Timing of P2Y12 Inhibitor Administration in Patients With STEMI Undergoing Primary PCI.

BACKGROUND: The optimal timing of P2Y12 inhibitor administration in patients with ST-segment elevation myocardial infarction (STEMI) has not been completely elucidating. OBJECTIVES: This analysis from a prospective multicenter registry sought to assess the safety and effectiveness of P2Y12 inhibitor pretreatment in patients transferred for primary percutaneous coronary intervention (PCI) within a regional STEMI network. METHODS: Pretreatment was defined as P2Y12 inhibitor administration before coronary angiography. Endpoints were major adverse cardiac events (MACE), major bleeding, and net adverse clinical events, a composite of MACE or major bleeding, within 30 days of index admission. Association of P2Y12 inhibitor pretreatment with outcomes was modeled using doubly robust weighted estimators based on propensity score analysis. RESULTS: Of 1,624 patients included, 1,033 received P2Y12 inhibitors before angiography and 591 in the catheterization laboratory (cath lab). The non-pretreated cohort more often had history of coronary artery disease and were more likely to receive antiplatelet therapy before the index admission. After adjustment for confounding and dependent censoring, pretreatment with P2Y12 inhibitors predicted lower risk of MACE (adjusted HR: 0.53; 95% CI: 0.37-0.76), without increasing bleeding risk (adjusted HR: 0.62; 95% CI: 0.36-1.05), resulting in superior net clinical benefit (adjusted HR: 0.47; 95% CI: 0.26-0.86) compared with in-cath lab administration of P2Y12 inhibitors. There was a significant treatment-by-time interaction for MACE risk, whereby the observed benefits of pretreatment only became apparent when time between P2Y12 inhibitor administration and PCI was longer than 80 minutes. CONCLUSIONS: In contemporary patients with STEMI transferred for primary PCI, pretreatment with P2Y12 inhibitors was associated with a significant time-dependent reduction of 30-day MACE without increasing bleeding risk.

Postural Stability and Cognitive Performance of Subjects With Parkinson's Disease During a Dual-Task in an Upright Stance.

BACKGROUND: The reviewed studies on center of pressure (COP) displacement in Parkinson's disease (PD) subjects show important methodological differences and contradictory results with regard to healthy subjects. The dual-task paradigm method has been used to examine cognitive prioritization strategies to control concurrent postural and cognitive tasks. The motor requirements, such as pronouncing words, involved in the cognitive tasks used in double-task conditions could be related to the heterogeneity of the results. RESEARCH OBJECTIVE: To compare postural sway and cognitive performance in subjects with PD and controls using a dual-task paradigm with a cognitive task free of motor demands. We tried to examine the prioritization strategy of PD patients regarding healthy adults to control for concurrent postural and cognitive tasks. MATERIALS AND METHODS: 25 subjects with PD and 20 healthy controls carried out a postural task under both single-task and dual-task conditions. The postural task was to stand as still as possible, with eyes first open and then closed. The dual-task condition added a concurrent cognitive task based on phoneme monitoring. COP displacement variables and cognitive performance were compared between the groups and within-subject factors were also examined. RESULTS: PD participants showed higher COP displacement results than the controls. All participants shortened the mean sway radius in dual-task conditions compared with single-task conditions; only healthy subjects presented less transversal COP sway in dual-task conditions than in single-task conditions. The cognitive performance of PD patients on a phoneme monitoring task worsened when they carried it out while maintaining balance in a standing position compared to sitting. The opposite effect occurred in control subjects. CONCLUSION: This study confirms the negative influence of Parkinson's disease on the control of standing stability, increasing the COP sway amplitude. The attentional demands of a postural task, such as standing balance, may be greater in PD patients than in healthy subjects. This would affect the performance of patients during dual-task conditions to be able to control a postural task while performing other cognitive tasks. In these conditions, cognitive performance would be negatively affected. These results suggest that subjects with PD, at least during initial disease stages, prioritize postural control over other concurrent tasks, as is also seen in healthy subjects.

Subjective analysis of the application of enhancement filters on magnetic resonance imaging of the temporomandibular joint.

