Sustained ventricular arrhythmias in unstable angina patients: results of the ARIAM database.

BACKGROUND: The aim of this study was to investigate patients with unstable angina (UA) and the predictive factors of these arrhythmias and to determine whether this complication behaves as an independent variable with regard to mortality, increased length of stay in an ICU/CCU, and the performance of percutaneous coronary intervention (PCI). MATERIAL/METHODS: The retrospective cohort study included all patients diagnosed with UA and included in the Spanish "ARIAM" database between June 1996 and December 2005. Univariate and multivariate analyses were performed to evaluate the factors associated with these arrhythmias. 17,616 patients were included. RESULTS: Sustained ventricular tachycardia (SVT) occurred in 0.5%. The factors associated with its development were age, cardiogenic shock, and non-sustained ventricular tachycardia. SVT was associated with mortality (adjusted OR: 9.836, 95%CI: 1.81-53.33). Ventricular fibrillation (VF) occurred in 1%. In the multivariate study the variables that persistently associated independently with the development of VF were gender, Killip class, and high degree atrioventricular block (HDAVB). VF was associated with higher mortality (27.1% vs. 0.9%). Nevertheless, VF was not seen to be a variable independently associated with mortality in UA patients. Only VF was an independent variable in length of stay (adjusted OR: 2.059, 95%CI: 1.175-3.609). Neither SVT nor VF were independent variables associated with PCI. CONCLUSIONS: Patients with UA complicated by SVT or VF represent a special high-risk subgroup with poor prognosis, which could lead to their being stratified towards a poor prognosis subgroup.

[Evaluation of a health care programme with nursing tutor in a hospital traumatological facility in a hospital, Granada, Spain, 2004]. / Evaluación de un programa de atención sanitaria con enfermera tutora en cirugía de traumatologia en un hospital de Granada, 2004.

BACKGROUND: The current trend in patient care is towards a more humanized and higher-quality healthcare. The objective of the present study was to evaluate the results of implementing a programme of healthcare with a reference nurse who welcomes the patient at hospital admission, visits regularly during hospital stay, and resolves doubts and problems. METHODS: Quasi-experimental study (149 cases and 454 non-tutored controls) in patients admitted for scheduled trauma surgery at the Virgen de las Nieves University Hospital, Granada. Sociodemographic and clinical data were gathered at admission. At 15 days after discharge, patients were administered with an interviewer-administered Zung score and an ad hoc questionnaire on satisfaction with different healthcare aspects during hospital stay and understanding of information received. Bivariate analyses and linear and multivariate logistic regression analyses were performed with a study of confounding variables. RESULTS: For the outcome variable anxiety level non-tutored patients had a B coefficient of 2.64 (p<0,01) in the multivariate linear regression analysis controlling for the other variables in the final model: sex, presence of informal career, professional activity, days of hospital stay and understanding of health information. For the outcome variable inadequate understanding information non-tutored patients showed an odds ratio of 3.48 in the multivariate analysis controlling for educational level and presence of informal career. Satisfaction with he friendliness of health care personnel and with the hospital setting did not significantly difference, although the percentage of dissatisfied patients was higher in the non-tutored group: 15% vs 11% (p= 0.34) and 18% vs 12 % (p= 0.11) respectively. CONCLUSIONS: The implemented continued care programme proved effective for these patients, increasing their understanding of information received and reducing anxiety levels.

Evaluación de un programa de atención sanitaria con enfermera tutora en cirugía de traumatología en un hospital de Granada, 2004 / Evaluation of a health care programme with nursing tutor in a hospital traumatological facility in a hospital. Granada, Spain, 2004

