Amphetamine-related intoxications in people living with HIV: An observational study in an emergency department in Barcelona (Spain) from 2018 to 2020.

BACKGROUND: Stimulant drugs, particularly amphetamines, are more commonly implicated in drug-related deaths in people living with HIV; however, the clinical characteristics of amphetamine-related intoxication in people living with HIV are poorly described. MATERIAL AND METHODS: We conducted a retrospective study in people living with HIV who were admitted for amphetamine-related intoxication to an emergency department of a teaching hospital between 2018 and 2021. Severe intoxication (SI) was arbitrarily defined as requiring admission to the emergency medical support unit and receiving medical treatment for ≥6 h. RESULTS: In total, 170 male patients with a median age of 36.2 + 7.5 years were included in the study. A total of 77 (45.3%) individuals had mental disorders, and 120 (85.7%) had HIV-1 RNA suppression, with a median CD4 cell count of 696 (interquartile range 490-905). In total, 61 (37.9%) individuals were on ritonavir/cobicistat-based regimens. Presenting clinical syndromes included agitation in 60 (35.3%) subjects, anxiety in 37 (21.7%), psychosis in 27 (15.8%), chest pain in 26 (15.3%) and altered level of consciousness in 20 (11.7%). SI was observed in 48 (28.2%) individuals, 12 (7.1%) required admission to the intensive care unit, and two (1.2%) died. Altered level of consciousness (odds ratio [OR] 6.5; 95% confidence interval [CI] 2.2-18.9; p < 0.01), psychosis (OR 5.8; 95% CI 2.2-15.1; p < 0.01) and suicide attempt (OR 4.6; 95% CI 1.8-11.6; p 0.01) were associated with SI in the adjusted analysis. CONCLUSIONS: Amphetamine-related intoxication causes high morbidity in people living with HIV. Healthcare providers serving these patients should consider incorporating harm-reduction measures in the prevention of amphetamine-related intoxication.

International Validation of the Canadian Syncope Risk Score : A Cohort Study.

BACKGROUND: The Canadian Syncope Risk Score (CSRS) was developed to predict 30-day serious outcomes not evident during emergency department (ED) evaluation. OBJECTIVE: To externally validate the CSRS and compare it with another validated score, the Osservatorio Epidemiologico della Sincope nel Lazio (OESIL) score. DESIGN: Prospective cohort study. SETTING: Large, international, multicenter study recruiting patients in EDs in 8 countries on 3 continents. PARTICIPANTS: Patients with syncope aged 40 years or older presenting to the ED within 12 hours of syncope. MEASUREMENTS: Composite outcome of serious clinical plus procedural events (primary outcome) and the primary composite outcome excluding procedural interventions (secondary outcome). RESULTS: Among 2283 patients with a mean age of 68 years, the primary composite outcome occurred in 7.2%, and the composite outcome excluding procedural interventions occurred in 3.1% at 30 days. Prognostic performance of the CSRS was good for both 30-day composite outcomes and better compared with the OESIL score (area under the receiver-operating characteristic curve [AUC], 0.85 [95% CI, 0.83 to 0.88] vs. 0.74 [CI, 0.71 to 0.78] and 0.80 [CI, 0.75 to 0.84] vs. 0.69 [CI, 0.64 to 0.75], respectively). Safety of triage, as measured by the frequency of the primary composite outcome in the low-risk group, was higher using the CSRS (19 of 1388 [0.6%]) versus the OESIL score (17 of 1104 [1.5%]). A simplified model including only the clinician classification of syncope (cardiac syncope, vasovagal syncope, or other) variable at ED discharge-a component of the CSRS-achieved similar discrimination as the CSRS (AUC, 0.83 [CI, 0.80 to 0.87] for the primary composite outcome). LIMITATION: Unable to disentangle the influence of other CSRS components on clinician classification of syncope at ED discharge. CONCLUSION: This international external validation of the CSRS showed good performance in identifying patients at low risk for serious outcomes outside of Canada and superior performance compared with the OESIL score. However, clinician classification of syncope at ED discharge seems to explain much of the performance of the CSRS in this study. The clinical utility of the CSRS remains uncertain. PRIMARY FUNDING SOURCE: Swiss National Science Foundation & Swiss Heart Foundation.

