Quality of life improvement in patients with bone metastases undergoing palliative radiotherapy.

Background: The aim of the study was to analyze the impact of palliative radiotherapy on quality of life (QoL) in patients with symptomatic bone metastases. Materials and methods: We present the results from a prospective multicentric study including 128 patients who provided pre- and post-radiotherapy (one month after treatment) brief pain inventory (BPI) assessments. Worst pain was recorded using the BPI (range: 0-10). Pain response was described according to the International Bone Metastases Consensus on palliative radiation. Regarding QoL, for each pre- and post-radiation BPI-questionnaire, scores from the interference domains were summed and averaged to obtain an overall interference score. Results: There was a significant correlation between radiation treatment response and improvement in all functional interference domains except sleeping. Patients > 75 years old presented a significantly higher improvement in general activity, mood and relationships with others compared to patients ≤ 75 years old. Patients presenting a baseline pain score ≥ 8 showed a higher improvement in the general activity item (p = 0.049). There was no statistically significant association between pretreatment ECOG, chemotherapy, primary tumor location and radiation schedule with any of the functional interference items. Conclusions: Patients who report pain relief after palliative radiotherapy also present a better quality of life including physical and psychosocial aspects.

Prospective multicentre analysis of the therapeutic approach and prognostic factors determining overall survival in elderly patients with non-small-cell lung carcinoma treated with curative intent.

Objective: To analyse patterns of treatment with curative intent commonly used in elderly patients with locally advanced non-small-cell lung carcinoma (NSCLC) and predictive factors of overall survival in routine clinical practice. Methods: This multicentre prospective study included consecutive patients aged ≥65 years old diagnosed with NSCLC between February 2014 and January 2018. Inclusion criteria: age ≥65 years, stage IIIA/IIIB NSCLC. Treatment decisions were taken by a multidisciplinary committee. Kaplan-Meier curves and log-rank test were used to identify which clinical/treatment-associated variables, or pre-treatment quality of life (QOL) considering EORTC QLQ-C30 (and LC13 module) were predictive of overall survival. Results: A total of 139 patients were recruited. Median follow-up was 9.9 months (1.18-57.36 months) with a median survival of 14 months (range 11-17 months). In the group>75-year-old patients, the committee recommended chemotherapy and sequential radiotherapy (55.6%) or radiotherapy alone (22.2%), rather than surgery (3.7%) or concomitant radiochemotherapy (16.5%). However, in 65- to 75-year-old patients, surgery and concomitant radiochemotherapy were recommended in half of cases (p=0.003). Regarding multivariate analysis, the risk of death was higher in patients with pre-existing heart disease (p=0.002), low score for physical functioning (p=0.0001), symptoms of dysphagia (p=0,01), chest pain (p=0.001), and those not undergoing surgical treatment (p=0.024). Conclusions: Patients >75 years received more conservative treatments. Surgery improved survival and should be carefully considered, regardless of patient age. Comorbidities and poor baseline QOL are predictive of shorter survival. Advances in knowledge: Measuring these parameters before treatment may help us to define a population of frail patients with a poorer prognosis to facilitate decision making in clinical practice.

Reducing Unnecessary Treatments for Acute Bronchiolitis Through an Integrated Care Pathway.

OBJECTIVES: To analyze the impact of an integrated care pathway on reducing unnecessary treatments for acute bronchiolitis. METHODS: We implemented an evidence-based integrated care pathway in primary care (PC) centers and the referral emergency department (ED). This is the third quality improvement cycle in the management of acute bronchiolitis implemented by our research team. Family and provider experiences were incorporated by using design thinking methodology. A multifaceted plan that included several quality improvement initiatives was adopted to reduce unnecessary treatments. The primary outcome was the percentage of infants prescribed salbutamol. Secondary outcomes were prescribing rates of other medications. The main control measures were hospitalization and unscheduled return rates. Salbutamol prescribing rate data were plotted on run charts. RESULTS: We included 1768 ED and 1092 PC visits, of which 913 (51.4%) ED visits and 558 (51.1%) PC visits occurred in the postintervention period. Salbutamol use decreased from 7.7% (interquartile range [IQR] 2.8-21.4) to 0% (IQR 0-1.9) in the ED and from 14.1% (IQR 5.8-21.6) to 5% (IQR 2.7-8) in PC centers. In the ED, the overall epinephrine use rate fell from 9% (95% confidence interval [CI], 7.2-11.1) to 4.6% (95% CI, 3.4-6.1) (P < .001). In PC centers, overall corticosteroid and antibiotic prescribing rates fell from 3.5% (95% CI, 2.2-5.4) to 1.1% (95% CI, 0.4-2.3) (P =.007) and from 9.5% (95% CI; 7.3-12.3) to 1.7% (95% CI, 0.9-7.3) (P <.001), respectively. No significant variations were noted in control measures. CONCLUSIONS: An integrated clinical pathway that incorporates the experiences of families and clinicians decreased the use of medications in the management of bronchiolitis.

