Eva Madrid

Long-term Adherence to National Guidelines for Secondary Prevention of Ischemic Stroke: A Prospective Cohort Study in a Public Hospital in Chile

BACKGROUND Clinical guidelines for the secondary prevention of ischemic stroke have been developed, but their publication is insufficient to make them effective. Our aim was to investigate adherence to Chilean guidelines, its associated variables, and to determine prognosis at follow-up. METHODS We prospectively included all consecutive patients discharged with a diagnosis of ischemic stroke from Valparaíso Regional Hospital between July 15, 2007 and January 15, 2008. Patient follow-up was performed at 5, 10, and 15 months using a standardized questionnaire. We used the Chi-square and Fisher exact tests to compare discrete variables and multivariate logistic regression analysis to adjust for potential confounding factors. A Cox regression model was fitted. RESULTS We included 156 patients; 128 patients (82%) completed follow-up. Adherence to oral anticoagulation decreased significantly compared to all other medications during follow-up (P = .004). This was not associated with any of the studied variables. Adherence to antihypertensives, statins, and hypoglycemic medications remained >65% without a significant variation. Patients with cardioembolic stroke had greater mortality (P = .003) and recurrence rates. CONCLUSIONS The observed significant decrease in adherence to oral anticoagulation in patients with cardioembolic stroke suggests a need for the implementation of specific strategies to achieve the desired secondary prevention goals in these patients. Future research into the evaluation of other factors that could be associated with the lack of adherence to these guidelines, measurements of therapeutic goals, and new therapeutic strategies that are easier to use and that are associated with less risk could improve the prognosis of these patients.

La hiponatremia al momento de ingreso como factor de riesgo de mortalidad hospitalaria

Background: Patients who develop hyponatremia during their hospitalization have higher hospital mortality. Aim: To determine if the presence of hyponatremia on admission to the emergency room is a risk factor for hospital mortality. Patients and Methods: Two hundred forty five patients consecutively admitted to the emergency room and then transferred to the Medicine Department, where they finally died, were matched for age and gender with 245 control subjects admitted to the emergency room and hospitalized in the Medicine Department at the same time, but survived. The dependent variable was death, and the exposure variable was hyponatremia. Admission diagnosis and Charlson comorbidity index was considered as confounding variables. Results: Hyponatremia at admission occurred in 30 and 17% of patients who died and survived, respectively, rendering an adjusted odds ratio for death of 2.13 (95% confidence intervals = 1.27-3.57). Charlson Comorbidity Index according to age score was higher in subjects with hyponatremia compared to those without hyponatremia (8.1 ± 3.1 and 7.2 ± 2.8; p = 0.01). Multivariate analysis showed that age, gender, length of stay, cause of hospitalization and chronic diseases did not significantly modify the effect of hyponatremia on hospital mortality. Conclusions: Hyponatremia on admission at emergency room had a significant association with hospital mortality. Subjects with hyponatremia had a higher Charlson Comorbidity Index score.

Ten years after the FDA black box warning for antidepressant drugs: a critical narrative review

Background The United States Food and Drug Administration (FDA) has warned about the increased suicidality risk associated with the use of selective serotonin reuptake inhibitors (SSRI) and venlafaxine in children and adolescents. Objectives To critically appraise the available evidence supporting the FDA Black box warning concerning to the use of antidepressants in child and adolescents. Methods A critical review of articles in Medline/PubMed and SciELO databases regarding the FDA Black box warning for antidepressants, and the impact of FDA warnings on antidepressant prescriptions and suicide rates. Results The warning was based on surveys that did not report either cases of suicide nor a significant difference supporting an increased suicidality rate. The concept was defined in an ambiguous way and there is currently more available evidence to support such definition. The use of SSRI and venlafaxine has been associated to lower suicidality rates, but the prescription fall due to the warning increased suicide rates. Discussion Suicidality is an inherent feature of depressive disorders so it would be desirable to consider how much of the phenomenon may be attributed to antidepressants per se. It would be appropriate to consider that suicide rates might increase also as a consequence of the warning.

