Epidemiología de la fibrilación auricular en España en los últimos 20 años

Atrial fibrillation is the most common sustained arrhythmia. Because of its potentially serious clinical consequences (heart failure, stroke, and cognitive impairment), atrial fibrillation has important socioeconomic and health implications. This article reviews the major studies on the epidemiology of atrial fibrillation in Spain. Recent data suggest that in people older than 40 years, the prevalence of atrial fibrillation may be more than 4%. Given the current Spanish demography, these data would imply that more than 1 million people in Spain have atrial fibrillation.     

Influencia de la positividad del anti-HBc en el donante en la selección del donante pulmonar

Introduction

The risk of hepatitis B virus (HBV) transmission through donor organs with HBsAg(−) and anti-HBc(+) serology has not been extensively studied in lung transplantation. The objectives of this study are to ascertain the influence of the anti-HBc(+) on the acceptance of the lung for transplantation, to comment on the published literature and to suggest an algorithm for action.

Methods

A survey conducted in the 7 Spanish lung transplantation teams. The updated search of the literature was performed using medical databases from 1994 to February 2012.

Results

All of the teams vaccinate the lung recipients against HBV, although none quantify the anti-HBs titers. When given an anti-HBc(+) donor, 3 teams change their strategy: one does not accept the offer, one selects the receptor from among patients in emergency status and another adds pharmacological prophylaxis. Only 3 publications refer to the serologic evolution of the receptors. At the moment there have been no reported cases of hepatitis B or HBsAg positivity post-transplant, but 4 out of the 50 anti-HBc(−) receptors changed to anti-HBc(+) in the follow-up.

Conclusions

The presence of anti-HBc in the donor influences the decision to accept a lung donor, although there is little information on its repercussions. To date, there has been no reported case of transmission of HBV, but post-transplant anti-HBc seroconversions have been described, which suggests contact with viral particles. Although rare, an anti-HBc(+) donor can harbor a hidden HBV infection. The risk of infection can be reduced with adequate anti-HBs titers or with appropriate pharmacological measures.     

Evaluación del impacto del nuevo marco legal sanitario sobre los inmigrantes en situación irregular en España: el caso de la infección por el virus de la inmunodeficiencia humana

The immigrant population in Spain, whether legal or not, has been entitled to healthcare under the same conditions as the Spanish population since the year 2000. The entry into vigour of the Royal Decree-Law 12/2012 of 20 April has significantly restricted this right, so that unauthorized or non-resident foreigners may now only receive emergency care, if they are under 18 or pregnant women. Out of an estimated 459,909 illegal immigrants in our country, 2,700 to 4,600 are probably infected with HIV; 1,800 to 3,220 know that they are infected, and 80% of the latter could receive antiretroviral treatment. The Royal Decree-Law is likely to cause many undesirable consequences in this population infected with HIV: increasing mortality, promoting the emergence of opportunistic diseases, increasing hospital admissions, increasing infections in the population (by HIV and other pathogens), or contributing to mother to child transmission of HIV. The expected increase in morbidity and mortality will be a greater cost in patient care, a cost which will be significantly higher in the more immunosuppressed patients. Therefore, the enforcement of the Royal Decree-Law will be much less cost-effective in the short term than was expected, and will negatively affect our country's public health, especially for those patients infected with HIV who will not be covered, thus increasing healthcare medium to long term costs, and moving away from the international health goals that were established.     

Endocarditis infecciosa en 2 hospitales universitarios españoles que difieren en su localización y en la presencia de servicio quirúrgico

Objectives

To assess possible differences in clinical presentation, microbiology, morbidity and mortality of infective endocarditis between two Spanish hospitals, one on the mainland that has cardiac surgery and one in the Canary Islands without this service.

Method

A total of 229 patients consecutively diagnosed of endocarditis between 2005 and 2012, including pediatric population, were studied in the Reina Sofía Hospital (Córdoba, n = 119) and Nuestra Señora de Candelaria Hospital (Tenerife, n = 110). We compared the clinical, microbiological and echocardiographic data and analyzed mortality differences by binary logistic regression analysis.

Results

There were no differences in underlying heart disease, proportion of surgery, or the microbiological profile. The proportion of infections attributable to catheter was higher in the Canary Islands hospital (13.6% vs 3.4%). Mortality was also higher (31.8% vs 18.5%, P = .020), although this difference was no longer significant in the multivariate analysis (OR = 1.85; 95% CI, 0.70-4.87; P = .213). Age (OR = 1.04/year; 95% CI, 1.01-1.07; P = .006), cardiac complications (OR = 5.05; 95% CI, 1.78-14.34; P = .002), persistent sepsis (OR = 4.89; 95% CI, 2.09-11.46; P < .001), and emergent surgery (OR = 4.43, 95% CI, 1.75-11.19; P = .002) were independent predictors of death. Time to surgery, length of stay in the hospital without a surgical service (20 [13-30.5] vs 13 [6-25] days; P = .019) was not associated with outcome.

