Fibrosis assessment in patients with nonalcoholic fatty liver disease: Adherence to proposed algorithms and barriers to complying with them

INTRODUCTION AND AIMS

Fibrosis staging in patients with nonalcoholic fatty liver disease (NAFLD) is carried out through the application of stepwise algorithms but there is little real-world data on their use. Our aim was to calculate the number of patients with NAFLD and indeterminate or high risk for fibrosis, assessed through noninvasive scores, that consequently underwent further staging evaluation.

MATERIALS AND METHODS

A cross-sectional multicenter cohort study was conducted on patients with NAFLD evaluated by hepatologists within the time frame of June 1 and July 31, 2018. The FIB-4 and NAFLD fibrosis scores were calculated in all the patients, and if at least one of the scores suggested indeterminate or high risk for fibrosis, we believed the patient should have undergone additional fibrosis staging assessment.

RESULTS

The study included 238 patients. The median time interval from NAFLD diagnosis and inclusion in the analysis was 12.2 months (IQR 3.0-36.5). A total of 128 (54%) patients had at least one noninvasive score that suggested indeterminate or high risk for fibrosis but studies to confirm the fibrosis grade (elastography, biopsy, etc.) were performed on only 72 (56%). The main barriers encountered by the physicians for applying the staging algorithms were related to health insurance coverage and imaging study costs.

CONCLUSIONS

A high percentage of patients with NAFLD were at indeterminate or high risk for fibrosis, according to noninvasive scores, but additional studies were carried out on only half of them, showing low adherence to current recommendations.

Fibrosis assessment in patients with nonalcoholic fatty liver disease: Adherence to proposed algorithms and barriers to complying with them

INTRODUCTION AND AIMS

Fibrosis staging in patients with nonalcoholic fatty liver disease (NAFLD) is carried out through the application of stepwise algorithms but there is little real-world data on their use. Our aim was to calculate the number of patients with NAFLD and indeterminate or high risk for fibrosis, assessed through noninvasive scores, that consequently underwent further staging evaluation.

MATERIALS AND METHODS

A cross-sectional multicenter cohort study was conducted on patients with NAFLD evaluated by hepatologists within the time frame of June 1 and July 31, 2018. The FIB-4 and NAFLD fibrosis scores were calculated in all the patients, and if at least one of the scores suggested indeterminate or high risk for fibrosis, we believed the patient should have undergone additional fibrosis staging assessment.

RESULTS

The study included 238 patients. The median time interval from NAFLD diagnosis and inclusion in the analysis was 12.2months (IQR 3.0-36.5). A total of 128 (54%) patients had at least one noninvasive score that suggested indeterminate or high risk for fibrosis but studies to confirm the fibrosis grade (elastography, biopsy, etc.) were performed on only 72 (56%). The main barriers encountered by the physicians for applying the staging algorithms were related to health insurance coverage and imaging study costs.

CONCLUSIONS

A high percentage of patients with NAFLD were at indeterminate or high risk for fibrosis, according to noninvasive scores, but additional studies were carried out on only half of them, showing low adherence to current recommendations.

Telemedicine: contributions, difficulties and key factors for implementation in the prison setting

Information and communication technologies are transforming the way we understand health, via a hyper-connected world in which patients, professionals and society take on new challenges and roles. This change is creating an ecosystem called connected health, in which telemedicine acquires special importance when distance (not only geographical), is a critical factor. It can respond to financial, social or safety needs or questions of dignity, as is the case with prisoners when they are transferred handcuffed and under custody to hospitals. Bringing health services closer to patients who cannot autonomously travel contributes towards humanising healthcare. Tele-consultations, long-distance encounters between patients and health professionals, reduce the direct and social costs inherent to habitual clinical practice and are very highly valued by patients in prison. Despite its potential benefits in the prison setting, the implementation of telemedicine in Spain continues to be scarce and irregular, which, amongst other things, is due to a lack of awareness of this healthcare practice, the severe shortage of resources currently endemic to the prison health service system and the lack of interoperability solutions for clinical information between the healthcare administration and the prison health services, which unfortunately continue to depend on an organisation outside the healthcare ambit (the Ministry of Home Affairs), despite the legal provisions requiring them to be fully integrated into regional health services. The SARA (Administration Applications and Networks Systems) Network and the Reúnete© Service offer solid, secure, free technology is available to all prisons, to set in motion telemedicine programs at a nationwide level.

[Experience of implementing the ISO 9001:2015 standard for the accreditation of a paediatric hospital emergency department]

OBJECTIVE

The aim of this paper was to describe the process for accrediting a paediatric hospital emergency department to ISO 9001:2015 standards. The implementation process began in February 2015 and lasted 18months.

MATERIAL AND METHODS

The project started with the decision by the Head of Department to improve service quality. A Quality Committee was established with representation of the medical, nursing and administrative staff. Training sessions were held on quality management systems and ISO standards for employees. A meeting took place among members of the Emergency Department to define the main processes, and 14 were identified, documented and included in the processes map. Workgroups were then created to review and redesign the medical and nurse protocols.

