Psychosocial factors related to health and well-being in patients with cardiovascular disease

1. Introducción y objetivos. Actualmente, la amplitud de la expectativa vital lleva consigo convivir con enfermedades crónicas, apreciándose que un 71% de muertes en el mundo son debidas a esta causa (Organización Mundial de la Salud, 2018); entre las cuales destacan las Enfermedades Cardiovasculares (ECVs), con 17.9 millones de personas fallecidas anualmente, duplicando a la segunda causa de muerte que es el cáncer. Igualmente, en nuestro país, uno de los principales retos que trae consigo el envejecimiento de la población española es el incremento de personas con enfermedades crónicas, como sería el caso de las ECVs (Instituto Nacional de Estadística, 2018). Por lo que la adopción de hábitos que fomenten un estilo de vida saludable, serían pautas que ayudarían a incrementar el bienestar y la calidad de vida de las personas afectadas. Con la intención de abordar este reto surge la presente Tesis Doctoral que se dirige a evaluar diferentes variables psicosociales que se han relacionado con la salud y el bienestar de este grupo de población. Tal y como Miller, Chen y Cole (2009) afirman, la salud está fuertemente relacionada con variables psicosociales que actúan como determinantes de los hábitos de vida. En esta línea, Sheeran, Gollwitzer y Bargh (2013) han realizado una revisión de las principales teorías que abordan el estudio de los procesos cognitivos (p. ej., intenciones, metas) precursores de conductas saludables (p. ej., dietas, conductas de riesgo); destacando que la Teoría Social Cognitiva (TSC) formulada por Bandura (1997) es una de las más influyentes en el ámbito de la Psicología de la Salud, en concreto, la autoeficacia como la variable que ha recibido mayor atención. Específicamente, la presente Tesis Doctoral, ha seguido una investigación con un diseño longitudinal que ha pretendido explorar a una amplia muestra de pacientes cardíacos. Una gran parte de la muestra ha sido reclutada a través de la colaboración con el estudio CORDIOPREV, del equipo de investigación “Nutrigenómica. Síndrome metabólico” del Instituto Maimónides de Investigación Biomédica de Córdoba - IMIBIC- y Hospital Universitario Reina Sofía de Córdoba. En concreto, la presente Tesis Doctoral ha tratado de abordar dos objetivos generales: un primer objetivo general ha consistido en validar varios modelos SEM (Structural Equation Model) que permitan determinar el peso e interacción de algunas de las principales variables psicosociales asociadas a la ECV en la salud general percibida de los pacientes cardíacos; un segundo objetivo general ha tratado de probar la efectividad de un programa de intervención psicológica breve basado en la auto-monitorización de pacientes cardíacos a través de la herramienta m-Health. 2. Contenido de la investigación. La investigación desarrollada en la presente Tesis Doctoral se encuentra constituida por los siguientes tres estudios que han tratado de abordar los objetivos generales de partida. ESTUDIO 1. Un estudio longitudinal sobre la salud percibida en pacientes cardiovasculares: el papel de conscientiousness, el bienestar subjetivo y la autoeficacia cardíaca. El objetivo de este estudio consistió en analizar los roles de conscientiousness, bienestar subjetivo y creencias de autoeficacia en la enfermedad cardiovascular. La muestra comprendió 514 pacientes cardíacos (edad media 63.57 años) que fueron evaluados dos veces durante un intervalo de nueve meses. En el Tiempo 1, los participantes respondieron un cuestionario que evaluaba conscientiousness, bienestar subjetivo percibido (afecto positivo y negativo, satisfacción con la vida), autoeficacia cardíaca y salud relacionada con la calidad de vida. Las mismas variables (excepto conscientiousness) se reevaluaron en el Tiempo 2. Los resultados mostraron que conscientiousness tenía una relación positiva con el bienestar subjetivo, la autoeficacia cardíaca y la salud relacionada con la calidad de vida en el Tiempo 1. Además, la autoeficacia cardíaca en el Tiempo 1 tenía un efecto longitudinal positivo en la salud relacionada con la calidad de vida en el Tiempo 2, mientras se controlaron los efectos autorregresivos. Los análisis de mediación indicaron que la relación entre conscientiousness y la salud relacionada con la calidad de vida estuvo mediada por el afecto positivo y la autoeficacia cardíaca. Estos resultados sugieren la utilidad de las intervenciones psicosociales destinadas a promover el afecto positivo y las creencias de autoeficacia entre los pacientes con ECV. ESTUDIO 2. Creencias de positividad y autoeficacia para explicar la calidad de vida relacionada con la salud en pacientes cardiovasculares. El objetivo de esta investigación fue examinar la relación longitudinal de la positividad y las variables autorreguladoras específicas de la salud (autoeficacia para el manejo del afecto negativo y la autoeficacia cardíaca) sobre la salud relacionada con la calidad de vida en pacientes con enfermedad cardiovascular. Se probó un modelo explicativo y longitudinal de la salud relacionada con la calidad de vida con un total de 550 pacientes cardíacos. Los participantes respondieron un cuestionario dos veces a intervalos de nueve meses, evaluando su nivel de positividad, creencias de autoeficacia específicas para la salud y salud relacionada con la calidad de vida. Los análisis mediacionales demostraron que las creencias de autoeficacia específicas para la salud median la relación entre la positividad y la salud relacionada con la calidad de vida. Con respecto a la autoeficacia para el manejo del afecto negativo, el factor de angustia y desánimo mostró un efecto directo e indirecto sobre la salud, mientras que el factor de ira solo mostró