Prognostic accuracy of SIRS criteria, qSOFA score and GYM score for 30-day-mortality in older non-severely dependent infected patients attended in the emergency department.

The aim of this study was to determine the accuracy of systemic inflammatory response syndrome (SIRS), quick Sepsis-related Organ Failure Assessment (qSOFA) score and GYM score to predict 30-day mortality in older non-severely dependent patients attended for an episode of infection in the emergency department (ED). We performed an analytical, observational, prospective cohort study including patients 75 years of age or older, without severe functional dependence, attended for an infectious process in 69 Spanish EDs for 2-day three-seasonal periods. Demographic, clinical and analytical data were collected. The primary outcome was 30-day mortality after the index event. We included 1071 patients, with a mean age of 83.6 [standard deviation (SD) 5.6] years; 544 (50.8%) were men. Seventy-two patients (6.5%) died within 30 days. SIRS criteria ≥ 2 had a sensitivity of 65% [95% confidence interval (CI) 53.1-75.9] and a specificity of 49% (95% CI 46.0-52.3), a qSOFA score ≥ 2 had a sensitivity of 28% (95% CI 18.2-39.8) and a specificity of 94% (95% CI 91.9-95.1), and a GYM score ≥ 1 had a sensitivity of 81% (95% CI 69.2-88.6) and a specificity of 45% (95% CI 41.6-47.9). A GYM score ≥ 1 and a qSOFA score ≥ 2 were the cut-offs with the highest sensitivity (p < 0.001) and specificity (p < 0.001), respectively. The area under the curve (AUC) was 0.73 (95% CI 0.66-0.79; p < 0.001) for the GYM score, 0.69 (95% CI 0.61-0.76; p < 0.001) for the qSOFA score and 0.65 (95% CI 0.59-0.72; p < 0.001) for SIRS. A GYM score ≥ 1 may be the most sensitive score and a qSOFA score ≥ 2 the most specific score to predict 30-day mortality in non-severely dependent older patients attended for acute infection in EDs.

Diagnostic accuracy of combining C-Reactive protein and Alvarado Score among 2-to-20-year-old patients with acute appendicitis suspected presenting to Emergency Departments.

OBJECTIVE: Main objective was whether the combination of C-Reactive Protein (CRP) and Alvarado Score (AS) increase the diagnosis accuracy of AS among 2-to-20-year-old patients with suspected acute appendicitis presenting to Emergency Departments. METHODS: This is a secondary analysis of prospective cohort study consecutively including all patients from 2 to 20 years of age attended for suspected acute appendicitis in 4 Spanish Emergency Departments during 6-month period. We collected demographic, clinical, analytic and radiographic, and surgical data. AS categories were retrospectively calculated as low (0-4 points), intermediate (5-6 points) or high (7-10 points). The cut-off levels were >0.5 mg/dl for CRP. The outcome was diagnosis of acute appendicitis within 14 days of the index visit. RESULTS: A total of 331 patients with suspected of acute appendicitis (mean age 11.8 (SD 3.8) years; 52.9% males) were recruited. According to AS, 108 (32.6%) were at low risk, 76 at (23.0%) intermediate risk and 147 (44.4%) at high risk of acute appendicitis. One hundred and sixteen (35.0%) cases had confirmed histopathological diagnosis of acute appendicitis. The AUCs of ROC were 0.76 (0.70-0.81) for AS and 0.79 (95% CI 0.75-0.84) for CRP-AS being the difference statistically significant (p=0.003). The CRP for diagnosis acute appendicitis in low risk AS group had negative predictive value of 95.8% (95%CI 87.3-98.9) and likelihood ratio negative of 0.4 (95%CI 0.2-1.0).. CONCLUSIONS: CRP-AS has shown to increase the diagnostic accuracy of AS for acute appendicitis. This approach may be useful to rule out the diagnosis of acute appendicitis in paediatric patients attended for abdominal pain suggestive of acute appendicitis.

[Comparison of different strategies for short-term death prediction in the infected older patient]. / Comparación de distintas estrategias para la predicción de muerte a corto plazo en el paciente anciano infectado.

