Mortality risk model validation in a prospective cohort of patients from the sixth wave of the COVID-19 pandemic in a hospital emergency department. / Validación del modelo de riesgo de mortalidad en una cohorte prospectiva de pacientes de la sexta ola epidémica de la COVID-19 en un servicio de urgencias hospitalario.

OBJECTIVES: To validate risk factors for mortality in patients treated for COVID-19 in a hospital emergency department during the sixth wave of the pandemic. MATERIAL AND METHODS: Prospective observational noninterventional study. We included patients over the age of 18 years with a confirmed diagnosis of COVID-19 between December 1, 2021, and February 28, 2022. For each patient we calculated a risk score based on age 50 years or older (2 points) plus 1 point each for the presence of the following predictors: Barthel index less than 90 points, altered level of consciousness, ratio of arterial oxygen saturation to fraction of inspired oxygen less than 400, abnormal breath sounds, platelet concentration less than 100 × 109/L, C-reactive protein level of 5 mg/dL or more, and glomerular filtration rate less than 45 mL/min. The model was assessed with the area under the receiver operating characteristic curve (AUC). RESULTS: Of the 1156 patients included, 790 (68%) had received at least 2 vaccine doses. The probability of 30-day survival was 96%. A risk score was calculated for 609 patients. Four hundred seventeen patients were at low risk of death, 180 were at intermediate risk, and 10 were at high risk. The probability of death within 30 days was 1%, 13%, and 50% for patients in the 3 risk groups, respectively. The sensitivity, specificity, and positive and negative predictive values of a risk score of 3 points or less were 88%, 72%, 19%, 99%, respectively.The AUC for the model was 0.87. CONCLUSION: The risk model identified low risk of mortality and allowed us to safely discharge patients treated for COVID-19 in our tertiary-care hospital emergency department.

OBJETIVO: Validación de un indicador de mortalidad derivado durante los primeros meses de la pandemia de la COVID-19 en pacientes con COVID-19 atendidos durante la sexta ola epidémica en un servicio de urgencias hospitalario (SUH). METODO: Estudio observacional prospectivo no intervencionista. Se incluyeron pacientes > 18 años diagnosticados de casos confirmados de COVID-19 (1 diciembre 2021-28 febrero 2022). Se calculó el indicador para cada paciente: edad $ 50 años (2 puntos), índice de Barthel 90 puntos (1 punto), alteración de consciencia (1 punto), índice de SaO2/FIO2 400 (1 punto), auscultación respiratoria patológica (1 punto), plaquetas 100 x 109/L (1 punto), proteína C reactiva $ 5 mg/dL (1 punto) y filtrado glomerular 45 mL/min (1 punto). El rendimiento del indicador se valoró con el análisis del área bajo la curva de la característica operativa del receptor (ABC-COR). RESULTADOS: De los 1.156 pacientes incluidos en el estudio, 790 (68%) habían recibido como mínimo una dosis de vacuna. La probabilidad de supervivencia a los 30 días de la serie fue del 96%. El indicador de riesgo se pudo calcular en 609 pacientes. Cuatrocientos diecisiete pacientes se clasificaron como de riesgo bajo, 182 de riesgo intermedio y 10 de riesgo alto. La probabilidad de mortalidad a los 30 días fue de 1%, 13% y 50%, respectivamente. La sensibilidad, especificidad y valores predictivos positivo y negativo para un punto de corte menor o igual a 3 puntos fue 88%, 72%, 19%, 99%, respectivamente. El ABC-COR para el indicador fue de 0,87. CONCLUSIONES: Un valor del indicador de bajo riesgo permite dar de alta con seguridad a los pacientes con COVID-19 que se atienden en un SUH de un centro de tercer nivel.

Risk score for mortality due to COVID-19: a prospective temporal validation cohort study in the emergency department of a tertiary care hospital. / Validación temporal de un modelo de riesgo de mortalidad por COVID-19 en una cohorte prospectiva en un servicio de urgencias de un hospital de tercer nivel.

