RECALMIN. La atención al paciente en las unidades de Medicina Interna del Sistema Nacional de Salud / RECALMIN. Patient care in the internal medicine units of the Spanish national health system

Objetivos. Elaborar un diagnóstico de situación sobre la asistencia en las unidades de medicina interna (UMI) en España y desarrollar, basándose en el análisis anterior, propuestas de mejora de calidad en dichas unidades. Material y métodos. Estudio descriptivo transversal entre las UMI de hospitales generales de agudos del Sistema Nacional de Salud (SNS), con datos referidos a 2013. Las variables de estudio fueron recogidas mediante un cuestionario ad hoc. Resultados. De un total de 260hospitales identificados en el SNS español, se han obtenido 142respuestas de 139hospitales de toda España, que representan el 53,5% de las UMI del SNS. La media de internistas por UMI fue de 14±8, siendo la tasa media de internistas por cada 100.000 habitantes de 7,2±3,3. El promedio de altas hospitalarias de las UMI en 2013 fue de 2.987±2.066 y las altas anuales por internista 232±107. El 61% de las UMI ha desarrollado una unidad de interconsulta y el 41% un programa de atención sistemática al paciente crónico complejo. En el 33% de las UMI se realiza un pase de visita multidisciplinar y un 60% de las mismas planifica el alta. Conclusiones. La encuesta RECALMIN 2013 desvela aspectos relevantes sobre la organización, estructura y gestión de las UMI. La notable variabilidad hallada en los indicadores de estructura, actividad y gestión probablemente refleja diferencias notables en eficiencia y productividad y, por tanto, propicia un amplio margen de mejora (AU)

Objectives. To perform a situation analysis of the care provided by internal medicine units (IMUs) in Spain and to develop, based on this analysis, proposals for improving the quality of care in these units. Material and methods. A descriptive, cross-sectional study of the IMUs of general acute care hospitals of the Spanish National Health System (SNHS), with data referring to 2013. The study variables were collected via an ad hoc questionnaire. Results. Of the total 260hospitals identified in the SNHS, 142responses were obtained from 139hospitals throughout Spain, which represents 53.5% of the IMUs in the SNHS. The mean number of internists per IMU was 14±8, with a mean rate of 7.2±3.3 internists per 100,000 inhabitants. In 2013, the average number of hospital discharges from the IMU was 2,987±2,066, and those discharged by internists was 232±107. Sixty-one percent of the IMUs had implemented an interconsultation unit, and 41% had implemented a systematic care program for complex chronic patients. Thirty-three percent of the IMUs conducted multidisciplinary rounds, and 60% of these IMUs planned the discharge. Conclusions. The 2013 RECALMIN survey revealed a number of important aspects of the organisation, structure and management of IMUs. The remarkable variability in the indicators of structure, activity and management probably reflect significant differences in efficiency and productivity, which therefore provide significant room for improvement (AU)

[RECALMIN. Patient care in the internal medicine units of the Spanish national health system]. / RECALMIN. La atención al paciente en las unidades de Medicina Interna del Sistema Nacional de Salud.

OBJECTIVES: To perform a situation analysis of the care provided by internal medicine units (IMUs) in Spain and to develop, based on this analysis, proposals for improving the quality of care in these units. MATERIAL AND METHODS: A descriptive, cross-sectional study of the IMUs of general acute care hospitals of the Spanish National Health System (SNHS), with data referring to 2013. The study variables were collected via an ad hoc questionnaire. RESULTS: Of the total 260hospitals identified in the SNHS, 142responses were obtained from 139hospitals throughout Spain, which represents 53.5% of the IMUs in the SNHS. The mean number of internists per IMU was 14±8, with a mean rate of 7.2±3.3 internists per 100,000 inhabitants. In 2013, the average number of hospital discharges from the IMU was 2,987±2,066, and those discharged by internists was 232±107. Sixty-one percent of the IMUs had implemented an interconsultation unit, and 41% had implemented a systematic care program for complex chronic patients. Thirty-three percent of the IMUs conducted multidisciplinary rounds, and 60% of these IMUs planned the discharge. CONCLUSIONS: The 2013 RECALMIN survey revealed a number of important aspects of the organisation, structure and management of IMUs. The remarkable variability in the indicators of structure, activity and management probably reflect significant differences in efficiency and productivity, which therefore provide significant room for improvement.

