Teresa Seoane-Pillado

Incidence of cardiovascular events after kidney transplantation and cardiovascular risk scores: study protocol.

BackgroundCardiovascular disease (CVD) is the major cause of death after renal transplantation. Not only conventional CVD risk factors, but also transplant-specific risk factors can influence the development of CVD in kidney transplant recipients.The main objective of this study will be to determine the incidence of post-transplant CVD after renal transplantation and related factors. A secondary objective will be to examine the ability of standard cardiovascular risk scores (Framingham, Regicor, SCORE, and DORICA) to predict post-transplantation cardiovascular events in renal transplant recipients, and to develop a new score for predicting the risk of CVD after kidney transplantation.Methods/DesignObservational prospective cohort study of all kidney transplant recipients in the A Coruña Hospital (Spain) in the period 1981-2008 (2059 transplants corresponding to 1794 patients).The variables included will be: donor and recipient characteristics, chronic kidney disease-related risk factors, pre-transplant and post-transplant cardiovascular risk factors, routine biochemistry, and immunosuppressive, antihypertensive and lipid-lowering treatment. The events studied in the follow-up will be: patient and graft survival, acute rejection episodes and cardiovascular events (myocardial infarction, invasive coronary artery therapy, cerebral vascular events, new-onset angina, congestive heart failure, rhythm disturbances and peripheral vascular disease).Four cardiovascular risk scores were calculated at the time of transplantation: the Framingham score, the European Systematic Coronary Risk Evaluation (SCORE) equation, and the REGICOR (Registre Gironí del COR (Gerona Heart Registry)), and DORICA (Dyslipidemia, Obesity, and Cardiovascular Risk) functions.The cumulative incidence of cardiovascular events will be analyzed by competing risk survival methods. The clinical relevance of different variables will be calculated using the ARR (Absolute Risk Reduction), RRR (Relative Risk Reduction) and NNT (Number Needed to Treat).The ability of different cardiovascular risk scores to predict cardiovascular events will be analyzed by using the c index and the area under ROC curves. Based on the competing risks analysis, a nomogram to predict the probability of cardiovascular events after kidney transplantation will be developed.DiscussionThis study will make it possible to determine the post-transplant incidence of cardiovascular events in a large cohort of renal transplant recipients in Spain, to confirm the relationship between traditional and transplant-specific cardiovascular risk factors and CVD, and to develop a score to predict the risk of CVD in these patients.

Tendencias en mortalidad por infarto de miocardio. Estudio comparativo entre España y Estados Unidos: 1990-2006

INTRODUCTION AND OBJECTIVES Mortality from myocardial infarction is declining in high income countries, but the magnitude of this decline could differ between countries. We sought to compare the mortality trends from myocardial infarction between Spain and the United States. METHODS This was an observational retrospective study. Crude data were obtained from public databases. Standardized mortality rates were calculated for the last 17 years available for both countries (1990 to 2006), and stratified by age and sex. Joinpoint regression analysis was used for the trends analysis and projections. RESULTS There has been a steady decline in mortality from myocardial infarction in both countries from 1990 to 2006. However, the magnitude of this decline was greater in the United States (relative reductions in men: 42.7% [Spain] and 59.7% [United States], and in women: 40% [Spain] and 57.4% [United States]). The estimated annual percentages of decline in mortality were greater in the United States (men: -10.7%, women: -5.1%) than in Spain (men: -1.9%, women: -5.1%). Projections for 2012 suggest that the mortality from myocardial infarction will be lower in men in the United States (53.33/100,000) than in Spain (81.52/100,000), while for women it will be equal (32.56/100,000 in the United States and 33.56/100,000 in Spain). CONCLUSIONS The decline in mortality from myocardial infarction has been more pronounced in the United States than in Spain, and projections for upcoming years suggest in the United States it will evolve to rates below those expected in Spain for men and equal rates for women.

Dependence for basic and instrumental activities of daily living after hip fractures

The objective of the study is to determine basic activities of daily living (Barthel Index) and instrumental activities of daily living (Lawton-Brody Index) before and after hip fracture. Follow-up study of patients (n=100) with hip fracture, operated at Complejo Hospitalario Universitario de A Coruña (Spain). Period January/2009-December/2011. Demographic characteristic of the patients, Charlson Index, Glomerular filtration rate, Barthel index, Lawton index, type of proximal femur fracture and surgical treatment delay were recorded. Multivariate regression was performed. Informed patient consent and ethical review approval were obtained. Before fracture were independent for activities of daily living (ADL) a 38.0%, at 90 days were 15.4%. The Barthel index score decreased from 75.2±28.2 to 56.5±31.8) (p<0.0001). If we consider the age, gender, comorbidity (Charlson index), renal function, fracture type and surgical delay objectify the only independent variable to predict dependency effect is age. If we also consider the Barthel score objectify the variable that significantly modifies that score at 90 days is the baseline value of the index. The prevalence of independence for instrumental activities of daily living (IADL) at the baseline moment is 11% and at 90 days is decreased to 2.2%. There is a decrease in the independence effect in all activities. The variable predictor of independence for all activities after taking into consideration age, sex, comorbidity, fracture type, surgical delay and renal function is the baseline score of the Barthel and Lawton index.

