Videolaryngoscope versus conventional technique for insertion of a transesophageal echocardiography probe in intubated ICU patients (VIDLARECO trial): A randomized clinical trial

BACKGROUND

Transesophageal echocardiogram probe insertion in intubated critically ill patients can be difficult, leading to complications, such as gastric bleeding or lesions in the oropharyngeal mucosa. We hypothesised that the use of a videolaryngoscope would facilitate the first attempt at insertion of the transesophageal echocardiogram probe and would decrease the incidence of complications compared to the conventional insertion technique.

METHODS

In this clinical trial, patients were randomly assigned the insertion of a transesophageal echocardiogram probe using a videolaryngoscope or conventional technique. The primary outcome was the successful transesophageal echocardiogram probe insertion on the first attempt. The secondary outcomes included total success rate, number of insertion attempts, and incidence of pharyngeal complications.

RESULTS

A total of 100 intubated critically ill patients were enrolled. The success rate of transesophageal echocardiogram probe insertion on the first attempt was higher in the videolaryngoscope group than in the conventional group (90% vs. 58%; absolute difference, 32%; 95% CI 16%-48%; p < 0.001). The overall success rate was higher in the videolaryngoscope group than in the conventional group (100% vs. 72%; absolute difference, 28%; 95% CI 16%-40%; p < 0.001). The incidence of pharyngeal mucosal injury was smaller in the videolaryngoscope group than in the conventional group (14% vs. 52%; absolute difference, 38%; 95% CI 21%-55%; p < 0.001).

CONCLUSIONS

Our study showed that in intubated critically ill patients required transesophageal echocardiogram, the use of videolaryngoscope resulted in higher successful insertion on the first attempt with lower rate of complications when compared with the conventional insertion technique.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04980976.

Impact of Universal Use of the McGrath Videolaryngoscope as a Device for All Intubations in the Cardiac Operating Room. A Prospective Before-After VIDEOLAR-CAR Study

OBJECTIVE

Tracheal intubation in cardiac surgery patients has a higher incidence of difficult laryngoscopic views compared with patients undergoing other types of surgery. The authors hypothesized that using the McGrath Mac videolaryngoscope as the first intubation option for cardiac surgery patients improves the percentage of patients with "easy intubation" compared with using a direct Macintosh laryngoscope.

DESIGN

A prospective, observational, before-after study.

SETTING

At a tertiary-care hospital.

PARTICIPANTS

One thousand one hundred nine patients undergoing cardiac surgery.

INTERVENTION

Consecutive patients undergoing cardiac surgery were intubated using, as the first option, a Macintosh laryngoscope (preinterventional phase) or a McGrath Mac videolaryngoscope (interventional phase).

MEASUREMENTS AND MAIN RESULTS

The main objective was to assess whether the use of the McGrath videolaryngoscope, as the first intubation option, improves the percentage of patients with "easy intubation," defined as successful intubation on the first attempt, modified Cormack-Lehane grades of I or IIa, and the absence of the need for adjuvant airway devices. A total of 1,109 patients were included, 801 in the noninterventional phase and 308 in the interventional phase. The incidence of "easy intubation" was 93% in the interventional phase versus 78% in the noninterventional phase (p < 0.001). First-success-rate intubation was higher in the interventional phase (304/308; 98.7%) compared with the noninterventional phase (754/801, 94.1%; p = 0.005). Intubation in the interventional phase showed decreases in the incidence of difficult laryngoscopy (12/308 [3.9%] v 157/801 [19.6%]; p < 0.001), as well as moderate or difficult intubation (5/308 [1.6%] v 57/801 [7.1%]; p < 0.001).

CONCLUSIONS

The use of the McGrath videolaryngoscope as the first intubation option for tracheal intubation in cardiac surgery improves the percentage of patients with "easy" intubation," increasing glottic view and first-success-rate intubation and decreasing the incidence of moderate or difficult intubation.

Relationships between Patient-Reported Outcome Measures and Clinical Measures in Naïve Neovascular Age-Related Macular Degeneration Patients Treated with Intravitreal Ranibizumab

Our objective was to evaluate changes in patient-reported outcome measures using the NEI-VFQ 25 questionnaire during a treat and extend regimen in naive neovascular Age-Related Macular Degeneration patients, and its correlation with anatomical and functional data. We conducted a prospective observational study. Patients underwent a treat and extend regimen with intravitreal ranibizumab for neovascular Age-Related Macular Degeneration. Initial response was evaluated at 4th month, and subsequently in every follow-up visit. If a clinical response was achieved, the injection interval was extended in two-week increments, up to a maximum of 12 weeks. Quality of life was assessed using the NEI-VFQ 25 questionnaire at baseline, 4th months, and 12th months. Patients were categorized as good or poor responders based on Best corrected visual acuity, central foveal thickness, intraretinal fluid, or subretinal fluid. Treatment with ranibizumab led to a significant improvement in quality of life, with a mean increase in NEI-VFQ 25 score of 4.27 points in the 12th month. No significant differences in improvement were observed between good and poor responders. Quality of life scores in neovascular Age-Related Macular Degeneration patients improved with intravitreal treatment regardless of the clinical response. The early response following the loading phase could indicate better quality of life after one year of treatment, with Best corrected visual acuity being the clinical parameter with the greatest influence on quality of life.

