Development and Validation of Case-Finding Algorithms for Digestive Cancer in the Spanish Healthcare Database BIFAP

BACKGROUND

electronic health records (EHRs) are helpful tools in epidemiology despite not being primarily collected for research. In Spain, primary care physicians play a central role and manage patients even in specialized care. All of this introduces variability that may lead to diagnostic inconsistencies. Therefore, data validation studies are crucial, so we aimed to develop and validate case-finding algorithms for digestive cancer in the primary care database BIFAP.

METHODS

from 2001 to 2019, subjects aged 40-89 without a cancer history were included. Case-finding algorithms using diagnostic codes and text-mining were built. We randomly sampled, clustered, and manually reviewed 816 EHRs. Then, positive predictive values (PPVs) and 95% confidence intervals (95% CIs) for each cancer were computed. Age and sex standardized incidence rates (SIRs) were compared with those reported by the National Cancer Registry (REDECAN).

RESULTS

we identified 95,672 potential cases. After validation, the PPV (95% CI) for hepato-biliary cancer was 87.6% (81.8-93.4), for esophageal cancer, it was 96.2% (93.1-99.2), for pancreatic cancer, it was 89.4% (84.5-94.3), for gastric cancer, it was 92.5% (88.3-96.6), and for colorectal cancer, it was 95.2% (92.1-98.4). The SIRs were comparable to those reported by the REDECAN.

CONCLUSIONS

the case-finding algorithms demonstrated high performance, supporting BIFAP as a suitable source of information to conduct epidemiologic studies of digestive cancer.

Risk of Ischemic Stroke Associated with Calcium Supplements and Interaction with Oral Bisphosphonates: A Nested Case-Control Study

Conflicting results about the association of calcium supplements (CS) with ischemic stroke (IS) have been reported. We tested this hypothesis by differentiating between CS alone (CaM) and CS with vitamin D (CaD) and between cardioembolic and non-cardioembolic IS. We examined the potential interaction with oral bisphosphonates (oBs). A nested case-control study was carried out. We identified incident IS cases aged 40-90 and randomly sampled five controls per case matched by age, sex, and index date. Current users were compared to non-users. An adjusted odds ratios (AOR) and 95% CI were computed through conditional logistic regression. Only new users were considered. We included 13,267 cases (4400 cardioembolic, 8867 non-cardioembolic) and 61,378 controls (20,147 and 41,231, respectively). CaM use was associated with an increased risk of cardioembolic IS (AOR = 1.88; 95% CI: 1.21-2.90) in a duration-dependent manner, while it showed no association with non-cardioembolic IS (AOR = 1.05; 95% CI: 0.74-1.50); its combination with oBs increased the risk of cardioembolic IS considerably (AOR = 2.54; 95% CI: 1.28-5.04), showing no effect on non-cardioembolic. CaD use was not associated with either cardioembolic (AOR = 1.08; 95% CI: 0.88-1.31) or non-cardioembolic IS (AOR = 0.98; 95% CI: 0.84-1.13) but showed a small association with cardioembolic IS when combined with oBs (AOR = 1.35; 95% CI: 1.03-1.76). The results support the hypothesis that CS increases the risk of cardioembolic IS, primarily when used concomitantly with oBs.

Association of oral bisphosphonates with cardioembolic ischemic stroke: a nested case-control study

Background: Bisphosphonates have been reported to increase the risk of atrial fibrillation. Therefore, it is conceivable that they may increase the risk of cardioembolic ischemic stroke (IS). However, most epidemiological studies carried out thus far have not shown an increased risk of IS, though none separated by the main pathophysiologic IS subtype (cardioembolic and non-cardioembolic) which may be crucial. In this study, we tested the hypothesis that the use of oral bisphosphonates increases specifically the risk of cardioembolic IS, and explored the effect of treatment duration, as well as the potential interaction between oral bisphosphonates and calcium supplements and anticoagulants. Methods: We performed a case-control study nested in a cohort of patients aged 40-99 years, using the Spanish primary healthcare database BIFAP, over the period 2002-2015. Incident cases of IS were identified and classified as cardioembolic or non-cardioembolic. Five controls per case were randomly selected, matched for age, sex, and index date (first recording of IS) using an incidence-density sampling. The association of IS (overall and by subtype) with the use of oral bisphosphonates within the last year before index date was assessed by computing the adjusted odds ratios (AOR) and their 95% CI using a conditional logistic regression. Only initiators of oral bisphosphonates were considered. Results: A total of 13,781 incident cases of IS and 65,909 controls were included. The mean age was 74.5 (SD ± 12.4) years and 51.6% were male. Among cases, 3.15% were current users of oral bisphosphonates, while among controls they were 2.62%, yielding an AOR of 1.15 (95% CI:1.01-1.30). Of all cases, 4,568 (33.1%) were classified as cardioembolic IS (matched with 21,697 controls) and 9,213 (66.9%) as non-cardioembolic IS (matched with 44,212 controls) yielding an AOR of 1.35 (95% CI:1.10-1.66) and 1.03 (95% CI: 0.88-1.21), respectively. The association with cardioembolic IS was clearly duration-dependent (AOR≤1 year = 1.10; 95% CI:0.82-1.49; AOR>1-3 years = 1.41; 95% CI:1.01-1.97; AOR>3 years = 1.81; 95% CI:1.25-2.62; p for trend = 0.001) and completely blunted by anticoagulants, even in long-term users (AOR>1 year = 0.59; 0.30-1.16). An interaction between oral bisphosphonates and calcium supplements was suggested. Conclusion: The use of oral bisphosphonates increases specifically the odds of cardioembolic IS, in a duration-dependent manner, while leaves materially unaffected the odds of non-cardioembolic IS.

Emerging mitochondrial-mediated mechanisms involved in oligodendrocyte development

Oligodendrocytes are the myelinating glia of the central nervous system and are generated after oligodendrocyte progenitor cells (OPCs) transition into pre-oligodendrocytes and then into myelinating oligodendrocytes. Myelin is essential for proper signal transmission within the nervous system and axonal metabolic support. Although the intrinsic and extrinsic factors that support the differentiation, survival, integration, and subsequent myelination of appropriate axons have been well investigated, little is known about how mitochondria-related pathways such as mitochondrial dynamics, bioenergetics, and apoptosis finely tune these developmental events. Previous findings suggest that changes to mitochondrial morphology act as an upstream regulatory mechanism of neural stem cell (NSC) fate decisions. Whether a similar mechanism is engaged during OPC differentiation has yet to be elucidated. Maintenance of mitochondrial dynamics is vital for regulating cellular bioenergetics, functional mitochondrial networks, and the ability of cells to distribute mitochondria to subcellular locations, such as the growing processes of oligodendrocytes. Myelination is an energy-consuming event, thus, understanding the interplay between mitochondrial dynamics, metabolism, and apoptosis will provide further insight into mechanisms that mediate oligodendrocyte development in healthy and disease states. Here we will provide a concise overview of oligodendrocyte development and discuss the potential contribution of mitochondrial mitochondrial-mediated mechanisms to oligodendrocyte bioenergetics and development.

EBUS-guided transbronchial mediastinal cryobiopsy in the diagnosis of mediastinal lesions: safety, feasibility and diagnostic yield – experience in 50 cases

Background

Endobronchial ultrasound guided transbronchial needle aspiration (EBUS-TBNA) is the technique of choice in the study of mediastinal and hilar lesions; however, it can be affected by the insufficiency of intact biopsy samples, which might decrease its diagnostic yield for certain conditions, thus requiring re-biopsies or additional diagnostic procedures such as mediastinoscopy when probability of malignancy remains high.

