Beta-blocker therapy and prognosis of heart failure patients with new-onset diabetes mellitus.

BACKGROUND: The influence of beta-blocker therapy (bisoprolol or carvedilol) (bB) on the prognosis of heart failure (HF) patients with diabetes mellitus (DM) is uncertain. AIMS: To assess the effect of bB on the prognosis of HF patients with new-onset DM treated with a contemporary medical regime. METHODS: Prospective study of 5314 HF patients with previously unknown DM. Mean age was 71.8±7.9 years, 53.0% were women, and 50.2% had HF with preserved ejection fraction (HFpEF). During a median follow-up of 56.9±18.2 months, 68.9% of the patients died, 88.6% were hospitalised for HF, and 1519 (27.3%) developed DM (62.3% of them received bB, 947 patients). We propensity-matched 572 HF patients with DM on bB, with 572 HF patients with DM non-treated with bB. RESULTS: Beta-blocker therapy was associated with a decreased hazard risk (HR) of all-cause death [HR: 0.68, CI 95% (0.61-0.75)], mainly because of a reduced risk of death from cardiovascular causes [HR: 0.70 (0.64-0.77)] (p<0.001). Similarly, bB was associated with a decreased HR of hospitalisation [HR: 0.82 (0.72-0.92)] (p<0.001). Nevertheless, the 30-day re-admission rate and the number of visits were not significantly associated with bB. These relationships of bB with prognosis were maintained, independently of the gender, the type of HF (HFpEF ot HFdEF), the comorbidities and the medication used (p<0.01). CONCLUSION: Therapy with bB, bisoprolol or carvedilol, is associated with a reduced mortality and morbidity of HF patients with new-onset DM, not only in men but also in women, as well as in patients with HFpEF or HFdEF.

Fluctuations of the anthropometric indices and mortality of patients with incident heart failure: a prospective study in the community.

BACKGROUND: The relationship between the fluctuations of the anthropometric indices (AIs) and the prognosis of patients with incident heart failure (HF) in a population-based cohort is unknown. AIMS: To assess the relationship between the fluctuations of the AIs, body mass index (BMI), waist hip ratio (WHR), and weight height ratio (WHeR) and the prognosis of patients with incident HF. METHODS: Anthropometric indices were prospectively measured in a 10-year population-based study of 6492 patients with incident HF (GAMIC cohort). 4530 patients (66.7%) died, during a mean follow-up of 72.7 ± 14.2 months. A time-updated analysis of the changes of the AIs was performed to assess their association with mortality and morbidity (hospitalisations and visits). RESULTS: Patients with incident HF presenting ≥ 5% decrease or ≥ 7% increase of the AIs have an increased mortality [HR ≥ 1.65 (1.52-2.34) or HR ≥ 1.71 (1.58-1.85), respectively, p < 0.001]. Mortality risk increased ≥ 1.43-fold (p = -0.0003) for each 10% change in the AIs. There was an accelerated pattern of reduction in the AIs in the 6 months prior to death, and an accelerated increase in the AIs in the 3 months prior to hospitalisation. These observations were independent of the aetiology (ischaemic vs. non-ischaemic), the type of HF (systolic vs. non-systolic), and other predictors of mortality. CONCLUSIONS: Time-updated changes (increase or decrease) of the AIs, BMI, WHR and weight height ratio are independently associated with the mortality of patients with incident HF.

Comparison of two HIV testing strategies in primary care centres: indicator-condition-guided testing vs. testing of those with non-indicator conditions.

