One-Year Changes in Optic Nerve Head Parameters in Recovered COVID-19 Patients.

BACKGROUND: The main purpose was to evaluate the changes in peripapillary retinal nerve fiber layer (RNFL) thickness and vessel density (VD) in post-COVID-19 patients during 12-month follow-up. METHODS: In this prospective study, patients with COVID-19 who were attended in the Hospital Clinico San Carlos (Madrid, Spain) were included. All patients underwent a complete ophthalmological examination, optic nerve head optical coherence tomography (OCT), and OCT angiography (OCTA) using the Cirrus HD-OCT 5,000 with AngioPlex OCTA 1, 3, and 12 months after laboratory-confirmed diagnosis. Sociodemographic data, medical history, disease severity, and laboratory workup were registered. RESULTS: A total of 180 eyes of 90 patients with SARS-CoV-2 infection were included; the mean age was 55.5 ± 8.9 years, and 46 patients (51%) were females. The mean visual acuity was 0.76 ± 0.16, and no abnormalities attributable to SARS-CoV-2 were detected in the ocular or fundus examination. No differences in the OCT and OCTA data were found between severity groups in each visit (all P > 0.05). Overall, there was a decrease in RNFL global thickness ( P < 0.001) from the first to the last visit, and an increase in VD and flux index was noted in some sectors at the 12-month examination. A significant correlation was detected at 12 months between vascularization parameters and RNFL thickness. CONCLUSIONS: One year after SARS-CoV-2 infection, changes in peripapillary RNFL thickness and vascularization occur, possibly indicating a recovery in such parameters.

[Impact of medium-term outcomes of inappropriate prescribing in older patients discharged from a short stay unit]. / Impacto de los resultados a medio plazo de la prescripción inadecuada en los pacientes ancianos dados de alta desde una unidad de corta estancia.

OBJECTIVE: To study the association between the potential inappropriate prescriptions (PIP) and the 30 and 180-day adverse event rate after discharge from a Short Stay Unit (SSU). METHODOLOGY: A retrospective cohort observational study was conducted on patients aged ≥75years discharged from an SSU from February to April, 2014. STOPP-START criteria version2 was used. The main outcome was 30 and 180-day adverse event rate after being discharged. RESULTS: A total of 179 patients, with a mean age of 84 (SD5) years were included. The presence of ≥1PIP after being discharged was not associated with a 30 and 180-day composite adverse event. Patients with ≥1PIP related to a cerebro-cardiovascular process were at higher risk of an adverse event at 30 days after discharge (adjusted OR, 2.1; 95%CI: 1.0-3.2; P=.045), those with ≥1PIP related to neuropsychiatric process and risk of fall were at higher risk of increased 30-day functional impairment (adjusted OR, 6.3; 95%CI: 1.7-22.5; P=.005), and those with ≥1PIP related to omission of cardiovascular system were at higher risk of 180-day hospital readmission (adjusted OR, 3.6; 95%CI: 1.5-8.3; P=.003). CONCLUSIONS: The presence of adverse events in older patients discharged from SSU may be associated with PIP, identified by STOPP-START criteria, and more specifically with drugs related to cardiovascular, neuropsychiatric disorders, and falls.

[Frequent attenders in Primary Health Care Centres and frequent attenders in Emergency Departments]. / Hiperfrecuentación en Atención Primaria e hiperfrecuentadores en Urgencias.

OBJECTIVE: To identify predictors of frequent attenders (HF) in Primary Health Care (PHC) centres in a sample of frequent attenders (HF) in Emergency Departments (ED). DESIGN: This was an observational, retrospective, multicentre cohort study. PARTICIPANTS: The HF patients were selected from patients seen in the ED between January 1 and December 31, 2013. Setting Patients were recruited from 17 public hospitals of the Community of Madrid, Spain. METHOD: Variables on the index visit to the ED were collected. The sample was analysed in terms of being or not being an HF user in PHC. An HF user is considered a patient who made at least 10 visits in each level of care for a year. RESULTS: A total of 1284 HF patients were included. An analysis was performed on 423 (32.9%) HF users in ED with 16 (12-25) visits to PHC vs. 861 (67.1%) non-HF users in ED, with 4 (2-6) visits to PHC. Independent predictors of HF in PHC: over 65 years (OR: 1.51; 95% CI: 1.07-2.13; P=.019), cognitive impairment (OR: 1.63; 95% CI: 1.01-2.65; P=.049), taking >3 drugs (OR: 1.56; 95% CI: 1.06-2.30; P=.025), and living in the community vs. nursing home or homeless (OR: 3.05; 95% CI: 1.14-8.16; P=.026). CONCLUSIONS: Among HF patients in the ED, the fact that of being over 65 years, taking 3or more drugs, suffering cognitive impairment, and living in the community, are also considered to be predictors of HF in PHC.

SEMES' long road to specialty status for emergency medicine in Spain. / El largo camino de SEMES hacia la especialidad de Medicina de Urgencias y Emergencias en España.

