[Clostridium difficile infections in Spanish Internal Medicine departments during the period 2005-2010: the burden of the disease]. / Infección por Clostridium difficile en el período 2005-2010 en los Servicios de Medicina Interna españoles: el peso de la enfermedad.

INTRODUCTION: Clostridium Difficile infection (CDI) is increasing in Spain. A review is presented of this infection in order to evaluate the burden of the disease in this country. MATERIAL: An analytical retrospective and descriptive study was conducted by analyzing the Minimum Basic Data Set of patients admitted to Internal Medicine Departments and with and without CDI between the years 2005-2010. Clinical and demographical variables were compared. RESULTS: Mean age was 75.5 years (SD 15.4), 54.9% were women and mean stay was 22.2 days (SD 24.8). The Cost [(€ 5,001 (SD 4,985) vs [€ 3,934 (SD 2,738)] and diagnostic complexity [2.04 (SD 2.62) vs [1.67 (SD 1.47)] were also different. Mortality for all causes was 12.5% vs 9.8%. Death risk showed a 30% increase (odds ratio 1.30, 95% confidence interval;1.21-1.39) and readmission rate was 30.4% vs 13.5%. Distribution of cases showed season variations (more cases in winter), and annual incidence increased during the study period. Comorbidities associated to increased risk of acquiring CDI were: anemia, human immunodeficiency virus, dementia, malnutrition, chronic renal failure, and living in a nursing home. CONCLUSION: The results showed a clear negative impact of CDI on hospital admissions. A trend towards progression in its incidence without changes in mortality or readmission rates was observed, in common with the rest of Europe and the Western World.

Executive summary of the consensus document for the training and development of clinical ultrasound in Internal Medicine: Recommendations from the Clinical Ultrasound Working Group of the Spanish Society of Internal Medicine (GTECO-SEMI).

INTRODUCTION: Given the increasing adoption of clinical ultrasound in medicine, it is essential to standardize its application, training, and research. OBJECTIVES AND METHODS: The purpose of this document is to provide consensus recommendations to address questions about the practice and operation of clinical ultrasound units. Nineteen experts and leaders from advanced clinical ultrasound units participated. A modified Delphi consensus method was used. RESULTS: A total of 137 consensus statements, based on evidence and expert opinion, were considered. The statements were distributed across 10 areas, and 99 recommendations achieved consensus. CONCLUSIONS: This consensus defines the most important aspects of clinical ultrasound in the field of Internal Medicine, with the aim of standardizing and promoting this healthcare advancement in its various aspects. The document has been prepared by the Clinical Ultrasound Working Group and endorsed by the Spanish Society of Internal Medicine.

Usefulness of lung ultrasound in the early identification of severe COVID-19: results from a prospective study.

AIM: There is growing evidence regarding the imaging findings of coronavirus disease 2019 (COVID-19) in lung ultrasound (LUS); however, its role in predicting the prognosis has yet to be explored. The aim of the study was to assess the relationship between lung ultrasound findings with the degree of respiratory failure measured by the PaO2/FiO2 ratio (PaFi) andthe prognosis of these patients: need for non-invasive mechanical ventilation (NIMV), admission to the Intensive Care Unit (ICU) and mortality. MATERIAL AND METHOD: Prospective, longitudinal and observational study performed in patients with confirmed COVID-19 underwent a LUS examination and laboratory tests. RESULTS: A total of 107 patients were enrolled: 93.4% with bilateral involvement and 73.83% presented at least one consolidation. A good inverse correlation (Rho Spearman coefficient -0.897) between the ultrasound score and PaFi was obtained. The AUC for identification of patients with more severe respiratory failure, a moderate and severe ARDS, was 0.97 (CI 95%: 0.95-1) and a cut-off score of 34.5 showed a sensitivity of 0.94 and a specificity of 0.91. The Kappa index showed a high concordance (0.83) of the classification by ultrasound lunginvolvement and ARDS. CONCLUSIONS: The combination of the ultrasound score and the presence of respiratory failure can easily identify patients with a higher risk to present complications.

Heart failure and in-hospital mortality in elderly patients after elective noncardiac surgery in Spain.