RESULTS

Thirty-five medical and fifteen nursing protocols were incorporated into the management system, and quality indicators were established that allowed the whole process to be monitored. A risk register was created to record identified risks, their severity, likelihood of occurrence, and actions taken to prevent or reduce those risks. The Emergency Department underwent an external audit during June 2016, and was certified to the requirements demanded by the international ISO 9001:2015 standard.

CONCLUSIONS

The conclusion is that implementation of a quality management system on ISO and its certification is completely achievable, and has contributed to better patient management.

[Needs in rare diseases during paediatric age]

All rare diseases present a common set of challenges to the sufferers and their families: diagnosis, dealing with symptoms, health information, obtaining helpful medical care, availability of medications, disability and emotional impact. Children with rare disorders are an important population from health care services, and social services perspectives, and families are providing long-term care for these chronically ill children. The impact of rare disorders in children is far-reaching, extending beyond the child to all those with whom he/she has contact. Multiple facets of life are affected including social an family relationships, economical well-being and activities of daily living. The assessment of needs for rare disorders treatment is a critical step in providing high quality care and achieving patients' and families' satisfaction. Findings from different studies show that people with rare diseases have medical and social needs. Social needs are becoming more relevant in developed countries where health care services, even with limitations, have greater availability than social services. Furthermore, it seems that health care and social services for persons with rare diseases need to be improved to address the patients' needs and to provide better support to families. Validated tools with good psychometric properties are still needed to assess quality of care on the basis of patients and family needs.

Use of Enteric-Coated Mycophenolate Sodium in De Novo Renal Transplant Recipients With High Incidence of Delayed Graft Function

Patients with delayed graft function (DGF) are at risk of increased incidence for acute rejection episodes (ARE). Mycophenolate mofetil or induction therapy has produced a reduction in ARE incidence. An open, prospective, 3-month trial was performed in a group of Argentinian renal transplant recipients. We recruited 46 patients, 71.7% men, aged 41.7 +/- 13.8 years; including 36 (78.3%) recipients of cadaveric donors (CD) who were aged 43.4 +/- 15.5 years with a cold ischemia time of 19.4 hours +/- 5.4 minutes, and 10 (27.7%) recipients of living donors (LD) aged 37.8 +/- 12.9 years. HLA mismatches >or= 3 were observed in 58.4% of CD and in 7% of LD. All patients received two doses of basiliximab (20 mg each, days 0 and 4), cyclosporine microemulsion (CsA-ME) monitored by the second-hour concentrations (C2), enteric-coated mycophenolate sodium (EC-MPS; 720 mg twice a day, and steroids. A 58% incidence of DGF was observed. At the end of the third month the incidence of biopsy-proven ARE was 15%, with a median serum creatinine of was 1.54 +/- 0.42 mg/dL, including three grafts lost. Two patients died. No patient required EC-MPS dose discontinuation but 20% of patients required dose adjustments. The absence of discontinuations and the low incidence of dose adjustments of EC-MPS in this high-risk de novo population provided support of a suitable tolerability profile for this EC-MPS, and the possibility to impact efficacy results.

Participation of RANTES and T-Cell Apoptosis in Human Renal Allograft

The aim of this study was to evaluate the serum RANTES (Regulated upon Activation of Normal T cell Expressed and Secreted) levels and the expression of CCR5, as well as the percentage of apoptotic cells, in peripheral T lymphocytes from renal transplanted patients with acute rejection (AR), chronic rejection (CR) or stable evolution (SE). RANTES serum levels were determined by enzyme-linked immunoadsorbent assay and CCR5 expression, as well as the percentage of apoptotic lymphocytes, on a FACScan flow cytometer. After staining with different antibodies, the cells were subjected to three-colour flow cytometric analysis. Data analysis was performed using winmdi 2.5 software. The serum RANTES level and percentages of CCR5/CD4 and CCR5/CD8 T lymphocytes in CR, AR and SE were lower than that in the control group (P <0.05). The level of CD4 and CD8 T lymphocytes in early apoptosis was higher in AR patients than in CR, SE or C groups (P <0.05). In the case of late apoptosis, the percentage of apoptotic/necrotic cells was higher in the CR than AR, SE or C groups (P <0.05). The RANTES serum levels and the percentage of peripheral CCR5 T lymphocytes would not indicate the renal allograft state. The increase of early apoptotic T lymphocytes could be a marker of AR process and could also indicate the initial step in reducing the cytotoxic T lymphocytes, thus favouring the graft evolution.