The Effect of Systemic Parameters and Baseline Characteristics in Short-Term Response Analysis with Intravitreal Ranibizumab in Treatment-Naive Patients with Neovascular Age-Related Macular Degeneration

Anti-vascular endothelial growth factor drugs keep being the main therapy for neovascular age-related macular degeneration (AMD). Possible predictive parameters (demographic, biochemical and/or inflammatory) could anticipate short-term treatment response with ranibizumab. 46 treatment-naive patients were included in a prospective observational study. They underwent three monthly injections of intravitreal ranibizumab for neovascular AMD and the clinical examination was made at baseline and one month after the third injection. Demographic characteristics, co-morbidities and concomitant treatments were recorded at the baseline visit. Biochemical parameters, complete blood count and inflammation biomarkers were also measured at these times. Uric Acid was found to be statistically significant with a one-point difference between good and poor responders in both basal and treated patients, but only in basal parameters was statistical significance reached (p = 0.007 vs. p = 0.071 in treated patients). Cholesterol and inflammatory parameters such as white blood cell count and neutrophils were significantly reduced over time when treated with intravitreal ranibizumab. On the other hand, women seemed to have a worse prognosis for short-term response to intravitreal ranibizumab treatment. Uric acid may help identify possible non-responders before initial treatment with ranibizumab, and cholesterol and white blood cells could be good candidates to monitor short-term response to ranibizumab treatment.

Influence of Genetic Polymorphisms on the Short-Term Response to Ranibizumab in Patients With Neovascular Age-Related Macular Degeneration

Purpose

To determine whether genetic risk single nucleotide polymorphisms (SNPs) for age-related macular degeneration (AMD) influence short-term response to intravitreal ranibizumab treatment.

Methods

Forty-four treatment-naive AMD patients were included in a prospective observational study. They underwent three monthly injections of intravitreal ranibizumab for neovascular AMD. After an initial clinical examination (baseline measurement), a follow-up visit was performed to determine treatment response one month after the third injection (treatment evaluation). Patients were evaluated based on ophthalmoscopy, fluorescein angiography, optical coherence tomography (OCT), and OCT angiography. Peripheral venous blood was collected for DNA analysis at baseline visit. Patients were genotyped for single-nucleotide polymorphisms within AMD-relevant genes and classified on good or poor responders based on visual acuity, central retinal thickness, intraretinal fluid, and subretinal fluid.

Results

One hundred ten AMD-associated SNPs have been analyzed. Six were found to be relevant when associated to ranibizumab treatment response. The genetic variants rs890293 (CYP2J2), rs11200638 (HTRA1), rs405509 (APOE), rs9513070 (FLT1), and rs8135665 (SLC16A8) predisposed patients to a good response, whereas rs3093077 (CRP) was associated with a poor response. FTL1, SLC16A8, and APOE were the SNPs that showed significance (P < 0.05) but did not pass Bonferroni correction.

Conclusions

This is the first study that links novel polymorphisms in genes such as CRP, SCL16A8, or CYP2J2 to treatment response to ranibizumab therapy. On the other hand, HTRA1, FLT1, and APOE are linked to a good ranibizumab response. These SNPs may be good candidates for short-term treatment response biomarkers in AMD patients. However, further studies will be necessary to confirm our findings.

Cognitive Function with PCSK9 Inhibitors: A 24-Month Follow-Up Observational Prospective Study in the Real World-MEMOGAL Study

INTRODUCTION

The cognitive safety of monoclonal antibody proprotein convertase subtilisin/kexin type 9 inhibitors (PCSK9i) has been established in clinical trials, but not yet in real-world observational studies. We assessed the cognitive function in patients initiating PCSK9i, and differences in cognitive function domains, to analyze subgroups by the low-density lipoprotein cholesterol (LDL-C) achieved, and differences between alirocumab and evolocumab.

METHODS

This has a multicenter, quasi-experimental design carried out in 12 Spanish hospitals from May 2020 to February 2023. Cognitive function was assessed using the Montreal Cognitive Assessment (MoCA).

RESULTS

Among 158 patients followed for a median of 99 weeks, 52% were taking evolocumab and 48% alirocumab; the mean change from baseline in MoCA score at follow-up was + 0.28 [95% CI (- 0.17 to 0.73; p = 0.216)]. There were no significant differences in the secondary endpoints-the visuospatial/executive domain + 0.04 (p = 0.651), naming domain - 0.01 (p = 0.671), attention/memory domain + 0.01 (p = 0.945); language domain - 0.10 (p = 0.145), abstraction domain + 0.03 (p = 0.624), and orientation domain - 0.05 (p = 0.224)-but for delayed recall memory the mean change was statistically significant (improvement) + 0.44 (p = 0.001). Neither were there any differences in the three stratified subgroups according to lowest attained LDL-C level-0-54 mg/dL, 55-69 mg/dL and ≥ 70 mg/dL; p = 0.454-or between alirocumab and evolocumab arms.

CONCLUSION

We did not find effect of monoclonal antibody PCSK9i on neurocognitive function over 24 months of treatment, either in global MoCA score or different cognitive domains. An improvement in delayed recall memory was shown. The study showed no differences in the cognitive function between the prespecified subgroups, even among patients who achieved very low levels of LDL-C. There were no differences between alirocumab and evolocumab.

REGISTRATION

ClinicalTtrials.gov Identifier number NCT04319081.

Efficacy and Safety of Inhaled Ethanol in Early-Stage SARS-CoV-2 Infection in Older Adults: A Phase II Randomized Clinical Trial

BACKGROUND

Inhaled ethanol in the early stages of SARS-CoV-2 infection may reduce the viral load, decreasing progression and improving prognosis. The ALCOVID-19 trial was designed to study the efficacy and safety of inhaled ethanol in older adults at initial phases of infection.

