PUMA Study Research Articles

Can We Take Hyperuricemia as a Cardiovascular Risk?

Study conducted for Gouty arthritis at Pan Pakistan level in 2017 showed mean Uric Acid levels of 6.11±1.7mg/dl with frequency of hyperuricemia of 39% and having 27.9% male and 49.35 women respectively.1 This type of arthritis results from monosodium urate crystal deposition in and around the joints affecting big toe around the joints of hands and feet. Gout has been shown to increase with age and associated with diabetes & hypertension.2,3 It has also been shown that hyperuricemia may be tied to increased risk of cardiovascular disease mortality.4 Hyperuricemia has also shown to increase atherosclerosis by systemic inflammation and oxidative stress. It also causes endothelial dysfunction and oxidation of lipoproteins with formation of atherosclerotic plaques.5 Recent studies have shown hypertension, coronary artery disease, cardiovascular diseases, vascular dementia and preclampsia to be associated with high uric acid levels. The studies include Rotterdam (Serum Uric Acid Level and Myocardial infraction),2 PUMA study (Serum Uric Acid levels with cardiovascular events and deaths in hypertensive patients),6 PAMELA study (increased risk of cardiovascular deaths with increase of every 1mg /dl).4 Three important co-relation i.e. Hyperuricemia, atherosclerosis and heart failure need bit of understanding. In one study elevated uric acid levels (75.5mg/dl) in 90% of adolescents with essential hypertension7 and lower uric acid levels in teens with either white coat or secondary hypertension.7 Secondly association between increased uric acid levels and coronary artery calcification has shown an independent risk factor for subclinical atherosclerosis in young adults.8 Similar association was also seen in atherosclerotic vulnerable carotid plaque.9 Thirdly in cardiovascular health study incidence of heart failure was 21% with Chronic hyperuricemia and 18% without.10 For management of hyperuricemia (gout) multidisciplinary approach involving primary care physicians, rheumatologist and cardiologists might improve associated cardiovascular diseases other than primary pathology. Drugs like non-steroidal anti-inflammatory drug (NSAIDS), steroids & colchicine may improve Gout but improvement in cardiovascular comorbids are questionable.11,12 Though different epidemiological studies have shown hyperuricemia as an independent risk factor for cardiovascular diseases and hypertension. Further studies are needed that my elucidate association of increased uric acid level with cardiovascular diseases. Multidisciplinary approach, awareness and counselling patient will hopefully prevent onset of heart disease and improve survival outcomes for gouty patients.

External validation of the PUMA COPD diagnostic questionnaire in a general practice sample and the PLATINO study population.

BackgroundA seven-item prescreening questionnaire (gender, age, pack-years smoking, dyspnea, sputum, cough, previous spirometry data) was developed for COPD detection in the primary care setting (PUMA Study) of four Latin America countries.ObjectivesTo validate the PUMA prescreening COPD questionnaire externally in two different populations (primary care and general).MethodsThe PUMA prescreening COPD questionnaire score was applied to subjects from the Hospital Maciel, Montevideo (primary care), case-finding program and the PLATINO population (general) using PUMA study inclusion criteria. Post-bronchodilator FEV1/FVC <0.70 and lower limit of normal (LLN) criteria were used to define COPD. Area under the received operator curve (ROCAUC), sensitivity, specificity, predictive positive and negative values (PNV), number needed to treat (NNT), and best cut-points of the score were calculated.Results974 individuals from Hospital Maciel and 2512 from the PLATINO population were eligible, using post-bronchodilator FEV1/FVC <0.70, 45.1% and 18.7% had COPD, respectively, and using LLN 38.4% and 15.4% had COPD, respectively. From Hospital Maciel (post-bronchodilator FEV1/FVC <0.70), the best cut-point of ≥6 had moderate discriminatory power (ROCAUC 0.70), sensitivity 69.9%, specificity 62.1%, PNV 70.9%, and NNT of 3. The discriminatory power was 0.73 (ROCAUC) in the PLATINO population with three potential cut-points (Youden’s index): ≥3 (sensitivity 85.4%, specificity 46.9%), ≥4 (sensitivity 66.7%, specificity 66.5%), and ≥5 (sensitivity 51.5%, specificity 81.6%); the PNV at each cut-point was 93.3%, 89.9%, and 88.0%, respectively. The NNT was 5 for scores ≥3 and ≥4, and 4 for ≥5. The mean accuracy using the LLN for Hospital Maciel and PLATINO was 0.67 and 0.70, respectively.ConclusionExternal validation of the PUMA prescreening questionnaire in two Latin American populations (general and primary care) suggests moderate accuracy, similar to the original study in which the questionnaire was developed.

