Cold-related mortality due to cardiovascular diseases, respiratory diseases and cancer: a case-crossover study.

OBJECTIVES: The aim of this study was to identify the relationship between low temperatures in winter and mortality due to cancer, cardiovascular diseases and respiratory diseases. STUDY DESIGN: Case-crossover study. METHODS: A case-crossover study was performed in Cantabria (northern Spain) in the years 2004-2005; 3948 deaths were included. Odds ratios were estimated using conditional logistic regression, stratified by age, sex, and delay of exposure to low temperatures. RESULTS: There was an inverse dose-response relationship between temperature and mortality in the three causes of death studied; this result was consistent across genders and age groups. The higher OR for cancer mortality was seen on the first day of exposure (OR = 4.91; 95% CI: 1.65-13.07 in the whole population), and it decreased when exposure over several days in a row was considered; people aged 75 years or more were especially susceptible to cold temperatures (OR = 17.9; 95% CI: 2.38-134.8). Cardiovascular (OR = 2.63; 95% CI: 1.88-3.67) and respiratory mortality (OR = 2.72; 95% CI: 1.46-5.08) showed a weaker effect. CONCLUSION: There is a striking association between the extreme cold temperatures and mortality from cancer, not previously reported, which is more remarkable in the elderly. These results could be explained by a harvesting effect in which the cold acts as a trigger of death in terminally ill patients at high risk of dying a few days or weeks later.

Late-onset systemic lupus erythematosus in Northwestern Spain: differences with early-onset systemic lupus erythematosus and literature review.

To further investigate into the epidaemiology of systemic lupus erythematosus (SLE) in Southern Europe, we have assessed the incidence, clinical spectrum and survival of patients diagnosed with late-onset SLE (age ≥ 50 years) according to the 1982 American College of Rheumatology (ACR) classification criteria at the single hospital for a well-defined population of Lugo, Northwestern (NW) Spain. Between January 1987 and December 2006, 51 (39.3%) of the 150 patients diagnosed as having SLE fulfilled definitions for late-onset SLE. The predominance of women among late-onset SLE (4:1) was reduced when compared with that observed in early-onset SLE (7:1). However, the incidence of late-onset SLE was significantly higher in women (4.2 [95% confidence interval (CI): 3.1-5.6] per 100,000 population) than in men (1.3 [95% CI: 0.6-2.2] per 100,000 population) (p < 0.001). As observed in early-onset SLE, the most frequent clinical manifestation in patients with late-onset SLE was arthritis (71.2%). Renal disease was less common in late-onset SLE (13.5%) than in early-onset SLE (26.4%); p = 0.07). In contrast, secondary Sjögren syndrome was more commonly found in the older age-group (27.1% versus 12.1%; p = 0.03). A non-significantly increased incidence of serositis was also observed in late-onset SLE patients (33.9% versus 22.0%; p = 0.13). Hypocomplementaemia (72.9% versus 91.2%) and positive results for anti-DNA and anti-Sm (49.2% and 6.8% versus 68.1% and 23.1, respectively) were significantly less common in late-onset SLE patients than in early-onset SLE. The probability of survival was reduced in late-onset SLE (p < 0.001). With respect to this, the 10-year and 15-year survival probability were 74.9 % and 63.3% in the late-onset SLE group and 96.3% and 91.0% in patients with early-onset SLE, respectively. In conclusion, our results confirm that in NW Spain SLE is not uncommon in individuals 50 years and older. In keeping with earlier studies, late-onset SLE patients from NW Spain have some clinical and laboratory differences with respect to those individuals with early-onset SLE. Our data support the claim of a reduced probability of survival in the older age-group of SLE patients.

Predictors of cerebrovascular accidents in giant cell arteritis in a defined population.

