Las diferencias por sexo en la mortalidad tras un síndrome coronario agudo se incrementan en los países de menor riqueza y mayor desigualdad de ingresos / Sex differences in mortality after an acute coronary syndrome increase with lower country wealth and higher income inequality

Introducción y objetivos: Aunque se han comunicado varios factores asociados con las diferencias por sexo en el tratamiento y el pronóstico tras un síndrome coronario agudo (SCA), se sabe poco acerca de la influencia de factores socioeconómicos en las disparidades por sexo. Nuestro objetivo es evaluar el impacto de la riqueza nacional y la desigualdad de ingresos en las diferencias por sexo en la mortalidad tras un SCA. Métodos: Se evaluaron las diferencias entre varones y mujeres en la mortalidad a los 2 años del alta hospitalaria de 23.489 pacientes con SCA de los registros EPICOR y EPICOR Asia. Se utilizaron modelos de regresión de Cox ajustados para evaluar los terciles del producto interior bruto y de desigualdad de ingresos. Resultados: Las mujeres (24,3%) eran de más edad que los varones (65,5 frente a 59,4 años; p <0,001), tenían más comorbilidades, se las revascularizó con menos frecuencia (el 63,6 frente al 75,6%; p <0,001) y recibieron al alta menos tratamientos recomendados por las guías de práctica clínica. Comparadas con los varones, la mortalidad de las mujeres en el seguimiento fue mayor (el 6,4 frente al 4,9%; p <0,001). La asociación entre sexo y mortalidad cambió su dirección desde una hazard ratio (HR)=1,32 (IC95%, 1,17-1,49) en el análisis univariado a HR=0,76 (IC95%, 0,67-0,87) después de ajustar por variables de confusión. Estas diferencias fueron más evidentes a medida que la riqueza de los países se incrementaba (HRpaísesconbajonivelderiqueza=0,85; IC95%, 0,72-1,00; HRpaísesconnivelderiquezaintermedio=0,66; IC95%, 0,50-0,87; HRpaísesconelevadonivelderiqueza=0,60; IC95%, 0,40-0,90; pparatestdetendencia=0,115) y a medida que se equilibraba la desigualdad de ingresos (HRbajoíndicededesigualidad=0,54; IC95%, 0,36-0,81; HRíndicededesigualidadintermedio=0,66; IC95%, 0,50-0,88; HRaltoíndicededesigualidad=0,87; IC95%, 0,74-1,03; pparatestdetendencia=0,031) (AU)

Introduction and objectives: Although several factors associated with sex differences in the management and outcomes after acute coronary syndrome (ACS) have been reported, little is known about the influence of socioeconomic factors on sex disparities. Our aim was to evaluate the influence of country wealth and income inequality on national sex differences in mortality after ACS. Methods: Sex differences in 2-year postdischarge mortality were evaluated in 23 489 ACS patients from the EPICOR and EPICOR Asia registries. Adjusted Cox regression models by country-based terciles of gross national income per capita and income inequality were used. Results: Women (24.3%) were older than men (65.5 vs 59.4 years, P <.001), had more comorbidities, were less often revascularized (63.6% vs 75.6%, P <.001) and received fewer guideline recommended therapies at discharge. Compared with men, a higher percentage of women died during follow-up (6.4% vs 4.9%, P <.001). The association between sex and mortality changed direction from hazard ratio (HR) 1.32 (95%CI, 1.17-1.49) in the univariate assessment to HR 0.76 (95%CI, 0.67-0.87) after adjustment for confounders. These differences were more evident with increasing country wealth (HRlow-incomecountries = 0.85; 95%CI, 0.72-1.00; HRmid-incomecountries = 0.66; 95%CI, 0.50-0.87; HRhigh-incomecountries = 0.60; 95%CI, 0.40-0.90; trend test P = .115) and with decreasing income inequality (HRlow-inequalityindex = 0.54; 95%CI, 0.36-0.81; HRintermediate-inequalityindex = 0.66; 95%CI, 0.50-0.88; HRhigh-inequalityindex = 0.87; 95%CI, 0.74-1.03; trend test P = .031). Conclusions: Women with ACS living in high socioeconomic countries showed a lower postdischarge mortality risk compared with men. This risk was attenuated in countries with poorer socioeconomic background, where adjusted mortality rates were similar between women and men (AU)

Impact of Diabetes Mellitus and Frailty on Long-Term Outcomes in Elderly Patients with Acute Coronary Syndromes.

