Changes over time in the association between type 2 diabetes and post-discharge outcomes in decompensated chronic heart failure patients: Findings from the RICA Registry.

AIMS: Heart failure (HF) and diabetes are 2 strongly associated diseases. The main objective of this work was to analyze changes in the prognosis of patients with diabetes who were admitted for heart failure in 2 time periods. METHODS: This work is a prospective study comparing prognosis at one year of follow-up among patients with diabetes who were hospitalized for HF in either 2008-2011 or 2018. The patients are from the Spanish Society of Internal Medicine's National Heart Failure Registry (RICA, for its initials in Spanish). The primary endpoint was to analyze the composite outcome of total mortality and/or readmission due to HF in 12 months. A multivariate Cox regression model was used to evaluate the strength of association (hazard ratio [HR]) between diabetes and the outcomes between both periods. RESULTS: A total of 936 patients were included in the 2018 cohort, of which 446 (48%) had diabetes. The baseline characteristics of the populations from the 2 periods were similar. In patients with diabetes, the composite outcome was observed in 233 (47.5%) in the 2008-2011 cohort and 162 (36%) in the 2018 cohort [HR 1.48; 95% confidence interval (95%CI) 1.18-1.85; p < .001]. The proportion of readmissions (HR 1.39; 95%CI 1.07-1.80; p = .015) and total mortality (HR 1.60; 95%CI 1.20-2.14; p < .001) were also significantly higher in patients with diabetes from the 2008-2011 cohort compared to the 2018 cohort. CONCLUSIONS: In 2018, an improvement was observed in the prognosis for all-cause mortality and readmissions over one year of follow-up in patients with diabetes hospitalized for HF compared to the 2008-2011 period.

Factors associated with development of nephrotoxicity in patients treated with vancomycin versus daptomycin for severe Gram-positive infections: A practice-based study.

OBJECTIVE: To evaluate nephrotoxicity development in patients treated with vancomycin (VAN) and daptomycin (DAP) for proven severe Gram-positive infections in daily practice. METHODS: A practice-based, observational, retrospective study (eight Spanish hospitals) was performed including patients ≥18 years with a baseline glomerular filtration rate (GFR)>30 mL/min and/or serum creatinine level<2 mg/dL treated with DAP or VAN for >48h. Nephrotoxicity was considered as a decrease in baseline GRF to <50 mL/min or decrease of >10 mL/min from a baseline GRF<50 mL/min. Multivariate analyses were performed to determine factors associated with 1) treatment selection, 2) nephrotoxicity development, and 3) nephrotoxicity development within each antibiotic group. RESULTS: A total of 133 patients (62 treated with DAP, 71 with VAN) were included. Twenty-one (15.8%) developed nephrotoxicity: 4/62 (6.3%) patients with DAP and 17/71 (23.3%) with VAN (p=0.006). No differences in concomitant administration of aminoglycosides or other potential nephrotoxic drugs were found between groups. Factors associated with DAP treatment were diabetes mellitus with organ lesion (OR=7.81, 95%CI:1.39-4.35) and basal creatinine ≥0.9 mg/dL (OR=2.53, 95%CI:1.15-4.35). Factors associated with VAN treatment were stroke (OR=7.22, 95%CI:1.50-34.67), acute myocardial infarction (OR=6.59, 95%CI:1.51-28.69) and primary bacteremia (OR=5.18, 95%CI:1.03-25.99). Factors associated with nephrotoxicity (R2=0.142; p=0.001) were creatinine clearance<80 mL/min (OR=9.22, 95%CI:1.98-30.93) and VAN treatment (OR=6.07, 95%CI:1.86-19.93). Factors associated with nephrotoxicity within patients treated with VAN (R2=0.232; p=0.018) were congestive heart failure (OR=4.35, 95%CI:1.23-15.37), endocarditis (OR=7.63, 95%CI:1.02-57.31) and basal creatinine clearance<80 mL/min (OR=7.73, 95%CI:1.20-49.71). CONCLUSIONS: Nephrotoxicity with VAN was significantly higher than with DAP despite poorer basal renal status in the DAP group.

