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Background and objectives To prospectively compare the accuracy in initial staging and end-of-treatment restaging of diffuse large B-cell lymphoma (DLBCL) between 64-slice multidetector computed tomography (64MDCT) and 18FDG positron emission tomography/computed tomography (18FGD PET/CT) with intravenous contrast injection. Material and methods Randomized and blind controlled clinical multicentric trial that included biopsy-proven DLBCL patients. Seventy-two patients from five different hospitals in the region of Madrid, Spain, were enrolled in the study between January 2012 and June 2015. Thirty-six were randomly allocated to 18FDG PET/TC and the other 36–64MDCT for initial staging and end-of-treatment restaging. A nuclear medicine physician and a radiologist independently analyzed 18FDG PET/TC images and reached an agreement post hoc. 64MDCT images were separately evaluated by a different radiologist. Every set of images was compared to the reference standard that included clinical data, complementary tests and follow-up. The study was approved by participating centres’ ethics committees and written informed consent was obtained from all the participants. Results A good agreement was observed between both diagnostic techniques and the reference standard in initial staging [18FDG PET/CT (k = 0.5) and 64MDCT (k = 0.6)], although only the 18FDG PET/TC showed a good agreement with the reference standard for the end-of-treatment restaging (k = 0.7). Conclusion In DLBCL, both 18FDG PET/TC and 64MDCT have shown good agreement with the reference standard in initial staging. Nevertheless, 18FDG PET/CT has shown to be superior to 64MDCT in end-of-treatment response assessment.

Resumen Fundamento y objetivos Comparar prospectivamente la exactitud diagnostica de la tomografia computarizada de 64 detectores (TCMD64) y la tomografia por emision de positrones/tomografia computarizada (18FDG PET/TC) con contraste intravenoso en pacientes con linfoma difuso de celulas grandes B (LDCGB) en la estadificacion inicial y en la evaluacion de la respuesta al final del tratamiento. Material y metodos Ensayo clinico controlado multicentrico que incluyo 72 pacientes de 5 hospitales de la Comunidad de Madrid entre enero de 2012 y junio de 2015, aleatorizados de forma ciega a una diferente prueba de imagen inicial y final, 36 a 18FDG PET/TC y 36 a TCMD64. Un medico nuclear y un radiologo interpretaron la 18FDG PET/TC de manera independiente, llegando a un consenso post-hoc. Por otro lado, un radiologo ajeno interpreto la TCMD64 por separado. El patron de referencia incluyo datos clinicos, pruebas complementarias y seguimiento. El Comite Etico de cada hospital aprobo el estudio y los sujetos firmaron su consentimiento por escrito. Resultados Se observo buena concordancia de ambas pruebas diagnosticas con el patron de referencia en la estadificacion inicial (18FDG PET/CT [k = 0,5] y TCMD64 [k = 0,6]), existiendo solo buena concordancia en la evaluacion de la respuesta al final del tratamiento con la 18FDG PET/TC (k = 0,7). Conclusion En la estadificacion inicial de pacientes con LDCGB existe un grado de acuerdo satisfactorio de la 18FDG PET/TC y la TCMD64 con el patron de referencia, mientras que en la evaluacion de la respuesta al final del tratamiento la 18FDG PET/TC es superior a la TCMD64.

Objective. Sedation of neurocritically ill patients is one of the most challenging situation in ICUs. Quantitative knowledge on the sedation effect on brain activity in that complex scenario could help to uncover new markers for sedation assessment. Hence, we aim to evaluate the existence of changes of diverse EEG-derived measures in deeply-sedated (RASS-Richmond agitation-sedation scale -4 and -5) neurocritically ill patients, and also whether sedation doses are related with those eventual changes. Approach. We performed an observational prospective cohort study in the intensive care unit of the Hospital de la Princesa. Twenty-six adult patients suffered from traumatic brain injury and subarachnoid hemorrhage were included in the present study. Long-term continuous electroencephalographic (EEG) recordings (2141 h) and hourly annotated information were used to determine the relationship between intravenous sedation infusion doses and network and spectral EEG measures. To do that, two different strategies were followed: assessment of the statistical dependence between both variables using the Spearman correlation rank and by performing an automatic classification method based on a machine learning algorithm. Main results. More than 60% of patients presented a correlation greater than 0.5 in at least one of the calculated EEG measures with the sedation dose. The automatic classification method presented an accuracy of 84.3% in discriminating between different sedation doses. In both cases the nodes' degree was the most relevant measurement. Significance. The results presented here provide evidences of brain activity changes during deep sedation linked to sedation doses. Particularly, the capability of network EEG-derived measures in discriminating between different sedation doses could be the framework for the development of accurate methods for sedation levels assessment. Fil: Sanz García, Ancor. Universidad Autonoma de Madrid. Hospital Universitario de la Princesa; España Fil: Pérez Romero, Miriam. Universidad Autonoma de Madrid. Hospital Universitario de la Princesa; España Fil: Pastor, Jesús. Universidad Autonoma de Madrid. Hospital Universitario de la Princesa; España Fil: Sola, Rafael G.. Universidad Autonoma de Madrid. Hospital Universitario de la Princesa. Servicio de Neurocirugia. Grupo de Epilepsia; España Fil: Vega Zelaya, Lorena. Universidad Autonoma de Madrid. Hospital Universitario de la Princesa; España Fil: Vega, Gema. Universidad Autonoma de Madrid. Hospital Universitario de la Princesa; España Fil: Monasterio, Fernando. Universidad Autonoma de Madrid. Hospital Universitario de la Princesa; España Fil: Torrecilla, Carmen. Universidad Autonoma de Madrid. Hospital Universitario de la Princesa; España Fil: Pulido, Paloma. Universidad Autonoma de Madrid. Hospital Universitario de la Princesa. Servicio de Neurocirugia. Grupo de Epilepsia; España Fil: Ortega, Guillermo José. Universidad Autonoma de Madrid. Hospital Universitario de la Princesa; España. Consejo Nacional de Investigaciones Científicas y Técnicas; Argentina

