Regional variability in population acute myocardial infarction cumulative incidence and mortality rates in Spain 1997 and 1998

[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 00408Instituto de Salud Carlos III; FIS 96/0026-01 to 05Instituto de Salud Carlos III; FIS 97/1270Instituto de Salud Carlos III; FIS 98/153

Recursos hospitalarios y letalidad por infarto de miocardio. Estudio IBERICA

[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 05Insituto de Salud Carlos III; FIS97/1270Insituto de Salud Carlos III; FIS98/153

Diagnostic efficacy of sentinel node biopsy in oral squamous cell carcinoma : cohort study and meta-analysis

Objectives: To evaluate the efficacy of sentinel node biopsy (SNB) in oral squamous cell carcinoma (OSCC). Design: A prospective study of a cohort of 25 consecutive patients with OSCC anatomopathological confirmation through biopsy, without oncological pre-treatment, in clinical stage T1-T4N0, of these 25 patients 14 were T1-T2N0. The absence of regional disease (N0) was determined by means of clinical exploration and cervical tomography (CT). To establish the overall sensitivity of the technique, a meta-analysis was carried out of 10 series published to February 2005 where SNB had been applied to head and neck cancer, adding our 14 T1-T2N0 cases, thus making a total of 260 patients. Results: Identification by SNB was accurate in 96% of the 25 cases, with a sensitivity of 66.7%. Analyzing only the T1-T2N0 cases (n=14), the accuracy was 100% with a sensitivity of 1 (CI 95%, 0.29-1.00). The overall sensitivity was 93%. The accuracy in identifying the sentinel node varied between 66% and 100%. The SN was identified in 251 of 260 cases, of those, 71 were true positive, 5 false negative and 175 true negative. The overall sensitivity was 93.4% (CI 95%, 85.3-97.8), with a specificity of 100% (CI 95%, 0.98-100). The weighted negative probability quotient was 0.176 (CI 0.103-0.301) and that of positive probability 24.75 (CI 95%, 10.8-56.71). The weighted diagnostic odds ratio was 183.71 (CI 95%, 59.36-568.56). If we accept that the prevalence of hidden regional disease is 30%, a negative sentinel node has 5% possibility of having hidden disease. Conclusions: Our data provide a certain degree of evidence that, due to its high sensitivity, the SNB procedure can be applied to the initial stages of OSCC

The prevalence of diabetes-related complications and multimorbidity in the population with type 2 diabetes mellitus in the Basque Country

Background: Type 2 diabetes mellitus is associated with a diverse range of pathologies. The aim of the study was to determine the incidence of diabetes-related complications, the prevalence of coexistent chronic conditions and to report multimorbidity in people with type 2 diabetes living in the Basque Country. Methods: Administrative databases, in four cross sections (annually from 2007 to 2011) were consulted to analyse 149,015 individual records from patients aged >= 35 years with type 2 diabetes mellitus. The data observed were: age, sex, diabetes-related complications (annual rates of acute myocardial infarction, major amputations and avoidable hospitalisations), diabetes-related pathologies (prevalence of ischaemic heart disease, renal failure, stroke, heart failure, peripheral neuropathy, foot ulcers and diabetic retinopathy) and other unrelated pathologies (44 diseases). Results: The annual incidence for each condition progressively decreased during the four-year period: acute myocardial infarction (0.47 to 0.40%), major amputations (0.10 to 0.08%), and avoidable hospitalisations (5.85 to 5.5%). The prevalence for diabetes-related chronic pathologies was: ischaemic heart disease (11.5%), renal failure (8.4%), stroke (7.0%), heart failure (4.3%), peripheral neuropathy (1.3%), foot ulcers (2.0%) and diabetic retinopathy (7.2%). The prevalence of multimorbidity was 90.4%. The highest prevalence for other chronic conditions was 73.7% for hypertension, 13.8% for dyspepsia and 12.7% for anxiety. Conclusions: In the type 2 diabetes mellitus population living in the Basque Country, incidence rates of diabetes complications are not as high as in other places. However, they present a high prevalence of diabetes related and unrelated diseases. Multimorbidity is very common in this group, and is a factor to be taken into account to ensure correct clinical management.The authors wish to acknowledge the support received from Ricardo Samper Ochotorena, in addition to the funding collaboration and support received by the Sanofi-Aventis pharmaceutical company, in connection with increasing diabetes awareness

