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.

Patient safety certification in a Department of Intensive Care Medicine: our experience with standard UNE 179003:2013.

Systematic and structured methods must be used to ensure that healthcare risks are effectively managed. Spanish standard UNE 179003:2013 provides healthcare organizations with a framework and a systematic protocol for managing patient safety from a clinical and organizational perspective. Furthermore, it is useful in securing an efficient balance among health risk, health outcomes and costs. The UNE 179003:2013 certifies that a clinical service complies with rules and operating procedures aimed at reducing the incidence of adverse events. It also requires mandatory continuous improvement, given that the standard entails frequent monitoring of the risk management system through periodic audits. The aims of this paper are to describe the UNE 179003:2013 certification process in an Intensive Care Unit, propose a risk management program for critical patients, and offer some recommendations regarding its implementation.

Towards the personalization of septic shock resuscitation: the fundamentals of ANDROMEDA-SHOCK-2 trial.

Septic shock is a highly lethal and prevalent disease. Progressive circulatory dysfunction leads to tissue hypoperfusion and hypoxia, eventually evolving to multiorgan dysfunction and death. Prompt resuscitation may revert these pathogenic mechanisms, restoring oxygen delivery and organ function. High heterogeneity exists among the determinants of circulatory dysfunction in septic shock, and current algorithms provide a stepwise and standardized approach to conduct resuscitation. This review provides the pathophysiological and clinical rationale behind ANDROMEDA-SHOCK-2, an ongoing multicenter randomized controlled trial that aims to compare a personalized resuscitation strategy based on clinical phenotyping and peripheral perfusion assessment, versus standard of care, in early septic shock resuscitation.

Arterial hypertension diagnosis: A problem?

INTRODUCTION: Arterial hypertension (AHT), a leading risk factor in terms of attributable mortality, is a major public health problem, especially for primary care where most patients are diagnosed and followed up. Correct AHT diagnosis requires adequate theoretical knowledge and technical skills in physicians and nurses. The aim of this study was to evaluate the knowledge and skills used in initial AHT diagnosis by health professionals and to describe the factors that contribute to variability. METHODOLOGY: Cross-sectional observational study in a sample of 385 primary care physicians and nurses recruited in a Catalan health region. Using a validated questionnaire called ARC, we evaluated theoretical knowledge and analysed factors that may contribute to response variability. We also evaluated practical measurement skills using objective structured clinical examination tests. RESULTS: Medical and nursing primary care professionals had deficient knowledge and skills for initial AHT diagnosis and measurement, despite self-perceiving their knowledge to be sufficient. However, professionals who had received postgraduate or other AHT training in the previous year scored better in the ARC questionnaire. CONCLUSIONS: The results of this study point to insufficient AHT expertise to ensure quality clinical practice, suggesting that ongoing theoretical and practical training needs to be improved.

A new validated international questionnaire on health professionals' knowledge of hypertension diagnosis.

INTRODUCTION: Arterial hypertension is the main factor in attributable mortality. It is therefore considered one of the most important public health problems. Health professionals require special training and skills to make a diagnosis. No studies have been found in the literature search that use a validated instrument (questionnaire) to assess health professionals' theoretical and practical knowledge in diagnosing hypertension or measuring blood pressure. AIM: To design and validate an instrument for gauging health professionals' theoretical knowledge in measuring blood pressure for the initial diagnosis of hypertension. METHODOLOGY: Design, development, and validation of a questionnaire in three languages (English, Spanish, and Catalan) to assess knowledge based on the Rasch-item response theory model. RESULTS: A questionnaire in three languages was constructed and validated. It consisted of 23 questions on the theoretical knowledge of the initial diagnosis of hypertension and was called the ARC questionnaire. It met all the Rasch-IRT model criteria: item- and person-fit measurement, unidimensionality, local independence, invariance, targeting, and reliability. CONCLUSIONS: The ARC questionnaire is a validated tool that enables objective and uniform analyses of knowledge in the initial diagnosis of hypertension among medical and nursing professionals, comparing them over time. It allows for established strategies to be developed to enhance this knowledge.

