Impact In Terms Of Mortality Research Articles

Characterization and prognostic impact of ischemic etiology in heart failure with reduced left ventricular ejection fraction

Abstract Introduction and objectives Ischemic heart disease is the cause of 50-60% of cases of heart failure with reduced left ventricular ejection fraction (HF-rEF). The impact of ischemic etiology on left ventricular ejection fraction (LVEF) improvement and prognosis remains unclear. Our main objective was to analyze the differential clinical profile between ischemic and non-ischemic etiology, as well as its medium-to-long term prognosis. Methods Prospective study of a cohort of patients with HF-rEF in real clinical practice. A comparative analysis was performed between patients with HF-rEF of non-ischemic etiology (Group 1) and ischemic etiology (Group 2). Clinical, analytical, echocardiographic and therapeutic variables were analyzed, and the medium-to-long term impact in terms of mortality and hospital readmissions for HF was evaluated. Results 409 patients were analyzed. 276 patients (67.5%) had non-ischemic etiology and 133 patients (32.5%) had ischemic etiology. Group 2 was older (65.8±13.3vs70.8±10.3;p<0.001), more men (68.1%vs86.5%;p<0.001), higher prevalence of arterial hypertension (62.3%vs76.7%;p = 0.004), diabetes mellitus (38.8%vs67.7%; p<0.001), dyslipemia (52.4%vs82.7%;p<0.001), chronic kidney disease (34.4%vs56.4%;p<0.001), anemia (24.3%vs47.4%;p<0.001) and vascular comorbidity (25.7%vs54.9%;p<0.001) and lower prevalence of atrial fibrillation (56.2%vs44.4%;p = 0.025). In Group 2 there was a lower proportion of de novo HF (60.1%vs45.1%;p = 0.004) with longer HF evolution time (24.4±48.8vs61.5±89.3; p<0.001), a lower proportion of patients improving LVEF at follow-up (51.6%vs21.1%;p<0.001) and a higher baseline NTproBNP concentration [4463(IQR 1976-10431)vs5746(IQR 2336.5-13789);p = 0.039]. Regarding baseline treatment, in Group 1 there was a higher prescription of mineralocorticoid receptor antagonists (78.3%vs63.9%;p = 0.002) and less ICD implantation (6.5vs14.3%;p = 0.01), with no differences in the rest of the treatment. With a mean follow-up of 60 months, Group 2 had a higher readmission rate (39%vs50.3%;p<0.01) and higher HF mortality (26.8%vs41%;p<0.01), with differences from early stages. Conclusions Patients with HF-rEF of ischemic etiology associate a greater number of comorbidities, a lower percentage of de novo HF, longer time of HF evolution, lower percentage of LVEF improvement and higher baseline NTproBNP.

Systematic exploration of a decade of publications on psychiatric genetics in Latin America.

Psychiatric disorders have a great impact in terms of mortality, morbidity, and disability across the lifespan. Considerable effort has been devoted to understanding their complex and heterogeneous genetic architecture, including diverse ancestry populations. Our aim was to review the psychiatric genetics research published with Latin American populations from 2010 to 2019, and classify it according to country of origin, type of analysis, source of funding, and other variables. We found that most publications came from Brazil, Mexico, and Colombia. Also, local funds are generally not large enough for genome-wide studies in Latin America, with the exception of Brazil and Mexico; larger studies are often done in collaboration with international partners, mostly funded by US agencies. In most of the larger studies, the participants are individuals of Latin American ancestry living in the United States, which limits the potential for exploring the complex gene-environment interaction. Family studies, traditionally strong in Latin America, represent about 30% of the total research publications. Scarce local resources for research in Latin America have probably been an important limitation for conducting bigger and more complex studies, contributing to the reduced representation of these populations in global psychiatric genetics studies. Increasing diversity must be a goal to improve generalizability and applicability in clinical settings.

