Predictive value of the Global Activity Limitation Indicator (GALI) on all-cause mortality

OBJECTIVES

The Global Activity Limitation Indicator (GALI) is an instrument that measures long-term overall disability. The objective of this study was to evaluate GALI's predictive value on mortality while examining variations according to sex, age, and educational level.

STUDY DESIGN

Longitudinal study.

METHODS

This longitudinal study was based on 42,991 individuals aged ≥15 years who participated in the 2011-2012 National Health Survey and the 2014 European Health Survey in Spain. These records were linked to mortality data up to December 2021. GALI assessed self-reported functional limitation in the past 6 months and classified individuals into three categories: severely limited, limited but not severely, and not limited. Incidence rate ratios (IRR) were calculated using Poisson regression models, adjusting for sociodemographic, lifestyle, and health status variables.

RESULTS

Compared to individuals with no limitations, those with non-severe limitations had an IRR for mortality of 1.27 (95% CI: 1.16-1.38), and 2.04 (95% CI: 1.81-2.31) in those with severe limitations. Women with severe limitations exhibited a higher IRR (2.32; 95% CI: 1.98-2.71) compared to men (1.73; 95% CI: 1.45-2.08) (P for interaction = 0.005). Individuals <65 years with severe limitations showed a greater association (2.22; 95% CI: 1.58-3.10) than those ≥65 (1.49; 95% CI: 1.32-1.69) (P for interaction <0.001). Among individuals with lower educational attainment, the IRR was 2.08 (95% CI: 1.83-2.37), and 1.87 (95% CI: 1.37-2.56) for the higher education group (P for interaction = 0.017).

CONCLUSIONS

GALI is a robust predictor of all-cause mortality in the general population and subgroups. The association is stronger in women, individuals <65 years, and those with lower educational levels.

Alcohol consumption patterns and adherence to the Mediterranean diet in the adult population of Spain

PURPOSE

The objective is to evaluate the association between various indicators of alcohol consumption and the degree of adherence to the Mediterranean diet among the Spanish adult population.

METHODS

A cross-sectional study including 44,834 participants ≥ 15 years of age from the 2017 National Health Survey and the 2020 European Health Survey in Spain. Alcohol patterns were defined based on (1) average intake: individuals were classified as low risk (1-20 g/day in men and 1-10 g/day in women) and high risk (> 20 g/day in men or > 10 g/day in women), (2) binge drinking, and (3) alcoholic beverage preference. Non-adherence to the Mediterranean diet was defined as scoring < 7 points on an adapted Mediterranean Diet Adherence Screener index (range 0-10). Odds ratios (OR) were estimated using logistic regression models adjusted for relevant covariates.

RESULTS

Compared to non-drinkers, low and high-risk drinkers were more likely to report non-adherence to the Mediterranean diet: ORs 1.35 (95% CI 1.23; 1.49) and 1.54 (95% CI 1.34; 1.76), respectively. Similarly, reports of binge drinking less than once a month was associated with higher likelihood of non-adherence (OR 1.17; 95% CI 1.04; 1.31). Individuals reporting no preference for a specific beverage and those with a preference for beer or for spirits had lower adherence: ORs 1.18 (95% CI 1.05; 1.33), 1.31 (95% CI 1.17; 1.46), and 1.72 (95% CI 1.17; 2.54), respectively, while a preference for wine showed no association (OR 1.01; 95% CI 0.90; 1.13).

CONCLUSION

Alcohol consumption, even in low amounts, is associated with lower adherence to the Mediterranean diet. Therefore, alcoholic beverages should not be included in measures that define the Mediterranean diet.

Impact of psychological distress on mortality in Spain. The importance of early detection and treatment of mental disorders

BACKGROUND

Mental health problems account for 14% of mortality worldwide. The aim of this study was to evaluate the association between psychological distress and mortality in the Spanish adult population.

METHODS

Data came from a longitudinal study in population ≥15 years of age (n=21,005) who participated in the 2011-12 Spanish National Health Survey, which was linked to mortality records as of December 2020. Mental health was assessed with the GHQ-12, defining psychological distress as a dichotomous variable using a GHQ-12 score ≥3 as the cutoff point. Using Poisson regression, standardized mortality rate ratios (SRR) were estimated for all-cause, cardiovascular disease, and tumor-related mortality, adjusting for sociodemographic variables, lifestyles, and comorbidities.

RESULTS

The standardized overall mortality rate in individuals with and without psychological distress was 14.58 and 10.90 per 1000 person-years, respectively, estimating an SRR of 1.34 (95%CI: 1.19-1.50). The SRR for tumor-related mortality was 1.17 (95%CI: 0.90-1.53), and cardiovascular-related mortality was related to higher distress (GHQ-12 ≥ 4): SRR of 1.22 (95%CI: 0.98-1.51). Among psychological distressed individuals, the overall mortality SRR for those with a previous mental disorder diagnosis was 1.18 (95%CI: 0.91-1.53) versus 1.34 (95%CI: 1.18-1.54) for those without such diagnosis (p for interaction=0.067). Similarly, distressed participants taking prescription drugs for mental disorders had a lower mortality risk than those not taking them (p for interaction=0.016).

CONCLUSIONS

Individuals with psychological distress had a higher risk of overall-, cardiovascular disease- and tumor-related mortality. This association was higher among participants not previously diagnosed with a mental disorder and those not taking medication for mental issues.

Clinical characteristics and outcomes of people with severe mental disorders hospitalized due to COVID-19: A nationwide population-based study

OBJETIVE

Hospitalized COVID-19 patients with severe mental illness (SMI) have worse outcomes than counterparts without SMI. Barriers in access to acute care medical procedures among SMI patients may partially explain this phenomenon. Here, we examined differences in critical care admission and in-hospital mortality between hospitalized COVID-19 patients with and without SMI.

METHODS

This population-based study used Spain's nationwide electronic health records. Based on International Classification Diseases, Tenth Revision, ICD-10-CM codes, we identified all patients aged ≥15 years hospitalized due to COVID-19 between July 1st-December 31st, 2020, and compared patients with and without SMI in terms of (i) critical care admission and (ii) in-hospital mortality - overall and stratified by age. We used logistic regression models including sex, age, and comorbidity burden as measured by Charlson Comorbidity Index Score as covariates.

RESULTS

Of 118,691 hospital admissions due to COVID-19 of people aged ≥15 years, 1512 (1.3%) included a diagnosis of SMI. Compared to non-SMI patients, SMI patients had higher in-hospital mortality (OR,95%CI: 1.63,1.42-1.88) and were less frequently admitted to critical care (OR,95%CI: 0.70,0.58-0.85). Admission to critical care in SMI patients was lower than for non-SMI counterparts only among individuals aged ≥60 years. The magnitude of the difference in in-hospital mortality between SMI and non-SMI patients decreased as age increased.

CONCLUSIONS

Individuals with SMI had reduced critical care admission and increased in-hospital mortality compared non-SMI counterparts, suggesting that differences in delivery of acute care medical procedures may partially explain higher risk of negative outcomes among COVID-19 patients with SMI.

