Meteorological conditions and Legionnaires' disease sporadic cases-a systematic review.

A number of studies suggest that meteorological conditions are related to the risk of Legionnaires' disease (LD) but the findings are not consistent. A systematic review was conducted to investigate the association of weather with sporadic LD and highlight the key meteorological conditions related to this outcome. PubMed, EMBASE, The Cochrane Library and OpenGrey were searched on 26-27 March 2020 without date, language or location restrictions. Key words included "legionellosis", "legionnaires' disease", combined with "meteorological conditions", "weather", "temperature", "humidity", "rain", "ultraviolet rays", "wind speed", etc. Studies were excluded if they did not examine the exposure of interest, the outcome of interest and their association or if they only reported LD outbreak cases. The study was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and it was registered in PROSPERO (#CRD42020168869). There were 811 articles, of which 17 were included in the review. The studies investigated different meteorological variables and most of them examined the combined effect of several variables. The most commonly examined factors were precipitation and temperature, followed by relative humidity. The studies suggested that increased precipitation, temperature and relative humidity were positively associated with the incidence of LD. There was limited evidence that higher wind speed, pressure, visibility, UV radiation and longer sunshine duration were inversely linked with the occurrence of LD. A period of increased but not very high temperatures, followed by a period of increased precipitation, favour the occurrence of LD. Increased awareness of the association of temperature and precipitation and LD occurrence among clinicians and public health professionals can improve differential diagnosis for cases of sporadic community-acquired pneumonia and at the same time contribute to improving LD surveillance.

Mejora de la calidad de vida en cuidadores informales de personas dependientes mediante talleres educacionales / Improvement of quality of life for informal caregivers of dependent persons through educational workshops

Introducción: El envejecimiento de la población está asociado a un incremento de personasdependientes, estimándose que el 15% vive con alguna discapacidad. La prestación de cuidados afamiliares supone una responsabilidad añadida asociada a problemas relacionados con el cuidado, quepueden repercutir negativamente en los cuidadores. Por ello, planteamos diseñar y evaluar unprograma de cuidados, basado en la educación de los cuidadores, midiendo los conocimientos, lapercepción del dolor, la carga emocional y la calidad de vida relacionada con la salud.Objetivo: El objetivo principal es mejorar la calidad de vida de los cuidadores informales medianteintervenciones formativas, con el fin de disminuir la incapacidad causada por las tareas del cuidado.Método: Participaron 99 cuidadores pertenecientes al Distrito Sanitario Aljarafe-Sevilla Norte deAtención Primaria, divididos en grupo control e intervención. Diseñamos dos talleres educacionalessobre programas de atención a cuidadores informales. Cumplimentaron un cuestionario deconocimientos, y diferentes escalas validadas relacionadas con el dolor, los estados de salud y lacalidad de vida.Resultados: La mayor parte de los cuidadores presentaban problemas de espalda tomandomedicación para ello. La intervención implementada se asoció a un descenso del dolor duranteactividades básicas de la vida diaria, los cuidados y el descanso, y disminución del índice de esfuerzoen ambos grupos.Conclusiones: Los programas de intervención en cuidadores informales de pacientes dependientesresultan eficaces para mejorar el estado de salud y la calidad de vida de este colectivo por lo que sedebe fomentar su realización desde la Atención Primaria (AU)

Introduction: The ageing of the population is associated with an increase in the number of dependentpeople, with an estimate of 15% living with a disability. The provision of care to family members entailsan added responsibility associated with care-related problems, which can have a negative impact oncaregivers. Therefore, we propose to design and evaluate a caregiving programme based on caregivereducation, measuring knowledge, pain perception, emotional burden and health-related quality of life.Objective: The main objective is to improve the quality of life of informal caregivers through traininginterventions, in order to decrease the disability caused by caregiving tasks.Method: 99 caregivers belonging to the Aljarafe-Northern Seville Primary Care Health Districtparticipated, divided into control and intervention groups. We designed two educational workshops oncare programmes for informal caregivers. They completed a knowledge questionnaire, and differentvalidated scales related to pain, health states and quality of life.Results: Most of the caregivers presented back problems, for which they received pharmaceuticaltreatment. The implemented intervention was associated with a decrease in pain during basic activitiesof daily living, care and rest, as well as a reduction in strain index in both groups.Conclusions: Intervention programmes for informal carers of dependent patients are effective inimproving the state of health and quality of life of this group, and their implementation should thereforebe encouraged in primary care (AU)

[Toxoplasmosis in Spain, analysis of hospitalizations during the period 1997-2018.] / Toxoplasmosis en España, aná-lisis de las hospitalizaciones en el periodo 1997-2018.