Fundamento: La tendencia actual en la atención al paciente es hacia un aumento de la calidad en los servicios sanitarios. El objetivo de este trabajo fue evaluar los resultados de la aplicación de un programa de atención sanitaria a través de una enfermera de referencia que acogía al paciente al ingreso hospitalario, le visitaba regularmente durante su estancia y le resolvía dudas y problemas. Métodos: Estudio cuasi-experimental realizado en pacientes (149 casos y 454 controles) ingresados para cirugía traumatológica en el Hospital Virgen de las Nieves de Granada. Al ingreso se recogieron variables sociodemográficas y clínicas. A los 15 días tras el alta se les administró la "Escala heteroevaluada de ansiedad de Zung" y un cuestionario ad hoc sobre la satisfacción con diferentes aspectos de la atención sanitaria durante la estancia en el hospital y la comprensión de la información recibida. Se realizó análisis bivariante y análisis de regresión lineal y regresión logística multivariante con estudio de variables confundentes. Resultados: Para la variable nivel de ansiedad los pacientes no tutorizados en el análisis de regresión lineal multivariante tenían un coeficiente B=2,64 (p<0,01), controlando por la otras variables en el modelo final: sexo, presencia de cuidador informal actividad profesional, días de estancia, y comprensión de la información sanitaria. Para la variable de resultado insuficiente comprensión de la información los pacientes no tutorizados tenían una Odds Ratio de 3,48 en el análisis de regresión logística multivariante controlando por educación y presencia de cuidador informal. La satisfacción con la amabilidad del personal y con el medio hospitalario no se modificó significativamente aunque el porcentaje de insatisfacción fue mayor en el grupo no tutorizado, 15% frente a 11% (p= 0,34), y 18% frente a 12% (p=0,11) respectivamente. Conclusiones: El programa de atención continuada aplicado se ha manifestado eficaz para los pacientes, aumentando la comprensión de la información y disminuyendo los niveles de ansiedad (AU)

Background: The current trend in patient care is towards a more humanized and higher-quality healthcare. The objective of the present study was to evaluate the results of implementing a programme of healthcare with a reference nurse who welcomes the patient at hospital admission, visits regularly during hospital stay, and resolves doubts and problems. Methods: Quasi-experimental study (149 cases and 454 non-tutored controls) in patients admitted for scheduled trauma surgery at the Virgen de las Nieves University Hospital, Granada. Sociodemographic and clinical data were gathered at admission. At 15 days after discharge, patients were administered with an interviewer-administered Zung score and anad hoc questionnaire on satisfaction with different healthcare aspects during hospital stay and understanding of information received. Bivariate analyses and linear and multivariate logistic regression analyses were performed with a study of confunding variables. Results: For the outcome variable anxiety level non-tutored patiens had a B coeficient of 2.64 (p<0,01) in the multivariate linear regression analisys controlling for the other variables in the final model: sex, presence of informal carer, professional activitiy, days of hospital stay and understanding of health information. For the outcome variable inadequate understanding information non-tutored patients showed an odds ratio of 3.48 in the multivariate analysis controlling for educational level and presence of informal carer. Satisfaction with he friendliness of health care personnel and with the hospital setting did not significantly diference, although the percentage of dissatisfied patiens was higher in the non-tutored group: 15% vs 11% (p= 0.34) and 18% vs 12 % (p= 0.11) respectively. Conclusions: The implemented continued care programme proved effective for these patients, increasing their understanding of information received and reducing anxiety levels (AU)

Gender differences in management and outcome of patients with acute myocardial infarction.

BACKGROUND: The study objectives were to assess any gender differences in the application of diagnostic and therapeutic procedures and their impact on outcome in patients with acute myocardial infarction (AMI). METHODS: Prospective cohort study of patients in the PRIAMHO II registry. 58 randomly selected public hospitals in Spain included 6209 patients with AMI admitted to Coronary/Critical Care Unit from May 15 to December 15 2000 with 1-year follow-up. Data were gathered on use of coronary angiography and reperfusion procedures, on a combined outcome variable (including death, reinfarction, postinfarction angina, and stroke during hospital stay), and on 28-day and 1-year mortality rates. RESULTS: 4641 (74.75%) of the patients were male and 1568 (25.5%) female. No gender differences in coronary angiography or reperfusion therapy use were found. However, female sex alongside age, use of reperfusion therapy, diabetes mellitus, previous revascularization, previous AMI, and higher Killip class were predictors of the combined outcome variable, with an adjusted OR of 1.21 (CI 95% 1.02-1.42). CONCLUSIONS: No association was observed between the gender of patients with AMI and the application of diagnostic or therapeutic procedures. Nevertheless, female sex behaved as an independent adverse short-term prognostic factor.

Información recibida por los pacientes acerca de su estado de salud y su comprensión, antes y durante su hospitalización / Information received by patients on their health status and their understanding of it, before and during hospital admission

