miR-10b and miR-223-3p in serum microvesicles signal progression from prediabetes to type 2 diabetes.

PURPOSE: Type 2 diabetes frequently remains undiagnosed for years, whereas early detection of affected individuals would facilitate the implementation of timely and cost-effective therapies, hence decreasing morbidity. With the intention of identifying novel diagnostic biomarkers, we characterized the miRNA profile of microvesicles isolated from retroactive serum samples of normoglycemic individuals and two groups of subjects with prediabetes that in the following 4 years either progressed to overt diabetes or remained stable. METHODS: We profiled miRNAs in serum microvesicles of a selected group of control and prediabetic individuals participating in the PREDAPS cohort study. Half of the subjects with prediabetes were diagnosed with diabetes during the 4 years of follow-up, while the glycemic status of the other half remained unchanged. RESULTS: We identified two miRNAs, miR-10b and miR-223-3p, which target components of the insulin signaling pathway and whose ratio discriminates between these two subgroups of prediabetic individuals at a stage at which other features, including glycemia, are less proficient at separating them. In global, the profile of miRNAs in microvesicles of prediabetic subjects primed to progress to overt diabetes was more similar to that of diabetic patients than the profile of prediabetic subjects who did not progress. CONCLUSION: We have identified a miRNA signature in serum microvesicles that can be used as a new screening biomarker to identify subjects with prediabetes at high risk of developing diabetes, hence allowing the implementation of earlier, and probably more effective, therapeutic interventions.

Assessment of enlarged perivascular spaces and their relation to target organ damage and mild cognitive impairment in patients with hypertension.

BACKGROUND AND PURPOSE: Enlarged perivascular spaces (EPVS) have been recently considered a feature of cerebral small vessel disease. They have been related to aging, hypertension and dementia but their relationship with hypertension related variables (i.e. target organ damage, treatment compliance) and mild cognitive impairment (MCI) is not fully elucidated. Our aims were to investigate the relation between basal ganglia (BG) and centrum semiovale (CSO) EPVS with vascular risk factors, hypertension related variables and MCI. METHODS: In all, 733 hypertensive individuals free of stroke and dementia from the Investigating Silent Strokes in Hypertensives, a magnetic resonance imaging Study (ISSYS) underwent brain magnetic resonance imaging and cognitive testing to diagnose MCI or normal cognitive aging. RESULTS: The numbers of participants presenting high grade (>10) EPVS at the BG and CSO were 23.3% and 40.0%, respectively. After controlling for vascular risk factors, high grade BG EPVS were associated with age (odds ratio 1.68; 95% confidence interval 1.37, 2.06), poor antihypertensive compliance (1.49; 1.03, 2.14) and the presence of microalbuminuria (1.95; 1.16, 3.28), whereas in the CSO only age (1.38; 1.18, 1.63) and male sex were associated with EPVS (1.73; 1. 24, 2.42). MCI was diagnosed in 9.3% of the participants and it was predicted by EPVS in the BG (1.87; 1.03, 3.39) but not in the CSO. This last association was greatly attenuated after correction for lacunes and white matter hyperintensities. CONCLUSIONS: Basal ganglia EPVS are associated with the presence of microalbuminuria and poor adherence to antihypertensive drugs. The BG EPVS relation with MCI is not independent of the presence of other cerebral small vessel disease markers.

Determinants of survival and hospitalization in older, heart failure patients receiving home healthcare.

INTRODUCTION: Since reported evidence is both scarce and controversial, the objective of this study is to determine the risk factors involved in the prognosis of older patients with heart failure (HF) receiving home healthcare from primary care professionals. METHODS: Retrospective cohort community study was carried out in 52 primary healthcare centers in Barcelona (Spain). A follow-up was performed between January 2009 and December 2012 with 7461 HF patients aged >64years. Information was obtained from primary care electronic medical records containing clinical data, functional and cognitive status, total mortality, and hospital admissions for cardiovascular events. RESULTS: Mortality and hospitalization during follow-up were higher in older, HF patients who received home healthcare than those who did not (HR 1.39, 95% CI 1.22-1.58 and 1.92 95% CI 1.72-2.14, respectively). The most relevant determinants for mortality were male gender (HR 1.40, 95%CI 1.10-1.79), previous hospital admission for HF (HR 1.29 95%CI 1.05-1.60), and severe dependence in activities for daily living (ADL) (HR 1.33, 95%CI 1.06-1.67). In contrast, severely dependent ADL patients were not more frequently hospitalized as a consequence of cardiovascular events (0.97, 95% CI 0.77-1.23). CONCLUSIONS: Due to their greater comorbidity and age, mortality and hospitalization in patients requiring home healthcare were higher than those who did not. Among the HF patients receiving home care, mortality and hospital admissions were higher in men, older patients, and in those previously hospitalized for HF. Severe dependence in ADL determined a higher mortality but was not related to increased hospital admission rates.