Objective To explore and assess the relationship between electroencephalography (EEG) activity and intracranial pressure (ICP) in patients suffering from traumatic brain injury (TBI) and subarachnoid hemorrhage (SAH) during their stay in an intensive care unit. Approach We performed an observational prospective cohort study of adult patients suffering from TBI or SAH. Continuous EEG-ECG was performed during ICP monitoring. In every patient, variables derived from the EEG were calculated and the Granger causality (GC) methodology was employed to assess whether, and in which direction, there is any relationship between EEG and ICP. Main results One-thousand fifty-five hours of continuous multimodal monitoring were analyzed in 21 patients using the GC test. During 37.88% of the analyzed time, significant GC statistic was found in the direction from the EEG activity to the ICP, with typical lags of 25-50 s between them. When recordings were adjusted by sedation-perfusion and/or bolus-and handling, these percentages hardly changed. Significance Long-lasting, continuous and simultaneous EEG and ICP recordings from TBI and SAH patients provide highly rich and useful information, which has allowed for uncovering a strong relationship between both signals. The use of this relationship could lead to developing a medical device to measure ICP in a non-invasive way.

BACKGROUND Although bloodless cardiac surgery has been successfully performed for many years, studies with controls permitting transfusion are few and their results inconclusive. This study compares the outcome of cardiac surgery on Jehovah's Witnesses (JW) refusing transfusion, with that of controls permitting transfusion if required. METHODS Data from 172 operations in 162 JW were compared with 172 matched controls. Risk factors, preoperative, operative, 48 hour postoperative variables, outcome data and transfusions were recorded. RESULTS Preoperative and operative variables were similar in both groups except for more previous cardiac operations, and more frequent use of cell saver and aprotinin in JW, who bled less and had higher hemoglobin concentrations at all periods. Thirty-day mortality was higher in JW (9.9% vs. 3.5%; P=0.03) (Risk difference 6.4%; CI95%: 2.7-10.1). Nevertheless operative mortality was similar in both groups (9.9% vs. 7.6%; P=0.44). Mortality in low-risk subjects was higher in JW (8.9% vs. 1.0%; P=0.02) (Risk difference 7.9%; CI95%: 2.7-13.2). Moreover, death associated with hemorrhage and anemia tended to be more frequent in JW. Mortality of transfused controls (14.1%) and their matched JW (13.0%) was similar. In contrast, mortality of non-transfused controls was zero versus 6.3% in their matched JW (P=0.059). CONCLUSIONS Low-risk JW had significantly higher mortality than controls. Bleeding related deaths tended to be more frequent in JW. Blood-sparing maneuvers should be intensively implemented in both JW and patients permitting transfusion in order to reduce bleeding and the need for transfusion with its harmful effects.

Background The benefits of High-flow nasal cannula (HFNC) as primary intervention in patients with acute hypoxemic respiratory failure (AHRF) are still unknown. Our objective was to compare the HFNC therapy vs the conventional oxygen therapy (CO) in the prevention of endotracheal intubation (EI) in this patients. Methods Controlled clinical trial in patients with severe AHRF, to compare the HFNC with a control group (CG) treated by CO delivered through a face mask, on the need to perform EI. Findings Forty-six patients were included, 48% of whom needed EI: 63% in the CG and 33% in the IG, with significant differences (x2Pearson=4·7; p=0·03; RR= 0·5; IC95%:0·3-0·9). We obtained a NNT=3 patients treated to avoid an EI. EI occurred significantly later in the IG. Estimated_PaO2/FiO2, respiratory rate, and dyspnea were significantly better in the IG. Patients treated with HFNC who required EI presented a significant worsening after the first 8 hours, as compared to non-intubated IG patients. Mortality was 22% with no differences. The IG patients were hospitalized for almost half of the time in the ICU and in the ward, with significantly less hospital length of stay. Fourteen patients in the IG (58%) complained of excessive heat and 17% of noise. Three patients did not tolerate the HFNC. Interpretation Patients with severe acute hypoxemic respiratory failure who tolerate HFNC present a significantly lower need for endotracheal intubation compared to conventional oxygen therapy. Trial Registration Number: EUDRA CT number: 2012-001671-36 Funding: This study received a funding from: Spanish Ministry of Health, Social Services, and Equality. (No Exp.: EC11-103). Declaration of Interest: All authors declare no conflicts of interest. Ethical Approval: The study was reviewed and approved by University Hospital La Princesa Institutional Review Board. All study participants or their legal guardian, provided informed consent prior to study.