Improvement of left ventricular ejection fraction in patients with heart failure with reduced ejection fraction: Predictors and clinical impact

BackgroundA percentage of patients with heart failure with reduced ejection fraction (HFrEF) improve left ventricular ejection fraction (LVEF) in the evolution. This entity, defined for the first time in an international consensus as heart failure with improved ejection fraction (HFimpEF), could have a different clinical profile and prognosis than HFrEF. Our main aim was to analyze the differential clinical profile between the two entities, as well as the mid-term prognosis. Material-methodsProspective study of a cohort of patients with HFrEF who had echocardiographic data at baseline and follow-up. A comparative analysis of patients who improved LVEF with those who did not was made. Clinical, echocardiographic and therapeutic variables were analyzed, and the mid-term impact in terms of mortality and hospital readmissions for HF was assessed. ResultsNinety patients were analyzed. Mean age was 66.5(10.4) years, with a male predominance (72.2%). Forty five patients (50%) improved LVEF (Group-1,HFimpEF) and forty five patients (50%) sustained reduced LVEF (Group-2,HFsrEF). The mean time to LVEF improvement in Group-1 was 12.6(5.7) months. Group-1 had a more favorable clinical profile: lower prevalence of cardiovascular risk factors, higher prevalence of de novo HF (75.6% vs. 42.2%; p<0.05), lower prevalence of ischemic etiology (22.2% vs. 42.2%; p<0.05), with less basal dilatation of the left ventricle. At the end of follow-up (mean 19(1) months) Group-1 had a lower hospital readmission rate (3.1% vs. 26.7%; p<0.01), as well as lower mortality (0% vs. 24.4%; p<0.01). ConclusionPatients with HFimpEF seem to have a better mid-term prognosis in terms of reduced mortality and hospital admissions. This improvement could be conditioned by the clinical profile of patients HFimpEF.

Improvement of left ventricular ejection fraction in patients with heart failure with reduced ejection fraction: Predictors and clinical impact

BackgroundA percentage of patients with heart failure with reduced ejection fraction (HFrEF) improve left ventricular ejection fraction (LVEF) in the evolution. This entity, defined for the first time in an international consensus as heart failure with improved ejection fraction (HFimpEF), could have a different clinical profile and prognosis than HFrEF. Our main aim was to analyze the differential clinical profile between the two entities, as well as the mid-term prognosis. Material-methodsProspective study of a cohort of patients with HFrEF who had echocardiographic data at baseline and follow-up. A comparative analysis of patients who improved LVEF with those who did not was made. Clinical, echocardiographic and therapeutic variables were analyzed, and the mid-term impact in terms of mortality and hospital readmissions for HF was assessed. ResultsNinety patients were analyzed. Mean age was 66.5(10.4) years, with a male predominance (72.2%). Forty five patients (50%) improved LVEF (Group-1,HFimpEF) and forty five patients (50%) sustained reduced LVEF (Group-2,HFsrEF). The mean time to LVEF improvement in Group-1 was 12.6(5.7) months. Group-1 had a more favorable clinical profile: lower prevalence of cardiovascular risk factors, higher prevalence of de novo HF (75.6% vs. 42.2%; p<0.05), lower prevalence of ischemic etiology (22.2% vs. 42.2%; p<0.05), with less basal dilatation of the left ventricle. At the end of follow-up (mean 19(1) months) Group-1 had a lower hospital readmission rate (3.1% vs. 26.7%; p<0.01), as well as lower mortality (0% vs. 24.4%; p<0.01). ConclusionPatients with HFimpEF seem to have a better mid-term prognosis in terms of reduced mortality and hospital admissions. This improvement could be conditioned by the clinical profile of patients HFimpEF.

ODP230 Outcomes of DKA Based on Hospital Teaching Status: A National Inpatient Sample Analysis