Increasing emergency department admissions for chemsex-related intoxications in Barcelona, Spain, among people living with HIV: an observational study from 2018 to 2020.

BACKGROUND: Chemsex is a novel phenomenon referring to the use of drugs, including crystal methamphetamine, gammahydroxybutyric acid (GHB)/gamma-butyrolactone (GABA) and mephedrone, to facilitate, enhance, and prolong the sexual experience in men who have sex with men in large cities internationally. There is a growing concern about chemsex and fatal cases among people living with HIV on antiretroviral therapy. This study aimed to describe the clinical characteristics of chemsex-related intoxications. MATERIAL AND METHODS: An observational study was conducted in people living with HIV who were admitted for chemsex-related intoxications in an emergency department of a teaching hospital in Barcelona, Spain, from 2018 to 2020. Severe acute intoxications were defined according to the Poisoning Severity Score. RESULTS: One hundred and fifteen male patients with a median age of 35.6±7 years were included in the study:15 (13.1%) in 2018, 32 (27.8%) in 2019 and 68 (59.1%) in 2020. All patients had stable housing, 107(93.0%) were Spanish citizen and 32 (27.8%) had mental health disorders. Median CD4 lymphocyte count was 624 (500-765) cells/mm3 and 99 (86.1%) had HIV-1 RNA suppression. Poly-drug use was observed in 51(44.3%) cases and methamphetamine in 75(65,2%) and gammahydroxibutiric acid in 68 (59.1%) were the main drugs used. Potential drug interactions due to the inhibition of cytochrome P450 by antiviral therapy was determined in 36 (31.3%) patients. Severe intoxications cases affecting neurologic and respiratory systems were diagnosed in 12 (10.4%) patients and no patient died. CD4 cell counts ≤500 cells (O.R.:4.2; C.I.95%:1.2-14.6) and mental health disorders (O.R.: 2.9; C. I 95%: 0.8-9.9) were associated with severe acute drug intoxications in the bivariate analyses. CONCLUSIONS: Chemsex-related intoxications are an increasing clinical problem in people living with HIV. Chemsex should be routinely screened and addressed in clinical practice, particularly for people with mental illness and low CD4 cell counts, who are at higher risk for severe intoxications.

B-Type Natriuretic Peptides and Cardiac Troponins for Diagnosis and Risk-Stratification of Syncope.

