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Insulin treatment in type 2 diabetes mellitus patients is still essential and its usage has increased during recent years. Despite this, the level of control continues to be very poor. Insulin treatment is initiated with control levels above the recommendations set by the Clinical Practice Guidelines (CPG) and patients are exposed to very high blood glucose levels during long periods of time. This paper reviews the role of insulin in the different CPG, the criteria for therapy initiation and intensification, the beginning of the intensification and the different types of insulin which are commercialized in our country. Moreover, we discuss insulinization in special situations such as corticosteroid treatment, fragile elderly patients, palliative care situations, chronic kidney disease or during Ramadan. Finally, the problem of therapeutic inertia in insulinization is also addressed.

Critical patients, despite initial recovery in the intensive care unit (ICU), may require readmission to the ICU or even die in the same hospital episode. The objectives are to determine the incidence and to identify risk factors for ICU readmission, and to determine hospital mortality.Observational cohort study of all patients admitted consecutively for more than 24hours to the ICU of the University Hospital of Getafe between April 1, 2018 and September 30, 2018 and discharged alive from their first ICU admission.Of the 164 patients alive at ICU discharge, 14 (8.5%) were readmitted to ICU (2.4% at≤48hours). The adjusted risk of ICU readmission was higher in patients with disabling neurological deficits prior to ICU admission [odds ratio (OR) 7.96, 95% confidence interval (CI) 1.55-40.92] or who received vasoactive drugs (OR 5.07, 95% CI 1.41-18.29) during their ICU stay. Readmitted patients had higher hospital mortality (4 of 14 [29%] versus 5 of 150 [3%], P.001) and longer hospital stay (74.5 [37.5-99.75] days versus 16 [9-34] days, median [interquartile range], P=.001).Patients with disabling neurological deficits prior to hospital admission or who received vasoactive drugs during their ICU stay have a higher risk of readmission to the ICU, which increases hospital stay and mortality.

Resumen Introduccion Las estenosis de anastomosis ureteroileal son complicaciones frecuentes en conductos ileales y neovejigas ortotopicas. Analizamos su incidencia en funcion del tipo de derivacion urinaria y del abordaje quirurgico (abierto, laparoscopico o robotico). Describimos su manejo y los resultados obtenidos. Material y metodos Estudio retrospectivo descriptivo durante 6 anos en pacientes con derivacion urinaria empleando ileon (conducto ileal o neovejiga ileal). Se recogen datos demograficos, comorbilidades, datos quirurgicos (abordaje, complicaciones) y resultados. Seguimiento minimo de un ano. Comparacion entre grupos, mediante test de la chi al cuadrado en variables dicotomicas. Variables cuantitativas comparadas empleando la prueba de la t Student para grupos independientes o la prueba de Mann-Whitney. Consideramos significacion estadistica p Resultados Incluimos a 182 pacientes (84% varones y 16% mujeres). Edad media 68 anos. Abordaje de cistectomia: laparoscopica (67/37%), robotica (63/35%), abierta (43/24%). Tipo de derivacion: conducto ileal (138/76%) y neovejiga ileal ortotopica (44/24%). Tipo de reimplante: Bricker (108/59%) y Wallace (47/26%). Estenosis de anastomosis ureteroileal (50/27%): bilateral (26), izquierda (16) y derecha (8). Estenosis segun abordaje de cistectomia: laparoscopica (23/46%), robotica (16/32%), abierta (9/18%). Tratamiento de estenosis (33/18%): reimplante ureteroileal (13), nefrostomia permanente (13), dilatacion endoscopica (4), nefroureterectomia (2), endoureterotomia (1). Abordaje del reimplante: laparoscopico (5/38%), robotico (6/46%) y abierto (2/15%). Resultados tras reimplantes: reestenosis (0/0%), reintervencion (3/23%), estenosis ureteroileal contralateral posterior (1/8%). Conclusion El tipo de abordaje empleado en la cistectomia no parece influir en la aparicion de estenosis ureteroileales. Abordajes laparoscopicos y roboticos permiten su reparacion con resultados favorables en un porcentaje elevado de pacientes.