METHODS

Randomized, triple-blind, placebo-controlled phase II clinical trial. Experimental group (n = 38) inhaled 65° ethanol through an oxygen flow, while in the control group (n = 37), water for injection was used. General endpoint was to evaluate disease progression according to the modified World Health Organization (WHO) Clinical Progression Scale. Specific effectiveness endpoints were body temperature, oxygen saturation, viral load assessed by cycle threshold (Ct) on real-time polymerase chain reaction (RT-PCR), analytical biomarkers and use of antibiotics or corticosteroids. Specific safety outcomes were the absence of ethanol in plasma, electrographic, analytical, or respiratory alterations.

RESULTS

In the intention-to-treat population, no differences were found regarding disease progression. Mean Ct values increased over time in both groups, being numerically higher in the ethanol group, reaching a value above 33 only in the ethanol group on day 14, a value above which patients are considered non-infective. No differences were found in the other specific effectiveness endpoints. Inhaled ethanol was proven to be safe as no plasma ethanol was detected, and there were no electrocardiographic, analytical, or respiratory alterations.

CONCLUSIONS

The efficacy of inhaled ethanol in terms of the progression of SARS-CoV-2 infection was not demonstrated in the present trial. However, it is positioned as a safe treatment for elderly patients with early-stage COVID-19.

Synergism interaction between genetic polymorphisms in drug metabolizing enzymes and NSAIDs on upper gastrointestinal haemorrhage: a multicenter case-control study

BACKGROUND

Interindividual genetic variations contribute to differences in patients' response to drugs as well as to the development of certain disorders. Patients who use non-steroidal anti-inflammatory drugs (NSAIDs) may develop serious gastrointestinal disorders, mainly upper gastrointestinal haemorrhage (UGIH). Studies about the interaction between NSAIDs and genetic variations on the risk of UGIH are scarce. Therefore, we investigated the effect of 16 single nucleotide polymorphisms (SNPs) involved in drug metabolism on the risk of NSAIDs-induced UGIH.

MATERIALS AND METHODS

We conducted a multicenter case-control study of 326 cases and 748 controls. Participants were sub-grouped into four categories according to NSAID exposure and genetic profile. We estimated odds ratios (ORs) and their 95% confidence intervals (CI) using generalized linear mixed models for dependent binomial variables and then calculated the measures of interaction, synergism index (S), and relative excess risk due to interaction (RERI). We undertook stratified analyses by the type of NSAID (aspirin, non-aspirin).

RESULTS

We observed an excess risk of UGIH due to an interaction between any NSAID, non-aspirin NSAIDs or aspirin and carrying certain SNPs. The greatest excess risk was observed for carriers of: rs2180314:C>G [any NSAID: S = 3.30 (95%CI: 1.24-8.80), RERI = 4.39 (95%CI: 0.70-8.07); non-aspirin NSAIDs: S = 3.42 (95%CI: 1.12-10.47), RERI = 3.97 (95%CI: 0.44-7.50)], and rs4809957:A>G [any NSAID: S = 2.11 (95%CI: 0.90-4.97), RERI = 3.46 (95%CI: -0.40-7.31)]. Aspirin use by carriers of rs6664:C>T is also associated with increased risk of UGIH [OR_{aspirin(+),wild-type}: 2.22 (95%CI: 0.69-7.17) vs. OR_{aspirin(+),genetic-variation}: 7.72 (95%CI: 2.75-21.68)], yet larger sample size is needed to confirm this observation.

CONCLUSIONS

The joint effect of the SNPs s2180314:C>G and rs4809957:A>G and NSAIDs are more than three times higher than the sum of their individual effects. Personalized prescriptions based on genotyping would permit a better weighing of risks and benefits from NSAID consumption.KEY MESSAGESMulticenter case-control study of the effect of genetic variations involved in drug metabolism on upper gastrointestinal haemorrhage (UGIH) induced by NSAIDs (aspirin and non-aspirin).There is a statistically significant additive synergism interaction between certain genetic polymorphisms and NSAIDs on UGIH: rs2180314:C>G and rs4809957:A>G. The joint effect of each of these single nucleotide polymorphisms and NSAIDs on UGIH is more than three times higher than the sum of their individual effects.Genetic profiling and personalized prescriptions would be useful in managing the risks and benefits associated with NSAIDs.

Liver Brain Interactions: Focus on FGF21 a Systematic Review

Fibroblast growth factor 21 is a pleiotropic hormone secreted mainly by the liver in response to metabolic and nutritional challenges. Physiologically, fibroblast growth factor 21 plays a key role in mediating the metabolic responses to fasting or starvation and acts as an important regulator of energy homeostasis, glucose and lipid metabolism, and insulin sensitivity, in part by its direct action on the central nervous system. Accordingly, pharmacological recombinant fibroblast growth factor 21 therapies have been shown to counteract obesity and its related metabolic disorders in both rodents and nonhuman primates. In this systematic review, we discuss how fibroblast growth factor 21 regulates metabolism and its interactions with the central nervous system. In addition, we also state our vision for possible therapeutic uses of this hepatic-brain axis.

Impact of the COVID-19 pandemic in the lipid control of the patients that start PCSK9 inhibitors

OBJECTIVES

MEMOGAL study (NCT04319081) is aimed at evaluating changes in cognitive function in patients treated with PCSK9 inhibitors (PCSK9i). This is the first analysis: (1) discussion about the role of the Hospital Pharmacists during the pandemic, and also the assessment of the impact of COVID-19 in the lipid control; (2) descriptive analysis; (3) effectiveness in LDL cholesterol (LDL-c) reduction of alirocumab and evolocumab; (4) communicate PCSK9i safety.