BACKGROUND: Patients with heart failure (HF) undergoing noncardiac surgical procedures is rising worldwide. This study was aiming at analyzing the impact of heart failure (HF) on the outcomes (mortality, complications, readmissions, and length of stay) of elderly patients undergoing elective major noncardiac surgical procedures in Spain. METHODS: A retrospective observational study of patients undergoing noncardiac surgery was conducted. The Minimum Basic Data Set (MBDS) was used to collect information about the demographic characteristics of patients discharged from hospitals of the Spanish National Health System (SNHS), variables related to patients' medical conditions and surgeries conducted during the episode. RESULTS: A total of 996,986 selected procedures in the discharge record were identified in the period 2007-2015. HF was recorded as a secondary diagnosis in 22,367 discharges (2.24%). The mean age of patients was 76.6±7.27 years, with a difference in patients without and with HF: 76.5 (95% CI: 76.47-76.50) vs 82.8 (95% CI: 82.71-82.90). The number of selected surgical procedures increased by 13.2% (117,487 in 2015 vs. 103,744 in 2007), and the proportion of presence HF as a comorbidity increased by 24.4% (2.4% in 2015 v 1.9% in 2007). The proportion of women was higher in the HF group: 53.2% (95% CI: 53.18-53.22) vs 64.3% (95% CI: 64.20-64.44), with a longer average length of stay: 7.9 (95% CI: 7.9-7.9) vs 14.9 (95% CI 14.7-15.0) days, and women had a higher proportion of comorbidities. HF was found to be an independent risk factor in-hospital mortality in the multilevel risk adjustment model (OR=2.3; 95% CI: 2.2-2.4). CONCLUSIONS: Patients with HF undergoing any of the selected surgical procedures are older; there was women predominance and there is also an important burden of comorbidities than patients without HF undergoing these surgical procedures. HF in the selected procedures, increasing in-hospital mortality, mean length of stay, and the occurrence of adverse events in the Spanish population. The percentage of patients with HF who underwent the selected surgical procedures increased in the study period.

Importance of Lung Ultrasound Follow-Up in Patients Who Had Recovered from Coronavirus Disease 2019: Results from a Prospective Study.

There is growing evidence regarding the imaging findings of coronavirus disease 2019 (COVID-19) in lung ultrasounds, however, their role in predicting the prognosis has yet to be explored. Our objective was to assess the usefulness of lung ultrasound in the short-term follow-up (1 and 3 months) of patients with SARS-CoV-2 pneumonia, and to describe the progression of the most relevant lung ultrasound findings. We conducted a prospective, longitudinal and observational study performed in patients with confirmed COVID-19 who underwent a lung ultrasound examination during hospitalization and repeated it 1 and 3 months after hospital discharge. A total of 96 patients were enrolled. In the initial ultrasound, bilateral involvement was present in 100% of the patients with mild, moderate or severe ARDS. The most affected lung area was the posteroinferior (93.8%) followed by the lateral (88.7%). Subpleural consolidations were present in 68% of the patients and consolidations larger than 1 cm in 24%. One month after the initial study, only 20.8% had complete resolution on lung ultrasound. This percentage rose to 68.7% at 3 months. Residual lesions were observed in a significant percentage of patients who recovered from moderate or severe ARDS (32.4% and 61.5%, respectively). In conclusion, lung injury associated with COVID-19 might take time to resolve. The findings in this report support the use of lung ultrasound in the short-term follow-up of patients recovered from COVID-19, as a radiation-sparing, easy to use, novel care path worth exploring.

Prognostic utility of bedside lung ultrasound before discharge in patients with acute heart failure with preserved ejection fraction. / Utilidad pronóstica de la ecografía a pie de cama previa al alta en pacientes con insuficiencia cardíaca aguda y fracción de eyección preservada.

