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Resumen Introducción : Los dispositivos electrónicos y tecno logías de la comunicación se emplean cada vez más frecuentemente para brindar atención médica a los pacientes con hipertensión arterial. El objetivo prin cipal del trabajo fue evaluar la percepción de los mé dicos sobre la utilidad de las tecnologías digitales en hipertensión arterial. Los objetivos secundarios fueron evaluar la prevalencia de uso de tecnologías digitales en el seguimiento de pacientes con hipertensión arterial e identificar las barreras percibidas por los médicos para la implementación de las mismas en la República Argentina. Métodos : Estudio observacional, de corte transversal, multicéntrico, basado en un cuestionario autoadminis trado, en el ámbito de la República Argentina y coordi nado por el grupo de Epidemiología de la Sociedad Ar gentina de Hipertensión Arterial. Población: Médicos que realizan atención de pacientes con hipertensión arterial. Resultados : Se obtuvieron 247 respuestas, 35.6% fue ron mujeres y 64.4% hombres; el 92.3 % consideró de utilidad el uso de tecnologías digitales para mejorar la adherencia terapéutica. Reciben resultados de presión arterial en domicilio por algún medio digital 54.7%. Realizan habitualmente teleconsultas 41.3%, solamente el 6.1% por plataformas digitales específicas de salud, el 29.1% por plataformas no específicas, telefónicamente 21.9% y correo electrónico (asincrónicas) 10.9%. Las principales barreras percibidas fueron: disponibilidad, remuneración económica, reglamentación, problemas de conectividad y falta de tiempo. Conclusión : La percepción de los profesionales es favorable, considerándolas útiles para mejorar la ad herencia terapéutica, por lo que podría tener un efecto facilitador en la implementación de las mismas, aunque las barreras percibidas forman parte de cuestiones or ganizacionales a resolver.
Abstract Introduction : Electronic devices and communication technologies are increasingly used to provide medical care to patients with high blood pressure. The main objective was to evaluate doctors' perception on the usefulness of digital technologies in hypertension. The secondary objectives were to evaluate the prevalence of use of digital technologies in the follow-up of patients with hypertension and to identify the barriers perceived by doctors for their implementation in the Argentine Republic. Methods : Observational, cross-sectional, multicenter study, based on a self-administered questionnaire, in the Argentine Republic, and coordinated by the Epidemiol ogy group of the Argentine Society of Arterial Hyper tension. Population: Doctors who care for patients with high blood pressure. Results : 247 responses were obtained, 35.6% were women and 64.4% men; 92.3% indicated that the use of digital technologies was useful to improve therapeutic adherence; 54.7% received blood pressure results at home through some digital means; 41.3% regularly carry out teleconsultations, only 6.1% through specific digital health platforms, 29.1% through non-specific platforms, by telephone 21.9% and by email (asynchronous) 10.9%. The main perceived barriers were: availability, financial remuneration, regulations, connectivity problems and lack of time. Conclusion : The perception of professionals is fa vorable, as they considered these technologies useful to improve therapeutic adherence, which could have a facilitating effect on their implementation, although the perceived barriers are part of organizational issues to be resolved.
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INTRODUCTION: Electronic devices and communication technologies are increasingly used to provide medical care to patients with high blood pressure. The main objective was to evaluate doctors' perception on the usefulness of digital technologies in hypertension. The secondary objectives were to evaluate the prevalence of use of digital technologies in the follow-up of patients with hypertension and to identify the barriers perceived by doctors for their implementation in the Argentine Republic. METHODS: Observational, cross-sectional, multicenter study, based on a self-administered questionnaire, in the Argentine Republic, and coordinated by the Epidemiology group of the Argentine Society of Arterial Hypertension. POPULATION: Doctors who care for patients with high blood pressure. RESULTS: 247 responses were obtained, 35.6% were women and 64.4% men; 92.3% indicated that the use of digital technologies was useful to improve therapeutic adherence; 54.7% received blood pressure results at home through some digital means; 41.3% regularly carry out teleconsultations, only 6.1% through specific digital health platforms, 29.1% through non-specific platforms, by telephone 21.9% and by email (asynchronous) 10.9%. The main perceived barriers were: availability, financial remuneration, regulations, connectivity problems and lack of time. CONCLUSION: The perception of professionals is favorable, as they considered these technologies useful to improve therapeutic adherence, which could have a facilitating effect on their implementation, although the perceived barriers are part of organizational issues to be resolved.
Introducción: Los dispositivos electrónicos y tecnologías de la comunicación se emplean cada vez más frecuentemente para brindar atención médica a los pacientes con hipertensión arterial. El objetivo principal del trabajo fue evaluar la percepción de los médicos sobre la utilidad de las tecnologías digitales en hipertensión arterial. Los objetivos secundarios fueron evaluar la prevalencia de uso de tecnologías digitales en el seguimiento de pacientes con hipertensión arterial e identificar las barreras percibidas por los médicos para la implementación de las mismas en la República Argentina. Métodos: Estudio observacional, de corte transversal, multicéntrico, basado en un cuestionario autoadministrado, en el ámbito de la República Argentina y coordinado por el grupo de Epidemiología de la Sociedad Argentina de Hipertensión Arterial. Población: Médicos que realizan atención de pacientes con hipertensión arterial. Resultados: Se obtuvieron 247 respuestas, 35.6% fueron mujeres y 64.4% hombres; el 92.3 % consideró de utilidad el uso de tecnologías digitales para mejorar la adherencia terapéutica. Reciben resultados de presión arterial en domicilio por algún medio digital 54.7%. Realizan habitualmente teleconsultas 41.3%, solamente el 6.1% por plataformas digitales específicas de salud, el 29.1% por plataformas no específicas, telefónicamente 21.9% y correo electrónico (asincrónicas) 10.9%. Las principales barreras percibidas fueron: disponibilidad, remuneración económica, reglamentación, problemas de conectividad y falta de tiempo. Conclusión: La percepción de los profesionales es favorable, considerándolas útiles para mejorar la adherencia terapéutica, por lo que podría tener un efecto facilitador en la implementación de las mismas, aunque las barreras percibidas forman parte de cuestiones organizacionales a resolver.