TEXT: July 2 of this year saw the publication of Spanish Royal Decree 610/2024, which establishes emergency medicine as an official specialization. This event represents the culmination of a long-running effort to improve the care of patients in the emergency and urgent care system and throughout the national health service. This article offers a brief account of some of the legal, administrative, and political steps the Spanish Society of Emergency Medicine(SEMES) took to achieve this goal over the course of nearly 40 years. The effort has involved many SEMES members, who strictly speaking had the sole obligation of knowing how to care appropriately for patients based on clinical expertise along with organizational, scientific, and other professional skills. Competences in these areas have been shown to fall short in Spain. The article provides examples of some of the bright lights and dim shadows in our rule of law. Nonetheless, the long road traveled has also shown us how skills and knowledge are developed in adverse circumstances and crises, provided there is vocation for public service.

TEXTO: La publicación del Real Decreto 610/2024, de 2 de julio, por el que se establece el título de Médica/o Especialista en Medicina de Urgencias y Emergencias, supone la culminación de una larga reclamación, orientada al logro de la mejora en la atención a los pacientes en el sistema de urgencias y emergencias y, en definitiva, del propio Sistema Sanitario español. Este artículo está orientado, de manera muy resumida, hacia algunos de los aspectos jurídicos, administrativos y políticos desempeñados por la Sociedad Española de Medicina de Urgencias y Emergencias, SEMES durante casi 40 años. Esto implica a muchos de sus miembros, profesionales que, esencialmente, solo debían saber cómo atender adecuadamente a sus pacientes, desde su conocimiento clínico, organizativo y científico, entre otros. Estos aspectos se mostraron insuficientes en España. Se ejemplifican algunas luces y sombras del Estado de Derecho español. Pero también este camino muestra las capacidades y conocimientos que se llegan a desarrollar en situaciones adversas y crisis, siempre y únicamente desde la vocación de servicio público.

Differences in toxicology reports and hospital emergency care for patients suspected of experiencing drug-facilitated crimes: an analysis according to gender. / Atención de pacientes con sospecha de sumisión química en un servicio de urgencias hospitalario y resultados del análisis toxicológico: diferencias según el sexo.

OBJECTIVE: To analyze gender-related differences in patient and care characteristics and in toxicology findings in suspected cases of drug facilitated crime (DFC). METHODS: Observational cross-sectional study of all patients in suspected DFC cases attended in the emergency department of Hospital Clínico San Carlos and of their blood or urine samples analyzed by the National institute of Toxicology and Forensics in Madrid between March 1, 2015, and March 1, 2023. We analyzed variables from patient records and the toxicology reports according to gender. RESULTS: A total of 514 suspected DFC episodes were studied; 101 (19.6%) were proactive crimes, 61 (11.9%) opportunistic, and 352 (68.5%) mixed. The median (interquartile range) age was 25 years (21-34 years), and 370 (72%) were women. Eighty-three percent of the patients had amnesia, and 48% of the cases involved sexual assault or robbery. Toxicology identified substances in 78% of the patients (alcohol, 53%; street drugs, 37%; and/or psychopharmaceuticals or opioids, 23%). Independent variables associated with female gender in the multivariate analysis, according to adjusted odds ratio (aORs) were age less than 25 years (aOR, 2.73; 95% CI, 1.75 4.24; P < .001); physician-referred emergency (aOR, 1.77; 95% CI, 1.12-2.80; P = .03); robbery (aOR, 0.25; 95% CI, 0.15-0.41; P < .001); alcohol-positive test result (aOR, 1.91; 95% CI, 1.21-3.00; P = .01); and a drug-positive result (aOR, 0.43; 95% CI, 0.28-0.64; P < .001). Police and a forensic physician intervened in 13% of the cases, and in such cases the victim was more likely to be female (aOR, 3.97; 95% CI, 1.41-11.13; P < .001). Toxicology identified the presence of an unknown substance in 39%, and a woman was less likely to be involved in such cases (aOR, 0.43; 95% CI, 0.28-0.67; P < .001). CONCLUSIONS: The majority of victims of DFCs were female, and the crimes were mixed, involving involve alcohol, psychopharmaceuticals or street drugs. Female victims were more likely to be under the age of 25 years, be referred to the emergency service by a physician, be attended by a forensic physician for sexual assault, and have an alcoholpositive toxicology report. Women were also less likely to report a robbery or have a toxicology report identifying drugs or an unknown substance.