Suicide Following the COVID-19 Pandemic Outbreak: Variation Across Place, Over Time, and Across Sociodemographic Groups. A Systematic Integrative Review

PURPOSE OF REVIEW

To systematically examine changes in suicide trends following the initial COVID-19 outbreak, focusing on geographical and temporal heterogeneity and on differences across sociodemographic subgroups.

RECENT FINDINGS

Of 46 studies, 26 had low risk of bias. In general, suicides remained stable or decreased following the initial outbreak - however, suicide increases were detected during spring 2020 in Mexico, Nepal, India, Spain, and Hungary; and after summer 2020 in Japan. Trends were heterogeneous across sociodemographic groups (i.e., there were increases among racially minoritized individuals in the US, young adults and females across ages in Japan, older males in Brazil and Germany, and older adults across sex in China and Taiwan). Variations may be explained by differences in risk of COVID-19 contagion and death and in socioeconomic vulnerability. Monitoring geographical, temporal, and sociodemographic differences in suicide trends during the COVID-19 pandemic is critical to guide suicide prevention efforts.

The impact of the COVID-19 pandemic on suicide mortality in Spain: Differences by sex and age

BACKGROUND

Variations in suicide following the initial COVID-19 pandemic outbreak were heterogeneous across space, over time, and across population subgroup. Whether suicide has increased during the pandemic in Spain, a major initial COVID-19 hotspot, remains unclear, and no study has examined differences by sociodemographic group.

METHODS

We used 2016-2020 data on monthly suicide deaths from Spain's National Institute of Statistics. We implemented Seasonal Autoregressive Integrated Moving Average (SARIMA) models to control seasonality, non-stationarity, and autocorrelation. Using January 2016-March 2020 data, we predicted monthly suicide counts (95 % prediction intervals) between April and December 2020, and then compared observed and predicted monthly suicide counts. All calculations were conducted for the overall study population and by sex and age group.

RESULTS

Between April and December 2020, the number of suicides in Spain was 11 % higher-than-predicted. Monthly suicide counts were lower-than-expected in April 2020 and peaked in August 2020 with 396 observed suicides. Excess suicide counts were particularly salient during the summer of 2020 - largely driven by over 50 % higher-than-expected suicide counts among males aged 65 years and older in June, July, and August 2020.

DISCUSSION

The number of suicides increased in Spain during the months following the initial COVID-19 pandemic outbreak in Spain, largely driven by increases in suicides among older adults. Potential explanations underlying this phenomenon remain elusive. Important factors to understand these findings may include fear of contagion, isolation, and loss and bereavement - in the context of the particularly high mortality rates of older adults during the initial phases of the pandemic in Spain.

Light cigarette smoking and all-cause mortality in Spain. A national population-based cohort study

PURPOSE

Regular light cigarette consumption (light smoking) is increasing in many countries; however, few studies have assessed its impact on mortality. The main aim of this study is to estimate the association between the number of cigarettes consumed and all-cause mortality in Spain while focusing on light smoking.

METHODS

Longitudinal study based on data from 42,902 individuals aged ≥15 years included in the 2011-2012 (Spanish) National Health Survey or the 2014 European Health Survey for Spain. Data were linked with the mortality registry up to December 2020. Multivariate Cox regression models were used to estimate hazard ratios (HR) adjusted for sociodemographic variables, lifestyle factors, and health status indicators.

RESULTS

Compared to never smokers, the mortality HR for nondaily smokers was 1.30 (95% CI: 0.81-2.09), increasing to 2.23 (95% CI: 1.25-3.96) among those smoking 1-2 cigarettes/d, and to 1.54 (95%CI: 1.14-2.07) for consumers of 3-5 cigarettes/day. When individuals who reported trying to quit during the previous year were excluded, resulting HRs were 1.31 (95% CI: 0.81-2.10), 1.48 (95% CI: 0.69-3.19) and 1.64 (95% CI: 1.16-2.34), respectively.

CONCLUSIONS

Compared to never smokers, consumers of small quantities of tobacco, that is, light smoking, had an increased mortality risk. In view of these results, we suggest the need for awareness-raising campaigns regarding how smoking even a small number of cigarettes a day causes serious harm to one´s health.

Rural-urban gradients and all-cause, cardiovascular and cancer mortality in Spain using individual data

•

The literature reporting on rural-urban health status disparities remains inconclusive.

•

We analyzed data from a longitudinal population-based study using individual observations.

•

Our results show that the risks of all-cause and cancer mortality are greater in large cities than in other municipalities, with no clear urban-rural gradient.

•

Not differences were found among territories in cardiovascular mortality.

Predictive capacity of self-rated health on all-cause mortality in Spain: differences across sex, age and educational level

BACKGROUND

Published evidence on self-rated health's capacity to predict mortality and its variability across subpopulations lacks consistency. Our objective is to evaluate this predictive association and whether/how it varies by sex, age and educational attainment at the population level in Spain.

METHODS

Data came from a prospective longitudinal study based on 42 645 individuals aged ≥15 years who participated in the 2011-2012 and 2014 Spanish Health Surveys. Median follow-up time for mortality was 5.4 years. Cox proportional hazards models adjusted for sociodemographic, lifestyle and chronic disease variables were used to estimate the predictive capacity of self-rated health on mortality.

RESULTS

Self-rated health was associated with mortality with a dose-response effect (p value for linear trend <0.001). Compared with respondents who rated their health as very good, those rating it as very poor presented an HR of 3.33 (95% CI 2.50 to 4.44). Suboptimal self-rated health was a stronger predictor of mortality among 15-44 year-olds (HR 2.87; 95% CI 1.59 to 5.18), compared with the estimate for 45-64 year-olds (HR 1.86; 95% CI 1.45 to 2.39) (p value for interaction=0.001) and for those 65 and older (HR 1.51; 95% CI 1.36 to 1.68) (p value for interaction <0.001). Regarding educational attainment, the association was stronger for individuals with university studies (HR 2.51; 95% CI 1.67 to 3.76) than for those with only primary or no studies (HR 1.31; 95% CI 1.17 to 1.48) (p value for interaction=0.010). No statistically significant differences were observed between men and women.

CONCLUSIONS

Self-rated health may be considered a good predictor of all-cause mortality in the population of Spain, although the magnitude of this predictive association varies by age and educational level.

Role of Foreign-Born Status on Suicide Mortality in Spain Between 2000 and 2019: An Age-Period-Cohort Analysis

Objectives: To examine recent age-period-cohort effects on suicide among foreign-born individuals, a particularly vulnerable sociodemographic group in Spain. Methods: Using 2000-2019 mortality data from Spain's National Institute of Statistics, we estimated age-period-cohort effects on suicide mortality, stratified by foreign-born status (native- vs. foreign-born) and, among the foreign-born, by Spanish citizenship status, a proxy for greater socioeconomic stability. Results: Annual suicide mortality rates were lower among foreign- than native-born individuals. There was heterogeneity in age-period-cohort effects between study groups. After 2010, suicide mortality increased markedly among the foreign-born-especially for female cohorts born around 1950, and slightly among native-born women-especially among female cohorts born after the 1960s. Among native-born men, suicide increased linearly with age and remained stable over time. Increases in suicide among the foreign-born were driven by increases among individuals without Spanish citizenship-especially among cohorts born after 1975. Conclusion: After 2010, suicide in Spain increased markedly among foreign-born individuals and slightly among native-born women, suggesting an association between the downstream effects of the 2008 economic recession and increases in suicide mortality among socioeconomically vulnerable populations.