Identificación de factor de crecimiento vascular endotelial en células glandulares de tejido prostético maligno y benigno: Relación con la recidiva tumoral al año de la prostatectomía

BACKGROUND Prostate cancer (PC) is the second cause of death by cancer in men in Chile. Its behavior is so variable that it is necessary to search reliable prognostic markers. Vascular Endothelial Growth Factor (VEGF) is one of the most powerful pro-angiogenic factors. There is no agreement on its validity as a diagnostic or prognostic factor. AIM To search for VEFG in prostatic tissue. MATERIAL AND METHODS This study was performed in prostatectomy tissue coming from 41 patients with PC and 39 patients with benign prostatic hyperplasia (BPH). Specimens were studied using immunohistochemical staining for VEGF. The percentage of stained glandular cells per patient was calculated and associated with pathological diagnosis in cancer patients. RESULTS PC biopsies had a mean of 82% of VEGF (+) stained cells, while BPH had only 1.6% (p < 0.01). No relationship was found between the percentage of staining and recurrence at one year of follow-up in the case of PC. CONCLUSIONS These results would rule out VEGF as a prognostic factor in this series of patients.

Identification and description of controlled clinical trials published in Spanish Ophthalmology Journals.

ABSTRACT Purpose: Properly conducted controlled clinical trials (CCTs) provide the highest level of evidence for optimising decision-making in healthcare. Electronic search strategies do not exhaustively retrieve them, because of issues related to indexing, exclusion of journals in languages other than English, among others. A handsearch approach is therefore warranted. We aimed to identify all CCTs published in Ophthalmology journals in Spain, to describe their main features, and to submit them to the Cochrane Register of CCTs (CENTRAL). Methods: After identifying all Spanish Ophthalmology Journals, we conducted a systematic handsearch following Cochrane guidelines. When appropriate, results were compared against electronic searches. A descriptive analysis was completed, including risk of bias assessment. Results: We identified 18 eligible journals; 10 074 original articles, editorials, letters to the editor, abstracts and conference proceedings were assessed via handsearching for inclusion. Of these, 136 were subject to title and abstract screening, after which 102 were classified as CCTs. We identified three articles via electronic searches that had not been detected via handsearch, for a total of 105 CCTs. Among these, the most investigated pathologies were cataracts (32/105; 30.5%) and glaucoma (23/105 21.9%). Regarding risk of bias, 104/105 (99.0%) were deemed as “high risk of bias”, mainly due to flaws in sequence generation and allocation concealment. 15/105 (14.3%) mentioned conflicts of interest, half of which had something to declare. No CCT reported adherence to CONSORT. Conclusion: Spanish Ophthalmology journals publish a low number of CCTs, with limited methodological quality. Handsearching was more sensitive than the electronic searching. Abbreviations CCT: Controlled clinical trial

Trypophobia: What Do We Know So Far? A Case Report and Comprehensive Review of the Literature

In this article, we describe the case of a girl who suffers from a phobia to repetitive patterns, known as trypophobia. This condition has not yet been recognised by diagnostic taxonomies such as the Diagnostic and Statistical Manual of Mental Disorders. Trypophobia usually involves an intense and disproportionate fear towards holes, repetitive patterns, protrusions, etc., and, in general, images that present high-contrast energy at low and midrange spatial frequencies. It is commonly accompanied by neurovegetative symptoms. In the case we present here, the patient also suffered from generalised anxiety disorder and was treated with sertraline. After she was diagnosed, she showed symptoms of both fear and disgust towards trypophobic images. After some time following treatment, she only showed disgust towards said images. We finish this case report presenting a comprehensive literature review of the peer reviewed articles we retrieved after an exhaustive search about trypophobia, we discuss how this case report contributes to the understanding of this anxiety disorder, and what questions future studies should address in order to achieve a better understanding of trypophobia.

Cuestionario de actividades de la vida diaria (T-ADLQ): utilidad en pacientes con accidente cerebrovascular menor

Background: The inability to carry out activities of daily living (ADL) is prevalent in elderly people and it is associated with hypertension and stroke. Aim: To evaluate ADLs using the T-ADLQ in hypertensive patients with minor stroke. Subjects and Methods: T-ADLQ, Cognitive tests (Minimental and Addenbrooke), and Hamilton depression test were applied to 100 hypertensive ambulatory patients (55 without symptomatic stroke and 45 with ischemic stroke, Rankin ? 2). Results: In stroke patients the ability to perform ADL was significantly reduced compared with hypertensive patients without stroke. Cognitive dysfunction and depressive symptoms were associated with a lower ADL performance. Conclusions: The T-ADLQ is useful to evaluate ADL in hypertensive ambulatory patients with ischemic stroke.BACKGROUND The inability to carry out activities of daily living (ADL) is prevalent in elderly people and it is associated with hypertension and stroke. AIM To evaluate ADLs using the T-ADLQ in hypertensive patients with minor stroke. SUBJECTS AND METHODS T-ADLQ, Cognitive tests (Minimental and Addenbrooke), and Hamilton depression test were applied to 100 hypertensive ambulatory patients (55 without symptomatic stroke and 45 with ischemic stroke, Rankin ≤ 2). RESULTS In stroke patients the ability to perform ADL was significantly reduced compared with hypertensive patients without stroke. Cognitive dysfunction and depressive symptoms were associated with a lower ADL performance. CONCLUSIONS The T-ADLQ is useful to evaluate ADL in hypertensive ambulatory patients with ischemic stroke.