Objectives

Our objectives were to 1) attempt to reproduce this technique in the same conditions that we performed EBUS-TBNA, that is, in the bronchoscopy suite and under moderate sedation; 2) describe the method used for its execution; 3) determine its feasibility by accessing different lymph node stations applying our method; 4) analyze the diagnostic yield and its complications.

Methods

Prospective study of 50 patients who underwent EBUS-TBNA and EBUS-guided TMC in a single procedure using a 22-G TBNA needle and a 1.1 mm cryo-probe subsequently between January and August 2022. Patients with mediastinal lesions greater than 1 cm were recruited and EBUS-TBNA and TMC were performed in the same lymph node station.

Results

The diagnostic yield was 82% and 96% for TBNA and transbronchial mediastinal cryobiopsy, respectively. Diagnostic yields were similar for sarcoidosis, while cryobiopsy was more sensitive than TBNA in lymphomas and metastatic lymph nodes. As for complications, there was no pneumothorax and in no case was there significant bleeding. There were no complications during the procedure or in the follow-up of these patients.

Conclusions

TMC following our method is a minimally invasive, rapid, and safe technique that can be performed in a bronchoscopy suite under moderate sedation, with a higher diagnostic yield than EBUS-TBNA, especially in cases of lymphoproliferative disorders and mestastatic lymph nodes, or when more biopsy sample is needed for molecular determinations.

Distribution of microplastics present in a stream that receives discharge from wastewater treatment plants

The presence of microplastics (MPs) in freshwater systems that receive discharge of urban effluent implies a great environmental impact. In order to be able to generate proposals that solve this problem, it is necessary to know in detail the contributions of different MPs sources. The aim of this work was to study the contribution of urban sewage discharge to MPs pollution in a stream that runs through a medium-sized city. The spatial distribution of MPs with sizes between 100 μm and 1.5 mm present in surface water was measured and their characteristics, dimensions, shapes and identification were determined. Physical-chemical parameters of the stream water were measured, and a decrease in water quality was found due to wastewater treatment plants. The main source of MPs was effluent from the plants (97% of the total MPs), while the rest came from storm drains and discharge of tributaries. The maximum concentration of MPs found was around 72,000 MP/L (equivalent to 53 million MPs/s), at a point after discharge from both plants. Around 70% of MPs correspond to microfibers with a mean length of around 300 μm and a mean width of around 15 μm, and they are mainly polyethylene fibers. The remaining 30% of MPs are particles with lengths of around 140 μm. The transport of MPs between a point located after discharge of the plants and another point located about 3 km further on was studied, and no significant variation was found in the concentration of MPs. Electrical conductivity was used as a conservative tracer of MPs concentration. This work presents for the first time a detailed analysis of different contributions of MPs to a freshwater system in South America, which receives discharge of wastewater treatment plants, evidencing its important role in pollution.

Influenza Vaccination and Risk of Ischemic Stroke: A Population-Based Case-Control Study

BACKGROUND AND OBJECTIVES

To assess the relationship between influenza vaccination in the general population and risk of a first ischemic stroke (IS) during pre-epidemic, epidemic, and postepidemic periods.

METHODS

A nested case-control study was conducted in a Spanish primary care database over 2001-2015. Individuals aged 40-99 years with at least 1 year registry and no history of stroke or cancer were selected to conform the source cohort, from which incident IS cases were identified and classified as cardioembolic or noncardioembolic. Five controls per case were randomly selected, individually matched with cases for exact age, sex, and date of stroke diagnosis (index date). A patient was considered vaccinated when he/she had a recorded influenza vaccination at least 14 days before the index date within the same season. Adjusted odds ratios (aORs) and their respective 95% CIs were computed through a conditional logistic regression. Pneumococcal vaccination was used as a negative control.

RESULTS

From a cohort of 3,757,621 patients, we selected 14,322 incident IS cases (9,542 noncardioembolic and 4,780 cardioembolic) and 71,610 matched controls. Of them, 41.4% and 40.5%, respectively, were vaccinated yielding a crude OR of 1.05 (95% CI 1.01-1.10). Vaccinated patients presented a higher prevalence of vascular risk factors, diseases, and comedication than those nonvaccinated, and after full adjustment, the association of influenza vaccination with IS yielded an aOR of 0.88 (95% CI 0.84-0.92), appearing early (aOR15-30 days 0.79; 95% CI 0.69-0.92) and slightly declining over time (aOR>150 days 0.92; 95% CI 0.87-0.98). A reduced risk of similar magnitude was observed with both types of IS, in the 3 epidemic periods, and in all subgroups analyzed (men, women, individuals younger and older than 65 years of age, and those with intermediate and high vascular risk). By contrast, pneumococcal vaccination was not associated with a reduced risk of IS (aOR 1.08; 95% CI 1.04-1.13).

DISCUSSION

Results are compatible with a moderate protective effect of influenza vaccine on IS appearing early after vaccination. The finding that a reduced risk was also observed in pre-epidemic periods suggests that either the "protection" is not totally linked to prevention of influenza infection or it may be partly explained by unmeasured confounding factors.

Magnetic resonance imaging target fusion biopsy vs. transrectal ultrasound-guided biopsy - A comparative study of ISUP score upgrading risk in the final radical prostatectomy specimen

Objectives: The aim of this study was to com-pare the risk of International Society of Urological Pathology (ISUP) score upgrading between magnetic resonance imaging targeted fusion biopsy (MRI-TB) and tran-srectal ultrasound-guided biopsy (TRUS-B) in the final radical prostatectomy (RP) specimen pathological report.Materials and methods: This retrospective single center study included 51 patients with prostate cancer (PCa) diagnosed with MRI-TB and 83 patients diagnosed with TRUS-B between October/2019 and July/2021. We compared the rates of ISUP score upgrading between both groups after robotic-assisted radi-cal prostatectomy (RARP) and the specific transition of each ISUP score based on biopsy modality. The rate of ISUP score concordance and downgrading were also assessed. To define the intra and interobserver concordance for each ISUP score in biopsy and RP specimen for each biopsy modality, the Cohen’s Kappa coefficient was calculated. ISUP scores and biopsy modal-ity were selected for multivariate analysis and a logistic regres-sion model was built to provide independent risk factors of ISUP score upgrading.Results: The difference of the rate of upgrading between MRI-TB group and TRUS-B group was statistically significant (p = 0.007) with 42.2% of patients of TRUS-B group experiencing an upgrade in their ISUP score while only 19.6% in MRI-TB group. Concordance and downgrading rates did not statistically differ between the two groups. Strength of concordance using Cohen’s Kappa coefficient was fair in both groups but higher in MRI-TB group (TRUS-B group k = 0.230; p < 0.001; concordance: 47%vs. MRI/TB group k = 0.438; p < 0.001; concordance: 62.7%). Biopsy modality and ISUP 1 on biopsy were independent predic-tors of ISUP upgrading after RP.Conclusions: MRI-TB is highly accurate with lower risk of PCa upgrading after RP than TRUS-B. Patients with ISUP 1 on biopsy have greater susceptibility to upgrading their ISUP score.

