PURPOSE:Our purpose was to assess the efficacy of a phase III cardiac rehabilitation (CR) program, based on counseling in the maintenance of physical exercise, on the time spent on physical exercise per week in patients with ischemic heart disease who had completed a phase II CR program. METHODS:Open, controlled, cluster randomized clinical trial. The intervention group (IG) participated in a phase III CR program based on counseling in the maintenance of physical exercise. The control group (CG) received standard care at their primary health care center. The main outcome was the time spent engaging in physical exercise per week at 6 and 12 months measured by the 7-day Physical Activity Recall questionnaire. RESULTS:Fourteen primary health care centers were randomly assigned, 7 to the CG and 7 to the IG. Ninety-nine patients (54 CG, 45 IG, mean age 59.8 ± 9.3, 86% men) were analyzed. The mean time per week of moderate and vigorous activity at 12 months was 270.7 ± 292.6 min/week in the CG and 321.0 ± 216.9 min/week in the IG ( P = .124). Decreases in the percentages of patients who performed the recommended levels of physical exercise were observed in both groups (14% vs 9% in the CG and IG, respectively; P = .869). CONCLUSIONS:The intervention did not result in significant differences in the stated objectives of the CR program, although the IG performed a greater amount of moderate and/or vigorous exercise.

Population ageing has substantially transformed the profile of patients presenting to emergency departments, with an increase in clinical complexity characterized by frailty, functional and cognitive impairment, multimorbidity, and social vulnerability. Traditional care models, mainly focused on biomedical diagnosis, are limited in addressing this complexity, and existing screening tools usually assess isolated dimensions, thereby restricting their usefulness for clinical decision-making. The 3D/3D+ model was developed as a geriatric assessment tool designed to integrate both baseline status and the impact of the acute episode. Its development followed a hybrid effectiveness-implementation approach and was validated through observational studies including patients aged 75 years or older. The baseline component enabled frailty stratification with high concordance with reference scales, whereas the dynamic component identified the acute impact and was independently associated with mortality and adverse outcomes. Overall, the model demonstrates clinical validity, reproducibility, and practical utility for optimizing care decisions in Emergency Department (ED).

BACKGROUND Symptomatic gallstone disease (SGD) is a leading cause of gastrointestinal hospitalizations with the incidence and severity positively correlated with age. Although early cholecystectomy is the recommended treatment, elderly patients are often managed conservatively due to comorbidities and surgical risk. There is limited data on the recurrence patterns of SGD in the elderly population. AIM To characterize the clinical features, recurrence patterns, and predictors of recurrence in elderly patients with SGD who were managed non-operatively. METHODS A post hoc analysis was conducted using data from the multicenter RELAPSTONE cohort. The cohort included 3016 patients admitted with the first episode of SGD and did not undergo cholecystectomy during the index admission. Patients with prior biliary events or previous cholecystectomy were excluded. We defined elderly as an age >= 80 years. Demographic, clinical, laboratory, and imaging data were collected. Recurrence-free survival was analyzed using Kaplan-Meier curves. Multivariable Cox regression was utilized to identify independent predictors of recurrence. RESULTS Among the 3016 patients, 1087 (36.0%) were >= 80 years (median 86.5). At the index admission elderly patients had a higher comorbidity burden and more severe acute cholecystitis and cholangitis. Recurrence was less frequent in elderly patients (hazard ratio = 0.70; 95%CI: 0.61-0.80; P = 0.001), and recurrences occurred later in elderly patients (median 3.4 months vs 1.8 months; P < 0.001). However, elderly patients experienced more frequent multiple (51.7% vs 39.7%; P < 0.001) and more severe episodes, particularly for acute cholecystitis and cholangitis. The recurrence pattern differed between the elderly and non-elderly patients. The most frequent recurrence among the elderly patients was acute cholecystitis (29.7%). Independent protective factors against recurrence included prior endoscopic retrograde cholangiopancreatography with sphincterotomy and a higher level of white blood cell at the index admission. CONCLUSION SGD in elderly patients exhibited distinct clinical patterns with fewer but more severe episodes and age-specific recurrence patterns. Our findings could enable risk stratification to guide age-adapted interventions.

