Xavier Mundet

Trends in chronic complications of type 2 diabetic patients from Spanish primary health care centres (GEDAPS study): Ten year-implementation of St. Vincent recommendations

AIMS To assess the implementation of St. Vincent recommendations in Catalonia (Spain) between 1993 and 2003 following a program of Continuous Quality Improvement. METHODS 65 health centres (433 health professionals) took part in the study. From 1993 to 2003, 34 workshops on consensus guidelines and feedback referring to the variables that needed to be improved were carried out. Data collection was obtained concerning, socio-demographic information, and disease characteristics and complications from patients with type 2 diabetes mellitus (DM). RESULTS Most cardiovascular risk factors improved: glycosilated haemoglobin (HbA1c) was reduced by 0.7% (95% CI: -0.49:-0.90); total cholesterol by 0.54mmol/L (95% CI: -0.53:-0.55); non-high density lipoprotein cholesterol by 0.81mmol/L (95% CI: -0.80:-0.82); systolic blood pressure (SBP) by 6.02mmHg (95% CI: -5.79:-6.25), and diastolic blood pressure (DBP) by 2.65mmHg (95% CI: -2.4:-2.9), with the exception of smoking and obesity, which increased by 2.1% and 5.9%, respectively. Retinopathy and albuminuria decreased by 40.7% and 46% (p<0.001), respectively. The incidence of diabetic foot lesions and amputations decreased by 65.7% and 61.1% (p<0.001), respectively. The prevalence of macrovascular complications showed a slight reduction (p=0.037). Ischemic cardiomyopathy and cerebrovascular accidents decreased by 7.7% and 17.6%, respectively. CONCLUSIONS Our Continuous Quality Improvement program based on St. Vincent recommendations, had a positive impact on cardiovascular risk factors. We observed a reduction of chronic complications in type 2 DM patients.

Prevalence and Associated Factors of Silent Brain Infarcts in a Mediterranean Cohort of Hypertensives

Silent brain infarcts (SBIs) are detected by neuroimaging in approximately 20% of elderly patients in population-based studies. Limited evidence is available for hypertensives at low cardiovascular risk countries. Investigating Silent Strokes in Hypertensives: a Magnetic Resonance Imaging Study (ISSYS) is aimed to assess the prevalence and risk factors of SBIs in a hypertensive Mediterranean population. This is a cohort study in randomly selected hypertensives, aged 50 to 70 years old, and free of clinical stroke and dementia. On baseline, all participants underwent a brain magnetic resonance imaging to assess prevalence and location of silent infarcts, and data on vascular risk factors, comorbidities, and the presence of subclinical cardiorenal damage (left ventricular hypertrophy and microalbuminuria) were collected. Multivariate analyses were performed to determine SBIs associated factors. A total of 976 patients (49.4% men, mean age 64 years) were enrolled, and 163 SBIs were detected in 99 participants (prevalence 10.1%; 95% CI, 8.4%–12.2%), most of them (64.4%) located in the basal ganglia and subcortical white matter. After adjustment, besides age and sex, microalbuminuria and increasing total cardiovascular risk (assessed by the Framingham-calibrated for Spanish population risk function) were independently associated with SBIs. Male sex increased the odds of having SBIs in 2.5 as compared with females. Our results highlight the importance of considering both global risk assessment and sex differences in hypertension and may be useful to design future preventive interventions of stroke and dementia.

Short-Term Blood Pressure Variability Relates to the Presence of Subclinical Brain Small Vessel Disease in Primary Hypertension

Blood pressure (BP) variability is associated with stroke risk, but less is known about subclinical cerebral small vessel disease (CSVD). We aimed to determine whether CSVD relates to short-term BP variability independently of BP levels and also, whether they improve CSVD discrimination beyond clinical variables and office BP levels. This was a cohort study on asymptomatic hypertensives who underwent brain magnetic resonance imaging and 24-hour ambulatory BP monitoring. Office and average 24-hour, daytime and nighttime BP levels, and several metrics of BP variability (SD, weighted SD, coefficient of variation, and average real variability [ARV]) were calculated. Definition of CSVD was based on the presence of lacunar infarcts and white matter hyperintensity grades. Multivariate analysis and integrated discrimination improvement were performed to assess whether BP variability and levels were independently associated with CSVD and improved its discrimination. Four hundred eighty-seven individuals participated (median age, 64; 47% women). CSVD was identified in 18.9%, related to age, male sex, diabetes mellitus, use of treatment, ambulatory BP monitoring–defined BP levels, and ARV of systolic BP at any period. The highest prevalence (33.7%) was found in subjects with both 24-hour BP levels and ARV elevated. BP levels at any period and ARV (24 hours and nocturnal) emerged as independent predictors of CSVD, and discrimination was incrementally improved although not to a clinically significant extent (integrated discrimination improvement, 5.31%, 5.17% to 5.4%). Ambulatory BP monitoring–defined BP levels and ARV of systolic BP relate to subclinical CSVD in hypertensive individuals.