OBJECTIVE: The aim of this study was to determine the utility of a post hoc lactate added to SIRS and qSOFA score to predict 30-day mortality in older non-severely dependent patients attended for infection in the Emergency Department (ED). METHODS: We performed an analytical, observational, prospective cohort study including patients of 75 years of age or older, without severe functional dependence, attended for an infectious disease in 69 Spanish ED for 2-day three seasonal periods. Demographic, clinical and analytical data were collected. The primary outcome was 30-day mortality after the index event.The antimicrobial susceptibility data and extended-spectrum beta-lactamase (ESBL) production in isolates recovered from intra-abdominal (IAI) (n=1,429) and urinary tract (UTI) (n=937) infections during the 2016- 2017 SMART study in 10 Spanish hospitals were analysed. RESULTS: We included 739 patients with a mean age of 84.9 (SD 6.0) years; 375 (50.7%) were women. Ninety-one (12.3%) died within 30 days. The AUC was 0.637 (IC 95% 0.587-0.688; p<0.001) for SIRS ≥ 2 and 0.698 (IC 95% 0.635-0.761; p<0.001) for qSOFA ≥ 2. Comparing receiver operating characteristic (ROC) there was a better accuracy of qSOFA vs SIRS (p=0.041). Both scales improve the prognosis accuracy with lactate inclusion. The AUC was 0.705 (IC95% 0.652-0.758; p<0.001) for SIRS plus lactate and 0.755 (IC95% 0.696-0.814; p<0.001) for qSOFA plus lactate, showing a trend to statistical significance for the second strategy (p=0.0727). Charlson index not added prognosis accuracy to SIRS (p=0.2269) or qSOFA (p=0.2573). CONCLUSIONS: Lactate added to SIRS and qSOFA score improve the accuracy of SIRS and qSOFA to predict short-term mortality in older non-severely dependent patients attended for infection. There is not effect in adding Charlson index.

[Characteristics and epidemiological changes for patients with urinary tract infection in the emergency department]. / Características y cambios epidemiológicos de los pacientes coninfección del tracto urinario en los servicios de urgencias hospitalarios.

BACKGROUND: The aim of this paper is to determine both the prevalence of urinary tract infection (UTI) in the emergency department (ED) and the most relevant epidemiological changes in the last decade, as well as the profile and management of these patients. METHODS: Descriptive cross-sectional analysis at 49 Spanish ED during 12 months. All patients with infections and UTI diagnosis were included. All patients attended to in ED during the study were recorded as well. RESULTS: The study included 2,517 patients diagnosed with UTI, with a mean age of 55 (SD 23) years, 64.6%of whom were women. These patients represent 22%of infections in the ED and 3.2% of all patients in the ED. Thirty-six per cent were over 70 years old. Fifty one point nine per cent had some underlying disease (16.5%diabetes mellitus) and 32.7% had some risk factors for multi-resistant strains of bacteria. Eight point three percent met sepsis criteria. Seventy-one point nine percent of patients were directly discharged from the ED. CONCLUSIONS: UTI are very common infections in ED, with important associated comorbidities, high mean ages and a predominance in women. With respect to a decade before UTI has increased its prevalence (3.2%vs 2.1%) and the patients have a greater age [55.5 (SD 23) vs 52 (SD 22) years], more comorbidities (51.9% vs 40.6%) and clinical severity (8.3% vs 6.5%).

[Hospitalization of 780 episodes of infection in 10 Spanish emergency departments. Admission to conventional wards or short stay units?]. / Hospitalización de 780 episodios de infección en 10 servicios de urgencias españoles. ¿Ingreso convencional o unidad de corta estancia?

BACKGROUND: To study the clinical characteristics of patients with infection attending the emergency department (ED) and compare those admitted to a short stay unit (SSU) with those admitted to a conventional hospital ward (CHW). METHODS: A descriptive multicenter cross-sectional analysis of infected patients requiring admission from 10 ED with SSU. Data were collected for age, gender, comorbidities, risk factors for multiresistant pathogens, type of infection, sepsis criteria, microbiology and antibiotic treatment. RESULTS: We documented 780 admitted patients, mean age 70.43 years, 31% with heart disease, 29% COPD, 26% diabetes mellitus, 15% prior antibiotic therapy and solid neoplasm. Fifty-four percent were respiratory infections, 22% urinary infections and 8% intra-abdominal infections. Thirteen percent had septic syndrome and beta-lactam (64%) and fluoroquinolones (29%) were the most prescribed antibiotics. When comparing patients admitted to SSU (183) with those admitted to CHW (597), in the latter group there were more comorbidities (86% vs. 78%), more risk factors for multidrug-resistant pathogens (42% vs. 25%) and cultures from different sources were more frequently undertaken (80% vs. 64%) (p <0.05). CONCLUSIONS: According to our results, SSU may be an excellent alternative to CHW for patients with prevalent infection and less comorbidity and fewer risk factors for multidrug resistance.