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Hipertensión , Humanos , Femenino , Estudios Transversales , Masculino , Argentina , Persona de Mediana Edad , Encuestas y Cuestionarios , Adulto , Tecnología Digital , Telemedicina , Actitud del Personal de SaludRESUMEN
OBJECTIVE: Stroke is a global public health burden, and therefore it is critical to identify modifiable risk factors to reduce stroke incidence and improve outcomes. Depression is such a risk factor; however, the association between preexisting depression and stroke outcomes, such as independent ambulation, is not well studied, especially among racial-ethnic minority groups. To address this gap in the literature, effects of preexisting depression on ambulatory status at hospital discharge after stroke were evaluated among individuals participating in the racially and ethnically diverse Florida-Puerto Rico Collaboration to Reduce Stroke Disparities project. METHODS: Data were analyzed from a total of 42,031 ischemic stroke patients, who were independently ambulatory prior to their stroke, after discharge from 84 hospitals between 2014 and 2017. Preexisting depression was confirmed by medical history or antidepressant medication use. Multilevel multivariate logistic regression analyses were used to assess the association of preexisting depression with independent ambulation at hospital discharge. Effects of sex and race-ethnicity on this association were examined. RESULTS: Of 42,031 participants (mean±SD age=70.4±14.2 years; 48% were female; race-ethnicity: 16% Black, 12% Hispanic living in Florida, and 7% Hispanic living in Puerto Rico), 6,379 (15%) had preexisting depression. Compared with participants without depression, those with preexisting depression were older, were more likely to be female and non-Hispanic White, and had a greater burden of vascular risk factors or comorbid conditions. Independent ambulation at hospital discharge was less frequent among women, Black participants, and individuals with vascular risk factors or comorbid conditions. In multivariate models, preexisting depression decreased the likelihood of independent ambulation at discharge (odds ratio=0.88, 95% CI=0.81, 0.97). No interactions were found between preexisting depression and race-ethnicity or sex. CONCLUSIONS: Preexisting depression was independently associated with dependent ambulation at hospital discharge after stroke, regardless of sex and race-ethnicity. Treating depression may contribute to primary stroke prevention and could improve ambulatory status at discharge.
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Etnicidad , Accidente Cerebrovascular , Humanos , Femenino , Persona de Mediana Edad , Anciano , Anciano de 80 o más Años , Masculino , Puerto Rico/epidemiología , Florida/epidemiología , Depresión/epidemiología , Sistema de Registros , Grupos Minoritarios , Accidente Cerebrovascular/complicaciones , Accidente Cerebrovascular/epidemiologíaRESUMEN
Not available.
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COVID-19 , COVID-19/epidemiología , Humanos , México/epidemiología , Instituciones Académicas , EstudiantesRESUMEN
BACKGROUND: Knowledge on the prevalence and correlates of intracranial atherosclerotic disease (ICAD) is limited. We aimed to assess prevalence, clinical and neuroimaging correlates of ICAD in a cohort of older adults of Amerindian ancestry. METHODS: The study included 581 community-dwellers aged ≥60 years (mean age 71 ± 8.4 years; 57% women) living in rural Ecuadorian villages. ICAD was identified by means of CT determinations of carotid siphon calcifications (CSC) or MRA findings of significant stenosis of intracranial arteries. Fully-adjusted logistic regression models were fitted with biomarkers of ICAD as the dependent variables. RESULTS: A total of 205 (35%) of 581 participants had ICAD, including 185 with high calcium content in the carotid siphons and 40 with significant stenosis of at least one intracranial artery (20 subjects had both biomarkers). Increasing age, high fasting blood glucose, >10 enlarged basal ganglia-perivascular spaces and non-lacunar strokes were associated with high calcium content in the carotid siphons. In contrast, male gender, moderate-to-severe white matter hyperintensities, lacunar and non-lacunar strokes were associated with significant stenosis of intracranial arteries. Stroke was more common among subjects with any biomarker of ICAD than in those with no biomarkers (29% versus 9%, p < 0.001). Significant stenosis of intracranial arteries was more often associated with stroke than high calcium content in the carotid siphons, suggesting that CSC are more likely an ICAD biomarker than causally related to stroke. CONCLUSIONS: ICAD prevalence in Amerindians is high, and is significantly associated with stroke. CSC and significant stenosis of intracranial arteries may represent different phenotypes of ICAD.