OBJECTIVE:To determine the association of level of activation for self-management with the degree of anticoagulation control in a group of chronically anticoagulated patients. METHODS:Cross-sectional study of patients treated with oral antivitamin-k drugs attended at a specialized outpatient anticoagulation unit between November 2021 and June 2022. International normalized ratio (INR) values over the past 6 months were recorded. The degree of INR control was defined as the time the patient had remained within the therapeutic range (TTR) and was determined by the Rosendaal method. A TTR value >60% was taken as representing adequate control. Simple and multiple logistic regression models were conducted, with degree of INR control as dependent variable. RESULTS:One hundred and thirty-seven patients were included. The mean age was 59.6 years (SD 13.8; range 22 - 86) and 60.6% were males. A total of 67.9% of patients (95%CI: 60.0 to 75.8) had adequate INR control. Factors independently associated with adequate INR control were high levels of activation according to the PAM-13 scale (OR: 1.05; 95%CI: 1.02-1.09) and self-management monitoring mode (OR: 7.12; 95%CI: 2.10-24.06). CONCLUSION:The level of activation and the control mode were associated with a better degree of INR control. Knowing the factors associated with the degree of control allows us to identify the subgroups of chronic anticoagulated patients who require more individualized educational interventions. Self-management monitoring programs and patient activation appear to be useful tools in improving the INR control of anticoagulated patients.

Healthcare workers (HCWs) are at increased risk of SARS-CoV-2 infection due to their continuous exposure during the COVID-19 pandemic. Serological detection of anti-nucleocapsid (anti-N) antibodies offers a valuable approach to estimate cumulative infection rates, including asymptomatic and undiagnosed cases missed by molecular testing. We performed a longitudinal retrospective study involving HCWs at Althaia Xarxa Assistencial Universitària, Manresa (Spain), from June 2020 to November 2021. Participants underwent two rounds of serological testing with the Elecsys® Anti-SARS-CoV-2 assay (Roche) to quantify total anti-N antibodies. Concurrently, results from direct diagnostic tests (PCR or antigen detection) were collected. Seroprevalence, antibody concentrations, and infection rates—based on seroconversion and PCR/antigen positivity—were evaluated at both time points. Of the 758 HCWs included (84

El envejecimiento poblacional ha transformado el perfil de los pacientes en urgencias, presentando aumento en complejidad clínica caracterizada por fragilidad, deterioro funcional / cognitivo, comorbilidad y vulnerabilidad social. Los modelos tradicionales, centrados en diagnóstico biomédico, resultan limitados para abordar esta realidad, y las escalas de cribado existentes evalúan dimensiones aisladas, lo que restringe su utilidad en la toma de decisiones. Las 3D/3D+ se diseñó como una herramienta de valoración geriátrica capaz de integrar la situación basal y el impacto del episodio agudo. Su desarrollo siguió un enfoque híbrido de efectividad / implementación y fue validado mediante estudios observacionales en los pacientes de 75 años o más. El componente basal estratifica fragilidad con alta concordancia respecto a escalas de referencia y el componente dinámico identificó el impacto agudo y se asoció de forma independiente con mortalidad y eventos adversos. El modelo demuestra validez clínica, reproducibilidad y utilidad para optimizar decisiones asistenciales en los servicios de urgencias (SU).