International audience; ObjectivesThis study aimed at investigating the additional contribution of coronary artery calcium (CAC) score to SAFEHEART (Spanish Familial Hypercholesterolemia Cohort Study) risk equation (SAFEHEART-RE) for cardiovascular risk prediction in heterozygous familial hypercholesterolemia (HeFH).BackgroundCommon cardiovascular risk equations are imprecise for HeFH. Because of the high phenotype variability of HeFH, CAC score could help to better stratify the risk of atherosclerotic cardiovascular disease (ASCVD).MethodsREFERCHOL (French Registry of Familial Hypercholesterolemia) and SAFEHEART are 2 ongoing national registries on HeFH. We analyzed data from primary prevention HeFH patients undergoing CAC quantification. We used probability-weighted Cox proportional hazards models to estimate HRs. Area under the receiver-operating characteristic curve (AUC) and net reclassification improvement (NRI) were used to compare the incremental contribution of CAC score when added to the SAFEHEART-RE for ASCVD prediction. ASCVD was defined as coronary heart disease, stroke or transient ischemic attack, peripheral artery disease, resuscitated sudden death, and cardiovascular death.ResultsWe included 1,624 patients (mean age: 48.5 ± 12.8 years; men: 45.7%) from both registries. After a median follow-up of 2.7 years (interquartile range: 0.4-5.0 years), ASCVD occurred in 81 subjects. The presence of a CAC score of >100 was associated with an HR of 32.05 (95% CI: 10.08-101.94) of developing ASCVD as compared to a CAC score of 0. Receiving-operating curve analysis showed a good performance of CAC score alone in ASCVD prediction (AUC: 0.860 [95% CI: 0.853-0.869]). The addition of log(CAC + 1) to SAFEHEART-RE resulted in a significantly improved prediction of ASCVD (AUC: 0.884 [95% CI: 0.871-0.894] for SAFEHEART-RE + log(CAC + 1) vs AUC: 0.793 [95% CI: 0.779-0.818] for SAFEHEART-RE; P < 0.001). These results were confirmed also when considering only hard cardiovascular endpoints. The addition of CAC score was associated with an estimated overall net reclassification improvement of 45.4%.ConclusionsCAC score proved its use in improving cardiovascular risk stratification and ASCVD prediction in statin-treated HeFH.

Background During the initial COVID-19 outbreak, organizational changes were required to ensure adequate staffing in healthcare facilities. The extent to which organizational changes impacted the mental wellbeing of healthcare workers (HCWs) remains unexplored. Here we analyzed the association between three work-related stressors (reported access to protective equipment, change in job functions, and patient prioritization decision-making) and mental health outcomes (depression symptoms, psychological distress, suicidal thoughts, and fear of infection) in a large sample of Spanish HCWs during the initial COVID-19 outbreak. Methods We conducted a cross-sectional study including HCWs from three regions of Spain between April 24th and June 22nd, 2020. An online survey measured sociodemographic characteristics, work-related stressors, fear of infection, and mental health outcomes (depression [PHQ-9], psychological distress [GHQ-12], death wishes [C-SSRS]). We conducted mixed-effects regression models to adjust all associations for relevant individual- and region-level sources of confounding. Results We recruited 2,370 HCWs. Twenty-seven percent screened positive for depression and 74% for psychological distress. Seven percent reported death wishes. Respondents were more afraid of infecting their loved ones than of getting infected themselves. All work-related stressors were associated with depression symptoms and psychological distress in adjusted models. Limitations Non-probabilistic sampling, potential reverse causation. Conclusions Modifiable work-related stressors are associated with worse mental health among HCWs. Our results suggest that workplace prevention strategies for HCWs should provide sufficient protective equipment, minimize changes in job functions, favor the implementation of criteria for patient triage and on-call bioethics committees, and facilitate access to stepped-care, evidence-based mental health treatment.

