In order to assess potential risk factors for pneumonia within the first 8 d of ventilation, we studied 83 consecutive intubated patients undergoing continuous aspiration of subglottic secretions (CASS). Multivariate analysis showed the protective effect of antibiotic use (relative risk [RR] = 0.10; 95% confidence interval [CI] = 0.01 to 0.71), whereas failure of the CASS technique (RR = 5.29; 95% CI = 1.24 to 22.64) was associated with a greater risk of pneumonia. In addition, there was a trend toward a higher risk of pneumonia (RR = 2.57; 95% CI = 0.78 to 8.03) among patients with persistent intracuff pressures below 20 cm H2O. The remaining factors analyzed were not significant. Failure of CASS did not influence the development of pneumonia among patients undergoing antibiotic treatment (33.0% versus 38.5%, p > 0.20), but was strongly associated with pneumonia (42.1% versus 8.3%, p < 0.01) among intubated patients not receiving antibiotics. When multivariate analysis was repeated in this subpopulation, failure of CASS (RR = 7.52, 95% CI = 1.48 to 38.07) and persistent intracuff pressure below 20 cm H2O (RR = 4.23, 95% CI = 1.12 to 15.92) were factors independently associated with the development of pneumonia. We conclude that leakage of colonized subglottic secretions around the cuff of the endotracheal tube is the most important risk factor for pneumonia within the first 8 d of intubation. This study confirms the importance of maintaining adequate intracuff pressure and effective aspiration of subglottic secretions in preventing pneumonia in intubated patients not receiving antibiotic treatment.

Thirty consecutively intubated patients with pneumonia due to Pseudomonas aeruginosa (cases) were prospectively observed to establish the attributable mortality rate and the prognostic value of APACHE (Acute Physiological and Chronic Health Evaluation) II scores. Four cases did not receive accurate empirical therapy and were excluded from the study. APACHE II scores were calculated within 24 hours of admission (T0), at the time of the diagnosis of pneumonia (T1), and after 72 hours of therapy (T2). The outcomes for these cases (n = 26) were compared with those for matched controls (n = 52) without pneumonia. Six cases died of causes directly related to pneumonia (group D). Two cases whose conditions clinically improved died of cardiac complications, and 18 cases had clinical resolution (group R); however, only 15 of these cases were alive at discharge. The mean APACHE II score at admission was similar (P > .20) for group R, group D, and controls. In contrast, the mean score at T1 (15.40 +/- 6.07 vs. 20.83 +/- 4.66; P < .05) and the mean score at T2 (10.40 +/- 3.57 vs. 25.50 +/- 3.93; P < .01) differed significantly for groups R and D, respectively. The overall observed and predicted mortality rates among cases and controls were 42.3% and 28.1% and 28.8% and 28.7%, respectively, while the attributable mortality rate among cases was estimated to be 13.5% (95% confidence interval, 1.95%-25.04%). We conclude that the attributable mortality rate among intubated patients with pneumonia due to P. aeruginosa is high. The APACHE II score at admission is not useful as a prognostic factor, while progression of organ dysfunction after the onset of pneumonia is an ominous sign.

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This qualitative study evaluates a decision aid that includes the benefits and harms of breast cancer screening and analyses women's perception of the information received and healthcare professionals' perceptions of the convenience of providing it. Seven focus groups of women aged 40-69 years (n = 39) and two groups of healthcare professionals (n = 23) were conducted in Catalonia and the Canary Islands. The focus groups consisted of guided discussions regarding decision-making about breast cancer screening, and acceptability and feasibility of the decision aid. A content analysis was performed. Women positively value receiving information regarding the benefits and harms of breast cancer screening. Several women had difficulties understanding some concepts, especially those regarding overdiagnosis. Women preferred to share the decisions on screening with healthcare professionals. The professionals noted the lack of inclusion of some harms and benefits in the decision aid, and proposed improving the clarity of the statistical information. The information on overdiagnosis generates confusion among women and controversy among professionals. Faced with the new information presented by the decision aid, the majority of women prefer shared decision-making; however, its feasibility might be limited by a lack of knowledge and attitudes of rejection from healthcare professionals.

ObjectiveTo describe the overall sleep health of the Catalan population using data from the 2015 Catalan Health Survey and to compare the performance of two sleep health indicators: sleep duration and a 5-dimension sleep scale (SATED).MethodsMultistage probability sampling representative of the non-institutionalized population aged 15 or more years, stratified by age, gender and municipality size, was used, excluding nightshift-workers. A total of 4385 surveys were included in the analyses. Associations between sleep health and the number of reported chronic diseases were assessed using non-parametric smoothed splines. Differences in the predictive ability of age-adjusted logistic regression models of self-rated health status were assessed. Multinomial logistic regression models were used to assess SATED determinants.ResultsOverall mean (SD) sleep duration was 7.18 (1.16) hours; and SATED score 7.91 (2.17) (range 0–10), lower (worse) scores were associated with increasing age and female sex. Alertness and efficiency were the most frequently impaired dimensions across age groups. SATED performed better than sleep duration when assessing self-rated health status (area under the curve = 0.856 vs. 0.798; p-value <0.001), and had a linear relationship with the number of reported chronic diseases, while the sleep duration relationship was u-shaped.ConclusionsSleep health in Catalonia is associated with age and gender. SATED has some advantaged compared to sleep duration assessment, as it relates linearly to health indicators, has a stronger association with self-rated health status, and provides a more comprehensive assessment of sleep health. Therefore, the inclusion of multi-dimensional sleep health assessment tools in national surveys should be considered.

