Therapeutic agents tested in 238 COVID-19 hospitalized patients and their relationship with mortality

Background and objectives

In the last months great efforts have been developed to evaluate the more efficient therapeutic agents in the management of patients with COVID-19. Currently, no specific drug combination has consistently demonstrated an association with mortality. The aim of this study was to assess the pattern of associations observed between the different in-hospital treatments administered to a series of 238 patients admitted for COVID-19 and their relationship with mortality.

Methods

The electronic medical records of patients that discharged or died from COVID-19 in the Hospital Universitario San Cecilio (Granada, Spain) between March 16 and April 10, 2020 were analysed. From these records, information was obtained on sex, age, comorbidities at admission, clinical information, analytical parameters, imaging tests and empirical treatments used. The outcome variable was the in-hospital mortality. To estimate the associations between the different therapeutic alternatives and the risk of mortality, Hazard Ratios adjusted for age, sex, previous pathologies and severity at discharge were estimated using Cox Regression models.

Results

The most frequently used combination of drugs was low molecular weight heparins, hydroxychloroquine, and ritonavir/lopinavir. None of the analysed treatments showed independent association with mortality. The drugs that showed a greater inverse association with mortality were tocilizumab and corticoids.

Conclusions

The observed association patterns are consistent with previous literature. It seems necessary to design randomized controlled clinical trials that evaluate the possible protector effect of tocilizumab and corticoids in the risk of mortality for some subgroups of COVID-19 hospitalized patients.

Patient and Public Involvement in Sexual and Reproductive Health: Time to Properly Integrate Citizen's Input into Science

Evidence-based sexual and reproductive health is a global endeavor without borders. Inter-sectorial collaboration is essential for identifying and addressing gaps in evidence. Health research funders and regulators are promoting patient and public involvement in research, but there is a lack of quality tools for involving patients. Partnerships with patients are necessary to produce and promote robust, relevant and timely research. Without the active participation of women as stakeholders, not just as research subjects, the societal benefits of research cannot be realized. Creating and developing platforms and opportunities for public involvement in sexual and reproductive health research should be a key international objective. Cooperation between healthcare professionals, academic institutions and the community is essential to promote quality research and significant developments in women's health. This cooperation will be improved when involvement of citizens in the research process becomes standard.

[Therapeutic agents tested in 238 COVID-19 hospitalized patients and their relationship with mortality]

Antecedentes y objetivo

En los últimos meses se han realizado grandes esfuerzos para evaluar las terapias más eficaces en el manejo de pacientes con COVID-19. Actualmente ninguna combinación ha demostrado de manera consistente una relación clara con la mortalidad. Nuestro objetivo fue valorar el patrón de asociaciones observado entre los distintos tratamientos intrahospitalarios administrados a 238 pacientes ingresados por COVID-19 y la mortalidad.

Materiales y métodos

Se analizaron las historias clínicas electrónicas de aquellos pacientes dados de alta o que fallecieron por COVID-19 entre el 16 de marzo y el 10 de abril de 2020 en el Hospital Universitario San Cecilio (Granada, España). Se obtuvo información sobre sexo, edad, comorbilidades al ingreso, parámetros clínicos, analíticos, pruebas de imagen y tratamientos empíricos empleados. La variable de desenlace fue la mortalidad intrahospitalaria. Para estimar las asociaciones entre los diferentes tratamientos y el riesgo de mortalidad se estimaron, mediante modelos de regresión de Cox, hazard ratio ajustadas por edad, sexo, patologías previas y gravedad al ingreso.

Resultados

La combinación de fármacos más frecuentemente empleada fue la formada por heparina de bajo peso molecular (HBPM), hidroxicloroquina y ritonavir/lopinavir. Ninguno de los tratamientos utilizados mostró una asociación independiente con la mortalidad. Los fármacos que mostraron una asociación inversa de mayor magnitud fueron el tocilizumab y los corticoides.

Conclusiones

El patrón se asociaciones obtenido es consistente con lo reportado en la bibliografía. Parece oportuno diseñar ensayos aleatorizados que valoren el posible efecto protector de los corticoides y el tocilizumab sobre el riesgo de muerte en algunos subgrupos de pacientes hospitalizados por COVID-19.

Sociodemographic, clinical and laboratory factors on admission associated with COVID-19 mortality in hospitalized patients: A retrospective observational study

BACKGROUND

To identify and quantify associations between baseline characteristics on hospital admission and mortality in patients with COVID-19 at a tertiary hospital in Spain.

