Development and validation of a risk stratification model for prediction of disability and hospitalisation in patients with heart failure: a study protocol

BACKGROUND

Chronic heart failure (CHF) reduces quality of life and causes hospitalisation and death. Identifying predictive factors of such events may help change the natural history of this condition.

AIM

To develop and validate a stratification system for classifying patients with CHF, according to their degree of disability and need for hospitalisation due to any unscheduled cause, over a period of 1 year.

METHODS AND ANALYSIS

Prospective, concurrent, cohort-type study in two towns in the Madrid autonomous region having a combined population of 1 32 851. The study will include patients aged over 18 years who meet the following diagnostic criteria: symptoms and typical signs of CHF (Framingham criteria) and left ventricular ejection fraction (EF)<50% or structural cardiac lesion and/or diastolic dysfunction in the presence of preserved EF (EF>50%).Outcome variables will be(a) Disability, as measured by the WHO Disability Assessment Schedule V.2.0 Questionnaire, and (b) unscheduled hospitalisations. The estimated sample size is 557 patients, 371 for predictive model development (development cohort) and 186 for validation purposes (validation cohort). Predictive models of disability or hospitalisation will be constructed using logistic regression techniques. The resulting model(s) will be validated by estimating the probability of outcomes of interest for each individual included in the validation cohort.

ETHICS AND DISSEMINATION

The study protocol has been approved by the Clinical Research Ethics Committee of La Princesa University Teaching Hospital (PI-705). All results will be published in a peer-reviewed journal and shared with the medical community at conferences and scientific meetings.

A cluster-randomised clinical trial comparing two cardiovascular health education strategies in a child population: the Savinghearts project

Background

This paper describes a methodology for comparing the effects of an eduentertainment strategy involving a music concert, and a participatory class experience involving the description and making of a healthy breakfast, as educational vehicles for delivering obesity-preventing/cardiovascular health messages to children aged 7–8 years.

Methods/design

This study will involve a cluster-randomised trial with blinded assessment. The study subjects will be children aged 7–8 years of both sexes attending public primary schools in the Madrid Region. The participating schools (n=30) will be randomly assigned to one of two groups: 1) Group MC, in which the children will attend a music concert that delivers obesity-preventing/cardiovascular health messages, or 2) Group HB, in which the children will attend a participatory class providing the same information but involving the description and making of a healthy breakfast. The main outcome measured will be the increase in the number of correct answers scored on a knowledge questionnaire and in an attitudes test administered before and after the above interventions. The secondary outcome recorded will be the reduction in BMI percentile among children deemed overweight/obese prior to the interventions. The required sample size (number of children) was calculated for a comparison of proportions with an α of 0.05 and a β of 0.20, assuming that the Group MC subjects would show values for the measured variables at least 10% higher than those recorded for the subjects of Group HB. Corrections were made for the design effect and assuming a loss to follow-up of 10%. The maximum sample size required will be 2107 children. Data will be analysed using summary measurements for each cluster, both for making estimates and for hypothesis testing. All analyses will be made on an intention-to-treat basis.

Discussion

The intervention providing the best results could be recommended as part of health education for young schoolchildren.

Trial registration

Clinicaltrials.gov: NCT01418872

Efficacy of a strategy for implementing a guideline for the control of cardiovascular risk in a primary healthcare setting: the SIRVA2 study a controlled, blinded community intervention trial randomised by clusters

This work describes the methodology used to assess a strategy for implementing clinical practice guidelines (CPG) for cardiovascular risk control in a health area of Madrid.

Conditions that do not reach the threshold for mental disorder in Spanish psychiatric outpatients: prevalence, treatment and management

BACKGROUND

In recent years there has been controversy around the treatment demands of people who, without meeting diagnostic criteria for a mental disorder, have certain symptoms and are referred to mental health professionals.

AIMS

To determine the prevalence of individuals assessed by mental health service, referred from primary care, who do not meet the diagnosis criteria of mental disorders according to ICD-10. To analyze the medical treatment given to these individuals, measured by the indication for discharge or follow-up and by the pharmacological intervention decided in the first interview, as well as the associated variables.

