Recommendations for the care of patients with cardiovascular disease in health emergency situations: a call to action.

COVID-19 has had a negative impact on the health care of patients with cardiovascular disease and patients at high risk of cardiovascular disease. The restrictions affecting access to the health care system have conditioned the care received, resulting in poorer control and a higher risk of events. Taking action to improve the care provided during health emergencies is mandatory. It is important to promote the development of telemedicine and patient empowerment by fostering health literacy and a higher degree of self-care. In addition, primary care and coordination between health care levels should be improved. Moreover, the simplification and optimization of treatment, for example, using the cardiovascular polypill, have led to an improvement in adherence, better control of vascular risk factors, and a reduced risk of events. The present document provides specific recommendations for improving the care provided to patients under a health emergency.

Abnormal ankle-brachial index, cardiovascular risk factors and healthy lifestyle factors in hypertensive patients: prospective cohort study from a primary care urban population.

BACKGROUND: Peripheral arterial disease (PAD) and arterial stiffness (AS) may be hypertension-mediated vascular lesions. Both are determined by an abnormal ankle-brachial index (ABI) and are predictors of cardiovascular disease (CVD) and mortality. We assessed the relationship in urban hypertensive patients between an abnormal ABI and an ideal cardiovascular health (CVH) score, plus other healthy factors, with unfavourable outcomes. METHODS: We studied 243 hypertensive patients from a primary care urban population, followed for two years. Clinical data, comorbid conditions, including hypertension-mediated organ damage (HMOD) and hypertension-related comorbidities (HRC), hospitalizations and mortality were also recorded. RESULTS: A low prevalence of ideal CVH was observed in urban hypertensive patients. The ABI ≤ 0.9 group (n = 16) showed a higher proportion of prior CVD other than PAD, mortality and hospitalizations than the ABI > 1.4 group (n = 41), and a poorer lipid, metabolic and renal profile. An inverse relationship between CVH score and ABI ≤ 0.9 and unfavourable outcomes (HMOD, HRC, death or hospitalization) was observed. Chronic kidney disease (CKD) and diabetes were independently associated with an ABI ≤ 0.9. Age, sex, diabetes, CKD, ABI ≤ 0.9 and ideal cholesterol were also associated with outcomes, but not other CVH metrics. CONCLUSIONS: Besides a low prevalence of ideal CVH, an inverse relationship between CVH score and ABI ≤ 0.9 and unfavourable outcomes was observed in hypertensive patients from an urban population. Stronger efforts to promote ideal CVH may improve outcomes in this particular population.

Postoperative Diet with an Oligomeric Hyperproteic Normocaloric Supplement versus a Supplement with Immunonutrients in Colorectal Cancer Surgery: Results of a Multicenter, Double-Blind, Randomized Clinical Trial.

(1) Background: For normo-nourished colorectal cancer patients, the need for immunonutrients after elective surgery is not known. (2) Methods: Multicenter, randomized, double-blind, phase III clinical trial comparing the postoperative diet with 200 mL oligomeric hyperproteic normocaloric (OHN; experimental arm) supplement vs. 200 mL immunonutritional (IN) (active comparator) supplement twice a day for five days in 151 normo-nourished adult colorectal-resection patients following the multimodal rehabilitation ERAS protocol. The proportions of patients with complications (primary outcome) and those who were readmitted, hospitalized for <7 days, had surgical site infections, or died due to surgical complications (secondary outcome) were compared between the two groups until postoperative day 30. Tolerance to both types of supplement and blood parameters was also assessed until day 5. (3) Results: Mean age was 69.2 and 84 (58.7%) were men. Complications were reported in 41 (28.7%) patients and the incidence did not differ between groups (18 (25%) vs. 23 (32.4%) patients with OHN and IN supplement, respectively; p = 0.328). No significant differences were found for the rest of the variables. (4) Conclusions: IN supplement may not be necessary for the postoperative recovery of colorectal cancer patients under the ERAS regimen and with normal nutritional status at the time of surgery.

Management of Type 2 Diabetes Mellitus in Elderly Patients with Frailty and/or Sarcopenia.

The life expectancy of the population is increasing worldwide due to improvements in the prevention, diagnosis, and treatment of diseases. This favors a higher prevalence of type 2 diabetes mellitus (T2DM) in the elderly. Sarcopenia and frailty are also frequently present in aging. These three entities share common mechanisms such as insulin resistance, chronic inflammation, and mitochondrial dysfunction. The coexistence of these situations worsens the prognosis of elderly patients. In this paper, we review the main measures for the prevention and management of sarcopenia and/or frailty in elderly patients with T2DM.

Remdesivir in Very Old Patients (≥80 Years) Hospitalized with COVID-19: Real World Data from the SEMI-COVID-19 Registry.