MATERIAL AND METHODS

It is a prospective Real-World Evidence analysis of patients that take PCSK9i for the first time in the usual clinical practice, and they are included after the first dispensation in the public pharmacy consultations of 12 Hospitals in Galicia from May 2020 to April 2021. Baseline values of LDL-c are the previous values before taking PCSK9 and the follow-up values are in 6 months time.

RESULTS

89 patients were included. 86.5% with cardiovascular disease and 53.9% with statin intolerances. 78.8% of the patients were treated with high intensity statins. Statins most used were rosuvastatin (34.1%) and atorvastatin (20.5%). Baseline value of LDL-c was 148mg/dL and the follow-up value was 71mg/dL. The baseline value of patients treated with alirocumab (N=43) was 144mg/dL and 73mg/dL in the follow-up. With evolocumab (N=46) was 151mg/dL in basaline and 69mg/dL in follow-up. The LDLc- reduction was 51.21% with evolocumab and 51.05% with alirocumab. 43.1% of the patients showed values >70mg/dL in six month time; 19.4% between 69mg/dl and 55mg/dL and 37.5% <55mg/dL. 58.3% of the patients achieved a reduction >50% of LDL-c. The adverse events were: injection point reaction (N=2), myalgias (N=1), flu-like symptoms (N=1) and neurocognitive worsening (N=1).

CONCLUSIONS

(1) Despite the number of prescriptions was reduced because of the pandemic, the lipid control was not affected. (2) Half of the patients treated with PSCK9i is due to statins intolerance and the 86% is for secondary prevention. (2) The reduction results were similar to pivotal clinical trials. Despite this, 39% of the total of the patients and 60% of patients with dual teraphy did not reach the goal of ESC/EAS guidelines (<55mg/dL and/or reduction>50%). There were not significant differences between evolocumab and alirocumab: 51.21% vs 51.05% (P=.972). (3) There were not any adverse events of special interest. The possible neurocognitive worsening will be studied as the primary endpoint once the MEMOGAL study has been completed.

Moral distress among healthcare professionals working in intensive care units in Spain

OBJECTIVE

To assess moral distress (MD) among Spanish critical care healthcare professionals (HCPs).

DESIGN

Cross-sectional, prospective study.

SETTING

ICUs in Spain.

PARTICIPANTS

HCPs currently working in Spanish ICUs.

INTERVENTIONS

A 55-item questionnaire was electronically distributed.

MAIN VARIABLES

The questionnaire included work-related and socio-demographic characteristics, the Spanish version of the Measure of Moral Distress for Health Care Professionals (MMD-HP-SPA), and the Hospital Ethical Climate Survey (HECS).

RESULTS

In total, 1065 intensive care providers completed the questionnaire. Three out of four validity hypotheses were supported. MD was significantly higher for physicians (80, IQR 40-135) than for nurses (61, IQR 35-133, p=0.026). MD was significantly higher for those clinicians considering leaving their position (78, IQR 46-163 vs. 61, IQR 32-117; p<0.001). The MMD-HP-SPA was inversely correlated with the HECS (r=-0.277, p<0.001). An exploratory factor analysis revealed a four-factor structure, evidencing the patient, team, and system levels of MD.

CONCLUSIONS

In the study sample, Spanish intensivists report higher MD than nurses. Strategies to improve ICU ethical climate and to correct other related factors in order to mitigate MD at a patient, team, and system level should be implemented. Both groups of HCPs manifest a relevant intention to leave their position due to MD. Further studies are needed to determine the extent to which MD influences their desire to leave the job.

Effect of high versus low dose of dexamethasone on clinical worsening in patients hospitalised with moderate or severe COVID-19 Pneumonia: an open-label, randomised clinical trial

BACKGROUND

Low dose dexamethasone demonstrated clinical improvement in patients with coronavirus disease 2019 (COVID-19) needing oxygen therapy; however, evidence on the efficacy of high dose of dexamethasone is limited.

METHODS

We performed a randomised, open-label, controlled trial involving hospitalised patients with confirmed COVID-19 pneumonia needing oxygen therapy. Patients were randomly assigned in a 1:1 ratio to receive low dose dexamethasone (6 mg once daily for 10 days) or high dose dexamethasone (20 mg once daily for 5 days, followed by 10 mg once daily for additional 5 days). The primary outcome was clinical worsening within 11 days since randomisation. Secondary outcomes included 28-day mortality, time to recovery, and clinical status at day 5, 11, 14 and 28 on an ordinal scale ranging from 1 (discharged) to 7 (death).

RESULTS

A total of 200 patients (mean (sd) age, 64 (14) years; 62% male) were enrolled. Thirty-two patients of 102 (31.4%) enrolled in the low dose group and 16 of 98 (16.3%) in the high dose group showed clinical worsening within 11 days since randomisation (rate ratio, 0.427; 95% CI, 0.216-0.842; p=0.014). The 28-day mortality was 5.9% in the low dose group and 6.1% in the high dose group (p=0.844). There was no significant difference in time to recovery, and in the 7-point ordinal scale at day 5, 11, 14 and 28.

CONCLUSIONS

Among hospitalised COVID-19 patients needing oxygen therapy, high dose of dexamethasone reduced clinical worsening within 11 days after randomisation as compared with low dose.

Moral distress among healthcare professionals working in intensive care units in Spain

OBJECTIVE

To assess moral distress (MD) among Spanish critical care healthcare professionals (HCPs).