OBJECTIVES: The aim of the study was to compare prospectively indicator-condition (IC)-guided testing versus testing of those with non-indicator conditions (NICs) in four primary care centres (PCCs) in Barcelona, Spain. METHODS: From October 2009 to February 2011, patients aged from 18 to 65 years old who attended a PCC for a new herpes zoster infection, seborrhoeic eczema, mononucleosis syndrome or leucopenia/thrombopenia were included in the IC group, and one in every 10 randomly selected patients consulting for other reasons were included in the NIC group. A proportion of patients in each group were offered an HIV test; those who agreed to be tested were given a rapid finger-stick HIV test (€6 per test). Epidemiological and clinical data were collected and analysed. RESULTS: During the study period, 775 patients attended with one of the four selected ICs, while 66,043 patients presented with an NIC. HIV screening was offered to 89 patients with ICs (offer rate 11.5%), of whom 85 agreed to and completed testing (94.4 and 100% acceptance and completion rates, respectively). In the NIC group, an HIV test was offered to 344 persons (offer rate 5.2%), of whom 313 accepted (90.9%) and 304 completed (97.1%) testing. HIV tests were positive in four persons [prevalence 4.7%; 95% confidence interval (CI) 1.3-11.6%] in the IC group and in one person in the NIC group (prevalence 0.3%; 95% CI 0.01-1.82%; P < 0.009). If every eligible person had taken an HIV test, we would have spent €4650 in the IC group and €396,258 in the NIC group, and an estimated 36 (95% CI 25-49) and 198 persons (95% CI 171-227), respectively, would have been diagnosed with HIV infection. The estimated cost per new HIV diagnosis would have been €129 (95% CI €107-153) in the IC group and €2001 (95% CI €1913-2088) in the NIC group. CONCLUSIONS: Although the number of patients included in the study was small and the results should be treated with caution, IC-guided HIV testing, based on four selected ICs, in PCCs seems to be a more feasible and less expensive strategy to improve diagnosis of HIV infection in Spain than a nontargeted HIV testing strategy.

Ingresos evitados por el hospital de día médico polivalente / Decrease in hospitalizations due to polyvalent medical day hospital

Introducción. El hospital de día es una alternativa a la hospitalización, que mejora la accesibilidad y el confort del paciente, evitando ingresos. No obstante, la eficacia del hospital de día médico polivalente en la evitación de estancias hospitalarias no ha sido evaluada. Objetivo. Analizar las estancias evitadas por el hospital de día médico polivalente de un hospital universitario del Servicio Andaluz de Salud. Métodos. Estudio observacional prospectivo de los pacientes estudiados y/o tratados en el hospital de día médico polivalente del Hospital Universitario Puerto Real durante un año. Resultados. Se han atendido 3.640 pacientes, realizándose 1.413 procedimientos y 4.921 tratamientos i.v. La consulta de atención preferente del hospital de día médico polivalente realizó 2.182 visitas. Los motivos de consulta más frecuentes fueron los síntomas constitucionales (15,9%) y la anemia (14,5%). Tras la primera visita, el 21,5% de los casos fueron dados de alta y menos de un 3% eran ingresados. En el 16,8% de los casos se evitó la hospitalización convencional, con una disminución del 6,0% en la necesidad de camas (5% en la unidad de Medicina Interna). Los ingresos inadecuados y los reingresos en 30 días disminuyeron un 93,3% y un 4,2% respectivamente. La afección diagnosticada con mayor frecuencia es la neoplásica (26,0%), más de la cuarta parte de las camas liberadas se generan por pacientes con neoplasias (26,7%). Conclusión. Con este tipo de hospital de día médico polivalente se observa una mejora de la eficiencia asistencial, liberándose camas hospitalarias mediante la reducción de los ingresos, ingresos no adecuados y de los reingresos precoces en las unidades implicadas(AU)

Introduction. The day hospital is an alternative to hospitalization. This alternative improves accessibility and comfort of the patients, and avoids hospitalizations. Nevertheless, the efficacy of the polyvalent medical day hospital in avoiding hospitalizations has not been evaluated. Objective. To analyze hospital stays avoided by the polyvalent medical day hospital of a university hospital of the Andalusian Health Service. Methods. An observational prospective study of the patients studied and/or treated in the polyvalent medical day hospital of the Hospital Universitario Puerto Real over a one year period. Results. A total of 9640 patients were attended to, with 1413 procedures and 4921 i.v. treatments. There were 3182 visits to the priority consultation of the polyvalent medical day hospital. The most frequent consultation complaints were constitutional symptoms (15.9%) and anemia (14.5%). After the first visit, 21.5% of the patients were discharged and fewer than 3% were hospitalized. Hospitalization was avoided in 16.8% of the patients, there being a 6.0% decrease in the need for hospital beds (5.0% reduction in the internal medicine unit). Inadequate hospitalizations and 30-day readmissions decreased 93.3% and 4.2%, respectively. The most frequent diagnosis was neoplasm (26.0%), and most of the beds freed up were generated by patients diagnosed of neoplasm (26.7%). Conclusion. With this type of polyvalent medical day hospital, we have observed improved efficiency of health care, freeing up hospital beds by reducing hospitalizations, inadequate hospitalizations and re-admissions in the medical units involved(AU)

[Decrease in hospitalizations due to polyvalent medical day hospital]. / Ingresos evitados por el hospital de día médico polivalente.

