Neonatal outcomes after water birth: A retrospective cohort study.

OBJECTIVE: To compare neonatal outcomes between water births, births with immersion only during labour, and births in which immersion was never used. METHODS: A retrospective cohort study was performed including mother-baby dyads attended between 2009 and 2019 at the Hospital do Salnés regional hospital (Pontevedra, Spain). These women were categorised into 3 groups: water birth; immersion only during dilation; and women who never used immersion. Several sociodemographic-obstetric variables were studied and the main outcome was the admission of the neonate to the intensive care unit (NICU). Permission was obtained from the responsible provincial ethics committee. Descriptive statistics were used and between-group comparisons were performed using variance for continuous variables and chi-square for categorical variables. Multivariate analysis was performed with backward stepwise logistic regression and incidence risk ratios with 95%CI were calculated for each independent variable. Data were analysed using IBM SPSS® statistical software. RESULTS: A total of 1191 cases were included. 404 births without immersions; 397 immersions only during the first stage of labor; and 390 waterbirths were included. No differences were found in the need to transfer new-borns to a NICU (p = .735). In the waterbirth cohort, neonatal resuscitation (p < .001, OR: 0,1), as well as respiratory distress (p = .005, OR: 0,2) or neonatal problems during admission (p < .001, OR: 0,2), were lower. In the immersion only during labor cohort, less neonatal resuscitation (p = .003; OR: 0,4) and respiratory distress (p = .019; OR: 0,4) were found. The probability of not breastfeeding upon discharge was higher for the land birth cohort (p < .001, OR: 0,4). CONCLUSIONS: The results of this study indicated that water birth did not influence the need for NICU admission, but was associated with fewer adverse neonatal outcomes, such as resuscitation, respiratory distress, or problems during admission.

Breastfeeding and Obstetric Violence during the SARS-CoV-2 Pandemic in Spain: Maternal Perceptions.

Catalan legislation, a pioneer in Europe, has defined obstetric violence (OV) as "preventing or hindering access to truthful information, necessary for autonomous and informed decision-making". The definition also states that OV can affect physical and mental health, as well as sexual and reproductive health. Some authors have expressed concern about an increase in OV during the SARS-CoV-2 pandemic. During the pandemic, recommendations were also openly offered on the non-establishment and/or early abandonment of breastfeeding without scientific evidence to support them. Experiencing a traumatic childbirth can influence breastfeeding outcomes. Here, we conducted a cross-sectional study using a self-administered online questionnaire. The sample consisted of women who gave birth in Spain between March 2020 and April 2021. The mean age was 34.41 (±4.23) years. Of the women, 73% were employed, 78.2% had a university education, and almost all were Caucasian. Among the subjects, 3.3% were diagnosed with SARS-CoV-2 during pregnancy and 1% were diagnosed during delivery. Some of the women (1.6%) were advised to stop breastfeeding in order to be vaccinated. Women diagnosed with SARS-CoV-2 during delivery (p = 0.048), belonging to a low social class (p = 0.031), with secondary education (p = 0.029), or who suffered obstetric violence (p < 0.001) perceived less support and that the health care providers were less inclined to resolve doubts and difficulties about breastfeeding. Breastfeeding has been significantly challenged during the pandemic. In addition to all the variables to be considered that make breastfeeding support difficult, we now probably need to add SARS-CoV-2 diagnosis and OV.

Identification and Targeting of the Developmental Blockade in Extranodal Natural Killer/T-cell Lymphoma.