OBJECTIVE: Toxoplasmosis is a systemic infectious disease. Infection is acquired by ingestion of Toxoplasma gondii cysts or by vertical transmission mother-to-child during pregnancy (congenital toxoplasmosis). In Spain, the prevalence shows wide variability depending on the region and the study. The incidence in other European countries evidences a decline in recent years. The aim of this study was to characterize the presence and the epidemiological patterns of the disease in the Spanish population with information obtained of hospitalized cases with a diagnosis of toxoplasmosis at discharge. METHODS: The interactive platform of the Specialized Registry (RAE-MBD) of the Ministry of Health was used to obtain data on hospital discharges with "toxoplasmosis" diagnosis. Frequencies and rates of hospital discharges were calculated according to sex, age groups, region and diagnosis at discharge. Sequence graphs were generated to analysed the temporal evolution of the number of hospitalizations. The trends and slopes of the RHs were analyzed using "joinpoint" regression models, estimating the mean annual percentage change (PCAM) in the RHs and its 95% confidence interval. RESULTS: There were 13,704 cases with toxoplasmosis diagnosis at discharge, (58%) were men. The highest hospitalization rate (RH) was in the 15-44-year-old men group (5,804 discharges and HT=2.52). During the period studied a decrease in the number of discharges was observed, it was progressive and affected all the autonomous regions, being more pronounced in men (81.9% vs 63.9%). CONCLUSIONS: The number of hospitalizations in Spain decreased substantially during the studied period (1997-2018), similar to other European studies reported. The decrease was progressive and mainly affected men between 15-44 years.

OBJETIVO: La toxoplasmosis es una enfermedad infecciosa sistémica. Se contrae principalmente por ingestión de quistes y ooquistes de Toxoplasma gondii o por afectación fetal tras la primoinfección de la madre embarazada (toxoplasmosis congénita). La prevalencia en España presenta una gran variabilidad, dependiendo de la región y el estudio. La incidencia en otros países europeos refleja un descenso en los últimos años. El objetivo de este estudio fue caracterizar la presencia y el patrón epidemiológico de la enfermedad en la población española a partir de los casos hospitalizados con un diagnóstico de toxoplasmosis al alta. METODOS: A través de la plataforma interactiva del Registro de Atención Sanitaria Especializada (RAE-CMBD) del Ministerio de Sanidad se obtuvieron los datos de altas hospitalarias con diagnóstico "toxoplasmosis". Se calcularon frecuencias y tasas de altas hospitalarias (TH) según sexo, grupos de edad, comunidad autónoma y diagnóstico al alta. Se analizó la evolución temporal del número de hospitalizaciones a través de gráficos de secuencia. Las tendencias y las pendientes de las TH se analizaron mediante modelos de regresión "joinpoint", estimándose el porcentaje de cambio anual medio (PCAM) en las TH y su intervalo de confianza al 95%. RESULTADOS: Se contabilizaron 13.704 casos con diagnóstico toxoplasmosis al alta, el 58% hombres. La tasa de hospitalización (TH) más elevada se dio en hombres, en el grupo de 15-44 años (5.804 altas y TH=2,52). Se observa un descenso del 76,8% en el número de altas a lo largo del periodo estudiado, éste fue progresivo y afectó a todas las comunidades autónomas; siendo más acusado en hombres (81,9% vs 63,9%). CONCLUSIONES: El número de hospitalizaciones por toxoplasmosis en España se redujo notablemente a lo largo del periodo estudiado (1997-2018), mostrando una tendencia similar a la referida en otros estudios europeos. El descenso en los ingresos fue progresivo y afectó fundamentalmente a hombres de 15 a 44 años.

Evaluating the Impact of the Diabetes Mellitus Strategy for the National Health System: An Interrupted Time Series Analysis.

(1) Background: Diabetes mellitus is a significant public health problem. Macrovascular complications (stroke, acute myocardial infarction (AMI) and lower limb amputations (LLAs) represent the leading cause of morbi-mortality in DM. This work aims to evaluate the impact of the approval of the Diabetes Mellitus Strategy of the National Health System (SDM-NHS) on hospitalizations for those macrovascular complications related to DM; (2) Methods: Interrupted time series applying segmented regression models (Negative Binomial) adjusted for seasonality to data from hospital discharge records with a primary or secondary diagnosis of DM (code 250 ICD9MC); (3) Results: Between 2001 and 2015, there have been 7,302,750 hospital discharges with a primary or secondary diagnosis of DM. After the approval of the SDM-NHS, all the indicators showed a downward trend, modifying the previous trend in the indicators of AMI and LLA. The indicators of stroke and AMI also showed an immediate reduction in their rates; (4) Conclusions: After the approval of the SDM-NHS, an improvement has been observed in all the indicators of macrovascular complications of DM evaluated, although it is difficult to establish a causal relationship between the strategy and the effects observed. Interrupted time series is applicable for evaluating the impact of interventions in public health when experimental designs are not possible.

[Surveillance and epidemiology of Herpes Zoster in Spain.] / Vigilancia y epidemiología del herpes zóster en España.

