EPITRANS. Quality assessment of the epilepsy transition process.

OBJECTIVE: To analyze the differences in clinical management during the epilepsy transition process from pediatric to adult care and to determine the quality of life and degree of satisfaction of patients and caregivers during the transition. METHODS: This is a longitudinal study including patients with epilepsy transferred from pediatric to adult epilepsy care between 2013 and 2017. Patients had a minimum follow-up of 3 years before the transition visit and at least 3 years consulting in the adults section. Clinical characteristics were retrieved from the medical chart. Quality of life and satisfaction questionnaires were administered by online access to patients and caregivers at the end of the adult follow-up period. RESULTS: 99 patients (50.5 % women, mean transition age 16.5 ± 1 years old) were included. Before the transition visit, 90 % of patients received a transition discussion and 88 % had a formal clinical report. In the pediatric period, patients were visited more frequently, had more EEGs and genetic studies, and were seen by the same neuropediatrician (P<0.05). In the adult period, patients underwent a larger number of prolonged video EEGs and were prescribed polytherapy more often (P<0.05). Quality of life remained steady during the entire transition, but satisfaction with the care received was significantly higher during the pediatric period. CONCLUSIONS: Significant differences were seen in epilepsy care during transition from pediatric to adult management, and this had an impact on the degree of satisfaction reported by patients and caregivers. Our results provide evidence of the potential value of development and early implementation of a protocolled transition program.

Development of castration resistance in prostate cancer patients treated with luteinizing hormone-releasing hormone analogues (LHRHa): results of the ANARESISTANCE study.

PURPOSE: Evaluate the percentage of patients with prostate cancer treated with luteinizing hormone-releasing hormone analogues (LHRHa) that develop castration resistance after a follow-up period of 3 years. The secondary objective is to evaluate the variables potentially related to the progression to castration resistant prostate cancer (CRPC). METHODS: A post-authorization, nation-wide, multicenter, prospective, observational, and longitudinal study that included 416 patients treated with LHRHa between 2012 and 2017 is presented. Patients were followed for 3 years or until development of CRPC, thus completing a per-protocol population of 350 patients. A Cox regression analysis was carried out to evaluate factors involved in progression to CRPC. RESULTS: After 3 years of treatment with LHRHa 18.2% of patients developed CRPC. In contrast, in the subgroup analysis, 39.6% of the metastatic patients developed CRPC, compared with 8.8% of the non-metastatic patients. The patients with the highest risk of developing CRPC were those with a nadir prostate-specific antigen (PSA) > 2 ng/ml (HR 21.6; 95% CI 11.7-39.8; p < 0.001) and those receiving concomitant medication, most commonly bicalutamide (HR 1.8; 95% CI 1-3.1, p = 0.0431). CONCLUSIONS: The proportion of metastatic patients developing CRPC after 3 years of treatment with LHRHa is consistent with what has been previously described in the literature. In addition, this study provides new findings on CRPC in non-metastatic patients. Concomitant medication and nadir PSA are statistically significant predictive factors for the time to diagnosis of CRPC, the nadir PSA being the strongest predictor.

[Depressive symptoms and burden in family caregivers in Alzheimer's disease: a model of structural equations]. / Sintomas depresivos y sobrecarga en los familiares cuidadores en la enfermedad de Alzheimer: un modelo de ecuaciones estructurales.

INTRODUCTION: The care of patients with Alzheimer's disease increases the burden and depression of the main caregiver, although the relationship between the two is not clearly defined. AIMS: To explore the factors associated with depressive symptomatology and burden in the main caregiver and to apply a model of structural equations to identify the relationship between them. SUBJECTS AND METHODS: The sample consisted of 127 family caregivers of people with Alzheimer's disease, with a follow-up of 24 months. Multivariate regression analyses were performed to identify the characteristics of patients and caregivers associated with burden and depression of the main caregiver, and a model of structural equations was designed to analyse the relationship between the variables. RESULTS: In the model of structural equations, the burden had a direct effect on depression, both in the baseline assessment and at 24 months. The variables associated with burden were: schooling and the lower mental health of the main caregiver; and the behavioral alterations and the functional dependency of the patient. The lower cognitive level of the patient and the lower mental health of the main caregiver were associated with depression. The correlation between burden and depression increased from baseline to two years (r = 0.470 vs. r = 0.613). CONCLUSIONS: The deterioration of the patient and caregiver burden are risk factors for depression in the main caregiver. Interventions would be necessary to reduce the burden and prevent related depression.

