Cross-Sectional Analysis of Risk Factors for Outbreak of COVID-19 in Nursing Homes for Older Adults in the Community of Madrid.

INTRODUCTION: Nursing homes for older adults have been hot spots for SARS-CoV-2 infections and mortality. Factors that facilitate COVID-19 outbreaks in these settings need to be assessed. METHODS: A retrospective cross-sectional study of a cohort of residents and workers in nursing homes taking occasion of a point seroprevalence survey was done in the Community of Madrid. Factors related to outbreaks in these facilities were analyzed. RESULTS: A total of 369 nursing homes for older adults, making a population of 23,756 residents and 20,795 staff members, were followed from July to December 2020. There were 54.2% SARS-CoV-2 IgG+ results in residents and in 32.2% of workers. Sixty-two nursing homes (16.8%) had an outbreak during the follow-up. Nursing homes with outbreaks had more residents than those without (median number of 81 [IQR, 74] vs. 50 [IQR, 56], p < 0.001). Seropositivity for SARS-CoV-2 was lower in facilities with versus without outbreaks, for residents (42.2% [IQR, 55.7] vs. 58.7% [IQR, 43.4], p = 0.002) and for workers (23.9% [IQR, 26.4] vs. 32.8% [IQR, 26.3], p = 0.01). For both residents and staff, the number of infections in outbreaks was larger in centers with lower, as compared with intermediate or high seroprevalence. The size of the facility did not correlate with the number of cases in the outbreak. Taking the incidence of cases in the community as a time-dependent variable (p = 0.03), a Cox analysis (HR [95% CI], p) showed that intermediate or high seroprevalence among residents in the facility was related to a reduction of 55% (0.45 [0.25-0.80], p = 0.007) and 78% (0.22 [0.10-0.48], p < 0.001) in the risk of outbreaks, respectively, as compared with low sero-prevalence. Also, as compared with smaller, medium (1.91 [1.00-3.65], p = 0.05) or large centers (4.57 [2.38-8.75], p < 0.001) had more respective risk of outbreaks. CONCLUSIONS: The size of the facility and the seroprevalence among residents in nursing homes, and the incidence of infections in the community, are associated with the risk of outbreaks of COVID-19. Facilities with greater proportion of seropositives had smaller number of cases. Monitoring of immunity in nursing homes may help detect those at a greater risk of future cases.

A Pilot Study for the Evaluation of an Interferon Gamma Release Assay (IGRA) To Measure T-Cell Immune Responses after SARS-CoV-2 Infection or Vaccination in a Unique Cloistered Cohort.

Assessment of T-cell responses to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) antigens may be of value to determine long-lasting protection to breakthrough infections or reinfections. Interferon gamma release assay is a validated method to test cellular immunity in mycobacterial infections and has been proposed for patients with SARS-CoV-2 infection or vaccination. Quantitative IgG to spike and qualitative IgG to nucleocapsid antigens were determined by chemiluminescence microparticle immunoassay using the Architect platform (Abbott), and interferon gamma release assays against two Qiagen proprietary mixes of SARS-CoV-2 spike protein (antigen 1 and antigen 2) were performed for a selected group of subjects. A total of 121 subjects in a cloistered institution after a COVID-19 outbreak was studied. IgG spike levels and interferon gamma concentrations were highest among subjects after two doses of vaccine, followed by patients with a longer history of past COVID-19 and no vaccination. The best cutoff for the interferon gamma assay was 25 IU/L for all subgroups of individuals and the two sets of SARS-CoV-2 antigens studied. Testing T-cell response may be of clinical utility to determine immunity after exposure to SARS-CoV-2 antigens, with the interferon gamma concentration of 25 IU/L as the best cutoff either after infection or vaccination.

SARS-CoV-2 detection in wastewater as an early warning indicator for COVID-19 pandemic. Madrid region case study.