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Vida Independiente , Indígenas Sudamericanos , Arteriosclerosis Intracraneal/etnología , Salud Rural/etnología , Accidente Cerebrovascular/etnología , Calcificación Vascular/etnología , Factores de Edad , Anciano , Envejecimiento/etnología , Comorbilidad , Ecuador/epidemiología , Femenino , Estado de Salud , Humanos , Arteriosclerosis Intracraneal/diagnóstico por imagen , Masculino , Persona de Mediana Edad , Prevalencia , Medición de Riesgo , Factores de Riesgo , Accidente Cerebrovascular/diagnóstico por imagen , Calcificación Vascular/diagnóstico por imagenRESUMEN
OBJECTIVE: Information on the associations among arterial stiffness, carotid intima-media thickness (cIMT) and carotid plaques as biomarkers of atherosclerosis is limited in diverse populations. We aimed to assess whether aortic pulse wave velocity (aPWV) - as a surrogate of arterial stiffness - is associated with increased cIMT and the presence of carotid plaques in a cohort of older adults of Amerindian ancestry. METHODS: Atahualpa residents aged ≥60 years (n = 320) underwent aPWV determinations, and carotid ultrasounds for cIMT and plaque assessment. Multivariate models were fitted to assess the independent association between the aPWV, and cIMT and carotid plaques, after adjusting for relevant confounders. Differences in risk factors across these biomarkers were investigated. RESULTS: Mean values of aPWV were 10.3 ± 1.8 m/s, and those of cIMT were 0.91 ± 0.21 mm (24% had a cIMT >1 mm). Carotid plaques were observed in 118 (37%) subjects. In univariate analyses, risk factors associated with an increased aPWV included age, female gender, poor physical activity and high blood pressure. An increased cIMT was associated with age, male gender, a poor diet, high blood pressure and severe tooth loss. The presence of carotid plaques was associated with increasing age, poor physical activity and high blood pressure. Multivariate models showed a significant association between aPWV and cIMT (ß: 0.028; 95% C.I.: 0.001-0.056; p = 0.047) but not between aPWV and carotid plaques (OR: 1.14; 95% C.I.: 0.83-1.56; p = 0.423). CONCLUSIONS: This study shows an independent association between aPWV and cIMT but not with carotid plaques. These biomarkers may indicate distinct phenotypes for atherosclerosis.
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Enfermedades de las Arterias Carótidas/diagnóstico , Grosor Intima-Media Carotídeo , Placa Aterosclerótica , Análisis de la Onda del Pulso , Rigidez Vascular , Factores de Edad , Anciano , Anciano de 80 o más Años , Enfermedades de las Arterias Carótidas/diagnóstico por imagen , Enfermedades de las Arterias Carótidas/etnología , Enfermedades de las Arterias Carótidas/fisiopatología , Ecuador , Femenino , Estado de Salud , Humanos , Vida Independiente , Indígenas Sudamericanos , Masculino , Persona de Mediana Edad , Fenotipo , Valor Predictivo de las Pruebas , Medición de Riesgo , Factores de RiesgoRESUMEN
Adherence to antihypertensive medication is an important challenge that doctors often face in the treatment of hypertension. Good adherence is crucial to prevent cardiovascular complications. In consequence, the present study aimed at determining the prevalence of adherence to antihypertensive treatment and identifying associated clinical variables. A multicenter cross-sectional study was conducted in 12 cities of Argentina. A systematic sampling was performed in order to select patients with hypertension and under pharmacological treatment for at least 6 months. Physicians took three BP measurements, and the level of adherence was assessed using the self-administered Morisky questionnaire (MMAS-8). Participants were classified into three levels of adherence: high adherence-MMAS score of 8; medium adherence-MMAS scores of 6 to <8; and low adherence-MMAS scores of <6. A total of 1111 individuals (62 ± 12 years old, women 49.4%) were included in the present analysis; 159 (14.3%), 329 (29.6%) and 623 (56.1%) patients had low, medium, and high adherence, respectively. The prevalence of controlled hypertension increased only in high adherent patients: 42.8%, 42.2%, and 64.5% for low, medium, and high adherence groups, respectively. Similarly, systolic BP was lower only in the high adherence group. High educational level (OR 3.47, 95% CI 2.68-4.49) and diuretic treatment (OR 0.64, 95% CI 0.47-0.88) were independent predictors of high adherence. In conclusion, more than a half of treated hypertensive patients had a high level of adherence. These patients had lower BP values and higher control levels. A high educational level predicts high adherence.
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Hipertensión , Anciano , Antihipertensivos/uso terapéutico , Argentina/epidemiología , Estudios Transversales , Femenino , Humanos , Hipertensión/tratamiento farmacológico , Hipertensión/epidemiología , Masculino , Cumplimiento de la Medicación , Persona de Mediana EdadRESUMEN
La osteomielitis aguda y el tumor de Ewing, dos entidades óseas tan diferentes, una de naturaleza infecciosa como la osteomielitis, y otra de naturaleza neoplásica como el tumor de Ewing, pueden coincidir en sus características clínico-radiográficas y ser motivo, por ello, de confusión. No son infrecuentes, de hecho, las referencias a diagnósticos erróneos en este sentido.
Acute osteomyelitis and Ewing's tumor, two bone entities as different, one of an infectious nature such as osteomyelitis, and another of a neoplastic nature such as Ewing's tumor, may coincide in their clinical-radiographic characteristics and, therefore, cause confusion. In fact, references to erroneous diagnoses in this regard are not uncommon.