Novedades en la enfermedad tromboembólica venosa / News on venous thromboembolic disease

Este artículo recoge las últimas novedades que se han producido en diferentes aspectos de la enfermedad tromboembólica venosa (ETEV): a) profilaxis de la ETEV en cirugía ortopédica mayor; b) profilaxis de la ETEV en pacientes médicos; c) avances terapéuticos en la embolia pulmonar; d) en la trombosis venosa superficial; y e) perspectivas de futuro en la ETEV. Se resumen las 5 ponencias desarrolladas en la II Jornada de Novedades en Tratamiento Anticoagulante (Madrid, 18 noviembre de 2011), organizada por la Fundación para el Estudio de la Enfermedad Tromboembólica en España y auspiciada por la Sociedad Española de Medicina Interna, Sociedad Española de Neumología y Cirugía Torácica, Sociedad Española de Cardiología, Sociedad Española de Trombosis y Hemostasia, y Sociedad Española de Angiología y Cirugía Vascular(AU)

This paper brings together the latest developments that have occurred in different aspects of venous thromboembolism (VTE): VTE prophylaxis in high-risk orthopedic surgery and acutely ill hospitalized medical patients; therapeutic advances in pulmonary embolism and superficial vein thrombosis and VTE future prospects. It summarizes the reviews that five speakers made in-depth for the Second Day in New Anticoagulant Treatment, held in Madrid on November 18, 2011, organized by the Foundation for the Study of Thromboembolic Disease in Spain and endorsed by the Spanish Society of Internal Medicine, Spanish Society of Pneumology and Thoracic Surgery, Spanish Society of Cardiology, Spanish Society of Thrombosis and Haemostasis and the Spanish Society of Angiology and Vascular Surgery(AU)

[News on venous thromboembolic disease]. / Novedades en la enfermedad tromboembólica venosa.

This paper brings together the latest developments that have occurred in different aspects of venous thromboembolism (VTE): VTE prophylaxis in high-risk orthopedic surgery and acutely ill hospitalized medical patients; therapeutic advances in pulmonary embolism and superficial vein thrombosis and VTE future prospects. It summarizes the reviews that five speakers made in-depth for the Second Day in New Anticoagulant Treatment, held in Madrid on November 18, 2011, organized by the Foundation for the Study of Thromboembolic Disease in Spain and endorsed by the Spanish Society of Internal Medicine, Spanish Society of Pneumology and Thoracic Surgery, Spanish Society of Cardiology, Spanish Society of Thrombosis and Haemostasis and the Spanish Society of Angiology and Vascular Surgery.

Increased incidence of nonfatal cardiovascular events in stroke patients with sleep apnoea: effect of CPAP treatment.

Obstructive sleep apnoea (OSA) is a risk factor for stroke, but little is known about the effect of OSA and continuous positive airway pressure (CPAP) on the incidence of long-term, nonfatal cardiovascular events (CVE) in stroke patients. A prospective observational study was made in 223 patients consecutively admitted for stroke. A sleep study was performed on 166 of them. 31 had an apnoea/hypopnoea index (AHI) <10 events · h(-1); 39 had an AHI between 10 and 19 events · h(-1) and 96 had an AHI ≥ 20 events · h(-1). CPAP treatment was offered when AHI was ≥ 20 events · h(-1). Patients were followed up for 7 yrs and incident CVE data were recorded. The mean ± SD age of the subjects was 73.3 ± 11 yrs; mean AHI was 26 ± 16.7 events · h(-1). Patients with moderate-to-severe OSA who could not tolerate CPAP (AHI ≥ 20 events · h(-1); n = 68) showed an increased adjusted incidence of nonfatal CVE, especially new ischaemic strokes (hazard ratio 2.87, 95% CI 1.11-7.71; p = 0.03), compared with patients with moderate-to-severe OSA who tolerated CPAP (n = 28), patients with mild disease (AHI 10-19 events · h(-1); n = 36) and patients without OSA (AHI <10 events · h(-1); n = 31). Our results suggest that the presence of moderate-to-severe OSA is associated with an increased long-term incidence of nonfatal CVE in stroke patients and that CPAP reduces the excess of incidence seen in these patients.

[Impact of exacerbations on the clinical course of chronic obstructive pulmonary disease]. / Impacto de las exacerbaciones en la evolución de la EPOC.

The clinical course of chronic obstructive pulmonary disease (COPD) is marked by frequent exacerbations. Not all patients suffer exacerbations and not all decompensations have the same consequences; however, in the last few years, these episodes of clinical instability - especially if recurrent - have come to be viewed as a major element in the natural history of the disease insofar as they generate heavy workload and high costs, síntonegatively affect patients' quality of life, contribute to the multidimensional progression of the disease and, finally, affect its prognosis. The present article reviews the current scientific evidence on the impact of exacerbations on the clinical course of COPD and analyzes this impact from a multidimensional perspective. The need to base the management of COPD on clinical phenotypes is discussed, emphasizing the importance of the exacerbation phenotype, a clinical phenotype characterized by frequent exacerbations. This phenotype is often associated with the presence of cough and chronic expectoration, latent bronchial infection and bronchiectasis and leads to higher morbidity and mortality.

