Salvador Quintana

Risk Factors for Hospital Readmission in Patients with Chronic Obstructive Pulmonary Disease

Background: Hospital readmissions for acute exacerbation of chronic obstructive pulmonary disease (COPD) are one of the leading causes of healthcare expenditures worldwide. Objectives: To identify risk factors for hospital readmission in COPD patients. Methods:We prospectively evaluated 129 consecutive patients hospitalized for acute exacerbation of COPD. Clinical, spirometric and arterial blood gas variables were measured during hospitalization. Socioeconomic characteristics, comorbidity, dyspnea, functional dependence, depression, social support and quality of life were also analyzed. Readmission was defined as one or more hospitalizations in the following year. Results:During the follow-up period, 75 (58.5%) patients were readmitted. In bivariate analysis, readmission was associated with previous hospitalization for COPD in the past year, dyspnea scale, PaCO2 at discharge, depression, cor pulmonale, chronic domiciliary oxygen and quality of life measured by the St. George’s Respiratory Questionnaire. In multivariate analysis, the best predictor of readmission was the combination of hospitalization for COPD in the previous year (odds ratio, OR: 4.27; 95% confidence interval, CI: 1.5–12), the total score of the St. George’s Respiratory Questionnaire ≧50 points (OR: 2.36; 95% CI: 1.03–5.04) and PaCO2 at discharge ≧45 mm Hg (OR: 2.18; 95% CI: 0.84–5.06). With this model, the probability of readmission for patients without any of these variables was 7%, while it was 70% for the patients with all three variables present. Conclusion: The combination of quality of life, hospitalization for COPD in the previous year and hypercapnia at discharge are useful predictors of readmission at 1 year.

Effectiveness of a multiple intervention strategy for the control of the tiger mosquito (Aedes albopictus) in Spain.

This study was undertaken to evaluate the effectiveness of four complementary and combined strategies to minimize the presence of the invasive mosquito Aedes albopictus, firmly established in Sant Cugat del Vallès, Catalonia, Spain. A quasi-experimental design including six neighbourhoods was performed in 2008-2009. The abundance of mosquitoes was monitored through ovitraps. The multiple intervention strategy consisted of four actions: source reduction; larvicide treatments (Bacillus thuringiensis israelensis and diflubenzuron); adulticide treatments (alfacipermetrin); and cleaning up uncontrolled landfills. The results showed the number of eggs significantly reduced in the areas with intervention. In 2008, the accumulate median of eggs was 175 and 272 in the intervention and control areas, respectively. In 2009, these medians were 884 and 1668 eggs. In total, 3104 households were visited and 683 people were interviewed. During inspections inside the houses, the cooperation of citizens in 2009 was 16% higher than that in 2008 (95% CI 13-19%). These findings suggest that the strategy was effective in reducing the number of eggs. Citizen cooperation, an essential factor for success, was observed through a high level of collaboration by the home owners, who allowed entry into their private dwellings. This study could be a model for controlling the populations of Ae. albopictus in the Mediterranean region.

Repeat mediastinoscopy in all its indications: experience with 96 patients and 101 procedures

