Multicausal analysis of mortality due to diabetes mellitus in Spain, 2016-2018

OBJECTIVES

This study aimed to assess multicausal mortality due to diabetes from 2016-2018 in Spain. Specific objectives were to quantify the occurrence of diabetes as an underlying cause or as any registered cause on the death certificate.

MATERIALS AND METHODS

A cross-sectional descriptive study taking a multicausal approach.

RESULTS

Diabetes appears as an underlying cause of 2.3% of total deaths in Spain, and as any cause in 6.2%. In patients in whom Diabetes appears as an underlying cause on the death certificates, the 15 most frequent immediate causes are cardiovascular diseases in men(prevalence ratio 1,59)and women (PR1,31). In men, the causes associated with diabetes as any cause were skin diseases(prevalence ratio 1.33), followed by endocrine diseases(prevalence ratio 1.26)and genitourinary diseases (prevalence ratio1.14). In women, the causes associated with the presence of diabetes as any cause were endocrine (prevalence ratio 1.13)and genitourinary (prevalence ratio 1.04)diseases.

CONCLUSIONS

In patients in whom diabetes appears as an underlying cause on the death certificates, the 15 most frequent immediate causes are cardiovascular diseases. In men, the causes associated with the presence of diabetes as any cause of death are skin, endocrine and genitourinary diseases. In women, the causes associated with diabetes as any cause are endocrine and genitourinary.

Diabetes mellitus as a cause of premature death in small areas of Spain by socioeconomic level from 2016 to 2020: A multiple-cause approach

OBJECTIVE

This study aimed to assess premature mortality due to Diabetes in small areas of Spain between 2016 and 2020, and its relationship with socioeconomic level and the immediate cause of death. As a secondary objective, we evaluated the effect of the Covid 19 pandemic.

METHODS

This was an ecological study of premature mortality due to Diabetes from 2016 to 2020, with a focus on small areas. All deaths in people under 75 years of age due to Diabetes as the underlying cause were included RESULTS: The final sample comprised 7382 premature deaths in 5967 census tracts. Women living in census tracts with an high level of deprivation(RR=2.40) were at a significantly higher risk. Mortality from Diabetes increased with deprivation, especially people aged 0-54(RR=2.40). People with an immediate cause of death related to a circulatory disease, living in census tracts with an high level of deprivation(RR=3.86) was associated with a significantly greater risk of death with underlying Diabetes. When a disease of the circulatory system was recorded as the immediate cause of death, being 65-74 years (RR=71.01) was associated with a significantly higher risk of premature mortality.

CONCLUSIONS

Living in geographic areas with higher levels of socioeconomic deprivation is associated with a higher risk of premature death from Diabetes in Spain. This relationship has a greater impact on women, people under 54 years, and people at risk of death caused directly by diseases of the circulatory system. Premature mortality due to diabetes saw a modest increase in 2020.

[Predictive validity of the risk SCORE model in a Mediterranean population with arterial hypertension]

INTRODUCTION AND OBJECTIVES

Hypertension is the most prevalent risk factor globally. Calculation of cardiovascular risk in hypertensive patients before initiation of treatment is recommended. This study aimed to assess the predictive value and clinical utility of the SCORE scale in preventing cardiovascular events and all-cause mortality in patients with hypertension.

METHODS

Patients with hypertension from the ESCARVAL-RISK cohort were included. Cardiovascular risk was calculated using the SCORE scale. All deaths and cardiovascular events were recorded during a 5-year follow-up period. Sensitivity, specificity and predictive values were calculated for different cut-off points and the effect of different risk factors on the diagnostic accuracy of SCORE charts were assessed.

RESULTS

In a final cohort of 9834 patients, there were 555 cardiovascular events and 69 deaths. The recommended risk value for initiating drug treatment (5%) had a specificity of 92% for death and 91% for cardiovascular events, and a sensitivity of 20% for death and 22% for cardiovascular events. In addition, the scale classified 80.4% of patients who experienced a cardiovascular event and 78.3% of those who died as low risk. Age, body mass index, retinopathy and anticoagulant therapy were associated with reduced predictive ability of the SCORE scale, while being female was associated with better risk prediction.

CONCLUSIONS

The predictive ability of the SCORE scale for cardiovascular disease and total mortality in patients with hypertension is limited.

Association of Visiting the Physiotherapist with Mortality in the Spanish General Population: A Population-Based Cohort Study

Background and Objectives: The purpose of this retrospective population-based cohort study was to analyse the association between attendance of physiotherapy with mortality in the Spanish general population and describe the profile of people who do not visit a physiotherapist in Spain. Material and Methods: The data sources were the 2011/2012 National Health Survey (ENSE11) and the national database of death in Spain, and the participants were all adult respondents in the ENSE11. Results: Of 20,397 people, 1101 (5.4%) visited the physiotherapist the previous year, and the cumulative incidence of total mortality was 5.4% (n = 1107) at a mean follow-up of 6.2 years. Visiting the physiotherapist was associated with lower all-cause mortality in the population residing in Spain, quantified at 30.1% [RR = 0.699; 95% CI (0.528-0.927); p = 0.013]. The factors associated with not visiting a physiotherapist were the following: rating one's health as good (9.8%; n = 1017; p < 0.001), not having any hospital admission in the previous year (9.6%; n = 1788; p < 0.001), not having visited the general practitioner in the previous month (9.6%; n = 1408; p < 0.001), and not having attended a day hospital in the previous year (9.7%; n = 1836; p < 0.001). Conclusions: Visiting a physiotherapist was associated with a lower mortality from all causes in the population living in Spain.

[Factors associated with dissatisfaction with pharmacological treatment in patients with type 2 diabetes mellitus: A cross-sectional study]

BACKGROUND AND OBJECTIVES

Diabetes is a chronic disease with a high impact on both health and Quality of Life Related to Health (QLRH). To evaluate the satisfaction of treatment in patients with type 2 diabetes mellitus through the Diabetes Treatment Satisfaction Questionnaire (DTSQ) and its relationship with sociodemographic variables, with antidiabetic medication and clinical-analytical variables.

