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1.
Artigo em Inglês, Espanhol | MEDLINE | ID: mdl-31806416

RESUMO

INTRODUCTION: The aim of this study was to evaluate the association between biomass formation and the clinical characteristics and prognosis of Staphylococcus aureus infective endocarditis (IE). METHODS: We prospectively studied 209 S. aureus strains causing IE. Biomass formation was examined using the crystal violet assay and quantified spectrophotometrically. The average (SD) optical density of the biomass was compared for each clinical, microbiological (methicillin-resistance, vancomycin MIC≥1.5µg/ml) and molecular (clonal complex, agr type and agr dysfunction) variable according to their presence or absence. The primary clinical endpoints studied were in-hospital death, severe sepsis, persistent bacteraemia, symptomatic peripheral embolisms and prosthetic valve IE. RESULTS: Mean age was 66.1 years, 61.5% of patients were male and the median age-adjusted Charlson comorbidity index was 5 points (IQR 3-8). In-hospital mortality was 37.3%. Strains belonging to CC5 and CC22 had optical biomass densities [mean (SD) 1.573 (1.14) vs 0.942 (0.98) p<0.001 and 1.720 (0.94) vs 1.028 (1.04) p=0.001, respectively]. Strains belonging to CC5 and CC22 had significantly higher optical biomass densities [1.369 (1.18) vs 0.920 (0.93) p=0.008]. No statistically significant differences were found in the clinical endpoints studied. CONCLUSIONS: High biomass production was associated with CC5 and CC22 but not with higher hospital mortality, septic complications, type of endocarditis, methicillin-resistance, elevated vancomycin MIC or agr dysfunction.

2.
Stroke ; 50(12): 3400-3407, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31610765

RESUMO

Background and Purpose- The aim of the study was to determine the impact of individuals' socioeconomic status and their Primary Care Service Area Socioeconomic Index on survival after ischemic stroke. Methods- We conducted a nationwide population-based cohort study in Catalonia, Spain. We included all patients with first ischemic stroke admitted to a public hospital between January 1, 2015, and December 31, 2016. We measured both individual socioeconomic status (categorized as exempts, <€18 000 [$US 20 468] income per year, and >€18 000 income per year) and Primary Care Service Area Socioeconomic Index (from 0 to 100 categorized in quartiles). We used mixed-effects logistic and survival models to estimate odds ratios and hazard ratios for the short- (30 days) and the long-term (3 years) all-cause case fatality rates by individuals' socioeconomic status groups. Results- The cohort consisted of 16 344 ischemic stroke patients with 24 638 person-years of follow-up. We did not find an association between the lowest socioeconomic individual status and short-term survival (odds ratio, 1.03; 95% CI, 0.76-1.40), although we found it in patients with <€18 000 income/year (odds ratio, 1.26; 95% CI, 1.10-1.45). At long-term, after adjustment, we observed a gradient in mortality risk with decreasing individual socioeconomic status (hazard ratio, 1.52; 95% CI, 1.30-1.77). The Primary Care Service Area Socioeconomic Index had only an influence on short-term survival (odds ratio, 1.19; 95% CI, 1.03-1.37). Conclusions- Individuals' socioeconomic status was associated with short- and long-term survival in patients with ischemic stroke. Conversely, Primary Care Service Area Socioeconomic Index measures had an influence only in short-term survival. A small fraction of this association is due to differences in comorbidity and cardiovascular risk factors. Interventions addressing both individuals' and primary care service socioeconomic aspects might eventually affect differently short- and long-term survival.

