Sex- and age-related patterns in the use of analgesics in older patients in the emergency department.

BACKGROUND: Treatment of acute pain in older patients is a common challenge faced in emergency departments (EDs). Despite many studies that have investigated chronic analgesic use in the elderly, data on patterns of acute use, especially in EDs, of analgesics according to patient characteristics is scarce. OBJECTIVE: To investigate sex- and age-related patterns of analgesic use in the Spanish EDs and determine differences in age-related patterns according to patient sex. DESIGN: A secondary analysis of the Emergency Department and Elderly Needs (EDEN) multipurpose cohort. SETTING: Fifty-two Spanish EDs (17% of Spanish EDs covering 25% of Spanish population). PARTICIPANTS: All patients' ≥65 years attending ED during 1 week (April 1-7, 2019). Patient characteristics recorded included age, sex, chronic treatment with non-steroidal anti-inflammatory drugs (NSAIDs) and opiates, comorbidity, dependence, dementia, depression, ability to walk and previous falls. Analgesics used in the ED were categorized in three groups: non-NSAID non-opioids (mainly paracetamol and metamizole, PM), NSAIDs, and opiates. OUTCOME MEASURES: Frequency of analgesic use was quantified, and the relationship between sex and age and analgesic use (in general and for each analgesic group) was assessed by unadjusted and adjusted logistic regression and restricted cubic spline models. Interaction between sex and age was explored. MAIN RESULTS: We included 24 573 patients, and 6678 (27.2%) received analgesics in the ED: 5551 (22.6%) PM, 1661 (6.8%) NSAIDs and 937 (3.8%) opiates (1312 received combinations). Analgesics were more frequently used in women (adjusted OR = 1.076, 95%CI = 1.014-1.142), as well as with NSAID (1.205, 1.083-1.341). Analgesic use increased with age, increasing PM and decreasing NSAIDs use. Opiate use remained quite constant across age and sex. Interaction of sex with age was present for the use of analgesics in general ( P  = 0.006), for PM ( P  < 0.001) and for opiates ( P  = 0.033), with higher use of all these analgesics in women. CONCLUSION: Use of analgesics in older individuals in EDs is mildly augmented in women and increases with age, with PM use increasing and NSAIDs decreasing with age. Conversely, opiate use is quite constant according to sex and age. Age-related patterns differ according to sex, with age-related curves of women showing higher probabilities than those of men to receive any analgesic, PM or opiates.

Influence of income on in-hospital mortality in older adults during the first wave of the COVID-19 pandemic: results from the EDEN-33 study. / Influencia de la renta económica en la mortalidad intrahospitalaria de las personas mayores durante la primera ola de la pandemia por COVID-19: resultados del estudio EDEN-33.

OBJECTIVES: To determine whether income was associated with unexpected in-hospital mortality in older patients treated in Spanish public health system hospital emergency departments. MATERIAL AND METHODS: Fifty-one public health system hospital emergency departments in Spain voluntarily participated in the study. Together the hospitals covered 25% of the population aged 65 years or older included in all patient registers during a week in the pre-pandemic period (April 1-7, 2019) and a week during the COVID-19 pandemic (March 30 to April 5, 2020). We estimated a patient's gross income as the amount published for the postal code of the patient's address. We then calculated the standardized gross income (SGI) by dividing the patient's estimated income by the mean for the corresponding territory (Spanish autonomous community). The existence and strength of an association between the SGI and in-hospital mortality was evaluated by means of restricted cubic spline (RCS) curves adjusted for 10 patient characteristics at baseline. Odds ratios (ORs) for each income level were expressed in relation to a reference SGI of 1 (the mean income for the corresponding autonomous community). We compared the COVID-19 and pre-pandemic periods by means of first-order interactions. RESULTS: Of the 35 280 patients attended in the 2 periods, gross income could be ascertained for 21 180 (60%), 15437 in the pre-pandemic period and 5746 during the COVID-19 period. SGIs were slightly higher for patients included before the pandemic (1.006 vs 0.994; P = .012). In-hospital mortality was 5.6% overall and higher during the pandemic (2.8% pre-pandemic vs 13.1% during COVID-19; P .001). The adjusted RCS curves showed that associations between income and mortality differed between the 2 periods (interaction P = .004). Whereas there were no significant income-influenced differences in mortality before the pandemic, mortality increased during the pandemic in the lowest-income population (SGI 0.5 OR, 1.82; 95% CI, 1.32-3.37) and in higher-income populations (SGI 1.5 OR, 1.32; 95% CI, 1.04-1.68, and SGI 2 OR, 1.92; 95% CI, 1.14-3.23). We found no significant differences between patients with COVID-19 and those with other diagnoses (interaction P = .667). CONCLUSION: The gross income of patients attended in Spanish public health system hospital emergency departments, estimated according to a patient's address and postal code, was associated with in-hospital mortality, which was higher for patients with the lowest and 2 higher income levels. The reasons for these associations might be different for each income level and should be investigated in the future.