METHODS AND FINDINGS

This retrospective case series included 238 patients hospitalized for COVID-19 at Hospital Universitario Clínico San Cecilio (Granada, Spain) who were discharged or who died. Electronic medical records were reviewed to obtain information on sex, age, personal antecedents, clinical features, findings on physical examination, and laboratory results for each patient. Associations between mortality and baseline characteristics were estimated as hazard ratios (HR) calculated with Cox regression models. Series mortality was 25.6%. Among patients with dependence for basic activities of daily living, 78.7% died, and among patients residing in retirement homes, 80.8% died. The variables most clearly associated with a greater hazard of death were age (3% HR increase per 1-year increase in age; 95%CI 1-6), diabetes mellitus (HR 2.42, 95%CI 1.43-4.09), SatO2/FiO2 ratio (43% HR reduction per 1-point increase; 95%CI 23-57), SOFA score (19% HR increase per 1-point increase, 95%CI 5-34) and CURB-65 score (76% HR increase per 1-point increase, 95%CI 23-143).

CONCLUSIONS

The patients residing in retirement homes showed great vulnerability. The main baseline factors that were independently associated with mortality in patients hospitalized for COVID-19 were older age, diabetes mellitus, low SatO2/FiO2 ratio, and high SOFA and CURB-65 scores.

Problematic Internet Use in University Students: associated factors and differences of gender

The aim of this paper is to make a descriptive analysis of Problematic Internet Use in college students, evaluating the possible association with health problems and addictive behaviors, as well as gender differences in user types. A total of 2,780 students participated in the study between 2011 and 2014, 29% of them being males (age 20.8 ± 5.1 years) and 71% females (age 20.3 ± 4.4 years). The prevalence of Problematic Internet Use (PIU) assessed by the Internet Addiction Test was 6.08%. Being under 21 years of age and studying for degrees in subjects other than the health sciences were associated factors with a higher frequency of this problem, no differences by gender or type of address were found. The results show a significant association with some health problems (migraines, back pain, excess weight or obesity, insufficient rest), psychological aspects (risk of eating disorders, risk of mental disorder, depression), family problems and discrimination; with no associations with substance use (alcohol, cannabis or tobacco) being found. Concerning the time of Internet use, weekly hours were significantly higher in women than in men, both the total time as for leisure. The analysis of the profile use in problematic users revealed that males are related to aspects of entertainment such as games or shopping online and females are related to aspects of socialization, such as chats and social networks.

Validation and psychometric analysis of the Internet Addiction Test in Spanish among college students

Background

The wide use of the Internet in the workplace, academic or social field, can have an impact on daily life. One of the most used questionnaires worldwide to analyse these problems is the Internet Addiction Test (IAT). Our aim was to validate a Spanish version of the IAT and analyse its psychometric properties.

Methods

Population of study were college students participating in the uniHcos project (Universities of Granada, Huelva, Jaén, León, Salamanca, and Vigo). The questionnaire was translated and back-translated by two native English speakers. Reliability of scores was analysed using Pearson’s correlation coefficient and agreement was analysed using the Bland-Altman and Kappa techniques. Test dimensions were analysed by exploratory and confirmatory factor analysis.

Results

The reliability of scores was good (r = 0.899, Kappa = 0.650 and mean difference using Bland-Altman = −3.5). The psychometric assessment identified two factors (Emotional Investment; Performance and Time Management) which explained 55 % of the variance (total internal consistency of 0.91) and only 19 items. The confirmatory analysis showed an acceptable goodness of fit, especially when items 6 and 8 were related (RMSEA = 0.07 90%IC = 0.06 - 0.08; WRMR = 1.01, CFI = 0.96; TLI = 0.95). The two dimensions were negatively correlated with age and positively correlated with time spent online, especially for the purposes of leisure and entertainment.

Discussion

The results show good reliability and psychometric properties of the Spanish version of IAT with a two-dimensional solution. This result is partially in concordance with previous validations of the IAT in other languages that have found uni- and multi-dimensional solutions using different methodologies. Moreover, we want to highlight the possibility that some item of this questionnaire is outdated due to the technological and lifestyles changes and should be not taken into account.

Conclusion

The reliability and psychometric properties obtained in this study support the conclusion that this Spanish short version of the IAT represents a useful tool for the analysis of problems arising from misuse of the Internet.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-015-2281-5) contains supplementary material, which is available to authorized users.