Cognitive assessment protocol design in the ISSYS (Investigating Silent Strokes in hYpertensives: a magnetic resonance imaging Study).

Hypertension and silent cerebrovascular lesions (SCL) detected by brain magnetic resonance imaging (MRI) are associated with an increased risk of cognitive decline. In a prospective observational study in 1000 hypertensive patients, aged 50-70 years, with no prior history of stroke or dementia, we will study the presence of mild cognitive impairment (MCI) and the relationship between SCL and cognition. All participants will be assessed by means of the Dementia Rating Scale-2 (DRS-2) and will undergo a brain MRI. In order to better characterize MCI and future dementia risk in our cohort, those patients that are suspected to be cognitively impaired according to the DRS-2 results will have a further neurological evaluation and complete neuropsychological testing. Follow-up for the entire cohort is planned to last for at least 3 years.

[Hospitalizations due to ambulatory care sensitive conditions: selection of diagnostic codes for Spain]. / Las hospitalizaciones por ambulatory care sensitive conditions: selección del listado de códigos de diagnóstico válidos para España.

BACKGROUND: Hospitalisations due to Ambulatory Care Sensitive Conditions (ACSC) are considered an indicator to measure the use of hospital services because of health conditions that could have been prevented and controlled by primary health care. The objective of this study is to select the list of diagnostic codes to assess the performance of primary health care in Spain. METHODS: The five criteria proposed by Weissman and Solberg, to select an appropriate indicator, were applied to a first list of 87 ACSC diagnostic codes identified through bibliographic search. Information on two main criteria-whether care for a health condition was a primary health care role and whether hospitalisation was needed once the health problem occurred was obtained by means of the Delphi technique. A group of 44 experts gathered together for the study. For the remaining criteria, information came from the results of the Pilot study on hospitalisations due to ACSC in Catalonia, Spain. Meeting the five criteria was the criterion selected to evaluate the solving ability of primary health care. RESULTS: a) from the Delphi group: 42 (95.4%) participants completed the three rounds. The question on whether the care of the selected health conditions was responsibility of primary health care reached a high level of consensus (between 86.1 and 100%). The consensus on the need for hospitalisation was lower, from 75.7 to 88.6%, moreover, 5 diagnostic codes did not reach the established consensus, and b) from the ACSC selection process: five diagnostic codes did not meet the criteria and were excluded. Out of the remaining 82, all them were considered as health problems to be cared for at primary level and in 37 cases hospitalisation was considered always as necessary. Thirty-five diagnostic codes, that met the five criteria, represented the set of ACSC diagnostic codes in our setting. CONCLUSIONS: A set of 35 diagnostic codes of ACSC, adapted to our setting, is proposed to evaluate primary health care performance. The selected codes reduce significantly the limitations that stem from hospital admission criteria due to patient clinical characteristics, variations in hospital medical practice, and hospital admission policies.

Las hospitalizaciones por ambulatory care sensitive conditions: selección del listado de códigos de diagnóstico válidos para España / Hospitalizations due to ambulatory care sensitive conditions: selection of diagnostic codes for Spain