Extranodal natural killer/T-cell lymphoma (ENKTL) is an aggressive, rare lymphoma of natural killer (NK) cell origin with poor clinical outcomes. Here we used phenotypic and molecular profiling, including epigenetic analyses, to investigate how ENKTL ontogeny relates to normal NK-cell development. We demonstrate that neoplastic NK cells are stably, but reversibly, arrested at earlier stages of NK-cell maturation. Genes downregulated in the most epigenetic immature tumors were associated with polycomb silencing along with genomic gain and overexpression of EZH2. ENKTL cells exhibited genome-wide DNA hypermethylation. Tumor-specific DNA methylation gains were associated with polycomb-marked regions, involving extensive gene silencing and loss of transcription factor binding. To investigate therapeutic targeting, we treated novel patient-derived xenograft (PDX) models of ENKTL with the DNA hypomethylating agent, 5-azacytidine. Treatment led to reexpression of NK-cell developmental genes, phenotypic NK-cell differentiation, and prolongation of survival. These studies lay the foundation for epigenetic-directed therapy in ENKTL. SIGNIFICANCE: Through epigenetic and transcriptomic analyses of ENKTL, a rare, aggressive malignancy, along with normal NK-cell developmental intermediates, we identified that extreme DNA hypermethylation targets genes required for NK-cell development. Disrupting this epigenetic blockade in novel PDX models led to ENKTL differentiation and improved survival. This article is highlighted in the In This Issue feature, p. 85.

Obstetric Violence in Spain (Part III): Healthcare Professionals, Times, and Areas.

BACKGROUND: Obstetric violence is a worldwide public health problem, which seems greater in Spain. As no studies were found that identify the most representative healthcare professionals, times, and areas involved in obstetric violence, the objective of this work was to study at what time of maternity, with which professionals, and in what areas women identified obstetric violence. METHODS: This descriptive, retrospective, and cross-sectional study was performed from January 2018 to June 2019. The main variables were the area (hospital, primary care, both), the time (pregnancy, birth, puerperium), and the professionals attending to women. RESULTS: Our sample comprised 17,541 participants. The area identified with the most obstetric violence for the different studied variables was hospitals. Women identified more obstetric violence at time of birth. Findings such as lack of information and informed consent (74.2%), and criticism of infantile behavior and treatment (87.6%), stood out. The main identified healthcare professionals were midwives and gynecologists, and "other" professionals repeatedly appeared. CONCLUSIONS: Having identified the professionals, times, and areas of most obstetric violence in Spain, it seems necessary to reflect on not only the Spanish National Health System's structure and management but also on healthcare professionals' training.

Obstetric Violence in Spain (Part I): Women's Perception and Interterritorial Differences.

The decentralization of health systems can have direct repercussions on maternity care. Some inequalities can be noted in outcomes, like neonatal and child mortality in Spain. This study aimed to make the presence of obstetric violence in Spain visible as an interterritorial equity criterion. A descriptive, restrospective and cross-sectional study was conducted between January 2018 and June 2019. The sample comprised 17,541 questionnaires, which represented all Spanish Autonomous Communities. Of our sample, 38.3% perceived having suffered obstetric violence; 44.4% perceived that they had undergone unnecessary and/or painful procedures, of whom 83.4% were not requested to provide informed consent. The mean satisfaction with the attention women received obtained 6.94 points in the general sample and 4.85 points for those women who viewed themselves as victims of obstetric violence. Spain seems to have a serious problem with public health and respecting human rights in obstetric violence. Offering information to women and requesting their informed consent are barely practiced in the healthcare system, so it is necessary to profoundly reflect on obstetric practices with, and request informed consent from, women in Spain.

Obstetric Violence in Spain (Part II): Interventionism and Medicalization during Birth.

BACKGROUND: obstetric violence can partially be represented by the high number of interventions and medicalization rates during the birthing process. The objective of the present study was to determine the interventionism and medicalization levels during childbirth in Spain. METHODS: a descriptive, retrospective, and cross-sectional study was conducted between January 2018 and June 2019. RESULTS: the intervention percentages were 34.2% for Kristeller maneuver and 39.3% for episiotomy. Differences appeared in public, private, and mixed healthcare settings (p < 0.001). The mean satisfaction, with healthcare in the different settings, was estimated at 6.88 points (SD ± 2.146) in public healthcare, 4.76 points (SD ± 3.968) in private healthcare, and 8.03 points (SD ± 1.930) in mixed healthcare (p < 0.001). No statistically significant differences were found in Spanish autonomous communities. CONCLUSIONS: births in Spain seem to be highly intervened. In this study, a certain equity criterion was found concerning interventionism during childbirth in Spain. Healthcare influenced female intervention, satisfaction, and perception levels for obstetric violence; this evidences that female empowerment plays an important role.