OBJECTIVE: Herpes Zoster (HZ) results from reactivation of latent varicella-zoster virus infection and is associated with immunosuppression and ageing. HZ is of increasing importance in advanced societies. Vaccination appears as a powerful tool to reduce HZ as well as postherpetic neuralgia, the main zoster complication. This study aims to describe the temporal trend, the age and sex distribution of cases, hospitalisations and deaths by zoster occurred in Spain between 1998 and 2018. METHODS: The available information for zoster in Spain were used: cases from National Surveillance System (2014-2018), registries from Spanish hospitalisation database (1998-2018) and deaths from the Spanish mortality statistics (1999-2018). Incidence, hospitalization (HR) and mortality (MR) rates per year and period were calculated. Rates by age group and sex as well as percentage and cumulative percentage for cases and hospitalisations by age group, were also calculated. RESULTS: The global HZ incidence was 351.6/100,000 inhabitants and 625.5/100,000 among population aged 50 and over. The incidence increases with age, especially from the age of 50-54 years (41% increase over the 45-49 age group) and is always higher in women. The global HR was 6.75/100,000 and 15.7/100,000 in persons aged 50 and over; HR increases with age, especially from 60-64 years onwards (50% increase over 54-59 age group) and is always higher in men. The 68.8% of cases and 80.2% of hospitalisations for HZ occurred from the age of 50. CONCLUSIONS: In Spain HZ is a frequent and severe entity in adults and elderly people requiring public health interventions. The demographic changes and the introduction of vaccination require continued monitoring of HZ behaviour in terms of incidence and severity.

OBJETIVO: El herpes zóster (HZ) aparece debido a la reactivación de la infección latente por el virus de la varicela-zóster y está asociado a la inmunosupresión y al envejecimiento. El HZ es de creciente importancia en las sociedades avanzadas. La vacunación se vislumbra como una potente herramienta para reducir el zóster y su principal complicación: la neuralgia postherpética. El objetivo de este estudio fue describir la tendencia temporal y la distribución por grupos de edad y sexo de los casos, hospitalizaciones y muertes por HZ en España entre 1998 y 2018. METODOS: Se analizaron los casos de HZ notificados a la Red Nacional de Vigilancia Epidemiológica entre 2014-2018, las hospitalizaciones por HZ del registro RAE-CMBD entre 1998-2018 y las muertes por HZ de la Estadística de Mortalidad del INE entre 1999-2018. Se calcularon: tasas de incidencia, hospitalización (TH) y mortalidad (TM) anual y de periodo; tasas globales y por grupos de edad y sexo, así como porcentaje y porcentaje acumulado de casos y hospitalizaciones por grupos de edad. RESULTADOS: La incidencia global de HZ se estimó en 351,6 por cada 100.000 habitantes y en 625,5 por cada 100.000 habitantes en personas de 50 años o más. La incidencia se incrementó con la edad, sobre todo a partir de los 50-54 años (incremento del 41% respecto al grupo de 45-49 años) y fue siempre más alta en mujeres. La TH global por HZ fue 6,75 por cada 100.000 habitantes y 15,7 por cada 100.000 habitantes en personas de 50 años o más. La TH fue creciendo con la edad, sobre todo a partir de los 60-64 años (incremento del 50% respecto al grupo de 54-59 años) y resultó siempre más alta en hombres. El 68,8% de casos y el 80,2% de hospitalizaciones por HZ ocurrieron a partir de los 50 años. CONCLUSIONES: En España, el HZ es una entidad frecuente y grave en adultos y personas mayores, que requiere intervenciones en Salud Pública. Los cambios demográficos y la incorporación de la vacunación exigen seguir monitorizando estrechamente el comportamiento del HZ en términos de incidencia y gravedad.

The limits of single-group interrupted time series analysis in assessing the impact of smoke-free laws on short-term mortality.

BACKGROUND: Decreases in circulatory/respiratory morbimortality after the January-2006 Spanish partial smoke-free law have been found using designs without control groups, such as single-group interrupted time series (ITS), which are prone to biases. The aim was to reassess the law's impact on mortality using ITS designs with robustness checks. METHODS: A comprehensive cohort of people aged ≥25 in each calendar-year of 2002-2007, living in 13 of 18 Spanish regions, was followed up between 01/2002 and 12/2007. The law included a smoking ban in indoor public and workplaces, allowing exceptions in catering, hospitality and leisure venues, and other interventions. Post-law changes in monthly coronary/respiratory mortality were estimated using segmented regression, adjusting for relevant covariates, including seasonality, extreme temperatures, influenza incidence and air pollution. The validity of results was assessed using control outcomes, hypothetical law dates, and non-equivalent control groups, analysing their results as difference-in-differences (DID) designs. RESULTS: Significant immediate post-law decreases in coronary, respiratory and non-tobacco-related mortality were observed among people aged ≥70. A significant immediate post-law decrease in respiratory mortality (-12.7%) was also observed among people age 25-69, although this was neutralized by a subsequent upward trend before 1.5 years. More favourable post-law changes in coronary/respiratory mortality among the target (people aged 25-69) than control groups (people aged ≥70 or women aged ≥80) were not identified in DID designs. Establishing hypothetical law dates, immediate decreases began in February/March 2005 with maxima between April and July 2005. CONCLUSIONS: After robustness checks, the results do not support a clear positive impact of the 2006 Spanish smoke-free law on short-term coronary/respiratory mortality. The favourable immediate changes observed pre- and post-law could derive mainly from the harvesting effect of the January-2005 cold wave. This highlights the risks of assessing the impact of health interventions using both morbimortality outcomes and designs without a control group and adequate robustness checks.

Insights on the Use of Carbon Additives as Promoters of the Visible-Light Photocatalytic Activity of Bi2WO6.