Sex and gender disparities in patients with advanced gastroesophageal adenocarcinoma: data from the AGAMENON-SEOM registry

Background

Recommendations for research articles include the use of the term sex when reporting biological factors and gender for identities or psychosocial or cultural factors. There is an increasing awareness of incorporating the effect of sex and gender on cancer outcomes. Thus, these types of analyses for advanced gastroesophageal adenocarcinoma are relevant.

Patients and methods

Patients with advanced gastroesophageal adenocarcinoma from the Spanish AGAMENON-SEOM registry treated with first-line combination chemotherapy were selected. Epidemiology, characteristics of the disease, treatment selection, and results were examined according to sex.

Results

This analysis included 3274 advanced gastroesophageal adenocarcinoma patients treated with combination chemotherapy between 2008 and 2021: 2313 (70.7%) men and 961 (29.3%) women. Tumors in females were more frequently HER2-negative (67.8% versus 60.8%; P < 0.0001), grade 3 (45.4% versus 36.8%; P < 0.001), diffuse (43.3% versus 26.5%; P < 0.0001), and signet ring cell histology (40.5 versus 23.9%; P < 0.0001). Peritoneal spread was more common in women (58.6% versus 38.9%; P < 0.0001), while liver burden was lower (58.9% versus 71.1%; P < 0.0001). There were no significant differences in treatment recommendation. Treatment doses, density, and duration were comparable between sexes. Women experienced more diarrhea (46% versus 37%; P < 0.0001), neutropenia (51% versus 43%; P < 0.0001), and anemia (62% versus 57%; P < 0.0001). After a median 59.6-month follow-up [95% confidence interval (CI) 54.5-70.8], there were no statistically significant differences between the sexes in progression-free survival [6.21 months (95% CI 5.8-6.5 months) versus 6.08 months (95% CI 5.8-6.3 months); log-rank test, χ² = 0.1, 1 df, P = 0.8] or in overall survival [10.6 months (95% CI 9.8-11.1 months) versus 10.9 months (95% CI 10.4-11.4 months); log-rank test: χ² = 0.6, 1 df, P = 0.5].

Conclusion

This sex analysis of patients with advanced gastroesophageal adenocarcinoma from the AGAMENON-SEOM registry receiving first-line polychemotherapy found no differences in survival. Although women had worse prognostic histopathology, metastatic disease pattern, and greater toxicity, treatment allocation and compliance were equivalent.

•

Sex and gender are determinants of health inequalities and may affect treatments, tolerability, and therapeutic outcomes.

•

According to sex, subtle biological and clinical differences exist in advanced gastroesophageal adenocarcinoma.

•

Women with advanced gastroesophageal adenocarcinoma experience greater toxicity with therapeutic results comparable with men.

•

Stratification and analysis by sex in studies of gastroesophageal adenocarcinoma should be considered.

Selective Serotonin Reuptake Inhibitors and Risk of Noncardioembolic Ischemic Stroke: A Nested Case-Control Study

BACKGROUND

Multiple studies have reported that the use of selective serotonin reuptake inhibitors (SSRIs) is associated with an increased risk of ischemic stroke; however, this finding may be the result of a confounding by indication. We examined the association using different approaches to minimize such potential bias.

METHODS

A nested case-control study was carried out in a Spanish primary health-care database over the study period 2001 to 2015. Cases were patients sustaining an ischemic stroke with no sign of cardioembolic or unusual cause. For each case, up to 5 matched controls (for exact age, sex, and index date) were randomly selected. Antidepressants were divided in 6 pharmacological subgroups according to their mechanism of action. The current use of SSRIs (use within a 30-day window before index date) was compared with nonuse, past use (beyond 365 days) and current use of other antidepressants through a conditional logistic regression model to obtain adjusted odds ratios and 95% CI. Only initiators of SSRIs and other antidepressants were considered.

RESULTS

A total of 8296 cases and 37 272 matched controls were included. Of them, 255 (3.07%) were current users of SSRIs among cases and 834 (2.24%) among controls, yielding an adjusted odds ratio of 1.14 (95% CI, 0.97-1.34) as compared with nonusers, 0.94 (95% CI, 0.77-1.13) as compared with past-users and 0.74 (95% CI, 0.58-0.93) as compared with current users of other antidepressants. No relevant differences were found by duration (≤1, >1 year), sex, age (<70, ≥70 years old) and background vascular risk.

CONCLUSIONS

The use of SSRIs was not associated with an increased risk of noncardioembolic ischemic stroke. On the contrary, as compared with other antidepressants, SSRIs appeared to be protective.

Risk of ischaemic stroke among new users of glucosamine and chondroitin sulphate: a nested case–control study

Background:

Several studies have reported that the use of chondroitin sulphate (CS) and glucosamine may reduce the risk of acute myocardial infarction. Although it is thought that this potential benefit could be extended to ischaemic stroke (IS), the evidence is scarce.

Objective:

To test the hypothesis that the use of prescription glucosamine or CS reduces the risk of IS.

Design:

Case–control study nested in an open cohort.

Methods:

Patients aged 40–99 years registered in a Spanish primary healthcare database (BIFAP) during the 2002–2015 study period. From this cohort, we identified incident cases of IS, applying a case-finding algorithm and specific validation procedures, and randomly sampled five controls per case, individually matched with cases by exact age, gender and index date. Adjusted odds ratios (AORs) and 95% confidence interval (CI) were computed through a conditional logistic regression. Only new users of glucosamine or CS were considered.

Results:

A total of 13,952 incident cases of IS and 69,199 controls were included. Of them, 106 cases (0.76%) and 803 controls (1.16%) were current users of glucosamine or CS at index date, yielding an AOR of 0.66 (95% CI: 0.54–0.82) (for glucosamine, AOR: 0.55; 95% CI: 0.39–0.77; and for CS, AOR: 0.77; 95% CI: 0.60–0.99). The reduced risk among current users was observed in both sexes (men, AOR: 0.69; 95% CI: 0.49–0.98; women, AOR: 0.65; 95% CI: 0.50–0.85), in individuals above and below 70 years of age (AOR: 0.69; 95% CI: 0.53–0.89 and AOR: 0.59; 95% CI: 0.41–0.85, respectively), in individuals with vascular risk factors (AOR: 0.53; 95% CI: 0.39–0.74) and among current/recent users of nonsteroidal anti-inflammatory drugs (NSAIDs) (AOR: 0.71; 95% CI: 0.55–0.92). Regarding duration, the reduced risk was observed in short-term users (<365 days, AOR: 0.61; 95% CI: 0.48–0.78) while faded and became nonsignificant in long-term users (>364 days AOR: 0.86; 95% CI: 0.57–1.31).

Conclusions:

Our results support a protective effect of prescription CS and glucosamine in IS, which was observed even in patients at vascular risk.

Mini abstract

Our aim was to analyse whether the use of glucosamine or chondroitin sulphate (CS) reduces the risk of ischaemic stroke (IS). We detected a significant decrease.

Trends in the use of oral anticoagulants, antiplatelets and statins in four European countries: a population-based study

Purpose

To evaluate time trends in the prevalence of antithrombotic and statin use in four European countries.

Methods

Using population-based data from the United Kingdom, Denmark, Spain and Italy between 2010 and 2018, we calculated standardized annual prevalence proportions of antithrombotics and statin use, and changes in prevalence proportions (2018 vs. 2010).

