Air pollution and surrounding greenness in relation to ischemic stroke: A population-based cohort study.

BACKGROUND: Evidence for the association between environmental exposures and ischemic stroke (IS) is limited and inconsistent. We aimed to assess the relationship between exposure to air pollutants, residential surrounding greenness, and incident IS, and to identify population subgroups particularly sensitive to these exposures. METHODS: We used data from administrative health registries of the public healthcare system in Catalonia, Spain to construct a cohort of individuals aged 18 years and older without a previous stroke diagnosis at 1st January 2016 (n = 3 521 274). We collected data on sociodemographic characteristics and cerebrovascular risk factors, and derived exposure at the participant's residence to ambient levels of fine particulate matter (PM2.5), black carbon (BC), nitrogen dioxide (NO2), and Normalized Difference Vegetation Index (NDVI) in a 300 m buffer as an indicator of greenness. The primary outcome was IS diagnosis at any point during the follow-up. We used Cox proportional hazards models to estimate associations between environmental exposures and incident IS and stratified analyses to investigate effect modification. RESULTS: Between 1st January 2016 and 31st December 2017, 10 865 individuals were admitted to public hospitals with an IS diagnosis. Median exposure levels were: 17 µg/m3 PM2.5, 35 µg/m3 NO2, 2.28 µg/m3 BC and 0.27 NDVI. Individuals with higher residential exposure to air pollution were at greater risk of IS: HR 1·04 (95% CI:0·99-1·10) per 5 µg/m3 of PM2.5; HR 1.05 (95% CI:1·00-1·10) per 1 µg/m3 of BC; HR 1·04 (95% CI:1·03-1·06) per 10 µg/m3 of NO2. Conversely, individuals with higher residential surrounding green space, had lower risk of IS (HR 0·84; CI 95%:0·7-1.0). There was no evidence of effect modification by individual characteristics. CONCLUSIONS: Higher incidence of IS was observed in relation to long-term exposures to air pollution, particularly NO2, in a region that meets European health-based air quality standards. Residential surrounding greenness was associated with lower incidence of IS.

An apparatus for the continuous measurement of thickness during the electropolishing of superconducting cavities.

An apparatus allowing continuous acquisition of thickness measurements during electropolishing of superconducting cavities is described. The instrument is based on the ultrasound thickness measurement technique and allows the connection of up to six probes. The apparatus has been employed to monitor the surface treatment of PIP-II low beta single cell prototypes developed and manufactured by LASA-INFN and specifically to measure surface removal at different points of interest on the cavity surface. The apparatus facilitated the development and optimization of electropolishing parameters for incorporation into the cavity manufacturing process.

Heroin maintenance treatment: from idea to research to practice.

Maintaining opiate addicts on opiates has a long history. The idea to prescribe pharmaceutical morphine as a substitute for street heroin started in USA and was abolished on the basis of prohibitionist legislation. A new approach to maintain opiate addicts on substitution therapy was initiated in USA in 1963, with the prescription of methadone. This approach found, although slowly, increasing acceptance, and is nowadays considered to be a cornerstone in the management of opiate dependence and for the prevention of HIV/AIDS in opiate injectors. Since 1975, the concept of heroin maintenance treatment was re-activated in order to reach out to treatment-resistant heroin addicts. Research projects were performed in Switzerland, the Netherlands, Germany, Spain, Canada and in England, another one is planned in Belgium. Based on the unanimously positive outcomes, heroin maintenance has become routine treatment for otherwise untreatable heroin addicts in Switzerland, the Netherlands, Germany and England, and Denmark has set up heroin maintenance without new research trials.

Grado de conocimiento del documento de voluntades anticipadas por el enfermo crónico que acude a urgencias / Grade of knowledge about the advance directive document by the chronic patient who comes to the emergency department