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Humanos , Masculino , Adolescente , Osteomielitis/diagnóstico por imagen , Neoplasias Óseas/diagnóstico , Diagnóstico Diferencial , Sarcoma de EwingRESUMEN
Background and Purpose- We aimed to evaluate the current practice patterns, safety and outcomes of patients who receive endovascular therapy (EVT) having mild neurological symptoms. Methods- From Jan 2010 to Jan 2018, 127,794 ischemic stroke patients were enrolled in the Florida-Puerto Rico Stroke Registry. Patients presenting within 24 hours of symptoms who received EVT were classified into mild (National Institutes of Health Stroke Scale [NIHSS] ≤5) or moderate/severe (NIHSS>5) categories. Differences in clinical characteristics and outcomes were evaluated using multivariable logistic regression. Results- Among 4110 EVT patients (median age, 73 [interquartile range=20] years; 50% women), 446 (11%) had NIHSS ≤5. Compared with NIHSS >5, those with NIHSS ≤5 arrived later to the hospital (median, 138 versus 101 minutes), were less likely to receive intravenous alteplase (30% versus 43%), had a longer door-to-puncture time (median, 167 versus 115 minutes) and more likely treated in South Florida (64% versus 53%). In multivariable analysis younger age, private insurance (versus Medicare), history of hypertension, prior independent ambulation and hospital size were independent characteristics associated with NIHSS ≤5. Among EVT patients with NIHSS ≤5, 76% were discharged home/rehabilitation and 64% were able to ambulate independently at discharge as compared with 53% and 32% of patients with NIHSS >5. Symptomatic intracerebral hemorrhage occurred in 4% of mild stroke EVT patients and 6.4% in those with NIHSS >5. Conclusions- Despite lack of evidence-based recommendations, 11% of patients receiving EVT in clinical practice have mild neurological presentations. Individual, hospital and geographic disparities are observed among endovascularly treated patients based on the severity of clinical symptoms. Our data suggest safety and overall favorable outcomes for EVT patients with mild stroke.
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Isquemia Encefálica/terapia , Procedimientos Endovasculares/métodos , Fibrinolíticos/uso terapéutico , Accidente Cerebrovascular/terapia , Trombectomía , Activador de Tejido Plasminógeno/uso terapéutico , Anciano , Anciano de 80 o más Años , Isquemia Encefálica/diagnóstico , Isquemia Encefálica/tratamiento farmacológico , Isquemia Encefálica/cirugía , Femenino , Florida , Humanos , Masculino , Persona de Mediana Edad , Puerto Rico , Sistema de Registros , Índice de Severidad de la Enfermedad , Accidente Cerebrovascular/diagnóstico , Accidente Cerebrovascular/tratamiento farmacológico , Accidente Cerebrovascular/cirugía , Terapia Trombolítica , Resultado del TratamientoRESUMEN
Background and Purpose- Ischemic stroke (IS) secondary to atrial fibrillation (AF) is largely preventable with the use of anticoagulation. We sought to identify race-ethnicity and sex disparities with the use of direct oral anticoagulants (DOACs), aspirin, and warfarin in IS patients with AF and to identify temporal trends in the utilization of these medications. Methods- The FLiPER-AF Stroke Study (Florida Puerto Rico Atrial Fibrillation) included 24 040 IS cases enrolled in the Florida-Puerto Rico Collaboration to Reduce Stroke Registry from 2010 to 2016. Multivariable logistic regression models were performed to evaluate the effect of race-ethnicity and sex on utilization of DOACs, aspirin, and warfarin for stroke prevention in AF after adjustment for sociodemographic, hospital, and clinical factors. Results- Among 24 040 IS cases, 54% were women and 10% black, 12% FL-Hispanics, 4% PR-Hispanic, and 74% whites. From 2010 to 2016, DOAC use increased from 0% to 36%, warfarin use decreased from 51% to 17%, and aspirin use remained relatively stable (42%-40%). After adjustment, blacks had higher odds of warfarin (odds ratio, 1.22; 95% CI, 1.07-1.40) prescription at discharge compared with whites. Men had higher rates of aspirin (42.1% versus 38.8%), warfarin (33.6% versus 28.9%), and DOAC (21.3% versus 19.3%) use compared with women. After adjustment, women had lower odds of being discharged on aspirin (odds ratio, 0.92; 95% CI, 0.86-0.98) or warfarin (odds ratio, 0.91; 95% CI, 0.84-0.99). There was no sex difference in use of DOACs. Conclusions- Our study confirmed the increasing use of DOACs, downtrending use of warfarin, whereas aspirin use remained similar over the years. There are sex and race-ethnicity disparities in anticoagulation use in IS patients with AF. It is critical to understand underlying drivers of these disparities to develop better practice strategies for stroke prevention in patients with AF. Clinical Trial Registration- URL: https://www.clinicaltrials.gov . Unique identifier: NCT03627806.
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Anticoagulantes/administración & dosificación , Aspirina/administración & dosificación , Fibrilación Atrial , Isquemia Encefálica , Sistema de Registros , Accidente Cerebrovascular , Warfarina/administración & dosificación , Anciano , Anciano de 80 o más Años , Fibrilación Atrial/tratamiento farmacológico , Fibrilación Atrial/epidemiología , Fibrilación Atrial/etnología , Isquemia Encefálica/epidemiología , Isquemia Encefálica/etnología , Isquemia Encefálica/etiología , Isquemia Encefálica/prevención & control , Femenino , Florida/epidemiología , Humanos , Masculino , Puerto Rico/epidemiología , Accidente Cerebrovascular/epidemiología , Accidente Cerebrovascular/etnología , Accidente Cerebrovascular/etiología , Accidente Cerebrovascular/prevención & controlRESUMEN
Objective: Demographic differences (race/ethnicity/sex) in 9-1-1 emergency medical services (EMS) access and utilization have been reported for various time-dependent critical illnesses along with associated outcome disparities. However, data are lacking with respect to measuring the various components of time taken to reach definitive care facilities following the onset of acute stroke symptoms (i.e., stroke onset to 9-1-1 call, EMS response, time on-scene, transport interval) and particularly with respect to any differences across ethnicities and sex. Therefore, the specific aim of this study was to measure the various time intervals elapsing following the first symptom onset (FSO) from an acute stroke until stroke hospital arrival (SHA) and to delineate any race/ethnic/sex-related differences among any of those measurements. Methods: The Florida-Puerto Rico Stroke Registry (FLPRSR) is an on-going, voluntary stroke registry of hospitals participating in the Get with the Guidelines-Stroke initiative. The study population included patients treated at Florida hospitals participating in the FLPRSR between 2010 and 2014 who had called 9-1-1 and were managed and transported by EMS. In total, 10,481 patients (16% black, 8% Hispanic, 74% white) had complete data-sets that included birthdate/year, sex, ethnic background, date/hour/minute of FSO and date/hour/minute of EMS response, scene arrival, and SHA. Results: Median time from FSO to SHA was 339 minutes (interquartile range [IQR] of 284-442), 301 of which constituted the time elapsed from FSO to the 9-1-1 call (IQR =249-392) versus only 10 from 9-1-1 call to EMS arrival (IQR =7-14), 14 on-scene (IQR =11-18) and 12 for transport to SHA (IQR =8-19). The FSO to 9-1-1 call interval, being by far the longest interval, was longest among whites and blacks (302 minutes for both) versus 291 for Hispanics (p = 0.01). However, this 11-minute difference was not deemed clinically-significant. There were neither significant sex-related differences nor any racial/ethnic/sex differences in the relatively short EMS-related intervals. Conclusions: Following acute stroke onset, time elapsed for EMS response and transport is relatively short compared to the lengthy intervals elapsing between symptom onset and 9-1-1 system activation, regardless of demographics. Exploration of innovative strategies to improve public education regarding stroke symptoms and immediate 9-1-1 system activation are strongly recommended.