To prospectively compare the accuracy in initial staging and end-of-treatment restaging of diffuse large B-cell lymphoma (DLBCL) between 64-slice multidetector computed tomography (64MDCT) and 18FDG positron emission tomography/computed tomography (18FGD PET/CT) with intravenous contrast injection.Randomised and blind controlled clinical multicentric trial that included biopsy-proven DLBCL patients. Seventy-two patients from five different hospitals in the region of Madrid, Spain, were enrolled in the study between January 2012 and June 2015. Thirty-six were randomly allocated to 18FDG PET/TC and the other 36 to 64MDCT for initial staging and end-of-treatment restaging. A nuclear medicine physician and a radiologist independently analysed 18FDG PET/TC images and reached an agreement post-hoc. 64MDCT images were separately evaluated by a different radiologist. Every set of images was compared to the reference standard that included clinical data, complementary tests and follow-up. The study was approved by participating centres' ethics committees and written informed consent was obtained from all the participants.A good agreement was observed between both diagnostic techniques and the reference standard in initial staging [18FDG PET/CT (k=0.5) and 64MDCT (k=0.6)], although only the 18FDG PET/TC showed a good agreement with the reference standard for the end-of-treatment restaging (k=0.7).In DLBCL, both 18FDG PET/TC and 64MDCT have shown good agreement with the reference standard in initial staging. Nevertheless, 18FDG PET/CT has shown to be superior to 64MDCT in end-of-treatment response assessment.

ObjetivoElaborar el perfil del paciente con un inadecuado seguimiento y control de los factores de riesgo cardiovascular (FRCV) después de haber presentado un infarto agudo de miocardio (IAM).DiseñoEstudio de cohortes.EmplazamientoProvincia de Albacete.Nivel de atención primaria.ParticipantesCasos incidentes de IAM del registro IBERICA-Albacete que sobrevivieron a los 28 días.Mediciones principalesSe realizó una encuesta estructurada a pacientes, familiares o médicos de familia para conocer el seguimiento y control de los FRCV (hipertensión arterial [HTA], hipercolesterolemia, diabetes mellitus [DM], tabaquismo y obesidad), además del nivel de estudios, situación laboral y reincorporación al trabajo. Se definió como seguimiento inadecuado no realizar las visitas recomendadas, y como control inadecuado, si no se conseguían los niveles adecuados, o los pacientes fumaban. El análisis fue descriptivo y comparativo, bivariado y multivariado. La asociación se midió con el riesgo relativo (RR), y la estimación poblacional con el intervalo de confianza (IC) del 95%.ResultadosSe incluyó en el estudio a 655 pacientes; el 21% de ellos eran mujeres; el 46%, hipertensos; el 35%, hipercolesterolémicos; el 32%, diabéticos; el 36%, obesos y el 39%, fumadores activos, con una edad media de 61 años. En el seguimiento se produjo un 9% de pérdidas, y 576 pacientes presentaron algún FRCV: el 31% con inadecuado seguimiento (IC del 95%, 28-36) y el 46% con inadecuado control (IC del 95%, 41-51). El perfil de paciente con un seguimiento inadecuado era el de un joven, desempleado, con estudios universitarios, fumador, obeso y sin HTA; el del control inadecuado era un paciente fumador, diabético y desempleado.ConclusionesEl 31% de los pacientes con IAM realiza un seguimiento inadecuado de los FRCV a largo plazo, y el 46% un control inadecuado, y existen características en el IAM que los identifican.ObjectiveTo draw up a profile of patients with inadequate follow-up and control of cardiovascular risk factors (CVRF) after acute myocardial infarction (AMI).DesignCohort study.SettingPrimary care in Albacete, province of Castilla-La Mancha, Spain.ParticipantsAMI cases who survived at 28 days and recorded in the IBERICA-Albacete register.Main measurementsA structured survey of patients, families or family doctors to find out about the follow-up and control of CVRFs (arterial hypertension [AHT], hypercholesterolaemia, diabetes, smoking habits, and obesity), as well as education level, work situation and return to work. Inadequate follow-up is defined as when the recommended visits are not made, and inadequate control, when adequate levels are no obtained or they smoked. A descriptive, bivariate, and multivariate comparative analysis was performed. The association was measured using relative risk (RR), and the population estimation with the 95% confidence intervals (95% CI).ResultsThe sample included 21% females, 46% hypertensives, 35% with hypercholesterolaemia, 32% diabetics, 36% obeses, and 39% active smokers, with a mean age of 61 years. There was a 9% loss in follow-up, and 576 patients had a CVRF: 31% with inadequate follow-up (95% CI, 28-36) and 46% with inadequate control (95% CI, 41-51). The profile of a patient with inadequate follow-up was young, unemployed, with university education, smoker, obese and without AHT; that of an inadequately controlled patient was, a smoker, diabetic and unemployed.ConclusionsThere was inadequate follow-up of long term CVRFs in 31% of AMI patients, and 46% with inadequate control, there being characteristics in AMI that identify them.