un efecto indirecto. Los resultados del modelo de ecuaciones estructurales mostraron índices de ajuste adecuados para el modelo explicativo propuesto. De estos resultados se puede considerar que la positividad puede actuar como una disposición que facilita el uso de estrategias motivacionales relacionadas con la salud, tener más confianza en la capacidad para regular las propias emociones y seguir las recomendaciones del equipo médico-cardíaco, lo que permite a los pacientes percibir una mejor calidad de vida. Estos hallazgos apuntan a la necesidad de promover intervenciones psicosociales que incluyan estas variables disposicionales y motivacionales para aumentar la salud relacionada con la calidad de vida de los pacientes cardíacos. ESTUDIO 3. Efectividad experimental de los programas mindfulness y fortalecimiento positivo para la promoción del bienestar subjetivo emocional y la autoeficacia del manejo cardiovascular en pacientes cardíacos. Esta investigación analiza la efectividad de dos tipos de intervenciones psicológicas breves: programa de mindfulness y programa de fortalecimiento positivo, para promover el bienestar emocional subjetivo y la autoeficacia del manejo cardiovascular de los pacientes cardíacos a través de mHealth. 105 participantes con enfermedad cardiovascular fueron asignados aleatoriamente al grupo control o grupos experimentales. Fue un ensayo prospectivo controlado aleatorio a tres brazos. Se analizaron el afecto positivo-negativo, la positividad, la ansiedad-depresión y el manejo de la autoeficacia (enfermedad crónica y cardiovascular). El diseño de medidas repetidas y los análisis post hoc mostraron que tanto el programa en mindfulness como el grupo de fortalecimiento positivo a lo largo del tiempo tuvieron un efecto positivo sobre el afecto positivo-negativo y la autoeficacia del manejo de la enfermedad crónica en comparación con el grupo control. Las covariables de positividad y depresión mostraron efecto sobre el afecto positivo y la autoeficacia del manejo para la enfermedad crónica, mientras que la covariable de ansiedad solo influyó en el afecto negativo para ambos grupos de intervención. Ambas intervenciones psicológicas breves podrían ser valiosas para mejorar el bienestar subjetivo emocional y la autoeficacia del manejo de enfermedades crónicas utilizando mHealth. 3. Conclusión general. Los tres estudios que conforman la presente Tesis Doctoral se han basado en explorar varios factores psicosociales que actúan como variables protectoras de la ECV, con lo que se ha pretendido avanzar en la promoción de la salud percibida y el bienestar. Asimismo, tener en cuenta las variables psicológicas estudiadas en ambos modelos de ecuaciones estructurales propuestos (correspondientes a los Estudios 1 y 2) podría permitir examinar e implementar futuros programas de intervención psicológica dirigidos a mejorar la salud relacionada con la calidad de vida de los pacientes cardíacos. En cuanto al Estudio 3 ha pretendido arrojar luz a la comunidad científica desde un abordaje psicológico interventivo breve, comparando dos tipos de intervenciones -mindfulness y fortalecimiento positivo-, con un grupo de tratamiento considerado habitual, a través de la herramienta mHealth, para mejorar el componente emocional del bienestar subjetivo y la autoeficacia para el manejo de la enfermedad crónica y de la ECV, mostrando que ambas resultarían beneficiosas.1. Introduction and objectives. Currently, the breadth of life expectancy leads to living with chronic diseases, appreciating that 71% of deaths in the world are due to this cause (World Health Organization, 2018); among which Cardiovascular Diseases (CVD) stand out, with 17.9 million people dead annually, doubling the second cause of death that is cancer. Likewise, in our country, one of the main challenges that the aging of the Spanish population brings is the increase of people with chronic diseases, as would be the case of CVDs (National Statistics Institute, 2018). In this line, the adoption of habits that promote a healthy lifestyle, would be guidelines that would help increase the well-being and quality of life of the people affected. With the intention of addressing this challenge, this Doctoral Thesis arises, which is aimed at evaluating different psychosocial variables that have been related to the health and well-being of this population group. As Miller, Chen, and Cole (2009) state, health is strongly related to psychosocial variables that act as determinants of life habits. Along these lines, Sheeran, Gollwitzer, and Bargh (2013) have reviewed the main theories that address the study of cognitive processes (e.g., intentions, goals) precursors of healthy behaviors (e.g., diets, risk behaviors); highlighting that the Social Cognitive Theory formulated by Bandura (1997) is one of the most influential in the field of Health Psychology, specifically, self-efficacy as the variable that has received the most attention. This Doctoral Thesis has followed an investigation with a longitudinal design that has sought to explore a wide sample of cardiac patients. A large part of the sample has been recruited through the collaboration with the CORDIOPREV study, from the “Nutrigenomics. Metabolic syndrome” research team of the Maimonides Institute of Biomedical Research of Córdoba and Reina Sofía University Hospital of Córdoba. Specifically, this Doctoral Thesis has tried to address two general objectives: a first general objective has been to validate several SEM (Structural Equation Model) models that allow determining the weight and interaction of some of the main psychosocial variables associated with CVD in the general perceived health of cardiac patients; A second general objective has been to test the effectiveness of a