Prevalence and incidence of chronic complications and mortality in a cohort of type 2 diabetic patients in Spain

AIMS To evaluate the prevalence, incidence of micro- and macrovascular complications, final events, and mortality in type 2 diabetic patients, followed over a period of 10 years in Spain. METHODS Prospective, population-based cohort study. 317 type 2 diabetic patients treated at a Primary Care Centre, followed for 10 years. Variables were described by means of ratios, mean values and standard deviation. The chi(2) test was used to compare ratios and the Students t test to compare mean values. RESULTS Mean age in women (61%) was 61.2 years; men 66.7 years. With regard to the prevalence of complications, the following was observed: an increase in nephropathy (12%), in retinopathy (6.2%) and in neuropathy (2.1%), a decrease in ischemic cardiomyopathy (-6.2%), an increase in peripheral vascular disease (5.6%). Cerebrovascular event and diabetic foot remaining unchanged. The highest incidence rates (1000 subjects/year) were: nephropathy 43, neuropathy 39 and ischemic cardiomyopathy 32. The prevalence of cardiovascular risk factors increased over the follow-up; being high blood pressure the most noticeable (30%). Overall mortality was 28/1000 subjects/year, being cardiovascular disease the main cause (31.2%). CONCLUSIONS Our study determines the prevalence and incidence of chronic complications and risk factors in Spain.

Analysis of benzodiazepine withdrawal program managed by primary care nurses in Spain

BackgroundBenzodiazepine (BZD), the long-term treatment of which is harmful for cognitive function, is widely prescribed by General Practitioners in Spain. Based on studies performed in other countries we designed a nurse-led BZD withdrawal program adapted to Spanish Primary Care working conditions.ResultsA pseudo-experimental (before-after) study took place in two Primary Care Centres in Barcelona. From a sample of 1150 patients, 79 were identified. They were over 44 years old and had been daily users of BZD for a period exceeding six months. Out of the target group 51 patients agreed to participate. BZD dosage was reduced every 2-4 weeks by 25% of the initial dose with the optional support of Hydroxyzine or Valerian. The rating measurements were: reduction of BZD prescription, demographic variables, the Short-Form Health Survey (SF-12) to measure quality of life, the Medical Outcomes Study (MOS) Sleep Scale, and the Goldberg Depression and Anxiety Scale.By the end of the six-month intervention, 80.4% of the patients had discontinued BZD and 64% maintained abstinence at one year. An improvement in all parameters of the Goldberg scale (p <0.05) and in the mental component of SF-12 at 3.3 points (p = 0.024), as well as in most components of the MOS scale, was observed in the group that had discontinued BZD. No significant differences in these scales before and after the intervention were observed in the group that had not discontinued.ConclusionsAt one year approximately 2/3 of the patients had ceased taking BZD. They showed an overall improvement in depression and anxiety scales, and in the mental component of the quality of life scale. There was no apparent reduction in the sleep quality indicators in most of the analysed components. Nurses in a Primary Care setting can successfully implement a BZD withdrawal program.

The impact of a programme to improve quality of care for people with type 2 diabetes on hard to reach groups: The GEDAPS study

AIMS We investigated whether a continuous quality improvement programme in primary care for people with type 2 diabetes led to better care and outcomes in hard to reach groups. METHODS GEDAPS was implemented in Catalonia, Spain between 1993 (n=2239) and 2002 (n=5819). Process (e.g., education), intermediate (e.g., HbA1c) and final (e.g. retinopathy) outcomes were compared between urban and rural areas, and between younger (≤74 years) and older (≥75 years) individuals as examples of harder to reach groups. RESULTS In 1993, people in urban areas had significantly better or similar outcomes to rural areas; by 2002, most outcomes improved in urban and rural areas. For all outcomes, the improvement in rural areas was similar to or better than urban areas. Similarly, for most outcomes, the younger and older group improved, with the older group experiencing similar or better improvements than the younger group for all indicators, except coronary artery disease. CONCLUSIONS A quality improvement programme was associated with equivalent or better outcomes in hard to reach groups, regardless of whether they were specifically targeted. The ability to apply one programme to all populations could save time and money.