OBJECTIVES: Diabetes mellitus (DM) and frailty are common in older patients with acute coronary syndromes (ACS). No data exists about its prognostic impact on long-term outcomes and their possible interaction in this setting. DESIGN: Observational prospective study. SETTING: Multicenter registry conducted in 44 hospitals in Spain. PARTICIPANTS: Consecutive patients with ACS aged 80≥years. MEASUREMENTS: A comprehensive geriatric evaluation was performed during hospitalization, including frailty assessment by the FRAIL score. The impact of DM and frailty on the incidence of mortality/readmission at 24 months was analysed by a Cox regression model. RESULTS: A total of 498 patients were included (mean age 84.3 years). Prevalence of previous DM was 199/498 (40.0%). The rate of frail patients was 135/498 (27.1%). The incidence of mortality/readmission was higher frail patients (HR 2.49) (both p<0.001). In contrast, DM was not significantly associated to a higher rate of outcomes (HR 1.23, p=0.060) in the whole cohort. Among non-frail patients, patients with DM had a similar incidence of mortality or readmission (p=0.959). In contrast, among frail patients, DM was significantly associated with a higher incidence of events (HR 1.51, p=0.034). CONCLUSIONS: Unlike frailty status, DM was not associated to poorer long-term outcome in elderly patients with ACS. Among frail patients the presence of DM seems to provide additional prognostic information.

Exercise-related severe cardiac events.

Physical activity has benefits on health. However, there is a small risk of effort-related adverse events. The aim of this study is to describe exercise-related severe cardiovascular events and to relate them with the type of sport performed. We performed a ten-year retrospective study in eight Spanish cardiac intensive care units. Adverse cardiac events were defined as acute myocardial infarction, cardiac arrest or syncope related to physical activity. From 117 patients included, 109 were male (93.2%), and mean age was 51.6 ± 12.3 years; 56 presented acute myocardial infarction without cardiac arrest (47.9%), 55 sudden cardiac death (47.0%) and six syncope (5.1%). The sports with higher number of events were cycling (33%-28.2%), marathon or similar running competitions (19%-16.2%), gymnastics (18%-15.3%) and soccer (17%-14.5%). Myocardial infarction was observed more frequently in cyclists compared to other sports (69.7% vs 39.3%, P = .001). The most common cause of sudden cardiac death was myocardial infarction in those >35 years (23%-63.9%) and idiopathic ventricular fibrillation in younger patients (5%-62.5%). Significant coronary artery disease was present in 85 (79.4%). Only one patient with cardiac arrest presented with a non-shockable rhythm (asystole). Eleven patients (9.4%) died during hospitalization; in all cases, they had presented cardiac arrest. All discharged patients were alive at the end of follow-up. Exercise-related severe cardiac events are mainly seen in men. Coronary heart disease is very frequent; about half present acute myocardial infarction and the other half cardiac arrest. In our cohort, prognosis was good in patients without cardiac arrest.

Tratamiento del dolor irruptivo con fentanilo sublingual en pacientes con úlceras cutáneas crónicas / Breakthrough pain treatment with sublingual fentanyl in patients with chronic cutaneous ulcers

Objetivo. El presente estudio pretende establecer la eficacia y tolerabilidad de los opioides en el tratamiento del dolor en pacientes con úlceras cutáneas crónicas y dolor irruptivo incidental. Material y método. Estudio abierto, multicéntrico, prospectivo, no controlado, realizado en unidades del dolor y de úlceras de 5 hospitales de la Comunidad Valenciana. El criterio de inclusión fue dolor basal mayor o igual a 4 según la escala visual analógica o dolor irruptivo mayor o igual a 4 durante la cura. Los criterios de exclusión fueron alteraciones cognitivas, intolerancia a opioides y rechazo del paciente a dar el consentimiento. El protocolo estableció 5 momentos de evaluación: basal (primera visita), 15 días, un mes, 2 y 3 meses. La variable principal del estudio fue el dolor medido con la escala visual analógica en reposo, en movimiento y durante la cura. Se administraron opioides para el dolor basal y se administró fentanilo sublingual para el dolor irruptivo. Resultados. Treinta y dos pacientes (86,5%) completaron el estudio. El dolor basal experimentó una reducción media de 3,6 (DE 2,3) puntos en la escala visual analógica, el dolor en movimiento disminuyó 3,9 (DE 2,5), y el dolor durante la cura disminuyó 4,5 (DE 2,8), siendo en todos estadísticamente significativa (p < 0,001) desde el primer control. Catorce pacientes (43,8%) presentaron náuseas, 7 (21,9%), somnolencia y estreñimiento, 5 (15,6%), prurito, y uno (3,1%), vómitos. Conclusiones. Los resultados de nuestro estudio evidencian que el tratamiento con opioides en pacientes con úlceras cutáneas crónicas proporciona un alivio efectivo del dolor, tanto basalmente como durante la cura, con escasos efectos adversos (AU)