Objetivos. Determinar la cantidad de información que reciben los pacientes acerca de su estado de salud antes de su ingreso en el hospital y durante su estancia en él, su comprensión de la información y la relación de estas variables con el perfil sociodemográfico. Método. Estudio trasversal en el que se incluyeron 289 pacientes, de 16 años o más, ingresados desde octubre de 2004 hasta junio de 2005 en cirugía traumatológica programada, con buen estado cognitivo y capacidad auditiva para contestar preguntas por teléfono. Se recogieron variables sociodemográficas, grado de información y comprensión acerca de su problema de salud previo al ingreso y durante su estancia en el hospital. Resultados. En el análisis univariante tenían más riesgo de no comprender la información (p < 0,05) las personas que consideraron que habían sido poco o nada informadas acerca de su problema de salud, las que no tenían estudios o tenían sólo estudios primarios y las que vivían en áreas urbanas con menos de 10.000 habitantes. En el análisis multivariante, la percepción acerca de la cantidad de información recibida y el nivel de estudios mantuvieron la asociación con la comprensión previa de la información. Conclusiones. La información al paciente durante la estancia en el hospital es mejor comprendida que la recibida antes de su ingreso. La percepción de la cantidad de información recibida acerca de su salud es la variable más fuertemente relacionada con la comprensión de la información

Objective. To determine the amount of information received by patients on their health status before and during their hospital stay and their understanding of this information, and to relate these variables to their sociodemographic profile. Method. We performed a cross sectional study that included 289 patients aged >= 16 years old admitted for elective trauma surgery from october 2004 to june 2005. The patients had good cognitive status and sufficient auditory capacity to answer questions by telephone. Data were gathered on demographic variables, the amount of information received, and patients' understanding of their health problems before and during hospital stay. Results. In the univariate analysis, individuals who considered that that they had been little- or uninformed about their health problem or who had only primary schooling and lived in urban areas with < 10,000 inhabitants were at highest risk of not understanding the information (p < 0.05). In the multivariate analysis, perception of the amount of information received and educational level maintained the association with prior understanding of the information. Conclusions. Patients understand information given to them during hospital stay better than that received before hospital admission. Patients' perception of the amount of information received on their health is the variable most strongly related to their understanding of the information

Reversible myocardial dysfunction after cardiopulmonary resuscitation.

OBJECTIVE: Myocardial stunning frequently has been described in patients with an acute coronary syndrome. Recently, it has also been described in critically ill patients without ischaemic heart disease. It is possible that the most severe form of any syndrome, leading to cardio-respiratory arrest, may cause myocardial stunning. Myocardial stunning appears to have been demonstrated in experimental studies, though this phenomenon has not been sufficiently studied in human models. The aim of the present work has been to study and describe the possible development of myocardial dysfunction in patients resuscitated after cardio-respiratory arrest, in the absence of acute or previous coronary artery disease. DESIGN: Descriptive study of a case series. SETTING: The intensive care unit (ICU) of a provincial hospital. PATIENTS AND PARTICIPANTS: The study period was from April 1999 to June 2001. All patients admitted to the ICU with critical, non-coronary artery pathology, with no past history of cardiac disease, and those who were resuscitated after cardio-respiratory arrest, were included in the study. MEASUREMENTS AND RESULTS: Transthoracic and transoesophageal echocardiography was used to assess left ventricular ejection fraction (LVEF) and disturbances of segmental contractility. This study was carried out within the first 24h after admission, during the first week, during the second or third week, after 1 month, and between 3 and 6 months. Twenty-nine patients with a median age of 65 years (range 24--76) were included in the study. Twelve patients died. Twenty patients developed myocardial dysfunction; the initial LVEF in these patients was 0.28 (0.12--0.51), showing improvement over time in the patients who survived. All of these patients presented disturbances of segmental contractility which also became normal over time. CONCLUSIONS: After successful CPR, reversible myocardial dysfunction, consisting of systolic myocardial dysfunction and disturbances of segmental contractility, may occur.

[Malnutrition in hospitalized patients: prevalence and economic impact]. / Desnutrición en pacientes hospitalizados: prevalencia e impacto económico.

BACKGROUND AND OBJECTIVE: Malnutrition constitutes a serious problem of public health. We intended to know the prevalence of undernourishment in our hospital, as well as to assess the expenses generated by its presence. PATIENTS AND METHOD: A study of cohorts was designed to evaluate the nutritional state of randomly selected patients admitted to a third level hospital. We carried out a protocol of nutritional evaluation and quantified the associated costs including drugs, diet, and hospital stay according to diagnosis-related groups. RESULTS: In agreement with anthropometry and the index of corporal mass, the prevalence of malnutrition was 0.3% and 13.4%, respectively. When analyzing the biochemical markers, the prevalence rose to 65.7%. Patients with malnutrition at the time of admission underwent a 59.9% deterioration of their nutritional state. An increase of costs was observed in relation to the length of hospital stay (68.04% compared with normo-nourished patients). Costs related to consumption of medicines, especially antibiotics, were also higher, as well as costs related to nutritional support. CONCLUSIONS: Malnutrition is a phenomenon frequently observed in a hospital setting. Malnutrition associated costs are significant.

