Do physicians correctly calculate thromboembolic risk scores? A comparison of concordance between manual and computer-based calculation of CHADS2 and CHA2 DS2 -VASc scores.

BACKGROUND: Clinical risk scores, CHADS2 and CHA2 DS2 -VASc scores, are the established tools for assessing stroke risk in patients with atrial fibrillation (AF). AIM: The aim of this study is to assess concordance between manual and computer-based calculation of CHADS2 and CHA2 DS2 -VASc scores, as well as to analyse the patient categories using CHADS2 and the potential improvement on stroke risk stratification with CHA2 DS2 -VASc score. METHODS: We linked data from Atrial Fibrillation Spanish registry FANTASIIA. Between June 2013 and March 2014, 1318 consecutive outpatients were recruited. We explore the concordance between manual scoring and computer-based calculation. We compare the distribution of embolic risk of patients using both CHADS2 and CHA2 DS2 -VASc scores RESULTS: The mean age was 73.8 ± 9.4 years, and 758 (57.5%) were male. For CHADS2 score, concordance between manual scoring and computer-based calculation was 92.5%, whereas for CHA2 DS2 -VASc score was 96.4%. In CHADS2 score, 6.37% of patients with AF changed indication on antithrombotic therapy (3.49% of patients with no treatment changed to need antithrombotic treatment and 2.88% of patients otherwise). Using CHA2 DS2 -VASc score, only 0.45% of patients with AF needed to change in the recommendation of antithrombotic therapy. CONCLUSION: We have found a strong concordance between manual and computer-based score calculation of both CHADS2 and CHA2 DS2 -VASc risk scores with minimal changes in anticoagulation recommendations. The use of CHA2 DS2 -VASc score significantly improves classification of AF patients at low and intermediate risk of stroke into higher grade of thromboembolic score. Moreover, CHA2 DS2 -VASc score could identify 'truly low risk' patients compared with CHADS2 score.

Manejo de la sedación y la analgesia en unidades de cuidados intensivos neonatales españolas / Sedation and analgesia practices among Spanish neonatal intensive care units

INTRODUCCIÓN: El manejo del dolor y la sedación es una prioridad de los cuidados intensivos neonatales. Se diseñó un estudio con el objetivo de determinar la práctica clínica actual en relación con la sedación y la analgesia en unidades de cuidados intensivos neonatales en España e identificar factores asociados al uso de fármacos sedantes o analgésicos. MÉTODO: Estudio multicéntrico, observacional, longitudinal y prospectivo. RESULTADOS: Participaron 30 unidades neonatales y se reclutó a 468 neonatos. De estos, 198 (42,3%) recibieron medicación sedante o analgésica. En total, se usaron durante el período de estudio 19 fármacos distintos, de los cuales el más utilizado fue el fentanilo. Solo fentanilo, midazolam, morfina y paracetamol se usaron al menos en un 20% de los neonatos que recibieron sedación y/o analgesia. Se usaron 14 pautas distintas de fármacos en perfusión, siendo las más frecuentes la infusión de fentanilo y la combinación de fentanilo y midazolam. Las variables asociadas a recibir sedación y/o analgesia fueron el haber precisado ventilación invasiva (p = < 0,001; OR = 23,79), un score de CRIB>3 (p = 0,023; OR = 2,26), la existencia en la unidad de guías de evaluación del dolor (p < 0,001; OR = 3,82) y de un líder de dolor (p = 0,034; OR = 2,35). CONCLUSIONES: Casi la mitad de los neonatos ingresados en cuidados intensivos recibe medicación sedante y/o analgésica. Existe una importante variabilidad entre las unidades neonatales españolas en relación con las pautas de sedación y analgesia. Nuestros resultados permiten conocer el «estado del arte» y pueden servir de base para la elaboración de guías de práctica clínica a nivel nacional

INTRODUCTION: Pain management and sedation is a priority in neonatal intensive care units. A study was designed with the aim of determining current clinical practice as regards sedation and analgesia in neonatal intensive care units in Spain, as well as to identify factors associated with the use of sedative and analgesic drugs. METHOD: A multicenter, observational, longitudinal and prospective study. RESULTS: Thirty neonatal units participated and included 468 neonates. Of these, 198 (42,3%) received sedatives or analgesics. A total of 19 different drugs were used during the study period, and the most used was fentanyl. Only fentanyl, midazolam, morphine and paracetamol were used in at least 20% of the neonates who received sedatives and/or analgesics. In infusions, 14 different drug prescriptions were used, with the most frequent being fentanyl and the combination of fentanyl and midazolam. The variables associated with receiving sedation and/or analgesia were, to have required invasive ventilation (P<.001; OR=23.79), a CRIB score >3 (P=.023; OR=2.26), the existence of pain evaluation guides in the unit (P<.001; OR=3.82), and a pain leader(P=.034; OR=2.35). CONCLUSIONS: Almost half of the neonates admitted to intensive care units receive sedatives or analgesics. There is significant variation between Spanish neonatal units as regards sedation and analgesia prescribing. Our results provide evidence on the 'state of the art', and could serve as the basis of preparing clinical practice guidelines at a national level

[Sedation and analgesia practices among Spanish neonatal intensive care units]. / Manejo de la sedación y la analgesia en unidades de cuidados intensivos neonatales españolas.