TITLE: Sintomas depresivos y sobrecarga en los familiares cuidadores en la enfermedad de Alzheimer: un modelo de ecuaciones estructurales.Introduccion. El cuidado de los pacientes con enfermedad de Alzheimer incrementa la sobrecarga y la depresion del cuidador principal, aunque la relacion entre ambas no esta claramente definida. Objetivos. Explorar los factores asociados a la sintomatologia depresiva y la sobrecarga en el cuidador principal y aplicar un modelo de ecuaciones estructurales para identificar la relacion entre ellas. Sujetos y metodos. La muestra estuvo formada por 127 cuidadores familiares de personas con enfermedad de Alzheimer, con un seguimiento de 24 meses. Se realizaron analisis de regresion multivariante para identificar las caracteristicas de pacientes y cuidadores asociadas a la sobrecarga y la depresion del cuidador principal, y se diseño un modelo de ecuaciones estructurales para analizar la relacion entre las variables. Resultados. En el modelo de ecuaciones estructurales, la sobrecarga tuvo un efecto directo sobre la depresion, tanto en la evaluacion basal como a los 24 meses. Las variables asociadas a la sobrecarga fueron: la escolaridad y la menor salud mental del cuidador principal, y las alteraciones conductuales y la dependencia funcional del paciente. El menor nivel cognitivo del paciente y la menor salud mental del cuidador principal estuvieron asociados a la depresion. La correlacion entre sobrecarga y depresion aumento desde la evaluacion basal hasta los dos años (r = 0,47 frente a r = 0,613). Conclusiones. El deterioro del paciente y la sobrecarga son factores de riesgo para la depresion en el cuidador principal. Serian necesarias intervenciones para reducir la carga y poder prevenir la depresion relacionada.

Efficacy and safety of administering oral misoprostol by titration compared to vaginal misoprostol and dinoprostone for cervical ripening and induction of labour: study protocol for a randomised clinical trial.

BACKGROUND: Among the various methods available, the administration of prostaglandins is the most effective for inducing labour in women with an unfavourable cervix. Recent studies have compared treatment with various titrated doses of oral misoprostol with vaginal misoprostol or dinoprostone, indicating that the use of an escalating dose of an oral misoprostol solution is associated with a lower rate of caesarean sections and a better safety profile. The objective of this study is to assess which of these three therapeutic options (oral or vaginal misoprostol or vaginal dinoprostone) achieves the highest rate of vaginal delivery within the first 24 h of drug administration. METHODS: An open-label randomised controlled trial will be conducted in Araba University Hospital (Spain). Women at ≥41 weeks of pregnancy requiring elective induction of labour who meet the selection criteria will be randomly allocated to one of three groups: 1) vaginal dinoprostone (delivered via a controlled-release vaginal insert containing 10 mg of dinoprostone, for up to 24 h); 2) vaginal misoprostol (25 µg of vaginal misoprostol every 4 h up to a maximum of 24 h); and 3) oral misoprostol (titrated doses of 20 to 60 µg of misoprostol following a 3 h on + 1 h off regimen up to a maximum of 24 h). Both intention-to-treat analysis and per-protocol analysis will be performed. DISCUSSION: The proposed study seeks to gather evidence on which of these three therapeutic options achieves the highest rate of vaginal delivery with the best safety profile, to enable obstetricians to use the most effective and safe option for their patients. TRIAL REGISTRATION: NCT02902653 Available at: https://clinicaltrials.gov/show/NCT02902653 (7th September 2016).