Background: Pleural effusions are challenging to diagnose, with approximately 20-50% of malignant effusions not diagnosed by cytology. Human epididymal protein 4 (HE4) may be useful in the differential diagnosis of pleural effusions. In serum, this biomarker shows false-positive results in some benign diseases. The aim of this study was to evaluate the diagnostic utility of HE4 in this setting and to identify false positives. Methods: Concentrations of HE4, adenosine deaminase, % polynuclear cells, and C-reactive protein, were determined in 238 pleural fluid samples and the estimated glomerular filtration rate (eGFr) in serum. Results: HE4 values differed significantly (p < 0.01) between malignant [median (IQR)] [1065 (2085)] pmol/L and benign effusions [699 (589)] pmol/L. HE4 concentrations in gynecological and pulmonary tumors were significantly higher than in other tumors. For a cut-off point of 3050 pmol/L, 22 % sensitivity and 100 % specificity were obtained. In patients with benign disease, significant increases in HE4 were identified only in those with eGFr < 30 mL/ min/1.73 m(2) [1050(596)] pmol/L, and not in those with eGFr > 30 mL/min/1.73 m(2) [597(532)] pmol/L). Two cut-offs were established for maximum specificity, depending on the eGFr: 3050 pmol/L for eGFr < 30 mL/ min/1.73 m(2) and 1992 pmol/L for eGFr > 30 mL/min/1.73 m(2). A sensitivity of 28.5 % was obtained for patients with eGFr > 30 mL/min/1.73 m(2) and 36.3 % for patients with eGFr < 30 mL/min/1.73 m(2). The sensitivity using a specific cut-off point was 29.7 %. Conclusions: The determination of HE4 in pleural fluids demonstrates high specificity and low sensitivity. The use of specific cutoff points that are clinically adjusted improves sensitivity while maintaining maximum specificity.

Fragility hip fractures significantly impact long-term survival in patients over 65 years. Overall survival was 76.0

BACKGROUND AND AIMS:Cholecystectomy is recommended to prevent recurrence of biliary pancreatitis, but supporting evidence is limited for sludge- and microlithiasis-induced acute pancreatitis (AP). This study aimed to compare relapse patterns and risk factors between patients with sludge/microlithiasis-induced AP and gallstone-induced AP. METHODS:This analysis included 789 patients from the international, multicenter Relapstone cohort (Spain: 16 centers; Mexico: 2 centers), hospitalized between January 2018 and April 2020 with first-time biliary AP and no cholecystectomy during admission. Patients with sludge/microlithiasis-induced AP (n = 274) were compared to those with gallstone-induced AP (n = 515) regarding pancreatobiliary complications. Multivariate analysis was used to assess relapse risk factors. RESULTS:Pancreatobiliary complications occurred in 41.7 % of the gallstone cohort versus 32.1 % in the sludge/microlithiasis cohort (p = 0.01). Correspondingly, the gallstone AP cohort showed a significantly lower complication-free survival rate (log-rank p = 0.0022; median follow-up: 6.1 vs. 8.1 months). In multivariate analysis, older age in the gallstone group was significantly associated with lower relapse risk (HR = 0.54, 95 % CI: 0.39-0.74). CONCLUSION:This multicenter study reveals distinct differences in relapse risk between gallstone- and sludge/microlithiasis-induced AP, with gallstone AP showing a higher rate of complications in the absence of cholecystectomy.

BACKGROUND:Symptomatic gallstone disease is a common and burdensome condition, with early cholecystectomy recommended to prevent relapses. However, delayed cholecystectomies lack standardized prioritization criteria. This study aimed to identify determinants independently associated with shorter waiting times for delayed cholecystectomy, and to assess the alignment of current surgical prioritization with relapse predictors described in the previous RELAPSTONE study. METHODS:This was a post hoc analysis of the Spanish RELAPSTONE cohort, comprising patients admitted for a first episode of symptomatic gallstone disease between January 2018 and April 2020, who did not undergo cholecystectomy during the index hospital admission. The primary outcome was waiting time (in months) to delayed cholecystectomy. Linear regression models with β-coefficients were used to identify clinical factors associated with surgical delays (primary outcome of interest). Secondarily, the impact of relapse on prioritization was also evaluated. RESULTS:This study analysed 1508 patients of the 3016 included in the RELAPSTONE cohort. Median age was 68.2 (interquartile range 53.9-76.6) years; 51.4% were men. Median waiting time to delayed cholecystectomy was 4.5 (interquartile range 2.3-7.0) months. Initial presentation as acute cholecystitis (β = -2.2, P = 0.048) and multiple cholelithiasis (β = -0.6, P = 0.006) were linked to shorter waiting times, whereas older age (> 54 years; β = 0.8, P = 0.002), advanced liver disease (β = 2.4, P = 0.047), and relapse (β = 0.5, P = 0.036) were associated with longer delays, compared with their respective reference groups. Among 575 patients (38.1%) with relapse, time to delayed cholecystectomy did not differ by relapse type. Several known risk factors for relapse identified in previous RELAPSTONE analyses, including the performance of endoscopic sphincterotomy and leucocyte and alanine aminotransferase levels, did not influence prioritization. CONCLUSION:Determinants of surgical timing were not well aligned with previously identified predictors of relapse. These findings support the need for evidence-based triage strategies to improve timing and outcomes of delayed cholecystectomy.