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Servicios Médicos de Urgencia , Educación en Salud , Prioridades en Salud , Accidente Cerebrovascular/complicaciones , Accidente Cerebrovascular/diagnóstico , Evaluación de Síntomas , Anciano , Femenino , Florida/epidemiología , Hospitales , Humanos , Masculino , Persona de Mediana Edad , Puerto Rico/epidemiología , Sistema de Registros , Accidente Cerebrovascular/epidemiologíaRESUMEN
Background Racial/ethnic disparities in acute stroke care may impact stroke outcomes. We compared outcomes by race/ethnicity among elderly Medicare beneficiaries in hospitals participating in the FL-PR CReSD (Florida-Puerto Rico Collaboration to Reduce Stroke Disparities) registry with those in hospitals not participating in any quality improvement programs (non- QI ) in Florida and Puerto Rico (PR). Methods and Results The population included fee-for-service Medicare beneficiaries age 65+ in Florida and PR , discharged with primary diagnosis of ischemic stroke ( International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM], codes 433, 434, 436) in 2010-2013. We used mixed logistic models to assess racial/ethnic differences in outcomes (in-hospital, 30-day, and 1-year mortality, and 30-day readmission) for CR e SD and non- QI hospitals, adjusted for demographic and clinical characteristics. The study included 62 CR e SD hospitals (N=44 013, 84% white, 9% black, 4% Florida Hispanic, 1% PR Hispanic) and 113 non- QI hospitals (N=14 422, 78% white, 7% black, 5% Florida Hispanic, 8% PR Hispanic). For patients treated at CR e SD hospitals, there were no differences in risk-adjusted in-hospital mortality by race/ethnicity; blacks had lower 30-day mortality versus whites (odds ratio, 0.86; 95% confidence interval, 0.77-0.97), but higher 30-day readmission (hazard ratio, 1.09; 1.00-1.18) and 1-year mortality (odds ratio, 1.13; 1.04-1.23); Florida Hispanics had lower 30-day readmission (hazard ratio, 0.87; 0.78-0.98). PR Hispanic and black stroke patients treated at non- QI hospitals had higher risk-adjusted in-hospital, 30-day and 1-year mortality, but similar 30-day readmission versus whites treated in non- QI hospitals. Conclusions Disparities in outcomes were less common in CR e SD than non- QI hospitals, suggesting the benefits of quality improvement programs, particularly those focusing on racial/ethnic disparities.
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Etnicidad , Medicare/economía , Mejoramiento de la Calidad , Grupos Raciales , Sistema de Registros , Accidente Cerebrovascular/etnología , Anciano , Causas de Muerte/tendencias , Planes de Aranceles por Servicios/estadística & datos numéricos , Femenino , Florida/epidemiología , Humanos , Masculino , Puerto Rico/epidemiología , Estudios Retrospectivos , Accidente Cerebrovascular/economía , Tasa de Supervivencia/tendencias , Estados UnidosRESUMEN
BACKGROUND AND PURPOSE: Mild stroke is the most common cause for thrombolysis exclusion in patients acutely presenting to the hospital. Thrombolysis administration in this subgroup is highly variable among different clinicians and institutions. We aim to study the predictors of thrombolysis in patients with mild ischemic stroke in the FL-PR CReSD registry (Florida-Puerto Rico Collaboration to Reduce Stroke Disparities). METHODS: Among 73 712 prospectively enrolled patients with a final diagnosis of ischemic stroke or TIA from January 2010 to April 2015, we identified 7746 cases with persistent neurological symptoms and National Institutes of Health Stroke Scale ≤5 who arrived within 4 hours of symptom onset. Multilevel logistic regression analysis with generalized estimating equations was used to identify independent predictors of thrombolytic administration in the subgroup of patients without contraindications to thrombolysis. RESULTS: We included 6826 cases (final diagnosis mild stroke, 74.6% and TIA, 25.4%). Median age was 72 (interquartile range, 21); 52.7% men, 70.3% white, 12.9% black, 16.8% Hispanic; and median National Institutes of Health Stroke Scale, 2 (interquartile range, 3). Patients who received thrombolysis (n=1281, 18.7%) were younger (68 versus 72 years), had less vascular risk factors (hypertension, diabetes mellitus, and dyslipidemia), had lower risk of prior vascular disease (myocardial infarction, peripheral vascular disease, and previous stroke), and had a higher presenting median National Institutes of Health Stroke Scale (4 versus 2). In the multilevel multivariable model, early hospital arrival (arrive by 0-2 hours versus ≥3.5 hours; odds ratio [OR], 8.16; 95% confidence interval [CI], 4.76-13.98), higher National Institutes of Health Stroke Scale (OR, 1.87; 95% CI, 1.77-1.98), aphasia at presentation (OR, 1.35; 95% CI, 1.12-1.62), faster door-to-computed tomography time (OR, 1.81; 95% CI, 1.53-2.15), and presenting to an academic hospital (OR, 2.02; 95% CI, 1.39-2.95) were independent predictors of thrombolysis administration. CONCLUSIONS: Mild acutely presenting stroke patients are more likely to receive thrombolysis if they are young, white, or Hispanic and arrive early to the hospital with more severe neurological presentation. Identification of predictors of thrombolysis is important in design of future studies to assess the use of thrombolysis for mild stroke.