BACKGROUND: The utility of BNP (B-type natriuretic peptide), NT-proBNP (N-terminal proBNP), and hs-cTn (high-sensitivity cardiac troponin) concentrations for diagnosis and risk-stratification of syncope is incompletely understood. METHODS: We evaluated the diagnostic and prognostic accuracy of BNP, NT-proBNP, hs-cTnT, and hs-cTnI concentrations, alone and against those of clinical assessments, in patients >45-years old presenting with syncope to the emergency department in a prospective diagnostic multicenter study. BNP, NT-proBNP, hs-cTnT and hs-cTnI concentrations were measured in a blinded fashion. Cardiac syncope, as adjudicated by 2 physicians based on all information available including cardiac work-up and 1-year follow-up, was the diagnostic end point. EGSYS (Evaluation of Guidelines in Syncope Study), a syncope-specific diagnostic score, served as the diagnostic comparator. Death and major adverse cardiac events at 30 and 720 days were the prognostic end points. Major adverse cardiac events were defined as death, cardiopulmonary resuscitation, life-threatening arrhythmia, implantation of pacemaker/implantable cardioverter defibrillator, acute myocardial infarction, pulmonary embolism, stroke/transient ischemic attack, intracranial bleeding, or valvular surgery. ROSE (Risk Stratification of Syncope in the Emergency Department), OESIL (Osservatorio Epidemiologico della Sincope nel Lazio), SFSR (San Fransisco Syncope Rule), and CSRS (Canadian Syncope Risk Score) served as the prognostic comparators. RESULTS: Among 1538 patients eligible for diagnostic assessment, cardiac syncope was the adjudicated diagnosis in 234 patients (15.2%). BNP, NT-proBNP, hs-cTnT, and hs-cTnI were significantly higher in cardiac syncope versus other causes (P<0.01). The diagnostic accuracy for cardiac syncope, as quantified by the area under the curve, was 0.77 to 0.78 (95% CI, 0.74-0.81) for all 4 biomarkers, and superior to EGSYS (area under the curve, 0.68 [95%-CI 0.65-0.71], P<0.001). Combining BNP/NT-proBNP with hs-cTnT/hs-cTnI further improved diagnostic accuracy to an area under the curve of 0.81 (P<0.01). BNP, NT-proBNP, hs-cTnT, and hs-cTnI cut-offs, achieving predefined thresholds for sensitivity and specificity (95%), allowed for rule-in or rule-out of ≈30% of all patients. A total of 450 major adverse cardiac events occurred during follow-up. The prognostic accuracy of BNP, NT-proBNP, hs-cTnI, and hs-cTnT for major adverse cardiac events was moderate-to-good (area under the curve, 0.75-0.79), superior to ROSE, OESIL, and SFSR, and inferior to CSRS. CONCLUSIONS: BNP, NT-proBNP, hs-cTnT, and hs-cTnI concentrations provide useful diagnostic and prognostic information in emergency department patients with syncope. CLINICAL TRIAL REGISTRATION: URL: https://www. CLINICALTRIALS: gov. Unique identifier: NCT01548352.

Circadian, weekly, seasonal, and temperature-dependent patterns of syncope aetiology in patients at increased risk of cardiac syncope.

AIMS: It is unknown whether cardiac syncope, and possibly also other syncope aetiologies exhibit circadian, weekly, seasonal, and temperature-dependent patterns. METHODS AND RESULTS: We prospectively recorded the exact time, date, and outside temperature of syncope of patients >40 years old presenting with syncope to the emergency department in a diagnostic multicentre study. Two independent cardiologists/emergency physicians adjudicated the final diagnosis based on all information becoming available during clinical work-up including 1-year follow-up. Among 1230 patients, the adjudicated aetiology was cardiac in 14.6%, reflex in 39.2%, orthostatic in 25.7%, other non-cardiac in 9.7%, and unknown in 10.8% of patients. All syncope aetiologies occurred much more frequently during the day when compared with the night (P < 0.01). While reflex and orthostatic syncope showed a broad peak of prevalence with 80.9% of these events occurring between 4 am and 4 pm, cardiac syncope showed a narrow peak of prevalence with 70.1% of all events occurring between 8 am and 2 pm. A weekly pattern was present for most syncope aetiologies, with events occurring mainly from Monday to Friday (P < 0.01). Reflex syncope displayed a seasonal rhythm and was more common in winter (P < 0.01), while cardiac syncope stayed constant over the year. Syncope occurred most often when the outside temperature was coldest. Overall the patterns observed for cardiac syncope were similar to the patterns observed for its differential diagnosis. CONCLUSION: Syncope aetiologies in patients >40 years old display circadian, weekly, seasonal, and temperature-dependent patterns. Unfortunately, these patterns do not allow to reliably differentiate cardiac syncope from other aetiologies.

Post-translational modification of a chimeric EPO-Fc hormone is more important than its molecular size in defining its in vivo hematopoietic activity.