[Telemedicine and dementia: a need for the 21st century]. / Telemedicina y demencia: una necesidad para el siglo XXI.

INTRODUCTION: The ongoing process of information and communication technologies in health services implies a change in the conception, organization and management of these services. Telemedicine is a working method that allows health professionals to explore and/or treat a patient from an off-site location. In this review we provide a historical background on telemedicine, the evolution of its bibliometric impact, and its application for people with dementia. DEVELOPMENT: Telemedicine's applications have been developed in order to provide greater availability and easier access to healthcare to underserved people. The bibliometric study of telemedicine literature shows an increase in the number of bibliographic references related to telemedicine since 1995. During the last few years in Spain the research and development of telemedicine programs have increased significantly and at present there are telemedicine programs in all regions of the country. Although some of the needs of the patients with dementia may be unsuitable for communication and information technologies, their application could offer an added value to health services. This technology does not attempt to replace face-to-face medical consultations but rather to prevent some difficulties this kind of patients can present and improve their quality of life. CONCLUSIONS: Dementia could be an appropriate field in order to implement some telemedicine programs that may improve patient medical care, and reduce medical and management expenses for social and healthcare services.

Respuesta a la carta al editor referida a «Importancia del conocimiento óptimo de los profesionales sanitarios en el diagnóstico inicial de la HTA para su valoración» / Reply: Importance of the optimal knowledge of healthcare professionals in the initial diagnosis of high blood pressure

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[A retrospective, observational and multicentre study on patients with hyperactive bladder on treatment with mirabegron and oxybutinine under usual clinical practice conditions]. / Estudio observacional retrospectivo multicéntrico de pacientes con vejiga hiperactiva en tratamiento con mirabegrón y oxibutinina en condiciones de práctica clínica habitual.

OBJECTIVE: To evaluate therapeutic persistence, healthcare resources, medical costs and adverse events of oxybutynin and mirabegron treatments in patients with overactive bladder in routine medical practice. PATIENTS AND METHODS: An observational, retrospective, multicentre study was carried out using the records of patients attended to in 3 different geographic locations (Barcelona, Girona, Asturias). An analysis was made on the 2 study groups (oxybutynin and mirabegron). Follow-up time was one year. Persistence was defined as the time (months), without discontinuation of the initial treatment, or without change of treatment at least 60 days after the initial prescription. Primary endpoints: comorbidity, healthcare resources used, and adverse events. The data was analysed using the SPSSWIN Program, with a significance of P<.05. RESULTS: Of the total of1,277 patients included in the study, 42.9% were on oxybutynin and 57.1% mirabegron. The mean age was 69.3 years and 53.2% were female. Demographic characteristics and morbidity were similar between the drugs and had a similar persistence (35.0% oxybutynin vs. 32.2% mirabegron, P=.294), although their costs were lower (1,151.2 vs. €1,809.6, P<.001). The biggest differences were observed in the price of medication (279.2 vs. €692.3, P<.001; a variation of: -€413.1); and adverse events (9.7 vs. 4.9%, P<.001). CONCLUSIONS: Patients treated with oxybutynin vs. mirabegron for overactive bladder had similar persistence with the treatment, lower healthcare costs, but with higher oxybutynin vs. mirabegron adverse reaction rates.

A new validated international questionnaire on health professionals’ knowledge of hypertension diagnosis