OBJECTIVES: To validate a previously described hospital emergency department risk model to predict mortality in patients with COVID-19. MATERIAL AND METHODS: Prospective observational noninterventional study. Patients aged over 18 years diagnosed with COVID-19 were included between December 1, 2020, and February 28, 2021. We calculated a risk score for each patient based on age 50 years (2 points) plus 1 point each for the presence of the following predictors: Barthel index 90 points, altered level of consciousness, ratio of arterial oxygen saturation to fraction of inspired oxygen 400, abnormal breath sounds, platelet concentration 100 × 109/L, C reactive protein level 5 mg/dL, and glomerular filtration rate 45 mL/min. The dependent variable was 30-day mortality. We assessed the score's performance with the area under the receiver operating characteristic curve (AUC). RESULTS: The validation cohort included 1223 patients. After a median follow-up of 80 days, 143 patients had died; 901 patients were classified as having low risk (score, 4 points), 270 as intermediate risk (5-6 points), and 52 as high risk ( 7 points). Thirty-day mortality rates at each risk level were 2.8%, 22.5%, and 65.4%, respectively. The AUC for the score was 0.883; for risk categorization, the AUC was 0.818. CONCLUSION: The risk score described is useful for stratifying risk for mortality in patients with COVID-19 who come to a tertiary-care hospital emergency department.

OBJETIVO: Validación de un indicador de mortalidad previamente descrito en pacientes con COVID-19 en un servicio de urgencias hospitalario (SUH). METODO: Estudio observacional prospectivo no intervencionista. Se incluyeron pacientes 18 años diagnosticados de COVID-19 (1 de diciembre de 2020 hasta 28 de febrero de 2021). Se calculó el indicador para cada paciente: edad 50 años (2 puntos), índice de Barthel 90 puntos (1 punto), alteración de consciencia (1 punto), índice de SaO2/ FIO2 400 (1 punto), auscultación respiratoria patológica (1 punto), plaquetas 100 x 109/L (1 punto), proteína C reactiva 5 mg/dL (1 punto) y filtrado glomerular 45 mL/min (1 punto). La variable dependiente fue la mortalidad observada a 30 días. El rendimiento del indicador se valoró con el análisis del área bajo la curva de la característica operativa del receptor (ABC-COR). RESULTADOS: La validación del indicador se realizó sobre una cohorte de 1.223 pacientes. Tras una mediana de seguimiento de 80 días, 143 pacientes habían fallecido. Un total de 901 pacientes fueron catalogados como riesgo bajo (indicador 4 puntos), 270 lo fueron como riesgo intermedio (5-6 puntos) y 52 como riesgo alto ( 7 puntos). La mortalidad a 30 días observada en cada categoría fue de 2,8%, 22,5% y 65,4%, respectivamente. El ABC-COR fue de 0,883 para el indicador utilizado cuantitativamente y de 0,818 cuando se usó cualitativamente en forma de categorías de riesgo. CONCLUSIONES: El indicador descrito es una herramienta útil para estratificar el riesgo de mortalidad de los pacientes con COVID-19 que consultan a un SUH de un centro de tercer nivel.

Mortality in patients treated for COVID-19 in the emergency department of a tertiary care hospital during the first phase of the pandemic: Derivation of a risk model for emergency departments. / Análisis de mortalidad de los pacientes atendidos por COVID-19 en el servicio de urgencias de un hospital de tercer nivel en la fase incial de la pandemia. Derivación de un modelo de riesgo para urgencias.