Abstract Introduction Diabetic ketocidosis (DKA) is a serious complication of diabetes mellitus that is responsible for over 100,000 annual hospital admissions in the U. S. There is limited data comparing outcomes of patients with DKA based on the teaching status of the hospital. We aimed to evaluate any differences in terms of mortality, length of hospital stay (LOS) and healthcare burden in patients with DKA admitted in teaching versus non-teaching hospitals. Methods A retrospective cohort study was designed using data obtained from the 2018 National Inpatient Sample (NIS) database. Adult patients (age &amp;gt;18) admitted with a principal diagnosis of DKA were identified using the international diseases classification code, tenthrevision (ICD-10). They were then stratified into two cohorts based on the teaching status of hospital where they were admitted. Primary outcomes assessed were, mortality, length of stay (LOS), total hospital charge and total hospital cost. Secondary outcomes included sepsis, myocardial infarction (MI), intubation, mechanical ventilation, pressors requirement, acute kidney injury (AKI), acute respiratory failure, cerebrovascular accident (CVA) and need for blood transfusion. Results Of the total of 116,710 patients hospitalized with DKA that were analyzed, 65.15% were admitted in teaching hospitals and 34.84% in non-teaching institutions. Most patients in teaching and non-teaching hospitals had an age range between 18 and 44 years (78.6% and 77.6% respectively). Median annual income was between USS1-58,999 in majority of patients admitted in both teaching and non-teaching hospitals (36.42% and 36.99% respectively). A slightly greater proportion of patients admitted in a teaching hospital had either Medicare, Medicaid or a private insurance (87.85% vs 85.35%; p&amp;lt;0. 001). In-hospital mortality was higher in patient admitted in non-teaching institutions (0.22% vs 0.18%) however this was not statistically significant (p: 0.56). Mean LOS was longer in patients admitted in a teaching hospital (3. 05 vs. 2.66 days; p&amp;lt;0. 001). Mean total hospital charges (US$30,978 vs US$25,989; p&amp;lt;0. 001) and mean total hospital cost (US$7,271 vs US$6,942; p&amp;lt;0. 001) were also greater in teaching institutions. Patients admitted in teaching hospitals had higher rate of mechanical ventilation (1.78% vs 1.34%; p: 0. 013) and pressors requirement (0.27% vs 0.14%; p: 0. 038). These patients also had increased rate of AKI (38.79% vs 32.51%; p&amp;lt;0. 001) and acute respiratory failure (2.63% vs 1.94%; p: 0. 01). Other secondary outcomes including sepsis, MI, CVA, need for blood transfusion or intubation were not statistically significant. Conclusion Patients with DKA admitted in teaching hospitals had an increased length of stay, greater total hospital charge and cost. Some secondary outcomes including rate of AKI, acute respiratory failure, mechanical ventilation and pressors requirement were also greater in these patients. The teaching status of the institution did not have a statistically significant impact in terms of mortality or other secondary outcomes like sepsis, myocardial infarction or stroke. Presentation: No date and time listed

Remote monitoring heart failure patients with implanted heart devices: a descriptive exploratory qualitative study of nurses' experiences and competences in Italy.

Heart failure has an enormous impact in terms of mortality, morbidity, and costs for healthcare organizations. Indications for implanted heart devices, such as pacemakers or implantable cardioverter defibrillators (ICDs) are constantly increasing. With the arrival of the telemedicine, nurses play an important role in the remote management of chronic heart diseases. The purpose of this study was to describe the experiences of nurses who remotely monitor patients with an implanted heart device in Italy. A qualitative study with a phenomenological approach was conducted. The sample consisted of 7 nurses dedicated to remote monitoring (RM), from three cardiology clinics in Northern Italy. We conducted semi-structured interviews to understand the experience and training nurses received to conduct RM. From the analysis of the interviews, six themes were identified: 'Specialized knowledge and skills', 'Learn through practice', 'Organization of work', 'Decision making', 'Trust', and 'Need for information'. The majority of our sample developed their competencies directly on the field, in absence of a certified recognized pathway, on RM in patients with heart failure implanted with cardiac devices. Therefore, nurses performing RM activities do not receive the same type of education and training. Currently, in Italy, there is no standardised training for nurses who perform RM activities for heart failure patients with implanted heart device, and yet it is instrumental to have appropriate knowledge and training to effectively perform this type of activity and care.

Social representations of the vaccine

Vaccination has made it possible to combat many infectious diseases by reducing their impact in terms of mortality as well as morbidity. However, reservations about this primary prevention measure, as demonstrated by the difficulties in introducing vaccination against COVID-19. Through the analysis of social representations, we try to understand the reasons for these obstacles.

Racial Differences in Self‐Appraisal, Religious Coping, and Psychological Well‐being in Later Life During the COVID‐19 Pandemic