(1) Background: Large cohort studies of patients with COVID-19 treated with remdesivir have reported improved clinical outcomes, but data on older patients are scarce. Objective: This work aims to assess the potential benefit of remdesivir in unvaccinated very old patients hospitalized with COVID-19; (2) Methods: This is a retrospective analysis of patients ≥ 80 years hospitalized in Spain between 15 July and 31 December 2020 (SEMI-COVID-19 Registry). Differences in 30-day all-cause mortality were adjusted using a multivariable regression analysis. (3) Results: Of the 4331 patients admitted, 1312 (30.3%) were ≥80 years. Very old patients treated with remdesivir (n: 140, 10.7%) had a lower mortality rate than those not treated with remdesivir (OR (95% CI): 0.45 (0.29−0.69)). After multivariable adjustment by age, sex, and variables associated with lower mortality (place of COVID-19 acquisition; degree of dependence; comorbidities; dementia; duration of symptoms; admission qSOFA; chest X-ray; D-dimer; and treatment with corticosteroids, tocilizumab, beta-lactams, macrolides, and high-flow nasal canula oxygen), the use of remdesivir remained associated with a lower 30-day all-cause mortality rate (adjusted OR (95% CI): 0.40 (0.22−0.61) (p < 0.001)). (4) Conclusions: Remdesivir may reduce mortality in very old patients hospitalized with COVID-19.

A healthy lifestyle is associated with lower arterial stiffness in a metabolically healthy elderly population with overweight or obesity.

BACKGROUND AND AIMS: Arterial stiffness is linked with the development of cardiovascular and noncardiovascular diseases. In clinical practice, measurement of carotid-femoral pulse wave velocity (cf-PWV) has become a widely used study for the assessment of cardiovascular risk in elderly population. Our aim was to evaluate whether maintaining a healthy life, based on Mediterranean Diet (MedDiet) and regular practice of physical activity, are associated with arterial stiffness in an elderly, metabolically healthy with overweight or obesity (MHOe) population. INDIVIDUALS AND METHODS: A transversal, analytical-descriptive study in MHOe population (aged ≥65 years) with a BMI at least 27 kg/ m 2 who had one or less of the following cardiometabolic disorders: fasting plasma glucose at least 100 mg/dl, blood pressure at least 135/85 mmHg (or the use of blood pressure-lowering agents), low high-density lipoprotein (HDL) cholesterol (≤ 40 mg/dl for men, ≤50 mg/dl for women) or triglycerides at least 150 mg/dl (or the use of lipid-lowering therapies) was conducted. Blood pressure, height, weight, BMI, waist to hip ratio (WHR), practice of physical activity, MedDiet adherence and food intake along with cf-PWV were analysed. RESULTS: One hundred and fifty-eight MHOe individuals (age: 72.2 ±â€Š5.0 years, BMI: 31.6 ±â€Š3.8 kg/m 2 ) were recruited. One hundred and nine of them were younger than 75 years of age (young-old, age: 69.3 ±â€Š2.8 years and BMI: 32.0 ±â€Š3.9 kg/m 2 ) and 49 of them aged 75 years or older (old-old, age: 78.1 ±â€Š2.9 years and BMI: 30.7 ±â€Š3.6 kg/m 2 ). All population showed a strong adherence to the Med Diet due major consumption of homemade meal, olive oil and lean meats. In addition, they presented an important practice of all intensities of physical activity. Young-old individuals had a cf-PWV of 9.7 ±â€Š2.2 m/s and old-old individuals had a cf-PWV of 11.1 ±â€Š4.4 m/s. In all populations, a negative correlation between cf-PWV and BMI ( r  = -0.17, P  = 0.04) and a positive correlation with WHR in men ( r  = 0.18, P  = 0.03) was found. WHR shows a significantly positive correlation with the cf-PWV values in old-old women participants ( r  = 0.41, P  = 0.008). On the other side, only vigorous physical activity showed a negative correlation with cf-PWV in all population and in young-old individuals ( r  = -0.20; P  = 0.02 and r  = -0.22; P  = 0.03, respectively). CONCLUSION: Healthy lifestyle habits based on MedDiet adherence and regular practice of physical activity are associated with lower arterial stiffness in a metabolically healthy population with overweight or obesity older than 65 years compared with data from other elderly populations previously reported in the literature.

Metabolically healthy obesity: Inflammatory biomarkers and adipokines in elderly population.

