Estado nutricional, obesidad y eventos en pacientes con fibrilación auricular / Nutrition status, obesity and outcomes in patients with atrial fibrillation

Introducción y objetivos Se ha descrito un efecto protector paradójico de la obesidad en pacientes con fibrilación auricular (FA) cuya mecanismo no está claro. El objetivo de este estudio fue determinar el impacto del estado nutricional y el índice de masa corporal (IMC) en el pronóstico de los pacientes con FA. Métodos Se realizó un estudio de cohortes retrospectivo de pacientes con FA entre 2014 y 2017 de una única área sanitaria en España. La escala CONUT se utilizó para evaluar el estado nutricional. La asociación del IMC y escala CONUT con la mortalidad se analizó por regresión de Cox. La asociación con eventos embólicos y hemorrágicos se evaluó mediante análisis de riesgos competitivos. Resultados Entre los 14.849 pacientes, se observó sobrepeso y obesidad en 42,6% y 46,0%, respectivamente, mientras que malnutrición en 34,3%. Durante un seguimiento medio de 4,4 años, 3.335 pacientes murieron, 984 pacientes sufrieron un evento embólico y 1.317 una hemorragia. El IMC se asoció inversamente con la mortalidad, embolias y hemorragias en el análisis univariado; sin embargo, esta asociación se perdió después del ajuste por edad, sexo, comorbilidades y escala CONUT (HR para el combinado de eventos 0,98; IC95%, 0,95-1,01; p=0,719). Por el contrario, la escala CONUT si se asoció con la mortalidad, la embolia y la hemorragia (HR = 1,15; IC95%, 1,14-1,17; p<0,001). Conclusiones El IMC no fue un predictor independiente de eventos en pacientes con FA, a diferencia del estado nutricional, que mostró una fuerte asociación con la mortalidad, la embolia y la hemorragia (AU)

Introduction and objectives A paradoxical protective effect of obesity has been previously reported in patients with atrial fibrillation (AF). The aim of this study was to determine the impact of nutritional status and body mass index (BMI) on the prognosis of AF patients. Methods We conducted a retrospective population-based cohort study of patients with AF from 2014 to 2017 from a single health area in Spain. The CONUT score was used to assess nutritional status. Cox regression models were used to estimate the association of BMI and CONUT score with mortality. The association with embolism and bleeding was assessed by a competing risk analysis. Results Among 14 849 AF patients, overweight and obesity were observed in 42.6% and 46.0%, respectively, while malnutrition was observed in 34.3%. During a mean follow-up of 4.4 years, 3335 patients died, 984 patients had a stroke or systemic embolism, and 1317 had a major bleeding event. On univariate analysis, BMI was inversely associated with mortality, embolism, and bleeding; however, this association was lost after adjustment by age, sex, comorbidities, and CONUT score (HR for composite endpoint, 0.98; 95%CI, 0.95-1.01; P=.719). Neither obesity nor overweight were predictors of mortality, embolism, and bleeding events. In contrast, nutritional status—assessed by the CONUT score—was associated with mortality, embolism and bleeding after multivariate analysis (HR for composite endpoint, 1.15; 95%CI, 1.14-1.17; P<.001). Conclusion BMI was not an independent predictor of events in patients with AF in contrast to nutritional status, which showed a strong association with mortality, embolism, and bleeding (AU)

Análisis de la atención al infarto con elevación del segmento ST en España. Resultados del Registro de Código Infarto de la ACI-SEC / Analysis of the management of ST-segment elevation myocardial infarction in Spain. Results from the ACI-SEC Infarction Code Registry

Introducción y objetivos Las redes de Código Infarto deben garantizar una atención al infarto agudo de miocardio con elevación del segmento ST con buenos resultados clínicos y dentro de los parámetros de tiempo recomendados. No hay información contemporánea sobre el funcionamiento de estas redes en España. El objetivo es analizar las características clínicas de los pacientes atendidos, el tiempo hasta la reperfusión, las características de la intervención realizada y la mortalidad a 30 días. Métodos Registro prospectivo, observacional y multicéntrico de pacientes los consecutivos atendidos en 17 redes de Código Infarto en España (83 centros con Código Infarto) entre el 1 de abril y el 30 de junio de 2019. Resultados Se atendió a 5.401 pacientes (media de edad, 64±13 años; el 76,9% varones), de los que 4.366 (80,8%) sufrieron un infarto con elevación del ST. De estos, se trató al 87,5% con angioplastia primaria, al 4,4% con fibrinolisis y al 8,1% sin reperfusión. En los casos tratados con angioplastia primaria, el tiempo entre el inicio de los síntomas y la reperfusión fue 193 [135-315] min y el tiempo entre el primer contacto médico y la reperfusión, 107 [80-146] min. La mortalidad total a 30 días por infarto agudo de miocardio con elevación del ST fue del 7,9%, mientras que entre los pacientes tratados con angioplastia primaria fue del 6,8%. Conclusiones Se trató con angioplastia primaria a la inmensa mayoría de los pacientes con infarto agudo de miocardio con elevación del ST, y en más de la mitad de los casos el tiempo desde el primer contacto médico hasta la reperfusión fue <120 min. La mortalidad a 30 días fue relativamente baja (AU)