Age differences in presentation, diagnosis pathway and management of colorectal cancer

BACKGROUND The gap in survival between older and younger European cancer patients is getting wider. It is possible that cancer in the elderly is being managed or treated differently than in their younger counterparts. This study aims to explore age disparities with respect to the clinical characteristics of the tumour, diagnostic pathway and treatment of colorectal cancer patients. METHODS We conducted a multicenter cross sectional study in 5 Spanish regions. Consecutive incident cases of CRC were identified from pathology services. MEASUREMENTS From patient interviews, hospital and primary care clinical records, we collected data on symptoms, stage, doctors investigations, time duration to diagnosis/treatment, quality of care and treatment. RESULTS 777 symptomatic cases, 154 were older than 80 years. Stage was similar by age group. General symptoms were more frequent in the eldest and abdominal symptoms in the youngest. No differences were found regarding perception of symptom seriousness and symptom disclosure between age groups as no longer duration to diagnosis or treatment was observed in the oldest groups. In primary care, only ultrasound is more frequently ordered in those <65 years. Those >80 years had a significantly higher proportion of iron testing and abdominal XR requested in hospital. We observed a high resection rate independently of age but less adjuvant chemotherapy in Stage III colon cancer, and of radiotherapy in stage II and III rectal cancer as age increases. CONCLUSION There are no relevant age disparities in the CRC diagnosis process with similar stage, duration to diagnosis, investigations and surgery. However, further improvements have to be made with respect to adjuvant therapy.

Comorbidity as a predictor of mortality and mobility after hip fracture

To determine mortality and mobility rates after hip fracture.

Validity of Footprint Analysis to Determine Flatfoot Using Clinical Diagnosis as the Gold Standard in a Random Sample Aged 40 Years and Older

Background Research is needed to determine the prevalence and variables associated with the diagnosis of flatfoot, and to evaluate the validity of three footprint analysis methods for diagnosing flatfoot, using clinical diagnosis as a benchmark. Methods We conducted a cross-sectional study of a population-based random sample ≥40 years old (n = 1002) in A Coruña, Spain. Anthropometric variables, Charlson’s comorbidity score, and podiatric examination (including measurement of Clarke’s angle, the Chippaux-Smirak index, and the Staheli index) were used for comparison with a clinical diagnosis method using a podoscope. Multivariate regression was performed. Informed patient consent and ethical review approval were obtained. Results Prevalence of flatfoot in the left and right footprint, measured using the podoscope, was 19.0% and 18.9%, respectively. Variables independently associated with flatfoot diagnosis were age (OR 1.07), female gender (OR 3.55) and BMI (OR 1.39). The area under the receiver operating characteristic curve (AUC) showed that Clarke’s angle is highly accurate in predicting flatfoot (AUC 0.94), followed by the Chippaux-Smirak (AUC 0.83) and Staheli (AUC 0.80) indices. Sensitivity values were 89.8% for Clarke’s angle, 94.2% for the Chippaux-Smirak index, and 81.8% for the Staheli index, with respective positive likelihood ratios or 9.7, 2.1, and 2.0. Conclusions Age, gender, and BMI were associated with a flatfoot diagnosis. The indices studied are suitable for diagnosing flatfoot in adults, especially Clarke’s angle, which is highly accurate for flatfoot diagnosis in this population.

Diagnostic and treatment delay, quality of life and satisfaction with care in colorectal cancer patients: a study protocol

