Objective
To investigate the relationship between ambient temperature and atmospheric pressure (AP) and the severity of heart failure (HF) decompensations.
Methods
We analysed patients coming from ...the Epidemioloy Acute Heart Failure Emergency (EAHFE) Registry, a multicentre prospective cohort study enrolling patients diagnosed with decompensated HF in 26 emergency departments (EDs) of 16 Spanish cities. We recorded patient and demographic data and maximum temperature (
T
max
) and AP (AP
max
) the day before ED consultation. Associations between temperature and AP and severity endpoints were explored by logistic regression. We used restricted cubic splines to model continuous non-linear associations of temperature and AP with each endpoint.
Results
We analysed 16,545 patients. Daily
T
max
and AP
max
(anomaly) of the day before patient ED arrival ranged from 0.8 to 41.6° and from − 61.7 to 69.9 hPa, respectively. A total of 12,352 patients (75.2%) were hospitalised, with in-hospital mortality in 1171 (7.1%). The probability of hospitalisation by HF decompensation showed a U-shaped curve versus
T
max
and an increasing trend versus AP
max
. Regarding temperature, hospitalisation significantly increased from 20 °C (reference) upwards (25 °C: OR = 1.12, 95% CI = 1.04–1.21; 40 °C: 1.65, 1.13–2.40) and below 5.4 °C (5 °C: 1.21, 1.01–1.46). Concerning the mean AP of the city (anomaly = 0 hPa), hospitalisation increased when AP
max
(anomaly) was above + 7.0 hPa (atmospheric anticyclone; + 10 hPa: 1.14, 1.05–1.24; + 30 hPa: 2.02. 1.35–3.03). The lowest probability of mortality also corresponded to cold-mild temperatures and low AP, with a significant increased risk only found for
T
max
above 24.3 °C (25 °C: 1.13, 1.01–1.27; 40 °C: 2.05, 1.15–3.64) and AP
max
(anomaly) above + 3.4 hPa (+ 10 hPa: 1.21, 1.07–1.36; + 30 hPa: 1.73, 1.06–2.81). Sensitivity analysis confirmed the main analysis results.
Conclusion
Temperature and AP are independently associated with the severity of HF decompensations, with possible different effects on the need for hospitalisation and in-hospital mortality.
Aims
Benzodiazepines have been used as safe anxiolytic drugs for decades and some authors have suggested they could be an alternative for morphine for treating acute cardiogenic pulmonary oedema ...(ACPE). We compared the efficacy and safety of midazolam and morphine in patients with ACPE.
Methods and results
A randomized, multicentre, open‐label, blinded endpoint clinical trial was performed in seven Spanish emergency departments (EDs). Patients >18 years old clinically diagnosed with ACPE and with dyspnoea and anxiety were randomized (1:1) at ED arrival to receive either intravenous midazolam or morphine. Efficacy was assessed by in‐hospital all‐cause mortality (primary endpoint). Safety was assessed through serious adverse event (SAE) reporting, and the composite endpoint included 30‐day mortality and SAE. Analyses were made on an intention‐to‐treat basis. The trial was stopped early after a planned interim analysis by the safety monitoring committee. At that time, 111 patients had been randomized: 55 to midazolam and 56 to morphine. There were no significant differences in the primary endpoint (in‐hospital mortality for midazolam vs. morphine 12.7% vs. 17.9%; risk ratioRR 0.71, 95% confidence interval CI 0.29–1.74; p = 0.60). SAE were less common with midazolam versus morphine (18.2% vs. 42.9%; RR 0.42, 95% CI 0.22–0.80; p = 0.007), as were the composite endpoint (23.6% vs. 44.6%; RR 0.53, 95% CI 0.30–0.92; p = 0.03).
Conclusion
Although the number of patients was too small to draw final conclusions and there were no significant differences in mortality between midazolam and morphine, a significantly higher rate of SAEs was found in the morphine group.
There were no significant differences in mortality between morphine and midazolam but the rate of serious adverse events was significantly higher in the morphine group, although the number of patients was too small to draw final conclusions.
To analyze whether the high levels of air pollutants are related to a greater severity of decompensated heart failure (HF).
Patients diagnosed with decompensated HF in the emergency department of 4 ...hospitals in Barcelona and 3 in Madrid were included. Clinical data (age, sex, comorbidities, baseline functional status), atmospheric (temperature, atmospheric pressure) and pollutant data (SO
, NO
, CO, O
, PM
, PM
) were collected in the city on the day of emergency care. The severity of decompensation was estimated using 7-day mortality (primary indicator) and the need for hospitalization, in-hospital mortality, and prolonged hospitalization (secondary indicators). The association adjusted for clinical, atmospheric and city data between pollutant concentration and severity was investigated using linear regression (linearity assumption) and restricted cubic spline curves (no linearity assumption).