3.
BMJ Open ; 9(7): e028114, 2019 07 23.
Artigo em Inglês | MEDLINE | ID: mdl-31340964

RESUMO

OBJECTIVES: Guidelines recommending 12-month dual antiplatelet therapy (DAPT) in patients with ST-elevation acute coronary syndrome (STEACS) undergoing percutaneous coronary intervention (PCI) were published in year 2012. We aimed to describe the influence of guideline implementation on the trend in 12-month persistence with DAPT between 2010 and 2015 and to evaluate its relationship with DAPT duration regimens recommended at discharge from PCI hospitals. DESIGN: Observational study based on region-wide registry data linked to pharmacy billing data for DAPT follow-up. SETTING: All PCI hospitals (10) belonging to the acute myocardial infarction (AMI) code network in Catalonia (Spain). PARTICIPANTS: 10 711 STEACS patients undergoing PCI between 2010 and 2015 were followed up. PRIMARY AND SECONDARY OUTCOME MEASURES: Primary outcome was 12-month persistence with DAPT. Calendar year quarter, publication of guidelines, DAPT duration regimen recommended in the hospital discharge report, baseline patient characteristics and significant interactions were included in mixed-effects logistic regression based interrupted time-series models. RESULTS: The proportion of patients on-DAPT at 12 months increased from 58% (56-60) in 2010 to 73% (71-75) in 2015. The rate of 12-month persistence with DAPT significantly increased after the publication of clinical guidelines with a time lag of 1 year (OR=1.20; 95% CI 1.11 to 1.30). A higher risk profile, more extensive and complex coronary disease, use of drug-eluting stents (OR=1.90; 95% CI 1.50 to 2.40) and a 12-month DAPT regimen recommendation at discharge from the PCI hospital (OR=5.76; 95% CI 3.26 to 10.2) were associated with 12-month persistence. CONCLUSION: Persistence with 12-month DAPT has increased since publication of clinical guidelines. Even though most patients were discharged on DAPT, only 73% with potential indication were on-DAPT 12 months after PCI. A guideline-based recommendation at PCI hospital discharge was highly associated with full persistence with DAPT. Establishing evidence-based, common prescribing criteria across hospitals in the AMI-network would favour adherence and reduce variability.

4.
Eur Heart J Acute Cardiovasc Care ; : 2048872619849922, 2019 May 14.
Artigo em Inglês | MEDLINE | ID: mdl-31084380

RESUMO

Although revascularisation in non-ST-segment elevation acute coronary syndrome (NSTEACS) is associated with better outcomes, its impact in older adult patients is unclear. This is a retrospective analyses of three national NSTEACS registries conducted during the past decade in Spain. Patients aged 75 years and older were included: DESCARTES (DES; year 2002; n=534), MASCARA (MAS; 2005; n=1736) and DIOCLES (DIO; 2012; n=593). The adjusted association between revascularisation and total (inhospital and 6-month) mortality was estimated by two-stage meta-analysis (pooled effect across the three registries with inverse-variability weights) and one-stage meta-analysis (multilevel model with random effects across studies). The impact of revascularisation was assessed comparing the observed and the expected mortality based on a logistic regression model in the pooled database. Although revascularisation was associated with a lower risk of mortality in meta-analyses (two-stage: odds ratio 0.44, 95% confidence interval 0.29-0.67; one-stage: odds ratio 0.54, 95% confidence interval 0.36-0.81) and the revascularisation rate increased steadily from 2002 (DES 14.2%) to 2012 (DIO 43.7%), its impact was not patent across registries, probably because this increase was concentrated in low and medium-risk GRACE strata (tertile 1, 2 and 3: MAS 59%, 20% and 6%; DIO 64%, 39% and 19%, respectively). In conclusion, a consistent increase of revascularisation in NSTEACS in older adults was not followed by a decrease in mortality at 6 months, probably because the impact of this strategy is limited to the higher risk population, the stratum with the lowest revascularisation rate in real life.

6.
Gac Sanit ; 2019 Feb 10.
Artigo em Inglês | MEDLINE | ID: mdl-30745093

RESUMO

OBJECTIVE: To explore healthcare professionals' opinions about low-value practices, identify practices of this kind possibly present in the hospital and barriers and facilitators to reduce them. Low-value practices include those with little or no clinical benefit that may harm patients or lead to a waste of resources. METHOD: Using a mixed methodology, we carried out a survey and two focus groups in a tertiary hospital. In the survey, we assessed doctors' agreement, subjective adherence and perception of usefulness of 134 recommendations to reduce low-value practices from local and international initiatives. We also identified low-value practices possibly present in the hospital. In the focus groups with professionals from surgical and medical fields, using a phenomenological approach, we identified additional low-value practices, barriers and facilitators to reduce them. RESULTS: 169 doctors of 25 specialties participated (response rate: 7%-100%). Overall agreement with recommendations, subjective adherence and usefulness were 83%, 90% and 70%, respectively. Low-value practices form 22 recommendations (16%) were considered as possibly present in the hospital. In the focus groups, the professionals identified seven more. Defensive medicine and scepticism due to contradictory evidence were the main barriers. Facilitators included good leadership and coordination between professionals. CONCLUSIONS: High agreement with recommendations to reduce low-value practices and high perception of usefulness reflect great awareness of low-value care in the hospital. However, there are several barriers to reduce them. Interventions to reduce low-value practices should foster confidence in decision-making processes between professionals and patients and provide trusted evidence.