COVID-19 pandemic is ongoing for more than a year and has changed priorities and boosted some WBE studies. The aim of this work is to contributed to our knowledge sharing the methodology developed for SARS-CoV-2 detection in wastewater of Madrid region of over six million and a half inhabitants, where the sewer system is a combined system. At first, a pilot test in a small metropolitan area was carried out in order to define the criteria for the selection of the sampling points to be applied to the entire region. Methodologys for laboratory analysis and statistical analysis and interpretation of data are also presented. This work relies highly on fieldwork, so sewer network safe accessibility is paramount. A total of 289 sampling points were weekly characterised. Each sampling point represents a sewershed, some of them in a cascade distribution. Samples are tested for SARS-CoV-2 concentration (gc/L, genome copies per litre) and physicochemical parameters are also analysed to validate or discard what at first could be an unusual virus presence. Field results are correlated with health indicators such as incidence rates and hospitalisation data. This information is daily shared with regional health authorities, disaggregated by municipalities, or aggregated for the entire Madrid region. Results have proved to anticipate health indicators. The tool is used as an early warning indicator for COVID-19 pandemic. Further work is planned to apply the current scheme for a permanent epidemiological surveillance system of 87 sampling points to pinpoint infection hotspots and activate the linked sewersheds in the event of an outbreak.

The demography and characteristics of SARS-CoV-2 seropositive residents and staff of nursing homes for older adults in the Community of Madrid: the SeroSOS study.

BACKGROUND: Nursing homes for older adults have concentrated large numbers of severe cases and deaths for coronavirus disease 2019 (COVID-19). METHODS: Point seroprevalence study of nursing homes to describe the demography and characteristic of severe acute respiratory syndrome by coronavirus 2 (SARS-CoV-2) immunoglobulin G (IgG)-positive residents and staff. RESULTS: Clinical information and blood samples were available for 9,332 residents (mean age 86.7 ± 8.1 years, 76.4% women) and 10,614 staff (mean age 45.6 ± 11.5, 86.2% women). Up to 84.4% of residents had frailty, 84.9% co-morbidity and 69.3% cognitive impairment; 65.2% of workers were health-aides.COVID-19 seroprevalence was 55.4% (95% confidence interval (CI), 54.4-56.4) for older adults and 31.5% (30.6-32.4) for staff. In multivariable analysis, frailty of residents was related with seropositivity (odds ratio (OR): 1.19, P = 0.02). In the case of staff, age > 50 years (2.10, P < 0.001), obesity (1.19, P = 0.01), being a health-aide (1.94, P < 0.001), working in a center with high seroprevalence in residents (3.49, P < 0.001) and contact with external cases of COVID-19 (1.52, P < 0.001) were factors associated with seropositivity. Past symptoms of COVID-19 were good predictors of seropositivity for residents (5.41, P < 0.001) and staff (2.52, P < 0.001). CONCLUSIONS: Level of dependency influences risk of COVID-19 among residents. Individual and work factors, contacts outside the nursing home are associated with COVID-19 exposure in staff members. It is key to strengthen control measures to prevent the introduction of COVID-19 into care facilities from the community.

The obesity paradox in stroke: impact on mortality and short-term readmission.

BACKGROUND: The aim of the present study was to assess the association of obesity with the mortality of hospitalized patients with acute stroke and the risk of readmission in less than 30 days. METHODS: A retrospective chart review of a cohort of consecutive patients admitted with stroke as the primary reason for discharge in Spain between January 1, 2005, and December 31, 2011, was performed. Patients with a diagnosis of obesity were identified. The mortality and readmittance indexes of obese patients were compared against the subpopulation without theses diagnosis. RESULTS: A total of 201,272 stroke admittances were analyzed, and 14,047 (7.0%) diagnosis of obesity were identified. In-hospital global mortality reached 14.9%, and readmittance risk was 5.9%. Obese patients showed a lower in-hospital mortality risk (odds ratio [OR], .71; 95% confidence interval [CI], .67-.76) and early readmittance risk (OR, .89; 95% CI, .82-.96) than the nonobese even after adjusting for possible confounding factors. CONCLUSIONS: Obesity in those hospitalized for stroke is associated with reduced in-hospital mortality risk and early readmittance.

Systemic involvement in primary Sjogren's syndrome evaluated by the EULAR-SS disease activity index: analysis of 921 Spanish patients (GEAS-SS Registry).