AbstractOlder adults from minority groups, especially those with pre‐existing health conditions, have been generally considered the most vulnerable to the COVID‐19. Due to greater health disadvantages prior to the pandemic, its adverse health impact in terms of mortality has been disproportionately higher on Blacks than Whites. The existing health disadvantages and worsening economic conditions due to the pandemic are likely to be anxiety‐inducing that could adversely impact the mental health of Black older adults. Existing studies conducted in the pre‐pandemic era have documented paradoxical findings on race differences in later life psychological well‐being. Even with significant structural disadvantages, Black older adults tended to report significantly better psychological well‐being (e.g., lower depressive symptoms) than White adults. The racial differences in coping mechanisms have been cited as an explanation for such paradoxical findings. Based on our national web‐based survey (N=1764, aged 50 years or older), we examined race differences in coping resources such as religious coping and self‐appraisal and their impacts on anxiety and depressive symptoms. We documented greater concerns about the personal impacts of the pandemic among Blacks than their White counterparts. The greater concerns about the pandemic were associated with poorer psychological well‐being outcomes. Yet Blacks reported fewer depressive symptoms and lower anxiety than Whites. Our study finds subjective religiosity, religious coping, and emotional support to be responsible for better psychological well‐being among Blacks than Whites. Our study highlights policy implications of coping resources for racial differences in later life psychological well‐being.

Ischemic Stroke; A Severe Complication In Patients Admitted To Resuscitation

Stroke is a real public health problem because of its incidence and morbimortality. Ischemic stroke (AVCI) accounts for 80% of strokes. It is the third leading cause of overall mortality in industrialized countries, after heart disease and cancer, and the leading cause of physical disability acquired. The objective of our study was to describe the clinical characteristics, and factors of Cardiovascular Risk (LRIF) and the factors associated with death in patients admitted for stroke (AVCI) and them in a resuscitation ward. Methods: Retrospective study over a 12-month period (between January 1, 2018 and January 1, 2019), conducted in the medical-surgical emergency room. Results: A total of 147 strokes: 110 AVCI (84%). The age of the patients included in the study ranged from 49 to 77 years. The average age was 66 years - 10.9 years, 75% of AVCI occurring after 65 years. Sex divided into 47 women (42.72%). And 63 men (57.28%). Ischemic strokes: The main vascular risk factors three risk factors: severe high blood pressure (0.007), diabetes (0.05) and emboligenic heart disease (0.017). Other risk factors found are tobacco (13.09%), obesity (10.7%), dyslipidemia (08.3%), alcohol (7.1%). 17, 8% of patients had a history of formed stroke or TIA (Table 1). The onset of neurological symptomatology was brutal in 70% (77 patients). The clinical examination at admission found consciousness disorders with a NIHSS score of 5 to 15 in 45.54% of cases (49 patients). 23 patients (20.9%) had a NIHSS score of 15 and 39 patients (35.45). Para clinical cardiac evaluation (ECG, Echocoeur) objective a complete arrhythmia by atrial fibrillation (AC/FA) in 11.4% of cases, left atrial hypertrophy in 40% of cases and left ventricular hypertrophy in 89% of cases. The length of hospitalization in resuscitation ranged from 1 to 46 days with an average of 13.4 days (-10.1). Among the 110 patients 22 died or (20%). Three risk factors associated with the poor prognosis: NIHSS SUP(p - 0.0001), anisocoria(p - 0.006) and long stay in reanimation(p - 0.013). Conclusion: Ischemic strokes have a major public health impact in terms of mortality or morbidity because of the physical and psychological consequences they can cause. The management of cardiovascular risk factors, the first of which is the HTA, keeps its interest with the peculiarity of diabetic balance and the cessation of tobacco in combination with a diet. Cardiovascular assessment (ACFA, HAG, HVG) plays an important role in stroke management. Primary and secondary stroke prevention requires the prevention of thromboembolic accidents (ACFA) Stroke remains a challenge.

Incorporating genetic selection into individual-based models of malaria and other infectious diseases.

IntroductionControl strategies for human infections are often investigated using individual‐based models (IBMs) to quantify their impact in terms of mortality, morbidity and impact on transmission. Genetic selection can be incorporated into the IBMs to track the spread of mutations whose origin and spread are driven by the intervention and which subsequently undermine the control strategy; typical examples are mutations which encode drug resistance or diagnosis‐ or vaccine‐escape phenotypes.Methods and resultsWe simulated the spread of malaria drug resistance using the IBM OpenMalaria to investigate how the finite sizes of IBMs require strategies to optimally incorporate genetic selection. We make four recommendations. Firstly, calculate and report the selection coefficients, s, of the advantageous allele as the key genetic parameter. Secondly, use these values of “s” to calculate the wait time until a mutation successfully establishes itself in the pathogen population. Thirdly, identify the inherent limits of the IBM to robustly estimate small selection coefficients. Fourthly, optimize computational efficacy: when “s” is small, fewer replicates of larger IBMs may be more efficient than a larger number of replicates of smaller size.DiscussionThe OpenMalaria IBM of malaria was an exemplar and the same principles apply to IBMs of other diseases.