Physical and social environmental factors related to co-occurrence of unhealthy lifestyle behaviors

Previous work identifying determinants of co-occurrence of behavioral risk factors have focused on their association with individuals' characteristics with scant attention paid to their relationship to contextual factors. Data came from 21,007 individuals ≥15 years of age who participated in the cross-sectional 2011-2012 Spanish National Health Survey. Two indicators were defined by tobacco consumption, alcohol intake, diet, physical activity, and body mass index. The first indicator, based on dichotomized measures, ranges from 0 to 5. The second one (unhealthy lifestyle index), ranges from 0 to 15, with 0 denoting the healthiest score. Among the determinants, we examined social support, five perceived characteristics of the neighborhood, and the socioeconomic deprivation index of the census tract of residence. Data were analyzed using multilevel linear and logistic regression models adjusted for the main sociodemographic characteristics. Using the dichotomized indicator, the probability of having 3-5 risk factors versus <3 factors was associated with low social support (Odds Ratio [OR] 1.50; 95% Confidence Interval [CI]: 1.25-1.80). Issues surrounding neighborhood cleanliness (OR = 1.18; 95%CI: 1.04-1.33), air pollution (OR = 1.38; 95%CI: 1.16-1.64), and street crime (OR = 1.21; 95%CI: 1.03-1.42) were associated with determinants of co-occurrence. Risk factors co-occurrence increased as deprivation level increased: the OR for the highest deprivation quintile versus the lowest was 1.30 (95%CI: 1.14-1.48). Similar results were observed when using the unhealthy lifestyle index. Poorer physical and social environments are related to greater co-occurrence of risk factors for chronic diseases. Health promotion interventions targeting the prevention of risk factors should consider the contextual characteristics of the neighborhood environment.

Trends in suicide mortality in Spain, 2000-2019: Moderation by foreign-born status

BACKGROUND

Suicide rates in Spain remained stable during the early 21st century. Suicide rates among specific socially vulnerable groups, however, remain unknown, and there are no data on suicide mortality rates and trends among migrants living in Spain.

METHODS

We analyzed Spain's 2000-2019 suicide mortality data by migration status (native- vs. foreign-born), examining crude and age-standardized rates and trends overall and by sex, age-group, suicide method, Spanish citizenship status, and country of origin, using joinpoint regression models.

RESULTS

Annual crude suicide mortality rates were higher among native- than foreign-born individuals (9.2 versus 6.2 por 100.000 inhabitants, respectively). While suicide rates decreased among native-born men and remained roughly stable among native-born women - with slight decreases among older native-born women, they increased after 2010 among foreign-born men aged 15-44 and ≥65 years and foreign-born women aged ≥65 years. Increases in suicide trends among foreign-born residents in Spain were largely driven by increases specific to individuals without Spanish citizenship.

LIMITATIONS

Suicide mortality data are subject to potential errors due to underreporting of suicide in death certificates CONCLUSIONS: Between 2010-2019, suicide in Spain increased only among foreign-born residents. These findings should enhance our understanding of the dynamics and potential actionable causes of suicide among migrants living in Spain.

Suicidal and accidental drug poisoning mortality among older adults and working-age individuals in Spain between 2000 and 2018

BACKGROUND

Although medication poisoning in older adults is considered an increasingly important, but preventable cause of death, it has received relatively little attention. We explored recent trends and correlates of suicidal and accidental fatal drug poisonings among older and working-age individuals using nationwide data from Spain.

METHODS

We identified all 15,353 fatal drug poisonings involving decedents aged ≥15 years in Spain between 2000 and 2018 and divided them by age into older adults (≥65 years) and working-age (15-64 years) individuals. For each age group, we analyzed time trends in suicidal and accidental fatal drug poisoning rates (overall and by ICD-10 drug categories) using joinpoint regressions. To understand the specific drugs classified as "Non-psychotropic/non-specified", we used 2018 data including substance-specific ICD-10 supplementary codes. We explored relevant sociodemographic correlates of suicidal and accidental fatal poisoning rates using multivariable negative binomial regressions.

RESULTS

Between 2000 and 2018, suicidal fatal poisonings increased faster among older (from 0.19 to 0.63 per 100,000 - average annual change: 7.7%) than working-age individuals (from 0.40 to 0.72 per 100,000 - average annual change: 3.8%). Accidental fatal poisonings increased among older adults (from 0.25 to 2.67 per 100,000 - average annual change: 16.2%) but decreased among working-age counterparts (from 2.38 to 1.42 per 100,000 - average annual change: - 1.9%). Anticoagulants and cardiac-stimulants glycosides accounted for 70% of the 223 accidental fatal poisonings due to non-psychotropic/non-specified drugs registered among older adults in 2018. Roles of gender and urban dwelling in suicidal and accidental poisonings were heterogeneous across age groups.

CONCLUSION

Increases in suicidal drug poisonings were faster among older than working-age individuals. Accidental fatal poisonings increased only among older adults. Our findings that (i) sociodemographic correlates were heterogeneous across age groups and (ii) anticoagulant and cardiac-stimulant glycosides were particularly salient drivers of accidental poisonings among older adults have implications for prevention.

Clustering of unhealthy lifestyle behaviors, self-rated health and disability

The main objective was to identify sociodemographic characteristics of the population at risk for a greater clustering of unhealthy behaviors and to evaluate the association of such clustering with self-rated health status and disability. Data come from the 2017 Spanish National Health Survey with a sample of 21,947 participants of 15 years of age or older. Based on tobacco consumption, risk drinking, unbalanced diet, sedentarism, and body mass index <18.5/≥25 we created two indicators of risk factor clustering: 1) Number of unhealthy behaviors (0-5); and 2) Unhealthy lifestyle index (score: 0-15). Self-rated health was dichotomized into "optimal" and "suboptimal," and disability was classified as "no disability," "mild," and "severe" based on the Global Activity Limitation Index (GALI). We estimated prevalence ratios (PR) adjusted for covariates using generalized linear models using the clustering count variable, and dose-response curves using the unhealthy lifestyle index. Most participants (77.4%) reported 2 or more risk factors, with men, middle-age individuals, and those with low socioeconomic status being more likely to do so. Compared to those with 0-1 risk factors, the PR for suboptimal health was 1.26 (95% CI:1.18-1.34) for those reporting 2-3 factors, reaching 1.43 (95% CI:1.31-1.55) for 4-5 factors. The PR for severe activity limitation was 1.66 (95% CI:1.35-2.03) for those reporting 2-3 factors and 2.06 (95% CI:1.59-2.67) for 4-5 factors. The prevalence of both health indicators increased in a non-linear fashion as the unhealthy lifestyle index score increased, increasing rapidly up to 5 points, slowing down between 5 and 10 points, and plateauing afterwards.

Survival Patterns of Human Prion Diseases in Spain, 1998–2018: Clinical Phenotypes and Etiological Clues

Background

Human transmissible spongiform encephalopathies (TSEs) are a group of fatal neurodegenerative disorders of short duration. There are few studies on TSE survival. This study sought to analyze the survival and related factors of a TSE patient cohort, based on a nationwide surveillance system in Spain.