OBJETIVO: Determinar si el nivel económico durante la primera ola pandémica tuvo una influencia diferente a la esperable en la mortalidad intrahospitalaria de los pacientes mayores atendidos en los servicios de urgencias (SU) de los hospitales públicos españoles. METODO: Cincuenta y un SU públicos españoles que participaron voluntariamente y que dan cobertura al 25% de la población incluyeron todos los registros de pacientes de edad 65 años atendidos durante una semana del periodo preCOVID (1-4-2019 a 7-4-2019) y una semana del periodo COVID (30-3-2020 a 5-4-2020). Se identificó la renta bruta (RB) asignada al código postal de residencia de cada paciente y se calculó la RB normalizada (RBN) dividiendo aquella por la RB media de su comunidad autónoma. La existencia y fuerza de la relación entre RBN y mortalidad intrahospitalaria se determinó mediante curvas spline cúbicas restringidas (SCR) ajustadas por 10 características basales del paciente. Las OR para cada situación económica se expresó en relación con una RBN de 1 (referencia, renta correspondiente a la media de la comunidad autónoma). La comparación entre periodo COVID y no COVID se realizó mediante el estudio de interacción de primer grado. RESULTADOS: De los 35.280 registros de pacientes atendidos en ambos periodos, se disponía de la RB en 21.180 (60%): 15.437 del periodo preCOVID y 5.746 del periodo COVID. La RBN de los pacientes incluidos fue discretamente superior en el periodo preCOVID (1,006 versus 0,994; p = 0,012). La mortalidad intrahospitalaria fue del 5,6%, y fue superior durante el periodo COVID (2,8% versus 13,1%; p 0,001). Las curvas SCR ajustadas mostraron una asociación entre nivel económico y mortalidad diferente entre ambos periodos (p interacción = 0,004): en el periodo preCOVID no hubo diferencias significativas de mortalidad en función de la RBN, mientras que en el periodo COVID la mortalidad se incrementó en rentas bajas (OR = 1,82, IC 95% = 1,32-3,37 para RBN de 0,5) y en rentas altas (OR = 1,32, IC 95% = 1,04-1,68 y OR = 1,92, IC 95% = 1,14-3,23 para RBN de 1,5 y 2, respectivamente), sin diferencias significativas entre pacientes con COVID y con otros diagnósticos (p interacción = 0,667). CONCLUSIONES: Durante la primera ola de la pandemia COVID, la RB asignada al código postal de residencia de los pacientes atendidos en los SU públicos españoles se asoció con la mortalidad intrahospitalaria, que aumentó en pacientes de rentas bajas y altas. Las razones de estas asociaciones pueden ser distintas para cada segmento económico y deben ser investigadas en el fututo.

[Impacto de la dependencia funcional de los pacientes mayores atendidos en los servicios de Urgencias españoles durante la primera ola pandémica de la COVID-19 sobre la mortalidad a 30, 180 y 365 días en función del diagnóstico (COVID versus no COVID).] / Impact of functional dependency of elderly patients seen in Spanish emergency departments during the first wave of the COVID-19 pandemic on mortality at 30, 180 and 365 days depending on the diagnosis (COVID versus non-COVID).

OBJECTIVE: Functional assessment is part of geriatric assessment. How it is performed in hospital Emergency Departments (ED) is poorly understood, let alone its prognostic value. The aim of this paper was to investigate whether baseline disability to perform basic activities of daily living (BADL) was an independent prognostic factor for death after the index visit to the ED during the first wave of the COVID-19 pandemic and whether it had a different impact on patients with and without diagnosis of COVID-19. METHODS: A retrospective observational study of the EDEN-Covid (Emergency Department and Elder Needs during COVID) cohort was carried out, consisting of all patients aged ≥65 years seen in 52 Spanish EDs selected by chance during 7 consecutive days (30/3/2020 to 5/4/2020). Demographic, clinical, functional, mental and social variables were analyzed. Dependence was categorized with the Barthel index (BI) as independent (BI=100), mild-moderate dependence (100>BI>60) and severe-total dependence (BI<60), and their crude and adjusted association was evaluated with mortality at 30, 180 and 365 days using COX proportional hazards models. RESULTS: Of 9,770 enrolled patients with a mean age of 79 years, 51% were men, 6,305 (64.53%) were independent, 2,340 (24%) had mild-moderate dependence, and 1,125 (11.5%) severe-total dependence. The number of deaths at 30 days in these three groups was 500 (7.9%), 521 (22.3%) and 378 (33.6%), respectively; at 180 days it was 757 (12%), 725 (30.9%) and 526 (46.8%); and at 365 days 954 (15.1%), 891 (38.1%) and 611 (54.3%). In relation to independent patients, the adjusted risks (hazard ratio) of dying within 30 days associated with mild-moderate and severe-total dependency were 1.91 (95% CI: 1.66-2.19) and 2.51. (2.11-2.98); at 180 days they were 1.88 (1.68-2.11) and 2.64 (2.28-3.05); and at 365 days they were 1.82 (1.64-2.02) and 2.47 (2.17-2.82). This negative impact of dependency on mortality was greater in patients diagnosed with COVID-19 than in non-COVID-19 (p interaction at 30, 180 and 365 days of 0.36, 0.05 and 0.04). CONCLUSIONS: The functional dependence of older patients who attend Spanish EDs during the first wave of the pandemic is associated with mortality at 30, 180 and 365 days, and this risk is significantly higher in patients treated for COVID-19.