BACKGROUND AND OBJECTIVE: The utility of lung ultrasound as a prognostic tool for patients with acute heart failure is well known, but most studies have been conducted in mixed groups of patients with preserved and reduced ejection fraction. While some subgroup analysis suggests that lung ultrasound is useful regardless of ejection fraction, no specific studies have addressed this question. Our objective is to determine the utility of bedside lung ultrasound as a prognostic tool for patients with preserved ejection fraction, acute heart failure. MATERIAL AND METHODS: Prospective cohort study with 3-month follow-up after bedside lung ultrasound before discharge in patients hospitalized for acute heart failure with preserved ejection fraction. The number of Blines was determined. Two groups were formed: less than 15Blines (unexposed) and 15Blines or more (exposed). They were compared in terms of readmission and death attributable to worsening heart failure. RESULTS: The exposed group was at higher risk of readmission (HR: 2.39; 95%CI: 1.12-5.12; P=.024), even after multivariable adjustment (HR: 2.46; 95%CI: 1.11-5.46, P=.03). Differences between groups in terms of mortality were not statistically significant (HR: 1.28; 95%CI: .23-6.98). CONCLUSION: Subclinical congestion evaluated with lung ultrasound before discharge is associated with worse prognosis in patients with acute heart failure and preserved ejection fraction. Patients with 15Blines are 2.5times more likely to be readmitted for acute heart failure than less congestive patients.

Impact of Heart Failure on In-Hospital Outcomes after Surgical Femoral Neck Fracture Treatment.

BACKGROUND: Femoral neck fracture (FNF) is a common condition with a rising incidence, partly due to aging of the population. It is recommended that FNF should be treated at the earliest opportunity, during daytime hours, including weekends. However, early surgery shortens the available time for preoperative medical examination. Cardiac evaluation is critical for good surgical outcomes as most of these patients are older and frail with other comorbid conditions, such as heart failure. The aim of this study was to determine the impact of heart failure on in-hospital outcomes after surgical femoral neck fracture treatment. METHODS: We performed a retrospective study using the Spanish National Hospital Discharge Database, 2007-2015. We included patients older than 64 years treated for reduction and internal fixation of FNF. Demographic characteristics of patients, as well as administrative variables, related to patient's diseases and procedures performed during the episode were evaluated. RESULTS: A total of 234,159 episodes with FNF reduction and internal fixation were identified from Spanish National Health System hospitals during the study period; 986 (0.42%) episodes were excluded, resulting in a final study population of 233,173 episodes. Mean age was 83.7 (±7) years and 179,949 (77.2%) were women (p < 0.001). In the sample, 13,417 (5.8%) episodes had a main or secondary diagnosis of heart failure (HF) (p < 0.001). HF patients had a mean age of 86.1 (±6.3) years, significantly older than the rest (p < 0.001). All the major complications studied showed a higher incidence in patients with HF (p < 0.001). Unadjusted in-hospital mortality was 4.1%, which was significantly higher in patients with HF (18.2%) compared to those without HF (3.3%) (p < 0.001). The average length of stay (LOS) was 11.9 (±9.1) and was also significantly higher in the group with HF (16.5 ± 13.1 vs. 11.6 ± 8.7; p < 0.001). CONCLUSIONS: Patients with HF undergoing FNF surgery have longer length of stay and higher rates of both major complications and mortality than those without HF. Although their average length of stay has decreased in the last few years, their mortality rate has remained unchanged.

Heart Failure Is a Poor Prognosis Risk Factor in Patients Undergoing Cholecystectomy: Results from a Spanish Data-Based Analysis.

