Estrategias de mantenimiento de contacto e intervenciones psicoterapéuticas breves para la prevención del suicidio: estudio de implementación, efectividad y coste-efectividad

Tesis doctoral inédita leída en la Universidad Autónoma de Madrid, Facultad de Medicina, Departamento de Psiquiatría. Fecha de lectura: 11-05-2020Esta tesis tiene embargado el acceso al texto completo hasta el 11-11-2021This study has been financially-supported partly by: Instituto de Salud Carlos III (ISCIII PI13/02200; PI16/01852), Delegación del Gobierno para el Plan Nacional de Drogas (20151073), American Foundation for Suicide Prevention (AFSP) (LSRG-1-005-16), Comunidad de Madrid (Actividades I+D en Biomedicina B2017/BMD-3740. AGES-CM 2CM) and Structural Funds of the European Unio

The impact of dementia on hospital outcomes for elderly patients with sepsis: A population-based study

BACKGROUND: Prior studies have suggested that dementia adversely influences clinical outcomes and increases resource utilization in patients hospitalized for acute diseases. However, there is limited population-data information on the impact of dementia among elderly hospitalized patients with sepsis. METHODS: From the 2009-2011 National Hospital Discharge Database we identified hospitalizations in adults aged ≥65 years. Using ICD9-CM codes, we selected sepsis cases, divided them into two cohorts (with and without dementia) and compared both groups with respect to organ dysfunction, in-hospital mortality and the use of hospital resources. We estimated the impact of dementia on these primary endpoints through multivariate regression models. RESULTS: Of the 148 293 episodes of sepsis identified, 16 829 (11.3%) had diagnoses of dementia. Compared to their dementia-free counterparts, they were more predominantly female and older, had a lower burden of comorbidities and were more frequently admitted due to a principal diagnosis of sepsis. The dementia cohort showed a lower risk of organ dysfunction (adjusted OR: 0.84, 95% Confidence Interval [CI]: 0.81, 0.87) but higher in-hospital mortality (adjusted OR: 1.32, 95% [CI]: 1.27, 1.37). The impact of dementia on mortality was higher in the cases of younger age, without comorbidities and without organ dysfunction. The cases with dementia also had a lower length of stay (-3.87 days, 95% [CI]: -4.21, -3.54) and lower mean hospital costs (-3040€, 95% [CI]: -3279, -2800). CONCLUSIONS: This nationwide population-based study shows that dementia is present in a substantial proportion of adults ≥65s hospitalized with sepsis, and while the condition does seem to come with a lower risk of organ dysfunction, it exerts a negative influence on in-hospital mortality and acts as an independent mortality predictor. Furthermore, it is significantly associated with shorter length of stay and lower hospital costs.This work was supported by a grant from Instituto de Salud Carlos III (grant number: PI09/0597)S

Effect of dementia on the incidence, short-term outcomes, and resource utilization of invasive mechanical ventilation in the elderly: a nationwide population-based study

BACKGROUND: Though the prevalence of dementia among hospitalized patients is increasing, there is limited population data in Europe about the use of life-support measures such as invasive mechanical ventilation in these patients. Our objective is to assess whether dementia influences the incidence, outcomes, and hospital resource use in elderly patients undergoing mechanical ventilation. METHODS: Using ICD-9-CM codes, all hospitalizations involving invasive mechanical ventilation in adults aged ≥ 65 years were identified in the Spanish national hospital discharge database covering the period 2000-2013. The cases identified were stratified into two cohorts (patients with or without dementia) in which main outcome measures were compared. The impact of dementia on in-hospital mortality and hospital resource use were assessed through multivariable models. Trends were assessed through joinpoint regression analysis and results expressed as average annual percentage change. RESULTS: Of the 259,623 cases identified, 5770 (2.2%) had been assigned codes for dementia. Cases with dementia were older, had a lower Charlson comorbidity score, and less frequently received prolonged mechanical ventilation or were assigned a surgical DRG. Circulatory disease was the most common main diagnosis in both cohorts. No significant impact of dementia was observed on in-hospital mortality (adjusted OR 1.04, [95% CI] 0.98, 1.09). In the cohort with dementia, the incidence of mechanical ventilation underwent an average annual increase over time of 5.39% (95% CI 4.0, 6.7) while this rate was 1.62% (95% CI 0.9, 2.4) in cases without dementia. However, unlike this cohort, mortality in cases with dementia did not significantly decline over time. Geometric mean hospital cost and stay were lower among cases with than without dementia (- 14% [95% CI - 12%, - 15%] and - 12% [95% CI, - 9%, - 14%], respectively), and these differences increased over time. CONCLUSION: This nationwide population-based study suggests no impact of dementia on in-hospital mortality in elderly patients undergoing invasive mechanical ventilation. However, dementia is significantly associated with shorter stay and hospital costs. Our data also identifies a recent marked increase in the use of this life-support measure in elderly patients with dementia and that this increase is much greater than that observed in elderly individuals without dementia.This research was supported by the Instituto de Salud Carlos III (grant number PI14/00081). The funding source has no role in the design and conduct of the study, the analysis and interpretation of data, or in the writing of the manuscript.S