Introducción: Las hospitalizaciones por ambulatory care sensitive conditions (ACSC) constituyen un indicador que mide la utilización de los servicios hospitalarios por problemas de salud que podrían haber sido prevenidos y controlados en la atención primaria. El objetivo principal de este estudio es seleccionar el listado de códigos de diagnóstico de ACSC para evaluar la capacidad de resolución de la atención primaria en España. Métodos: La selección inicial se realizó a partir de un listado de 87 códigos de diagnóstico de ACSC identificados en la bibliografía, mediante la aplicación de los 5 criterios que definen el indicador como apropiado propuestos por Solberg y Weissman. Mediante un estudio Delphi se obtuvo información sobre el cumplimiento de dos de los criterios fundamentales: si los cuidados del problema de salud son función de la atención primaria y si la hospitalización es necesaria cuando el problema de salud se ha producido. Un total de 44 expertos participaron en el estudio. La información necesaria sobre el cumplimiento de los otros criterios se obtuvo a partir de un "estudio piloto sobre las hospitalizaciones por ACSC en Cataluña". El criterio definitivo de inclusión en el listado para evaluar la capacidad de resolución de la atención primaria fue el cumplimiento de los 5 criterios. Resultados: a) del estudio Delphi: un total de 42 participantes (95,4 por ciento) completaron las tres rondas. El nivel de consenso obtenido en la pregunta sobre si los cuidados de los problemas de salud propuestos son función de la atención primaria fue entre el 86,1 y el 100 por ciento, mientras que el consenso sobre la necesidad de hospitalización fue relativamente inferior, entre el 75,7 y el 88,6 por ciento, y 5 códigos de diagnóstico no obtuvieron el consenso establecido, y b) del proceso de selección del listado de ACSC: 5 fueron excluidos por no cumplir los criterios. De los 82 restantes, el 100 por ciento obtuvo el consenso respecto a que son problemas de salud propios de la atención primaria, y sólo 37 códigos de diagnóstico se clasificaron como que la hospitalización es necesaria siempre. Por la aplicación de los 5 criterios, se seleccionaron 35 códigos de diagnóstico que constituyen el listado de ACSC válido en nuestro entorno sanitario. Conclusión: Se propone un listado de 35 códigos de diagnóstico de ACSC adaptado a nuestro entorno sanitario, que permite el análisis de la capacidad de resolución de la atención primaria, pues minimiza las limitaciones derivadas de la influencia de las características clínicas de los pacientes, la variabilidad de la práctica clínica hospitalaria, o las políticas de admisión de los centros (AU)

[The characteristics of digoxin utilization in a population under emergency care for heart failure or auricular fibrillation]. / Características de la utilización de digoxina en una población atendida en urgencias por insuficiencia cardíaca o fibrilación auricular.

BACKGROUND: With the aim of studying the characteristics of the use of digoxin in a population which attended a hospital emergency department for heart failure or auricular fibrillation a 3 month observational study was carried out in the emergency department of the Ciudad Sanitaria de la Vall d'Hebron. METHODS: One hundred twelve patients treated with digoxin who went to the emergency department for heart failure and/or decompensated auricular fibrillation were studied. Clinical and pharmacological histories, determination of digoxinemia and the usual complementary explorations were performed. RESULTS: It was found that 50% of the patients were not adequately controlled and treatment was not followed in 21% of the patients. No significant relation was found between the doses of digoxin and the age of the patients. In multivariant analysis (multiple lineal regression) digoxinemia was related with the doses (beta = 0.22, p = 0.01), cardiac frequency (beta = 0.19, p < 0.05), and compliance (beta = 0.18, p = 0.05). Among the patients in whom the cause of decompensation of cardiac failure could not be identified, one third (31%) were found to have infratherapeutic digoxinemia. CONCLUSIONS: Most patients with cardiac decompensation attending an emergency department are those who are not adequately controlled in primary health care and the rate of incomplete following of the prescription is high. Furthermore, one third of the patients who decompensate with no clinically apparent reason has an infratherapeutic plasma concentration of digoxin.

[The use of digoxin in primary care]. / Estudio de utilización de la digoxina en atención primaria.

OBJECTIVE: A study aimed at a population attended at the Primary Health level was designed, in order to reach a greater understanding of the use of Digoxin by doctors and patients. DESIGN: A crossover observational study, carried out wholly at the Primary Care level. PATIENTS: 205 patients under long-term Digoxin treatment were studied. 94 (46%) were men and 111 (54%) women. The average age (SD) was 67 (13). MEASUREMENTS AND MAIN RESULTS: The indication was considered adequate in 62.9% of patients. The average dose (AD) of Digoxin was 0.163 mg a day (0.04): the age of the patients is not taken into account on working out the dose of Digoxin. 52 patients (25.4%) recognised they had not properly carried out the prescription. In this group the view that Digoxin was unnecessary was more common (X = 10.63; p = 0.001). The average Digoxinemia (AD) was 0.85 (0.46) ng/ml. 57% of patients had plasmatic levels below a therapeutic level. The variables related to plasmatic level were: daily dosage (r = 0.4, p = 0.001); age (r = 0.2, p = 0.001; plasmatic creatinine (r = 0.3, p = 0.001); clearing of creatinine (r = -0.4, p = 0.001) and compliance (t = 2.42, p = 0.01). The same independent variables were identified as significant in the multivariant analysis. The week-end break from dosage supposed a fall in the plasmatic levels of 67.7%. CONCLUSIONS: In spite of being a widely-used drug, the dosage of Digoxin is not adequately worked out and compliance is a long way from the optimum. Digoxinemia correlates to the dosage, renal function and compliance with the prescription.