ObjetivosLos términos «activación del paciente» y «empoderamiento del paciente» se utilizan para describir hasta qué punto los individuos son capaces de gestionar su propia atención sanitaria. Los resultados de salud y la calidad de vida mejoran en los pacientes que son más activos en el autocuidado. El objetivo de este estudio fue identificar determinantes sociodemográficos, clínicos, sociológicos y psicológicos asociados a la activación en un grupo de pacientes crónicamente anticoagulados.MétodosEstudio transversal de pacientes tratados con antivitamina K oral atendidos en una unidad ambulatoria especializada en anticoagulantes entre noviembre de 2021 y junio de 2022. La variable dependiente principal fue el nivel de activación para el autocuidado según la Medida de activación del paciente de 13 ítems. (PAM-13). Se realizaron modelos de regresión lineal simple y múltiple para identificar los determinantes asociados a la puntuación PAM-13.ResultadosSe seleccionó para el estudio un total de 137 pacientes que cumplieron con todos los criterios de inclusión. La edad media fue de 59,6 años (DE 13,8; rango 22-86) y el 60,6% eran varones. El 60% presentó un nivel IV de activación según la escala PAM-13. La puntuación media de activación fue de 73,9 (DE 15,4). Los factores asociados de forma independiente a una activación de autocuidado significativamente menor fueron: visitas al departamento de urgencias en los últimos 12 meses, riesgo social intermedio, síntomas de ansiedad, síntomas de estrés y baja autoeficacia.ConclusionesSe encontraron cinco determinantes asociados a la activación. Conocer los factores que modifican el nivel de activación puede ayudar a identificar subgrupos de pacientes anticoagulados crónicos que tienen menos probabilidades de autocuidado y, por lo tanto, son candidatos a las intervenciones educativas personalizadas.

Abstract Background In standard weaning from mechanical ventilation, a successful spontaneous breathing test (SBT) consisting of 30 min 8 cmH2O pressure-support ventilation (PSV8) without positive end-expiratory pressure (PEEP) is followed by extubation with continuous suctioning; however, these practices might promote derecruitment. Evidence supports the feasibility and safety of extubation without suctioning. Ultrasound can assess lung aeration and respiratory muscles. We hypothesize that weaning aiming to preserve lung volume can yield higher rates of successful extubation. Methods This multicenter superiority trial will randomly assign eligible patients to receive either standard weaning [SBT: 30-min PSV8 without PEEP followed by extubation with continuous suctioning] or lung-volume-preservation weaning [SBT: 30-min PSV8 + 5 cmH2O PEEP followed by extubation with positive pressure without suctioning]. We will compare the rates of successful extubation and reintubation, ICU and hospital stays, and ultrasound measurements of the volume of aerated lung (modified lung ultrasound score), diaphragm and intercostal muscle thickness, and thickening fraction before and after successful or failed SBT. Patients will be followed for 90 days after randomization. Discussion We aim to recruit a large sample of representative patients (N = 1600). Our study cannot elucidate the specific effects of PEEP during SBT and of positive pressure during extubation; the results will show the joint effects derived from the synergy of these two factors. Although universal ultrasound monitoring of lungs, diaphragm, and intercostal muscles throughout weaning is unfeasible, if derecruitment is a major cause of weaning failure, ultrasound may help clinicians decide about extubation in high-risk and borderline patients. Trial registration The Research Ethics Committee (CEIm) of the Fundació Unió Catalana d’Hospitals approved the study (CEI 22/67 and 23/26). Registered at ClinicalTrials.gov in August 2023. Identifier: NCT05526053.