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Isquemia Encefálica/diagnóstico , Isquemia Encefálica/tratamiento farmacológico , Sistema de Registros , Accidente Cerebrovascular/diagnóstico , Accidente Cerebrovascular/tratamiento farmacológico , Terapia Trombolítica , Factores de Edad , Anciano , Anciano de 80 o más Años , Femenino , Florida , Humanos , Masculino , Persona de Mediana Edad , Puerto Rico , Factores de RiesgoRESUMEN
BACKGROUND AND PURPOSE: In the United States, about half of acute ischemic stroke patients treated with tPA (tissue-type plasminogen activator) receive treatment within 60 minutes of hospital arrival. We aimed to determine the proportion of patients receiving tPA within 60 minutes (door-to-needle time [DTNT] ≤60) and 45 minutes (DTNT ≤45) of hospital arrival by race/ethnicity and sex and to identify temporal trends in DTNT ≤60 and DTNT ≤45. METHODS: Among 65 654 acute ischemic stroke admissions in the National Institute of Neurological Disorders and Stroke-funded FL-PR CReSD study (Florida-Puerto Rico Collaboration to Reduce Stroke Disparities) from 2010 to 2015, we included 6181 intravenous tPA-treated cases (9.4%). Generalized estimating equations were used to determine predictors of DTNT ≤60 and DTNT ≤45. RESULTS: DTNT ≤60 was achieved in 42% and DTNT ≤45 in 18% of cases. After adjustment, women less likely received DTNT ≤60 (odds ratio, 0.81; 95% confidence interval, 0.72-0.92) and DTNT ≤45 (odds ratio, 0.73; 95% confidence interval, 0.57-0.93). Compared with Whites, Blacks less likely had DTNT ≤45 during off hours (odds ratio, 0.68; 95% confidence interval, 0.47-0.98). Achievement of DTNT ≤60 and DTNT ≤45 was highest in South Florida (50%, 23%) and lowest in West Central Florida (28%, 11%). CONCLUSIONS: In the FL-PR CReSD, achievement of DTNT ≤60 and DTNT ≤45 remains low. Compared with Whites, Blacks less likely receive tPA treatment within 45 minutes during off hours. Treatment within 60 and 45 minutes is lower in women compared with men and lowest in West Central Florida compared with other Florida regions and Puerto Rico. Further research is needed to identify reasons for delayed thrombolytic treatment in women and Blacks and factors contributing to regional disparities in DTNT.
Asunto(s)
Disparidades en Atención de Salud/tendencias , Accidente Cerebrovascular/tratamiento farmacológico , Accidente Cerebrovascular/etnología , Terapia Trombolítica/tendencias , Tiempo de Tratamiento/tendencias , Activador de Tejido Plasminógeno/administración & dosificación , Administración Intravenosa , Anciano , Anciano de 80 o más Años , Población Negra/etnología , Conducta Cooperativa , Femenino , Fibrinolíticos/administración & dosificación , Florida/etnología , Disparidades en Atención de Salud/normas , Humanos , Masculino , Persona de Mediana Edad , Agujas , Estudios Prospectivos , Puerto Rico/etnología , Sistema de Registros , Estudios Retrospectivos , Factores Sexuales , Accidente Cerebrovascular/diagnóstico , Terapia Trombolítica/métodos , Tiempo de Tratamiento/normas , Población Blanca/etnologíaRESUMEN
OBJECTIVES: Although disparities in stroke care and outcomes have been well documented nationally, state-based registries to monitor acute stroke care in Florida (FL) and Puerto Rico (PR) have not been established. The FL-PR Collaboration to Reduce Stroke Disparities (CReSD) was developed to evaluate race-ethnicity and regional disparities in stroke care performance. The objective of this study was to assess and compare hospital characteristics within a large quality improvement registry to identify characteristics associated with better outcomes for acute ischemic stroke care. METHODS: Trained personnel from 78 FL-PR CReSD hospitals (69 FL, 9 PR) completed a 50-item survey assessing institutional characteristics across seven domains: acute stroke care resource availability, emergency medical services integration, stroke center certification, data collection and use, quality improvement processes, FL-PR CReSD recruitment incentives, and hospital infrastructure. RESULTS: The rate of survey completion was 100%. Differences were observed both within FL and between FL and PR. Years participating in Get With The Guidelines-Stroke (8.9 ± 2.6 years FL vs 4.8 ± 2.4 years PR, P < 0.0001) and proportion of hospitals with any stroke center certification (94.2% FL vs 11.1% PR, P < 0.0001) showed the largest variations. Smaller hospital size, fewer years in Get With The Guidelines-Stroke, and lack of stroke center designation and acute stroke care practice implementation may contribute to poorer outcomes. CONCLUSIONS: Results from our survey indicated variability in hospital- and system-level characteristics in stroke care across hospitals in Florida and Puerto Rico. Identification of these variations, which may explain potential disparities, can help clinicians understand gaps in stroke care and outcomes and targeted interventions to reduce identified disparities can be implemented.
