Short-term effects of air pollution and noise on emergency hospital admissions in Madrid and economic assessment.

INTRODUCTION: The aim of this study was to study the effect of air pollution and noise has on the population in Madrid Community (MAR) in the period 2013-2018, and its economic impact. METHODS: Time series study analysing emergency hospital admissions in the MAR due to all causes (ICD-10: A00-R99), respiratory causes (ICD-10: J00-J99) and circulatory causes (ICD-10: I00-I99) across the period 2013-2018. The main independent variables were mean daily PM2.5, PM10, NO2, 8-h ozone concentrations, and noise. We controlled for meteorological variables, Public Holidays, seasonality, and the trend and autoregressive nature of the series, and fitted generalised linear models with a Poisson regression link to ascertain the relative risks and attributable risks. In addition, we made an economic assessment of these hospitalisations. RESULTS: The following associations were found: NO2 with admissions due to natural (RR: 1.007, 95% CI: 1.004-1.011) and respiratory causes (RR: 1.012, 95% CI: 1.005-1.019); 8-h ozone with admissions due to natural (RR: 1.049, 95% CI: 1.014-1.046) and circulatory causes (RR: 1.088, 95% CI: 1.039-1.140); and diurnal noise (LAeq7-23h) with admissions due to natural (RR: 1.001, 95% CI: 1.001-1.002), respiratory (RR: 1.002, 95% CI: 1.001-1.003) and circulatory causes (RR: 1.003, 95% CI: 1.002-1.005). Every year, a total of 8246 (95% CI: 4580-11,905) natural-cause admissions are attributable to NO2, with an estimated cost of close on €120 million and 5685 (95% CI: 2533-8835) attributed to LAeq7-23h with an estimated cost of close on €82 million. CONCLUSIONS: Nitrogen dioxide, ozone and noise are the main pollutants to which a large number of hospitalisations in the MAR are attributed, and are thus responsible for a marked deterioration in population health and high related economic impact.

Improving tablet coating robustness by selecting critical process parameters from retrospective data.

CONTEXT: Although tablet coating processes are widely used in the pharmaceutical industry, they often lack adequate robustness. Up-scaling can be challenging as minor changes in parameters can lead to varying quality results. OBJECTIVE: To select critical process parameters (CPP) using retrospective data of a commercial product and to establish a design of experiments (DoE) that would improve the robustness of the coating process. MATERIALS AND METHODS: A retrospective analysis of data from 36 commercial batches. Batches were selected based on the quality results generated during batch release, some of which revealed quality deviations concerning the appearance of the coated tablets. The product is already marketed and belongs to the portfolio of a multinational pharmaceutical company. RESULTS: The Statgraphics 5.1 software was used for data processing to determine critical process parameters in order to propose new working ranges. DISCUSSION AND CONCLUSIONS: This study confirms that it is possible to determine the critical process parameters and create design spaces based on retrospective data of commercial batches. This type of analysis is thus converted into a tool to optimize the robustness of existing processes. Our results show that a design space can be established with minimum investment in experiments, since current commercial batch data are processed statistically.

How heatwaves affect short-term emergency hospital admissions due to bacterial foodborne diseases.

The coming decades are likely to see of extreme weather events becoming more intense and frequent across Europe as a whole and around the Mediterranean in particular. The reproduction rate of some microorganisms, including the bacteria that cause foodborne diseases, will also be affected by these events. The aim of this study was thus to ascertain whether there might be a statistically significant relationship between emergency hospital admissions due to the principal bacterial foodborne diseases (BFDs) and the various meteorological variables, including heatwaves. We conducted a time-series study, with daily observations of both the dependent variable (emergency hospital admissions due to BFDs) and the independent variables (meteorological variables and control variables of chemical air pollution) across the period 2013-2018 in the Madrid Region (Spain), using Generalised Linear Models with Poisson regression, in which control and lag variables were included for the purpose of fitting the models. We calculated the threshold value of the maximum daily temperature above which such admissions increased statistically significantly, analysed data for the whole year and for the summer months alone, and estimated the relative and attributable risks. The estimated attributable risk was 3.6 % for every one-degree rise in the maximum daily temperature above 12 °C throughout the year, and 12.21 % for every one degree rise in temperature above the threshold heatwave definition temperature (34 °C) in summer. Furthermore, different meteorological variables displayed a statistically significant association. Whereas hours of sunlight and mean wind speed proved significant in the analyses of both the whole year and summer, the variables "rain" and "relative humidity", only showed a significant relationship in the analysis for the whole year. High ambient temperature is a risk factor that favours the increase in emergency hospitalisations attributable to the principal BFDs, with a greater impact being observed on days coinciding with heatwave periods. The results yielded by this study could serve as a basis for implementing BFD prevention strategies, especially on heatwave days.