AimsThe terms “patient activation” and “patient empowerment” are used to describe the extent to which individuals are able to manage their own healthcare. Health outcomes and quality of life improve in patients who are more active in health care. The aim of this study was to identify sociodemographic, clinical, sociological and psychological determinants associated with activation in a group of chronically anticoagulated patients.MethodsCross-sectional study of patients treated with oral antivitamin-k drugs attended at a specialized outpatient anticoagulant unit between November 2021 and June 2022. The main dependent variable was the level of patient activation according to the 13-item Patient Activation Measure (PAM-13). Simple and multiple linear regression models were conducted to identify the determinants associated with PAM-13 score.ResultsA total of 137 patients who met all the inclusion criteria were recruited for the study. The mean age was 59.6 years (SD 13.8; range 22 - 86) and 60.6% were male. Sixty per cent presented a level IV of activation according to the PAM-13 scale. Mean patient activation score was 73.9 (SD 15.4). The factors independently associated with significantly lower activation were: emergency department visits in the past 12 months, intermediate social risk, anxiety symptoms, stress symptoms and low self-efficacy.ConclusionsFive determinants were found to be associated with activation. Knowing the factors that modify the level of activation can help to identify subgroups of chronic anticoagulated patients who are less likely to engage in self-management and are therefore candidates for tailored educational interventions.

BackgroundDelayed cholecystectomy in patients with symptomatic gallstone disease is associated with recurrence. Limited data on the recurrence patterns and the factors that determine them are available.ObjectiveWe aimed to determine the pattern of relapse in each symptomatic gallstone disease (acute pancreatitis, cholecystitis, cholangitis, symptomatic choledocholithiasis, and biliary colic) and determine the associated factors.MethodsRELAPSTONE was an international multicenter retrospective cohort study. Patients (n = 3016) from 18 tertiary centers who suffered a first episode of symptomatic gallstone disease from 2018 to 2020 and had not undergone cholecystectomy during admission were included. The main outcome was relapse-free survival. Kaplan-Meier curves were used in the bivariate analysis. Multivariable Cox regression models were used to identify prognostic factors associated with relapses.ResultsMean age was 76.6 [IQR: 59.7-84.1], and 51% were male. The median follow-up was 5.3 months [IQR 2.1-12.4]. Relapse-free survival was 0.79 (95% CI: 0.77-0.80) at 3 months, 0.71 (95% CI: 0.69-0.73) at 6 months, and 0.63 (95% CI: 0.61-0.65) at 12 months. In multivariable analysis, older age (HR = 0.57; 95% CI: 0.49-0.66), sphincterotomy (HR = 0.58, 95% CI: 0.49-0.68) and higher leukocyte count (HR = 0.79; 95% CI: 0.70-0.90) were independently associated with lower risk of relapse, whereas higher levels of alanine aminotransferase (HR = 1.22; 95% CI: 1.02-1.46) and multiple cholelithiasis (HR = 1.19, 95% CI: 1.05-1.34) were associated with higher relapse rates.ConclusionThe relapse rate is high and different in each symptomatic gallstone disease. Our independent predictors could be useful for prioritizing patients on the waiting list for cholecystectomies. image