Conclusions

There are differences in the presentation of endocarditis between two distant hospitals in Spain. The different hospital mortality can not be directly related to the presence of a surgery service.     

Prevalencia y características epidemiológicas del esófago de Barrett en la provincia de Barcelona

Introduction

The prevalence of Barrett's esophagus (BE) varies from 0.45% to 2.2% in patients who undergo upper endoscopy and is > 12% when the indication is for reflux symptoms. The prevalence has progressively increased in recent years but is unknown in the population of the province of Barcelona.

Objectives

To determine the prevalence of BE and its epidemiological characteristics in our population.

Patients and methods

We prospectively evaluated patients referred to the Endoscopy Unit of Hospital Clinic and Hospital General de Catalunya for an upper endoscopy. We excluded patients with known BE, prior upper endoscopy, esophagogastric surgery or refusal to participate in the study. Demographic data, alcohol intake, Helicobacter pylori infection and consumption of antisecretory agents were recorded, among other information. Participants completed a standardized questionnaire to assess the presence of gastroesophageal reflux disease (GERD) symptoms and their severity.

Results

Between July 2010 and July 2012, we included 200 patients (100 in each center). The mean age was 48.9 ± 15.6 years and the majority were women (n = 120, 60%). Symptoms of GERD were present in 46 patients (23%) and some degree of esophagitis was present in 31 (15.5%). Infection by H. pylori was present in 29.7%. BE was found endoscopically in 14 (7%) patients, but was histologically confirmed in only 8 (4%). The only variable that correlated with the finding of BE was male sex.

Conclusion

The prevalence of BE in our environment is similar to that reported in Western countries. The absence of reflux symptoms does not rule out the possibility of BE.     

Tos ferina en España. Situación epidemiológica y estrategias de prevención y control. Recomendaciones del Grupo de Trabajo de Tos ferina

A large increase of pertussis incidence has been observed in recent years in countries with high vaccination coverage. Outbreaks of pertussis are increasingly being reported. The age presentation has a bipolar distribution: infants younger 6 months that have not initiated or completed a vaccination schedule, and adolescents and adults, due to the lost of natural or vaccine immunity over time. These epidemiological changes justify the need to adopt new vaccination strategies in order to protect young infants and to reduce pertussis incidence in all age groups.     

Factores asociados con el control del asma en pacientes de atención primaria en España: el estudio CHAS

Background

Asthma control is inadequate in all populations studied to date, leading to a major part of the cost of the disease. The aim of our study was to evaluate the prevalence of uncontrolled asthma in primary care patients and identify the associated factors.

Methods

We carried out a cross-sectional study of the population of primary care asthmatic patients over 18 years old in Spain (n=2159). Asthma control was measured with the Asthma Control Questionnaire (ACQ). The sociodemographic variables and treatment compliance were measured using a questionnaire. We built logistic-regression models using Asthma control, a dichotomous variable generated from ACQ score.

Results

The prevalence of uncontrolled asthma was 63.9%. Treatment with oral corticosteroids (OCS) (OR=6.55), greater asthma severity (OR=3.11), presence of a distressing event (OR=2.44), lower significance given to treatment compliance (OR=1.66) and living in a rural area (OR=1.29) are associated with uncontrolled asthma. On the contrary, sex, age, obesity, smoking, alcohol intake and educational level had no effect on asthma control.

Conclusions

In Spain asthma is still uncontrolled and some factors leading to this situation appear to be modifiable by the health system.     

Evolución del uso de la ventilación mecánica no invasiva en enfermedad pulmonar obstructiva crónica en una región española, 1997-2010

Introduction

Noninvasive mechanical ventilation (NIV) appeared in the 1980s as an alternative to invasive mechanical ventilation (IMV) in patients with acute respiratory failure. We evaluated the introduction of NIV and the results in patients with acute exacerbation of chronic obstructive pulmonary disease in the Region of Murcia (Spain).

Subjects and methods

A retrospective observational study based on the minimum basic hospital discharge data of all patients hospitalised for this pathology in all public hospitals in the region between 1997 and 2010. We performed a time trend analysis on hospital attendance, the use of each ventilatory intervention and hospital mortality through joinpoint regression.