OBJETIVO: La valoración funcional forma parte de la valoración geriátrica. No se conoce bien cómo se realiza en los servicios de Urgencias hospitalarios (SUH) y menos aún su valor pronóstico. El objetivo de este trabajo fue investigar si la dependencia funcional basal para realizar las actividades básicas de la vida diaria (ABVD) era un factor pronóstico independiente de muerte tras la visita índice al SUH durante la primera ola pandémica de la COVID-19 y si tuvo un impacto diferente en pacientes con y sin diagnóstico de COVID-19. METODOS: Se realizó un estudio observacional retrospectivo de la cohorte EDEN-Covid (Emergency Department and Elder Needs during COVID) formada por todos los pacientes de edad mayor o igual a 65 años atendidos en 52 SUH españoles, seleccionados por oportunidad durante siete días consecutivos (del 30 de marzo al 5 de abril de 2020). Se analizaron variables demográficas, clínicas, funcionales, mentales y sociales. La dependencia se categorizó con el índice de Barthel (IB) en independiente (IB=100), dependencia leve-moderada (100>IB>60) y dependencia grave-total (IB<60), y se evaluó su asociación cruda y ajustada con la mortalidad a 30, 180 y 365 días mediante modelos de riesgos proporcionales de COX. RESULTADOS: De 9.770 pacientes incluidos con una media de edad de 79 años, un 51% eran hombres, 6.305 (64,53%) eran independientes, 2.340 (24%) tenían dependencia leve-moderada y 1.125 (11,5%) dependencia grave-total. El número de fallecidos a 30 días en estos tres grupos fue 500 (7,9%), 521 (22,3%) y 378 (33,6%), respectivamente; a 180 días fue 757 (12%), 725 (30,9%) y 526 (46,8%); y a 365 días 954 (15,1%), 891 (38,1%) y 611 (54,3%). En relación a los pacientes independientes, los riesgos (hazard ratio) ajustados de fallecer a 30 días, asociados a dependencia leve-moderada y grave-total, fueron 1,91 (IC 95%: 1,66-2,19) y 2,51 (2,11-2,98); a 180 días fueron de 1,88 (1,68-2,11) y 2,64 (2,28-3,05); y a 365 días fueron 1,82 (1,64-2,02) y 2,47 (2,17-2,82). Este impacto negativo de la dependencia sobre la mortalidad fue mayor en pacientes diagnosticados de COVID-19 que en los no COVID-19 (p interacción a 30, 180 y 365 días de 0,36, 0,05 y 0,04). CONCLUSIONES: La dependencia funcional de los pacientes mayores que acuden a SUH españoles durante la primera ola pandémica se asocia a mortalidad a 30, 180 y 365 días, y este riesgo es significativamente mayor en los pacientes atendidos por COVID-19.

Relationship between the structure, function and endothelial damage, and vascular ageing and the biopsychological situation in adults diagnosed with persistent COVID (BioICOPER study). A research protocol of a cross-sectional study.

Background: SARS-CoV-2 infection affects the vascular endothelium, which mediates the inflammatory and thrombotic cascade. Moreover, alterations in the endothelium are related to arterial stiffness, which has been established as a marker of cardiovascular disease. The objective of this study is to analyse how the structure, vascular function, vascular ageing and endothelial damage are related to the biopsychological situation in adults diagnosed with persistent COVID and the differences by gender. Methods: This cross-sectional, descriptive, observational study will be carried out in the Primary Care Research Unit of Salamanca (APISAL) and in the BioSepsis laboratory of the University of Salamanca. The sample will be selected from the persistent COVID monographic office at the Internal Medicine Service of the University Hospital of Salamanca, and from the population of subjects diagnosed with persistent COVID in the clinical history of Primary Care. Through consecutive sampling, the study will include 300 individuals diagnosed with persistent COVID who meet the diagnosis criteria established by the WHO, after they sign the informed consent. Endothelial damage biomarkers will be measured using ELLA-SimplePlexTM technology (Biotechne). Their vascular structure and function will be analysed by measuring the carotid intima-media thickness (Sonosite Micromax); the pulse wave and carotid-femoral pulse wave velocity (cfPWV) will be recorded with Sphygmocor System®. Cardio Ankle Vascular Index (CAVI), brachial-ankle pulse wave velocity (baPWV) and ankle-brachial index will be analysed with Vasera VS-2000®. The integral assessment of the subjects with persistent COVID will be conducted with different scales that evaluate fatigue, sleep, dyspnea, quality of life, attention, nutrition state, and fragility. We will also evaluate their lifestyles (diet, physical activity, smoking habits and alcohol consumption), psychological factors, and cognitive deterioration, which will be gathered through validated questionnaires; moreover, physical activity will be objectively measured using a pedometer for 7 days. Body composition will be measured through impedance using an Inbody 230. Vascular ageing will be calculated with 10 and 90 percentiles of cfPWV and baPWV. Furthermore, we will analyse the presence of vascular injury in the retina, heart, kidneys and brain, as well as cardiovascular risk. Demographic and analytical variables will also be gathered. Discussion: Arterial stiffness reflects the mechanic and functional properties of the arterial wall, showing the changes in arterial pressure, blood flow, and vascular diameter that occur with each heartbeat. SARS-CoV-2 affects the endothelial cells that are infected with this virus, increasing the production of pro-inflammatory cytokines and pro-thrombotic factors, which can cause early vascular ageing and an increase of arterial stiffness. Persistent COVID is a complex heterogeneous disorder that affects the lives of millions of people worldwide. The identifications of potential risk factors to better understand who is at risk of developing persistent COVID is important, since this would enable early and appropriate clinical support. It is unknown whether vascular alterations caused by COVID-19 resolve after acute infection or remain over time, favouring the increase of arterial stiffness and early vascular ageing. Therefore, it is necessary to propose studies that analyse the evolution of persistent COVID in this group of patients, as well as the possible variables that influence it. Clinical Trial registration: ClinicalTrials.gov, identifier NCT05819840.

A case-control analysis of stroke in COVID-19 patients: Results of unusual manifestations of COVID-19-study 11.