brief psychological intervention program based on the self-monitoring of cardiac patients through the m- Health tool. 2. Content of the research. The research developed in this Doctoral Thesis is constituted by the following three studies that have tried to address the general objectives of departure. STUDY 1. A longitudinal study on perceived health in cardiovascular patients: The role of conscientiousness, subjective wellbeing and cardiac self-efficacy. Cardiovascular disease (CVD) is the world’s most prevalent chronic disease and the leading chronic cause of morbidity. There are several psychosocial factors associated with quality of life during CVD. Our main objectives were to analyze the roles of conscientiousness, subjective wellbeing and self-efficacy beliefs. The sample comprised 514 patients (mean age 63.57 years) who were assessed twice over a nine-month interval. At Time 1, participants answered a questionnaire assessing conscientiousness, perceived subjective wellbeing (positive and negative affect, life satisfaction), cardiac self-efficacy and health-related quality of life (HRQoL). The same variables (except for conscientiousness) were re-assessed at Time 2. Results showed that conscientiousness had a positive relation with subjective wellbeing, cardiac self-efficacy, and HRQoL at Time 1. Moreover, cardiac self-efficacy at Time 1 had a positive longitudinal effect on HRQoL at Time 2, while controlling for autoregressive effects. Mediation analyses indicated that the relationship between conscientiousness and HRQoL was mediated by positive affect and cardiac self-efficacy. These results suggest the usefulness of psychosocial interventions aimed at promoting positive affect and self-efficacy beliefs among CVD patients. STUDY 2. Positivity and self-efficacy beliefs to account for health-related quality of life in cardiovascular patients. The aim of this research is to examine the longitudinal relationship of positivity and health-specific self-regulatory variables (self-efficacy in managing negative affect and cardiac self-efficacy) to health-related quality of life in patients with cardiovascular disease. An explanatory and longitudinal model of health-related quality of life was tested with a total of 550 cardiac patients. Participants answered a questionnaire twice at interval of nine months, assessing their level of positivity, health-specific self-efficacy beliefs, and health-related quality of life. Mediational analyses demonstrated that healthspecific self-efficacy beliefs mediate the relationship between positivity and healthrelated quality of life. Regarding self-efficacy in managing negative affect, the despondency-distress factor showed a direct and indirect effect on health while the anger factor showed only an indirect effect. The results of the structural equation model show adjustment indices suitable for the proposed explanatory model. Positivity may act as a disposition that facilitates the use of motivational strategies related with health—being more confident in their ability to regulate their emotions and to follow the recommendations of their cardiac-medical team—enabling thus patients to perceive higher quality of life. These findings point to the need to promote psychosocial interventions that include these dispositional and motivational variables to increase the health-related quality of life of cardiac patients. STUDY 3. Experimental effectiveness of mindfulness and positive strengthening programs for the promotion of emotional subjective wellbeing and cardiovascular management self-efficacy in cardiac patients. This research analyzes the effectiveness of two types of brief psychological interventions – mindfulness and positive strengthening programs – to promote emotional subjective wellbeing and cardiovascular management self-efficacy of cardiac patients using mHealth. 105 participants with cardiovascular disease were randomly assigned to the control group or experimental groups. It was a three-arm randomized controlled prospective trial. Positive-negative affect, positivity, anxiety–depression and management self-efficacy -chronic and cardiovascular disease- were analyzed. Repeated-measures design and post hoc analyses showed that mindfulness and positive strengthening groups across time had a positive effect on positive-negative affect and management self-efficacy for chronic disease in comparison with the control group. Positivity and depression covariates showed effect on positive affect and management self-efficacy for chronic disease, whereas anxiety covariate influenced only on negative affect for both intervention groups. Both brief psychological interventions could be valuable for improving emotional subjective wellbeing and management self-efficacy for chronic disease using mHealth. 3. General conclusion. The three studies that have been take up this Doctoral Thesis have been based on exploring several psychosocial factors that act as protective variables of CVD, which has sought to advance in the promotion of perceived health and well-being. Moreover, considering the psychological variables studied in both models of proposed structural equations (corresponding to Studies 1 and 2) could allow examining and implementing future psychological intervention programs aimed at improving health related to the quality of life of cardiac patients. Regarding Study 3, it has sought to shed light on the scientific community from a brief interventive psychological approach, comparing two types of interventions -mindfulness and positive strengthening-, with a treatment group considered habitual, through the mHealth tool, to improve the self-efficacy for the management of chronic disease and CVD, as well as the emotional component of subjective well-being

