[Asthma emergencies: can we lower the rate of readmission after discharge?]. / Asma en urgencias: podemos disminuir la tasa de reingresos tras el alta?

INTRODUCTION: The rate of readmission among asthmatic emergency patients varies. In 1991 we observed a 9% rate of readmission following emergency room release. Studies of the number of readmissions or request for medical care are used as the basis for recommendations for releasing patients from hospital emergency care. No studies have assessed disease stability following release or factors related to stability. OBJECTIVES: To assess the course of disease and clinical stability of patients in the period immediately following release from emergency room care. To determine factors that might predict such stability. to determine the rate of readmission in the month following release after applying a treatment protocol and release criteria, with follow-up examination 72 h later. MATERIAL AND METHODS: Prospective, descriptive study with follow-up 72 h and one month after release. SETTING: Emergency and pneumology departments of a general hospital. PERIOD: six months. PATIENTS: 82 asthmatic patients released from the emergency room. RESULTS: Two patients (2.43% were readmitted. At the first follow-up visit (72 h) 81 patients (98.78%) were seen. At the second visit, 66 patients (80.5%) were examined. We observed stability in 70.3% of patients at 72 h and in 86.4% after on month. Stability was statistically related to whether peak expiratory flow greater or less than 70% (76.92% stable versus 46.66% unstable) (p < 0.05). No other clinical, epidemiological or treatment variables recorded upon release were found to influence stability. CONCLUSIONS: 1) A large proportion of patients are in stable condition 72 h after release. 2) When peak expiratory flow upon release is > 70%, stability is significantly increased 72 h later. 3) Our 2.43% rate of readmission one month after release is very low. 4) No differences in stability were seen to be related to oral corticoid prescription upon release.

[Early discharge and home health care program for patients with exacerbated COPD and asthma]. / Programa de altas precoces y asistencia domiciliaria en pacientes con exacerbación de enfermedad pulmonar obstructiva crónica y asma.

OBJECTIVE: To shorten hospital stays of patients with exacerbated chronic obstructive pulmonary disease (COPD) or asthma by way of a home care program and to assess whether the program increased the number of readmissions. METHODS: Patients admitted due to COPD exacerbation or asthma who did not need critical care and were discharged before the fourth day. A registered nurse experienced with respiratory disease patients and in regular contact with the pneumologist who supervised the program made follow-up home care visits to give instructions and check compliance with treatment. RESULTS: Sixty-nine patients enrolled in the program, 53 with COPD and 16 with asthma. A mean 7.2 home care visits per patient were made. The mean hospital stay was 3.69 ( 0.5 days for patients receiving home care and 7.89 ( 5 days for those who received no home care (p < 0.005). Severity of COPD in terms of age, FEV1 and PaO2 was similar in both groups, as follows: FEV1 was 39.4 12% and PaO2 66.3 7,7% for patients receiving home care; FEV1 was 40.6 ( 12% and PaO2 was 64.3 ( 7% for those receiving no home care (ns). The mean hospital stay overall for both groups was 7.4 (4.9 days; the mean hospital stay for the same diseases in the same previous the year before the study was 8.3 ( 5.5 (p < 0.05). The rate of readmissions for new exacerbations within 30 days of discharge was 4.3% (3/69) in the group receiving home care and 7.2% (29/401) among patients receiving only hospital care (ns.). A questionnaire survey at the end of the program showed satisfaction to be very high. CONCLUSIONS: A program of home care provided by a registered nurse experienced with respiratory diseases allows mean hospital stay to be reduced without increasing the number of readmissions within 30 days, with high patient satisfaction.

[Persistent hemoptysis secondary to extensive epithelioid angiosarcoma]. / Hemoptisis de repetición secundarias a un angiosarcoma epitelioide generalizado.

Pulmonary angiosarcoma is an unusual cause of diffuse pulmonary hemorrhage. Angiosarcomas are rare malignant vascular tumors accounting for 1% to 2% of all sarcomas. Angiosarcomas have been detected in nearly all organs, but lung involvement is unusual, accounting for less than 7%. The literature describes approximately 10 isolated cases of primary pulmonary angiosarcoma as opposed to the more common metastatic type. Given that primary and metastatic types are clinicopathologically similar, the presence of a distant primary sarcoma must be ruled out before a diagnosis of primary pulmonary angiosarcoma can be made. A pathological diagnosis requires a finding of polygonal or oval cells with atypical irregular nuclei and vascular spaces lined with such cells surrounded by hemorrhagic phenomena. Immunohistochemical analysis is positive for specific endothelial cell markers such as CD31 and factor VIII, and coexpression of keratin is a frequent finding.

