Commentary : beyond vague causal effect estimation of obesity on health outcomes

In the current issue of epidemiology, Danaei and colleagues elegantly estimated both the direct effect and the indirect effect-that is, the effect mediated by blood pressure, cholesterol, glucose, fibrinogen, and high-sensitivity C-reactive protein-of body mass index (BMI) on the risk of coronary heart disease (CHD). they analyzed data from 9 cohort studies including 58,322 patients and 9459 CHD events, with baseline measurements between 1954 and 2001. Using sophisticated and cutting-edge methods for direct and indirect effect estimations, the authors estimated that half of the risk of overweight and obesity would be mediated by blood pressure, cholesterol, and glucose. Few additional percentage points of the risk would be mediated by fibrinogen and hs-CRP. How should we understand these estimates? Can we say that if obese persons reduce their body weight and reach a normal body weight, their excess risk of CHD would be reduced by half through an improvement in these mediators and by half through the reduction in BmI itself? Is that also true if these individuals are prevented from becoming obese in the first place? Can we also conclude that if these mediators are well controlled in obese individuals through other means than a body weight reduction, their excess risk of CHD would be reduced by half? Let us confront these estimates with observations from studies evaluating 2 interventions to reduce body weight, that is, bariatric surgery in patients with severe obesity and intensive lifestyle intervention in overweight patients with diabetes

Validation of a model to predict adverse outcomes in patients with pulmonary embolism.

AIMS: To validate a model for quantifying the prognosis of patients with pulmonary embolism (PE). The model was previously derived from 10 534 US patients. METHODS AND RESULTS: We validated the model in 367 patients prospectively diagnosed with PE at 117 European emergency departments. We used baseline data for the model's 11 prognostic variables to stratify patients into five risk classes (I-V). We compared 90-day mortality within each risk class and the area under the receiver operating characteristic curve between the validation and the original derivation samples. We also assessed the rate of recurrent venous thrombo-embolism and major bleeding within each risk class. Mortality was 0% in Risk Class I, 1.0% in Class II, 3.1% in Class III, 10.4% in Class IV, and 24.4% in Class V and did not differ between the validation and the original derivation samples. The area under the curve was larger in the validation sample (0.87 vs. 0.78, P=0.01). No patients in Classes I and II developed recurrent thrombo-embolism or major bleeding. CONCLUSION: The model accurately stratifies patients with PE into categories of increasing risk of mortality and other relevant complications. Patients in Risk Classes I and II are at low risk of adverse outcomes and are potential candidates for outpatient treatment.

Consolidation whole abdomen irradiation following adjuvant carboplatin-paclitaxel based chemotherapy for advanced uterine epithelial cancer: feasibility, toxicity and outcomes.

BACKGROUND: To evaluate feasibility and preliminary outcomes associated with sequential whole abdomen irradiation (WAI) as consolidative treatment following comprehensive surgery and systemic chemotherapy for advanced endometrial cancer. METHODS: We conducted a retrospective analysis of patients treated at our institution from 2000 to 2011. Inclusion criteria were stage III-IV endometrial cancer patients with histological proof of one or more sites of extra-uterine abdomen-confined disease, treated with WAI as part of multimodal therapy. Endpoints were feasibility, acute toxicity, late effects, recurrence-free survival (RFS) and overall survival (OS). Twenty patients were identified. Chemotherapy consisted of 3 to 6 cycles of a platinum-paclitaxel regimen in 18 patients. WAI was delivered using conventional technique to a median total dose of 27.5 Gy. RESULTS: No grade 4 toxicities occurred during chemotherapy or radiotherapy. No radiation dose reduction was necessary. Three patients developed small bowel obstruction, all in the context of recurrent intraperitoneal disease. Kaplan-Meier estimates and 95% confidence intervals for RFS and OS at one year were 63% (38-80%) and 83% (56-94%) and at 3 years 57% (33-76%) and 62% (34-81%), respectively. On univariate Cox analysis, stage IVB and serous papillary (SP) histology were found to be statistically significantly (at the p = 0.05 level) associated with worse RFS and OS. The peritoneal cavity was the most frequent site of initial failure. CONCLUSIONS: Consolidative WAI following chemotherapy is feasible and can be performed without interruption with manageable acute and late toxicity. Patients with endometrioid adenocarcinoma, especially stage FIGO III, had favorable outcomes possibly meriting prospective evaluation of the addition of WAI following chemotherapy in selected patients. Patients with SP do poorly and do not routinely benefit from this approach.

Risk factor impact on blood flow velocities and clinical outcomes of stented cervical and intracranial stenoses: preliminary observations.