Results

Prevalence proportion of statins increased from 24.8% to 24.6% (UK), 21.0% to 22.3% (Region of Southern Denmark [RSD]), 12.9% to 14.3% (Udine, Italy), and 20.3% to 23.2% (Spain). Prevalence proportions of antithrombotics declined in all four countries: 18.7% to 15.9% (UK; − 2.8% points), 18.9% to 18.1% (RSD; − 0.8% points), 17.7% to 16.6% (Udine; − 1.1% points) and 15.0% to 13.6% (Spain; − 1.4% points). These declines were driven by reductions in low-dose aspirin use: 15.3% to 8.9% (UK; − 6.4% points), 16.3% to 9.5% (RSD; − 6.8% points), 13.5% to 11.6% (Udine; − 1.9% points), and 10.2% to 8.8% (Spain; − 1.4% points). In the UK, low-dose aspirin use declined from 9.1% to 4.3% (− 4.8% points) for primary CVD prevention, and from 49.6% to 36.9% (− 12.7% points) for secondary prevention. Oral anticoagulant use gradually increased but did not fully account for the decrease in low-dose aspirin use.

Conclusions

Antithrombotic use in the UK, RSD, Udine and Spain declined between 2010 and 2018, driven by a reduction in use of low-dose aspirin that is not completely explained by a gradual increase in OAC use. Use of statins remained constant in the UK, and increased gradually in the RSD, Udine and Spain.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00228-021-03250-6.

Inflammatory and nutritional biomarkers as predictors of non-resectability and early recurrence in pancreatic and periampullary cancer

BACKGROUND

Some pancreatic tumors considered resectable on the preoperative staging are unresectable during surgical exploration. Moreover, some patients subjected to tumor resection have an early recurrence.

METHODS

Patients with pancreatic or periampullary carcinoma diagnosed between January 2005 and August 2017 in Hospital Prof. Doutor Fernando Fonseca were retrospectively analyzed. Biochemical and radiological inflammatory biomarkers were compared according to disease staging at diagnosis, intraoperative staging and early recurrence (<6 months).

RESULTS

391 patients were included. Neutrophil-to-lymphocyte ratio (NLR), lymphocyte-tomonocyte ratio, C-reactive-protein-to-albuminemia ratio (CRP/ALB), Prognostic Nutritional Index, modified Glasgow Prognostic Score and CA19-9 were associated with metastatic disease at diagnosis. NLR, CRP/ALB, mGPS and CA19-9 were independent predictors of disease staging at diagnosis on multivariate analysis. 108 patients underwent surgery, of which 23,8% were found to have unresectable disease at intra-operative staging. 26,9% had early disease recurrence. CRP/ALB and CA19-9 were significantly higher in patients with evidence of disease at 6 months postoperatively. Computed tomography sarcopenia index HUAC was significantly lower in patients with evidence of disease at 6 months postoperatively. When adjusted for histology, none of the biomarkers were independent predictors of unresectable disease or early recurrence.

CONCLUSIONS

NLR, CRP/ALB, mGPS and CA19-9 at diagnosis were predictors of disease staging with low performance. Preoperative inflammatory biomarkers were not predictors of unresectable disease or early recurrence.

Influenza vaccine and risk of acute myocardial infarction in a population-based case-control study

OBJECTIVE

To assess the relationship between influenza vaccination and risk of a first acute myocardial infarction (AMI) in the general population by different epidemic periods.

METHODS

This is a population-based case-control study carried out in BIFAP (Base de datos para la investigación farmacoepidemiológica en atención primaria), over 2001-2015, in patients aged 40-99 years. Per each incident AMI case, five controls were randomly selected, individually matched for exact age, sex and index date (AMI diagnosis). A patient was considered vaccinated when he/she had a recorded influenza vaccination at least 14 days before the index date within the same season. The association between influenza vaccination and AMI risk was assessed through a conditional logistic regression, computing adjusted ORs (AOR) and their respective 95% CIs. The analysis was performed overall and by each of the three time epidemic periods per study year (pre-epidemic, epidemic and postepidemic).

RESULTS

We identified 24 155 AMI cases and 120 775 matched controls. Of them, 31.4% and 31.2%, respectively, were vaccinated, yielding an AOR of 0.85 (95% CI 0.82 to 0.88). No effect modification by sex, age and background cardiovascular risk was observed. The reduced risk of AMI was observed shortly after vaccination and persisted over time. Similar results were obtained during the pre-epidemic (AOR=0.87; 95% CI 0.79 to 0.95), epidemic (AOR=0.89; 95% CI 0.82 to 0.96) and postepidemic (AOR=0.83; 95% CI 0.79 to 0.87) periods. No association was found with pneumococcal vaccine (AOR=1.10; 95% CI 1.06 to 1.15).

CONCLUSIONS

Results are compatible with a moderate protective effect of influenza vaccine on AMI in the general population, mostly in primary prevention, although bias due to unmeasured confounders may partly account for the results.

O-225 Effects of SARS-Corona virus 2 on IVF treatment parameters: A cohort study of post COVID-19 patients

Study question

Does recovery from SARS–Corona virus 2 (SARS–CoV-2) infection negatively effect IVF cycle parameters?

Summary answer

Female IVF treatment parameters were comparable to the pre-Covid-19 infection cycle performance. Sperm concentration and motility demonstrated lower mean counts following Covid-19 infection.

What is known already

Corona-virus disease-19 (Covid-19) is a global pandemic caused by SARS–Corona virus 2 (SARS–CoV-2). The virus primarily affects the respiratory system, but other systemic and immune mediated effects have been reported. The spikes of SARS-CoV-2 have strong affinity for the Angiotensin converting enzyme (ACE) 2 receptor, leading to an increased Angiotensin II (Ang II) mediated pro-inflammatory response. ACE2 receptors exist in the human reproductive tract (more in males) and pose a regulatory role together with Ang II. So far, reports have been inconsistent regarding testicular effects. Other implications involving fertility and fertility treatment post infection are scarce.

Study design, size, duration

In this retrospective cohort study, IVF cycle performance was compared before and after Corona-virus disease-19. Patients were included only in cases where an IVF cycle was initiated within 3 months of Covid-19 recovery, between March 2020-December 2020.

Participants/materials, setting, methods

The study was conducted in a University affiliated IVF unit. Post Covid- 19 cycle parameters were compared to previous cycles of the same individual prior to infection. If previous cycles were not available, parameters were compared to non-exposed patients of same age, same treatment and identical indication. Sperm concentration and motility were compared before and after infection. Non exposure was defined by a lack of past Covid-19 diagnosis and a negative PCR throughout the treatment.

Main results and the role of chance

All together, including the matched cycles, we compared 40 cycles which started within 3 months of recovery: 26 fresh stimulation cycles and 14 frozen thawed transfer cycles. In 28 of these cycles the patient could serve as its own control. Mean age for the female partner was 33.2 years ±6.5 years. Eight male partners presented post infection and provided fresh samples for a cycle involving fertilization. We compared stimulation parameters including maximal Estradiol level, stimulation length, FSH dosage, number of oocytes retrieved, fertilization rates, number of embryos created, high quality embryo number and endometrial thickness. All of these were comparable to non-exposed cycles (generalized estimating equations, p values &gt;0.1). No complications were recorded, specifically no thromboembolic events or respiratory complications. A total of 8 patients conceived: 1 was a chemical pregnancy, 1 extra-uterine pregnancy, 3 miscarriages and 3 ongoing, of those 1 was complicated by early bleeding. Male sperm analyses showed a trend towards lower post disease parameters, not reaching a statistical significance: 23mil/ml compared to 13.6 and 20.7% progressive motility compared to 12.3% (p values 0.09 and 0.17, respectively).