Less Can Be More When Targeting Interleukin-6-Mediated Cytokine Release Syndrome in Coronavirus Disease 2019.

Coronavirus disease 2019 pandemic caused by severe acute respiratory syndrome-coronavirus-2 is a worldwide public health emergency that will have a lasting generational impact in terms of mortality and economic devastation. Social distancing to prevent viral transmission and supportive care of infected patients are the main interventions now available. This global health crisis therefore merits innovative therapies. Cytokine release syndrome mediated by interleukin-6 is a critical driver of coronavirus disease 2019 mortality. Herein, we review and discuss key immunologic effects of direct interleukin-6 blockade, downstream nonselective Janus kinase inhibition, and selective Janus kinase 2 suppression to treat coronavirus disease 2019–related cytokine release syndrome. We provide evidence that selective targeting of interleukin-6 or Janus kinase 2 is well informed by existing data. This contrasts with broad, nonselective blockade of Janus kinase-mediated signaling, which would inhibit both deleterious and beneficial cytokines, as well as critical host antiviral immunity.

Un brote epidémico en perspectiva socio-demográfica

Este estudio propone examinar la incidencia de la pandemia más cruenta del siglo XX en una ciudad del interior de la Argentina. La denominada “grippe española” sobrevino en dos etapas, durante 1918 y 1919, generando configuraciones socio-demográficas particulares. A partir de un abordaje cuanti-cualitativo, anclado en fuentes periodísticas y estadísticas oficiales, nuestra indagación pretende colocar en perspectiva el caso de la ciudad de Córdoba, en la región central del país, que mostraría rasgos específicos. Analizamos el desarrollo de la enfermedad considerando dos variables clave: el impacto por edad y sexo y su desarrollo en términos espaciales. Partimos de entender que existiría una correlación entre distribución geográfica, niveles de pobreza y condiciones sanitarias, análisis que se desarrollará sólo para la segunda oleada, debido a que tuvo un mayor impacto en términos de la mortalidad.

PCV93 RESOURCE USE AND COSTS OF ACUTE CORONARY SYNDROME: A LITERATURE REVIEW

Cardiovascular disease is a leading cause of morbidity and mortality and high use of healthcare resources in developed countries. This study assessed to review the literature on the resource use and costs of acute coronary syndrome. A literature review was made using the Medline, EMBASE, PubMed, CINAHL and Cochrane Library databases. Clinical trials and observational studies were included. The full text of articles was reviewed. No metanalysis was possible due to wide variations in the data (2019). Thirty-eight articles were included. We collected data on the clinical management of these patients, including the initial evaluation, confirmation of the diagnosis, risk assessment, selection of type of revascularization, hospital discharge and the follow up were taken into account. However, despite the existence of numerous national and international clinical practice guidelines, there are wide variations in adherence to their recommendations. The potential impact in terms of mortality and morbidity of the measures taken in the period immediately after coronary occlusion, both outside hospital and on arrival, justify the development of a comprehensive plan for the care of patients with ACS. The best cost-effective measures focus on reducing early mortality, serious complications and/or delays in the administration of reperfusion and, possibly, an increase in the use of primary angioplasty and/or coronary angiography, to name a few examples. ACS is an important health problem and is one of the main priorities in the health policies of most countries due to its high health costs. Coordination between different care levels is essential. In spite of the wide variations in the quantification of the cost ACS, the most notable costs are those corresponding to the days of hospitalization (admissions and subsequent re-admissions). These data show the importance of primary prevention, and the need for more aggressive interventions in secondary prevention, as recommended by scientific societies.