The results are coherent with the studies that show that performance based examination using SPs can be used without introducing biases into students score.

Background ICU patients undergoing invasive mechanical ventilation experience cognitive decline associated with their critical illness and its management. The early detection of different cognitive phenotypes might reveal the involvement of diverse pathophysiological mechanisms and help to clarify the role of the precipitating and predisposing factors. Our main objective is to identify cognitive phenotypes in critically ill survivors 1 month after ICU discharge using an unsupervised machine learning method, and to contrast them with the classical approach of cognitive impairment assessment. For descriptive purposes, precipitating and predisposing factors for cognitive impairment were explored. Methods A total of 156 mechanically ventilated critically ill patients from two medical/surgical ICUs were prospectively studied. Patients with previous cognitive impairment, neurological or psychiatric diagnosis were excluded. Clinical variables were registered during ICU stay, and 100 patients were cognitively assessed 1 month after ICU discharge. The unsupervised machine learning K-means clustering algorithm was applied to detect cognitive phenotypes. Exploratory analyses were used to study precipitating and predisposing factors for cognitive impairment. Results K-means testing identified three clusters (K) of patients with different cognitive phenotypes: K1 (n = 13), severe cognitive impairment in speed of processing (92%) and executive function (85%); K2 (n = 33), moderate-to-severe deficits in learning-memory (55%), memory retrieval (67%), speed of processing (36.4%) and executive function (33.3%); and K3 (n = 46), normal cognitive profile in 89% of patients. Using the classical approach, moderate-to-severe cognitive decline was recorded in 47% of patients, while the K-means method accurately classified 85.9%. The descriptive analysis showed significant differences in days (p = 0.016) and doses (p = 0.039) with opioid treatment in K1 vs. K2 and K3. In K2, there were more women, patients were older and had more comorbidities (p = 0.001) than in K1 or K3. Cognitive reserve was significantly (p = 0.001) higher in K3 than in K1 or K2. Conclusion One month after ICU discharge, three groups of patients with different cognitive phenotypes were identified through an unsupervised machine learning method. This novel approach improved the classical classification of cognitive impairment in ICU survivors. In the exploratory analysis, gender, age and the level of cognitive reserve emerged as relevant predisposing factors for cognitive impairment in ICU patients. Trial registration ClinicalTrials.gov Identifier:NCT02390024; March 17,2015.

BackgroundHealth professionals and organizations in developed countries adapt slowly to the increase of ethnically diverse populations attending health care centres. Several studies report that attention to immigrant mental health comes up with barriers in access, diagnosis and therapeutics, threatening equity. This study analyzes differences in exposure to antidepressant drugs between the immigrant and the native population of a Spanish health region.MethodsCross-sectional study of the dispensation of antidepressant drugs to the population aged 15 years or older attending the public primary health centres of a health region, 232,717 autochthonous and 33,361 immigrants, during 2008. Data were obtained from computerized medical records and pharmaceutical records of medications dispensed in pharmacies. Age, sex, country of origin, visits, date of entry in the regional health system, generic drugs and active ingredients were considered. Statistical analysis expressed the percentage of persons exposed to antidepressants stratified by age, gender, and country of origin and prevalence ratios of antidepressant exposition were calculated.ResultsAntidepressants were dispensed to 11% of native population and 2.6% of immigrants. Depending on age, native women were prescribed antidepressants between 1.9 and 2.7 times more than immigrant women, and native men 2.5 and 3.1 times more than their immigrant counterparts. Among immigrant females, the highest rate was found in the Latin Americans (6.6%) and the lowest in the sub-Saharans (1.4%). Among males, the highest use was also found in the Latin Americans (1.6%) and the lowest in the sub-Saharans (0.7%). The percentage of immigrants prescribed antidepressants increased significantly in relation to the number of years registered with the local health system. Significant differences were found for the new antidepressants, prescribed 8% more in the native population than in immigrants, both in men and in women.ConclusionsAll the immigrants, regardless of the country of origin, had lower antidepressant consumption than the native population of the same age and sex. Latin American women presented the highest levels of consumption, and the sub-Saharan men the lowest. The prescription profiles also differed, since immigrants consumed more generics and fewer recently commercialized active ingredients.