Association of cyclists' age and sex with risk of involvement in a crash before and after adjustment for cycling exposure

This study aimed to estimate the association of cyclists' age and sex with the risk of being involved in a crash with and without adjustment for their amount of exposure. We used the distribution of the entire population and cyclists (total and non-responsible) involved in road crashes in Spain between 1993 and 2009 held by the Spanish National Institute of Statistics and the Spanish General Traffic Directorate to calculate rates of exposure and involvement in a crash. Males aged 45-49 years were used as the reference category to obtain exposure rate ratios (ERR) and unadjusted crash rate ratios (URR). We then used these values in decomposition analysis to calculate crash rate ratios adjusted for exposure (ARR). The pattern of ARR was substantially different from URR. In both sexes the highest values were observed in the youngest age groups, and the values decreased as age increased except for a slight increase in the oldest age groups. In males, a slight increase in the lowest and highest age categories was observed for crashes resulting in severe injury or death, and a decrease was observed for the youngest cyclists who were wearing a helmet. The large differences between age and sex groups in the risk of involvement in a cycling crash are strongly dependent on differences in their exposure rates. Taking exposure rates into account, cyclists younger than 30 years and older than 65 years of age had the highest risk of being involved in a crash.

Comparison of two methods to assess the effect of age and sex on the risk of car crashes

BACKGROUND

This study was designed to compare two methods (direct measurement of exposure and quasi-induced exposure) for assessing the effect of age and sex on the risk of being involved in a car crash in Spain.

METHODS

Spanish crash rates (per 10,000,000 driver-km) for age and sex groups of drivers aged 18-64 years old were obtained for 2004-2007, using information from the Spanish General Traffic Office (census of reported car crashes) and the Spanish Household Survey on Alcohol and Drugs (estimate of the mean km driven for each car driver). The rate ratios estimated by direct exposure estimates were compared to those obtained with the quasi-induced exposure method, which compares the age and sex of responsible and non-responsible drivers involved in the same clean collision (in which only one of the drivers committed a driving infraction).

RESULTS

Both methods detected an increased risk of involvement in a crash for the youngest (18-20 years) and the oldest drivers (60-64 years), compared to middle-aged drivers (45-49 years). However, the rate ratios obtained with the quasi-induced method for the youngest group (2.0 for men, 1.6 for women) were much lower than those obtained with crash rates (13.4 for men, 5.7 for women). Both methods detected a similar increase in the risk of involvement of male drivers compared to women in the youngest age group. This excess risk for men was maintained with increasing age up to 45-49 years when the quasi-induced method was used. However, direct comparisons of crash rates revealed an increased risk of involvement in women compared to men of the same age from 25-29 years onward.

CONCLUSIONS

Both direct measurement of driving exposure and the quasi-induced exposure method detected some well-known patterns of risk associated with driver's age and sex. However, factors that could explain important differences between the two methods deserve attention, especially those related with the excess risk for the youngest drivers as well as sex-related risk.

Comparison between two quasi-induced exposure methods for studying risk factors for road crashes

This study was designed to compare estimates from two quasi-induced exposure methods of the effects of driver- and vehicle-related conditions on the risk of causing a road crash for drivers of vehicles with four or more wheels. From the Spanish register of road crashes with victims, the authors selected, for 1993-2002, all 755,329 drivers of >or=4-wheeled vehicles involved in single-vehicle crashes or in two-vehicle collisions in which only one of the drivers was considered responsible. Multinomial and logistic regression models were used to obtain the odds ratio for each driver- and vehicle-related variable. Construction of these models was based on the assumptions of classical quasi-induced exposure methods and on the method (a paired-by-collision analysis of responsible and nonresponsible drivers) proposed by Perneger and Smith (Am J Epidemiol 1991;134:1138-45). The main driver-dependent conditions for any type of crash were psychophysical circumstances (alcohol use and sleepiness). The effect of most driver- and vehicle-related characteristics was higher for single-vehicle crashes than for two-vehicle collisions. Furthermore, both classical and paired-by-collision analyses yielded similar estimates and can be considered equally useful alternatives for assessing the effect of driver and vehicle characteristics on the risk of causing a collision between two vehicles.

Driver dependent factors and the risk of causing a collision for two wheeled motor vehicles

OBJECTIVE

To assess the effect of driver dependent factors on the risk of causing a collision for two wheeled motor vehicles (TWMVs).

DESIGN

Case control study.

SETTING

Spain, from 1993 to 2002.

SUBJECTS

All drivers of TWMVs involved in the 181 551 collisions between two vehicles recorded in the Spanish registry which did not involve pedestrians, and in which at least one of the vehicles was a TWMV and only one driver had committed a driving infraction. The infractor and non-infractor drivers constituted the case and control groups, respectively.

MAIN OUTCOME MEASURES

Logistic regression analyses were used to obtain crude and adjusted odds ratio estimates for each of the driver related factors recorded in the registry (age, sex, nationality, psychophysical factors, and speeding infractions, among others).

RESULTS

Inappropriate speed was the variable with the greatest influence on the risk of causing a collision, followed by excessive speed and driving under the influence of alcohol. Younger and older drivers, foreign drivers, and driving without a valid license were also associated with a higher risk of causing a collision. In contrast, helmet use, female sex, and longer time in possession of a driving license were associated with a lower risk.