Pseudomonas aeruginosa bloodstream infections in children and adolescents: risk factors associated with carbapenem resistance and mortality.

BACKGROUND: Pseudomonas aeruginosa bloodstream infections (PA-BSIs) are a serious disease and a therapeutic challenge due to increasing resistance to carbapenems. Our objectives were to describe the prevalence and risk factors associated with carbapenem resistance (CR) and mortality in children with PA-BSI. METHODS: A retrospective, multi-centre study was carried out, including patients aged <20 years with PA-BSI in four tertiary hospitals in Madrid (Spain) during 2010-2020. Risk factors for CR PA-BSIs and 30-day mortality were evaluated in a multi-variable logistic regression model. RESULTS: In total, 151 patients with PA-BSI were included, with a median age of 29 months (interquartile range: 3.5-87.1). Forty-five (29.8%) cases were CR, 9.9% multi-drug resistant and 6.6% extensively drug resistant. The prevalence of CR remained stable throughout the study period, with 26.7% (12/45) of CR mediated by VIM-type carbapenemase. Patients with BSIs produced by CR-PA were more likely to receive inappropriate empiric treatment (53.3% vs 5.7%, P<0.001) and to have been previously colonized by CR-PA (8.9% vs 0%, P=0.002) than BSIs caused by carbapenem-susceptible P. aeruginosa. CR was associated with carbapenem treatment in the previous month (adjusted odds ratio (aOR) 11.15) and solid organ transplantation (aOR 7.64). The 30-day mortality was 23.2%, which was associated with mechanical ventilation (aOR 4.24), sepsis (aOR 5.72), inappropriate empiric antibiotic therapy (aOR 5.86), and source control as a protective factor (aOR 0.16). CONCLUSION: This study shows a concerning prevalence of CR in children with PA-BSIs, leading to high mortality. Inappropriate empiric treatment and sepsis were associated with mortality. The high prevalence of CR with an increased risk of inappropriate empiric treatment should be closely monitored.

Unilateral pulmonary edema associated factors after minimally invasive mitral valve surgery.

BACKGROUND AND OBJECTIVES: In recent years, minimally invasive cardiac surgery (MICS) has been developed and applied to a greater number of pathologies, especially in mitral valve surgeries, as it obtains results comparable to those of conventional techniques while entailing lower surgical trauma and shorter recovery time. MICS requiring one-lung ventilation has been associated to the appearance of unilateral pulmonary edema (UPE), which is a potentially serious complication. The objective is determining the incidence of UPE after mitral MICS and its development associated factors. MATERIAL AND METHODS: Observational descriptive and single-center study analyzing data from patients undergoing mitral valve MICS (right mini-thoracotomy) consecutively collected between the years 2015 and 2017. RESULTS: A total of 93 patients were included and 26 presented UPE. The most common complications after mitral valve MICS were atrial fibrillation (38.7%), UPE (28%) and transient and/or definitive second- or third-degree auriculoventricular block (19.4%). The UPE group had longer ICU stay (3.3 ± 8.0 vs. 1.84 ± 2.23 days) and longer total hospitalization length-of-stay (15.5 ± 34.7 vs. 10.6 ± 7.5 days). The mortality in the UPE group was 3.9%. A significant association was found between the following collected variables and the development of postoperative UPE: preoperative baseline pulse oximetry, preoperative use of ACE inhibitors, postoperative atrial fibrillation and 24 first-hours cumulative chest tube drainage volume on the first 24 h. CONCLUSIONS: The incidence of UPE is high and its appearance is associated with a longer ICU and total length of stay. More studies are required to understand its pathophysiology and apply measures to help decreasing its appearance.

Temporal evolution of threshold temperatures for extremely cold days in Spain.