[Second consensus report on the use of antimicrobial agents in exacerbations of chronic obstructive pulmonary disease]. / Segundo documento de consenso sobre uso de antimicrobianos en la exacerbación de la enfermedad pulmonar obstructiva crónica.

Aware of the importance of chronic obstructive pulmonary disease (COPD), a panel of experts belonging to the Spanish Society of Respiratory Medicine and Thoracic Surgery (SEPAR), the Spanish Society of Chemotherapy (SEQ) and the Spanish Society of Family and Community Medicine (SEMFyC) issued a statement of consensus in 2000 to serve as the basis for adequate antibiotic control of the disease. Three years later, in accordance with significant scientific progress made in this area, the statement has been thoroughly revised. The new paper in fact constitutes a second consensus statement on the use of antibiotics in COPD exacerbations. When several scientific associations expressed interest in joining the project and contributing to it the Spanish Society of Emergency Medicine (SEMES), the Spanish Society of General Medicine (SEMG) and the Spanish Society of Rural and General Medicine (SEMERGEN) their incorporation led SEPAR and SEMFyC to change the structure of the statement and certain aspects of its content. Additionally, a new group of antibiotics, the ketolides, has joined the therapeutic arsenal. Telithromycin, the single representative of the group for the moment, can be considered not only an alternative treatment but even the drug of choice in certain clinical settings that are analyzed in the new statement. Those developments, along with others, such as the increasingly recognized action of levofloxacin against Pseudomonas aeruginosa and the steady action of amoxicillin with clavulanic acid when administered at recommended doses every 8 hours, provide new antimicrobial therapeutic protocols for COPD. Finally, the statement includes a scientific analysis of other groups of antimicrobial agents (macrolides, oral cephalosporins, etc.) and guidelines for both primary care physicians and specialists to follow when prescribing them.

[Inguinal tumor as the first manifestation of a pancreatic pseudocyst]. / Tumoración inguinal como primera manifestación de un seudoquiste pancreático.

We report a case of pancreatic pseudocyst in alcoholic pancreatitis, that presented as a mass in the inguinal region. The mechanism of this peculiar clinical presentation was the dissemination of the content of the pseudocyst along the psoas muscle. We review the involvement of psoas muscle in pancreatic pathology, giving emphasis to reports of inguinal or thigh masses as initial manifestations.

[Local thrombolysis in renal artery embolism]. / Fibrinolisis local en el embolismo de la arteria renal.

Renal artery embolism is an infrequent entity that occurs in patients with underlying cardiac diseases. Diagnosis is usually difficult unless the index of suspicion is high. Local thrombolysis with low-dose fibrinolytic agents is an useful therapeutic intervention. We present 2 cases of renal artery embolism treated with intra-arterial urokinase and review clinical features and therapeutic options.

[Characteristics and epidemiological changes for patients with community-acquired pneumonia in hospital emergency departments]. / Características y cambios epidemiológicos de los pacientes con neumonía adquirida en la comunidad en los servicios de urgencias hospitalarios.

BACKGROUND: The aim of this paper is to determine both the prevalence of community-acquired pneumonia (CAP) in the A & E Department and the most relevant epidemiological changes in the last decade, as well as the profile and management of these patients. METHODS: Descriptive cross-sectional analysis at 49 Spanish A & E Departments during 12 months. All patients with infections, respiratory infection or CAP diagnosis were included. All patients attended to in A & E during the study were recorded as well. RESULTS: CAP has increased its prevalence among patients in the A & E Departments in the past decade (0.85% to 1.35%, p <0.001). Fifty-one per cent were over 70 years old. Sixty-nine point eight per cent had some underlying disease and 17.8% had risk factors. Eleven point seven per cent met sepsis criteria, 4.6% severe sepsis and 3% septic shock. Thirty-seven per cent of patients were directly discharged from the A & E Departments. CONCLUSIONS: The impact and prevalence of CAP in A & E Departments has increased in the last decade. It is the most common cause of sepsis, severe sepsis and septic shock, admission to intensive care units and death due to infectious disease.