Characteristics of patients who died in the hospital emergency service during the SARS-CoV-2 pandemic: a retrospective cohort study in a tertiary hospital in Spain.

The objective of this study is to analyze the characteristics of patients who died in the Hospital Emergency Department (HED) of a Spanish third-level hospital, with a special focus on those who died due to SARS-CoV-2. A retrospective cohort study was conducted, including all patients over 18 years old who died in the Hospital Emergency Department (HED) of a Spanish third-level hospital located in Badalona, Spain, from Jun 2019 to Dec 2020. Various sociodemographic, clinical, and diagnostic variables of the patients were analyzed to identify potential risk factors associated with mortality. During the first wave of the COVID-19 pandemic, a total of 72 patients died in the HED, representing a 42% increase compared to the pre-pandemic period. Of the deceased patients, 11% were attributed to SARS-CoV-2. Furthermore, it was found that patients who died from SARS-CoV-2 during the first wave were significantly younger than those in the second wave, with an average age of 78.6 ± 3.1 years in the first wave and 91.8 ± 4.8 years in the second wave. No significant differences were found regarding gender or associated comorbidities. Overall, the mortality rate at the HED in relation to COVID-19 was low, and infected patients died at younger ages during the first wave compared to the second wave.

Impact of emergency department management of isolated superficial vein thrombosis of the lower limbs: a secondary analysis of data from the ALTAMIRA study. / Impacto del manejo en urgencias en la evolución de los pacientes con trombosis venosa superficial aislada de miembros inferiores: subanálisis del estudio ALTAMIRA.

OBJECTIVES: To describe the management of superficial vein thrombosis (SVT) of the lower limbs in patients treated in Spanish hospital emergency departments (EDs). To evaluate the impact of ED management of venous thromboembolic complications on outcomes and to determine the characteristics of patients who develop complications. MATERIAL AND METHODS: The retrospective multicenter ALTAMIRA study (Spanish acronym for risk factors, complications, and assessment of Spanish ED management of SVT) used recorded data for consecutive patients with a diagnosis of isolated SVT treated in 18 EDs. We gathered data on symptomatic venous thromboembolic disease (deep vein thrombosis, pulmonary embolism, or the extension or recurrence of SVT), clinically significant bleeding, and 180-day mortality. Cox regression analysis was used to explore variables associated with complications. RESULTS: A total of 703 patients were included. Anticoagulation was prescribed for 84.1% of the patients for a median of 30 days (interquartile range, 15-42 days); 81.3% were treated with low molecular weight heparin. A prophylactic dose was prescribed for 48% and an intermediate therapeutic dose for 52%. Sixty-four patients (9.2%) developed symptomatic thromboembolic disease within 180 days, 12 (1.7%) experienced clinically significant bleeding, and 4 (0.6%) died. Complications developed later in patients receiving anticoagulant therapy than in those not taking an anticoagulant (66 vs 11 days , P=.009), and 76.6% of those developing complications were not on anticoagulant when symptoms appeared. A history of thromboembolic disease was associated with developing complications (adjusted hazard ratio, 2.20; 95% confidence interval, 1.34-3.62). CONCLUSION: ED treatment of SVT varies and is often suboptimal. The incidence of thromboembolic complications after SVT is high. Starting anticoagulation in the ED delays the development of complications. Patients with a history of thromboembolic disease are more at risk of complications.

OBJETIVO: Describir el manejo terapéutico de los pacientes con trombosis venosa superficial (TVS) aislada de miembros inferiores en servicios de urgencias hospitalarios (SUH) españoles. Evaluar el impacto del tratamiento instaurado en urgencias en la evolución, en términos de complicaciones de enfermedad tromboembólica venosa (ETV), y conocer las características de los pacientes que sufren complicaciones. METODO: El estudio multicentrico (18 SUH) ALTAMIRA (fActores de riesgo, compLicaciones y evaluación del manejo de la TVS de Miembros Inferiores en hospitales españoles atendidos en los seRvicios de urgenciAs) creó un cohorte retrospectivo de pacientes consecutivos con diagnóstico objetivo de TVS aislada. Se recogieron las complicaciones de ETV sintomáticas (trombosis venosa profunda, tromboembolia pulmonar y extensión o recurrencia de TVS), sangrados clínicamente relevantes y defunciones a 180 días. Se evaluaron las variables asociadas a las complicaciones mediante una regresión de Cox. RESULTADOS: Se incluyeron 703 pacientes. El 84,1% recibieron anticoagulación durante 30 días (rango intercuartil 15-42), 81,3% con heparina de bajo peso molecular (48% dosis profilácticas, 52% intermedias-terapéuticas). En 180 días, 64 pacientes (9,1%) tuvieron complicación de ETV, 12 (1,7%) tuvieron sangrado clínicamente relevante, y 4 fallecieron (0,6%). Los pacientes en que se instauró anticoagulación en urgencias tardaron más tiempo en desarrollar complicaciones (66 vs 11 días, p = 0,009). El 76,6% de los que se complicaron no estaban anticoagulados en ese momento. La ETV previa se asoció de forma independiente con el desarrollo de complicaciones (hazard ratio ajustada 2,20; intervalo de confianza del 95%: 1,34-3,62). CONCLUSIONES: El tratamiento en urgencias de la TVS aislada es heterogéneo y con frecuencia subóptimo. La incidencia de complicaciones de ETV es elevada. El tratamiento anticoagulante iniciado en urgencias supone un retraso en el desarrollo de complicaciones. Los pacientes con ETV previa tienen más riesgo de complicaciones.