OBJECTIVE: The aim of this study was to investigate the effect of enhancement filters on magnetic resonance imaging (MRI) of the temporomandibular joint (TMJ). STUDY DESIGN: In total, 66 MRI scans of the TMJ were analyzed without filtration and with the application of 2 filters: Sharpen 1 and Sharpen 2 (OnDemand software). Two dentomaxillofacial radiologists examined the original and filtered images individually. Intra- and interobserver concordance was measured by using generalized estimating equations. The observers evaluated the subjective image quality and the visibility of 3 components of the TMJ: disk, condyle, and articular eminence. The images were ranked on a 4-point scale, from poor to excellent. The image quality of all filtered images was compared by using the χ2 test and Bonferroni correction for multiple comparisons. RESULTS: Intra- and interobserver concordance was good. The images filtered with Sharpen 1 and Sharpen 2 provided better definition of the structures compared with nonfiltered images, providing the highest scores for subjective image quality for all structures (P < .0001). CONCLUSIONS: The use of enhancement filters led to improved subjective quality and may improve the diagnostic efficacy of MRI in TMJ evaluation.

Prolonged Mechanical Ventilation as a Predictor of Mortality After Cardiac Surgery.

BACKGROUND: Mortality among the small percentage of cardiac surgery patients receiving prolonged mechanical ventilation is high, but this issue appears to be inadequately addressed in guidelines. METHODS: This study is a retrospective analysis of prospective, multi-center, and observational study in Spain including all adults undergoing cardiac surgery in 3 Andalusian hospitals between June 2008 and December 2012. RESULTS: The study included 3,588 adults with mean ± SD age of 63.5 ± 12.8 y and with median (interquartile range) EuroSCORE of 5 (3-7) points. Prolonged mechanical ventilation (> 24 h) was required by 415 subjects (11.6%), with ICU mortality of 44.3% (184 subjects), and was not required by 3,173 subjects (88.4%), with ICU mortality of 3.1% (99 subjects, P < .001). Prolonged mechanical ventilation was associated with more complications and was required by 4.5% of subjects with a EuroSCORE <5, 11.2% with a score of 5-7, 27.2% with a score of 8-10, and 32.2% with a score > 10. In the multivariable analysis, ICU mortality was associated with illness severity, duration of bypass surgery, surgery type, and prolonged mechanical ventilation (odds ratio 15.19, 95% CI 11.56-22.09). The main cause of death was multiple organ failure and sepsis in subjects who required prolonged mechanical ventilation (50.3%) and cardiogenic shock in those who did not (59.2%). CONCLUSION: Prolonged postoperative mechanical ventilation was required by 10-20% of cardiac surgery subjects, who constitute a specific group that represents most of the postoperative mortality, which is associated with multiple organ failure and sepsis.

Seguridad y eficacia clínica con prasugrel y ticagrelor en síndrome coronario agudo. Resultados de un registro multicéntrico en el mundo real / Safety and efficacy of prasugrel and ticagrelor in acute coronary syndrome. Results of a 'real world' multicenter registry

Introducción y objetivos: La incorporación de los nuevos antiagregantes (NAA) prasugrel y ticagrelor a la práctica clínica está siendo errática. Los datos del mundo real todavía son escasos. Se analizó la tendencia temporal de uso de NAA, su seguridad y eficacia clínica frente a clopidogrel en una cohorte actual de pacientes con síndrome coronario agudo (SCA). Métodos: Estudio multicéntrico observacional retrospectivo de pacientes con SCA ingresados en unidades coronarias incluidos de forma prospectiva en el registro ARIAM-Andalucía entre 2013 y 2015. Se analizaron las tasas de eventos cardiovasculares mayores y hemorragias intrahospitalarias mediante modelos de propensión y regresión multivariante. Resultados: Se incluyó a 2.906 pacientes: el 55% recibió clopidogrel y el 45% NAA. Un 60% presentó SCA con elevación del segmento ST. El uso de NAA se incrementó de forma significativa a lo largo del estudio. El grupo de clopidogrel presentó mayor edad y comorbilidad. La tasa de mortalidad total, el ictus isquémico y la trombosis del stent fue menor con NAA (2 frente a 9%, p < 0,0001; 0,1 frente a 0,5%, p = 0,025; 0,07 frente a 0,5%, p = 0,025, respectivamente). No hubo diferencias en la tasa de hemorragias totales (3 frente a 4%; p = NS). Tras el análisis de propensión, se mantuvo la reducción de mortalidad con NAA (OR = 0,37; IC95%, 0,13-0,60; p< 0,0001) sin incremento en las hemorragias totales (OR = 1,07; IC95%, 0,18-2,37; p = 0,094). Conclusiones: En el mundo real, los NAA se usan de forma selectiva en sujetos más jóvenes y con menor comorbilidad. Su uso se asocia con una reducción de eventos cardiacos mayores, incluida mortalidad, sin aumentar las hemorragias en comparación con clopidogrel (AU)