DESIGN

descriptive study.

SCOPE

urban area.

POPULATION

all patients referred to the Salamanca mental health service during a year, without any exclusion (n = 1,187).

VARIABLES

sociodemographics; clinical and health service utilization gathered through clinical interview, GHQ-28, SCL-90-R and an expectations scale.

RESULTS

Of the 1,004 patients who attended interview, 24.4% (CI 95%: 21.6-27.0) did not present any diagnosable mental disorder (Z codes); they constitute the body of this study. 50.8% of these were referred from primary care with a psychotropic drug treatment already prescribed. Any drug intervention (addition, suspension or modification) was performed in 37.2% of the cases by the mental health service. Regardless of the treatment indicated, 52% were discharged after the first interview.

CONCLUSIONS

The prevalence of patients who failed to reach diagnostic criteria for a mental disorder in this health service is similar to other studies, in spite of the filter provided by primary care. Many individuals without a diagnosable mental disorder received treatment both in primary care and in the mental health service.

Impact of comprehensive and intensive treatment of risk factors concerning cardiovascular mortality in secondary prevention: MIRVAS Study

INTRODUCTION AND OBJECTIVES

The aim was to determine whether secondary prevention involving the comprehensive and intensive treatment of cardiovascular risk factors reduces cardiovascular events and cardiovascular mortality at 3-year follow up.

METHODS

The study design comprised a randomized, controlled, open trial in a routine clinical practice setting. In total, 247 patients who presented with acute coronary syndrome or stroke were selected. They were randomized to comprehensive and intensive treatment of cardiovascular risk factors (n=121) or to follow-up based on usual care (n=126). The main study outcomes were the number of cardiovascular events and cardiovascular mortality at 3-year follow-up. The percentage of patients in whom each risk factor was successfully controlled was a secondary outcome.

RESULTS

Overall, 88.8% of patients assigned to the intensive treatment group had a low-density lipoprotein cholesterol level <100mg/dl compared with 56.4% of the usual-care group (relative risk [RR]=1.57; 95% confidence interval [CI], 1.28-1.93), and 75.7% of diabetics had a hemoglobin A(1c) <7% compared with 28.6% of the usual-care group (RR=2.65; 95% CI, 1.13-6.19). There were four deaths due to cardiovascular causes and 26 nonfatal events in the intensive treatment group versus 17 deaths and 54 nonfatal events in the usual-care group. The cumulative survival rate at 3 years was 97.4% in the intervention group and 85.5% in the control group (p=.003).

CONCLUSIONS

Secondary prevention involving comprehensive and intensive treatment of cardiovascular risk factors reduced both morbidity and mortality at 3-year follow up.

Ten-year fatal and non-fatal myocardial infarction incidence in elderly populations in Spain: the EPICARDIAN cohort study

Background

In Spain, more than 85% of coronary heart disease deaths occur in adults older than 65 years. However, coronary heart disease incidence and mortality in the Spanish elderly have been poorly described. The aim of this study is to estimate the ten-year incidence and mortality rates of myocardial infarction in a population-based large cohort of Spanish elders.

Methods

A population-based cohort of 3729 people older than 64 years old, free of previous myocardial infarction, was established in 1995 in three geographical areas of Spain. Any case of fatal and non-fatal myocardial infarction was investigated until December 2004 using the "cold pursuit method", previously used and validated by the the WHO-MONICA project.

Results

Men showed a significantly (p < 0.001) higher cumulative incidence of myocardial infarction (7.2%; 95%CI: 5.94-8.54) than women (3.8%; 95%CI: 3.06-4.74). Although cumulative incidence increased with age (p < 0.05), gender-differences tended to narrow. Adjusted incidence rates were higher in men (957 per 100 000 person-years) than in women (546 per 100 000 person-years) (p < 0.001) and increased with age (p < 0.001). The increase was progressive in women but not in men. Adjusted mortality rates were also higher in men than in women (p < 0.001), being three times higher in the age group of ≥ 85 years old than in the age group of 65-74 years old (p < 0.001).