Limitations, reasons for caution

Current results are based on a small sample size, still insufficient for deducing definite conclusions or guidelines. Pregnancy outcome following IVF treatment in Covid-19 recoverees should further be studied. By the time of the conference, the number of cases is expected to be significantly higher.

Wider implications of the findings

This study provides preliminary data regarding the effects of SARS-COV-2 infection on IVF treatment outcomes. Despite the small sample size, treatment parameters seem unaffected, however, sperm performance seems to be compromised. Health policy and patients’ decisions regarding whether or not to postpone IVF procedures necessitates additional data.

Trial registration number

Not applicable - retrospective

Risk of acute myocardial infarction among new users of chondroitin sulfate: A nested case-control study

Objective

To test the hypothesis that the use of chondroitin sulfate (CS) or glucosamine reduces the risk of acute myocardial infarction (AMI).

Design

Case-control study nested in a primary cohort of patients aged 40 to 99 years, using the database BIFAP during the 2002–2015 study period. From this cohort, we identified incident cases of AMI and randomly selected five controls per case, matched by exact age, gender, and index date. Adjusted odds ratios (AOR) and 95% confidence interval (CI) were computed through a conditional logistic regression. Only new users of CS or glucosamine were considered.

Results

A total of 23,585 incident cases of AMI and 117,405 controls were included. Of them, 89 cases (0.38%) and 757 controls (0.64%) were current users of CS at index date, yielding an AOR of 0.57 (95%CI: 0.46–0.72). The reduced risk among current users was observed in both short-term (<365 days, AOR = 0.58; 95%CI: 0.45–0.75) and long-term users (>364 days AOR = 0.56; 95%CI:0.36–0.87), in both sexes (men, AOR = 0.52; 95%CI:0.38–0.70; women, AOR = 0.65; 95%CI:0.46–0.91), in individuals over or under 70 years of age (AOR = 0.54; 95%CI:0.38–0.77, and AOR = 0.61; 95%CI:0.45–0.82, respectively) and in individuals at intermediate (AOR = 0.65; 95%CI:0.48–0.91) and high cardiovascular risk (AOR = 0.48; 95%CI:0.27–0.83), but not in those at low risk (AOR = 1.11; 95%CI:0.48–2.56). In contrast, the current use of glucosamine was not associated with either increased or decreased risk of AMI (AOR = 0.86; 95%CI:0.66–1.08).

Conclusions

Our results support a cardioprotective effect of CS, while glucosamine seems to be neutral. The protection was remarkable among subgroups at high cardiovascular risk.

OP0234 RISK OF ACUTE MYOCARDIAL INFARCTION AMONG NEW USERS OF CHONDROITIN SULPHATE: A NESTED CASE-CONTROL STUDY

Background:

There is some evidence from epidemiological studies suggesting that CS and glucosamine could play a role in cardiovascular disease (CVD) prevention (1-4).Studies to date have included prevalent users, therefore a bias that overestimates protection cannot be excluded.

Objectives:

To test the hypothesis that chondroitin sulphate (CS) or glucosamine reduce the risk of acute myocardial infarction (AMI).

Methods:

Case-control study nested in a primary cohort composed of patients aged 40 to 99 years, with at least one year of follow-up in the BIFAP database during the 2002-2015 study period. From this cohort of patients, we identified incident cases of AMI and randomly selected five controls per case, matched by exact age, gender, and index date. Adjusted odds ratios (AOR) and their corresponding 95% confidence interval (CI)) were calculated through a conditional logistic regression. Only new users of CS or glucosamine were considered.

Results:

A total of 23,585 incident cases of AMI and 117,405 controls were included. The mean age was 67.0 (SD 13.4) years and 71.75% were male, in both groups. 558 (2.37%) cases and 3,082 (2.62%) controls used or had used CS. The current use of CS was associated with a lower risk of AMI (AOR 0.57; 95%CI: 0.46–0.72) and disappeared after discontinuation (recent and past users). The reduced risk among current users was observed in both short-term (<365 days AOR 0.58; 95%CI: 0.45-0.75) and long-term users (>364 days AOR 0.56; 95%CI 0.36-0.87), in both sexes (men, AOR=0.52; 95%CI:0.38-0.70; women, AOR=0.65; 95%CI: 0.46-0.91), in individuals over or under 70 years of age (AOR=0.54; 95%CI:0.38-0.77, and AOR=0.61; 95%CI:0.45-0.82, respectively) and in individuals at intermediate (AOR=0.65; 95%CI:0.48-0.91) and high cardiovascular risk (AOR=0.48;95%CI:0.27-0.83), but not in those at low risk (AOR=1.11; 95%CI:0.48-2.56). In contrast, the current use of glucosamine was not associated with either increased or decreased risk of AMI (AOR= 0.86; CI95% 0.66-1.08)

Conclusion:

Our results support a cardioprotective effect of CS, while no effect was observed with glucosamine. The highest protection was found among subgroups at higher cardiovascular risk.

References:

[1]Ma H, Li X, Sun D, Zhou T, Ley SH, Gustat J, et al. Association of habitual glucosamine use with risk of cardiovascular disease: prospective study in UK Biobank. BMJ. 2019;365(Journal Article):l1628.

[2]de Abajo FJ, Gil MJ, Garcia Poza P, Bryant V, Oliva B, Timoner J, et al. Risk of nonfatal acute myocardial infarction associated with non-steroidal antiinflammatory drugs, non-narcotic analgesics and other drugs used in osteoarthritis: a nested case-control study. PharmacoepidemiolDrug Saf. 2014;23(11):1128–38.

[3]Li Z-H, Gao X, Chung VC, Zhong W-F, Fu Q, Lv Y-B, et al. Associations of regular glucosamine use with all-cause and cause-specific mortality: a large prospective cohort study. Ann Rheum Dis. 2020 Apr 6;annrheumdis-2020-217176.

[4]King DE, Xiang J. Glucosamine/Chondroitin and Mortality in a US NHANES Cohort. J Am Board Fam Med. 2020 Dec;33(6):842–7.

Disclosure of Interests:

Ramón Mazzucchelli Speakers bureau: UCB, Lilly, Grant/research support from: Pfizer, Roche, Amgen, Sara Rodriguez-Martin: None declared, Alberto García-Vadillo: None declared, Miguel Gil: None declared, Antonio Rodríguez-Miguel: None declared, Diana Barreira-Hernández: None declared, Alberto García-Lledó: None declared, Francisco de Abajo: None declared

Risk of acute myocardial infarction among new users of bisphosphonates: a nested case-control study

OBJECTIVE

To test the hypothesis that bisphosphonates reduce AMI risk among new users and to assess whether the effect depends on the duration of treatment.

METHODS

Case-control study nested in a primary cohort composed of patients aged 40 to 99 years, with at least 1-year registry in the BIFAP database throughout the study period 2002-2015. Out of this cohort, incident AMI cases were identified and five controls per case were randomly selected, matched by exact age, sex, and index date. The association of AMI with current, recent and past use of bisphosphonates was assessed by computing adjusted odds ratios (AOR) and their corresponding 95% confidence interval (CI) through an unconditional logistic regression. Only initiators of bisphosphonates were considered.