INTRODUCTION: The day hospital is an alternative to hospitalization. This alternative improves accessibility and comfort of the patients, and avoids hospitalizations. Nevertheless, the efficacy of the polyvalent medical day hospital in avoiding hospitalizations has not been evaluated. OBJECTIVE: To analyze hospital stays avoided by the polyvalent medical day hospital of a university hospital of the Andalusian Health Service. METHODS: An observational prospective study of the patients studied and/or treated in the polyvalent medical day hospital of the Hospital Universitario Puerto Real over a one year period. RESULTS: A total of 9640 patients were attended to, with 1413 procedures and 4921 i.v. treatments. There were 3182 visits to the priority consultation of the polyvalent medical day hospital. The most frequent consultation complaints were constitutional symptoms (15.9%) and anemia (14.5%). After the first visit, 21.5% of the patients were discharged and fewer than 3% were hospitalized. Hospitalization was avoided in 16.8% of the patients, there being a 6.0% decrease in the need for hospital beds (5.0% reduction in the internal medicine unit). Inadequate hospitalizations and 30-day readmissions decreased 93.3% and 4.2%, respectively. The most frequent diagnosis was neoplasm (26.0%), and most of the beds freed up were generated by patients diagnosed of neoplasm (26.7%). CONCLUSION: With this type of polyvalent medical day hospital, we have observed improved efficiency of health care, freeing up hospital beds by reducing hospitalizations, inadequate hospitalizations and re-admissions in the medical units involved.

Mortality and morbidity of heart failure treated with digoxin. A propensity-matched study.

BACKGROUND: The role of digoxin in the prognosis of patients with heart failure (HF) remains unclear. AIMS: To evaluate the relationship of commencing treatment with digoxin (CTDig) with the mortality and the morbidity of patients with HF. METHODS: Prospective study over 8 years on 4467 patients with HF. Main outcomes were all-cause and cardiovascular mortality, hospitalisations and visits. We analyse the independent relationship of CTDig, with the mortality and the morbidity, stratifying patients for cardiovascular comorbidity, after propensity score-matching for potential confounders (1421 patients who CTDig vs. another 1421 patients non-exposed to digoxin). RESULTS: During a median follow up of 46.1 months, 1872 patients (65.9%) died, and 2203 (77.5%) were hospitalised. CTDig was associated with a lower all-cause mortality (HR = 0.90 [95% CI, 0.84-0.97]), and cardiovascular mortality (HR = 0.87 [0.81-0.96]), hospitalisation (HR = 0.91 [0.86-0.97]), 30-day readmission for HF (HR = 0.88 [0.79-0.95]), and visits (HR = 0.94 [0.90-0.98]) (p < 0.001 in all cases), after adjustment for the propensity to take digoxin, other medications, and other potential confounders. These effects of digoxin were independent of gender, or type of HF (systolic or non-systolic). CONCLUSION: The data suggest that therapy with digoxin is associated with an improved mortality and morbidity of HF, including women and patients with non-systolic HF.

Mortality of newly diagnosed heart failure treated with amiodarone A propensity-matched study.

BACKGROUND: Studies on the safety of amiodarone therapy in heart failure (HF) presented conflicting results. We evaluated the relationship of commencing treatment with amiodarone (CTA) with the mortality and the morbidity of patients newly diagnosed with HF. METHODS: Prospective cohort study over 7 years on 3734 patients with HF. Main outcomes were all-cause and cardiovascular mortality, hospitalizations and visits. 739 patients who commenced treatment with amiodarone were propensity-matched with another 739 patients. Non-commencing treatment with amiodarone. We analyze the independent relationship of commencing treatment with amiodarone, with the mortality and the morbidity, stratifying patients for cardiovascular co-morbidity, after propensity score-matching. RESULTS: During a median follow-up of 46.1 months, 644 (43.6%) died, and 1086 (73.5%) were hospitalized. Commencing treatment with amiodarone was associated with a higher all-cause mortality (HR 1.70 [CI 95%, 1.50 to 1.91]), particularly among women (HR: 1.77 [1.55 to 2.00]), and among patients with non-systolic HF (HR: 1.87 [1.66 to 2.09], P<0.001 in all the cases), even after adjustment for the propensity to take amiodarone, or other medications, and other potential confounders. Commencing treatment with amiodarone was not associated with cardiovascular mortality, hospitalizations, or visits. CONCLUSION: The commencement of treatment with amiodarone is associated with an increased mortality of patients with heart failure, mainly in women and in patients with non-systolic heart failure.