OBJECTIVE: To evaluate systemic involvement in primary SS in a large cohort of Spanish patients using the EULAR-SS disease activity index (ESSDAI) definitions. METHODS: Systemic involvement was characterized using ESSDAI definitions for the 10 clinical domains (constitutional, lymphadenopathy, glandular, articular, cutaneous, pulmonary, renal, peripheral nervous system, central nervous system and muscular). ESSDAI scores at diagnosis, during follow-up and cumulated at the last visit were calculated. RESULTS: The cohort consisted of 921 patients. After a mean follow-up of 75 months, 77 (8%) patients still had an ESSDAI score of zero at the last visit. Organ by organ, the percentage of patients who developed activity during the follow-up (ESSDAI score ≥ 1 at any time) ranged between 1.4% and 56%, with articular, pulmonary and peripheral neurological involvement being the most common. Logistic multivariate regression analysis showed the following features at diagnosis and had the closest association with systemic activity (statistically significant independent variables in at least two domains): cryoglobulinaemia in five domains; anaemia, lymphopenia and low C3 levels in three domains each and age <35 years in two domains. Sicca features, ANA and RF at diagnosis were not associated with a higher cumulated activity score in any clinical domain. CONCLUSION: Primary SS is undeniably a systemic disease, with the joints, lungs, skin and peripheral nerves being the most frequently involved organs. Cytopenias, hypocomplementaemia and cryoglobulinaemia at diagnosis strongly correlated with higher cumulated ESSDAI scores in the clinical domains. Clinically the ESSDAI provides a reliable picture of systemic involvement in primary SS.

Frequency of hypoglycemia and its impact on length of stay, mortality, and short-term readmission in patients with diabetes hospitalized in internal medicine wards.

OBJECTIVE: To evaluate whether hypoglycemia is associated with increases in length of stay (LOS), inpatient mortality, and readmission among patients with diabetes hospitalized in internal medicine wards. METHODS: A retrospective cohort study was carried out using the Basic Minimum Data Set registry of the Spanish National Health System, which contains clinical and administrative information for every patient discharged from system hospitals. The analysis included patients discharged between January 2005 and December 2010 and had a primary (i.e., reason for the admission) or secondary diagnosis of diabetes and a secondary diagnosis of hypoglycemia. The associations between hypoglycemia and the study outcomes (mortality, readmission, and LOS) were evaluated using multivariate and multilinear regression models that included age, sex, and the Charlson index as covariates. RESULTS: During the study period, 3,361,104 patients were admitted to internal medicine wards in the National Health System. Of these, 921,306 (27.4%) had diagnoses of diabetes, and among these patients, 46,408 (5%) had secondary hypoglycemia. A total of 4,754 (10.2%) patients with secondary hypoglycemia died during their hospital stays, compared with 83,508 (9.5%) patients without hypoglycemia. The multivariate/multilinear regression models demonstrated significant associations between the presence of secondary hypoglycemia and greater inpatient mortality (odds ratio [OR] 1.24, 95% confidence interval [CI] 1.20-1.28), a greater likelihood of readmission (OR 1.20, 95% CI 1.17-1.23), and an increased LOS (ß 1.24, 95% CI 1.15-1.35). CONCLUSION: Hypoglycemia in patients with diabetes hospitalized in internal medicine wards is associated with increases in the LOS, inpatient mortality, and early readmission.

Hip fracture in hospitalized medical patients.

BACKGROUND: The aim of the present study is to analyze the incidence of hip fracture as a complication of admissions to internal medicine units in Spain. METHODS: We analyzed the clinical data of 2,134,363 adults who had been admitted to internal medicine wards. The main outcome was a diagnosis of hip fracture during hospitalization.Outcome measures included rates of in-hospital fractures, length of stay and cost. RESULTS: A total of 1127 (0.057%) admittances were coded with an in-hospital hip fracture. In hospital mortality rate was 27.9% vs 9.4%; p < 0.001, and the mean length of stay was significantly longer for patients with a hip fracture (20.7 days vs 9.8 days; p < 0.001). Cost were higher in hip-fracture patients (6927€ per hospitalization vs 3730€ in non fracture patients). Risk factors related to fracture were: increasing age by 10 years increments (OR 2.32 95% CI 2.11-2.56), female gender (OR 1.22 95% CI 1.08-1.37), admission from nursing home (OR 1.65 95% CI 1.27-2.12), dementia (1.55 OR 95% CI1.30-1.84), malnutrition (OR 2.50 95% CI 1.88-3.32), delirium (OR 1.57 95% CI 1.16-2.14), and anemia (OR 1.30 95%CI 1.12-1.49). CONCLUSIONS: In-hospital hip fracture notably increased mortality during hospitalization, doubling the mean length of stay and mean cost of admission. These are reasons enough to stress the importance of designing and applying multidisciplinary plans focused on reducing the incidence of hip fractures in hospitalized patients.