7.
PLoS One ; 13(12): e0209000, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-30543676

RESUMO

The estimation of the Sample Size Requirement (SSR) when using a binary composite endpoint (i.e. two or more outcomes combined in a unique primary endpoint) is not trivial. Besides information about the rate of events for each outcome, information about the strength of association between the outcomes is crucial, since it can determine an increase or decrease of the SSR. Specifically, the greater the strength of association between outcomes the higher the SSR. We present Bin-CE, a free tool to assist clinicians for computing the SSR for binary composite endpoints. In a first step, the user enters a set of candidate outcomes, the assumed rate of events for each outcome and the assumed effect of therapy on each outcome. Since the strength of the association between outcomes is usually unknown, a semi-parametric approach linking the a priori clinical knowledge of the potential degree of association between outcomes with the exact values of these parameters was programmed with Bin-CE. Bin-CE works with a recursive algorithm to choose the best combination of outcomes that minimizes the SSR. In addition, Bin-CE computes the sample size using different algorithms and shows different figures plotting the magnitude of the sample size reduction, and the effect of different combinations of outcomes on the rate of the primary endpoint. Finally, Bin-CE is programmed to perform sensitivity analyses. This manuscript presents the mathematic bases and introduces the reader to the use of Bin-CE using a real example.


Assuntos
Determinação de Ponto Final/métodos , Internet , Algoritmos , Tamanho da Amostra
8.
Front Neurol ; 9: 427, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-29928257

RESUMO

Stroke, and mainly ischemic stroke, is the second cause of death and disability. To confront the huge burden of this disease, innovative stroke systems of care are mandatory. This requires the development of national stroke plans to offer the best treatment to all patients eligible for reperfusion therapies. Key elements for success include a high level of organization, close cooperation with emergency medical services for prehospital assessment, an understanding of stroke singularity, the development of preassessment tools, a high level of commitment of all stroke teams at Stroke Centres, the availability of a disease-specific registry, and local government involvement to establish stroke care as a priority. In this mini review, we discuss recent evidence concerning different aspects of stroke systems of care and describe the success of the Catalan Stroke Programme as an example of innovation. In Catalonia, reperfusion treatment rates have increased in recent years and currently are among the highest in Europe (17.3% overall, 14.3% for IVT, and 6% for EVT in 2016).

9.
Int J Cardiol ; 250: 35-42, 2018 Jan 01.
Artigo em Inglês | MEDLINE | ID: mdl-29056239

RESUMO

BACKGROUND: The relation between STEMI and air pollution (AP) is scant. We aimed to investigate the short term association between AP and the incidence of STEMI, and STEMI-related ventricular arrhythmias (VA) and mortality. METHODS: The study was carried out in the area of Barcelona from January 2010 to December 2011. Daily STEMI rates and incidence of STEMI-related VA and mortality were obtained prospectively. The corresponding daily levels of the main pollutants were recorded as well as the atmospheric variables. Three cohorts were defined in order to minimize exposure bias. The magnitude of association was estimated using a time-series design and was adjusted according to atmospheric variables. RESULTS: The daily rate of hospital admissions for STEMI was associated with increases in PM 2.5, PM 10, lead and NO2 concentrations. VA incidence and mortality were associated with increases in PM 2.5 and PM 10 concentrations. In the most specific cohort, BCN (Barcelona) Attended & Resident, STEMI incidence was associated with increases in PM 2.5 (1.009% per 10µg/m3) and PM 10 concentrations (1.005% per 10µg/m3). VA was associated with increases in PM 2.5 (1.021%) and PM 10 (1.015%) and mortality was associated with increases in PM 2.5 (1.083%) and PM 10 (1.045%). CONCLUSIONS: Short-term exposure to high levels of PM 2.5 and PM 10 is associated with increased daily STEMI admissions and STEMI-related VA and mortality. Exposure to high levels of lead and NO2 is associated with increased daily STEMI admissions, and NO2 with higher mortality in STEMI patients.