Early tacrolimus exposure does not impact long-term outcomes after liver transplantation.

BACKGROUND: Tacrolimus trough levels (TTL) during the first weeks after liver transplantation (LT) have been related with long-term renal function and hepatocellular carcinoma recurrence. Nevertheless, the significance of trough levels of tacrolimus during the early post-transplant period for the long-term outcome is under debate. AIM: To evaluate the effect of TTL during the first month on the long-term outcomes after LT. METHODS: One hundred fifty-five LT recipients treated de novo with once-daily tacrolimus were retrospectively studied. Patients with repeated LT or combined transplantation were excluded as well as those who presented renal dysfunction prior to transplantation and/or those who needed induction therapy. Patients were classified into 2 groups according to their mean TTL within the first month after transplantation: ≤ 10 (n = 98) and > 10 ng/mL (n = 57). Multivariate analyses were performed to assess risk factors for patient mortality. RESULTS: Mean levels within the first month post-transplant were 7.4 ± 1.7 and 12.6 ± 2.2 ng/mL in the ≤ 10 and > 10 groups, respectively. Donor age was higher in the high TTL group 62.9 ± 16.8 years vs 45.7 ± 17.5 years (P = 0.002) whilst mycophenolate-mofetil was more frequently used in the low TTL group 32.7% vs 15.8% (P = 0.02). Recipient features were generally similar across groups. After a median follow-up of 52.8 mo (range 2.8-81.1), no significant differences were observed in: Mean estimated glomerular filtration rate (P = 0.69), hepatocellular carcinoma recurrence (P = 0.44), de novo tumors (P = 0.77), new-onset diabetes (P = 0.13), or biopsy-proven acute rejection rate (12.2% and 8.8%, respectively; P = 0.50). Eighteen patients died during the follow-up and were evenly distributed across groups (P = 0.83). Five-year patient survival was 90.5% and 84.9%, respectively (P = 0.44), while 5-year graft survival was 88.2% and 80.8%, respectively (P = 0.42). Early TTL was not an independent factor for patient mortality in multivariate analyses. CONCLUSION: Differences in tacrolimus levels restricted to the first month after transplant did not result in significant differences in long-term outcomes of LT recipients.

Initiatives to reduce treatments in bronchiolitis in the emergency department and primary care.

We performed a quality improvement initiative to reduce unnecessary treatments for acute bronchiolitis (AB) in primary care (PC) and the referral paediatric emergency department (ED). The quality improvement initiative involved two seasons: 2016-2017 (preintervention) and 2017-2018 (postintervention). We distributed an evidence-based protocol, informative posters and badges with the slogan 'Bronchiolitis, less is more'. We also held interactive sessions, and paediatricians received weekly reports on bronchodilator prescription. The main outcome was the percentage of infants prescribed salbutamol. Secondary outcomes were epinephrine, antibiotic and corticosteroid prescription rates. Control measures were ED visit and hospitalisation rates, triage level, length of stay, intensive care admission and unscheduled returns with admission. We included 1878 ED and 1192 PC visits of which 855 (44.5%) and 534 (44.7%) occurred in the postintervention period, respectively. In the ED, salbutamol and epinephrine prescription rates fell from 13.8% (95% CI 11.8% to 16%) to 9.1% (95% CI 7.3% to 11.2%) (p<0.01) and 10.4% (95% CI 8.6% to 12.4%) to 9% (95% CI 7.2% to 11.1%) (n.s.), respectively. In PC, salbutamol, corticosteroid and antibiotic prescription rates fell from 38.3% (95% CI 34.6% to 42.0%) to 15.9% (95% CI 12.9% to 19.5%) (p<0.01), 12.9% (95% CI 10.5% to 15.7%) to 3.6% (95% CI 2.2% to 5.7%) (p<0.01) and 29.6% (95% CI 26.2% to 33.2%) to 9.5% (95% CI 7.2% to 12.5%) (p<0.01), respectively. No significant variations were noted in control measures. We safely decreased the use of unnecessary treatments for AB. Collaboration between PC and ED appears to be an important factor for success.

Paediatric Escherichia coli bacteraemia presentations and high-risk factors in the emergency department.