A total of 5292 decompensations were included, with a median age of 83 years (IQR=76-88) and 56% women. The medians (IQR) of the daily pollutant averages were: SO
=2.5μg/m
(1.4-7.0), NO
=43μg/m
(34-57), CO=0.48mg/m
(0.35-0.63), O
=35μg/m
(25-48), PM
=22μg/m
(15-31) and PM
=12μg/m
(8-17). Mortality at 7 days was 3.9%, and hospitalization, in-hospital mortality, and prolonged hospitalization were 78.9, 6.9, and 47.5%, respectively. SO
was the only pollutant that showed a linear association with the severity of decompensation, since each unit of increase implied an OR for the need for hospitalization of 1.04 (95% CI 1.01-1.08). The restricted cubic spline curves study also did not show clear associations between pollutants and severity, except for SO
and hospitalization, with OR of 1.55 (95% CI 1.01-2.36) and 2.71 (95% CI 1.13-6.49) for concentrations of 15 and 24μg/m
, respectively, in relation to a reference concentration of 5μg/m
.
Exposure to ambient air pollutants, in a medium to low concentration range, is generally not related to the severity of HF decompensations, and only SO
may be associated with an increased need for hospitalization.
Preoperative treatment and adequate surgery increase local control in rectal cancer. However, modalities and indications for neoadjuvant treatment may be controversial. Aim of this study was to ...assess the trends of preoperative treatment and outcomes in patients with rectal cancer included in the Rectal Cancer Registry of the Spanish Associations of Surgeons.
This is a STROBE-compliant retrospective analysis of a prospective database. All patients operated on with curative intention included in the Rectal Cancer Registry were included. Analyses were performed to compare the use of neoadjuvant/adjuvant treatment in three timeframes: I)2006–2009; II)2010–2013; III)2014–2017. Survival analyses were run for 3-year survival in timeframes I-II.
Out of 14,391 patients,8871 (61.6%) received neoadjuvant treatment. Long-course chemo/radiotherapy was the most used approach (79.9%), followed by short-course radiotherapy ± chemotherapy (7.6%). The use of neoadjuvant treatment for cancer of the upper third (15-11 cm) increased over time (31.5%vs 34.5%vs 38.6%,p = 0.0018). The complete regression rate slightly increased over time (15.6% vs 16% vs 18.5%; p = 0.0093); the proportion of patients with involved circumferential resection margins (CRM) went down from 8.2% to 7.3%and 5.5% (p = 0.0004). Neoadjuvant treatment significantly decreased positive CRM in lower third tumors (OR 0.71, 0.59–0.87, Cochrane-Mantel-Haenszel P = 0.0008). Most ypN0 patients also received adjuvant therapy. In MR-defined stage III patients, preoperative treatment was associated with significantly longer local-recurrence-free survival (p < 0.0001), and cancer-specific survival (p < 0.0001). The survival benefit was smaller in upper third cancers.
There was an increasing trend and a potential overuse of neoadjuvant treatment in cancer of the upper rectum. Most ypN0 patients received postoperative treatment. Involvement of CRM in lower third tumors was reduced after neoadjuvant treatment. Stage III and MRcN + benefited the most.
Anal abscess is the most frequent urgent proctological problem. The recurrence rate and reported incidence of fistula after drainage and debridement of an anal abscess is widely variable. The ...objective of this study is to analyse the long-term recurrence rate and the incidence of fistula after drainage and urgent debridement of an anal abscess.
Retrospective observational study of a prospective cohort with anal abscess of cryptoglandular origin. All patients (n = 303) were evaluated two months and one year after the intervention. At the 5
year, all the medical records were reviewed and a telephone call or appointment was made for an assessment if necessary. Specific antecedents of anal pathology, abscess characteristics, time and type of recurrence, presence of symptoms in the first revision and presence of clinical and/or ultrasound fistula were recorded.
Mean follow-up 119.7 months. Recurrence rate 48.2% (82.2% in the first year). Two hundred twenty-two ultrasounds performed. Incidence of ultrasound fistula: 70% symptomatic vs. 2.4% asymptomatic (p < 0.001). Global incidence of fistula 40.3%. The history of anal pathology and the presence of symptoms in the postoperative review significantly increase the possibility of recurrence (p < 0.001). The fistula is statistically more frequent if the abscess recurs (p < 0.001) CONCLUSION: After drainage and debridement of an anal abscess, half of the patients relapse and 40% develop fistula especially in the first year, so longer follow-ups are not necessary. Endoanal ultrasound for the evaluation of the presence of fistula is highly questionable in the absence of signs or symptoms.
