The Role of Vascular Imaging atReferral Centers in the Drip and Ship Paradigm.

BACKGROUND: In drip-and-ship protocols, non-invasive vascular imaging (NIVI) at Referral Centers (RC), although recommended, is not consistently performed and its value is uncertain. We evaluated the role of NIVI at RC, comparing patients with (VI+) and without (VI-) vascular imaging in several outcomes. METHODS: Observational, multicenter study from a prospective government-mandated population-based registry of code stroke patients. We selected acute ischemic stroke patients, initially assessed at RC from January-2016 to June-2020. We compared and analyzed the rates of patients transferred to a Comprehensive Stroke Center (CSC) for Endovascular Treatment (EVT), rates of EVT and workflow times between VI+ and VI- patients. RESULTS: From 5128 ischemic code stroke patients admitted at RC; 3067 (59.8%) were VI+, 1822 (35.5%) were secondarily transferred to a CSC and 600 (11.7%) received EVT. Among all patients with severe stroke (NIHSS ≥16) at RC, a multivariate analysis showed that lower age, thrombolytic treatment, and VI+ (OR:1.479, CI95%: 1.117-1.960, p=0.006) were independent factors associated to EVT. The rate of secondary transfer to a CSC was lower in VI+ group (24.6% vs. 51.6%, p<0.001). Among transferred patients, EVT was more frequent in VI+ than VI- (48.6% vs. 21.7%, p<0.001). Interval times as door-in door-out (median-minutes 83.5 vs. 82, p= 0.13) and RC-Door to puncture (median-minutes 189 vs. 178, p= 0.47) did not show differences between both groups. CONCLUSION: In the present study, NIVI at RC improves selection for EVT, and is associated with receiving EVT in severe stroke patients. Time-metrics related to drip-and-ship model were not affected by NIVI.

Acute Stroke Care Is at Risk in the Era of COVID-19: Experience at a Comprehensive Stroke Center in Barcelona.

BACKGROUND AND PURPOSE: The purpose of the study is to analyze how the coronavirus disease 2019 (COVID-19) pandemic affected acute stroke care in a Comprehensive Stroke Center. METHODS: On February 28, 2020, contingency plans were implemented at Hospital Clinic of Barcelona to contain the COVID-19 pandemic. Among them, the decision to refrain from reallocating the Stroke Team and Stroke Unit to the care of patients with COVID-19. From March 1 to March 31, 2020, we measured the number of emergency calls to the Emergency Medical System in Catalonia (7.5 million inhabitants), and the Stroke Codes dispatched to Hospital Clinic of Barcelona. We recorded all stroke admissions, and the adequacy of acute care measures, including the number of thrombectomies, workflow metrics, angiographic results, and clinical outcomes. Data were compared with March 2019 using parametric or nonparametric methods as appropriate. RESULTS: At Hospital Clinic of Barcelona, 1232 patients with COVID-19 were admitted in March 2020, demanding 60% of the hospital bed capacity. Relative to March 2019, the Emergency Medical System had a 330% mean increment in the number of calls (158 005 versus 679 569), but fewer Stroke Code activations (517 versus 426). Stroke admissions (108 versus 83) and the number of thrombectomies (21 versus 16) declined at Hospital Clinic of Barcelona, particularly after lockdown of the population. Younger age was found in stroke admissions during the pandemic (median [interquartile range] 69 [64-73] versus 75 [73-80] years, P=0.009). In-hospital, there were no differences in workflow metrics, angiographic results, complications, or outcomes at discharge. CONCLUSIONS: The COVID-19 pandemic reduced by a quarter the stroke admissions and thrombectomies performed at a Comprehensive Stroke Center but did not affect the quality of care metrics. During the lockdown, there was an overload of emergency calls but fewer Stroke Code activations, particularly in elderly patients. Hospital contingency plans, patient transport systems, and population-targeted alerts must act concertedly to better protect the chain of stroke care in times of pandemic.

Influence of the uncertainty in the validation of PBPK models: A case-study for PFOS and PFOA.