BACKGROUND AND AIMS: Obesity is linked to elevated levels of inflammatory serum markers such as C-reactive protein (CRP), interleukin-6 (IL-6), and tumor necrosis factor alpha (TNFa). Adiponectin and resistin are adipokines related to obesity. It has been described that adipose tissue presents a high production and secretion of these diverse pro-inflammatory molecules, which may have local effects on the physiology of fat cells as well as systemic effects on other organs. Our aim was to evaluate the impact that lifestyle modifications, by following a Mediterranean Diet (MedDiet) program and physical activity (PA) training, would have on inflammatory biomarkers and adipokine profile in a Metabolically Healthy Obese (MHO) elderly population from Malaga (Andalusia, Spain). SUBJETCS AND METHODS: Subjects aged ≥65 years (65 to 87 years old) with obesity (BMI ≥30 kg/m2) were included in this study if they met ≤1 of the following criteria: systolic blood pressure ≥130 mmHg and/or diastolic blood pressure ≥ 85 mmHg; triglycerides ≥150 mg/dL; HDL-C <40mg/dL in men and <50mg/dL women; and fasting blood glucose ≥100mg/dL. Selected subjects underwent a personalized intensive lifestyle modification. Anthropometric measurements, PA, MedDiet adherence, analytical parameters, and inflammatory biomarkers were analyzed after 12 months of intervention. RESULTS: 166 MHO elderly subjects, 40 (24.1%) male and 126 (75.9%) female (p < 0.0001), aged 71.7±5.2 years old (65 to 87 years old) were included in the study. After 12 months of intervention, only the waist circumference was significantly reduced in all the population (-2.5 cm, p<0.0001), although weight and BMI were maintained. MedDiet adherence increased significantly (p<0.001), but all intensity levels of PA decreased significantly (p<0.001). Concerning inflammatory biomarkers, only TNFa serum increased their levels after the intervention (p<0.001). Regarding the adipokine profile, adiponectin concentrations experienced a significant increment (p<0.001); besides, resistin concentrations decreased significantly (p<0.001). In this sense, only TNFa, adiponectin, and resistin correlated with PA. Adiponectin also correlates with insulin, triglycerides and HDL-c in baseline conditions and after 12 months of intervention; CRP, IL-6, TNFa, adiponectin, and resistin concentrations correlated with anthropometric parameters and some intensities of PA. In addition, adiponectin levels correlates with insulin, triglycerides and HDL-c. In baseline conditions, resistin levels correlated positively with TNFa (p = 0.01) and CRP (p<0.0001) levels. TNFa and IL-6 correlated positively with CRP (p = 0.03 and p<0.0001, respectively). After 12 months of intervention, only IL-6 correlated positively with CRP (p = 0.006). In addition, adipokines levels correlated positively during the process of lifestyle modification. However, during this process, only IL-6 correlated positively with itself (p<0.0001) and with CRP (p = 0.03). CONCLUSION: Healthy aging is a multifactorial biological process in which lifestyle is essential. The presence of obesity in elderly metabolically healthy population is not a problem necessarily. Elderly MHO population who eat a MedDiet and practice regularly PA are capable to modulate their production of inflammatory cytokines (CRP, IL-6, TNFa) and adipokines profile (adiponectin, resistin), preventing other metabolic disorders.

The importance of association of comorbidities on COVID-19 outcomes: a machine learning approach.

BACKGROUND: The individual influence of a variety of comorbidities on COVID-19 patient outcomes has already been analyzed in previous works in an isolated way. We aim to determine if different associations of diseases influence the outcomes of inpatients with COVID-19. METHODS: Retrospective cohort multicenter study based on clinical practice. Data were taken from the SEMI-COVID-19 Registry, which includes most consecutive patients with confirmed COVID-19 hospitalized and discharged in Spain. Two machine learning algorithms were applied in order to classify comorbidities and patients (Random Forest -RF algorithm, and Gaussian mixed model by clustering -GMM-). The primary endpoint was a composite of either, all-cause death or intensive care unit admission during the period of hospitalization. The sample was randomly divided into training and test sets to determine the most important comorbidities related to the primary endpoint, grow several clusters with these comorbidities based on discriminant analysis and GMM, and compare these clusters. RESULTS: A total of 16,455 inpatients (57.4% women and 42.6% men) were analyzed. According to the RF algorithm, the most important comorbidities were heart failure/atrial fibrillation (HF/AF), vascular diseases, and neurodegenerative diseases. There were six clusters: three included patients who met the primary endpoint (clusters 4, 5, and 6) and three included patients who did not (clusters 1, 2, and 3). Patients with HF/AF, vascular diseases, and neurodegenerative diseases were distributed among clusters 3, 4 and 5. Patients in cluster 5 also had kidney, liver, and acid peptic diseases as well as a chronic obstructive pulmonary disease; it was the cluster with the worst prognosis. CONCLUSION: The interplay of several comorbidities may affect the outcome and complications of inpatients with COVID-19.

LONG-TERM EVOLUTION OF CONTINENCE AND QUALITY OF LIFE AFTER SPHINCTEROPLASTY FOR OBSTETRIC FECAL INCONTINENCE.