El rol moderador de la eficacia percibida de las medidas de prevención frente al COVID-19 en la relación entre la percepción de riesgo y la salud mental percibida

The pandemic situation caused by COVID-19 led countries to adopt harsh and prolonged (over time) measures that—along with the high number of infections and deaths and continuous negative information—have affected the mental health of individuals. In this study, the impact on mental health of the COVID-19 health crisis in Spain was explored through the perceived efficacy of pandemic containment measures as a moderator of the relationship that COVID-19 perceived risk establishes with stress and depression. A questionnaire composed of scales conceived to measure COVID-19 perceived risk, perceived efficacy of COVID-19 prevention measures, stress, and depression was completed by 478 adults living in Spain (66.9% females, Mage= 36.30, SD= 15.32) between May 16, 2021, and June 6, 2021. The results confirmed the moderating role of per-ceived efficacy. Perceived efficacy acted as a protective factor for stress and depression by decreasing the negative impact that perceived risk had on both variables related to mentaldistress. Also, the perception that participants had about the effectiveness of prevention measures appeared to be a relevant protective factor regarding mental health during the pandemic. This study highlights the relevance of psychological interventions and government policies that improve positive risk communication and provide adequate information regarding the effectiveness of health-prevention measuresLa pandemia del COVID-19 ha llevado a los países a adoptar severas y prolongadas medidas que junto con el alto número de contagios y muertes y la continua información negativa ha afectado la salud mental de las personas. Este estudio analiza el impacto de la crisis sanitaria del COVID-19 en España explorando el rol moderador de la eficacia percibida de las medidas de contención en la relación que establece la percepción del riesgo del COVID-19 con el estrés y la depresión. Un total de 478 adultos residentes en España (un66.9% mujeres; Medad= 36.30, DT= 15.32) completaron un cuestionario con escalas concebidas para medir el riesgo percibido del COVID-19, la eficacia percibida de las medidas de protección, el estrés y la depresión entre el 16 de mayo y el 6 de junio de 2021. Los resultados confirmaron el rol moderador de la eficacia percibida, la cual actuó como un factor protector del estrés y la depresión al disminuir el impacto negativo que la percepción de riesgo del COVID-19 tiene en ambas variables relacionadas con el distrés mental. La percepción que tienen los individuos sobre la efectividad de las medidas de protección parece ser un factor protector relevante en relación con la salud mental durante una pandemia. Se subraya la relevancia de intervenciones psicológicas y de políticas gubernamentales que mejoren la comunicación positiva del riesgo y la información adecuada sobre la eficacia de las medidas de protección