Physiologically-based pharmacokinetic (PBPK) models are mathematical representations of the human body aimed at describing the time course distribution of chemicals in human tissues. Since parameterization of PBPK models is based on empirical estimation and experimental data, simulation results may have high degree of uncertainty. As a consequence, the reliability of model validation is highly affected. In this study, the parametric uncertainty associated with PBPK models developed for perfluorooctane sulfonic acid (PFOS) and perfluorooctanoic acid (PFOA) were analyzed and the different validation approaches were discussed for a case-study in Tarragona County (NE of Spain). Physicochemical parameters and dietary intake of PFOS and PFOA were estimated from previous investigations performed in Tarragona County. A sensitivity analysis (SA) was performed to understand the degree of influence of input parameters on the final outcomes. The uncertainty of the PBPK models' outcome was assessed by propagating the parametric uncertainty using the Latin Hypercube Sampling (LHS) technique. The elimination constants (Tm and Kt) as well as the Free fraction and the Intake, were the most influential parameters according to the SA results, being up to 83% for PFOS and 99.9% for PFOA. The validation of the PBPK model, which was performed using different approaches, showed clear discrepancies in the visual validation when compared with the statistical analysis.

PCDD/Fs in plasma of individuals living near a hazardous waste incinerator. A comparison of measured levels and estimated concentrations by PBPK modeling.

The construction of the first and, until now, only hazardous waste incinerator (HWI) in Spain finished in 1998. To assess its potential impact on the population living in the vicinity, a surveillance program was established. It includes the periodical biomonitoring of PCDD/Fs body burden. On the basis of this program, in 2012 we determined the levels of PCDD/Fs in plasma of nonoccupationally exposed individuals living near the HWI. The results were compared with those of the baseline study, and with those of two previous surveys (2002 and 2007). A multicompartment, physiologically based pharmacokinetic (PBPK) model was also applied to estimate the levels of PCDD/Fs in plasma. The model was validated by comparing the results with our experimental data (baseline, 2002, 2007, and 2012). The current mean concentration was 6.18 pg I-TEQ/g lipid, with a range between 2.03 and 18.8 pg I-TEQ/g lipid. In 1998 (baseline), the mean concentration of PCDD/Fs in plasma was 27.0 pg I-TEQ/g lipid (reduction of 77%, p < 0.001). Significant reductions were also noted in our previous 2002 and 2007 surveys, with mean concentrations of 15.7 and 9.36 pg I-TEQ/g lipid, respectively. However, the comparison between simulated (using the PBPK model) and experimental results was very successful, as PCDD/F values in plasma were very similar (7.95 vs 6.18 pg I-TEQ/g lipid). The levels of PCDD/Fs in plasma of nonoccupationally exposed individuals living near the HWI here assessed are comparatively lower than most recently reported values.

Predicting Drug-Drug Interactions between Rifampicin and Ritonavir-Boosted Atazanavir Using PBPK Modelling.

OBJECTIVES: The aim of this study was to simulate the drug-drug interaction (DDI) between ritonavir-boosted atazanavir (ATV/r) and rifampicin (RIF) using physiologically based pharmacokinetic (PBPK) modelling, and to predict suitable dose adjustments for ATV/r for the treatment of people living with HIV (PLWH) co-infected with tuberculosis. METHODS: A whole-body DDI PBPK model was designed using Simbiology 9.6.0 (MATLAB R2019a) and verified against reported clinical data for all drugs administered alone and concomitantly. The model contained the induction mechanisms of RIF and ritonavir (RTV), the inhibition effect of RTV for the enzymes involved in the DDI, and the induction and inhibition mechanisms of RIF and RTV on the uptake and efflux hepatic transporters. The model was considered verified if the observed versus predicted pharmacokinetic values were within twofold. Alternative ATV/r dosing regimens were simulated to achieve the trough concentration (Ctrough) clinical cut-off of 150 ng/mL. RESULTS: The PBPK model was successfully verified according to the criteria. Simulation of different dose adjustments predicted that a change in regimen to twice-daily ATV/r (300/100 or 300/200 mg) may alleviate the induction effect of RIF on ATV Ctrough, with > 95% of individuals predicted to achieve Ctrough above the clinical cut-off. CONCLUSIONS: The developed PBPK model characterized the induction-mediated DDI between RIF and ATV/r, accurately predicting the reduction of ATV plasma concentrations in line with observed clinical data. A change in the ATV/r dosing regimen from once-daily to twice-daily was predicted to mitigate the effect of the DDI on the Ctrough of ATV, maintaining plasma concentration levels above the therapeutic threshold for most patients.

Priority in interhospital transfers of patients with severe COVID-19: development and prospective validation of a triage tool. / Desarrollo y validación prospectiva de la escala TIHCOVID: una herramienta de triaje y priorización del traslado interhospitalario de pacientes COVID-19 graves.

