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a b s t r a c t Objective: To estimate the additional cost attributable to nosocomial infection (NI) in a pediatric intensive care unit (PICU) and related factors. Methods: A prospective cohort study was conducted in all children admitted to the PICU of a tertiary- care pediatric hospital between 2008 and 2009. Descriptive and bivariate analyses were conducted of total direct costs due to PICU stay and medical procedures in patients with and without NI. A log-linear regression model was performed to determine the factors associated with higher total cost. Results: A total of 443 patients were studied and the prevalence of NI was 11.3%. The difference in the median total cost was D 30,791.4 per patient between groups with and without NI. The median cost of PICU length of stay in patients with NI was almost eight times higher than the median cost of patients without NI. In patients with NI, the highest costs related to medical procedures were associated with antibiotics, enteral and parenteral feeding, and imaging tests. In the multivariate model, the factors asso- ciated with higher cost were infection, the performance of cardiovascular surgery, urgent admission, a higher pediatric risk mortality score, and the presence of immunosuppression. By contrast, older children and those with surgical admission generated lower cost. Conclusions: NI was associated with an increase in total cost, which implies that the prevention of these infections through specific interventions could be cost-effective and would help to increase the safety of healthcare systems.

Background The long-term prognostic influence of depression on patients hospitalized for heart failure (HF) is unknown. No previous study has examined systematically the mechanisms of the relationship between depression and mortality in HF. Methods Prospective study of 433 patients hospitalized for HF-related emergencies in 4 Spanish hospitals. Baseline depressive symptoms were assessed with the 10-item Geriatric Depression Scale (GDS). The association between depressive symptoms and mortality was summarized with hazard ratios (HRs) obtained from Cox regression, with sequential adjustment for possible mechanisms of the association. Results Of the 433 study participants, 103 (23.8%) had major depression (GDS-10 ≥5) at baseline. During a mean follow-up of 5.7 years, 305 deaths (70%) occurred. Compared with those who were not depressed, subjects with major depression showed higher mortality (age and sex-adjusted HR 1.52, 95% CI 1.15-2.01). Subsequent adjustment for comorbidity reduced the HR to 1.45 (95% CI 1.10-1.93). Additional adjustment for severity of cardiac lesion and for lifestyles, foremost physical inactivity, led to a HR of 1.27 (95% CI 0.95-1.70). After further adjustment for pharmacologic treatment of HF and particularly for disability in instrumental activities of daily living, the HR dropped almost to the null value (HR 1.10, 95% CI 0.82-1.49). Conclusions Depressive symptoms in patients hospitalized for HF are associated with higher long-term mortality; this association is largely explained by the frequent comorbidity, physical inactivity, and disability of these patients.

This study examines the relationship between social network and hospital readmission and mortality in older patients with heart failure.Prospective study conducted with 371 patients, age 65 and older, admitted for heart failure-related emergencies at 4 Spanish hospitals. Social network was measured at baseline with a 4-item questionnaire that ascertained whether subjects were married, lived with another person(s), saw or had telephone contact with family members daily or almost daily, and were at home alone for less than 2 hours per day. Social network was deemed "high" where all 4 items were present, "moderate" where 3 were present, and "low" where 2 or fewer were present. Analyses were performed using Cox models, and adjusted for the main confounders. A total of 55% of patients had high or moderate social networks. During a median follow-up of 6.5 months, 135 (36.4%) patients underwent a first emergency rehospitalization and 68 (18.3%) died. Compared with patients with high social network, hospital readmission was more frequent among those who had moderate (hazard ratio [HR] 1.87; 95% confidence interval [CI] 1.06-3.29; P.05) and low social networks (HR 1.98; 95% CI 1.07-3.68; P.05). This relationship showed a positive dose-response (p for linear trend 0.042). The magnitude of this association was comparable to that of other important predictors of readmission, such as previous hospitalization. No relationship was observed between social network and death.A very simple questionnaire measuring social network can identify patients with a higher short-term risk of hospital readmission.