Introduction: Arterial hypertension is the main factor in attributable mortality. It is therefore considered one of the most important public health problems. Health professionals require special training and skills to make a diagnosis. No studies have been found in the literature search that use a validated instrument (questionnaire) to assess health professionals’ theoretical and practical knowledge in diagnosing hypertension or measuring blood pressure. Aim: To design and validate an instrument for gauging health professionals’ theoretical knowledge in measuring blood pressure for the initial diagnosis of hypertension. Methodology: Design, development, and validation of a questionnaire in three languages (English, Spanish, and Catalan) to assess knowledge based on the Rasch-item response theory model. Results: A questionnaire in three languages was constructed and validated. It consisted of 23 questions on the theoretical knowledge of the initial diagnosis of hypertension and was called the ARC questionnaire. It met all the Rasch-IRT model criteria: item- and person-fit measurement, unidimensionality, local independence, invariance, targeting, and reliability. Conclusions: The ARC questionnaire is a validated tool that enables objective and uniform analyses of knowledge in the initial diagnosis of hypertension among medical and nursing professionals, comparing them over time. It allows for established strategies to be developed to enhance this knowledge.(AU)

Introducción: La hipertensión arterial es el principal factor de mortalidad atribuible. Es por eso que se considera uno de los problemas de salud pública más importantes. Los profesionales de la salud necesitan una formación y unas habilidades especiales para realizar un diagnóstico. En la literatura actual no se han encontrado estudios que utilicen un instrumento validado (cuestionario) para evaluar los conocimientos teóricos y prácticos de los profesionales de la salud en el diagnóstico de la hipertensión o medición de la tensión arterial. Objetivo: Diseñar y validar un instrumento para medir los conocimientos teóricos de los profesionales de la salud en la medida de la tensión arterial para el diagnóstico inicial de la hipertensión. Metodología: Diseño, desarrollo y validación de un cuestionario en tres idiomas (inglés, español y catalán) para evaluar los conocimientos basados en el modelo de Rasch (teoría de la respuesta al ítem). Resultados: Se construyó y validó un cuestionario en tres idiomas. Constaba de 23 preguntas sobre los conocimientos teóricos en el diagnóstico inicial de hipertensión que se denominó cuestionario ARC. Cumplió con todos los criterios del modelo Rasch-IRT: medición de ajuste (fit) al ítem y a la persona, unidimensionalidad, independencia local, invarianza, targeting y fiabilidad. Conclusiones: El cuestionario ARC es una herramienta validada que permite realizar análisis objetivos y uniformes de los conocimientos en el diagnóstico inicial de la hipertensión entre profesionales de medicina y de enfermería, comparándolos en el tiempo. Permite desarrollar estrategias establecidas para potenciar este conocimiento.(AU)

Persistence and concomitant medication in patients with overactive bladder treated with antimuscarinic agents in primary care. An observational baseline study.

OBJECTIVE: To assess therapeutic persistence and its relationship with concomitant medication in patients treated with fesoterodine versus tolterodine and solifenacin for overactive bladder (OAB) in standard clinical practice conditions. MATERIAL AND METHODS: An observational, multicentre retrospective study was performed based on medical registries of patients followed-up in primary care (PC). Three study groups were analysed. Persistence was defined as the time (in months) without withdrawing from the initial therapy or without changing to another medication for at least 30 days after the initial prescription. The concomitant medications were antidepressants, anxiolytic/hypnotic agents, antibiotics, antiseptic agents, laxatives and skin products. We employed the SPSSWIN program version 17 (statistical significance, P<.05). RESULTS: We selected 3094 patients for the study. The median age was 54.0 years and 62.2% were women. The patients treated with fesoterodine shown greater treatment persistence (12 months) when compared with those who took solifenacin and tolterodine (40.2% vs. 34.7% and 33.6%, respectively; P=.008). They also showed a lower use of concomitant medication (1.1 vs. 1.2 and 1.2 drugs, respectively; percentages: 61.6% vs. 67.1% and 70.1%, respectively; P<.03). CONCLUSIONS: The patients undergoing OAB treatment with fesoterodine, when compared with those taking solifenacin and tolterodine, were associated with greater treatment persistence and a reduced use of concomitant medication.

[Pseudomononucleosis induced by diphenylhydantoin (author's transl)]. / Pseudomononucleosis inducida por defenilhidantoína.