Predicted change in the number of permanent medical teachers from 2017 to 2026. The training of future physicians in critical condition. / Evolución previsible en el número de profesores permanentes de Medicina del 2017 al 2026. La formación de los futuros médicos en situación crítica.

The significant and progressive reduction in the number of permanent teachers in medical schools (professor, associate professor and assistant professor) is a reason for concern for the National Conference of Deans. This reduction will intensify in the coming decade (2017-2026). Forty-three percent of the permanent faculty will retire, as will 55% of the faculty linked to clinical areas, 34% of the faculty not linked to clinical areas and 32% of the faculty of basic areas. This deficit is significant now, and, in a few years, the situation will be unsustainable, especially in the clinical areas. This report reveals the pressing need to adopt urgent measures to alleviate the present situation and prevent a greater problem. The training of future physicians, immediately responsible for the health of our society, depends largely on the theoretical and practical training taught in medical schools, with the essential collaboration of healthcare institutions. Paradoxically, while the number of teachers decreases substantially, there is an exponential increase in the number of medical schools and students who are admitted every year without academic or healthcare justification.

A new clinical score for the prognosis of status epilepticus in adults.

BACKGROUND AND PURPOSE: The severity of status epilepticus (SE) has an important impact in clinical outcomes. The Status Epilepticus Severity Score (STESS) is a score for predicting mortality in SE at admission. The baseline modified Rankin Scale (mRS) might be a prognostic factor for assessing the short-tem outcomes of SE. Therefore, our aim was to evaluate the effectiveness of mRS and whether its addition to the STESS improves the prediction of mortality. METHODS: Consecutive patients with SE and aged >16 years were recruited during 3 years. Receiver operating characteristic curves and a logistic regression model were developed to estimate the scores of the new score, designated as modified STESS (mSTESS), and it was subsequently compared with the STESS. RESULTS: In all, 136 patients were included. Mean age was 62.01 ± 17.62 (19-95) years, and 54% were male. The capacity of the STESS to predict mortality was 74.3% (95% confidence interval 63.8%-81.8%), whilst the capacity of the mRS to predict mortality was 65.2% (95% confidence interval 54.2%-76.2%). The logistic regression model and receiver operating characteristic curves enabled the classification of mRS as follows: 0, mRS = 0; 1, mRS = 1-3; and 2, mRS > 3. These values, when added to the other items of the STESS, resulted in the mSTESS with scores between 0 and 8 points. The capacity of the mSTESS to predict mortality was 80.1%. An mSTESS > 4 established an overall accuracy of 81.8% for predicting mortality, which was considerably higher than the overall accuracy of STESS ≥ 3 (59.6%). CONCLUSIONS: The baseline mRS was associated with high mortality risk. It is proposed to use mSTESS to improve the prediction of mortality risk in SE.

Practical application of brief cognitive tests.

INTRODUCTION: Brief cognitive tests (BCT) may help detect cognitive impairment (CI) in the clinical setting. Several BCT have been developed and/or validated in our country, but we lack specific recommendations for use. DEVELOPMENT: Review of studies on the diagnostic accuracy of BCT for CI, using studies conducted in Spain with BCT which take less than 20 min. We provide recommendations of use based on expert consensus and established on the basis of BCT characteristics and study results. CONCLUSION: The Fototest, the Memory Impairment Screen (MIS) and the Mini-Mental State Examination (MMSE) are the preferred options in primary care; other BCT (Clock Drawing Test [CDT], test of verbal fluency [TVF]) may also be administered in cases of negative results with persistent suspected CI or concern (stepwise approach). In the specialised care setting, a systematic assessment of the different cognitive domains should be conducted using the Montreal Cognitive Assessment, the MMSE, the Rowland Universal Dementia Assessment, the Addenbrooke's Cognitive Examination, or by means of a stepwise or combined approach involving more simple tests (CDT, TVF, Fototest, MIS, Memory Alteration Test, Eurotest). Associating an informant questionnaire (IQ) with the BCT is superior to the BCT alone for the detection of CI. The choice of instruments will depend on the patient's characteristics, the clinician's experience, and available time. The BCT and IQ must reinforce - but never substitute - clinical judgment, patient-doctor communication, and inter-professional dialogue.