MATERIALS AND METHODS

This cross-sectional study was conducted in General University Hospital of San Juan de Alicante between September 2016 and December 2017. Two hundred thirty-two patients diagnosed with type 2 diabetes mellitus at least 1 year before inclusion, treated with antidiabetic medication were included. The Spanish version of the DTSQ scale was used to measure satisfaction with treatment. Factors associated with low satisfaction were analyzed by applying the Chi-square test for qualitative variables and Student-T for quantitative variables. To estimate magnitudes of association, logistic models were adjusted.

RESULTS

Two hundred thirty-two patients were included in this study. 21.5% of the patients presented low satisfaction with the treatment. Patients who presented low satisfaction with treatment were associated with medications that could cause hypoglycemia (OR: 2.872 [1.195-6.903]), HbA1c levels higher than 7% (OR: 2.260 [1.005-5.083]) and drugs administered by the route oral (OR: 2.749 [1.233-6.131]).

CONCLUSIONS

Patients with type 2 diabetes mellitus who had a lower score on the DTSQ questionnaire were associated with medications that produced hypoglycaemia, and with higher levels of HbA1c higher than 7%, and those who took oral medication.

Lifestyle and cardiovascular mortality in menopausal women: a population-based cohort study

INTRODUCTION AND OBJECTIVES

There are models for cardiovascular risk prediction in the general population, but the prediction of risk in postmenopausal women has not been specifically studied. This study aimed to determine the association of lifestyle habits and chronic diseases with cardiovascular risk in menopausal women, as well as to build a risk scale.

METHODS

Retrospective population-based cohort study using data from the 2011 National Health Survey of Spain as a data source, Women ≥ 50 years were included. The characteristics that best defined the life habits of the study women were collected, as well as their health status and self-reported medical history at the time of the survey. Follow-up data on all-cause mortality were obtained from participants from 2011 to 2017.

RESULTS

A total of 5953 women ≥ 50 years of age were included, with a mean age of 66.4 ± 11.4 years. The incidence of cardiovascular mortality in the follow-up period was 4%. Vegetable consumption less than 1 time/week (HR, 1.758), smoking (HR, 1.816) or excess hours of sleep (≥ 9h/day, HR, 1.809), or o have main daily activity sitting most of the time (HR, 2.757) were related to cardiovascular mortality. The predictive model presents an honest C-index in test sample of 0.8407 (95%CI, 0.8025-0.8789).

CONCLUSIONS

Life habits such as the consumption of vegetables, daily main activity, sleeping hours or smoking are risk factors for cardiovascular mortality of great relevance among menopausal women. A simple 6-year self-reported risk scale with high predictive capacity is provided.

Early Detection of Atrial Fibrillation in Community Pharmacies-CRIFAFARMA Study

BACKGROUND

Atrial fibrillation (AF) is the most common arrhythmia to appear in clinical practice. People with AF have 5 times the risk of stroke compared to the general population.

OBJECTIVE

This study aimed to determine the prevalence of AF in people over the age of 50 without known AF, who presented to a community pharmacy to check their cardiovascular risk factors, to identify risk factors associated with AF, and to assess the risk of stroke in people who screened positive for AF.

METHODS

A multicenter observational descriptive study of a screening program took place from May to December 2016. A blood pressure monitor (Microlife Watch BP Home) was used to screen for AF, and the CHA2DS2-VASc questionnaire was used to assess stroke risk.

RESULTS

The study included 452 adults over the age of 50. The CRIFAFARMA study detected a prevalence of AF of 9.1%. Risk factors for AF were: age of 75 years or older (P = .024), lack of physical activity (P = .043), diabetes (P < .001), dyslipidemia (P = .003), and history of cardiovascular disease (P = .003). Diabetes (OR 2.79, P = .005) and dyslipidemia (OR 2.16, P = .031) had a combined explanatory capacity in the multivariable logistic regression model adjusted for age. 85% were at high risk of stroke according to the CHA2DS2-VASc scale.

CONCLUSIONS

AF was detected in more than 9% of the included population. Factors associated with AF were advanced age, lack of physical activity, diabetes, dyslipidemia, and history of cardiovascular disease, with diabetes and dyslipidemia standing out as the factors with independent explanatory capacity.

[Analysis of two health attendance models for the non-hospital emergencies in Gipuzkoa: Retrospective study]

BACKGROUND AND OBJECTIVE

Out-of-hospital medical emergency services are defined as a functional organization that performs a set of sequential human and material activities. The objective of this study was to compare the mortality of patients attended by the out-of-hospital medical emergency services in 2 neighboring Spanish regions with different models of healthcare transport assistance for emergency care.

MATERIAL AND METHOD

Retrospective observational cohort study, done between June 1, 2007 and December 31, 2008 in 2 regions of Gipuzkoa, Alto Deba (AD) and Bajo Deba (BD). The study variables were age, sex and place of exposure (AD/BD), heart rate, blood pressure, initial reason for the call defined by the European Resuscitation Council, unconsciousness and digestive bleeding. 3452 subjects were analyzed.

RESULTS

The risk of in situ mortality in BD was 1.31 times higher than in AD (P=.050), that of hospital mortality in BD was 0.71 times lower than in AD (P=.011) and the risk of mortality at one year between counties and the combined mortality (in situ+hospital) did not contribute significant differences.

CONCLUSIONS

Mortality (in situ+in-hospital, and one year aftercare) of patients treated by the out-of-hospital emergency medical services in AD (non-medicalized healthcare transport model) was similar to that of the BD region (mixed healthcare transport model).

A modified Delphi consensus study to identify improvement proposals for COPD management amongst clinicians and administrators in Spain

AIMS

To identify the obstacles hindering the appropriate management of chronic obstructive pulmonary disease (COPD) in Spain based on consensus amongst clinicians and administrators.

