Fernando Rubinstein

Preoperative 6-minute walk test adds prognostic information to Euroscore in patients undergoing aortic valve replacement

Aims: The authors investigated the additive prognostic value of the 6-minute walk test (6MWT) to Euroscore in patients with severe aortic stenosis undergoing aortic valve replacement (AVR) Methods and results: 208 patients with severe AS underwent the 6MWT before AVR, as part of a randomised trial (ASSERT) comparing stented and stentless aortic valves. Clinical follow-up was available for 200 patients up to 12 months. The rate of death, myocardial infarction (MI) or stroke (time to first event) was 13% (n = 14) in patients walking <300 metres compared to 4% (n = 4) in those who walked ⩾300 metres (p = 0.017). When rate of death, MI or stroke by Euroscore risk was stratified by 6-minute walking distance, the 6MWT added prognostic information. In a Cox regression analysis 6MWT distance was the only variable retained as an independent predictor of the composite outcome of death, MI or stroke at 12 months (HR 0.28 95% CI 0.09 to 0.85, p = 0.025). Conclusions: The 6MWT is safe and feasible to carry out in patients with severe aortic stenosis before AVR, and provides potentially important functional and prognostic information to clinical assessment and the Euroscore risk score.

Colorectal Cancer Staging: Reappraisal of N/PN Classification

PURPOSE: Current American Joint Committee on Cancer and the Union Internationale Contre le Cancer TNM classification disregards location of positive nodes, discontinuing N3 category, which constitutes a major modification to 1987 version. This study was designed to assess the impact of the recategorization of former N3 cases and the reliability of the current N1-N2 subcategorization of Stage III patients. METHODS: Prospectively collected data from 1,391 patients (55.8 percent males; median age, 64 (range, 21–97) years), operated on with curative intent between 1980 and 1999, were analyzed. The median follow-up was 60 (interquartile range, 27–97) months with 129 cases lost to follow-up. RESULTS: Of positive node cases, 25.3 percent were former N3. Among them, 30.5 percent migrated to the N1 group and 69.5 percent to the N2 group. The proportions of former N3 cases in N1 and N2 groups were 12.5 percent and 46.1 percent, respectively (P < 0.001). Node-positive patients had an actuarial five-year survival rate of 56.7 percent (95 percent confidence interval, 53–59), with a significant difference between N1/N2 categories (63.6 vs. 44.1 percent, respectively; P < 0.001). Although apical node involvement and more than three positive nodes were associated with poorer outcomes in univariate analysis, only the number of positive nodes had independent association (hazard ratio, 1.6 (range, 1.2–2.2); P < 0.001). Integration of former N3 cases did not modify outcomes. CONCLUSIONS: The recategorization of former N3 involved a high proportion of positive node cases. Current N1/N2 categories clearly defined different outcomes and were not modified by the integration of former N3.

Validation of a Telephone‐administered Geriatric Depression Scale in a Hispanic Elderly Population

OBJECTIVE: To develop and validate a Spanish version of the Geriatric Depression Scale (GDS) for telephone administration.DESIGN, SETTING, AND PATIENTS: The original version of the GDS was translated into Spanish. A random sample of 282 ambulatory elderly individuals was contacted by phone. Those completing the phone GDS (GDS-T) were asked to schedule an appointment within two weeks in which we collected data on demographics, physical exam, functional and mental status, and a face-to-face version of the GDS (GDS-P). We estimated question-to-question κ statistics and the Pearson correlation coefficient between the GDS-T and GDS-P scores. We evaluated reliability of the GDS-T and GDS-P using the Cronbach’s α coefficient. We estimated the sensitivity, specificity, and criterion validity of the GDS using the DSM IV criteria for depression as our gold standard.RESULTS: Thirty patients (11%) refused to participate. Of the remaining 252 patients, 169 (67%) attended the personal interview. The Cronbach’s α coefficient was 0.85 for GSD-P and 0.88 for GDS-T. Sensitivity and specificity were 88% and 82% for GDS-P and 84% and 79% for GDS-T. The prevalence of depression in the group completing both scales was 12.8% using the GDS-P and 14.9% using the GDS-T (P>.05). Among those who only completed the GDS-T, the prevalence was 22.7% (P<.05) suggesting that depressed patients kept their appointments less frequently.CONCLUSIONS: The telephone GDS had high internal consistency and was highly correlated with the validated personal administration of the scale, suggesting that it could be a valid instrument for screening of depression among elderly ambulatory Spanish-speaking patients. Because the depression rate was significantly higher among those not presenting to the personal evaluation, the adoption of GDS-T may help detect and plan early interventions in patients who otherwise would not be identified.

Laparoscopic colorectal resections: a simple predictor model and a stratification risk for conversion to open surgery.