Methods

Survival analyses were performed on 1,530 cases diagnosed across the period 1998–2018 in Spain. We calculated median survival times and plotted survival curves using the Kaplan–Meier method for all cases and for sporadic TSE (sTSE) and genetic TSE (gTSE). Crude and adjusted Cox proportional hazard models were used to identify variables associated with shorter survival.

Findings

Median age at onset decreased from the sporadic forms to gTSE and, lastly, to acquired TSE. Overall median and interquartile range (IQR) survival time was 5.2 (IQR, 3.0–11.7) months and 4.9 (IQR, 2.8–10.8) months in sporadic cases and 9 (IQR, 4.9 to over 12) months in genetic cases, p &lt; 0.001. Male sex, older age at onset, presence of 14-3-3 protein, typical MRI, and MM and VV polymorphisms at codon 129 were associated with shorter survival. gTSE showed higher survival in crude comparisons but not after adjustment.

Interpretation

TSE survival in Spain replicates both the magnitude of that shown and the TSE entity-specific population patterns observed in Western countries but differs from features described in Asian populations, such as the Japanese. The reduction in differences in survival between gTSE and sTSE on adjusting for covariates and international patterns might support the view that gTSE and sTSE share causal and pathophysiological features.

Recent trends of invasive mechanical ventilation in older adults: a nationwide population-based study

BACKGROUND

Critical care demand for older people is increasing. However, there is scarce population-based information about the use of life-support measures such as invasive mechanical ventilation (IMV) in this population segment.

OBJECTIVE

To examine the characteristics and recent trends of IMV for older adults.

METHODS

Retrospective cohort study on IMV in adults ≥65 years using the 2004-15 Spanish national hospital discharge database. Primary outcomes were incidence, inhospital mortality and resource utilization. Trends were assessed for average annual percentage change in rates using joinpoint regression models.

RESULTS

233,038 cases were identified representing 1.27% of all-cause hospitalizations and a crude incidence of 248 cases/100,000 older adult population. Mean age was 75 years, 62% were men and 70% had comorbidities. Inhospital mortality was 48%. Across all ages, about 80% of survivors were discharged home. Incidence rates of IMV remained roughly unchanged over time with an average annual change of -0.2% (95% confidence interval (CI): -0.9, 0.6). Inhospital mortality decreased an annual average of -0.7% (95% CI: -0.5, -1.0), a trend detected across age groups and most clinical strata. Further, there was a 3.4% (95% CI: 3.0, 3.8) annual increase in the proportion of adults aged ≥80 years, an age group that showed higher mortality risk, lower frequency of prolonged IMV, shorter hospital stays and lower costs.

CONCLUSIONS

Overall rates of IMV remained roughly stable among older adults, while inhospital mortality showed a decreasing trend. There was a notable increase in adults aged ≥80 years, a group with high mortality and lower associated hospital resource use.

Small area influences on the individual unhealthy lifestyle behaviors: A multilevel analysis of discriminatory accuracy

We estimated the discriminatory power of area of residence (census tract) on the prevalence of main risk factors for chronic diseases. Results, based on a sample of 21,007 participants from the 2011-2012 National Health Survey of Spain, show a differential influence of the geosocial environment on the four health risk factors. Accounting for census tracts substantially increases the discriminatory power regarding at-risk alcohol consumption, unbalanced diet, and leisure-time sedentarism but not tobacco consumption. However, the socioeconomic characteristics of the tracts played a minor role. Further research on the specific geosocial contextual variables explaining variability in these risk factors is necessary.

Individual and Contextual Factors Associated With Hazardous Drinking in Spain: Evidence From a National Population-Based Study

BACKGROUND

Heavy drinking (HD) and binge drinking (BD) exhibit marked differences in their relationships with contextual-level factors imbedded in geographical areas of residence. The objective is to identify sociodemographic factors, both at the individual and at the contextual level, associated with these 2 main hazardous consumption patterns.

METHODS

Cross-sectional study using data from the 2011 to 2012 National Health Survey in Spain. The sample included 21,007 individuals ≥15 years of age. HD was defined as an alcohol intake of ≥40 g/d in men and ≥24 g/d in women. BD was defined as the consumption in the previous month of ≥6 alcoholic drinks (men) or ≥5 drinks (women) within 4 to 6 hours. Individual-level variables included sociodemographic factors, urban/rural residence, smoking, and perceived social support. Contextual-level variables covered percentage of population with no schooling, unemployment rate, and hospitality industry-related economic activity, all at the census tract level. We analyzed data using multilevel logistic regression and calculated areas under the curve (AUC).

RESULTS

Being male, smoking, high-income, and low perceived social support were associated with both hazardous drinking patterns. Younger individuals were at higher risk for BD but at lower risk for HD. BD was more common among rural than urban dwellers (odds ratios [OR] = 1.35; 95% CI: 1.05 to 1.72), whereas HD was less likely in participants residing in areas with high unemployment rates (OR = 0.62; 95% CI: 0.41 to 0.93). HD was more likely in census tracts with higher levels of hospitality industry activity (OR = 1.74; 95% CI: 1.20 to 2.54). The AUC increased substantially for both HD and BD when the census tract variable was entered in the respective models (reaching 89.5 and 93.3%, respectively).

CONCLUSIONS

Except for age, both drinking patterns have similar associations with individual-level variables but disparate links to contextual-level indicators. In both cases, accounting for area of residence substantially increased the ability to discriminate between high-risk drinkers from nonhazardous alcohol consumers.

Use and outcomes of mechanical ventilation for people with severe mental disorders admitted due to natural causes: A nationwide population-based study

OBJECTIVE

To characterize temporal trends and outcomes of invasive mechanical ventilation (MV) for people with severe mental disorders (SMD) admitted due to natural causes.

METHODS

We identified all 224,507 hospitalizations of patients aged 15-69 who underwent MV in Spain between 2000 and 2015, excluding poisonings and injuries, and divided them by presence of an SMD diagnosis. We compared the two study groups regarding demographic and clinical characteristics and examined time trends in the incidence of MV and in-hospital mortality.

RESULTS

SMD patients were younger and had fewer comorbidities and lower in-hospital mortality than the non-SMD group. However, among patients admitted due to circulatory diseases, SMD patients had higher mortality risk (OR = 1.39; 95%CI = 1.22-1.59). In the SMD group, the increase in MV use quadrupled that of non-SMD patients (Average Annual Percent Change = 6.9%; 95%CI = 5.5-8.3 vs. 1.5%; 0.9-2.0, respectively). Overall in-hospital mortality declined similarly in both study groups. While the SMD group's circulatory-specific mortality also decreased, by 2015 it remained elevated in comparison to non-SMD patients (44% vs. 38%, respectively).

CONCLUSION

The increase in MV use due to natural causes among people with SMD outpaced that of non-SMD patients, with comparable decreasing trends in mortality. Although declining, SMD patients' higher circulatory-specific mortality risk requires further investigation.