METHODS

A two-round modified Delphi questionnaire was sent to clinicians (pulmonologists and GPs) and administrators, all experts in COPD. The scientific committee developed the statements and selected the participating experts. Four areas were explored: diagnosis, training, treatment, and clinical management. Panellists' agreement was assessed using a 9-point Likert scale, with scores of 1 to 3 indicating disagreement and 7 to 9, agreement. Consensus was considered to exist when 70% of the participants agreed or disagreed with the statement.

RESULTS

Respective response rates for the first and second round were 68% and 91% for clinicians, and 60% and 100% for administrators. The statements attracting the highest degree of consensus were: "Not enough nursing resources (time, staff, duties) are allocated for performing spirometry" (85.3% clinicians; 75% administrators); "Nurses need specific training in COPD" (84.8% clinicians; 100% administrators); "Rehabilitation programs are necessary for treating patients with COPD" (94.1% clinicians; 91.7% administrators); and "Integrated care processes facilitate the deployment of educational programs on COPD" (79.4% clinicians; 83.3% administrators).

CONCLUSIONS

This document can inform the development and implementation of specific initiatives addressing the existing obstacles in COPD management.

WHAT'S KNOWN

COPD is a prevalent and underdiagnosed disease that causes substantial morbidity and mortality. The National COPD Strategy established objectives and work programmes to apply in Spain. There are barriers impeding the application of interventions contemplated in the COPD strategy.

WHAT'S NEW

Different agents involved in COPD management agree that the main challenges to improve COPD management are resource shortages in primary care nursing and lack of training in the use of COPD clinical guidelines. Clinicians and administrators involved in COPD management support the implementation of urgent measures to tackle the underdiagnosis of COPD, especially in primary care, along with the routine inclusion of respiratory rehabilitation programmes for COPD.

Renal function and attributable risk of death and cardiovascular hospitalization in participants with diabetes from a registry-based cohort

AIMS

To estimate the attributable risk of renal function on all-cause mortality and cardiovascular hospitalization in patients with diabetes.

METHODS

A prospective cohort study in 19,469 adults with diabetes, free of cardiovascular disease, attending primary care in Spain (2008-2011). The estimated glomerular filtration rate (eGFR) and other variables were collected and patients were followed to the first hospitalization for coronary or stroke event, or death, until the end of 2012. The cumulative incidence of the study endpoints by eGFR categories was graphically displayed and adjusted population attributable risks (PARs) for low eGFR was calculated.

RESULTS

Mean follow-up was 3.2 years and 506 deaths and 1720 hospitalizations were recorded. The cumulative risk for the individual events increased as eGFR levels decreased. The PAR associated with having an eGFR of 60mL/min/1.73m² or less was 11.4% (95% CI 4.8-18.3) for all-cause mortality, 9.2% (95% CI 5.3-13.4) for coronary heart disease, and 2.6% (95% CI -1.8 to 7.4) for stroke.

CONCLUSIONS

Reduced eGFR levels were associated with a larger proportion of avoidable deaths and cardiovascular hospitalizations in people with diabetes compared to previously reported results in people with other cardiovascular risk factors.

Incubation period of COVID-19: A systematic review and meta-analysis

BACKGROUND AND OBJECTIVE

The incubation period of COVID-19 helps to determine the optimal duration of the quarantine and inform predictive models of incidence curves. Several emerging studies have produced varying results; this systematic review aims to provide a more accurate estimate of the incubation period of COVID-19.

METHODS

For this systematic review, a literature search was conducted using Pubmed, Scopus/EMBASE, and the Cochrane Library databases, covering all observational and experimental studies reporting the incubation period and published from 1 January 2020 to 21 March 2020.We estimated the mean and 95th percentile of the incubation period using meta-analysis, taking into account between-study heterogeneity, and the analysis with moderator variables.

RESULTS

We included seven studies (n = 792) in the meta-analysis. The heterogeneity (I2 83.0%, p < 0.001) was significantly decreased when we included the study quality and the statistical model used as moderator variables (I2 15%). The mean incubation period ranged from 5.6 (95% CI: 5.2 to 6.0) to 6.7 days (95% CI: 6.0 to 7.4) according to the statistical model. The 95th percentile was 12.5 days when the mean age of patients was 60 years, increasing 1 day for every 10 years.

CONCLUSION

Based on the published data reporting the incubation period of COVID-19, the mean time between exposure and onset of clinical symptoms depended on the statistical model used, and the 95th percentile depended on the mean age of the patients. It is advisable to record sex and age when collecting data in order to analyze possible differential patterns.

Long-term outcomes of transvaginal ultrasound-guided aspiration versus traditional conservative surgery as treatment for endometriomas: A retrospective study of cohorts

AIM

To evaluate if the long-term results (on fertility, need of hysterectomy and persistence of endometriosis) after a minimally invasive intervention (transvaginal ultrasound-guided puncture-aspiration [TUGPA]) for endometriomas are significantly different from performing the traditional conservative surgery (CS) by laparoscopy or laparotomy.

METHODS

We performed a retrospective study of cohorts on patients undergoing surgery for ovarian endometriomas between January 1998 and April 2015. Cohort 1 consisted of 75 women whose first intervention for endometriomas had been TUGPA. For the cohort 2, we selected a randomized paired case in which the first operation for endometriomas had been CS by laparoscopic or laparotomy (another set of 75 patients).

RESULTS

There were significantly more recurrences and the time to recurrence and repetition of operations were also significantly shorter in patients with TUGPA. However, there were no significant differences in overall pregnancy/delivery outcomes, in hysterectomy performances, or in endometriosis persistence at the last follow-up visit. There were no significant differences related to the symptoms or to analytical presurgical values but the application of multivariate analysis with binary logistic regression to each dependent variable adjusted for age, symptoms, and presurgical analyses showed a significant risk of recurrence and reoperation of TUGPA versus CS.