Introduction and objectives ST-segment elevation myocardial infarction (STEMI) networks should guarantee STEMI care with good clinical results and within the recommended time parameters. There is no contemporary information on the performance of these networks in Spain. The objective of this study was to analyze the clinical characteristics of patients, times to reperfusion, characteristics of the intervention performed, and 30-day mortality. Methods Prospective, observational, multicenter registry of consecutive patients treated in 17 STEMI networks in Spain (83 centers with the Infarction Code), between April 1 and June 30, 2019. Results A total of 5401 patients were attended (mean age, 64±13 years; 76.9% male), of which 4366 (80.8%) had confirmed STEMI. Of these, 87.5% were treated with primary angioplasty, 4.4% with fibrinolysis, and 8.1% did not receive reperfusion. In patients treated with primary angioplasty, the time between symptom onset and reperfusion was 193 [135-315] minutes and the time between first medical contact and reperfusion was 107 [80-146] minutes. Overall 30-day mortality due to STEMI was 7.9%, while mortality in patients treated with primary angioplasty was 6.8%. Conclusions Most patients with STEMI were treated with primary angioplasty. In more than half of the patients, the time from first medical contact to reperfusion was <120 minutes. Mortality at 30 days was relatively low (AU)

El modelo Clinical outcomes, healthcare resource utilization, and related costs (COHERENT). Aplicación en pacientes con insuficiencia cardiaca / The Clinical outcomes, healthcare resource utilization, and related costs (COHERENT) model. Application in heart failure patients

Introducción y objetivos: Los resultados combinados se utilizan ampliamente, pero tienen diversas limitaciones. El modelo Clinical outcomes, healthcare resource utilization and related costs (COHERENT) es una aproximación nueva para presentar y comparar visualmente todos los componentes de los resultados combinados (incidencia, tiempo, duración) y los costes relacionados. El objetivo es evaluar su utilidad en una cohorte de pacientes. Métodos: Se diseñó un sistema de colores que representa gráficamente el porcentaje de pacientes en cada situación clínica (estado vital y ubicación: domicilio, urgencias, hospital), codificada jerárquicamente, en cada momento del seguimiento. Se aplicó a 1.126 pacientes con insuficiencia cardiaca aguda de 25 hospitales seguidos durante 30 días tras su visita a urgencias, y se calculó el tiempo en cada situación clínica y sus costes sanitarios. Resultados: El modelo ilustra visualmente los componentes del objetivo combinado a los 30 días (el 2,12% en urgencias, el 23,6% en hospitalización índice, el 2,7% en reingresos, el 65,5% vivo en casa y el 6,02% fallecido) y muestra diferencias significativas entre grupos de pacientes, hospitales o sistemas sanitarios. El instrumento también calcula y muestra los costes diarios y acumulados (total, 4.895.070 euros; media, 144,91 euros/paciente/día). Conclusiones: El modelo COHERENT es un nuevo método para mostrar visualmente resultados combinados y sus costes que permite comparar grupos de pacientes y cohortes. El nuevo sistema puede ser útil como un nuevo criterio de valoración para ensayos clínicos o estudios observacionales, y un instrumento para la evaluación comparativa, la planificación clínica, el análisis económico y la implementación de la atención sanitaria basada en valor (AU)

Introduction and objectives: Composite endpoints are widely used but have several limitations. The Clinical outcomes, healthcare resource utilization and related costs (COHERENT) model is a new approach for visually displaying and comparing composite endpoints including all their components (incidence, timing, duration) and related costs. We aimed to assess the validity of the COHERENT model in a patient cohort. Methods: A color graphic system displaying the percentage of patients in each clinical situation (vital status and location: at home, emergency department [ED] or hospital) and related costs at each time point during follow-up was created based on a list of mutually exclusive clinical situations coded in a hierarchical fashion. The system was tested in a cohort of 1126 patients with acute heart failure from 25 hospitals. The system calculated and displayed the time spent in each clinical situation and health care resource utilization-related costs over 30 days. Results: The model illustrated the times spent over 30 days (2.12% in ED, 23.6% in index hospitalization, 2.7% in readmissions, 65.5% alive at home, and 6.02% dead), showing significant differences between patient groups, hospitals, and health care systems. The tool calculated and displayed the daily and cumulative health care-related costs over time (total, €4 895 070; mean, €144.91 per patient/d). Conclusions: The COHERENT model is a new, easy-to-interpret, visual display of composite endpoints, enabling comparisons between patient groups and cohorts, including related costs. The model may constitute a useful new approach for clinical trials or observational studies, and a tool for benchmarking, and value-based health care implementation (AU)

