Esophageal biomechanics assessed by impedance planimetry (EndoFLIPTM) in healthy subjects and in patients with eosinophilic esophagitis. Normality values.

BACKGROUND: active eosinophilic esophagitis is associated with esophageal caliber, distensibility and motility changes that may be reversed with treatment. OBJECTIVES: to study esophageal diameter, distensibility and contractility in healthy subjects compared to patients with eosinophilic esophagitis, both before and after treatment. METHODS: a quasi-experimental study, EndoFLIP™, was used to analyze the esophageal body and esophago-gastric junction (EGJ) in all three groups, and a program was designed to obtain esophageal diameter, distensibility and contractility values. RESULTS: ten healthy volunteers (24-61 years, six men) and nine patients with eosinophilic esophagitis (21-52 years, seven men) were included. The esophagogastric junction distensibility index was 5.07 mm2/Hg in the control subjects, 2.40 mm2/Hg in the subjects with eosinophilic esophagitis before treatment and 2.46 mm2/Hg after treatment. The distensibility plateau was 20.02 mm, 15.43 mm and 17.41 mm, respectively, and the diameter was 21.90 mm, 17.73 mm and 18.30 mm, showing significant differences (p < 0.05), except between control subjects and patients after treatment (p = 0.079). Repetitive antegrade contractions developed in 90 % of control subjects, 66.7 % of eosinophilic esophagitis patients before treatment and 88.9 % of the latter after treatment (p > 0.05). CONCLUSIONS: esophago-gastric junction distensibility index, distensibility plateau and diameter values were higher in controls than in patients, although six weeks of treatment seems a short period to observe significant changes in esophageal biomechanics. Repetitive antegrade contractions are the predominant pattern in healthy subjects and eosinophilic esophagitis. We provide normality values for esophageal biomechanics, measured by impedance planimetry in our setting.

Role of SpO2/FiO2 Ratio and ROX Index in Predicting Early Invasive Mechanical Ventilation in COVID-19. A Pragmatic, Retrospective, Multi-Center Study.

The ability of COVID-19 to compromise the respiratory system has generated a substantial proportion of critically ill patients in need of invasive mechanical ventilation (IMV). The objective of this paper was to analyze the prognostic ability of the pulse oximetry saturation/fraction of inspired oxygen ratio (SpO2/FiO2) and the ratio of SpO2/FiO2 to the respiratory rate-ROX index-as predictors of IMV in an emergency department in confirmed COVID-19 patients. A multicenter, retrospective cohort study was carried out in four provinces of Spain between March and November 2020. The discriminative power of the predictive variable was assessed through a prediction model trained using a derivation sub-cohort and evaluated by the area under the curve (AUC) of the receiver operating characteristic (ROC) on the validation sub-cohort. A total of 2040 patients were included in the study. The IMV rate was 10.1%, with an in-hospital mortality rate of 35.3%. The performance of the SpO2/FiO2 ratio was better than the ROX index-AUC = 0.801 (95% CI 0.746-0.855) and AUC = 0.725 (95% CI 0.652-0.798), respectively. In fact, a direct comparison between AUCs resulted in significant differences (p = 0.001). SpO2 to FiO2 ratio is a simple and promising non-invasive tool for predicting risk of IMV in patients infected with COVID-19, and it is realizable in emergency departments.

Systematic review and meta-analysis of fluid therapy protocols in acute pancreatitis: type, rate and route.

BACKGROUND: Adequate fluid resuscitation is paramount in the management of acute pancreatitis (AP). The aim of this study is to assess benefits and harms of fluid therapy protocols in patients with AP. METHODS: MEDLINE, Embase, Science Citation Index and clinical trial registries were searched for randomised clinical trials published before May 2020, assessing types of fluids, routes and rates of administration. RESULTS: A total 15 trials (1073 participants) were included. Age ranged from 38 to 73 years; follow-up period ranged from 0.5 to 6 months. Ringer lactate (RL) showed a reduced number of severe adverse events (SAE) when compared to normal saline (NS) (OR 0.48; 95%CI 0.29-0.81, p = 0.006); additionally, NS showed reduced SAE (RR 0.38; 95%IC 0.27-0.54, p < 0.001) and organ failure (RR 0.30; 95%CI 0.21-0.44, p < 0.001) in comparison with hydroxyethyl starch (HES). High fluid rate fluid infusion showed increased mortality (OR 2.88; 95%CI 1.41-5.88, p = 0.004), increased number of SAE (RR 1.42; 95%CI 1.04-1.93, p = 0.030) and higher incidence of sepsis (RR 2.80; 95%CI 1.51-5.19, p = 0.001) compared to moderate fluid rate infusion. CONCLUSIONS: In patients with AP, RL should be preferred over NS and HES should not be recommended. Based on low-certainty evidence, moderate-rate fluid infusion should be preferred over high-rate infusion.