Introduccion y objetivos La paraoxonasa 1 (PON1) y la paraoxonasa 2 (PON2) son enzimas antioxidantes cuyos polimorfismos PON1-192 y PON2-311 se han relacionado con el riesgo de infarto agudo de miocardio, con resultados discordantes. El objetivo de este estudio es determinar la asociacion con el riesgo de infarto agudo de miocardio (IAM) de los polimorfismos PON1-192 y PON2-311 y su interaccion. Metodos Se realizo un estudio de casos y controles en el que se recluto a 746 pacientes consecutivos con IAM y 1.796 controles libres de enfermedad cardiovascular seleccionados al azar de la misma poblacion de la que provenian los casos, en 4 comunidades autonomas espanolas entre 1999 y 2000. Se determinaron los polimorfismos PON1-192 y PON2-311, ademas de los factores clasicos de riesgo cardiovascular. Se estimaron modelos de regresion logistica para los analisis multivaribles. Resultados Las odds ratio (OR) del genotipo QQ del polimorfismo PON1-192 y el SS del PON2-311 (presen-tes en el 50 y el 66% de la poblacion, respectivamente) de presentar un IAM fueron 1,26 (intervalo de confianza [IC] del 95%, 1,02-1,55) y 1,25 (IC del 95%, 1,04-1,50), respectivamente, en comparacion con los portadores de los alelos R y C. Ademas, para los sujetos que presentan ambos genotipos QQ y SS, la OR ajustada de tener un IAM se incremento hasta 1,41 (IC del 95%, 1,13-1,76). Conclusiones Nuestros resultados indican que los polimorfismos PON1-192 y PON2-311 son factores de riesgo de IAM independientes en nuestra poblacion.

Introduction and objectives Two particular polymorphisms, namely PON1-192 and PON2-311, in the genes encoding the antioxidant enzymes paraoxonase-1 (PON1) and paraoxonase-2 (PON2) have been associated with an increased risk of acute myocardial infarction (AMI). However, previous findings have been contradictory. The aim of this study was to investigate the association between the PON1-192 and PON2-311 polymorphisms and their interaction on AMI risk. Methods This case-control study involved 746 consecutive AMI patients and 1796 control subjects without cardiovascular disease, who were randomly selected from the same population from which the patients came. All participants were recruited between 1999 and 2000 from four Spanish autonomous regions. All were assessed for the presence of PON1-192 and PON2-311 and for classical cardiovascular risk factors. Multivariate analysis was carried out using logistic regression modeling. Results The odds ratios (OR) of AMI for patients with the PON1-192 QQ and PON2-311 SS genotypes (who comprised 50% and 66% of the population, respectively) were 1.26 (95% confidence interval [Cl], 1.02-1.55) and 1.25 (95% Cl, 1.04-1.50), respectively, compared with R and C allele carriers. Moreover, in patients with both QQ and SS genotypes, the adjusted OR of AMI increased to 1.41 (95% Cl, 1.13-1.76). Conclusiones Our results indicate that the PON1-192 and PON2-311 polymorphisms were independent risk factors of AMI in our population.

Background Smoking is a risk factor for coronary heart disease, but it has been associated with better short-term prognosis in hospitalized patients with acute myocardial infarction. The aims of this study were to determine the association between smoking and myocardial infarction 28-day case-fatality in hospitalized patients and at the population level; and, whether smokers presenting with fatal myocardial infarction are more likely to die before reaching a hospital. Design and methods Population-based myocardial infarction registry, carried out in 1997-1998 in seven regions of Spain, used standardized methods to find and analyze suspected myocardial infarction patients (10 654 patients; 7796 hospitalized). Four categories of smoking status were defined: never-smokers, former smokers for more than 1 year, former smokers for less than 1 year, and current smokers. Results The main end-point was 28-day case-fatality, found to be 20.1, 17.1, 15.6, and 8.9%, in the four smoking status categories, respectively, for hospitalized patients; and 37.4, 33.0, 24.5, and 23.2%, respectively, at population level. Hospitalized current smokers had lower age, sex, and comorbidity-adjusted 28-day case-fatality than never-smokers (odds ratio = 0.71; 95% confidence interval: 0.56-0.90). This association held at population level (odds ratio = 0.68; 95% confidence interval: 0.60-0.76), in which former smoking was also associated with lower case-fatality. In fatal cases, recent former smokers presented a lower risk of out-of-hospital death than never-smokers (odds ratio = 0.47; 95% confidence interval: 0.29-0.77), whereas current smoking was marginally associated with out-of-hospital death (odds ratio = 1.22; 95% confidence interval: 0.99-1.50). Conclusions Current smoking is associated with lower 28-day case-fatality in hospitalized myocardial infarction patients. This association held at population level. Among fatal cases, smoking is associated with higher and recent former smoking with lower risk of dying out-of-hospital.