OBJECTIVES: The role of angioplasty/stenting procedures, neurointerventionist experience, vascular risk factors, medical treatment and blood flow velocities were analysed to identify possible causes of intra-stent restenosis (ISR) following stenting of cervical and/or intracranial arteries, assuming progressive atherosclerosis to be the shared mechanism in both territories. Patients. 26 cerebrovascular patients subjected to stenting of severe (≥85%) symptomatic or asymptomatic carotid stenoses or moderate-to-severe (≥50%) intracranial or vertebral stenoses were included. METHODS: Clinical, radiological and ultrasonographic follow-up data were analysed retrospectively. RESULTS: Overall, stenting of the internal carotid artery (ICA) induced significant reductions in peak systolic velocities at 2 years (96±31cm/s vs. 358.2±24.9cm/s at baseline). The procedure-related ischemic complications rate was 7.4% (one hemispheric stroke and one TIA). The rate of ISR≤50% was 8% in the ICA at 2 years; was 50% in the common carotid artery (CCA) at 1 year, with concomitant distal ICA stenosis in 75% of CCA stenting, but all ISR were asymptomatic. Patients with ISR of the ICA were significantly younger (56.8±4.5 vs. 71.3±3.6 years, P=0.042) and had significantly more risk factors (5.5±0.9 vs. 3±0.3, P=0.012). No ISR≥70% was detected. CONCLUSIONS: ISR is relatively infrequent and, when present, it is mild and asymptomatic. Restenosis is more frequent in younger patients and those with several risk factors, and it may also be related to stenting of previous carotid endarterectomy.

La normativa municipal española a mediados del siglo XIX. Espacio electoral y definición social del modelo liberal en Lleida

El análisis y la comparación de las leyes municipales y, más concretamente, de los censos electorales de Lleida en el periodo liberal que abarcó de 1837 a 1853 muestra como se adoptaron diversos modelos electorales en ese momento según fuese el partido que gobernase. Así, cuando lo hicieron los progresistas elaboraron una ley electoral descentralizada y ampliaron el censo de electores hasta llegar a cubrir las capas medias de la sociedad de Lleida, mientras que los moderados, cuando lo hicieron, legislaron para jerarquizar el poder del Estado del centro a las provincias y recortaron el censo hasta dejar a los 250 mayores contribuyentes de la ciudad. El segundo objetivo del estudio ha mostrado la evolución del electorado municipal del municipio a raíz de la abertura liberal que significó el triunfo de la Revolución Burguesa, que propició que los sectores que vivieron una coyuntura económica favorable, principalmente los dedicados al comercio, se situasen en los primeros lugares entre los mayores contribuyentes en detrimento de otros grupos, el campesinado, que permanecían estancados.

El proceso electoral en España y Cataluña según la Constitución de 1812

En el presente trabajo se analiza la normativa electoral y su aplicación incluida en el articulado de la Constitución de 1812. Para ello en primer lugar se estudia el espíritu del proyecto electoral constitucional. Posteriormente se analiza su aplicación en los comicios para elegir las Cortes Ordinarias de 1813 en las dos realidades que contempla: los territorios de la metrópoli y los de ultramar. Analizada la normativa electoral, establecemos el Parlamento teórico resultante y su aplicación real. Finalmente, realizamos un análisis prosopográfico de los diputados elegidos en España y Cataluña, establecemos la morfología del parlamentario tipo y lo comparamos con los resultados de las dos realidades electorales apuntadas.

Proceso electoral y prosopografía de los diputados de las Cortes Extraordinarias de Cádiz (1810-1813)

En el presente trabajo analizamos el proceso de elección de los diputados españoles en las Cortes Extraordinarias de Cádiz (1810-1813), la sociología de estos parlamentarios y su asistencia en el Parlamento. Después de efectuar el análisis observamos en primer lugar que hubo cuatro modalidades de elección de los diputados y que, una vez escogidos, nunca se cubrieron todos los puestos de diputado otorgados. En segundo lugar, detectamos que los diputados elegidos por los diversos entes que participaron en el proceso electoral fueron en su mayoría de condición social acomodada y representativos de la sociedad española, sobresaliendo en número el grupo de diputados eclesiásticos, de leyes y funcionarios.

Outcomes of minimally invasive simple prostatectomy for benign prostatic hyperplasia: a systematic review and meta-analysis.