The authors report a patient who developed a mononucleotic syndrome after 2 months treatment with diphenylhydantoin. The clinical and biological criteria needed to establish the diagnosis of pseudomononucleosis are listed, while other possible causes described in the literature have been excluded. Complications which may occur during anti-convulsant therapy with diphenylhydantoin are reviewed and the few cases of pseudomononucleosis in the literature noted. Diagnosis was established through eliminating other possible causes, as the only definite test-drug induced reaction-is hazardous to the patient.

Computer aided diagnosis system for retinal analysis: automatic assessment of the vascular tortuosity.

The tortuosity of a vessel, that is, how many times a vessel curves, and how these turns are, is an important value for the diagnosis of certain diseases. Clinicians analyze fundus images manually in order to estimate it, but there is many drawbacks as it is a tedious, time-consuming and subjective work. Thus, automatic image processing methods become a necessity, as they make possible the efficient computation of objective parameters. In this paper we will discuss Sirius (System for the Integration of Retinal Images Understanding Service), a web-based application that enables the storage and treatment of various types of diagnostic tests and, more specifically, its tortuosity calculation module.

Arterial hypertension diagnosis: A problem? / Diagnóstico de hipertensión arterial: ¿un problema?

Introduction: Arterial hypertension (AHT), a leading risk factor in terms of attributable mortality, is a major public health problem, especially for primary care where most patients are diagnosed and followed up. Correct AHT diagnosis requires adequate theoretical knowledge and technical skills in physicians and nurses. The aim of this study was to evaluate the knowledge and skills used in initial AHT diagnosis by health professionals and to describe the factors that contribute to variability. Methodology: Cross-sectional observational study in a sample of 385 primary care physicians and nurses recruited in a Catalan health region. Using a validated questionnaire called ARC, we evaluated theoretical knowledge and analysed factors that may contribute to response variability. We also evaluated practical measurement skills using objective structured clinical examination tests. Results: Medical and nursing primary care professionals had deficient knowledge and skills for initial AHT diagnosis and measurement, despite self-perceiving their knowledge to be sufficient. However, professionals who had received postgraduate or other AHT training in the previous year scored better in the ARC questionnaire. Conclusions: The results of this study point to insufficient AHT expertise to ensure quality clinical practice, suggesting that ongoing theoretical and practical training needs to be improved. (AU)

Introducción: La hipertensión arterial (HTA) es un factor de riesgo destacado en términos de mortalidad atribuible, y un gran problema de salud pública, en especial para la atención primaria, donde se diagnostica y se realiza el seguimiento a la mayoría de los pacientes. El diagnóstico correcto de HTA requiere un conocimiento teórico y una competencia técnica adecuados por parte de médicos y enfermeros. El objetivo de este estudio fue evaluar el conocimiento y las competencias aplicados al diagnóstico inicial de HTA por parte de los profesionales sanitarios, así como describir los factores que contribuyen a la variabilidad. Metodología: Estudio observacional transversal de una muestra de 385 médicos y enfermeros de atención primaria seleccionados en una región sanitaria de Cataluña. Utilizando un cuestionario validado denominado ARC, evaluamos el conocimiento técnico y analizamos los factores que probablemente contribuyen a la variabilidad de la respuesta. También evaluamos las técnicas prácticas de medición utilizando una prueba de examen clínico objetivo. Resultados: Los profesionales médicos y enfermeros de atención primaria tenían un conocimiento deficiente para realizar el diagnóstico y la medición iniciales de HTA, a pesar de autopercibir que dicho conocimiento es suficiente. Sin embargo, los profesionales que recibieron formación de posgrado en HTA durante el último año obtuvieron una mejor puntuación en el cuestionario ARC. Conclusiones: Los resultados de este estudio señalan una experiencia insuficiente sobre HTA para garantizar una práctica clínica de calidad, lo cual demuestra que debe mejorarse la formación teórica y práctica continua. (AU)

Estudio observacional retrospectivo multicéntrico de pacientes con vejiga hiperactiva en tratamiento con mirabegrón y oxibutinina en condiciones de práctica clínica habitual / A retrospective, observational and multicentre study on patients with hyperactive bladder on treatment with mirabegron and oxybutinine under usual clinical practice conditions