Pronóstico de la insuficiencia cardíaca aguda basado en datos clínicos de congestión / Prognosis of acute heart failure based on clinical data of congestion

Antecedentes y objetivos Evaluar si los síntomas/signos de congestión en pacientes con insuficiencia cardíaca aguda (ICA) atendidos en los servicios de urgencias hospitalarios (SUH) permiten predecir la evolución a corto plazo. Pacientes y métodos Pacientes consecutivos diagnosticados de ICA en 45 SUH del registro EAHFE. Recogimos variables clínicas de congestión sistémica (edemas en miembros inferiores, ingurgitación yugular, hepatomegalia) y pulmonar (disnea de esfuerzo, disnea paroxística nocturna, ortopnea y crepitantes pulmonares) analizando su asociación con la mortalidad por cualquier causa a 30 días, de forma cruda y ajustada por diferencias entre grupos. Resultado Analizamos 18.120 pacientes (mediana=83 años, rango intercuartil [RIC]=76-88; mujeres=55,7%). El 44,6% presentaba >3 síntomas/signos congestivos. Individualmente, el riesgo ajustado de muerte a 30 días se incrementó un 14% para la existencia de ingurgitación yugular (hazard ratio [HR]=1,14; intervalo de confianza al 95% [IC 95%]=1,01-1,28) y un 96% para la disnea de esfuerzo (HR=1,96; IC 95%=1,55-2,49). Valorados conjuntamente, el riesgo se incrementó progresivamente con el número de síntomas/signos presentes; así, respecto a los pacientes sin síntomas/signos de congestión, el riesgo incrementó un 109, 123 y 156% en pacientes con 1-2, 3-5 y 6-7 síntomas/signos, respectivamente. Estas asociaciones no mostraron interacción con la disposición final del paciente tras su atención en urgencias (alta/hospitalización), con excepción de edemas en extremidades inferiores, que tuvieron mejor pronóstico en pacientes dados de alta (HR=0,66; IC 95%=0,49-0,89) que en los hospitalizados (HR=1,01; IC 95%=0,65-1,57; p interacción <0,001). Conclusión La presencia de mayor número de síntomas/signos congestivos se asoció a una mayor mortalidad de cualquier causa a los 30 días. Individualmente, la ingurgitación yugular y la disnea de esfuerzo se asocian a mayor mortalidad a corto plazo (AU)

Background and objectives This work aims to assess whether symptoms/signs of congestion in patients with acute heart failure (AHF) evaluated in hospital emergency departments (HED) allows for predicting short-term progress. Patients and methods The study group comprised consecutive patients diagnosed with AHF in 45 HED from EAHFE Registry. We collected clinical variables of systemic congestion (edema in the lower extremities, jugular vein distention, hepatomegaly) and pulmonary congestion (dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, and pulmonary crackles) and analyzed their individual and group association with all-cause 30-day of mortality crudely and adjusted for differences between groups. Results We analyzed 18,120 patients (median=83 years, interquartile range [IQR]=76-88; women=55.7%). Of them, 44.6% had >3 congestive symptoms/signs. Individually, the 30-day adjusted risk of death increased 14% for jugular vein distention (hazard ratio [HR]=1.14, 95% confidence interval [95% CI]=1.01-1.28) and 96% for dyspnea on exertion (HR=1.96, 95% CI=1.55-2.49). Assessed jointly, the risk progressively increased with the number of symptoms/signs present; compared to patients without symptoms/signs of congestion, the risk increased by 109%, 123%, and 156% in patients with 1-2, 3-5, and 6-7 symptoms/signs, respectively. These associations did not show interaction with the final disposition of the patient after their emergency care (discharge/hospitalization) with the exception of edema in the lower extremities, which had a better prognosis in discharged patients (HR=0.66, 95% CI=0.49 -0.89) than hospitalized patients (HR=1.01, 95% CI=0.65-1.57; interaction p<0.001). Conclusion The presence of a greater number of congestive symptoms/signs was associated with greater all-cause 30-day mortality. Individually, jugular vein distention and dyspnea on exertion were associated with higher short-term mortality (AU)