CONCLUSIONS

Those patients with endometriomas who underwent TUGPA (with or without associated medications) had a significant increase in recurrence and the need for reoperation. However, in the long-term there were no significant differences in the results of pregnancy/childbirth, need for hysterectomy, or in the clinical or doubtful persistence of endometriosis.

Impact of patients' perception of COPD and treatment on adherence and health-related quality of life in real-world: Study in 53 community pharmacies

BACKGROUND

Patient adherence to treatment in chronic obstructive pulmonary disease (COPD) is essential to optimize disease management. We aimed to assess the impact of patients' perception of their treatment and disease on adherence and Health-Related Quality of Life (HRQL) in patients attending a community pharmacy, where usually subjects have a better condition than those in clinical settings.

METHODS

We performed a cross-sectional study of 318 patients with COPD in treatment with inhalers in the last 3 months from 53 community pharmacies. We assessed HRQL with St George's Respiratory Questionnaire (SGRQ). Persistence was assessed from the three previous refills and adherence through the Test of Adherence to Inhalers test.

RESULTS

Persistence was achieved by 78.6% of the patients and 58.5% had good adherence. Patients having a multidose DPI and those with MDI showed a 2.8-fold and 4.1-fold increased association, respectively, with intermediate/poor adherence in comparison with those having a single dose DPI. Those patients who did not have knowledge about COPD (aOR 2.106, p = 0.006) and those who thought that the inhaler effectiveness was fair/poor (aOR 2.361, p = 0.006) were more likely to have intermediate/poor adherence. Overall SGRQ score was significantly worse in patients with intermediate/poor adherence (p = 0.036) and in those who thought the inhaler's effectiveness was fair/poor (p < 0.001).

CONCLUSIONS

The type of inhaler and patients' knowledge and perceptions of their disease and treatment were associated with good adherence and higher HRQL. Clinicians should promote shared-decision making in the choice of inhaler depending on patients' individual abilities and beliefs.

The influence of hemoglobin A1c levels on cardiovascular events and all-cause mortality in people with diabetes over 70 years of age. A prospective study

AIM

Glycated hemoglobin A1c (HbA1c) is a reliable risk factor of cardiovascular diseases in diabetic patients, but information about this relationship in elderly patients is scarce. The aim of this study is to analyze, the relationship between HbA1c levels and the risk of mayor adverse cardiovascular events (MACE) in patients with diabetes over 70 years.

METHODS

Prospective study of subjects with diabetes using electronic health records from the universal public health system in the Valencian Community, Spain, 2008-2012. We included men and women aged≥70 years with diabetes who underwent routine health examinations in primary care. Primary endpoint was the incidence of MACE: all-cause mortality and/or hospital admission due to coronary heart disease or stroke. A standard Cox and Cox-Aalen models were adjusted.

RESULTS

5016 subjects were included whit a mean age of 75.1 years (46.7% men). During an average follow-up of 49 months (4.1 years), 807 (16.1%) MACE were recorded. The incidence of MACE was 20.6 per 1000-person-years. Variables significantly associated to the incidence of MACE were male gender (HR: 1.61), heart failure (HR: 2.26), antiplatelet therapy (HR: 1.39), oral antidiabetic treatment (HR: 0.74), antithrombotics (HR: 1.79), while age, creatinine, HbA1c and peripheral arterial disease were time-depend associated variables.

CONCLUSION

These results highlights the importance of HbA1c level in the incidence of cardiovascular events in older diabetic patients.

Incubation period of COVID-19: A systematic review and meta-analysis

Background and objective

The incubation period of COVID-19 helps to determine the optimal duration of the quarantine and inform predictive models of incidence curves. Several emerging studies have produced varying results; this systematic review aims to provide a more accurate estimate of the incubation period of COVID-19.

Methods

For this systematic review, a literature search was conducted using Pubmed, Scopus/EMBASE, and the Cochrane Library databases, covering all observational and experimental studies reporting the incubation period and published from 1 January 2020 to 21 March 2020.We estimated the mean and 95th percentile of the incubation period using meta-analysis, taking into account between-study heterogeneity, and the analysis with moderator variables.

Results

We included seven studies (n = 792) in the meta-analysis. The heterogeneity (I² 83.0%, p < 0.001) was significantly decreased when we included the study quality and the statistical model used as moderator variables (I² 15%). The mean incubation period ranged from 5.6 (95% CI: 5.2–6.0) to 6.7 days (95% CI: 6.0–7.4) according to the statistical model. The 95th percentile was 12.5 days when the mean age of patients was 60 years, increasing 1 day for every 10 years.

Conclusion

Based on the published data reporting the incubation period of COVID-19, the mean time between exposure and onset of clinical symptoms depended on the statistical model used, and the 95th percentile depended on the mean age of the patients. It is advisable to record sex and age when collecting data in order to analyze possible differential patterns.

Trends in mortality due to motor vehicle traffic accident injuries between 1987 and 2011 in a Spanish region (Comunitat Valenciana)

OBJECTIVE

To analyse the time evolution of the rates of mortality due to motor vehicle traffic accidents (MVTA) injuries that occurred among the general population of Comunitat Valenciana between 1987 and 2011, as well as to identify trend changes by sex and age group.

METHODS

An observational study of annual mortality trends between 1987 and 2011. We studied all deaths due to MVTA injuries that occurred during this period of time among the non-institutionalised population residing in Comunitat Valenciana (a Spanish Mediterranean region that had a population of 5,117,190 inhabitants in 2011). The rates of mortality due to MVTA injuries were calculated for each sex and year studied. These rates were standardised by age for the total population and for specific age groups using the direct method (age-standardised rate - ASR). Joinpoint regression models were used in order to detect significant trend changes. Additionally, the annual percentage change (APC) of the ASRs was calculated for each trend segment, which is reflected in statistically significant joinpoints.