A prospective, mixed-methods, before and after study to identify the evidence base for the core components of an effective Paediatric Early Warning System and the development of an implementation package containing those core recommendations for use in the UK: Paediatric early warning system \u2013 utilisation and mortality avoidance\u2013 the PUMA study protocol

BackgroundIn hospital, staff need to routinely monitor patients to identify those who are seriously ill, so that they receive timely treatment to improve their condition. A Paediatric Early Warning System is a multi-faceted socio-technical system to detect deterioration in children, which may or may not include a track and trigger tool. It functions to monitor, detect and prompt an urgent response to signs of deterioration, with the aim of preventing morbidity and mortality. The purpose of this study is to develop an evidence-based improvement programme to optimise the effectiveness of Paediatric Early Warning Systems in different inpatient contexts, and to evaluate the feasibility and potential effectiveness of the programme in predicting deterioration and triggering timely interventions.MethodsThis study will be conducted in two district and two specialist children’s hospitals. It deploys an Interrupted Time Series (ITS) design in conjunction with ethnographic cases studies with embedded process evaluation. Informed by Translational Mobilisation Theory and Normalisation Process Theory, the study is underpinned by a functions based approach to improvement. Workstream (1) will develop an evidence-based improvement programme to optimise Paediatric Early Warning System based on systematic reviews. Workstream (2) consists of observation and recording outcomes in current practice in the four sites, implementation of the improvement programme and concurrent process evaluation, and evaluation of the impact of the programme. Outcomes will be mortality and critical events, unplanned admission to Paediatric Intensive Care (PICU) or Paediatric High Dependency Unit (PHDU), cardiac arrest, respiratory arrest, medical emergencies requiring immediate assistance, reviews by PICU staff, and critical deterioration, with qualitative evidence of the impact of the intervention on Paediatric Early Warning System and learning from the implementation process.DiscussionThis paper presents the background, rationale and design for this mixed methods study. This will be the most comprehensive study of Paediatric Early Warning Systems and the first to deploy a functions-based approach to improvement in the UK with the aim to improve paediatric patient safety and reduce mortality. Our findings will inform recommendations about the safety processes for every hospital treating paediatric in-patients across the NHS.Trial registrationSponsor: Cardiff University, 30–36 Newport Road, Cardiff, CF24 0DE Sponsor ref.: SPON1362–14.Funder: National Institute for Health Research, Health Services & Delivery Research Programme (NIHR HS&DR) Funder reference: 12/178/17.Research Ethics Committee reference: 15/SW/0084 [13/04/2015].PROSPERO reference: CRD42015015326 [23/01/2015].ISRCTN: 94228292 https://doi.org/10.1186/ISRCTN94228292 [date of application 13/05/2015; date of registration: 18/08/2015]. Prospective registration prior to data collection and participant consent commencing in September 2014.