We have explored the impact of the incorporation of various amounts of carbons from varied physicochemical features as additives to Bi2WO6 for the photocatalytic degradation of a dye using simulated solar light. Data has revealed that the composition and acidic character of the carbon additive are important parameters in the performance of the Bi2WO6/carbon catalysts. The presence of a carbon additive improved the conversion of the dye, evidencing the occurrence of charge transfer reactions that involve radical mediated reactions. The catalysts prepared with 2 and 5 wt.% of carbon additive outperformed the bare semiconductor, despite the shielding effect of the carbon matrix. The acidic nature of the Bi2WO6/carbon catalysts governs the degradation pathway (due to the preferential adsorption of the dye), that proceeds via the deethylation of the auxochrome groups of the dye at short irradiation times, followed by the cleavage of the chromophore at long irradiation times. Regarding the characteristics of the carbons, the photocatalytic degradation rate is accelerated by carbons of acidic character and high oxygen content, whereas the porosity seems to play a minor role. The presence of the carbon additives also affects the toxicity of the treated solutions, rendering lower values after shorter irradiation periods.

Short-term association between road traffic noise and healthcare demand generated by Parkinson's disease in Madrid, Spain / Asociación a corto plazo entre el ruido del tráfico y la demanda de atención sanitaria generada por la enfermedad de Parkinson en Madrid, España

Objective: To analyse whether there is a short-term association between road traffic noise in the city of Madrid and Parkinson's disease (PD)-related demand for healthcare. Methods: Time-series analysis (2008-2009) using variables of analysis linked to emergency and daily PD-related demand for healthcare (ICD-10: G20-G21), namely, PD-hospital admissions (HAs), PD-outpatient visits (OVs) and PD-emergency medical calls in Madrid. The noise pollution measurements used were Leqd, equivalent sound level for the daytime hours (from 8 a.m. to 10 p.m.), and Leqn, equivalent sound level for night time hours (from 10 p.m. to 8 a.m.) in dB(A). We controlled for temperature, pollution, trends and seasons, and used the Poisson regression model to calculate relative risk (RR). Results: The association between Leqd and HAs was found to be linear. Leqd and Leqn at lag 0.1 and temperature at lags 1 and 5 were the only environmental variables associated with increased PD-related healthcare demand. The RR (lag 0) for Leqd and HA was 1.07 (1.04-1.09), the RR (lag 0) for Leqd and OV was 1.28 (1.12-1.45), and the RR (lags 0.1) for Leqn and emergency medical calls was 1.46 (1.06-2.01). Conclusion: The above results indicate that road traffic noise is a risk factor for PD exacerbation. Measures to reduce noise-exposure levels could result in a lower PD-related healthcare demand

Objetivo: Analizar si existe una asociación a corto plazo entre el ruido del tráfico en Madrid y la demanda de asistencia sanitaria por enfermedad de Parkinson (EP). Métodos: Análisis de series temporales (2008-2009) utilizando variables de demanda sanitaria urgente y diaria por EP (CIE-10: G20-G21): admisiones hospitalarias (AH), visitas ambulatorias (VA) y llamadas médicas (112) en Madrid. Los indicadores de ruido fueron Leqd (nivel de ruido diurno equivalente, de 8 a 22h) y Leqn (nivel de ruido nocturno equivalente, de 22 a 8h) en dB(A). Se controló por temperatura, contaminación, tendencias y estacionalidades, y se realizó regresión de Poisson para calcular el riesgo relativo (RR). Resultados: La asociación entre Leqd y AH por EP es lineal. Leqd y Leqn en el retardo 0,1 y la temperatura en los retardos 1 y 5, fueron las variables ambientales asociadas con el aumento de la demanda sanitaria. Se obtuvo un RR (lag 0) para Leqd y AH de 1,07 (1,04-1,09), y un RR (lag 0) para Leqd y VA de 1,28 (1,12-1,45). El RR (retardos 0,1) para Leqn y llamadas al 112 fue de 1,46 (1,06-2,01). Conclusión: Los resultados apuntan que el ruido es un factor de riesgo para la exacerbación de la EP. Las medidas para reducir la exposición al ruido podrían dar lugar a una menor demanda de asistencia sanitaria relacionada con la EP

Cold-related mortality vs heat-related mortality in a changing climate: A case study in Vilnius (Lithuania).