OBJECTIVE: We investigated the incidence, predictor variables, clinical characteristics, and stroke outcomes in patients with COVID-19 seen in emergency departments (EDs) before hospitalization. METHODS: We retrospectively reviewed all COVID-19 patients diagnosed with stroke during the COVID-19 outbreak in 62 Spanish EDs. We formed two control groups: COVID-19 patients without stroke (control A) and non-COVID-19 patients with stroke (control B). We compared disease characteristics and four outcomes between cases and controls. RESULTS: We identified 147 strokes in 74,814 patients with COVID-19 seen in EDs (1.96‰, 95% confidence interval [CI] = 1.66‰ to 2.31‰), being lower than in non-COVID-19 patients (6,541/1,388,879, 4.71‰, 95% CI = 4.60‰ to 4.83‰; odds ratio [OR] = 0.42, 95% CI = 0.35 to 0.49). The estimated that standardized incidences of stroke per 100,000 individuals per year were 124 and 133 for COVID-19 and non-COVID-19 individuals, respectively (OR = 0.93 for COVID patients, 95% CI = 0.87 to 0.99). Baseline characteristics associated with a higher risk of stroke in COVID-19 patients were hypertension, diabetes mellitus, and previous cerebrovascular and coronary diseases. Clinically, these patients more frequently presented with confusion, decreased consciousness, and syncope and higher D-dimer concentrations and leukocyte count at ED arrival. After adjustment for age and sex, the case group had higher hospitalization and intensive care unit (ICU) admission rates (but not mortality) than COVID-19 controls without stroke (OR = 3.41, 95% CI = 1.27 to 9.16; and OR = 3.79, 95% CI = 1.69 to 8.50, respectively) and longer hospitalization and greater in-hospital mortality than stroke controls without COVID-19 (OR = 1.55, 95% CI = 1.24 to 1.94; and OR = 1.77, 95% CI = 1.37 to 2.30, respectively). CONCLUSIONS: The incidence of stroke in COVID-19 patients presenting to EDs was lower than that in the non-COVID-19 reference sample. COVID-19 patients with stroke had greater need for hospitalization and ICU admission than those without stroke and longer hospitalization and greater in-hospital mortality than non-COVID-19 patients with stroke.

Frequency, Risk Factors, Clinical Characteristics, and Outcomes of Spontaneous Pneumothorax in Patients With Coronavirus Disease 2019: A Case-Control, Emergency Medicine-Based Multicenter Study.

BACKGROUND: Recent reports of patients with coronavirus disease 2019 (COVID-19) developing pneumothorax correspond mainly to case reports describing mechanically ventilated patients. The real incidence, clinical characteristics, and outcome of spontaneous pneumothorax (SP) as a form of COVID-19 presentation remain to be defined. RESEARCH QUESTION: Do the incidence, risk factors, clinical characteristics, and outcomes of SP in patients with COVID-19 attending EDs differ compared with COVID-19 patients without SP and non-COVID-19 patients with SP? STUDY DESIGN AND METHODS: This case-control study retrospectively reviewed all patients with COVID-19 diagnosed with SP (case group) in 61 Spanish EDs (20% of Spanish EDs) and compared them with two control groups: COVID-19 patients without SP and non-COVID-19 patients with SP. The relative frequencies of SP were estimated in COVID-19 and non-COVID-19 patients in the ED, and annual standardized incidences were estimated for both populations. Comparisons between case subjects and control subjects included 52 clinical, analytical, and radiologic characteristics and four outcomes. RESULTS: We identified 40 occurrences of SP in 71,904 patients with COVID-19 attending EDs (0.56‰; 95% CI, 0.40‰-0.76‰). This relative frequency was higher than that among non-COVID-19 patients (387 of 1,358,134, 0.28‰; 95% CI, 0.26‰-0.32‰; OR, 1.93; 95% CI, 1.41-2.71). The standardized incidence of SP was also higher in patients with COVID-19 (34.2 vs 8.2/100,000/year; OR, 4.19; 95% CI, 3.64-4.81). Compared with COVID-19 patients without SP, COVID-19 patients developing SP more frequently had dyspnea and chest pain, low pulse oximetry readings, tachypnea, and increased leukocyte count. Compared with non-COVID-19 patients with SP, case subjects differed in 19 clinical variables, the most prominent being a higher frequency of dysgeusia/anosmia, headache, diarrhea, fever, and lymphopenia (all with OR > 10). All the outcomes measured, including in-hospital death, were worse in case subjects than in both control groups. INTERPRETATION: SP as a form of COVID-19 presentation at the ED is unusual (< 1‰ cases) but is more frequent than in the non-COVID-19 population and could be associated with worse outcomes than SP in non-COVID-19 patients and COVID-19 patients without SP.

Automatic image analyser to assess retinal vessel calibre (ALTAIR). A new tool to evaluate the thickness, area and length of the vessels of the retina.

BACKGROUND AND OBJECTIVES: The examination of the fundus allows to evaluate retinal the microcirculation in vivo. We assess the reliability and validity of ALTAIR software, and to evaluate its clinical relevance by the association of thickness, area and length of the retinal vessels with other measures of vascular structure and function, target organ damage and cardiovascular risk. METHODS: Cross-sectional study involving a total of 250 subjects aged 62 ±â€¯9 years, 51 % males. In a random subsample of 60 subjects (118 retinographies), we estimated the intraobserver, interobserver and interdevice intraclass correlation coefficients (ICC) of the measurements of retinal vascular thickness, area and length in 3 concentric circles. Concurrent validity was assessed with all 250 subjects (495 retinographies), analysing the relationship to age, blood pressure, target organ damage, vascular structure and function, and cardiovascular risk. RESULTS: Of the sample, 69 % were diagnosed with hypertension and 17 % with diabetes. Intraobserver ICC ranged from 0.640 for venous length to 0.906 for arterial area. Interobserver ICC ranged from 0.809 for arterial length to 0.916 for venous area, and interdevice ICC for arteriovenous ratio (AVR) was 0.887, thickness of arteries 0.590 and vein thickness 0.677. We found a moderate correlation between retinal vascular parameters and vascular structure and function, and target organ damage. In multiple linear regression analysis, the association with blood pressure, albumin/creatinine ratio, carotid intima-media thickness and cardiovascular risk is maintained. CONCLUSION: The ALTAIR tool has been useful for analysing the thickness, area and length of retinal vessels, with adequate reliability and a concomitant association of retinal vessel measurements with other cardiovascular parameters and cardiovascular risk. Therefore, in addition to thickness, the area and length of retinal vessels could also play a role in the prediction of cardiovascular risk.

Clinical Characteristics, Treatment, and Outcome of Trochleitis.