Asunto(s)
Disparidades en Atención de Salud/etnología , Disparidades en Atención de Salud/estadística & datos numéricos , Hospitales Especializados/organización & administración , Colaboración Intersectorial , Accidente Cerebrovascular/etnología , Accidente Cerebrovascular/terapia , Florida , Adhesión a Directriz , Encuestas de Atención de la Salud , Disparidades en Atención de Salud/tendencias , Hospitales Especializados/tendencias , Humanos , Evaluación de Resultado en la Atención de Salud/estadística & datos numéricos , Puerto Rico , Mejoramiento de la Calidad/organización & administración , Mejoramiento de la Calidad/tendencias , Sistema de Registros , Accidente Cerebrovascular/epidemiologíaRESUMEN
BACKGROUND: Racial-ethnic disparities in acute stroke care can contribute to inequality in stroke outcomes. We examined race-ethnic disparities in acute stroke performance metrics in a voluntary stroke registry among Florida and Puerto Rico Get With the Guidelines-Stroke hospitals. METHODS AND RESULTS: Seventy-five sites in the Florida Puerto Rico Stroke Registry (66 Florida and 9 Puerto Rico) recorded 58 864 ischemic stroke cases (2010-2014). Logistic regression models examined racial-ethnic differences in acute stroke performance measures and defect-free care (intravenous tissue plasminogen activator treatment, in-hospital antithrombotic therapy, deep vein thrombosis prophylaxis, discharge antithrombotic therapy, appropriate anticoagulation therapy, statin use, smoking cessation counseling) and temporal trends. Among ischemic stroke cases, 63% were non-Hispanic white (NHW), 18% were non-Hispanic black (NHB), 14% were Hispanic living in Florida, and 6% were Hispanic living in Puerto Rico. NHW patients were the oldest, followed by Hispanics, and NHBs. Defect-free care was greatest among NHBs (81%), followed by NHWs (79%) and Florida Hispanics (79%), then Puerto Rico Hispanics (57%) (P<0.0001). Puerto Rico Hispanics were less likely than Florida whites to meet any stroke care performance metric other than anticoagulation. Defect-free care improved for all groups during 2010-2014, but the disparity in Puerto Rico persisted (2010: NHWs=63%, NHBs=65%, Florida Hispanics=59%, Puerto Rico Hispanics=31%; 2014: NHWs=93%, NHBs=94%, Florida Hispanics=94%, Puerto Rico Hispanics=63%). CONCLUSIONS: Racial-ethnic/geographic disparities were observed for acute stroke care performance metrics. Adoption of a quality improvement program improved stroke care from 2010 to 2014 in Puerto Rico and all Florida racial-ethnic groups. However, stroke care quality delivered in Puerto Rico is lower than in Florida. Sustained support of evidence-based acute stroke quality improvement programs is required to improve stroke care and minimize racial-ethnic disparities, particularly in resource-strained Puerto Rico.
Asunto(s)
Isquemia Encefálica/etnología , Etnicidad , Disparidades en Atención de Salud , Grupos Raciales , Sistema de Registros , Enfermedad Aguda , Anciano , Isquemia Encefálica/prevención & control , Femenino , Florida/epidemiología , Estudios de Seguimiento , Humanos , Masculino , Pronóstico , Puerto Rico/epidemiología , Estudios Retrospectivos , Factores SocioeconómicosRESUMEN
BACKGROUND AND PURPOSE: Sex-specific disparities in stroke care including thrombolytic therapy and early hospital admission are reported. In a large registry of Florida and Puerto Rico hospitals participating in the Get With The Guidelines-Stroke program, we sought to determine sex-specific differences in ischemic stroke performance metrics and overall thrombolytic treatment. METHODS: Around 51 317 (49% women) patients were included from 73 sites from 2010 to 2014. Multivariable logistic regression with generalized estimating equations evaluated sex-specific differences in the prespecified Get With The Guidelines-Stroke metrics for defect-free care in ischemic stroke, adjusting for age, race-ethnicity, insurance status, hospital characteristics, individual risk factors, and the presenting stroke severity. RESULTS: As compared with men, women were older (73±15 versus 69±14 years; P<0.0001), more hypertensive (67% versus 63%, P<0.0001), and had more atrial fibrillation (19% versus 16%; P<0.0001). Defect-free care was slightly lower in women than in men (odds ratio, 0.96; 95% confidence interval, 0.93-1.00). Temporal trends in defect-free care improved substantially and similarly for men and women, with a 29% absolute improvement in women (P<0.0001) and 28% in men (P<0.0001), with P value of 0.13 for time-by-sex interaction. Women were less likely to receive thrombolysis (odds ratio, 0.92; 95% confidence interval, 0.86-0.99; P=0.02) and less likely to have a door-to-needle time <1 hour (odds ratio, 0.83; 95% confidence interval, 0.71-0.97; P=0.02) as compared with men. CONCLUSIONS: Women received comparable stroke care to men in this registry as measured by prespecified Get With The Guidelines metrics. However, women less likely received thrombolysis and had door-to-needle time <1 hour, an observation that calls for the implementation of interventions to reduce sex disparity in these measures.