RESULTS

For all ages, ASRs decrease greatly in both men and women (70% decrease between 1990 and 2011). In 1990 and 2011, men have rates of 36.5 and 5.2 per 100,000 men/year, respectively. In the same years, women have rates of 8.0 and 0.9 per 100,000 women/year, respectively. This decrease reaches up to 90% in the age group 15-34 years in both men and women. ASR ratios for men and women increased over time for all ages: this ratio was 3.9 in 1987; 4.6 in 1990; and 5.8 in 2011. For both men and women, there is a first significant segment (p<0.05) with an increasing trend between 1987 and 1989-1990. After 1990, there are 3 segments with a significant decreasing APC (1990-1993, 1993-2005 and 2005-2011, in the case of men; and 1989-1996, 1999-2007 and 2007-2011, in the case of women).

CONCLUSION

The risk of death due to motor vehicle traffic accidents injuries has decreased significantly, especially in the case of women, for the last 25 years in Comunitat Valenciana, mainly as of 2006. This may be a consequence of the road-safety measures that have been implemented in Spain and in Comunitat Valenciana since 2004. The economic crisis that this country has undergone since 2008 may have also been a contributing factor to this decrease. Despite the decrease, ASR ratios for men and women increased over time and it is still a high-risk cause of death among young men. It is thus important that the measures that helped decrease the risk of death are maintained and improved over time.

Self-rated health and mortality: a follow-up study of a Spanish population

OBJECTIVES

Self-rated health (SRH) is known to be a valid indicator for the prediction of health outcomes. The aims of this study were to describe and analyse the associations between SRH and health status, socio-economic and demographic characteristics; and between SRH and mortality in a Spanish population.

STUDY DESIGN

Longitudinal study.

METHODS

A sample of 5275 adults (age ≥21 years) residing in the Valencian Community (Spanish Mediterranean region) was surveyed in 2005 and followed for four years. SRH was categorized into good and poor health. The response variable was mortality (dead/alive), obtained from the local mortality register. Logistic regression models were adjusted in order to analyse the associations between SRH and health status, socio-economic and demographic characteristics; odds ratios were calculated to measure the associations. Poisson regression models were adjusted in order to analyse the associations between mortality and explanatory variables; the relative risk of death was calculated to measure the associations.

RESULTS

Poor SRH was reported by 25.9% of respondents, and the mortality rate after four years of follow-up was 3.6%. An association was found between SRH and the presence of chronic disease and disability in men and women. A perception of poor health vs good health led to a mortality risk of 3.0 in men and 2.7 in women. SRH was predictive of mortality, even after adjusting for all other variables. In men and women, the presence of disability provided additional predictive ability.

CONCLUSIONS

SRH was predictive of mortality in both men and women, and acted as a mediator between socio-economic, demographic and health conditions and mortality.

[Information and worry among patients with non-oncohematological pathologies upon arrival at the hematology clinic]

PURPOSE

Patients are frequently referred to the haematologist to be studied due to the presence of processes that are not properly haematological. We have studied the group of outpatients with non-oncohaematological pathologies referred to our external haematology clinic to evaluate their knowledge about the reason for consultation, the existence or not of worry upation and its degree at the arrival.

PATIENTS AND METHODS

We have made a prospective study including all patients with non-oncohaematological processes (n = 204) who were referred for the first time to our external consultation between April and October 1997. We evaluated in each patient, using an inquest, the following data: age, sex, origin (hospital consultations or urban or rural health centres), reason for consultation, knowledge of the reason for consultation (yes/partially/no), existence or not of worry (yes/no) and when present, its degree (low, moderate, high). The inquiry was made to the parents in those patients aged under 12 years. We have analyzed all adults, each group of adult patients (rural, urban, hospital) separately and compared one group to each other, all pediatric patients and we have compared as well the overall results obtained with adult patients with those from the parents of pediatric patients.

RESULTS

1) Adult patients (n = 169; 78 referred from hospital, 59 from urban and 32 from rural health centres): with respect to the knowledge of the reason for consultation 49.7% of them knew it perfectly, 20.1% partially, and 30.2% did not know about it. 48.5% of patients arrived worried to the clinic, 16.6% of them with a high degree, 17.8% moderate and 14.2% low. 2) Adults referred from primary health care (urban versus rural health centres): We have found neither significant differences in the knowledge of the reason for consultation, worry or its degree with respect to age, sex or origin (urban or rural), nor in the worry or its degree with respect to the patient knowledge of the reason for consultation. 3) Adults referred from other hospital units: The mean age of patients who knew the reason for consultation was significatively lower than that observed in the group who did not (respectively 43.3 and 57 years) (p = 0.003). These differences did not exist with respect to sex. Differences in the existence or not of worry with respect to sex were almost significant, women arrive more worried than men (57.1% and 31.8% respectively, p = 0.07). No significant differences were found in the existence or not of worry and its degree with respect to age or knowledge of the reason for consultation. 4) Comparison between both groups of adults patients (hospital consultation and health centres): No significant differences in the knowledge of the reason for consultation, existence or not of worry and its degree have been found with respect to the other parameters studied. 5) Paediatric patients (n = 35; 8 referred from hospital, 14 from urban and 13 rural health centres): With respect to the knowledge of the reason for consultation 62.9% of them knew it perfectly, 17.1% partially and 20% did not know about it. 80% of patients' parents arrived worried at consultation, 45.7% with a high degree, 20% moderate and 14.3% low. 6) Comparison between paediatrics and adult patients: we have only found significative differences in the existence or not of worry (80% and 48.5% respectively, p = 0.001) and its degree (65.7% of parents with moderate or high worry and 34.4% of adults, p = 0.0004). Parents of paediatric patients arrive at our consultation more worried and with a higher worry degree than the other adults.

CONCLUSION

We consider that patients referred to our external consultation of haematology for the first time arrive with a poor knowledge of their reason for consultation. This observation does not seem to have any relation with age, sex or origin (hospital consultations, urban or rural health centres). (ABSTRACT TRUNCATED)

Phakic anterior chamber lenses for the correction of myopia: a 7-year cumulative analysis of complications in 263 cases

OBJECTIVE

To perform a prospective, clinical trial to determine the potential cumulative complications of patients implanted with angle-supported phakic intraocular lenses (PIOLs) for the correction of myopia.