Quiste primario de bazo / Primary splenic cyst

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Resultados de la psicoterapia psicoanalítica infanto-juvenil focal en una unidad de tratamientos especializados en la red pública de salud mental / Results of Psychoanalytical Psychotherapy for children and adolescents in a Specialized Treatment Division of the Public Mental Health System / Resultats de la psicoteràpia psicoanlítica infantil i juvenil focal en una unitat de tractaments especializats en la xarxa pública de Salut mental

El objetivo de este estudio es describir la asociación entre variables pre-tratamiento, el tratamiento y variables posttratamiento (resultado). El tratamiento realizado ha sido psicoterapia psicoanalítica de tipo focal, que se ha llevado a cabo en una unidad especializada en este tipo de trabajos (UPPIJ: Unitat de Psicoteràpia Psicoanalítica infantil i juvenil de Sant Pere Claver), la cual trabaja dentro del marco de la red pública de salud mental de Cataluña. Se constata una relación estadísticamente significativa entre la edad del paciente, la dinámica familiar y el grado de motivación, por una parte y, por otra, una valoración del éxito del tratamiento por parte del clínico al final de éste

The aim of the study is to determine associations between pre-treatment, in-treatment and post-treatment variables (results). The treatment studied was focal psychoanalytical psychotherapy, performed by specialized division (UPPIJ: Unitat de Psicoteràpia Psicoanalítica infantil i juvenil de Sant Pere Claver) of the public mental health system of Catalonia. A positive correlation was found between ages of patients, family dynamics and motivation scores on the one hand and the clinicians’ final evaluations on the other

Resultats de la psicoteràpia psicoanalítica infantil i juvenil focal en una unitat de tractaments especialitzats en la xarxa pública de salut mental. L’objectiu d’aquest estudi és descriure l’associació entre variables pre-tractament, el tractament i variables post-tractament (resultat). El tractament realitzat ha estat psicoteràpia psicoanalítica de tipus focal, que s’ha dut a terme en una unitat especialitzada en aquest tipus de treball (UPPIJ: Unitat de Psicoteràpia Psicoanalítica infantil i juvenil de Sant Pere Claver), la qual treballa dins el marc de la xarxa pública de salut mental de Catalunya. Es constata una relació estadísticament significativa entre l’edat del pacient, la dinàmica familiar i el grau de motivació, d’una banda, i, d’una altra, una valoració de l’èxit del tractament per part del clínic al final d’aquest

Economic analysis of thrombo inCode, a clinical-genetic function for assessing the risk of venous thromboembolism.

BACKGROUND: Patients with venous thromboembolism (VTE) commonly have an underlying genetic predisposition. However, genetic tests nowadays in use have very low sensitivity for identifying subjects at risk of VTE. Thrombo inCode(®) is a new genetic tool that has demonstrated very good sensitivity, thanks to very good coverage of the genetic variants that modify the function of the coagulation pathway. OBJECTIVE: To conduct an economic analysis of risk assessment of VTE from the perspective of the Spanish National Health System with Thrombo inCode(®) (a clinical-genetic function for assessing the risk of VTE) versus the conventional/standard method used to date (factor V Leiden and prothrombin G20210A). METHODS: An economic model was created from the National Health System perspective, using a decision tree in patients aged 45 years with a life expectancy of 81 years. The predictive capacity of VTE, based on identification of thrombophilia using Thrombo inCode(®) and using the standard method, was obtained from two case-control studies conducted in two different populations (S. PAU and MARTHA; 1,451 patients in all). Although this is not always the case, patients who were identified as suffering from thrombophilia were subject to preventive treatment of VTE with warfarin, leading to a reduction in the number of VTE events and an increased risk of severe bleeding. The health state utilities (quality-adjusted life-years [QALYs]) and costs (in 2013 EUR values) were obtained from the literature and Spanish sources. RESULTS: On the basis of a price of EUR 180 for Thrombo inCode(®), this would be the dominant option (more effective and with lower costs than the standard method) in both populations. The Monte Carlo probabilistic analyses indicate that the dominance would occur in 100 % of the simulations in both populations. The threshold price of Thrombo inCode(®) needed to reach the incremental cost-effectiveness ratio (ICER) generally accepted in Spain (EUR 30,000 per QALY gained) would be between EUR 3,950 (in the MARTHA population) and EUR 11,993 (in the S. PAU population). CONCLUSION: According to the economic model, Thrombo inCode(®) is the dominant option in assessing the risk of VTE, compared with the standard method currently used.