Epidemiology and Trends of Sepsis in Young Adults Aged 20-44 Years: A Nationwide Population-Based Study

Background: While sepsis may have especially marked impacts in young adults, there is limited population-based information on its epidemiology and trends. Methods: Population-based longitudinal study on sepsis in adults aged 20–44 years using the 2006–2015 Spanish national hospital discharge database. Cases are identified by an ICD-9-CM coding strategy. Primary endpoints are incidence and in-hospital mortality. Trends are assessed for annual percentage change (AAPC) in rates using Joinpoint regression models. Results: 28,351 cases are identified, representing 3.06‰ of all-cause hospitalisations and a crude incidence of 16.4 cases/100,000 population aged 20–44. The mean age is 36 years, 58% of cases are men, and around 60% have associated comorbidities. Seen in one third of cases, the source of infection is respiratory. Single organ dysfunction is recorded in 45% of cases. In-hospital mortality is 24% and associated with age, comorbidity and extent of organ dysfunction. Incidence rates increase over time in women (AAPC: 3.8% (95% CI: 2.1, 5.5)), whereas case-fatality decline with an overall AAPC of −5.9% (95% CI −6.6, −5.2). Our results indicate that sepsis is common in young adults and associated with high in-hospital mortality, though it shows a decreasing trend. The substantial increase in incidence rates in women needs further research.

Effect of dementia on the incidence, short-term outcomes, and resource utilization of invasive mechanical ventilation in the elderly: a nationwide population-based study

BACKGROUND

Though the prevalence of dementia among hospitalized patients is increasing, there is limited population data in Europe about the use of life-support measures such as invasive mechanical ventilation in these patients. Our objective is to assess whether dementia influences the incidence, outcomes, and hospital resource use in elderly patients undergoing mechanical ventilation.

METHODS

Using ICD-9-CM codes, all hospitalizations involving invasive mechanical ventilation in adults aged ≥ 65 years were identified in the Spanish national hospital discharge database covering the period 2000-2013. The cases identified were stratified into two cohorts (patients with or without dementia) in which main outcome measures were compared. The impact of dementia on in-hospital mortality and hospital resource use were assessed through multivariable models. Trends were assessed through joinpoint regression analysis and results expressed as average annual percentage change.

RESULTS

Of the 259,623 cases identified, 5770 (2.2%) had been assigned codes for dementia. Cases with dementia were older, had a lower Charlson comorbidity score, and less frequently received prolonged mechanical ventilation or were assigned a surgical DRG. Circulatory disease was the most common main diagnosis in both cohorts. No significant impact of dementia was observed on in-hospital mortality (adjusted OR 1.04, [95% CI] 0.98, 1.09). In the cohort with dementia, the incidence of mechanical ventilation underwent an average annual increase over time of 5.39% (95% CI 4.0, 6.7) while this rate was 1.62% (95% CI 0.9, 2.4) in cases without dementia. However, unlike this cohort, mortality in cases with dementia did not significantly decline over time. Geometric mean hospital cost and stay were lower among cases with than without dementia (- 14% [95% CI - 12%, - 15%] and - 12% [95% CI, - 9%, - 14%], respectively), and these differences increased over time.

CONCLUSION

This nationwide population-based study suggests no impact of dementia on in-hospital mortality in elderly patients undergoing invasive mechanical ventilation. However, dementia is significantly associated with shorter stay and hospital costs. Our data also identifies a recent marked increase in the use of this life-support measure in elderly patients with dementia and that this increase is much greater than that observed in elderly individuals without dementia.

The impact of dementia on hospital outcomes for elderly patients with sepsis: A population-based study

BACKGROUND

Prior studies have suggested that dementia adversely influences clinical outcomes and increases resource utilization in patients hospitalized for acute diseases. However, there is limited population-data information on the impact of dementia among elderly hospitalized patients with sepsis.

METHODS

From the 2009-2011 National Hospital Discharge Database we identified hospitalizations in adults aged ≥65 years. Using ICD9-CM codes, we selected sepsis cases, divided them into two cohorts (with and without dementia) and compared both groups with respect to organ dysfunction, in-hospital mortality and the use of hospital resources. We estimated the impact of dementia on these primary endpoints through multivariate regression models.

RESULTS

Of the 148 293 episodes of sepsis identified, 16 829 (11.3%) had diagnoses of dementia. Compared to their dementia-free counterparts, they were more predominantly female and older, had a lower burden of comorbidities and were more frequently admitted due to a principal diagnosis of sepsis. The dementia cohort showed a lower risk of organ dysfunction (adjusted OR: 0.84, 95% Confidence Interval [CI]: 0.81, 0.87) but higher in-hospital mortality (adjusted OR: 1.32, 95% [CI]: 1.27, 1.37). The impact of dementia on mortality was higher in the cases of younger age, without comorbidities and without organ dysfunction. The cases with dementia also had a lower length of stay (-3.87 days, 95% [CI]: -4.21, -3.54) and lower mean hospital costs (-3040€, 95% [CI]: -3279, -2800).

CONCLUSIONS

This nationwide population-based study shows that dementia is present in a substantial proportion of adults ≥65s hospitalized with sepsis, and while the condition does seem to come with a lower risk of organ dysfunction, it exerts a negative influence on in-hospital mortality and acts as an independent mortality predictor. Furthermore, it is significantly associated with shorter length of stay and lower hospital costs.

Inequalities in the risk of disability due to traffic injuries in the Spanish adult population, 2009-2010

BACKGROUND

Although traffic injuries (TIs) are an important cause of disability the related factors are little known. We aimed to estimate the differences in risk of TI-related disability according to individual characteristics that might generate health inequalities.

METHODS

Cross-sectional study using a representative Spanish population sample drawn from the European Health Interview Survey 2009/2010. We calculated traffic crashes in the preceding year which resulted in injuries. Disability was measured using the Global Activity Limitation Indicator and four indicators of limitations (sensory, physical functional, self-care and domestic activities). Principal socio-demographic and behavioural/lifestyle variables were studied. We used multivariate logistic regression to estimate the risk (ORs) of TI-related disability in the sample as whole and disability-related factors in persons who had experienced TIs.

RESULTS

Persons with TIs had a higher risk of global disability (OR = 1.61; 95%CI:1.17-2.20), physical functional limitations (OR = 1.96; 95%CI:1.33-2.89) and self-care limitations (OR = 1.73; 95%CI:0.98-3.05). Among persons with TIs, GALI-related risk was higher in women (OR = 3.06, p = 0.002) and persons aged over 30 years (OR_31-45years = 6.81, p < 0.001; OR_46-64years = 5.96, p = 0.011; OR_>64years = 4.54, p = 0.047). Lower risk was observed among persons with a higher educational level (OR = 0.22, p = 0.003). The risk of disability among persons with TIs who consumed illegal drugs was OR = 3.9 (p = 0.023).

CONCLUSIONS

Traffic injuries in the preceding year are associated with higher risk of disability, which is unevenly distributed. Individual (women and persons over 30 years), socio-economic (lower educational level) and behavioural (illegal drug use) factors are involved. Actions aimed at changing the unequal risk among vulnerable subgroups and providing health, social and protective services should be implemented.