OBJECTIVES: To develop a risk model to predict 30-day mortality after emergency department treatment for COVID-19. MATERIAL AND METHODS: Observational retrospective cohort study including 2511 patients with COVID-19 who came to our emergency department between March 1 and April 30, 2020. We analyzed variables with Kaplan Meier survival and Cox regression analyses. RESULTS: All-cause mortality was 8% at 30 days. Independent variables associated with higher risk of mortality were age over 50 years, a Barthel index score less than 90, altered mental status, the ratio of arterial oxygen saturation to the fraction of inspired oxygen (SaO2/FIO2), abnormal lung sounds, platelet concentration less than 100 000/mm3, a C-reactive protein concentration of 5 mg/dL or higher, and a glomerular filtration rate less than 45 mL/min. Each independent predictor was assigned 1 point in the score except age, which was assigned 2 points. Risk was distributed in 3 levels: low risk (score of 4 points or less), intermediate risk (5 to 6 points), and high risk (7 points or above). Thirty-day risk of mortality was 1.7% for patients who scored in the low-risk category, 28.2% for patients with an intermediate risk score, and 67.3% for those with a high risk score. CONCLUSION: This mortality risk stratification tool for patients with COVID-19 could be useful for managing the course of disease and assigning health care resources in the emergency department.

OBJETIVO: Derivar un modelo de riesgo para estimar la probabilidad de mortalidad a los 30 días de la visita a urgencias de pacientes con COVID-19. METODO: Estudio observacional de cohortes retrospectivo de 2.511 pacientes con COVID-19 atendidos en el servicio de urgencias hospitalario (SUH) del 1 de marzo al 30 de abril de 2020. Se realizó análisis de supervivencia mediante Kaplan Meier y regresión de Cox. RESULTADOS: La mortalidad por cualquier causa a los 30 días fue de un 8%. Los factores asociados de forma independiente a mayor mortalidad fueron: edad 50 años, índice de Barthel 90 puntos, alteración del nivel de consciencia, índice de SaO2/FIO2 400, auscultación respiratoria anómala, cifra de plaquetas 100.000/mm3, PCR 5 mg/dL y filtrado glomerular 45 mL/min. A estos factores se les asignó una puntuación de 1, excepto a la edad, que se le asignó un valor de 2 puntos. Se dividió el modelo de riesgo en 3 categorías: riesgo bajo (menor o igual a 4 puntos), riesgo intermedio (5-6 puntos) y riesgo alto (igual o superior a 7 puntos). Para los pacientes clasificados como de bajo riesgo la probabilidad de mortalidad a los 30 días fue del 1,7%, en los casos de riesgo intermedio fue del 28,2% y para los de alto riesgo fue del 67,3%. CONCLUSIONES: Disponer de una herramienta para estratificar el riesgo de mortalidad de los pacientes con COVID-19 que consultan a un SUH podría ser de utilidad para la gestión de los recursos sanitarios disponibles.

Factors associated with revisits by patients with SARS-CoV-2 infection discharged from a hospital emergency department. / Factores asociados a revisita en pacientes con diagnóstico de infección por SARS-CoV-2 dados de alta de un servicio de urgencias hospitalario.

OBJECTIVES: To analyze emergency department (ED) revisits from patients discharged with possible coronavirus disease 2019 (COVID-19). MATERIAL AND METHODS: Retrospective observational study of consecutive patients who came to the ED over a period of 2 months and were diagnosed with possible COVID-19. We analyzed clinical and epidemiologic variables, treatments given in the ED, discharge destination, need to revisit, and reasons for revisits. Patients who did or did not revisit were compared, and factors associated with revisits were explored. RESULTS: The 2378 patients included had a mean age of 57 years; 49% were women. Of the 925 patients (39%) discharged, 170 (20.5%) revisited the ED, mainly for persistence or progression of symptoms. Sixty-six (38.8%) were hospitalized. Odds ratios (ORs) for the following factors showed an association with revisits: history of rheumatologic disease (OR, 2.97; 95% CI, 1.10-7.99; P = .03), digestive symptoms (OR, 1.73; 95% CI, 1.14-2.63; P = .01), respiratory rate over 20 breaths per minute (OR, 1.03; 95% CI, 1.0-1.06; P = .05), and corticosteroid therapy given in the ED (OR, 7.78; 95% CI, 1.77-14.21, P = .01). Factors associated with hospitalization after revisits were age over 48 years (OR, 2.57; 95% CI, 1 42-4.67; P = .002) and fever (OR, 4.73; 95% CI, 1.99-11.27; P = .001). CONCLUSION: Patients under the age of 48 years without comorbidity and with normal vitals can be discharged from the ED without fear of complications. A history of rheumatologic disease, fever, digestive symptoms, and a respiratory rate over 20 breaths per minute, or a need for corticosteroid therapy were independently associated with revisits. Fever and age over 48 years were associated with a need for hospitalization.

