Cardiovascular disease and survival in non-small cell lung cancer: a multicenter prospective assessment.

PURPOSE: Chronic inflammation contributes to cancer development via multiple mechanisms. We hypothesized that cardiovascular diseases (CVD) are also an independent risk factor for survival in non-small cell lung cancer (NSCLC). MATERIALS AND METHODS: Prospective multicenter data from 345 consecutive NSCLC patients treated from January 2013 to January 2017 were assessed. Median follow-up for all patients was 13 months (range 3-60 months). There were 109 patients with baseline heart disease (HD 32%), 149 with arterial hypertension (43%), 85 with diabetes mellitus (25%), 129 with hyperlipidemia (37%) and 45 with venous thromboembolism events (VTE 13%). A total of 289 patients (84%) were treated with platinum-based chemotherapy (CT), 300 patients (87%) received thoracic radiation therapy (RT; median radiation dose: 60 Gy [range 12-70]); and 50 (15%) patients underwent surgery. RESULTS: Our cohort consisted of 305 men (88%) and 40 (12%) women, with a median age of 67 years (range 31-88 years). Seventy percent had a Karnofsky performance status (KPS) ≥ 80. Multivariate analyses showed a lower OS and higher risk of distant metastasis in patients with advanced stages (p = 0.05 and p < 0.001, respectively) and HD (HR 1.43, p = 0.019; and HR 1.49, p = 0.025, respectively). Additionally, patients with VTE had lower local control (HR 1.84, p = 0.025), disease-free survival (HR 1.64, p = 0.020) and distant metastasis-free survival (HR 1.73, p = 0.025). CONCLUSIONS: HD and VTE are associated with a higher risk of mortality and distant metastasis in NSCLC patients. Chronic inflammation associated with CVDs could be an additional pathophysiologic factor in the development of distant metastasis.

Cystic parathyroid adenoma: Primary hyperparathyroidism without 99mTc-MIBI uptake. / Adenoma quístico paratiroideo: hiperparatiroidismo primario sin captación de 99mTc-MIBI.

Cystic parathyroid adenoma is a rare disease (<0.01% of all cervical masses) that associates primary hyperparathyroidism in 9% of cases. Parathyroid scintigraphy is essential for its diagnosis with uncommon false negative results. Hybrid SPECT/CT equipments allow a more accurate diagnosis. Functional cystic parathyroid adenomas are surgically treated. A case of a 64-year-old woman with diagnoses of hyperparathyroidism and a cystic parathyroid adenoma without uptake in scintigraphy is described.

Consideraciones en torno a la formación del residente en cirugía de pared abdominal en España / Training of residents in abdominal wall surgery in Spain

La formación del residente en cirugía de la pared abdominal constituye un aspecto fundamental en la formación quirúrgica, representando globalmente un 20% de su actividad. En el presente artículo, se analiza el estado actual de la formación del residente en este tipo de cirugía en España teniendo en cuenta el amplio espectro en el que se desarrolla: servicios generales, unidades funcionales específicas, programas de cirugía mayor ambulatoria. Para ello, partiendo de las especificaciones del programa de la especialidad, se han utilizado datos concretos obtenidos de diversas fuentes de información directas, así como una revisión de los resultados obtenidos por los residentes en cirugía herniaria. En general los residentes en nuestro país manifiestan su conformidad con la formación recibida, y los resultados objetivos registrados se adecuan a los planteados en el programa. Sin embargo, sería importante estructurar en sus itinerarios docentes, un periodo de rotación en alguna Unidad específica y su implicación en programas de cirugía mayor ambulatoria (AU)

The training of residents in abdominal wall surgery is a fundamental aspect of surgical training, representing globally 20% of its activity. In this paper, we analyze the current state of resident training in this kind of surgery in Spain, taking into account the broad spectrum it covers: general services, specific functional units, ambulatory surgery programs. To do this, based on the specifications of the specialty program, specific data were used from several different sources of direct information and a review of the results obtained by residents in hernia surgery. In general, our residents agree with their training and the recorded results are in line with objectives outlined in the program. However, it would be important to structure their teaching schedules, a rotation period in any specific unit and their involvement in outpatient surgery programs (AU)

[Training of residents in abdominal wall surgery in Spain]. / Consideraciones en torno a la formación del residente en cirugía de pared abdominal en España.

The training of residents in abdominal wall surgery is a fundamental aspect of surgical training, representing globally 20% of its activity. In this paper, we analyze the current state of resident training in this kind of surgery in Spain, taking into account the broad spectrum it covers: general services, specific functional units, ambulatory surgery programs. To do this, based on the specifications of the specialty program, specific data were used from several different sources of direct information and a review of the results obtained by residents in hernia surgery. In general, our residents agree with their training and the recorded results are in line with objectives outlined in the program. However, it would be important to structure their teaching schedules, a rotation period in any specific unit and their involvement in outpatient surgery programs.

[Timing of tourniquet release in total knee arthroplasty doesn't affect on transfusion needs]. / El momento de retirada del manguito de isquemia en las artroplastias totales de rodilla no influye en la necesidad de transfusión.