OBJECTIVES: To develop and validate a triage scale (Spanish acronym, TIHCOVID) to assign priority by predicting critical events in patients with severe COVID-19 who are candidates for interhospital transfer. MATERIAL AND METHODS: Prospective cohort study in 2 periods for internal (February-April 2020) and external (October-December 2020) validation. We included consecutive patients with severe COVID-19 who were transported by the emergency medical service of Catalonia. A risk model was developed to predict mortality based on variables recorded on first contact between the regional emergency coordination center and the transferring hospital. The model's performance was evaluated by means of calibration and discrimination, and the results for the first and second periods were compared. RESULTS: Nine hundred patients were included, 450 in each period. In-hospital mortality was 33.8%. The 7 predictors included in the final model were age, comorbidity, need for prone positioning, renal insufficiency, use of high-flow nasal oxygen prior to mechanical ventilation, and a ratio of PaO2 to inspired oxygen fraction of less than 50. The performance of the model was good (Brier score, 0.172), and calibration and discrimination were consistent. We found no significant differences between the internal and external validation steps with respect to either the calibration slopes (0.92 [95% CI, 0.91-0.93] vs 1.12 [95% CI, 0.6-1.17], respectively; P = .150) or discrimination (area under the curve, 0.81 [95% CI, 0.75-0.84] vs 0.85 [95% CI, 0.81-0.89]; P = .121). CONCLUSION: The TIHCOVID tool may be useful for triage when assigning priority for patients with severe COVID-19 who require transfer between hospitals.

OBJETIVO: Desarrollar y validar una escala predictiva de eventos críticos en pacientes con infección grave por COVID-19 candidatos a traslado interhospitalario (TIH) que facilite el triaje y la priorización del transporte sanitario. METODO: Estudio de cohortes prospectivo divido en dos periodos: validación interna (febrero-abril 2020) y validación externa (octubre-diciembre 2020). Se incluyeron consecutivamente los pacientes con infección grave por COVID-19 trasladados por el Sistema de Emergencias Médicas de Cataluña. Se construyó un modelo predictivo de las variables asociadas a la mortalidad recogidas en el momento del primer contacto entre el hospital emisor y el centro de coordinación. Se calculó el rendimiento del modelo y se comparó la validación interna y externa, evaluando la calibración y la discriminación. RESULTADOS: Se incluyeron 900 pacientes, 450 pacientes en cada periodo de estudio. La mortalidad durante el ingreso fue del 33,8%. Las 7 variables predictoras incluidas en el modelo final fueron edad, comorbilidad, pronación, insuficiencia renal aguda, uso de oxigenoterapia de alto flujo previa a la ventilación mecánica invasiva, tabaquismo activo y un valor de PaO2/FiO2 50. El modelo mostró un buen rendimiento (Brier = 0,172) y consistencia en la calibración y discriminación. No se objetivaron diferencias en la pendiente de calibración [0,92 (IC 95%: 0,91-0,93) vs 1,12 (IC 95%: 0,6-1,17); p = 0,150] ni en la capacidad discriminativa [ABC 0,81 (IC 95%: 0,75-0,84) vs ABC de 0,85 (IC 95%: 0,81-0,89), p = 0,121] entre la validación interna y externa. CONCLUSIONES: La escala TIHCOVID puede ser de ayuda para el triaje de pacientes con infección COVID-19 grave que precisan traslado interhospitalario.

Comment on Lionte et al. Association of Multiple Glycemic Parameters at Hospital Admission with Mortality and Short-Term Outcomes in Acutely Poisoned Patients. Diagnostics 2021, 11, 361.

We have read with great interest the article by Lionte et al., "Association of multiple glycemic parameters at hospital admission with mortality and short-term outcomes in acutely poisoned patients", recently published in your journal [...].

Early intravenous nitroglycerin use in prehospital setting and in the emergency department to treat patients with acute heart failure: Insights from the EAHFE Spanish registry.