AIM: Escherichia coli (E coli) is a known cause of paediatric bacteraemia. The main objective was to characterise the emergency department (ED) presentations of paediatric E coli bacteraemia and secondarily to identify those related to greater severity. METHODS: This was a sub-study of a multicentre cross-sectional prospective registry including all with E coli bacteraemia episodes between 2011 and 2016. We used multiple correspondence and cluster analysis to identify different patterns. RESULTS: We included 291 patients and 43 met criteria for severe disease (14.3%, 95% confidence interval 11.2-19.3). We identified four types of paediatric E coli bacteraemia presentations. Two (178 patients, 61.2%) were related to well-appearing previously healthy infants with associated urinary tract infection (UTI). Well-appearing children older than 12 months old with underlying disease (n = 60, 20.6%) and non-well-appearing children of different ages (n = 53, 18.2%) corresponded to the other two types; these had associated UTI infrequently and higher severity rate (15% and 50.9%, respectively, higher when compared with the two previous types, P < .01), including the two patients who died. CONCLUSION: There were four different types of ED paediatric E coli bacteraemia presentations with different severity. Febrile young children with associated UTI showed the best outcome.

New-onset atrial fibrillation in patients with pneumococcal pneumonia. Impact of timing and duration on short- and medium-term mortality.

OBJETIVES: To assess the incidence, related factors, timing and duration of new- onset atrial fibrillation in a cohort of consecutive patients diagnosed with pneumococcal pneumonia. METHODS: Observational study including all immunocompetent adults hospitalized for pneumococcal pneumonia. Patients were classified by time (atrial fibrillation recognized on emergency room arrival or developed during hospitalization) and duration (paroxysmal or persistent). Patients were followed-up for 6 months after discharge. RESULTS: We included 1092 patients, of whom 109 (9.9%) had new-onset atrial fibrillation. An early event was documented in 87 (79.8%) cases. Arrhythmia was classified as paroxysmal in 78 patients. Older age, heavy drinking, respiratory rate ≥ 30/minute, leukopenia, severe inflammation and bacteremia were independent risk factors for developing new-onset atrial fibrillation on admission. Overall, 48 (4.4%) patients died during hospitalization, the rate being higher in those patients who developed new-onset arrhythmia (17.9% vs 2.9% p<0.001). Among patients with events recognized at admission, in-hospital mortality was higher in those with persistent arrhythmia (34.8% vs 6.3%, p = 0.002) and 6-month survival was better among those who developed paroxysmal event. CONCLUSIONS: The development of new-onset atrial fibrillation was associated with pneumonia severity, and higher in-hospital mortality. Bacteremia and severe systemic inflammation were factors associated with its development.

A retrospective study on the potential of 99m Tc-HDP imaging before therapy for individualizing treatments with 223 Ra-Cl2 for metastatic castration resistant prostate cancer.

PURPOSE: Research on dose-effect correlation is necessary to move toward an individualization of treatments of metastatic castration resistant prostate cancer (mCRPC) with 223 Ra-Cl2 . We first looked for a possible correlation of 99m Tc-HDP lesion uptake in pretreatment whole-body scans (WBSs) with lesion absorbed dose. Moreover, we looked for a possible correlation of 99m Tc-HDP lesion uptake in pretreatment WBSs and of lesion absorbed dose with relative change in the 99m Tc-HDP lesion uptake obtained from pre- and post-treatment WBSs in patients treated for mCRPC with six cycles of 223 Ra-Cl2 . METHODS: Eleven patients received six cycles of 55 kBq/kg of 223 Ra-Cl2 separated by 4 weeks. In addition, one patient received concomitant treatment with abiraterone and two patients with enzalutamide. The 99m Tc-HDP WBSs were acquired before the first cycle and after the sixth cycle of the treatment. For the lesions with the higher 99m Tc-HDP uptake, the absorbed dose was calculated for the first cycle. Lesion volume was determined from 99m Tc-HDP SPECT/CT images before the first cycle and 223 Ra-Cl2 activity in the lesions was determined from 223 Ra-Cl2 planar images after the first cycle. The effect of the treatment was evaluated from the relative change of the mean and the maximum counts in the lesions, both estimated from the WBSs acquired before the first cycle and after the sixth cycle. RESULTS: The absorbed dose was calculated for 30 lesions, with values ranging between 0.4 and 3.8 Gy (mean 1.5 Gy). A significant (P < 0.05) high positive linear correlation was found between the lesion absorbed dose in the first treatment cycle and the mean and maximum counts in the lesions in the WBSs acquired before the first cycle (R = 0.75 and 0.76, respectively). The relative change of the mean and the maximum counts in the lesions in the 99m Tc-HDP WBSs showed a significant (P < 0.05) high positive logarithmic correlation with the 99m Tc-HDP mean and maximum counts in the lesions before the first cycle (R = 0.79 and 0.78, respectively). Lastly, a significant (P < 0.05) high positive logarithmic correlation was also found between the relative change of the mean and the maximum counts in the lesions in the 99m Tc-HDP WBSs and the lesion absorbed dose (R = 0.86 and 0.85, respectively). For this correlation the influence of the administered activity and of the concomitant treatments was not found to be significant (P > 0.05). CONCLUSIONS: The high correlations found for the 99m Tc-HDP lesion uptake before the first cycle lesion with the relative change in the 99m Tc-HDP lesion uptake after the six cycles of 223 Ra-Cl2 , and with the lesion absorbed dose in the first cycle show the potential of pretreatment 99m Tc-HDP imaging in order to personalize the performance of these treatments.