Conclusion

Incidence of fatal and non-fatal myocardial infarction is high in the Spanish elderly population. Men show higher rates than women, but gender differences diminish with age.

Reproducibility of metacarpophalangeal bone mass measurements obtained by dual-energy X-ray absorptiometry in healthy volunteers and patients with early arthritis

The prognostic value of measuring hand bone mineral density (BMD) in patients with early arthritis (EA) has been recently assessed. In this work, we evaluate the reproducibility of measuring juxta-articular BMD by dual-energy X-ray absorptiometry (DXA) at the second to fifth metacarpophalangeal (MCP) joints. We obtained whole hand (WH) and MCP joint BMD measurements from 16 healthy subjects and from 22 patients with EA. The coefficient of variation, intraclass correlation coefficient (ICC), and smallest detectable difference (SDD) were calculated. The coefficient of variation ranged from 1.3% to 0.7% at MCP joints and from 1.4% to 0.9% in the WH measurements, respectively. The intra- and interobserver ICC for both WH and MCP joints ranged from 0.97 to 0.99. The SDD at the different anatomical locations analyzed ranged from 0.006 to 0.022 g/cm2 in healthy controls and from 0.005 to 0.010 g/cm2 in EA. Interestingly, patients who fulfilled rheumatoid arthritis criteria showed a lower bone mass than those with undifferentiated arthritis. Therefore, BMD measurements obtained by DXA at MCP joints were reproducible and it might be useful in the study of patients with EA.

Osteoporosis increases the severity of cartilage damage in an experimental model of osteoarthritis in rabbits

OBJECTIVE

To evaluate the effect of osteoporosis (OP) in cartilage damage developed in an experimental model of osteoarthritis (OA) in mature female rabbits in order to investigate the relationship between OP and OA.

METHODS

OA was experimentally induced by anterior cruciate section and partial medial meniscectomy in the left knee of 12 rabbits. OP was experimentally induced prior to OA in six rabbits by bilateral ovariectomy (OVX) and systemic corticosteroid administration during 4 weeks. Knees were evaluated with high resolution magnetic resonance imaging (MRI) before knee surgery to rule out any detrimental effect of corticosteroids on cartilage. Gross and microscopic cartilage changes were assessed 16 weeks after surgery in bilateral knees. Left knees were considered osteoarthritic or osteoarthritic plus osteoporotic. Right knees were used as osteoporotic and healthy controls, respectively. Bone mineral density (BMD) was measured with dual energy X-ray absorptiometry (DXA) at the lumbar spine, global knee and subchondral knee bone, and its variations correlated with cartilage abnormalities.

RESULTS

MRI before knee surgery disclosed no cartilage or bone abnormalities in any of the studied groups. OP increased the severity of cartilage abnormalities in experimental knee OA significantly (P<0.05). Cartilage damage was inversely correlated with BMD variations measured at the lumbar spine (r=-0.74; P=0.015). BMD changes in global and subchondral knee bone also showed a trend to correlate inversely with cartilage damage.

CONCLUSIONS

Prior induction of OP increases the severity of cartilage damage in experimental OA. Increase in cartilage damage correlates with bone loss. These findings suggest a direct relationship between OP and OA.

Bone mineral measurements of subchondral and trabecular bone in healthy and osteoporotic rabbits

INTRODUCTION

Experimental models of osteoporosis in rabbits are useful to investigate anabolic agents because this animal has a fast bone turnover with predominant remodelling over the modelling processes. For that purpose, it is necessary to characterize the densitometric values of each type of bony tissue.

OBJECTIVE

To determine areal bone mass measurement in the spine and in trabecular, cortical and subchondral bone of the knee in healthy and osteoporotic rabbits.