INTRODUCTION: Direct health effects of extreme temperatures are a significant environmental health problem in Lithuania, and could worsen further under climate change. This paper attempts to describe the change in environmental temperature conditions that the urban population of Vilnius could experience under climate change, and the effects such change could have on excess heat-related and cold-related mortality in two future periods within the 21st century. METHODS: We modelled the urban climate of Vilnius for the summer and winter seasons during a sample period (2009-2015) and projected summertime and wintertime daily temperatures for two prospective periods, one in the near (2030-2045) and one in the far future (2085-2100), under the Representative Concentration Pathway (RCP) 8.5. We then analysed the historical relationship between temperature and mortality for the period 2009-2015, and estimated the projected mortality in the near future and far future periods under a changing climate and population, assuming alternatively no acclimatisation and acclimatisation to heat and cold based on a constant-percentile threshold temperature. RESULTS: During the sample period 2009-2015 in summertime we observed an increase in daily mortality from a maximum daily temperature of 30 °C (the 96th percentile of the series), with an average of around 7 deaths per year. Under a no acclimatisation scenario, annual average heat-related mortality would rise to 24 deaths/year (95% CI: 8.4-38.4) in the near future and to 46 deaths/year (95% CI: 16.4-74.4) in the far future. Under a heat acclimatisation scenario, mortality would not increase significantly in the near or in the far future. Regarding wintertime cold-related mortality in the sample period 2009-2015, we observed increased mortality on days on which the minimum daily temperature fell below - 12 °C (the 7th percentile of the series), with an average of around 10 deaths a year. Keeping the threshold temperature constant, annual average cold-related mortality would decrease markedly in the near future, to 5 deaths/year (95% CI: 0.8-7.9) and even more in the far future, down to 0.44 deaths/year (95% C: 0.1-0.8). Assuming a "middle ground" between the acclimatisation and non-acclimatisation scenarios, the decrease in cold-related mortality will not compensate the increase in heat-related mortality. CONCLUSION: Thermal extremes, both heat and cold, constitute a serious public health threat in Vilnius, and in a changing climate the decrease in mortality attributable to cold will not compensate for the increase in mortality attributable to heat. Study results reinforce the notion that public health prevention against thermal extremes should be designed as a dynamic, adaptive process from the inception.

Papillary thyroid microcarcinoma: characteristics at presentation, and evaluation of clinical and histological features associated with a worse prognosis in a Latin American cohort.

Objective We aimed to describe the presentation of papillary microcarcinoma (PTMC) and identify the clinical and histological features associated with persistence/recurrence in a Latin American cohort. Subjects and methods Retrospective study of PTMC patients who underwent total thyroidectomy, with or without radioactive iodine (RAI), and who were followed for at least 2 years. Risk of recurrence was estimated with ATA 2009 and 2015 classifications, and risk of mortality with 7th and 8th AJCC/TNM systems. Clinical data obtained during follow-up were used to detect structural and biochemical persistence/recurrence. Results We included 209 patients, predominantly female (90%), 44.5 ± 12.6 years old, 183 (88%) received RAI (90.4 ± 44.2 mCi), followed-up for a median of 4.4 years (range 2.0-7.8). The 7th and 8th AJCC/TNM system classified 89% and 95.2% of the patients as stage I, respectively. ATA 2009 and ATA 2015 classified 70.8% and 78.5% of the patients as low risk, respectively. Fifteen (7%) patients had persistence/recurrence during follow-up. In multivariate analysis, only lymph node metastasis was associated with persistence/recurrence (coefficient beta 4.0, p = 0.016; 95% CI 1.3-12.9). There were no PTMC related deaths. Conclusions Our series found no mortality and low rate of persistence/recurrence associated with PTMC. Lymph node metastasis was the only feature associated with recurrence in multivariate analysis. The updated ATA 2015 and 8th AJCC/TNM systems classified more PTMCs than previous classifications as low risk of recurrence and mortality, respectively.

Papillary thyroid microcarcinoma: characteristics at presentation, and evaluation of clinical and histological features associated with a worse prognosis in a Latin American cohort

ABSTRACT Objective We aimed to describe the presentation of papillary microcarcinoma (PTMC) and identify the clinical and histological features associated with persistence/recurrence in a Latin American cohort. Subjects and methods Retrospective study of PTMC patients who underwent total thyroidectomy, with or without radioactive iodine (RAI), and who were followed for at least 2 years. Risk of recurrence was estimated with ATA 2009 and 2015 classifications, and risk of mortality with 7th and 8th AJCC/TNM systems. Clinical data obtained during follow-up were used to detect structural and biochemical persistence/recurrence. Results We included 209 patients, predominantly female (90%), 44.5 ± 12.6 years old, 183 (88%) received RAI (90.4 ± 44.2 mCi), followed-up for a median of 4.4 years (range 2.0-7.8). The 7th and 8th AJCC/TNM system classified 89% and 95.2% of the patients as stage I, respectively. ATA 2009 and ATA 2015 classified 70.8% and 78.5% of the patients as low risk, respectively. Fifteen (7%) patients had persistence/recurrence during follow-up. In multivariate analysis, only lymph node metastasis was associated with persistence/recurrence (coefficient beta 4.0, p = 0.016; 95% CI 1.3-12.9). There were no PTMC related deaths. Conclusions Our series found no mortality and low rate of persistence/recurrence associated with PTMC. Lymph node metastasis was the only feature associated with recurrence in multivariate analysis. The updated ATA 2015 and 8th AJCC/TNM systems classified more PTMCs than previous classifications as low risk of recurrence and mortality, respectively.

Heat and health in Antwerp under climate change: Projected impacts and implications for prevention.