Funcionamiento psicosocial en pacientes agudos y crónicos no psiquiátricos en régimen hospitalario: depresión, alexitimia y falta de asertividad

Background: Depression, alexithymia, and lack of assertiveness interfere with individual psychosocial functioning and may result in longer hospitalization stay and poorer therapeutic results. Aim:To analyze the psychosocial functioning in acute and chronic patients and its association with psychological, clinical and sociodemographic variables.Material and methods: We performed a cross-sectional study that included 80 inpatients of both sexes with organic pathology, aged between 18 to 70 years old, without any current psychiatric disorder. Clinical and sociodemographic data were collected from a semi-structured interview and hospital records. Beck Depression Inventory-IA, Toronto Alexithymia Scale-20 and Rathus Assertiveness Scale were administered. Results: Fifty five percent of patients had some degree of depression, 33% alexithymia and 34% lack of assertiveness. The levels of depression, alexithymia and lack of assertiveness in chronic patients were significantly higher than those observed in acute patients. Women and participants older than 60 years exhibited the highest degrees of depression. Alexithymia and lack of assertiveness were associated with a lower educational level. A negative significant correlation between alexithymia and assertiveness scores was observed among acute patients. Conclusions: Participants with chronic diseases had a lower psychosocial functioning.Less educated patients showed more alexithymic and less assertive features. We emphasized the need of a better management of these aspects by the health team, since social functioning might interfere with the outcome of physical illnesses.

Study 329 and the use of paroxetine in child and adolescent unipolar depression

Dear Editor, We have recently published the article “Ten years after the FDA black box warning for antidepressant drugs: a critical narrative review” regarding the warning issued in 2003 by the United States Food and Drug Administration (FDA) about the use of serotonin reuptake inhibitors and venlafaxine for the treatment of child and adolescent depression, and its association to an increased suicidality risk1. However, considering the new evidence emerged on the topic, we would like to update our article using new available information regarding paroxetine use, a serotonin reuptake inhibitor involved in FDA’s warning as well. In 2001, Keller et al. published the study “Efficacy of paroxetine in the treatment of adolescent major depression: a randomized, controlled trial”2 (Study 329), sponsored and conducted by SmithKline Beecham (which later became Glaxo SmithKline), concluding that paroxetine is generally well tolerated and effective for unipolar major depression in adolescents when compared with placebo. The “ghostwritten” published results of Study 329 were used for a marketing campaign characterizing paroxetine as remarkably effective and safe. After the campaign, over 2 million off-label prescriptions were written. In 2012, Glaxo SmithKline was fined a record

Association of glycaemia with perceived threat of illness in patients with type 2 diabetes

3 billion for dishonest encouragement of paroxetine use3. Additionally, the manuscript was made by a medical writer hired by the laboratory, and all the 22 authors in the manuscript denied having participated in writing the draft3. Recently, the British Medical Journal has published the reanalysis of Study 329, carried out by independent researchers4, using Clinical Data Records, in the context of the RIAT initiative “Restoring Invisible and Abandoned Trials,” and in order to check whether access to and reanalysis of a full dataset from a randomized controlled trial would have clinically relevant implications for evidence based medicine. The authors demonstrated that the antidepressant is neither safe nor effective in adolescent depression. Indeed, the effect of paroxetine was not significantly different from placebo for primary or secondary outcome measure. There were significant increases in harms, suicidal ideation and behavior in paroxetine group, while imipramine group displayed cardiovascular problems. The authors highlighted the need of making primary trial data and protocols available to increase the thoroughness of the evidence. In our study, Study 329 was not included, and neither was its reanalysis1. We consider of utmost relevance to take this case into account, especially when considering that the outcome of a clinical intervention is directly related to suicide spectrum. Although in our article we showed some criticism about the ambiguity of the FDA warning, we do not support, in whatever way, these type of practices, which discredit the medical community and science in general.