A new scoring system to stratify risk in unstable angina

BACKGROUND: We performed this study to develop a new scoring system to stratify different levels of risk in patients admitted to hospital with a diagnosis of unstable angina (UA), which is a complex syndrome that encompasses different outcomes. Many prognostic variables have been described but few efforts have been made to group them in order to enhance their individual predictive power. METHODS: In a first phase, 473 patients were prospectively analyzed to determine which factors were significantly associated with the in-hospital occurrence of refractory ischemia, acute myocardial infarction (AMI) or death. A risk score ranging from 0 to 10 points was developed using a multivariate analysis. In a second phase, such score was validated in a new sample of 242 patients and it was finally applied to the entire population (n = 715). RESULTS: ST-segment deviation on the electrocardiogram, age ≥ 70 years, previous bypass surgery and troponin T ≥ 0.1 ng/mL were found as independent prognostic variables. A clear distinction was shown among categories of low, intermediate and high risk, defined according to the risk score. The incidence of the triple end-point was 6 %, 19.2 % and 44.7 % respectively, and the figures for AMI or death were 2 %, 11.4 % and 27.6 % respectively (p < 0.001). CONCLUSIONS: This new scoring system is simple and easy to achieve. It allows a very good stratification of risk in patients having a clinical diagnosis of UA. They may be divided in three categories, which could be of help in the decision-making process

Assessment of VINO filters for correcting redgreen Color Vision Deficiency

In our ongoing research on the effectiveness of different passive tools for aiding Color Vision Deficiency (CVD) subjects, we have analyzed the VINO 02 Amp Oxy-Iso glasses using two strategies: 1) 52 observers were studied using four color tests (recognition, arrangement, discrimination, and color-naming); 2) the spectral transmittance of the lenses were used to model the color appearance of natural scenes for different simulated CVD subjects. We have also compared VINO and EnChroma glasses. The spectral transmission of the VINO glasses significantly changed color appearance. This change would allow some CVD subjects, above all the deutan ones, to be able to pass recognition tests but not the arrangement tests. To sum up, our results support the hypothesis that glasses with filters are unable to effectively resolve the problems related to color vision deficiency.The Spanish State Agency of Research (AEI); the Ministry for Economy, Industry and Competitiveness (MIMECO) (Grant numbers FIS2017-89258-P and DPI 2015-64571-R); European Union FEDER (European Regional Development Funds)

Drug utilization and cost in a Medicaid population: A simulation study of community vs. mail order pharmacy

<p>Abstract</p> <p>Background</p> <p>Outpatient drugs are dispensed through both community and mail order pharmacies. There is no empirical evidence that substitution of community pharmacy with mail order reduces overall drug expenditures. The need for evaluating the potential effects on utilization and costs of the possible extension of mail order services in Medicaid provides the rationale for conducting this study. This study compares drug utilization and drug product cost in community vs. mail order pharmacy dispensing services in a Medicaid population.</p> <p>Methods</p> <p>This study is a retrospective cohort study comparing utilization and cost patterns in community vs. mail order pharmacy. A simulation model was employed to assess drug utilization and cost in mail order pharmacy using community pharmacy claim data. The model assumed that courses of drug therapy (CDT) in mail order pharmacy would have utilization patterns similar to those found in community pharmacy. A 95% confidence interval surrounding changes in average utilization and average cost were estimated using bootstrap analysis. A sensitivity analysis was performed by varying drug selection criteria and supply, fill point, and medication possession ratio (MPR). Sub-analyses were performed to address differences between mail order and community pharmacy related to therapeutic class and dual-eligible patients.</p> <p>Data for the study derived from pharmacy claims database of Ohio Medicaid State program for the period January 2000-September 2004. Drug claims were aggregated to obtain a set of CDTs representing unique patient IDs and unique drug products. Drug product cost estimates excluded dispensing fees and were used to estimate the cost reduction required in mail order to become cost neutral in comparison with community pharmacy.</p> <p>Results</p> <p>The baseline model revealed that the use of mail order vs. community pharmacy would result in a 5.5% increase in drug utilization and a 5.4% cost reduction required in mail order to become cost neutral. Results from Ohio Medicaid drugs for chronic use revealed a 5.1% increase in utilization and a 4.9% cost reduction required to become cost neutral in comparison with community pharmacy.</p> <p>Conclusion</p> <p>The results of the simulation model indicate that mail order pharmacy increases drug utilization and can also increase drug product cost if the cost per unit is not reduced accordingly. Prior consideration should be given to the patient population, day-supply, disease, therapy, and insurance characteristics to ensure the appropriate use of mail order pharmacy services.</p

Uso de la estrategia de alta intensidad con estatinas ¿Se cumplen las pautas establecidas?