RESULTS

A total of 23,590 cases of AMI and 117,612 controls were included. The mean age was 66.8 (SD 13.4) years, and 72.52% was male, in both groups. About 276 (1.17%) cases and 1458 (1.24%) controls were current users of bisphosphonates yielding an AOR of 0.98 (95% CI 0.854-1.14). Recent and past use were not associated with a reduced risk, either, nor was it found a reduction with treatment duration (AOR less than 1 year = 0.92; 95% CI 0.73-1.15; AOR more than 1 year = 1.03; 95% CI 0.86-1.23). Stratified analysis by age, sex and background cardiovascular risk did not show an effect modification by these variables.

CONCLUSION

The results do not support a cardioprotective effect of bisphosphonates regardless of the duration of treatment, age, sex or background cardiovascular risk. However, a small protective effect could have been masked if patients with osteoporosis have had a background higher risk of AMI.

What has changed during the state of emergency due to COVID-19 on an Academic Urology Department of a Tertiary Hospital in Portugal

Objetivo

Comparar la actividad del Servicio de Urología de un Hospital Universitario Portugués durante el estado de alarma y el periodo equivalente del año anterior. Comparamos el número de consultas electivas y pruebas diagnósticas urológicas, el número y el tipo de cirugías electivas, así como las características demográficas de los pacientes y las principales causas de ingreso al Servicio de Urgencias (SU) de Urología durante los dos periodos mencionados.

Materiales y métodos

Los datos de 691 pacientes que acudieron a urgencias desde el 18 de marzo de 2020 hasta el 2 de mayo de 2020 -y del mismo periodo del año anterior- se recogieron del software medico institucional. Los datos recopilados fueron edad, sexo, fecha de visita al servicio de urgencias, derivación desde otros hospitales, color del triaje, causa del ingreso, diagnóstico al alta y la necesidad de cirugía de urgencia u hospitalización. Con la intención de identificar las asociaciones entre las variables demográficas y clínicas con el hecho de haber sido sometido a una cirugía de urgencia (variable), se aplicaron modelos de regresión logística.

Resultados

El análisis multivariante mostró asociación entre el sexo del paciente con el hecho de ser sometido a una cirugía, con una disminución del 65,6% en las probabilidades para el género masculino. El periodo (COVID versus sin-COVID) no mostró una asociación significativa con la cirugía.

Conclusión

Nuestro departamento experimentó una reducción importante en la actividad. También observamos una reducción de las causas urgentes para acudir a los servicios de urgencias considerados menos graves. El porcentaje de casos que requirieron cirugía de urgencia y hospitalización fue mayor durante el periodo COVID.

Factors that influence the response time in STEMI patients in Lisbon 2017

The success of the ST-segment elevation myocardial infarction (STEMI) approach is based on early diagnosis and on the institution of timely reperfusion therapy, with response times remaining variable. The objective of this study was to determine which factors influenced the response time to patients with STEMI until the treatment with coronary reperfusion from the prehospital service or the emergency room in three hospitals in the greater Lisbon area in 2017. An epidemiological, cross-sectional, retrospective, descriptive study with an analytical component was performed, with data from the National Institute of Medical Emergency (INEM) and clinical trials of patients. Patients who were not referred to these hospitals were excluded. Univariate statistical analysis was performed, as well as c2 tests, t-student and logistic regression model (r &lt; 0.05). The population included 95 patients, the majority being male (67.4%), and with a mean age of 63.8 years. 61.1% were hypertensive and the majority (87.4%) had no signs of previous heart failure. The mean door-to-balloon time was 159 minutes, with 57.4% showing time greater than 120 minutes. In patients in whom the INEM Coronary Greenway was activated, mean door-to-balloon time was 99 minutes. Diagnostic, symptom-admission and transport times showed a statistically significant association with the door-to-balloon time in the bivariate analysis. The times are fulfilled in the prehospital service, but in the hospital, services can be improved through the early accomplishment of electrocardiogram and the optimization of interhospital transport.

Key messages

Reducing ECG time and inter-hospital transport time improves STEMI response and outcome. Time is muscle is the main message for de concern of identifying influence factors of STEMI response time.

The impact of multidisciplinary team conferences in urologic cancer in a tertiary hospital

PURPOSE

Multidisciplinary team (MDT) conferences are currently the standard of care in cancer patients' management. Despite evidence supporting benefits to the majority of malignancies, a paucity of data exists examining the impact in urinary and male genital cancers. This study aims to evaluate the impact of MDT conferences in urologic cancer practice.

METHODS

Clinical plans discussed in urologic MDT conferences in Centro Hospitalar Universitário de Lisboa Central between January 2019 and December 2019 were retrospectively analysed. Clinical plans were categorized as accepted, changed, rejected (cases that had to be re-presented to the MDT because of insufficient staging or administrative issues) or no plan. MDT conferences' impact was assessed according to type of consultation, referral medical specialty and primary tumour type.

RESULTS

710 clinical plans were discussed at the MDT conferences. 61.8% were accepted, 10.6% were changed, 16.5% were rejected and 11.1% of cases referred to MDT discussion had no defined clinical plan. First consultations had a higher rate of accepted clinical plans (63.4%) versus subsequent consultations (56.4%). Referrals by the urology specialty had the highest rate of acceptances (64.3%). On the stratification by primary tumour site, testicular cancer had the highest acceptance rate (70.3%), whereas bladder cancer had the lowest (47.8%).

CONCLUSIONS

MDT conferences had an important impact in the management of 38.2% of cases. Therefore, all patients with urologic malignancies should be referred to MDT review to ensure optimal clinical care.

SAT0446 RISK OF ACUTE MYOCARDIAL INFARCTION (AMI) AMONG NEW USERS OF BISPHOSPHONATES: A NESTED CASE-CONTROL STUDY

Background:

Evidence suggest that bisphosphonates (BF) may inhibit atherosclerosis and vascular calcification. In several small-scale clinical trials, BF improved some intermediate targets of atherosclerosis. Observational studies found a lower risk of Acute Myocardial Infarction (AMI) or stroke among BF users compared to non-users. While this epidemiological evidence suggests that BF may protect against cardiovascular events a “prevalent user bias” cannot be excluded.

Objectives:

To analyze the hypothesis that BF reduce de risk of AMI in new users and assess whether the effect depends on the duration of treatment.

Methods:

Case-control study nested in a primary cohort composed of patients aged 40 to 99 years, with at least one year of follow-up in the BIFAP database during the 2002-2015 study period. From this cohort of patients, we identified incident cases of AMI and randomly selected five controls per case, matched by exact age, gender, and index date. Adjusted odds ratios (AOR) and their corresponding 95% confidence interval (CI) were calculated through an unconditional logistic regression. Only new users of BF were considered.