DESIGN

Cross-sectional, prospective study.

SETTING

ICUs in Spain.

PARTICIPANTS

HCPs currently working in Spanish ICUs.

INTERVENTIONS

A 55-item questionnaire was electronically distributed.

MAIN VARIABLES

The questionnaire included work-related and socio-demographic characteristics, the Spanish version of the Measure of Moral Distress for Health Care Professionals (MMD-HP-SPA), and the Hospital Ethical Climate Survey (HECS).

RESULTS

In total, 1065 intensive care providers completed the questionnaire. Three out of four validity hypotheses were supported. MD was significantly higher for physicians (80, IQR 40-135) than for nurses (61, IQR 35-133, p=0.026). MD was significantly higher for those clinicians considering leaving their position (78, IQR 46-163 vs. 61, IQR 32-117; p<0.001). The MMD-HP-SPA was inversely correlated with the HECS (r=-0.277, p<0.001). An exploratory factor analysis revealed a four-factor structure, evidencing the patient, team, and system levels of MD.

CONCLUSIONS

In the study sample, Spanish intensivists report higher MD than nurses. Strategies to improve ICU ethical climate and to correct other related factors in order to mitigate MD at a patient, team, and system level should be implemented. Both groups of HCPs manifest a relevant intention to leave their position due to MD. Further studies are needed to determine the extent to which MD influences their desire to leave the job.

Oral cancer awareness in North-Western Spain: a population-based study

Background

An early diagnosis depends greatly on patient awareness. Thus, the aim of this study was to investigate general awareness of oral cancer and knowledge about its risk factors, signs and symptoms.

Material and Methods

Cross-sectional population-based survey of randomly selected respondents conducted from March 1, 2015 to 30 June 2016.

Results

A total of 5,727 people entered the survey (response rate: 53%). When asked what cancers participants had heard about, 20.3% mentioned oral cancer. Regarding risk factors, tobacco was mentioned by 55.3% of the sample (n=3,169), followed by alcohol (12.5%; n=708), poor oral hygiene (10.8%; n=618), diet (6.5%; n=377), and genetics (4.5%; n=248).

Conclusions

General population has low awareness of oral cancer with poor knowledge of risk factors and main alarm signs. In addition, individuals in the risk group scored lower values in the main variables analysed; even those highly educated showed insufficient awareness and knowledge of oral cancer. In these circumstances, there is clear need for educational interventions tailored to the target audience and aimed at increasing knowledge and awareness of oral cancer to promote primary prevention of oral cancer and minimising the time interval of patients with symptomatic oral cancer in their path to treatment.

Key words:Oral cancer, awareness, risk factors, surveys and questionnaires, Spain.

Neurological Instability in Ischemic Stroke: Relation with Outcome, Latency Time, and Molecular Markers

The National Institutes of Health Stroke Scale (NIHSS) is commonly used to evaluate stroke neurological deficits and to predict the patient’s outcome. Neurological instability (NI), defined as the variation of the NIHSS in the first 48 h, is a simple clinical metric that reflects dynamic changes in the area of the brain affected by the ischemia. We hypothesize that NI may represent areas of cerebral instability known as penumbra, which could expand or reduce brain injury and its associated neurological sequels. In this work, our aim was to analyze the association of NI with the functional outcome at 3 months and to study clinical biomarkers associated to NI as surrogate biomarkers of ischemic and inflammatory penumbrae in ischemic stroke (IS) patients. We included 663 IS patients in a retrospective observational study. Neutral NI was defined as a variation in the NI scale between − 5 and 5% (37.1%). Positive NI is attributed to patients with an improvement of > 5% NI after 48 h (48.9%), while negative NI is assigned to patients values lower than − 5% (14.0%). Poor outcome was assigned to patients with mRS ≥ 3 at 3 months. We observed an inverse association of poor outcome with positive NI (OR, 0.35; 95%CI, 0.18–0.67; p = 0.002) and a direct association with negative NI (OR, 6.30; 95%CI, 2.12–18.65; p = 0.001). Negative NI showed a higher association with poor outcome than most clinical markers. Regarding good functional outcome, positive NI was the marker with the higher association (19.31; CI 95%, 9.03–41.28; p < 0.0001) and with the highest percentage of identified patients with good functional outcome (17.6%). Patients with negative NI have higher glutamate levels compared with patients with neutral and positive NI (p < 0.0001). IL6 levels are significantly lower in patients with positive NI compared with neutral NI (p < 0.0001), while patients with negative NI showed the highest IL6 values (p < 0.0001). High glutamate levels were associated with negative NI at short latency times, decreasing at higher latency times. An opposite trend was observed for inflammation, and IL6 levels were similar in patients with positive and negative NI in the first 6 h and then higher in patients with negative NI. These results support NI as a prognosis factor in IS and the hypothesis of the existence of a delayed inflammatory penumbra, opening up the possibility of extending the therapeutic window for IS.

Measuring family-centred care practices in adult intensive care units: The EMPATHIC-F questionnaire

BACKGROUND

Engaging relatives in the care of critically ill patients is associated with better outcomes. It is crucial to empower relatives to provide feedback. Valid satisfaction instruments are essential to identify best practices and areas for improvement.

AIM

The aim of the study was to adapt the Spanish version of the EMpowerment of PArents in The Intensive Care-30 (EMPATHIC-30) questionnaire in adult intensive care units (ICUs) and psychometrically test the EMpowerment of PAtients in The Intensive Care-Family (EMPATHIC-F) questionnaire to measure family satisfaction.