Temporal Series Analysis of Population Cycle Threshold Counts as a Predictor of Surge in Cases and Hospitalizations during the SARS-CoV-2 Pandemic.

Tools to predict surges in cases and hospitalizations during the COVID-19 pandemic may help guide public health decisions. Low cycle threshold (CT) counts may indicate greater SARS-CoV-2 concentrations in the respiratory tract, and thereby may be used as a surrogate marker of enhanced viral transmission. Several population studies have found an association between the oscillations in the mean CT over time and the evolution of the pandemic. For the first time, we applied temporal series analysis (Granger-type causality) to validate the CT counts as an epidemiological marker of forthcoming pandemic waves using samples and analyzing cases and hospital admissions during the third pandemic wave (October 2020 to May 2021) in Madrid. A total of 22,906 SARS-CoV-2 RT-PCR-positive nasopharyngeal swabs were evaluated; the mean CT value was 27.4 (SD: 2.1) (22.2% below 20 cycles). During this period, 422,110 cases and 36,727 hospital admissions were also recorded. A temporal association was found between the CT counts and the cases of COVID-19 with a lag of 9-10 days (p ≤ 0.01) and hospital admissions by COVID-19 (p < 0.04) with a lag of 2-6 days. According to a validated method to prove associations between variables that change over time, the short-term evolution of average CT counts in the population may forecast the evolution of the COVID-19 pandemic.

Venous thromboembolism in COPD hospitalized patients.

Patients with chronic obstructive pulmonary disease (COPD) are at increased risk for venous thromboembolism (VTE). We analyzed a large Spanish database to determine the incidence of VTE in these patients during hospitalization. A retrospective chart review of cohort of consecutive patients admitted with COPD as the primary reason for discharge in Spain between January 1st 2006 and December 31st 2007 was performed. For each patient, demographic data, risk factors for VTE and the diagnosis of VTE during hospitalization was recorded. We analyzed the clinical data of 313,233 adults with acute exacerbations of COPD admitted to the hospital at any public centre in Spain, in 2006 and 2007. We identify 3,562 new diagnosed VTE events among 270,840 COPD patients hospitalized more than two days (incidence 1.32%). Hospitalized-acquired VTE risk factors were male gender (odds ratio [OR] 1.77; CI95% 1.66-1.90), neoplasic disease (OR 2.93 CI95% 2.69-3.16, systemic arterial disease (OR 1.17 CI95% 1.10-1.36), decubitus ulcer (OR 1.19 CI95% 1.01-1.43), diabetes (OR 0.74 IC95% 0.69-0.81), and atrial fibrillation (OR 0.79 CI95% 0.72-0.87). VTE appears as a major threat to patients admitted for acute exacerbation of COPD, and pharmacologic prophylaxis should be considered in all high risk situations.

Humoral and Cellular Response after mRNA Vaccination in Nursing Homes: Influence of Age and of History of COVID-19.