Effect of comorbidities on the association between age and hospital mortality after fall-related hip fracture in elderly patients

The relation between age and mortality after hip fracture was analyzed in elderly patients. 5.5% of the 31,884 patients died. Compared to those 65-74 years old, the multivariate OR for mortality for those 75-84 and ≥85 were 2.11 (95% CI: 1.61-2.77) and 4.10 (95% CI: 3.14-5.35).

PURPOSE

To analyze the impact of Elixhauser comorbidities on the relation between age and mortality after hip fracture in elderly patients.

METHODS

Cross-sectional study of the population ≥65 years old hospitalized in Spain in 2013 with a diagnosis of fall-related hip fracture in the Basic Minimum Set Data (BMSD). The impact of Elixhauser comorbidities on the association between mortality and age groups (65-74, 75-84, ≥85) was analyzed by logistic regression models with progressive adjustment for demographic variables and comorbidities introduced individually.

RESULTS

We identified 31,884 patients, 5.5% of which died during hospitalization. Compared with those 65-74 years old, the multivariate OR of mortality for those 75-84 and ≥85 years old decreased from 2.23 (95% CI: 1.71-2.90) and 4.57 (95% CI: 3.54-5.90) to 2.11 (95% CI: 1.61-2.77) and 4.10 (95% CI: 3.14-5.35), respectively after adjustment for comorbidities. The OR of mortality for men was 1.77 (95% CI: 1.58-1.98) compared to women. The comorbidities with higher OR for mortality were congestive heart failure (OR: 3.88; 95% CI: 3.42-4.41), metastasis (OR: 3.44; 95% CI: 2.27-5.20), fluid and electrolyte disorders (OR: 2.95; 95% CI: 2.47-3.52), coagulation deficiencies (OR: 2.87; 95% CI: 2.08-3.96), and liver disease (OR: 2.40; 95% CI: 1.82-3.17).

CONCLUSIONS

The association between age and mortality after hip fracture remains after adjusting for numerous comorbidities. However, some potentially controllable disorders are associated with an increased risk for mortality, thus, improving their management could benefit survival.

Severity of disability related to road traffic crashes in the Spanish adult population

BACKGROUND

The severity of disability related to road traffic crashes has been little studied, despite the significant health and socio-economic impacts that determine victims' quality of life.

OBJECTIVE

To estimate the consequences of road traffic crashes on the severity of disability, in terms of individuals' capacity to execute activities and perform tasks in their current environment, using aids.

METHODS

Cross-sectional study conducted on community-dwelling participants in the "2008 National Survey of Disability", with data on 91,846 households having 20,425 disabled persons, 443 of whom had disability due to road traffic crashes. We measured severity using two indicators, i.e., the Capacity (CSI) and Performance (PSI) Severity Indices.

RESULTS

The highest proportion of disability was mild (CSI=70.5%; PSI=80.8%), while 7.6% (CSI) and 4.9% (PSI) was severe/complete respectively. The moderate/severe disability rate was 0.6 per thousand on the CSI, decreasing to 0.4 per thousand on the PSI. No differences were observed by age or sex. Moderate/severely disabled persons had a fourfold higher probability of being retired or unfit for work. Mental and nervous system impairments were more closely related to moderate/severe/complete problems of capacity and performance (p<0.001), disability for carrying out general tasks and demands, and interpersonal interactions and relationships (p<0.001). Being permanently bedridden (p<0.001), receiving aids (p<0.001), family support (p<0.05) and moving home (p<0.05) increased with an increase in the level of severity.

CONCLUSION

Road traffic crashes mainly cause mild disability. Moderate/severe disability is associated with lower work capacity, greater functional dependence, and increased need of aids, moving home and family support.

Characteristics, incidence and temporal trends of sepsis in elderly patients undergoing surgery

BACKGROUND

Despite increasing rates of surgery in the elderly, there is limited population-based information on sepsis in this age group. This study aimed to characterize the epidemiology and national trends of sepsis among elderly patients undergoing surgery in Spain.

METHODS

This population-based longitudinal study of patients aged 65 years or older, undergoing surgery between 2006 and 2011, used data from the national hospital discharge database. Patients were identified by ICD coding. Primary endpoints were incidence and case-fatality rates of sepsis. Predefined age groups were examined. In-hospital mortality-related factors were assessed by means of exploratory logistic regression. Trends were assessed for annual percentage change in rates using Joinpoint regression analysis.

RESULTS

A total of 44 342 episodes of sepsis were identified, representing 1·5 per cent of all 2 871 199 surgical hospital admissions of patients aged 65 years or older. The rates varied with age and sex. The in-hospital case-fatality rate was 43·9 per cent (19 482 patients), and associated with age, co-morbidity and organ dysfunction. Standardized rates of sepsis increased over time, with an annual change of 4·7 (95 per cent c.i. 1·4 to 8·5) per cent, whereas the case-fatality rate declined, with an overall annual change of -3·6 (-4·3 to -2·8) per cent. The decrease in mortality was more limited in patients with organ dysfunction and in the oldest age group.

CONCLUSION

Rates of sepsis are increasing among elderly patients undergoing surgery, whereas in-hospital case fatality, although common, is showing a decreasing trend.

Disability related to road traffic crashes among adults in Spain

BACKGROUND

Road traffic accidents cause substantial morbidity and disease burden; few studies have examined their impact on disability.

OBJECTIVE

To estimate the magnitude and distribution of disability due to road traffic accidents according to socio-demographic variables, and its main socioeconomic and health determinants.

METHODS

A cross-sectional study was conducted in community-dwelling participants in the "2008 Spanish National Disability Survey", a representative sample of 91,846 households with 20,425 disabled persons older than 15 years; 443 had disability due to road traffic accidents.

RESULTS

The prevalence was 2.1 per 1000 inhabitants (95% CI:1.8-2.3), with no differences by sex. Risk was highest among persons aged 31 to 64 years, and onset of disability showed a sharp inflection point at age 16 years in both sexes. Odds ratios (ORs) were higher (OR=1.3; 95% CI:1.1- 1.7) for participants with secondary education than for those with the lowest educational levels and were lower (OR: 0.5; 95% CI:0.3-0.8) for participants with the highest household income levels than for those with lowest. Only 24% of disabled participants were gainfully employed. As compared to other sources of disability, traffic crashes caused greater disability in terms of mobility (OR=3.1;p<0.001), a greater need for health/social services (OR=1.5;p=0.003), and more problems with private transportation (OR=1.6;p<0.001), moving around outside the home (OR=1.6;p<0.001) and changes in economic activity (OR=2.4;p<0.001).

CONCLUSIONS

The prevalence of disability due to road traffic accidents in Spain is lower than in other developed countries, with middle-aged and socio-economically underprivileged persons being the most affected. Disability due to road traffic accidents is related to a greater demand for social/health care support, problems of accessibility/commuting, and major changes in economic activity.

Epidemiology and recent trends of severe sepsis in Spain: a nationwide population-based analysis (2006-2011)

Background

Although severe sepsis constitutes an important burden for healthcare systems, there is limited nationwide data on its epidemiology in European countries. Our objective was to examine the most recent epidemiological characteristics and trends of severe sepsis in Spain, from a population perspective.