INTRODUCTION: Pain management and sedation is a priority in neonatal intensive care units. A study was designed with the aim of determining current clinical practice as regards sedation and analgesia in neonatal intensive care units in Spain, as well as to identify factors associated with the use of sedative and analgesic drugs. METHOD: A multicenter, observational, longitudinal and prospective study. RESULTS: Thirty neonatal units participated and included 468 neonates. Of these, 198 (42,3%) received sedatives or analgesics. A total of 19 different drugs were used during the study period, and the most used was fentanyl. Only fentanyl, midazolam, morphine and paracetamol were used in at least 20% of the neonates who received sedatives and/or analgesics. In infusions, 14 different drug prescriptions were used, with the most frequent being fentanyl and the combination of fentanyl and midazolam. The variables associated with receiving sedation and/or analgesia were, to have required invasive ventilation (P<.001; OR=23.79), a CRIB score >3 (P=.023; OR=2.26), the existence of pain evaluation guides in the unit (P<.001; OR=3.82), and a pain leader (P=.034; OR=2.35). CONCLUSIONS: Almost half of the neonates admitted to intensive care units receive sedatives or analgesics. There is significant variation between Spanish neonatal units as regards sedation and analgesia prescribing. Our results provide evidence on the "state of the art", and could serve as the basis of preparing clinical practice guidelines at a national level.

Indoleamine, 2-3 dioxygenase activity could be an early marker of graft rejection in heart transplantation.

BACKGROUND: The indoleamine, 2-3 dioxygenase (IDO) is an inducible intracellular enzyme with immunosuppressive effects mainly on lymphocyte populations. It has been postulated that indirect determination of IDO serum activity may be a marker of renal graft rejection, but its potential usefulness in heart transplantation (HT) is unknown. METHODS: This longitudinal study included 98 HT patients (83% males) who survived ≥1 year. Mean age was 54.14 ± 11.57 years. Serum IDO activity was analyzed one month after HT by means of high performance liquid chromatography and correlated with the cumulative incidence of acute rejection (AR) during one-year follow-up. AR was defined as biopsy-proven ≥ ISHLT grade 2R rejection or empirically treated non-biopsy-proven rejection. The study sample was divided into two groups: AR group (n = 51), including patients who experienced at least one AR episode during the first year after HT; No-AR group (N = 47), including the remaining patients. RESULTS: Mean serum IDO activity one month after HT was significantly higher (P = .021) in the AR group (3.32 ± 1.56) than in the no-AR group (2.62 ± 1.35). No significant association between serum IDO activity and gender (male: 3.1 ± 1.56, women: 2.43 ± 0.99, P = .092), recipient age (r = -.07, P = .943) or donor age (r = 0.108, P = 0.293) was observed. By means of binary logistic regression, an odds ratio of 1.4 [CI 95%: 1.033-1.876, P = .03] per unit increase of act-IDO was estimated, with no significant modification upon forced adjustment for age and sex. Mean glomerular filtration rate 1 month after HT was 67.01 ± 28.51 mL/min/m(2). No significant correlation between this parameter and serum IDO activity was observed (r = .160, P = .117). CONCLUSIONS: Our study suggests that serum IDO activity one month after HT might be associated with a higher risk of AR during one-year follow-up. This association seems to be independent of recipient gender, age or renal function.

The prognosis of noncutaneous, nonlymphomatous malignancy after heart transplantation: data from the Spanish Post-Heart Transplant Tumour Registry.