PURPOSE: Evaluate the long-term evolution of continence and patient's quality of life after surgical treatment for obstetric fecal incontinence. METHODS: A prospective longitudinal study was conducted including consecutive patients who underwent sphincteroplasty for severe obstetric fecal incontinence. The first phase analyzed changes in continence and impact on quality of life. The second phase studied the long-term evolution reevaluating the same group of patients six years later. Degree of fecal incontinence was calculated using the Cleveland Clinic Score. Quality of life assessment was carried out with the Fecal Incontinence Quality of Life Scale. RESULTS: 35 patients with median age of 55 (range, 28-73) completed the study. Phase One Results: After a postoperative follow-up of 30 months (4-132), Cleveland Clinic Score had improved significantly from a preoperative of 15.7 ± 3.1 to 6.1 ± 5 (p <0.001). Phase Two Results: median follow-up in phase two was 110 months (76- 204). The Cleveland Clinic Score lowered to 8.4 ± 4.9 (p = 0.04). There were no significant differences between phases one and two in terms of quality of life: lifestyle (3.47 ± 0.75 vs. 3.16 ± 1.04), coping/behavior (3.13 ± 0.83 vs 2.80 ± 1.09), depression/self-perception (3.65 ± 0.80 vs 3.32 ± 0.98) and embarrassment (3.32 ± 0.9 vs 3.12 ± 1). CONCLUSION: Sphincteroplasty offers good short-medium term outcomes in continence and quality of life for obstetric fecal incontinence treatment. Functional clinical results deteriorate over time but did not impact on patients' quality of life.

Statin Therapy in Very Old Patients: Lights and Shadows.

Atherosclerotic cardiovascular diseases (ASCVD) are the leading cause of death worldwide. High levels of total cholesterol-and of low-density lipoprotein cholesterol in particular-are one of the main risk factors associated with ASCVD. Statins are first-line treatment for hypercholesterolemia and have been proven to reduce major vascular events in adults with and without underlying ASCVD. Findings in the literature show that statins reduce coronary and cerebrovascular morbidity and mortality in middle-aged people, but their benefits in older adults are not as well-established, especially in primary prevention. Furthermore, many particularities must be considered regarding their use in old subjects, such as age-related changes in pharmacokinetics and pharmacodynamics, comorbidities, polypharmacy, and frailty, which decrease the safety and efficacy of statins in this population. Myopathy and a possible higher risk of falling along with cognitive decline are classic concerns for physicians when considering statin use in the very old. Additionally, some studies suggest that the relative risk for coronary events and cardiovascular mortality associated with high levels of cholesterol decreases after age 70, making the role of statins unclear. On the other hand, ASCVD are one of the most important causes of disability in old subjects, so cardiovascular prevention is of particular interest in this population in order to preserve functional status. This review aims to gather the current available evidence on the efficacy and safety of statin use in very old patients in both primary and secondary prevention.

Lifestyle Modification Program on a Metabolically Healthy Elderly Population with Overweight/Obesity, Young-Old vs. Old-Old. CONSEQUENCES of COVID-19 Lockdown in This Program.

The SARS-CoV-2 pandemic led to lockdowns, which affected the elderly, a high-risk group. Lockdown may lead to weight gain due to increased food intake and reduced physical activity (PA). Our study aimed to analyze the impact of a 12-month lifestyle intervention on a metabolically healthy overweight/obese elderly (MHOe) population and how the lockdown by COVID-19 affected this program. Methods: MHOe participants (65-87 years) were recruited to participate in a lifestyle modification intervention based on the Mediterranean diet (MedDiet) and regular PA. Participants were classified into two groups: young-old (<75 years) or old-old (≥75 years). Anthropometric and clinical characteristics, energy intake, and energy expenditure were analyzed at baseline and after 12 months of intervention. Results: The final sample included 158 MHOe participants of both sexes (age: 72.21 ± 5.04 years, BMI: 31.56 ± 3.82 kg/m2): 109 young-old (age: 69.26 ± 2.83 years, BMI: 32.0 ± 3.85 kg/m2) and 49 old-old (age: 78.06 ± 2.88 years, BMI: 30.67 ± 3.64 kg/m2). After 12 months of intervention and despite lockdown, the young-old group increased MedDiet adherence (+1 point), but both groups drastically decreased daily PA, especially old-old participants. Fat mass significantly declined in the total population and the young-old. Depression significantly increased (26.9% vs. 21.0%, p < 0.0001), especially in the old-old (36.7% vs. 22.0%, p < 0.0001). No significant changes were found in the glycemic or lipid profile. Conclusions: This study indicates that ongoing MedDiet intake and regular PA can be considered preventative treatment for metabolic diseases in MHOe subjects. However, mental health worsened during the study and should be addressed in elderly individuals.