Balance entre el efecto de los eventos embólicos frente a los hemorrágicos en la mortalidad de los pacientes ancianos con fibrilación auricular / Trade-off between the effects of embolic versus bleeding events on mortality in elderly patients with atrial fibrillation

Introducción y objetivos: La toma de decisiones clínicas sobre la anticoagulación de pacientes ancianos con fibrilación auricular (FA) requiere que se considere no solo la incidencia de eventos embólicos y hemorrágicos, sino también el riesgo de muerte tras esos efectos adversos. Nuestro objetivo es analizar el balance con respecto a la mortalidad entre los eventos embólicos y hemorrágicos en pacientes ancianos con FA. Métodos: Se analizó a todos los pacientes de 75 o más años de un área de salud española diagnosticados de FA entre 2014 y 2017 (n=9.365). El riesgo de muerte se estimó utilizando modelos de Cox que incluyeron los episodios embólicos y hemorrágicos como variables dependientes del tiempo. Resultados: Durante una mediana de seguimiento de 4,0 años, los eventos se asociaron con mayor mortalidad, tanto los embólicos (HR=2,39; IC95%, 2,12-2,69) como los hemorrágicos (HR=1,79; IC95%, 1,64-1,96). El riesgo de muerte fue un 33% mayor después de una embolia que después de una hemorragia (rRR=1,33; IC95%, 1,15-1,55), aunque con accidente isquémico transitorio el riesgo fue menor que con hemorragia (rRR=0,79; IC95%, 0,63-0,99). La mortalidad tras una hemorragia intracraneal fue similar que tras una embolia mayor (RR=1,00; IC95%, 0,75-1,29). Conclusiones: En los pacientes de edad avanzada con FA, los eventos embólicos parecen estar asociados con una mayor mortalidad que las hemorragias extracraneales, salvo los accidentes isquémicos transitorios. Con hemorragia intracraneal, el riesgo de muerte es similar al de una embolia mayor (AU)

Introduction and objectives: Clinical decision-making on anticoagulation in elderly patients with atrial fibrillation (AF) requires clinicians to consider not only the incidence of embolic and bleeding events, but also the risk of death following these adverse events. We aimed to analyze the trade-off between embolic and bleeding events with respect to mortality in elderly patients with AF. Methods: The study cohort comprised all patients aged ≥ 75 years from a Spanish health area diagnosed with AF between 2014 and 2017 (n=9365). The risk of death was investigated using Cox proportional hazards models, including embolic and bleeding events as time-dependent binary indicators. Results: During a median follow-up of 4.0 years, both embolic and bleeding events were associated with a higher risk of death (adjusted HR, 2.39; 95%CI, 2.12-2.69; and adjusted HR, 1.79; 95%CI, 1.64-1.96, respectively). The relative risk of death was 33% higher following an embolism than following a bleeding event (rRR, 1.33; 95%CI, 1.15-1.55), although for transient ischemic attack the risk was lower than for bleeding (rRR, 0.79; 95%CI, 0.63-0.99). The risk of death associated with intracranial hemorrhage was similar to that of major embolisms (RR, 1.00; 95%CI, 0.75-1.29). Conclusions: In elderly AF patients, embolic events appeared to be associated with a higher risk of mortality than extracranial bleeding, except for transient ischemic attacks, which have a better prognosis. For ICH, the mortality risk was similar to that of major embolism (AU)

Análisis de supervivencia en investigación cardiovascular (I): lo esencial / Survival analyses in cardiovascular research, part I: the essentials

Esta revisión establece una guía práctica que comprende los conceptos básicos de los análisis de supervivencia y su aplicación en el estudio de las enfermedades cardiovasculares, si bien gran parte del contenido puede extrapolarse a otras ramas de la medicina. Este es el primero de dos artículos académicos que sientan las bases para abordar las principales cuestiones metodológicas empleadas en estudios de supervivencia, y guían al lector desde los análisis más básicos hasta los más complejos. Esta revisión se centra en el tipo y la forma de los datos de supervivencia, así como en los métodos estadísticos más utilizados, como las pruebas no paramétricas, paramétricas y semiparamétricas. La interpretación y la valoración de la idoneidad de dichos métodos, así como sus ventajas e inconvenientes, se ilustran con estudios del ámbito de las enfermedades cardiovasculares. El artículo concluye aportando un conjunto de recomendaciones para guiar la estrategia del análisis de supervivencia, tanto en el contexto de un ensayo clínico aleatorizado como en el de estudios observacionales. En la segunda revisión se abordarán temas como el modelo de riesgos competitivos, el modelo de eventos recurrentes y los modelos multiestado (AU)