DESIGN

Bone mineral content and bone mineral density were measured in lumbar spine, global knee, and subchondral and cortical bone of the knee with dual energy X-ray absorptiometry using a Hologic QDR-1000/W densitometer in 29 skeletally mature female healthy New Zealand rabbits. Ten rabbits underwent triplicate scans for evaluation of the effect of repositioning. Osteoporosis was experimentally induced in 15 rabbits by bilateral ovariectomy and postoperative corticosteroid treatment for 4 weeks. Identical dual energy X-ray absorptiometry (DXA) studies were performed thereafter.

RESULTS

Mean values of bone mineral content at the lumbar spine, global knee, subchondral bone and cortical tibial metaphysis were: 1934+/-217 mg, 878+/-83 mg, 149+/-14 mg and 29+/-7.0 mg, respectively. The mean values of bone mineral density at the same regions were: 298+/-24 mg/cm(2), 455+/-32 mg/cm(2), 617+/-60 mg/cm(2) and 678+/-163 mg/cm(2), respectively. Bone mineral content and bone density of healthy rabbits followed a normal distribution at the four skeletal regions studied. Precision after triplicate repositioning yielded a coefficient of variation ranging from 2.6% to 3.8%. The least significant change ranged between 7.3% and 10.7%. Bone mineral density measured at the four different skeletal regions correlated significantly. Bone mineral density in osteoporotic rabbits was significantly lower in the four regions studied than that in controls, rendering a T-score of, respectively, -2.0+/-1.1 in the lumbar spine, -2.2+/-2.1 in the global knee, -1.9+/-0.6 in the subchondral bone, and -5.7+/-3.1 in the cortical tibia (P<0.05).

CONCLUSIONS

DXA is a reliable and precise method to evaluate the bone mass in rabbits. Our results also suggest that subchondral bone is a bone of mixed densitometric characteristics with marked cortical bone predominance.

[Cystic fibrosis in adults: inter- and intraobserver agreement for the Brasfield and Chrispin-Norman chest radiography scoring systems and correlation with clinical data and spirometry]

OBJECTIVE

Most chest radiography scoring systems for patients with cystic fibrosis have been developed for children but are also used for adults. Our aim was to evaluate the intra- and interobserver variability of 2 radiographic scoring systems in adults with cystic fibrosis and to assess the correlation of these systems with clinical and spirometric parameters.

PATIENTS AND METHODS

The chest x-rays of 24 adult patients with cystic fibrosis were compared using 2 scoring systems (Brasfield and Chrispin-Norman). The x-rays were scored by 2 radiologists and reevaluated 4 months later by 1 of the 2 observers. Intra- and interobserver agreement was assessed using the intraclass and Pearson's correlation coefficients. The radiographic scores were compared to lung function tests and other clinical data.

RESULTS

Both intra- and interobserver agreement were high (r > or = 0.9 and the intraclass correlation coefficient > or = 0.85 with both systems for both samples). Both scoring systems correlated with spirometry results: forced expiratory volume in the first second (FEV1) (r = 0.64 and r = 0.55), FEV1% (r = 0.75 and r = 0.72), and the percentage of forced vital capacity in relation to the predicted value (r = 0.63 and r = 0.056). We found no association between scoring system and sex, age, or body mass index.

CONCLUSIONS

Assessment of chest radiographs of adult patients with cystic fibrosis by the Brasfield and Chrispin-Norman scoring systems shows good intra- and interobserver agreement. Both systems correlate well with lung function variables, especially FEV1.

[Deep venous thrombosis of lower extremities in an Emergency Department. Utility of a clinical diagnosis model]

BACKGROUND

Deep vein thrombosis (DVT) is a difficult to diagnostic disease. The aim of this study was to determine the utility and accuracy of a risk stratification questionnaire and a diagnostic strategy, which were applied to patients with suspected DVT on lower extremities in an emergency department.