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Anal abscess is the most frequent urgent proctological problem. The recurrence rate and reported incidence of fistula after drainage and debridement of an anal abscess is widely ...variable. The objective of this study is to analyse the long-term recurrence rate and the incidence of fistula after drainage and urgent debridement of an anal abscess.
Retrospective observational study of a prospective cohort with anal abscess of cryptoglandular origin. All patients (n = 303) were evaluated two months and one year after the intervention. At the 5th year, all the medical records were reviewed and a telephone call or appointment was made for an assessment if necessary. Specific antecedents of anal pathology, abscess characteristics, time and type of recurrence, presence of symptoms in the first revision and presence of clinical and/or ultrasound fistula were recorded.
Mean follow-up 119.7 months. Recurrence rate 48.2% (82.2% in the first year). Two hundred twenty-two ultrasounds performed. Incidence of ultrasound fistula: 70% symptomatic vs. 2.4% asymptomatic (p < 0.001). Global incidence of fistula 40.3%. The history of anal pathology and the presence of symptoms in the postoperative review significantly increase the possibility of recurrence (p < 0.001). The fistula is statistically more frequent if the abscess recurs (p < 0.001).
After drainage and debridement of an anal abscess, half of the patients relapse and 40% develop fistula especially in the first year, so longer follow-ups are not necessary. Endoanal ultrasound for the evaluation of the presence of fistula is highly questionable in the absence of signs or symptoms.
El absceso anal es el problema proctológico urgente más frecuente. La tasa de recidiva y la incidencia de fístula publicada tras el drenaje y desbridamiento de un absceso anal es ampliamente variable. El presente estudio tiene como objetivo analizar la tasa de recurrencia y la incidencia de fístula a largo plazo tras el drenaje y desbridamiento urgente de un absceso anal.
Estudio observacional retrospectivo de una cohorte prospectiva con absceso anal de origen criptoglandular. Todos los pacientes (n = 303) fueron evaluados a los dos meses y al año de la intervención. Al quinto año se revisaron todas las historias clínicas y se llamó telefónicamente o se citó en consulta para valoración. Se registraron los antecedentes específicos de patología anal, características del absceso, momento y tipo de la recidiva, presencia de sintomatología en la primera revisión y presencia de fístula clínica y/o ecográfica.
Seguimiento medio de 119,7 meses. Tasa de recidiva 48,2% (82,2% en 1er año). Doscientas veintidós ecografías realizadas. Incidencia de fístula ecográfica: 70% sintomáticos vs. 2,4% asintomáticos (p < 0,001). Incidencia global de fístula 40,3%. Los antecedentes de patología anal y la presencia de clínica en la revisión postoperatoria aumentan significativamente la posibilidad de recidiva (p < 0,001). La fístula es estadísticamente más frecuente si el absceso presenta recurrencia (p < 0,001).
Tras el drenaje y desbridamiento de un absceso anal la mitad de los pacientes recidivan y un 40% desarrollan fístula. Seguimientos mayores de un año no son necesarios. La ecografía endoanal para la evaluación de la presencia de fístula es muy cuestionable en ausencia de signos o síntomas.
To analyze whether the high levels of air pollutants are related to a greater severity of decompensated heart failure (HF).
Patients diagnosed with decompensated HF in the emergency department of 4 ...hospitals in Barcelona and 3 in Madrid were included. Clinical data (age, sex, comorbidities, baseline functional status), atmospheric (temperature, atmospheric pressure) and pollutant data (SO2, NO2, CO, O3, PM10, PM2.5) were collected in the city on the day of emergency care. The severity of decompensation was estimated using 7-day mortality (primary indicator) and the need for hospitalization, in-hospital mortality, and prolonged hospitalization (secondary indicators). The association adjusted for clinical, atmospheric and city data between pollutant concentration and severity was investigated using linear regression (linearity assumption) and restricted cubic spline curves (no linearity assumption).
A total of 5292 decompensations were included, with a median age of 83 years (IQR=76–88) and 56% women. The medians (IQR) of the daily pollutant averages were: SO2=2.5μg/m3 (1.4–7.0), NO2=43μg/m3 (34–57), CO=0.48mg/m3 (0.35–0.63), O3=35μg/m3 (25–48), PM10=22μg/m3 (15–31) and PM2.5=12μg/m3 (8–17). Mortality at 7 days was 3.9%, and hospitalization, in-hospital mortality, and prolonged hospitalization were 78.9, 6.9, and 47.5%, respectively. SO2 was the only pollutant that showed a linear association with the severity of decompensation, since each unit of increase implied an OR for the need for hospitalization of 1.04 (95% CI 1.01–1.08). The restricted cubic spline curves study also did not show clear associations between pollutants and severity, except for SO2 and hospitalization, with OR of 1.55 (95% CI 1.01–2.36) and 2.71 (95% CI 1.13–6.49) for concentrations of 15 and 24μg/m3, respectively, in relation to a reference concentration of 5μg/m3.