Reversible myocardial dysfunction, a possible complication in critically ill patients without heart disease.

PURPOSE: Reversible myocardial dysfunction or myocardial stunning is frequently described in patients with episodes of acute coronary syndrome and has recently been reported in critically ill patients without ischaemic heart disease. This article presents a study and description of the possible existence of myocardial dysfunction in critically ill patients in our setting who present no acute episode or history of cardiovascular disease. DESIGN: Prospective, descriptive study. SETTING: The intensive care unit of a district hospital. PATIENTS AND PARTICIPANTS: The study included all patients admitted to the intensive care unit between March 1998 and March 2001 for noncardiac causes and with no history of heart disease, and who underwent echocardiographic examination for electrocardiographic changes, signs of cardiac insufficiency, persistent arrhythmias, or any other indication. Patients with sepsis or other critical illness known to be associated with myocardial dysfunction were excluded from the study. The study was carried out on those selected patients who developed myocardial dysfunction. MEASUREMENTS AND RESULTS: Transthoracic and transoesophageal echocardiography were carried out to assess the left ventricular ejection fraction and any segmental contractility disturbances. These investigations were carried out within 24 hours of admission, during the first week, during the second or third week, after one month and after three to 6 months. The electrocardiogram was assessed on admission and the changes over time were studied. Thirty-three patients were included in the study after detecting myocardial dysfunction; the median age of these patients was 63 years [range, 23-82 years]. Seven patients died. The median initial left ventricular ejection fraction was 0.34 [range, 0.16-0.48] and improved with time. Segmental contractility disturbances were detected initially in all patients and also normalized with time. All patients presented electrocardiogram changes that normalised in line with the echocardiographic changes. CONCLUSIONS: Reversible myocardial dysfunction can be develop in critically ill patients without primary heart disease. This syndrome is associated with systolic dysfunction, segmental contractility disturbances and electrocardiographic changes.

Ventricular fibrillation in acute myocardial infarction in Spanish patients: Results of the ARIAM database.

OBJECTIVE: The aim of this study has been to investigate the factors predisposing to primary or secondary ventricular fibrillation (VF) and the prognosis in Spanish patients with acute myocardial infarction (AMI) during their admission to the intensive care unit or the coronary care unit. DESIGN: A retrospective, observational study. SETTING: The intensive care units and coronary care units of 119 Spanish hospitals. PATIENTS: A retrospective cohort study including all the AMI patients listed in the ARIAM registry (Analysis of Delay in Acute Myocardial Infarction), a Spanish multicenter study. The study period was January 1995 to January 2001. MEASUREMENTS AND MAIN RESULTS: Factors associated with the onset of VF were studied by univariate analysis. Multivariate analysis was used to evaluate the independent factors for the onset of VF and for mortality. A total of 17,761 patients with AMI were included in the study; 964 (5.4%) developed VF (primary in 735 patients, secondary in 229). In multivariate analysis, the variables that continued to show an association with the development of VF were the Killip and Kimball class, peak creatine kinase, APACHE II score, age, and time from the onset of symptoms to the initiation of thrombolysis. The mortality in the patients with any VF was 31.8% (27.8% in patients with primary VF and 49.1% in patients with secondary VF). The development of VF is an independent predictive factor for mortality in patients with AMI, with a crude odds ratio of 5.12 (95% confidence interval, 4.41-5.95) and an adjusted odds ratio of 2.73 (95% confidence interval, 2.12-3.51). CONCLUSIONS: Despite the considerable improvement in the treatment of AMI in recent years, the onset of either primary or secondary VF is associated with a poor prognosis. It is usually accompanied by extensive necrosis.

Alteplase: double bolus versus accelerated regimen.