High daytime and nighttime ambulatory pulse pressure predict poor cognitive function and mild cognitive impairment in hypertensive individuals

High blood pressure accelerates normal aging stiffness process. Arterial stiffness (AS) has been previously associated with impaired cognitive function and dementia. Our aims are to study how cognitive function and status (mild cognitive impairment, MCI and normal cognitive aging, NCA) relate to AS in a community-based population of hypertensive participants assessed with office and 24-hour ambulatory blood pressure measurements. Six hundred ninety-nine participants were studied, 71 had MCI and the rest had NCA. Office pulse pressure (PP), carotid–femoral pulse wave velocity, and 24-hour ambulatory PP monitoring were collected. Also, participants underwent a brain magnetic resonance to study cerebral small–vessel disease (cSVD) lesions. Multivariate analysis–related cognitive function and cognitive status to AS measurements after adjusting for demographic, vascular risk factors, and cSVD. Carotid–femoral pulse wave velocity and PP at different periods were inversely correlated with several cognitive domains, but only awake PP measurements were associated with attention after correcting for confounders (beta = −0.22, 95% confidence interval (CI) −0.41, −0.03). All ambulatory PP measurements were related to MCI, which was independently associated with nocturnal PP (odds ratio (OR) = 2.552, 95% CI 1.137, 5.728) and also related to the presence of deep white matter hyperintensities (OR = 1.903, 1.096, 3.306). Therefore, higher day and night ambulatory PP measurements are associated with poor cognitive outcomes.

Assessment of enlarged perivascular spaces and their relation to target organ damage and mild cognitive impairment in patients with hypertension

Enlarged perivascular spaces (EPVS) have been recently considered a feature of cerebral small vessel disease. They have been related to aging, hypertension and dementia but their relationship with hypertension related variables (i.e. target organ damage, treatment compliance) and mild cognitive impairment (MCI) is not fully elucidated. Our aims were to investigate the relation between basal ganglia (BG) and centrum semiovale (CSO) EPVS with vascular risk factors, hypertension related variables and MCI.

Cognitive assessment protocol design in the ISSYS (Investigating Silent Strokes in hYpertensives: A magnetic resonance imaging Study) ☆

Hypertension and silent cerebrovascular lesions (SCL) detected by brain magnetic resonance imaging (MRI) are associated with an increased risk of cognitive decline. In a prospective observational study in 1000 hypertensive patients, aged 50-70 years, with no prior history of stroke or dementia, we will study the presence of mild cognitive impairment (MCI) and the relationship between SCL and cognition. All participants will be assessed by means of the Dementia Rating Scale-2 (DRS-2) and will undergo a brain MRI. In order to better characterize MCI and future dementia risk in our cohort, those patients that are suspected to be cognitively impaired according to the DRS-2 results will have a further neurological evaluation and complete neuropsychological testing. Follow-up for the entire cohort is planned to last for at least 3 years.

Dementia Rating Scale-2 normative data for middle-and older-aged Castilian speaking Spaniards

Abstract Objectives: The Dementia Rating Scale-2 (DRS-2) is frequently used as a dementia screening tool in clinical and research settings in Spain. The present study describes DRS-2 Total and subscale scores in community-dwelling Spaniards, aged 50–71, and provides normative data for its use in Castilian Spanish-speaking individuals. Methods: The sample consisted of 798 individuals who participated in an observational study on essential hypertension. Mean age was 62.8 years (SD = 5.4), mean education was 8.6 years (SD = 3.4) with 47.9% females. Almost all of them were receiving blood pressure-lowering drugs (93%) and most of them had fairly well-managed blood pressure control (M systolic/diastolic blood pressure = 142.3/77.0 ± 16.0/9.2 mm Hg). We applied a previously described method of data normalization from the Mayo’s Older Americans Normative Studies to obtain the Castilian Spanish DRS-2 norms. Results: Worse performance on Total and subscale scores was associated with older age (p < .05) and fewer years of education (p < .001). Women obtained lower raw Total scores than men (131.68 ± 7.2 vs. 133.10 ± 6.90, p < .005), but had fewer years of education (7.96 ± 3.33 vs. 9.17 ± 3.45, p < .001). This gender difference disappeared after correcting for age and years of education. Total and subscale scores are presented adjusted by age, and normative data are shown for Total scores adjusted by age and years of education. Conclusions: These norms are useful for studying cognitive status and cognitive decline in research and clinical settings in Castilian Spanish-speaking populations.