BACKGROUND AND OBJECTIVE: Although recommended for the treatment of acute heart failure (AHF), the use of intravenous (IV) nitroglycerin (NTG) is supported by scarce and contradicting evidence. In the current analysis, we have assessed the impact of IV NTG administration by EMS or in emergency department (ED) on outcomes of AHF patients. METHODS: We analyze AHF patients included by 45 hospitals that were delivered to ED by EMS. Patients were grouped according to whether treatment with IV NTG was started by EMS before ED admission (preED-NTG), during the ED stay (ED-NTG) or were untreated with IV NTG (no-NTG, control group). In-hospital, 30-day and 365-day all-cause mortality, prolonged hospitalization (>7 days) and 90-day post-discharge combined adverse events (ED revisit, hospitalization or death) were compared in EMS-NTG and ED-NTG respect to control group. RESULTS: We included 8424 patients: preED-NTG = 292 (3.5%), ED-NTG = 1159 (13.8%) and no-NTG = 6973 (82.7%). preED-NTG group had the most severely decompensated cases of AHF (p < 0.001) but it had lower in-hospital (OR = 0.724, 95%CI = 0.459-1.114), 30-day (HR = 0.818, 0.576-1.163) and 365-day mortality (HR = 0.692, 0.551-0.869) and 90-day post-discharge events (HR = 0.795, 0.643-0.984) than control group. ED-NTG group had mortalities similar to control group (in-hospital: OR = 1.164, 0.936-1.448; 30-day: HR = 0.980, 0.819-1.174; 365-day: HR = 0.929, 0.830-1.039) but significantly decreased 90-day post-discharge events (HR = 0.870, 0.780-0.970). Prolonged hospitalization rate did not differ among groups. Five different analyses confirmed these findings. CONCLUSIONS: Early prehospital IV NTG administration was associated with lower mortality and post-discharge events, while IV NTG initiated in ED only improved post-discharge event rate. Further studies are needed to assess the role of early prehospital administration of IV NTG to patients with AHF.

Regional variation in the incidence, general characteristics, and outcomes of prehospital cardiac arrest in Spain: the Out-of-Hospital Spanish Cardiac Arrest Registry. / Variabilidad regional en incidencia, características generales y resultados finales de la parada cardiaca extrahospitalaria en España: Registro OHSCAR.

OBJECTIVES: The incidence and outcomes of care for out-of-hospital cardiac arrest (OHCA) vary greatly from country to country. We aimed to study variation in the incidence, characteristics, and outcomes of care for OHCAs given by Spanish prehospital emergency services. MATERIAL AND METHODS: Descriptive retrospective analysis of data from the Out-of-Hospital Spanish Cardiac Arrest Registry (OHSCAR) from October 2013 to October 2014. Attempts by 19 Spanish emergency services to resuscitate patients were studied. All OHCA cases were reviewed to obtain the following data: incidence, patient and event characteristics, prior emergencies, resuscitation attempts, and the main treatments provided in the hospital. If a patient was admitted, we compared the neurologic status on hospital discharge. RESULTS: Statistically significant differences were detected between emergency services (P .0001) in the incidence of attempted resuscitation and all general characteristics except sex. Hospital treatments and outcomes also differed significantly: pulse had been restored on arrival of 30.5% of patients (range 21.3% to 56.1%, P .001), and 31.8% of admitted patients were discharged in cerebral performance categories 1 or 2 (range 17.2% to 58.3%, P .001). CONCLUSION: Differences in the incidence of resuscitation attempts, key variables, and survival at discharge from the hospital are present in OHCA cases attended by prehospital emergency services in different regions of Spain.

OBJETIVO: Existe gran variabilidad internacional en la incidencia y los resultados en la atención a la parada cardiaca extrahospitalaria (PCRE). El objetivo es conocer si existe variabilidad en la incidencia, características y resultados en supervivencia en la atención a la PCRE por los servicios extrahospitalarios de emergencias (SEM) de España. METODO: Análisis descriptivo, retrospectivo de los datos del registro OHSCAR correspondientes al periodo octubre 2013-octubre 2014, que incluye pacientes atendidos por 19 SEM de España con intento de reanimación. Se recogieron los casos atendidos y variables clave sobre la asistencia a una PCRE: incidencia, características del paciente, del evento, de la actuación previa a los equipos de emergencias (EE), de la reanimación realizada, y de los principales tratamientos hospitalarios. Se comparó la situación neurológica al alta hospitalaria de los casos con ingreso hospitalario. RESULTADOS: La incidencia de casos con intento de reanimación y todas las características generales, salvo la distribución por sexo, presentaron diferencias estadísticamente significativas entre los SEM participantes (p 0,001). Hubo diferencias significativas en los tratamientos hospitalarios recibidos y en los resultados finales, tanto en la proporción de pacientes que llegaron con pulso espontáneo al hospital, 30,5%, rango entre 21,3% y 56,1% (p 0,001), como en el porcentaje de altas hospitalaria con categoría 1 o 2 de la clasificación Cerebral Perfomance Categories (CPC), sobre el total de ingresados, 31,8%, rango entre 17,2% y 58,3% (p 0,001). CONCLUSIONES: Existe una importante variabilidad entre los SEM españoles en la incidencia de casos con intento de reanimación, en todas las variables clave y en la supervivencia al alta hospitalaria de la atención a la PCRE.