In contrast to research on heat waves, there are no studies in recent years that analyze the temporal evolution of threshold temperatures (Tthreshold) for extremely cold days (ECD). It is unknown whether threshold temperatures have increased more quickly than the minimum daily temperature (Tmin) in recent years. The objective of this study was to analyze the temporal evolution of the minimum daily temperature (Tmin) in a group of Spanish provinces and compare it with the evolution of threshold temperatures. An ecological, retrospective time series study was carried out using daily observations between January 1, 1983 and December 31, 2018 (36 years) in 10 provinces that are representative of the different climate territories in Spain. For each representative observatory in each province, the values of Tmin were obtained for the winter months (November-March). The value of Tthreshold was determined for each province and each year, using dispersion diagrams for the pre-whitened series, with daily mortality due to natural causes displayed on the Y axis (CIEX: A00-R99) and Tmin grouped by 10 degree intervals on the X axis. To determine the temporal evolution of Tmin and Tthreshold for each province, linear models were fitted, with time as the independent variable. During the winter months, Tmin increased at an average rate of 0.2 °C/decade (IC95: 0.1-0.3), while Tthreshold remained practically constant during the period, at 0.1 °C/decade (IC95% -0.1 0.3). These values are much lower than those obtained in the case of heat, both in terms of the evolution of maximum daily temperature and that of Tthreshold. In conclusion, the fact that this trend has been maintained across time in a scenario of climate change, with a slow increase in minimum daily temperatures and constant values of Threshold, suggests a decrease in the number of ECD.

[The Herbst triad: finger clubbing, hypoproteinemia and iron deficiency anemia associated with gastroesophageal reflux]. / Tríada de Herbst: acropaquías, hipoproteinemia y anemia ferropénica, asociadas a reflujo gastroesofágico.

Gastroesophageal reflux with hiatal hernia has been associated with unusual presentations, including rumination syndrome, Sandifer syndrome (reflux esophagitis, iron deficiency anemia and head cocking) and the Herbst triad (iron deficiency anemia, hypoproteinemia and finger clubbing). We report a new case of this rare disease. Lack of awareness of gastroesophageal reflux as a possible cause of these striking symptoms could lead to complications and delayed surgery.

Factores asociados al edema pulmonar unilateral después de la cirugía mínimamente invasiva de la válvula mitral / Unilateral pulmonary edema associated factors after minimally invasive mitral valve surgery

Antecedentes y objetivo: En los últimos años la cirugía cardíaca mínimamente invasiva (CCMI) se ha desarrollado y aplicado a mayor número de dolencias, especialmente en cirugías sobre la válvula mitral, por presentar resultados comparables a las técnicas convencionales con menor agresividad y tiempo de recuperación. La CCMI que necesita ventilación unipulmonar se ha asociado a la aparición de edema pulmonar unilateral (EPU), que constituye una complicación potencialmente grave. El objetivo es determinar la incidencia de EPU tras CCMI mitral y los factores asociados a su desarrollo. Material y métodos: Estudio observacional descriptivo y unicéntrico. Se analizaron los pacientes tratados con CCMI sobre válvula mitral (minitoracotomía derecha), recogidos de manera consecutiva entre los años 2015 y 2017. Resultados: Se incluyó a un total de 93 pacientes, de los cuales 26 presentaron EPU. Las complicaciones más habituales tras la CCMI mitral fueron: fibrilación auricular (38,7%), EPU (28%) y bloqueo auriculoventricular de segundo o tercer grado transitorio o definitivo (19,4%). El grupo EPU presentó mayor tiempo de estancia en UCI (3,3±8,0 vs. 1,84±2,23 días) y mayor tiempo total de hospitalización (15,5±34,7 vs. 10,6±7,5 días). La mortalidad en el grupo EPU fue del 3,9%. Se encontró asociación significativa entre las siguientes variables recogidas y el desarrollo de EPU postoperatorio: pulsioximetría basal preoperatoria, uso preoperatorio de IECA, fibrilación auricular postoperatoria y volumen de drenajes en las primeras 24h. Conclusiones: La incidencia de EPU es elevada y su aparición se asocia a mayor estancia en UCI y mayor tiempo total de hospitalización. Se requieren más estudios para comprender su fisiopatología y aplicar medidas que ayuden a disminuir su aparición.(AU)