BACKGROUND AND PURPOSE: To study the clinical characteristics, treatment options, and outcome of patients with trochleitis in our population. METHODS: Retrospective review of 59 patients diagnosed with trochleitis in the Ramon y Cajal Hospital Emergency Service between 2003 and 2010. Demographic data and trochleitis features were described. The relationship between outcome and treatment options was analyzed by SPSS. RESULTS: The estimated prevalence rate of trochleitis in our area was 12 per 100,000. The average age of patients was 43±18 years. The majority of cases were women (86%). One case was bilateral. Patients' chief complaints were continuous pain (66%), pain only with ocular movements (25%), or pain only with palpation (8%). Ocular movement limitations were presented in 14%. Diplopia was observed in 12%, and 19% complained of headache. Oral non-steroidal anti-inflammatory drugs (NSAIDs) were the first option for treatment in 85% of cases, associated with oral steroids in 8% of patients. Oral steroids were the first and only option for treatment in 3%. Symptoms completely resolved in 80%, with the worst responses seen in cases with motility disturbances. Peritrochlear triamcinolone acetonide was injected in 14% of cases, achieving a good response in 62%. CONCLUSIONS: The prevalence of trochleitis in our area is low, and this pathology is more frequent in females. Oral NSAIDs are efficient to resolve isolated pain, but the response is partial if diplopia or motility limitations are associated. Some non-responders achieved good results with peritrochlear triamcinolone. Successful management provides a good prognosis for most patients.

Variability of the multifocal electroretinogram based on the type and position of the electrode.

PURPOSE: To evaluate and compare the wave amplitude of multifocal electroretinogram (mfERG) measurements and discomfort from Dawson-Trick-Litzkow (DTL) electrode located on the cornea (cDTL) and on the conjunctival fornix (fDTL) and ERG-jet contact lens electrode (CL). METHODS: Thirty-six patients and 18 healthy volunteers were evaluated with three different methods (cDTL, fDTL and CL). Wave amplitude, number of artifacts, number of electrode dislocations and level of discomfort obtained with each electrode were compared. These variables were also compared between patients and healthy volunteers (control group). Comparisons between wave amplitudes were made using intraclass correlation coefficient (ICC). RESULTS: Responses by the three tested electrode were better correlated (ICC) in patient (0.616-0.756) than in control groups (0.342-0.679). CL provided the highest wave amplitude in both groups (p < 0.005), but it was associated with higher discomfort (p < 0.001) and the highest rate of dislocations (72 and 100 % in control and patients, respectively). Looking at the differences obtained by each electrode between both groups, CL seems to be able to differentiate patient from control in the ring 1 of the mfERG. By contrast, fDTL gave the lowest wave amplitude in both groups, but it had the advantage to, apparently, discriminate between patients and control group in rings 1 and 2. cDTL produced more artifacts than the other electrodes in both groups (p < 0.001). CONCLUSIONS: Although wave amplitude measurements with different electrodes were correlated, they cannot be directly compared, so it is mandatory to create an appropriate normative database with each electrode. Despite providing the lowest amplitudes, fDTL seems to offer the best features to perform mfERG regarding discomfort, number of artifacts and diagnostic capability.

Evolución del impacto de la cardiopatía isquémica en la reincorporación laboral de trabajadores españoles / Evolution of ischemic cardiopathy impact on spanish workers on their return to work

INTRODUCCIÓN: La cardiopatía isquémica es una de las principales causas de morbimortalidad en los países desarrollados dificultando la vuelta al trabajo de estos pacientes. Pretendemos estudiar la evolución de la incapacidad Temporal y Permanente en trabajadores españoles que causan baja por cardiopatía isquémica, así como analizar las variables que influyen en la reincorporación laboral. MATERIAL Y MÉTODOS: Estudio observacional retrospectivo de cohortes con pacientes menores 65 años que sufrieron un infarto agudo de miocardio (IAM) entre Enero de 2000 y mayo de 2011. Se recogieron datos clínicos, demográficos, socioeconómicos y laborales para analizar su relación con la reincorporación laboral. RESULTADOS: Se seleccionaron un total de 5067 pacientes, el 94% varones, y con una edad media de 54,3 años. Un total de 3.679 pacientes (72,6%) se reincorporaron a su actividad laboral tras el infarto, mientras que 1261 (24,9%) obtuvieron la incapacidad laboral permanente. La mayores tasas de incapacidad laboral se observan en los pacientes > 50 años, en los que han sufrido un mayor daño cardiaco (FEVI < 50%), en aquellos con un mayor número de arterias coronarias obstruidas y los que fueron revascularizados mediante cirugía. En cuanto a las variables socioeconómicas se reincorporan menos los trabajadores con salarios más bajos, los trabajadores por cuenta ajena y los que realizan trabajos en los que predomina la carga física y manual frente a las profesiones en que predomina el trabajo intelectual. No encontramos diferencias con respecto a la tasa de reincorporación entre hombres y mujeres o en función del diagnóstico que motivó la baja (síndrome coronario agudo vs. angina). Observamos que la tasa de reincorporación laboral se ha incrementado de forma progresiva en la última década. (Desde tasas de reincorporación del 60% en el 2000-2002 a tasas superiores al 80% a partir de 2010) Este incremento se observa en todos los sectores ocupacionales como en todos los tramos etarios en los que se distribuye la muestra CONCLUSIONES: En nuestro estudio se observa un aumento progresivo en los últimos años en el porcentaje de pacientes que se reincorporan al trabajo. Las variables que mejor predicen la reincorporación laboral tras sufrir una baja por cardiopatía isquémica son viables clínicas como la extensión del daño miocárdico (FEVI <50%/FEVI >50%) y el procedimiento de revascularización empleado (percutáneo/cirugía) así como las variables socioeconómicas referentes al tipo de trabajo (autónomo/cuenta ajena), ocupación profesional (carga física/carga intelectual) y la edad del trabajador