High-Sensitivity Troponin T: A Potential Safety Predictive Biomarker for Discharge from the Emergency Department of Patients with Confirmed Influenza.

The purpose of the study was to analyze the relationship between the high-sensitivity troponin T levels in patients with confirmed influenza virus infection and its severity determined by mortality during the care process. In addition, a high-sensitivity troponin T cut-off value was sought to allow us to a safe discharge from the emergency department. An analytical retrospective observational study was designed in which high-sensitivity troponin T is determined as an exposure factor, patients are followed until the resolution of the clinical picture, and the frequency of mortality is analyzed. We included patients ≥ 16 years old with confirmed influenza virus infection and determination of high-sensitivity troponin T. One hundred twenty-eight patients were included (96.9% survivors, 3.1% deceased). Mean and median blood levels of high-sensitivity troponin T of survivors were 26.2 ± 58.3 ng/L and 14.5 ng/L (IQR 16 ng/L), respectively, and were statistically different when compared with those of the deceased patients, 120.5 ± 170.1 ng/L and 40.5 ng/L (IQR 266.5 ng/L), respectively, p = 0.012. The Youden index using mortality as the reference method was 0.76, and the cut-off value associated with this index was 24 ng/L (sensitivity 100%, specificity 76%, NPV 100%, PPV 4%) with AUC of 88,8% (95% CI: 79.8−92.2%), p < 0.001. We conclude that high-sensitivity troponin T levels in confirmed virus influenza infection are a good predictor of mortality in our population, and this predictor is useful for safely discharging patients from the emergency department.

Profiles of patients with venous thromboembolic disease in the emergency department and their medium-term prognosis: data from the ESPHERIA registry. / Registro ESPHERIA: perfiles de pacientes con enfermedad tromboembólica venosa en urgencias y su asociación con el pronóstico a medio plazo.

OBJECTIVES: To assess the 180-day prognosis for patients of different profiles diagnosed with venous thromboembolism (VTE) in emergency departments (EDs). Secondary aims were to assess all-cause mortality and readmission rates and to describe the clinical characteristics and forms of presentation of deep vein thrombosis (DVT) and pulmonary thromboembolism (PTE) in each patient profile. MATERIAL AND METHODS: Secondary analysis of data from the ESPHERIA registry (Spanish acronym for Risk Profile of Patients with VTE Attended in Spanish Emergency Departments), which includes consecutive patients with symptomatic VTE treated in 53 EDs. The cases were divided according to 4 profiles: 1) unprovoked DVT, 2) DVT provoked by transient risk factors, 3)patients with cancer, and 4) patients with low cardiopulmonary reserve. The primary outcome was a composite of 180-day all-cause mortality or readmission. RESULTS: We studied 773 patients: 450 (58.2%) were classified as profile 1, 128 (16.6%) as profile 2, 115 (14.9%) as profile 3 , a nd 8 0 ( 10.3%) a s p rofile 4. We fo und di fferences be tween th e 4 pr ofiles in demographics, com orbidity, clinical presentation, type of DVT and location, management, and outcomes. One hundred ninety-five p atients (25.2%) had at least one of the adverse events included in the composite within 180 days: 69 (8.9%) died and 179 (23.2%) were readmitted. Hazard ratios (HR) indicated that DVT with low cardiopulmonary reserve (HR, 1.73; 95% CI, 1.12-2.68; P = .01)) or DVT with cancer (HR, 3.10; 95% CI, 2.22-4.34; P .001) were the profiles t hat w ere independently associated with the 180-day composite outcome. CONCLUSION: Classifying patients with DVT according to 4 profiles ( unprovoked, provoked by t ransient r isk f actors, associated with cancer, and associated with low cardiopulmonary reserve) when making the diagnosis is useful for assessing prognosis for all-cause mortality or readmission within 180 days. This classification could be useful for establishing a care and follow-up plan when discharging patients with DVT from the ED.