DESIGN

This is a cross-sectional, prospective study conducted in two adult ICUs. Participants were relatives of patients who were discharged alive from the ICUs with an ICU length-of-stay >24 hours. The EMPATHIC-F questionnaire is divided into five domains that are related to the family-centred care principles. Responses are provided on a 6-point ordinal Likert scale, a score of >5 is considered acceptable.

RESULTS

Patients' relatives confirmed the adaptation of the instrument. A total of 262 relatives responded to the EMPATHIC-F questionnaire (97% response rate). The empirical structure of the instrument was established by confirmatory factor analysis confirming 30 statements within five theoretically conceptualized domains: information, care and treatment, family participation, organization, and professional attitude. On item level, two statements scored a mean below 5.0. Cronbach's α at the domain level was between .64 and .75. Congruent validity was adequate between the five domains and four general satisfaction items (r's .26-.54). The non-differential validity was confirmed with no significant effect size between three patients' demographic characteristics and the domains.

CONCLUSIONS

The EMPATHIC-F questionnaire is a reliable and valid quality performance indicator to measure the perceptions of family members in adult ICU settings.

RELEVANCE TO CLINICAL PRACTICE

The EMPATHIC-F questionnaire can be used to benchmark and provides a framework for standardized quality improvement towards the development of a family-centred care philosophy within adult ICUs.

Random forest-based prediction of stroke outcome

We research into the clinical, biochemical and neuroimaging factors associated with the outcome of stroke patients to generate a predictive model using machine learning techniques for prediction of mortality and morbidity 3-months after admission. The dataset consisted of patients with ischemic stroke (IS) and non-traumatic intracerebral hemorrhage (ICH) admitted to Stroke Unit of a European Tertiary Hospital prospectively registered. We identified the main variables for machine learning Random Forest (RF), generating a predictive model that can estimate patient mortality/morbidity according to the following groups: (1) IS + ICH, (2) IS, and (3) ICH. A total of 6022 patients were included: 4922 (mean age 71.9 ± 13.8 years) with IS and 1100 (mean age 73.3 ± 13.1 years) with ICH. NIHSS at 24, 48 h and axillary temperature at admission were the most important variables to consider for evolution of patients at 3-months. IS + ICH group was the most stable for mortality prediction [0.904 ± 0.025 of area under the receiver operating characteristics curve (AUC)]. IS group presented similar results, although variability between experiments was slightly higher (0.909 ± 0.032 of AUC). ICH group was the one in which RF had more problems to make adequate predictions (0.9837 vs. 0.7104 of AUC). There were no major differences between IS and IS + ICH groups according to morbidity prediction (0.738 and 0.755 of AUC) but, after checking normality with a Shapiro Wilk test with the null hypothesis that the data follow a normal distribution, it was rejected with W = 0.93546 (p-value < 2.2e-16). Conditions required for a parametric test do not hold, and we performed a paired Wilcoxon Test assuming the null hypothesis that all the groups have the same performance. The null hypothesis was rejected with a value < 2.2e-16, so there are statistical differences between IS and ICH groups. In conclusion, machine learning algorithms RF can be effectively used in stroke patients for long-term outcome prediction of mortality and morbidity.

Shifting trends in modes of death in the Intensive Care Unit

PURPOSE

To describe the way patients die in a Spanish ICU, and how the modes of death have changed in the last 10 years.

MATERIALS AND METHODS

Retrospective observational study evaluating all patients who died in a Spanish tertiary ICU over a 10-year period. Modes of death were classified as death despite maximal support (D-MS), brain death (BD), and death following life-sustaining treatment limitation (D-LSTL).

RESULTS

Amongst 9264 ICU admissions, 1553 (16.8%) deaths were recorded. The ICU mortality rate declined (1.7%/year, 95% CI 1.4-2.0; p = 0.021) while ICU admissions increased (3.5%/year, 95% CI 3.3-3.7; p < 0.001). More than half of the patients (888, 57.2%) died D-MS, 389 (25.0%) died after a shared decision of D-LSTL and 276 (17.8%) died due to BD. Modes of death have changed significantly over the past decade. D-LSTL increased by 15.1%/year (95% CI 14.4-15.8; p < 0.001) and D-MS at the end-of-life decreased by 7.1%/year (95% CI 6.6-7.6; p < 0.001). The proportion of patients diagnosed with BD remained stable over time.

CONCLUSIONS

End-of-life practices and modes of death in our ICU have steadily changed. The proportion of patients who died in ICU following limitation of life-prolonging therapies substantially increased, whereas death after maximal support occurred significantly less frequently.

Observational multicentre prospective study to assess changes in cognitive function in patients treated with PCSK9i. Study protocol

OBJECTIVE

PCSK9 inhibitors have been shown to reduce LDLc by up to about 60% and 85% when used with high doses of statins and ezetimibe (2019 ESC/EAS Guidelines). These therapies may lead to very low levels of LDLc and have been associated with possible cognitive deterioration. No significant differences were found in the only specific  study (EBBINGHAUS). The objective is to prospectively evaluate cognitive  deterioration and its repercussion on quality of life and changes in LDLc in  patients starting treatment with PCKS9 inhibitors.