CONCLUSIONS

Although the main driver dependent factors related to the risk of causing a collision for a TWMV were similar to those documented for four wheeled vehicles, several differences in the pattern of associations support the need to study moped and motorcycle crashes separately from crashes involving other types of vehicles.

Efecto de la edad, el sexo y la experiencia de los conductores de 18 a 24 años sobre el riesgo de provocar colisiones entre turismos

OBJECTIVE

To assess the separate effects of age, sex, and experience on the risk of drivers aged 18-24 years being actively involved in a car collision in Spain from 1990 to 1999.

METHODS

For this matched case-control study, data were obtained from the Spanish Register of Traffic Crashes with Victims held by the General Directorate of Transport. The study population comprised all drivers involved in car collisions in which only one of the drivers committed a traffic infraction. Drivers who committed infractions constituted the case group while non-infracting drivers involved in the same collision were their corresponding matched controls. Drivers with incomplete or inconsistent data were excluded and a total of 123,586 cases and 140,482 controls was studied. Crude and adjusted (for the effect of potential confounders) odds ratio (OR) were obtained for each combination of driver age (from 18 to 24 years old), sex and years in possession of a driving license (from 0 to 7).

RESULTS

For each category of age and years in possession of a driving license, OR estimates for men were usually higher than those for women. In men, crude and adjusted OR significantly decreased with increasing number of years in possession of a driving license for each age group. A similar but less clear trend was also observed for female drivers. After adjustment for the effect of the number of years in possession of a driving license, driver age did not seem to be strongly associated with the risk of being actively involved in a car collision.

CONCLUSIONS

Our results suggest that the effect of inexperience is more important than that of age in explaining the higher risk of being involved in a traffic crash in the youngest drivers.

The influence of passengers on the risk of the driver causing a car collision in Spain. Analysis of collisions from 1990 to 1999

OBJECTIVE

To determine how the number of passengers, their age and their sex influence the risk of different types of Spanish drivers causing a collision between two or more cars.

METHODS

We selected, from the Spanish database of traffic crashes resulting in personal injuries or death, those collisions between two or more cars that occurred between 1990 and 1999 in which only one of the involved drivers committed a driving infraction. These drivers were considered the cases; non-infractor drivers were considered their matched controls. We collected information on the number, age and sex of the passengers in each vehicle, along with some potential confounding variables of the drivers and the vehicles involved. Crude and adjusted odds ratios were calculated for the main categories of driver and passenger.

RESULTS

A protective effect for the presence of passengers was detected (adjusted odds ratio: 0.69; 95% CI: 0.67-0.70). The protective effect was higher for drivers aged more than 45 years and lower for the youngest drivers (<24 years old). The strongest association was observed for female passengers who accompanied male drivers. The protective effect was lower for passengers older than 64 years.

CONCLUSIONS

Our results suggest that drivers are less likely to cause a car collision between two or more cars that results in personal injuries or death when they are accompanied by passengers, regardless of driver or passenger characteristics.

Association of main driver-dependent risk factors with the risk of causing a vehicle collision in Spain, 1990-1999

PURPOSE

To assess the strength of association of main driver-dependent risk factors with the risk of causing a collision between vehicles in Spain, from 1990 to 1999.

METHODS

The data for this paired-by-collision, case-control study were obtained from the Spanish Dirección General de Tráfico traffic crash database. The study included all 220284 collisions involving two or more vehicles with four or more wheels, in which only one of the drivers involved committed an infraction. Infractor drivers comprised the case group; noninfractor drivers involved in the same collision were their corresponding paired controls.

RESULTS

All driver-dependent factors were associated with the risk of causing a collision. The highest adjusted odds ratio estimates were obtained for sleepiness (64.35; CI, 45.12-91.79), inappropriate speed (28.33; CI, 26.37-30.44), and driving under the influence of alcohol with a positive breath test (22.32; CI, 19.64-25.37). An increase in the number of years in possession of a driving license showed a protective effect, albeit the strength of the effect decreased as age increased.

CONCLUSIONS

Our results emphasize the urgent need to implement strategies aimed mainly at controlling speeding, sleepiness, and alcohol consumption before driving-the main driver-dependent risk factors for causing a vehicle collision.

Risk compensation theory and voluntary helmet use by cyclists in Spain

OBJECTIVE

To obtain empirical data that might support or refute the existence of a risk compensation mechanism in connection with voluntary helmet use by Spanish cyclists.

DESIGN

A retrospective case series.

SETTING

Spain, from 1990 to 1999.

SUBJECTS

All 22 814 cyclists involved in traffic crashes with victims, recorded in the Spanish Register of Traffic Crashes with Victims, for whom information regarding helmet use was available.