OBJETIVO: Evaluar el pronóstico a 180 días de los pacientes diagnosticados de enfermedad tromboembólica venosa (ETV) en urgencias, en función de una clasificación por perfiles clínicos. Los objetivos secundarios fueron evaluar la mortalidad y el reingreso por todas las causas de manera individual, y describir las características clínicas y formas de presentación de trombosis venosa profunda (TVP) y tromboembolismo pulmonar (TEP), según dichos perfiles. METODO: Análisis secundario del registro ESPHERIA que incluye pacientes consecutivos con ETV sintomática de 53 servicios de urgencias (SU). Se dividió la muestra en 4 perfiles: ETV no provocada (perfil 1), ETV provocada por factores de riesgo transitorios (perfil 2), cáncer (perfil 3) y baja reserva cardiopulmonar (perfil 4). La variable de resultado primaria fue la compuesta mortalidad o reingreso por cualquier causa a 180 días. RESULTADOS: Se incluyeron 773 pacientes de los cuales 450 (58,2%) fueron clasificados en el perfil 1, 128 (16,6%) en el perfil 2, 115 pacientes (14,9%) en el perfil 3 y 80 (10,3%) en el perfil 4. Se documeô€‚˜taron diferencias demográficas, de comorbilidad, presentación clínica, tipo de ETV, manejo, ubicación y resultados entre los perfiles clínicos. Ciento noventa y cinco pacientes (25,2%) presentaron un resultado adverso compuesto a los 180 días, de los cuales 69 (8,9%) fallecieron y 179 (23,2%) sufrieron un nuevo ingreso por cualquier causa. La ETV asociada a baja reserva cardiopulmonar (HR 1,73; IC 95% 1,12-2,68; p = 0,01) y la ETV asociada a cáncer (HR 3,10; IC 95% 2,22-4,34; p 0,001) se asociaron de forma independiente con sufrir un resultado adverso en los primeros 180 días. CONCLUSIONES: Clasificar a los pacientes con ETV según factores de riesgo y comorbilidades en 4 perfiles (no provocada, provocada por factores transitorios, asociada a cáncer y asociada a baja reserva cardiopulmonar) resulta útil al momento del diagnóstico de la ETV para estimar el pronóstico en términos de mortalidad y reingreso a 180 días. Esta clasificación podría ayudar a establecer un plan de cuidados y seguimiento al alta en la ETV diagnosticada en urgencias.

The changing face of prosthetic valve endocarditis at a tertiary-care hospital: 1986-2005.

INTRODUCTION AND OBJECTIVES: To investigate changes in the clinical characteristics, etiology and prognosis of prosthetic valve endocarditis at a tertiary-care hospital. METHODS: Retrospective cohort study of all patients diagnosed with prosthetic valve endocarditis using modified Duke criteria between 1986 and 2005. The analysis covered two time periods: January 1986 to December 1995 (P1) and January 1996 to December 2005 (P2). RESULTS: In total, 133 episodes of endocarditis occurred in 122 patients. Of these, 73 (54.9%) were diagnosed in P1 and 60 (45.1%) in P2, with incidences of 2.19% and 2.18%, respectively. The patients' mean age (SD) was 52.6+/-16.6 years in P1 and 66.2+/-11.5 years in P2 (P=.0001). Clinical characteristics were similar in the two study periods. The increase in Enterococcus infection was remarkable (12.5% in P2 vs. 4.9% in P1; relative risk [RR]=2.5; 95% confidence interval [CI], 0.7-9.6), as was the decrease in viridans group Streptococcus infection (12.5% in P2 vs. 31.1% in P1; RR=0.4; 95% CI, 0.2-0.9). Some 90.4% of patients (63/73) underwent surgery in P1, while 68.3% (41/60) underwent surgery in P2. The difference was significant (RR=0.8; 95% CI, 0.6-0.9). The in-hospital mortality rate was 28.8% in P1 and 30% in P2 (RR=1; 95% CI, 0.6-1.7). CONCLUSIONS: Changes in the epidemiology and microbiological etiology of prosthetic valve endocarditis were observed over the 20-year study period. Diagnostic and therapeutic approaches also changed, but mortality remained high.

Clinical course and predictors of death in prosthetic valve endocarditis over a 20-year period.

OBJECTIVE: To compare early and late outcome of patients with prosthetic valve endocarditis treated medically versus surgically and to determine predictors of in-hospital death. We retrospectively reviewed patient's clinical records, including laboratory findings, surgery, and pathologic files, in an acute-care, 1200-bed teaching hospital. METHODS: One hundred thirty-three episodes of definite prosthetic valve endocarditis as defined by the Duke University diagnostic criteria occurred in 122 patients from January 1986 to December 2005. Logistic regression model was used to identify prognostic factors of in-hospital mortality. Long-term follow-up was made to assess late prognosis. RESULTS: Bioprostheses were involved in 52% of cases and mechanical valves in 48%. The aortic valve was affected in 45% of patients. Staphylococcus epidermidis was isolated in 23% of cases, Streptococcus spp in 21%, S aureus in 13%, and Enterococcus in 8%. Cultures were negative in 18% of cases. Twenty-six patients were treated medically and 107 with combined antibiotics and valve replacement. The operative mortality was 6.5% and the in-hospital mortality, 29%. Presence of an abscess at echocardiography, urgent surgical treatment, heart failure, thrombocytopenia, and renal failure were significant predictors of in-hospital death. Kaplan-Meier survival at 12 months was 42% in patients treated medically and 71% in those treated surgically (P = .0007). Freedom from endocarditis was 91% at the end of follow-up. CONCLUSIONS: Prosthetic valve endocarditis is a serious condition with high mortality. Patients with perivalvular abscess had a worse prognosis, and combined surgical and medical treatment could be the preferred approach to improve outcome.