OBJECTIVE: To examine the frequency and predictors of cerebrovascular accidents (CVA) in giant cell arteritis (GCA) patients from a defined population. METHODS: Retrospective study of biopsy-proven GCA patients diagnosed from 1981 through 2001 at the single hospital for the population of Lugo (Northwest Spain). RESULTS: Thirty (14.3%) of the 210 biopsy-proven GCA patients had CVA, 5 of them (16.7%) involving the vertebrobasilar territory. Five patients (4 of them involving the carotid territory) had CVA within the 2 years prior to the onset of GCA symptoms. Four patients had CVA within the first month after the diagnosis of the disease. Of these, 3 involved the vertebrobasilar territory. Another 5 patients suffered carotid stroke between the 4th and the 12th month after the disease diagnosis. The remaining 16 GCA patients had CVA (all but one involving the carotid territory) at least 1 year after the diagnosis of vasculitis. No differences in the clinical and laboratory features at the time of diagnosis between patients who had CVA and the rest of the biopsy-proven GCA patients were observed. However, hypertension and hyperlipidemia at the time of diagnosis of GCA were associated with the development of CVA (p < 0.05 for both). Also, anemia at the time of diagnosis (hemoglobin < 12 g/dL) [hazard ratio = 0.34 (95% CI 0.12 - 1.00; p = 0.05)] was negatively associated with CVA within the first 10 years after the diagnosis of the disease. Mortality in GCA patients with CVA was not significantly higher than that in patients without CVA (hazard ratio = 1.53; p = 0.14). CONCLUSION: The present study confirms that CVA may occur in GCA. Vertebrobasilar accidents are more common than carotid accidents at the time of diagnosis of the disease. Vascular risk factors should be carefully controlled in the follow-up of GCA patients.

Implications of upper respiratory tract infections and drugs in the clinical spectrum of Henoch-Schönlein purpura in children.

OBJECTIVE: To assess whether children with Henoch-Schonlein purpura (HSP) who had an upper respiratory tract infection (URTI) or received medication prior to the onset of the disease exhibited a different clinical spectrum of features and outcome from children without such a history. METHODS: Retrospective study of children (< or = 14 years old) with HSP diagnosed from 1980 through December 2001 at the single hospital for the Lugo region (Northwest Spain). Children with primary cutaneous vasculitis were classified as having HSP according to currently used criteria. Drugs or URTI were considered precipitating events if any new medication was taken or an URTI had occurred within a week prior to the onset of the vasculitis. A comparative analysis of clinical and laboratory features according to the presence or absence of URTI and drugs was conducted. RESULTS: Eighty-six children fulfilled the classification criteria for HSP. Eight of them were excluded from this analysis due to insufficient follow-up (less than 1 year post-diagnosis). An URTI and a history of drugs were reported to occur in 32/78 (41%) and 23/78 (30%) children respectively. No differences in the age at the onset of the disease, gender and seasonal incidence between children with or without URTI were observed. However, 23/32 (72%) children with URTI had hematuria with or without proteinuria, compared with only 18/46 (39%) children without history of URTI (p = 0.004). This higher incidence of renal manifestations in HSP with URTI was not associated with more severe nephritis or with a significantly higher frequency of renal sequelae or relapses of the disease. No statistically significant differences between children with or without a history of drugs were observed. CONCLUSION: Although in unselected children with HSP a history of URTI seems to be associated with a higher incidence of nephritis, it does not influence the outcome of the disease.

Comparación de dos métodos para el cálculo de la incertidumbre en los análisis de laboratorio / Comparing two methods in the estimation of the uncertainty in laboratory quality

Objetivo: Comparación de dos métodos para el cálculo de incertidumbres en el control de calidad de los laboratorios. Métodos: Mediante una simulación por ordenador, se comparan el método delta (propuesto por la International Organization for Standardization y por la Entidad Nacional de Acreditación) y un método basado en el bootstrap. La simulación incluye varias situaciones en las que las condiciones ambientes y la relación entre las variables medidas se van modificando. Resultados: El porcentaje medio de cobertura de los intervalos de confianza al 95 por ciento es ligeramente más alto y más próximo al nominal en el bootstrap que en el delta. Las mayores diferencias se aprecian en la distribución de los porcentajes de cobertura: mientras en el bootstrap un gran número de simulaciones tienen porcentajes de cobertura próximos al 95 por ciento, en el delta los porcentajes obtenidos ofrecen mucha mayor dispersión, llegando en ocasiones al 100 por ciento de cobertura o descendiendo hasta el 80 por ciento o incluso menores. El bootstrap ofrece resultados superponibles, incluso cuando intervienen variables desconocidas que no han podido ser medidas o cuando las variables consideradas están correlacionadas. En cambio, el método delta ofrece resultados más pobres en estas dos circunstancias. Conclusión: La incertidumbre en el control de calidad de los laboratorios puede ser obtenida por bootstrap con ventaja sobre el método delta (AU)