DESIGN

Nonrandomized, prospective, comparative trial.

PARTICIPANTS

Two hundred sixty-three eyes of 160 consecutive patients were included.

INTERVENTION

Angle-supported anterior chamber intraocular lenses were implanted into phakic eyes.

MAIN OUTCOME MEASURES

Night halos and glare were recorded. Central endothelial cell count, postoperative inflammation, applanation tonometry, cataract development, retinal detachment, and pupil ovalization were recorded by the same physician.

RESULTS

Night halos and glare were reported as significant by 20.2% at 1 year and 10% at year 7 of follow-up. This complication was significantly lower in the larger optical zone PIOL (ZSAL-4) than in the ZB5M/ZB5MF group (P < 0.05). Acute postoperative iritis was observed in 4.56% of cases. High intraocular pressure that required antiglaucoma medications appeared in 7.2% of cases. Central corneal endothelial cell density was significantly decreased at postoperative month 3 (P < 0.0001). The percentages of cell loss were 3.76% at month 3 and 1.83% at year 1, and then the percentages decreased by 1.37% more at year 2, 0.72% at year 3, 0.3% at year 4, 0.6% at year 5, 0.4% at year 6, and 0.56% at year 7. The total cumulative loss of central endothelial cells after 7 years was 8.37%. Pupil ovalization was present in 5.9% of cases, although smaller degrees of this complication were observed in another 10.3%. Retinal detachment appeared in 3% of cases. The PIOL explantation was decided in 11 cases (4.18%) because of cataract development (9 cases) and extreme pupil ovalization associated with severe glare (2 cases). The Kaplan-Meier cumulative survival analysis study showed an expected period free from complication of 86.5% for IOP elevation, 98.75% for endothelial cell count inferior to 1500 cells/mm2, 86.97% for pupil ovalization, 95.43% for retinal detachment, and 89.02% for explantation.

CONCLUSIONS

Angle-supported PIOL appeared to be well tolerated by the corneal endothelium with a low rate of other complications. Pupil ovalization seemed to be a specific problem for this type of PIOL.

Gonadotropic and thyrotropic cells from the Mediterranean yellowtail (Seriola dumerilii; Risso, 1810): immunocytochemical and ultrastructural characterization

BACKGROUND

Gonadotropins GTH I and GTH II from the pituitary of Mediterranean (M.) yellowtail (Seriola dumerilii) were isolated and characterized, and antisera to the whole GTH II molecule (anti-My alpha,betaGTH II) and to its beta-subunit (anti-My betaGTH II) were obtained. At the light microscopic level, anti-My alpha,betaGTH II reacted with My betaGTH II-immunoreactive cells (GTH II cells), thyroid-stimulating hormone (TSH) cells, and a third cell population, which could have been GTH I cells. The aim of this study was the ultrastructural characterization of GTH and TSH cells in M. yellowtail using the immunogold method in order to provide a basis for future research into reproduction of this species.

METHODS

Pituitaries from mature male and female specimens reared in captivity were dissected out and processed for electron microscopy. The immunogold method was carried out by using anti-My alpha,betaGTH II, anti-My alpha,betaGTH II preabsorbed with the alpha subunit of the M. yellowtail GTH (My alphaGTH-subunit), anti-My betaGTH II, anti-human (h) alpha,betaTSH, and anti-h betaTSH sera to reveal gonadotropic and thyrotropic cells.

RESULTS

M. yellowtail gonadotropic cells were very heterogeneous with regard to their size, shape, and ultrastructural features. Cells were found with numerous, round, variably electron-dense, secretory granules and globules; others were found with their cytoplasm occupied mostly by dilated cisternae of rough endoplasmic reticulum (RER) and scarce secretory granules; and other intermediate cell forms were found that showed varying proportions of secretory granules and dilated RER. The secretory granules and globules were immunogold labeled with anti-My alpha,betaGTH II, and the reaction was weaker in the latter. A similar immunogold-labeling pattern was found with anti-My betaGTH II and with anti-My alpha,betaGTH II preabsorbed with the My alphaGTH-subunit, although some cells that showed the same ultrastructural features described above were not immunogold labeled and could have been GTH I cells. Thyrotropic cells had small, round, secretory granules of medium or high electron density that were immunogold labeled with anti-My alpha,betaGTH II, anti-h alpha,betaTSH, and anti-h betaTSH sera, but not with anti-My betaGTH II or anti-My alpha,betaGTH II serum preabsorbed with the My alphaGTH-subunit. All of the cell forms described for gonadotropes and thyrotropes were also found in a state of involution.

CONCLUSIONS

Gonadotropes that are of a single morphological type but that vary in ultrastructure are present in the pituitary of captive M. yellowtail. GTH II- and putative GTH I-producing cells were distinguishable from one another and from TSH cells by their different reactions to anti-My alpha,betaGTH II, anti-My betaGTH II, and anti-My alpha,betaGTH II preabsorbed with the My alphaGTH-subunit.

[Acute myeloid leukemia in those over 70 years of age. Experience using low-dose ara-C treatment]

PURPOSE

The treatment of elderly patients with acute myeloid leukaemia (AML) remains controversial. We present the results of the treatment of a group of patients aged above 70 years with AML diagnosed in our Hospital since 1990.

PATIENTS AND METHODS

We have studied retrospectively the cases of AML in patients older than 70 years diagnosed in our Service since January 1990 to June 1996. Induction treatment was performed, in all cases but one, with two cycles of Ara-C 10 mg/m2/12 h s.c. for 21 days and after haematological recuperation, if complete remission had been achieved, monthly maintenance treatment with Ara-C (25 mg/m2/12 h oral x 5 days), prednisone (40 mg/m2/day x 5 days) y vincristine (1 mg/m2 i.v. x 1 day) was begun.