Influencia de las intervenciones realizadas durante el parto en la duración de la lactancia materna / Influence of the interventions during labour on breastfeeding duration

Objetivo: Analizar la influencia de diferentes intervenciones clínicas realizadas durante el parto sobre el inicio y mantenimiento de la lactancia materna (LM) a los 4, 6 y 12 meses. Método: Estudio observacional prospectivo. Se llevó a cabo en el Hospital do Salnés de Vilagarcía de Arousa (Pontevedra). La población de estudio fueron mujeres que dieron a luz entre marzo y diciembre de 2016 con intención de amamantar. Se realizó seguimiento de la muestra durante 12 meses o hasta abandonar la LM. La variable de resultado fue la duración total de la LM. Las variables independientes fueron una serie de intervenciones frecuentes en el proceso perinatal. También se analizó el efecto acumulativo negativo de dichas intervenciones sobre la LM. Resultados: Se obtuvo una muestra de 189 mujeres. El tiempo de LM mediano fue de 12 meses en el grupo sin intervenciones, de 10 meses en el grupo de 1-3 intervenciones y de 5 en el grupo de 4 o más intervenciones, siendo las diferencias estadísticamente significativas (p= 0,014). Los eventuales factores de confusión o ajuste se estudiaron mediante análisis multivariante. Cabe destacar el efecto positivo de no utilizar la epidural para conseguir una LM que se mantenga hasta los 12 meses ( odds ratio 2,1; p= 0,03). Conclusiones: Es necesario un mayor esfuerzo por parte de las instituciones para capacitar y sensibilizar al personal sanitario en cuanto a las normas y prácticas relacionadas con la atención amigable a la madre, así como dar a conocer el efecto acumulativo negativo de las intervenciones realizadas en el parto. Las mujeres que necesiten múltiples intervenciones durante el parto podrían precisar ayuda suplementaria para mejorar sus resultados en la LM

Objective: To evaluate the influence of different clinical procedures (operations) during labour on the beginning and maintenance of breastfeeding at 4, 6 and 12 months. Method: An observational-prospective study was carried out at the Salnés Hospital (Vilagarcía de Arousa, Pontevedra). The study population were women who had given birth between March and December 2016 and had the intention of breastfeeding their babies. The sample of 189 women were followed for 12 months or until breastfeeding was ceased. The result variable was the total length of breastfeeding. Independent variables were a series of frequent procedures during labour. The negative accumulative effect on breastfeeding was also analysed. Results: The average breastfeeding time was 12 months in the group undergoing no procedures, 10 months in the group undergoing 1-3 procedures and 5 months in the group undergoing 4 or more procedures. The statistical differences are significant (p= 0.014). The potential confusion or adjustment factors were analysed by means of multivariate analysis. It is worth highlighting the positive effect of not using the epidural to achieve an LM that is maintained until 12 months (odds ratio 2.1; p= 0.03). Conclusions: A greater effort is necessary on behalf of the institutions to not only train and sensitize their staff about the guidelines and practice related to offering kind care to the mother, but also making them aware of the negative accumulative effect of the procedures carried out during labour. Women who undergo several procedures during labour may need extra support in order to improve their breastfeeding results

Human AML activates the aryl hydrocarbon receptor pathway to impair NK cell development and function.

Acute myeloid leukemia (AML) can evade the mouse and human innate immune system by suppressing natural killer (NK) cell development and NK cell function. This is driven in part by the overexpression of microRNA (miR)-29b in the NK cells of AML patients, but how this occurs is unknown. In the current study, we demonstrate that the transcription factor aryl hydrocarbon receptor (AHR) directly regulates miR-29b expression. We show that human AML blasts activate the AHR pathway and induce miR-29b expression in NK cells, thereby impairing NK cell maturation and NK cell function, which can be reversed by treating NK cells with an AHR antagonist. Finally, we show that inhibition of constitutive AHR activation in AML blasts lowers their threshold for apoptosis and decreases their resistance to NK cell cytotoxicity. Together, these results identify the AHR pathway as a molecular mechanism by which AML impairs NK cell development and function. The results lay the groundwork in establishing AHR antagonists as potential therapeutic agents for clinical development in the treatment of AML.