Assuntos
Poluição do Ar/efeitos adversos , Arritmias Cardíacas/diagnóstico , Arritmias Cardíacas/epidemiologia , Material Particulado/efeitos adversos , Infarto do Miocárdio com Supradesnível do Segmento ST/diagnóstico , Infarto do Miocárdio com Supradesnível do Segmento ST/epidemiologia , Poluentes Atmosféricos/efeitos adversos , Estudos de Coortes , Monitoramento Ambiental/métodos , Humanos , Estudos Prospectivos , Sistema de Registros , Fatores de Risco , Estações do Ano , Espanha/epidemiologia , Fatores de Tempo
10.
Eur J Health Econ ; 19(7): 945-956, 2018 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-29170843

RESUMO

OBJECTIVES: The economic crisis in Europe might have limited access to some innovative technologies implying an increase of waiting time. The purpose of the study is to evaluate the impact of waiting time on the costs and benefits of transcatheter aortic valve replacement (TAVR) for the treatment of severe aortic stenosis. METHODS: This is a cost-utility analysis from the perspective of the Spanish National Health Service. Results of two prospective hospital registries (158 and 273 consecutive patients) were incorporated into a probabilistic Markov model to compare quality adjusted life years (QALYs) and costs for TAVR after waiting for 3-12 months, relative to immediate TAVR. We simulated a cohort of 1000 patients, male, and 80 years old; other patient profiles were assessed in sensitivity analyses. RESULTS: As waiting time increased, costs decreased at the expense of lower survival and loss of QALYs, leading to incremental cost-effectiveness ratios for eliminating waiting lists of about 12,500 € per QALY. In subgroup analyses prioritization of patients for whom higher benefit was expected led to a smaller loss of QALYs. Concerning budget impact, long waiting lists reduced spending considerably and permanently. CONCLUSIONS: A shorter waiting time is likely to be cost-effective (considering commonly accepted willingness-to-pay thresholds in Europe) relative to 3 months or longer waiting periods. If waiting lists are nevertheless seen as unavoidable due to severe but temporary budgetary restrictions, prioritizing patients for whom higher benefit is expected appears to be a way of postponing spending without utterly sacrificing patients' survival and quality of life.


Assuntos
Estenose da Valva Aórtica/terapia , Substituição da Valva Aórtica Transcateter/economia , Listas de Espera , Idoso de 80 Anos ou mais , Análise Custo-Benefício , Europa (Continente) , Implante de Prótese de Valva Cardíaca , Humanos , Masculino , Estudos Prospectivos , Qualidade de Vida , Resultado do Tratamento
11.
J Am Med Dir Assoc ; 18(9): 780-784, 2017 Sep 01.
Artigo em Inglês | MEDLINE | ID: mdl-28578883

RESUMO

OBJECTIVE: To compare outcomes and costs for patients with orthogeriatric conditions in a home-based integrated care program versus conventional hospital-based care. DESIGN: Quasi-experimental longitudinal study. SETTING: An acute care hospital, an intermediate care hospital, and the community of an urban area in the North of Barcelona, in Southern Europe. PARTICIPANTS: In a 2-year period, we recruited 367 older patients attended at an orthopedic/traumatology unit in an acute hospital for fractures and/or arthroplasty. INTERVENTION: Patients were referred to a hospital-at-home integrated care unit or to standard hospital-based postacute orthogeriatric unit, based on their social support and availability of the resource. MEASUREMENTS: We compared home-based care versus hospital-based care for Relative Functional Gain (gain/loss of function measured by the Barthel Index), mean direct costs, and potential savings in terms of reduction of stay in the acute care hospital. RESULTS: No differences were found in Relative Functional Gain, median (Q25-Q75) = 0.92 (0.64-1.09) in the home-based group versus 0.93 (0.59-1) in the hospital-based group, P =.333. Total health service direct cost [mean (standard deviation)] was significantly lower for patients receiving home-based care: €7120 (3381) versus €12,149 (6322), P < .001. Length of acute hospital stay was significantly shorter in patients discharged to home-based care [10.1 (7)] than in patients discharged to the postacute orthogeriatric hospital-based unit [15.3 (12) days, P < .001]. CONCLUSION: The hospital-at-home integrated care program was suitable for managing older patients with orthopedic conditions who have good social support for home care. It provided clinical care comparable to the hospital-based model, and it seems to enable earlier acute hospital discharge and lower direct costs.