Impacto de las exacerbaciones en la evolución de la EPOC / Impact of exacerbations on the clinical course of chronic obstructive pulmonary disease

El curso clínico de la enfermedad pulmonar obstructiva crónica (EPOC) se ve salpicado con frecuencia por la presencia de exacerbaciones. Aunque no todos los pacientes sufren exacerbaciones y no todas estas descompensaciones tienen las mismas consecuencias, lo cierto es que en los últimos años hemos pasado a considerar estos episodios de inestabilidad clínica, especialmente si son repetidos, como elementos destacados en la historia natural de la enfermedad por cuanto generan una gran carga asistencial y enormes costes, impactan de forma negativa sobre la calidad de vida de los pacientes, contribuyen de forma decidida a la progresión multidimensional de la enfermedad y, finalmente, condicionan su pronóstico. El artículo revisa la evidencia científica actual acerca del impacto de la exacerbación sobre la evolución de la EPOC, analizando esta repercusión desde una perspect iva multidimensional. Además, introduce la necesidad de orientar el manejo de la EPOC hacia los fenotipos clínicos, destacando especialmente la importancia del fenotipo agudizador, un fenotipo clínico que se caracteriza por presentar repetidos episodios de agudización, que se asocia con frecuencia a la presencia de tos y expectoración crónica, infección bronquial latente y bronquiectasias, y que se caracteriza por presentar mayor morbimortalidad (AU)

The clinical course of chronic obstructive pulmonary disease (COPD) is marked by frequent exacerbations. Not all patients suffer exacerbations and not all decompensations have the same consequences; however, in the last few years, these episodes of clinical instability – especially if recurrent – have come to be viewed as a major element in the natural history of the disease insofar as they generate heavy workload and high costs síntonegatively affect pat ients’ quality of life, contribute to the multidimensional progression of the disease and, finally, affect its prognosis. The present article reviews the current scientific evidence on the impact of exacerbations on the clinical course of COPD and analyzes this impact from a multidimensional perspective. The need to base the management of COPD on clinical phenotypes is discussed, emphasizing the importance of the exacerbat ion phenotype, a clinical phenotype characterized by frequent exacerbations. This phenotype is often associated with the presence of cough and chronic expectorat ion, latent bronchial infect ion and bronchiectasis and leads to higher morbidity and mortality (AU)

Comorbilidad de los pacientes ingresados por insuficiencia cardiaca en los servicios de medicina interna / Morbidity from patients admitted for heart failure in the departaments of internal medicine

Antecedentes y objetivosLos pacientes con insuficiencia cardiaca (IC) presentan con frecuencia patologías asociadas. Se desconoce en toda su extensión la influencia de estas comorbilidades en la mortalidad y otras variables clínicas. Hemos analizado la comorbilidad de los pacientes ingresados por IC en los servicios de medicina interna de hospitales de España y su relación con diversas variables sociodemográficas y clínicas.Pacientes y métodosEstudiamos de forma prospectiva 2.127 pacientes (desde el 1 de octubre del año 2000 al 28 de febrero del año 2001) con IC, ingresados en 51 hospitales de diferentes categorías (comarcales–hospitales universitarios), en los que un internista se ofreció a colaborar. La comorbilidad se calculó con el índice de Charlson.ResultadosLa edad media fue de 77 años (mujeres, el 57%). El 45% había tenido al menos un ingreso en el último año. El 41% tenía una clase funcional iii/iv de la New York Heart Association. La fracción de eyección se halló conservada en el 53% de los enfermos. Se indentificaron patologías asociadas en el 60% de los pacientes (diabetes mellitus, el 39%; enfermedad pulmonar obstructiva crónica, el 31%). El índice de Charlson medio fue de 5,4 puntos (rango: 2–11 puntos). La mortalidad intrahospitalaria global fue del 6,1%. Durante el ingreso hospitalario fallecieron más pacientes en el grupo de mayor comorbilidad (Charlson ≥3 puntos, el 8,4%) que entre los enfermos con menor índice de Charlson (1–2 puntos, el 5,2%; p<0,01). Los tratamientos prescritos fueron similares en ambos grupos. En el análisis multivariante, la comorbilidad se asoció de forma independiente con enfermos del sexo masculino, de edad mayor de 75 años, clase funcional iii/iv de la New York Heart Association y grado de incapacidad física...(AU)

Background and objetivesHeart Failure (HF) patients present frecuently comorbidities. Little is known about the impact of these comorbidities in morbimortality. We analized the comorbidities of HF patients admitted in Spanish internal medicine units and its relation with different socio-demografics and clinical variables.Patients and methodsWe studied prospectivaly 2127 patients (admitted from 01.10.2000–28.02.2001) with HF in 51 Hospitals of different categories (from local hospitals to universitary hospitals) in which an internist was available to collaborate in the study. Comorbidities were estimated by the Charlson index.ResultsMean age was 77 years (women 57%). 45% of patients have had a previous admission in the last year. 41% had a functional stage NYHA iii/iv.ResultsEyection fraction was preserved in 53% of patients. Comorbidities were identified in 60% of patients (diabetes mellitus, 39%; chronic lung disease 31%). The average Charlson index was 5.4 points (range 2–11 points). Global inhospital mortality was 6.1%. During the admission more patients died in the Group with higher comorbidities (Charlson, >3 points; 8.4%) than in the Group with low Charlson index (1–2, 5.2%; p<0.01). Treatments prescribed were similar in both groups. In a multivariant analisis comorbidities was associated independently with masculin gender, age superior to 75 years, functional status NYHA iii/iv and disfunctional physical capacity.ConclusionsComorbidities determined by Charlson index were associated with more frequent admission, longer stay in hospital, higher discapacity and higher mortality. These results enhance the importance of comorbidities in prognosis of heart failure patients admitted in internal medicine units in Spain(AU)

[Morbidity from patients admitted for heart failure in the departments of internal medicine]. / Comorbilidad de los pacientes ingresados por insuficiencia cardiaca en los servicios de medicina interna.