Immunodiagnostic Tests' Predictive Values for Progression to Tuberculosis in Transplant Recipients: A Prospective Cohort Study.

BACKGROUND: Little is known about the predictive value for progression to tuberculosis (TB) of interferon-γ release assays and how they compare with the tuberculin skin test (TST) in assessing the risk of TB infection in transplant recipients. METHODS: We screened 50 liver transplant (LT) and 26 hematopoietic stem cell transplant (HSCT) recipients with both QuantiFERON-TB Gold In-tube (QFT-GT) and TST and prospectively followed them for a median of 47 months without preventive chemoprophylaxis. RESULTS: In the LT cohort, 1 in 22 (4.5%) QFT-GT-positive patients developed posttransplant TB, compared with none of the QFT-GT-negative patients. In the HSCT cohort, none of the 7 QFT-GT-positive patients developed TB, whereas 1 case (5.3%) progressed to active TB among the 19 QFT-GT-negative patients. Comparable results were obtained with the TST: in the LT group, 1 of 23 TST-positive and none of the 27 TST-negative patients developed TB; and in the HSCT group, none of the 8 TST-positive and one of the 18 TST-negative patients progressed to active TB. CONCLUSIONS: In this cohort of transplant recipients, the positive predictive value of QFT-GT for progression to active TB was low and comparable to that of TST. Although the risk of developing TB in patients with negative results at baseline is very low, some cases may still occur.

Prevention of anti-tumor necrosis factor-associated tuberculosis: a 10-year longitudinal cohort study.

BACKGROUND: The extent to which anti-tumor necrosis factor (TNF)-associated tuberculosis can be prevented is unclear, and there is no established guidance on the optimal screening strategy for latent tuberculosis (LTBI) in patients about to start anti-TNF therapy. We aimed to determine the effectiveness of a comprehensive program for the prevention of anti-TNF-associated tuberculosis, and to evaluate 3 LTBI screening strategies and the need for retesting patients with negative results at baseline. METHODS: In total, 726 patients were screened prior to anti-TNF therapy using 1 of 3 diagnostic strategies over 3 consecutive periods: first, a 2-step tuberculin skin test (TST); second, a 2-step TST plus QuantiFERON-TB Gold In-Tube test (QFT-GIT) (2-step TST/QFT); and third, a single-step TST plus QFT-GIT (TST/QFT). Infected patients were offered preventive therapy. We assessed differences in the incidence of tuberculosis between anti-TNF exposed and nonexposed patients, and between the 3 study periods. RESULTS: Tuberculosis developed during the first year in 2.85 per 1000 exposed patient-years (3/1052 patient-years) and 1.77 per 1000 nonexposed patient-years (1/566 patient-years). No cases occurred beyond the first year of treatment. LTBI diagnoses decreased with the single-step TST/QFT (26.5%) compared with the 2-step TST (42.5%; P < .001) and 2-step TST/QFT (38.5%; P = .02); the incidence of tuberculosis among exposed patients did not change significantly across the 3 periods (2.63/1000, 3.91/1000, and 2.4/1000 patient-years, respectively). CONCLUSIONS: Although anti-TNF-associated tuberculosis can be reduced, some risk remains during the first year of therapy. Neither the 2-step TST nor systematic retesting after negative baseline testing is justified.

Panhipopituitarismo por adenoma hipofisario gigante / Panhypopituitarism by giant pituitary adenoma

No disponible

Diagnosis of tuberculosis infection by tuberculin skin test and a whole-blood interferon-γ release assay in patients considered for anti-tumor necrosis factor-α therapy.