Effect of a rehabilitation-based chronic disease management program targeting severe COPD exacerbations on readmission patterns.

BACKGROUND: Pulmonary rehabilitation (PR) is recommended after a severe COPD exacerbation, but its short- and long-term effects on health care utilization have not been fully established. AIMS: The aims of this study were to evaluate patient compliance with a chronic disease management (CDM) program incorporating home-based exercise training as the main component after a severe COPD exacerbation and to determine its effects on health care utilization in the following year. MATERIALS AND METHODS: COPD patients with a severe exacerbation were included in a case-cohort study at admission. An intervention group participated in a nurse-supervised CDM program during the 2 months after discharge, comprising of home-based PR with exercise components directly supervised by a physiotherapist, while the remaining patients followed usual care. RESULTS: Nineteen of the twenty-one participants (90.5%) were compliant with the CDM program and were compared with 29 usual-care patients. Compliance with the program was associated with statistically significant reductions in admissions due to respiratory disease in the following year (median [interquartile range]: 0 [0-1] vs 1 [0-2.5]; P=0.022) and in days of admission (0 [0-7] vs 7 [0-12]; P=0.034), and multiple linear regression analysis confirmed the protective effect of the CDM program (ß coefficient -0.785, P=0.014, and R2=0.219). CONCLUSION: A CDM program incorporating exercise training for COPD patients without limiting comorbidities after a severe exacerbation achieves high compliance and reduces admissions in the year following after the intervention.

Evolución de la asociación de diabetes y eventos posalta en pacientes con insuficiencia cardíaca crónica descompensada: hallazgos del registro RICA / Changes over time in the association between type 2 diabetes and post-discharge outcomes in decompensated chronic heart failure patients: Findings from the RICA Registry

Objetivos: La insuficiencia cardíaca (IC) y la diabetes son 2procesos fuertemente asociados. El objetivo principal fue analizar la evolución del pronóstico de los pacientes con diabetes que ingresan por IC a lo largo de 2períodos. Métodos: Estudio prospectivo para comparar el pronóstico a un año de seguimiento entre los pacientes con diabetes que ingresan por IC en 2008-2011 y 2018. Los pacientes proceden del Registro Nacional de Insuficiencia Cardíaca (RICA) de la Sociedad Española de Medicina Interna. El objetivo primario fue analizar el desenlace combinado de mortalidad total o ingreso por IC durante 12 meses. Se utilizó una regresión multivariante de Cox para evaluar la fuerza de asociación (hazard ratio [HR]) de la diabetes y los desenlaces entre ambos períodos. resultados: Se incluyó a un total de 936 pacientes en la cohorte de 2018, de los que 446 (48%) tenían diabetes. Las características basales de la población de los 2períodos fueron similares. En los pacientes con diabetes se observó el desenlace combinado en 233 (47,5%) en la cohorte de 2008-2011 y 162 (36%) en la cohorte de 2018 (HR 1,48; intervalo de confianza del 95% [IC95%] 1,18-1,85; p <0,001). La proporción de ingresos (HR 1,39; IC95% 1,07-1,80; p=0,015) y la mortalidad total (HR 1,60; IC95% 1,20-2,14; p <0,001) también fueron significativamente mayores en los pacientes con diabetes de la cohorte de 2008-2011 con respecto a la del 2018. Conclusiones: En 2018 se observa una mejoría del pronóstico de la mortalidad total y los reingresos durante un año de seguimiento en pacientes con diabetes hospitalizados por IC con respecto al período de 2008-2011 (AU)