BACKGROUND AND OBJECTIVES: Heart Failure (HF) patients present frequently comorbidities. Little is known about the impact of these comorbidities in morbimortality. We analyzed the comorbidities of HF patients admitted in Spanish internal medicine units and its relation with different socio-demographics and clinical variables. PATIENTS AND METHODS: We studied prospectively 2127 patients (admitted from 01.10.2000-28.02.2001) with HF in 51 Hospitals of different categories (from local hospitals to university hospitals) in which an internist was available to collaborate in the study. Comorbidities were estimated by the Charlson index. RESULTS: Mean age was 77 years (women 57%). 45% of patients have had a previous admission in the last year. 41% had a functional stage NYHA iii/iv. Eyection fraction was preserved in 53% of patients. Comorbidities were identified in 60% of patients (diabetes mellitus, 39%; chronic lung disease 31%). The average Charlson index was 5.4 points (range 2-11 points). Global inhospital mortality was 6.1%. During the admission more patients died in the Group with higher comorbidities (Charlson, >3 points; 8.4%) than in the Group with low Charlson index (1-2, 5.2%; p<0.01). Treatments prescribed were similar in both groups. In a multivariant analysis comorbidities was associated independently with masculine gender, age superior to 75 years, functional status NYHA iii/iv and dysfunctional physical capacity. CONCLUSIONS: Comorbidities determined by Charlson index were associated with more frequent admission, longer stay in hospital, higher discapacity and higher mortality. These results enhance the importance of comorbidities in prognosis of heart failure patients admitted in internal medicine units in Spain.

Obstructive sleep apnea has little impact on quality of life in the elderly.

STUDY OBJECTIVE: To analyze the impact of the number of respiratory sleep disorders or clinically related conditions (especially excessive daytime sleepiness [EDS]), on health related quality of life (HRQoL) in subjects over 65 years of age, as compared to younger subjects and the general population. METHODS: Two hundred and twelve adult patients with obstructive sleep apnea (OSA, AHI> or =10) divided into two age groups, over 65 (n=109, mean age 74.6 [6,8] years, and 65 or under (n=103, mean age 51.7, [6,5] years). General, anthropometric and clinical data related to OSA (epworth sleepiness score [ESS]), comorbidities (Charlson comorbidity index [CCI]), HRQoL (SF-36 questionnaire), use of psychotropic medications and habitual polygraphic/polysomnographic parameters were recorded and compared between the two age groups. The HRQoL values in each age group were compared with the values in the general population, adjusted for age and gender. RESULTS: In patients 65 and under, both the presence of OSA as well as the presence of EDS (ESS>11) were associated with an important deterioration in HRQoL as compared to normal reference values. The principal determinants of HRQoL were the presence of EDS (p<0.04), body mass index (p<0.03) and the apnea-hypopnea index (AHI) (p<0.04). Nevertheless, in subjects over 65 years of age, the presence of OSA or EDS had only a slight impact on HRQoL, relative to normal values. In this age group, the principal determinants of HRQoL were the presence of comorbidities (CCI, p<0.01), age (p<0.01), oxygen desaturation parameters (p<0.04) and the use of psychotropic medications (p<0.04). CONCLUSION: In elders, the presence of OSA with or without EDS has little impact on HRQoL measures.

Dissociation of lung function, dyspnea ratings and pulmonary extension in bronchiectasis.

UNLABELLED: Bronchiectasis is a heterogeneous disease in terms of its clinical and functional presentation. Some isolated parameters have been used to assess the severity of bronchiectasis or its response to treatment. A study was undertaken to evaluate whether lung function, dyspnea and extension of the disease are separate entities in the impact of bronchiectasis upon patients using factor analysis. Patients with bronchiectasis diagnosed by high-resolution computed tomography (HRCT) and airflow obstruction defined by FEV1/FVC<70% were included. Data were collected relating to clinical history, three different clinical ratings of dyspnea (Medical Research Council (MRC), Borg scale and Basal Dyspnea Index), the extent of bronchiectasis and functional variables. A total of 81 patients (mean age (SD): 69.5 (8.7)) years were included. The degree of dyspnea (MRC) was 1.9 (0.8). Mean FEV1 was 1301 ml (56.9% pred.). Four factors were found that accounted for 84.1% of the total data variance. Factor 1 (45.6% of the data variance) included the three measurements of dyspnea. Factor 2 (16% variance) comprised airflow obstruction parameters (FEV1, FEV1/FVC and PEF). Factor 3 (13.8% variance) included RV/TLC and RV (lung hyperinflation). Factor 4 (8.6% variance) included bronchiectasis extent. Dyspnea was more closely correlated with lung hyperinflation (r:0.33-0.54) than with airflow obstruction parameters (r:0.17-0.26). CONCLUSIONS: Airflow obstruction, dyspnea, lung hyperinflation and the lung extent of the bronchiectasis are four independent entities in the impact of bronchiectasis upon patients.