Gammadelta T cells and interleukin-6 levels could provide information regarding the progression of human renal allograft

We have determined the percentage of alphabeta and gammadelta T cells by flow cytometry as well as serum interleukin-6 (IL-6) and soluble interleukin-6 receptor (sIL-6R) levels by enzyme-linked immunosorbent assay in kidney allograft recipients with acute, chronic or stable graft evolution. The percentage of CD4 and CD8 T cells in transplanted patients was lower than in the control group (P < 0.001) with the exception of CD8 gammadelta T cells from patients with stable evolution (P > 0.05). The serum levels of IL-6 and sIL-6R in acute and chronic rejection were higher than in the controls (P < 0.05). No differences in IL-6 levels were observed between the stable evolution and the control groups (P > 0.05). The levels of sIL-6R were higher in stable evolution patients than in the controls (P < 0.05) and no differences were observed between the chronic and stable evolution patients (P > 0.05). IL-6 decreased in patients with a favourable evolution, increased in those with an increased renal dysfunction and was maintained when the renal dysfunction was not modified. These results suggest that gammadelta T cells could participate in renal allograft maintenance and that IL-6 but not sIL-6R serum levels may provide a prognostic marker for measuring the evolution of kidney allograft.

Quality of life in patients with schizophrenia in five European countries: the EPSILON study

OBJECTIVE

To compare subjective quality of life (QOL) and objective QOL indicators in patients with schizophrenia from five European sites: Amsterdam, Copenhagen, London, Santander and Verona.

METHOD

A representative sample of 404 patients with schizophrenia, in contact with mental health services, was randomly selected and evaluated with the Lancashire Quality of Life Profile (EU).

RESULTS

The level of satisfaction in certain domains, religion, family and social relations appears to be associated with local style of living and culture while work, finances, and safety were more independent from local variations. In addition to the severity of symptoms, frequency of contacts with family, friendship and age appear as predictors of QOL, all of them influenced by the characteristics of the surroundings.

CONCLUSION

The centres participating in the study presented differences in subjective measures of QOL, objective indicators and also in service provision and styles of living.

Assessment instruments: standardization of the European Service Mapping Schedule (ESMS) in Spain

OBJECTIVE

To adapt the European Service Mapping Schedule (ESMS) for use in Spain and assess the quality of this schedule.

METHOD

Following linguistic and conceptual translation, 77 services in five Spanish catchment areas were described by independent local raters, including two experts in health services research. Feasibility (applicability. acceptability and practicality), descriptive validity and overall percentage agreement were assessed.

RESULTS

ESMS feasibility was considered adequate. The tree system facilitates reporting and comparison of data. Face, content and discriminant validity are adequate for almost all services. The overall reliability was high but completion of the service utilization section required expert supervision. The ESMS revealed large differences in service availability and utilization in the five different areas of Spain.

CONCLUSION

The ESMS has proved useful for describing mental health services in Spain, and facilitates comparisons between catchment areas.

Development, internal consistency and reliability of the Verona Service Satisfaction Scale--European Version. EPSILON Study 7. European Psychiatric Services: Inputs Linked to Outcome Domains and Needs

BACKGROUND

Satisfaction with mental health services is an important quality and outcome variable. The Verona Service Satisfaction Scale (VSSS) is a well-established method for measuring service satisfaction.

AIM

To report the development and reliability study of the European Version of the VSSS (VSSS-EU).

METHOD

A sample of people with schizophrenia on the case-load of local mental health services in the five European participating countries was assessed. The VSSS-EU was administered at one site in each country at two points in time. Internal consistency and test-retest reliability were assessed and compared between the five sites.

RESULTS

The alpha coefficient for the VSSS-EU total score in the pooled sample was 0.96 (95% CI 0.94-0.97) and ranged from 0.92 (95% CI 0.60-1.00) to 0.96 (95% CI 0.93-0.98) across the sites. Test-retest reliability for VSSS-EU total score, pooled over sites, was 0.82 (95% CI 0.78-0.85) and ranged from 0.73 (95% CI 0.6-0.86) to 0.93 (95% CI 0.89-0.97) across the sites.

CONCLUSION

VSSS-EU is a reliable instrument for measuring service satisfaction in people with schizophrenia, for use in comparative cross-national research projects and in routine clinical practice in mental health services across Europe.

Translation and cross-cultural adaptation of outcome measurements for schizophrenia. EPSILON Study 2. European Psychiatric Services: Inputs Linked to Outcome Domains and Needs

BACKGROUND

Research on the comparison of mental health services has identified the need for internationally standardised and reliable measurements.

AIMS

To describe the strategies adopted in the European Psychiatric Services: Inputs Linked to Outcome Domains and Needs (EPSILON) Study for the translation and cross-cultural adaptation of five European versions of the instruments.

METHOD

A protocol was developed for translation of the outcome scales, describing each step in the translation procedure. Disputed items were discussed in focus groups, which faced seven tasks: a list of topics to be discussed; choosing where the group should meet; composition of participants; conducting the group; data collection; data completion afterwards; reporting results.

RESULTS

Modifications made to instruments were: changes in the instrument structure, contents and concepts; adjustments to the instrument structure; and modifications to the instrument manual.