Community-acquired pneumonia in chronic obstructive pulmonary disease: a Spanish multicenter study.

Community-acquired pneumonia (CAP) is an infectious illness that frequently motivates hospital admission when comorbid conditions are present. However, the epidemiology of CAP in relation to the underlying disease of the patients is not well known. We performed a prospective multicenter study with the aim of assessing the clinical characteristics, etiology, and outcome of chronic obstructive pulmonary disease (COPD) patients with CAP. Between October 1992 and December 1994 we studied 124 COPD patients (mean FEV1 40 +/- 11% of predicted, mean FVC/FEV1 49 +/- 10) admitted because of CAP to one of the participating centers. An attempt to obtain an etiologic diagnosis was performed by means of blood cultures (n = 123), sputum cultures (n = 97), pleural fluid cultures (n = 17), protected specimen brush samples (n = 41), percutaneous transthoracic needle aspiration (n = 41), and serology (n = 106). Etiologic diagnosis was achieved in 80 (64%) of cases, however, diagnosis based upon valid techniques was only possible in 73 (59%) cases. The main causal microorganisms were the following: Streptococcus pneumoniae in 32 (43%), Chlamydia pneumoniae in 9 (12%), Hemophilus influenzae in 7 (9%), Legionella pneumophila in 7 (9%), Streptococcus viridans in 3 (4%), Coxiella burnetii in 3 (4%), Mycoplasma pneumoniae in 2 (3%), Nocordia asteroides 2, Aspergillus ssp. 1, and others 10. In three of these cases the etiology was polymicrobial. Bacteremia was present in 19 (15%) cases; S. pneumoniae was the most frequent isolate (13 cases). Antibiotic treatment was modified in 22 cases due to etiologic findings, and in 9 due to therapeutic failure. Ten patients died (8%), and 22 needed mechanical ventilation, the mortality rate in the latter population being 23%. Total or partial resistance of S. pneumoniae to penicillin was observed in 10 of 32 (31%) isolations, and to erythromycin in 2 (6%). The results of this study are important for the standardization of empiric antibiotic strategies in COPD patients with pneumonia.

Programa de altas precoces y asistencia domiciliaria en pacientes con exacerbación de enfermedad pulmonar obstructiva crónica y asma / Early discharge and home health care program for patients with COPD exacerbation or asthma

OBJETIVOS: Acortar las estancias hospitalarias en enfermos ingresados por exacerbación de enfermedad pulmonar obstructiva crónica (EPOC) y asma, con un programa de asistencia domiciliaria, y evaluar si esta medida aumentaba el número de reingresos. MÉTODOS: Los enfermos ingresados por una exacerbación de EPOC y asma que no presentaban una situación crítica eran dados de alta antes del cuarto día. Posteriormente, los días siguientes al alta, eran asistidos en su domicilio por una diplomada universitaria de enfermería, con experiencia en enfermedad respiratoria, que adiestraba y se aseguraba de la cumplimentación del tratamiento, estando en contacto permanente con un neumólogo responsable del plan. El programa se desarrolló durante 6 meses. RESULTADOS: Se incluyeron en el programa de asistencia domiciliaria 69 enfermos entre ellos, 53 casos de EPOC y 16 de asma. Se realizaron un promedio de 7,2 visitas domiciliarias por paciente. La estancia media del grupo de asistencia domiciliaria fue de 3,69 ñ 0,5 días y 7,89 ñ 5 días en el grupo sin atención domiciliaria (p < 0,005). La gravedad de los enfermos con EPOC en cuanto a edad, FEV1 y PaO2 fue similar en los 2 grupos: FEV1 39,4 ñ 12 por ciento y PaO2 66,3 ñ 7,7 por ciento en el grupo de asistencia domiciliaria, y FEV1 40,6 ñ 12 por ciento y PaO2 64,3 ñ 7 por ciento en el grupo sin atención domiciliaria (NS). La estancia media global de los 2 grupos fue de 7,4 ñ 4,9 días y la correspondiente a la misma enfermedad en el mismo período del año previo de 8,3 ñ 5,5 días (p < 0,05). El índice de reingresos por nuevas exacerbaciones, a los 30 días siguientes al alta, fue del 4,3 por ciento (3 de 69) en el grupo con atención domiciliaria y del 7,2 por ciento (29 de 401) en el grupo con atención exclusivamente hospitalaria (NS). Una encuesta realizada al final del programa demostró índices de satisfacción muy elevados. CONCLUSIONES: Un programa de asistencia domiciliaria con una diplomada universitaria de enfermería con experiencia en enfermedad respiratoria permite reducir la estancia media, sin que aumenten el número de reingresos a los 30 días, consiguiéndose altos índices de satisfacción en los enfermos (AU)