Positive effect of CPAP treatment on the control of difficult-to-treat hypertension.

The aim of the present study was to analyse the role of continuous positive airway pressure (CPAP) treatment in patients with difficult-to-control hypertension (DC-HT) and sleep apnoea. An Autoset (ResMed, Sydney, Australia) study was performed in 60 patients diagnosed with DC-HT based on two 24-h ambulatory blood pressure monitorisation (ABPM) studies. CPAP was offered to patients with an apnoea/hypopnoea index (AHI) > or =15 events.h(-1). After 3 months of treatment, repeat ABPM was performed to evaluate the effect of CPAP upon the blood pressure values. A total of 39 (65%) patients received CPAP treatment, but only 33 completed the study. The mean+/-sd systolic and diastolic blood pressures (SBP and DBP, respectively) were 154.8+/-14 and 90+/-8.8 mmHg. Patients had a mean+/-sd AHI of 37.7+/-18.2 events.h(-1). Only three patients presented a dipper nocturnal pressure pattern. CPAP treatment significantly reduced SBP (-5.2 mmHg), and particularly the nocturnal values (-6.1 mmHg), but not DBP. Considering only those patients who tolerated CPAP, the decrease in SBP was greater (-7.3 mmHg). Furthermore, CPAP treatment significantly increased the percentage of patients who recovered the dipper pattern (three (9.1%) out of 33 versus 12 (36.4%) out of 33). Continuous positive airway pressure treatment significantly reduces systolic blood pressure, particularly at night, and normalises the nocturnal pressure pattern in patients with difficult-to-control hypertension and sleep apnoea.

Ictus isquémico y apnea del sueño. Relación entre transtornos respiratorios durante el sueño y estenosis carotídea. Respuesta / Ischemic stroke and sleep apnea. Relationship between sleep breathing disorders and carotid stenosis. Response

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[Sleep-disordered breathing in patients with difficult-to-control hypertension]. / Trastornos respiratorios durante el sueño en pacientes con hipertensión arterial de difícil control.

OBJECTIVE: To analyze the relationship between sleep-disordered breathing and difficult-to-control arterial hyper-tension. PATIENTS AND METHODS: Patients were considered to have difficult-to-control hypertension when mean systolic blood pressure was 125 mm Hg or higher and/or mean diastolic blood pressure was more than or equal to 80 mm Hg (as recorded during 2 24-hour ambulatory monitoring studies) despite the use of 3 or more antihypertensive drugs. Respiratory polygraphy using the AutoSet device (ResMed Corp, Sydney, Australia) was then performed to study sleep-disordered breathing in all patients. RESULTS: Forty-nine patients with a mean (SD) age of 68.1 (9.1) years, mean systolic and diastolic pressures of 152.5 (13)/89.2 (8.5) mm Hg, and an average of 3.5 prescribed drugs were included in the study. The mean apnea-hypopnea index (AHI) was 26.2 (19.5) and events were predominantly obstructive. Patients with severe sleep apnea-hypopnea syndrome (SAHS) (AHI > or = 30; 40.8%) showed more uncontrolled daytime (P = .017) and nighttime (P = .033) systolic pressure than the rest, as well as higher daytime diastolic pressure (P = .035) and a greater consumption of drugs than those without severe SAHS (AHI < 10; 28.6%) (P = .041). The study population as a whole showed a significant correlation between blood pressure and obesity. There was a significant correlation (adjusted for age and sex) with AHI only in patients with SAHS. AHI was found to be the independent predictor with the greatest effect on blood pressure in these patients. CONCLUSIONS: Prevalence of SAHS was very high in patients with difficult-to-control hypertension. In patients with SAHS, AHI was found to be the independent predictor with the greatest affect on arterial blood pressure.

Trastornos respiratorios durante el sueño en pacientes con hipertensión arterial de difícil control / Sleep-disordered breathing in patients with difficult-to-control hypertension

Objetivo: Analizar la relación existente entre los trastornos respiratorios durante el sueño y la hipertensión arterial de difícil control (HTAr). Pacientes y métodos: Se consideró HTAr cuando las cifras medias de la presión arterial sistólica (PAS) eran mayores o iguales a 125 mmHg y/o la diastólica (PAD) era igual o superior a 80 mmHg según el registro de 2 estudios de monitorización ambulatoria durante 24 h a pesar de la utilización de 3 o más fármacos antihipertensivos. Se realizó posteriormente una poligrafía respiratoria (Autoset) para el estudio de los trastornos respiratorios durante el sueño en todos los pacientes. Resultados: Se incluyó en el estudio a 49 pacientes con una media (± desviación estándar) de edad de 68,1 ± 9,1 años, PAS/PAD media de 152,5 ±13/89,2 ±8,5 mmHg y una media de 3,5 fármacos prescritos. El índice de apneas-hipopneas (IAH) fue de 26,2 ± 19,5, de predominio obstructivo. Los pacientes con síndrome de apneas-hipopneas durante el sueño (SAHS) grave (IAH ≥ 30; 40,8%) presentaron mayor descontrol de la PAS tanto diurna (p = 0,017) como nocturna (p = 0,033) que el resto de pacientes, así como mayor PAD diurna (p = 0,035) y toma de un mayor número de fármacos que quienes no lo presentaban (IAH < 10; 28,6%) (p = 0,041). Tomados en su conjunto, los pacientes presentaron una correlación significativa entre las cifras de la presión arterial y la obesidad, además de existir una correlación ajustada significativa con el IAH sólo en los pacientes con SAHS. El IAH se mostró como el predictor independiente que más influyó en las cifras de la presión arterial de estos pacientes. Conclusiones: En pacientes con HTAr la prevalencia de SAHS fue muy elevada. En los pacientes con SAHS, el IAH se mostró como el factor predictivo independiente más importante de las cifras de presión arterial