A novel form of human disease with a protease-sensitive prion protein and heterozygosity methionine/valine at codon 129: Case report

Background: Sporadic Creutzfeldt-Jakob disease (sCJD) is a rare neurodegenerative disorder in humans included in the group of Transmissible Spongiform Encephalopathies or prion diseases. The vast majority of sCJD cases are molecularly classified according to the abnormal prion protein (PrPSc) conformations along with polymorphism of codon 129 of the PRNP gene. Recently, a novel human disease, termed "protease-sensitive prionopathy", has been described. This disease shows a distinct clinical and neuropathological phenotype and it is associated to an abnormal prion protein more sensitive to protease digestion. Case presentation: We report the case of a 75-year-old-man who developed a clinical course and presented pathologic lesions compatible with sporadic Creutzfeldt-Jakob disease, and biochemical findings reminiscent of "protease-sensitive prionopathy". Neuropathological examinations revealed spongiform change mainly affecting the cerebral cortex, putamen/globus pallidus and thalamus, accompanied by mild astrocytosis and microgliosis, with slight involvement of the cerebellum. Confluent vacuoles were absent. Diffuse synaptic PrP deposits in these regions were largely removed following proteinase treatment. PrP deposition, as revealed with 3F4 and 1E4 antibodies, was markedly sensitive to pre-treatment with proteinase K. Molecular analysis of PrPSc showed an abnormal prion protein more sensitive to proteinase K digestion, with a five-band pattern of 28, 24, 21, 19, and 16 kDa, and three aglycosylated isoforms of 19, 16 and 6 kDa. This PrPSc was estimated to be 80% susceptible to digestion while the pathogenic prion protein associated with classical forms of sporadic Creutzfeldt-Jakob disease were only 2% (type VV2) and 23% (type MM1) susceptible. No mutations in the PRNP gene were found and genotype for codon 129 was heterozygous methionine/valine. Conclusions: A novel form of human disease with abnormal prion protein sensitive to protease and MV at codon 129 was described. Although clinical signs were compatible with sporadic Creutzfeldt-Jakob disease, the molecular subtype with the abnormal prion protein isoforms showing enhanced protease sensitivity was reminiscent of the "protease-sensitive prionopathy". It remains to be established whether the differences found between the latter and this case are due to the polymorphism at codon 129. Different degrees of proteinase K susceptibility were easily determined with the chemical polymer detection system which could help to detect proteinase-susceptible pathologic prion protein in diseases other than the classical ones

Public health surveillance: a pressing need.