Prevalence of atrial fibrillation and its associated factors in Spain: An analysis of 6 population-based studies. DARIOS Study. / Prevalencia de fibrilación auricular y factores asociados en España, análisis de seis estudios de base poblacional. Estudio DARIOS.

BACKGROUND AND OBJECTIVES: Atrial fibrillation (AF) is the most common type of arrhythmia. The purpose of this study was to determine the prevalence of atrial fibrillation and its relationship with cardiovascular risk factors in Spain. METHODOLOGY: Cross-sectional study based on a grouped analysis of 17,291 randomized individuals recruited in 6 population studies. RESULTS: The prevalence of atrial fibrillation was 1.5% (95% CI:1.3-1.7%). Men had a greater prevalence of the disease than women (1.9 vs. 1.1%, respectively). The prevalence of atrial fibrillation progressively increased with age: 0.05% for patients younger than 45 years, 0.5% for those between 45-59 years of age, 2.3% for those between 60-74 years of age and 6.3% for those older than 75 years. The percentage of individuals who were underwent anticoagulant treatment was 74.3%. The risk factors significantly associated with arrhythmia were an age older than 60 years (odds ratio [OR]: 7.6; 95% CI: 5.1-11.2), the male sex (OR:1.8; 95% CI: 1.4-2.4), arterial hypertension (OR:1.6; 95% CI: 1.2-2.1), obesity (OR:1.5; 95% CI:1.2-2.1) and a history of coronary artery disease (OR:1.9; 95% CI: 1.3-3.0). CONCLUSION: Atrial fibrillation is a common disease in elderly individuals, while its prevalence is low in individuals younger than 60 years. Most individuals with atrial fibrillation were on anticoagulant treatment. The risk factors for this type of arrhythmia are age, the male sex, hypertension, obesity and a history of coronary artery disease.

Derivation and validation of BOREAS, a risk score identifying candidates to develop cold-induced hypertension.

INTRODUCTION: Blood pressure increases in cold periods, but its implications on prevalence of hypertension and on individual progression to hypertension remain unclear. Our aim was to develop a pre-screening test for identifying candidates to suffer hypertension only in cold months among non-hypertensive subjects. METHODS: We included 95,277 subjects registered on a primary care database from Girona (Catalonia, Spain), with ≥ 3 blood pressure measures recorded between 2003 and 2009 and distributed in both cold (October-March) and warm (April-September) periods. We defined four blood pressure patterns depending on the presence of hypertension through these periods. A Cox model determined the risk to develop vascular events associated with blood pressure patterns. A logistic regression distinguished those nonhypertensive individuals who are more prone to suffer cold-induced hypertension. Validity was assessed on the basis of calibration (using Brier score) and discrimination (using the area under the receiver operating characteristics). RESULTS: In cold months, the mean systolic blood pressure increased by 3.3 ± 0.1 mmHg and prevalence of hypertension increased by 8.2%. Cold-induced hypertension patients were at higher vascular events risk (Hazard ratio=1.44 [95% Confidence interval 1.15-1.81]), than nonhypertensive individuals. We identified age, diabetes, body mass index and prehypertension as the major contributing factors to cold-induced hypertension onset. DISCUSSION: Hypertension follows a seasonal pattern in some individuals. We recommend screening for hypertension during the cold months, at least in those nonhypertensive individuals identified as cold-induced hypertensive by this assessment tool.