Results

We identified 30.027 hospital discharges. Joinpoint analysis: downward trend in attendance (annual percentage change [APC] = −3.4, 95% CI: − 4.8; −2.0, P <.05) and in the group without ventilatory intervention (APC = −4.2%, −5.6; −2.8, P <.05); upward trend in the use of NIV (APC = 16.4, 12.0; 20. 9, P <.05), and downward trend that was not statistically significant in IMV (APC = −4.5%, −10.3; 1.7). We observed an upward trend without statistical significance in overall mortality (APC = 0.5, −1.3; 2.4) and in the group without intervention (APC = 0.1, −1.6; 1.9); downward trend with statistical significance in the NIV group (APC = −7.1, −11.7; −2.2, P <.05) and not statistically significant in the IMV group (APC = −0,8, −6, 1; 4.8). The mean stay did not change substantially.

Conclusions

The introduction of NIV has reduced the group of patients not receiving assisted ventilation. No improvement in results was found in terms of mortality or length of stay.     

Hipertensión intraabdominal: consecuencias sobre la circulación esplácnica. Estudio preliminar en un modelo de ascitis

Introduction

Intra-abdominal hypertension is defined as a rise in intra-abdominal pressure leading to progressive dysfunction of the abdominal organs.

Objective

To evaluate the effects of intra-abdominal hypertension on the splanchnic circulation in a porcine animal model with a view to determining the diagnostic method of choice.

Material and methods

A total of 10 swine were divided into 2 groups: a control group and a group with an ascites pressure of 20 mmHg. Transvesical and transperitoneal intra-abdominal pressures were registered, and the correlation between the measurements obtained was determined. Concentrations of lactic acid, alanine aminotransferase, glucose and gastric mucosal pH were also obtained. We registered the mean arterial and abdominal perfusion pressures, and the correlation of the latter with gastric mucosal pH and lactic acid concentrations. The parameters were registered for a total of 3 hours.

Results

We observed a high correlation between transvesical and transperitoneal measurements of intra-abdominal pressure (R² = 0.98). In the 20 mmHg pressure group, lactic acid concentrations increased significantly at 180 min (p < 0.011). Gastric mucosal pH differed significantly between the 2 groups from the beginning of the study (p = 0.004) and significantly decreased from 120 min onward. Mean arterial and abdominal perfusion pressures gradually decreased during the trial, with early significant changes in the abdominal perfusion pressure (p = 0.001), and a good correlation with the remaining study parameters. There were no significant changes in hepatic indicators.

Conclusions

We believe the transvesical approach to be the technique of choice to determine intra-abdominal pressure. Abdominal perfusion pressure is a sensitive marker of intra-abdominal hypertension, and gastric mucosal pH is the first parameter to be affected.     

Primera fase de validación del algoritmo europeo de evaluación funcional previa a la resección pulmonar: cuantificación del cumplimiento de las recomendaciones en la práctica clínica real

Objective

To quantify the degree of compliance with the recommendations of the clinical practice guidelines published in 2009 by the ERS and the ESTS regarding the preoperative assessment of risk of lung resection in daily clinical practice at a tertiary hospital.

Method

A prospective, observational study of real-time data collected from consecutive patients who had been referred for evaluation from September 2009 to December 2010. We recorded the presence or absence of the recommended studies included in the algorithm, their results and, when a test was missing, the reasons why it was not performed. Hospital mortality and cardio-respiratory morbidity rates are also presented.

Results

173 patients were evaluated. In 171 cases, lung resection was performed, with a mortality of 1.2% and a cardio-respiratory morbidity of 11.7%. The failure rate of the first level of the algorithm was 4.6% and for the second level (VO_2max test) it was 26%. The absence of exercise tests was mainly due to hospital structural problems and the patients’ inability to perform it. Out of the patients who performed the exercise testing, 31 reached a VO_2max of 20 ml/kg-min or more and underwent surgery without calculation of FEV₁ppo and DCLOppo; 35 patients required the calculation to determine their operability and in 2 cases the intervention was not recommended due to functional inoperability of the patient.

Conclusions

The validation process found lack of compliance with the proposed algorithm in 18.5% of the cases basically due to the absence of the exercise tests. The rate of adherence to the algorithm recommendations should be improved before performing any other validation studies.     