OBJECTIVE: To determine whether the removal of the ischaemia tourniquet to perform haemostasis during knee replacement surgery, reduces bleeding, the need for transfusions, the incidence of complications, the incidence of further surgery, and the hospital stay. PATIENTS AND METHOD: A non-randomised, prospective, descriptive and observational study was conducted on patients subjected to primary knee replacement with only one anaesthetist and 2 surgical teams. The same surgical technique and prosthesis model was used, with 2 schemes for ischaemia removal and drainage management. The patients were divided into 2 groups. In group i, the ischaemia tourniquet was released during the operation, before wound closure, and leaving the drainages without a vacuum. In group ii the tourniquet was released when the limb was bandaged and the drainages were connected to a vacuum. The parameters recorded were; bleeding during surgery, bleeding due to the drainages, monitoring the haemoglobin and haematocrit, incidence of complications and further surgery, transfusion needs, and hospital stay. RESULTS: The study included 100 patients. The mean bleeding during surgery was 230,0mL in group i and 2,0mL in group ii (P<.05). The bleeding due to the drainages in group i was 531,2mL and 601,6mL in Group ii (P>.05). The total bleeding was 754,3mL in group i and 621,6mL in group ii. There were statistically significant differences in both cases (P<.05). The transfusion incidence in both groups was 16,7%. There were no significant differences between either group as regards medical complications or further surgery. A longer hospital stay was observed in group ii. CONCLUSION: In this study, the need for transfusions in knee replacement surgery is not influenced by the time of releasing the ischaemia tourniquet. There is also no relationship between the incidence in postoperative complications and further surgery and the time of removing the tourniquet. The preoperative haemoglobin was the only predictive factor of transfusion in our study.

Resultados de la campaña “ahora sí” / No disponible

Introducción: La Sociedad Española de Cardiología (SEC), Sociedad Española de Médicos de Atención Primaria, (SEMERGEN) y Sociedad Española de Neumología y Cirugía Torácica, (SEPAR) quisieron aprovechar la oportunidad que les brindaba la implantación de la nueva ley reguladora del consumo del tabaco en los lugares públicos, para promover una campaña en favor de la prevención y el control del tabaquismo. Objetivo: Los principales objetivos han sido: informar a toda la población general sobre los diferentes aspectos sanitarios relacionados con el tabaquismo, formar a los profesionales sanitarios en las disciplinas de prevención, diagnóstico y tratamiento del tabaquismo y crear o potenciar recursos sanitarios para ayudar a dejar de fumar. Metodología: La campaña ha sido dirigida por un comité constituido por expertos de las tres sociedades cientí cas y se ha llevado a cabo con la colaboración de los colegios o ciales de médicos y de los ayuntamientos. La campaña, que ha tenido una duración de 8 meses, se ha realizado en 13 ciudades de tamaño medio y repartidas por todo el territorio español: Alcobendas, Ávila, Cáceres, Calatayud, Córdoba, Cuenca, Girona, Irún, Las Palmas de Gran Canaria, Menorca, Ontinyent, Oviedo y Xátiva. La campaña consistió en la distribución de carteles informativos, ruedas de prensa, notas de prensa, realización de charlas para adultos, charlas para jóvenes, realización de cursos de formación en diagnóstico y tratamiento del tabaquismo para profesionales sanitarios y creación de consultas de tabaquismo o potenciaciónde las existentes. Resultados: Se han realizado 13 ruedas de prensa a las que acudieron 74 medios informativos. Se han repartidomas 7800 carteles. Se impartieron un total de 13 charlas dirigidas a la población general y 10 dirigidas a los jóvenes. Ello ha supuesto que se ha llegado de forma directa a un total de 500 personas adultas y a un total de 400 jóvenes. Se calcula que los mensajes de la campaña han llegado a más de 24.500.000 de ciudadanos en todo el territorio español. Se han realizado un total de 11 cursos que han servido para formar a 317 profesionales sanitarios. Se ha actuado en 14 consultas tratándose a un total de 466 fumadores. De estas 14 consultas, 5 eran consultas establecidas con anterioridad y 9 han sido consultas de nueva creación. Todas ellas continúan sus trabajos después de la nalización de la campaña. Conclusiones: La campaña “Ahora Si” ha servido para enviar mensajes sanitarios en favor del control del tabaquismo a mas de 24.500.000 de ciudadanos, ha facilitado la formación de 317 profesionales sanitarios y ha potenciado y creado nuevos recursos sanitarios asistenciales en tabaquismo (AU)

Introduction: Sociedad Española de Cardiología (SEC), Sociedad Española de Médicos de Atención Primaria, (SEMERGEN) and Sociedad Española de Neumología y Cirugía Torácica, (SEPAR) have wanted to take advantage from the implementation of the new Spanish anti-smoking Law in order to promote a campaign in favor of smoking control. Objective: The main objectives are as follows: to give information about smoking to the Spanish general population, to teach health professionals on smoking control and to create and develop smoking cessation resources. Methods: The campaign has been conducted by experts from the three scienti c societies and in collaboration with physicians colleages and representatives of the local administration. The campaign has lasted 8 months and has taken places in 13 medium size towns: Alcobendas, Ávila, Cáceres, Calatayud, Córdoba, Cuenca, Girona, Irún, Las Palmas de Gran Canaria, Menorca, Ontinyent, Oviedo y Xátiva. The campaign consisted of distribution of posters, media meetings, talks for adults and children, training courses for health professionals and development of smoking cessation resources. Results: 13 media meetings were undertaken. 7800 posters were distributed. 13 talks were spoken focusing general population and 10 focusing young people. The campaign impacted directely to 500 adults and 400 youngs. The campaign impacted indirectely in more tan 24.500.000 people. 11 training courses gave knowledge on smoking cessation to 317 health professionals. 14 of ces for smoking cessation has been created and all of them continue working after the campaign has nished Conclusions: “Ahora Si” campaign has served to send messages in favour of smoking control to more than 24.500.000 people all over the Spain, has increased knowledge on smoking cessation in 317 health professionals and has increased the number of Spanish smoking cessation resources