From Lauren's diffuse gastric cancer to WHO's poorly cohesive carcinoma. Clinicopathological and prognostic characteristics.

INTRODUCTION: since Lauren classified gastric cancer into intestinal-type adenocarcinoma and diffuse gastric carcinoma back in 1965, countless categorizations have been published that attempt to elucidate the clinicopathological and prognostic differences between histological subtypes. OBJECTIVE: a retrospective study was performed of gastric cancer cases managed in a third-level site over ten years in order to compare subtypes between the most widely used classifications (Lauren and World Health Organization [WHO]). METHODS: a comparative study of the most relevant clinicopathological characteristics and a multivariate survival analysis were performed. RESULTS: significant differences exist between histological subtypes in terms of age, gender, location, extension, stage and treatment received. A univariate overall survival analysis revealed better survival rates for intestinal-type adenocarcinoma as compared to diffuse carcinoma (hazard ratio [HR]: 1.405 [1.024-1.927]) according to the Lauren's classification. Furthermore, there was a better prognosis of mucinous carcinoma (HR: 0.378 [0.164-0.868]), though failing to prove a poorer prognosis of poorly cohesive (HR: 1.242 [0.878-1.757]) and signet cell (HR: 1.354 [0.792-2.314]) carcinomas, according to the WHO classification. In the multivariate overall survival analysis, the following poor prognosis factors were identified: male gender, local infiltration (T), nodal invasion (N) and received adjuvant therapy. CONCLUSION: although the various histological subtypes show significant clinicopathological differences, further studies are needed to compare them and clarify the prognostic relevance of each one.

Pain response and quality of life assessment in patients with moderate/severe neuropathic pain due to bone metastasis undergoing treatment with palliative radiotherapy and tapentadol: A prospective multicentre pilot study.

INTRODUCTION: To assess pain response rate (RR) and quality of life (QoL), in patients with moderate/severe neuropathic pain (NP) due to bone metastasis (BM) undergoing palliative 3D radiotherapy plus tapentadol. METHODS: We conducted a prospective multicentre pilot study. Patients were assessed before radiotherapy using the validated questionnaire (Douleur Neuropathique en 4 questions). Response to radiotherapy (8 Gy-30 Gy/1-10fr) at one and two months was assessed according the International Bone Metastases Consensus criteria. INCLUSION CRITERIA: radiological evidence of BM, NP according to DN4 (cut-off score ≥ 4), no spinal cord compression, worst pain score ≥ 5/10. Nonparametric Mann-Whitney U test compared changes in QoL among response groups. RESULTS: Seventeen patients (13 men, 4 woman), median age 67 years (42-81), were included. Pre-treatment median pain severity was 7.5 (5-10). Median dose of tapentadol administered before radiotherapy was 100 mg/24 h (100-300 mg). Overall RR 1 month after radiotherapy was 10/16 = 62.5%: 3/16 (18.8%) achieving a complete response (CR) and 7/16 (43.8%) a partial response (PR). Overall RR 2 months after RT was 5/10 (50%): 10% a CR and 40% a PR. ITT RR for this study at 1 and 2 months was 10/17 = 59% and 5/17 = 29%, respectively. Patients responding to radiotherapy had significant improvement in EORTC QLQ-C30 emotional functioning (EF) (p = 0.025) and fatigue symptom scale scores (p = 0.035) one month after radiotherapy. Painful site symptom QLQ-BM22 scores improved 2 months after radiotherapy (p = 0.024). CONCLUSIONS: Palliative radiotherapy plus tapentadol shows an acceptable pain response and QoL improvement especially regarding EF, fatigue and painful site symptom scales in patients with moderate/severe NP due to BM. Therefore, it could be an alternative to manage NP in daily practice.

Risk Factors for Severe Anaphylaxis in Children.