Epidemiología de la endocarditis infecciosa en España en los últimos 20 años

Infective endocarditis is an uncommon disease, with an estimated incidence of 3.1 to 3.7 episodes per 100 000 inhabitants/year. The incidence is highest in elderly people. The microorganisms most frequently isolated in infective endocarditis are staphylococci and streptococci. In the last few decades, the spectrum of heart diseases predisposing to infective endocarditis has changed, since degenerative heart disease is the most common valve disease, and there are an increasing number of infective endocarditis patients without previously known valve disease. In addition, up to one-third of infective endocarditis patients become infected through contact with the health system. These patients are more frail, which leads to higher in-hospital mortality. As a result of substantial epidemiological changes, few cases of infective endocarditis can be prevented by antibiotic prophylaxis. Despite advances in medical and surgical treatment, in-hospital mortality among infective endocarditis patients is high. Nevertheless, there is room for improvement in reducing the rate of nosocomial bacteremia, the prompt diagnosis of infective endocarditis in at-risk patients, and the early identification of patients with a highest risk of complications, as well as in the creation of multidisciplinary teams for the management of this disease.     

Documento de consenso sobre diagnóstico,tratamiento y prevención de la tuberculosis

Pulmonary TB should be suspected in patients with respiratory symptoms longer than 2–3 weeks. Immunosuppression may modify clinical and radiological presentation. Chest X-ray shows very suggestive, albeit sometimes atypical, signs of TB. Complex radiological tests (CT scan, MR) are more useful in extrapulmonary TB.     

Formación neumológica en centros extranjeros. A propósito de una estancia

Training in pulmonology at overseas centers may require a considerable effort, and although such an experience could even imply a financial burden for the trainee, the benefits far outweigh the material costs. The desire for personal and scientific growth should encourage young pulmonologists and medical residents to rotate outside Spain and become acquainted with other health care systems, customs, dynamics, and resources in order to obtain quality training and added value that will further enrich our specialty. Any pulmunologist wishing to undergo specialized training at an overseas institution will necessarily consider questions such as the relevance of the stay and its objectives, timing, availability of centers, eligibility, and funding agencies. Based on one resident's personal experience, we attempt to answer several of these questions.     

La endocarditis infecciosa en el siglo xxi: cambios epidemiológicos,terapéuticos y pronósticos

Infective endocarditis (IE) is an uncommon and severe disease. Nowadays, in developed countries, IE patients are older, usually have a degenerative heart valve disease, and up to 30% acquire this infection within the health care system. In consequence, staphylococci species are the most frequently isolated microorganisms. Antimicrobial treatment for IE has significantly changed over the last decades. In IE episodes due to Staphylococcus aureus, cloxacillin-resistance makes antimicrobial election more difficult. Other microorganisms, such as enterococci and some species of streptococci, show high rates of resistance to antimicrobial agents established in guidelines. Despite improvements in the diagnosis, and medical and surgical treatment of IE, this disease continues to be associated with high rates of in-hospital mortality. At present, due to epidemiological changes, antimicrobial prophylaxis can avoid few cases of IE. Prevention of nosocomial bacteremia, an early diagnosis of IE, prompt identification of IE patients at a higher risk of mortality, and a multidisciplinary approach of this disease could be valid strategies in order to improve the outcome of these patients.     

Diferencias en función de la gravedad de la atenuación pulmonar en varones con EPOC

Background and objetives

We compare the inspiratory and expiratory regional lung densities between different levels of COPD severity (as assessed by the GOLD scale and by the BODE index), and to assess the relationship between regional lung densities and functional lung parameters.

Patients and methods

Fifty-five stable moderate-severe COPD men were selected. Functional evaluation included dyspnoea scale, blood gases, spirometry, plethysmography, diffusing capacity and six-minute walk test. Severity was classified according the GOLD scale and the BODE index. High resolution computed tomography (HRCT) scans of the entire lung at full inspiration and two sections at full expiration were obtained. Densitometry software was used to calculate the densities of the lung areas.

Results

Inspiratory and expiratory mean lung densities (MLD) of the lower lobes were significantly lower in very severe and severe COPD patients than in moderate patients. In contrast, we only found differences between the upper lobe MLD values of moderate and severe COPD patients. Inspiratory and expiratory HRCT densities were similar among all BODE quartiles, for both the upper and lower lobes. In a multiple regression analysis, airway obstruction parameters were mainly related to the expiratory MLD of the lower lobes, whereas lung hyperinflation parameters were predicted by the inspiratory MLD of the lower lobes. Lastly, diffusion capacity was independently related to the expiratory/inspiratory MLD of the lower lobes and to the inspiratory MLD of the upper lobes.

Conclusions

There are differences in lung attenuation measurements by HRCT between the varying levels of COPD severity as assessed by the GOLD scale.