BACKGROUND: The incidence of cholecystectomy is increasing as the result of the aging worldwide. Our aim was to determine the influence of heart failure on in-hospital outcomes in patients undergoing cholecystectomy in the Spanish National Health System (SNHS). METHODS: We conducted a retrospective study using the Spanish National Hospital Discharge Database. Patients older than 17 years undergoing cholecystectomy in the period 2007-2015 were included. Demographic and administrative variables related to patients' diseases as well as procedures were collected. RESULTS: 478,111 episodes of cholecystectomy were identified according to the data from SNHS hospitals in the period evaluated. From all the episodes, 3357 (0.7%) were excluded, as the result the sample was represented by 474,754 episodes. Mean age was 58.3 (+16.5) years, and 287,734 (60.5%) were women (p < 0.001). A primary or secondary diagnosis of HF was identified in 4244 (0.89%) (p < 0.001) and mean age was 76.5 (+9.6) years. A higher incidence of all main complications studied was observed in the HF group (p < 0.001), except stroke (p = 0.753). Unadjusted in-hospital mortality was 1.1%, 12.9% in the group with HF versus 1% in the non HF group (p < 0.001). Average length of hospital stay was 5.4 (+8.9) days, and was higher in patients with HF (16.2 + 17.7 vs. 5.3 + 8.8; p < 0.001). Risk-adjusted in-hospital mortality models' discrimination was high in both cases, with AUROC values = 0.963 (0.960-0.965) in the APRG-DRG model and AUROC = 0.965 (0.962-0.968) in the CMS adapted model. Median odds ratio (MOR) was high (1.538 and 1.533, respectively), stating an important variability of risk-adjusted outcomes among hospitals. CONCLUSIONS: The presence of HF during admission increases in hospital mortality and lengthens the hospital stay in patients undergoing cholecystectomy. However, mortality and hospital stay have significantly decreased during the study period in both groups (HF and non HF patients).

Alternative CPAP methods for the treatment of secondary serious respiratory failure due to pneumonia by COVID-19.

INTRODUCTION: The use of devices that provide continuous positive pressure in the airway has shown improvement in various pathologies that cause respiratory failure. In the COVID 19 pandemic episode the use of these devices has become widespread, but, due to the shortage of conventional CPAP devices, alternative devices have been manufactured. The objective of this study is to describe the use of these devices, as well as their efficacy. MATERIAL AND METHODS: Data are collected from patients admitted for Pneumonia due to COVID 19 at the IFEMA Field Hospital. Data are collected from 23 patients with respiratory failure and need for ventilatory support. RESULTS: Study carried out on a total of 23 patients, dated admission to IFEMA. Alternative CPAP was used in five patients (21.7%), while ventilatory support with a reservoir mask or Ventimask Venturi effect was used in the remaining 18 patients (78.3%). A progressive increase in saturation is observed in those patients in whom alternative CPAP was used (from 94% on average to 98% and 99% on average after 30 and 60 min with the mask, respectively), although this change was not significant (p = 0.058 and p = 0.122 respectively). No significant change in RF was observed at the beginning and end of the measurement in patients who used alternative CPAP (p = 0.423), but among those who did not use alternative CPAP (p = 0.001). A statistically significant improvement in the variable oxygen saturation / fraction inspired by oxygen is observed in patients who used alternative CPAP (p = 0.040). CONCLUSION: The use of these devices has helped the ventilatory work of several patients by improving their oxygenation parameters. To better observe the evolution of patients undergoing this therapy and compare them with patients with other types of ventilatory support, further studies are necessary.

INTRODUCCIÓN: El uso de dispositivos que aportan presión positiva continua en la vía aérea ha demostrado mejoría en diversas patologías que producen insuficiencia respiratoria. En el episodio de pandemia por COVID 19 el uso de estos dispositivos se ha generalizado, pero, debido a la escasez de dispositivos convencionales de CPAP, se han fabricado dispositivos alternativos. El objetivo de este estudio es describir el uso de estos dispositivos, así como su eficacia. MATERIAL Y MÉTODOS: Se recogen datos de pacientes ingresados por Neumonía por COVID 19 en el Hospital de campaña de IFEMA. Se recogen datos de pacientes con insuficiencia respiratoria y necesidad de soporte ventilatorio. RESULTADOS: Estudio realizado sobre un total de 23 pacientes, con fecha ingreso en IFEMA. Se empleó CPAP alternativa en cinco pacientes (21,7%), mientras que en los 18 pacientes restantes (78,3%) se usó soporte ventilatorio con mascarilla reservorio o Ventimask efecto Venturi. Se observa un aumento progresivo de la saturación en aquellos pacientes en los que se empleó CPAP alternativa (de 94% de promedio a 98% y 99% de promedio tras 30 y 60 minutos con la máscara, respectivamente), aunque este cambio no resultó significativo (p = 0,058 y p = 0,122 respectivamente). No se observó un cambio significativo de frecuencia respiratoria al inicio y final de la medición en pacientes que usaron CPAP alternativa (p = 0,423) pero si entre los que no la usaron (p = 0,001). Se observa una mejoría estadísticamente significativa en la variable Saturación de oxigeno / Fracción inspirado de oxígeno en los pacientes que usaron CPAP alternativa (p = 0,040). CONCLUSIÓN: El uso de estos dispositivos ha ayudado al trabajo ventilatorio de varios pacientes mejorando sus parámetros de oxigenación. Para observar mejor la evolución de los pacientes sometidos a esta terapia y compararlos con pacientes con otro tipo de soporte ventilatorio, son necesarios más estudios en los que se aleatorice su uso.