OBJECTIVE: To identify risk factors associated with severe anaphylaxis in children. STUDY DESIGN: We carried out a multicenter prospective observational study including children less than 18 years old diagnosed with anaphylaxis in 7 Spanish pediatric emergency departments (EDs) between May 2016 and April 2018. Children were considered to have severe anaphylaxis if they met one or more of the following criteria: requirement for 2 or more doses of epinephrine, clinically important biphasic reaction, endotracheal intubation, intensive care unit admission, and/or death. RESULTS: We included 453 episodes of anaphylaxis. Of these, 61 were classified as severe anaphylaxis (13.5%, 95% CI [10.6-16.9]): 53 (11.7%) required more than 1 dose of epinephrine, and there were 14 (3.1%) cases of clinically important biphasic reactions, 2 (0.4%) intubations in the ED, and 6 (1.3%) admissions to the intensive care unit. No patients died. In the multivariable regression, we identified 5 independent risk factors for severe anaphylaxis: history of asthma (P = .002; OR 2.705, 95% CI [1.431-5.113]), onset of the symptoms less than 5 minutes after the allergen exposure (P = .002; OR 2.619, 95% CI [1.410-4.866]), non-well appearance (P = .005; OR 2.973, 95% CI [1.380-6.405]), tachycardia (P = .014; OR 2.339, 95% CI [1.191-4.959]), and hypotension (P = .036; OR 3.725, 95% CI [1.087-12.762]). CONCLUSIONS: Childhood anaphylaxis is usually well controlled in the ED. Children with a history of asthma, rapid onset of the symptoms, who are non-well appearing, or have tachycardia or hypotension upon arrival to the ED are more likely to have severe episodes.

Non-bacteremic pneumococcal pneumonia: general characteristics and early predictive factors for poor outcome.

Purpose: Nowadays, most cases of pneumococcal community-acquired pneumonia (PCAP) are diagnosed by positive urinary antigen. Our aims were to analyse process of care in patients hospitalised with non-bacteremic PCAP (NB-PCAP) and identify factors associated with poor outcome (PO) in this population.Methods: We conducted a prospective study, including patients hospitalised for NB-PCAP (positive urinary antigen and negative blood culture) over a 15 year period. We performed multivariate analysis of predisposing factors for PO, defined as need for mechanical ventilation and/or shock and/or in-hospital death.Results: Of the 638 patients included, 4.1% died in hospital and 12.8% had PO. Host-related factors were similar in patients with and without PO, but patients with PO had higher illness severity on admission. Adjusted analysis revealed the following independent factors associated with PO: being a nursing home resident (OR: 6.156; 95% CI: 1.827-20.750; p = .003), respiratory rate ≥30 breaths/min (OR: 3.030; 95% CI: 1.554-5.910; p = .001), systolic blood pressure <90 mmHg (OR: 4.789; 95% CI: 1.967-11.660; p = .001), diastolic blood pressure <60 mmHg (OR: 2.820; 95% CI: 1.329-5.986; p = .007), pulse rate ≥125 beats/min (OR: 3.476; 95% CI: 1.607-7.518; p = .002), pH <7.35 (OR: 9.323; 95% CI: 3.680-23.622; p < .001), leukocytes <4000/µL (OR: 10.007; 95% CI: 2.960-33.835; p < .001), and severe inflammation (OR: 2.364; 95% CI 1.234-4.526; p = .009). The area under the curve for predicting PO was 0.890 (95% CI: 0.851-0.929).Conclusions: Since patients with PO seem different and had worse in-hospital course, we identified eight independent risk factors for PO measurable on admission.

Impacto de una intervención en las consultas de Enfermería de Atención Primaria para la mejora de la calidad de la colonoscopia de cribado / Impact of an intervention in primary care nursing units for improvement in the quality of colonoscopy screening

OBJETIVO: analizar la efectividad de una intervención enfermera en Atención Primaria (AP) para la mejora de la preparación colónica de las personas que se realizan una colonoscopia de cribado. MÉTODO: estudio de evaluación antes (invitación 2015 del Programa de Cribado de Cáncer Colorrectal -PCCR-) después (invitación 2018 del PCCR) en una Unidad de Atención Primaria del País Vasco, sobre 154 personas que se hicieron la colonoscopia de confirmación tras tener resultado positivo en el PCCR. La intervención llevada a cabo por profesionales de Enfermería de AP constó de la realización de una consulta específica para instruir a los pacientes sobre la preparación colónica a través de una lista de comprobación disponible en la historia clínica digital, y una llamada recordatorio 24 horas antes de la colonoscopia. La variable principal fue la calidad de la preparación colónica (escala de Boston). Se utilizó Chi-cuadrado o el test exacto de Fisher en los análisis bivariantes. RESULTADOS: 135 personas aceptaron participar en el estudio. El 54,1% visualizó los vídeos sobre la preparación. El 94,8% recibió la llamada telefónica. La variable de resultado "calidad de la preparación de la colonoscopia" mostró diferencias estadísticamente significativas entre los dos años comparados, pudiéndose observar una preparación adecuada en más casos en el año 2018 que en el año 2015 (97,8% vs. 88,7%; p = 0,003). CONCLUSIONES: la realización de la intervención enfermera orientada a una mejor preparación colónica siguiendo la lista de comprobación estandarizado y disponible en la historia clínica, además de la llamada telefónica 24 horas antes de la colonoscopia, resultó efectiva en la mejora de la calidad de la limpieza colónica. También, ha supuesto la creación de un registro del proceso de atención de Enfermería