Objetivos. Evaluar el conocimiento del documento de voluntades anticipadas (DVA) en pacientes con enfermedades crónicas que acuden a urgencias por descompensación y en sus acompañantes. Conocer el posicionamiento del paciente a redactar el DVA e investigar factores asociados. Material y método. Estudio descriptivo sobre pacientes con enfermedad crónica atendidos en urgencias de un hospital urbano universitario. Se consignaron variables clinicodemográficas y, tras el control de su sintomatología, se efectuó una entrevista-encuesta oral y anónima. Como variables dependientes se consideraron el conocimiento previo del DVA y la predisposición a confeccionarlo. Se analizó si existían variables asociadas a ellas. Resultados. Se entrevistaron 380 personas. Los acompañantes, con respecto a los pacientes, eran más frecuentemente mujeres (el 76 frente a el 42%; p<0,001), más jóvenes (58±15 frente a 73±12; p<0,001) y con mejor conocimiento de la enfermedad (el 88 frente a el 74%; p<0,001) y del DVA (el 28 frente a el 16%; p<0,001). Tan solo un 5% de los pacientes había recibido información del DVA de su médico y el único factor asociado al buen conocimiento fue haber finalizado estudios secundarios (p<0,05). El 46% se mostró favorable a realizar el DVA, y el único factor asociado fue una edad igual o inferior a 70 años (p<0,05). El 88% de los pacientes se mostró partidario de distribuir folletos informativos en urgencias. Conclusiones. Se constata un desconocimiento generalizado del DVA en pacientes con enfermedades crónicas y en sus acompañantes. No obstante, casi la mitad de los pacientes estarían dispuestos a su confección. Los servicios de urgencia hospitalarios pueden contribuir a mejorar la información(AU)

Objective. To evaluate the patient's and their caregiver's knowledge of the advance directive document (ADD) in patients with chronic diseases who come to the emergency department due to decompensation and their caregivers. To discover the patient's willingness and associated factors to draw up an ADD. Material and methods. A descriptive cohort study including patients with an acutely decompensated chronic evolving disease attending the ED medicine section at an urban tertiary teaching hospital was performed. The patients’ demographic and clinical variables were recorded. After control of their symptoms, an anonymous structured oral interview was also administered. Dependent variables included were previous knowledge of the ADD, and the patient willingness to draw it up. The relationship among independent and dependent variables was analyzed. Results. A total of 380 people (190 patients and 190 carers) were analyzed. Compared with patients, carers were more frequently women (76% vs 42%, p<0.001), younger (58±15 vs 73±12, p<0.001), and had a better knowledge of the disease (88% vs 74%, p<0.001) and of the ADD (28% vs 16%, p<0.001). Only 5% of the patients had received ADD information from their physician. The only factor associated with the patients’ previous knowledge of the ADD was to have completed at least secondary school (p<0.05). Forty-six percent of patients were favorable to the drawing up of an ADD. The only variable associated with such a willingness was to be 70 or younger (p<0.05). Eighty-eight percent of the patients were in favor of the distribution of information leaflets in the ED. Conclusions. There is poor patient and carer knowledge regarding the ADD among patients with chronic diseases. Nonetheless, almost half of patients would be willing to draw up an ADD. EDs can contribute to improve the information about it(AU)

[Grade of knowledge about the advance directive document by the chronic patient who comes to the emergency department]. / Grado de conocimiento del documento de voluntades anticipadas por el enfermo crónico que acude a urgencias.

OBJECTIVE: To evaluate the patient's and their caregiver's knowledge of the advance directive document (ADD) in patients with chronic diseases who come to the emergency department due to decompensation and their caregivers. To discover the patient's willingness and associated factors to draw up an ADD. MATERIAL AND METHODS: A descriptive cohort study including patients with an acutely decompensated chronic evolving disease attending the ED medicine section at an urban tertiary teaching hospital was performed. The patients' demographic and clinical variables were recorded. After control of their symptoms, an anonymous structured oral interview was also administered. Dependent variables included were previous knowledge of the ADD, and the patient willingness to draw it up. The relationship among independent and dependent variables was analyzed. RESULTS: A total of 380 people (190 patients and 190 carers) were analyzed. Compared with patients, carers were more frequently women (76% vs 42%, p<0.001), younger (58+/-15 vs 73+/-12, p<0.001), and had a better knowledge of the disease (88% vs 74%, p<0.001) and of the ADD (28% vs 16%, p<0.001). Only 5% of the patients had received ADD information from their physician. The only factor associated with the patients' previous knowledge of the ADD was to have completed at least secondary school (p<0.05). Forty-six percent of patients were favorable to the drawing up of an ADD. The only variable associated with such a willingness was to be 70 or younger (p<0.05). Eighty-eight percent of the patients were in favor of the distribution of information leaflets in the ED. CONCLUSIONS: There is poor patient and carer knowledge regarding the ADD among patients with chronic diseases. Nonetheless, almost half of patients would be willing to draw up an ADD. EDs can contribute to improve the information about it.

Ethical perspectives in caring for people living with addictions: The European experience.