To assess the performance of QuantiFERON®-TB Gold in-Tube (QFT-GIT; Cellestis, Carnegie, Australia) and tuberculin skin test (TST) in patients with immune-mediated inflammatory diseases (IMID), before anti-tumor necrosis factor-α (TNF-α) therapy, and to compare the results with those from the healthy population. Three hundred fourteen subjects (214 with IMID and 100 controls) underwent simultaneous QFT-GIT and TST. QFT-GIT was positive in 21% of IMID patients and in 16% of controls (P = 0.29). Among IMID patients, 21% tested positive by QFT-GIT and 24%, by TST (P = 0.30). Positive QFT-GIT results were not affected by immunosuppressive therapy (odds ratio, 0.78; 95% confidence interval [CI], 0.36-1.68; P = 0.52). Agreement between both tests in those patients who tested positive by one of the tests was 50% (95% CI, 37.2-62.8). QFT-GIT is useful for identifying IMID patients requiring treatment of latent tuberculosis before anti-TNF therapy. However, given the poor agreement between TST and QFT-GIT, we advocate a strategy of simultaneous testing to optimize diagnostic sensitivity.

Detection of latent tuberculosis by the tuberculin skin test and a whole-blood interferon-γ release assay, and the development of active tuberculosis in HIV-seropositive persons.

This study evaluated the QuantiFERON-TB Gold In-Tube (QFT-GIT; Cellestis, Carnegie, Australia) test and the tuberculin skin test (TST) for the detection of latent tuberculosis infection (LTBI) in HIV-infected adults. One hundred thirty-five HIV-seropositive persons and 135 controls underwent TST and QFT-GIT. HIV-infected patients who gave a positive result on either test were offered chemoprophylaxis. The prevalence of LTBI was 6.7% by TST and 9.6% by QFT-GIT (P = 0.3) in HIV-seropositive subjects, and 34.8% by TST and 21.5% by QFT-GIT (P = 0.02) among controls. TST reactivity declined sharply as CD4(+) cells fell (15.8%, 10.3%, and 0% for >500, 301-500 and ≤300 CD4(+) cells/mm(3), respectively; P = 0.002). A less pronounced fall occurred with QFT-GIT (15.8%, 13.8%, and 0% for >500, 301-500, and <100 CD4(+) cells/mm(3), respectively; P = 0.03). No cases of tuberculosis occurred during follow-up (0.26 per 100 person-years). Simultaneous testing with TST and QFT-GIT for targeting of chemoprophylaxis, early in the course of HIV infection, might minimize the risk of tuberculosis in these patients.

Comparison of the 2-step tuberculin skin test and the quantiFERON-TB Gold In-Tube Test for the screening of tuberculosis infection before liver transplantation.

The ability of interferon-gamma release assays (IGRAs) to detect latent tuberculosis (TB) infection before liver transplantation (LT)is not well established. The aims of this study were (1) to compare the ability of the tuberculin skin test (TST) and the QuantiFERON-TB Gold In-Tube (QFT-IT) test (a whole-blood IGRA) to diagnose latent TB infections in patients awaiting LT and (2) to correlate the results with the severity of liver disease. We conducted a prospective, cross-sectional study of patients who were evaluated for LT between July 2008 and July 2010. The 95 patients who were included underwent the 2-step TST and the QFT-IT test. The mean Model for End-Stage Liver Disease (MELD) score was 13.8. Forty-four patients (46.3%) had positive TST results, 42 (44.2%) had positive QFT-IT results, and 2 (2.1%) had indeterminate QFT-IT results. Simultaneous TST and QFT-IT testing yielded a positivity rate of 55.8% [95% confidence interval (CI) = 45.3-65.9] with either test, and the 2-step TST yielded a positivity rate of 46.3% (95% CI = 36.1-56.8); the difference was 9.5% (P = 0.004). In an adjusted analysis, the rates for positive TST results were lower in patients with MELD scores > or = 18 [odds ratio (OR) = 0.2, 95% CI = 0.04-0.7], lower in Child-Pugh-Turcotte (CPT) class C patients versus CPT class A patients (OR = 0.1, 95% CI = 0.02-0.6), and higher in males (OR = 6.4, 95% CI = 1.9-22.0). In contrast, only being male (OR = 3.5, 95% CI = 1.1-11.0) was associated with positive QFT-IT results; no association was found with the MELD score (OR = 0.8, 95% CI = 0.2-2.8) or the CPT class (OR = 0.3; 0.05-1.4). In conclusion, the QFT-IT test is better than the TST for detecting latent TB infection in patients with more advanced liver disease. Our results support the regular use of the QFT-IT test for screening patients with end-stage liver disease for latent TB infection before LT.