Nosocomial infection, indices of intrinsic infection risk, and in-hospital mortality in general surgery.

The objectives of this paper are to assess whether two indices of intrinsic infection risk (the SENIC and the NNIS index) predict in-hospital mortality and the attributable in-hospital mortality due to nosocomial infection in surgical patients. A prospective study on 4714 patients admitted to three hospitals has been carried out. The relative risk and its 95% confidence interval (CI) were estimated. Multiple-risk factors adjusted for odds ratios (OR) were yielded by logistic regression analysis. Overall, 119 patients (2.5%) died before hospital discharge. Both the SENIC and the NNIS indices were related to in-hospital mortality in crude data. After controlling for several variables (age, sex, ASA score, cancer, renal failure, diabetes mellitus, stay at the ICU), the SENIC index did not show any significant trend with mortality (P = 0.252), whereas the trend was significant for the NNIS index (P < 0.001). Risk of death in patients with one nosocomial infection was 7.5%, and in patients developing more than one nosocomial infection was 17.1%. After adjusting for several confounding variables, the development of an organ/space surgical site infection was significantly related to mortality (OR = 4.5, 95% CI 1.5-15.6) as was blood infection (OR = 17.3, 95% CI 3.5-87.0). The association of a surgical site infection and either a respiratory tract infection or a blood infection also increased significantly the risk of in-hospital mortality (OR = 3.3, 95% CI 1.2-8.7). In conclusion, the NNIS index is a good predictor of in-hospital mortality. Patients developing an organ/space surgical site infection and/or a blood infection have an increased risk of in-hospital mortality.

The effect of frequency of chart review on the sensitivity of nosocomial infection surveillance in general surgery.

OBJECTIVE: To assess the sensitivity of different frequencies of nosocomial infection surveillance (NIS) in general surgery. DESIGN: Data obtained with a prospective daily NIS are compared with those of hypothetical cross-sectional studies carried out with different frequencies (from one weekly visit up to one visit every other day). SETTING: General surgery services at three hospitals. MAIN OUTCOME MEASURE: Sensitivity in the detection of nosocomial infection (overall and stratified by site), compared to a gold standard of prospective surveillance of every patient's complete medical record daily from the first day after surgery until discharge and once more after discharge. PATIENTS: 5,859 patients. RESULTS: 837 nosocomial infections were detected by the gold standard (58.8% were surgical-site infections [SSI]). The sensitivity of weekly NIS for all infections was 74.5% (95% confidence interval [CI95], 71.4%-77.5%) and varied from 65.1% (CI95, 56.2%-73.3%) for urinary tract infection to 83.3% (CI95, 62.6%-95.3%) for respiratory tract infection; it was 76.4% (CI95, 72.4%-80.1%) for SSI. As expected, sensitivity increased with the frequency of NIS. Performing NIS every 4 days improved sensitivity significantly, to 82.3% (CI95, 79.5%-84.8%) for all infections and 83.3% (CI95, 79.7%-86.5%) for SSI. One visit every other day increased the sensitivity for all infections by another 4.9%, mainly due to increased detection of urinary tract and other less severe infections. CONCLUSIONS: The sensitivity of two visits a week exceeded that of one weekly visit by approximately 8%, and one visit every other day added another 5% increase. Results varied according to duration of infection and postdischarge hospital stay.

A survey of postoperative pain treatment in children of 3-14 years.