European policy and practice in caring for people living with addictions is based on defined values (human rights, medical ethics) and on research evidence for the effects and impact of interventions. The focus of the paper is on risk management approaches to reduce the negative consequences of continued illicit drug use, being the ethically most debatable issue. The legal and policy positions are set by the European Council and Commission, and their translation into practice is documented centrally in the European Monitoring Centre on Drugs and Drug Addiction, showing the general trends as well as national differences. The European experience with the risk management approaches is presented in terms of research evidence on their effects and side-effects; this evidence is justifying the present practice. The perspectives for the future are set to follow the same lines, in a continued effort to find a balance of interests, in cooperation of authorities and civil society, and guided by ongoing research.

Which future for social psychiatry?

Social psychiatry started over a century ago under the auspices of mental and racial hygiene, but after World War II it embraced concepts of community-based care and de-institutionalization. The major psychiatric reforms in the second half of the last century were mainly based on such concepts, including the reforms of Swiss and especially Zurich psychiatry. The present needs for psychiatric care, and the specific political and economic conditions for a continuation along this line are explored and found to be favourable. Also, the profile of future psychiatrists, as formulated by professional associations and expert groups, corresponds to concepts of social psychiatry. The World Health Organization stimulates service improvements in the same direction. The consequences concern the education and training, and the professional role of future psychiatrists. Finally, the future of social psychiatry will be shaped by public expectations and acceptance of community-based services.

Conocimientos acerca de su enfermedad y de los documentos de voluntades anticipadas en los pacientes con enfermedades crónicas evolutivas descompensadas que consultan en urgencias / Knowledge and awareness about their condition and about the “Vital Testament” documents among patients with evolutive decompensated chronic diseases consulting at Emergency Departments

Objetivos: Analizar el grado de conocimiento del paciente con enfermedad crónica que acude a urgencias respecto a diferentes aspectos de la evolución natural de su enfermedad y si existen factores asociados a este conocimiento, así como su posicionamiento con diferentes aspectos del testamento vital, su predisposición a redactarlo y si existen factores asociados a esta predisposición. Material y método: Se incluyeron pacientes afectados de diversas enfermedades crónicas cuya evolución natural supusiera un acortamiento de la expectativa de vida que fueron atendidos en una unidad de urgencias medicina hospitalaria. Se recogieron características clínico-epidemiológicas y se les realizó una encuesta con preguntas referentes al grado de conocimiento de su enfermedad y del testamento vital. Como variables independientes se consideraron el buen o mal conocimiento de las posibilidades evolutivas de su enfermedad y su predisposición o no a redactar un testamento vital, y se analizó si existía alguna variable clínico-epidemiológica o de opinión asociada a estas variables independientes. Resultados: Se entrevistaron 160 pacientes, con una edad de 74±11 años y el 67% mujeres. El 47% tenía un grado de conocimiento de su enfermedad bueno, que se asoció de forma significativa con una edad inferior o igual a 70 años (p<0,001) y con haber estado ingresado previamente en una unidad de cuidados intensivos (p<0,001). A pesar de ello, el 78% se consideraba globalmente bien informado por su equipo médico habitual y sólo el 38% deseaba recibir mayor información. El conocimiento previo acerca de en qué consiste el testamento vital lo tenían el 19% de pacientes y en sólo un 3% alguno de sus médicos habituales le había hablado del mismo. El 50% de pacientes se mostraron favorables a realizarlo, y no existió ningún factor asociado a dicha predisposición. Conclusiones: En los pacientes afectados de enfermedades crónicas que consultan en urgencias se constata una mala información acerca de su enfermedad y un desconocimiento mayor aún de la posibilidad que tienen de poder realizar un documento de voluntades anticipadas (AU)

Aims and purpose: To analyse, among patients with chronic conditions attending the Emergency Departments, the degree of awareness and knowledge regarding various aspects of the natural course of their conditions and whether there are factors associated thereto, as well as their personal position regarding various aspects of the so-called “Vital Testament”, their predisposition to prepare such a document and eventual factors associated thereto. Material and methods: The study population included patients with diverse chronic diseases, the natural course of which might entail a shortening of their life expectancy, who attended a hospitalary Outpatient Emergency Department. Clinico-epidemiological features were recorded and a survey questionnaire was administered with items regarding their degree of knowledge about their condition and about the “Vital Testament”. The independent variables were the good or bad knowledge of the evolutive possibilities of their condition and their predisposition to prepare or not a “Vital Testament”; and an assessment was performed regarding whether there was any vlinico-epidemiological or opinion variable associated to the independent variables. Results: One hundred and sixty patients were interviewed (age range 74 ± 11 years; 67% females). Forty-seven per cent of them evidenced good knwoledge of their conditions, in association with age <=70 years (p<0.001) and with previous admission into an Intensive Care Unit (p<0.001). Despite this, 78% of the interviewed patients considered themselves to be overall well informed by their usual attending medical teams, and only 38% wished to receive further information. Previous knowledge about what a “Vital Testament” is and entails was present in 19% of the patients, and only 3% stated that their attending physicians had talked to them about it. Fifty percent of the patients declared themselves willing to prepare such a dicument, and there was not any factor associated to such predisposition. Conclusions: Among patients with chronic conditions attending Emergency Departments there is an insufficient degree of awareness and knowledge regarding their conditions, and an even poorer one regarding their possibility to prepare a “Vital Testament” (Anticipated Last Will) document (AU)

Right bundle branch block-induced Q waves simulating anterior myocardial infarction extension.