MAIN OUTCOME MEASURES

Crude and adjusted odds ratios for the relation between committing a traffic violation and using a helmet.

RESULTS

Fifty four percent of the cyclists committed a traffic violation other than a speeding infraction. Committing a traffic violation was associated with a lower frequency of helmet use (adjusted odds ratio (aOR) 0.63, 95% confidence interval (CI) 0.58 to 0.69). Cycling at excessive or dangerous speed, a violation observed in 4.5% of the sample, was not significantly associated with helmet use either alone (aOR 0.95, 95% CI 0.56 to 1.61) or in combination with any other violation (aOR 0.97, 95% CI 0.79 to 1.20).

CONCLUSIONS

The results suggest that the subgroup of cyclists with a higher risk of suffering a traffic crash are also those in which the health consequences of the crash will probably be higher. Although the findings do not support the existence of a strong risk compensation mechanism among helmeted cyclists, this possibility cannot be ruled out.

Impact of different levels of carbohydrate intolerance on neonatal outcomes classically associated with gestational diabetes mellitus

OBJECTIVE

To compare the influence of different levels of carbohydrate intolerance on neonatal outcomes.

STUDY DESIGN

The cohort constituted by the 1962 pregnant women screened for gestational diabetes who gave birth at the University Hospital of Granada (Spain) in the year 1995 was followed retrospectively. Women were classified into three groups: diagnosis of gestational diabetes, positive screen but non-gestational diabetes, and negative screen. Frequency of adverse newborn outcomes were quantified for each group and compared for statistical significance.

RESULTS

Gestational diabetes was associated with a greater incidence of high birth weight, hypoglycemia and hypocalcemia. Adequate metabolic control of the illness reduced the risk of adverse outcomes. Birth weight traced a positive slope with respect to the degree of carbohydrate intolerance. Regardless of carbohydrate intolerance, macrosomia was always higher among gravidae with gestational diabetes risk factors than among women without them.

CONCLUSION

Both maternal gestational diabetes risk factors and greater carbohydrate intolerance in gravidae are associated with an increase in adverse newborn outcomes.

Proportion of hospital deaths potentially attributable to nosocomial infection

OBJECTIVE

To determine the fraction of hospital deaths potentially associated with nosocomial infection (NI).

DESIGN

A matched (1:1) case-control study.

SETTING

An 800-bed, tertiary-care, teaching hospital.

PATIENTS

All patients older than 14 years who were admitted to the hospital between January 1, 1990, and January 1, 1991, were eligible. All 524 consecutive deaths that occurred in the hospital comprised the case group. For each case, a control patient was matched for primary admission diagnosis and admission date.

OUTCOME MEASURES

The proportion of hospital deaths potentially associated with NI was estimated from the population attributable risk (PAR) adjusted for age, gender, service, severity of illness, length of stay, and quality of the medical record.

RESULTS

For stays longer than 48 hours, the PAR for all NIs was estimated to be 21.3% (95% confidence interval [CI95], 16.8%-30.5%). The greatest proportion of deaths potentially associated with NIs was observed in patients with only one infection (PAR, 15.0%; CI95, 10.9%-22.6%) and bacteremia or sepsis (PAR, 7.7%; CI95, 4.6%-11.6%).

CONCLUSIONS

NIs are associated with a large proportion of intrahospital deaths. This information may help clinicians and healthcare managers to assess the impact of programs for the prevention and control of NIs on intrahospital death.

Application of the induced exposure method to compare risks of traffic crashes among different types of drivers under different environmental conditions

The authors used the induced exposure method to compare risks of traffic crashes among different types of Spanish drivers under different environmental conditions. The authors analyzed traffic crashes recorded by the Spanish Dirección General de Tráfico for the years 1991 and 1992 to compare proportions of drivers in different age/sex categories who were involved in single-vehicle and multivehicle crashes under different psychological and physical conditions. Crash risk was 1.42- to 2.35-fold greater in men than in women, depending on driver category and environmental factors. Risk was also significantly higher in the 18- to 24-year-old age group (1.75- to 2.87-fold greater than in drivers aged 25-49 years) and under abnormal psychological-physical conditions (1.69- to 4.10-fold greater among drivers under the influence of alcohol). Twilight and night driving, driving in urban areas, and driving on weekends and legal holidays were also associated, though nonsignificantly, with a slightly higher traffic crash risk. These findings are consistent with earlier reports, and they support the usefulness of the induced exposure method as an easy and economical tool with which to analyze data contained in traffic crash records.