[Alternative CPAP methods for the treatment of secondary serious respiratory failure due to pneumonia by COVID-19]. / Métodos alternativos de CPAP para el tratamiento de insuficiencia respiratoria grave secundaria a neumonía por COVID-19.

INTRODUCTION: The use of devices that provide continuous positive pressure in the airway has shown improvement in various pathologies that cause respiratory failure. In the COVID-19 pandemic episode the use of these devices has become widespread, but, due to the shortage of conventional continuous positive airway pressure (CPAP) devices, alternative devices have been manufactured. The objective of this study is to describe the use of these devices, as well as their efficacy. MATERIAL AND METHODS: Data are collected from patients admitted for pneumonia due to COVID-19 at the IFEMA Field Hospital. Data are collected from 23 patients with respiratory failure and need for ventilatory support. RESULTS: Study carried out on a total of 23 patients, dated admission to IFEMA. Alternative CPAP was used in five patients (21.7%), while ventilatory support with a reservoir mask or Ventimask Venturi effect was used in the remaining 18 patients (78.3%). A progressive increase in saturation is observed in those patients in whom alternative CPAP was used (from 94% on average to 98 and 99% on average after 30 and 60 minutes with the mask, respectively), although this change was not significant (p = 0.058 and p = 0.122, respectively). No significant change in RF was observed at the beginning and end of the measurement in patients who used alternative CPAP (p = 0.423), but among those who did not use alternative CPAP (p = 0.001). A statistically significant improvement in the variable oxygen saturation / fraction inspired by oxygen is observed in patients who used alternative CPAP (p = 0.040) CONCLUSION: The use of these devices has helped the ventilatory work of several patients by improving their oxygenation parameters. To better observe the evolution of patients undergoing this therapy and compare them with patients with other types of ventilatory support, further studies are necessary.

Comparison of Lung Ultrasound versus Chest X-ray for Detection of Pulmonary Infiltrates in COVID-19.

Point-of-care lung ultrasound (LUS) is an attractive alternative to chest X-ray (CXR), but its diagnostic accuracy compared to CXR has not been well studied in coronavirus disease 2019 (COVID-19) patients. We conducted a prospective observational study to assess the correlation between LUS and CXR findings in COVID-19 patients. Ninety-six patients with a clinical diagnosis of COVID-19 underwent an LUS exam and CXR upon presentation. Physicians blinded to the CXR findings performed all LUS exams. Detection of pulmonary infiltrates by CXR versus LUS was compared between patients categorized as suspected or confirmed COVID-19 based on reverse transcriptase-polymerase chain reaction. Sensitivities and correlation by Kappa statistic were calculated between LUS and CXR. LUS detected pulmonary infiltrates more often than CXR in both suspected and confirmed COVID-19 subjects. The most common LUS abnormalities were discrete B-lines, confluent B-lines, and small subpleural consolidations. Most important, LUS detected unilateral or bilateral pulmonary infiltrates in 55% of subjects with a normal CXR. Substantial agreement was demonstrated between LUS and CXR for normal, unilateral or bilateral findings (Κ = 0.48 (95% CI 0.34 to 0.63)). In patients with suspected or confirmed COVID-19, LUS detected pulmonary infiltrates more often than CXR, including more than half of the patients with a normal CXR.

[Mortality in internal medicine departments]. / Mortalidad en los servicios de medicina interna.