OBJETIVO: Analizar las diferencias en las características de los pacientes atendidos por sospecha de sumisión química (SQ) y en los resultados del análisis toxicológico (AT) en función del sexo. METODO: Estudio observacional transversal retrospectivo que incluyó a todos los casos con SQ atendidos en el servicio de urgencias del Hospital Clínico San Carlos y las muestras (sangre o orina) para el AT en el Instituto Nacional de Toxicología y Ciencias Forenses de Madrid entre el 1 de marzo de 2015 y el 1 de marzo de 2023. Se analizan variables de la historia clínica y del AT según el sexo. RESULTADOS: Se incluyeron 514 episodios con sospecha de SQ [101 (19,6%) proactiva, 61 (11,9%) oportunista y 352 (68,5%) mixta] en pacientes con una mediana de 25 años (RIC: 21-34), 370 (72%) de sexo femenino. El 83% presentó amnesia y el 48% asoció agresión sexual o robo. En el 78% se identificó alguna sustancia en el AT (53% alcohol etílico, 37% drogas y/o 23% psicofármaco u opiáceos). En el análisis multivariado las variables que se asociaron de manera independiente con el sexo femenino fueron la edad menor de 25 años con ORa de 2,73 (IC 95%: 1,75-4,24; p < 0,001), con médico deriva a urgencias con ORa de 1,77 (IC 95%: 1,12-2,80; p = 0,03), delito de robo con de ORa 0,25 (IC 95%: 0,15-0,41; p < 0,001), alcohol etílico en el AT con ORa 1,91 (IC 95%: 1,21-3,00; p = 0,01) y alguna droga en el AT con ORa 0,43 (IC 95%: 0,28-0,64; p < 0,001). En el 13% de casos hubo intervención policial y médico-forense y fue más probable que fuera a una mujer, con ORa 3,97 (IC 95%: 1,41-11,13; p < 0,001). En el 39% de AT se identificó alguna sustancia desconocida y fue menos probable que fuera mujer, con ORa de 0,43 (IC 95%: 0,28-0,67; p < 0,001). CONCLUSIONES: La mayoría de casos registrados fueron mujeres con sospecha de SQ mixta por alcohol, psicofármacos o drogas de abuso. Las mujeres presentaron mayor probabilidad de tener menos de 25 años, ser derivada a urgencias por un médico, de intervención médico-forense por agresión sexual y encontrar alcohol etílico en el AT.

Optic nerve and macular optical coherence tomography in recovered COVID-19 patients.

PURPOSE: To investigate the peripapillary retinal nerve fiber layer thickness (RNFLT), macular RNFLT, ganglion cell layer (GCL), and inner plexiform layer (IPL) thickness in recovered COVID-19 patients compared to controls. METHODS: Patients previously diagnosed with COVID-19 were included, while healthy patients formed the historic control group. All patients underwent an ophthalmological examination, including macular and optic nerve optical coherence tomography. In the case group, socio-demographic data, medical history, and neurological symptoms were collected. RESULTS: One hundred sixty patients were included; 90 recovered COVID-19 patients and 70 controls. COVID-19 patients presented increases in global RNFLT (mean difference 4.3; CI95% 0.8 to 7.7), nasal superior (mean difference 6.9; CI95% 0.4 to 13.4), and nasal inferior (mean difference 10.2; CI95% 2.4 to 18.1) sectors of peripapillary RNFLT. Macular RNFL showed decreases in COVID-19 patients in volume (mean difference -0.05; CI95% -0.08 to -0.02), superior inner (mean difference -1.4; CI95% -2.5 to -0.4), nasal inner (mean difference -1.1; CI95% -1.8 to -0.3), and nasal outer (mean difference -4.7; CI95% -7.0 to -2.4) quadrants. COVID-19 patients presented increased GCL thickness in volume (mean difference 0.04; CI95% 0.01 to 0.07), superior outer (mean difference 2.1; CI95% 0.8 to 3.3), nasal outer (mean difference 2.5; CI95% 1.1 to 4.0), and inferior outer (mean difference1.2; CI95% 0.1 to 2.4) quadrants. COVID-19 patients with anosmia and ageusia presented an increase in peripapillary RNFLT and macular GCL compared to patients without these symptoms. CONCLUSIONS: SARS-CoV-2 may affect the optic nerve and cause changes in the retinal layers once the infection has resolved.

Procalcitonin concentration in the emergency department predicts 30-day mortality in COVID-19 better than the lymphocyte count, the neutrophil-tolymphocyte ratio, or the C-reactive protein level. / Procalcitonina es superior a recuento linfocitario, índice neutrófilo/linfocito y proteína C reactiva para la predicción de mortalidad a 30 días de pacientes con COVID-19 en el servicio de urgencias.

OBJECTIVES: Although many demographic and clinical predictors of mortality have been studied in relation to COVID-19, little has been reported about the prognostic utility of inflammatory biomarkers. MATERIAL AND METHODS: Retrospective cohort study. All patients with laboratory-confirmed COVID-19 treated in a hospital emergency department were included consecutively if baseline measurements of the following biomarkers were on record: lymphocyte counts, neutrophil-to-lymphocyte ratio NRL, and C-reactive protein (CRP) and procalcitonin (PCT) levels. We analyzed associations between the biomarkers and all-cause 30-day mortality using Cox regression models and dose-response curves. RESULTS: We included 896 patients, 151 (17%) of whom died within 30 days. The median (interquartile range) age was 63 (51-78) years, and 494 (55%) were men. NLR, CRP and PCT levels at ED presentation were higher, while lymphocyte counts were lower, in patients who died compared to those who survived (P .001). The areas under the receiver operating characteristic curves revealed the PCT concentration (0.79; 95% CI, 0.75-0.83) to be a better predictor of 30-day mortality than the lymphocyte count (0.70; 95% CI, 0.65-0.74; P .001), the NLR (0.74; 95% CI, 0.69-0.78; P = .03), or the CRP level (0.72; 95% CI, 0.68-0.76; P .001). The proposed PCT concentration decision points for use in emergency department case management were 0.06 ng/L (negative) and 0.72 ng/L (positive). These cutoffs helped classify risk in 357 patients (40%). Multivariable analysis demonstrated that the PCT concentration had the strongest association with mortality. CONCLUSION: PCT concentration in the emergency department predicts all-cause 30-day mortality in patients with COVID-19 better than other inflammatory biomarkers.