Importancia de algunos aspectos técnicos del procedimiento de estimulación percutánea del nervio tibial posterior en pacientes con incontinencia fecal / Importance of some technical aspects of the procedure of percutaneous posterior tibial nerve stimulation in patients with fecal incontinence

Introducción: Los resultados de la estimulación percutánea del nervio tibial posterior (PTNS) en el tratamiento de la incontinencia fecal (IF) parecen discretos. El objetivo del estudio es valorar la relación de algunos aspectos técnicos con la respuesta clínica: localización del nervio, respuesta distal (motora o sensitiva) y acomodación. Métodos: Estudio prospectivo de pacientes con IF sometidos a terapia de PTNS. La repuesta clínica se valoró mediante la escala de Wexner, diario defecatorio y manometría anorrectal. Resultados: Se estudiaron 32 pacientes. La intensidad de localización (cercanía al nervio) no se correlacionó con cambios clínicos ni manométricos. La respuesta motora se relacionó con un descenso en la escala de Wexner [12,12 (± 5,39) a 7,71 (± 4,57) p < 0,005], el número de episodios de incontinencia pasiva [8,78 (± 9,64) a 4,11 (± 7,11) p = 0,025], el número total de episodios de incontinencia [16,11 (± 16,03) a 7,78 (± 11,34) p = 0,009] y el número de días con ensuciamiento fecal [6,89 (± 5,53) a 2,56 (± 4,13) p = 0,002] y con un aumento de la longitud del conducto anal manométrico en reposo [4,55 (± 0,596) a 4,95 (± 0,213) p = 0,004]. El incremento de estimulación (acomodación) se correlacionó de forma inversa con la disminución en la escala de Wexner (r = -0,677 p < 0,005) y el número de días con ensuciamiento (r = -0,650 p = 0,022). Conclusiones: La respuesta motora durante la PTNS parece relacionarse con una mejor respuesta clínica. El fenómeno de acomodación podría asociarse con peores resultados. La cercanía del electrodo al nervio no parece tener trascendencia, siempre que se consiga una buena respuesta distal. (AU)

Introduction: The results of percutaneous posterior tibial nerve stimulation (PTNS) in the treatment of fecal incontinence (IF) are modest. The aim of the study is to assess the relationship of some technical aspects with the clinical response: location of the nerve, distal response (motor or sensory) and accommodation. Methods: Prospective study of patients with FI undergoing PTNS therapy. The clinical response was assessed using the Wexner scale, defecation diary and anorectal manometry. Results: 32 patients were studied. The intensity of localization (proximity to the nerve) was not correlated with clinical or manometric changes. Motor response was associated with a decrease on the Wexner scale [12.12 (± 5.39) to 7.71 (± 4.57) p < 0.005], the number of episodes of passive incontinence [8.78 (± 9.64) to 4.11 (± 7.11) p = 0.025], the total number of incontinence episodes [16.11 (± 16.03) to 7.78 (± 11.34) p = 0.009] and the number of days with faecal soiling [6.89 (± 5.53) to 2.56 (± 4.13) p = 0.002] and with an increase in the length of the manometric anal canal at rest [4.55 (± 0.596) to 4.95 (± 0.213) p = 0.004]. The increase in stimulation (accommodation) was inversely correlated with the decrease in the Wexner scale (r = -0.677 p < 0.005) and the number of days with soiling (r = -0.650 p = 0.022). Conclusions: The motor response during PTNS seems to be related to a better clinical response. The accommodation phenomenon could be associated with worse results. The proximity of the electrode to the nerve does not seem to be important as long as a good distal response is achieved. (AU)

Importance of some technical aspects of the procedure of percutaneous posterior tibial nerve stimulation in patients with fecal incontinence.

INTRODUCTION: The results of percutaneous posterior tibial nerve stimulation (PTNS) in the treatment of fecal incontinence (IF) are modest. The aim of the study is to assess the relationship of some technical aspects with the clinical response: location of the nerve, distal response (motor or sensory) and accommodation. METHODS: Prospective study of patients with FI undergoing PTNS therapy. The clinical response was assessed using the Wexner scale, defecation diary and anorectal manometry. RESULTS: 32 patients were studied. The intensity of localization (proximity to the nerve) was not correlated with clinical or manometric changes. Motor response was associated with a decrease on the Wexner scale [12.12 (±5.39) to 7.71 (±4.57) P < .005], the number of episodes of passive incontinence [8.78 (±9.64) to 4.11 (±7.11) P = .025], the total number of incontinence episodes [16.11 (±16.03) to 7.78 (±11.34) P = .009] and the number of days with fecal soiling [6.89 (±5.53) to 2.56 (±4.13) P = .002] and with an increase in the length of the manometric anal canal at rest [4.55 (±0.596) to 4.95 (±0.213) P = .004]. The increase in stimulation (accommodation) was inversely correlated with the decrease in the Wexner scale (r = -0.677 P < .005) and the number of days with soiling (r = -0.650 P = .022). CONCLUSIONS: The motor response during PTNS seems to be related to a better clinical response. The accommodation phenomenon could be associated with worse results. The proximity of the electrode to the nerve does not seem to be important as long as a good distal response is achieved.