Predictive value of a screen for gestational diabetes mellitus: influence of associated risk factors

BACKGROUND

There is a need for solid evidence of the relative advantages of universal vs. selective screening for gestational diabetes mellitus. Our study of a broad obstetric population determines the positive predictive value of the 50-g oral glucose challenge test for screening in the presence and absence of classical gestational diabetes risk factors.

METHODS

A retrospective cohort study was carried out with a total of 2,574 pregnant women. Clinical information was obtained from hospital records and each patient's medical history, and gestational diabetes risk factors were quantified for each pregnant woman. The positive predictive value of a screen was determined with respect to the number of risk factors.

RESULTS

Age 30 or over, family history of diabetes, obesity (BMI > or =27) and previous fetal macrosomia were established as the most frequent risk factors. Just over half (54.2%) of our population presented one or more risk factors. Screening covered 75% of the population, and was positive in 15% of the cases. Diagnosis was confirmed in 64 cases, 57 of them at risk, and seven with no risk factors. We obtained an overall positive predictive value of 21.8% (CI 17.3-27.0). This figure increases with the number of risk factors, from 12% for the women with no risk factors, to 40% for those presenting three or more risk factors.

CONCLUSIONS

A selective screening program that takes into account the clinical background and characteristics of each pregnant woman allows a high yield of true positives while reducing the possible undesirable effects associated with false positives.

Changes in serum cholesterol in employees after three years of multifactorial intervention

BACKGROUND

To assess long-term effectiveness of a multifactorial intervention at the work-site on serum cholesterol levels.

METHODS

Individualized face-to-face counseling was given to 1,555 employees (76.7% male; mean age = 42.3 years) by occupational physicians at four work-sites. After 3 years, a blinded assessment of the adequacy of the intervention was done. Implementation of the intended intervention by physicians was assessed as adequate in two work-sites (927 employees) and inadequate in the other two (628 employees). Observed changes in serum cholesterol were analyzed in the followed-up individuals. Follow-up rates at each work-site were 78.6% and 44.5% for the adequate intervention, and 85.5% and 60.4% for the inadequate intervention. Changes in serum cholesterol were controlled for potential confounding factors (pre-test levels of risk factors, age, sex, body mass index, educational level, marital status, physical activity and alcohol consumption) by multiple linear regression procedures.

RESULTS

When the intervention was adequately performed, serum cholesterol was significantly lowered with a mean reduction of 14.3 mg/dl (95% C.I.: 11.0 to 17.6) in those employees with baseline levels > or = 200 mg/dl.

CONCLUSIONS

Adequacy of implementation of work-site programs determines their long-term effectiveness in reducing mean serum cholesterol levels.

Proportion of hospital deaths associated with adverse events

OBJECTIVES

To determine the fraction of hospital deaths potentially associated with the occurrence of adverse events (AE).

DESIGN

A paired (1:1) case-control study.

SETTING

An 800-bed, teaching tertiary care hospital.

PATIENTS

All patients older than 14 years admitted to the hospital between January 1, 1990, and January 1, 1991, were eligible. All 524 consecutive deaths (death rate of 3.74%) that occurred in the hospital comprised the case group. For each case, a control patient was matched for both primary diagnosis on admission and admission date.

MEASUREMENTS

The proportion of hospital deaths associated with adverse events (defined as problems of any nature and seriousness faced by the patient during hospitalization, and potentially traceable to clinical or administrative management) was estimated from attributable risks adjusted for age, sex, service, severity of illness, length of stay, and quality of the medical record.

RESULTS

For stays longer than 48 hours, the adjusted attributable risk for all adverse events was estimated to be 0.51 (0.40-0.61). When the data were stratified according to the category of adverse event, the attributable risks remained significant except for administrative problems. The greatest proportion of deaths associated with adverse events was observed for surgical adverse events [0.56 (0.38-0.71)] and nosocomial infection [0.22 (0.14-0.28)].

CONCLUSIONS

A significant proportion of intrahospital deaths were associated with AE. These results suggest the need to consider programs focused on the prevention of mortality from AE.

Effects of heavy water on hepatic intracellular pH and phosphatidylcholine turnover. A 31P NMR study

The short term effect of heavy water (2H2O) in intracellular pH (pHi) and phosphatidylcholine (PtdCho) turnover have been studied by 31P NMR spectroscopy in the perfused mouse liver metabolizing alanine. Hepatic pHi decreased from 7.19 +/- 0.01 (n = 10) to 7.01 +/- 0.03 (n = 4) after the addition of 6 mM alanine to Krebs Ringer bicarbonate (KRB) perfusion medium. Replacement of 50% of the KRB water with 2H2O during alanine perfusion inhibited the intracellular acidification induced by alanine and caused i) a decrease in the hepatic content of PtdCho, and ii) increases in phosphocholine and glycerophosphocholine, respectively. Amiloride (1 mM) of 5-(N-ethyl-N-isopropyl)-amiloride (10 microM), two previously reported inhibitors of the Na+/H+ exchangers, mimicked the effects produced by 2H2O on pHi and PtdCho turnover. Replacement of 50% of the KRB water with 2H2O or the addition of 1mM amiloride to KRB only, did not modify pHi nor increase the levels of phosphocholine of glycerophosphocholine. Thus, the observed increases are the result of alanine perfusion in the presence of 2H2O or amiloride. These results suggest that 2H2O behaves similarly to previously reported inhibitors of Na+/H+ exchange, disclosing also a novel role for PtdCho metabolism in the regulation on hepatic pHi.