Objective: To analyze the relationship between sleep-disordered breathing and difficult-to-control arterial hyper-tension. Patients and methods: Patients were considered to have difficult-to-control hypertension when mean systolic blood pressure was 125 mm Hg or higher and/or mean diastolic blood pressure was more than or equal to 80 mm Hg (as recorded during 2 24-hour ambulatory monitoring studies) despite the use of 3 or more antihypertensive drugs. Respiratory polygraphy using the AutoSet device (ResMed Corp, Sydney, Australia) was then performed to study sleep-disordered breathing in all patients. Results: Forty-nine patients with a mean (SD) age of 68.1 (9.1) years, mean systolic and diastolic pressures of 152.5 (13)/89.2 (8.5) mm Hg, and an average of 3.5 prescribed drugs were included in the study. The mean apnea-hypopnea index (AHI) was 26.2 (19.5) and events were predominantly obstructive. Patients with severe sleep apnea-hypopnea syndrome (SAHS) (AHI ≥ 30; 40.8%) showed more uncontrolled daytime (P=.017) and nighttime (P=.033) systolic pressure than the rest, as well as higher daytime diastolic pressure (P=.035) and a greater consumption of drugs than those without severe SAHS (AHI < 10; 28.6%) (P=.041). The study population as a whole showed a significant correlation between blood pressure and obesity. There was a significant correlation (adjusted for age and sex) with AHI only in patients with SAHS. AHI was found to be the independent predictor with the greatest effect on blood pressure in these patients. Conclusions: Prevalence of SAHS was very high in patients with difficult-to-control hypertension. In patients with SAHS, AHI was found to be the independent predictor with the greatest affect on arterial blood pressure

Severe acute exacerbations and mortality in patients with chronic obstructive pulmonary disease.

BACKGROUND: Patients with chronic obstructive pulmonary disease (COPD) often present with severe acute exacerbations requiring hospital treatment. However, little is known about the prognostic consequences of these exacerbations. A study was undertaken to investigate whether severe acute exacerbations of COPD exert a direct effect on mortality. METHODS: Multivariate techniques were used to analyse the prognostic influence of acute exacerbations of COPD treated in hospital (visits to the emergency service and admissions), patient age, smoking, body mass index, co-morbidity, long term oxygen therapy, forced spirometric parameters, and arterial blood gas tensions in a prospective cohort of 304 men with COPD followed up for 5 years. The mean (SD) age of the patients was 71 (9) years and forced expiratory volume in 1 second was 46 (17)%. RESULTS: Only older age (hazard ratio (HR) 5.28, 95% CI 1.75 to 15.93), arterial carbon dioxide tension (HR 1.07, 95% CI 1.02 to 1.12), and acute exacerbations of COPD were found to be independent indicators of a poor prognosis. The patients with the greatest mortality risk were those with three or more acute COPD exacerbations (HR 4.13, 95% CI 1.80 to 9.41). CONCLUSIONS: This study shows for the first time that severe acute exacerbations of COPD have an independent negative impact on patient prognosis. Mortality increases with the frequency of severe exacerbations, particularly if these require admission to hospital.

Ictus isquémico y apnea del sueño. Relación entre trastornos respiratorios durante el sueño y estenosis carotídea / Ischemic stroke and sleep apnea. Relationship between sleep breathing disorders and carotid stenosis