RESULTS

During the period of study 48 patients with AML have been diagnosed in our Service, among them 22 (45.8%) were older than 70 years. One of them could not be considered for the study as not all data from him could be compiled. Among the other 21 patients 5 presented previous haematological processes (4 myelodysplastic syndrome and 1 Waldenström's macroglobulinemia). Initial diagnosis according to FAB classification for AML was as follows: 7 M1, 6 M2, 4 M4, 2 M5 and 2 M6. From these 21 patients 2 received no treatment due to rapid progression and death, among the other 19, one was directly treated with a modification of the maintenance treatment with vincristine and prednisone without response (survival 2 months). The other 18 patients were treated with low-dose Ara-C (described above), among them 3 (16.7%) were not evaluable as they did not finish the first cycle of induction treatment; 8 (44.4%) showed no response; 2 (11.1%) achieved partial remission and 5 (27.8%) complete remission. One patient did not show any response after two cycles of low-dose Ara-C but she obtained complete remission when treated with Ara-C and idaurubicin. Overall mean survival was 5.7 months (median 2; 95% confidence interval 1.6-9.8 months). In the group of patients treated with low-dose Ara-C mean survival was 6.6 months (median 3.5; 95% confidence interval 1.9-11.2 months).

CONCLUSION

We consider that the treatment with low-dose Ara-C is a valid option in the treatment of elderly patients (aged 70 or above) with AML because 28% complete remissions can be achieved, specially in those ones in which other more aggressive treatments are not possible.

Evaluation of the OptiMAL test for rapid diagnosis of Plasmodium vivax and Plasmodium falciparum malaria

The development of rapid and specific diagnostic tests to identify individuals infected with malaria is of paramount importance in efforts to control the severe public health impact of this disease. This study evaluated the ability of a newly developed rapid malaria diagnostic test, OptiMAL (Flow Inc., Portland, Oreg.), to detect Plasmodium vivax and Plasmodium falciparum malaria during an outbreak in Honduras. OptiMAL is a rapid (10-min) malaria detection test which utilizes a dipstick coated with monoclonal antibodies against the intracellular metabolic enzyme parasite lactate dehydrogenase (pLDH). Differentiation of malaria parasites is based on antigenic differences between the pLDH isoforms. Since pLDH is produced only by live Plasmodium parasites, this test has the ability to differentiate live from dead organisms. Results from the OptiMAL test were compared to those obtained by reading 100 fields of traditional Giemsa-stained thick-smear blood films. Whole-blood samples were obtained from 202 patients suspected of having malaria. A total of 96 samples (48%) were positive by blood films, while 91 (45%) were positive by the OptiMAL test. The blood films indicated that 82% (79 of 96) of the patients were positive for P. vivax and 18% (17 of 96) were infected with P. falciparum. The OptiMAL test showed that 81% (74 of 91) were positive for P. vivax and 19% (17 of 91) were positive for P. falciparum. These results demonstrated that the OptiMAL test had sensitivities of 94 and 88% and specificities of 100 and 99%, respectively, when compared to traditional blood films for the detection of P. vivax and P. falciparum malaria. Blood samples not identified by OptiMAL as malaria positive normally contained parasites at concentrations of less than 100/microl of blood. Samples found to contain P. falciparum were further tested by two other commercially available rapid malaria diagnostic tests, ParaSight-F (Becton Dickinson, Cockeysville, Md.) and ICT Malaria P.f. (ICT Diagnostics, Sydney, Australia), both of which detect only P. falciparum. Only 11 of the 17 (65%) P. falciparum-positive blood samples were identified by the ICT and ParaSight-F tests. Thus, OptiMAL correctly identified P. falciparum malaria parasites in patient blood samples more often than did the other two commercially available diagnostic tests and showed an excellent correlation with traditional blood films in the identification of both P. vivax malaria and P. falciparum malaria. We conclude that the OptiMAL test is an effective tool for the rapid diagnosis of malaria.

HIV-1 infection in women is associated with severe nutritional deficiencies

Nutritional deficiencies may contribute to immune dysregulation, and have been shown to be sensitive markers of HIV-1 disease progression. Only limited information exists, however, regarding the nutritional profile of HIV-1-seropositive drug abusers. Immune and nutritional measurements were obtained in a subsample of 125 subjects from a larger cohort of drug users being followed for HIV-1 infection and cofactors of disease progression. Nutritional deficiencies, particularly vitamins A, E, and zinc, were widespread with up to 86% of the drug users exhibiting at least one nutritional alteration. Although immune parameters (CD4 count, CD8 count, beta2-microglobulin) were similar in the HIV-1-infected men and women, women had significantly poorer overall nutritional status, as measured by plasma proteins, which are considered to be sensitive markers of malnutrition. A comparison of individuals with advanced disease (CD4 count <200/mm3) revealed significantly lower levels of plasma prealbumin (p < .01), selenium, (p < .05), and greater deficiency of vitamins A (p < .01) and E (p < .05) in women than in men. The greater severity of nutritional deficiencies noted in HIV-1-infected women may be an important determinant of disease progression and survival.

Immunocytochemical and ultrastructural characterization of melanotropin and adrenocorticotropin cells from the Mediterranean yellowtail (Seriola dumerilii, Risso 1810)

BACKGROUND

Melanotropin (MSH) and adrenocorticotropin (ACTH) are pituitary hormones derived from a common precursor: the proopiomelanocortin (POMC), which is processed differently in the melanotropic and corticotropic cells of several vertebrates. While ACTH is a major final product in corticotropes, it is further processed into alpha-MSH and corticotropin-like intermediate lobe peptide (CLIP) in melanotropes. Cells which are immunoreactive to ACTH (ACTH cells) and to both alpha-MSH and ACTH (MSH cells) have been described in a number of teleosts, including the Mediterranean yellowtail, by light microscopic immunocytochemistry. However, these cells have been ultrastructurally characterized only in a few species. In this paper, we use electron microscopy to identify and characterize the cells producing MSH and ACTH in M. yellowtail (Seriola dumerilii).