Suicidal and accidental drug poisoning mortality among older adults and working-age individuals in Spain between 2000 and 2018

Background: Although medication poisoning in older adults is considered an increasingly important, but preventable cause of death, it has received relatively little attention. We explored recent trends and correlates of suicidal and accidental fatal drug poisonings among older and working-age individuals using nationwide data from Spain. Methods: We identified all 15,353 fatal drug poisonings involving decedents aged ≥15 years in Spain between 2000 and 2018 and divided them by age into older adults (≥65 years) and working-age (15-64 years) individuals. For each age group, we analyzed time trends in suicidal and accidental fatal drug poisoning rates (overall and by ICD-10 drug categories) using joinpoint regressions. To understand the specific drugs classified as "Non-psychotropic/non-specified", we used 2018 data including substance-specific ICD-10 supplementary codes. We explored relevant sociodemographic correlates of suicidal and accidental fatal poisoning rates using multivariable negative binomial regressions. Results: Between 2000 and 2018, suicidal fatal poisonings increased faster among older (from 0.19 to 0.63 per 100,000 - average annual change: 7.7%) than working-age individuals (from 0.40 to 0.72 per 100,000 - average annual change: 3.8%). Accidental fatal poisonings increased among older adults (from 0.25 to 2.67 per 100,000 - average annual change: 16.2%) but decreased among working-age counterparts (from 2.38 to 1.42 per 100,000 - average annual change: - 1.9%). Anticoagulants and cardiac-stimulants glycosides accounted for 70% of the 223 accidental fatal poisonings due to non-psychotropic/non-specified drugs registered among older adults in 2018. Roles of gender and urban dwelling in suicidal and accidental poisonings were heterogeneous across age groups. Conclusion: Increases in suicidal drug poisonings were faster among older than working-age individuals. Accidental fatal poisonings increased only among older adults. Our findings that (i) sociodemographic correlates were heterogeneous across age groups and (ii) anticoagulant and cardiac-stimulant glycosides were particularly salient drivers of accidental poisonings among older adults have implications for prevention.This study was supported by the Instituto de Salud Carlos III (grant number PI19CIII/00037). The funders had neither role in study design, data collection, analysis, decision to publish, nor preparation of the manuscript.S

Role of Foreign-Born Status on Suicide Mortality in Spain Between 2000 and 2019: An Age-Period-Cohort Analysis

Objectives: To examine recent age-period-cohort effects on suicide among foreign-born individuals, a particularly vulnerable sociodemographic group in Spain. Methods: Using 2000-2019 mortality data from Spain's National Institute of Statistics, we estimated age-period-cohort effects on suicide mortality, stratified by foreign-born status (native- vs. foreign-born) and, among the foreign-born, by Spanish citizenship status, a proxy for greater socioeconomic stability. Results: Annual suicide mortality rates were lower among foreign- than native-born individuals. There was heterogeneity in age-period-cohort effects between study groups. After 2010, suicide mortality increased markedly among the foreign-born-especially for female cohorts born around 1950, and slightly among native-born women-especially among female cohorts born after the 1960s. Among native-born men, suicide increased linearly with age and remained stable over time. Increases in suicide among the foreign-born were driven by increases among individuals without Spanish citizenship-especially among cohorts born after 1975. Conclusion: After 2010, suicide in Spain increased markedly among foreign-born individuals and slightly among native-born women, suggesting an association between the downstream effects of the 2008 economic recession and increases in suicide mortality among socioeconomically vulnerable populations.This work was supported by the National Institute of Mental Health (Grant number R01-MH121410) and the Instituto de Salud Carlos III (Grant number FIS PI19CIII/00037). The funders had no role in the conception, design, or execution of the study.S