CONCLUSION

Use of focus groups is an adequate method to apply if concepts, constructs and translation issues are to be addressed; otherwise, less time-consuming methods should be considered.

Client Socio-Demographic and Service Receipt Inventory--European Version: development of an instrument for international research. EPSILON Study 5. European Psychiatric Services: Inputs Linked to Outcome Domains and Needs

BACKGROUND

Cross-cultural comparison of mental health service utilisation and costs is complicated by the heterogeneity of service systems. For data to be locally meaningful yet internationally comparable, a carefully constructed approach to its collection is required.

AIMS

To develop a research method and instrument for the collection of data on the service utilisation and related characteristics of people with mental disorders, as the basis for calculating the costs of care.

METHOD

Various approaches to the collection of service use data and key stages of instrument development were identified in order to select the most appropriate methods.

RESULTS

Based on previous work, and following translation and cross-cultural validation, an instrument was developed: the Client Socio-Demographic and Service Receipt Inventory--European Version (CSSRI-EU). This was subsequently administered to 404 people with schizophrenia across five countries.

CONCLUSION

The CSSRI-EU provides a standardised yet adaptable method for collating service receipt and associated data alongside assessment of patient outcomes.

Quality of life in schizophrenia: development, reliability and internal consistency of the Lancashire Quality of Life Profile--European Version. EPSILON Study 8. European Psychiatric Services: Inputs Linked to Outcome Domains and Needs

BACKGROUND

This paper, part of the European Psychiatric Services: Inputs Linked to Outcome Domains and Needs (EPSILON) Study, reports the development, reliability and internal consistency of the Lancashire Quality of Life Profile--European Version (LQoLP-EU) in a representative sample of people with schizophrenia from five European sites.

METHOD

The LQoLP-EU was administered to a total sample of 404 patients to check its internal consistency, and a sub-sample of 294 patients was interviewed a second time within 7-15 days to verify its test-retest reliability.

RESULTS

Internal consistency of the total domains, perceived QoL scale (Life Satisfaction Scale, LSS) was good at 0.87. Of the nine subjective QoL domains Work and Leisure showed the lowest internal consistency (0.30 and 0.56 respectively), the values of the remaining sub-scales ranging between 0.62 and 0.88. The pooled ICC score for LSS was 0.82, and for the nine subjective QoL domain sub-scales it ranged from 0.61 (Safety) to 0.75 (Living Situation). There were significant differences between the sites in alpha and ICCs for sub-scales, but not for the LSS.

CONCLUSION

The LQoLP-EU has good internal consistency and reliability in the five European centres.

[Spanish version of the new World Health Organization Disability Assessment Schedule II (WHO-DAS-II): initial phase of development and pilot study. Cantabria disability work group]

The aim of the present paper is to present the initial phases of the development of the Spanish version of the "World Health Organization Disablement Assessment Schedule II" WHO-DAS-II and also to describe the quantitative and qualitative methodological strategies used in the elaboration process of an instrument: i) compatible with the new International Classification of Functioning and Disability -ICIDH-2- of the World Health Organisation; ii) with criteria of cross-cultural applicability and; iii) to allow us to assess the disability in all its dimensions.

Alcohol consumption in a rural area of Cantabria

A two-stage cross-sectional survey was performed in a representative rural sample of the autonomous community of Cantabria, to investigate the social, medical and psychopathological factors associated with alcohol consumption. Alcohol consumption was investigated by means of a specific questionnaire. Mental and physical health was evaluated in the first-stage sample using: (1) the General Health Questionnaire, (2) the Cornell Medical Index. In the second stage all members of the sample were interviewed at home using the 140-item version of the Present State Examination (PSE-9). We found that 25.4% of males and 0.6% of females were consuming more than 63 alcohol units per week. Alcohol consumption was significantly associated with different social variables. Although it was possible to detect an increase in weekend drinking, especially in the heavy alcohol users, daily alcohol consumption, mainly around meals, was the predominant drinking pattern. We also found a significant inverse association between excessive alcohol consumption and the presence of physical or mental illness. Excessive alcohol use tended to be associated in males with depression and in females, with anxiety.

The Cantabria first episode schizophrenia study: a summary of general findings

This article describes the general findings of the initial cross-sectional stage of a prospective follow-up study of all first episodes of schizophrenia that occurred in the Autonomous Community of Cantabria over a 2-year period and that established contact with any mental health service. The project comprises: i) a 2-year cross-sectional stage, in which the sample was gathered and studied with structured psychiatric instruments such as the Present State Examination and the Scales for the Assessment of Negative and Positive Symptoms (SANS and SAPS), and; ii) a continuous follow-up. We detected, in the risk age ranged of 15-54 years, an incidence of 1.9 per 10,000 inhabitants per year for schizophrenia and of 1.3 per 10,000 inhabitants per year for the S+ CATEGO diagnosis, without any significant gender difference of morbidity. The mean age for the total schizophrenic population was 26 years, being significantly higher in women than in men. In contrast with what happens with marital status, type of household or urban/rural way of life, there was no gender difference in relation to the other sociodemographic variables. The way in which nosological and clinical variables are associated with first episodes of schizophrenia was also examined in this study. We found that 75% of patients reached a maximum CATEGO-ID level, 71% received a S+ CATEGO diagnosis, 59% presented first-rank symptoms of schizophrenia and that the percentage of a schizophrenic negative syndrome, as identified by the SANS and SAPS, was very low.(ABSTRACT TRUNCATED AT 250 WORDS)