OBJETIVO: Analizar las revisitas y los factores asociados a la misma en pacientes con diagnóstico de posible COVID-19 dados de alta de un servicio de urgencias hospitalario (SUH). METODO: Estudio observacional, retrospectivo que incluyó pacientes consecutivos que consultaron al SUH en un periodo de 2 meses y fueron diagnosticados de posible de COVID-19. Se analizaron variables clínico-epidemiológicas, tratamiento administrado en urgencias, destino final, revisita al SUH y motivo de esta. Se hizo un análisis comparativo entre ambos grupos (revisita sí/no) y se identificaron factores asociados a la revisita. RESULTADOS: Se incluyeron 2.378 pacientes (edad media 57 años; 49% mujeres). De los pacientes dados de alta (39% del total; n = 925), 170 (20,5%) reconsultaron al SUH, principalmente por persistencia o progresión de síntomas, y 66 (38,8%) precisaron ingreso. Los factores relacionados con la revisita fueron: antecedentes de enfermedad reumatológica [OR: 2,97 (IC 95%: 1,10-7,99, p = 0,03)], síntomas digestivos [OR: 1,73 (IC 95%: 1,14-2,63, p = 0,01)], frecuencia respiratoria $ 20 [OR: 1,03 (IC 95%: 1,0-1,06, p = 0,05)] y haber recibido tratamiento con esteroides en urgencias [OR: 7,78 (IC 95%: 1,77-14,21, p = 0,01)]. Los factores asociados al ingreso en la revisita fueron la edad $ 48 años [OR: 2,57 (IC 95%: 1,42-4,67, p = 0,002)] y presentar fiebre [OR: 4,73 (IC 95%: 1,99-11,27, p = 0,001)]. CONCLUSIONES: Los pacientes con posible COVID-19 menores de 48 años, sin comorbilidad y con signos vitales normales podrían ser dados de alta desde urgencias sin temor a sufrir complicaciones. Los antecedentes de enfermedad reumatológica, fiebre, sintomas digestivos, frecuencia respiratoria $ 20/min o necesidad de tratamiento con esteroides fueron factores independientes de revisita, y la fiebre y edad $ 48 años de necesidad de ingreso.

[Ethical and legal features of living donor kidney transplantation. Management and coordination of the process of living donation]. / Aspectos éticos y legales del trasplante renal de donante vivo. Gestion y coordinacion del proceso de donacion de vivo.

OBJECTIVES: Living donors for kidney transplantation have attracted interest from different points of view because medical issues are accompanied by other features involving ethical, legal and social issues. We analyze all aspects involved in living donation for kidney transplantation. METHODS: We analyze: (1) ETHICAL ISSUES: requirements to become living donor, donor-receptor relationship, informed consent, donor's motivations, risk/benefit. (2) Legal issues: We review Spanish laws and Council of Europe's recommendations. (3) We also analyze how to coordinate the process in order to guarantee protection to donors. RESULTS/CONCLUSIONS: Living donor kidney transplantation is a growing therapeutic option. The process of living donation should comply with several legal and ethical requirements, and cooperation between different professionals to guarantee protection to donors.

Successful liver and kidney transplantation from cadaveric donors with left-sided bacterial endocarditis.