METHOD

It is a postauthorization, multicentre, non-randomized, prospective study. Patients starting treatment for the first time with PCSK9 inhibitors will be recruited in 11 Galician Hospitals over a period of 12 months and with 24 months of follow-up. The primary outcome will be to evaluate changes in cognitive function using the Montreal  Cognitive Assessment (MOCA) questionnaire. The secondary outcome will be to evaluate changes in quality of life using the EuroQol-5D. Changes in LDLc will be assessed. The sample size will be 275 patients, taking into account a loss to follow-up of no more than 10%. The primary outcome  will be studied through the dichotomous variable cognitive deterioration (0/1). Cognitive changes over the follow-up period will be analysed using  the McNemar test. In addition, an analytical approach using logistic regression will be followed to identify patients at risk of cognitive deterioration. As a result, this analysis will obtain a frequency measurement: the odds ratio (OR). The specific objectives will be studied  using bivariate analysis. Continuous contrast variables will be studied using the t-test or ANOVA and categorical variables will be studied using the chi- square test.

CONCLUSIONS

The MEMOGAL study will provide information on safety in  terms of cognitive deterioration in patients starting treatment with PCSK9 inhibitors.

People would rather see a physician than a dentist when experiencing a long-standing oral ulceration. A population-based study in Spain

BACKGROUND

Primary care physicians have been reported to be the first choice for patients with oral ulcerations. This study investigates the health-seeking behaviour of lay public in Galicia (North-western Spain) if experiencing a long-standing oral ulceration.

MATERIAL AND METHODS

Cross-sectional population-based survey of randomly selected respondents conducted from March 1, 2015 to 30 June 2016.

RESULTS

A total of 5,727 pedestrians entered the study (response rate: 53%), mostly in the 45-64 age group (30.2%; n=1,728), 47.7% of them (n=2,729) were males. Most participants (42.1%; n=2,411) reported to visit their dentist once a year and had secondary or compulsory education as their highest educational achievement (28.18%, n=1,614; 28%, n=1,600 respectively). When questioned what they would do if they had a wound/ulceration lasting longer than 3 weeks, most participants answered they would go to see their primary care physician (62.8%; n=3,597) and less than one quarter of the sample (23.8%; n=1,371) would seek consultation with their dentist.

CONCLUSIONS

General Galician population would seek professional consultation about a long-standing oral ulceration, relying mostly on primary care physicians. Those neglecting these lesions are elderly, less-schooled people and unaware of oral cancer.

Family nurses, oral hygiene, and educational implications: a cross-sectional study

OBJECTIVE

To describe family nurses self-reported oral hygiene practices and to compare them with those of their potential patients in a public, free, and universal primary healthcare system.

MATERIAL AND METHODS

Cross-sectional study using an anonymous questionnaire applied to randomly selected participants and their family nurses.

RESULTS

A total of 1,394 people entered the study (1,326 laypersons, 66 nurses). Not all nurses reported to brush their teeth daily. Daily interdental cleaning scored percentages lower than mouthwashes. Devices like oral irrigators or tongue scrappers were not used by family nurses.

CONCLUSIONS

Nurses' oral self-care routines are similar to those of university graduates, with poor reported interdental cleaning. Oral health promotion activities may contribute to nurse's oral health and could have a positive effect on their patients.

Quality of cross-infection control in dental laboratories. A critical systematic review

Purpose

To identify reported practices for cross-infection control in dental laboratories and to quantify the importance of the flaws encountered.

Data sources

Systematic search (cross-infection AND dental laboratory) at EMBASE, PubMed, SciELO and Scopus databases.

Study selection

Papers reporting on cross-sectional studies providing original data about cross-infection knowledge, practices and attitudes of dental technicians. Papers reporting on a single laboratory or institution were excluded.

Data extraction

Data extraction was undertaken independently by three reviewers using a purpose made form. The outcome of this study was analyzed in five aspects, namely process organization, disinfection, working environment, use of individual protective equipment and vaccination policy.

Results of data synthesis

The systematic search output was 1651 references and 11 papers were finally selected. Flaws were more frequently identified in terms of vaccination policy, biological safety of the working environment and use of individual protective equipment (100%). Slightly better results were found in terms of organization of the cross-infection control process (89.47%) and disinfection practices (85.71%). The application of the formula for disclosing the relative importance of the flaws identified in the literature prioritizes the need for interventions aimed at improving the organization of the cross-infection control procedures, followed by training in item disinfection. The control of the working environment together with the use of individual protective equipments rank closely in importance, followed by the existence of a vaccination policy.

Conclusions

Sub-standard cross-contamination practices seem to be a common finding in dental laboratories, which may well compromise the quality of certain dental treatments.

Primary care physicians and nurses: Targets for basic periodontal education

BACKGROUND

Early diagnosis may improve patients' quality of life and reduce the lifelong social and financial burden inherent to treatment. Growing evidence supports the importance of a healthy periodontium in systemic health. Diagnosis depends on the patient and the healthcare professional. As many patients seek physicians' advice first, this study aims at assessing periodontal knowledge in a general population and their primary care physicians and nurses.

METHODS

This is a cross-sectional study using an anonymous questionnaire applied to randomly selected laypersons (March to June 2016), and to physicians and nurses at their workplaces (October to December 2016) in Ourense, Spain. Sample size for the general population was determined by quota sampling.

RESULTS

A total of 1,469 people entered the study. All healthcare workers and 624 (47.1%) laypersons were familiar with periodontitis. Bacterial etiology of periodontitis was recognized by 25 (4%) laypersons, 23 (34.3%) physicians, and 11 (16.6%) nurses. The following periodontal problems were experienced: 1) gingival redness: laypersons 14.4%, physicians 16.4%, and nurses 21.2%; 2) gingival bleeding: laypersons 22.2%, physicians 50.7%, and nurses 50%; 3) tooth mobility: laypersons 34.9%, physicians 7.4%, and nurses 6%; and 4) bleeding while toothbrushing: laypersons 44.3%, physicians 8.9%, and nurses 15.1%. More than a third of laypersons (37%) think periodontitis is related to other health problems, together with 53% of physicians and 47% of nurses.