Introduccion y objetivos En este trabajo se estima la prevalencia de depresion y se identifican los factores biomedicos y psicosociales asociados en ancianos hospitalizados con insuficiencia cardiaca en Espana. Metodos Se estudio a 433 pacientes ≥ 65 anos ingresados de urgencia en 4 hospitales espanoles desde enero de 2000 hasta junio de 2001, con diagnostico principal o secundario de insuficiencia cardiaca. Se considero que habia depresion ante la presencia de 3 sintomas en la Escala de Depresion Geriatrica de 10 items. Resultados Del total de pacientes estudiados, 210 (48,5%) presentaron depresion. Las cifras correspondientes fueron 71 (37,6%) en varones y 139 (57,0%) en mujeres. La depresion fue mas frecuente en los pacientes con las siguientes caracteristicas: grado funcional III-IV de la NYHA (odds ratio ajustada [ORa] = 2,00; intervalo de confianza [IC] del 95%, 1,23-3,24); peor puntuacion en los aspectos fisicos de la calidad vida (ORa = 3,14; IC del 95%,1,98-4,99); dependencia en 1 o 2 actividades basicas de la vida diaria (ABVD) (ORa = 2,52; IC del 95%, 1,41-4,51); dependencia en 3 o mas ABVD (ORa = 2,47; IC del 95%, 1,20-5,07); limitacion en alguna actividad instrumental de la vida diaria (ORa = 2,20; IC del 95%, 1,28-3,79); hospitalizacion previa por insuficiencia cardiaca (ORa = 1,71; IC del 95%, 1,93-5,45); estaban solos en casa mas de 2 h al dia (ORa = 3,24; IC del 95%, 1,93-5,45); menor satisfaccion con el medico de atencion primaria (ORa = 1,90; IC del 95%, 1,14-3,17). Conclusiones La depresion es muy frecuente en los ancianos hospitalizados con insuficiencia cardiaca, y se asocia con varios factores biomedicos y psicosociales. Esta elevada frecuencia, el peor pronostico de la insuficiencia cardiaca en presencia de sintomas depresivos y la existencia de instrumentos diagnosticos sencillos y un tratamiento eficaz apoyan el cribado sistematico de la depression en estos pacientes.

Introduction and objectives This study provides an estimate of the prevalence of depression, and identifies associated medical and psychosocial factors, in elderly hospitalized patients with heart failure (HF) in Spain. Methods The study included 433 patients aged 65 years or more who underwent emergency admission at four Spanish hospitals between January 2000 and June 2001 and who had a primary or secondary diagnosis of HF. Depression was defined as the presence of three or more symptoms on the 10-item Geriatric Depression Scale. Results In total, 210 (48.5%) study participants presented with depression: 71 men (37.6%) and 139 women (57.0%). Depression was more common in patients with the following characteristics: NYHA functional class III-IV (adjusted odds ratio or aOR=2.00, 95% confidence interval or 95% CI, 1.23–3.24), poor score on the physical domain of the quality-of-life assessment (aOR=3.14; 95% CI, 1.98–4.99), being dependent for one or two basic activities of daily living (BADLs) (aOR=2.52; 95% CI, 1.41–4.51), being dependent for >3 BADLs (aOR=2.47; 95% CI, 1.20–5.07), being limited in at least one instrumental activity of daily living (aOR=2.20: 95% CI, 1.28–3.79), previous hospitalization for HF (aOR=1.71; 95% CI, 1.93–5.45), spending more than 2 hours/day alone at home (aOR=3.24; 95% CI, 1.93–5.45), and being dissatisfied with their primary care physician (aOR=1.90; 95% CI, 1.14–3.17). Conclusions Depression is very common in elderly hospitalized patients with HF and is associated with several medical and psychosocial factors. The high prevalence of depression, the poorer prognosis for HF in patients with depressive symptoms, and the existence of simple diagnostic tools and effective treatment argue in favor of systematic screening for depression in these patients.

High blood pressure (BP) has been ranked as the most important risk factor worldwide regarding attributable deaths. Dietary habits are major determinants of BP. Among them, frequent intake of low-fat dairy products may protect against hypertension. Our aim was to assess the relationship between low-fat dairy product intake and BP levels and their changes after 12-month follow-up in a cohort of asymptomatic older persons at high cardiovascular risk recruited into a large-scale trial assessing the effects of Mediterranean diets on cardiovascular outcomes. Data from 2290 participants, including 1845 with hypertension, were available for analyses. Dairy products were not a specific part of the intervention; thus, data were analysed as an observational cohort. Dietary information was collected with validated semi-quantitative FFQ and trained personnel measured BP. To assess BP changes, we undertook cross-sectional analyses at baseline and at the end of follow-up and longitudinal analyses. A statistically significant inverse association between low-fat dairy product intake and systolic BP was observed for the 12-month longitudinal analysis. In the longitudinal analysis, the adjusted systolic and diastolic BP were significantly lower in the highest quintile of low-fat dairy product intake (-4.2 (95% CI -6.9, -1.4) and -1.8 (95% CI -3.2, -0.4) mmHg respectively), whereas the point estimates for the difference in diastolic BP indicated a modest non-significant inverse association. Intake of low-fat dairy products was inversely associated with BP in an older population at high cardiovascular risk, suggesting a possible protective effect against hypertension. © The Author 2008., The PREDIMED study is funded by public resources from the Spanish Ministry of Health (Fondo de Investigación Sanitaria PI04233, PI051839, PI070240, PI052368, PI052584, PI051458, PI042234, RTIC G03/140, RD06/0045/0000 and CIBER CB06/03 Fisiopatología de la Obesidad y Nutrición) and from the Generalitat Valenciana (GRUPOS2004-43 and ACOMP06109).