PURPOSE: (1) To assess the outcomes of minimally invasive simple prostatectomy (MISP) for the treatment of symptomatic benign prostatic hyperplasia in men with large prostates and (2) to compare them with open simple prostatectomy (OSP). METHODS: A systematic review of outcomes of MISP for benign prostatic hyperplasia with meta-analysis was conducted. The article selection process was conducted according to the PRISMA guidelines. RESULTS: Twenty-seven observational studies with 764 patients were analyzed. The mean prostate volume was 113.5 ml (95 % CI 106-121). The mean increase in Qmax was 14.3 ml/s (95 % CI 13.1-15.6), and the mean improvement in IPSS was 17.2 (95 % CI 15.2-19.2). Mean duration of operation was 141 min (95 % CI 124-159), and the mean intraoperative blood loss was 284 ml (95 % CI 243-325). One hundred and four patients (13.6 %) developed a surgical complication. In comparative studies, length of hospital stay (WMD -1.6 days, p = 0.02), length of catheter use (WMD -1.3 days, p = 0.04) and estimated blood loss (WMD -187 ml, p = 0.015) were significantly lower in the MISP group, while the duration of operation was longer than in OSP (WMD 37.8 min, p < 0.0001). There were no differences in improvements in Qmax, IPSS and perioperative complications between both procedures. The small study sizes, publication bias, lack of systematic complication reporting and short follow-up are limitations. CONCLUSIONS: MISP seems an effective and safe treatment option. It provides similar improvements in Qmax and IPSS as OSP. Despite taking longer, it results in less blood loss and shorter hospital stay. Prospective randomized studies comparing OSP, MISP and laser enucleation are needed to define the standard surgical treatment for large prostates.

El enigma del voto étnico o las tribulaciones del movimiento indígena: reflexiones sobre los resultados de la primera vuelta electoral (2006) en las províncias de la sierra (Coyuntura)

Con toda seguridad, uno de los aspectos que más sorprendieron a la opinión pública ecuato" riana de los resultados de la primera vuelta de las elecciones presidenciales de octubre de 2006, fue el triunfo sin paliativos de la candidatura de Gilmar Gutiérrez en las provincias del callejón interandino y el aparente hundimiento del candidato de Pachakutik en escenarios como los de Cañar; Chimborazo, Bolívar, Cotopaxi o lmbabura, otrora verdaderos baluartes del poder de convocatoria del movimiento indígena.

Los diputados catalanes en las Cortes de Cádiz (1810-1813) : proceso electoral y prosopografía

En el presente trabajo pretendemos analizar el proceso de elección de los diputados catalanes que representaron al Principado de Cataluña en las Cortes de Cádiz (1810-1813), la sociología de los parlamentarios y su comportamiento en el Parlamento según la ideología que manifestaron. Para el estudio hemos cruzado, principalmente, los datos del Diccionario Biográfico de los Parlamentarios Españoles (Madrid, 2010) y la documentación del Archivo del Congreso de los Diputados. Tras el análisis del proceso electoral, primero observamos que nunca se cubrieron todos los puestos otorgados a Cataluña. En segundo lugar, los diputados elegidos fueron, en su mayoría, de condición social acomodada, representativos de la sociedad catalana y acordes con sus homónimos españoles, sobresaliendo en número los grupos de diputados eclesiásticos, abogados y nobles. En tercer lugar, a diferencia del caso global español, destacamos que la adscripción política de la representación catalana fue de mayoría realista y se mostró globalmente contraria a la legislación liberal aprobada en Cádiz.

Perceptions of twelve-step mutual-help groups and their associations with motivation, treatment attendance and alcohol outcomes among chronically homeless individuals with alcohol problems.

BACKGROUND: Twelve-step mutual-help groups (TMGs) are among the most available forms of support for homeless individuals with alcohol problems. Qualitative research, however, has suggested that this population often has negative perceptions of these groups, which has been shown to be associated with low TMG attendance. It is important to understand this population's perceptions of TMGs and their association with alcohol outcomes to provide more appropriate and better tailored programming for this multiply affected population. The aims of this cross-sectional study were to (a) qualitatively examine perception of TMGs in this population and (b) quantitatively evaluate its association with motivation, treatment attendance and alcohol outcomes. METHODS: Participants (N=62) were chronically homeless individuals with alcohol problems who received single-site Housing First within a larger evaluation study. Perceptions of TMGs were captured using an open-ended item. Quantitative outcome variables were created from assessments of motivation, treatment attendance and alcohol outcomes. RESULTS: Findings indicated that perceptions of TMGs were primarily negative followed by positive and neutral perceptions, respectively. There were significant, positive associations between perceptions of TMGs and motivation and treatment attendance, whereas no association was found for alcohol outcomes. CONCLUSIONS: Although some individuals view TMGs positively, alternative forms of help are needed to engage the majority of chronically homeless individuals with alcohol problems.