Effectiveness of Thrombectomy in Stroke According to Baseline Prognostic Factors: Inverse Probability of Treatment Weighting Analysis of a Population-Based Registry.

BACKGROUND AND PURPOSE:  In real-world practice, the benefit of mechanical thrombectomy (MT) is uncertain in stroke patients with very favorable or poor prognostic profiles at baseline. We studied the effectiveness of MT versus medical treatment stratifying by different baseline prognostic factors. METHODS:  Retrospective analysis of 2,588 patients with an ischemic stroke due to large vessel occlusion nested in the population-based registry of stroke code activations in Catalonia from January 2017 to June 2019. The effect of MT on good functional outcome (modified Rankin Score ≤2) and survival at 3 months was studied using inverse probability of treatment weighting (IPTW) analysis in three pre-defined baseline prognostic groups: poor (if pre-stroke disability, age >85 years, National Institutes of Health Stroke Scale [NIHSS] >25, time from onset >6 hours, Alberta Stroke Program Early CT Score <6, proximal vertebrobasilar occlusion, supratherapeutic international normalized ratio >3), good (if NIHSS <6 or distal occlusion, in the absence of poor prognostic factors), or reference (not meeting other groups' criteria). RESULTS:  Patients receiving MT (n=1,996, 77%) were younger, had less pre-stroke disability, and received systemic thrombolysis less frequently. These differences were balanced after the IPTW stratified by prognosis. MT was associated with good functional outcome in the reference (odds ratio [OR], 2.9; 95% confidence interval [CI], 2.0 to 4.4), and especially in the poor baseline prognostic stratum (OR, 3.9; 95% CI, 2.6 to 5.9), but not in the good prognostic stratum. MT was associated with survival only in the poor prognostic stratum (OR, 2.6; 95% CI, 2.0 to 3.3). CONCLUSIONS:  Despite their worse overall outcomes, the impact of thrombectomy over medical management was more substantial in patients with poorer baseline prognostic factors than patients with good prognostic factors.

An Online Training Intervention on Prehospital Stroke Codes in Catalonia to Improve the Knowledge, Pre-Notification Compliance and Time Performance of Emergency Medical Services Professionals.

Strokes are a time-dependent medical emergency. The training of emergency medical service (EMS) professionals is essential to ensure the activation of stroke codes with pre-notification, as well as a rapid transfer to achieve early therapy. New assessment scales for the detection of patients with suspected large vessel occlusion ensures earlier access to endovascular therapy. The aim of this study was to evaluate the impact on an online training intervention focused on the Rapid Arterial oCclusion Evaluation (RACE) scoring of EMS professionals based on the prehospital stroke code in Catalonia from 2014 to 2018 in a pre-post intervention study. All Catalonian EMS professionals and the clinical records from primary stroke patients were included. The Kirkpatrick model guided the evaluation of the intervention. Data were collected on the knowledge on stroke recognition and management, pre-notification compliance, activated stroke codes and time performance of EMS professionals. Knowledge improved significatively in most items and across all categories, reaching a global achievement of 82%. Pre-notification compliance also improved significantly and remained high in the long-term. Increasingly higher notification of RACE scores were recorded from 60% at baseline to 96.3% in 2018, and increased on-site clinical care time and global time were also observed. Therefore, the online training intervention was effective for increasing EMS professionals' knowledge and pre-notification compliance upon stroke code activation, and the wide adoption of a new prehospital scale for the assessment of stroke severity (i.e., the RACE scale) was achieved.

[Prehospital emergency care of patients exposed to poisoning: Assessment of epidemiological, clinical characteristics and quality of care]. / Atención prehospitalaria urgente de los pacientes pediátricos expuestos a tóxicos: características epidemiológico-clínicas y evaluación de la calidad asistencial.