Objetivo. Evaluar la persistencia terapéutica, el coste sanitario y las reacciones adversas en pacientes tratados con oxibutinina y mirabegrón para el tratamiento de la vejiga hiperactiva en condiciones de práctica médica habitual. Pacientes y métodos. Se diseñó un estudio observacional, multicéntrico, retrospectivo, realizado a partir de registros médicos de pacientes pertenecientes a 3 áreas geográficas distintas (Barcelona, Girona, Asturias). Se analizaron los 2 grupos de estudio (oxibutinina y mirabegrón). El seguimiento se realizó durante un año. La persistencia se definió como el tiempo (meses) sin abandono del tratamiento inicial o sin cambio a otra medicación al menos 60 días después de la prescripción inicial. Principales medidas: comorbilidad, uso de recursos sanitarios y reacciones adversas. Programa SPSSWIN; p<0,05. Resultados. Se analizaron 1.277 sujetos. La media de edad fue de 69,3 años y el 53,2% fueron mujeres. Por grupos: 42,9% oxibutinina y 57,1% mirabegrón. Las características demográficas y la morbilidad fueron parecidas. Los pacientes en tratamiento con oxibutinina en comparación con mirabegrón presentaron una similar persistencia al tratamiento (35,0 vs. 32,2%, p=0,294), aunque menores costes (1.151,2 vs. 1.809,6€, p<0,001). Las diferencias mayores se observaron en el precio de la medicación (279,2 vs. 692,3€, p<0,001; diferencia: −4131,€) y en las reacciones adversas (9,7 vs. 4,9%, p<0,001). Conclusiones. Los pacientes en tratamiento con oxibutinina frente a mirabegrón para la vejiga hiperactiva se asociaron a una parecida persistencia al tratamiento, menores costes sanitarios y mayores tasas de reacciones adversas de oxibutinina frente a mirabegrón

Objective. To evaluate therapeutic persistence, healthcare resources, medical costs and adverse events of oxybutynin and mirabegron treatments in patients with overactive bladder in routine medical practice. Patients and methods. An observational, retrospective, multicentre study was carried out using the records of patients attended to in 3 different geographic locations (Barcelona, Girona, Asturias). An analysis was made on the 2 study groups (oxybutynin and mirabegron). Follow-up time was one year. Persistence was defined as the time (months), without discontinuation of the initial treatment, or without change of treatment at least 60 days after the initial prescription. Primary endpoints: comorbidity, healthcare resources used, and adverse events. The data was analysed using the SPSSWIN Program, with a significance of P<.05. Results. Of the total of1,277 patients included in the study, 42.9% were on oxybutynin and 57.1% mirabegron. The mean age was 69.3 years and 53.2% were female. Demographic characteristics and morbidity were similar between the drugs and had a similar persistence (35.0% oxybutynin vs. 32.2% mirabegron, P=.294), although their costs were lower (1,151.2 vs. €1,809.6, P<.001). The biggest differences were observed in the price of medication (279.2 vs. €692.3, P<.001; a variation of: −€413.1); and adverse events (9.7 vs. 4.9%, P<.001). Conclusions. Patients treated with oxybutynin vs. mirabegron for overactive bladder had similar persistence with the treatment, lower healthcare costs, but with higher oxybutynin vs. mirabegron adverse reaction rates (AU)

Medición de la microcirculación retiniana luego del tratamiento antihipertensivo / Measuring retinal circulation after antihypertensive treatment