This review provides a practical guide to the essentials of survival analysis and their reporting in cardiovascular studies, although most of its key content can be extrapolated to other medical fields. This is the first in a series of 2 educational articles laying the groundwork to address the most relevant statistical issues in survival analyses, which will smoothly drive the reader from the most basic analyses to the most complex situations. The focus will be on the type and shape of survival data, and the most common statistical methods, such as nonparametric, parametric and semiparametric models. Their adequacy, interpretation, advantages and disadvantages are illustrated by examples from the field of cardiovascular research. This article ends with a set of recommendations to guide the strategy of survival analyses for a randomized clinical trial and observational studies. Other topics, such as competing risks, multistate models and recurrent-event methods will be addressed in the second article (AU)

Análisis de supervivencia en investigación cardiovascular (II): metodología estadística en situaciones complejas / Survival analyses in cardiovascular research, part II: statistical methods in challenging situations

Esta revisión es la segunda parte de 2 artículos sobre metodología estadística. En el primero, se describían los conceptos básicos del análisis de supervivencia y los métodos estadísticos más comúnmente utilizados y se aportaba un conjunto de recomendaciones para ayudar a establecer una estrategia de análisis de supervivencia, tanto en el contexto de un ensayo clínico aleatorizado como en el de un estudio observacional. En este segundo artículo, se introducen el modelo estratificado de Cox y el modelo de fragilidad y se ilustra el sesgo de tiempo inmortal secundario a una evaluación errónea de variables dependientes del tiempo. Para abordar el problema de la existencia de múltiples eventos clínicos, se introducen distintas aproximaciones estadísticas, como el análisis de riesgos competitivos, los modelos multiestado y el modelo de eventos recurrentes. Todos ellos se ilustran con ejemplos del campo cardiovascular, y se resumen las principales ventajas y limitaciones de cada uno de los métodos estadísticos. Por último, se presentan algunas consideraciones generales sobre métodos estadísticos alternativos, con asunciones menos restrictivas, como el método win ratio, el tiempo de supervivencia medio restringido y el modelo de tiempo de evento acelerado (AU)

This article is the second of a series of 2 educational articles. In the first article, we described the basic concepts of survival analysis, summarizing the common statistical methods and providing a set of recommendations to guide the strategy of survival analyses in randomized clinical trials and observational studies. Here, we introduce stratified Cox models and frailty models, as well as the immortal time bias arising from a poor assessment of time-dependent variables. To address the issue of multiplicity of outcomes, we provide several modelling strategies to deal with other types of time-to-event data analyses, such as competing risks, multistate models, and recurrent-event methods. This review is illustrated with examples from previous cardiovascular research publications, and each statistical method is discussed alongside its main strengths and limitations. Finally, we provide some general observations about alternative statistical methods with less restrictive assumptions, such as the win ratio method, the restrictive mean survival time, and accelerated failure time model (AU)

Prognosis of acute heart failure based on clinical data of congestion.

BACKGROUND AND OBJECTIVES: This work aims to assess whether symptoms/signs of congestion in patients with acute heart failure (AHF) evaluated in hospital emergency departments (HED) allows for predicting short-term progress. PATIENTS AND METHODS: The study group comprised consecutive patients diagnosed with AHF in 45 HED from EAHFE Registry. We collected clinical variables of systemic congestion (edema in the lower extremities, jugular vein distention, hepatomegaly) and pulmonary congestion (dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, and pulmonary crackles) and analysed their individual and group association with all-cause 30-day of mortality crudely and adjusted for differences between groups. RESULTS: We analysed 18,120 patients (median = 83 years, interquartile range [IQR] = 76-88; women = 55.7%). Of them, 44.6% had > 3 congestive symptoms/signs. Individually, the 30-day adjusted risk of death increased 14% for jugular vein distention (hazard ratio [HR] = 1.14, 95% confidence interval [95%CI] = 1.01-1.28) and 96% for dyspnea on exertion (HR = 1.96, 95% CI = 1.55-2.49). Assessed jointly, the risk progressively increased with the number of symptoms/signs present; compared to patients without symptoms/signs of congestion, the risk increased by 109%, 123 %, and 156% in patients with 1-2, 3-5, and 6-7 symptoms/signs, respectively. These associations did not show interaction with the final disposition of the patient after their emergency care (discharge/hospitalization) with the exception of edema in the lower extremities, which had a better prognosis in discharged patients (HR = 0.66, 95% CI = 0.49-0.89) than hospitalised patients (HR = 1.01, 95% CI = 0.65-1.57; interaction p < 0.001). CONCLUSION: The presence of a greater number of congestive symptoms/signs was associated with greater all-cause 30-day mortality. Individually, jugular vein distention and dyspnea on exertion were associated with higher short-term mortality.