OBJECTIVE: To describe the characteristics of paediatric patients with suspected poisoning treated by advanced life support (ALS) units, and to evaluate quality indicators (QI) for the prehospital emergency care of these patients. METHOD: A one-year observational study of patients under 18 years of age exposed to poisoning and treated by an ALS unit of the Medical Emergency System in Catalonia. Severe clinical criteria were defined, with 8 QI being evaluated for prehospital emergency care of poisoned paediatric patients. RESULTS: The study included a total of 254 patients, with a median age of 14 years-old (p25-75 = 7-16), with intentional poisoning in 50.8% of cases. The most frequently involved toxic agent was carbon monoxide (CO) (33.8%). Poisoning was found in 48.8% of those patients, being serious in 16.5%. Intentionally (OR 5.1; 95% CI: 1.9-13.8) and knowledge of the time of exposure (OD 3.1; 95% CI: 1.3-7.3) were independent risk factors associated with the appearance of severe clinical symptoms. Five QI did not reach the quality standard and included, availability of specific clinical guidelines, activated charcoal administration in selected patients, oxygen therapy administration at maximum possible concentration in carbon monoxide poisoning, electrocardiographic assessment in patients exposed to cardiotoxic substances, and recording of the minimum data set. CONCLUSIONS: Paediatric patients attended by ALS units showed specific characteristics, highlighting the involvement of CO and adolescents with voluntary poisoning. The QI assessment was useful to detect weak points in the quality of care of these patients and to develop strategies for improvement.

Health care quality indicators and improvements to make in the prehospital care of adults exposed to carbon monoxide. / Indicadores de calidad y puntos de mejora en la asistencia prehospitalaria de los pacientes adultos expuestos a monóxido de carbono.

OBJECTIVES: To describe health care quality indicators in cases of carbon monoxide (CO) exposure attended by prehospital services and to explore factors associated with the use of pulse CO-oximetry (SpCO) for the noninvasive estimation of CO saturation of arterial blood. MATERIAL AND METHODS: Cohort study of patients exposed to CO and transported by advanced life support units of the Emergency Medical Services of Catalonia between January 2015 and December 2017. We selected 11 applicable quality indicators and used multivariate analysis to explore factors associated with the recording of SpCO. RESULTS: We studied 1676 cases of CO exposure. SpCO was recorded in 1108 cases (66.1%). CO saturation exceeded 10% in 358 patients (32.3%). Adherence was deficient in 5 of the 11 applicable quality indicators. Multivariate analysis showed less use of pulse CO-oximetry when another toxic exposure was present (odds ratio [OR], 0.34; 95% CI, 0.11- 1.00) and when the first responder was from the advanced life support service (OR, 0.43; 95% CI, 0.31-0.59). SpCO was used more in the presence of a history of mental health problems (OR, 3.01; 95% CI,1.27-7.17), headache (OR, 2.13; 95% CI, 1.2-3.72), and along with use of oxygen therapy (OR, 10.33; 95% CI, 5.46-19.53). CONCLUSION: Prehospital attendance of episodes of CO exposure is marked by failure to comply with some health care quality indicators. We detected factors associated with under use of SpCO as well as areas to target for improvement.

OBJETIVO: Investigar la calidad asistencial en los episodios de exposición a monóxido de carbono (CO) asistidos por unidades prehospitalarias mediante indicadores de calidad (IC) y las variables relacionadas con el uso del pulsicooxímetro para medir de forma incruenta el porcentaje de saturación de la hemoglobina con CO (SpCO). METODO: . Estudio de cohorte de los episodios de exposición a CO atendidos por las unidades de soporte vital avanzado (SVA) del Sistema de Emergencias Médicas de Cataluña. Se seleccionaron 11 IC y se diseñó un análisis multivariante para investigar las variables relacionadas con el uso del pulsicooxímetro. RESULTADOS: Se recogieron 1.676 episodios de exposición a CO. En 1.108 (66,1%) se registró la SpCO con pulsicooxímetro, siendo SpCO > 10% en 358 (32,3%). De los 11 IC, cinco no alcanzaron el estándar recomendado. El análisis multivariante mostró un menor uso del pulsicooxímetro cuando había asociación con otro tóxico, OR 0,34 (IC 95% 0,11-1,00) y cuando la primera asistencia era realizada por SVA médico, OR 0,43 (IC 95% 0,31-0,59). Hubo mayor uso del pulsicooxímetro ante la presencia de antecedentes psiquiátricos OR 3,01 (IC 95% 1,27-7,17), la cefalea OR 2,13 (IC 95% 1,22-3,72) y el uso de oxigenoterapia OR 10,33 (5,46-19,53). CONCLUSIONES: En la asistencia prehospitalaria de los episodios de exposición al CO existe una falta de cumplimiento de algunos IC. Hay variables relacionadas con la infrautilización del pulsicooxímetro, con puntos de mejora.

Pediatric televisits and telephone triage: impact on use of a hospital emergency department. / Impacto de las consultas y triajes telefónicos pediátricos en el uso del servicio de urgencias hospitalario.