Morbimortalidad y consumo de recursos asociados tras síndrome coronario agudo en una población española / Morbi-mortality and use of recourses after acute coronary syndrome in a Spanish population

Objetivo. Describir el manejo de los pacientes con síndrome coronario agudo (SCA) y determinar sus consecuencias clínicas y económicas en la población española. Pacientes y métodos. Estudio multicéntrico y retrospectivo basado en revisión de registros médicos, de dos años de seguimiento con pacientes de 6 centros de Atención Primaria y dos hospitales. Se incluyeron pacientes mayores de 30 años, que padecieron un primer SCA entre 2003 y 2007. Grupos: pacientes con SCA con y sin elevación del segmento ST. Variables: sociodemográficas, comorbilidades, síndrome metabólico (SM), parámetros bioquímicos, fármacos, incidencia acumulada (mortalidad total y eventos cardiovasculares [ECV]: incluyendo infarto de miocardio, accidente vasculocerebral y arteriopatía periférica que requieren hospitalización]) y costes totales. Análisis estadístico: regresión logística, curvas Kaplan-Meier y ANCOVA; p<0 05 esultados. Fueron incluidos 1.020 pacientes. Edad media: 69 años; 65% hombres. Grupos: SCA con elevación ST (N=632; 62%). Comorbilidades: hipertensión (56%), dislipemia (46%) y diabetes (38%). Prevalencia de SM: 59% (IC 95%: 56-62%). Todos los parámetros bioquímicos mejoraron tras dos años. El coste medio por paciente fue de 14.069 € (87% costes directos y el 13% costes por pérdida de productividad). Costes directos: Atención Primaria (20%), atención especializada (67%); los costes de hospitalización representaron el 63% de los costes totales. El coste medio por paciente con más de un ECV fue 22.750 € vs 12.380 € de los que presentaron un único evento (p<0 001 incidencia acumulada: mortalidad total 14 cve: 16 Conclusiones. En la práctica clínica habitual y a pesar de los esfuerzos clínicos realizados, los pacientes con SCA siguen manteniendo un elevado riesgo de sufrir futuros ECV, representando un alto coste para el sistema sanitario(AU)

Objectives. To describe the management of patients suffering acute coronary syndrome (ACS) and to determine its clinical and economic consequences in a Spanish population. Methods. A multicenter, retrospective claim database study including patient medical records from 6 primary care centers, two hospitals and two years of follow-up was carried out. Patients ≥30 years, suffering a first acute coronary syndrome (ACS), between 2003 and 2007, were included. Groups: acute coronary syndrome with and without ST segment elevation. Variables: socio-demographic, co-morbidities, metabolic syndrome (MS), biochemical parameters, drugs, cumulative incidence (total mortality and cardiovascular events (CVE: including myocardial infarction, stroke and peripheral artery disease) and total costs. Statistical analysis: logistic regression, Kaplan-Meier curves and ANCOVA; (P<.05). Results. A total of 1020 patients were included. Mean age: 69 years; males: 65%. Groups: ST segment elevation ACS (N=632; 62%). Co-morbidities: hypertension (56%), dyslipidemia (46%) and diabetes (38%). Prevalence of MS: 59% (CI 95%: 56-62%). All biochemical parameters had improved after two years of follow-up. The average total cost per patient was €14,069 (87% direct costs; 13% productivity loss costs). Direct costs: primary care (20%), specialty care (67%); hospitalization costs represented 63% of total costs. The average total cost for patients presenting more than one CVE was 22,750€ vs 12,380€ for those patients who suffered only one (P<.001). Cumulative incidence: total mortality 14%; CVE: 16%. Conclusions. In the current clinical practice, and despite the clinical efforts carried out, patients with an ACS are still at a high risk of suffering further CVE, representing a high cost burden to the health care system(AU)

[Morbi-mortality and use of recourses after acute coronary syndrome in a Spanish population]. / Morbimortalidad y consumo de recursos asociados tras síndrome coronario agudo en una población española.

OBJECTIVES: To describe the management of patients suffering acute coronary syndrome (ACS) and to determine its clinical and economic consequences in a Spanish population. METHODS: A multicenter, retrospective claim database study including patient medical records from 6 primary care centers, two hospitals and two years of follow-up was carried out. Patients ≥30 years, suffering a first acute coronary syndrome (ACS), between 2003 and 2007, were included. Groups: acute coronary syndrome with and without ST segment elevation. VARIABLES: socio-demographic, co-morbidities, metabolic syndrome (MS), biochemical parameters, drugs, cumulative incidence (total mortality and cardiovascular events (CVE: including myocardial infarction, stroke and peripheral artery disease) and total costs. STATISTICAL ANALYSIS: logistic regression, Kaplan-Meier curves and ANCOVA; (P<.05). RESULTS: A total of 1020 patients were included. Mean age: 69 years; males: 65%. Groups: ST segment elevation ACS (N=632; 62%). Co-morbidities: hypertension (56%), dyslipidemia (46%) and diabetes (38%). Prevalence of MS: 59% (CI 95%: 56-62%). All biochemical parameters had improved after two years of follow-up. The average total cost per patient was €14,069 (87% direct costs; 13% productivity loss costs). Direct costs: primary care (20%), specialty care (67%); hospitalization costs represented 63% of total costs. The average total cost for patients presenting more than one CVE was 22,750€ vs 12,380€ for those patients who suffered only one (P<.001). Cumulative incidence: total mortality 14%; CVE: 16%. CONCLUSIONS: In the current clinical practice, and despite the clinical efforts carried out, patients with an ACS are still at a high risk of suffering further CVE, representing a high cost burden to the health care system.