OBJECTIVE: to analyze the efficacy of a Primary Care (PC) nursing intervention for the colonic preparation of patients undergoing colonoscopy screening. METHOD: a before (2015 invitation by the Colorectal Cancer Screening Program - CCSP) and after (2018 invitation by the CCSP) evaluation study at a Primary Care Unit in the Basque Country, including 154 persons who underwent confirmation colonoscopy after obtaining a positive result in the CCSP. The intervention was conducted by PC Nursing professionals, and consisted of a specific training consultation for patients about colonic preparation, through a check-list available at the electronic clinical record, and a reminder call 24 hours prior to the colonoscopy. The primary variable was the quality of the colonic preparation (Boston Scale). Chi-square or Fisher's exact test were used at bivariate analyses. RESULTS: in total, 135 persons accepted to participate in the study; 54.1% of them viewed the videos on preparation, and 94.8% of them received the phone call. The "quality of the colonoscopy preparation" outcome variable showed statistically significant differences between both years compared: an adequate preparation could be observed in more cases in 2018 than in 2015 (97.8% vs. 88.7%; p = 0.003). CONCLUSIONS: conducting the nursing intervention, targeted to a better colonic preparation, and following the standard check-list available in the clinical record, as well as the phone call 24 hours prior to the colonoscopy, proved to be effective for the improvement of colonic cleansing. Moreover, it has led to the creation of a Nursing care process record

Pattern of relapse and dosimetric analysis of a single dose 19 Gy HDR-brachytherapy phase II trial.

PURPOSE: To report the pattern of relapse within the prostate with reference to the initial site of disease in patients treated with single fraction 19-Gy. METHODS AND MATERIALS: Forty-four patients were treated according to a prospective study of single-fraction HDR-brachytherapy. Treatment was delivered using 192Ir to a dose of 19 Gy prescribed to the prostate. Patients who experienced a biochemical failure underwent a re-staging multiparametric MRI (mpMRI) and MRI-TRUS fusion biopsy to rule-out local recurrence. In patients with visible Dominant intraprostatic lesions (DIL) on pretreatment mpMRI, the site of local relapse was compared with the initial site of disease. The dose received by the site of recurrence was investigated. RESULTS: The median follow-up period was 48 months (range 29-63). The PSA nadir was reached at 24 months follow-up, with a median value of 1.07 ng/mL. To date, 14 patients (32%) have experienced biochemical failure (4 patients low-risk and 10 intermediate-risk; p = 0.013). Re-staging mpMRI was performed in 11/14 patients. Eleven patients underwent MRI-TRUS fusion biopsy confirming local relapse in all patients. The analysis of DVH of all 44 patients revealed that patients with biochemical failure had received significantly lower doses in terms of V100, V125 and D90 (p = 0.032, p = 0.018 and p = 0.018 respectively). In patients with DILs on diagnostic mpMRI, the mean D90 and D98 on DIL were lower for patients with biochemical failure. CONCLUSIONS: This dosimetric analysis demonstrates a dose-response relationship in patients treated with single fraction 19 Gy. Patients with intermediate risk disease, with visible DIL on mpMRI and patients treated with cooler implants have higher incidence of biochemical and local failure.

Evaluation of an intervention supporting breastfeeding among late-preterm infants during in-hospital stay.

BACKGROUND: Late-preterm infants show lower breastfeeding rates when compared with term infants. Current practice is to keep them in low-risk wards where clinical guidelines to support breastfeeding are well established for term infants but can be insufficient for late-preterm. OBJECTIVE: The aim of this study was to evaluate an intervention supporting breastfeeding among late-preterm infants in a maternity service in the Basque Country, Spain. METHODS: The intervention was designed to promote parents' education and involvement, provide a multidisciplinary approach and decision-making, and avoid separation of the mother-infant dyad. A quasi-experimental study was conducted with a control (n=212) and an intervention group (n=161). Data was collected from clinical records from November 2012 to January 2015. Feeding rate at discharge, breast-pump use, incidence of morbidities, infant weight loss and hospital stay length were compared between the two groups. RESULTS: Infants in the control group were 50.7% exclusive breastfeeding, 37.8% breastfeeding, and, 11.5% formula feeding at discharge, whereas in the intervention group, frequencies were 68.4%, 25.9%, and 5.7%, respectively (p=0.002). Mothers in the intervention group were 2.66 times more likely to use the breast-pump after almost all or all feeds and 2.09 times more likely to exclusively breastfeed at discharge. There were no significant differences in morbidities and infant weight loss between groups. Hospital stay was longer for infants who required phototherapy in the intervention group (p=0.009). CONCLUSION: The intervention resulted in a higher breastfeeding rate at discharge. Interventions aimed to provide specific support among late-pretem infants in maternity services are effective.