[Development and verification of the Spanish version of the "scanning system" psychiatric interview ("Questionnaires for clinical evaluation in neuropsychiatry"]

The SCAN System (Schedules for Clinical Assessment in Neuropsychiatry) represents the latest stage in a 30 year line of development. It is a set of instruments aimed at assessing, measuring and classifying the psychopathology and behaviour associated with the mayor psychiatric disorders of adult life. The SCAN System has several components: the SCAN interview, the Glossary of differential definitions, the CATEGO5 program and the CAPSE (Computer Assisted PSE versión). This latest element is a computerised versión of the System, combining the SCAN's interview, Glossary and CATEGO5. The SCAN interview has 3 components, the tenth edition of the Present State Examination (PSE10), the Item Group Checklist (IGC) and the Clinical History Schedule (CHS), whose main features are described in the paper. The CATEGO5 suite of computer programs consists in a set of utilities concerned with data entry and diagnosis. The Entry program is used to enter data recorded manually during a SCAN interview and the diagnosis programs derive diagnosis according to ICD-10 and DSM-III-R/DSM-IV criteria. This report analyses the main methods and results of the "Field Trials" that took place in 20 Centres of different countries. These studies showed that the diagnosis and symptoms scores have a high degree of reliability and that this is also applicable to the spanish version. In conclusion, we consider that the SCAN System is once of the more suitable psychiatric diagnostic instruments currently available.

Pathways to psychiatric care in Cantabria

This article delineates the pathways taken in different health areas of Cantabria (Spain) by a series of newly referred patients to the mental health services and explores the influence of sociodemographic, medical and service-related factors on the delays in referral. The work forms part of an ongoing World Health Organization multicentre research programme aimed at exploring and optimizing the quality of mental health care in different centres of the world. We found that, in a rural health area, the majority of newly referred patients establish the first contact with the general practitioner and to a lesser extent with the hospital doctor and from there directly progress to the psychiatric services; in the urban health area there is a greater tendency to contact specialized medical and psychiatric services. Delays in these health areas are remarkably short and are comparable to the ones in other European centres. Our data also show that somatic symptoms are the main presenting problem both at the primary care and at the mental health level; and that, in general, psychotropic drug prescriptions are high both in hospital and in general medical settings, and that women were more often prescribed psychotropic medication than men.

[Factors implicated in the "routes of care" in mental health]

We analyze in this paper the way in which different sociodemographic and clinical factors influence, in different health areas of Cantabria (Spain), the pathways taken for patients suffering from "new psychiatric illness". The work is part of a Multicentric International Research Project developed by the World Health Organization aimed at evaluating and improving the quality of mental health care in different centres of the world. The general pathway to mental health services, in Cantabria, is dominated by the general practitioner (54.3%) and by the "hospital doctor/medical specialist" (26.4%), been therefore similar to the one found in other Spanish speaking centres, like Granada and Cuba; the differences are, however, much larger with the one found in Mexico city. It is also, possible to observe in our data that the pathways are influenced by clinical factors, among which the more relevant one is one related to the characteristics of the psychopathology. Thus in general we found that two factors like, the presence of "psycho-organic" syndromes and the severity of the psychopathology appears to influence: i) the degree of complexity of the pathway, which is higher in the "psycho-organic" and in the more severe forms of psychiatric disorders; ii) the protagonist which assumes, in detriment of the general practitioner, other "helping agencies" which is also increased in the "organic" and more severe disorders. We also found that other aspects like: the act of establishing "contact" with services, the delay in the obtention of help, and the prescription of psychotropic medicines, were also influenced by different sociodemographic, clinical and service related variables.

The epidemiology of head injury in Cantabria

The epidemiology of head injury was studied in Cantabria, Spain, using a methodological design consisting of a cross-selectional analysis of one year of duration and an additional one year follow-up of all the patients included in the initial sample. The 477 cases identified represent a rate of 91/100,000, with males showing a head injury rate 2.7 times higher that than for females. Sixty per cent of all cases involved traffic accidents, falls accounted for 24% and industrial accidents were the cause in 8%. The annual age-adjusted mortality rate was 19.7/100,000. Over 92% of all deaths occurred prior to hospital admission. The presence of alcohol intoxication was evaluated in 211 cases by determining the osmolar gap. It was found that 51% of all the cases examined presented clear evidence of acute alcohol intoxication.