Background and objectives: In recent years, minimally invasive cardiac surgery (MICS) has been developed and applied to a greater number of pathologies, especially in mitral valve surgeries, as it obtains results comparable to those of conventional techniques while entailing lower surgical trauma and shorter recovery time. MICS requiring one-lung ventilation has been associated to the appearance of unilateral pulmonary edema (UPE), which is a potentially serious complication. The objective is determining the incidence of UPE after mitral MICS and its development associated factors. Material and methods: Observational descriptive and single-center study analyzing data from patients undergoing mitral valve MICS (right mini-thoracotomy) consecutively collected between the years 2015 and 2017. Results: A total of 93 patients were included and 26 presented UPE. The most common complications after mitral valve MICS were atrial fibrillation (38.7%), UPE (28%) and transient and/or definitive second- or third-degree auriculoventricular block (19.4%). The UPE group had longer ICU stay (3.3±8.0 vs. 1.84±2.23 days) and longer total hospitalization length-of-stay (15.5±34.7 vs. 10.6±7.5 days). The mortality in the UPE group was 3.9%. A significant association was found between the following collected variables and the development of postoperative UPE: preoperative baseline pulse oximetry, preoperative use of ACE inhibitors, postoperative atrial fibrillation and 24 first-hours cumulative chest tube drainage volume on the first 24h. Conclusions: The incidence of UPE is high and its appearance is associated with a longer ICU and total length of stay. More studies are required to understand its pathophysiology and apply measures to help decreasing its appearance.(AU)

[Effect of the smoking habit on carbohydrate metabolism]. / Influencia del hábito de fumar sobre el metabolismo hidrocarbonado.

Mechanism tobacco favours arteriosclerosis aren't clear. Hyperglycemia in smokers would be help factor. On value relationship between tobacco, fasting plasma glucose and hemoglobin A1c in a coal-miner working population, made up of 1,379 males, 38 years old average. We find meaning difference in hemoglobin A1c and fasting plasma glucose values between smokers and non-smokers. Hemoglobin A1c are more elevated in smokers while glycemia are more elevated in non-smokers. We rapport some reason over these divergent results. Hemoglobin A1c elevated in smokers suggest that the tobacco has negative influence on glucose metabolism.

[Interpretation of the tuberculin test in children with CD4 lymphocyte cell mediated immunity changes]. / Interpretación de la prueba de tuberculina en niños con alteración de la inmunidad celular mediada por linfocitos CD4.

Immunosuppression could be a cause of a false negative tuberculin skin test (TST) result. A cross-sectional study was performed on a population of immigrants and internationally adopted children to analyse whether CD4 cell counts could modify the TST results. A total of 1074 children were included between January 2003 and December 2008. CD4 cell counts were performed on 884 children, in whom 5.3% had CD4 values <25%. There were no differences in TST results among children with normal and pathological CD4 cell counts. Several studies, including this one, have shown that there is no direct association between the CD4 value and the TST results. These results should be confirmed with larger series and with a higher percentage of children with CD4 values <25%.

[Urinary tract infections: antibiotic resistance and clinical follow up]. / Infecciones del tracto urinario: sensibilidad antimicrobiana y seguimiento clínico.

The initial treatment of the urinary tract infections (UTI) is empirical and it is a priority to determine the antibiotic resistance of most common germs in a population. Furthermore, due to the suspicion of acute pyelonephritis the presence of renal scarring should be ruled out as this may lead to further complications. A retrospective longitudinal study was performed on all children under 14 years diagnosed with UTI from January 1 2009 to December 31 2009. The in vitro susceptibility to the most important urinary pathogens was analysed, along with the presence of scars, and a subsequent follow-up. The most frequently isolated bacteria were E. coli (80%), P. mirabilis (9.7%) and K. pneumoniae (4.2%). In the antibiogram, E coli showed a high sensitivity to fosfomycin (99.1%), cefotaxime (98.2%) cefuroxime (97.3%) and gentamicin (95.6%). The sensitivity obtained against amoxicillin-clavulanate was 83.2%, while that obtained against cotrimoxazole was 78.9%. Post-pyelonephritis scars were found in 19% of patients with febrile UTI, 17% out-patients and 20% of those admitted.