BACKGROUND: The advantages associated with the laparoscopic approach are lost when conversion is required. Available predictive models have failed to show external validation. Body surface area is a recently described risk factor not included in these models. OBJECTIVE: The aim of this study was to develop a clinical rule including body surface area for predicting conversion in patients undergoing elective laparoscopic colorectal surgery. DESIGN: This was a prospective cohort study. SETTING: This study was conducted at a single large tertiary care institution. PATIENTS: Nine hundred sixteen patients (mean age, 63.9; range, 14–91 years; 53.2% female) who underwent surgery between January 2004 and August 2011 were identified from a prospective database. MAIN OUTCOME MEASURES: Conversion rate was analyzed related to age, sex, obesity, disease location (colon vs rectum), type of disease (neoplastic vs nonneoplastic), history of previous surgery, and body surface area. A predictive model for conversion was developed with the use of logistic regression to identify independently associated variables, and a simple clinical prediction rule was derived. Internal validation of the model was performed by using bootstrapping. RESULTS: The conversion rate was 9.9% (91/916). Rectal disease, large patient size, and male sex were independently associated with higher odds of conversion (OR, 2.28 95%CI, 1.47–3.46]), 1.88 [1.1–3.44], and 1.87 [1.04–3.24]). The prediction rule identified 3 risk groups: low risk (women and nonlarge males), average risk (large males with colon disease), and high risk (large males with rectal disease). Conversion rates among these groups were 5.7%, 11.3%, and 27.8% (p < 0.001). Compared with the low-risk group, ORs for average- and high-risk groups were 2.17 (1.30–3.62, p = 0.004) and 6.38 (3.57–11.4, p < 0.0001). LIMITATIONS: The study was limited by the lack of external validation. CONCLUSION: This predictive model, including body surface area, stratifies patients with different conversion risks and may help to inform patients, to select cases in the early learning curve, and to evaluate the standard of care. However, this prediction rule needs to be externally validated in other samples (see Video, Supplemental Digital Content 1, http://links.lww.com/DCR/A137).

Research: increasing value, reducing waste

www.thelancet.com Vol 383 March 29, 2014 1125 research priority setting, patients and clinicians are mentioned as the principal users of research. While both these groups are clearly important to setting of research priorities, it is disappointing that no reference is made to health-care commissioners. Commissioners are responsible for buying care on behalf of their populations and ensuring its eff ective delivery. They therefore have considerable interest in and infl uence on the design of services and the treatments they paid for. Within the UK, NHS England is the primary body for commissioning health care in England and has a budget of about £100 million, which is spent either directly commissioning some services or through other organisations such as Clinical Commissioning Groups. To make cost-eff ective decisions at a population level, commissioners need to use the best available evidence and therefore should be considered major users of research evidence. Currently, it is highly likely that substantial sums are wasted on poorly evidenced commissioning decisions. Under the Health and Social Care Act 2012, commissioners in England have a duty to promote research and the use of evidence, and engagement in research priority setting is a key way of exercising this duty. NHS England have set out an ambition to do this. Input from commissioners is crucial if service delivery questions and population needs are to be considered alongside the more individualorientated priorities of clinicians and patients.

Avoidable hospitalizations for ambulatory care sensitive conditions as an indicator of primary health care effectiveness in Argentina.

Avoidable hospitalizations for ambulatory care sensitive conditions (AH-ACSCs) identify health problems that could be avoided by improving primary health care (PHC). On the basis of hospital discharges from Argentine public sector facilities, an expert panel convened to define a list of AH-ACSCs for children and adults. AH-ACSCs represented less than 30% of hospitalizations. Compared with country averages, poorer districts showed large differences in trends for adults but not for children. Despite that AH-ACSCs have demonstrated empirical validity to evaluate health system performance, its implementation to assess PHC in countries like Argentina, with pluralistic and fragmented health care systems, remains a big challenge.

Validación de un instrumento para la evaluación de la interpretación de los resultados de estudios de investigación en los residentes de un hospital universitario.

La informacion medica que hoy en dia se publica en revistas de interes cientifico es abundante. En este contexto, la habilidad para interpretar criticamente los estudios de investigacion resulta ser esencial con el objeto de ofrecer a los pacientes una atencion medica de alta calidad [1,2]. Evaluar adecuadamente lo relevante de esta informacion requiere que el medico sea capaz de reconocer los distintos disenos de investigacion, interpretar las pruebas estadisticas mas frecuentemente utilizadas y comprender como se informan los resultados. Un estudio [1] realizado en 11 programas de residencias de Medicina Interna en Connecticut (EE. UU.) y otro en Dinamarca [3], ambos utilizando una prueba de eleccion de opciones multiples, han demostrado que los medicos sin entrenamiento formal en epidemiologia y estadistica presentaban una pobre comprension de las pruebas estadisticas mas utilizadas y una interpretacion limitada de los resultados de las investigaciones. Solo el 21% de los medicos era capaz de analizar correctamente los articulos de investigacion presentados. A partir de estos estudios y de una encuesta realizada a los directores de programa de residencias en EE. UU. [4] surge una fuerte recomendacion de tener en cuenta un entrenamiento mas efectivo en este campo en el diseno de los programas de formacion del medico residente. En este escenario nos hemos propuesto desarrollar y validar un instrumento que permita conoValidacion de un instrumento para la evaluacion de la interpretacion de los resultados de estudios de investigacion en los residentes de un hospital universitario