Assuntos
Artroplastia/reabilitação , Prestação Integrada de Cuidados de Saúde/economia , Fraturas Ósseas/reabilitação , Serviços Hospitalares de Assistência Domiciliar/economia , Idoso , Idoso de 80 Anos ou mais , Custos e Análise de Custo , Feminino , Hospitalização/economia , Humanos , Estudos Longitudinais , Masculino , Recuperação de Função Fisiológica/fisiologia
12.
Am J Epidemiol ; 185(9): 832-841, 2017 05 01.
Artigo em Inglês | MEDLINE | ID: mdl-28402501

RESUMO

Although composite endpoints (CE) are common in clinical trials, the impact of the relationship between the components of a binary CE on the sample size requirement (SSR) has not been addressed. We performed a computational study considering 2 treatments and a CE with 2 components: the relevant endpoint (RE) and the additional endpoint (AE). We assessed the strength of the components' interrelation by the degree of relative overlap between them, which was stratified into 5 groups. Within each stratum, SSR was computed for multiple scenarios by varying the events proportion and the effect of the therapy. A lower SSR using CE was defined as the best scenario for using the CE. In 25 of 66 scenarios the degree of relative overlap determined the benefit of using CE instead of the RE. Adding an AE with greater effect than the RE leads to lower SSR using the CE regardless of the AE proportion and the relative overlap. The influence of overlapping decreases when the effect on RE increases. Adding an AE with lower effect than the RE constitutes the most uncertain situation. In summary, the interrelationship between CE components, assessed by the relative overlap, can help to define the SSR in specific situations and it should be considered for SSR computation.


Assuntos
Estudos Epidemiológicos , Tamanho da Amostra , Métodos Epidemiológicos , Humanos
14.
Stroke ; 48(2): 375-378, 2017 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-28062859

RESUMO

BACKGROUND AND PURPOSE: Whether intravenous thrombolysis adds a further benefit when given before endovascular thrombectomy (EVT) is unknown. Furthermore, intravenous thrombolysis delays time to groin puncture, mainly among drip and ship patients. METHODS: Using region-wide registry data, we selected cases that received direct EVT or combined intravenous thrombolysis+EVT for anterior circulation strokes between January 2011 and October 2015. Treatment effect was estimated by stratification on a propensity score. The average odds ratios for the association of treatment with good outcome and death at 3 months and symptomatic bleedings at 24 hours were calculated with the Mantel-Haenszel test statistic. RESULTS: We included 599 direct EVT patients and 567 patients with combined treatment. Stratification through propensity score achieved balance of baseline characteristics across treatment groups. There was no association between treatment modality and good outcome (odds ratio, 0.97; 95% confidence interval, 0.74-1.27), death (odds ratio, 1.07; 95% confidence interval, 0.74-1.54), or symptomatic bleedings (odds ratio, 0.56; 95% confidence interval, 0.25-1.27). CONCLUSIONS: This observational study suggests that outcomes after direct EVT or combined intravenous thrombolysis+EVT are not different. If confirmed by a randomized controlled trial, it may have a significant impact on organization of stroke systems of care.


Assuntos
Procedimentos Endovasculares/tendências , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/tratamento farmacológico , Trombectomia/tendências , Administração Intravenosa , Idoso , Idoso de 80 Anos ou mais , Terapia Combinada , Procedimentos Endovasculares/mortalidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Sistema de Registros , Acidente Vascular Cerebral/mortalidade , Trombectomia/mortalidade , Terapia Trombolítica/mortalidade , Terapia Trombolítica/tendências , Resultado do Tratamento
16.
Maturitas ; 88: 65-9, 2016 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-27105701