Introduction and objectives Generally, cardiovascular risk factors are poorly controlled after myocardial infarction. The objective of this study was to determine the effect of these risk factors on long-term morbidity and mortality in patients experiencing a myocardial infarction. Methods In total, 655 acute myocardial infarction survivors recorded in the IBERICA database for the Spanish province of Albacete were followed up. Provincial healthcare center databases and the regional death registry were consulted, and semistructured interviews were carried out. Bivariate and multivariate descriptive and comparative statistical analyses were performed. Results The median follow-up period was 5.5 years. At the end of the study, 74% of patients had hypertension or hypercholesterolemia, 39% had diabetes, 36% were obese, 13% smoked, and 1% were alcoholics. Overall, 48% of patients experienced a cardiovascular event. Uncontrolled hypercholesterolemia was found to be a risk factor for angina (odds ratio [OR], 2.4, 95% confidence interval [CI], 1.1-5.1), and uncontrolled diabetes was a risk factor for reinfarction (OR, 3.5, 95% CI, 1.6-7.6) and stroke (OR, 10.6, 95% CI, 3.6-31.2), both of which occurred earlier in patients with uncontrolled diabetes. In total, 115 (18%) patients died, with more than 50% of deaths being due to cardiovascular causes. Uncontrolled hypertension and diabetes were the most important risk factors for both overall and early mortality, whereas controlled hypercholesterolemia appeared to be a protective factor. Conclusions The prevalence of cardiovascular risk factors in patients who have experienced a myocardial infarction is very high. Control of these risk factors influences both cardiovascular events and long-term mortality.

Introduction and objectives Analysis of the effect of treatment in observational studies is complex due to differences between treated and nontreated patients. Calculating the probability of receiving treatment conditioned on relevant covariates (propensity score [PS]) has been proposed as a method to control for these differences. We report an application of PS to assess the association between reperfusion treatment and 28-day case fatality in patients with acute myocardial infarction (AMI). Method We describe the procedure used to calculate PS for receiving reperfusion treatment, and different strategies to analyze the association between PS and case fatality with regression modeling and matching. Data were from a population-based registry of 6307 patients with AMI in Spain during 1997–98. Results The PS for reperfusion was calculated in 5622 patients. In the multivariate analysis, reperfusion was associated with lower case fatality (OR=0.59; 95% confidence interval [95% CI], 0.46–0.77). When PS was included as a covariate, this association became non-significant (OR=0.76; 95% CI, 0.57–1.01). In the subgroup of matched patients with a similar PS (n=3138), treatment was not associated with case fatality (OR=0.95; 95% CI, 0.72–1.26). When the influence of cases with missing data on PS was controlled for, reperfusion treatment was associated with lower fatality (OR=0.66; 95% CI, 0.55–0.80). Conclusions Calculating propensity score is a method that controls for differences between treated and nontreated patients. This score has limitations when matching is incomplete and when data are missing. Results of the present example suggest that reperfusion treatment reduces AMI case fatality.

Introduccion y objetivos. Determinar el efecto de un tratamiento en estudios observacionales es problematico por las diferencias existentes entre tratados y no tratados. Un metodo propuesto para controlar estas diferencias es calcular la probabilidad condicionada por covariables de recibir el tratamiento, Propensity Score (PS). Presentamos una aplicacion de este metodo analizando la asociacion entre reperfusion y letalidad a 28 dias en pacientes con infarto agudo de miocardio (IAM). Metodo. Se presenta como calcular la PS de recibir reperfusion y las diferentes estrategias para analizar posteriormente su asociacion con la letalidad mediante modelos de regresion y apareamiento. Utilizamos datos de un registro poblacional de IAM realizado en Espana entre 1997 y 1998 que incluyo 6.307 IAM. Resultados. Se calculo la PS de reperfusion en 5.622 pacientes. En el analisis multivariado la reperfusion se asocio con menor letalidad (odds ratio [OR] = 0,59; intervalo de confianza [IC] del 95%, 0,46-0,77); al ajustar ademas por la PS de reperfusion esta asociacion no fue significativa (OR = 0,76; IC del 95%, 0,57-1,01). En el subgrupo de pacientes apareados, tratados y no tratados con PS de reperfusion similar (n = 3.138), este tratamiento no se asocio con letalidad (OR = 0,95; IC del 95%, 0,72-1,26). Controlando el impacto de los casos con datos insuficientes en la PS de reperfusion, esta se asocio con menor letalidad (OR = 0,66; IC del 95%, 0,55-0,80). Conclusiones. El calculo de la PS es un metodo para controlar las diferencias entre los grupos tratado y no tratado. Tiene limitaciones cuando el apareamiento es incompleto o hay datos insuficientes en la PS calculada. Los resultados del ejemplo presentado indican que la reperfusion reduce la letalidad del IAM.

The Expert Patients Program (EPP), an educational intervention for chronic diseases aimed at nonprofessionals, has high nonparticipation and dropout rates. We used quantitative and qualitative methods to identify the prevalence of and reasons for nonparticipation in 100 patients with acute myocardial infarction and 69 with stroke. We confirmed a high prevalence of refusal, identifying three groups based on degree of participation: patients who refused to attend (51%), patients who attended and then dropped out (10%), and patients who attended (39%). Patients who refused to participate or dropped out were mainly women and former/current smokers with a better-than-average physical condition. In addition, they were invited to participate in the EPP long after their cardiovascular event. We found that the degree of participation depended upon the patient’s individual and social context and the professional profile of the recruiter. Therefore, tailored strategic interventions should be designed for each type of participation.