Introduction and objectives: The incorporation of the new antiplatelet agents (NAA) prasugrel and ticagrelor into routine clinical practice is irregular and data from the 'real world' remain scarce. We aimed to assess the time trend of NAA use and the clinical safety and efficacy of these drugs compared with those of clopidogrel in a contemporary cohort of patients with acute coronary syndromes (ACS). Methods: A multicenter retrospective observational study was conducted in patients with ACS admitted to coronary care units and prospectively included in the ARIAM-Andalusia registry between 2013 and 2015. In-hospital rates of major cardiovascular events and bleeding with NAA vs clopidogrel were analyzed using propensity score matching and multivariate regression models. Results: The study included 2906 patients: 55% received clopidogrel and 45% NAA. A total of 60% had ST-segment elevation ACS. Use of NAA significantly increased throughout the study. Patients receiving clopidogrel were older and were more likely to have comorbidities. Total mortality, ischemic stroke, and stent thrombosis were lower with NAA (2% vs 9%, P < .0001; 0.1% vs 0.5%, P = .025; 0.07% vs 0.5%, P = .025, respectively). There were no differences in the rate of total bleeding (3% vs 4%; P = NS). After propensity score matching, the mortality reduction with NAA persisted (OR, 0.37; 95%CI, 0.13 to 0.60; P < .0001) with no increase in total bleeding (OR, 1.07; 95%CI, 0.18 to 2.37; P = .094). Conclusions: In a 'real world' setting, NAA are selectively used in younger patients with less comorbidity and are associated with a reduction in major cardiac events, including mortality, without increasing bleeding compared with clopidogrel (AU)

Safety and Efficacy of Prasugrel and Ticagrelor in Acute Coronary Syndrome. Results of a "Real World" Multicenter Registry.

INTRODUCTION AND OBJECTIVES: The incorporation of the new antiplatelet agents (NAA) prasugrel and ticagrelor into routine clinical practice is irregular and data from the "real world" remain scarce. We aimed to assess the time trend of NAA use and the clinical safety and efficacy of these drugs compared with those of clopidogrel in a contemporary cohort of patients with acute coronary syndromes (ACS). METHODS: A multicenter retrospective observational study was conducted in patients with ACS admitted to coronary care units and prospectively included in the ARIAM-Andalusia registry between 2013 and 2015. In-hospital rates of major cardiovascular events and bleeding with NAA vs clopidogrel were analyzed using propensity score matching and multivariate regression models. RESULTS: The study included 2906 patients: 55% received clopidogrel and 45% NAA. A total of 60% had ST-segment elevation ACS. Use of NAA significantly increased throughout the study. Patients receiving clopidogrel were older and were more likely to have comorbidities. Total mortality, ischemic stroke, and stent thrombosis were lower with NAA (2% vs 9%, P < .0001; 0.1% vs 0.5%, P = .025; 0.07% vs 0.5%, P = .025, respectively). There were no differences in the rate of total bleeding (3% vs 4%; P = NS). After propensity score matching, the mortality reduction with NAA persisted (OR, 0.37; 95%CI, 0.13 to 0.60; P < .0001) with no increase in total bleeding (OR, 1.07; 95%CI, 0.18 to 2.37; P = .094). CONCLUSIONS: In a "real world" setting, NAA are selectively used in younger patients with less comorbidity and are associated with a reduction in major cardiac events, including mortality, without increasing bleeding compared with clopidogrel.

Prolonged QT interval in ST-elevation myocardial infarction and mortality: new prognostic scale with QT, Killip and age.