BACKGROUND: Excessive summer heat is a serious environmental health problem in several European cities. Heat-related mortality and morbidity is likely to increase under climate change scenarios without adequate prevention based on locally relevant evidence. METHODS: We modelled the urban climate of Antwerp for the summer season during the period 1986-2015, and projected summer daily temperatures for two periods, one in the near (2026-2045) and one in the far future (2081-2100), under the Representative Concentration Pathway (RCP) 8.5. We then analysed the relationship between temperature and mortality, as well as with hospital admissions for the period 2009-2013, and estimated the projected mortality in the near future and far future periods under changing climate and population, assuming alternatively no acclimatization and acclimatization based on a constant threshold percentile temperature. RESULTS: During the sample period 2009-2013 we observed an increase in daily mortality from a maximum daily temperature of 26°C, or the 89th percentile of the maximum daily temperature series. The annual average heat-related mortality in this period was 13.4 persons (95% CI: 3.8-23.4). No effect of heat was observed in the case of hospital admissions due to cardiorespiratory causes. Under a no acclimatization scenario, annual average heat-related mortality is multiplied by a factor of 1.7 in the near future (24.1deaths/year CI 95%: 6.78-41.94) and by a factor of 4.5 in the far future (60.38deaths/year CI 95%: 17.00-105.11). Under a heat acclimatization scenario, mortality does not increase significantly in the near or in the far future. CONCLUSION: These results highlight the importance of a long-term perspective in the public health prevention of heat exposure, particularly in the context of a changing climate, and the calibration of existing prevention activities in light of locally relevant evidence.

Emergency multiple sclerosis hospital admissions attributable to chemical and acoustic pollution: Madrid (Spain), 2001-2009.

INTRODUCTION: Multiple sclerosis (MS) is the most prevalent neurological disease among young adults in Spain. A number of recent studies have linked traffic-related pollution, both chemical and acoustic, to the aetiology and exacerbation of neurodegenerative diseases. OBJECTIVE: To analyse the existence of a significant short-term association between daily emergency MS hospital admissions and chemical and acoustic pollution caused by traffic in Madrid. METHODOLOGY: We conducted a longitudinal ecological time series study, in which the dependent variable was the number of daily emergency MS hospital admissions (ICD-9: 340) registered in Madrid from 1 January 2001 to 31 December 2009. The independent variables were daily mean concentrations (µg/m3) of PM2.5, PM10, O3 and NO2. Equivalent diurnal (Leqd), nocturnal (Leqn) and daily equivalent noise levels (Leq24) were also considered. In addition, we controlled for linear trends, seasonality and the autoregressive nature of the series itself. Day of the week was also added as a covariate. Significant environmental variables were determined using Poisson GLM models. Relative risk (RR) and attributable risk (AR) values were calculated for increases of 10µg/m3 in the case of chemical pollutants and 1dB(A) in noise levels. RESULTS: While there was no association between chemical pollutants caused by traffic and MS admissions, such an association was in evidence for Leqd at lag zero. This association is linear without a threshold, with there being a level above 67dB(A) from which this effect is more pronounced. The RRs were as follows: for all Leqd values, 1.21 (95% CI: 1.16, 1.26); and for Leqd >67dB(A), 1.62 (95% CI: 1.24, 2.13). CONCLUSION: The above results indicate that traffic noise can exacerbate MS symptoms, leading to hospital admissions due to this cause.

Short-term association between road traffic noise and healthcare demand generated by Parkinson's disease in Madrid, Spain.

OBJECTIVE: To analyse whether there is a short-term association between road traffic noise in the city of Madrid and Parkinson's disease (PD)-related demand for healthcare. METHODS: Time-series analysis (2008-2009) using variables of analysis linked to emergency and daily PD-related demand for healthcare (ICD-10: G20-G21), namely, PD-hospital admissions (HAs), PD-outpatient visits (OVs) and PD-emergency medical calls in Madrid. The noise pollution measurements used were Leqd, equivalent sound level for the daytime hours (from 8 a.m. to 10 p.m.), and Leqn, equivalent sound level for night time hours (from 10 p.m. to 8 a.m.) in dB(A). We controlled for temperature, pollution, trends and seasons, and used the Poisson regression model to calculate relative risk (RR). RESULTS: The association between Leqd and HAs was found to be linear. Leqd and Leqn at lag 0.1 and temperature at lags 1 and 5 were the only environmental variables associated with increased PD-related healthcare demand. The RR (lag 0) for Leqd and HA was 1.07 (1.04-1.09), the RR (lag 0) for Leqd and OV was 1.28 (1.12-1.45), and the RR (lags 0.1) for Leqn and emergency medical calls was 1.46 (1.06-2.01). CONCLUSION: The above results indicate that road traffic noise is a risk factor for PD exacerbation. Measures to reduce noise-exposure levels could result in a lower PD-related healthcare demand.

Neck Sonography and Suppressed Thyroglobulin Have High Sensitivity for Identifying Recurrent/Persistent Disease in Patients With Low-risk Thyroid Cancer Treated With Total Thyroidectomy and Radioactive Iodine Ablation, Making Stimulated Thyroglobulin Unnecessary.