BACKGROUND: Recombinant erythropoietin (EPO) has been marketed as biopharmaceutical for anemia and chronic renal failure. Long-acting EPO variants that aimed at achieving less frequent dosing have been generated, either by the addition of glycosylation sites or increasing its molecular weight. METHODS: The hEPO cDNA linked to the human IgG Fc fragment was cloned as a single codifying gene on the pAdtrack-CMV vector, yielding the recombinant adenoviral genome. For in vitro and in vivo expression assays cervical cancer cell line (SiHa) and nulliparous goats were used, respectively. The hematopoietic activity of EPO-Fc, expressed as the differential increment of hematocrit was evaluated in B6D2F1 mice. NP-HPLC of the 2AB-labeled N-glycan was carried out to profile analysis. RESULTS: The direct transduction of mammary secretory cells with adenoviral vector is a robust methodology to obtain high levels of EPO of up to 3.5mg/mL in goat's milk. SiHa-derived EPO-Fc showed significant improvement in hematopoietic activity compared to the commercial hEPO counterpart or with the homologous milk-derived EPO-Fc. The role of the molecular weight seemed to be important in enhancing the hematopoietic activity of SiHa-derived EPO-Fc. However, the lack of sialylated multi-antennary glycosylation profile in milk-derived EPO-Fc resulted in lower biological activity. CONCLUSIONS: The low content of tri- or tetra-antennary sialylated N-glycans linked to the chimeric EPO-Fc hormone, expressed in the goat mammary gland epithelial cells, defined its in vivo hematopoietic activity. GENERAL SIGNIFICANCE: The sialylated N-glycan content plays a more significant role in the in vivo biological activity of hEPO than its increased molecular weight.

Severity of emergency department presentations due to acute drug toxicity in Europe: a longitudinal analysis over a 6-year period (2014-2019) stratified by sex.

OBJECTIVE: To investigate whether the severity of acute recreation drug toxicity presentations to emergency departments (EDs) in Europe has changed in recent years and to uncover potential sex differences. DESIGN: We analysed presentations to 36 EDs in 24 European countries relating to acute recreational drug toxicity, with separate analysis for presentations involving lone use of cannabis, cocaine, and heroin. As severity markers, we calculated rates of hospitalization, admission to ICU, intubation, and death by annual quarters between 2014 and 2019. Trends on severity over time were estimated by logistic regression. Differences between men and women were assessed by interaction. Sensitivity analysis was performed including only EDs that provided data for all 24 quarters. Analyses of intoxications taken altogether were adjusted by age and sex, while of lone intoxications being also adjusted by ethanol co-ingestion. RESULTS: There were 43 633 presentations (median age = 31 years, interquartile range = 25-40 years, men = 76.5%) resulting in 10 344 hospitalizations (23.9%), 2568 ICU admissions (5.9%), 1391 intubations (3.2%), and 171 deaths (0.39%). Hospitalization, ICU admission and death did not differ by sex, but intubation was more frequent in men (3.4% vs. 2.3%, P < 0.001). No significant changes in the severity of drug intoxications over time were found when considered altogether, neither for lone cannabis (n = 4264) nor cocaine (n = 3562). Conversely, significant increases in hospitalization [odds ratios (OR) = 1.023, 95% confidence interval (CI) = 1.004-1.041], ICU admission (OR = 1.080, 95% CI = 1.042-1.118) and in intubation (OR = 1.049, 95% CI = 1.001-1.099) were detected for lone heroin presentations (n = 1997). Sensitivity analysis (32 245 presentations, 14 EDs, 9 countries) confirmed the overall absence of changes in severity markers (except for death rate, which significantly decreased by quarter: OR = 0.968, 95% CI = 0.943-0.994). Additionally, it suggested an increased risk over time of intubation for cocaine (OR = 1.068, 95% CI = 1.009-1.130) and confirmed the increased risk of ICU admission for heroin (OR = 1.058, 95% CI = 1.013-1.105). Changes in severity over time did not differ according to sex in the main analysis of the whole cohort, while a significantly higher decrease in risk of death in men was found in the sensitivity analysis (OR = 0.894, 95% CI = 0.825-969 vs. OR = 0.949, 95% CI = 0.860-1.048; P interaction = 0.042). CONCLUSIONS: The severity of presentations to European EDs remained mainly unchanged during 2014-2019, but the risk of death may have decreased. Conversely, intubation in lone cocaine and ICU admission in lone heroin intoxications have increased. Although men and women exhibited a similar pattern over the period for the majority of comparisons, our data suggest that women exhibited a smaller decrease of the overall risk of death.