[ES] La vigilancia en salud pública es el marco óptimo para el control de las enfermedades y la toma de decisiones basadas en la evidencia. Su definición incluye todos los ámbitos en los que la autoridad sanitaria interviene (análisis de la situación de salud, definición de prioridades, evaluación de políticas e investigación sanitaria)1,2. Además, es el origen de la decisión basada en la evidencia en salud pública y tiene valor incluso cuando no existen intervenciones posibles, ya que sus hallazgos contribuyen a la planificación o inspiran nuevas líneas de investigación2. Conscientes de la necesidad de ir más allá de las enfermedades infecciosas, en 1970, los Centers for Disease Control and Prevention de los Estados Unidos se reorientaron para incorporar las enfermedades crónicas y los factores de riesgo en sus sistemas de vigilancia, al igual que otros países desarrollados2-4. La vigilancia en salud pública solo tiene sentido cuando va unida a la puesta en marcha de medidas para el control de las enfermedades y de los riesgos para la salud; su meta es «información para la acción». Para ello, requiere el reconocimiento de la autoridad sanitaria, capacidad ejecutiva y una presencia relevante en las Administraciones sanitarias integrantes del conjunto del Estado. En Espana, ˜ el concepto de vigilancia en salud pública se ha incorporado recientemente con la Ley 33/2011 General de Salud Pública (LGSP). Dentro de este contexto, tratamos de valorar nuestra trayectoria histórica, así como sus debilidades y fortalezas, para poner en marcha un proyecto de vigilancia en salud pública en Espana. [EN] Objectives To describe anti-tuberculosis drug consumption in Spain for the period, 1985–1995, compare the associated time trend and geographical pattern against case reports of tuberculosis (TB), and estimate the number of persons undergoing anti-tuberculosis therapy in 1995. Methods The official Drug Database was used to ascertain consumption of anti-tuberculosis drugs (isoniazid, rifampicin, pyrazinamide and ethambutol) in Spain during the period, 1985–1995. The technical units of measurement used for comparison purposes were daily defined dose (DDD) and DDD rate per day per 100,000 population. Annual trends and geographical patterns of consumption were plotted. The respective numbers of persons treated in 1995 with each of the four drugs were first estimated and then compared against TB case reports. Results There was an overall decline in the consumption of isoniazid, rifampicin and ethambutol over the period, 1985–1995, though the former two registered rises in 1991 and 1992. Pyrazinamide consumption showed growth throughout the study period. The highest 1995 consumption rates were registered by Galicia, Cantabria, Asturias, the Basque Country, Ceuta and Melilla, and the lowest by the Canary Islands and Navarre. Comparisons run against TB case reports revealed a greater degree of underreporting in certain provinces. In 1995, approximately 18,858 persons (48 per 100,000 population) must be assumed to have undergone pyrazinamide therapy in Spain, indicating that the reported TB rate of 22 per 100,000 population could well represent underreporting in excess of 100%. Conclusions The trend in anti-tuberculosis drug consumption reflects shifts in treatment guidelines and is compatible with a rise in TB incidence in recent years. Major underreporting of TB marked by wide inter-regional and -provincial differences was in evidence. Pyrazinamide consumption is probably the best indicator for estimating minimum TB incidence.S

A novel form of human disease with a protease-sensitive prion protein and heterozygosity methionine/valine at codon 129: Case report

Background: Sporadic Creutzfeldt-Jakob disease (sCJD) is a rare neurodegenerative disorder in humans included in the group of Transmissible Spongiform Encephalopathies or prion diseases. The vast majority of sCJD cases are molecularly classified according to the abnormal prion protein (PrPSc) conformations along with polymorphism of codon 129 of the PRNP gene. Recently, a novel human disease, termed "protease-sensitive prionopathy", has been described. This disease shows a distinct clinical and neuropathological phenotype and it is associated to an abnormal prion protein more sensitive to protease digestion. Case presentation: We report the case of a 75-year-old-man who developed a clinical course and presented pathologic lesions compatible with sporadic Creutzfeldt-Jakob disease, and biochemical findings reminiscent of "protease-sensitive prionopathy". Neuropathological examinations revealed spongiform change mainly affecting the cerebral cortex, putamen/globus pallidus and thalamus, accompanied by mild astrocytosis and microgliosis, with slight involvement of the cerebellum. Confluent vacuoles were absent. Diffuse synaptic PrP deposits in these regions were largely removed following proteinase treatment. PrP deposition, as revealed with 3F4 and 1E4 antibodies, was markedly sensitive to pre-treatment with proteinase K. Molecular analysis of PrPSc showed an abnormal prion protein more sensitive to proteinase K digestion, with a five-band pattern of 28, 24, 21, 19, and 16 kDa, and three aglycosylated isoforms of 19, 16 and 6 kDa. This PrPSc was estimated to be 80% susceptible to digestion while the pathogenic prion protein associated with classical forms of sporadic Creutzfeldt-Jakob disease were only 2% (type VV2) and 23% (type MM1) susceptible. No mutations in the PRNP gene were found and genotype for codon 129 was heterozygous methionine/valine. Conclusions: A novel form of human disease with abnormal prion protein sensitive to protease and MV at codon 129 was described. Although clinical signs were compatible with sporadic Creutzfeldt-Jakob disease, the molecular subtype with the abnormal prion protein isoforms showing enhanced protease sensitivity was reminiscent of the "protease-sensitive prionopathy". It remains to be established whether the differences found between the latter and this case are due to the polymorphism at codon 129. Different degrees of proteinase K susceptibility were easily determined with the chemical polymer detection system which could help to detect proteinase-susceptible pathologic prion protein in diseases other than the classical ones