Pelvic fractures due to high energy trauma present a high risk of associated injuries that compromise the functional and vital prognosis of the patients. The objective of this study was to analyze the relationship between traumatic pelvic fractures and their associated injuries according to the Tile classification.Retrospective observational study of patients who suffered traumatic pelvic fractures (Type A, B or C of the Tile classification) with concomitant associated injuries, analyzing hemoglobin levels, between 6/2013 and 1/2016.A total of 42 patients were included; of those 69% (n = 29) were males, mean age was 48 years. 45% (n = 19) suffered traffic accidents and 26.2% (n = 11) falls. There was a different proportion in pelvic injuries: Tile A (n = 15, 35.7%), B (n = 20, 47.6%), and C (n = 7, 16.6%) of cases. 54.8% (n = 23) underwent surgery, 21.4% (n = 9) needed temporary or definitive external fixation. Significant differences were found between Tile A type and scapula fractures (P = .032), and Tile B with sacral fractures (P = .033) and visceral injuries (P = .049), while there is a tendency without a statistical significal between Tile C and costal fractures. 61.9% (n = 26) needed blood transfusion; 9.5% (n = 4) presented hypovolemic shock.Tile A pelvic fractures were associated with scapular fractures, and Tile B with transforaminal fractures of the sacrum and with visceral injuries (lungs, liver and genitourinary). The small number of Tile C prevent us to confirm an association with any pathology, although they are the ones which presnt more hemodynamically instability and thoracic injuries.

Producción Científica, Landscapes of oak (Quercus) forests alternated with extensive fields dominated by rockroses (Cistus) are widespread throughout the Mediterranean Basin. Due to the recurrency of fires and the mycological potential of both Quercus forests and Cistus fields, adequate management of this landscape is a key forest management objective. Although both Quercus and Cistus species are considered super-productive in terms of fungal production and diversity, fungal diversity and productivity vary depending on the stand age and structure. The aim of this study was to assess the complementary mycological potential of these ecosystems by studying sporocarp production, diversity, and community composition to elucidate management practices that would enhance fungal diversity and productivity within a fire management framework. We collected sporocarps over a period of four consecutive years (2012–2015) in young Cistus plots (1-m tall Cistus), old Cistus plots (2-m tall Cistus), and Quercus Forest plots. Our analyses showed that age as well as dominant vegetation influences sporocarp production, diversity, and richness, with young Cistus stands most suited to high levels of sporocarp productivity and diversity. In addition, a progressive restructuring of the fungal community was observed from a large, diverse community in Cistus early-stage stands to a smaller, less diverse but well-defined community in Quercus stands, transiting through an intermediate composition in old Cistus fields. Based on our findings, we suggest that a management process that not only favors stand rejuvenation would achieve greater sporocarp production and richness, including edible commercial species, while reducing the amount of fuel. In addition, the differentiated diversity of the Quercus stands plays an important role in terms of landscape diversity, being necessary the recommendation of a rejuvenation management in order to protect this stands associated diversity. We propose that these goals could be best achieved with a mosaic landscape model to connect the different stages of succession, enabling greater interconnectivity and, hence, allowing the presence of different “fungal stages” at the landscape level., Ministerio de Ciencia e Innovación (PID2019-105188RB-I00)

Background Cutaneous manifestations have been included in COVID-19 patients’ clinical spectrum. Our objective was to determine the association between skin lesions in children and SARS-CoV2 infection, analyzing others possible infectious/autoimmune etiologies. Material and methods Observational, multicenter, cross-sectional study, about children with skin manifestations from April to May 2020. The diagnosis of SARS-CoV2 was performed by PCR in nasopharyngeal exudate and/or presence of antibodies by serology. Results Sixty-two children were included, 9 (14.5%) presented positive antibodies to SARS-CoV-2, with no positive PCR to SARS-Cov-2 in those patients in whom it was made. Patients with positive serology to SARS-CoV-2 presented chilblains and/or vesicular-bullous skin lesions more frequently (66.7% vs. 24.5%, p = 0.019). Generalized, urticarial and maculopapular rash was more common in patients with negative antibodies (37.7 vs. 0%, p = 0.047), others pathogens were isolated in 41.5% of these patients. There were no significant differences in the positivity for autoantibodies between both groups. Conclusion In our study, the presence of chilblains-like and/or vesicular lesions were significantly related to SARS-CoV2 previous contact.