Objective. The aim of the study was to assess the efficacy and safety of opioids in the management of pain in those patients with chronic cutaneous ulcers and breakthrough/incidental pain. Material and method. An open-label, multicentre, prospective, uncontrolled study was conducted in the pain and ulcer units of 5 hospitals across the Comunidad Valenciana. Eligibility criteria were baseline pain 4 in the visual analogue scale or breakthrough procedural pain 4. Exclusion criteria were cognitive impairment, opioid intolerance, or patient refusal to provide informed consent. The protocol scheduled 5 controls: baseline (enrolment), 15 days, one month, 2 months, and 3 months. The main outcome measure of the study was the visual analogue scale score during rest, movement and procedures. Opioids were administered for release of the baseline pain, and sublingual fentanyl for breakthrough pain. Results. A total of 32 patients (86.5%) completed the study. Baseline pain achieved a mean improvement of 3.6 visual analogue scale points (SD 2.3), movement pain improved by 3.9 points (SD 2.5) and procedural pain improved by 4.5 points (SD 2.8), and the mean pain intensity improvement was statistically significant from the first control and at all controls thereafter (P < .001). Nausea was reported by 14 patients (43.8%), drowsiness and constipation by 7 (21.9%), itching by 5 (15.6%), and one (3.1%) reported vomiting. Conclusions. Structured assessment of pain is a key concept in the management of patient with chronic cutaneous ulcers. The results of this study suggest that opioid therapy provides clinically significant pain relief with few adverse effects (AU)

[Breakthrough pain treatment with sublingual fentanyl in patients with chronic cutaneous ulcers]. / Tratamiento del dolor irruptivo con fentanilo sublingual en pacientes con úlceras cutáneas crónicas.

OBJECTIVE: The aim of the study was to assess the efficacy and safety of opioids in the management of pain in those patients with chronic cutaneous ulcers and breakthrough/incidental pain. MATERIAL AND METHOD: An open-label, multicentre, prospective, uncontrolled study was conducted in the pain and ulcer units of 5 hospitals across the Comunidad Valenciana. Eligibility criteria were baseline pain 4 in the visual analogue scale or breakthrough procedural pain 4. Exclusion criteria were cognitive impairment, opioid intolerance, or patient refusal to provide informed consent. The protocol scheduled 5 controls: baseline (enrolment), 15 days, one month, 2 months, and 3 months. The main outcome measure of the study was the visual analogue scale score during rest, movement and procedures. Opioids were administered for release of the baseline pain, and sublingual fentanyl for breakthrough pain. RESULTS: A total of 32 patients (86.5%) completed the study. Baseline pain achieved a mean improvement of 3.6 visual analogue scale points (SD 2.3), movement pain improved by 3.9 points (SD 2.5) and procedural pain improved by 4.5 points (SD 2.8), and the mean pain intensity improvement was statistically significant from the first control and at all controls thereafter (P<.001). Nausea was reported by 14 patients (43.8%), drowsiness and constipation by 7 (21.9%), itching by 5 (15.6%), and one (3.1%) reported vomiting. CONCLUSIONS: Structured assessment of pain is a key concept in the management of patient with chronic cutaneous ulcers. The results of this study suggest that opioid therapy provides clinically significant pain relief with few adverse effects.

Quality of life and exercise in renal disease.

Many publications describe the advantages of physical exercise in improving quality of life. The aim of this study was to highlight the need for physical activity when patients commence haemodialysis. A correlation was found between muscular deterioration and the years on haemodialysis and it was accentuated in men. From our study we recommend adequate physical activity at the beginning of, and during the lifetime of haemodialysis to enhance the physical and psychological well being of patients.

Covariant discretization of axis-symmetric linear optical systems.

We propose a discretization strategy for systems with axial symmetry. This strategy replaces the continuous position coordinates by a discrete set of sensor points, on which the discrete wave fields transform covariantly with the group of 2 x 2 symplectic matrices. We examine polar arrays of sensors (i.e., numbered by radius and angle) and find the complete, orthonormal sets of discrete-waveguide Meixner functions; when the sensors come closer together, these tend to the Laguerre eigenmodes of the continuous waveguide. In particular, the fractional Hankel transforms are discretized in order to define the fractional Hankel-Meixner transforms and similarly for all axis-symmetric linear optical maps. Coherent states appear in the discrete cylindrical waveguide. Covariant discretization leads to the same Wigner phase-space function for both the discrete and the continuum cases. This reinforces a Lie-theoretical model for the phase space of discrete systems.