OBJETIVO: Existen múltiples variables demográficas y clínicas predictivas de mortalidad en pacientes con COVID-19. Sin embargo, hay menos información sobre el valor pronóstico de los biomarcadores inflamatorios. METODO: Estudio de cohorte retrospectivo. Se incluyeron de forma consecutiva todos los pacientes con COVID-19, confirmado por laboratorio, atendidos en un servicio de urgencias hospitalario (SUH) y con valor basal de los siguientes biomarcadores: recuento linfocitario, índice neutrófilo/linfocito (INL), proteína C reactiva (PCR) y procalcitonina (PCT). La relación entre los biomarcadores y la mortalidad total a 30 días se analizó mediante una regresión de Cox y gráficos de dosis-respuesta. RESULTADOS: Se incluyeron 896 pacientes, 151 (17%) fallecieron en los primeros 30 días. La mediana de edad fue de 63 años (51-78) y 494 (55%) eran hombres. El valor de INL, PCR y PCT fue mayor, mientras que el recuento linfocitario fue menor, en los pacientes que fallecieron respecto a los que sobrevivieron (p 0,001). La PCT fue superior al recuento linfocitario, INL y PCR en la predicción de mortalidad a 30 días (ABC 0,79 [IC 95%: 0,75-0,83] vs 0,70 [IC 95%: 0,65-0,74], p 0,001; 0,74 [IC 95%: 0,69-0,78], p = 0,03; y 0,72 [IC 95%: 0,68-0,76], p 0,001). Los puntos de decisión de PCT propuestos, 0,06 ng/l para exclusión y 0,72 ng/l para inclusión de muerte a 30 días, podrían facilitar la toma de decisiones en urgencias. Hubo 357 pacientes (40%) con valores de PCT en estas categorías. El análisis multivariable mostró una mayor asociación con la mortalidad para PCT que en los otros biomarcadores estudiados. CONCLUSIONES: PCT es el biomarcador con mejor capacidad para predecir mortalidad a 30 días por cualquier causa en pacientes con COVID-19 valorados en un SUH.

Proteomic changes related to "bewildered" circulating platelets in the acute coronary syndrome.

Acute coronary syndromes (ACS) are associated with platelet activation. The aim of the present study was to study the protein expression level associated with glycolysis, oxidative stress, cytoskeleton and cell survival in platelets obtained during an ACS. Platelets from 42 coronary ischemic patients, divided into patients admitted within 24 h after the onset of chest pain (ACS group; n=16) and patients with stable coronary ischemic disease (CAD, n=26), were analyzed using proteomics. The expression levels of proteins involved in cellular cytoskeleton (F-actin capping, ß-tubulin, α-tubulin isotypes 1 and 2, vinculin, vimentin and two Ras-related protein Rab-7b isotypes), glycolysis pathway (glyceraldehyde-3-phosphate dehydrogenase, lactate dehydrogenase and two pyruvate kinase isotypes) and cellular-related antioxidant system (manganese superoxide dismutase) and even the expression and activity of glutathione-S-transferase were significantly reduced in platelets from ACS patients compared to CAD patients. Moreover, reduction in the expression of proteins associated with cell survival such as proteasome subunit ß type 1 was also observed in ACS platelets compared with CAD platelets. Principal component and logistic regression analysis suggested the existence of factors (proteins) expressed in the platelets inversely associated with acute coronary ischemia. In summary, these results suggest the existence of circulating antioxidant, cytoskeleton and glycolytic-"bewildered" platelets during the acute phase of a coronary event.

Functional status and inflammation after preseason training program in professional and recreational soccer players: a proteomic approach.

The purpose of the study was to determine if an intensive pre- season training program modifies the inflammatory status in professional soccer players and if this inflammatory profile may be associated with the physical state. We compared plasma protein biomarkers, using proteomics, and the physiological state and cardiac function in 12 professional soccer players and 9 recreational soccer players. Reduced cardiac low frequency [LF] after the pre- season training program previous competition with respect to recreational soccer players was found. No differences were found in cardiac high frequency, cardiac high frequency/low frequency ratio, tension index and oxygen volume consumption. Alpha-1-antitrypsin isotype-3, fibrinogen-gamma isotypes-1, 2 and 3 and vitamin-D-binding protein isotype-1 were reduced in professionals players compared with those in recreational players. However, an increased content of alpha-1-antitrypsin isotype-6 and alpha-1-antichymotrypsin 1 and 4 were found in professional soccer players. Spearman's analysis showed a positive correlation between LF and fibrinogen-gamma chain isotype 3; but LF was negatively correlated with alpha-antichymotrypsin isotype 4. Professional soccer players submitted to an intensive training showed differences in the content of plasma proteins associated with inflammatory/oxidative stress and thrombosis with respect to recreational soccer players. Proteomics analysis in combination with the analysis of cardiac function assessment may be useful to know more in depth molecular processes associated with sport and intensive exercise. Key pointsProteomics allow us to find differences in the plasma protein content in sportsmen.Just after pre-season training program, professional soccer players showed lower content of circulating proteins associated with inflammation compared to recreational soccer players.Proteomic analysis in combination with the analysis of cardiac function may be useful to know more in depth molecular inflammatory and oxidative processes associated with the sport.