Interpretación de la prueba de tuberculina en niños con alteración de la inmunidad celular mediada por linfocitos CD4 / Interpretation of the tuberculin test in children with CD4 lymphocyte cell mediated immunity changes

La inmunosupresión puede ser causa de un falso negativo en la interpretación de la prueba de tuberculina (PT). Se realiza un estudio transversal en una población de niños adoptados e inmigrantes para analizar si la alteración de la inmunidad celular mediada por linfocitos CD4 puede modificar el resultado de la PT. Se incluyó a 1.074 niños (enero de 2003-diciembre de 2008). El estudio de subpoblaciones linfocitarias se efectuó en 884 niños. Un 5,3% tuvo valores de linfocitos CD4 < 25%. No existieron diferencias en el resultado de la PT entre niños con valores normales y patológicos de linfocitos CD4. Varios estudios, incluyendo nuestra serie, han demostrado que no existe una correlación directa entre el valor porcentual de linfocitos CD4 y el resultado de la PT. No obstante, estos resultados deberían confirmarse con series más numerosas y con un mayor porcentaje de niños con valores porcentuales de linfocitos CD4 < 25%

Immunosuppression could be a cause of a false negative tuberculin skin test (TST) result. A cross-sectional study was performed on a population of immigrants and internationally adopted children to analyse whether CD4 cell counts could modify the TST results. A total of 1074 children were included between January 2003 and December 2008. CD4 cell counts were performed on 884 children, in whom 5.3% had CD4 values <25%. There were no differences in TST results among children with normal and pathological CD4 cell counts. Several studies, including this one, have shown that there is no direct association between the CD4 value and the TST results. These results should be confirmed with larger series and with a higher percentage of children with CD4 values <25%

Internationally adopted children: what vaccines should they receive?

It is of paramount importance to know the vaccination status in internationally adopted children, so that they can be correctly immunized. This study ascertains the seroprotection rate for vaccine-preventable diseases and the validity of the immunization cards in 637 adopted children. The absence of the immunization card (13% of children) correlated with a poor global vaccine protection. Children with immunization records (87%) had a better global seroprotection but the information obtained from the card did not accurately predict seroprotection for each particular antigen. The best variable to predict the status of seroprotection was the country of origin. The highest rate of protection was found in children from Eastern Europe and, in descending order, India, Latin America, China and Africa. General recommendations for immunization of internationally adopted children are difficult to establish. Actions for vaccination have to be mainly implemented on the basis of the existence of the immunization card and of the country of origin.

Infecciones del tracto urinario: sensibilidad antimicrobiana y seguimiento clínico / Urinary tract infections: antibiotic resistance and clinical follow up

El tratamiento inicial de las infecciones del tracto urinario (ITU) es empírico por lo que es prioritario conocer la resistencia antibiótica de los microorganismos más frecuentes en una población. Además, tras la sospecha de pielonefritis aguda se debe descartar la presencia de cicatriz renal que puede dar lugar a complicaciones posteriores. Presentamos un estudio longitudinal y retrospectivo de todos los menores de 14 años diagnosticados de ITU desde el 1 de enero del 2009 hasta el 31 de diciembre del 2009. Se analizaron los datos de sensibilidad a antimicrobianos de los patógenos urinarios más importantes, el seguimiento posterior y la presencia de cicatrices. Las bacterias aisladas con mayor frecuencia fueron: Escherichia coli (80%) Proteus mirabillis (9,7%) y Klebsiella pneumoniae (4,2%). En el antibiograma, E. coli presentó una alta sensibilidad frente a fosfomicina (99,1%), cefotaxima (98,2%) cefuroxima (97,3%) y gentamicina (95,6%). La sensibilidad obtenida frente a amoxicilina-clavulánico fue del 83,2%, mientras que la obtenida frente a cotrimoxazol fue del 78,9%.Se encontraron cicatrices pospielonefríticas en el 19% de los pacientes con ITU febril, 17% de los no ingresados y 20% de los ingresados(AU)

The initial treatment of the urinary tract infections (UTI) is empirical and it is a priority to determine the antibiotic resistance of most common germs in a population. Furthermore, due to the suspicion of acute pyelonephritis the presence of renal scarring should be ruled out as this may lead to further complications. A retrospective longitudinal study was performed on all children under 14 years diagnosed with UTI from January 1 2009 to December 31 2009. The in vitro susceptibility to the most important urinary pathogens was analysed, along with the presence of scars, and a subsequent follow-up. The most frequently isolated bacteria were E. coli (80%), P. mirabilis (9.7%) and K. pneumoniae (4.2%). In the antibiogram, E coli showed a high sensitivity to fosfomycin (99.1%), cefotaxime (98.2%) cefuroxime (97.3%) and gentamicin (95.6%). The sensitivity obtained against amoxicillin-clavulanate was 83.2%, while that obtained against cotrimoxazole was 78.9%.Post-pyelonephritis scars were found in 19% of patients with febrile UTI, 17% out-patients and 20% of those admitted(AU)