Mortality risk model for patients with suspected COVID-19 based on information available from an emergency dispatch center. / Modelo de riesgo de mortalidad en pacientes con sospecha de enfermedad por COVID-19 basado en información del centro coordinador de urgencias.

OBJECTIVES: To develop and validate a scale to stratify risk of 2-day mortality based on data collected during calls to an emergency dispatch center from patients with suspected coronavirus disease 2019 (COVID-19). MATERIAL AND METHODS: Retrospective multicenter study of consecutive patients over the age of 18 years with suspected COVID-19 who were transported from home over the course of 3 months after telephone interviews with dispatchers. We analyzed clinical and epidemiologic variables and comorbidities in relation to death within 2 days of the call. Using data from the development cohort, we built a risk model by means of logistic regression analysis of categorical variables that were independently associated with 2-day mortality. The scale was validated first in a validation cohort in the same province and then in a cohort in a different province. RESULTS: A total of 2320 patients were included. The mean age was 79 years, and 49.8% were women. The overall 2-day mortality rate was 22.6% (376 deaths of patients with severe acute respiratory syndrome coronavirus 2 infection). The model included the following factors: age, location (rural location as a protective factor), institutionalization, desaturation, lung sounds (rhonchi), and altered mental status. The area under the receiver operating characteristic curve for death within 2 days was 0.763 (95% CI, 0.725-0.802; P .001). Mortality in patients at high risk (more than 2.4 points on the scale) was 60%. CONCLUSION: This risk scale derived from information available to an emergency dispatch center is applicable to patients with suspected COVID-19. It can stratify patients by risk of early death (within 2 days), possibly helping with decision making regarding whether to transport from home or what means of transport to use, and destination.

OBJETIVO: Derivar y validar una escala basada en variables recogidas durante la llamada a un centro coordinador de urgencias (CCU) que permita estratificar el riesgo de mortalidad a 2 días en pacientes con sospecha de enfermedad por COVID-19. METODO: Estudio multicéntrico retrospectivo que incluyó a los pacientes consecutivos 18 años durante 3 meses, catalogados como caso sospechoso de COVID-19 después de la entrevista telefónica del CCU y que precisaron evacuación. Se analizaron variables clínico-epidemiológicas, comorbilidades y resultado de muerte a los 2 días. Se derivó una escala con las variables categóricas asociadas de forma independiente con la mortalidad a 2 días mediante regresión logística, en la cohorte de derivación. La escala se validó mediante una cohorte de validación y otra de revalidación obtenida en una provincia distinta. RESULTADOS: Se incluyeron 2.320 pacientes (edad mediana 79 años, 49,8% mujeres). La mortalidad global fue del 22,6% (376 casos en pacientes con SARS-CoV-2). El modelo incluyó edad, localización (zona rural como variable protectora), institucionalización, desaturación, roncus, taquipnea y alteración del nivel de conciencia. El área bajo la curva (ABC) para la mortalidad a 2 días fue de 0,763 (IC 95%: 0,725-0,802; p 0,001). La mortalidad en los pacientes de alto riesgo (> 2,4 puntos) fue del 60%. CONCLUSIONES: La escala, derivada a través de información obtenida con datos del CCU, es aplicable a pacientes con sospecha de infección por COVID-19, estratifica el riesgo de mortalidad precoz (menos de 2 días) y puede ser una herramienta que ayude en la toma de decisiones, referidas a su evacuación, destino o vector de transporte.

Proton pump inhibitor therapy reverses endoscopic features of fibrosis in eosinophilic esophagitis.