Effect of vitamin E administered to men in infertile couples on sperm and assisted reproduction outcomes: a double-blind randomized study.

OBJECTIVE: To evaluate the influence on sperm parameters and in vitro fertilization (IVF) outcomes of the administration of 400 mg/day of vitamin E for 3 months to men from infertile couples who are undergoing IVF. DESIGN: Double-blind, placebo-controlled, randomized study. SETTING: Human reproduction unit of a university hospital. PATIENTS: A total of 101 couples, 50 in the vitamin E group and 51 in the placebo group, undergoing IVF, among whom 64.4% of cases had an abnormal spermiogram according to World Health Organization (WHO) criteria. INTERVENTIONS: Vitamin E (α-tocopherol), 400 mg daily by mouth for 3 months, with sperm analysis performed immediately before starting the treatment and 3 months later on the day of IVF. MAIN OUTCOME MEASURES: WHO sperm parameters and IVF outcomes. RESULTS: Although there was a statistically significant increase in progressive motility in the vitamin E group compared with before-treatment values, a similar increase occurred in the placebo group. Normal morphology was even better in the placebo group. Regarding IVF outcomes, better fertilization rates were observed in the placebo group, but the live-birth rate per transfer was statistically significantly higher in the vitamin E group: 17 (41.46%) of 41 versus 9 (20.46%) of 44 in the placebo group. Although the clinical pregnancy rates (both per transfer and per cycle started) and the implantation rate were somewhat higher in the vitamin E group (43.9% and 25%; 36.0% and 22.0%; and 24.7% and 14.1%, respectively), the increase was not statistically significant. CONCLUSIONS: The effect of vitamin E on classic sperm parameters was not an improvement over placebo. Nonetheless, vitamin E administration was associated with a statistically significantly higher live-birth rate, and there was a trend toward better results in other IVF parameters. CLINICAL TRIAL REGISTRATION NUMBER: Eudra CT 2007-000960-25.

Epidemiology of acute pediatric poisonings in Spain: a prospective multicenter study from the Spanish Society of Pediatric Emergency Medicine.

OBJECTIVE: To identify types of childhood poisoning exposures leading to consultation to emergency departments (ED) in Spain. METHODS: We carried out a multicenter prospective registry-based cohort study including children with acute poisonings presenting to 55 pediatric EDs of the Spanish Society of Pediatric Emergency Medicine between 2008 and 2017, during previously designated certain days. RESULTS: During the study period, we registered 749 803 pediatric ED presentations, of which 1749 were for poisonings (0.23%). Most commonly involved toxicants were therapeutic drugs (845, 48.3%), household products (387, 22.1%), ethanol (168, 9.6%), cosmetics (88, 5%) and CO (73, 4.2%). We identified five types of poisoning presentations. Two types occurring at home involving young children accounted for 1368 episodes (78.2%): non-intentional ingestions and dosage error of therapeutic drugs (791, 45.2%), and non-intentional ingestions of household products and cosmetics (577, 33%). Most commonly involved toxicants were benzodiazepines and detergents in each group. The remaining three groups required more interventions in the ED and had a lower rate of outpatient management: intentional ingestion of therapeutic drugs (105, 6%, frequently suicide attempts, mainly with benzodiazepines or combinations of therapeutic drugs), non-intentional inhalation of CO (76, 4.3%) and recreational ingestion of ethanol or use of illicit drugs (200, 11.4%). The distribution of these groups showed differences related to sex, domestic habits of storage of toxicants, symptoms, management in the ED and patient disposition. CONCLUSION: We identified five different types of childhood poisoning presentations to Spanish EDs. Best practices need to be identified for prevention of these episodes. European Journal of Emergency Medicine XXX: 000-000 Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Factors influencing long-term survival after hospitalization with pneumococcal pneumonia.