Reduced retinal vessel density in COVID-19 patients and elevated D-dimer levels during the acute phase of the infection.

PURPOSE: To describe macular vessel density and perfusion in COVID-19 patients using coherence tomography angiography (OCTA) and to investigate whether there is a correlation between retinal vascular abnormalities and clinical and laboratory parameters. METHODS: Cross-sectional analysis conducted at the Hospital Clinico San Carlos in Madrid, Spain. Patients with laboratory-confirmed COVID-19 that were attended in the Emergency Department (ED) from March 23 to March 29, 2020 were included. Fundus examination and OCTA were performed 4 weeks after being attended in ED. Macular OCTA parameters were analyzed and correlated with clinical (severity and hypoxemia- oxygen saturation<92%) and laboratory parameters during hospital stay (D-Dimer-DD, lactate dehydrogenase-LDH and C-reactive protein-CRP). RESULTS: 80 patients were included, mean age 55(SD9) years old; 46.3% male. We reported macular vessel density and perfusion measurements in COVID-19 patients. Those patients with D-Dimer≥500ng/ml during SARS-CoV-2 infection had a decrease of central vessel density (mean difference 2.2; 95%CI 0.4-3.9) and perfusion density (mean difference 4.9; 95%CI 0.9-8.9) after the acute phase of COVID-19. These variations of vessel density and perfusion density were not documented in patients with LDH≥500U/L, CRP≥10mg/L and hypoxemia. CONCLUSIONS: COVID-19 patients showed short-term retinal vasculature abnormalities which may be related to a prothrombotic state associated with SARS-CoV-2 infection. Since the retinal microvasculature shares many morphological and physiological properties with the vasculature of other vital organs, further research is needed to establish whether patients with increased D-Dimer levels require more careful assessment and follow-up after COVID-19.

Optic Nerve Head Vessel Density Assessment in Recovered COVID-19 Patients: A Prospective Study Using Optical Coherence Tomography Angiography.

PRECIS: Vascular diseases have been linked to alterations in optic nerve head perfusion. PURPOSE: The main objective was to investigate the changes in peripapillary vessel density (VD) in post coronavirus disease (COVID-19) patients. METHODS: In this prospective pilot exploratory study, patients with COVID-19 that were attended in the Emergency Department of Hospital Clinico San Carlos (Madrid) were included. All patients underwent optic nerve head optical coherence tomography angiography using the Cirrus HD-OCT 500 with AngioPlex OCTA (Zeiss, Dublin, CA) 4 and 12 weeks after diagnosis by positive reverse transcriptase-polymerase chain reaction test from nasopharyngeal swab at the Emergency Department. Sociodemographic data, medical history, disease severity, and laboratory work-up were collected. RESULTS: One hundred and eighty eyes of 90 patients with severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) infection were included. None of the patients reported visual changes. Severe patients were older, more frequently hispanic, dyslipidemic, and presented lower lymphocytes counts, as well as increased ferritin, D-dimer, fibrinogen, and international normalized ratio levels. No changes in optic nerve head vascularization were observed when both visits were compared. No correlation was found between VD and clinical parameters, disease severity and laboratory work-up. CONCLUSIONS: Changes to peripapillary VD were not observed in patients with COVID-19 in the early months following diagnosis.

Reduced retinal vessel density in COVID-19 patients and elevated D-dimer levels during the acute phase of the infection.

PURPOSE: To describe macular vessel density and perfusion in COVID-19 patients using coherence tomography angiography (OCTA) and to investigate whether there is a correlation between retinal vascular abnormalities and clinical and laboratory parameters. METHODS: Cross-sectional analysis conducted at the Hospital Clinico San Carlos in Madrid, Spain. Patients with laboratory-confirmed COVID-19 that were attended in the Emergency Department (ED) from March 23 to March 29, 2020 were included. Fundus examination and OCTA were performed 4 weeks after being attended in ED. Macular OCTA parameters were analyzed and correlated with clinical (severity and hypoxemia- oxygen saturation < 92%) and laboratory parameters during hospital stay (D-Dimer-DD, lactate dehydrogenase-LDH and C-reactive protein-CRP). RESULTS: 80 patients were included, mean age 55(SD9) years old; 46.3% male. We reported macular vessel density and perfusion measurements in COVID-19 patients. Those patients with D-Dimer ≥ 500 ng/ml during SARS-CoV-2 infection had a decrease of central vessel density (mean difference 2.2; 95%CI 0.4-3.9) and perfusion density (mean difference 4.9; 95%CI 0.9-8.9) after the acute phase of COVID-19. These variations of vessel density and perfusion density were not documented in patients with LDH ≥ 500 U/L, CRP ≥ 10 mg/L and hypoxemia. CONCLUSIONS: COVID-19 patients showed short-term retinal vasculature abnormalities which may be related to a prothrombotic state associated with SARS-CoV-2 infection. Since the retinal microvasculature shares many morphological and physiological properties with the vasculature of other vital organs, further research is needed to establish whether patients with increased D-Dimer levels require more careful assessment and follow-up after COVID-19.