Methods

Analysis of the 2006-2011 National Hospital Discharge Registry. Cases were identified by combining specific ICD-9CM codes. We estimated demographics, clinical characteristics and outcomes and calculated age- and sex- adjusted estimations of incidence and mortality rates. Trends were assessed in terms of annual percent change (APC) in rates using joinpoint regression analysis.

Results

Over the 6-year period we identified 240939 cases of severe sepsis nationwide representing 1.1% of all hospitalisations and 54% of hospitalisations with sepsis. Incidence was 87 cases per 100,000 population. Overall 58% of cases were men, 66% were over the age of 65 and about 67% had associated comorbidities. Bacteremia was coded in 16% of records. Almost 54% of cases had one organ dysfunction, 26% two and around 20% three or more dysfunctions. In-hospital case-fatality was 43% and associated with age, gender, comorbidities and organ dysfunctions, among others. We found significant demographic and clinical changes over time with an increase in the mean age of cases, comorbidities, number of organ dysfunctions and in the number of cases with gram-negative pathogens. Furthermore, even with gender disparities, standardised incidence and mortality rates increased with an overall APC of 8.6% (95% CI 5.1, 12.1) and 6% (95% CI 1.9, 10.3), respectively. Conversely, we detect a significant decrease in case-fatality rates with an overall APC of -3.24% (95% CI: -4.2, -2.2).

Conclusions

This nationwide population-based study shows that hospitalizations with severe sepsis are frequent and associated with substantial in-hospital mortality in Spain. Furthermore it indicates that the incidence and mortality rates of severe sepsis have notably increased in recent years, showing also a significant increase in the age and severity of the affected population. Despite this, there has been a significant decreasing trend in case-fatality rates over time. This information has significant implications for health-care system planning and may prove useful to estimate future care requirements.

Electronic supplementary material

The online version of this article (doi:10.1186/s12879-014-0717-7) contains supplementary material, which is available to authorized users.

Trends in infectious disease mortality rates, Spain, 1980-2011

Using mortality data from National Institute of Statistics in Spain, we analyzed trends of infectious disease mortality rates in Spain during 1980-2011 to provide information on surveillance and control of infectious diseases. During the study period, 628,673 infectious disease-related deaths occurred, the annual change in the mortality rate was -1.6%, and the average infectious disease mortality rate was 48.5 deaths/100,000 population. Although the beginning of HIV/AIDS epidemic led to an increased mortality rate, a decreased rate was observed by the end of the twentieth century. By codes from the International Classification of Diseases, 9th revision, the most frequent underlying cause of death was pneumonia. Emergence and reemergence of infectious diseases continue to be public health problems despite reduced mortality rates produced by various interventions. Therefore, surveillance and control systems should be reinforced with a goal of providing reliable data for useful decision making.

Safety of balloon kyphoplasty in the treatment of osteoporotic vertebral compression fractures in Europe: a meta-analysis of randomized controlled trials

PURPOSE

The study aims to evaluate the safety of balloon kyphoplasty in the treatment of painful osteoporotic vertebral compression fractures in Europe.

METHODS

Systematic review of the literature, until September 2013, and meta-analysis of randomized controlled trials performed in Europe assessing the safety of balloon kyphoplasty in patients with symptomatic osteoporotic vertebral fractures. Outcomes sought include cement leaks, serious clinical complications and new vertebral fractures.

RESULTS

Six randomized controlled trials fulfilled the inclusion criteria. These studies included data on 525 treated levels in 424 patients. Cement leakages were detected in 18.3 % (95 % CI 11.6, 23.0) of fractures intervened. In about 0.5 % (95 % CI 0.1, 1.1) of fractures leakages proved to be symptomatic. Serious clinical complications were recorded in 11.5 % (95 % CI 1.1, 21.7) of patients treated with balloon kyphoplasty with several of these cases requiring intensive treatment or postoperative surgery. New vertebral fractures were detected in 20.7 % (95 % CI 0.4, 40.9) of patients treated but rates showed an upward pattern when the follow-up period increased. In 54 % of such cases, the fractures were located in regions adjacent to the treated level.

CONCLUSIONS

The safety profile and associated complications of balloon kyphoplasty shown in this analysis, based on the evidence provided by existing randomized controlled trials, can be of help to the practicing clinician who must contrast them with the potential benefits of the technique. These data represent an important step towards a balanced evaluation of the intervention though, a better reporting and more reliable data on long-term assessment of potential sequelae are needed.

[Premature mortality excess related to influenza in Spain during an interpandemic period]

BACKGROUND

The indicator of Potential Years of Life Lost (PYLL) has been frequently used to analysis of premature mortality and recently has been used to estimate the impact of the last influenza A(H1N1)pdm09 pandemic. The aim of this study was to estimate the excess deaths from pneumonia and influenza (P&I) in Spain and the PYLL during the period 1980-2008, measuring the mortality attributable to influenza regarding the type/subtype of influenza dominant in each season.

METHODS

Monthly excess deaths were calculated with cyclical regression models. The PYLL calculation was performed as the product of the number of excess deaths and the difference between life expectancy at birth and years lived for each age group. The analysis of the variation between P&I excess deaths and PYLL, depending on the predominant influenza virus type/subtype was carried out with a Poisson regression analysis.

RESULTS

In seasons dominated by influenza virus A(H3) the average P&I excess deaths was estimated at 1,348, and for PYLL in 5.297, while in seasons dominated by A(H1) or B the average P&I excess deaths was 648, and for PYLL 2.885. The adjusted rate ratios of excess (2.11, CI-95%=2.05-2.16) and PYLL (1.86, CI-95%=1.83-1.88) indicate that the relative frequencies for both indicators are significantly larger in seasons dominated by influenza virus A(H3).

CONCLUSIONS

Excess deaths and PYLL doubled when comparing seasons predominantly subtype A(H3) and other influenza viruses.

Efficacy and safety of metformin for treatment of overweight and obesity in adolescents: an updated systematic review and meta-analysis

OBJECTIVE

To assess the efficacy and safety of using metformin in overweight and obese adolescents without related morbidity.

METHODS

We conducted a systematic review and meta-analysis of randomized clinical trials published until June 2011, comparing metformin to placebo or other interventions. Our primary variables were baseline BMI changes and development of adverse effects.

RESULTS

Nine studies (498 participants, mean age 14.2 years; mean BMI 36.4 kg/m² met the inclusion criteria. In all but one study, metformin was combined with lifestyle modification and was compared to placebo combined with changes in lifestyle. Analysis showed that metformin reduced mean BMI by 1.42 kg/m² (95% CI -2.18, 0.66), fasting insulin by 9.9 µU/ml (95% CI -13.8, -6.06) and the HOMA index by -1.78 (95% CI -3.32, -0.23). No changes in any other parameter were observed. No statistical differences were found in the rate of adverse events (33% metformin, 32% placebo).The withdrawal rates due to side effects in the metformin and placebo groups were 2.7% and 2.5%, respectively.

CONCLUSIONS

The available evidence indicates that, in the short term, administration of metformin in addition to lifestyle modification is relatively effective for reducing BMI and hyperinsulinemia among obese adolescents without related morbidity, and displays an acceptable safety pattern. Nevertheless, its long-term impact is unknown.

Hospital admissions due to physical disease in people with schizophrenia: a national population-based study

OBJECTIVES

To examine nonpsychiatric hospitalizations in people with schizophrenia and to describe the epidemiological features of these admissions.