OBJECTIVES: To analyze the characteristics of remote telephone consultations (televisits) and triage of pediatric emergencies attended by the 24-hour emergency service of Catalonia (CatSalut Respon), and to describe the impact of televisits on callers' decisions about whether or not to come to the emergency department and their opinion of the call service. MATERIAL AND METHODS: Observational cross-sectional study. During the call, cases were classified according the Spanish and Andorran triage system. Patients who were sent to the hospital underwent triage again, and the 2 assigned triage levels were compared. The families were later called to check data and ask their opinion of the service. Sociodemographic and clinical data related to the cases were recorded. RESULTS: A total of 370 televisits were made. Most cases (300, 81%) were not emergencies. Seventy-five callers (20.3%) were advised to go to an emergency department. Fever (P = .002) and questions about medication (P < .001) were the problems significantly associated with nonurgent cases. Nearly 46% of the cases classified as serious during telephone triage were also considered serious when the child was brought to the emergency department. The rate of agreement between the 2 triage levels was moderate. Over half the parents stated they had intended to go to the hospital before calling the service; 46% changed their mind based on the call. CONCLUSION: Fever and questions about medication were significantly associated with televisits for nonurgent cases. Nearly half the parents changed their mind about going to the emergency department after a televisit.

OBJETIVO: Analizar las características de las teleconsultas y triajes telefónicos pediátricos atendidos por CatSalut Respon y describir su impacto sobre la actitud y la decisión final de los padres-usuarios de acudir o no a urgencias. METODO: Estudio observacional transversal. Durante la teleconsulta los pacientes se clasificaron según los niveles del sistema español de triaje. Aquellos que fueron derivados a urgencias se volvieron a clasificar en el hospital, y se compararon los niveles de triaje. Posteriormente, se realizó una llamada de verificación. Se recogieron variables sociodemográficas y clínicas. RESULTADOS: Se analizaron 370 teleconsultas, fundamentalmente no urgentes (n = 300; 81%). Un 20,3% (n = 75) fueron derivadas a urgencias. La fiebre (p = 0,002) y las dudas de medicación (p < 0,001) fueron motivos significativos de teleconsulta no urgente. Casi un 46% de los casos con niveles de gravedad altos en el triaje de la llamada también fueron clasificados con niveles de gravedad altos en el triaje posterior realizado en el servicio de urgencias hospitalario, mostrando una concordancia moderada. Más del 50% de los padres tenían intención de acudir a urgencias antes de la teleconsulta y un 46% cambiaron de actitud tras realizar esta llamada. CONCLUSIONES: Fiebre y dudas de medicación fueron motivos estadísticamente significativos de teleconsulta no urgente. La consulta telefónica produjo un cambio de actitud en casi la mitad de los padres.

[Catalan hospital emergency department heads' opinions on the creation of a residency program for specializing in emergency medicine]. / Opinión de los responsables de los servicios de urgencias hospitalarios de Cataluña acerca de la creación de la especialidad de Medicina de Urgencias y Emergencias.

OBJECTIVES: To understand the opinions of emergency department (ED) heads in Catalonia on their support for a residency program for specializing in emergency medicine (EM) and on their beliefs about the impact such a program would have. MATERIAL AND METHODS: Heads of ED were asked if there would be support (from them, their staff, and their hospital) for a residency program to train specialists in EM. They were also asked their opinion on the impact that specialization would have on quality of care and costs in their department. Responses were compared by type of hospital and ED and by affiliation or not with the Spanish Society of Emergency Medicine (SEMES). RESULTS: Responses were received from 79 of the 82 heads of hospital EDs in Catalonia (96%). They reported that favorable opinions toward creation of an EM specialization were held by them personally (93.7%; 95% CI, 85.8%-97.9%), by their in their departments (88.6%; 95% CI, 79.4%-94.7%), and by staff in their hospitals (48.7%; 95% CI, 36.7%-59.6%). A majority thought that the impact of specialization would be good in the short term (82.0%; 95% CI, 71.7%-89.8%) and in the medium and long term (94.8%; 95% CI, 87.2%-98.6%). The respondents were neutral about whether there would be an impact on costs (60.3%; 95% CI, 48.6%-71.2%). More heads in mid-sized hospitals, private hospitals, and nonmembers of SEMES thought that creating a specialty would raise ED costs (p<0,05). CONCLUSION: The heads of Catalan ED, their staff, and their hospitals' staffs hold favorable opinions of the proposal to create a residency program allowing specialization in EM. They foresee short-, medium-, and long-term benefits for the EDs and scarce impact on costs.