La escala Identification of Senior at Risk predice la mortalidad a los 30 días en los pacientes mayores con insuficiencia cardiaca aguda / Identification of Senior At Risk scale predicts 30-day mortality among older patients with acute heart failure

Objetivo: Evaluar la utilidad de la escala de cribado de la fragilidad (Identification of Senior at Risk [ISAR]) para predecir la mortalidad a los 30 días en los pacientes mayores atendidos por insuficiencia cardiaca aguda (ICA) en los servicios de urgencias hospitalarios (SUH). Diseño: Estudio multicéntrico observacional de cohorte multipropósito. Ámbito: Registro OAK-3. Participantes: Pacientes ≥ 65 años atendidos por ICA en 16 SUH españoles de enero a febrero del 2016. Intervención: Ninguna. Variables: La variable de estudio fue la escala ISAR. La variable de resultado fue la mortalidad por cualquier causa a los 30 días. Resultados: Se incluyó a 1.059 pacientes (edad media 85±5,9 años). Ciento sesenta (15,1%) casos tuvieron 0-1 puntos, 278 (26,3%) 2 puntos, 260 (24,6%) 3 puntos, 209 (19,7%) 4 puntos y 152 (14,3%) 5-6 puntos de la escala ISAR. Noventa y cinco (9,0%) pacientes fallecieron a los 30 días. La frecuencia de mortalidad se incrementó en relación a la categoría del ISAR (p tendencia lineal <0,001). El área bajo la curva de la escala ISAR fue de 0,703 (intervalo de confianza del 95%, 0,655-0,751; p <0,001). Tras el ajuste por las categorías del modelo de riesgo EFFECT, hubo un incremento progresivo de la razón de ventajas de los grupos de la escala ISAR en comparación con el grupo de referencia (0-1 puntos). Conclusiones: La escala ISAR es una herramienta breve y sencilla que debería ser considerada para el despistaje de la fragilidad en la valoración inicial de los pacientes mayores con insuficiencia cardiaca aguda de cara a predecir la mortalidad a 30 días

Objective: To assess the value of frailty screening tool (Identification of Senior at Risk [ISAR]) in predicting 30-day mortality risk in older patients attended in emergency department (ED) for acute heart failure (AHF). Design: Observational multicenter cohort study. Setting: OAK-3 register. Subjects: Patients aged ≥65 years attended with ADHF in 16 Spanish EDs from January to February 2016. Intervention: No. Variables: Variable of study was ISAR scale. The outcome was all-cause 30-day mortality. Results: We included 1059 patients (mean age 85±5,9 years old). One hundred and sixty (15.1%) cases had 0-1 points, 278 (26.3%) 2 points, 260 (24.6%) 3 points, 209 (19.7%) 4 points, and 152 (14.3%) 5-6 points of ISAR scale. Ninety five (9.0%) patients died within 30 days. The percentage of mortality increased in relation to ISAR category (lineal trend P value <.001). The area under curve of ISAR scale was 0.703 (95%CI 0.655-0.751; P<.001). After adjusting for EFFECT risk categories, we observed a progressive increase in odds ratios of ISAR scale groups compared to reference (0-1 points). Conclusions: scale is a brief and easy tool that should be considered for frailty screening during initial assessment of older patients attended with AHF for predicting 30-day mortality

Identification of Senior At Risk scale predicts 30-day mortality among older patients with acute heart failure. / La escala Identification of Senior at Risk predice la mortalidad a los 30 días en los pacientes mayores con insuficiencia cardiaca aguda.

OBJECTIVE: To assess the value of frailty screening tool (Identification of Senior at Risk [ISAR]) in predicting 30-day mortality risk in older patients attended in emergency department (ED) for acute heart failure (AHF). DESIGN: Observational multicenter cohort study. SETTING: OAK-3 register. SUBJECTS: Patients aged ≥65 years attended with ADHF in 16 Spanish EDs from January to February 2016. INTERVENTION: No. VARIABLES: Variable of study was ISAR scale. The outcome was all-cause 30-day mortality. RESULTS: We included 1059 patients (mean age 85±5,9 years old). One hundred and sixty (15.1%) cases had 0-1 points, 278 (26.3%) 2 points, 260 (24.6%) 3 points, 209 (19.7%) 4 points, and 152 (14.3%) 5-6 points of ISAR scale. Ninety five (9.0%) patients died within 30 days. The percentage of mortality increased in relation to ISAR category (lineal trend P value <.001). The area under curve of ISAR scale was 0.703 (95%CI 0.655-0.751; P<.001). After adjusting for EFFECT risk categories, we observed a progressive increase in odds ratios of ISAR scale groups compared to reference (0-1 points). CONCLUSIONS: scale is a brief and easy tool that should be considered for frailty screening during initial assessment of older patients attended with AHF for predicting 30-day mortality.