OBJETIVO: Evaluar la densidad vascular (DV) y la perfusión vascular (PV) retiniana en pacientes con COVID-19 mediante una angiografía por tomografía de coherencia óptica (OCTA), e investigar si existe una correlación entre las anomalías vasculares de la retina y los parámetros clínicos y de laboratorio. MÉTODOS: Análisis transversal realizado en el Hospital Clínico San Carlos, Madrid. Se incluyeron pacientes con diagnóstico confirmado de COVID-19 atendidos en el Servicio de Urgencias (SU) del 23 al 29 de marzo del 2020. Se realizó una exploración oftalmológica y OCTA cuatro semanas después de acudir al SU. Se analizaron los parámetros maculares de OCTA y se correlacionaron con parámetros clínicos (gravedad e hipoxemia-saturación de oxígeno < 92%) y de laboratorio durante la estancia hospitalaria (dímero D [DD], lactato deshidrogenasa [LDH] y proteína C reactiva [CRP]. RESULTADOS: Se incluyeron 80 pacientes, edad media 55 (DE nueve) años; 46,3% hombres. Las personas con DD > 500 ng/mL durante la infección por SARS-CoV-2 tuvieron una disminución de la DV central (diferencia de medias 2,2; IC 95% 0,4 a 3,9) y PV central (diferencia de medias 4,9; IC 95% 0,9 a 8,9) después de la fase aguda de COVID-19. Estas variaciones no se documentaron en los pacientes con LDH > = 500 U/L, CRP > = 10 mg/L y con hipoxemia. CONCLUSIONES: Los pacientes con COVID-19 mostraron anomalías de la vasculatura retiniana a corto plazo que pueden estar relacionadas con un estado protrombótico asociado con la infección por SARS-CoV-2. Dado que la microvasculatura de la retina comparte muchas propiedades morfológicas y fisiológicas con la vasculatura de otros órganos vitales, es necesario seguir investigando para determinar si los pacientes con niveles elevados de DD requieren una evaluación y un seguimiento más cuidadoso.

Different protein expression in normal and dysfunctional platelets from uremic patients.

Although many uremic patients show platelet dysfunctionality, there are others with normal platelet functionality and even with thrombotic tendencies. Our aim was to evaluate changes in the expression of proteins in functional and dysfunctional uremic platelets. Using the platelet function analyzer (PFA-100) assay, uremic patients were divided according to their platelet functionality into normal (n=7) and dysfunctional (n=8). There were no significant differences in the number of circulating platelets and hematocrit and hemoglobin levels. Two-dimensional electrophoresis and mass spectrometry were used to determine and identify changes in protein expression. The closure time (CT) in the PFA-100 assay was significantly prolonged in the dysfunctional uremic platelets. In the dysfunctional platelets, actin-interacting protein-1 isotype 1 was down-regulated, while integrin IIb was up-regulated. Glutathione-S-transferase isotypes 1 and 2 and peroxiredoxin VI were up-regulated in the dysfunctional platelets. Pearson analysis showed a negative correlation between the platelet expression of integrin IIb and creatinine clearance. A positive correlation was found between creatinine clearance and glutathione-S-transferase isotype 2. Serum uric acid concentration was positively correlated with CT values and glutathione-S-transferase isotype 1. In conclusion, the analysis of the protein expression in uremic platelets with normal and dysfunctional activity revealed differences which may occur at the megakaryocyte level.

[Prognostic value of functional assessment at admission in an emergency short-stay unit]. / Valor pronóstico de la valoración funcional al ingreso en una unidad de corta estancia de Urgencias.