Respuesta de los autores: Los acontecimientos adversos a medicamentos originados en el servicio de urgencias y el estudio EVADUR / No disponible

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Evaluación de los acontecimientos adversos a medicamentos originados en el servicio de urgencias / Evaluation of adverse drug reactions in emergency department practice

OBJETIVO: Determinar la incidencia y caracterizar los acontecimientos adversos a medicamentos (AAM) originados en el servicio de urgencias (SU) de un hospital de tercer nivel. Identificar factores de riesgo asociados a la ocurrencia de AAM y evaluar los errores de medicación (EM) implicados en la aparición de los AAM prevenibles. MÉTODO: Estudio observacional descriptivo de revisión de historias clínicas. Durante 3 meses se seleccionaron pacientes atendidos en el SU que finalmente ingresaron en el centro. La identificación de los AAM se realizó siguiendo una metodología previamente establecida basada en la utilización de señales alertantes (triggers). Se utilizaron los algoritmos de Karch-Lasagna y Hallas para evaluar la causalidad y el cuestionario de Schumock-Thornton para la evitabilidad de los AAM. Todos los posibles AAM fueron validados por dos revisores. RESULTADOS: Se detectaron 31 AAM en los 237 pacientes incluidos, que representan una incidencia del 13%. La mayoría de los AAM presentó una relación de causalidad posible o probable (61% y 29%). El 45% de los AAM fue debido a errores de medicación (EM), que podrían haber sido evitados. Entre los AAM evitables, la principal manifestación fue la alteración de la glucemia atribuida al grupo de antidiabéticos. El principal error implicado fue la falta de prescripción de un medicamento necesario (50%) o la omisión en su administración (21%). En el caso de los AAM inevitables, las principales manifestaciones fueron taquicardia e hiperglicemia asociadas a salbutamol y corticoides respectivamente. Los únicos factores asociados a una mayor prevalencia de AAM fueron el número de fármacos administrados en el SU y la atención en el área de mayor gravedad del SU. CONCLUSIONES: La incidencia de AAM durante la estancia en el SU es elevada y potencialmente prevenible. Estos resultados coinciden con la incidencia descrita en el ámbito hospitalario

OBJECTIVE: To assess the incidence of adverse drug reactions (ADRs) in the emergency department of a tertiary care hospital, to determine the characteristics of the ADRs, to identify related risk factors, and to evaluate medication errors associated with preventable ADRs. METHODS: Descriptive observational study based on data extracted from medical records. Patients admitted to hospital after attendance in the emergency department over a 3-month period were included. ADRs were found following a previously established method to identify ADR clues, or triggers, in patient records. The Karch-Lasagna scale and the Hallas algorithm were used to evaluate causality, and the Schumock-Thornton questionnaire was used to assess ADR preventability. All events that were candidates for classification as ADRs were validated by 2 data collectors. RESULTS: In the records for the 237 patients included, 31 ADRs were detected (incidence, 13%). Most of the ADRs could be assigned a possible (61%) or probable (29%) cause. Forty-five percent of the ADRs were caused by medication errors and could have been prevented. The most common preventable ADRs were hypo- or hyperglycemia related to antidiabetic medication. The most common errors involved failure to prescribe a necessary medication (50%) or failure to administer one (21%). The most common unavoidable ADRs were tachycardia and hyperglycemia related to salbutamol and corticosteroids, respectively. The only factors associated with a higher prevalence of ADRs were the number of drugs administered in the emergency department and admission to the acute-care section of the department. CONCLUSIONS: The incidence of ADRs in this study was high and preventable events were detected. These findings are consistent with evaluations of ADRs in the hospital setting)