There is a lack of information concerning the characteristics of pediatric postoperative pain in Southern European countries. The aim of this study was to document how postoperative pain in children was managed routinely at Spanish surgical wards.The study was carried out in three hospitals on the first postoperative day. Children were divided in four groups according to their age (years): Group I (3-5), II (6-8), III (9-11) and IV (12-14). The parameters evaluated were: analgesia characteristics (type of prescription, drug used and route of administration, prescribed dose and whether the drug was or was not administered, need of non-prescribed analgesics) and the postoperative pain intensity. The results were analysed using descriptive statistics. U-Mann Whitney, chi(2), ANOVA, Kruskall-Wallis and Student's t -test were also used.A total of 348 children ranging from 3 to 14 years were studied. The average age (+/- SD) was 8.2 +/- 3.3 and the majority were male (74%). Urologic surgery was the most frequent type of operation, with age (p<0.05) and hospital differences (p<0.001). The majority of the patients (52%) were prescribed an analgesic, but only 26% of them had an analgesia order at fixed dosage intervals. Differences among the hospitals were observed (p<0.001). The most commonly used analgesics were metamizol, propyphenazone, paracetamol and codeine. Differences in choice of drug in relation to age and hospital were significant (p< 0.001). Rectal was the preferred route of drug administration. Patient's age was unrelated with the prescribed analgesic dose. An average of 68% of prescriptions were given and half of the patients without scheduled analgesia needed to have analgesics administered. Around 20% of patients had high pain scores.Few paediatric patients are given analgesics at fixed dose intervals to treat postoperative pain. Pain relief therapy for children differs notably to that of adults, in respect to the drugs prescribed and the administered route. Copyright 1999 European Federation of Chapters of the International Association for the Study of Pain.

Comparison of two procedures to estimate the hospital stay attributable to nosocomial infection: matched cohort study versus analysis of covariance of the total unmatched cohort.

We compare the results of a matched cohort study with those yielded by analysis of covariance (ANCOVA) in the cohort where the matched study was nested to assess whether the matching design underestimates (as it has been assumed) the extra length of hospitalization due to nosocomial infection. A total of 218 patients developed hospital infection in a cohort of 1483 general surgery patients; 161 were successfully matched 1:1 for surgical procedure, ASA score, age (+/-10 years), emergency-scheduled surgery, preoperative stay, and, whenever possible, number of diagnoses and sex. Unmatched infected patients (57, 23.1%) were different from matched ones. There were no differences for the variables between matched infected patients and their pairs. The matched cohort study overestimates the extra LOH due to hospital infection. The use of ANCOVA in the total cohort obviates the selection bias of the matched cohort design.

[Risk factors associated with the development of surgical wound infection in a general surgery service]. / Factores de riesgo asociados al desarrollo de infección de herida quirúrgica en un servicio de cirugía general.

BACKGROUND: To evaluate incidence, etiology and risk factors of surgical wound infection (SWI) in a service of general surgery in a tertiary hospital. METHODS: Retrospective cohort study. The relative risk (RR) and its 95% confidence interval (CI) have been used as a measure of association between risk factors and SWI. Multiple logistic regression has been selected as multivariate analysis. RESULTS: Of 619 surgical patients, 60 (9.7%) developed SWI. The most frequently isolated microorganism was Enterococcus (26%), but a higher prevalence of gram negative was also found. On admission, the factors associated with SWI were: diabetes mellitus (RR = 2.5, CI95% = [1.0-6.3]), age older than 65 years (RR = 2.66, CI95% = [0.8-9.0]) and contaminated and dirty surgery (linear trends chi square, p = 0.044); among the amendable medical care factors, the duration of the surgery is the unique to be pointed out with an increment of 5 /1000 per minute (p = 0.011). The admission an emergency unit presented a non significant adjusted RR of SWI near to 3 (CI95% = [0.9-9.6]). CONCLUSIONS: SWI is related most importantly to risk factors at admission not amendable by the physician. Our results showed that the only factor susceptible to be changed is the duration of the surgical intervention.