Background and objective: With the development of image processing techniques, it has become possible to measure the changes in retinal vessels of hypertensive patients by means of eye fundus photographs. Patients and method: In this paper we aim to classify retinal vessels automatically into arterioles and venules. In order to do so, we have compared three different strategies based on the colour of the pixels in images through an analysis of 78 hypertensive patients' eye fundus images. The first strategy classifies all the vessels by applying a clustering algorithm. The second divides the retinal image into four quadrants and classifies the vessels that belong to the same quadrant independently from the rest of the vessels. The third strategy classifies the vessels by dividing the retinal image into four quadrants that are rotated inside the mentioned image. Results: The third strategy was the one that obtained the best results, since it minimizes the number of unclassified vessels. In the initially analysed set of 20 images, we correctly classified 86.53% of the vessels, and this percentage remains similar in a set of 58 images examined by three medical experts. This confirms the validity of the method that automatically calculates the arteriovenous ratio (AVR).Conclusion: Our results are an improvement on those previously described in the bibliography, reducing the number of non-classified vessels. Furthermore, the method entails low computational costs.

Fundamento y objetivo: El desarrollo de técnicas de procesado de imágenes ha devuelto interés para poder medir de una forma objetiva los cambios en la estructura microvascular del hipertenso a través de las fotografías digitales del fondo de ojo. Pacientes y método: Para clasificar de forma automática los vasos de la retina en arteriolas y vénulas, con una elevada precisión, hemos comparado tres estrategias diferentes basadas en la información del color de los pixeles de la imagen del fondo de ojo, analizando 78 imágenes de fondo de ojo de hipertensos. La primera estrategia clasificaría todos los vasos aplicando un algoritmo de agrupamiento. La segunda divide la retina en cuatro cuadrantes y clasifica los vasos que pertenecen al mismo cuadrante independientemente del resto de los vasos. La tercera estrategia clasifica los vasos dividiendo la retina en cuadrantes que son rotados. Resultados: La mejor estrategia resultó la tercera porque minimiza el error y el número de vasos no clasificados. La característica vectorial más determinante está basada en la media o la mediana del componente gris del espacio de color RGB. Para las 20 imágenes inicialmente analizadas hemos clasificado correctamente el 86.53% de los vasos, y este porcentaje permanece similar en el grupo de 58 imágenes examinadas por tres expertos, lo que confirma la validez del método, para el cálculo del índice arteriovenoso de forma automática. Conclusión: Nuestros resultados son superiores a los descritos previamente, reduciendo además el número de vasos no clasificados. Por otro lado, el costo computacional del método es bajo

[Prognostic factors of mortality in a cohort of patients with in-hospital cardiorespiratory arrest]. / Factores pronósticos de mortalidad en una cohorte de pacientes con parada cardiorrespiratoria hospitalaria.

OBJECTIVE: To define the prognostic factors related with mortality of patients who suffer cardiorespiratory arrest (CRA) in the hospital, according to Utstein style guidelines. DESIGN: A descriptive and prospective study covering a 30-month consecutive period of all the patients who suffered at least one episode of in-hospital CRA. A Cox regression multivariate analysis was made to identify the independent factors associated with mortality. SETTING: A medical-surgical center in Hospital "Virgen de las Nieves" (HUVN), Granada (Spain). PATIENTS: All the patients attended due to CRA in the hospital, except for those occurring in the operating and recovery room areas. They were followed-up to hospital discharge. MAIN VARIABLES: Mortality on hospital discharge. RESULTS: 203 patients who suffered at least one cardiorespiratory arrest in the hospital, with a median age of 67 years and preponderance of male (60.6%). The most common location was in intensive care medicine unit (48%) and cardiac etiology (62%). Hospital survival rate was 23.15%. In multivariate analysis, strong predictors of mortality were administration of any dose of epinephrine during resuscitation maneuvers (OR 3.4; CI 95%. 1.6-7), total duration of resuscitation (HR 1.018; CI 95%, 1.012-1.024) and as protective factors the first ventricular fibrillation/ventricular tachycardia rhythm with no pulse (HR 0.6; CI 95%, 0.4-0.9) and witnessed by a doctor (HR 0.6; CI 95%, 0.5-0.9). CONCLUSIONS: The type of witness was identified among the predictors of mortality on hospital discharge after an episode of cardiac arrest. This becomes important because the qualification of healthcare personnel can be improved through adequate training.