Learning and social commitment. Towards the awareness of the students of Childhood Education and Social Education of the University of Córdoba

El presente artículo describe un proyecto de innovación metodológica llevado a cabo en las asignaturas Historia de la Educación Contemporánea y Social, de primer curso del Grado en Educación Social, y Psicología de la Salud, del Grado en Educación Infantil. El trabajo ha consistido en el diseño y desarrollo de experiencias de aprendizaje-servicio (ApS), que es una metodología educativa que combina procesos de adquisición del saber y de atención a la comunidad en un único proyecto bien articulado en el que los participantes aprenden mientras intervienen en necesidades reales del entorno. Esta estrategia didáctica permite aprender contenidos curriculares y formar actitudes y compromisos ciudadanos. Se busca, pues, además de la ganancia en conocimientos, la sensibilización del alumnado ante las problemáticas de los demás y la implicación en actuaciones tendentes a solventarlas; el análisis de la realidad, en definitiva, para mejorarla a la luz de fuentes de información variadas y ricas y a través del trabajo en grupo, el compromiso social, la capacidad reflexiva y el juicio crítico.The paper describes a methodological innovation project carried out in the subjects History of Contemporary and Social Education, first year of the Degree in Social Education, and Health Psychology, of the Degree in Infantile Education. The work consisted in the design and development of Service Learning experiences, which is an educational methodology that combines knowledge acquisition and community service processes in a single, well-articulated project in which participants learn while intervening in real needs. of the environment. This didactic strategy allows to learn curricular contents and to form citizen attitudes and commitments. It is sought, then, in addition to the gain in knowledge, the sensitization of the students before the problems of the others and the implication in actions tending to solve them; the analysis of reality, in short, to improve it in the light of varied and rich sources of information and through group work, social commitment, reflective capacity and critical judgment

A Brief mHealth-Based Psychological Intervention in Emotion Regulation to Promote Positive Subjective Well-Being in Cardiovascular Disease Patients: A Non-Randomized Controlled Trial