Asthma\u2013COPD overlap syndrome (ACOS) in primary care of four Latin America countries: the PUMA study

BackgroundAsthma–COPD overlap syndrome (ACOS) prevalence varies depending on the studied population and definition criteria. The prevalence and clinical characteristics of ACOS in an at-risk COPD primary care population from Latin America was assessed.MethodsPatients ≥40 years, current/ex-smokers and/or exposed to biomass, attending routine primary care visits completed a questionnaire and performed spirometry. COPD was defined as post-bronchodilator forced expiratory volume in 1 s/forced vital capacity (FEV1/FVC) < 0.70; asthma was defined as either prior asthma diagnosis or wheezing in the last 12 months plus reversibility (increase in post-bronchodilator FEV1 or FVC ≥200 mL and ≥12%); ACOS was defined using a combination of COPD with the two asthma definitions. Exacerbations in the past year among the subgroups were evaluated.ResultsOne thousand seven hundred forty three individuals completed the questionnaire, 1540 performed acceptable spirometry, 309 had COPD, 231 had prior asthma diagnosis, and 78 asthma by wheezing + reversibility. ACOS prevalence in the total population (by post-bronchodilator FEV1/FVC < 0.70 plus asthma diagnosis) was 5.3 and 2.3% by post-bronchodilator FEV1/FVC < 0.70 plus wheezing + reversibility. In the obstructive population (asthma or COPD), prevalence rises to 17.9 and 9.9% by each definition, and to 26.5 and 11.3% in the COPD population. ACOS patients defined by post-bronchodilator FEV1/FVC < 0.7 plus wheezing + reversibility had the lowest lung function measurements. Exacerbations for ACOS showed a prevalence ratio of 2.68 and 2.20 (crude and adjusted, p < 0.05, respectively) (reference COPD).ConclusionsACOS prevalence in primary care varied according to definition used. ACOS by post-bronchodilator FEV1/FVC < 0.7 plus wheezing + reversibility represents a clinical phenotype with more frequent exacerbations, which is probably associated with a different management approach.

Classification of COPD Patients According to ALAT and GOLD Staging Systems Using PUMA Study Data

IntroductionSeveral classification systems use different criteria when assessing COPD stages. The objective of this study was to compare the prevalence and distribution of COPD stages using Global initiative for chronic Obstructive Lung Disease (GOLD) recommendations and Latin American Thoracic Association (ALAT) guidelines in a primary-care population. MethodsSubjects attending routine primary care visits, ≥40 years of age, current or former smokers or exposed to biomass, completed a questionnaire and performed spirometry. COPD was defined as post-bronchodilator FEV1/FVC<0.70 and categorized according to GOLD-2013 criteria and ALAT-2014 guideline. The BODEx index was used to assess the prognostic value of the stratification systems. ResultsA total of 1743 subjects completed the interview, 1540 performed acceptable spirometry. COPD prevalence according to GOLD-2013 was 20.1% and had a U-shaped stage distribution (group A: 9.3%, B: 4.3%, C: 2.0%, D: 4.6%). According to ALAT, prevalence was 19.7% with a bell-shaped stage distribution (mild: 2.9%, moderate: 9%, severe: 5.4%, very-severe: 2.7%). Approximately 73% of patients were stratified as moderate (45.4%) or severe (27.3%) by ALAT guidelines, whereas using GOLD-2013 criteria the majority of subjects (approximately 69%) were in group A (46.3%) or group B (22.7%). BODE index score increased as COPD worsened according to ALAT stratification. This is not observed with GOLD-2013 criteria (similar values for B and C groups). ConclusionsDisease stages differ under ALAT and GOLD-2013 criteria. ALAT identified a greater proportion of COPD subjects in the moderate and severe categories compared with GOLD-2013, where the majority were categorized in group A. Future evaluation of the ALAT classification should address its predictive ability in terms of hospitalizations and mortality.

Development of a simple screening tool for opportunistic COPD case finding in primary care in Latin America: The PUMA study.