BACKGROUND: Long-standing inflammation leads to esophageal remodeling with stricture formation in patients with eosinophilic esophagitis (EoE). The ability of proton pump inhibitors (PPI) to reverse endoscopic features of fibrosis is still unknown. OBJECTIVE: To investigate the effect of a short course of PPI treatment in reducing endoscopic findings indicative of esophageal fibrosis in EoE patients. METHODS: Cross-sectional analysis of the EoE CONNECT registry. Patients who received PPI to induce EoE remission were evaluated. Endoscopic features were graded using the EoE Endoscopic Reference Score (EREFS), with rings and strictures indicating fibrosis. Results were compared to those from patients treated with swallowed topic corticosteroids (STC). RESULTS: Clinico-histological remission was achieved in 83/166 adult patients treated with PPI (50%) and in 65/79 (82%) treated with STC; among responders, 60 (36%) and 57 (72%) patients respectively achieved deep histological remission (<5 eosinophils/hpf). At baseline, mean±SD EREFS was lower in patients treated with PPI compared to those who received STC (p < 0.001). Short term treatment significantly reduced EREFS scores in patients treated either with PPI or STC as well as rings and strictures. Among patients treated with PPI, deep histological remission (<5 eosinophils/hpf) provided further reduction in total EREFS score. CONCLUSION: Effective PPI therapy for EoE significantly reduced endoscopic esophageal fibrosis in the short term.

Prehospital troponin as a predictor of early clinical deterioration.

BACKGROUND AND OBJECTIVES: Elevated troponin T (cTnT) values are associated with comorbidities and early mortality, in both cardiovascular and noncardiovascular diseases. The objective of this study is to evaluate the prognostic accuracy of the sole utilization of prehospital point-of-care cardiac troponin T to identify the risk of early in-hospital deterioration, including mortality within 28 days. METHODS: We conducted a prospective, multicentric, controlled, ambulance-based, observational study in adults with acute diseases transferred with high priority by ambulance to emergency departments, between 1 January and 30 September 2020. Patients with hospital diagnosis of acute coronary syndrome were excluded. The discriminative power of the predictive cTnT was assessed through a discrimination model trained using a derivation cohort and evaluated by the area under the curve of the receiver operating characteristic on a validation cohort. RESULTS: A total of 848 patients were included in our study. The median age was 68 years (25th-75th percentiles: 50-81 years), and 385 (45.4%) were women. The mortality rate within 28 days was 12.4% (156 cases). The predictive ability of cTnT to predict mortality presented an area under the curve of 0.903 (95% CI: 0.85-0.954; P < .001). Risk stratification was performed, resulting in three categories with the following optimal cTnT cut-off points: high risk greater than or equal to 100, intermediate risk 40-100 and low risk less than 40 ng/L. In the high-risk group, the mortality rate was 61.7%, and on the contrary, the low-risk group presented a mortality of 2.3%. CONCLUSIONS: The implementation of a routine determination of cTnT on the ambulance in patients transferred with high priority to the emergency department can help to stratify the risk of these patients and to detect unknown early clinical deterioration.

Blood Biomarkers for Assessing Headaches in Healthcare Workers after Wearing Biological Personal Protective Equipment in a COVID-19 Field Hospital.

The coronavirus disease 2019 (COVID-19) has led to a pandemic, which among other things, has highlighted biosafety as a key cornerstone in the management of disease transmission. The aim of this work was to analyze the role played by different blood biomarkers in predicting the appearance of headaches in healthcare workers wearing personal protective equipment (PPE) in a COVID-19 treatment unit. A prospective cohort study of 38 healthcare workers was performed during April 2020. Blood analysis, performed just before the start of a 4 hour shift, was carried out on all volunteers equipped with PPE. At the end of their shifts and after decontamination, they were asked if they had suffered from headache in order to obtain a binary outcome. The baseline creatinine value reflected a specific odds ratio of 241.36 (95% CI: 2.50-23,295.43; p = 0.019) and an area under the curve (AUC) value of 0.737 (95%CI: 0.57-0.90; p < 0.01). Blood creatinine is a good candidate for predicting the appearance of a de novo headache in healthcare workers after wearing PPE for four hours in a COVID-19 unit.

Accuracy of prehospital point-of-care lactate in early in-hospital mortality.