Análisis del impacto presupuestario para el Sistema Nacional de Salud de la combinación fija de amlodipino 5 o 10mg y atorvastatina 10mg / Analysis of the budget impact for the Spanish National Health System of the fixed combination of amlodipine 5 or 10mg and atorvastatin 10mg

Objetivo Realizar un análisis de impacto presupuestario (AIP) de la introducción en la prestación sanitaria del sistema nacional de salud (SNS) de la combinación fija (CF) de amlodipino 5 o 10mg y atorvastatina 10mg en la indicación aprobada. Material y métodos El AIP se ha realizado desde la perspectiva del SNS para un periodo de 3 años (2009–2011). Se ha diseñado un modelo de decisión tipo árbol (árbol de pacientes) construido a partir de datos epidemiológicos y la literatura científica para estimar la población hipertensa susceptible de tratamiento con la CF. El AIP, por año y en total, se ha calculado imputando el coste a PVP-IVA de la CF al número de pacientes a tratar, del que se sustrae el coste del tratamiento antihipertensivo que se sustituye y el coste por paciente promedio actualizado de los eventos cardiovasculares prevenidos para el SNS por el uso de la CF en el periodo de referencia. Resultados La población susceptible de tratamiento con la CF es de 51.104 pacientes (1.er año), con una tasa de crecimiento entre 1–2% en los sucesivos años, lo que supone un coste (€) anual de 15,9M (2009), 19,9M (2010) y 24,1M (2011), totalizando 60,0M. El AIP se ve compensado mostrando valores de impacto negativo para el SNS cuando se descuentan los costes del tratamiento antihipertensivo sustituido y eventos cardiovasculares prevenidos, mostrando un ahorro de 69,9M € en 3 años. Conclusión El AIP de la CF de atorvastatina y amlodipino muestra que su uso en la indicación aprobada podría generar ahorros netos para el SNS en el periodo 2009–2011 de 9,9M (AU)

Objective To carry out a Budget Impact Analysis (BIA) of the inclusion of the administration, within the Spanish National Health System (SNS), of the fixed combination (FC) of amlodipine 5 or 10mg and atorvastatin 10mg for approved indications. Materials and Methods A BIA was carried out from the SNS perspective for a 3 year period (2009–2011). A tree type decision model was designed (tree of patients), based on epidemiological data and scientific literature, to estimate the hypertensive population that could be treated with a FC. The total per annum BIA was calculated by attributing the retail price- VAT of the FC to the number of patients to be treated, and deducting the cost of the treatment for hypertension that was replaced and the updated average cost per patient of cardiovascular events (CVEs) prevented by the use of the FC by the SNS during the period of study. Results The patient population susceptible to treatment with the FC was 51,104 patients (1st year), with a growth rate of between 1–2% over the following years, which means an annual cost (€) of 15.9M (2009), 19.9M (2010) and 24.1M (2011), with a total of 60.0M. The BIA was compensated showing negative impact values for the SNS when the cost of replaced antihypertensive treatment and prevented CVEs was deducted, with savings of €69.9M over 3 years. Conclusion The BIA of a FC of atorvastatin and amlodipine shows that the use of this medication for approved indications could generate net savings for the SNS of €9.9M for the period 2009–2011 (AU)

[Analysis of the budget impact for the Spanish National Health System of the fixed combination of amlodipine 5 or 10mg and atorvastatin 10mg]. / Análisis del impacto presupuestario para el Sistema Nacional de Salud de la combinación fija de amlodipino 5 o 10mg y atorvastatina 10mg.

OBJECTIVE: To carry out a Budget Impact Analysis (BIA) of the inclusion of the administration, within the Spanish National Health System (SNS), of the fixed combination (FC) of amlodipine 5 or 10mg and atorvastatin 10mg for approved indications. MATERIALS AND METHODS: A BIA was carried out from the SNS perspective for a 3 year period (2009-2011). A tree type decision model was designed (tree of patients), based on epidemiological data and scientific literature, to estimate the hypertensive population that could be treated with a FC. The total per annum BIA was calculated by attributing the retail price- VAT of the FC to the number of patients to be treated, and deducting the cost of the treatment for hypertension that was replaced and the updated average cost per patient of cardiovascular events (CVEs) prevented by the use of the FC by the SNS during the period of study. RESULTS: The patient population susceptible to treatment with the FC was 51,104 patients (1(st) year), with a growth rate of between 1-2% over the following years, which means an annual cost (euro) of 15.9M (2009), 19.9M (2010) and 24.1M (2011), with a total of 60.0M. The BIA was compensated showing negative impact values for the SNS when the cost of replaced antihypertensive treatment and prevented CVEs was deducted, with savings of euro69.9M over 3 years. CONCLUSION: The BIA of a FC of atorvastatin and amlodipine shows that the use of this medication for approved indications could generate net savings for the SNS of euro9.9M for the period 2009-2011.