[Sociocultural and healthcare factors influencing the choice and duration of breast feeding in a regional hospital]. / Lactancia materna en un hospital comarcal: factores socioculturales y sanitarios que pueden influir en su elección y mantenimiento.

OBJECTIVES: To determine the prevalence of breastfeeding in the health area of Salnés Hospital (Vilagarcía, Pontevedra, Spain) and the influence of social and healthcare factors on the initiation and duration of breastfeeding. To evaluate compliance with each of the BFHI (Baby Friendly Hospital Initiative) "Ten Steps to Successful Breastfeeding" defined by the WHO/UNICEF. METHOD: The study population included all the women who gave birth in Salnés Hospital between august 2004 and september 2005. All the women were administered a questionnaire before discharge. A prospective study was performed by telephone interviews at 4, 6 and 12 months postpartum. A database was created using SPSS 13.0 for Windows. Statistical analysis was performed using Student's t-test and the Mann-Whitney non-parametric test for quantitative variables, and the Chi-square test for categorical variables. RESULTS: At discharge, 66.3% (134) of newborns were exclusively breastfed. At 6 months postpartum, 23.7% (31) of the women continued exclusive breastfeeding, and 10.2% (13) continued at 12 months. Factors with a significant effect on breastfeeding initiation were the partner's educational level and women's attendance at prenatal classes. Factors with a positive effect on maintaining breastfeeding were maternal non-smoking, a partner with tertiary education and the recommendation of on-demand breastfeeding by the healthcare provider. CONCLUSIONS: Compliance with the BFHI "Ten Steps to Successful Breastfeeding" was fairly satisfactory, but the prevalence of breastfeeding should be higher. The father should be included in prenatal education.

Lactancia materna en un hospital comarcal: factores socioculturales y sanitarios que pueden influir en su elección y mantenimiento / Sociocultural and healthcare factors influencing the choice and duration of breast feeding in a regional hospital

Objetivos. Conocer la prevalencia de la lactancia materna (LM) en el área de salud del Hospital del Salnés (Vilagarcía, Pontevedra), así como factores sociosanitarios asociados a su inicio y duración. Conocer el grado de cumplimiento del decálogo de la Iniciativa de Hospital Amigo de los Niños (IHAN). Método. La población del estudio son mujeres que tuvieron un hijo en el Hospital del Salnés entre agosto de 2004 y septiembre de 2005, a las que se les pasó una encuesta al alta. Se realizó un estudio prospectivo mediante encuesta telefónica a los 4, 6 y 12 meses. Se utilizó SPSS para Windows 13.0. El estudio estadístico de las variables se realizó empleando la prueba de la t de Student, el test de Mann-Whitney, y la 2. Resultados. El 66,3 % (134) de los niños recibía LM exclusiva al alta. A los 6 meses seguía el 23,7% (31) y a los 12 el 10,2% (13). Influyen en el inicio de la LM el nivel de estudios de la pareja y que la mujer asista a clases de preparación maternal. En el mantenimiento influyen el tabaquismo de la mujer, el nivel de estudios de la pareja y que el niño lacte a demanda. Conclusiones. El grado de cumplimiento del decálogo de la IHAN es bastante satisfactorio, pero no la prevalencia de LM, que debería aumentar. El padre debe incorporarse a la labor educativa prenatal