BACKGROUND: Emergency medical services (EMS) routinely face complex scenarios where decisions should be taken with limited clinical information. The development of fast, reliable and easy to perform warning biomarkers could help in such decision-making processes. The present study aims at characterizing the validity of point-of-care lactate (pLA) during prehospital tasks for predicting in-hospital mortality within two days after the EMS assistance. MATERIALS AND METHODS: Prospective, multicentric, ambulance-based and controlled observational study without intervention, including six advanced life support and five hospitals. The pLA levels were recorded during EMS assistance of adult patients. The validity of pLA to determine the in-hospital mortality was assessed by the area under the curve (AUC) of the receiver operating curve (ROC). RESULTS: A total of 2997 patients were considered in the study, with a median of 69 years (IQR 54-81) and 41.4% of women. The median pLA value was 2.7 mmol/L (1.9-3.8) in survivors and 5.7 mmol/L (4.4-7.6) in nonsurvivors. The global discrimination level of pLA reached an AUC of 0.867, being 1.9 mmol/L and 4 mmol/L the cut-off point for low and high mortality. The discrimination value of pLA was not affected by sex, age or pathology. CONCLUSIONS: Our results highlight the clinical importance of prehospital pLA to determine the in-hospital risk of mortality. The incorporation of pLA into the EMS protocols could improve the early identification of risky patients, leading to a better care of such patients.

Risk for early death in acutely ill older adults attended by prehospital emergency medical services. / Modelo de riesgo de mortalidad precoz en pacientes ancianos con enfermedad aguda atendidos por servicios de emergencias prehospitalarias.

OBJECTIVES: To develop and validate a prehospital risk model to predict early in-hospital mortality (#48 hours) in patients aged 65 years or older. MATERIAL AND METHODS: Prospective multicenter observational study in a cohort of patients aged 65 years or older attended by advanced life support emergency services and transferred to 5 Spanish hospitals between April 2018 and July 2019. We collected demographic, clinical and laboratory variables. A risk score was constructed and validated based on the analysis of prehospital variables associated with death within 48 hours. Predictors were selected by logistic regression. RESULTS: A total of 1759 patients were recruited. The median age was 79 years (interquartile range, 72-85 years), and 766 (43.5%) were women. One hundred eight patients (6.1%) died within 48 hours. Predictors in the Prehospital Older Adults Warning Scale (POAWS) were age, systolic blood pressure, temperature, the ratio of oxygen saturation to the fraction of inspired oxygen, score on the Glasgow coma scale, and lactic acid concentration in venous blood. The area under the receiver operating characteristic curve of the model to predict early mortality was 0.853 (95% CI, 0.80-0.91; P<.001). Mortality in patients at high risk (POAWS score, >7) was 69%. CONCLUSION: The prehospital POAWS score can be used to stratify risk for death within 48 hours in patients aged 65 years or older.

OBJETIVO: Diseñar y validar un modelo predictivo de mortalidad hospitalaria precoz (# 48 horas) en pacientes $ 65 años y basado en variables determinadas a nivel prehospitalario. METODO: Estudio multicéntrico de cohorte prospectivo y observacional. Se incluyeron pacientes $ 65 años atendidos por unidades de soporte vital avanzado y trasladados a un servicio de urgencias hospitalario. Se recogieron variables demográficas, clínicas y analíticas. Se construyó y validó una escala de puntuación mediante la categorización de las variables seleccionadas mediante regresión logística en función de la mortalidad en # 48 horas. RESULTADOS: Se reclutaron 1.759 pacientes, la edad mediana fue de 79 años (RIC 72-85), 766 eran mujeres (43,5%), y fallecieron 108 pacientes (6,1%) en # 48 horas. El modelo predictivo ­escala POAWS (Prehospital Older Adults Warning Score)­ incluyó la edad, presión arterial sistólica, temperatura, saturación de oxígeno en relación con la fracción inspirada de oxígeno, escala de coma de Glasgow y ácido láctico en sangre venosa. El área bajo la curva de la característica operativa del receptor para la mortalidad en # 48 horas fue de 0,853 (IC 95%: 0,80-0,91; p < 0,001). La mortalidad en los pacientes de alto riesgo (> 7 puntos en la escala) fue del 69%. CONCLUSIONES: La escala POAWS desarrollada en el presente estudio puede ser de utilidad para estratificar el riesgo de muerte de los patientes de 65 o más años durante las 48 horas siguientes a la atención en el ámbito prehospitalario.