex, Charlson's comorbidity score and extensive tumour invasion. Type of follow-up strategy employed after diagnosis does not affect the prognosis of the disease.

A cardiovascular educational intervention for primary care professionals in Spain: positive impact in a quasi-experimental study.

BACKGROUND: Routine general practice data collection can help identify patients at risk of cardiovascular disease. AIM: To determine whether a training programme for primary care professionals improves the recording of cardiovascular disease risk factors in electronic health records. DESIGN AND SETTING: A quasi-experimental study without random assignment of professionals. This was an educational intervention study, consisting of an online-classroom 1-year training programme, and carried out in the Valencian community in Spain. METHOD: The prevalence rates of recording of cardiovascular factors (recorded every 6 months over a 4-year period) were compared between intervention and control group. Clinical relevance was calculated by absolute risk reduction (ARR), relative risk reduction (RRR), and number of patients needed-to-attend (NNA), to avoid under-recording, with their 95% confidence intervals (CIs). Linear regression models were used for each of the variables. RESULTS: Of the 941 professionals initially registered, 78.1% completed the programme. The ARR ranged from 1.87% (95% CI = 1.79 to 1.94) in the diagnosis of diabetes to 15.27% (95% CI = 15.14 to 15.40) in the recording of basal blood glucose. The NNA ranged from 7 in blood pressure, cholesterol, and blood glucose recording to 54 in the diagnosis of diabetes. The RRR ranged from 26.7% in the diagnosis of diabetes to 177.1% in the recording of the Systematic Coronary Risk Evaluation (SCORE). The rates of change were greater in the intervention group and the differences were significant for recording of cholesterol (P<0.001), basal blood glucose (P<0.001), smoking (P<0.001), alcohol (P<0.001), microalbuminuria (P = 0.001), abdominal circumference (P<0.001), and SCORE (P<0.001). CONCLUSION: The education programme had a beneficial effect at the end of the follow-up that was significant and clinically relevant.

Clinical predictors of major adverse cardiovascular events during long-term follow-up after carotid endarterectomy.

BACKGROUND: Those patients who undergo a carotid endarterectomy (CEA) will present a higher cardiovascular risk during follow-up than the general population. The objective of this study was to determine the prognostic factors and validate the accuracy of 3 cardiovascular risk scores as predictors of major adverse cardiovascular events (MACEs) during long-term follow-up after CEA. METHODS: Observational retrospective follow-up study with 416 CEAs conducted consecutively in 385 patients from 1994 to 2011. The primary end point was MACE, single event including myocardial infarction, stroke, and cardiovascular death. Preoperative risk factors and medical treatment at discharge were collected. A general cardiovascular risk score, the Revised Cardiac Risk Index (RCRI), was used, and 2 scores specific for CEA (Halm and Tu). Descriptive analysis and Cox regression were conducted. Informed consent from patients was obtained and approval by the ethics committee. RESULTS: The median follow-up was 4.94 years. MACEs appeared in 22.1% (95% confidence interval [CI], 18.0-26.2%) of the series during follow-up. The MACEs rate at 1 year, 3 years, and 5 years, was 3.1%, 9.3%, and 15.8%, respectively. In the Cox regression model, the MACE predictor variables were: the presence of peripheral artery disease (hazard ratio [HR], 1.69; 95% CI, 1.06-2.70) and RCRI (HR,1.61; 95% CI, 1.04-2.50). The RCRI area under the curve for predicting events, with a 2.5 cutoff point, was 0.59 with 85.9% sensitivity and a positive predictive value of 25.2%. CONCLUSIONS: Peripheral artery disease and high RCRI have an independent effect on predicting MACEs. The 3 different scores have a low ability for predicting MACEs during long-term follow-up.

Impact of musculoskeletal pain on health-related quality of life among fishing sector workers.

This study aims to determine the impact of musculoskeletal pain (in terms of intensity of the pain, location and functional disability due to back pain) and other factors (socio-demographic, lifestyle and co-morbidity) on the health-related quality of life on a group of shellfish gatherers. This observational transversal study included 929 shellfish gatherers (18-69 years, 98.7 % women) who completed a self-administered questionnaire, including socio-demographic and lifestyle questions, co-morbidity, intensity and location of musculoskeletal pain, and Roland-Morris Disability Questionnaire (RMDQ). Health-related quality of life was assessed using the 36-item Short Form Survey (SF-36). Physical component summary (PCS) and mental component summary (MCS) of the SF-36 were considered as outcome variables. The impact of the different factors on the PCS and MCS scores was evaluated using a stepwise linear regression analysis. Physical health was found to be independently associated to intensity of musculoskeletal pain (regression coefficient, B = -0.96), number of locations with musculoskeletal pain (MSP) (B = -0.77), presence of pain in the hip-knee (B = -2.26), self-reported rheumatic disorders (B = -2.79), lower back pain (B = -1.62) and age (B = -0.06). Mental health was associated with the presence of self-reported depressive syndrome (B = -1043.1) and RMDQ score (B = -42.2). The sample had significantly lower values than the reference population in all of the dimensions of the SF-36. Intensity of the pain, pain in the hip-knee, lower back pain, functional disability due to back pain and number of locations with musculoskeletal pain were found to have a detrimental impact on the physical health of the workers. Depressive syndrome and greater functional disability due to back pain, in turn, predict worse mental health.

Quality of life and related factors in a cohort of plaque-type psoriasis patients in La Coruña, Spain.