Objetivo. Evaluar si existe alguna asociación entre el número de trastornos respiratorios durante el sueño (TRS) y la estenosis carotídea extracraneal (ECS) significativa en pacientes que han sufrido un ictus isquémico o ataque isquémico transitorio (AIT). Pacientes y métodos. A 68 pacientes (72,2 años; 68 % varones) supervivientes a los 2 meses de un ictus isquémico o AIT se les recogieron variables generales, antropométricas, caracteristicas y repercusión del ictus y clinica relacionada con el síndrome de apneas-hipopneas durante el sueño (SAHS). Se efectuó el estudio neurovascular mediante doppler continuo carotídeo y doppler transcraneal, realizando angiorresonancia y/o arteriografía cerebral ante sospecha de estenosis superiores al 50 %, así como una poligrafía respiratoria pasado el proceso agudo para valorar el número y tipo de TRS. Resultados. Quince pacientes (22,1 %) presentaron una ECS. El 80 % de estos pacientes tenían un índice de apneashipopneas (lAH) > 30. Los pacientes con ECS sufrían mayor somnolencia (p = 0,01), un IAH más elevado (36,2 frente a 21,9; P = 0,003) Y una mayor desaturación nocturna de oxígeno (p = 0,01). También fue significativa mente superior en este grupo la presencia de hipertensión arterial (HTA) (p = 0,003), diabetes mellitus (p = 0,01) e hipercolesterolemia (p = 0,02), aunque en el análisis de regresión logística tan sólo la presencia de HTA (odds ratio [OR]: 12,7) y de un IAH > 30 (OR: 13,6) presentaron un poder predictivo independiente de ECS. Conclusiones. La presencia de un elevado número de TRS presenta un valor predictivo de ECS independiente de la presencia de HTA. Los pacientes con ECS presentan más clínica relacionada con el SAHS previa al ictus, por lo que éste podría ser anterior al evento neurológico y funcionar como factor de riesgo para el mismo en este grupo de pacientes

Objetive. To investigate the possible relation between the number of sleep breathing disorders (SBD) and significant extracranial carotid stenosis (ECS) in patients suffering ischemic stroke or transient ischemic attack (TIA). Patients and methods. Sixty-eight patients (72.2 years; 68 OJo males) surviving two months after ischemic stroke or TIA were studied, with the collection of general and anthropometric variables, the characteristics and repercussions of stroke, and the clinical manifestations related to sleep apnea-hypopnea syndrome (SAHS). Neurovascular status was evaluated by carotid continuous doppler flowmetry and transcraneal doppler, with cerebral MR-angio and/or arteriography when suspecting stenosis > 50 %, and respiratory polygraphy after the acute phase to assess the number and type of SBD. Results. Fifteen patients (22.1 %) presented ECS. Of these, 80 % had an apnea-hypopnea index (AHI) > 30. The patients with ECS presented increased drowsiness (p = 0.01), greater AHI (36.2 vs 21.9; P = 0.003), and increased nocturnal oxygen desaturation (p = 0.01). Arterial hypertension (AHT) was also significantly more prevalent in this group of patients (p = 0.003), as was diabetes mellitus (p = 0.01) and hypercholesterolemia (p = 0.02) though logistic regression analysis only showed ART (odds ratio [OR]: 12,7) and AHI > 30 (OR: 13,6) to exhibit independent ECS predictive capacity. ConcIusions. The presence of numerous SBD is predictive of ECS, independently of the presence of ART. Patients with ECS have more SAHS related clinical mainfestations prior to stroke; as a result, SAHS could be anterior to the neurological event and act as a risk factor for the latter in this group

[Ischemic stroke and sleep apnea. Relationship between sleep breathing disorders and carotid stenosis]. / Ictus isquémico y apnea del sueño. Relación entre trastornos respiratorios durante el sueño y estenosis carotídea.

OBJECTIVE: To investigate the possible relation between the number of sleep breathing disorders (SBD) and significant extracranial carotid stenosis (ECS) in patients suffering ischemic stroke or transient ischemic attack (TIA). PATIENTS AND METHODS: Sixty-eight patients (72.2 years; 68 % males) surviving two months after ischemic stroke or TIA were studied, with the collection of general and anthropometric variables, the characteristics and repercussions of stroke, and the clinical manifestations related to sleep apnea-hypopnea syndrome (SAHS). Neurovascular status was evaluated by carotid continuous doppler flowmetry and transcraneal doppler, with cerebral MR-angio and/or arteriography when suspecting stenosis > 50 %, and respiratory polygraphy after the acute phase to assess the number and type of SBD. RESULTS: Fifteen patients (22.1 %) presented ECS. Of these, 80 % had an apnea-hypopnea index (AHI) > 30. The patients with ECS presented increased drowsiness (p = 0.01), greater AHI (36.2 vs 21.9; p = 0.003), and increased nocturnal oxygen desaturation (p = 0.01). Arterial hypertension (AHT) was also significantly more prevalent in this group of patients (p = 0.003), as was diabetes mellitus (p = 0.01) and hypercholesterolemia (p = 0.02) though logistic regression analysis only showed AHT (odds ratio [OR]: 12,7) and AHI > 30 (OR: 13,6) to exhibit independent ECS predictive capacity. CONCLUSIONS: The presence of numerous SBD is predictive of ECS, independently of the presence of AHT. Patients with ECS have more SAHS related clinical manifestations prior to stroke; as a result, SAHS could be anterior to the neurological event and act as a risk factor for the latter in this group of patients.

[Internal consistency and validity of the Spanish version of the St. George's respiratory questionnaire for use in patients with clinically stable bronchiectasis]. / Consistencia interna y validez de la versión española del St. George's Respiratory Questionnaire para su uso en pacientes afectados de bronquiectasias clínicamente estables.