INTRODUCTION: To determine the prognostic value of functional impairment on the final destination of elders admitted for acute medical illness to an emergency short-stay unit (ESSU). MATERIAL AND METHODS: We performed a prospective analysis of patients aged more than 65 years old admitted to the ESSU of Hospital Clínico San Carlos in Madrid in April 2008. A protocol was designed that included epidemiologic variables (age and gender), clinical variables (reason for admission, comorbidity measured by the Charlson Index [CI]) and functional variables (previous, admission and functional decline [FD] measured with the Barthel [BI] and Lawton Indexes [LI]). The prognostic value of FD on the decision to admit patients was analyzed through ROC curves and the cut points that maximized sensitivity and specificity were determined. RESULTS: Sixty patients were included with a mean age of 80.7 (SD 8.2) years and 71.7% were women. The reasons for admission were acute infections in 31.7%, heart failure in 23.3%, syncope in 15.0%, intestinal obstruction in 11.7%, gastrointestinal bleeding in 10.0%, and arrhythmias in 8.3%. The mean CI was 2.27 (1.45). Functional assessment was as follows: mean previous BI score: 79.25 (SD 25) and at admission: 62.92 (SD 28.19). Mean previous LI score: 4.85 (SD 2.45) and at admission: 2.98 (SD 2.42).): BI-FD: 20% (1.25-38.23), LI-FD 37.5% (16.7-70.2%). FD was found in 100% of the patients. The mean length of stay was 1.70 (SD 0.62) days. Discharge destination was home discharge in 46.7% and hospitalization unit in 53.3%. Multivariate analysis according to discharge destination (home vs hospitalization) provided the following results : BI-FI > or = 16% (OR=7.99 [1.1-60.5], p=0.037), LI-FI > or =35% (OR=19.6 [0.04-0.52], p <0.0001). CONCLUSIONS: Patients with significant FD in the emergency room should not be admitted to an ESSU since significant FD is a prognostic factor for transfer to a conventional ward.

Diagnostic groups and short-term outcomes in suspected COVID-19 cases treated in an emergency department. / Categorías diagnósticas y resultados a corto plazo en los pacientes con sospecha de COVID-19 atendidos en un servicio de urgencias.

OBJECTIVES: The primary objective was to describe the clinical characteristics and 30-day mortality rates in emergency department patients with coronavirus disease 2019 (COVID-19) in different diagnostic groupings. MATERIAL AND METHODS: Secondary analysis of the COVID-19 registry compiled by the emergency department of Hospital Clínico San Carlos in Madrid, Spain. We selected suspected COVID-19 cases treated in the emergency department between February 28 and March 31, 2020. The cases were grouped as follows: 1) suspected, no polymerase chain reaction (PCR) test (S/no-PCR); 2) suspected, negative PCR (S/PCR-); 3) suspected, positive PCR (S/PCR+); 4) highly suspected, no PCR, or negative PCR (HS/no or PCR-); and 5) highly suspected, positive PCR (HS/PCR+). We collected clinical, radiologic, and microbiologic data related to the emergency visit. The main outcome was 30-day all-cause mortality. Secondary outcomes were hospitalization and clinical severity of the episode. RESULTS: A total of 1993 cases (90.9%) were included as follows: S/no-PCR, 17.2%; S/PCR-, 11.4%; S/PCR+, 22.1%; HS/no PCR or PCR-, 11.7%; and HS/PCR+, 37.6%. Short-term outcomes differed significantly in the different groups according to demographic characteristics; comorbidity and clinical, radiographic, analytical, and therapeutic variables. Thirty-day mortality was 11.5% (56.5% in hospitalized cases and 19.6% in cases classified as severe). The 2 HS categories and the S/PCR+ category had a greater adjusted risk for 30-day mortality and for having a clinically severe episode during hospitalization in comparison with S/PCR- cases. Only the 2 HS categories showed greater risk for hospitalization than the S/PCR- cases. CONCLUSION: COVID-19 diagnostic groups differ according to clinical and laboratory characteristics, and the differences are associated with the 30-day prognosis.

OBJETIVO: El objetivo principal fue describir el perfil clínico y la mortalidad a los 30 días de diferentes categorías diagnósticas en los casos de COVID-19 atendidos en un servicio de urgencias (SU). METODO: Análisis secundario del registro COVID-19_URG-HCSC. Se seleccionaron los casos sospechosos de COVID-19 atendidos en un SU de Madrid desde el 28 de febrero hasta el 31 de marzo de 2020. La muestra se dividió: 1) sospecha con PCR no realizada (S/PCR NR); 2) sospecha con PCR negativa (S/PCR­); 3) sospecha con PCR positiva (S/ PCR+); 4) alta sospecha con PCR negativa o no realizada (AS/PCR­ o NR); y 5) alta sospecha con PCR positiva (AS/ PCR+). Se recogieron variables clínicas, radiológicas y microbiológicas del episodio de urgencias. La variable de resultado principal fue la mortalidad por cualquier causa a los 30 días. Las variables secundarias fueron el ingreso y la gravedad del episodio. RESULTADOS: Se incluyeron 1.993 pacientes; 17,2% S/PCR NR, 11,4% S/PCR­, 22,1% S/PCR+, 11,7% AS/PCR­ o NR y 37,6% AS/PCR+. Se hallaron diferencias estadísticamente significativas respecto a las variables demográficas, comorbilidad, clínicas, radiográficas, analíticas y terapéuticas y de resultados a corto plazo en función las categorías diagnósticas. La mortalidad global a los 30 días fue de un 11,5%, 56,5% casos fueron hospitalizados y 19,6% casos sufrieron un episodio grave. Las categorías de AS y de S/PCR+ tuvieron un incremento del riesgo ajustado de mortalidad a los 30 días y de sufrir un episodio grave durante el ingreso hospitalario respecto a S/PCR­. En relación al ingreso, solo las categorías de AS tuvieron un incremento del riesgo ajustado de hospitalización respecto a la categoría de S/PCR­. CONCLUSIONES: Existen diferentes categorías diagnósticas de la enfermedad COVID-19 en función del perfil clínico y microbiológico que tienen correlato con el pronóstico a 30 días.