Results:

A total of 23,590 cases of IAM and 117,612 controls were included. The mean age was 66.8 (SD 13.4) years and 72.52% were male, in both groups. 584 (2,47%) cases and 2,892 (2.46%) controls used or had used some bisphosphonate. The use of BF was not associated with a lower risk of IAM (AOR 0.97; 95%CI: 0.84–1.13). Nor was it associated with the duration of treatment (AOR less than 1 year = 0.91; 95%CI: 0.72-1.15);AOR more than 1 year= 1.01; 95%CI: 0.84-1.21). The stratified analysis by age and sex also did not show either a protective effect of BF. Detailed results by BF type are shown in the following table:

Cases (%)Controls (%)Non-adjusted ORAdjusted ORN=23590N=117612(95% CI)(95% CI)BisphosphonatesNon users23006 (97.52)114720 (97.54)1 (Ref.)1 (Ref.)Current276 (1.17)1458 (1.24)0.93 (0.81-1.06)0.97 (0.84-1.13)Recent109 (0.46)478 (0.41)1.13 (0.92-1.40)1.11 (0.89-1.40)Past199 (0.84)956 (0.81)1.04 (0.89-1.21)1.01 (0.86-1.20)Alendronic acidNon users23338 (98.93)116421 (98.99)1 (Ref.)1 (Ref.)Current88 (0.37)469 (0.40)0.91 (0.72-1.15)0.97 (0.76-1.24)Recent46 (0.19)201 (0.17)1.17 (0.84-1.61)1.18 (0.83-1.66)Past118 (0.50)521 (0.44)1.12 (0.91-1.37)1.13 (0.91-1.40)Alendronic acid+VitDNon users23509 (99.66)117155 (99.61)1 (Ref.)1 (Ref.)Current34 (0.14)207 (0.18)0.81 (0.56-1.17)0.89 (0.60-1.31)Recent15 (0.06)77 (0.07)0.94 (0.54-1.63)0.71 (0.40-1.29)Past32 (0.14)173 (0.15)0.92 (0.63-1.35)0.83 (0.56-1.25)Alendronic acid (all)Non users23274 (98.66)116057 (98.68)1 (Ref.)1 (Ref.)Current122 (0.52)671 (0.57)0.89 (0.73-1.08)0.95 (0.77-1.18)Recent58 (0.25)261 (0.22)1.11 (0.83-1.48)1.03 (0.76-1.39)Past136 (0.58)623 (0.53)1.08 (0.89-1.31)1.05 (0.86-1.29)Ibandronic acidNon users23504 (99.64)117174 (99.63)1 (Ref.)1 (Ref.)Current41 (0.17)216 (0.18)0.96 (0.68-1.34)1.00 (0.70-1.42)Recent18 (0.08)69 (0.06)1.24 (0.74-2.09)1.38 (0.80-2.36)Past27 (0.11)153 (0.13)0.87 (0.57-1.31)0.88 (0.57-1.35)Risedronic acidNon users23355 (99.00)116446 (99.01)1 (Ref.)1 (Ref.)Current102 (0.43)527 (0.45)0.95 (0.76-1.18)0.99 (0.79-1.25)Recent47 (0.20)186 (0.16)1.27 (0.92-1.75)1.17 (0.83-1.66)Past86 (0.36)453 (0.39)0.94 (0.75-1.19)0.93 (0.72-1.19)

Conclusion:

Our results do not support a cardioprotective effect of BF, regardless of the duration of treatment, age, sex or background cardiovascular risk.

Disclosure of Interests:

None declared

Use of renin-angiotensin-aldosterone system inhibitors and risk of COVID-19 requiring admission to hospital: a case-population study

BACKGROUND

Concerns have been raised about the possibility that inhibitors of the renin-angiotensin-aldosterone system (RAAS) could predispose individuals to severe COVID-19; however, epidemiological evidence is lacking. We report the results of a case-population study done in Madrid, Spain, since the outbreak of COVID-19.

METHODS

In this case-population study, we consecutively selected patients aged 18 years or older with a PCR-confirmed diagnosis of COVID-19 requiring admission to hospital from seven hospitals in Madrid, who had been admitted between March 1 and March 24, 2020. As a reference group, we randomly sampled ten patients per case, individually matched for age, sex, region (ie, Madrid), and date of admission to hospital (month and day; index date), from Base de datos para la Investigación Farmacoepidemiológica en Atención Primaria (BIFAP), a Spanish primary health-care database, in its last available year (2018). We extracted information on comorbidities and prescriptions up to the month before index date (ie, current use) from electronic clinical records of both cases and controls. The outcome of interest was admission to hospital of patients with COVID-19. To minimise confounding by indication, the main analysis focused on assessing the association between COVID-19 requiring admission to hospital and use of RAAS inhibitors compared with use of other antihypertensive drugs. We calculated odds ratios (ORs) and 95% CIs, adjusted for age, sex, and cardiovascular comorbidities and risk factors, using conditional logistic regression. The protocol of the study was registered in the EU electronic Register of Post-Authorisation Studies, EUPAS34437.

FINDINGS

We collected data for 1139 cases and 11 390 population controls. Among cases, 444 (39·0%) were female and the mean age was 69·1 years (SD 15·4), and despite being matched on sex and age, a significantly higher proportion of cases had pre-existing cardiovascular disease (OR 1·98, 95% CI 1·62-2·41) and risk factors (1·46, 1·23-1·73) than did controls. Compared with users of other antihypertensive drugs, users of RAAS inhibitors had an adjusted OR for COVID-19 requiring admission to hospital of 0·94 (95% CI 0·77-1·15). No increased risk was observed with either angiotensin-converting enzyme inhibitors (adjusted OR 0·80, 0·64-1·00) or angiotensin-receptor blockers (1·10, 0·88-1·37). Sex, age, and background cardiovascular risk did not modify the adjusted OR between use of RAAS inhibitors and COVID-19 requiring admission to hospital, whereas a decreased risk of COVID-19 requiring admission to hospital was found among patients with diabetes who were users of RAAS inhibitors (adjusted OR 0·53, 95% CI 0·34-0·80). The adjusted ORs were similar across severity degrees of COVID-19.

INTERPRETATION

RAAS inhibitors do not increase the risk of COVID-19 requiring admission to hospital, including fatal cases and those admitted to intensive care units, and should not be discontinued to prevent a severe case of COVID-19.

FUNDING

Instituto de Salud Carlos III.

Base de Datos para la Investigación Farmacoepidemiológica en Atención Primaria (BIFAP): A data resource for pharmacoepidemiology in Spain

PURPOSE

Base de Datos para la Investigación Farmacoepidemiológica en Atención Primaria (BIFAP) is a population based database administered by the AEMPS (Spanish Agency for Medicines) of longitudinal electronic medical records (EMR) of patients attended in primary care. Its main purpose is to serve as source of information for independent studies on drug safety and support of medicines regulation activities. This article aim is to describe the characteristics of BIFAP, how to access the database and a summary of its potential for research.

METHODS

Health problems are registered by primary care physicians as episodes of care and include socio-demographic data, results of diagnostic procedures, lifestyle data, general data, and interventions. A proportion of data on hospitalizations and specialist care are currently available through linkage with other data sources. EMRs of the Spanish healthcare system are provided by the regional administrations. Specific data extraction and standardization processes are performed.

RESULTS

BIFAP includes data from 12 million patients starting in 2001 and updated annually. Validation of drug and diagnosis definitions has been ascertained. Participation in international collaborative projects and a number of articles in peer reviewed journals reflect its contribution to the knowledge of the risks associated with medicines and drug utilization patterns.

CONCLUSIONS

BIFAP is a useful tool for generating scientific evidence on medicines related issues, helping regulatory decision making in Europe. The main strengths of BIFAP are related to large sample size, population-based, longitudinal nature and annual update of data. BIFAP shares common challenges with similar data sources including accurate and efficient identification of health outcomes and of treatment exposure.

Differential effects of antidepressant subgroups on risk of acute myocardial infarction: A nested case-control study

The primary objective of this study was to investigate the association between antidepressants use and the risk of acute myocardial infarction (AMI).