The emotional impact that a cardiovascular disease may have on a person’s life can affect the prognosis and comorbidity of the disease. Therefore, emotion regulation is most important for the management of the disease. The aim of this study was to analyze the effectiveness of a brief mHealth psychological intervention in emotion regulation to promote positive subjective well-being in cardiovascular disease patients. The study sample (N = 69, 63.7 ± 11.5 years) was allocated to either the experimental group (n = 34) or control group (n = 35). The intervention consisted of a psychoeducational session in emotion regulation and an mHealth-based intervention for 2 weeks. Positive subjective well-being as a primary outcome and self-efficacy to manage the disease as a secondary outcome were assessed at five time points evaluated over a period of 6 weeks. The experimental group showed higher improvement in positive subjective well-being and self-efficacy for managing the disease compared to the control group over time. The experimental group also improved after the intervention on all outcome measures. Brief mHealth interventions in emotion regulation might be effective for improving positive subjective well-being and self-efficacy to manage the disease in cardiovascular patients

The Role of Emotional Regulation and Affective Balance on Health Perception in Cardiovascular Disease Patients According to Sex Differences

One of the challenges of aging is the increase of people with chronic diseases, such as cardiovascular disease (CVD). Men and women experience the disease differently. Therefore, it has an impact on how CVD is treated and its outcomes. This research analyzed the relationship between psychosocial variables and health promotion among cardiovascular patients, paying special attention to sex differences. A longitudinal study with cardiovascular patients (747 in phase 1 (122 women) and 586 in phase 2 (83 women)) was carried out. Participants were evaluated based on their sociodemographic characteristics, affective balance, regulatory negative affect self-efficacy, stress and anxiety regulation strategies, and perceived global health. Results showed that men presented significantly higher scores in positive affect, affective balance, and self-efficacy to regulate negative emotions, while women presented significantly higher scores in negative affect and the use of passive strategies to cope with stressful situations. Regression analyses showed that all psychological variables studied in phase 1 were significant predictors of health perception in phase 2. According to the results, it is necessary to include strategies to improve cardiovascular health through education and emotional regulation, with a gender focus.Ministerio de Economía y Competitividad PSI2014–58609-RMinisterio de Ciencia, Innovación y Universidades PDI2019-107304RB-I0

A Brief mHealth-Based Psychological Intervention in Emotion Regulation to Promote Positive Subjective Well-Being in Cardiovascular Disease Patients: A Non-Randomized Controlled Trial.

The emotional impact that a cardiovascular disease may have on a person's life can affect the prognosis and comorbidity of the disease. Therefore, emotion regulation is most important for the management of the disease. The aim of this study was to analyze the effectiveness of a brief mHealth psychological intervention in emotion regulation to promote positive subjective well-being in cardiovascular disease patients. The study sample (N = 69, 63.7 ± 11.5 years) was allocated to either the experimental group (n = 34) or control group (n = 35). The intervention consisted of a psychoeducational session in emotion regulation and an mHealth-based intervention for 2 weeks. Positive subjective well-being as a primary outcome and self-efficacy to manage the disease as a secondary outcome were assessed at five time points evaluated over a period of 6 weeks. The experimental group showed higher improvement in positive subjective well-being and self-efficacy for managing the disease compared to the control group over time. The experimental group also improved after the intervention on all outcome measures. Brief mHealth interventions in emotion regulation might be effective for improving positive subjective well-being and self-efficacy to manage the disease in cardiovascular patients

Congreso del alumnado como herramienta para el desarrollo de habilidades competenciales en los Grados de Educación Infantil y Primaria