Aims Although the vital prognosis of heart failure (HF) is generally poor, it varies substantially between patients. This study examined whether health-related quality of life (HRQoL) predicts long-term mortality in HF. It also evaluated the role of generic and disease-specific HRQoL questionnaires. Methods and results We studied 416 patients admitted for HF-related emergencies to four hospitals in Spain in 2000–2001. Health-related quality of life was measured at study baseline with a generic questionnaire, the SF-36, and with a disease-specific one, the Minnesota Living with Heart Failure (MLWHF) questionnaire. Patients were followed prospectively to 2007 to ascertain all-cause mortality. During follow-up, 290 (69.7%) patients died. After adjustment for biomedical, healthcare, and social variables, a poor mental component summary (MCS) score on the SF-36 was associated with higher mortality [hazard ratio (HR) 1.38; 95% confidence interval (CI) 1.06–1.76]. For MLWHF, a poor physical component summary (PCS) score predicted higher mortality (HR 1.31; 95% CI 1.01–1.70). In a stepwise Cox model that included the PCS scores of both the SF-36 and the MLWHF, only the PCS of the MLWHF was retained with P < 0.05. However, when both MCS scores were included, only the MCS of the SF-36 was retained with P < 0.05. Conclusion The SF-36 MCS and the MLWHF PCS predict long-term mortality in patients with HF. Future research should identify the determinants of HRQoL and refine interventions to improve it.

High blood pressure (BP) has been ranked as the most important risk factor worldwide regarding attributable deaths. Dietary habits are major determinants of BP. Among them, frequent intake of low-fat dairy products may protect against hypertension. Our aim was to assess the relationship between low-fat dairy product intake and BP levels and their changes after 12-month follow-up in a cohort of asymptomatic older persons at high cardiovascular risk recruited into a large-scale trial assessing the effects of Mediterranean diets on cardiovascular outcomes. Data from 2290 participants, including 1845 with hypertension, were available for analyses. Dairy products were not a specific part of the intervention; thus, data were analysed as an observational cohort. Dietary information was collected with validated semi-quantitative FFQ and trained personnel measured BP. To assess BP changes, we undertook cross-sectional analyses at baseline and at the end of follow-up and longitudinal analyses. A statistically significant inverse association between low-fat dairy product intake and systolic BP was observed for the 12-month longitudinal analysis. In the longitudinal analysis, the adjusted systolic and diastolic BP were significantly lower in the highest quintile of low-fat dairy product intake (-4.2 (95% CI -6.9, -1.4) and -1.8 (95% CI -3.2, -0.4) mmHg respectively), whereas the point estimates for the difference in diastolic BP indicated a modest non-significant inverse association. Intake of low-fat dairy products was inversely associated with BP in an older population at high cardiovascular risk, suggesting a possible protective effect against hypertension.

OBJECTIVE: To assess the effectiveness of an intervention aimed to increase adherence to a Mediterranean diet. DESIGN: A 12-month assessment of a randomized primary prevention trial. SUBJECTS/SETTINGS: One thousand five hundred fifty-one asymptomatic persons aged 55 to 80 years, with diabetes or > or =3 cardiovascular risk factors. INTERVENTION: Participants were randomly assigned to a control group or two Mediterranean diet groups. Those allocated to the two Mediterranean diet groups received individual motivational interviews every 3 months to negotiate nutrition goals, and group educational sessions on a quarterly basis. One Mediterranean diet group received free virgin olive oil (1 L/week), the other received free mixed nuts (30 g/day). Participants in the control group received verbal instructions and a leaflet recommending the National Cholesterol Education Program Adult Treatment Panel III dietary guidelines. MAIN OUTCOME MEASURES: Changes in food and nutrient intake after 12 months. STATISTICAL ANALYSES: Paired t tests (for within-group changes) and analysis of variance (for between-group changes) were conducted. RESULTS: Participants allocated to both Mediterranean diets increased their intake of virgin olive oil, nuts, vegetables, legumes, and fruits (P