RESUMO

OBJECTIVE: Older citizens with orthopaedic conditions need specialised care for the facilitation of early community reintegration and restitution of physical function. We introduced a new community care programme as an alternative to usual hospital rehabilitation for orthopaedic patients. STUDY DESIGN: This was an observational study of a cohort of older orthopaedic patients attending a hospital-at-home integrated care programme (HHU), compared with a contemporary cohort of users of a geriatric rehabilitation unit (GRU) in the urban area of Badalona, Catalonia, Spain. MAIN OUTCOMES MEASURES: Functional gain at discharge was measured using the Barthel Index (BI). Other outcomes were: length of intervention (days), rehabilitation efficiency and discharge destination. RESULTS: Over the 2 years of the study we assessed 270 patients (69 at HHU; 201 at GRU). We found no significant differences in baseline characteristics between HHU and GRU groups-mean (IQR) or % age 83 (79-87) vs. 84 (79-88), cognitive impairment 27.5% vs. 24.9%, functional decline 40 (31-48) vs. 43 (32-58). Overall, we found no statistically significant differences between HHU and GRU groups on functional gain: 35 (22-45) vs. 32 (18-46), and discharge home 85.5% vs. 86.1%. Length of intervention was shorter in the HHU group, 43 (32-56) vs. 57 (44-81); p<0.01, for hip fracture patients. In a multivariate analysis, the adjusted mean difference in rehabilitation efficiency between HHU and GRU groups in the hip fracture subgroup was 0.27 (0.09 to 0.46); p=0.004. CONCLUSIONS: This hospital-at-home service obtained similar clinical results to the usual hospital-based rehabilitation care, and for hip fracture patients attending that service, rehabilitation efficiency was better.


Assuntos
Transtornos Cognitivos , Prestação Integrada de Cuidados de Saúde , Fraturas do Quadril/reabilitação , Hospitais , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Ortopedia , Espanha
17.
Clin Res Cardiol ; 105(6): 508-17, 2016 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-26646556

RESUMO

BACKGROUND AND PURPOSE: The risk of neurological damage following transcatheter aortic valve implantation (TAVI) vs. surgical aortic valve replacement (SAVR) in severe aortic stenosis patients deemed to be at intermediate surgical risk is unknown. In this target population, the degree of neurological damage was compared using brain diffusion-weighted magnetic resonance imaging (DW-MRI) and cognitive testing. METHODS: Forty-six consecutive patients undergoing TAVI (78.0 ± 8.3 years; STS score 4.4 ± 1.7) and 37 patients undergoing SAVR (78.9 ± 6.2 years, STS score 4.7 ± 1.7) were compared. DW-MRI was performed in 67 patients (40 in TAVI vs. 27 in SAVR group) within the first 15 days post-procedure. A cognitive assessment was performed at baseline and at 3 months follow-up. The occurrence of potential cognitive impairment post-intervention was determined using the reliable change index (RCI). RESULTS: Baseline characteristics were comparable in TAVI and SAVR groups except for the presence of severe calcified aorta, which occurred more frequently in the TAVI group [17 (37 %) vs. 0 (0 %), p < 0.001]. Three patients presented a clinical stroke: 1 (2.2 %) in TAVI group vs. 2 (5.4 %) in SAVR group, (p = 0.58). No differences were observed in the rate of acute ischemic cerebral lesions detected by DWI in patients undergoing TAVI vs. SAVR [18 (45 %) in TAVI vs. 11 (40.7 %) in SAVR, adjusted OR 0.95; 95 % CI 0.25-3.65; p = 0.94]. TAVI was associated with a lower number of DWI lesions (adjusted OR 0.54; 95 % IC 0.37-0.79; p = 0.02). An older age was a predictor of the occurrence of acute lesions (OR 1.13; 95 % CI 1.03-1.23; p = 0.01), and the use of vitamin-K antagonist therapy had a protective effect (OR 0.25; 95 % CI 0.07-0.92; p = 0.037) regardless the type of intervention. Overall no significant changes were observed in global cognitive scores post-intervention (p = 0.23). The RCI showed mild cognitive decline in nine patients undergoing TAVI (26.4 %) and in six patients in the SAVR group (30.0 %) (p = 0.96). There was no association between the number and total volume of lesions and the occurrence of cognitive decline (CC Spearman 0.031, p = 0.85 and -0.011, p = 0.97, respectively). CONCLUSIONS: TAVI and SAVR were associated with a similar rate of acute silent ischemic cerebral lesions in intermediate risk patients. Although acute lesions occurred very frequently in both strategies, their cognitive impact was not clinically relevant.