Why people with probable minor psychiatric morbidity consult a doctor

This epidemiological investigation examines factors determining medical consultation in people with probable minor psychiatric morbidity. About 54% of people with probable minor psychiatric morbidity and about 23% of the (numerically much greater) remainder with lower probability of psychiatric morbidity consulted a doctor, usually a primary care physician, in the two weeks prior to a research interview. Medical consultation rates were higher in females than in males. The dominant finding was that in people with probable minor psychiatric morbidity physical illness was strongly associated with medical consultation. Almost 89% of males and 97% of females with probable minor psychiatric morbidity and physical illness consulted a doctor in the two weeks prior to interview. Logistic regression modelling was used to investigate the joint effects on medical consultation of physical illness and six socio-demographic variables, and physical illness emerged as the major single determinant of medical consultation in women and, in men, it exerted its effect through an interaction with lower educational level.

Sex differences in mental illness: a community study of the influence of physical health and sociodemographic factors

This paper examines sex differences in psychiatric morbidity, using data from a community sample. The PSE-CATEGO-ID system was used to evaluate psychopathology. Six sociodemographic factors and physical illness were taken as independent variables. Females exhibit both a significantly higher psychiatric morbidity than males and a predominance of syndromes closely related to depression (SD; OD syndromes) and anxiety (GA; SA; TE; IT syndromes). Logistic modelling analysis, carried out separately for each sex, yielded different models. Psychiatric illness in men was best predicted by physical illness, unemployment and the interaction between the two. In contrast, physical illness emerged, in women, as the only factor exerting significant effects on psychiatric morbidity.

[Morbidity and mortality in craniocerebral trauma: epidemiologic study in Cantabria]

Morbidity and mortality of the patients with head injury (HI) admitted to our institution during one year were prospectively evaluated. Four hundred and seventy seven fulfilled the inclusion criterial this represents an incidence of HI of 91/100,000/year for our community. Male/female ratio was 2,9/1. Traffic accidents were the most common cause of HI (60%). The clinical evaluation at admission with the Glasgow coma scale classified 88% of HIs as mild and 12% as moderate or severe. Recovery, following the Glasgow outcome scale, was good in 97%. The greater initial severity of HI and the lack of protective measures were respectively associated with a poorer clinical outcome and with a higher incidence of cranial and cerebral lesions. There were eigth hospital deahts, all in the group with severe scores; thus, the mortality rate in this group was 33%. Deaths outside the hospital were 95, i.e., 92% of the overall mortality. Our results confirm the public health relevance of HI, the very high prognostic value of the current evaluation scales and the insufficient use of protective measures in our area. Finally, the high rates or death outside the hospital suggest that emergency medical care outside the hospital is poor.

[Epidemiology and course of craniocerebral injuries in children in Cantabria]

We present the epidemiology and the outcome of the patients younger than 15 years-old who were admitted to our hospital during 1986 with the diagnosis of head injury. One hundred and fifty-five met the required inclusion criteria, this offers an incidence of head injury in children of 139/100,000. The boy/girl ratio was 2.1/1. The commonest causes were traffic accidents (45%), mainly those knocked down or on bicycles, and falls (41%). According to the Glasgow Coma Scale 88.5% of the head injuries were slight, only 11.5% being moderate or severe. The outcome was good in 97%. There were two intrahospital deaths, that happened in the 8 patients with severe head injury, giving a mortality rate of 25% for this group; and 5 deaths out of hospital. Thus, the global mortality secondary to head injury for children was 6.3/100,000 and year. These data show: a) the sanitary importance of the head injury in children; b) the necessity of a separate study of the head injury in children since the precipitating causes and the clinical outcome are specific; and c) the shortcomings in the urgent out of hospital medical attention, as indicates an out of hospital mortality rate of 71% which is well above that of other developed countries.

[The Ionescu-Shiley bioprosthesis in the aortic position. Medium to long-term evaluation]

From August 1977 through October 1984, 241 patients underwent aortic valve replacement with the Ionescu-Shiley prosthesis. The average age was 50.8 years (range 15 to 78). Aortic valve replacement was performed alone in 121 patients (50.2%) and with associated surgery in 120 (49.8%). Cumulative duration of follow-up was 1,260.08 patient-years, with a mean follow-up of 5.32 years per patient. Five patients were lost to follow-up. There were 26 hospital deaths and 15 late deaths (1.19% per patient-year). The expected 10.5 year actuarial survival rate was 82 +/- 2.9%. Twelve thromboembolic episodes occurred in 7 patients (7 central and 5 peripheral). The linearized thromboembolic rate was 0.95% per patient-year: 0.32% for patients with isolated aortic valve replacement and 0.63% for patients with concomitant surgery. Freedom from thromboembolic events at 10.5 years was 78 +/- 12%. Structural valve failure was found in 24 patients (1.9% per patient-year) with an actuarial rate of freedom for primary tissue failure of 72.6 +/- 6.1% at 10.5 years. Reoperation was required in 39 cases (3.09% per patient-year) due to primary tissue failure (n:24), paravalvular leak (n:7), infective endocarditis (n:6) and valve thrombosis (n:2). In conclusion, this pericardial bioprosthesis has demonstrated an adequate performance at mid and long-term follow-up, but somehow less satisfactory than previously reported.