Aims: Heart failure (HF) and diabetes are 2strongly associated diseases. The main objective of this work was to analyze changes in the prognosis of patients with diabetes who were admitted for heart failure in 2time periods. Methods: This work is a prospective study comparing prognosis at one year of follow-up among patients with diabetes who were hospitalized for HF in either 2008-2011 or 2018. The patients are from the Spanish Society of Internal Medicine's National Heart Failure Registry (RICA, for its initials in Spanish). The primary endpoint was to analyze the composite outcome of total mortality and/or readmission due to HF in 12 months. A multivariate Cox regression model was used to evaluate the strength of association (hazard ratio [HR]) between diabetes and the outcomes between both periods. Results: A total of 936 patients were included in the 2018 cohort, of which 446 (48%) had diabetes. The baseline characteristics of the populations from the 2periods were similar. In patients with diabetes, the composite outcome was observed in 233 (47.5%) in the 2008-2011 cohort and 162 (36%) in the 2018 cohort [HR 1.48; 95% confidence interval (95%CI) 1.18-1.85; p<.001]. The proportion of readmissions (HR 1.39; 95%CI 1.07-1.80; p=.015) and total mortality (HR 1.60; 95%CI 1.20-2.14; p<.001) were also significantly higher in patients with diabetes from the 2008-2011 cohort compared to the 2018 cohort. Conclusions: In 2018, an improvement was observed in the prognosis for all-cause mortality and readmissions over one year of follow-up in patients with diabetes hospitalized for HF compared to the 2008-2011 period (AU)

The role of endogenous nitric oxide in the response of coronary blood flow to tachycardia.

BACKGROUND: The role of endogenous nitric oxide as mediator of flow-dependent dilation is well established. However, its role in the adaptation of coronary blood flow to tachycardia is less well defined. This study was designed to determine whether nitric oxide is a mediator in pacing-induced hyperaemia. METHODS: Twenty pigs were instrumented for coronary blood flow, aortic pressure and atrial pacing measurements. Their heart rate was increased by 20 beats every 5 min. Coronary blood flow was measured basally and at each pacing interval before and after each of the following interventions: intracoronary saline infusion (n = 6), N omega-nitro-L-arginine methyl ester infusion (L-NAME, 20 micrograms/kg per min intracoronarily, n = 9) and infusion of L-NAME plus L-arginine (0.3 mg/kg per min intracoronarily, n = 5). RESULTS: The coronary peak flow increased with atrial pacing. The maximum increase in coronary blood flow with pacing was significantly reduced after infusion of L-NAME (159 +/- 33 versus 143 +/- 30%), whereas no change was observed in the saline group (163 +/- 28 versus 172 +/- 29%). However, it increased significantly in the group receiving L-NAME plus L-arginine (147 +/- 29 versus 182 +/- 40%). CONCLUSIONS: In the pig, the increase in coronary blood flow and therefore the vasodilation of the microvasculature that accompanies tachycardia depend, partly, on the release of endogenous nitric oxide.

[Effect of cyclooxygenase inhibition on the adaptation of coronary blood flow to tachycardia]. / Efecto de la inhibición de la ciclooxigenasa en la adaptación del flujo coronario a la taquicardia.

BACKGROUND: The role of different endothelium-derived vasoactive substances in the regulation of coronary circulation during tachycardia is not well defined. In order to elucidate the contribution of prostacyclin to the adaptation of coronary blood flow to tachycardia, the effect of meclofenamate, a cyclooxygenase inhibitor on the coronary blood flow response to rapid atrial pacing was analyzed in a porcine model. METHODS: A group of seventeen pigs were instrumented for coronary blood flow, aortic pressure and atrial pacing. Heart rate was increased by 20 beats every 5 minutes. Coronary blood flow and aortic pressure were measured, and coronary resistance calculated, basally and at each pacing interval, before and after saline serum (n = 6), meclofenamate 5 mg/kg, i.v. (n = 7) or meclofenamate 35 mg/kg, i.v. (n = 4). RESULTS: Neither saline nor meclofenamate modified the normal increase of coronary blood flow provoked by rapid atrial pacing (163 +/- 28% increase before versus 172 +/- 29% after saline; 159 +/- 21% increase before versus 161 +/- 22% after meclofenamate low doses and 201 +/- 39% before vs 172 +/- 36 after meclofenamate high doses). There were no differences in the response of coronary vascular resistance to tachycardia before and after meclofenamate (44% reduction vs 40% respectively). CONCLUSION: Cyclooxygenase blockade does not modify the response of coronary circulation to rapid atrial pacing, suggesting that prostacyclin does not play a limiting role in the regulation of coronary blood flow during tachycardia in this model.