Comorbilidades y consumo de recursos sanitarios en población fumadora. Un análisis desde Atención Primaria / Comorbidity and health resources use in smokers. An analysis from a primary care setting

FundamentoMedir el perfil de morbilidad, la consecución de objetivos terapéuticos, el uso de recursos y la incidencia de eventos cardiovasculares (ECV) de sujetos fumadores en Atención Primaria (AP).Pacientes y métodosDiseño retrospectivo y multicéntrico. Se incluyó a todos los pacientes fumadores de más de treinta años de edad de cinco equipos de AP (año 2006). Se formó una cohorte comparativa formada por no fumadores. Las principales medidas fueron presencia de ECV, edad, sexo, índice de Charlson, comorbilidad, parámetros clínicos y costes directos (fijos y variables; visitas, medicamentos, pruebas y derivaciones). Se empleó un análisis de regresión logística y un análisis de la covarianza para la corrección del modelo (p<0,05).ResultadosSe incluyó a 55.653 pacientes. Un 20,8% (intervalo de confianza del 95%: 20,5–21,1%) fueron fumadores. El promedio de edad de los fumadores fue menor (48,2 frente a 55,9 años), con predominio de varones (60,8%) (p<0,01) y similar índice de Charlson (0,3 frente a 0,3; p=no significativa [NS]). La proporción de fumadores en hipertensos fue del 18,8% y en diabéticos del 9,6%. La prevalencia de ECV en fumadores fue del 4,9 frente al 4,2% y la incidencia acumulada/anual del 14,2 frente al 12,5‰ (p<0,028). Los fumadores mostraron mayores niveles de triglicéridos séricos (136,3 mg/dl) y colesterol ligado a lipoproteínas de baja densidad (128,0 mg/dl) (p<0,001). El tabaquismo tuvo una relación independiente con el alcoholismo (odds ratio [OR]=5,3) y la enfermedad pulmonar obstructiva crónica (OR=2,5) en presencia de ECV (OR=1,2) (p<0,001). Los costes directos corregidos no mostraron diferencias: 660,10 frente a 654,11 € (p=NS) (en todos sus componentes)...(AU)

BackgroundTo ascertain the morbidity profile, achievement of the clinical control objectives, resources use and the incidence of cardiovascular events (CVE) in smoking subjects in Primary Care settings (PC).MethodsRetrospective multicentric study. All smoker subjects older than thirty years attended in any of five PC settings were included. A comparative cohort was established with non-smokers. Primary measures were: presence of CVE, age, gender, Charlson index, history/co-morbidity and clinics parameters and direct costs (fixed and variable; visits, drugs, diagnostic test and referrals). Multiple logistic regression analysis and ANCOVA models were applied for models correction, P<0.05.Results55,653 patients were included. 20.8% (95% confidence intervals [CI]:20.5–21.1%) were smokers. Non-smokers were younger (48.2 versus 55.9 years), with more men (60.8%), P<0.01; and a similar Charlson index (0.3 versus 0.3; P=NS). The proportion of smokers in hypertensive population was 18.8% and in diabetics 9.6%. CVE presence in smokers were 4.9% versus 4.2% and the accumulated incidence/annual of 14.2‰ versus 12.5‰, P<0.028. Smokers showed higher levels of serum triglycerides (136.3 mg/dl) and LDL-cholesterol (128.0 mg/dl, P<0.001). Smoking habit was independent related to the alcoholism (Odds ratio, OR=5.3) and the EPOC (OR=2.5), in presence of CVE (OR=1.2, P<0.001). Adjusted direct costs non differences showed: €660.10 versus €654.11, P=NS (in all components).ConclusionsCVE annual incidence in smoking subjects was greater, with a minor average of age. Smokers presented a similar number of co-morbidities and total/patient costs. Clinical control objectives should be better in Primary prevention of the cardiovascular risk factors. To give up smoking should be the best strategy to diminish CVE incidence(AU)

[Comorbidity and health resources use in smokers. An analysis from a primary care setting]. / Comorbilidades y consumo de recursos sanitarios en población fumadora. Un análisis desde Atención Primaria.

BACKGROUND: To ascertain the morbidity profile, achievement of the clinical control objectives, resources use and the incidence of cardiovascular events (CVE) in smoking subjects in Primary Care settings (PC). METHODS: Retrospective multicentric study. All smoker subjects older than thirty years attended in any of five PC settings were included. A comparative cohort was established with non-smokers. Primary measures were: presence of CVE, age, gender, Charlson index, history/co-morbidity and clinics parameters and direct costs (fixed and variable; visits, drugs, diagnostic test and referrals). Multiple logistic regression analysis and ANCOVA models were applied for models correction, P<0.05. RESULTS: 55,653 patients were included. 20.8% (95% confidence intervals [CI]:20.5-21.1%) were smokers. Non-smokers were younger (48.2 versus 55.9 years), with more men (60.8%), P<0.01; and a similar Charlson index (0.3 versus 0.3; P=NS). The proportion of smokers in hypertensive population was 18.8% and in diabetics 9.6%. CVE presence in smokers were 4.9% versus 4.2% and the accumulated incidence/annual of 14.2 per thousand versus 12.5 per thousand, P<0.028. Smokers showed higher levels of serum triglycerides (136.3 mg/dl) and LDL-cholesterol (128.0 mg/dl, P<0.001). Smoking habit was independent related to the alcoholism (Odds ratio, OR=5.3) and the EPOC (OR=2.5), in presence of CVE (OR=1.2, P<0.001). Adjusted direct costs non differences showed: euro660.10 versus euro654.11, P=NS (in all components). CONCLUSIONS: CVE annual incidence in smoking subjects was greater, with a minor average of age. Smokers presented a similar number of co-morbidities and total/patient costs. Clinical control objectives should be better in Primary prevention of the cardiovascular risk factors. To give up smoking should be the best strategy to diminish CVE incidence.

[Kidney disease: therapeutic implications in heart failure and coronary heart disease]. / Enfermedad renal: implicaciones terapéuticas en insuficiencia cardíaca y cardiopatía isquémica.