Objectives Sedation and ventilation overnight after cardiac surgery is common practice. However, early extubation may be feasible with no increase in postoperative complications. This study examines (1) if early extubation is possible in a significant number of patients, (2) if it reduces ICU stay, and (3) if this practice increases postoperative complications. Design Prospective, controlled, randomized clinical trial. Patients and methods We randomized 404 consecutive patients to early extubation (7 to 11 h postoperatively) (group A, 201 patients) or conventional extubation (between 8 and 12 AM the following day) (group B, 203 patients). Variables included type and severity of the disease, surgical risk, type of operation, operative incidences, postoperative complications, duration of mechanical ventilation, intubation and ICU stay, bleeding, reoperation, vasoactive drugs, and mortality. Results Groups were comparable. Extubation within the preestablished time was successful in 60.2% of patients in group A and 74.4% in group B. Median ICU stay was 27 h in group A and 44 h in group B (p=0.008). Discharge from ICU within the first 24 h postoperatively was 44.3% in group A and 30.5% in group B (p=0.006). There was no significant difference in complications between groups. Successfully extubated patients in group A had more reintubation and prolonged ventilation than in group B. Conclusions (1) Sixty percent of our patients were extubated within 11 h of operation. (2) As a result, the length of stay in ICU was reduced and the percentage of patients discharged within 24 h was increased. (3) There was no increase in clinically important postoperative complications.

Objective The aims of this study were to analyze the dose–response association between leisure time physical activity (PA) practice and myocardial infarction (MI), considering not only the total amount but also the amount of PA at different levels of intensity, and to determine whether these associations were modified by age. Method In a population-based age- and sex-matched case–control study, all first acute MI patients aged 25 to 74 years were prospectively registered in four Spanish hospitals between 2002 and 2004. Controls were randomly selected from population-based samples recruited during the same period of time. The Minnesota PA questionnaire was administered to assess total energy expenditure in PA and in light-, moderate-, and high-intensity PA. Results Finally, 1339 cases and 1339 controls were included. The association between PA and MI likelihood was non-linear, with significantly lower MI odds at low practice levels (≥ 500 MET·min/week), lowest odds around 1500 MET·min/week, and a plateau thereafter. Light- (in subjects older than 64 years), moderate-, and high-intensity PA produced similar benefits. Conclusion Most of the population could reduce their likelihood of MI by engaging in PA at a moderate level of intensity or, in individuals older than 64 years, at a light level of intensity.

OBJECTIVE: To draw up a profile of patients with inadequate follow-up and control of cardiovascular risk factors (CVRF) after acute myocardial infarction (AMI). DESIGN: Cohort study. SETTING: Primary care in Albacete, province of Castilla-La Mancha, Spain. PARTICIPANTS: AMI cases who survived at 28 days and recorded in the IBERICA-Albacete register. MAIN MEASUREMENTS: A structured survey of patients, families or family doctors to find out about the follow-up and control of CVRFs (arterial hypertension [AHT], hypercholesterolaemia, diabetes, smoking habits, and obesity), as well as education level, work situation and return to work. Inadequate follow-up is defined as when the recommended visits are not made, and inadequate control, when adequate levels are no obtained or they smoked. A descriptive, bivariate, and multivariate comparative analysis was performed. The association was measured using relative risk (RR), and the population estimation with the 95% confidence intervals (95% CI). RESULTS: The sample included 21% females, 46% hypertensives, 35% with hypercholesterolaemia, 32% diabetics, 36% obeses, and 39% active smokers, with a mean age of 61 years. There was a 9% loss in follow-up, and 576 patients had a CVRF: 31% with inadequate follow-up (95% CI, 28-36) and 46% with inadequate control (95% CI, 41-51). The profile of a patient with inadequate follow-up was young, unemployed, with university education, smoker, obese and without AHT; that of an inadequately controlled patient was, a smoker, diabetic and unemployed. CONCLUSIONS: There was inadequate follow-up of long term CVRFs in 31% of AMI patients, and 46% with inadequate control, there being characteristics in AMI that identify them.

Two particular polymorphisms, namely PON1-192 and PON2-311, in the genes encoding the antioxidant enzymes paraoxonase-1 (PON1) and paraoxonase-2 (PON2) have been associated with an increased risk of acute myocardial infarction (AMI). However, previous findings have been contradictory. The aim of this study was to investigate the association between the PON1-192 and PON2-311 polymorphisms and their interaction on AMI risk.This case-control study involved 746 consecutive AMI patients and 1796 control subjects without cardiovascular disease, who were randomly selected from the same population from which the patients came. All participants were recruited between 1999 and 2000 from four Spanish autonomous regions. All were assessed for the presence of PON1-192 and PON2-311 and for classical cardiovascular risk factors. Multivariate analysis was carried out using logistic regression modeling.The odds ratios (OR) of AMI for patients with the PON1-192 QQ and PON2-311 SS genotypes (who comprised 50% and 66% of the population, respectively) were 1.26 (95% confidence interval [CI], 1.02-1.55) and 1.25 (95% CI, 1.04-1.50), respectively, compared with R and C allele carriers. Moreover, in patients with both QQ and SS genotypes, the adjusted OR of AMI increased to 1.41 (95% CI, 1.13-1.76).Our results indicate that the PON1-192 and PON2-311 polymorphisms were independent risk factors of AMI in our population.