INTRODUCTION: Malignancy is a major complication in the management of solid organ transplant patients. Skin cancers show a better prognosis than other neoplasms, but not all others are equal: Ideally, patient management must take into account the natural history of each type of cancer in relation to the transplanted organs. We sought to determine the prognosis of various groups of noncutaneous nonlymphomatous (NCNL) cancers after heart transplantation (HT). METHODS: We retrospectively analyzed the records of the Spanish Post-Heart-Transplant Tumour Registry, which collects data on posttransplant tumors in all patients who have undergone HT in Spain since 1984. Data were included in the study up to December 2008. We considered only the first NCNL post-HT tumors. RESULTS: Of 4359 patients, 375 developed an NCNL cancer. The most frequent were cancers of the lung (n=97; 25.9%); gastrointestinal tract (n=52; 13.9%); prostate gland (n=47; 12.5%; 14.0% of men), bladder (n=32; 8.5%), liver (n=14; 3.7%), and pharynx (n=14; 3.7%), as well as Kaposi's sarcoma (n=11; 2.9%). The corresponding Kaplan-Meier survival curves differed significantly (P<.0001; log-rank test), with respective survival rates of 47%, 72%, 91%, 73%, 36%, 64%, and 73% at 1 year versus 26%, 62%, 89%, 56%, 21%, 64%, and 73% at 2 years; and 15%, 51%, 77%, 42%, 21%, 64%, and 52% at 5 years post-diagnosis, respectively. CONCLUSION: Mortality among HT patients with post-HT NCNL solid organ cancers was highest for cancers of the liver or lung (79%-85% at 5 years), and lowest for prostate cancer (23%).

Safety of statins when response is carefully monitored: a study of 336 heart recipients.

BACKGROUND: Statins are used as first-line drugs against hypercholesterolemia after heart transplantation. Randomized clinical trials have shown that they reduce cholesterol levels, and the incidence of rejection and coronary vasculopathy. Adverse effects have been related to the use of certain statins, high statin dosages, comorbidities, and coadministration with cyclosporine. However, estimation of the risk of adverse effects for a given patient is difficult. The aims of this study were to determine the incidence of various kinds of adverse effect of statins; to evaluate certain potential risk factors; and to assess the efficacy of early response to signs of adverse effects. METHODS: Between April 1991 and December 2003, we retrospectively evaluated 336 heart transplant patients (including 55 women) with regard to the occurrence of possible adverse effects of statins (rhabdomyolysis, myalgia, hepatotoxicity, high CK without muscle symptoms, and others). Resolution on reduction of dosage or discontinuance and/or change of statin were deemed to constitute confirmation of cause. Relations were sought between adverse effects and age, sex, immunosuppressive therapy, kidney failure, body mass index (BMI), arterial hypertension, and diabetes mellitus. RESULTS: Possible adverse events of statins were suffered by 60 patients, all of them men. The causal role of statins was confirmed in 41 (12.2% of all 336): hepatotoxicity was suffered by 13, high CK without muscle ache or weakness by 18, rhabdomyolysis by 5, myalgia by 3, and other effects by 2. The incidence of confirmed statin-related complications was higher among patients with BMI >29 kg/m(2) than among those with lower BMI (P = .055). None of the patients with confirmed statin-related complications needed dialysis, none died, and permanent suspension of statin treatment was only necessary in 13 cases (3.9% of the 336). CONCLUSIONS: Some 10% to 20% of HT patients appear to suffer adverse side effects of initial statin therapy. However, early detection of such effects through diligent clinical and analytical monitoring allows the therapy to be modified in time to minimize the appearance of severe complications. In only a minority of cases permanent suspension of statin therapy is necessary.

Seguridad cardiovascular de los inhibidores de la ciclooxigenasa 2 / Cardiovascular safety of ciclooxigenase 2 inhibitors

Los inhibidores de la ciclooxigenasa 2 (celecoxib y rofecoxib) son fármacos antiinflamatorios no esteroideos potentes y con un excelente perfil de seguridad cardiovascular. Sin embargo, en un artículo reciente se sugiere que estos fármacos podrían presentar un incremento del riesgo de complicaciones cardiovasculares tromboembólicas. En el presente artículo analizamos los datos disponibles hasta la fecha sobre la seguridad cardiovascular de los inhibidores de la ciclooxigenasa 2 (AU)

[Analysis of the appropriate use of -blockers post-infarction]. / Análisis del uso adecuado de los bloqueadores beta en el postinfarto.

INTRODUCTION: The use of ss-blockers in patients with acute myocardial infarction has shown to improve the survival and reduce the risk of a new reinfarction. AIM: To quantify the use of ss-blockers in patients with acute myocardial infarction in Galicia, Spain. METHODS: We used the database of the RIGA study (Registry of Infarctions in Galicia) including 655 consecutive patients admitted to any hospital of Galicia for acute myocardial infarction from February to July, 1995. An extensive review of the literature was previously made to establish therapeutic criteria for the use of ss-blockers in patients with acute myocardial infarction. The survey of the RIGA database was compared with the criteria established to determine the definition of appropriate usage. RESULTS: 210 out of 655 patients (32%) received ss-blockers. Interestingly, treatment (or lack of treatment) with ss-blockers was deemed appropriated in 51.4% of the patients. This inadequacy was related to the use of ACE inhibitors, calcium antagonists and thrombolysis. CONCLUSION: The use of ss-blockers in Galicia in patients admitted with acute myocardial infarction was markedly lower than that established by standard criteria and the use of ACE inhibitors, calcium channel blockers and thrombolysis was related to less appropriate use.