OBJECTIVES: Follow-up of patients with low-risk differentiated thyroid cancer treated with total thyroidectomy and radioiodine requires neck sonography and thyroglobulin (Tg). The need to stimulate Tg is controversial. The goal of this study was to compare the diagnostic performances of sonography plus suppressed or stimulated Tg in low-risk thyroid cancer. METHODS: After total thyroidectomy and radioiodine, patients with low-risk thyroid cancer were retrospectively identified as having structural or biochemical persistence/recurrence. We compared the diagnostic performance of suppressed and stimulated Tg to detect persistence/recurrence. RESULTS: We included 148 patients with low-risk thyroid cancer who were followed for a median of 3.7 years. Persistence/recurrence was found in 8 patients (5.4%; 5 structural disease and 3 biochemical disease). Thyroglobulin was not stimulated in 72 patients (group 1) and stimulated in 76 (group 2). In group 1, 5 patients (6.9%) had structural neck persistence/recurrence (3 with suppressed Tg ≥ 1 ng/mL and 2 with suppressed Tg < 1 ng/mL). Four patients underwent surgery, and 1 was surveilled. All 5 patients had suppressed Tg lower than 1 ng/mL at the end of follow-up. In group 2, stimulated Tg did not identify additional cases of structural persistence/recurrence but classified 3 patients (3.9%) as having biochemical persistence/recurrence. One patient received a second dose of radioiodine, and the other 2 were surveilled; all were without disease at the end of follow-up. Suppressed and stimulated Tg had negative predictive values for persistence/recurrence of 97% and 100%, respectively. CONCLUSIONS: In low-risk thyroid cancer treated with total thyroidectomy and radioiodine, sonography and suppressed or stimulated Tg have similar negative predictive values for persistence/recurrence. Importantly, the coexistence of negative sonographic findings and suppressed Tg lower than 1 ng/mL makes the addition of stimulated Tg unlikely to identify clinically important disease.

Efficacy and safety of topical sevoflurane in the treatment of chronic skin ulcers.

PURPOSE: Results of efficacy and safety assessments of topical sevoflurane use in patients with long-term treatment-refractory vascular ulcers are reported. METHODS: Patients were randomly assigned to receive sevoflurane instillations (1 mL per cm2 of ulcer area 1-4 times daily) plus standard wound care (ulcer cleaning, debridement, and dressing changes) or standard care only. Topical sevoflurane was initiated during hospitalization, with self- or nurse-administered instillations continued after discharge. Study participants were evaluated at least once weekly for 1 month and then every 2 weeks for up to 90 days. The primary efficacy measures were debridement-related and overall pain (assessed using a 10-point visual analog scale), daily opioid use, and ulcer size; secondary measures were patient and clinician impressions of improvement and ulcer-related admissions during treatment. The primary safety endpoint was intolerable sevoflurane-related adverse effects. RESULTS: Compared with the group receiving standard care alone (n = 5), the sevoflurane group (n = 10) had significant (p = 0.001) reductions in mean ± S.D. scores for debridement-related pain on day 1 of treatment and at subsequent time points; the sevoflurane group also had significant reductions in overall pain, daily opioid use, and ulcer size. Outcomes in terms of patient- and clinician-rated improvement and emergency admissions also favored the sevoflurane group. Mild localized reddening in the area surrounding ulcers occurred in 4 sevoflurane-treated patients. CONCLUSION: Direct application of sevoflurane onto vascular ulcers resulted in an intense and long-lasting analgesia and was associated with a progressive reduction of ulcer size.

Saharan dust intrusions in Spain: Health impacts and associated synoptic conditions.

BACKGROUND: A lot of papers have been published about the impact on mortality of Sahara dust intrusions in individual cities. However, there is a lack of studies that analyse the impact on a country and scarcer if in addition the analysis takes into account the meteorological conditions that favour these intrusions. OBJECTIVES: The main aim is to examine the effect of Saharan dust intrusions on daily mortality in different Spanish regions and to characterize the large-scale atmospheric circulation anomalies associated with such dust intrusions. METHODS: For determination of days with Saharan dust intrusions, we used information supplied by the Ministry of Agriculture, Food & Environment, it divides Spain into 9 main areas. In each of these regions, a representative province was selected. A time series analysis has been performed to analyse the relationship between daily mortality and PM10 levels in the period from 01.01.04 to 31.12.09, using Poisson regression and stratifying the analysis by the presence or absence of Saharan dust advections. RESULTS: The proportion of days on which there are Saharan dust intrusions rises to 30% of days. The synoptic pattern is characterised by an anticyclonic ridge extending from northern Africa to the Iberian Peninsula. Particulate matter (PM) on days with intrusions are associated with daily mortality, something that does not occur on days without intrusions, indicating that Saharan dust may be a risk factor for daily mortality. In other cases, what Saharan dust intrusions do is to change the PM-related mortality behaviour pattern, going from PM2.5. CONCLUSIONS: A study such as the one conducted here, in which meteorological analysis of synoptic situations which favour Saharan dust intrusions, is combined with the effect on health at a city level, would seem to be crucial when it comes to analysing the differentiated mortality pattern in situations of Saharan dust intrusions.

Evaluation of short-term mortality attributable to particulate matter pollution in Spain.