PATIENTS AND METHOD

A prospective cohort study was performed in 569 outpatients with clinical suspected DVT during 14 months. The applied questionnaire stratified patients into three pre-test probability categories. Items included signs, symptoms, risk factors and potential alternative diagnosis, which were based on a modified Wells clinical model. DVT was diagnosed by the combined use of clinical model, compression ultrasonography (CUS) and follow-up CUS one week later in those moderate-high risk patients with an initial normal test. These patients were followed over three months for the development of venous thromboembolic complications.

RESULTS

Two hundred three (35.7%) patients were classified as having a low, 186 (32.7%) moderate and 180 (31.6%) high clinical probability. Overall, DVT was diagnosed in 153 patients (26%; CI95%, 23.2-30.7%): 144 (96%) at the initial CUS, 6 (3.5%) at the second testing and 3 over the 3-month follow-up period. 22 patients had a low pretest probability (11%; CI95%, 7-16%), 43 (23%; CI95%, 17-30%) moderate, and 88 (49%; CI95%, 41-56%) high pretest probability. The difference in the prevalence of DVP among risk categories was significant (p < 0.00001). When the high and moderate groups were joined, the model had a 86% sensitivity, a 90% negative predictive value and a 43% specificity for diagnosis of DVT.

CONCLUSIONS

The clinical model used in this study is accurate and feasible, though it is not enough to take clinical decisions. The diagnostic strategic used is effective but not efficient.

[Clinical predictors of long-term outcome of lithium prophylaxis in bipolar disorder]

INTRODUCTION

In spite of the frequent prophylactic use of lithium salts in affective disorders, few papers have been published about clinical outcome predictors in long-term follow-up.

OBJECTIVE

To identify clinical predictors of long-term outcome in a sample of bipolar outpatients on lithium treatment.

METHODS

An intervention study was conducted in a case series of all patients treated, at least for two years, at two Affective Disorders ambulatory Units. It was examined the association between two dependent outcome variables (presence vs absence of relapses and number of relapses/person/year) and the rest of clinical variables.

RESULTS

139 outpatients diagnosed of bipolar disorder were included in the sample. In each case, therapeutic lithium dosages were administered. Delay time to start treatment since the disorder has begun was the only variable useful to predict weakly outcome. The time spent without treatment and the association with other mood stabilizers or neuroleptics correlates with bad outcome.

CONCLUSION

Whichever clinical characteristics of the sample may be, patients should be treated as soon as possible with lithium to get better outcome.

[Effectiveness of lithium in the prophylaxis of affective disorders]

Lithium effectiveness in manic depressive illness is still controversial. Recent naturalistic trials on lithium effectiveness as a mood stabilizer offer poorer results than previous controlled studies. These previous studies have methodological deficiencies.

OBJECTIVE

To determine the effectiveness of lithium treatment as a mood stabilizer under real clinical conditions.

METHODOLOGY

An intervention study in a case series of all patients treated at least for two years at two Affective Disorders ambulatory Units was conducted to evaluate the incidence of episodes by year, before and during lithium therapy.

RESULTS

152 patients were included. (91% were bipolar patients). Most of them were in monotherapy. The average time of illness before lithium treatment was 13 years, and cases were followed up a media of 8 years. Only 33% of the sample had no relapses during lithium therapy. An average of 1.38 (+/- 2.89) episodes/person year was estimated previous to lithium therapy and was decreased to 0.35 (+/- 0.47) phases/person year during lithium therapy.

CONCLUSIONS

Although the total absence of relapses is not attained in most of the patients, our results support the lithium effectiveness to reduce the relapses in bipolar patients.

Patellar height ratios in children: an interobserver study of three methods

Several indices for patellar height measurement have been described to relate patellofemoral instability and maltracking. No known study has proved interobserver reliability of these indices when applied to growing knees. This study included comparisons of three of these indices: Caton-Deschamps, Blackburne-Peel, and Koshino. Three observers measured patellar height on 36 lateral radiographs of children's knees. The best interobserver agreement was achieved by the Caton-Deschamps method, a simple, reliable, and reproducible index that is not affected by skeletal maturation.