[The use of acetylsalicylic acid in patients with ischemic cardiomyopathy cared for in Spanish emergency services (results of the EVICURE Study). Evaluacion del Manejo de la cardiopatia isquemica en los Servicios de Urgencias Hospitalarios of the Sociedad Espanola de Medicina de Urgencias y Emergencias (SEMES)]. / Utilizacin del cido acetilsaliclico en pacientes con cardiopata isquemica atendidos en los servicios de urgencias espaoles (resultados del estudio EVICURE).

BACKGROUND: Acetyl salicylic acid is a drug with demonstrated effectiveness in ischemic cardiomyopathy. The objective of our study was to know the use of this drug in the emergency services of Spain. PATIENTS AND METHOD: The EVICURE study analyzes the use of acetyl salicylic acid in 35 emergency services of Spanish hospitals. RESULTS: 2,168 patients were studied. Of the 473 patients with stable angina, 9.2% received acetyl salicylic acid before going to the hospital and 90,7% at the arrival to the hospital, of 1,067 with unstable angina 13% received acetyl salicylic acid before the arrival to the hospital and 56% at the arrival to the hospital. Of 600 patients affected of myocardial infarction only 17% received acetyl salicylic acid before the arrival to the hospital and 59.8% received this drug in the emergency room. CONCLUSIONS: The use of acetyl salicylic acid in patients affected of ischemic cardiopathy assisted in the emergency services of Spain is improperly low.

[Status of thrombolytic therapy for acute myocardial infarction in the emergency departments of Cataluna, Spain]. / Situación del tratamiento trombolítico del infarto agudo de miocardio en los Servicios de Urgencias de Cataluña.

OBJECTIVES: The aim of the present study was to know the situation of thrombolysis in Catalonia. MATERIAL AND METHODS: A questionnaire was sent to all the hospitals in Catalonia regarding to the administration of thrombolytic treatment in their hospitals. RESULTS: 29 centres replied (18 primary, 10 secondary and 1 tertiary), serving a total catchment population of 4.2 million and with a total number of 2,853 AMIs in. The mean time from the onset of symptoms to arrival at hospital was 176.3 +/- 96 min and from arrival of the patient at the hospital to the initiation of thrombolysis was 78.7 +/- 73.8 min. Most commonly, it was the Emergency Department staff who took the decision on thrombolysis (17 centres). A total of 47 +/- 12% of the AMIs received thrombolytic treatment with 61.76 +/- 42.77% of these treatments being carried out in the Emergency Departments. The internal delay to initiating thrombolysis was of 33.7 +/- 11.9 min in the centres without an ITU versus 112 +/- 8 min in those centres with an ITU (p = 0.0067). In the centres with an ITU but in which it was the doctor in the Emergency Department who took the decision on thrombolysis (n = 7), the internal delay was shorter (84.3 +/- 80.59 min). CONCLUSIONS: There is a shorter delay in the administration of thrombolytic treatment in those emergency departments which do not have access to an ITU or Coronary Unit than in the Emergency Departments which do have this access. If the decision to carry out thrombolysis is taken by the emergency department doctors there is a substantial reduction in the time to its administration.

[Myocardial necrosis is not observed during acute cocaine abuse detectable by the serum levels of troponin T]. / No se observa necrosis miocárdica durante el consumo agudo de cocaína detectable por niveles plasmáticos de troponina T.