OBJECTIVE To evaluate the accuracy of repeat mediastinoscopy (reMS) in all its indications, and to analyse survival in the group of patients who underwent induction chemotherapy or chemoradiotherapy for pathologically proven stage III-N2 non-small-cell lung cancer (NSCLC). METHODS From July 1992 to February 2009, 96 patients (87 men; median age: 61.3 years), underwent 101 reMSs (five patients required a second reMS) for the following indications: restaging after induction therapy for pathologically proven N2 disease (84 cases), inadequate first mediastinoscopy (five), metachronous second primary (six) and recurrent lung cancer (six). Patients with N2-NSCLC, who had received induction therapy and had positive reMS, underwent definitive chemotherapy or chemoradiotherapy. Patients in whom reMS was negative underwent thoracotomy for lung resection and systematic nodal dissection (SND). SND was considered the gold standard to compare the negative results of reMS. Pathologic findings were reviewed and staging values were calculated using the standard formulas. Follow-up data were completed in January 2010, and survival analysis was performed by the Kaplan-Meier method. RESULTS In the group of reMS for restaging after induction therapy, the staging values were: sensitivity 0.74, specificity 1, positive predictive value 1, negative predictive value 0.79 and diagnostic accuracy 0.87. We also determined the diagnostic value of this technique according to the type of induction treatment. In terms of accuracy, no statistically significant differences were found. Median survival time in patients with true negative reMS was 51.5 months (95% confidence interval (CI) 0-112), and in the combined group of patients with positive and false-negative reMS, median survival time was 11 months (95% CI 7.6-14.1) (p=0.0001). In the group of miscellaneous indications, all staging values were 1. CONCLUSION ReMS is feasible in all the indications described. After induction therapy, it is a useful procedure to select patients for lung resection with high accuracy, independently of the induction treatment used or the intensity of the first mediastinoscopy. The persistence of lymph node involvement after induction therapy has a poor prognosis. Therefore, techniques providing cytohistological evidence of nodal downstaging are advisable to avoid unnecessary thoracotomies.

Obstructive sleep apnea and metabolic syndrome in spanish population.

Obstructive sleep apnea (OSA) is a clinical picture characterized by repeated episodes of obstruction of the upper airway. OSA is associated with cardiovascular risk factors, some of which are components of metabolic syndrome (MS). Objectives: First, determine the prevalence of MS in patients with OSA visited in sleep clinic. Second, evaluate whether there is an independent association between MS components and the severity of OSA. Methods: Patients with clinical suspicion of OSA were evaluated by polysomnography. Three groups were defined according to apnea hypoapnea index (AHI): no OSA (AHI <5), mild-moderate (AHI≥ 5 ≤30), and severe (AHI> 30). All patients were determined in fasting blood glucose, total cholesterol, HDL cholesterol, triglycerides and insulin. MS was defined according to criteria of National Cholesterol Education Program (NCEP). Results: A total of 141 patients (mean age 54 ± 11 years) were evaluated. According to AIH, 25 subjects had no OSA and 116 had OSA (41mild-moderate and 75 severe). MS prevalence ranged from 43-81% in OSA group. Also, a significant increase in waist circumference, triglycerides, glucose, blood pressure levels, and a decrease in HDL cholesterol levels was observed in more severe OSA patients. All polysomnographic parameters correlated significantly with metabolic abnormalities. After a multiple regression analysis, abdominal obesity (p <0.02), glucose (p <0.01) and HDL cholesterol (p <0.001) were independently associated with OSA. Conclusions: Our findings show high prevalence of MS in OSA, especially in severe group. A significant association between OSA and some of the components of MS was found in Spanish population.

Control of the Asian tiger mosquito (Aedes albopictus) in a firmly established area in Spain: risk factors and people's involvement.

BACKGROUND The tiger mosquito is a competent vector of dengue and chikungunya in Europe. Therefore, evaluating control strategies is a priority. In this work we aimed to determine the key factors affecting Aedes albopictus production, the preferred larval habitats, and we explored the involvement of the citizens in Sant Cugat, Spain. METHODS A source-reduction campaign including door-to-door visits and interviews to local inhabitants (2008-2010) and larval surveys (2010) was carried out. RESULTS Civil workers inspected 3720 premises and interviewed 820 local inhabitants. Larval habitats, detected in 7.2% of the premises (n=266), were negatively associated with primary residence OR=0.4 (95% CI 0.3-0.6); and positively associated with schools OR=2.4 (95% CI 1.1-5.0), solid waste OR=5.1 (95% CI 3.0-8.9), scuppers OR=5.0 (95% CI 3.5-7.3) among other variables. Preventive measures were taken by 83.2% of householders (n=682). In 2010, 10.3% more citizens claimed to avoid having stagnant water compared with 2008. Simultaneously another 10.3% stopped using insecticides. CONCLUSION Solid waste, scuppers and vegetable gardens were found to be important factors characterizing premises with larval habitats. People claimed to know about this insect and they considered it to be an important issue that diminished their quality of life.