Exposure to ambient air pollutants, in a medium to low concentration range, is generally not related to the severity of HF decompensations, and only SO2 may be associated with an increased need for hospitalization.
Analizar si la exposición a contaminantes del aire en 2 grandes ciudades españolas está relacionada con la gravedad de las descompensaciones de la insuficiencia cardiaca (IC).
Se estudiaron pacientes con IC descompensada en urgencias de 4 hospitales de Barcelona y 3 de Madrid. Se recogieron datos clínicos (edad, sexo, comorbilidades, situación funcional basal), atmosféricos (temperatura, presión atmosférica) y de contaminantes (SO2, NO2, CO, O3, PM10, PM2,5) el día de atención en urgencias. La gravedad de la descompensación se estimó mediante la mortalidad a 7 días (indicador primario) y la necesidad de hospitalización, mortalidad intrahospitalaria y hospitalización prolongada (indicadores secundarios). Se investigó la asociación ajustada por datos clínicos, atmosféricos y ciudad entre concentración de contaminantes y gravedad, mediante regresión logística (asunción de linealidad) y curvas spline cúbicas restringidas (no asunción de linealidad).
Se incluyeron 5.292 descompensaciones, con edad mediana de 83 años (RIC=76–88) y 56% mujeres. Las medianas (RIC) de los promedios diarios de contaminantes fueron: SO2=2,5μg/m3 (1,4–7,0), NO2=43μg/m3 (34–57), CO=0,48mg/m3 (0,35–0,63), O3=35μg/m3 (25–48), PM10=22μg/m3 (15–31) y PM2,5=12μg/m3 (8–17). La mortalidad a 7 días fue del 3,9%, y la hospitalización, la mortalidad intrahospitalaria y la hospitalización prolongada, del 78,9, 6,9 y 47,5%, respectivamente. El SO2 fue el único contaminante que mostró asociación lineal con la gravedad de la descompensación, ya que cada unidad de incremento supuso una OR para necesidad de hospitalización de 1,04 (IC 95% 1,01–1,08). El estudio mediante curvas spline cúbicas restringidas tampoco mostró asociaciones nítidas entre contaminantes y gravedad, excepto para SO2 y hospitalización, con OR de 1,55 (IC 95% 1,01–2,36) y de 2,71 (IC 95% 1,13–6,49) para concentraciones de 15 y 24μg/m3, respectivamente, en relación con una concentración de referencia de 5μg/m3.
La exposición a contaminantes del aire ambiente, en un rango de concentraciones medio a bajo, en general no está relacionado con la gravedad de las descompensaciones de la IC, y solo el SO2 podría estar asociado a una mayor necesidad de hospitalización.
The MIMO clinical trial showed that patients with acute cardiogenic pulmonary edema (ACPE) treated with midazolam had fewer serious adverse events than those treated with morphine. Atrial ...fibrillation (AF) is a common comorbidity in heart failure and affects patient's outcome.
The primary endpoint of this substudy is to know if AF modified the reduced risk of serious adverse events in the midazolam arm compared to morphine. The first secondary endpoint is to know if AF modified the reduced risk of serious adverse events or death at 30 days in the midazolam arm. The second secondary objective of this substudy is to analyze whether AF modified the reduced risk of midazolam against morphine on the total number of serious adverse events per patient.
We conducted a secondary analysis of the MIMO trial. Patients more than 18 years old clinically diagnosed with ACPE and with dyspnea and anxiety were randomized (1:1) at emergency department arrival to receive either intravenous midazolam or morphine.
In this post hoc analysis, we calculated the relative risk (RR) of serious adverse events in patients with and without AF. Calculating the Cochran-Mantel-Haenszel interaction test, we evaluated if AF modified the reduced risk of serious adverse events in the midazolam arm compared to morphine.
One hundred eleven patients (median = 78.9 years; IQR, 72.3-83.7; women, 52.2%) were randomized in the MIMO trial, 55 to receive midazolam and 56 to morphine. All randomized patients received the assigned drug and there were no losses to follow-up. Forty-four patients (39.6%) had AF. In the AF group, the RR for the incidence of serious adverse events in the midazolam versus morphine arm was 0.42 (95% CI, 0.14-1.3). In the group without AF, the RR was 0.46 (95% CI, 0.21-1). The presence of AF did not modify the reduced risk of serious adverse events in the midazolam arm compared with morphine ( P for interaction = 0.88).
This post hoc analysis of the MIMO trial suggests that the reduced risk of serious adverse events in the midazolam group compared to morphine is similar in patients with and without AF.
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