Impact of Arterial Stiffness on All-Cause Mortality in Patients Hospitalized With COVID-19 in Spain.

Older age and cardiovascular comorbidities are well-known risk factors for all-cause mortality in patients with coronavirus disease 2019 (COVID-19). Hypertension and age are the 2 principal determinants of arterial stiffness (AS). This study aimed to estimate AS in patients with COVID-19 requiring hospitalization and analyze its association with all-cause in-hospital mortality. This observational, retrospective, multicenter cohort study analyzed 12 170 patients admitted to 150 Spanish centers included in the SEMI-COVID-19 Network. We compared AS, defined as pulse pressure ≥60 mm Hg, and clinical characteristics between survivors and nonsurvivors. Mean age was 67.5 (±16.1) years and 42.5% were women. Overall, 2606 (21.4%) subjects died. Admission systolic blood pressure (BP) <120 and ≥140 mm Hg was a predictor of higher all-cause mortality (23.5% and 22.8%, respectively, P<0.001), compared with systolic BP between 120 and 140 mm Hg (18.6%). The 4379 patients with AS (36.0%) were older and had higher systolic and lower diastolic BP. Multivariate analysis showed that AS and systolic BP <120 mm Hg significantly and independently predicted all-cause in-hospital mortality (adjusted odds ratio [ORadj]: 1.27, P=0.0001; ORadj: 1.48, P=0.0001, respectively) after adjusting for sex (males, ORadj: 1.6, P=0.0001), age tertiles (second and third tertiles, ORadj: 2.0 and 4.7, P=0.0001), Charlson Comorbidity Index (second and third tertiles, ORadj: 4.8 and 8.6, P=0.0001), heart failure, and previous and in-hospital antihypertensive treatment. Our data show that AS and admission systolic BP <120 mm Hg had independent prognostic value for all-cause mortality in patients with COVID-19 requiring hospitalization.

Importance of some technical aspects of the procedure of percutaneous posterior tibial nerve stimulation in patients with fecal incontinence. / Importancia de algunos aspectos técnicos del procedimiento de estimulación percutánea del nervio tibial posterior en pacientes con incontinencia fecal.

INTRODUCTION: The results of percutaneous posterior tibial nerve stimulation (PTNS) in the treatment of fecal incontinence (IF) are modest. The aim of the study is to assess the relationship of some technical aspects with the clinical response: location of the nerve, distal response (motor or sensory) and accommodation. METHODS: Prospective study of patients with FI undergoing PTNS therapy. The clinical response was assessed using the Wexner scale, defecation diary and anorectal manometry. RESULTS: 32 patients were studied. The intensity of localization (proximity to the nerve) was not correlated with clinical or manometric changes. Motor response was associated with a decrease on the Wexner scale [12.12 (± 5.39) to 7.71 (± 4.57) p < 0.005], the number of episodes of passive incontinence [8.78 (± 9.64) to 4.11 (± 7.11) p = 0.025], the total number of incontinence episodes [16.11 (± 16.03) to 7.78 (± 11.34) p = 0.009] and the number of days with faecal soiling [6.89 (± 5.53) to 2.56 (± 4.13) p = 0.002] and with an increase in the length of the manometric anal canal at rest [4.55 (± 0.596) to 4.95 (± 0.213) p = 0.004]. The increase in stimulation (accommodation) was inversely correlated with the decrease in the Wexner scale (r = -0.677 p < 0.005) and the number of days with soiling (r = -0.650 p = 0.022). CONCLUSIONS: The motor response during PTNS seems to be related to a better clinical response. The accommodation phenomenon could be associated with worse results. The proximity of the electrode to the nerve does not seem to be important as long as a good distal response is achieved.

Metabolically Healthy Obesity: Presence of Arterial Stiffness in the Prepubescent Population.

AIM: Arteriosclerotic cardiovascular disease, one of the world's leading causes of death, first manifests itself at an early age. The identification of children who may have increased cardiovascular risk in the future could be an important prevention strategy. Our aim was to assess the clinical, analytical, and dietary variables associated with arterial stiffness (AS), measured by carotid-femoral pulse wave velocity (cfPWV) in a prepubescent population with metabolically healthy obesity (MHO). SUBJECTS AND METHODS: A cross-sectional study in prepubescent subjects with obesity who had ≤1 metabolic syndrome criteria (abdominal perimeter and blood pressure ≥90th percentile, triglycerides >150 mg/dL, HDL-cholesterol <40 mg/dL, fasting plasma glucose ≥100 mg/dL) was conducted. Adherence to Mediterranean Diet, blood pressure, BMI, waist/height ratio (WHtR), glycemic status, lipid profile, and cfPWV were analyzed. 75 MHO children (boys: 43; girls: 32; p = 0.20) (age = 10.05 ± 1.29 years; BMI = 25.29 ± 3.5 kg/m2) were included. RESULTS: We found a positive correlation between cfPWV and weight (r = 0.51; p < 0.0001), BMI (r = 0.44; p < 0.0001), WHtR (r = 0.26; p = 0.02), fasting insulin levels (r = 0.28; p = 0.02), and insulin resistance (Homeostatic Model Assessment of Insulin Resistance (HOMA-IR) index) (r = 0.25; p = 0.04). Multiple linear regression analysis identified BMI and HOMA-IR as independent parameters associated with cfPWV. CONCLUSIONS: Prepubescent children with obesity who were shown to be metabolically healthy presented with arterial stiffness, which is closely related to BMI and the state of insulin resistance.