[Surveillance of hospital infections: validity of a selective system based on risk markers]

BACKGROUND

In order to achieve simultaneously a higher quality of hospital care and cost-containment, an objective assessment of alternative systems for surveillance of hospital infections is needed in our country. This assessment will allow to make a rational choice of the system to be used at each hospital.

METHODS

719 patients admitted to a Vascular Surgery ward were studied. Sensitivity, specificity, and predictive values for a selective system of surveillance of nosocomial infection (NI) were assessed. This selective system attempted to contain costs by means of limiting the revision of records to those patients who presented fever, prescription of antibiotics after admission or who required laboratory cultures. In this selective method charts revision was retrospectively performed by nurses.

RESULTS

A low sensitivity (50.9%) and acceptable values for specificity and predictive values were found.

CONCLUSIONS

Although this selective method requires only 20% of the reference method's time, its association with an important reduction in sensitivity precludes its systematic use and confines it eventually to low risk wards.

Exposure to pesticides and cryptorchidism: geographical evidence of a possible association

Synthetic hormone-disrupting chemicals may play a role in the increased frequency of cryptorchidism observed in some studies. We used a spatial ecological design to search for variations in orchidopexy rates in the province of Granada in Spain and to search for relationships between these differences and geographical variations in exposure to pesticides. Orchidopexy rates were estimated for the period from 1980 to 1991 in all municipalities and health care districts served by the University of Granada Hospital. A random sample of males of the same age (1-16 years) admitted for any reason during the same period was used to estimate inpatient control rates. Each municipality was assigned to one of four levels of pesticide use. We used Poisson homogeneity tests to detect significant differences in rates of orchidopexy between districts and between levels of pesticide use. Poisson and logistic regression models were also used to estimate the strength of association between orchidopexy and level of pesticide use. Orchidopexy rates tended to be higher in districts near the Mediterranean coast where intensive farming is widespread. The city of Granada, where the reference hospital is located, also had higher figures both for orchidopexy and inpatient control rates. Regression models showed that the strength of association between orchidopexy and level of pesticide use tended to increase with higher levels of use, with the exception of level 0 (mainly in the city of Granada). Our results are compatible with a hypothetical association between exposure to hormone-disruptive chemicals and the induction of cryptorchidism. Several methodological limitations in the design make it necessary to evaluate the results with caution.

Exposure to pesticides and cryptorchidism: geographical evidence of a possible association

Synthetic hormone-disrupting chemicals may play a role in the increased frequency of cryptorchidism observed in some studies. We used a spatial ecological design to search for variations in orchidopexy rates in the province of Granada in Spain and to search for relationships between these differences and geographical variations in exposure to pesticides. Orchidopexy rates were estimated for the period from 1980 to 1991 in all municipalities and health care districts served by the University of Granada Hospital. A random sample of males of the same age (1-16 years) admitted for any reason during the same period was used to estimate inpatient control rates. Each municipality was assigned to one of four levels of pesticide use. We used Poisson homogeneity tests to detect significant differences in rates of orchidopexy between districts and between levels of pesticide use. Poisson and logistic regression models were also used to estimate the strength of association between orchidopexy and level of pesticide use. Orchidopexy rates tended to be higher in districts near the Mediterranean coast where intensive farming is widespread. The city of Granada, where the reference hospital is located, also had higher figures both for orchidopexy and inpatient control rates. Regression models showed that the strength of association between orchidopexy and level of pesticide use tended to increase with higher levels of use, with the exception of level 0 (mainly in the city of Granada). Our results are compatible with a hypothetical association between exposure to hormone-disruptive chemicals and the induction of cryptorchidism. Several methodological limitations in the design make it necessary to evaluate the results with caution.