Resumen Introduccion y objetivo El manejo de tumoraciones renales ≤ 4 cm en poblacion anciana o con comorbilidades supone un reto, constituyendo las terapias ablativas una alternativa interesante. El objetivo es evaluar la radiofrecuencia percutanea en el tratamiento de masas renales pequenas en nuestro centro, las complicaciones asociadas y los resultados obtenidos. Material y metodos Evaluacion retrospectiva de las radiofrecuencias realizadas entre abril de 2010 y abril de 2020 en nuestro centro. Se revisaron datos demograficos, comorbilidades asociadas, caracteristicas tumorales, complicaciones y resultados oncologicos y funcionales. Resultados Se trataron 57 tumores en 53 pacientes. Seguimiento medio de 48,2 meses. Se obtuvo un 89,5% de ablaciones completas. Hubo un 19,3% de complicaciones. Fueron catalogadas como mayores un 3,5% y un 5,3% segun Clavien-Dindo y SIR. Se encontro asociacion estadisticamente significativa entre el resultado inicial de la ablacion y la edad (p = 0,047), el score RENAL modificado (RENAL-m) (p = 0,044), la presencia de componente quistico (p = 0,049) y el tamano tumoral (p = 0,01). El punto de corte de tamano quedo establecido en 25 mm (p = 0,012). En el analisis multivariante, unicamente el tamano permanecio como predictor de resultado inicial de ablacion (p = 0,01; OR 1,183; IC 95% 1,041-1,345). La supervivencia cancer especifica y supervivencia libre de recurrencia a cinco anos fueron del 98,1% y del 89,5% respectivamente. Se observo una disminucion media del MDRD-4 de 6,59 mL/min (p = 0,005) en los seis primeros meses tras radiofrecuencia (RFA). Conclusiones Dados los excelentes resultados oncologicos y funcionales demostrados, la radiofrecuencia percutanea guiada por ecografia es una terapia eficaz y segura en el tratamiento de masas renales pequenas en pacientes seleccionados.

Introduction and objective The management of renal tumors ≤4 cm in elderly population or patients with comorbidities is a challenge, for which ablative therapies are an interesting alternative. The objective is to evaluate in our center the role of percutaneous radiofrequency in the treatment of small renal masses, the associated complications and the results obtained. Material and methods Retrospective evaluation of the radiofrequency treatments carried out between April 2010 and April 2020 in our center. Demographic data, associated comorbidities, tumor characteristics, complications and oncological and functional outcomes were reviewed. Results Fifty-seven tumors were treated in 53 patients. Mean follow-up of 48.2 months. The percentage of complete ablations obtained was of 89.5%. There were 19.3% of complications. According to Clavien-Dindo and SIR classification systems, 3.5% and 5.3% were major complications. A statistically significant association was found between the initial result of ablation and age (p = 0.047), RENAL-m (p = 0.044), the presence of cystic component (p = 0.049) and tumor size (p = 0.01). The cut-off point for size was established at 25 mm (p = 0.012). In multivariate analysis, only size remained as a predictor of initial ablation result (p = 0.01 OR = 1.183 CI 95% = 1.041–1.345). Cancer-specific survival and 5-year recurrence-free survival were 98.1% and 89.5%, respectively. A mean decrease of MDRD-4 of 6.59 mL/min (p = 0.005) was observed in the first 6 months after RFA. Conclusions Given the excellent oncological and functional results demonstrated, ultrasound-guided percutaneous radiofrequency ablation is an effective and safe treatment for small renal masses in selected patients.