Nutritional risk index predicts survival in patients undergoing transcatheter aortic valve replacement

BackgroundAmong patients undergoing transcatheter aortic valve replacement (TAVR), prognosis is impacted by nutritional status, but the influence of the nutritional risk index (NRI) is unknown. Here we calculated the NRI to determine the prevalence and prognostic impact in terms of mortality of malnutrition in TAVR patients. Methods and resultsThis retrospective multicenter study included 941 patients who underwent TAVR between 2008 and 2016 (mean age, 80.7 ± 6.5 years; 57% female). The NRI was calculated as 1.519 × albumin (g/L) + 41.7 × (real weight [kg] / ideal weight [kg]). The mean NRI was 98.1 ± 7.0%. The patients were stratified into the following groups based on malnutrition risk: severe (NRI < 83.5; n = 83; 8.82%), moderate (83.5 ≥ NRI < 97.5; n = 370; 39.32%), mild (97.5 ≥ NRI < 100; n = 102; 10.84%), and no risk (NRI ≥ 100; n = 386; 41.02%). During the follow-up period (2.1 ± 1.1 years), 186 patients died, representing 19.8% of the total cohort. Cox regression models were used to analyze the relationship between NRI and mortality during follow-up. Compared to patients with no or mild nutritional risk, those with moderate or severe nutritional risk had a 45% greater risk of mortality during follow-up (adjusted HR, 1.45; 95% CI, 1.05–1.99; P = 0.021). ConclusionMalnutrition is common among TAVR patients. Our present data indicated that the NRI was independently associated with increased risk of death during long-term follow-up after TAVR. Based on its potential to improve risk prediction, NRI appears to be a promising tool for the clinical assessment of patients who are candidates for TAVR.

¿Es posible reducir la prevalencia de demencia? Necesitamos nuevos enfoques para enfrentar la demencia

Dementia is recognised as a public health problem with high incidence and prevalence, as well as an increase in its burden of disease and associated with mortality. The different treatments have not provided clinical results that modify the course of the disease or reduce its impact in terms of mortality or disability.This review indicates that it is feasible to avoid the development of dementia despite the fact that age continues to be an important non-modifiable risk factor. The control of widely recognised modifiable and aetiopathogenically-related factors can decrease the number of cases of dementia.Multimodal interventions focused on the control of these risk factors continue to show inconsistent results; therefore, new trials should be carried out in addition to applying the clinical precision medicine approach that provides evidence to improve public health decision-making in order to address this problem.

Impact of a self-care education programme on patients with type 2 diabetes in primary care in the Basque Country

Introduction : Type 2 diabetes mellitus (DM2) is a disease with high prevalence and significant impact in terms of mortality and morbidity. The increased prevalence of the disease requires the implementation of new strategies to promote patient self-management. The Spanish Diabetes Self-Management (SDSMP) proved to be effective in other settings. The objective of this study is to assess its effectiveness in terms of care for DM2 patients in primary care settings within the Basque Health Service – Osakidetza (Spain). Methods : This is a randomized clinical trial in which patients diagnosed with DM2, 18-79 years of age, from four health regions within the Basque Health Service have been randomized into two groups: an intervention group, who has followed the SDSMP, and a control group, who has received usual care in accordance with the clinical guidelines for DM2 and existing regulations in our region. The intervention has consisted of 2.5-hour group sessions once a week for six weeks. The sessions cover target setting and problem solving techniques, promotion of physical exercise, basic knowledge of nutrition, proper use of medication, effective communication with relatives and health professionals, and basic knowledge about DM2 and its complications. This content is complemented by educational material: books, leaflets and CDs. The primary outcome measure has been the change in glycated hemoglobin (HbA1c), and secondary outcome measures have included changes in levels of physical activity and intake of fruit and vegetables, cardiovascular risk, quality of life, self-efficacy, number of consultations and drug prescriptions. The results have been analyzed 6, 12 and 24 months after the intervention by a repeated measures approach . Results : 594 patients have been included in the longitudinal analysis, 297 in each group (Control Group and Intervention Group). They have been monitored for two years. 532 patients have completed the whole monitoring. Overall, 59.75 % of the sample were male, with mean (SD) age 63.9(8.5) years old. The majority of participants (93.25%) were recruited by healthcare staff. The HbA1c basal average was 7.1 (1.66), the average blood pressure was 136.64/79.13 (19.2/11.3) and the BMI was 30.26 (4.92). Self-efficacy significantly improved both overall and in the different areas, namely, diet, physical activity and control of the disease. Significant differences in fruit consumption have been discovered as well. Satisfaction rate is very high. No statistically significant differences between the control and the intervention groups have been found in the HbA1c, cardiovascular variables, nor in the frequency of visits at primary care, ED and hospital admissions. Neither in the quality of life and the physical exercise. Anyway, we could affirm that there are significant differences in basal data and the following in many of the variables, but this difference happens in both groups. Discussion : Many initiatives aiming at an improvement in diabetes control have been implemented over the clinical trial period of time, within the “Strategy to tackle the challenge of chronicity in the Basque Country” frame, as the improved of diabetes clinical indicators through the clinical management Contract Program or D-Plan project. These initiatives have obtained positive outcomes and they have proved that diabetes control has improved in all its variables along this period of time. This situation has had direct effect on the research outcomes. Self-efficacy increase, considered as the first step to reach a successful change of behavior, gets reinforced with a qualitative analysis that addresses the following: patients are more conscious, more able to manage diabetes properly, not just from a physical point of view, but from an emotional and social dimension, too. Conclusion : Diabetes care in the Basque Country is good. Both standard care and the SDSMP can be considered suitable tools to improve diabetes control. At the same time, an evolution towards a more collaborative professional-patient relationship model can be seen in the care provided to patients. It is not just about empowering patients; there is work to be done with health professionals so they accept this change in the role of patients. A further research should be done to assess if this kind of interventions would obtain better outcomes in other pathologies less popular in the Health System.