Heart failure (HF) is more prevalent and evolves more rapidly in patients with renal failure (RF). Renal failure not only produces myocardial damage, but also induces the development of clinical heart failure thus making the treatment of these patients more difficult. The incidence of HF in patients with RF is around 15%. Renal function in patients with RF is lower than in the general population. This is true for patients with preserved and depressed left ventricular ejection fraction (LVEF). HF mortality increases 30% for every 1-mg/dL increase in creatinine and renal function should always be considered when assessing the cardiovascular risk and therapeutic alternatives of cardiovascular patients. Angiotensin converting enzyme inhibitors, Angiotensin receptor blockers and aldosterone blockers may cause acute renal failure and serum creatinine and potassium should be closely monitored. Chronic RF is a human model of accelerated atherosclerosis. It induces a rapid progression of coronary atherosclerosis and make atherosclerotic plaques more vulnerable to acute coronary syndromes (ACS) because of coagulation changes inherent to RF. Ischemia is also more frequent due to the imbalance between oxygen requirements and supplies. Chronic RF is associated with a worse outcome in patients with ACS and increases the risk of bleeding, and is associated with a higher mortality in patients under surgical or percutaneous coronary revascularization. Of the patients treated with an interventional coronary procedure (ICP), 3,3% suffer acute RF. Saline administration at a dose of 1 ml/kg/h for 12 hours before and 12 hours after ICP prevents the development of acute RF. Although the role of N-acetylcysteine is under discussion, taking into account the favourable risk profile of this drug, it seems reasonable to administer N-acetylcysteine in addition to saline administration. In ACS patients with severe RF, the risk of severe bleeding depends upon the anticoagulation regimen, increasing particularly when unfractionated heparin is used in combination with GP IIb/IIIa inhibitors.

[Effect of intensive treatment with atorvastatin versus standard doses of statins on the risk of stroke. A meta-analysis from five randomized trials including 25,709 patients]. / Efecto del tratamiento intensivo con atorvastatina frente a dosis estándar de estatinas en el riesgo de ictus de pacientes con enfermedad coronaria previa. Metaanálisis de cinco ensayos aleatorizados con 25.709 pacientes.

AIM: To evaluate the efficacy of intensive lipid lowering treatment with atorvastatin versus standard doses of statins (simvastatin, atorvastatin, lovastatin or pravastatin) on the risk of stroke, using meta-analytic techniques. PATIENTS AND METHODS: The meta-analysis included 5 randomized trials that met the inclusion criteria: comparison between intensive atorvastatin treatment (atorvastatin 80 mg or target LDL < 70 mg/dL) and standard doses of statins, with a clinical follow-up of more than 12 months and stroke as clinical endpoint. TNT (n = 9,917) atorvastatin 80 mg vs. 10 mg; IDEAL (n = 8,888) atorvastatin 80 mg vs. simvastatin 20-40 mg; PROVE-IT (n = 4,162) atorvastatin 80 mg vs. pravastatin 40 mg; ALLIANCE (n = 2,442) atorvastatin 80 mg or target LDL < 70 mg/dL vs. standard treatment; and VBBS (n = 300) atorvastatin 80 mg vs. low dose lavastatin. The selected studies included secondary prevention patients (acute coronary syndrome, stable coronary disease and patients eligible for angioplasty). 25,709 patients were included (12,910 allocated to intensive atorvastatin treatment, and 12,799 to standard doses of statins). Stroke incidence, as reported from each trial, was compared between both treatments. RESULTS: Out of the 25,709 patients, 713 (2.77%) suffered a stroke during follow-up. The incidence of stroke was significantly reduced with intensive atorvastatin treatment in comparison with conventional doses of statins: 2.52% (n = 325) vs. 3.03% (n = 388); relative risk = 0.83; 95% confidence interval = 0.72-0.96; p = 0.0121. CONCLUSIONS: Intensive lipid lowering treatment with atorvastatin is associated with a 17% relative risk reduction of stroke in comparison with conventional doses of statins in secondary prevention population.

Efecto del tratamiento intensivo con atorvastatina frente a dosis estándar de estatinas en el riesgo de ictus de pacientes con enfermedad coronaria previa. Metaanálisis de cinco ensayos aleatorizados con 25.709 pacientes / Effect of intensive tretament with atorvastatin versus standard doses of statins on the risk of stroke. A meta analysis form five randomized trials incluiding 25, 709 patients

Objetivo. Evaluar, mediante técnicas de metaanálisis, la eficacia hipolipemiante del tratamiento intensivo con atorvastatina frente a dosis estándar de estatinas (sinvastatina, atorvastatina, lovastatina o pravastatina) en el riesgo de ictus en pacientes con enfermedad coronaria previa. Pacientes y métodos. Se incluyeron los cinco ensayos clínicos realizados hasta enero de 2006 que cumplieron los siguientes criterios: comparación de atorvastatina intensiva –80 mg u objetivo de lipoproteínas de baja densidad (LDL) < 70 mg/dL– con dosis estándar de estatinas; duración de más de 12 meses e ictus como objetivo del estudio (secundario o principal combinado). TNT (n = 9.917): atorvastatina 80 mg frente a 10 mg; IDEAL (n = 8.888): atorvastatina 80 mg frente a sinvastatina 20-40 mg; PROVE-IT (n = 4.162): atorvastatina 80 mg frente a pravastatina 40 mg; ALLIANCE (n = 2.442): atorvastatina 80 mg u objetivo LDL < 70 mg/dL frente a dosis estándar de estatinas; y VBSS (n = 300): atorvastatina 80 mg frente a dosis bajas de lovastatina. Los estudios considerados incluyeron población en prevención secundaria (síndrome coronario agudo, enfermedad coronaria estable, pacientes elegibles para angioplastia). Se incluyeron 25.709 pacientes (12.910 en la rama con atorvastatina intensiva y 12.799 en la rama con dosis estándar de estatinas). Se comparó la incidencia de ictus entre ambas ramas. Resultados. 713 pacientes (2,77%) de los 25.709 sufrió un ictus durante el seguimiento. La incidencia de ictus fue significativamente menor en la rama atorvastatina intensiva que en la rama tratada con dosis estándar de estatinas: 2,52% (n = 325) frente a 3,03% (n = 388); riesgo relativo = 0,83; intervalo de confianza al 95% = 0,72-0,96; p = 0,0121. Conclusiones. En pacientes con enfermedad coronaria previa, el tratamiento hipolipemiante intensivo con atorvastatina se asocia a una reducción del 17% en el riesgo de ictus en comparación con dosis estándar de estatinas (AU)