[Pattern of the distribution of total cholesterol and cHDL cholesterol Spanish children and adolescents: RICARDIN Study]. / Patrón de la distribución de colesterol total y cHDL en niños y adolescentes españoles: estudio RICARDIN.

BACKGROUND: The RICARDIN Study multicenter study of cardiovascular risk factors in children and adolescents has described the standards of normality of blood cholesterol levels in the Spanish school population. The objective of the present study was to compare mean values of cholesterol between different regions of Spain, and to compare the global mean with a pool international study. Also, the pattern of total cholesterol and cHDL by age and sex using mathematical model is described, and comparison with two international studies carried out in USA and Japan is performed. SUBJECTS AND METHODS: 10,683 children aged 6 to 18 were selected from 7 different Spanish provinces (Madrid, Vizcaya, Lugo, Badajoz, Murcia, Asturias and Barcelona). Blood samples were obtained by capilar puncture (Reflotron). RESULTS: Mean values of total cholesterol was different among provinces, and globally, were lower than the international pooled population, although the pattern observed in each population was very similar. Total cholesterol curve for Spanish boys showed a curvilinear trend that can be estimated through a cubic function that explains 89% of observed data, while for girls the best estimate was obtained through an inverse function (R2 = 0.40). cHDL for boys showed a cubic function as the best estimate (R2 = 0.90), while for girls the best estimate was obtained through a quadratic function (R2 = 0.59). CONCLUSIONS: There are important physiological variations of total cholesterol level by age and sex in children and adolescents. The pattern of cholesterol does not follow a linear model but a curvilinear one, that need to be considered in clinically assessing individual determinations of cholesterol, since highest percentiles can vary by age and sex.

[An epidemiological study on cardiovascular risk factors in 35-64 years old Spanish population]. / Estudio epidemiológico de los factores de riesgo cardiovascular en la población Española de 35 a 64 años.

BACKGROUND: Cardiovascular disease (CVD), specifically Coronary Health Disease and Cerebrovascular Disease, are the first cause of death in Spain. Information about their main modifiable risk factors (RF) distribution is needed in order to CVD prevention. The purpose of this paper is to estimate these RF prevalence and distribution by age, sex and habitat groups, i.e. tobacco smoking, cholesterolemia, high blood pressure, and obesity in the Spanish population. METHODS: A random cluster sampling cross-sectional study, stratified by habitat (rural and urban), age and sex, was carried out on 2021 men and women of 35 to 64 years of age in 1989. Definition criteria for variables studied were those from WHO and European Atherosclerosis Society. Additional data for study were treatment and control level of hypertensives, cardiovascular drugs consumption and CVD family history. RESULTS: Participation rate was 73.3%. Mean cholesterolemia was 211.2 mg/dl (210.1 mg/dl in males and 211.9 mg/dl in females). Mean systolic blood pressure was 132.3 mmHg (133.4 and 131.6 mmHg in men and women, respectively). Mean Quetelet Index was 27.5 kg/m2 (27.2 and 27.6 for men and women). 49.4% of males and 16.7% of females were smokers (25.7% and 78.3% were never smokers, respectively). Prevalence of hypercholesterolemia (> or = 250 mg/dl) was 18.6% in men and 17.6% in women, and that of high blood pressure (> or = 160/95 mmHg) was 21.5% in men (49.1% of them treated, and 26.7% controlled), and 19% in women (60.9% treated and 38% controlled). 18.4% of men and 27.4% of women had a Quetelet Index greater than thirty. 15 to 20% of individuals reported a CVD family history. For all these variables there were generally differences according to age, sex, and habitat. CONCLUSIONS: Risk factors distributions and prevalences in Spanish middle-aged individuals rank relatively high. This suggest need of further study and control of them to address CVD prevention properly.

[Guidelines for the elaboration of programs for the primary prevention of cardiovascular diseases. The Working Group for Primary Cardiovascular Prevention]. / Directrices para la elaboración de programs de prevención primaria de enfermedades cardiovasculares. Grupo de Trabajo de Prevención Primaria Cardiovascular.

This paper, elaborated by consensus between experts from Scientific Societies and the Health Administration, is aimed at providing general guidelines for the elaboration and prompting of cardiovascular disease primary prevention programmes, through individual risk factors screening and control. It is expected to be helpful for primary care professionals. After reviewing the rationale and logistics of the programmes starting in the Spanish context, an outline for the risk screening and assessment of the individuals attending the health services is set out. The strategies for high risk individuals control and the periodic health examination of low risk subjects are developed, emphasizing the multifactorial approach. Lastly operational criteria for the management of each risk factor taking simultaneously into account the whole risk picture, embracing definition criteria and consensus recommendations, are stated.