Eficacia y seguridad de distintas cepas de BCG en el tratamiento del tumor vesical en práctica clínica habitual / Safety and efficacy of various strains of bacille Calmette-Guérin in the treatment of bladder tumours in standard clinical practice

Introducción: La evolución natural del tumor vesical no músculo infiltrante (TVNMI) es la recidiva con elevado porcentaje de progresión. La BCG se ha demostrado eficaz para disminuir estos porcentajes, pero hay pocos estudios comparativos entre cepas. Material y métodos: Registro observacional, prospectivo y multicéntrico, estudiándose 433 pacientes con visita de seguimiento a 12 meses de 961 registrados y evaluado supervivencia libre de enfermedad (SLE), de progresión (SLP) cáncer-específica (SE) y efectos adversos. Se estudiaron las cepas Tice, Russian, Tokyo, Connaught y RIVM. Resultados: Los datos sociodemográficos, antecedentes de TVNMI, comorbilidades, tamaño, número, estadio, grado, CIS asociado y Re-RTU, están bien balanceados. SLE: 85 recidivas (19,6%). La mediana del tiempo de SLE fue 20 meses. Al comparar las diferentes cepas, no se detectaron diferencias estadísticamente significativas (Log-rank test, p = 0,93). SLP: 33 progresiones (7,62%). Al comparar las diferentes cepas, no se detectaron diferencias estadísticamente significativas (Log-rank test, p = 0,69). SE: fallecieron 7 pacientes (1,68%). Al comparar la SE entre las diferentes cepas, no se detectaron diferencias (Log-rank test, p = 0,93). En seguridad, el 33,3% habían presentado algún tipo de efecto adverso, mayoritariamente clínica urinaria baja no ITU < 48h, > 48h y hematuria. Según los Common Toxicity Criteria de la European Organisation for Research and Treatment of Cancer, el 92,7% eran grado 1. No se obtuvieron diferencias estadísticamente significativas relevantes entre cepas. Conclusiones: En este análisis intermedio, el riesgo de recidiva, progresión, muerte específica y seguridad es independiente de la cepa de BCG utilizada

Background: The natural progression of bladder tumours (nonmuscle-invasive bladder cancer [NMIBC]) is recurrence with a high rate of progression. Bacille Calmette-Guérin (BCG) has been shown effective in reducing these rates, but there are few comparative studies between strains. Material and methods: An observational, prospective and multicentre registry studied 433 patients with a 12-month follow-up visit from 961 registered patients, assessing disease-free survival (DFS), progression-free survival (PFS) cancer-specific survival (CSS) and adverse effects. We studied the Tice, Russian, Tokyo, Connaught and RIVM strains. Results: The sociodemographic data, NMIBC history, comorbidities, size, number, stage, grade, associated carcinoma in situ and transurethral resection were well balanced. DFS: There were 85 relapses (19.6%). The median DFS time was 20months. When comparing the various strains, we detected no statistically significant differences (log-rank test; P =.93). LPS: There were 33 cases of progression (7.62%). When comparing the various strains, we detected no statistically significant differences (log-rank test; P = .69). CSS: Seven patients died (1.68%). When comparing the various strains, we detected no statistically significant differences (log-rank test; P = .93). In terms of safety, 33.3% of the patients presented some type of adverse effect, mostly lower urinary symptoms (no urinary tract infections) < 48 h, > 48 h and haematuria. According to the Common Toxicity Criteria of the European Organisation for Research and Treatment of Cancer, 92.7% of the patients were grade 1. There were no statistically significant differences between the strains. Conclusions: In this intermediate analysis, the risk of recurrence, progression, specific death and safety were independent of the BCG strain employed

Safety and efficacy of various strains of bacille Calmette-Guérin in the treatment of bladder tumours in standard clinical practice. / Eficacia y seguridad de distintas cepas de BCG en el tratamiento del tumor vesical en práctica clínica habitual.