Background: Most residents and staff in nursing homes have received full vaccination. Factors related to the immune response to vaccination might be related to the risk of future severe COVID-19 and may guide the need for vaccine boosters. Design: Nursing homes that were tested in a point survey in July-October 2020 were again analyzed after a vaccination campaign in June-July 2021. Immune responses according to IgG against nucleocapsid and spike antigens, and CD4 and CD8 interferon-gamma release assay against spike antigens, were evaluated. Results: A total of 1973 subjects were tested (61.7% residents, 48.3% staff), with a mean (SD) follow-up of 46.4 (3.6) weeks between assessments. More than half of residents and more than a third of staff had evidence of COVID-19 before vaccination; 26.9% and 22.7% had seroreversion of IgG-N, and 8.9% and 4.6% had IgG-N seroconversion at second assessment, respectively. Up to 96.8% of residents and 98.1% of workers had positive IgG-S after a mean of 19.9 (2.1) weeks after vaccination. In residents with vs without a history of COVID-19, IgG-S titers were 4.11 (0.54) vs. 2.73 (0.74) logAU/mL (p < 0.001); in workers these titers were 3.89 (0.61) vs. 3.15 (0.64) logAU/mL (p < 0.001). Linear regression analysis showed that younger age (OR: −0.03 per 10 years-older [95% CI, −0.04 to −0.02], p < 0.001) and evidence of COVID-19 (OR: 1.14 [95% CI, 1.08 to 1.20], p < 0.001) are associated with greater IgG-S titers after vaccination. A direct association was found between IgG-S titers and the intensity of IFN-gamma response against spike antigens. Conclusions: Waning of humoral response and reinfection seems to be more frequent in older as compared to younger adults, although cellular responses shortly after vaccination are comparable between these groups. Younger age and prior COVID-19 are related to greater humoral response after vaccination against SARS-CoV-2.

Social Restrictions versus Testing Campaigns in the COVID-19 Crisis: A Predictive Model Based on the Spanish Case.

The global COVID-19 spread has forced countries to implement non-pharmacological interventions (NPI) (i.e., mobility restrictions and testing campaigns) to preserve health systems. Spain is one of the most severely impacted countries, both clinically and economically. In an effort to support policy decision-making, we aimed to assess the impacts of different NPI on COVID-19 epidemiology, healthcare costs and Gross Domestic Product (GDP). A modified Susceptible-Exposed-Infectious-Removed epidemiological model was created to simulate the pandemic evolution. Its output was used to populate an economic model to quantify healthcare costs and GDP variation through a regression model which correlates NPI and GDP change from 42 countries. Thirteen scenarios combining different NPI were consecutively simulated in the epidemiological and economic models. Both increased testing and stringency could reduce cases, hospitalizations and deaths. While policies based on increased testing rates lead to higher healthcare costs, increased stringency is correlated with greater GDP declines, with differences of up to 4.4% points. Increased test sensitivity may lead to a reduction of cases, hospitalizations and deaths and to the implementation of pooling techniques that can increase throughput testing capacity. Alternative strategies to control COVID-19 spread entail differing economic outcomes. Decision-makers may utilize this tool to identify the most suitable strategy considering epidemiological and economic outcomes.

Virological Correlates of IgM-IgG Patterns of Response to SARS-CoV-2 Infection According to Targeted Antigens.

The virological meaning of the different patterns of serology in COVID-19 has been little examined in clinical settings. Asymptomatic subjects with IgM-spike (S) and IgG-nucleocapsid (N) determinations by chemiluminescence were studied for SARS-CoV-2 shedding in respiratory secretions by transcription-mediated amplification (TMA). In subjects showing IgM-S positive and IgG-N negative, IgG-S was determined by lateral flow assay. A total of 712 individuals were tested: 30.0% presented IgM-S(+)/IgG-N(-), 25.8% had IgM-S(+)/IgG-N(+) and 44.2% had IgM-S(-)/IgG-N(+); the proportion with TMA(+) were comparable in these three groups: 12.1, 8.7 and 10.5%, respectively. In individuals with IgM-S(+)/IgG-N(-), IgG-S(+) was detected in 66.5%. The frequency of IgM-S(+)/IgG-S(-) in the total population was 10.0%, of whom 24.1% had TMA(+); the chances for TMA(+) in subjects with an IgM-S(+) alone pattern were 2.4%. Targeting of the same SARS-CoV-2 antigen seems to be better for the characterization of IgM/IgG patterns of response. IgM-S(+) alone reactivity is rare, and a small proportion is associated with viral shedding.

Admittances characteristics by sepsis in the Spanish internal medicine services between 2005 and 2015: mortality pattern.