AIMS: To analyze the relation between prolonged QT interval and mortality in patients with ST-elevation myocardial infarction and complementarity with Killip, Thrombolysis in Myocardial Infarction (TIMI) and Acute Physiology and Chronic Health Evaluation-II (APACHE-II) scales. METHODS: A nested cohort case-control study was conducted in a Spanish hospital. The cohort consisted of patients with ST-elevation myocardial infarction admitted between 2008 and 2010 (n = 524). The cases were the patients who died (n = 38) and the controls (n = 81) were a random sample of those who survived (one of every six). RESULTS: The corrected QT (QTc) interval of first ECG (prehospital-or-hospital admission) was prolonged in 18 of the 35 patients who died (51.4%) and in 12 of the controls (16.7%; P < 0.001). APACHE-II, TIMI and Killip scores were higher in the patients who had died (P < 0.001). Mortality with prolonged QTc (19.3%) was 20%, and 4.5% were with normal QTc (80.7%; P < 0.001).Logistic regression showed a relation between mortality with prolonged QTc and TIMI [odds ratio (OR) 3.57(1.16-10.97)]. A second model was constructed with APACHE-II and prolonged QTc [OR 6.47(1.77-23.59)]; receiver operating characteristic (ROC) curve area [0.92(0.87-0.97)], and individually, for APACHE-II was 0.88 (0.81-0.95). A new score was constructed: QTc (not prolonged: 0 points, prolonged: 7 points), age (<65 years: 0 points, 65-74 years: 6 points, ≥75 years: 9 points), Killip (I: 0 points, II-III: 4 points, IV: 17 points). ROC area: 0.88. CONCLUSIONS: Hospital mortality was higher with prolonged QTc at prehospital-or-hospital admission, given equal Killip, TIMI and APACHE values. Discrimination of Killip, TIMI and APACHE values can be improved with prolonged QTc. Discrimination of a model including Killip, age and prolonged QTc is quite good. We have made a new simple prognostic scale with these variables.

Gait Pattern and Cognitive Performance During Treadmill Walking in Parkinson Disease.

OBJECTIVE: The aim of this study was to explore whether attentional demands are involved in gait improvements in Parkinson disease (PD) patients when they walk on a treadmill. DESIGN: Nineteen individuals with idiopathic PD and 19 age-matched healthy controls participated in this study. Participants walked on a treadmill and on overground under single task (walk only) and dual task (walk performing a simultaneous cognitive task) conditions. The dual-task paradigm was used to reveal the attention allocation behavior. Gait pattern and cognitive performance was measured. RESULTS: The PD group showed reduced gait variability when walking on a treadmill in comparison with overground. However, this reduction did not deteriorate during the dual task. Moreover, there were no differences in the cognitive performance between treadmill and overground walking. CONCLUSIONS: This study does not support the proposition attentional resource allocation as a possible mechanism for the treadmill-associated gait improvements observed in PD.

Treadmill training improves overground walking economy in Parkinson's disease: a randomized, controlled pilot study.

Gait disturbances are one of the principal and most incapacitating symptoms of Parkinson's disease (PD). In addition, walking economy is impaired in PD patients and could contribute to excess fatigue in this population. An important number of studies have shown that treadmill training can improve kinematic parameters in PD patients. However, the effects of treadmill and overground walking on the walking economy remain unknown. The goal of this study was to explore the walking economy changes in response to a treadmill and an overground training program, as well as the differences in the walking economy during treadmill and overground walking. Twenty-two mild PD patients were randomly assigned to a treadmill or overground training group. The training program consisted of 5 weeks (3 sessions/week). We evaluated the energy expenditure of overground walking, before and after each of the training programs. The energy expenditure of treadmill walking (before the program) was also evaluated. The treadmill, but not the overground training program, lead to an improvement in the walking economy (the rate of oxygen consumed per distance during overground walking at a preferred speed) in PD patients. In addition, walking on a treadmill required more energy expenditure compared with overground walking at the same speed. This study provides evidence that in mild PD patients, treadmill training is more beneficial compared with that of walking overground, leading to a greater improvement in the walking economy. This finding is of clinical importance for the therapeutic administration of exercise in PD.

Evaluation of prognostic scale Thrombolysis In Myocardial Infarction and Killip. An ST-elevation myocardial infarction new scale.