Background: Secondary prevention in patients < 76 years with history of a vascular event or previous revascularization includes the use of high intensity-statin therapy. Objective: The aim of this study is to evaluate the 1-year adherence to treatment since patients’ discharge from the coronary care unit. Methods: We conducted a prospective study of consecutive patients between January and November 2015. Median follow-up was 9 months. Results: A total of 210 patients were included; 83% were men and median age was 59 years (52-67.5). Most patients (74.5%) were discharged with atorvastatin 40 mg/day, 19% with rosuvastatin 20 mg/day, 2.7% with atorvastatin 80 mg/day and 3.9% with rosuvastatin 40 mg/day. Half of the patients continued with high-intensity statins, 28% reduced the dose and 22% stopped the treatment. Conclusions: Only half of the patients with high vascular risk or history of recent revascularization continues with the treatment after one year.Los pacientes que han sufrido un síndrome coronario agudo (SCA) o han sido revascularizados están en riesgo de sufrir nuevos eventos isquèmicos en la evolución, por lo cual la prevención secundaria es fundamental. La guía americana para el manejo del colesterol publicada en el año 2013[i] generó un cambio  radical en la visión del tratamiento hipolipemiante en los pacientes de alto riesgo vascular, poniendo como objetivo la dosis de estatina en vez de los valores de LDL a alcanzar. Es sabido que es más probable mantener los tratamientos a largo plazo si se han instrumentado ya desde el alta de la internación[ii]. Realizamos este trabajo con el objetivo de evaluar el cumplimiento al año de la indicación de estatinas de alta intensidad de una población externada de la unidad coronaria bajo esa precisa indicación luego de haber padecido un evento cardiovascular o haber sido sometido a una revascularización miocárdica.  

La monitorización continua de la calidad de los resultados de la cirugía cardíaca

Propósito del trabajo: Aunque la aplicación de los gráficos variables ajustados por vida (VLAD = variable life-adjusted display) fue propuesta hace una década, existen pocas publicaciones sobre su uso en la monitorización de la mortalidad en cirugía cardíaca, y a nuestro entender, ninguna aplicada a morbilidad u otros parámetros de control de calidad. El objetivo de este estudio fue demostrar la utilidad de un modelo de control de calidad en cirugía cardíaca, basado en la monitorización continua de las complicaciones y muertes con gráficos VLAD. Material y método: Se realizó una monitorización continua de los resultados de morbilidad y mortalidad con VLAD, en una serie prospectiva de 502 cirugías cardíacas. Se confeccionaron curvas VLAD para monitorizar mortalidad, reoperación por sangrado, mediastinitis, accidente cerebrovascular (ACV), infarto de miocardio y necesidad de diálisis postcirugía. La mortalidad se ajustó con el EuroSCORE, mientras que las complicaciones se ajustaron con un puntaje de riesgo de morbilidad, y en base a tasas esperadas fijas de riesgo de complicación. Adicionalmente se gráfico el empleo de arteria mamaria en la serie de coronarios. Resultados: Las curvas VLAD de mortalidad y morbilidad ajustadas por riesgo, permitieron identificar varios conjuntos de resultados adversos (conglomerados) ocurridos en distintos períodos de tiempo, así como también la relación temporal entre ellos. Asimismo se pudo determinar a lo largo de la serie, la vida neta ganada, las complicaciones evitadas y la tasa de uso de arteria mamaria. Conclusiones: La monitorización continua con gráficos VLAD permitió el control en tiempo real de los resultados de la cirugía cardíaca. No sólo fue útil para el seguimiento de la mortalidad, sino que pudo adaptarse para la monitorización de la morbilidad ajustada por riesgo, y para el control de una buena práctica quirúrgica, como es el uso de la arteria mamaria en la cirugía coronaria

Decompensated Heart Failure. What Are We Talking About?

The aim of this study was to know the problematic posed by a significant range of patients hospitalized for heart failure inprivate urban centers which do not receive patients referred with end-stage disease. Baseline characteristics and outcome of865 consecutive elderly patients hospitalized due to heart failure were analyzed in two of the above-mentioned centers. Meanage was 81 years and 48% were women. Heart failure was of coronary etiology in 25.5% of cases and chagasic in 0.4%, and 78%of patients were hypertensive. Average comorbidities were 3 per patient. Half of the patients had preserved systolic function.Systolic blood pressure on admission was 145 mmHg and ≥ 170 mmHg in 25% of cases. Average hospital stay was 6 days andin-hospital mortality 6.13%. The one-year evolution of these patients is a matter of great concern, with 70% of readmissionsand 40.12% mortality. It should be pointed out that half of the post discharge deaths were not due to heart failure.El objetivo del trabajo es conocer la problemática de una franja significativa de pacientes hospitalizados por insuficienciacardíaca en centros urbanos privados que no son receptores de derivaciones de pacientes en estadios avanzados. Se analizaronlas características basales y la evolución de 865 pacientes consecutivos hospitalizados por insuficiencia cardíaca en dos centroscon las características precitadas. Se trata de una población anciana –mediana de edad 81 años– 48% mujeres. La etiologíacoronaria era de 25,5%, y la chagásica, 0,4% y el 78%, hipertensos. El promedio de comorbilidades fue de 3 por paciente. Lamitad tenía función sistólica preservada. La presión sistólica de ingreso fue de 145mmHg, y en el 25% fue ≥ 170 mmHg. Laestadía promedio fue 6 días, y la mortalidad intrahospitalaria 6,13%. Es muy preocupante la evolución de estos pacientes alaño, con un 70% de reinternación y 40,12% de mortalidad. Debe destacarse que cerca de la mitad de los fallecimientos posaltano fueron debido a insuficiencia cardíaca