BACKGROUND: Studies in recent years suggest an increase in the incidence of sepsis but a decrease in mortality. The aim of this study is to describe the characteristics of patients discharged after a sepsis episode from Spanish internal medicine services between 2005 and 2015. RESULTS: Since 2005, in which there were a total of 4,319 cases, sepsis hospitalizations has been consistently increasing yearly reaching a total of 25,820 cases in 2015. We observed that septic patients are older and with higher comorbidity than the general population admitted in Internal Medicine. On the other hand, we found a decreasing trend in the mortality rates of patients with sepsis in our series going from 35.7% in 2005 to 30.1% in 2015 (p < 0.005). DISCUSSION: In our study, a higher comorbidity at admission and developing complications during admittance, conditioned a higher probability of death due to sepsis. The variables that were associated with increased mortality risk were age, acute renal failure, acute respiratory failure, lactic acidosis, septic shock and chronic heart failure. CONCLUSION: As in other similar studies, we observed an increase in the hospitalizations by sepsis as a diagnosis at discharge during the study period in Internal Medicine services with a simultaneous decrease in mortality. Comorbidity at admission and complications during admittance condition mortality.

Prolonged length of stay in hospitalized internal medicine patients.

BACKGROUND: Targeting patients with prolonged hospitalizations may represent an effective strategy for reducing average hospital length of stay (LOS). OBJECTIVE: We sought to characterize predictors of prolonged hospitalization among internal medicine patients in an effort to guide future improvement efforts. DESIGN: We conducted a retrospective cohort study using administrative data of internal medicine patients from all hospitals of the Spanish Public Health Service between January 1st, 2005 and December 31st, 2013. Multivariable logistic regression was performed to assess the association between sociodemographic and clinical variables and prolonged LOS, defined as >30days. KEY RESULTS: Of 5,275,139 discharges, 166,470 (3.2%) had a prolonged LOS. Prolonged hospitalizations accounted for 17.4% of total inpatient days and contributed 0.5days to an average LOS of 9.8days during the study period. Prolonged hospitalizations were associated with younger age (odds ratio [OR]: 0.97 per 10-year increase in age, 95% confidence interval [CI]: 0.96-0.98) and male gender (OR 0.88 IC95% 0.87-0.89). Compared to patients without prolonged LOS, prolonged LOS patients were more likely to require a palliative care consult (OR: 2.48, 95% CI: 2.39-2.58), surgery (OR: 6.9 95% CI: 6.8-7.0); and be discharged to a post-acute-care facility (OR: 2.91, 95% CI: 2.86-2.95). CONCLUSIONS: Prolonged hospitalizations in a small proportion of patients were an important contributor to overall LOS and particularly affected complex hospital stays who were not discharged home.

Low prevalence of hyponatremia codification in departments of internal medicine and its prognostic implications.

OBJECTIVE: Hyponatremia is the most frequent ionic disorder among ambulatory and hospitalized populations. The aim of the study is to describe the profile of patients admitted to internal medicine departments of Spanish hospitals with a diagnostic codification of hyponatremia in their discharge sheets. METHODS: Data from the Minimum Basic Data Set (MBDS) of discharged patients from all departments of internal medicine (IM) of the Spanish National Health System (NHS) between 2007 and 2010 were analyzed to describe the profile of patients with diagnostic codification of hyponatremia. RESULTS: A total of 2,134,363 admittances were analyzed, identifying 31,933 (1.5%) with a diagnostic code of hyponatremia (18.3% as principal diagnosis and 81.7% as secondary diagnosis). Mortality among patients with codified hyponatremia was markedly higher than in patients without this condition (13.1% vs 9.8% [OR 1.38; 95% CI 1.33-1.41]). Hyponatremia codification was independently associated with a higher risk of readmission (OR 1.33 CI 95% 1.29-1.38). Average length of stay for patients with hyponatremia was 11.67 days (SD 13.01), compared to 9.84 days (SD 11.61) among the general population admitted to IM (p < 0.001). Mean cost per admission in the presence of codified hyponatremia was €4023 (SD €2531), compared to €3537 (SD €2858.02); p < 0.001. Hyponatremia was more prevalent among patients with the following conditions: dementia, chronic and acute renal failure, hepatic cirrhosis, pressure ulcers, heart failure, and depression. CONCLUSIONS: We found an extremely low prevalence of hyponatremia codification in our series (1.5%). Hyponatremia is underreported and undertreated although numerous studies have shown its devastating impact on hospital admittance. The first step in order to improve this situation is to raise awareness among physicians about a problem that despite its high prevalence is still overlooked.