BACKGROUND: Prognostic systems are complex. So it is necessary to find tools, which are easy to use and have good calibration and discrimination. OBJECTIVES: The objective of this study is to evaluate the usefulness of Killip, Thrombolysis In Myocardial Infarction (TIMI), and age to develop a new prognostic scale for patients with ST-elevation myocardial infarction (STEMI). METHODS: The study population included all patients with STEMI consecutively admitted to the Intensive Care Unit of Carlos Haya Hospital, Malaga, Spain. Top variables included are Killip and TIMI, hospital mortality, intensive care unit stay, treatment received, and care times intervals. RESULTS: The results are 806 patients; 75.6% men; age 63.11 ± 12.83 years old; TIMI, 3.57 ± 2.38; Killip I, 81.4%; and hospital mortality, 11.3%. Mortality increased in relation to age, TIMI, and Killip (P < .001). Receiver operating characteristic (ROC) area for TIMI is 0.832 (0.786-0.878) and Killip, 0.757 (0.698-0.822). Thrombolysis In Myocardial Infarction classification was associated with Killip and age by multiple linear regression. Patients were stratified into 5 groups according to Killip and age: Killip I and younger than 65 years (n = 369; mortality, 1.4%; odds ratio [OR], 1), Killip I and 65 to 75 years old (n = 173; mortality, 6.9%; OR, 5.43 [1.88-15.66]), Killip I and older than 75 years (n = 112; mortality, 18.9%; OR, 13.03 [4.69-36.21]), Killip II to III (n = 129; mortality, 31%; OR, 22.72 [12.55-85.29]), Killip IV (n = 20; mortality, 80%; OR, 291.2 [71.32-1189]). ROC area is 0.84 (0.798-0.883). We created a scale with scores based on the ß coefficient of logistical regression. CONCLUSIONS: The TIMI scale discriminated hospital mortality correctly for STEMI. It performed better than Killip alone and similar to a simple model that included age and Killip. The 2-variable model consists of a simple scale with 5 categories.

Spatiotemporal parameters of gait during treadmill and overground walking in Parkinson's disease.

Despite the increasing number of studies that have examined the therapeutic effect of treadmill training programs in Parkinson's disease (PD), there has been little research to evaluate the modifications of gait induced by treadmill walking. We investigated spatiotemporal differences between treadmill and overground walking in patients with PD. PD patients significantly increased their step length and step height; and reduced their cadence, step width and step width variability on the treadmill in comparison with walking overground. PD patients are able to attenuate their short shuffling steps when walking on a treadmill.

Reflexiones sobre el TDAH: estudio de casos / Reflections on ADHD: case study

El trastorno por déficit de atención con o sin hiperactividad (TDAH) es un motivo de consulta muy frecuente en los servicios de salud mental infantil y juvenil. Este artículo, integrando aportaciones teóricas psicoanalíticas y biológico-cognitivistas, revisa cuatro casos clínicos con diagnóstico de TDAH, con el objetivo de presentar diferentes tipos de abordajes. Se expone cómo bajo una conducta explícita congruente con dicho diagnóstico existen matices psicopatológicos susceptibles de un tratamiento diferente al exclusivamente farmacológico, también eficiente para la red pública (AU)

Attention Deficit Hyperactivity Disorder (ADHD) is a very frequent reason for consultation in child and juvenile mental health services. Considering theoretical contributions from the psychoanalytic and biological-cognitive paradigms, the author revises four clinical cases diagnosed with ADHD in order to present different treatment approaches. The paper aims to show how under an explicit conduct consistent with the diagnosis of ADHD, there are certain psychopathological characteristics susceptible of a different approach than the exclusively pharmacological one and which can also constitute an efficient treatment in the public mental health network (AU)

Reliability of squat and countermovement jump tests in children 6 to 8 years of age.

The aim of this study was to determine the reliability of the squat jump test (SJ) and countermovement jump test (CMJ), in fifty-six children (30 girls and 26 boys) with ages ranging from 6 to 8 years. Each subject performed two evaluation sessions (T1, T2) with seven days between tests. The results show that the CMJ test has a high intratrial reproducibility in T1 and T2 measured through intraclass correlation coefficient (ICC ≥ 0.95). The ICC for the SJ test had a high value (0.99) only in T1. The variability for both tests among children under 9 years of age is higher than those reported for adult subjects in other studies. The intersession reliability was questionable with a high methodical error (ME= 9.86-15.1%, for the SJ and CMJ, respectively) and a significant worsening of the results of CMJ in T2 (p < .05).

Ventral premotor to primary motor cortical interactions during noxious and naturalistic action observation.