METHODS

We conducted a nested case-control study using a primary care database over the period 2002-2015. From a cohort of patients aged 40-99 years, we identified incident AMI cases and randomly selected 5 controls per case, matched to cases for exact age, sex and index date. Exposure to antidepressants were categorised as current, recent, past and nonusers. Adjusted odds ratio (AOR) and 95% confidence interval (CI) were computed using conditional logistic regression to assess the association between the current use of different antidepressants subgroups and AMI as compared to nonuse. Dose and duration effects were explored.

RESULTS

Totals of 24 155 incident AMI cases and 120 775 controls were included. The current use of antidepressants as a group was associated with a reduced risk (AOR = 0.86; 95% CI: 0.81-0.91), but mainly driven by selective serotonin reuptake inhibitors (AOR = 0.86; 95% CI:0.81-0.93). A reduced risk was also observed with trazodone (AOR = 0.76;95% CI: 0.64-0.91), and clomipramine (AOR = 0.62; 95% CI: 0.40-0.96), whereas no significant effect was observed with other antidepressants. A duration-dependent effect was suggested for selective serotonin reuptake inhibitors, trazodone and clomipramine, while there was no clear dose-dependency.

CONCLUSION

This study suggests that current use of antidepressants interfering selectively with the reuptake of serotonin, and those antagonizing the 5-HT_2A receptor, are associated with a decrease in AMI risk and should be the antidepressants of choice in patients at cardiovascular risk.

Predictive factors for omitting lymphadenectomy in patients with node-positive breast cancer treated with neo-adjuvant systemic therapy

A pathologic complete response (pCR) in the axilla occurs in 30%-40% of patients with initially node-positive breast cancer after neo-adjuvant chemotherapy (NACT). Debate persists about whether to perform systematic axillary lymphadenectomy (ALND) in patients with initial node-positive disease and clinical complete response after NACT. We aimed to identify predictive factors of axillary pCR (ypN0) after NACT. This retrospective study analyzed data for all patients with initial biopsy-proven node-positive disease who underwent ALND after NACT between June 2008 and December 2016 at our institution. Clinical and pathologic features, recurrence and specific mortality rates were compared between patients who achieved an axillary pCR and those who did not (ypN0 vs ypN+, respectively). A total of 331 patients were included, of whom 128 (38.7%) became ypN0 after NACT. Among patients with >2 suspicious axillary lymph nodes before treatment, 54 (38%) achieved ypN0 status. The independent predictors of ypN0 were Ki-67 > 30 (OR 1.98; 95% CI, 1.146-3.381), HER2 positivity (OR 2.6; 95% CI, 1.354-5.108), nonluminal molecular-like subtype (OR 4.15; 95% CI, 2.068-5.108), and clinical complete response, defined as negative clinical and ultrasonographic findings (OR 2.8; 95% CI, 1.110-7.081). After a mean follow-up of 61 months, distant disease-free and overall survival rates were higher in patients with ypN0 disease (HR 4.14; 95% CI, 2.03-8.43) than ypN+ patients. Complete clinical response and the presence of nonluminal molecular-like subtypes independently predicted ypN0. Patients meeting these criteria might be suitable form omitting ALND and just performing targeted axillary procedures to patients meeting these criteria.

Use of methylphenidate and risk for valvular heart disease: A case-control study nested in the BIFAP cohort

PURPOSE

To examine the association between use of methylphenidate and the risk for valvular heart disease (VHD) in the Spanish primary care database BIFAP.

METHODS

Case-control study nested in a cohort of patients aged 5 to 25 years between 2002 and 2014, based in a general practice research database. Cases were people with a validated diagnosis of VHD. Ten controls per case were matched on age, sex, and calendar year. Multivariable conditional logistic regression was used to estimate odds ratios (ORs) of VHD comparing patients ever treated with methylphenidate vs never users, as well as by time since last use, treatment duration, and variations in case inclusion criteria.

RESULTS

From a cohort of 1 596 284 patients, we identified 262 valid cases of VHD. No difference in the incidence of VHD was observed when comparing "ever users" of methylphenidate with "never users" (adjusted OR 0.52, 95%CI 0.16-1.69). A similar result was found comparing current, recent, or past users of methylphenidate. Differences were not significant when both valid and probable cases were included as events of interest (adjusted OR 0.59, 95%CI 0.22-1.63).

CONCLUSIONS

In this first-ever population-based study on this issue, association between methylphenidate and the incidence of VHD among persons in the 5 to 25 years age range was neither confirmed nor excluded. Additional studies may be required to clarify the presence or absence of this relationship.

Risk of Myocardial Infarction Among New Users of Calcium Supplements Alone or Combined With Vitamin D: A Population-Based Case-Control Study

A population‐based case‐control study was conducted to evaluate the risk of acute myocardial infarction among new users of calcium supplements either in monotherapy (CaM) or in combination with vitamin D (CaD). A total of 23,025 cases and 114,851 controls randomly sampled from the underlying cohort and matched with cases by age, sex, and index date were included. New users of CaM and CaD were categorized as current users, recent users, past users, and nonusers. We computed adjusted odds ratios (AORs) and their 95% confidence intervals (CIs) among current users as compared with nonusers through a conditional logistic regression. No increased risk was associated with CaM overall (59 cases (0.26%) and 273 controls (0.24%); AOR = 0.80; 95% CI 0.59–1.09), nor was it found in any of the conditions examined. Instead, the use of CaD was associated with a decreased risk (275 cases (1.19%) and 1,160 controls (1.45%); AOR = 0.78; 95% CI 0.67–0.90), dose and duration‐dependent, and particularly evident in patients with a high cardiovascular risk (AOR = 0.59; 95% CI 0.43–0.81).

Clopidogrel and Low-Dose Aspirin, Alone or Together, Reduce Risk of Colorectal Cancer

BACKGROUND & AIMS

The antiplatelet effect of low-dose aspirin, via inhibition of cyclooxygenase-1, might contribute to its ability to reduce the risk of colorectal cancer (CRC). Antiplatelet agents with a different mechanism, such as clopidogrel, might have the same effects. We aimed to quantify the effects of low-dose aspirin and clopidogrel on the risk of CRC in a Mediterranean population.

METHODS

We performed a nested case-control study using a primary care database (Base de datos para la Investigación Farmacoepidemiológica en Atención Primaria) in Spain. We collected data, from 2001 through 2014, on 15,491 incident cases of CRC and 60,000 randomly selected individuals (controls), frequency-matched to cases by age, sex, and year. To estimate the association between exposure to different antiplatelet agents and the risk of colorectal cancer, we built multiple logistic regression models and computed the adjusted-odds ratios (AORs) and their respective 95% CIs.

RESULTS

Use of low-dose aspirin was associated with a reduced risk of CRC overall (AOR, 0.83; 95% CI, 0.78-0.89) and in patients receiving treatment for more than 1 year (AOR, 0.79; 95% CI, 0.73-0.85). Use of clopidogrel was associated with a decreased risk of CRC overall (AOR, 0.8; 95% CI, 0.69-0.93) and in patients receiving treatment for more than 1 year (AOR, 0.65; 95% CI, 0.55-0.78). Dual antiplatelet therapy had the same effect as either drug taken as monotherapy. No modification by sex or age was observed.

CONCLUSIONS

In a nested case-control study of a primary care database in Spain, we found clopidogrel use, alone or in combination with low-dose aspirin, to reduce the risk of CRC by 20% to 30%, a magnitude similar to that of low-dose aspirin alone. These data support the concept that inhibiting platelets is an effective strategy for prevention of CRC.