Admission of nursing home residents to a hospital internal medicine department.

OBJECTIVE: Hospitalization of nursing home residents is costly and potentially exposes residents to iatrogenic disease and psychological harm. DESIGN AND SETTING: In this study, we analyzed the data from the Basic Minimum Data Set of patients hospitalized from the nursing home who were discharged from all the internal medicine departments at the National Health Service hospitals in Spain between 2005 and 2008, according to the data provided by the Ministry of Health and Consumer Affairs. RESULTS: Between January 2005 and December 2008, 2,134,363 patients were admitted to internal medicine departments in Spain, of whom 45,757 (2.1%) were nursing home residents. Overall, 7898 (17.3%) patients died during hospitalization, 2442 (30.91%) of them in the first 48 hours. The following variables were the significant predictors of in-hospital mortality in multivariate analysis: age (odds ratio [OR] 1.02, 95% confidence intervals [CI] 1.02-1.03), female gender (OR 1.13, 95% CI 1.13-1.17), dementia (OR 1.09, 95% CI 1.03-1.16), previous feeding tube (OR 1.34, 95% CI 1.09-1.79), malignant disease (OR 2.03, 95% CI 1.86-2.23), acute infectious disease (OR 1.18, 95% CI 1.12-1.25), pressure sores (OR 1.88, 95% CI 1.62-1.95), acute respiratory failure (OR 2.00, 95% CI 1.90-2.10), and nosocomial pneumonia (OR 2.5, 95% CI 2.23-2.72). CONCLUSIONS: Two of every 100 patients admitted to internal medicine departments came from nursing homes. The rate of mortality is very high in these patients, with almost one third of patients dying in the first 48 hours, which suggests that many of these transfers were unnecessary. The cost of these admissions for 1 year was equivalent to the annual budget of a 300- to 400-bed public hospital in Spain. The mechanism of coordination between nursing homes and public hospitals must be reviewed with the aim of containing costs and facilitating the care of patients in the last days of life.

Influence of obesity and malnutrition on acute heart failure.

INTRODUCTION AND OBJECTIVES: Obesity is an independent risk factor for the development of heart failure. Several recent studies have found better outcomes of heart failure for obese patients, an observation termed as the "obesity paradox." On the other hand, the negative effect of malnutrition on the evolution of heart failure has also been clearly established. METHODS: Data from the Minimum Basic Data Set were analyzed for all patients discharged from all the departments of internal medicine in hospitals of the Spanish National Health System between the years 2006 and 2008. The information was limited to those patients with a primary or secondary diagnosis of heart failure. Patients with a diagnosis of obesity or malnutrition were identified. The mortality and readmission indexes of obese and malnourished patients were compared against the subpopulation without these diagnoses. RESULTS: A total of 370,983 heart failure admittances were analyzed, with 41,127 (11.1%) diagnosed with obesity and 4105 (1.1%) with malnutrition. In-hospital global mortality reached 12.9% and the risk of readmission was 16.4%. Obese patients had a lower in-hospital mortality risk (odds ratio [OR]: 0.65, 95% confidence interval [95%CI]: 0.62-0.68) and early readmission risk (OR: 0.81, 95%CI: 0.78-0.83) than nonobese patients. Malnourished patients had a much higher risk of dying while in hospital (OR: 1.83 95%CI: 1.69-1.97) or of being readmitted within 30 days after discharge (OR: 1.39, 95%CI: 1.29-1.51), even after adjusting for possible confounding factors. CONCLUSIONS: Obesity in patients admitted for HF substantially reduces in-hospital mortality risk and the possibility of early readmission, whereas malnutrition is associated with important increases in in-hospital mortality and risk of readmission in the 30 days following discharge.