Fatal manganese intoxication due to an error in the elaboration of Epsom salts for a liver cleansing diet.

We describe the case of a 50-year-old man with a fatal intoxication after accidental massive oral ingestion of manganese. The patient presented with lethargy, diffuse abdominal pain, vomiting, and profuse diarrhea after ingesting Epsom salts (magnesium sulfate heptahydrate) during a liver cleansing diet. Despite intensive care management with intubation, prone position ventilation, continuous venovenous hemofiltration, and multiple transfusions, he progressed to refractory shock with multiple organ dysfunction resulting in death within 72 h. Similar patients arrived at several hospitals with identical epidemiology (all had ingested the same salt obtained in the same place). Clinical and forensic investigations (X-ray diffraction) discovered that the supplier had mistakenly prepared the salts with hydrated manganese sulfate instead of magnesium sulfate heptahydrate. The results enabled the other patients to be successfully treated for hydrated manganese sulfate intoxication with life support in the intensive care unit and chelation therapy (EDTA). We describe the clinical presentation of acute manganese poisoning and alert professionals to the risk of an increasingly popular diet. This case demonstrates the importance of collaboration between clinicians, pathologists, and forensic scientists to resolve a difficult-to-diagnose case.

Medidas de restricción física en un hospital de agudos y en dos centros de media y larga estancia: estudio de prevalencia y análisis de aspectos éticos relacionados con su indicación y puesta en práctica

Resumen Fundamento Se realiza un estudio de prevalencia de pacientes sometidos a restriccion fisica (RF) durante su ingreso hospitalario en centros de agudos y de larga estancia. Los objetivos son cuantificar esta practica y estudiar sus caracteristicas, asi como promover la elaboracion de una guia de actuacion para un correcto uso de la RF. Pacientes y metodo Se han llevado a cabo dos cortes transversales mediante entrevistas al personal responsable de los enfermos hospitalizados y la revision de las historias clinicas de todos los pacientes con RF en un hospital de agudos (Hospital Mutua de Terrassa [HMT]), en un centro de convalecencia y media estancia (Centre sociosanitari Vallparadis) y en un centro de larga estancia (Centre Residencial l’Ametlla del Valles), todos pertenecientes al Grup Mutua de Terrassa. Este trabajo se ha promovido desde el Comite de Etica Asistencial del HMT. Resultados La prevalencia de enfermos con RF oscila entre el 1,5 y el 27,8%, dependiendo del corte y del centro. En el centro de agudos, el motivo mas frecuente para aplicar sujecion a los pacientes es evitar que se retiren sueros o sondas (27,3%), mientras que en los otros centros es el de evitar caidas (33,3%). El material utilizado no siempre esta homologado (el 31% en el HMT y en mas del 80% en el centro de larga estancia). El grado de implicacion del medico en esta decision es bajo y raramente queda reflejado por escrito (inferior al 5% en el centro de enfermos agudos). Se utilizan pocas alternativas al uso de restriccion fisica. Conclusiones Se ha constatado que es aconsejable elaborar una guia de actuacion que contemple cuando, como y quien ha de tomar la decision de aplicar restriccion fisica a los pacientes. No es en absoluto habitual que conste el hecho de la RF en ningun documento de la historia clinica a excepcion de los registros de enfermeria; asimismo, no siempre se utiliza el material homologado. No se contemplan alternativas a la RF en la mayoria de situaciones. El estamento medico no se siente muy implicado en el tema de la RF.