Utility of Liver Function Tests and Fatty Liver Index to Categorize Metabolic Phenotypes in a Mediterranean Population.

The aim of this study was to analyze the utility of liver function tests (LFT) and fatty liver index (FLI), a surrogate marker of non-alcoholic fatty liver disease, in the categorization of metabolic phenotypes in a Mediterranean population. A cross-sectional study was performed on a random representative sample of 2233 adults assigned to a health center in Málaga, Spain. The metabolic phenotypes were determined based on body mass index (BMI) categorization and the presence or absence of two or more cardiometabolic abnormalities (high blood pressure, low high-density lipoprotein (HDL) cholesterol, hypertriglyceridemia, pre-diabetes) or type 2 diabetes. No difference was observed between metabolically healthy and metabolically abnormal phenotypes on LFT. The mean FLI of the population was 41.1 ± 28.6. FLI was significantly higher (p < 0.001) in the metabolically abnormal phenotypes in all BMI categories. The proportion of individuals with pathological FLI (≥60) was significantly higher in the metabolically abnormal overweight and obese phenotypes (p < 0.001). On a multivariate model adjusted for sex, age, and waist circumference, a significant correlation was found between pathological FLI and metabolically abnormal phenotypes in the overweight and obese BMI categories. Area under the curve (AUC) of FLI as a biomarker was 0.76, 0.74, and 0.72 for the metabolically abnormal normal-weight, overweight, and obese groups, respectively. Liver biochemistry is poorly correlated with metabolic phenotypes. Conversely, a good correlation between FLI, as a marker of non-alcoholic fatty liver disease (NAFLD), and metabolically abnormal phenotypes in all BMI ranges was found. Our study suggests that FLI may be a useful marker for characterizing metabolically abnormal phenotypes in individuals who are overweight or obese.

Randomised, double-blind, placebo-controlled clinical trial for evaluating the efficacy of intracoronary injection of autologous bone marrow mononuclear cells in the improvement of the ventricular function in patients with idiopathic dilated myocardiopathy: a study protocol.

BACKGROUND: Cellular therapies have been increasingly applied to diverse human diseases. Intracoronary infusion of bone marrow-derived mononuclear cells (BMMNC) has demonstrated to improve ventricular function after acute myocardial infarction. However, less information is available about the role of BMMNC therapy for the treatment of dilated myocardiopathies (DCs) of non-ischemic origin. This article presents the methodological description of a study aimed at investigating the efficacy of intracoronary injection of autologous BMMNCs in the improvement of the ventricular function of patients with DC. METHODS: This randomised, placebo-controlled, double-blinded phase IIb clinical trial compares the improvement on ventricular function (measured by the changes on the ejection fraction) of patients receiving the conventional treatment for DC in combination with a single dose of an intracoronary infusion of BMMNCs, with the functional recovery of patients receiving placebo plus conventional treatment. Patients assigned to both treatment groups are monitored for 24 months. This clinical trial is powered enough to detect a change in Left Ventricular Ejection Fraction (LVEF) equal to or greater than 9%, although an interim analysis is planned to re-calculate sample size. DISCUSSION: The study protocol was approved by the Andalusian Coordinating Ethics Committee for Biomedical Research (Comité Coordinador de Ética en Investigación Biomédica de Andalucia), the Spanish Medicines and Medical Devices Agency (Agencia Española de Medicamentos y Productos Sanitarios), and is registered at the EU Clinical Trials Register (EudraCT: 2013-002015-98). The publication of the trial results in scientific journals will be performed in accordance with the applicable regulations and guidelines to clinical trials. TRIAL REGISTRATION: ClinicalTrials.gov Identifier NCT02033278 (First Posted January 10, 2014): https://clinicaltrials.gov/ct2/show/NCT02033278 ; EudraCT number: 2013-002015-98, EU CT Register: https://www.clinicaltrialsregister.eu/ctr-search/search?query=2013-002015-98 . Trial results will also be published according to the CONSORT statement at conferences and reported peer-reviewed journals.