BACKGROUND: Ischemic cardiopathy is one of the main causes of morbidity and mortality in developed countries. It affects the patients quality of life and interferes with their return to work, thus generating a significant economic cost. The aim of our study is to assess labor conditions of patients who suffered an acute myocardial infarction (AMI), highlighting the factors that could have an impact on their return-to-work time. MATERIALS AND METHODS: Observational retrospective study with patients under 65 years old who suffered an AMI between January 2000 and May 2011. Data concerning clinical, social, demographic and labor circumstances was collected to better understand its relation with the return to work. RESULTS: A total of 5.067 patients with Coronary Heart Disease (hereinafter referred to as CHD) were selected. 94% of the samples were men, under 54.3 years old. 3679 out of 5067 patients (72. 6%) returned to work after a heart infarct whereas 1261 (24.9%) did not return, obtaining the permanent incapacity to work. Among the clinical and patient factors, the main determinants were age (mostly <50 years), severity of AMI, poor left ventricular function (EF >50% / EF >50%) and revascularization procedures (percutaneous coronary interventions -PCI- and coronary artery bypass graft surgery, CABG). Regarding the economic and job-related factors three variables were found to be the strongest predictors of returning to work: job demands (physically demanding jobs vs. intellectually demanding jobs), incomes and job conditions (self-employment vs. employees). There were no significant differences on the returning-to-work rate between men or women or between sick leave due to an acute coronary syndrome or due to an angina. We observed that the return-to-work activity increased gradually from 2000-2011 (from rates of 60% in 2000-2002 to over 80% in 2010). This increase is present in all occupational activities as well as in all age ranges. CONCLUSION: In our study we observed a gradual increase of patients returning to work in recent years. The variables used to better predict the return-to-work time in a period of sick leave after a CHD episode are categorized as follows: clinic viable like the extent of myocardial damage (LVEF <50%/LVEF >50%) and the revascularization procedures (Percutaneous coronary intervention (PCI) or coronary artery bypass graft surgery, CABG), socioeconomic variables related to the kind of job (self-employment vs. employees) and lastly labor conditions like job demands (physical-demanding jobs vs. intellectual-demanding jobs) or age

Relationship of 24-h blood pressure variability with vascular structure and function in hypertensive patients.

OBJECTIVES: To analyze the relationship of 24-h blood pressure variability (BPV) with vascular structure and function using the SD and the coefficient of variation (CV). PATIENTS AND METHODS: A cross-sectional study was carried out in 344 hypertensive patients (aged 54.1±11.7 years, 59.6% men). BPV was estimated with the SD and CV over 24-h, both awake and sleep, by ambulatory blood pressure monitoring. Vascular structure and function were evaluated by the ambulatory arterial stiffness index (AASI), the pulse wave velocity (PWV) using SphygmoCor and the carotid intima-media thickness (IMT) as assessed by ultrasound. RESULTS: The systolic blood pressure (SBP) variability was greater than the diastolic blood pressure (DBP) variability using the SD and less using CV (P<0.001). SBP variability showed a positive correlation with the IMT, PWV and AASI. The CV of the DBP showed a positive correlation with the PWV and the AASI, whereas the SD of the DBP showed a negative correlation with the AASI. In the multiple regression analysis, after adjustment, the BPV measure that maintained their associations with the IMT was the CV of awake DBP and that with the PWV were the CV and the SD of 24-h and awake SBP/DBP. The AASI maintained the associations with the BPV measure in 24-h DBP, but not in SBP. The odds ratio of the SD and the CV for vascular damage varied between 1.182 and 1.276. CONCLUSION: BPV in hypertensive patients, as evaluated by both SD and CV, is associated with arterial stiffness as evaluated with the PWV. The ambulatory blood pressure monitoring is more accessible at the clinic than the PWV; therefore, the assessment of BPV (24-h, awake and sleep) may be useful for assessment of arterial stiffness.

Variabilidad de la frecuencia cardiaca de 24 horas y lesión vascular aterosclerótica / 24 hour heart rate variability and atherosclerotic vascular damage

Introducción: El objetivo del estudio es analizar la relación entre la variabilidad de la frecuencia cardiaca de 24h y la estructura y función vascular en pacientes con factores de riesgo cardiovascular. Métodos Estudio descriptivo transversal. Se incluyeron 301 pacientes (edad media, 54±12años; 61,8% varones) con algún factor de riesgo. La variabilidad de la frecuencia cardiaca se evaluó con la monitorización ambulatoria de 24h (DS_FC24h); el grosor íntima-media (GIM) carotídeo, con ecografía; la rigidez arterial, con la velocidad de la onda del pulso (VOP) y el índice de rigidez arterial ambulatoria (AASI), y los parámetros hemodinámicos, con el índice de aumento de la presión arterial periférico (PAIx) y central (CAIx).Resultados Todos los parámetros evaluados son mayores en los primeros cuartiles de la DS_FC24h, a excepción del PAIx, aunque la VOP no alcanza la significación estadística. Encontramos una correlación negativa de la DS_FC24h con la GIM media (r=-0,271; p<0,01), la VOP (r=-0,120; p<0,05), el AASI (r=-0,322; p<0,01), el PAIx (r=-0,122; p<0,05) y el CAIx (r=-0,248; p<0,01). Sin embargo, al ajustar por edad se pierde la significación de la VOP y del PAIx. En los modelos de regresión lineal múltiple, solo el GIM, el AASI y el CAIx mantienen la significación después de los ajustes. Conclusión La variabilidad de la frecuencia cardiaca muestra una relación inversa con el grosor íntima-media carotídeo, el índice de rigidez arterial ambulatoria y el augmentation index central. La relación con la velocidad de la onda del pulso y el augmentation index periférico parace estar mediada por la edad (AU)