Opportunistic chronic obstructive pulmonary disease (COPD) case finding approaches for high-risk individuals with or without symptoms is a feasible option for disease identification. PUMA is an opportunistic case finding study conducted in primary care setting of Argentina, Colombia, Venezuela and Uruguay. The objectives were to measure COPD prevalence in an at-risk population visiting primary care for any reason, to assess the yield of this opportunistic approach and the accuracy of a score developed to detect COPD. Subjects attending routine primary care visits, ≥40 years of age, current or former smokers or exposed to biomass smoke, completed a questionnaire and performed spirometry. COPD was defined as post-bronchodilator (post-BD) forced expiratory volume in 1 s (FEV1 )/forced vital capacity (FVC) < 0.70 and the lower limit of normal of FEV1 /FVC. A total of 1743 subjects completed the interview; 1540 performed acceptable spirometry. COPD prevalence was 20.1% (n = 309; ranging from 11.0% in Venezuela to 29.6% in Argentina) when defined using post-BD FEV1 /FVC < 0.70, and 14.7% (n = 226; ranging from 8.3% in Venezuela to 21.8% in Colombia) using the lower limit of normal. Logistic regression analysis for both definitions showed that the risk of COPD was significantly higher for persons >50 years, heavy smokers (>30 pack-years), with dyspnoea, and having prior spirometry. A simple score and a weighted score constructed using the following predictive factors: gender, age, pack-years smoking, dyspnoea, sputum, cough and spirometry, had a mean accuracy for detecting COPD (post-BD FEV1 /FVC < 0.70) of 76% and 79% for the simple and weighted scores, respectively. This simple seven-item score is an accurate screening tool to select subjects for spirometry in primary care.

Bronchodilator treatment for COPD in primary care of four Latin America countries: The multinational, cross-sectional, non-interventional PUMA study

Background and objectiveBronchodilators (BDs) are the cornerstone of COPD treatment. However, their underuse has been reported in real-life studies. PUMA is a primary-care study from Argentina, Colombia, Venezuela and Uruguay that could help understand the BD use in terms of frequency for long-acting (LA-BD) and short-acting (SA-BD) BDs alone or associated with corticosteroids (CS), and the use as-needed or on regular basis. MethodsThis is a multicentre, multinational, cross-sectional, non-interventional study including no randomised primary-care centres from each country (total 57 centres) without connection with respiratory specialists. Subjects attending routine visits, at-risk for COPD (≥40 years, current or former smokers or exposed to biomass) completed a questionnaire and performed spirometry. COPD was defined as post-BD FEV1/FVC<0.70 and by the lower limit of normal (LLN). Prior physician diagnosis of emphysema, chronic bronchitis or COPD was also determined. Results1743 patients were interviewed, 1540 completed spirometry, 309 had COPD by post-BD FEV1/FVC<0.70, 226 by LLN, and 102 had prior medical diagnosis. A total of 77/309 COPD patients by spirometry (24.9%) used BD (3.6% LA-BDs), 15.2% used BD + CS (13.6% LA-BD + CS). Among these patients, SA-BDs (monotherapy) were the most commonly used medication both as-needed (4.5%) and on a regular basis (17.5%). Similar findings were observed using the LLN criteria. In those with prior medical diagnosis, 66/102 (64.7%) used BDs (9.8% LA-BD), and 25.6% used BD + CS (13.6% LA-BD + CS); among them SA-BDs were the most commonly medication used as-needed (9%) and on a regular basis (48.1%). Having health insurance with medication coverage increased the use of BDs. ConclusionsUp to 60% of COPD patients by spirometry and 10% of those with prior medical diagnosis attending a primary care sample of four Latin American countries did not use BDs. LA-BDs are widely underused on a regular-basis (2.6% and 8.3% of patients with spirometric and medical-diagnosis, respectively) This represents a considerable gap between guideline recommendations and BD prescribing pattern in these centres.

