Impact of a clinical pathway for stroke patients

OBJECTIVE: To assess the impact of the implementation of a clinical pathway for stroke patients. METHODS: We performed a controlled intervention study without random allocation that compared two non-concomitant cohorts of stroke patients corresponding to the periods immediately before (control group) and after (intervention group) the implementation of a clinical pathway. The main outcome measures were: a) quality of care indicators; b) improvements in functional capacity (Barthel score) and neurological function (Canadian scale); c) nosocomial complications; d) satisfaction, and e) mean length of hospital stay. RESULTS: One hundred and thirty-nine patients were recruited. Sixty-nine corresponded to the period before implementation of the pathway and 70 corresponded to the period after implementation. There were no significant differences between the two groups on admission. A 36.5% reduction in the time from admission to mobilization was observed. No significant differences were observed between the groups for the other quality of care indicators, or in improvements in functional and neurological capacity. Nosocomial complications occurred in 44.5% of patients in the control group compared with 28.6% in the intervention group (p = .039). No significant differences were observed in the overall satisfaction assessment, but patients in the intervention group showed greater satisfaction in the dimensions of "information" and "trust and professionalism". The mean length of hospital stay was reduced from 11 to 10 days. CONCLUSIONS: The implementation of the stroke clinical pathway contributed to reducing the length of hospital stay and the number of inpatient complications, as well as to improving some quality of care indicators.     

Women, family demands and health: the importance of employment status and socio-economic position

Although it is generally assumed that women engaged in paid work have better health than full-time homemakers, little is known about the situation in Southern European countries like Spain or about differences in the impact of family demands by employment status or the potential interaction with educational level. The objectives of this study are to analyse whether inequalities in health exist among housewives and employed women, and to assess whether the relationship between family demands and health differs by employment status. Additionally, for both objectives we examine the potential different patterns by educational level. The data have been taken from the 1994 Catalonian Health Survey (Spain). The sample was drawn from all women aged 25-64 years who were employed or full-time homemakers and married or cohabiting. Four health indicators (self-perceived health status, limiting long-standing illness, chronic conditions and mental health) and two health related behaviours (hours of sleeping and leisure-time physical activity) were analysed. Family demands were measured through household size, living with children under 15 and living with elderly. Overall, female workers had a better health status than housewives, although this pattern was more consistent for women of low educational level. Conversely, the health related behaviours analysed were less favourable for workers, mainly for those of low educational level. Among workers of low educational level, family demands showed a negative effect in most health indicators and health related behaviours, but had little or no negative association at all in workers of high educational level or in full-time homemakers. Moreover, among women of low educational level, both workers and housewives, living with elderly had showed a negative association with poor health status and health related behaviours. These results emphasise the need of considering the interaction between family demands, employment status and educational level in analysing the impact of family demands on women's health as well as in designing family policies and programmes of women's health promotion.     

External validation of a prognostic model for predicting survival of cirrhotic patients with refractory ascites

OBJECTIVE: Cirrhotic patients with refractory ascites (RA) have a poor prognosis, although individual survival varies greatly. A model that could predict survival for patients with RA would be helpful in planning treatment. Moreover, in cases of potential liver transplantation, a model of these characteristics would provide the bases for establishing priorities of organ allocation and the selection of patients for a living donor graft. Recently, we developed a model to predict survival of patients with RA. The aim of this study was to establish its generalizability for predicting the survival of patients with RA. METHODS: The model was validated by assessing its performance in an external cohort of patients with RA included in a multicenter, randomized, controlled trial that compared large-volume paracentesis and peritoneovenous shunt. The values for actual and model-predicted survival of three risk groups of patients, established according to the model, were compared graphically and by means of the one-sample log-rank test. RESULTS: The model provided a very good fit to the survival data of the three risk groups in the validation cohort. We also found good agreement between the survival predicted from the model and the observed survival when patients treated with peritoneovenous shunt and with paracentesis were considered separately. CONCLUSION: Our survival model can be used to predict the survival of patients with RA and may be a useful tool in clinical decision making, especially in deciding priority for liver transplantation.     

Deprivation and AIDS in a southern European city: different patterns across transmission group

OBJECTIVE: To analyse deprivation and AIDS among three AIDS transmission groups (men who have sex with men--MSM, heterosexuals, and intravenous drug users--IDUs) in Barcelona, Spain, during the period 1990-95. METHODS: This is an ecological study, the unit of analysis being the neighbourhoods. Included were AIDS cases residents in Barcelona. The association among AIDS rate and deprivation was studied using Spearman correlation coefficients and Poisson regression. RESULTS: For MSM, inner city neighbourhood residence meant a greater risk of AIDS; but lower educational level was inversely related with AIDS rates. For heterosexuals, variables related with AIDS rates were younger age, inner city areas and social unrest for women, and extreme poverty for men. Among UDIs variables related with AIDS were unemployment and social unrest for both sexes. CONCLUSION: The association between AIDS rates and deprivation differs across transmission groups in a southern European city.     

Molecular mechanisms and therapeutical implications of intramembrane receptor/receptor interactions among heptahelical receptors with examples from the striatopallidal GABA neurons

The molecular basis for the known intramembrane receptor/receptor interactions among G protein-coupled receptors was postulated to be heteromerization based on receptor subtype-specific interactions between different types of receptor homomers. The discovery of GABAB heterodimers started this field rapidly followed by the discovery of heteromerization among isoreceptors of several G protein-coupled receptors such as delta/kappa opioid receptors. Heteromerization was also discovered among distinct types of G protein-coupled receptors with the initial demonstration of somatostatin SSTR5/dopamine D2 and adenosine A1/dopamine D1 heteromeric receptor complexes. The functional meaning of these heteromeric complexes is to achieve direct or indirect (via adapter proteins) intramembrane receptor/receptor interactions in the complex. G protein-coupled receptors also form heteromeric complexes involving direct interactions with ion channel receptors, the best example being the GABAA/dopamine D5 receptor heteromerization, as well as with receptor tyrosine kinases and with receptor activity modulating proteins. As an example, adenosine, dopamine, and glutamate metabotropic receptor/receptor interactions in the striatopallidal GABA neurons are discussed as well as their relevance for Parkinson's disease, schizophrenia, and drug dependence. The heterodimer is only one type of heteromeric complex, and the evidence is equally compatible with the existence of higher order heteromeric complexes, where also adapter proteins such as homer proteins and scaffolding proteins can exist. These complexes may assist in the process of linking G protein-coupled receptors and ion channel receptors together in a receptor mosaic that may have special integrative value and may constitute the molecular basis for some forms of learning and memory.     

Neuropsychologic differences between bilateral dyskinetic and spastic cerebral palsy

This study compared the neuropsychologic performance of 30 adolescents and adults with bilateral dyskinetic, mixed, and spastic cerebral palsy aged between 16 and 38 years. The sample was relatively homogeneous in terms of motor severity; no patients were able to walk unaided. In all subjects, we evaluated the general function of nonverbal reasoning and the following specific neuropsychologic areas: language, visual perception, memory, praxis, and frontal functions. Individuals with dyskinetic cerebral palsy had better auditory comprehension, visuospatial abilities, immediate visual memory, and working verbal memory than those with spastic cerebral palsy. Frontal function was the only cognitive function on which subjects with dyskinetic cerebral palsy had lower scores. We conclude that the neuropsychologic profiles of dyskinetic and spastic cerebral palsy are different.