Aim. To evaluate the efficacy of intensive lipid lowering treatment with atorvastatin versus standard doses of statins (simvastatin, atorvastatin, lovastatin or pravastatin) on the risk of stroke, using meta-analytic techniques. Patients and methods. The meta-analysis included 5 randomized trials that met the inclusion criteria: comparison between intensive atorvastatin treatment (atorvastatin 80 mg or target LDL < 70 mg/dL) and standard doses of statins, with a clinical follow-up of more than 12 months and stroke as clinical endpoint. TNT (n = 9,917) atorvastatin 80 mg vs. 10 mg; IDEAL (n = 8,888) atorvastatin 80 mg vs. simvastatin 20-40 mg; PROVE-IT (n = 4,162) atorvastatin 80 mg vs. pravastatin 40 mg; ALLIANCE (n = 2,442) atorvastatin 80 mg or target LDL < 70 mg/dL vs. standard treatment; and VBBS (n = 300) atorvastatin 80 mg vs. low dose lavastatin. The selected studies included secondary prevention patients (acute coronary syndrome, stable coronary disease and patients eligible for angioplasty). 25,709 patients were included (12,910 allocated to intensive atorvastatin treatment, and 12,799 to standard doses of statins). Stroke incidence, as reported from each trial, was compared between both treatments. Results. Out of the 25,709 patients, 713 (2.77%) suffered a stroke during follow-up. The incidence of stroke was significantly reduced with intensive atorvastatin treatment in comparison with conventional doses of statins: 2.52% (n = 325) vs. 3.03% (n = 388); relative risk = 0.83; 95% confidence interval = 0.72-0.96; p = 0.0121. Conclusions. Intensive lipid lowering treatment with atorvastatin is associated with a 17% relative risk reduction of stroke in comparison with conventional doses of statins in secondary prevention population (AU)

Enfermedad renal: implicaciones terapéuticas en insuficiencia cardíaca y cardiopatía isquémica / Kidney disease: therapeutic implications in heart failure and coronary heart diseas

La insuficiencia cardíaca (IC) en pacientes con insuficiencia renal (IR) es más frecuente y evoluciona de forma más rápida. La IR no sólo condiciona daño miocárdico, sino que facilita el desarrollo de IC clínica y dificulta el tratamiento. La incidencia de IC en pacientes con IR se sitúa en torno al 15%. La función renal de los pacientes con IC está disminuida, tanto en los casos de función sistólica preservada como en los de función sistólica disminuida. La mortalidad de la IC aumenta en un 30% por cada aumento de 1 mg/dl de creatinina; por tanto, la función renal siempre debe tenerse en cuenta a la hora de estratificar el riesgo y evaluar las alternativas terapéuticas. Los inhibidores de la enzima de conversión de la angiotensina, los antagonistas de los receptores de la angiotensina II y los antagonistas de la aldosterona pueden precipitar IR aguda, por lo que en todos los pacientes se debe vigilar de forma atenta el potasio sérico y los valores de creatinina. La IR crónica es un modelo humano de aterosclerosis acelerada, no sólo produce una rápida progresión de la aterosclerosis coronaria, sino que hace más probables los episodios agudos y más frecuente la isquemia, debido a las alteraciones de la coagulación propias de la IR y al deterioro del equilibrio entre oferta y demanda de oxígeno. La presencia de IR crónica predice la mala evolución de los pacientes con síndrome coronario agudo (SCA), aumenta el riesgo de hemorragia y se asocia a una mortalidad mayor en los pacientes sometidos a revascularización percutánea o quirúrgica. El 3,3% de los individuos sometidos a intervención coronaria percutá- nea (ICP) presentan un episodio de IR aguda. La administración de suero salino a dosis de 1 ml/kg/h las 12 h precateterismo y poscateterismo previene el desarrollo de IR aguda tras una ICP. Aunque el papel de la N-acetilcisteína es controvertido, dado su buen perfil de seguridad, parece razonable administrarla junto con el suero salino. En pacientes con SCA con IR grave, el riesgo de hemorragia grave depende del régimen de anticoagulación, el cual aumenta especialmente cuando se combinan heparina no fraccionada e inhibidores de la glucoproteína IIb/IIIa (AU)