Bacterial infections are frequent in cadaveric organ donors and can be transmitted to the transplantation recipient, which could have devastating consequences for the recipients if adequate preventive measures are not adopted. From the 355 consecutive brain dead cadaveric organ donors procured at our center in the last four years, 2000-2003, four of them (1.1%) had bacterial endocarditis as cause of death. The bacteria responsible for the endocarditis were Staphylococcus epidermidis, coagulase-negative Staphylococcus, Staphylococcus hominis and Streptococcus viridans, respectively. We performed five kidney and two liver transplantations on seven recipients. All donors and recipients received antibiotic treatment against the germ causing the respective endocarditis. Infection by the bacteria responsible for the endocarditis in the respective donors was not transmitted to any of the recipients. Six of the seven recipients were alive with normal-functioning grafts after between 13 and 24 months' follow-up. Transplantectomy was performed on one kidney recipient due to thrombosis of the renal vein of the graft not related to the endocarditis. Liver and kidney transplantation from donors dying from bacterial endocarditis can be performed without causing the transmission of infection to the recipient or the dysfunction of the graft.

Enzymatic diagnosis of oxidative phosphorylation defects on muscle biopsy: better on tissue homogenate or on a mitochondria-enriched suspension?

BACKGROUND: The enzymatic analysis of mitochondrial respiratory chain (MRC) complexes of skeletal muscle is an important step in the diagnosis of mitochondrial disorders. Because of its lesser turbidity and increased sensitivity, mitochondrial fractionation has been increasingly considered the diagnostic method of choice compared with the more classical analysis of muscle homogenate. In circumstances in which mitochondria become abnormal in number, size or shape, the process of mitochondrial enrichment made by sequential centrifugation and washing may favor the selection of the most normal mitochondria, eliminating the most abnormal ones. In this situation, the study of muscle homogenate, paradoxically, may better reflect what happens in vivo. CASE REPORT: To exemplify this situation we present a 60-year-old woman with a complete mitochondrial phenotype and a 70% heteroplasmic presence of the mtDNA A3243G mutation in muscle tissue. The respiratory and enzymatic activities from mitochondria-enriched muscle suspension were within normal control limits. In contrast, when muscle homogenate was studied, enzyme activities of complexes I, III, and V were found to be decreased. CONCLUSIONS: Although mitochondria-enriched muscle suspensions are usually more informative than muscle homogenates for studies of MRC, in some situations it may be necessary to study both to uncover the biochemical defect.

Muscle diseases in elders: a 10-year retrospective study.

BACKGROUND: Muscle complaints are frequent among older adults, but histological data in this setting are scarce. Our objective was to detect the major categories of muscle diseases in the elderly population based on histological study. METHODS: We reviewed all muscle biopsies performed in our hospital on patients older than the age of 65 during a 10-year period (1988-1997). As a control group, we included the next patient younger than 65 who underwent muscle biopsy after each elderly patient. We recorded demographic, clinical, and histological data of the patients, as well as the final diagnosis. Concordance between pre- and postbiopsy diagnosis was also analyzed. RESULTS: We included 239 muscle biopsies corresponding to elderly patients and 239 to controls. Compared with the control group, elderly patients more frequently exhibited type II fiber atrophy and were diagnosed with a specific myopathy. The latter was achieved in 86 cases (36%), idiopathic inflammatory myopathies and vasculitis being the most frequent diagnoses. Interestingly, in about one quarter of the elderly patients in whom a definite diagnosis of muscle disease was achieved, this diagnosis had not been clinically suspected prior to muscle biopsy. Overall, in 60 out of 239 elderly patients (25%), a specific therapeutic regimen could be instituted on the basis of the muscle biopsy results. CONCLUSIONS: Muscle diseases are not rare in elderly patients. Therefore, muscle biopsy constitutes a safe and useful tool for diagnosis because, if not performed, some potentially treatable diseases may be undiagnosed or misdiagnosed.