[Abstract] Background: Myocardial infarction (MI) incidence and mortality display a high geographic variation. Aims: The objective of the present study was to analyze MI mortality, cumulative incidence rate variability in seven regions of Spain from 1997 to 1998. Methods and Results: Standardized methods were used to identify, find, register, and classify MI cases that were classified as definite, possible, insufficient-dataMI, and non-MI. The total population of the seven monitored regions was 7,364,682 inhabitants. Of the 11,256 cases fulfilling eligibility criteria to investigate, 10,660 were selected to calculate MI rates: 6554 (61.5%)non-fatal definite MI, 1179 (11.1%)fatal definite MI, 1859 (17.4%)fatal possible MI, 1068 (10.0%)fatal cases with insufficient data. The IBERICA 25–74 years age-standardized cumulative incidence rates for men and women, were 207 (range: 175–252) and 45 (range: 36–65) per 100,000, respectively. The age-standardized mortality rates for men and women, were 73 (range: 62–94) and 20 (range: 13–29) per 100,000, respectively. Age-standardized case-fatality was 31.4 and 24.2% in men aged 25–74 and 35–64 years, respectively, and 32.7 and 27.0%, respectively, in women. Conclusions: MI cumulative incidence and mortality rates are low compared with other industrialized countries but, vary considerably among regions in a Mediterranean country like Spain. Cataluña. Comissió Interdepartamental de Recerca i Innovació Tecnològica; CIRIT/2001 SGR 00408 Instituto de Salud Carlos III; FIS 96/0026-01 to 05 Instituto de Salud Carlos III; FIS 97/1270 Instituto de Salud Carlos III; FIS 98/1535

[Abstract] Introduction and objectives. To determine the proportion of patients with myocardial infarction (MI) not admitted to a coronary care unit (CCU), the variables associated with admission into a CCU, and whether admission to a CCU, and the availability of coronary angiography in the same hospital, were associated with 28-day case fatality. Patients and method. Population-based registry of MI in patients 25 to 74 years of age, admitted during 1996-1998. Demographic and clinical characteristics were recorded, as well as management, clinical course and survival after 28 days. Hospitals were classified according to the availability of a CCU and catheterization laboratory (advanced hospital), CCU only (intermediate hospital) or neither (basic hospital). Admission to the CCU was also recorded. Results. In all, 9046 cases of MI were recorded; in 11.3% the patient was not admitted to a CCU. Age, smoking (OR=1.33; 95% CI, 1.08-1.64), non-Q MI (OR=0.62; 95% CI, 0.49-0.78) or undetermined location of MI (OR=0.34; 95% CI, 0.23-0.50), Killip 4 score on admission (OR=0.63; 95% CI, 0.40-1.00) and delay in arrival at the hospital >6 h were associated with CCU admission. Patients admitted to a CCU showed a lower case fatality in the first 24 h (4.2% vs 23.5%), which was independent of comorbidity, severity and treatment. The 24-hour survivors admitted to a basic hospital had higher case fatality (17.3% vs 7.8%) than other groups, which was related to differences in treatment. Conclusions. CCU admission is associated with a lower case fatality in the first 24 h. Admission to a basic hospital is associated with a higher 28-day case fatality even in patients who survive 24 h. [Resumen] Introducción y objetivos. Determinar el porcentaje de pacientes con infarto agudo de miocardio (IAM) que no ingresan en una unidad de cuidados intensivos coronaries (UCIC), las variables asociadas al ingreso en una UCIC y si el ingreso en una UCIC, su disponibilidad y la de hemodinámica en el hospital se asocian a la letalidad a 28 días. Pacientes y método. Registro poblacional (1996-1998) de casos de IAM en pacientes con edades comprendidas entre los 25 y los 74 años. Se recogieron variables demográficas, clínicas, el ingreso en UCIC y la letalidad a los 28 días. Se clasificaron los hospitales según la disponibilidad de UCIC y hemodinámica (hospital avanzado), solamente UCIC (hospital intermedio) o ninguno (hospital básico). Resultados. Se registraron 9.046 casos; el 11,3% no ingresó en una UCIC. La edad, el consumo de tabaco (odds ratio [OR] = 1,33; intervalo de confianza [IC] del 95%, 1,08-1,64), el infarto sin onda Q (OR = 0,62; IC del 95%, 0,49-0,78) o ilocalizable (OR = 0,34; IC del 95%, 0,23-0,50), el grado Killip 4 al ingreso (OR = 0,63; IC del 95%, 0,40-1,00) y el retraso > 6 h en llegar al hospital se asociaron al ingreso en UCIC. Los pacientes ingresados en UCIC presentaban menor letalidad que los ingresados en hospitales básicos en las primeras 24 h (el 4,2 frente al 23,5%), independientemente de la gravedad del IAM y de las variables relacionadas con el tratamiento. Los su-pervivientes a 24 h que ingresaban en un hospital bÁsico presentaban mayor letalidad a los 28 días (el 17,3 frente al 7,8%), relacionada con las variables de tratamiento. Conclusiones. El ingreso en una UCIC se asocia a una menor letalidad de los pacientes con IAM en las primeras 24 h. El ingreso en un hospital bÁsico se asocia a una mayor letalidad a los 28 días. Insituto de Salud Carlos III; FIS96/0026-01 to 05 Insituto de Salud Carlos III; FIS97/1270 Insituto de Salud Carlos III; FIS98/1535