OBJECTIVE: To analyze the reliability and validity of the St. George's Respiratory Questionnaire (SGRQ) for use in patients with clinically stable bronchiectasis. MATERIAL AND METHODS: The SGRQ (50 items on 3 scales--symptoms, activity, and impact) was administered to 102 patients (mean [SD] age, 69.5 [8.7] years; 63% men) with clinically stable bronchiectasis. Disease severity was classified according parameters such as airflow obstruction (forced expiratory volume in 1 second), colonization by Pseudomonas aeruginosa, extent of bronchiectasis, symptoms, daily quantity of sputum, and number of exacerbations. Internal consistency (Cronbach's alpha and correlation between items and between item and scale), concurrent validity (correlation between items and clinical variables), predictive validity (correlation between items and severity), and construct validity (factorial analysis of main components) were assessed. RESULTS: The internal consistency of the SGRQ was excellent (Cronbach's alpha between 0.81 and 0.87 for the different scales, and 0.90 for the overall score). Concurrent validity was high, as correlations between items and clinical variables were significant and followed the expected distribution. The SGRQ differentiated between degrees of disease severity, regardless of the clinical variable used. The factorial analysis showed a construct of 4 factors that were only moderately similar to the original structure of the questionnaire, due mainly to inclusion of a small number of questions with conditioned response and others with low discriminatory capacity. CONCLUSIONS: The SGRQ shows excellent concurrent and predictive internal consistency and validity, though restructuring of the original construct would be advisable before use in patients with stable bronchiectasis.

Consistencia interna y validez de la versión española del St. George’s Respiratory Questionnaire para su uso en pacientes afectados de bronquiectasias clínicamente estables / Internal consistency and validity of the spanish version of the St. George´s Respiratory Questionnaire for use in patients with clinically stable bronchiectasis

OBJETIVO: Analizar la fiabilidad y validez del St. George’s Respiratory Questionnaire (SGRQ) para su uso en pacientes afectados de bronquiectasias estables. MATERIAL Y MÉTODOS: El SGRQ (50 ítems en 3 escalas: síntomas, actividad e impacto) se administró a 102 pacientes (edad media ± desviación estándar de 69,5 ± 8,7 años; 63% varones) con bronquiectasias clínicamente estables. Se clasificó la gravedad según diferentes parámetros: obstrucción al flujo respiratorio (volumen espiratorio forzado en el primer segundo), colonización por Pseudomonas aeruginosa, extensión de las bronquiectasias, síntomas, cantidad de esputo diario y número de agudizaciones. Se calcularon la consistencia interna (alfa de Cronbach y correlación ítem-ítem e ítems-escala), la validez concurrente (correlación ítems-variables medidas), la validez predictiva (correlación ítems-parámetros de gravedad) y la validez de constructo (análisis factorial de componentes principales). RESULTADOS: La consistencia interna del SGRQ fue excelente (alfa de Cronbach entre 0,81 y 0,87 para las distintas escalas, y 0,90 para la puntuación total). La validez concurrente fue elevada, ya que las correlaciones ítems-variables medidas fueron significativas y se distribuyeron de la forma prevista. El SGRQ permitió diferenciar adecuadamente los distintos grados de gravedad de la enfermedad independientemente de los parámetros utilizados. El análisis factorial mostró un constructo de 4 factores que se asemejaba tan solo de forma moderada a la estructura original del cuestionario, sobre todo por la inclusión de preguntas con bajo porcentaje de respuestas obligadas y otras con bajo poder discriminatorio. CONCLUSIONES: El SGRQ presenta una excelente consistencia interna y validez tanto concurrente como predictiva, si bien sería recomendable una reestructuración previa del constructo original para su uso en pacientes con bronquiectasias estables

OBJECTIVE: To analyze the reliability and validity of the St. George’s Respiratory Questionnaire (SGRQ) for use in patients with clinically stable bronchiectasis. MATERIAL AND METHODS: The SGRQ (50 items on 3 scales— symptoms, activity, and impact) was administered to 102 patients (mean [SD] age, 69.5 [8.7] years; 63% men) with clinically stable bronchiectasis. Disease severity was classified according parameters such as airflow obstruction (forced expiratory volume in 1 second), colonization by Pseudomonas aeruginosa, extent of bronchiectasis, symptoms, daily quantity of sputum, and number of exacerbations. Internal consistency (Cronbach’s alpha and correlation between items and between item and scale), concurrent validity (correlation between items and clinical variables), predictive validity (correlation between items and severity), and construct validity (factorial analysis of main components) were assessed. RESULTS: The internal consistency of the SGRQ was excellent (Cronbach’s alpha between 0.81 and 0.87 for the different scales, and 0.90 for the overall score). Concurrent validity was high, as correlations between items and clinical variables were significant and followed the expected distribution. The SGRQ differentiated between degrees of disease severity, regardless of the clinical variable used. The factorial analysis showed a construct of 4 factors that were only moderately similar to the original structure of the questionnaire, due mainly to inclusion of a small number of questions with conditioned response and others with low discriminatory capacity. CONCLUSIONS: The SGRQ shows excellent concurrent and predictive internal consistency and validity, though restructuring of the original construct would be advisable before use in patients with stable bronchiectasis