Assuntos
Estenose da Valva Aórtica/terapia , Valva Aórtica/cirurgia , Isquemia Encefálica/etiologia , Cateterismo Cardíaco/efeitos adversos , Implante de Prótese de Valva Cardíaca/efeitos adversos , Idoso , Idoso de 80 Anos ou mais , Estenose da Valva Aórtica/diagnóstico , Estenose da Valva Aórtica/cirurgia , Isquemia Encefálica/diagnóstico por imagem , Isquemia Encefálica/fisiopatologia , Isquemia Encefálica/psicologia , Cateterismo Cardíaco/instrumentação , Cateterismo Cardíaco/métodos , Distribuição de Qui-Quadrado , Cognição , Imagem de Difusão por Ressonância Magnética , Feminino , Próteses Valvulares Cardíacas , Implante de Prótese de Valva Cardíaca/instrumentação , Implante de Prótese de Valva Cardíaca/métodos , Humanos , Modelos Logísticos , Masculino , Análise Multivariada , Testes Neuropsicológicos , Razão de Chances , Valor Preditivo dos Testes , Estudos Prospectivos , Desenho de Prótese , Medição de Risco , Fatores de Risco , Índice de Gravidade de Doença , Fatores de Tempo , Resultado do Tratamento
18.
Int J Cardiol ; 182: 321-8, 2015 Mar 01.
Artigo em Inglês | MEDLINE | ID: mdl-25585368

RESUMO

OBJECTIVE: To evaluate cost-effectiveness of transfemoral TAVR vs surgical replacement (SAVR) and its determinants in patients with severe symptomatic aortic stenosis and comparable risk. METHODS: Patients were prospectively recruited in 6 Spanish hospitals and followed up over one year. We estimated adjusted incremental cost-effectiveness ratio (ICER) (Euros per quality-adjusted life-year [QALY] gained) using a net-benefit approach and assessed the determinants of incremental net-benefit of TAVR vs SAVR. RESULTS: We analyzed data on 207 patients: 58, 87 and 62 in the Edwards SAPIEN (ES) TAVR, Medtronic-CoreValve (MC) TAVR and SAVR groups respectively. Average cost per patient of ES-TAVR was €8800 higher than SAVR and the gain in QALY was 0.036. The ICER was €148,525/QALY. The cost of MC-TAVR was €9729 higher than SAVR and the QALY difference was -0.011 (dominated). Results substantially changed in the following conditions: 1) in patients with high preoperative serum creatinine the ICERs were €18,302/QALY and €179,618/QALY for ES and MC-TAVR respectively; 2) a 30% reduction in the cost of TAVR devices decreased the ICER for ES-TAVR to €32,955/QALY; and 3) imputing hospitalization costs from other European countries leads to TAVR being dominant. CONCLUSIONS: In countries with relatively low health care costs TAVR is not likely to be cost-effective compared to SAVR in patients with intermediate risk for surgery, mainly because of the high cost of the valve compared to the cost of hospitalization. TAVR could be cost-effective in specific subgroups and in countries with higher hospitalization costs.


Assuntos
Estenose da Valva Aórtica/cirurgia , Análise Custo-Benefício/métodos , Custos Hospitalares/tendências , Medição de Risco/métodos , Substituição da Valva Aórtica Transcateter/métodos , Idoso , Idoso de 80 Anos ou mais , Estenose da Valva Aórtica/diagnóstico , Estenose da Valva Aórtica/economia , Ecocardiografia , Feminino , Artéria Femoral , Seguimentos , Implante de Prótese de Valva Cardíaca/economia , Implante de Prótese de Valva Cardíaca/métodos , Humanos , Masculino , Estudos Prospectivos , Fatores de Risco , Índice de Gravidade de Doença , Espanha/epidemiologia , Fatores de Tempo , Substituição da Valva Aórtica Transcateter/economia
19.
Int J Cardiol ; 177(1): 261-5, 2014 Nov 15.
Artigo em Inglês | MEDLINE | ID: mdl-25499390