De acuerdo con la literatura, uno de los objetivos fundamentales del Espacio Europeo de Educación Superior es que el alumnado debe desarrollar una serie de competencias, siendo agentes activos de su propio conocimiento, primando el aprendizaje por descubrimiento guiado por el profesor. Siguiendo esta línea, desarrollamos un proyecto de innovación docente con el objetivo de fomentar en los estudiantes una actitud activa y autónoma hacia la adquisición de su propio conocimiento. Para ello, los estudiantes siguieron una metodología de aprendizaje basado en la investigación, potenciando una actitud crítica sustentada en criterios científicos. Así surgió el « I Congreso de Psicología y Educación: el Congreso de los Estudiantes » llevado a cabo en la Facultad de Ciencias de la Educación de la Universidad de Córdoba. Un Congreso Científico donde los alumnos que cursaban distintas asignaturas de Psicología en los grados de Educación Infantil y Primaria fueron los protagonistas de las presentaciones orales, así como de los pósteres científicos, sobre temáticas cuyo eje fundamental fue la Psicología en el ámbito educativo. Un año más tarde se celebró su segunda edición continuando en la misma línea de actuación. En ésta se consiguió perseverar en los objetivos y perfeccionar la forma de llevar a cabo la experiencia adaptándola a nuevas temáticas y ampliando la participación.According to the literature, one of the main aims of the European Higher Education Area is that students must develop basic competences, being active agents of their own knowledge, emphasizing discovery learning and the role of the professor as a guide. Following this line, we have developed a project of educational innovation which main aim was fostering autonomy and active learning in students. With this purpose, the students followed a learning methodology based on research and promoting a critical attitude rooted in scientific approach. Thus, the «I Congress of Psychology and Education: the Congress of Students» emerged at the Faculty of Education of the University of Cordoba. A Scientific Congress where the students, who were studying different Psychology subjects in the Bachelor of Early Childhood Education or Bachelor of Primary Education, were the agents of the oral presentations, as well as the scientific posters. The main topic was Educational psychology. In the same line, one year later, it was celebrated the second edition of the Congress. In this edition, we expanded the participation and topics and the methodology was improved

Treatment with tocilizumab or corticosteroids for COVID-19 patients with hyperinflammatory state: a multicentre cohort study (SAM-COVID-19)

Objectives: The objective of this study was to estimate the association between tocilizumab or corticosteroids and the risk of intubation or death in patients with coronavirus disease 19 (COVID-19) with a hyperinflammatory state according to clinical and laboratory parameters. Methods: A cohort study was performed in 60 Spanish hospitals including 778 patients with COVID-19 and clinical and laboratory data indicative of a hyperinflammatory state. Treatment was mainly with tocilizumab, an intermediate-high dose of corticosteroids (IHDC), a pulse dose of corticosteroids (PDC), combination therapy, or no treatment. Primary outcome was intubation or death; follow-up was 21 days. Propensity score-adjusted estimations using Cox regression (logistic regression if needed) were calculated. Propensity scores were used as confounders, matching variables and for the inverse probability of treatment weights (IPTWs). Results: In all, 88, 117, 78 and 151 patients treated with tocilizumab, IHDC, PDC, and combination therapy, respectively, were compared with 344 untreated patients. The primary endpoint occurred in 10 (11.4%), 27 (23.1%), 12 (15.4%), 40 (25.6%) and 69 (21.1%), respectively. The IPTW-based hazard ratios (odds ratio for combination therapy) for the primary endpoint were 0.32 (95%CI 0.22-0.47; p < 0.001) for tocilizumab, 0.82 (0.71-1.30; p 0.82) for IHDC, 0.61 (0.43-0.86; p 0.006) for PDC, and 1.17 (0.86-1.58; p 0.30) for combination therapy. Other applications of the propensity score provided similar results, but were not significant for PDC. Tocilizumab was also associated with lower hazard of death alone in IPTW analysis (0.07; 0.02-0.17; p < 0.001). Conclusions: Tocilizumab might be useful in COVID-19 patients with a hyperinflammatory state and should be prioritized for randomized trials in this situatio

Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

Abstract Background Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres. Methods This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low–middle-income countries. Results In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of ‘single-use’ consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low–middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia. Conclusion This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high– and low–middle–income countries