According to the WHO, 3 million deaths are attributable to air pollution due to particulate matter (PM) world-wide. However, there are no specific updated studies which calculate short-term PM-related cause specific mortality in Spain. The objective is to quantify the relative risks (RRs) and attributable risks (ARs) of daily mortality associated with PM10 concentrations, registered in Spanish provinces and to calculate the number of PM-related deaths. We calculated daily mortality due to natural (ICD-10: A00 R99), circulatory (ICD-10: I00 I99) and respiratory causes (ICD-10: J00 J99) for each province across the period 2000-2009. Mean daily concentrations of PM10, NO2 and O3 was used. For the estimate of RRs and ARs, we used generalised linear models with a Poisson link. A meta-analysis was used to estimate RRs and ARs in the provinces with statically significant results. The overall RRs obtained for these provinces, corresponding to increases of 10 µ g/m3 in PM10 concentrations were 1.009 (95% CI: 1.006 1011) for natural, 1.026 (95% CI: 1.019 1033) for respiratory, and 1.009 (95% CI: 1.006 1012) for circulatory-cause mortality. This amounted to an annual overall total of 2683 deaths (95% CI: 852 4354) due to natural, 651 (95% CI: 359 1026) due to respiratory, and 556 (95% CI: 116 1012) due to circulatory causes, with 90% of this mortality lying below the WHO guideline values. This study provides an updated estimate of the effect had by this type of pollutant on causes of mortality, and constitutes an important basis for reinforcing public health measures.

Effects of noise on telephone calls to the Madrid Regional Medical Emergency Service (SUMMA 112).

BACKGROUND: Although the effects of noise on population morbidity and mortality have been observed both in the short and long term, the morbidity and mortality indicators used to date have not enabled information on such health effects to be accessed in real time. At an international level, there are relatively few studies, mostly recent, which have considered an alternative indicator, such as the demand for medical attention provided by emergency services, taking into account environmental factors other than noise. OBJECTIVES: To ascertain the short-term effect of road-traffic noise levels on medical care, broken down by organic, circulatory and respiratory causes, provided by the Madrid Regional Medical Emergency Service (Servicio de Urgencia Médica de Madrid/SUMMA 112). METHODS: We used an ecological time-series study and fitted Poisson regression models, to analyse the number of daily, cause-specific episodes of care provided in situ by SUMMA 112, via emergency ambulance dispatches, across the period 01/01/2008-31/12/2009. To this end, we considered diurnal (Leqd: 7-23h), nocturnal (Leqn: 23-7h) and daily (Leq24: 24h) noise (in db(A)) as the principal factor, and chemical air pollution (µg/m3) and temperature (°C) as the control variables. We also controlled for trend and seasonalities, the autoregressive nature of the series, and day of the week. RESULTS: Nocturnal noise exceeded the WHO threshold (55 db(A)) on 100% of nights, despite displaying a downward trend across the study period. For all causes, with the exception of emergency calls due to ischaemic disease, it was nocturnal rather than diurnal noise levels that had a short-term effect (lags 0-1) on SUMMA 112 calls, with this impact being greater for respiratory than for circulatory causes. Hence, for every increase of 1db in Leqn, the relative risks (RRs) were as follows: 1.11 (95% CI 1.09-1.13) for organic causes; 1.14 (95% CI: 1.11-1.18) for respiratory causes; and 1.08 (95% CI: 1.05-1.10) for circulatory causes. CONCLUSION: SUMMA 112 data give access to real-time information on the health effects associated with increases in noise levels, which cannot be obtained via mortality or hospital-admission data, since these are collected in the longer term. Accordingly, this is something that would be immediately applicable in any future implementation of a syndromic surveillance system focusing on the effects of environmental pollutants on health.

Effect of Environmental Factors on Low Weight in Non-Premature Births: A Time Series Analysis.

OBJECTIVE: Exposure to pollutants during pregnancy has been related to adverse birth outcomes. LBW can give rise to lifelong impairments. Prematurity is the leading cause of LBW, yet few studies have attempted to analyse how environmental factors can influence LBW in infants who are not premature. This study therefore sought to analyse the influence of air pollution, noise levels and temperature on LBW in non-premature births in Madrid during the period 2001-2009. METHODS: Ecological time-series study to assess the impact of PM2.5, NO2 and O3 concentrations, noise levels, and temperatures on LBW among non-premature infants across the period 2001-2009. Our analysis extended to infants having birth weights of 1,500 g to 2,500 g (VLBW) and less than 1,500 g (ELBW). Environmental variables were lagged until 37 weeks with respect to the date of birth, and cross-correlation functions were used to identify explaining lags. Results were quantified using Poisson regression models. RESULTS: Across the study period 298,705 births were registered in Madrid, 3,290 of which had LBW; of this latter total, 1,492 were non-premature. PM2.5 was the only pollutant to show an association with the three variables of LBW in non-premature births. This association occurred at around the third month of gestation for LBW and VLBW (LBW: lag 23 and VLBW: lag 25), and at around the eighth month of gestation for ELBW (lag 6). Leqd was linked to LBW at lag zero. The RR of PM2.5 on LBW was 1.01 (1.00 1.03). The RR of Leqd on LBW was 1.09 (0.99 1.19)(p<0.1). CONCLUSIONS: The results obtained indicate that PM2.5 had influence on LBW. The adoption of measures aimed at reducing the number of vehicles would serve to lower pregnant women's exposure. In the case of noise should be limited the exposure to high levels during the final weeks of pregnancy.