METHODS

We analyzed the 2000-2004 Spanish National Hospital Discharge Registry, identified records coded for schizophrenia (295.xx), selected admissions due to non-psychiatric causes and characterized the physical diseases using the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) system and the Deyo-Charlson Index.

RESULTS

From all 2000-2004 hospitalizations in subjects with schizophrenia, 21 484 records (34%) were eligible for analysis. The mean age was 53 years, 61% were men. The mean number of ICD-9-CM codes was 2.3. The main diagnoses at discharge were injury-poisoning (19%) and respiratory (15%), digestive (14%) and circulatory diseases (12%), but there were significant age and gender-related differences. Inhospital mortality was 6.9% and the mean age of death was 63 years. Circulatory, respiratory diseases and neoplasms accounted for 21%, 18% and 17% of deaths, respectively. Inhospital mortality significantly correlated with age, the Deyo-Charlson Index and some specific processes.

CONCLUSIONS

Hospitalizations due to physical disease are frequent among people with schizophrenia and associated with a substantial burden and in-hospital mortality in Spain. This information may prove useful for the design and application of preventive and therapeutic programs in the early and silent phases of the most prevalent physical diseases.

Balloon kyphoplasty in malignant spinal fractures: a systematic review and meta-analysis

BACKGROUND

Spinal fractures are a common source of morbidity in cancer patients. Balloon Kyphoplasty (BKP) is a minimally invasive procedure designed to stabilize fractures and correct vertebral deformities. We performed a meta-analysis to determine the efficacy and safety of BKP for spinal fractures in cancer patients.

METHODS

We searched several electronic databases up to September 2008 and the reference lists of relevant publications for studies reporting on BKP in patients with spinal fractures secondary to osteolytic metastasis and multiple myeloma. Outcomes sought included pain relief, functional capacity, quality of life, vertebral height, kyphotic angle and adverse events. Studies were assessed for methodological bias, and estimates of effect were calculated using a random-effects model. Potential reasons for heterogeneity were explored.

RESULTS

The literature search revealed seven relevant studies published from 2003 to 2008, none of which were randomized trials. Analysis of those studies indicated that BKP resulted in less pain and better functional outcomes, and that these effects were maintained up to 2 years post-procedure. While BKP also improved early vertebral height loss and spinal deformity, these effects were not long-term. No serious procedure-related complications were described. Clinically asymptomatic cement leakage occurred in 6% of all treated levels, and new vertebral fractures in 10% of patients. While there is a lack of studies comparing BKP to other interventions, some data suggested that BKP provided similar pain relief as vertebroplasty and a lower cement leakage rate.

CONCLUSION

It appears that there is level III evidence showing BKP is a well-tolerated, relatively safe and effective technique that provides early pain relief and improved functional outcomes in patients with painful neoplastic spinal fractures. BKP also provided long-term benefits in terms of pain and disability. However, the methodological quality of the original studies prevents definitive conclusions being drawn. Further investigation into the use of BKP for spinal fractures in cancer patients is warranted.

Outcomes of new quality standards of follitropin alfa on ovarian stimulation: meta-analysis of previous studies

BACKGROUND

Human follicle-stimulating hormone (hFSH; follitropin alfa) can be employed therapeutically to induce ovarian follicular development in assisted reproduction treatments. Current recombinant hFSH (r-hFSH) preparations available for clinical use are labeled either in terms of the bioactivity expressed in international units (IU) or in mass (microg). Several clinical trials have tried to assess the clinical implications of the physicochemical improvements in the dosing of follitropin alfa filled by mass (FbM). The aim of this study was to perform a meta-analysis of previous studies in order to assess the efficacy and safety of ovarian stimulation using follitropin alfa FbM compared with follitropin alfa filled by international units (FbIU).

METHODS

A literature search was carried out in scientific databases to find published articles and abstracts comparing both hormone preparations. A fixed effects model meta-analysis was performed. The variables studied include the average dose (IU), days of treatment, estradiol peak, follicles >14 mm, number of extracted oocytes, number of embryos obtained, number of cases of ovarian hyperstimulation syndrome (OHSS), and clinical pregnancies.

RESULTS

A total of six studies met the stated criteria and were included in the meta-analysis. In these studies, the average r-hFSH dose per patient was 230.29 IU less with administration of follitropin alfa FbM compared with FbIU, and the number of days of treatment was reduced by 0.48. In addition, a significantly greater number of oocytes (0.84) were extracted, more embryos (0.88) were obtained, and a higher peak level of estradiol (613.08 pmol/L) was achieved in the patients undergoing ovarian stimulation with follitropin alfa FbM. However, no statistically significant differences were observed in the number of follicles >14 mm, clinical pregnancies, or OHSS cases.

CONCLUSION

Follitropin alfa FbM, a technologically modified formulation of r-hFSH, is as safe as follitropin alfa FbIU but requires a smaller dose over a shorter period to produce more oocytes and final embryos.

Meta-analysis of percutaneous radiofrequency ablation versus ethanol injection in hepatocellular carcinoma

BACKGROUND

Percutaneous radiofrequency ablation (RFA) has gained popularity in the treatment of hepatocellular carcinoma (HCC). However, its role versus other conventional minimally invasive therapies is still a matter of debate. The purpose of this work is to analyse the efficacy and safety of RFA versus that of ethanol injection (PEI), the percutaneous standard approach to treat nonsurgical HCC.

METHODS

Systematic review and meta-analysis of randomised or quasi-randomised controlled trials published up to August 2008 in PubMed, ISI Web of Science and The Cochrane Library. Overall survival, local recurrence rate and adverse effects were considered as primary outcomes. Studies were critically appraised and estimates of effect were calculated according to the random-effects model. Inconsistency across studies was evaluated using the I2 statistic. Sensitivity analyses were conducted to explore statistical heterogeneity.

RESULTS

Six studies were eligible. The studies reported data on 396 patients treated by RFA and 391 treated by PEI. In general, subjects were in Child-Pugh class A (74%) and had unresectable HCC (mean size 2.5 cm). Mean follow-up was 25 +/- 11 months. The survival rate showed a significant benefit for RFA over PEI at one, two, three and four years. The advantage in survival increased with time with Relative Risk values of: 1.28 (95%CI:1.12-1.45) and 1.24 (95%CI:1.05-1.48) for RFA versus PEI at 3- and 4-years respectively. Likewise, RFA achieved significantly lower rates of local recurrence (RR: 0.37, 95%CI: 0.23-0.59). The overall rate of adverse events was higher with RFA (RR:2.55, 95%CI: 1.8-3.6) yet no significant differences were found concerning major complications (RR:1.85, 95%CI: 0.68-5.01). There was not enough evidence supporting a better cost-effectiveness ratio for RFA compared to PEI.

CONCLUSION

Available evidence from adequate quality controlled studies support the superiority of RFA versus PEI, in terms of better survival and local control of the disease, for the treatment of patients with relatively preserved liver function and early-stage non-surgical HCC. However, the higher rate of adverse events displayed is something that will have to be tested with appropriate weighting of the possible benefits in each individual case. Overall cost-effectiveness of RFA needs further evaluation.