[The Mitroflow bioprosthesis. Results after 6 years]

From March 1982 through December 1986, 139 Mitroflow pericardial heart valves were utilized in 129 patients. There were 69 males and 60 females, with an average age of 55.2 years (range 26 to 74 years). Eighty-nine patients underwent isolated aortic valve replacement, 27 isolated mitral valve replacement, three isolated tricuspid valve replacement and ten mitral-aortic valve replacement. In 20.9% additional cardiac surgery was performed. Maximum follow-up was 6 years with a mean of 43.9 months. The cumulative follow-up was 491 patients/year. Overall hospital mortality was 1.6% (2 cases). There were 3 late deaths in this series (2.4%). The linearized incidence of late mortality was 0.49% per patient/year. The survival actuarial curve was 96% +/- 1.8. The incidence of thromboembolism was 1.22% per patient/year, and the actuarial thromboembolism-free rate was 93% +/- 2.7. Three patients developed primary tissue failure of the Mitroflow valve in the mitral position. The linearized incidence of primary tissue failure was 0.73% per patient-year and the actuarial freedom from primary tissue failure was 95% +/- 3.2%. A total of 4 patients underwent reoperation (0.49% per patient/year). In conclusion, the clinical performance of the Mitroflow pericardial heart valve at medium-term follow-up is satisfactory; however a significant number of early primary tissue failures have already occurred in the mitral position.

[Long-term experience with flexible mitral annuloplasty]

Reconstructive surgery of the mitral valve is nowadays generally accepted to be a valid alternative to replacement. There is however little information on the long term stability of these techniques and specially the incidence of reoperation. In order to study this question all patients who had a Durán flexible ring annuloplasty performed between january 1975 and december 1976 were reviewed up to december 1987. Eighty seven flexible rings were placed in 85 patients. Aortic and/or tricuspid surgery was simultaneously performed in 44.8% of the patients. There were 2 hospital deaths (2.3% ) and 3 late deaths (3.5%). Ten patients were lost to follow up, all within 2 years after surgery. There were 18 thromboembolic events (11 central and seven peripheral) with one death. Thirteen patients required reoperation (17.8%) In 11 the valve was replaced and a new flexible ring annuloplasty was done in two, without mortality. The causes for reoperation were regurgitation in eight (10.9%) and stenosis in five (5.8%). When the lesion was regurgitant the average interval between operations was 20.6 months, and when stenotic of 87.8 months. It can be concluded that reconstructive surgery of the mitral valve, in this predominantly rheumatic group of patients, has an incidence or reoperation close to 18% at 12-13 years follow up.

Generation of chordae tendineae with polytetrafluoroethylene stents. Results of mitral valve chordal replacement in sheep

Surgical repair of ruptured or elongated chordae tendineae of the mitral valve is one of the most complex reconstructive techniques in cardiac surgery. Various surgical procedures have been described to repair chordal abnormalities of the anterior leaflet of the mitral valve with unpredictable results. Mitral valve replacement is usually recommended in that situation. This report describes a simple repair technique that we have devised. We resected one or two marginal chordae of the anterior leaflet of the mitral valve in 35 sheep and replaced them with a double-armed, pledget-supported, expanded polytetrafluoroethylene suture. The 30 surviving animals were studied hemodynamically and were electively put to death 3, 6, 9, 18, and 24 months after the operation. Mitral insufficiency did not develop in any of the sheep. All specimens had a normal mitral valve without thrombosis. The polytetrafluoroethylene suture remained pliable and was incorporated into the anterior leaflet and papillary muscle. Scanning and transmission electron microscopy showed that the suture was completely covered by a sheath of tissue with a collagen structure remarkably similar to that of a native chorda. Calcification was not detected in the new chordae. This reproducible and safe technique may considerably simplify the difficult repair of chordal abnormalities.

Mitroflow heart valve: 5.5 years clinical experience

From March 1982 through December 1986, 139 Mitroflow pericardial heart valves were utilized in 129 patients. There were 69 males and 60 females, with an average age of 55.2, range 26 to 74 years. Eighty-nine patients underwent isolated aortic valve replacements, 27 isolated mitral valve replacements, 3 isolated tricuspid valve replacements, 10 mitro-aortic valve replacements. In 27 cases (20.9%) additional cardiac surgery was performed. Maximum follow-up was 5.5 years with a mean of 37.9 months. The cumulative follow-up was 407.25 patient-years. Overall hospital mortality was 1.6% (2 cases). There were 3 late deaths in this series (2.4%). The linearized incidence of late mortality was 0.49% per patient-year. The survival actuarial curve was 96% +/- 1.8. The incidence of thromboembolism was 1.22% per patient-year, and the actuarial thromboembolism-free rates was 93% +/- 2.7. Prosthetic endocarditis occurred in one patient. Three patients developed primary tissue failure of the Mitroflow valve in the mitral position. The linearized incidence of primary tissue failure was 0.73% per patient-year and the actuarial freedom from primary tissue failure was 95% +/- 3.2. A total of 4 patients underwent reoperation (0.49% per patient-year). In conclusion, the clinical performance of the Mitroflow pericardial heart valve at medium-term follow-up is satisfactory, however a significant number of early mitral primary tissue failures have already occurred.