20 p. - Supplementary material related to this article can be found, in the online version, at doi: https://doi.org/10.1016/j.ejrh.2021.100781., [EN] Study region Old Las Salinas spring in Medina del Campo, Duero river basin, central Spain. Study focus Medina del Campo groundwater body (MCGWB) is a multilayer semiconfined aquifer subject to intensive pumping since the 1970’s, where the current existence of spas where there used to be traditional baths could confirm the existence of deep groundwater flow paths. The old spring of Las Salinas (OSLS) is a saline anomaly in an aquifer with predominance of CaCO3H waters whose occurrence has not yet been formally explained. Long-term geological, geophysical, hydrogeological and hydrochemical records were integrated and complemented with field work to clarify its existence. New hydrological insights for the region Outcomes led to the conclusion that the hydrochemistry of the Olmedo and Palacio de las Salinas salt baths is associated with the existence of a major threshold in the impervious basement of the aquifer, which intercepted deep regional groundwater flow and caused upwelling to the surface under unperturbed conditions. These results allow for the development of a conceptual flow model at the regional scale that explains the changes in natural water chemistry that have been identified in recent decades., This research has received funding from the European Union H2020 Programme under Grant Agreement No. 730497 for the research project NAIAD-NAture Insurance value: Assessment and Demonstration.

Background Inconsistent doses and schemes are commonly used in older patients receiving cancer chemotherapy. We performed this study in patients with cancer and age ≥ 70 years to determine the frequency of undertreatment and overtreatment as well as factors influencing the decision to modify chemotherapy doses. Patients and Methods Patients aged ≥70 years starting new chemotherapy regimens were prospectively included in a multicentre study. The schedule and drug doses were determined by the treating oncologist. Pre-chemotherapy assessment included sociodemographics, treatment details and geriatric assessment (GA) variables. Association between these factors and undertreatment (use of less intensive cancer treatment [LICT] in a fit patient) or overtreatment (use of standard cancer treatment in an unfit older patient) were examined by multivariate logistic regression. Results Three- hundred ninety-seven patients were included, 43% of whom received LICT. If not adjusted for GA, toxicity did not differ between those receiving LICT (38%) or standard doses of chemotherapy (37%). If the dose of chemotherapy was analyzed according to the results of GA 61 (15%) patients had been undertreated and 133 (34%) had been overtreated. Undertreatment was related with increasing age and decreased renal function. Factors related with overtreatment were younger age, curative intention of treatment, prescription of G-CSF as primary prophylaxis and adequate cognitive status. Overtreated patients had more grade 3–4 toxicity than those receiving treatment adapted to fragility (42% vs 31%; p Conclusions The use of chemotherapy without considering GA leads to overtreatment more commonly than undertreatment in older patients with cancer. Oncologists should take into account the results of GA to stratify patients and to avoid under or overtreatment.

The relationship between psychotic symptoms and global measures of functioning has been widely studied. No previous study has assessed so far the interplay between specific clinical symptoms and particular areas of functioning in first-episode psychosis (FEP) using network analysis methods. A total of 191 patients with FEP (age 24.45 ± 6.28 years, 64.9% male) participating in an observational and longitudinal study (AGES-CM) comprised the study sample. Functioning problems were assessed with the WHO Disability Assessment Schedule (WHODAS), whereas the Positive and Negative Syndrome Scale (PANSS) was used to assess symptom severity. Network analysis were conducted with the aim of analysing the patterns of relationships between the different dimensions of functioning and PANSS symptoms and factors at baseline. According to our results, the most important nodes were “conceptual disorganization”, “emotional withdrawal”, “lack of spontaneity and flow of conversation”, “delusions”, “unusual thought content”, “dealing with strangers” and “poor rapport”. Our findings suggest that these symptoms and functioning dimensions should be prioritized in the clinical assessment and management of patients with FEP. These areas may also become targets of future early intervention strategies, so as to improve quality of life in this population, This work was supported by the Madrid Regional Government (R&D activities in Biomedicine (grant number S2017/BMD-3740 - AGES-CM 2-CM)) and Structural Funds of the European Union. Ana Izquierdo’s work is supported by the PFIS predoctoral program (FI17/00138) from the Instituto de Salud Carlos III (Spain) and co-funded by the European Union (ERDF/ESF, "A way to make Europe”/ “Investing in your future”) and The Biomedical Research Foundation of La Princesa University Hospital. Angela Ib´a˜nez thanks the support of CIBERSAM and of the Spanish Ministry of Science, Innovation and Universities. Instituto de Salud Carlos III (PI16/00834 and PI19/01295) co-financed by ERDF Funds from the European Commission. Covadonga M. Díaz-Caneja holds a Juan Rod´es Grant from Instituto de Salud Carlos III (JR19/00024). Celso Arango was supported by the Spanish Ministry of Science and Innovation. Instituto de Salud Carlos III (SAM16PE07CP1, PI16/02012, PI19/ 024), co-financed by ERDF Funds from the European Commission, “A way of making Europe”, CIBERSAM. Madrid Regional Government (B2017/BMD-3740 AGES-CM-2), European Union Structural Funds. European Union Seventh Framework Program under grant agreements FP7-4-HEALTH-2009-2.2.1-2-241909 (Project EU-GEI), FP7- HEALTH- 2013-2.2.1-2-603196 (Project PSYSCAN) and FP7- HEALTH-2013- 2.2.1-2-602478 (Project METSY); and European Union H2020 Program under the Innovative Medicines Initiative 2 Joint Undertaking (grant agreement No 115916, Project PRISM, and grant agreement No 777394, Project AIMS-2-TRIALS), Fundaci´on Familia Alonso, Fundaci´on Alicia Koplowitz and Fundaci´on Mutua Madrile˜na