COPD Screening in Primary Care in Four Latin American Countries: Methodology of the PUMA Study

IntroductionThe prevalence of COPD among patients treated in the healthcare system in Latin America is unknown. The PUMA study (Prevalencia y práctica habitUal –diagnóstico y tratamiento– en población de riesgo de EPOC en Médicos generalistas de 4 países de América Latina) screened at-risk patients attending primary care centers to evaluate the prevalence, diagnosis, and treatment of COPD in this setting. The aim of this report is to describe the study methodology. MethodsMulticenter, observational, cross-sectional study conducted in Argentina, Colombia, Uruguay, and Venezuela. Subjects were ≥40 years, smokers, former smokers, and/or exposed to fossil fuels attending primary care centers. Eligible patients underwent pre- and post-bronchodilator spirometry and completed standardized questionnaires on demographics, smoking, exposure to environmental/domestic pollution, symptoms/history, and management of respiratory diseases, comorbidities, and use of healthcare resources. ResultsA total of 57 centers in 4 countries participated; 1907 patients were included, 1743 completed the PUMA questionnaire and 1540 patients underwent validated spirometry. ConclusionsWe describe the methodology used in the PUMA study, the first systematic multicenter study in four Latin American countries aimed at detecting COPD cases confirmed by spirometry in primary care. Approximately 90% of patients who completed the PUMA questionnaire underwent valid spirometry tests. This gives room for reflection on the feasibility of opportunistic screening at the primary care level to detect patients in the early stages of COPD or with undiagnosed COPD, and improve the diagnosis and management of this disease.

Detección de casos de EPOC en atención primaria en 4 países de Latinoamérica: metodología del Estudio PUMA

IntroductionThe prevalence of COPD among patients treated in the healthcare system in Latin America is unknown. The PUMA study (Prevalencia y práctica habitUal –diagnóstico y tratamiento– en población de riesgo de EPOC en Médicos generalistas de 4 países de América Latina) screened at-risk patients attending primary care centers to evaluate the prevalence, diagnosis and treatment of COPD in this setting. The aim of this report is to describe the study methodology. MethodsMulticenter, observational, cross-sectional study conducted in Argentina, Colombia, Uruguay and Venezuela. Subjects were≥40 years, smokers, former smokers and/or exposed to fossil fuels attending primary care centers. Eligible patients underwent pre- and post- bronchodilator spirometry and completed standardized questionnaires on demographics, smoking, exposure to environmental/domestic pollution, symptoms/history and management of respiratory diseases, comorbidities, and use of healthcare resources. ResultsA total of 57 centers in 4 countries participated; 1,907 patients were included, 1,743 completed the PUMA questionnaire and 1,540 patients underwent validated spirometry. ConclusionsWe describe the methodology used in the PUMA study, the first systematic multicenter study in four Latin American countries aimed at detecting COPD cases confirmed by spirometry in primary care. Approximately 90% of patients who completed the PUMA questionnaire underwent valid spirometry tests. This gives room for reflection on the feasibility of opportunistic screening at the primary care level to detect patients in the early stages of COPD or with undiagnosed COPD, and improve the diagnosis and management of this disease.

Impact of Burnout and Psychosocial Work Characteristics on Future Long-Term Sickness Absence. Prospective Results of the Danish PUMA Study Among Human Service Workers

The objective of this study was to examine if burnout and psychosocial factors predicted long-term sickness absence (>2 weeks) at work unit level. Data were collected prospectively at 82-work units in human services (PUMA cohort, PUMA: Danish acronym for Burnout, Motivation and Job satisfaction) followed up during the proceeding 18 months regarding onset of long-term sickness absence. Questionnaire data regarding burnout and psychosocial factors were aggregated at work unit level. We used Poisson regression models with psychosocial factors and burnout as predictors of long-term sickness absence for more than 18 months based on data from a national absence register. Long-term sickness absence was predicted by psychosocial factors and by burnout at work unit level. To reduce sickness absence, organizations within human services should improve the psychosocial work environment, and equally important, the organizations should be attentive to employees with symptoms of burnout.