Recall bias in a case-control study of low birth weight

The role of report/recall bias in case-control studies of low birth weight (LBW) was investigated in women who gave birth at a tertiary hospital. Prenatal exposure information reported at the postpartum interview was compared with that documented during pregnancy in obstetric records. 169 cases of LBW and 198 controls were selected. The two sets of information on case mothers and control mothers were compared, using the medical record as a reference. Kappa values were estimated. No trend was observed to increase/decrease the sensitivity and specificity of recall. Agreement on alcohol use was very low (kappa = 0.11 for case mothers and 0.03 for control mothers): on obstetrical records, only 12 mothers of cases reported habitual alcohol intake at the first prenatal care visit, whereas in the interview 69 said yes to the same question; in control mothers, the figures were 4 and 89 respectively. Odds ratios (ORs) of exposure estimated from the two sets of data did not differ importantly in 8 variables. Interview data yielded ORs for hypertension (8.39 versus 4.63), anemia (0.44 versus 0.99) that were farther from the null, and ORs in the opposite direction for alcohol (0.83 versus 1.61) and any drug (0.64 versus 1.42). In conclusion, given that OR figures are similar for most variables and no trend is observed in sensitivity/specificity, mothers of normal births can be an adequate reference group, using personal interviews to obtain information on lifestyle, and medical records for conditions.

The effect of completeness of medical records on the determination of appropriateness of hospital days

Although the Appropriateness Evaluation Protocol (AEP) has been widely used during the past decade, several methodological concerns have not yet been properly resolved, including the possible influence of low completeness of the medical records on the results yielded by the AEP in retrospective studies. We examined medical records for a random sample of 345 patient-days with the AEP, according to a protocol that included several variables potentially related to inappropriateness. The completeness of physician and nursing notes was also assessed. The proportion of inappropriate days of hospitalization was 36.2%. In the crude analysis, significantly higher proportions of inappropriateness were found for lower values of completeness. Factors related to the inappropriateness of stay were summer season, elective admission, no previous admissions, surgical and medical-surgical service in charge, and the day sampled falling within the last third of the hospital stay. Adjustment for the completeness level of medical records did not substantially change the strength of the association between these factors and the inappropriateness of hospital stay. Completeness level itself did not show any significant association with the proportion of inappropriate days in the adjusted analysis.

Epidemiology, therapy and costs of nosocomial infection

In the current climate of cost containment and quality control, nosocomial infection is a worrisome adverse event in hospital care. Hospitalised patients require care for increasingly severe illnesses, and are therefore more susceptible to infection, especially by opportunistic micro-organisms. It is thus necessary to accurately assess and adjust for the severity of the underlying illness in studies of risk factors involved in nosocomial infections. The appearance of new diagnostic and therapeutic techniques provides novel opportunities for infection control and represents a constant challenge to hospital systems. The continuous selection of resistant flora, together with the identification of new pathogens, calls for a reconsideration of hospital policies regarding the dispensation of antibiotics. Epidemiological surveillance continues to be the most important aspect of attempts to monitor infection control programmes, and to identify changes in risk factors that may increase the infection rate. Among the major challenges now facing the infection control practitioner is the use of nosocomial infection rates as an indicator of quality of care. Awareness of infection statistics would serve as a stimulus to the prevention and control of infection, but would be useless if not accompanied by adequate systems to guarantee the comparability of data from different studies and centres. Suitably sensitive and specific surveillance systems should be developed, and the use of site-specific and procedure-specific infection rates adjusted for the patient's intrinsic risk should be encouraged.

Haemopoietic phagocytes in the early differentiating avian retina

The existence of specialised phagocytic cells is described in regions of the retinal neuroepithelium undergoing intense cell death during early differentiation of the avian embryo retina (2.5-5 days of incubation). These results were obtained using routine techniques for light microscopy, acid phosphatase histochemistry and immunocytochemical staining with antibodies MB-1 and QH-1, both specific for quail endothelial cells and all blood cells except mature erythrocytes. Specialised phagocytes were distinguishable from neuroepithelial cells on the basis of morphological criteria: in the former, the nucleus was not oval in shape and was not oriented perpendicular to basement membrane neuroepithelium. The cytoplasm of the specialised phagocytes was often filled with dead cell fragments. In contrast to neuroepithelial cells, the specialised phagocytes showed acid phosphatase activity and were labelled with both MB-1 and QH-1 antibodies in normal quail embryos and chick----quail yolk sac chimeras. Moreover, some acid phosphatase positive and MB-1/QH-1 positive cells also appeared in the presumptive vitreous body, at the edges of the optic cup and in the surrounding mesenchyme. As the vitreal cells and the specialised phagocytes of the neural retina were immunolabelled in chick----quail yolk sac chimeras, we conclude that they are derived from haemopoietic cells in the yolk sac. Some images suggest that these cells enter the vitreous body from the surrounding mesenchyme and traverse the basement membrane of the neuroepithelium in the optic disc region to give rise to the specialised phagocytes of the retinal neuroepithelium.