UNLABELLED: Mortality is an important indicator of clinical activity. The aim of this paper is to analyze the mortality in Internal Medicine (IM) departments in our country taking into account the characteristics of the patients seen at our hospitals. MATERIAL AND METHODS: Patients attended at the IM Departments of Spanish hospitals during 2006 were analyzed through the CMBD (minimum basic set of data; in Spanish: <>) which collects administrative and clinical data of all patients admitted to the public and private hospital of our state. Global and specific mortality by DRG were established and compared with the national standard published by the Spanish Health and Consume Ministry for that same year. RESULTS: In general hospitals of the National Health Service for the year 2006, 3,589,718 patients were discharged, 522,268 (14.5%) of them from IM departments. Of this last group, 46.6% were female, with a mean age of 70.4 years (SD 11.6) and a mean weight of 1.72 (SD 1.39). Global mortality was 9.5% compared to a national standard of 4.1%. Comparing by DRG, mortality was in general higher in IM. CONCLUSIONS: Global mortality as well as specific mortality by DRG is higher than the general mortality. This could be explained by the characteristics of the population admitted in IM: older, seriously ill, with more co-morbidities, admitted trough the emergency department and consuming more resources than the general population.

[Use of lung ultrasound as a prognostic tool in outpatients with heart failure]. / Utilidad pronóstica de la ecografía pulmonar en el seguimiento ambulatorio de pacientes con insuficiencia cardiaca.

OBJECTIVES: To assess the prognostic value of lung ultrasound for patients with chronic heart failure. METHODS: Prospective observational cohort study, in which a lung ultrasound was performed on 54 patients at a heart failure outpatient consultation. Ultrasonography was classified as positive or negative for ultrasound interstitial syndrome depending on the number of B lines observed. Patients were followed up for six months; considering emergency visits, readmissions and deaths due to heart failure as markers of poor prognosis. RESULTS: 53.7% (29) of the patients had ultrasound interstitial syndrome. Among them, 48.3% (14) were readmitted, compared to 16% (4) of those without the syndrome (P=.012). Considering any of the events previously described as end points (readmissions, emergencies and deaths), we found that in the group of patients with ultrasound interstitial syndrome, 55.2% (16) had at least one of these complications, compared to 20% (5) of participants without the syndrome (P=.008). CONCLUSIONS: Lung ultrasound in the outpatient setting is useful in predicting which patients are at increased risk of heart failure decompensation in the mid-term.

[Soluble interleukin-2 and tumor necrosis factor receptor in liver cirrhosis. Relationship with clinical severity and prognosis]. / Receptores solubles de la interleucina 2 y del factor de necrosis tumoral en la cirrosis hepática de diversas etiologías. Relación con el pronóstico y la gravedad clínica.

BACKGROUND AND OBJECTIVE: The mechanism responsible for the beginning and progression of hepatic injury in liver cirrhosis of viral and alcoholic etiology are unknown currently. However, there are abnormalities in the immune system which may be implied in the pathogenesis. PATIENTS AND METHOD: The concentrations of the soluble receptor of tumor necrosis factor (sTNF-R55) and the soluble receptor of interleukin-2 (sIL-2R) in 49 cirrhotic patients were determined by enzyme-linked inmunoassay. Patients were grouped according to the etiology (33 alcoholic and 16 viral) and prognosis (Child-Pugh classification) and they were compared with the values obtained in 26 healthy non-drinkers who made up the control group. RESULTS: The concentrations of sTNF-R55 and sIL-2R were significantly higher in both groups of patients when compared with controls. We found significant differences in sTNF-R55 concentrations in viral and alcoholic but not in sIL-2R concentrations. There was a positive correlation between the concentrations of both receptors and the degrees of Child-Pugh classification, as well as with albumin, total bilirubin and alkaline phosphatase (all of them parameters related to the severity and prognosis of liver cirrhosis). CONCLUSIONS: The serum concentrations of soluble receptors of tumor necrosis factor and interleukin-2 correlate with the prognosis of liver cirrhosis independently of its etiology. This fact may reflect the stimulation of T lymphocytes, monocytes and macrophages, in liver cirrhosis.