Introduction: The aim of this study is to analyse the relationship between the 24 hour heartrate variability and vascular structure and function in patients with cardiovascular risk factors. Methods: A descriptive, cross-sectional study was conducted on 301 patients (mean age 54 ± 12years, 61.8% males) with any risk factor. The 24 hour heart rate variability (DS FC24 h) was assessed using an outpatient monitoring device. The rest of the variables were the carotidintima-media thickness (CIMT), measured by ultrasound, arterial stiffness with pulse-wave velocity (PWV), the ambulatory arterial stiffness index, and the haemodynamic parameters with the peripheral arterial pressure (PAIx) and central arterial pressure (CAIx) index. Results: All the parameters evaluated were higher in the first quartiles of the DS FC24 h, with the exception of the PAIx, although the PWV did not reach statistical significance. There was a negative correlation between the DS FC24 h and the mean CIMT (r = ---0.271; P < .01), the PWV (r = ---0.120; P < .05), AASI (r = ---0,322; P < .01), PAIx (r = ---0,122; P < .05 and CAIx (r = ---0,248;P < .01). However, on adjusting for age the significance of the PWV and PAIx was lost. In the multiple regression models, only the CIMT, AASI, and the CAIx remained significant after the adjustments. Conclusion: The heart rate variability shows an inverse relationship with carotid intima-mediathisckness, the ambulatory arterial stiffness index, and central augmentation index. The relationship with the pulse wave velocity and the peripheral augmentation index appears to be associated with age (AU)

Office and 24-hour heart rate and target organ damage in hypertensive patients.

BACKGROUND: We investigated the association between heart rate and its variability with the parameters that assess vascular, renal and cardiac target organ damage. METHODS: A cross-sectional study was performed including a consecutive sample of 360 hypertensive patients without heart rate lowering drugs (aged 56 ± 11 years, 64.2% male). Heart rate (HR) and its standard deviation (HRV) in clinical and 24-hour ambulatory monitoring were evaluated. Renal damage was assessed by glomerular filtration rate and albumin/creatinine ratio; vascular damage by carotid intima-media thickness and ankle/brachial index; and cardiac damage by the Cornell voltage-duration product and left ventricular mass index. RESULTS: There was a positive correlation between ambulatory, but not clinical, heart rate and its standard deviation with glomerular filtration rate, and a negative correlation with carotid intima-media thickness, and night/day ratio of systolic and diastolic blood pressure. There was no correlation with albumin/creatinine ratio, ankle/brachial index, Cornell voltage-duration product or left ventricular mass index. In the multiple linear regression analysis, after adjusting for age, the association of glomerular filtration rate and intima-media thickness with ambulatory heart rate and its standard deviation was lost. According to the logistic regression analysis, the predictors of any target organ damage were age (OR = 1.034 and 1.033) and night/day systolic blood pressure ratio (OR = 1.425 and 1.512). Neither 24 HR nor 24 HRV reached statistical significance. CONCLUSIONS: High ambulatory heart rate and its variability, but not clinical HR, are associated with decreased carotid intima-media thickness and a higher glomerular filtration rate, although this is lost after adjusting for age. TRIAL REGISTRATION: ClinicalTrials.gov: NCT01325064.

Relationships of night/day heart rate ratio with carotid intima media thickness and markers of arterial stiffness.

OBJECTIVES: To analyze the relationship between office and ambulatory heart rate, and its variability, and arterial stiffness in patients with primary arterial hypertension. METHODS: A cross-sectional study was conducted in a primary care setting, with the inclusion of 356 hypertensive patients aged 30-80 years. Office and ambulatory blood pressure, heart rate, night/day heart rate ratio and the corresponding standard deviations, were determined. Arterial stiffness was assessed according to carotid intima media thickness, pulse wave velocity, the central and peripheral augmentation index, and the ambulatory arterial stiffness index. RESULTS: Carotid intima media thickness, central and peripheral augmentation index, and ambulatory arterial stiffness index were negatively correlated to office and ambulatory heart rate and its standard deviation, and positively correlated to the night/day heart rate ratio. Pulse wave velocity showed a negative correlation to 24 h standard deviation heart rate and a positive correlation to nocturnal heart rate and the night/day heart rate ratio. For each 10 bpm increment in 24 h heart rate, the pulse wave velocity increased 0.42 m/s (95%CI: 0.23-0.60) and ambulatory arterial stiffness index decreased 0.01 (95%CI: 0.01-0.02); in the case of office heart rate, the peripheral augmentation index decreased 4.74 (95%CI: 3.15-6.33) and central augmentation index decreased 3.52 (95%CI: 2.43-4.30), while for 24 h standard deviation heart rate, carotid intima media thickness decreased 0.03 mm (95%CI: 0.01-0.06). CONCLUSIONS: Office and ambulatory heart rate, and the corresponding standard deviations, are inversely associated to the arterial stiffness markers, with the exception of pulse wave velocity, where a direct correlation is observed. A greater increase in night/day ratio, i.e., a lesser decrease in nocturnal heart rate, is associated to increased arterial stiffness.

Relationship between ambulatory arterial stiffness index and subclinical target organ damage in hypertensive patients.

Increased arterial stiffness has been shown to predict cardiovascular risk in hypertensive patients. Our objective was to evaluate the relationship between the ambulatory arterial stiffness index (AASI) and subclinical organ damage (SOD). The design was a cross-sectional study. Subjects included 554 hypertensive patients with and without drug treatment (mean age 57±12 years, 60.6% men). The AASI was defined as 1 minus the regression slope of diastolic over systolic blood pressure (BP) readings obtained from 24-h recordings. Renal damage was evaluated on the basis of glomerular filtration rate (GFR) and microalbuminuria; vascular damage was measured by carotid intima-media thickness (IMT) and ankle/brachial index (ABI); and cardiac damage was evaluated on the basis of the Cornell voltage-duration product (VDP) and left ventricular mass index. The mean AASI was 0.38±0.07 (0.39±0.07 in treated patients and 0.37±0.06 in nontreated subjects). The AASI showed a positive correlation with IMT (r=0.417, P<0.001) and Cornell VDP (r=0.188, P<0.001), and a negative correlation with GFR (r=-0.205, P=0.001) and the ABI. The variables associated with the presence of SOD were AASI (odds ratio (OR)=3.89) and smoking (OR=1.55). The variables associated with IMT were smoking and waist circumference, whereas those associated with GFR were AASI, body mass index and waist circumference. In turn, smoking, total cholesterol and glycosylated hemoglobin A1c were associated with the ABI. Increased AASI implies a greater presence of SOD in primary hypertensive patients with or without BP-lowering drug treatment.