CONCLUSIONS

Our results show a low degree of periodontal knowledge both amongst the public and their primary care physicians and nurses and unveil unreliable targets (primary healthcare workers) for educational interventions to improve early diagnosis and treatment of periodontal disorders.

Is it Useful to Calculate Minimal Erythema Dose Before Narrowband UV-B Phototherapy?

INTRODUCTION AND OBJECTIVES

The starting dose for narrowband UV-B phototherapy is determined by a patient's skin phototype or minimal erythema dose (MED). Calculation of MED identifies patients with unsuspected photosensitivity. The aim of this study was to investigate the influence of factors such as concomitant use of photosensitizing agents, diagnosis, and combination with acitretin in patients with psoriasis on the frequency and severity of adverse effects in patients with a low MED to narrowband UV-B phototherapy.

MATERIAL AND METHODS

We undertook a retrospective observational cohort study between February 1, 2009 and March 31, 2015. MED values were classified as normal or low.

RESULTS

In total, 302 patients with different skin conditions started narrowband UV-B phototherapy at a dose determined by their MED. No differences were found between patients with a low MED and those with a normal MED for number of drugs taken (P=.071) or use of photosensitizing agents (P=0.806). Following adjustment for age, sex, and phototype, the multivariate analysis showed that psoriasis exerted a protective effect against a low MED (OR=0.31 [95% CI, 0.16-0.58]). No significant risk of erythema or pruritus was detected in patients with a low MED (OR=1.68; 95% CI, 0.91-3.29 and OR=2.04; 95% CI, 0.99-4.22, respectively).

CONCLUSIONS

Psoriasis protects against a low MED. Although erythema and pruritus were more common in patients with a low MED, the differences were not significant.

[Effect of socioeconomic status on mortality in urban areas: a systematic critical review]

Socioeconomic inequalities cause more disease and death than most risk factors, especially in cities. This systematic review of the scientific evidence included articles in English, Spanish, Portuguese, and Italian and excluded studies with low levels of evidence and those that did not analyze associations between mortality and socioeconomic status in urban settings. Articles were selected by two independent reviewers, and data extraction used evidence tables. A total of 1,509 records were obtained, and 24 were included. All the studies showed higher mortality rates in poorer areas. Six studies showed an association with cardiovascular diseases, four with lung diseases, and three with AIDS, infectious and parasitic diseases, and cirrhosis. The selected studies showed low consistency in the results and important methodological limitations that prevented comparisons between studies or the extraction of relevant conclusions.

Is posturography able to identify fallers in patients with Parkinson's disease?

INTRODUCTION

Parkinson' disease (PD) is one of the most prevalent neurodegenerative diseases, and more than half of patients with PD experience falls. Research for clinically useful risk factors predicting falls has yielded inconsistent findings so far. Hence the aim of the study is to validate two different posturography techniques and one modified-timed up and go test (TUG) in discriminating fallers and non-fallers among PD patients.

METHODS

32 patients diagnosed with idiopathic PD were assessed with: Dizziness handicap inventory, Activities-specific balance confidence scale, modified-TUG, sensorial organization test (SOT) and limits of stability (LOS) of computer dynamic posturography, results of free-field body sway analysis with Vertiguard device and number of falls.

RESULTS

Fallers had longer time to perform modified-TUG and required more steps. On average, fallers performed SOT and LOS significantly worse and Vertiguard device indicated a higher risk of falling. Based on the area under the curve of receiver operating characteristics analyses, the overall accuracy of directional control of LOS and steps in modified-TUG are close to 0.9 (high accuracy). Also assessment with Vertiguard device is more efficient in identifying fallers than the parameters of SOT.

DISCUSSION

Our results indicate that LOS, mobile posturography (Vertiguard), vestibular input of SOT and number of steps taken in modified-TUG are very useful to identify fallers in PD patients.

Prevalence of CYP2C9 polymorphisms in the south of Europe

CYP2C9 is a major liver enzyme responsible of the metabolism of many clinically important drugs. The presence of CYP2C9 genetic polymorphisms has been associated with marked interindividual variability in its catalytic activity that could result in drug toxicity. Here we present frequencies of the most common CYP2C9 coding variants CYP2C9*2 (C430T) and CYP2C9*3 (A1075C) in representative samples of four regions from Spain (Basque Country, n=358; Catalonia, n=240; Central Spain, n=190 and Galicia, n=288) and one northern Italian region, (Verona, n=164), which range between 0.125 and 0.165 in the case of CYP2C9*2 and between 0.071 and 0.085 for CYP2C9*3. No significant differences between CYP2C9 allele frequencies were found comparing all the sampled populations. A more extensive comparative analysis using allele frequency data of populations widely spread over Europe was performed, showing significant differences in the CYP2C9*2 allele frequencies distribution between some of the regions, being quite homogeneous in the case of CYP2C9*3 variant. The results obtained show that above 40% of our samples carry a mutate allele, which can result in a poor metabolization of low therapeutic index drugs as oral anticoagulants (warfarin, acenocoumarol), oral antidiabetic drugs and some non-steroidal anti-inflammatory drugs. Our study constitutes both a large (n=1240) and robust allele frequency database on CYP2C9 polymorphisms, which represents one of the most numerous CYP2C9*2 and *3 database existing to date.