Asunto(s)
Isquemia Encefálica/tratamiento farmacológico , Disparidades en Atención de Salud , Accidente Cerebrovascular/tratamiento farmacológico , Terapia Trombolítica , Factores de Edad , Anciano , Anciano de 80 o más Años , Isquemia Encefálica/diagnóstico , Femenino , Fibrinolíticos/uso terapéutico , Humanos , Masculino , Persona de Mediana Edad , Sistema de Registros , Factores de Riesgo , Índice de Severidad de la Enfermedad , Factores Sexuales , Accidente Cerebrovascular/diagnóstico , Factores de Tiempo , Activador de Tejido Plasminógeno/uso terapéuticoRESUMEN
Objetivo: Determinar los niveles séricos de vitamina D en pacientes obesos que serán sometidos a Cirugía Bariátrica en Venezuela. Métodos: Investigación de carácter descriptivo, diseño no experimental, transversal que incluyó 32 pacientes consecutivos que cumplían criterios de selección para cirugía bariátrica y firmaron consentimiento informado. Se les determinó edad, sexo, co-morbilidades, lugar de procedencia. Se realizaron mediciones de peso (kg), talla (m), y se calculó el índice de masa corporal, de acuerdo al cual se determinó el grado de sobrepeso y obesidad. Se realizaron mediciones séricas de Vitamina D y perfil metabólico óseo tales como calcio sérico, relación calcio/ creatinina, fosforo sérico, creatinina, fosfatasa alcalina, C- Telopéptido (CTX), parathormona (PTH), y urinarias como calcio urinario, fósforo urinario, reabsorción tubular de fosfato. Resultados: Predominó el sexo femenino, 25 casos (78,1%). La edad promedio fue 39,41±10,99 años. Las comorbilidades frecuentemente asociadas a obesidad fueron: enfermedad arterial hipertensiva (37,5%), diabetes mellitus (21,9%) e hipotiroidismo (18,8%). En 50% de los casos se presentó obesidad grado III para ambos sexos. Los parámetros bioquímicos del metabolismo óseo oscilaron dentro del rango de normalidad, sin embargo el promedio de Vitamina D fue bajo, de 26,27±9,76 ng/ml; el 80% se encontraba en rango de insuficiencia, < 30 ng/ml, y el 32% en rango de deficiencia, < 20 ng/mL. Conclusión: Los pacientes obesos venezolanos que van a ser sometidos a cirugía bariátrica presentan una disminución de sus niveles séricos de vitamina D, con un alto porcentaje en rango de insuficiencia y deficiencia, similar a lo reportado en estudios realizados a nivel mundial.
General: To determine serum vitamin D levels in obese patients who will undergo bariatric surgery in Venezuela. Methods: Descriptive research, not experimental, cross-sectional design that included 32 consecutive patients who fulfilled criteria for bariatric surgery and signed informed consent. It was determined age, gender, co-morbidities, place of origin. Measurements of weight (kg) and height (m) were taken and BMI was calculated, according to which the degree of overweight and obesity was determined. Measurements of serum vitamin D and bone metabolic profile such as serum calcium, calcium/creatinine ratio, serum phosphorus, creatinine, alkaline phosphatase, C-Telopeptide (CTX), parathormona (PTH), and urinary determinations such as urinary calcium, phosphorus urine and tubular reabsorption of phosphate, were performed. Results: Females predominated, 25 cases (78.1%). The average age was 39.41 ± 10.99 years. The co-morbidities frequently associated with obesity were: hypertensive heart disease (37.5%), diabetes mellitus (21.9%) and hypothyroidism (18.8%). Obesity grade III was presented in 50% of cases for both sexes. The biochemical parameters of bone metabolism ranged within the normal range, however, the Vitamin D average was low, 26.27±9.76 ng/ ml; 80% were in the range of insufficiency, < 30 ng/ml and 32% in the range of deficiency, < 20 ng/ml. Conclusion: The Venezuelan obese patients who are going to undergo bariatric surgery have a decrease in serum levels of vitamin D, with a high percentage in the range of insufficiency and deficiency, similar to those reported in studies conducted worldwide.
RESUMEN
The objective of the present research was to evaluate commercially available milk powders according to their protein oxidative modifications and antioxidant capacity, and to evaluate if these characteristics are related to physical quality parameters such as dispersibility or stability during storage. Fifteen commercially processed spray-dried milk powders were evaluated: 6 whole milk powders (WMP), 4 skim milk powders (SMP), and 5 infant formula powders (IFP). Protein oxidative status was measured as protein carbonyl (PC) content, dityrosine content, and extent of protein polymerization. The level of PC was slightly lower in SMP than in WMP, whereas IFP had more than twice as much PC as WMP (2.8 ± 0.4, 2.1 ± 0.2, and 6.5 ± 1.3 nmol/mg of protein for WMP, SMP, and IFP, respectively). No differences were detected in dityrosine accumulation. Although all the possible pairs of parameters were tested for correlations, we found that 4 parameters were linked: PC, whey content, protein aggregate level, and dispersibility. After 9 mo of storage at -20°C or room temperature, all milk samples were analyzed to evaluate changes in protein oxidative status (PC, dityrosine, and protein integrity) and related parameters. Compared with the initial condition, PC increased in all tested samples after 9 mo of storage at -20°C or at room temperature. Stored milk powders had increased PC and decreased dispersibility compared with prestorage levels. Our results highlight the importance of protein oxidative status in milk powder and its relationship to other related quality parameters, such as protein integrity and dispersibility. Our findings suggest that the understanding of such relationships could help in developing quality differentiation for different types of milk powders in the product market.