New approach to managing COVID-19 pandemic in a complex tertiary care medical centre in Madrid, Spain

The COVID-19 pandemic is putting healthcare systems under unprecedented stress to accommodate unexpected numbers of patients forcing a quick re-organization. This article describes the staff management experience of a third level referral hospital in the city of Madrid, Spain, one of the cities and hospitals with the largest number of COVID19 cases. A newly created COVID-19-specific Clinical Management Unit (CMU) coordinated all clinical departments and conducted real-time assessments of the availability and needs of medical staff, alongside the hospital's general management board. The Unit was able to (i) redeploy up to 285 physicians every week to bolster medical care in COVID-19 wards and forecast medical staff requirements for the upcoming week so all departments could organize their work while coping with COVID-19 needs, (ii) overview all clinical activities conducted in a medicalized hotel, and (iii) recruit a team of roughly 90 volunteer medical students to accelerate data collection and evidence generation. The main advantage of a clinical management unit composed by a member of every job category - its ability to generate rapid, locally-adapted responses to unexpected challenges - made it perfect for the unprecedented increase in healthcare need generated by the COVID-19 pandemic

Critical Care Requirements Under Uncontrolled Transmission of SARS-CoV-2

Objectives. To estimate the critical care bed capacity that would be required to admit all critical COVID-19 cases in a setting of unchecked SARS-CoV-2 transmission, both with and without elderly-specific protection measures. Methods. Using electronic health records of all 2432 COVID-19 patients hospitalized in a large hospital in Madrid, Spain, between February 28 and April 23, 2020, we estimated the number of critical care beds needed to admit all critical care patients. To mimic a hypothetical intervention that halves SARS-CoV-2 infections among the elderly, we randomly excluded 50% of patients aged 65 years and older. Results. Critical care requirements peaked at 49 beds per 100 000 on April 1-2 weeks after the start of a national lockdown. After randomly excluding 50% of elderly patients, the estimated peak was 39 beds per 100 000. Conclusions. Under unchecked SARS-CoV-2 transmission, peak critical care requirements in Madrid were at least fivefold higher than prepandemic capacity. Under a hypothetical intervention that halves infections among the elderly, critical care peak requirements would have exceeded the prepandemic capacity of most high-income countries. Public Health Implications. Pandemic control strategies that rely exclusively on protecting the elderly are likely to overwhelm health care systems.S

Personalized therapy in locally advanced head and neck squamous-cell carcinoma

[ES] Introducción: El paciente con cáncer epidermoide de cabeza y cuello local/regionalmente avanzado (CECCLA) presenta características muy heterogéneas en cuanto a comorbilidades, localización y etiología tumoral . Estos factores resultan determinantes a la hora de elegir el mejor abordaje terapéutico. Material y métodos: Se ha realizado una exhaustiva revisión de la literatura para identificar los factores más determinantes a la hora de seleccionar tratamiento para estos pacientes con especial hincapié en la quimioterapia de inducción por ser la opción más discutida. Resultados: Para la selección terapéutica es necesario tomar en cuenta factores derivados del individuo siendo los más relevantes la edad y el estado general, junto a otros dependientes del tumor como estadio, localización y etiopatogenia, entre estos últimos el origen viral (HPV, EBV) cobra cada vez más importancia. Dentro de las opciones terapéuticas la quimiorradioterapia se considera el tratamiento estándar avalado por diversos ensayos clínicos y el metaanálisis. La quimioterapia de inducción ha sido una de las últimas opciones en incorporarse al inventario terapéutico, mejorando los resultados en cuento a funcionalidad y supervivencia, sin embargo la toxicidad añadida y la falta de comparaciones con la quimiorradioterapia concurrente, obligan a un uso juicioso. Conclusión: La decisión de tratamiento en el paciente con CECCLA es un proceso complejo y multifactorial que ha de realizarse necesariamente en el contexto de comités multidisciplinares que garanticen los máximos niveles de eficacia y seguridad