Heart failure (HF) is more prevalent and evolves more rapidly in patients with renal failure (RF). Renal failure not only produces myocardial damage, but also induces the development of clinical heart failure thus making the treatment of these patients more difficult. The incidence of HF in patients with RF is around 15%. Renal function in patients with RF is lower than in the general population. This is true for patients with preserved and depressed left ventricular ejection fraction (LVEF). HF mortality increases 30% for every 1-mg/dL increase in creatinine and renal function should always be considered when assessing the cardiovascular risk and therapeutic alternatives of cardiovascular patients. Angiotensin converting enzyme inhibitors, Angiotensin receptor blockers and aldosterone blockers may cause acute renal failure and serum creatinine and potassium should be closely monitored. Chronic RF is a human model of accelerated atherosclerosis. It induces a rapid progression of coronary atherosclerosis and make atherosclerotic plaques more vulnerable to acute coronary syndromes (ACS) because of coagulation changes inherent to RF. Ischemia is also more frequent due to the imbalance between oxygen requirements and supplies. Chronic RF is associated with a worse outcome in patients with ACS and increases the risk of bleeding, and is associated with a higher mortality in patients under surgical or percutaneous coronary revascularization. Of the patients treated with an interventional coronary procedure (ICP), 3,3% suffer acute RF. Saline administration at a dose of 1ml/kg/h for 12 hours before and 12 hours after ICP prevents the development of acute RF. Although the role of N-acetylcisteine is under discussion, taking into account the favourable risk profile of this drug, it seems reasonable to administer N-acetylcisteine in addition to saline administration. In ACS patients with severe RF, the risk of severe bleeding depends upon the anticoagulation regimen, increasing particulary when unfractionated heparin is used in combination with GP IIb/IIIa inhibitors (AU)

Blood acid-base and plasma electrolyte values in healthy ostriches: the effect of age and sex.

The effect of age and sex on blood acid-base and plasma electrolyte values was determined in venous blood samples from 45 clinically healthy ostriches (Struthio camelus) from 26 days to 6 years of age. Animals were divided by age into four groups and the group of adults was divided by sex into two subgroups. Blood samples were collected without sedation. There was a significant (P<0.05) age difference in blood values of base excess (BE), plasma HCO(3)(-), total CO(2) (TCO(2)), Na(+), K(+), Cl(-) and anion gap (AG). The highest plasma concentrations of Na(+), Cl(-) and value of AG were found in adult ostriches with a steady decrease to chicks. A significant (P<0.05) sex difference in adult animals with higher blood pH, lower blood values of pCO(2), BE, plasma concentrations of HCO(3)(-), TCO(2) and K(+) was found in females. We concluded that blood acid-base values and plasma electrolyte concentrations in ostriches are affected by age and sex.

Morbilidad y costes asociados al síndrome depresivo en sujetos con ictus en un ámbito poblacional / Morbidity and costs associated with depressive syndrome in stroke sufferers in a population

Objetivo: Medir la morbilidad y los costes asociados al síndrome depresivo (SD) en sujetos con ictus en población atendida por equipos de atención primaria y en condiciones de práctica clínica habitual. Método: Estudio transversal de carácter retrospectivo. Se incluyeron pacientes adultos con presencia de ictus y de SD atendidos por 5 equipos de atención primaria durante el año 2006. Se formó una cohorte comparativa con el resto de pacientes sin SD. Las principales medidas fueron: edad, sexo, historial/comorbilidad, índice de Charlson, parámetros clínicos y costes totales (visitas, pruebas complementarias, derivaciones y medicamentos). Se efectuó un análisis de regresión logística y de ANCOVA para la corrección de los modelos. Resultados: El total de pacientes atendidos con ictus fue de 2.566. Un 17,7% (intervalo de confianza del 95%, 16,2-19,2%) se identificaron con SD; promedio de edad: 69,5 años (desviación estándar: 12,6); el 57,2% eran mujeres. En la corrección del modelo, el sexo femenino (odds ratio [OR]: 2,1), la obesidad (OR: 1,1) y las neuropatías (OR: 2,2) se asociaron significativamente al SD en sujetos con ictus. Los costes totales ajustados del SD fueron superiores en la mayoría de sus componentes, 2.037,55 frente a 1.498,24 ¿, p < 0,001. El 73,4% de los costes se derivó de los medicamentos. Conclusiones: La prevalencia del SD en sujetos con ictus es elevada, se asocia al sexo femenino y a la presencia de obesidad y neuropatías. Los costes de estos pacientes son altos y ocasionan un elevado consumo de recursos sanitarios (AU)

Objective: To measure morbidity and the associated costs of depressive disorders (DD) in subjects who have had a stroke in a population treated by primary care settings under usual clinical practice conditions. Method: Cross-sectional, retrospective studies. Adult stroke patients with DD were included in the study, and treated by five primary care settings (PCS) during 2006. A comparative group was formed with the rest of non-DD patients. The main measurements taken were: age, sex, history/co-morbidity, Charlson index, clinical parameters and corresponding outpatient costs; drugs, diagnostic tests, referrals and visits. Multiple logistic regression analysis and ANCOVA were used to correct the models. Results: A total of 2,566 stroke patients were assessed. 17.7% (95% CI, 16.2-19.2%) were identified as having DD; average age: 69.5 years (12.6); 57.2% of those were female. In the correction of the model, females (OR: 2.1), obesity (OR: 1.1) and neuropathy (OR: 2.2), were significantly associated with DD in stroke patients. The adjusted total costs of DD were higher in most components, ¿ 2,037.55 versus ¿ 1,498.24, p < 0.001. 73.4% of the total cost was drugs-derived. Conclusions: Prevalence of DD was higher in stroke patients, and was more associated with females, obesity and neuropathy. The patient cost is high and patients use more health resources (AU)