Enhancement of splenic-macrophage Fcgamma receptor expression by treatment with estrogens.

Splenic-macrophage Fcgamma receptors (FcgammaRs) participate in the pathophysiologies of immune-complex diseases and in host defense against infection. Modulation of macrophage FcgammaR expression is an immuno-therapeutic target. Glucocorticoids, sex steroids, and dopaminergic drugs modulate macrophage FcgammaR expression. Previous data indicate that estradiol increases macrophage FcgammaR expression. Nevertheless, the effects of clinically used estrogens upon macrophage FcgammaR expression are unknown. We assessed the effects of treatment with commonly used estrogens on the expression of macrophage FcgammaRs using a guinea pig experimental model. Six estrogens have been studied: ethynylestradiol (Et), mestranol (M), chlortianisene (Ct), promestriene, 17-epiestriol, and 17beta-estradiol. Following in vivo treatment of guinea pigs, we determined the clearance of immunoglobulin G (IgG)-sensitized erythrocytes in vivo, the binding of IgG-sensitized erythrocytes by isolated splenic macrophages, and splenic-macrophage FcgammaR cell surface expression. Estrogens enhance the clearance of IgG-sensitized erythrocytes by increasing splenic-macrophage FcgammaR expression. Et, M, and Ct were more effective than the other estrogens. Flow cytometry and fluorescence microscopy with monoclonal antibodies demonstrated that estrogens increase the cell surface expression of FcgammaR1 and -2 more than that of FcgammaR2. These data indicate that treatment with commonly used estrogens enhances the clearance of IgG-sensitized cells by improving splenic-macrophage FcgammaR expression.

[Fungal sinusitis. Report of four cases]. / Sinusitis fúngica. A propósito de cuatro casos.

Fungal sinusitis has a nonspecific clinical presentation, is refractory to standard medical treatment and may produce expansion and erosion of the sinus wall. Various factors have been implicated in the development of fungal sinusitis: anatomical factors in the osteomeatal complex, tissular hypoxia, traumatic factors, massive exposure to fungal spores, allergy and immunosuppression. Our study of four cases diagnosed in the department included the clinical, pathological, and radiological features of fungal sinusitis. Five forms are described. Bacterial infection often occurs. The diagnosis of fungal sinusitis requires a high level of clinical and pathological suspicion. Before surgery, fungal sinusitis is suggested by the clinical and radiological features, and is confirmed by histological study. Culture of the tissue sometimes leads to identification of the fungus. Surgical removal of the infection is the main treatment for every form of fungal sinusitis.

Additional data in support of the quadruplicated white-ivory reversion system to test for somatic genotoxicity in Drosophila melanogaster.

Cyclophosphamide, ethyl methanesulfonate, propyleneimine and tritiated water were tested in a new short-term somatic mutation bioassay, previously described by Green and coworkers (1986), to evaluate the suitability of the quadruplicated white-ivory system of Drosophila melanogaster for genotoxicity testing of chemicals. A 2.9-kb tandemly duplicated sequence of w+ within a w+ gene is responsible for the white-ivory phenotype. Reversion of wi to w+ is, in general, associated with the loss of the appended 2.9 kb or other alterations affecting this duplicated region. The appearance of light (white or nearly white) phenotypes could be due to the loss of some wi copies. Thus, in the eyes of adult males resulting from treated larvae, we can detect 2 types of sectors (red and light) on the orange-yellow background. Our results indicate that the genetic system used in this somatic assay is sensitive to the genotoxic effects of the 4 compounds tested. All 4 compounds tested were positive. Tritiated water had weak effects, cyclophosphamide was characterized by small revertant clones and ethyl methanesulfonate and propyleneimine by large clone size. From the available data, we feel that the wi system can be considered of potential value for genotoxicity testing.