BACKGROUND: Recently we can use a new family of serological markers to objective myocardial damage with hig sensibility and specificity. One of these markers is T troponin (c-TNT). Some cocaine abusers have chest pain during drug consumption due to myocardial ischemia produced by the drug. OBJECTIVE: To study if in the chest pain appeared after cocaine consumption a c-TNT increased is objective, showing myocardial cellular damage. PATIENTS AND METHODS: We studied 65 patients; 35 cocaine abusers that were admitted into the emergency room for chest pain after cocaine consumption and 30 patients with no coronary chest pain. To all of them were determined c-TNT and CK. RESULTS: An increase in c-TNT or CK was not observed in both groups. CONCLUSION: We don't observe an increase in c-TNT in the group of cocaine abusers that evidence myocardial cellular damage.

[Usefulness of troponin T and troponin I in the diagnosis and prognostic stratification of patients with ischemic cardiopathy attending an emergency service]. / Utilidad de la troponina T y troponina I en el diagnóstico y estratificación pronóstica de los pacientes con cardiopatía isquémica que acuden a un Servicio de Urgencias.

BACKGROUND: Diagnostic of chest pain in the emergency services supposes a serious problem. This study wants objective if the new non enzymatic markers of myocardial necrosis (T troponin and I troponin) may be an aid for the diagnostic and prognostic stratification of patients with myocardial ischemia. PATIENTS AND METHODS: 82 successive patients who went to the emergency room for chest pain were studied. Electrocardiogram and blood samples were obtained at 0,4, and 12 house of admission. A clinic-evolutive study was performed at discharge, and they were classified in 3 categories: a) myocardial infarction, b) unstable angina (Braunwald classification) and no coronary pains. RESULTS: In the 27 patients with myocardial infarction the markers of troponin group were more sensitive than creatinine kinase to determine myocardial necrosis at 4 hours of admission. Of 41 patients with unstable angina, 34% were of Braunwald III-B class. Troponin group markers discriminate a group of high risk patients, 70% of the patients that need an emergency coronarography for bad clinical evolution were troponin group marker positive. CONCLUSIONS: The use in the emergency room of troponin necrosis markers (T and I troponin) allows to optimize the sanitary resources, detecting quickly the patients with acute myocardial infarction and discriminate a group of high risk of patients with angina.

[Economic crisis: cost and effectiveness of short stay hospital units]. / En plena crisis económica: coste y efectividad de las unidades de estancia corta hospitalarias.

BACKGROUND: Length of stay is the main determinant of the cost of hospitalization, which is why strategies must be implemented to reduce conventional hospital stays while maintaining quality levels. Short Stay Units (SSU) were created with the aim of reducing hospital stays in a certain group of patients and pathologies. The aim of this paper is to evaluate the literature on the evidence of decreased length of stay, efficiency, readmissions in the emergency department, cost-effectiveness, and mortality of these units. METHODS: We made a systematic review of the literature, using the MeSH terms "Observation Unit", "Short-Stay Ward", "Monday to Friday Clinic" , "Monday to Friday Surgery Ward", "Short Stay Hospitalization", "Alternative to Conventional Hospitalization", "Alternative Admissions" in the MEDLINE database, Web of Knowledge and the Cochrane Library from January 1 1960 to January 1 2012. The studies reviewed were selected according to the U.S. Preventive Services Task Force Protocol. RESULTS: The SSU made it possible in certain groups of patients to reduce the period of stay and maintain efficiency, showing no increases in emergency readmissions or mortality. CONCLUSIONS: The SSU can be an instrument to reduce the cost of the health process in a certain group of pathologies.

Comentarios al artículo: «Influencia de las unidades de corta estancia en la calidad de atención hospitalaria en España. Revisión sistemática» / Comments on the article: «Influence of short-stay units on the quality of health care in Spain. A systematic review»

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