Burnout as a predictor of self-reported sickness absence among human service workers: prospective findings from three year follow up of the PUMA study

Aim: To investigate whether burnout predicts sickness absence days and sickness absence spells in human service workers. Method: A total of 824 participants from an ongoing prospective study in different...

Burnout among employees in human service work: design and baseline findings of the PUMA study

To present the theoretical framework, design, methods, and baseline findings of the first Danish study on determinants and consequences of burnout, and the impact of workplace interventions in human service work organizations. A 5-year prospective intervention study comprising 2,391 employees from different organizations in the human service sector: social security offices, psychiatric prison, institutions for severely disabled, hospitals, and homecare services. Data were collected at baseline and at two follow-ups. The authors developed a new burnout tool (the Copenhagen Burnout Inventory) covering work-related, client-related, and personal burnout. The study includes potential determinants of burnout (e.g. the psychosocial work environment, social relations outside work, lifestyle factors, and personality aspects) and consequences of burnout (e.g. poor health, low job satisfaction, turnover, and absenteeism). Here, the focus is on the description of the study population at baseline, including associations of work burnout with psychosocial work environment scales and absence. Response rate at baseline was 80.1%. Midwives and homecare workers had high levels on both work- and client-related burnout. Prison officers had the highest level on client-related burnout. Supervisors and office assistants had low levels on both scales. Work burnout showed the highest correlations with job satisfaction (r = -0.51), quantitative demands (r = 0.48), role-conflicts (r = 0.44), and emotional demands (r = 0.42). Sickness absence was 13.9 vs 6.0 days among participants in the highest and lowest work burnout quartile, respectively. The findings indicate that study design and methods are adequate for the upcoming prospective analyses of aetiology and consequences of burnout and of the impact of workplace interventions.

Psychosocial Work Characteristics as Predictors for Burnout: Findings From 3-Year Follow Up of the PUMA Study

The objective of this study was to investigate the impact of psychosocial work characteristics on burnout. A total of 1772 participants in different human service sector organizations were eligible for the cross-sectional analyses (baseline) and 952 for the prospective analyses. We measured 14 psychosocial work characteristics and three types of burnout. Linear regression models were used for analyzing associations between psychosocial work characteristics at baseline and burnout at baseline and at 3 years of follow up. Low possibilities for development, high meaning of work, low predictability, high quality of leadership, low role clarity, and high role conflicts predicted burnout at 3 years of follow up after the psychosocial work characteristics were adjusted for each other, potential confounders, and burnout level at baseline. Psychosocial work characteristics were prospectively associated with burnout, suggesting that improving the psychosocial work environment may reduce future burnout in human service work.

The Copenhagen Burnout Inventory: A new tool for the assessment of burnout

So far, the large majority of studies on burnout in the international literature have employed the Maslach Burnout Inventory (MBI). In this paper we criticize the MBI on a number of points and present a new tool for the measurement of burnout: the Copenhagen Burnout Inventory (CBI). The CBI consists of three scales measuring personal burnout, work-related burnout, and client-related burnout, for use in different domains. On the basis of an ongoing prospective study of burnout in employees in the human service sector, the PUMA study (Project on Burnout, Motivation and Job Satisfaction; N=1914 at baseline), we analysed the validity and reliability of the CBI. All three scales were found to have very high internal reliability, and non-response rates were small. The scales differentiated well between occupational groups in the human service sector, and the expected pattern with regard to correlations with other measures of fatigue and psychological well-being was found. Furthermore, the three scales predicted future sickness absence, sleep problems, use of pain-killers, and intention to quit. Analyses of changes over time showed that substantial proportions of the employees changed with regard to burnout levels. It is concluded that the analyses indicate very satisfactory reliability and validity for the CBI instrument. The CBI is being used in a number of countries and translations into eight languages are available.