Coexistence of protease sensitive and resistant prion protein in 129VV homozygous sporadic Creutzfeldt-Jakob disease: a case report

Introduction: The coexistence of different molecular types of classical protease-resistant prion protein in the same individual have been described, however, the simultaneous finding of these with the recently described protease-sensitive variant or variably protease-sensitive prionopathy has, to the best of our knowledge, not yet been reported. Case presentation: A 74-year-old Caucasian woman showed a sporadic Creutzfeldt-Jakob disease clinical phenotype with reactive depression, followed by cognitive impairment, akinetic-rigid Parkinsonism with pseudobulbar syndrome and gait impairment with motor apraxia, visuospatial disorientation, and evident frontal dysfunction features such as grasping, palmomental reflex and brisk perioral reflexes. She died at age 77. Neuropathological findings showed: spongiform change in the patient"s cerebral cortex, striatum, thalamus and molecular layer of the cerebellum with proteinase K-sensitive synaptic-like, dot-like or target-like prion protein deposition in the cortex, thalamus and striatum; proteinase K-resistant prion protein in the same regions; and elongated plaque-like proteinase K-resistant prion protein in the molecular layer of the cerebellum. Molecular analysis of prion protein after proteinase K digestion revealed decreased signal intensity in immunoblot, a ladder-like protein pattern, and a 71% reduction of PrPSc signal relative to non-digested material. Her cerebellum showed a 2A prion protein type largely resistant to proteinase K. Genotype of polymorphism at codon 129 was valine homozygous. Conclusion: Molecular typing of prion protein along with clinical and neuropathological data revealed, to the best of our knowledge, the first case of the coexistence of different protease-sensitive prion proteins in the same patient in a rare case that did not fulfill the current clinical diagnostic criteria for either probable or possible sporadic Creutzfeldt-Jakob disease. This highlights the importance of molecular analyses of several brain regions in order to correctly diagnose rare and atypical prionopathie

Análisis de la asociación entre un tratamiento y un acontecimiento de interés en estudios observacionales utilizando la probabilidad de recibir el tratamiento (Propensity Score): Un ejemplo con la reperfusión miocárdica

Introducción y objetivos. Determinar el efecto de un tratamiento en estudios observacionales es problemático por las diferencias existentes entre tratados y no tratados. Un método propuesto para controlar estas diferencias es calcular la probabilidad condicionada por covariables de recibir el tratamiento, Propensity Score (PS). Presentamos una aplicación de este método analizando la asociación entre reperfusión y letalidad a 28 días en pacientes con infarto agudo de miocardio (IAM). Método. Se presenta cómo calcular la PS de recibir reperfusión y las diferentes estrategias para analizar posteriormente su asociación con la letalidad mediante modelos de regresión y apareamiento. Utilizamos datos de un registro poblacional de IAM realizado en España entre 1997 y 1998 que incluyó 6.307 IAM. Resultados. Se calculó la PS de reperfusión en 5.622 pacientes. En el análisis multivariado la reperfusión se asoció con menor letalidad (odds ratio [OR] = 0,59; intervalo de confianza [IC] del 95%, 0,46-0,77); al ajustar además por la PS de reperfusión esta asociación 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 reperfusión similar (n = 3.138), este tratamiento no se asoció 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 reperfusión, ésta se asoció con menor letalidad (OR = 0,66; IC del 95%, 0,55-0,80). Conclusiones. El cálculo de la PS es un método 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 reperfusión reduce la letalidad del IAM