What seems to explain suicidality in Yucatan Mexican young adults? findings from an app-based mental health screening test using the SMART-SCREEN protocol

The relationship between suicidality, depression, anxiety, and well-being was explored in young adults (median age 20.7 years) from the State of Yucatan (Mexico), which has a suicide rate double that of other Mexican states. A cross-sectional study was carried out in 20 universities in Yucatan and 9,366 students were surveyed using validated questionnaires built into a smartphone app, applying partial least squares structural equation models. High suicide risk was assessed in 10.8% of the sample. Clinically relevant depression and anxiety levels were found in 6.6% and 10.5% of the sample, respectively, and 67.8% reported high well-being. Comparably higher levels of suicide risk, depression and anxiety, and lower well-being were found in women, who were also somewhat older than men in our study. Furthermore, path analysis in the structural equation model revealed that depression was the main predictor of suicidal behaviour as well as of higher anxiety levels and lower self-perceived well-being in the total sample and in both genders. Our findings draw attention to the association between suicidality, depression, anxiety, and well-being in Yucatan young adults and gender differences with this regard. Mental health screening via smartphone might be a useful tool to reach large populations and contribute to mental health policies, including regional suicide prevention effortsOpen Access funding provided thanks to the CRUE-CSIC agreement with Springer Nature. No funding was received for this stud

Induction chemotherapy in advanced laryngeal cancer.

[ES]Introducción: El cáncer de laringe es la neoplasia más frecuente de las vías aerodigestivas superiores, y de los que más impacto psicosocial producen. Material y métodos. Realizamos un estudio retrospectivo y analítico de 32 pacientes diagnosticados de carcinoma epidermoide avanzado de laringe en nuestro centro durante 48 meses consecutivos (Junio 2012-Junio 2014). Tras la revisión de las historias clínicas de forma retrospectiva, describimos el algoritmo diagnóstico-terapeútico que realizamos. Resultados: En un 9,4% de los casos se detuvo el tratamiento con preservación del órgano (TOP) por mala tolerancia. Otro 9,4% muestran respuesta completa con la quimioterapia. El 21,9 % de los pacientes precisan rescate quirúrgico. Un 9,4 % de los pacientes fallecieron por complicaciones derivadas del tratamiento. Discusión: El tratamiento del tumor laríngeo localmente avanzado es controvertido. Los pacientes que reciben TOP suponen un reto tanto terapéutico como de seguimiento y rehabilitación posteriores. Este subgrupo de pacientes supone actualmente el 65,3 % de los pacientes tratados en nuestro centro por carcinoma de laringe. Conclusiones: El TOP constituye una alternativa pero requiere individualizar cada caso. Debemos insistir en la importancia de la prevención primaria y secundaria, ante el aumento de la incidencia de la enfermedad. [EN] Introduction: Laryngeal cancer is the most common neoplasm of the upper aerodigestive tract, and more psychosocial impact produced. Material and methods. A retrospective and analytical study of 32 patients diagnosed with advanced laryngeal squamous cell carcinoma at our institution for 48 consecutive months (June 2012-June 2014). After reviewing the clinical records retrospectively, we describe the diagnostic and therapeutic algorithm we perform. Results: In 9.4% of cases treatment with organ preservation (TOP) due to poor tolerance stopped. Another 9.4% show complete response to chemotherapy. 21.9% of patients required surgical salvage. 9.4% of patients died from complications of treatment. Discussion: The treatment of locally advanced laryngeal tumor is controversial. Patients receiving TOP pose a therapeutic challenge as both tracking and Rehabilitation. This subgroup of patients currently accounts for 65.3% of patients treated in our hospital for laryngeal carcinoma. Conclusions: The TOP is an alternative but requires individualize each case. We stress the importance of primary and secondary prevention, with the increased incidence of the disease