OBJETIVO: Conocer la opinión de los responsables de los servicios de urgencias hospitalarios (SUH) de Cataluña respecto al soporte e impacto que tendría la creación de la especialidad primaria de Medicina de Urgencias y Emergencias (MUE). METODO: Se solicitó la opinión a los responsables de SUH respecto al respaldo a una futura especialidad primaria de MUE (personal, en su servicio y en su hospital) y la estimación del impacto (cualitativo y económico) que tendría en su SUH. Se compararon las respuestas en función del tipo de hospital y SUH y de su afiliación a la Sociedad Española de Medicina de Urgencias y Emergencias (SEMES). RESULTADOS: Contestaron 79 de los 82 responsables de los SUH de Cataluña (96%), que percibieron una posición favorable a la creación de la especialidad, tanto ellos personalmente (93,7%; IC 95%: 85,8-97,9) como en sus SUH (88,6%; 79,4- 94,7) y hospitales (48,7%; 36,7-59,6). El 82,0% (71,7-89,8) opinó que la especialidad tendría un efecto positivo a corto plazo y el 94,8% (87,2-98,6) que también lo tendría a medio-largo plazo, y respecto al impacto económico, la opinión mayoritaria fue que sería neutro (60,3%; 48,6-71,2). Los responsables de SUH con actividad media, de hospitales privados y no afiliados a SEMES consideraron más frecuentemente que la creación de la especialidad encarecería el SUH (p < 0,05). CONCLUSIONES: Los responsables de los SUH catalanes tienen una opinión favorable y también la perciben en su servicio y su hospital respecto a la creación de la especialidad primaria de MUE y consideran que tendría efectos beneficiosos a corto, medio y largo plazo para el SUH, con un escaso impacto económico.

PBPK modeling for PFOS and PFOA: validation with human experimental data.

In recent years, because of the potential human toxicity, concern on perfluoroalkyl substances (PFASs) has increased notably with special attention to perfluorooctanoic acid (PFOA) and perfluorooctane sulfonate (PFOS). Unfortunately, there is currently an important knowledge gap on the burdens of these chemicals in most human tissues, as the reported studies have been mainly focused on plasma. In order to overcome these limitations, the use of physiologically-based pharmacokinetic (PBPK) models has been extended. The present study was aimed at testing an existing PBPK model for their predictability of PFOS and PFOA in a new case-study, and also to adapt it to estimate the PFAS content in human tissue compartments. Model validation was conducted by means of PFOA and PFOS concentrations in food and human drinking water from Tarragona County (Catalonia, Spain), and being the predicted results compared with those experimentally found in human tissues (blood, liver, kidney, liver and brain) of subjects from the same area of study. The use of human-derived partition coefficient (Pk) data was proven as more suitable for application to this PBPK model than rat-based Pk values. However, the uncertainty and variability of the data are still too high to get conclusive results. Consequently, further efforts should be carried out to reduce parametric uncertainty of PBPK models. More specifically, a deeper knowledge on the distribution of PFOA and PFOS within the human body should be obtained by enlarging the number of biological monitoring studies on PFASs.

A PBPK model to estimate PCDD/F levels in adipose tissue: comparison with experimental values of residents near a hazardous waste incinerator.

This study was aimed at determining the concentrations of polychlorinated dibenzo-p-dioxins and polychlorinated dibenzofurans (PCDD/Fs) in 15 samples of adipose tissue from subjects who had been living in the vicinity of a hazardous waste incinerator (HWI). The results were compared with levels obtained in previous surveys carried out in 1998 (baseline study), 2002 and 2007. The current (2013) concentrations of PCDD/Fs in adipose tissue ranged from 2.8 to 46.3 pg WHO-TEQ/g fat (mean and median concentrations: 11.5 and 7.4 pg WHO-TEQ/g fat, respectively), being significantly lower (64%) than those observed in 1998. In contrast, no significant differences in the mean PCDD/F concentrations were noted in the period 2002-2013. The significant decrease of the PCDD/F content in fat, also noted in other biological monitors such as plasma and breast milk, is in agreement with the reduction in the dietary intake of PCDD/Fs found in the same area of study. Similarly to other investigations across Europe, an increase of PCDD/F levels in adipose tissue in relation to age was observed, while no significant differences were noted according to gender. A multicompartmental physiologically-based pharmacokinetic (PBPK) model was also applied to estimate the levels of PCDD/Fs in adipose tissue. When comparing the modeled and experimental concentrations of PCDD/Fs in that tissue, very similar values were obtained for the four surveys, which indicates this can be a reliable tool to predict the internal dose of PCDD/Fs.