Objectives. To determine the prevalence of breastfeeding in the health area of Salnés Hospital (Vilagarcía, Pontevedra, Spain) and the influence of social and healthcare factors on the initiation and duration of breastfeeding. To evaluate compliance with each of the BFHI (Baby Friendly Hospital Initiative) “Ten Steps to Successful Breastfeeding” defined by the WHO/UNICEF. Method. The study population included all the women who gave birth in Salnés Hospital between august 2004 and september 2005. All the women were administered a questionnaire before discharge. A prospective study was performed by telephone interviews at 4, 6 and 12 months postpartum. A database was created using SPSS 13.0 for Windows. Statistical analysis was performed using Student’s t-test and the Mann-Whitney non-parametric test for quantitative variables, and the Chi-square test for categorical variables. Results. At discharge, 66.3% (134) of newborns were exclusively breastfed. At 6 months postpartum, 23.7% (31) of the women continued exclusive breastfeeding, and 10.2% (13) continued at 12 months. Factors with a significant effect on breastfeeding initiation were the partner’s educational level and women’s attendance at prenatal classes. Factors with a positive effect on maintaining breastfeeding were maternal non-smoking, a partner with tertiary education and the recommendation of on-demand breastfeeding by the healthcare provider. Conclusions. Compliance with the BFHI “Ten Steps to Successful Breastfeeding” was fairly satisfactory, but the prevalence of breastfeeding should be higher. The father should be included in prenatal education

Predictors of in-hospital mortality present at admission among patients hospitalised because of decompensated heart failure.

Chronic heart failure (HF) is associated with a poor prognosis and causes considerable mortality. The aim of this study was to identify the admission characteristics useful to predict in-hospital mortality in patients admitted because of decompensation of HF. We evaluated 414 patients (age 76.2 years, 57% women). The hospital mortality rate was 11.1%. We identified 4 independent predictors of mortality: low Barthel index (odds ratio 1.03; 95% confidence interval 1.01-1.04), creatinine level >200 mumol/l (odds ratio 3.40; 95% confidence interval 1.51-7.66), peripheral oedema (odds ratio 3.12; 95% confidence interval 1.28-7.58) and the protective effect of the new onset of the disease (odds ratio 0.2; 95% confidence interval 0.08-0.77). In conclusion, the mortality of patients admitted to the hospital with an exacerbation of HF can be predicted if either poor functional capacity, renal insufficiency, peripheral oedema or previous diagnoses of HF are present. This clinical finding may help clinicians in their decision making in HF in the emergency room.

Hospitalization due to acute heart failure. Role of the precipitating factors.

BACKGROUND AND AIMS: Many precipitating factors for decompensation of a chronic, stable heart failure (HF) have been described. OBJECTIVES: To evaluate the precipitating factors associated with HF decompensation among 293 patients admitted to a teaching hospital because of acute HF. RESULTS: 173 women and 120 men were included, and mean age was 76.7 years. In 221 patients (75%) there was some evidence of a factor that was potentially accountable for the decompensation of HF; a combination of two or more factors could be elicited in 100 patients. Except for a worse prior functional status, no differences were found between patients with and without identified precipitating factors. CONCLUSIONS: Precipitating factors may be identified in most patients suffering an acute episode of decompensation of HF. The majority of these factors appear to be preventable, and should thus be avoidable with a better, more comprehensive control of the HF patient.

[Functional assessment of elderly patients admitted for heart failure]. / Valoración funcional en pacientes ancianos ingresados por insuficiencia cardiaca.

The aim of our study was to evaluate the usefulness of functional assessment in very old patients admitted for heart failure. We assessed 188 patients aged >79 years. Their mean age was 84.6 (3.5) years, and 67% were female. Twenty-five patients (13%) died. Mortality was higher in those with more severe disability, with more comorbid conditions (as determined by the Charlson index), and with a low hematocrit and a high creatinine level. Logistic regression analysis showed that the Barthel index, the Charlson index, and the serum creatinine level were statistically significant factors. Functional assessment may help in the identification of elderly patients at a higher risk of death following hospital admission for heart failure.