Impacto de la crisis económica en la actividad de un comité ético de investigación clínica

Objetivos: Analizar el impacto de la crisis economico-social en volumen y financiacion de los ensayos clinicos (EC) y estudios observacionales (EO) a partir de la actividad de un Comite Etico de Investigacion Clinica (CEIC). Metodo: Se revisaron las memorias del CEIC desde 2003 hasta 2012. Se analizo la financiacion de los EC y los EO clasificandolos en cuatro grupos: 1) promovidos por la industria farmaceutica, 2) por sociedades cientificas con soporte de la industria, 3) por sociedades apoyadas por las administraciones publicas y 4) sin financiacion. Se compararon dos periodos: precrisis (2003- 2007) y crisis (2008-2012). Resultados: Se evaluaron 744 protocolos: un 71% del grupo 1, un 9% del grupo 2, un 3% del grupo 3 y un 17% carecia de financiacion. En cuanto a los EO, un 40%, un 5,4%, un 8,6% y un 46% correspondian a los grupos 1, 2, 3 y 4 respectivamente. Analizando periodo crisis versus precrisis, se observaron diferencias estadisticamente significativas en el numero de los EC de fase 2 y fase 3 que disminuyeron y en los EO que aumentaron. En el periodo crisis respecto al precrisis, el Grupo 4 aumento de manera estadisticamente significativa. Conclusiones: La evolucion del numero total de estudios evaluados por el CEIC tiende a mantenerse e incluso incrementarse en el tiempo. El CEIC mantiene su actividad e incluso la incrementa, a expensas de EO con y sin financiacion.

Impact of the economic crisis on the activity of a clinical research ethics committee

PURPOSE Analyze the impact of economic and social crisis in volume and funding of clinical trials (CT) and observational studies (ES) from the activity of an Research Ethics Committee (REC). METHOD REC memories 2003-2012 were reviewed. Financing of evaluated projects, CT and OS were analyzed classifying them into four groups: 1) promoted by pharmaceutical industry, 2) by scientific societies with industry support, 3) by scientific societies with government support and 4) unfunding.Two periods were compared: pre-crisis (2003-2007) and crisis (2008-2012). RESULTS During 10 studied years, 744 protocols were evaluated: a 71% of group 1, a 9% of group 2, a 3% of group 3 and a 17% was no funding. Regarding OS, 40%, 5,4%, 8,6% and 46% were the groups 1, 2, 3 and 4 respectively. Analyzing crisis versus pre-crisis period, statistically significant differences were observed in the decreasing of number of CT phase 2 and 3 and in the rising EO. Comparing crisis related to the pre-crisis period, the Group 4 increased statistically significantly. CONCLUSIONS Evolution of total number of studies evaluated by REC tends to be maintained and even increased over time. REC maintains its activity and even increased at the expense of financing and unfunded OS.

Assessing practical skills in cardiopulmonary resuscitation: Discrepancy between standard visual evaluation and a mechanical feedback device

Abstract This paper aims to analyze agreement in the assessment of external chest compressions (ECC) by 3 human raters and dedicated feedback software. While 54 volunteer health workers (medical transport technicians), trained and experienced in cardiopulmonary resuscitation (CPR), performed a complete sequence of basic CPR maneuvers on a manikin incorporating feedback software (Laerdal PC v 4.2.1 Skill Reporting Software) (L), 3 expert CPR instructors (A, B, and C) visually assessed ECC, evaluating hand placement, compression depth, chest decompression, and rate. We analyzed the concordance among the raters (A, B, and C) and between the raters and L with Cohens kappa coefficient (K), intraclass correlation coefficients (ICC), Bland–Altman plots, and survival–agreement plots. The agreement (expressed as Cohens K and ICC) was ≥0.54 in only 3 instances and was ⩽0.45 in more than half. Bland–Altman plots showed significant dispersion of the data. The survival–agreement plot showed a high degree of discordance between pairs of raters (A–L, B–L, and C–L) when the level of tolerance was set low. In visual assessment of ECC, there is a significant lack of agreement among accredited raters and significant dispersion and inconsistency in data, bringing into question the reliability and validity of this method of measurement.