Characterization and Clinical Impact of Bloodstream Infection Caused by Carbapenemase-Producing Enterobacteriaceae in Seven Latin American Countries.

IntroductionInfections caused by carbapenem-resistant Enterobacteriaceae are a public health problem associated with higher mortality rates, longer hospitalization and increased healthcare costs. We carried out a study to describe the characteristics of patients with carbapenemase-producing Enterobacteriaceae (CPE) and non-CPE bloodstream infection (BSI) from Latin American hospitals and to determine the clinical impact in terms of mortality and antibiotic therapy.MethodsBetween July 2013 and November 2014, we conducted a multicenter observational study in 11 hospitals from 7 Latin American countries (Argentina, Colombia, Ecuador, Guatemala, Mexico, Peru, Venezuela). Patients with BSI caused by Enterobacteriaceae were included and classified either as CPE or non-CPE based on detection of blaKPC, blaVIM, blaIMP, blaNDM and blaOXA-48 by polymerase chain reaction.Enrolled subjects were followed until discharge or death. Demographic, microbiological and clinical characteristics were collected from medical records. Both descriptive and inferential statistics were used to analyze the information.ResultsA total of 255 patients with Enterobacteriaceae BSI were included; CPE were identified in 53 of them. In vitro non-susceptibility to all screened antibiotics was higher in the patients with CPE BSI, remaining colistin, tigecycline and amikacin as the most active drugs. Combination therapy was significantly more frequent in the CPE BSI group (p < 0.001). The most common regimen was carbapenem + colistin or polymyxin B. The overall mortality was 37% (94/255). Overall and attributable mortality were significantly higher in patients with CPE BSI (p < 0.001); however, we found that patients with CPE BSI who received combination therapy and those who received monotherapy had similar mortality. After multivariate adjustment, CPE BSI (adjusted odds ratio [aOR] 4; 95% confidence interval [CI] 1.7–9.5; p = 0.002) and critical illness (aOR 6.5; 95% CI 3.1–13.7; p < 0.001) were independently associated with in-hospital mortality.ConclusionsThis study provides valuable data on the clinical characteristics and mortality risk factors in patients with CPE BSI. We determined that CPE infection is an independent mortality predictor and thus Latin American hospitals should perform campaigns on prevention and control of CPE BSI.

Impact of a self-care education programme on patients with type 2 diabetes in primary care in the Basque Country

BackgroundType 2 diabetes mellitus (DM2) is a disease with high prevalence and significant impact in terms of mortality and morbidity. The increased prevalence of the disease requires the implementation of new strategies to promote patient self-management. The Spanish Diabetes Self-Management Program (SDSMP) has proven to be effective in other settings. The objective of this study is to assess its effectiveness in terms of care for DM2 patients in primary care settings within the Basque Health Service – Osakidetza (Spain).Method/DesignThis is a randomised clinical trial in which patients diagnosed with DM2, 18–79 years of age, from four health regions within the Basque Health Service will be randomised into two groups: an intervention group, who will follow the SDSMP, and a control group, who will receive usual care in accordance with the clinical guidelines for DM2 and existing regulations in our region. The intervention consists of 2,5 hour-group sessions once a week for six weeks. The sessions cover target setting and problem solving techniques, promotion of physical exercise, basic knowledge of nutrition, proper use of medication, effective communication with relatives and health professionals, and basic knowledge about DM2 and its complications. This content is complemented by educational material: books, leaflets and CDs. The primary outcome measure will be the change in glycated haemoglobin (HbA1c), and secondary outcome measures will include changes in levels of physical activity and intake of fruit and vegetables, cardiovascular risk, quality of life, self-efficacy, number of consultations and drug prescriptions. The results will be analysed 6, 12 and 24 months after the intervention.DiscussionIf the intervention were to be effective, the programme should be spread to the entire diabetic population in the Basque Country and it could also be applied for other diseases.Trial registrationClinicalTrials.gov identifier NCT01642394