Reconstrucción de la continuidad digestiva tras cirugía de la diverticulitis aguda complicada. Estudio retrospectivo multicéntrico / Stoma reversal after surgery for complicated acute diverticulitis: A multicentre retrospective study

INTRODUCCIÓN: El objetivo del estudio es analizar la tasa de reconstrucción del estoma tras cirugía por diverticulitis aguda complicada (DAC), su demora, factibilidad, complicaciones y factores de riesgo de mantenerlo. MÉTODOS: Estudio retrospectivo multicéntrico de pacientes intervenidos mediante cirugía urgente por DAC con realización de un estoma en 10 hospitales durante 6 años. Se analiza la frecuencia de reconstrucción del estoma, fundamentalmente de los terminales, y el tiempo en que se produce, así como los factores relacionados con ella. RESULTADOS: De 385 pacientes intervenidos por DAC, a 312 (81%) se les realizó un estoma: 292 fueron colostomías terminales y 20 estomas derivativos. Durante el seguimiento, en 161 (51,6%), se intentó el cierre a una mediana de 9 meses. Las causas más frecuentes de no efectuarlo fueron la comorbilidad y el fallecimiento del paciente. La edad más avanzada se mostró factor adverso en el análisis multivariante y la tasa actuarial de reconstrucción fue mayor en hombres y en quienes no se realizó un Hartmann. La cirugía pudo completarse en todos menos en un paciente y en 4 se asoció un estoma derivativo. La morbimortalidad fue del 35,7 y 1,9%, respectivamente. Hubo un 8,4% de reintervenciones y un 6% de fallos de sutura, quedando 12 pacientes (7,9%) con un estoma tras el intento de reconstrucción. CONCLUSIONES: La cirugía de la DAC se asocia muy frecuentemente a la construcción de un estoma terminal, que en casi un 50% no se reconstruirá. Además, la intervención de reconstrucción tiene una demora notable y está asociada a una morbimortalidad nada despreciable

INTRODUCTION: The aim was to analyse the stoma reversal rate after surgery for complicated acute diverticulitis (CAD), and more specifically the end-stoma-reversal, as well as the delay, feasibility, complications and risk factors for stoma maintenance. METHODS: A multicentre retrospective study of patients who had undergone urgent surgery for CAD with stoma formation in ten hospitals during a period of 6 years. The frequency of reversal over time and the factors affecting the decision for reversal were analysed. RESULTS: Out of 385 patients operated for CAD, 312 underwent stoma creation: 292 end colostomies and 20 diverting stomas. During follow-up, stoma reversal surgery was performed in 161 patients (51.6%) after a median of 9 months. The main causes for not performing stoma reversal were comorbidities and the death of the patient. Advanced age was an adverse factor in the multivariate analysis, and the actuarial rate of reversal was higher in men and in patients with no previous Hartmann's operation. Stoma reversal surgery was completed in all but one patient, and a loop ileostomy was associated in four. Morbidity and mortality rates were 35.7% and 1.9%, respectively. A total of 8.4% of patients underwent re-operation, and 6% experienced an anastomotic leak. Twelve patients remained with a stoma after the attempted reconstruction surgery. CONCLUSIONS: Surgery for CAD is frequently associated with an end stoma, which will ultimately not be reversed in almost 50% of patients. Moreover, reversal surgery is frequently delayed and is associated with significant morbidity and mortality

Stoma reversal after surgery for complicated acute diverticulitis: A multicentre retrospective study. / Reconstrucción de la continuidad digestiva tras cirugía de la diverticulitis aguda complicada. Estudio retrospectivo multicéntrico.

INTRODUCTION THE AIM: was to analyse the stoma reversal rate after surgery for complicated acute diverticulitis (CAD), and more specifically the end-stoma-reversal, as well as the delay, feasibility, complications and risk factors for stoma maintenance. METHODS: A multicentre retrospective study of patients who had undergone urgent surgery for CAD with stoma formation in ten hospitals during a period of 6 years. The frequency of reversal over time and the factors affecting the decision for reversal were analysed. RESULTS: Out of 385 patients operated for CAD, 312 underwent stoma creation: 292 end colostomies and 20 diverting stomas. During follow-up, stoma reversal surgery was performed in 161 patients (51.6%) after a median of 9 months. The main causes for not performing stoma reversal were comorbidities and the death of the patient. Advanced age was an adverse factor in the multivariate analysis, and the actuarial rate of reversal was higher in men and in patients with no previous Hartmann's operation. Stoma reversal surgery was completed in all but one patient, and a loop ileostomy was associated in four. Morbidity and mortality rates were 35.7% and 1.9%, respectively. A total of 8.4% of patients underwent re-operation, and 6% experienced an anastomotic leak. Twelve patients remained with a stoma after the attempted reconstruction surgery. CONCLUSIONS: Surgery for CAD is frequently associated with an end stoma, which will ultimately not be reversed in almost 50% of patients. Moreover, reversal surgery is frequently delayed and is associated with significant morbidity and mortality.