Background We studied the determinants of hemodynamics and analyzed the incidence, risk factors, and clinical impact of pulmonary homograft dysfunction following Ross surgery, after a 20-year follow-up at our referral center. Methods From 1997 to 2017, a total of 142 patients underwent surgery using the Ross procedure. The development of moderate-severe stenosis (peak transhomograft pressure gradient 36 mm Hg or greater) and surgical or percutaneous Ross homograft reinterventions were evaluated by echocardiography in the immediate postoperative period and at annual intervals. Results After 20 years of follow-up, 31% of patients had moderate-severe homograft stenosis, and 9.1% had had to undergo one or two reinterventions, of which, six were valve replacements and seven were percutaneous interventions. At 1, 5, and 20 years, 89.4%, 74.6%, and 69% of these patients, respectively, were free from moderate-severe stenosis; and 99.3%, 95.7%, and 90.9%, respectively, had freedom from homograft reintervention. The pediatric group had a higher risk factor for homograft stenosis (hazard ratio 3.70; 95% confidence interval, 1.56 to 7.20, P = .002), whereas donor age behaved as a protective factor (hazard ratio 0.98; 95% confidence interval, 0.95 to 0.99; P = .044). Pulmonary homograft stenosis tended to appear in the first year (10.6%) or at 5 years (25.4%). Conclusions Pulmonary homografts implanted in the Ross procedure offer satisfactory long-term results, but the level of homograft dysfunction is not negligible. Young recipient and donor age were associated with a higher rate of homograft stenosis during follow-up. Moreover, homograft dysfunction usually occurred during the first few years of follow-up, and may have been related to immune responses.

Resumen Objetivos Conocer la prevalencia de enfermedad renal cronica (ERC) y determinar los factores asociados al deterioro de la funcion renal en poblacion asistida en atencion primaria. Pacientes y metodo Estudio transversal y multicentrico realizado en los pacientes basales del estudio IBERICAN (identificacion de la poblacion espanola de riesgo cardiovascular y renal). Se considero ERC a un filtrado glomerular estimado (FGe) Resultados Se incluyeron 7.895 pacientes (edad media 57,9 ± 14,8 anos; 54,5% mujeres). El 14,4% (IC 95%: 13,6-15,1) presentaba ERC; en hombres un 16,1% (IC 95%: 14,9-17,3) y en mujeres un 12,9% (IC 95%: 11,9-14,0). Se observo un aumento continuo de la prevalencia con la edad (24,8% ≥ 65 anos) y con la agregacion de FRCV. Las variables que mas se asociaron a la probabilidad de padecer ERC fueron hipertrofia ventricular izquierda (OR: 1,95; p Conclusiones Catorce de cada 100 pacientes incluidos en el estudio IBERICAN presenta ERC. La prevalencia de ERC afecta a la cuarta parte de pacientes ≥ 65 anos y aumenta exponencialmente con la agregacion de FRCV.