METHODS

Pituitaries from adult specimens were dissected and processed for conventional and immunocytochemical electron microscopy. An immunogold technique was performed using anti-synthetic alpha-MSH and anti-human (h) ACTH (1-24) sera.

RESULTS

MSH cells had round secretory granules with a granular content of varying electron density and compactness, which were immunogold-labeled with anti-alpha-MSH. Homogeneous and electron-dense secretory granules found in the Golgi area of these cells reacted with both anti-alpha-MSH and anti-hACTH (1-24). ACTH cells had round secretory granules with a homogeneous and medium or high electron-dense core and narrow clear halo, which were grouped in the cell area near the neurohypophysis (NH). Some granules showed an osmiophilic semicore in the medium electron-dense content, which has not been described in other teleost pituitary cells. Immunogold-labeling over the secretory granules only was obtained with all the antisera used. Some ACTH cells showed involutive features.

CONCLUSIONS

MSH and ACTH are respective final products of the POMC in two ultrastructurally different cells of the pituitary of M. yellowtail, MSH and ACTH cells. The immature granules in the Golgi area of MSH cells seem to be the site of proteolitic cleavage of ACTH into alpha-MSH and CLIP.

Immunocytochemical and ultrastructural characterization of prolactin, growth hormone, and somatolactin cells from the Mediterranean yellowtail (Seriola dumerilii, Risso 1810)

BACKGROUND

Prolactin (PRL), growth hormone (GH), and somatolactin (SL) are structurally related pituitary hormones that belong to a peptide family. Whereas growth hormone and prolactin are present in the hypophysis of all vertebrates, somatolactin, a recently discovered hormone, has been found only in fish. It has been demonstrated immunocytochemically in a few teleost species; ultrastructurally, cells producing this hormone have been characterized only in one species of salmon. In this paper, we identify and characterize ultrastructurally the cells producing these three hormones in Mediterranean yellowtail (Seriola dumerilii).

METHODS

Pituitaries from adult specimens were dissected out and processed for electron microscopy. The immunogold technique was performed in some ultrathin sections using fish primary antibodies.

RESULTS

PRL cells had round, peripherally distributed, very electron-dense, homogeneous secretory granules of variable size. GH cells had dense, round secretory granules with a conspicuous scalloped membrane, which were grouped in the cell area near the neurohypophysis. SL cells had round, polymorphic, or very irregularly shaped secretory granules, the last seeming to arise from the fusion of various secretory granules. The population of secretory granules varied greatly from one cell to another. In all cases, immunogold labeling was seen exclusively in the secretory granules. Exocytosis was observed in all cell types. Some of the PRL, GH, and SL cells showed involutive features.

CONCLUSIONS

PRL, GH, and SL, although structurally and functionally related, are secreted by ultrastructurally different cells in the pituitary of M. yellowtail.

[Comparative study of the stability of oral anticoagulant treatments (warfarin vs acenocoumarol)]

PURPOSE

To compare the stability of the effect of two oral anticoagulants, one of them (acenocoumarol) with a short half life and the other one with a long half life (warfarin) in patients in the stable phase of treatment (at least 2 months with treatment before entering the study).

PATIENTS AND METHODS

During a year period (January-December 1993) a comparative study of two groups of 53 patients each was performed: group 1 patients were treated with warfarin and group 2 with acenocoumarol. Both groups were paired with respect to age, sex, diagnosis for anticoagulant therapy and desired therapeutic range (INR 3-4.5). The mean value of controls per patient, the dosage changes, the evolutive controls and the incidence of haemorrhagic and thromboembolic episodes were studied.

RESULTS

The controls performed in group 1 were 728 in total with a mean value of 13.74 per patient and 800 in group 2 with a mean value of 15.09 per patient. A change in the dosage was performed in 214 controls in patients of group 1 and in 269 of group 2. Seventeen patients had 38 haemorrhagic episodes (2 major and 36 minor) in group 1, and 6 of group 2 had 20 episodes (2 major and 18 minor). Significant differences were observed in the mean value of controls (p = 0.04), the evolutive controls (p < 0.001), the global incidence of haemorrhages (p = 0.008) and incidence of minor ones (p = 0.006). No significant differences in dosage were observed. In both groups no thromboembolic episodes during the period of study were reported.

CONCLUSIONS

Anticoagulant treatment with warfarin is more stable than with acenocoumarol. The total controls and the mean value of controls per patient are decreased. Nevertheless with warfarin we have observed a greater incidence of haemorrhagic episodes.

Myelopoiesis in the thymus of the sea bass, Dicentrarchus labrax L. (teleost)

BACKGROUND

In vertebrates the thymus is primarily regarded as a lymphoid organ whose importance lies in its capacity to produce a large number of lymphocytes that enter the circulation as T cells. In higher vertebrates the organ has also been regarded as a site for myelopoiesis, but this capacity has not been observed in fish. In this study we describe morphologically the presence of intrathymic developing myeloid cells in the sea bass.

METHODS

The thymus samples were morphologically studied by transmission electron microscopy.

RESULTS

We describe the coexistence of cells in different stages of erythropoiesis and granulopoiesis that appear to be developing in situ in some thymus lobes. Degenerated thymocytes and epithelial-reticular cells occur simultaneously in the same areas.

CONCLUSIONS

The coexistence of different cellular components of erythropoiesis and the heterophilic series of granulopoiesis with areas of necrosis suggests a relationship between both processes that is influenced by the microenvironment. Our observations also suggest that the presence of intrathymic developing myeloid cells may imply a nonimmunological role for the thymus.

Children at high risk for congenital dislocation of the hip: late presentation

Several studies of risk factors and screening for congenital dislocation of the hip (CDH) have been reported, but some children are diagnosed too late and poor prognosis can be expected even with selective screening programs. The frequency of risk factors in late CDH presentation is not known.