Efectividad de una estrategia de intervención preventiva, basada en entrevistas telefónicas estructuradas, en una población laboral con riesgo cardiovascular moderado/alto / Effectiveness of a preventive intervention strategy based on structured telephone interviews in a working population with a moderate to high cardiovascular risk

ObjetivoEvaluar la efectividad de una estrategia de intervención preventiva sobre el estilo de vida, basada en entrevistas telefónicas.DiseñoEstudio de intervención cuasiexperimental.EmplazamientoServicio de Prevención de Ibermutuamur (Mutua de Accidentes de Trabajo y Enfermedades Profesionales de la Seguridad Social).Participantes4.792 trabajadores con nivel de riesgo cardiovascular (RCV) moderado/alto en el reconocimiento médico laboral (RML) que otorgaron su consentimiento. Se excluyeron los sujetos con antecedentes de enfermedad cardiovascular o que recibían tratamiento antihipertensivo, hipolipemiante o antidiabético.IntervenciónSe pudo contactar telefónicamente con 3.085 trabajadores, a los que se realizó seguimiento en los meses primero, cuarto y octavo tras el RML, enfatizando recomendaciones cardiosaludables. Al resto de trabajadores (n=1.707), solo se les realizó el RML inicial y final.Mediciones principalesEl RCV se estimó según el modelo SCORE europeo. Todos los sujetos recibieron un informe, una carta dirigida a su médico de atención primaria con los factores de RCV detectados, su nivel de riesgo y recomendaciones sobre modificación del estilo de vida(AU)

ResultadosEl 71,5% de los trabajadores eran mayores de 45 años, el 95,0% varones, el 76,6% trabajadores manuales y el 69,7% fumadores. Ambos grupos mostraron mejoría en los parámetros lipídicos, presión arterial, abandono del hábito tabáquico y RCV global en el segundo RML. El grupo A presentó una mayor mejoría en la presión arterial, lípidos (excepto colesterol-HDL), índice de masa corporal, glucemia, abandono del hábito tabáquico (23,5% vs 19,4%, p=0,001) y en el estrato de riesgo (46,6% vs 37,7%, p=0,0001). Un 52,9% de los trabajadores declaró haber llevado la carta informativa a su médico de Atención Primaria, que aconsejó modificar la dieta (47%), o añadir tratamiento antihipertensivo (19,5%), hipolipemiante (16,7%), antidiabético (4,4%) y antitabaco (2,9%).ConclusionesLa estrategia de intervención sobre el estilo de vida, basada en entrevistas telefónicas, en trabajadores de RCV moderado-alto, puede ser efectiva. El envío de información preventiva y la participación de Atención Primaria pueden contribuir, per se, a los cambios positivos observados(AU)

ObjectiveThis study assesses the effectiveness of a structured telephone survey on cardiovascular prevention, in modifying lifestyle, on cardiovascular risk parameters, percentage of smoking cessation and overall cardiovascular risk (CVR).DesignQuasi-experimental study of preventive intervention.SettingIbermutuamur (Spanish Accident and Health Insurance Company). Centres established throughout Spain.ParticipantsA total of 4,792 workers with moderate/high cardiovascular risk who had agreed to be contacted by phone. Subjects with a previous diagnosis of cardiovascular disease and those receiving treatment for hypertension, hypercholesterolemia or diabetes were excluded.InterventionA final total of 3,085 workers were contacted and were followed up by telephone surveys on the first, fourth and eighth month after the initial check up (CU) in order to emphasise cardiovascular health advice (Group A); we failed to contact 1,707 workers, who only attended the baseline and one year CUs (Group B).Principal outcomesCUs included medical records and physical examination, with two blood pressure measurements, Body Mass Index (BMI), and biochemical parameters.Principal outcomesCardiovascular risk was stratified following the European cardiovascular SCORE. Individuals with a relative risk higher than 4 were also considered as high-risk. All workers were informed about their cardiovascular risk profile (CVRF) and healthy cardiovascular lifestyle measures. They were also given a letter for their General Practitioner (GP) to inform them on the worker's cardiovascular risk level(AU)

ResultsA total of 71.5% of the workers were over 45 years, 95.0% males, 76.6% manual workers (“Blue Collar”) and 69.7% smokers. Both groups showed improvement in lipid parameters, blood pressure, smoking cessation and overall cardiovascular risk in the second CU. There were significant differences in favour of Group A as regards blood pressure, lipids (except HDL cholesterol), BMI, glycaemia, smoking cessation (A: 23.5%/B: 19.44%, P=0.001) and CVR stratum improvement (A: 46.6%/B: 37.7%, P=0.0001). The large majority (85%) of workers read preventive recommendations; 33% knew their risk level and 73% knew their CVRF. 52.9% gave the letter to the GP, which led them to start therapies on diet (47%), hypertension (19.5%), dyslipidaemia (16.7%), diabetes (4.4%) and smoking (2.9%) and no changes were made in 36.5% of cases.ConclusionsThe results of this study suggests that cardiovascular prevention strategy based on structured telephone surveys on high/moderate CVR subjects to promote lifestyle changes could be effective at reducing CVR. A clinical trial is required for confirmation. Sending information on CVRF following routine medial CUs and Primary Care involvement, could contribute to the positive changes observed(AU)