A concept generally accepted in clinical electrocardiography is the assumption that a right bundle branch block (RBBB) does not alter significantly the initial portion of the QRS complex and because the left bundle branch is intact, the septum is activated normally in a left-to-right direction. We report a woman with an acute anterior myocardial infarction (MI) in which a small R wave was present in leads V1 and V4, but with the development of RBBB associated with PR-interval prolongation, these R waves were replaced by Q waves. Subsequently, the electrocardiographic features of anterior MI disappeared concomitantly with the loss of RBBB. The clinical and electrophysiologic implications of these findings are discussed.

Obstructive shock due to labor-related diaphragmatic hernia.

OBJECTIVE: To report diaphragmatic hernia as a cause of obstructive shock in the peripartum period. DESIGN: Case report. SETTING: An adult, 12-bed medical/surgical intensive care unit of a general hospital. PATIENTS: One patient who developed an obstructive shock following vaginal labor and was transferred under mechanical ventilation from a local hospital. INTERVENTIONS: Central venous pressure, blood pressure, blood gas analysis, electrocardiogram, and chest radiograph during and after obstructive shock. MEASUREMENTS AND MAIN RESULTS: During shock, systolic blood pressure was 60 mm Hg, central venous pressure was +12 mm Hg, and the electrocardiogram showed a supraventricular tachycardia and an acute cor pulmonale pattern. Chest radiograph showed signs of left diaphragmatic hernia and right mediastinal shift. Chest ultrasound examination demonstrated loops of bowel in the left pleural space. After surgical resolution of the left diaphragmatic hernia, the patient's blood pressure increased to 120/80 mm Hg, the central venous pressure decreased to +1 mm Hg, and the PaO2 increased to 154 torr (20.5 kPa) while receiving mechanical ventilation with an FiO2 of 50%. The electrocardiogram showed disappearance of the acute cor pulmonale pattern. The chest radiograph showed a central venous catheter located in a persistent left superior vena cava without abnormalities of the diaphragm, the mediastinum, or the lung. CONCLUSION: Diaphragmatic hernia must be included in the differential diagnosis of obstructive shock in pregnant patients.

Influence of continuous hemofiltration on the hemodynamics of trauma patients.

BACKGROUND: The aim of this prospective randomized controlled study was to investigate the effects of continuous venovenous hemofiltration on the hemodynamics and respiratory function of critically ill trauma patients with multiple organ dysfunction syndrome. METHODS: Thirty consecutive critically ill, mechanically ventilated, trauma patients with multiple organ dysfunction syndrome (without kidney failure) who had invasive hemodynamic monitoring for management of hypotension or hypoxemia were randomized to treatment with or without continuous venovenous hemofiltration. Hemodynamics profile was recorded immediately before and at 6, 12, 24, and 48 hours after the hemofiltration was started (mean of three set data each time). No changes in ventilatory parameters were performed during the study. RESULTS: Thirty patients were analyzed (15 with and 15 without hemofiltration). Both groups were similar in age (36 +/- 18 versus 36 +/- 14 years) and severity scores (Injury Severity Score, 32 +/- 16 versus 30 +/- 11; Acute Physiology and Chronic Health Evaluation II score, 22 +/- 7 versus 21 +/- 6; Goris score, 5.2 +/- 1.7 versus 5.2 +/- 1.8) and received similar inotropic support. We found a significant improvement in mean arterial pressure (80 +/- 9 to 94 +/- 8 (mm Hg), p = 0.01) and partial pressure of oxygen in arterial blood/inspiratory oxygen supply index (124 +/- 40 to 204 +/- 44, p = 0.03) in the intervention group during the study period. We did not find any other significant change in variables studied. CONCLUSIONS: Continuous venovenous hemofiltration is associated with a significant improvement in hemodynamic and respiratory variables in critically ill trauma patients with multiple organ dysfunction syndrome. This improvement can help in the management of these patients. Further work is necessary to define whether this technique can reduce the high mortality of this disease.