Inflammation is involved in cardiovascular diseases. Some studies have found that the Mediterranean diet (MD) can reduce serum concentrations of inflammation markers. However, none of these studies have analyzed the influence of genetic variability in such a response. Our objective was to study the effect of the -765G>C polymorphism in the cyclooxygenase-2 (COX-2) gene and the -174G>C polymorphism in the interleukin-6 (IL-6) gene on serum concentrations of IL-6, C-reactive protein, intercellular adhesion molecule 1 (ICAM-1) and vascular cell adhesion molecule-1 as well as their influence on the response to a nutritional intervention with MD. An intervention study in a high cardiovascular risk Mediterranean population (314 men and 407 women) was undertaken. Participants were randomly assigned to consume a low-fat control diet or a MD supplemented with virgin olive oil or nuts. Measures were obtained at baseline and after a 3-mo intervention period. At baseline, the COX-2 -765G>C polymorphism was associated with lower serum IL-6 (5.85 ± 4.82 in GG vs. 4.74 ± 4.14 ng/L in C-allele carriers; P = 0.002) and ICAM-1 (265.8 ± 114.8 in GG vs. 243.0 ± 107.1 μg/L in C-carriers; P = 0.018) concentrations. These differences remained significant after multivariate adjustment. The IL-6 -174G>C polymorphism was associated with higher (CC vs. G-carriers) serum ICAM-1 concentrations in both men and women and with higher serum IL-6 concentrations in men. Following the dietary intervention, no significant gene x diet interactions were found. In conclusion, although COX-2 -765G>C and IL-6 -174G>C polymorphisms were associated with inflammation, consuming a MD (either supplemented with virgin olive oil or nuts) reduced the concentration of inflammation markers regardless of these polymorphisms., Supported by grants PI052368, PI051458, PI042234, PI051839, PI052584, PI040233, PI070240, PI070954, G03/140, RD06/0045/0000, RD06/0045/0001, CNIC06, and CB06/03 from the Instituto de Salud Carlos III, Madrid, Spain; by grants GRUPOS2004-43 and ACOMP06109 from the Generalitat Valenciana, Spain; and by grant PI41/2005 from the Navarra Government, Spain.

This study provides an estimate of the prevalence of depression, and identifies associated medical and psychosocial factors, in elderly hospitalized patients with heart failure (HF) in Spain.The study included 433 patients aged 65 years or more who underwent emergency admission at four Spanish hospitals between January 2000 and June 2001 and who had a primary or secondary diagnosis of HF. Depression was defined as the presence of three or more symptoms on the 10-item Geriatric Depression Scale.In total, 210 (48.5%) study participants presented with depression: 71 men (37.6%) and 139 women (57.0%). Depression was more common in patients with the following characteristics: NYHA functional class III-IV (adjusted odds ratio or aOR=2.00, 95% confidence interval or 95% CI, 1.23-3.24), poor score on the physical domain of the quality-of-life assessment (aOR=3.14; 95% CI, 1.98-4.99), being dependent for one or two basic activities of daily living (BADLs) (aOR=2.52; 95% CI, 1.41-4.51), being dependent foror =3 BADLs (aOR=2.47; 95% CI, 1.20-5.07), being limited in at least one instrumental activity of daily living (aOR=2.20: 95% CI, 1.28-3.79), previous hospitalization for HF (aOR=1.71; 95% CI, 1.93-5.45), spending more than 2 hours/day alone at home (aOR=3.24; 95% CI, 1.93-5.45), and being dissatisfied with their primary care physician (aOR=1.90; 95% CI, 1.14-3.17).Depression is very common in elderly hospitalized patients with HF and is associated with several medical and psychosocial factors. The high prevalence of depression, the poorer prognosis for HF in patients with depressive symptoms, and the existence of simple diagnostic tools and effective treatment argue in favor of systematic screening for depression in these patients.

Background: We sought to examine the relationship between health-related quality of life (HRQL) and a first emergencyrehospitalizationandmortalityinpatientswith heart failure (HF) having a wide variation in ventricular ejection fraction and functional status. Methods: Prospective study conducted with 394 patients admitted for HF-related emergencies at 4 Spanish hospitals. Baseline HRQL was measured with a generic questionnaire, the Medical Outcomes Study 36-item Short Form Survey (SF-36), and with an HF-specific instrument, the Minnesota Living With Heart Failure (MLWHF)questionnaire.Coxproportionalhazardsmodels were used to calculate hazard ratios (HRs) for hospitalization and death on the basis of HRQL scores. Results: During a median follow-up of approximately 6 months, 138 patients (35.0%) underwent a first emergency rehospitalization and 70 (17.8%) died. After adjustment for biomedical, psychosocial, and health care variables, the frequency of hospital readmission was higher in patients with worse scores on the SF-36 physical functioning (HR, 1.65; 95% confidence interval [CI], 1.11-2.44; P=.01), general health (HR, 1.73; 95% CI, 1.19-2.52; P=.003), and mental health (HR, 1.65; 95% CI, 1.10-2.47;P=.02) subscales. Results were similar for the mortality end point. For the MLWHF questionnaire, worse overall and worse physical and emotional summary scores were associated with higher mortality. Conclusions: Worse HRQL is associated with hospital readmission and death in patients with HF. The magnitude of this association, for both physical and mental HRQL components, is comparable to that for other wellknownpredictorsofhospitalreadmissionanddeath,such as personal history of diabetes, previous hospitalizations, and treatment with angiotensin-converting enzyme inhibitors. Arch Intern Med. 2005;165:1274-1279