Within the motor system, cortical areas such as the primary motor cortex (M1) and the ventral premotor cortex (PMv), are thought to be activated during the observation of actions performed by others. However, it is not known how the connections between these areas become active during action observation or whether these connections are modulated by the volitional component induced by the action observed. In this study, using a paired pulse transcranial magnetic stimulation (ppTMS) method, we evaluated the excitability of PMv-M1 connections during the observation of videos showing a human hand reaching to grasp a ball (naturalistic grasping video) or a switched on soldering iron (noxious grasping video). The results show that the observation of the naturalistic grasping action increased the M1 excitability and changed the strength of the PMv-M1 connections. The observation of the noxious grasping action did not induce any change in the excitability of the PMv-M1 connections throughout the video, but the strength of PMv-M1 connectivity was reduced. These results demonstrate that the PMv-M1 connections are modulated differently depending on whether the action observed would or would not be performed in real life.

Treadmill walking in Parkinson's disease patients: adaptation and generalization effect.

We examined the adaptation and generalization effect of one familiarization treadmill walking session on gait in patients with Parkinson's disease (PD) with different degrees of disease severity. Eight moderate PD patients (Hoehn and Yahr stage 2-2.5), eight advanced PD patients (Hoehn and Yahr 3), and eight matched control subjects participated in this study. Subjects first walked overground on a 10-m walkway at a self-selected speed (pretreadmill). They then performed a 20-min treadmill training session, followed by three trials of overground walking (Post1, Post2, Post3). Cadence, step length, speed, and coefficient of variation of stride time (CV) were recorded. During the treadmill session the advanced PD patients significantly decreased their cadence (t = 3.9, P

Results of a dental care protocol for mentally handicapped patients set in a primary health care area in Spain.

OBJECTIVE: Disabled people have the same right as other people to receive the health care they need, but they sometimes have difficulties to achieve it. In Castilla y Leon it has come into effect a law to guarantee Primary and Secondary Care coordination to provide dental treatment under sedation or anaesthesia to mentally disabled people who need it. Our aim is to evaluate the results of the implementation of such a law through a specific protocol in our health setting. STUDY DESIGN: Descriptive, made in a Health Area over a year, on mentally disabled people who were sent to hospital for treatment under anaesthesia after Primary Dental Care Units assessment. It has been studied the age, gender, mental disease, dental diagnosis and treatment undergone. RESULTS: 108 patients attended the program (51% male), with a mean age of 31 years. 67% presented profound learning disability, 19% mental illness with disability, 11% presented cerebral palsy and another 3% had autism. Most frequent dental pathologies were caries (86%) and dental plaque (71%). Most common dental procedures were tooth extraction (78%), professional tooth cleaning (75%) and fillings (67%). CONCLUSIONS: We achieved to provide necessary dental treatment to a large number of disabled people, who would not have received it otherwise. It was a challenge to plan and implement the protocol coordinating Health Care Levels and workers. It still has to be done an economic and efficiency analysis of procedures and a patient satisfaction study.

Results of a dental care protocol for mentally handicapped patients set in a primary health care area in Spain

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Disabled people have the same right as other people to receive the health care they need, but they sometimes have difficulties to achieve it. In Castilla y Leon it has come into effect a law to guarantee Primary and Secondary Care coordination toprovide dental treatment under sedation or anaesthesia to mentally disabled people who need it. Our aim is to evaluate the results of the implementation of such a law through a specific protocol in our health setting.Study design:Descriptive, made in a Health Area over a year, on mentally disabled people who were sent to hospital for treatment under anaesthesia after Primary Dental Care Units assessment. It has been studied the age, gender, mental disease, dentaldiagnosis and treatment undergone.Results:108 patients attended the program (51% male), with a mean age of 31 years. 67% presented profound learning disability, 19% mental illness with disability, 11% presented cerebral palsy and another 3% had autism. Most frequent dentalpathologies were caries (86%) and dental plaque (71%). Most common dental procedures were tooth extraction (78%), professional tooth cleaning (75%) and fillings (67%).Conclusions:We achieved to provide necessary dental treatment to a large number of disabled people, who would not have received it otherwise. It was a challenge to plan and implement the protocol coordinating Health Care Levels and workers. It still has to be done an economic and efficiency analysis of procedures and a patient satisfaction study