Clinical presentation and outcome across age categories among patients with COVID-19 admitted to a Spanish Emergency Department.

PURPOSE: To determine the differences by age-dependent categories in the clinical profile, presentation, management, and short-term outcomes of patients with laboratory-confirmed COVID-19 admitted to a Spanish Emergency Department (ED). METHODS: Secondary analysis of COVID-19_URG-HCSC registry. We included all consecutive patients with laboratory-confirmed COVID-19 admitted to the ED of the University Hospital Clinico San Carlos (Madrid, Spain). The population was divided into six age groups. Demographic, baseline and acute clinical data, and in-hospital and 30-day outcomes were collected. RESULTS: 1379 confirmed COVID-19 cases (mean age 62 (SD 18) years old; 53.5% male) were included (18.1% < 45 years; 17.8% 45-54 years; 17.9% 55-64 years; 17.2% 65-74 years; 17.0% 75-84 years; and 11.9% ≥ 85 years). A statistically significant association was found between demographic, comorbidity, clinical, radiographic, analytical, and therapeutic variables and short-term results according to age-dependent categories. There were less COVID-specific symptoms and more atypical symptoms among older people. Age was a prognostic factor for hospital admission (aOR = 1.04; 95% CI 1.02-1.05) and in-hospital (aOR = 1.08; 95% CI 1.05-1.10) and 30-day mortality (aOR = 1.07; 95% CI 1.04-1.09), and was associated with not being admitted to intensive care (aOR = 0.95; 95% CI 0.93-0.98). CONCLUSIONS: Older age is associated with less COVID-specific symptoms and more atypical symptoms, and poor short-term outcomes. Age has independent prognostic value and may help in shared decision-making in patients with confirmed COVID-19 infection.

Planning to reduce 30-day adverse events after discharge of frail elderly patients with acute heart failure: design and rationale for the DEED FRAIL-AHF trial. / Planificación del alta desde urgencias para reducir eventos adversos a 30 días en pacientes mayores frágiles con insuficiencia cardiaca aguda: diseño y justificación del ensayo clínico DEED FRAIL-AHF.

OBJECTIVES: To demonstrate the efficacy of a system for comprehensive care transfer (Multilevel Guided Discharge Plan [MGDP]) for frail older patients diagnosed with acute heart failure (AHF) and to validate the results of MGDP implementation under real clinical conditions. The MGDP seeks to reduce the number of adverse outcomes within 30 days of emergency department (ED) discharge. MATERIAL AND METHODS: We will enroll frail patients over the age of 70 years discharged home from the ED with a main diagnosis of AHF. The MGDP includes the following components: 1) a checklist of clinical recommendations and resource activations, 2) scheduling of an early follow-up visit, 3) transfer of information to the primary care doctor, and 4) written instructions for the patient. Phase 1 of the study will be a matched-pair cluster-randomized controlled trial. Ten EDs will be randomly assigned to the intervention group and 10 to the control group. Each group will enroll 480 patients, and the outcomes will be compared between groups. Phase 2 will be a quasi-experimental study of the intervention in 300 new patients enrolled by the same 20 EDs. The outcomes will be compared to those for each Phase-1 group. The main endpoint at 30 days will be a composite of 2 outcomes: revisits to an ED and/for hospitalization for AHF or cardiovascular death. CONCLUSION: The study will assess the efficacy and feasibility of comprehensive MGDP transfer of care for frail older AHF patients discharged home.

OBJETIVO: Demostrar la eficacia de una intervención integral en la transición de cuidados (Plan de Alta Guiado Multinivel, PAGM) para disminuir eventos adversos a 30 días en ancianos frágiles con insuficiencia cardiaca aguda (ICA) dados de alta desde servicios de urgencias (SU) y validar los resultados de dicha intervención en condiciones reales. METODO: Se seleccionarán pacientes 70 años frágiles con diagnóstico principal de ICA dados del alta a su domicilio desde SU. La intervención consistirá en aplicar un PAGM: 1) lista de verificación sobre recomendaciones clínicas y activación de recursos; 2) programación de visita precoz; 3) transmisión de información a atención primaria; 4) hoja de instrucciones al paciente por escrito. Fase 1: ensayo clínico con asignación al azar por conglomerados emparejado. Se asignará de forma aleatoria 10 SU (N = 480) al grupo de intervención y 10 SU (N = 480) al grupo de control. Se compararán los resultados entre grupo de intervención y control. Fase 2: estudio cuasi-experimental. Se realizará la intervención en los 20 SU (N = 300). Se comparará los resultados entre la fase 1 y 2 del grupo de intervención y entre la fase 1 y 2 del grupo de control. La variable principal de resultado es compuesta (revisita a urgencias u hospitalización por ICA o mortalidad de origen cardiovascular) a los 30 días del alta. CONCLUSIONES: El estudio valorará la eficacia y factibilidad de una intervención integral en la transición de cuidados para reducir resultados adversos a 30 días en ancianos frágiles con ICA dados de alta desde los SU.