Prostate cancer (PCa) is a major public health concern for men globally and the most commonly diagnosed cancer among men in the European Union (EU). Despite large trials suggesting benefits from early detection of PCa, risks of overdiagnosis and overtreatment are evident. In 2022, the EU Commission proposed introducing prostate-specific antigen (PSA) testing for men in an organised setting, in combination with magnetic resonance imaging (MRI) scanning as a follow-up test to minimise these risks. PRostate cancer Awareness and Initiative for Screening Europe (PRAISE-U) is a pilot study evaluating the implementation of a risk-stratified population-based approach to PCa screening in Ireland, Lithuania, Poland, and two areas in Spain (Galicia and Manresa) for feasibility, efficacy, and cost effectiveness. As per the protocol designed for the pilots, men aged 50-69 yr residing within the catchment area of the study sites will be invited to participate. Those consenting to participate will undergo PSA testing, and men with PSA >3 ng/ml will undergo risk stratification before MRI and, if necessary, after MRI before undergoing biopsy. A collaborative user board comprising health care professionals, patients, and decision-makers will be formed to provide stakeholder input throughout the study. PRAISE-U will be evaluated on three major pillars: analysis of clinical and programme outcomes, psychosocial impact, and cost effectiveness. A set of key performance indicators (KPIs) has been developed to be piloted in the PRAISE-U pilot sites. The KPIs will serve to assess the performance and outcomes of risk-stratified PCa screening at each site. A REDCap database will be used to collect and manage pseudoanonymised data from the pilot sites. Ethics approval was obtained from each pilot site. The PRAISE-U pilot implementation is expected to commence in the 3rd quarter of 2024 for 12 mo and provide valuable data on the implementation outcomes of a risk-stratified screening approach across Europe. The findings is expected to inform the development of an optimised screening strategy with an acceptable benefit to harm ratio.

The 3D/3D+ multidimensional geriatric assessment tool provides an optimal model of emergency care for patients aged 75 and over who attend the Emergency Department (ED). The baseline, or static, component (3D) stratifies the degree of frailty prior to the acute illness, while the current, or dynamic, component (3D+) assesses the multidimensional impact caused by the acute illness and helps to guide the choice of care facility for patients upon their discharge from the ED. The objective of this study was to evaluate the prognostic value of the 3D/3D+ to predict short- and long-term adverse outcomes in ED patients aged 75 years and older. Multivariable logistic regression models were used to identify the predictors of mortality 30 days after 3D/3D+ assessment. Two hundred and seventy-eight patients (59.7% women) with a median age of 86 years (interquartile range: 83–90) were analyzed. According to the baseline component (3D), 83.1% (95% CI: 78.2–87.3) presented some degree of frailty. The current component (3D+) presented alterations in 60.1% (95% CI: 54.1–65.9). The choice of care facility at ED discharge indicated by the 3D/3D+ was considered appropriate in 96.4% (95% CI: 93.0–98.0). Thirty-day all-cause mortality was 19.4%. Delirium and functional decline were the dimensions on the 3D/3D+ that were independently associated with 30-day mortality. These two dimensions had an area under receiver operating characteristic of 0.80 (95% CI: 0.73–0.86) for predicting 30-day mortality. The 3D/3D+ tool enhances the provision of comprehensive care by ED professionals, guides them in the choice of patients’ discharge destination, and has a prognostic validity that serves to establish future therapeutic objectives.

INTRODUCTION:Obstetric antiphospholipid syndrome (OAPS) is an autoimmune disease related to antiphospholipid antibodies (aPL) with primaryinflammatory injury followed by clot cascade activation and thrombus formation. Complement system activation and their participation in aPL-related thrombosis is unclosed. METHODS:We haveanalysed adverse pregnancy outcomes (APO) related to low complement (LC) levels in a cohort of 1048 women fulfilling classification criteria for OAPS. RESULTS:Overall, 223 (21.3%) women presented LC values, during pregnancy. The length of pregnancy was shorter in OAPS women with LC compared to those with normal complement (NC) (median: 33 weeks, interquartile range: [24-38] vs. 35 weeks [27-38]; p = 0.022). Life new-born incidence was higher in patients with NC levels than in those with LC levels (74.4% vs. 67.7%; p = 0.045). Foetal losses were more related to women with triple or double aPL positivity carrying LC than NC values (16.3% vs. 8.0% NC; p = 0.027). Finally, some placental vasculopathies were affected in OAPS patients with LC as late Foetal Growth Restriction (FGR >34 weeks) rise to 7.2% in women with LC vs. 3.2% with NC (p = 0.007). DISCUSSION:Data from our registry indicate that incidence of APO was higher in OAPS women with LC levels and some could be reverted by the correct treatment.