Long-term evaluation of the Ionescu-Shiley pericardial xenograft bioprosthesis in the aortic position

From August 1977 through October 1984, 241 patients underwent aortic valve replacement with the Ionescu-Shiley pericardial valve. There were 130 males and 11 females in this series with an average age of 50.8 years (range 15 to 78 years). Isolated aortic valve replacement was performed in 121 patients (50.2%) and associated cardiac surgery in 120 (49.8%). Valve size was 21 mm or smaller in 107 cases (50.2%). Cumulative duration of follow-up was 1,260 patient-years with a mean follow-up of 5.16 years per patient. Five patients were lost to follow-up. Maximum follow-up was 10.5 years. There were 26 hospital deaths and 15 late deaths (1.19% per pt-yr). The expected 10.5 year actuarial survival rate is 82% +/- 2.9%. Twelve thromboembolic episodes occurred in seven patients--seven central and five peripheral events. The thromboembolic rate was 0.95% per patient-year--32% for patients with isolated aortic valve replacement and 0.63% for patients with concomitant surgery. Freedom from thromboembolic episodes at 10.5 years is 73% +/- 12%. Structural valve deterioration was found in 24 patients (1.9% per pt-yr) with an actuarial freedom from primary tissue failure of 77.5% +/- 5.4% at 10.5 years. Reoperation was required in 39 cases (3.09% per pt-yr)--primary tissue failure (n = 24), paravalvular leak (n = 7), infective endocarditis (n = 6), and valve thrombosis (n = 2).

Stability of mitral reconstructive surgery at 10-12 years for predominantly rheumatic valvular disease

All consecutive patients who underwent Duran flexible ring annuloplasty in 1975 and 1976 were reviewed until June 1987. Eighty-seven annuloplasties were performed in 85 patients. Aortic, tricuspid, or both surgeries were simultaneously performed in 44.8%. The hospital mortality was 2.3% (two of 85). Ten patients were lost to follow-up within 2 years after surgery, and there were three late deaths. Thromboembolic events were detected in 18 patients (seven peripheral and 11 central with one death); nine patients had partial recovery, and eight had full recovery. At the time of the thromboembolic event, eight patients were receiving anticoagulants; four, antiaggregants; one, both anticoagulants and antiaggregants; and five, none. Thirteen patients (13 of 73, 17.8%) required reoperation between 1 month and 11 years postoperatively. The valve was replaced in 11 patients, and two underwent a new flexible ring annuloplasty. The cause for reoperation was regurgitation in eight patients (10.9%), for whom the mean interval between operations was 20.6 months (range, 1 month-11 years). Stenosis was the cause for reoperation in five patients (6.8%), for whom the mean interval between operations was 87.8 months (range, 4-11 years). We conclude that reconstructive surgery after 10-12 years of follow-up for this group of predominantly rheumatic patients has an incidence of failure of approximately 18% attributable to incorrect surgery (11%) and restenosis (7%).

Long-term results of conservative repair of rheumatic aortic valve insufficiency

From July 1974 to January 1986, 50 patients underwent conservative repair for rheumatic aortic valvular disease at our institution. Eleven were male and 39 female, with an average age of 39.5 years (range 17-57). The aortic lesion was associated in all cases with a predominant mitral lesion. Twenty-five also had tricuspid disease which was surgically treated in 17. Twenty-six had aortic regurgitation and 24, a mixed lesion. The surgical techniques used were: (1) commissurotomy, (2) annuloplasty, (3) cusp free edge unfolding and (4) supra-aortic crest enhancement. Two patients had one cusp extended with pericardium. There were 3 hospital deaths (6%). Six patients were lost to follow-up at different periods. Maximum follow-up was 12.58 years with a mean of 7.78 years per patient. Twelve required reoperation with 3 deaths. Three reoperations were due to failure of the mitral bioprosthesis without reoperation on the aortic valve. Of the remaining 9 patients who had aortic and mitral dysfunction, 4 had severe aortic insufficiency. The actuarial freedom from reoperation at 13 years was 75% and the overall actuarial survival was 86%. It is concluded that these surgical techniques can be applied successfully in moderate rheumatic aortic valve disease accompanying a predominant mitral lesion. This is particularly relevant when a mitral reconstruction has been performed.