BACKGROUND: Psoriasis can significantly affect the physical, psychological, and social aspects of a patient's life. Many studies have evaluated the effects of psoriasis on quality of life (QoL), but results in many cases are contradictory. OBJECTIVES: This study was conducted to assess the relationships between the characteristics of psoriasis (cutaneous severity, arthropathy, treatment) and comorbidities with QoL and to determine which factors have a major influence. METHODS: We assessed demographic data, the severity of cutaneous involvement, psoriasis treatment, presence of arthropathy, psoriasis duration, smoking status, alcohol intake, and the presence of comorbidities. Concomitant diseases were evaluated using the Charlson Comorbidity Index and the National Cholesterol Education Program Adult Treatment Panel III (ATP-III) criteria for metabolic syndrome. Quality of life was assessed using the Dermatology Life Quality Index (DLQI). RESULTS: Multivariate analysis showed that factors associated with QoL impairment included gender (women experienced greater impact: odds ratio [OR] 2.85, 95% confidence interval [CI] 1.48-5.49; P = 0.002); psoriasis duration (patients with longer durations of psoriasis and psoriasis treatment experienced less impairment: OR 0.96, 95% CI 0.94-0.99; P = 0.004); and treatment type (impact was lower in patients receiving biologic drugs than in those using topical treatment [OR 3.15, 95% CI 1.50-6.62; P = 0.002] and in those using biologics compared with those using conventional systemic treatment [OR 2.23, 95% CI 0.98-5.05; P = 0.053]). Psoriasis severity measured according to scores on the Psoriasis Area and Severity Index (PASI) and body surface area affected was not related to QoL impairment. Comorbidities were associated with impaired QoL in the univariate analysis but not after adjusting for other covariates. CONCLUSIONS: Factors associated with greater impairment of QoL were gender, psoriasis duration, and type of treatment. Patients receiving systemic and biologic therapies reported better QoL.

Age differences in presentation, diagnosis pathway and management of colorectal cancer.

BACKGROUND: The gap in survival between older and younger European cancer patients is getting wider. It is possible that cancer in the elderly is being managed or treated differently than in their younger counterparts. This study aims to explore age disparities with respect to the clinical characteristics of the tumour, diagnostic pathway and treatment of colorectal cancer patients. METHODS: We conducted a multicenter cross sectional study in 5 Spanish regions. Consecutive incident cases of CRC were identified from pathology services. MEASUREMENTS: From patient interviews, hospital and primary care clinical records, we collected data on symptoms, stage, doctors investigations, time duration to diagnosis/treatment, quality of care and treatment. RESULTS: 777 symptomatic cases, 154 were older than 80 years. Stage was similar by age group. General symptoms were more frequent in the eldest and abdominal symptoms in the youngest. No differences were found regarding perception of symptom seriousness and symptom disclosure between age groups as no longer duration to diagnosis or treatment was observed in the oldest groups. In primary care, only ultrasound is more frequently ordered in those <65 years. Those >80 years had a significantly higher proportion of iron testing and abdominal XR requested in hospital. We observed a high resection rate independently of age but less adjuvant chemotherapy in Stage III colon cancer, and of radiotherapy in stage II and III rectal cancer as age increases. CONCLUSION: There are no relevant age disparities in the CRC diagnosis process with similar stage, duration to diagnosis, investigations and surgery. However, further improvements have to be made with respect to adjuvant therapy.

Diagnostic and treatment delay, quality of life and satisfaction with care in colorectal cancer patients: a study protocol.

BACKGROUND: Due to recent improvements in colorectal cancer survival, patient-reported outcomes, including health-related quality of life and satisfaction with care, have become well-established endpoints to determine the impact of the disease on the lives of patients.The aim of this study is to determine prospectively, in a cohort of colorectal cancer incident cases: a) health-related quality of life, b) satisfaction with hospital-based care, and c) functional status. A secondary objective is to determine whether diagnostic/therapeutic delay influence quality of life or patients' satisfaction levels. METHODS/DESIGN: Single-centre prospective follow-up study of colorectal cancer patients diagnosed during the period 2011-2012 (n = 375).This project was approved by the corresponding ethics review board, and informed consent is obtained from each patient. After diagnosis, patients are interviewed by a trained nurse, obtaining information on sociodemographic characteristics, family history of cancer, first symptoms, symptom perception and reaction to early symptoms. Quality of life is assessed with the EORTC QLQ-C30 and QLQ-CR29 questionnaires, and patients' satisfaction with care is determined using the EORTC IN-PATSAT32. Functional status is measured with the Karnofsky Performance Status Scale.Clinical records are also reviewed to collect information on comorbidity, tumour characteristics, treatment, hospital consultations and exploratory procedures.Symptoms-to-diagnosis interval is defined as the time from the date of first symptoms until the cytohistological confirmation of cancer. Treatment delay is defined as the time between diagnosis and surgical treatment.All the patients will be followed-up for a maximum of 2 years. For survivors, assessments will be re-evaluated at one and two years after the diagnosis.Multiple linear/logistic regression models will be used to identify variables associated with the patients' functional status, quality of life and satisfaction with care score. Changes in quality of life over time will be analysed with linear mixed-effects regression models. DISCUSSION: The results will provide a deeper understanding of the impact of colorectal cancer from a more patient-centred approach, allowing us to identify groups of patients in need of additional attention, as well as areas for improvement. Special attention will be given to the relationship between diagnostic/therapeutic delay and patients' quality of life and satisfaction with the care received.