BackgroundDue to recent improvements in colorectal cancer survival, patient-reported outcomes, including health-related quality of life and satisfaction with care, have become well-established endpoints to determine the impact of the disease on the lives of patients.The aim of this study is to determine prospectively, in a cohort of colorectal cancer incident cases: a) health-related quality of life, b) satisfaction with hospital-based care, and c) functional status. A secondary objective is to determine whether diagnostic/therapeutic delay influence quality of life or patients’ satisfaction levels.Methods/designSingle-centre prospective follow-up study of colorectal cancer patients diagnosed during the period 2011–2012 (n = 375).This project was approved by the corresponding ethics review board, and informed consent is obtained from each patient. After diagnosis, patients are interviewed by a trained nurse, obtaining information on sociodemographic characteristics, family history of cancer, first symptoms, symptom perception and reaction to early symptoms. Quality of life is assessed with the EORTC QLQ-C30 and QLQ- CR29 questionnaires, and patients’ satisfaction with care is determined using the EORTC IN-PATSAT32. Functional status is measured with the Karnofsky Performance Status Scale.Clinical records are also reviewed to collect information on comorbidity, tumour characteristics, treatment, hospital consultations and exploratory procedures.Symptoms-to-diagnosis interval is defined as the time from the date of first symptoms until the cytohistological confirmation of cancer. Treatment delay is defined as the time between diagnosis and surgical treatment.All the patients will be followed-up for a maximum of 2 years. For survivors, assessments will be re-evaluated at one and two years after the diagnosis.Multiple linear/logistic regression models will be used to identify variables associated with the patients’ functional status, quality of life and satisfaction with care score. Changes in quality of life over time will be analysed with linear mixed-effects regression models.DiscussionThe results will provide a deeper understanding of the impact of colorectal cancer from a more patient-centred approach, allowing us to identify groups of patients in need of additional attention, as well as areas for improvement. Special attention will be given to the relationship between diagnostic/therapeutic delay and patients’ quality of life and satisfaction with the care received.

Podiatric medical abnormalities in a random population sample 40 years or older in Spain.

BACKGROUND Podiatric medical abnormalities are highly prevalent, yet few random population studies exist that determine the presence of pathologic abnormalities in the feet, despite their importance. The aim of this study was to determine the prevalence of podiatric medical abnormalities in a random sample population 40 years or older. METHODS An observational study was conducted of a random sample population (n = 1,002) located in A Coruña, Spain. Anthropometric variables, comorbidity (Charlson score), quality of life (36-item Short-Form Health Survey), and podiatric medical examination findings were studied. A descriptive analysis and multivariate logistic regression were performed. RESULTS The most common diseases were claw toes (69.7%), hallux valgus (38%), and hallux extensus (15.8%), which increased with age and female sex. The most frequent metatarsal formula was index minus (40.9%), followed by index plus minus (35.0%). The most frequent digital formula was Egyptian foot (57.1%), followed by Greek foot (31.4%). In this study, although the presence of podiatric medical abnormalities reduced the probability of enjoying a better quality of life, it did not do so significantly. After taking into account age, sex, comorbidity, body mass index (BMI), and the presence of podiatric medical abnormalities, the variables with an independent effect that modified the physical component of quality of life were sex (female), comorbidity, and BMI. CONCLUSIONS There was a high prevalence of podiatric medical abnormalities, which increased with age and female sex. Comorbidity, BMI, and sex modified quality of life independently of podiatric medical abnormalities.

A randomized clinical trial to determine the effect of angiotensin inhibitors reduction on creatinine clearance and haemoglobin in heart failure patients with chronic kidney disease and anaemia

Chronic kidney disease is a common comorbidity in elderly patients with heart failure. Evidence supports the use of angiotensin inhibitors for patients with heart failure. However, there is little evidence with which to assess the risk and benefits of this treatment in elderly patients with renal dysfunction.

Clinical-Pathological Characteristics and Prognosis of a Cohort of Oesophageal Cancer Patients: a Competing Risks Survival Analysis

Background To determine the clinical course, follow-up strategies, and survival of oesophageal cancer patients using a competing risks survival analysis. Methods We conducted a retrospective and prospective follow-up study. The study included 180 patients with a pathological diagnosis of oesophageal cancer in A Coruña, Spain, between 2003 and 2008. The Kaplan-Meier methodology and competing risks survival analysis were used to calculate the specific survival rate. The study was approved by the Ethics Review Board (code 2011/372, CEIC Galicia). Results The specific survival rate at the first, third, and fifth years was 40.2%, 18.1%, and 12.4%, respectively. Using the Kaplan-Meier methodology, the survival rate was slightly higher after the third year of follow-up. In the multivariate analysis, poor prognosis factors were female sex (hazard ratio [HR] 1.94; 95% confidence interval [CI], 1.24–3.03), Charlson’s comorbidity index (HR 1.17; 95% CI, 1.02–1.33), and stage IV tumours (HR 1.70; 95% CI, 1.11–2.59). The probability of dying decreased with surgical and oncological treatment (chemotherapy and/or radiotherapy) (HR 0.23; 95% CI, 0.12–0.45). The number of hospital consultations per year during the follow-up period, from diagnosis to the appearance of a new event (local recurrences, newly appeared metastasis, and newly appeared neoplasias) did not affect the probability of survival (HR 1.03; 95% CI, 0.92–1.15). Conclusions The Kaplan-Meier methodology overestimates the survival rate in comparison to competing risks analysis. The variables associated with a poor prognosis are female sex, Charlson’s comorbidity score and extensive tumour invasion. Type of follow-up strategy employed after diagnosis does not affect the prognosis of the disease.