Background and Purpose: Stroke is one of the leading causes of death and disability in western countries. Improving attention to stroke demands better public information about the illness. The aim of the present study was to determine the current knowledge of stroke among the Spanish population. Methods: We conducted a population-based telephone interview in Spain. A total of 3,000 respondents were selected at random following a systematic procedure aimed at filling the sex/age community quotas. Results: A total of 16,016 telephone calls were made. Three thousand respondents were eligible and 2,884 completed the telephone interview. Only 4.5% of respondents knew the term stroke, 1,719 (59.6%) participants were able to mention at least one stroke risk factor, and only 940 (32.6%) could mention at least one stroke sign without prompting. Most respondents considered stroke to be a severe and dangerous illness that can be treated, but less than half of the respondents went immediately to a hospital when faced with a stroke event. Suitable stroke knowledge was only achieved by 302 (10.5%) respondents. Those who had home-based occupations and no previous stroke experience were less likely to have suitable stroke knowledge. Conclusions: This study confirms that our community is still unfamiliar with stroke. Wide population-based educational programs are needed to increase public knowledge of stroke. Our results indicate that people with home-based occupations should be the main target of our education campaigns.

[Resumen] Introducción y objetivos. Los datos sobre el manejo de los pacientes con infarto agudo de miocardio (IAM) que llegan a un hospital en España no garantizan la exhaustividad en el registro. El objetivo de este trabajo es conocer las características y el manejo de los pacientes con IAM que llegan a todos los hospitales de distintas áreas de 8 comunidades autónomas españolas. Métodos. El estudio IBERICA es un registro poblacional de IAM entre 25 y 74 años de edad realizado en ocho comunidades autónomas españolas. Para este trabajo se incluyeron los casos de IAM que llegaron vivos al hospital durante 1997. Se recogen las características, tratamiento y evolución a los 28 días del episodio. Se realizó un análisis descriptivo y se calculó el coeficiente de variación. Resultados. Se registraron 4.041 casos de IAM: el 79,9% eran varones y la edad media fue de 61,1 años. El 10,9% (IC del 95%: 9,9-11,9%) no ingresaron en una unidad de cuidados intensivos cardiológicos, existiendo una gran variabilidad entre las zonas (coeficiente de variación del 53%). Existe también una gran variabilidad en la realización e indicación de técnicas diagnósticas y terapéuticas invasivas y no invasivas, así como en el tratamiento farmacológico empleado: únicamente la utilización de antiagregantes (91,5%) Y trombólisis (41,8%) presenta un coeficiente de variación < 10%. La letilidad a los 28 días fue del 16,2% (IC del 95%: 15,1-17,4%) con un coeficiente de variación del 20,6%. Conclusión. Las características de los pacientes varían entre las zonas estudiadas. Las diferencias geográficas en el manejo y pronóstico sugieren que puede existir desigualdades en la atención al enfermo con IAM en España. [Abstract] Introduction and objective. Although some in-hospital studies have described the management of acute myocardial infarction (MI) patients in Spain, none has been able to guarantee the exhaustiveness of patient registry. This study sought to determine the clinical characteristics and in-hospital management of patients with MI in eight Spanish population registries. Methods. The IBERICA study is a population-based MI registry carried out in the 25 to 74 year-old population, in eight Spanish regions in 1997. A standardized methology was used to register and investigate all MI arriving alive to a hospital. Clinical characteristics, cardiovascular risk factors prevalence, pharmacological treatment, invasive and non- invasive procedures performed and complications at 28 days of evolution were recorded. A descriptive analysis was performed and the variation coefficient (VC) was calculated. Results. In 1997, 4,041 MI patients were registered, 79.9% were men with a mean age of 61.1 years. Although 10.9% (95% CI: 9.9-11.9%) were not admitted to the coronary care unit, a large variability existed among different areas (VC = 53%). There was a high variability in the utilization and performance of non-invasive and invasive procedures among regions, as well as in the use of pharmacological treatment. Only the use of antiaggregants (91.5%) and thrombolytic theraphy (41.8%) showed a low variability (VC < 10%). Twenty-eight day mortality was 16.2% (95% el: 15.1-17.4%) with a high variability being observed among the different regions (VC = 20.6%). Conclusion. Patient characteristics vary among the different Spanish regions. The differences in management and prognosis suggest a lack of equality in the health care provided to MI patients in the different regions in Spain.