RESUMO

Pulmonary valve replacement (PVR) reduces right ventricular (RV) volumes in the setting of long-term pulmonary regurgitation after Tetralogy of Fallot (ToF) repair; however, little is known of its effect on RV diastolic function. Right atrial volumes may reflect the burden of RV diastolic dysfunction. The objective of this paper is to evaluate the clinical, echocardiographic, biochemical and cardiac magnetic resonance (CMR) variables, focusing particularly on right atrial response and right ventricular diastolic function prior to and after elective PVR in adult patients with ToF. This prospective study was conducted from January 2009 to April 2013 in consecutive patients > 18 years of age who had undergone ToF repair in childhood and were accepted for elective PVR. Twenty patients (mean age: 35 years; 70% men) agreed to enter the study. PVR was performed with a bioporcine prosthesis. Concomitant RV reduction was performed in all cases when technically possible. Pulmonary end-diastolic forward flow (EDFF) decreased significantly from 5.4 ml/m(2) to 0.3 ml/m(2) (p < 0.00001), and right atrial four-chamber echocardiographic measurements and volumes by 25% (p = 0.0024): mean indexed diastolic/systolic atrial volumes prior to surgery were 43 ml/m(2) (SD+/-4.6)/63 ml/m(2) (SD+/-5.5), and dropped to 33 ml/m(2) (SD+/-3)/46 ml/m(2) (SD+/-2.55) post-surgery. All patients presented right ventricular diastolic and systolic volume reductions, with a mean volume reduction of 35% (p < 0.00001). Right ventricular diastolic dysfunction was common in a population of severely dilated RV patients long term after ToF repair. Right ventricular diastolic parameters improved as did right atrial volumes in keeping with the known reduction in RV volumes, after PVR.


Assuntos
Volume Cardíaco/fisiologia , Átrios do Coração/fisiopatologia , Implante de Prótese de Valva Cardíaca , Insuficiência da Valva Pulmonar/cirurgia , Valva Pulmonar/cirurgia , Tetralogia de Fallot/complicações , Função Ventricular Direita/fisiologia , Adulto , Ecocardiografia , Feminino , Seguimentos , Átrios do Coração/diagnóstico por imagem , Humanos , Masculino , Estudos Prospectivos , Insuficiência da Valva Pulmonar/etiologia , Insuficiência da Valva Pulmonar/fisiopatologia , Volume Sistólico , Tetralogia de Fallot/fisiopatologia , Tetralogia de Fallot/cirurgia , Resultado do Tratamento
20.
Cerebrovasc Dis ; 38(5): 328-36, 2014.
Artigo em Inglês | MEDLINE | ID: mdl-25428822

RESUMO

BACKGROUND: Among the acute ischemic stroke patients with large vessel occlusions and contraindications for the use of IV thrombolysis, mainly on oral anticoagulation or presenting too late, primary endovascular therapy is often performed as an alternative to the standard therapy even though evidence supporting the use of endovascular reperfusion therapies is not yet established. Using different statistical approaches, we compared the functional independence rates at 3 months among patients undergoing primary endovascular therapy and patients treated only with IV thrombolysis. METHODS: We used data from a prospective, government-mandated and externally audited registry of reperfusion therapies for ischemic stroke (January 2011 to November 2012). Patients were selected if treated with either IV thrombolysis alone (n = 1,582) or primary endovascular thrombectomy (n = 250). A series of exclusions were made to homogenize the clinical characteristics among the two groups. We then carried out multivariate logistic regression and propensity score matching analyses on the final study sample (n = 1,179) to compare functional independence at 3 months, as measured by the modified Rankin scale scores 0-2, between the two groups. RESULTS: The unadjusted likelihood of good outcome was poorer among the endovascular group (OR: 0.69; 95% CI: 0.47-1.0). After adjustment, no differences by treatment modality were seen (OR: 1.51; 95% CI: 0.93-2.43 for primary endovascular therapy). Patients undergoing endovascular thrombectomy within 180-270 min (OR: 2.89; 95% CI: 1.17-7.15) and patients with severe strokes (OR: 1.84; 95% CI: 1.02-3.35) did better than their intravenous thrombolysis counterparts. The propensity score-matched analyses with and without adjustment by additional covariates showed that endovascular thrombectomy was as effective as intravenous thrombolysis alone in achieving functional independence (OR for unadjusted propensity score matched: 1.35; 95% CI: 0.9-2.02, OR for adjusted propensity score matched: 1.45; 95% CI: 0.91-2.32). CONCLUSION: This comparative effectiveness study shows that in ischemic stroke patients with contraindications for IV thrombolysis, primary endovascular treatment might be an alternative therapy at least as effective as IV thrombolysis alone. Randomized controlled trials are urgently needed.


Assuntos
Procedimentos Endovasculares , Fibrinolíticos/uso terapêutico , Acidente Vascular Cerebral/tratamento farmacológico , Terapia Trombolítica , Ativador de Plasminogênio Tecidual/uso terapêutico , Adulto , Idoso , Idoso de 80 Anos ou mais , Isquemia Encefálica/tratamento farmacológico , Procedimentos Endovasculares/métodos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Resultado do Tratamento
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