Evaluation of adherence to recommendations within 3 months after comprehensive geriatric assessment by an inpatient geriatric consultation team

Frail elderly patients during their hospitalization can benefit of a comprehensive geriatric assessment (CGA) by an inpatient geriatric consultation team (IGCT). This assessment yields recommendations aiming to improve medical and social management during the patient's hospital stay and after discharge. This study examines the socio-demographic profile of patients assessed by the IGCT and describes the type of recommendations, their adherence rate at 3months and their impact in terms of mortality, rehospitalization, and institutionalization. Retrospective, single center study including all patients assessed by the IGCT during the 4first months of 2009. These 151patients fulfilled criteria of either medical and/or social frailty or had been submitted to an inappropriate in-hospital trajectory. Hospital records and telephone follow-up (with informal and/or professional caregivers as well as primary care physicians) were used to monitor the implementation of recommendations up to three months after hospital discharge. Mean age of the 151patients was 85.6years, 63% were women. 94% of patients lived at home, 70% had a non-supportive environment, 85% were frail and 11% had dementia. On admission, 64% of them had an acute functional loss. 93% of patients were admitted via the emergency room where 67% benefited from CGA. The median hospital duration stay was 14days. At discharge, 76% of patients went back home, 12% were institutionalized and 12% had died. Three months after discharge, 18% of the 134patients surviving hospitalization had been readmitted, 26% institutionalized and 12% had died. The CGA yielded an average of 7recommendations (median value). The mean adherence rate was 78%. The majority of medical recommendations concerned ancillary care and standard medical management, showing high adherence rates (95%). Recommendations concerning the management of cognitive problems were less frequent and overall poorly adhered to (62%). Mean adherence rate was maximal (97%) when the number of recommendations was limited to4 and it dropped under 80% with more than 5recommendations. The recommendations concerning management at home were generally followed (60-77%). Regarding to social outcomes, the main recommendation was to mobilize home assistance and its financial support. There was no significant difference between adherence rate in the hospital and in the community. The extent of adherence rate did not correlate with mortality or readmission at 3months.

Angiotensin-degrading serine peptidase: A new chymotrypsin-like activity in the venom of Bothrops jararaca partially blocked by the commercial antivenom

Snakebite envenomation is considered a highly relevant public health hazard in South America, having an impact in terms of mortality and morbidity. In Brazil, Bothrops (sensu latu) poisoning is responsible for 90% of the snakebites and in patients treated at the Vital Brazil Hospital (Butantan Institute) this index reaches 97.5%. The objective of the present study was to analyze more specifically the ability of the antibothropic antivenom, produced by the Butantan Institute, São Paulo, Brazil, to neutralize metallo-and serine peptidases, known as the major toxins present in Bothrops jararaca venom. A set of Fret peptides (Free Ressonance Energy Transfer) was studied using the BjV (B. jararaca venom) and site-directed inhibitors PMSF, EDTA and 1,10-phenanthroline. Two substrates were reached to be used as specific tools for studies with metallo peptidases, Abz-FASSAQ-EDDnp, and the serine peptidases, Abz-RPPGFSPFRQ-EDDnp. In disagreement with the literature, the use of both substrates and the antibothropic serum showed a weak neutralization of the serine peptidases present in this venom and a strong neutralization of the metallo peptidases. In order to investigate possible mechanisms of action that have not yet been described for the serine peptidases from the BjV, the present study shows for the first time a new tyrosine-specific chymotrypsin-like and angiotensin-degrading serine peptidase activity, that was partially blocked by the antibothropic serum. In conclusion, the antivenom presented a good neutralization of metallo peptidases but not of serine peptidases, indicating that further studies about serine peptidases immunogenicity are necessary to improve the antibothropic serum.