OBJECTIVE: To assess survival and identify predictors of survival more than 30-days after discharge in a cohort of consecutive patients diagnosed with pneumococcal pneumonia. METHODS: Observational study including all consecutive immunocompetent adult patients surviving more than 30-days after hospitalization. The bacteriological diagnosis was based on the results of urinary antigen testing and/or blood culture. Life expectancy was calculated for each patient considering their sex, age and date of discharge. RESULTS: We included 1114 patients that survived more than 30- days after discharge. Of them, 431 (38.6%) died during follow-up (median follow-up of 6.7 years). Age, history of cancer, liver disease, chronic renal disease, chronic obstructive pulmonary disease, cerebrovascular disease, atrial arrhythmia and coronary disease, red cell distribution width (RDW) > 15%, positive blood culture, hematocrit < 30% and living in a nursing home were independent risk factors for reduced long-term survival after hospital discharge. Cumulative 1-, 3- and 5-year survival rates were 93.9%, 85.3% and 76%, respectively. Among non-survivors, 361 (83.8%) died earlier than expected given their life expectancy. CONCLUSIONS: Survival after hospital discharge is mainly associated with age and comorbidities. The findings of bacteremia and elevated RDW on admission could help identify patients at high risk of long-term mortality.

Late toxicity after single dose HDR prostate brachytherapy and EBRT for localized prostate cancer: Clinical and dosimetric predictors in a prospective cohort study.

PURPOSE: To describe the genitourinary (GU) and gastrointestinal (GI) late toxicity profile and to analyse the clinical and dosimetry outcomes predictors of the combination of EBRT and high-dose-rate (HDR) prostate brachytherapy (BT) for localized prostate cancer. MATERIALS AND METHODS: Between January 2012 and May 2017, 210 patients were included in a prospective protocol. Treatment consisted in HDR-BT (15 Gy single fraction) plus 3DCRT (37.5 Gy/15 fractions). Univariate and multivariate logistic regressions were used to analyse the impact of variables on late toxicity. RESULTS: Median age was 71 (56-82), 12.4% of patients had low, 44.3% intermediate and 41% high-risk prostate cancer. Median prostate volume was 28.4 cc. Median V100, V150, V200 were 98.2%, 27% and 7.4% respectively. Median urethra Dmax, rectum D1cc and D2cc, were 113.5%, 62.2%% and 54.2% respectively. After a median follow-up of 41 months (5-75) late G2 GU and GI late toxicity was observed in 14.8% and 5.2% of patients respectively. Late G3 GU and GI toxicity occurred in 0% and 1% of patients respectively. There were no outcome correlations with late G ≥ 2 GU toxicity on univariate analysis. Previous cardiovascular comorbidity (p = 0.042), and dose to the rectum D2cc (p = 0.016) and D1cc (p = 0.017) were associated with G ≥ 2 GI toxicity. Multivariate analysis showed that rectum D1cc (HR11.56; 95%CI 1.4-92.1; p = 0.021) and prior history of cardiovascular disease (HR3.6; 95%CI 1-12.9; p = 0.045) remained independent predictors of G ≥ 2 GI toxicity. CONCLUSIONS: There is a low incidence of late GU and GI morbidity using single fraction HDR-BT and hypofractionated EBRT. Previous cardiovascular disease and dose to the rectum were observed to correlate with GI toxicity.

Participation in a population-based screening for colorectal cancer using the faecal immunochemical test decreases mortality in 5 years.

BACKGROUND: The steady increase in colorectal cancer (CRC) could be reversed through timely secondary prevention (screening) as a main strategy. The aims of this study were to determine the main features of CRC, survival rate and related factors for different types of identified CRCs in a population-based screening programme using the faecal immunochemical test (FIT). MATERIALS AND METHODS: The CRCs in the susceptible population to be screened between 2009 and 2014 were identified and classified into four groups: (a) nonscreening-detected CRC (diagnosed before first screening invitation and nonparticipants), (b) screening-detected CRC, (c) interval cancer (IC) FIT (diagnosed between screening rounds after a negative FIT) and (d) IC colonoscopy (diagnosed before the colonoscopy surveillance, which is recommended after the screening colonoscopy). Patient demographics and epidemiological characteristics, tumour characteristics and survival were compared between the four groups. RESULTS: 5909 individuals were diagnosed with a CRC. The median follow-up of survival was 4.6 years (range: 0-9 years). The study highlights a significant difference (P<0.0001) in the 5-year survival in the screening-detected CRC group compared with those who had nonscreening-detected CRCs (90.1 vs. 66.7%). Although ICs are not desirable events, the 5-year survival rate is significantly higher with respect to nonparticipants (P<0.0001) (76.3 vs. 60.5%), this being the group with the lowest survival rate. CONCLUSION: The significantly higher 5-year survival rate of 23.4% of the participants in the screening programme suggests that incidence and mortality rates of CRC will decrease in the near future for participants in screening programmes. A high participation rate is essential to achieve health benefits, irrespective of the type of participation.