BACKGROUND: The natural progression of bladder tumours (nonmuscle-invasive bladder cancer [NMIBC]) is recurrence with a high rate of progression. Bacille Calmette-Guérin (BCG) has been shown effective in reducing these rates, but there are few comparative studies between strains. MATERIAL AND METHODS: An observational, prospective and multicentre registry studied 433 patients with a 12-month follow-up visit from 961 registered patients, assessing disease-free survival (DFS), progression-free survival (PFS) cancer-specific survival (CSS) and adverse effects. We studied the Tice, Russian, Tokyo, Connaught and RIVM strains. RESULTS: The sociodemographic data, NMIBC history, comorbidities, size, number, stage, grade, associated carcinoma in situ and transurethral resection were well balanced. DFS: There were 85 relapses (19.6%). The median DFS time was 20months. When comparing the various strains, we detected no statistically significant differences (log-rank test; P=.93). LPS: There were 33 cases of progression (7.62%). When comparing the various strains, we detected no statistically significant differences (log-rank test; P=.69). CSS: Seven patients died (1.68%). When comparing the various strains, we detected no statistically significant differences (log-rank test; P=.93). In terms of safety, 33.3% of the patients presented some type of adverse effect, mostly lower urinary symptoms (no urinary tract infections) <48h, >48h and haematuria. According to the Common Toxicity Criteria of the European Organisation for Research and Treatment of Cancer, 92.7% of the patients were grade1. There were no statistically significant differences between the strains. CONCLUSIONS: In this intermediate analysis, the risk of recurrence, progression, specific death and safety were independent of the BCG strain employed.

[Pelvic lymph node dissection (extended vs standard) and prostate cancer]. / Linfadenectomía (ampliada vs estándar) y cáncer de próstata.

The role and the potential benefit, if any, of pelvic lymphadenectomy in prostate cancer are still controversially discussed. It is generally accepted that PLND at time of radical prostatectomy is the only reliable diagnostic procedure to achieve as much individual histological staging information as possible to trigger postoperative adjuvant management. However, the extent of pelvic lymph node dissection (limited vs. extended) and the most suitable candidates for this procedure are still a matter of intense debate. The aim of this review is to critically evaluate the current status on lymph node dissection in prostate cancer.

Linfadenectomía (ampliada vs estándar) y cáncer de próstata / Pelvic lymph node dissection (extended vs standard) and prostate cancer

El papel y el beneficio potencial de la linfadenectomía en el cáncer de próstata sigue siendo motivo de controversia. Generalmente se acepta que la linfadenectomía en el momento de realizarse la prostatectomía radical es el único procedimiento diagnóstico que nos acerca a un estadiaje anatomopatológico más preciso permitiéndonos un mejor manejo postoperatorio. Sin embargo la extensión de la disección linfática (limitada vs extensa) y los candidatos más adecuados para estos procedimientos sigue siendo motivo de intenso debate. El propósito de este artículo de revisión es una evaluación crítica del papel actual de la disección linfática en el cáncer de próstata (AU)

The role and the potential benefit, if any, of pelvic lymphadenectomy in prostate cancer are still controversially discussed. It is generally accepted that PLND at time of radical prostatectomy is the only reliable diagnostic procedure to achieve as much individual histological staging information as possible to trigger postoperative adjuvant management. However, the extent of pelvic lymph node dissection (limited vs. extended) and the most suitable candidates for this procedure are still a matter of intense debate. The aim of this review is to critically evaluate the current status on lymph node dissection in prostate cancer (AU)

Amyloid beta-protein1-42 increases cAMP and apolipoprotein E levels which are inhibited by beta1 and beta2-adrenergic receptor antagonists in mouse primary astrocytes.

Amyloid beta-protein (Abeta) increases apolipoprotein E (apoE) levels in astrocytes which could alter lipid trafficking. The mechanism for the Abeta-induced increase in apoE levels is not well understood. It is well established that stimulation of beta-adrenergic receptors (betaARs) increases cAMP levels. Elevation of cAMP levels increases apoE abundance. The current study determined if Abeta(1-42) stimulation of cAMP and apoE levels could be inhibited by betaAR antagonists in astrocytes. We demonstrate that Abeta(1-42) but not the reverse protein Abeta(42-1) or Abeta(1-40) stimulated cAMP formation and this stimulation was inhibited by selective betaAR antagonists in mouse primary cortical astrocytes. Abeta(1-42) significantly increased apoE levels which were significantly inhibited by the betaAR selective antagonists with the greatest inhibition observed with the beta(2) antagonist. Separate lines of evidence have suggested that agonist-induced stimulation of betaARs and increases in apoE abundance may serve a neuroprotective role in astrocytes. Our results indicate a potential interaction between betaARs and apoE which may contribute to reducing Abeta(1-42) neurotoxicity.