BACKGROUND: The purpose of our study was to compare the efficacy and safety of alteplase in acute myocardial infarction (AMI), when administered in a double bolus regimen or an accelerated regimen during admission to an intensive care or coronary care unit (ICU/CCU). MATERIAL/METHODS: A retrospective cohort study including all the AMI patients treated with alteplase recorded in the ARIAM register (Analysis of Delay in AMI), a multi-center register in which 77 Spanish hospitals participate. The study period was from January 1995 to January 2000. RESULTS: 4,615 AMI patients were studied. The accelerated regimen (Group I) was administered to 57.51% (2,654 patients) and the remaining 42.49% (1,961 patients) received the double bolus regimen (Group II). There were no differences in mortality or in the incidence of hemorrhagic stroke between the groups. The mortality was 7.15% in Group I versus 6.43% in Group II (not significant). The incidence of hemorrhagic stroke was 1.09% in Group I versus 1.22% in Group II (not significant). Fewer coronary angiographies were required in Group I (6.28% vs. 8.99%; p<0.001) and fewer rescue angioplasties (10.67% vs. 21.88%, p=0.03). Group I also showed a smaller requirement for stent insertion (2.45% vs. 4.77%; p<0.0001) and for assistance using intra-aortic balloon contrapulsation (0.47% vs. 1.36%; p=0.02). CONCLUSIONS: The two regimens appear to be similar in efficacy and safety. Nevertheless, from these results it may be hypothesized that further revascularization techniques are required after double bolus administration.

Influence of age on clinical course, management and mortality of acute myocardial infarction in the Spanish population.

BACKGROUND: To assess age-related differences in cardiovascular risk factors, clinical course and management of patients with acute myocardial infarction (AMI) in intensive care (ICU) or coronary care units (CCU). METHODS: A retrospective cohort study was conducted of all AMI patients listed in the ARIAM register (Analysis of Delay in AMI), a multi-centre register in which 119 Spanish hospitals participated. The study period was from January 1995 to January 2001. A univariate analysis was carried out to evaluate differences between different age groups. Multivariate analysis was used to assess whether age difference was an independent predisposing factor for mortality and for differences in patient management. RESULTS: 17,761 patients were admitted to the ICUs/CCUs with a diagnosis of AMI. The distribution by ages was: <55 years, 3,954 patients (22.3%); 55-64 years, 3,593 (22.2%); 65-74 years, 5,924 (33.4%); 75-84 years, 3,686 (20.8%); and >84 years, 604 (3.4%) (P<0.0001); 24.6% of the patients were female, and the relative proportion of females increased with age. There were clear differences in risk factors between the different age groups, with a predominance of tobacco, cholesterol and family history of heart disease in the younger patients. The incidence of complications, including haemorrhagic complications, increased significantly with age. The older age groups had a lower rate of thrombolysis and less use of revascularisation techniques. The mortality of the above groups was 2.6, 5.4, 10.7, 17.7 and 25.8%, respectively. Age difference was an independent predictive variable for mortality and the administration of thrombolysis. CONCLUSIONS: The distinct age groups differed in cardiovascular risk factors, management and mortality. Age is a significant independent predictive variable for mortality and for the administration of thrombolysis.

Objetivación de la gravedad mediante el sistema APACHE-III aplicado en España / Severity assessment by APACHE III system in Spain

FUNDAMENTO: Evaluar el funcionamiento de la ecuación de predicción del sistema pronóstico APACHE (Acute Physiology, Age and Chronic Health Evaluation) III al aplicarse en España. PACIENTES Y MÉTODO: Estudio prospectivo multicéntrico de cohortes en el que se incluyó a 10.786 pacientes adultos procedentes de 86 unidades de cuidados intensivos españolas. Durante las primeras 24 h del ingreso se recogieron los siguientes datos: variables fisiológicas del Acute Physiology Score (APS), edad, comorbilidades para calcular la puntuación APACHE III; procedencia y diagnóstico principal para aplicar la ecuación de predicción de mortalidad del sistema APACHE III. La variable resultado fue la mortalidad hospitalaria. RESULTADOS: La edad media (desviación estándar) de los pacientes fue 57,74 (0,16) años, un 68 por ciento varones. Los pacientes no quirúrgicos representan el 76 por ciento. La puntuación APACHE III fue 53,75 (0,25); la mortalidad observada y la esperada fueron del 21,3 y el 19,8 por ciento, respectivamente, con una razón estandarizada de mortalidad de 1,07. El estadístico Hosmer-Lemershow obtenido (H) fue 135,6 (C) 133,91 (p < 0,001). El área bajo la curva ROC fue 0,808 y la clasificación correcta para niveles de riesgo del 50 por ciento fue del 82 por ciento. El ajuste de la ecuación fue mejor en diagnósticos no quirúrgicos y en pacientes procedentes de urgencias. La calibración fue buena para riesgos inferiores al 60 por ciento pero infraestimó ligeramente los riesgos observados por encima de este nivel. CONCLUSIONES: La ecucación americana APACHE III se ajusta de forma aceptable al aplicarse a pacientes críticos españoles, pero con limitaciones. Las diferencias en el case-mix de ambas bases de datos podrían explicar las discrepancias encontradas (AU)