Do ART and Chemsex Drugs Get Along? Potential Drug-Drug Interactions in a Cohort of People Living with HIV Who Engaged in Chemsex: A Retrospective Observational Study.

INTRODUCTION: People living with HIV (PLWH) who engaged in chemsex are at risk of potential drug-drug interactions (pDDIs) with recreational drugs. This study aimed to characterize pDDIs between antiretroviral treatment (ART) and chemsex drugs and evaluate their association with unscheduled relevant hospital consultations. METHODS: We conducted a single-center, retrospective, observational study in a series of gay, bisexual, and other men who have sex with men (gbMSM) living with HIV who engaged in chemsex and who attended a tertiary hospital in Barcelona, Spain, from February 2018 through August 2019. Associations between all recorded pDDIs and relevant unscheduled consultations were estimated using the incidence rate (IR) per 100 person-years of those events compared between patients with no pDDI (green flag) or moderate severity pDDI (orange flag) with patients with high severity pDDI (red flag) using the incidence rate ratio (IRR). RESULTS: Among 172 PLWH engaged in chemsex, 249 ART regimens were prescribed: 44% based on integrase inhibitors, 30% on boosted ART, and 26% based on non-nucleoside reverse transcriptase inhibitors. The substances and recreational drugs most frequently used were erectile dysfunction agents (83%), methamphetamine (79%), GHB (77%), and alkyl nitrites (71%). Polydrug use was reported in 52%. We observed 2048 pDDIs. Of these, 23% were orange flag pDDIs; 88% related to boosted ARTs. The IR of the 285 unscheduled relevant episodes in patients with orange flag pDDIs was 64.67 (95% CI 40.07-89.28). The IRR of green flag pDDIs was 1.05 (95% CI 0.60-1.8; p = 0.876). CONCLUSION: One in four pDDIs were of moderate severity but no significant increase in the incidence of unscheduled relevant consultations was observed. A high number of unscheduled consultations, predominantly for psychiatric events and intoxication, were observed. Beyond using non-boosted ART to minimize pDDIs, other factors related to the practice of chemsex must be addressed, in order to offer a better approach.

Performance of the American Heart Association/American College of Cardiology/Heart Rhythm Society versus European Society of Cardiology guideline criteria for hospital admission of patients with syncope.

BACKGROUND: Current American College of Cardiology/American Heart Association/Heart Rhythm Society (ACC/AHA/HRS) and European Society of Cardiology (ESC) guidelines recommend different strategies to avoid low-yield admissions in patients with syncope. OBJECTIVE: The purpose of this study was to directly compare the safety and efficacy of applying admission criteria of both guidelines to patients presenting with syncope to the emergency department in 2 multicenter studies. METHODS: The international BASEL IX (BAsel Syncope EvaLuation) study (median age 71 years) and the U.S. SRS (Improving Syncope Risk Stratification in Older Adults) study (median age 72 years) were investigated. Primary endpoints were sensitivity/specificity for the adjudicated diagnosis of cardiac syncope (BASEL IX only) and 30-day major adverse cardiovascular events (30d-MACE). RESULTS: Among 2560 patients in the BASEL IX and 2085 in SRS studies, ACC/AHA/HRS and ESC criteria recommended admission for a comparable number of patients in BASEL IX (27% vs 28%), but ACC/AHA/HRS criteria less often in SRS (19% vs 32%; P <.01). Recommendations were discordant in ∼25% of patients. In BASEL IX, sensitivity for cardiac syncope and 30d-MACE among patients without admission criteria was comparable for ACC/AHA/HRS and ESC criteria (64% vs 65%, P = .86; and 67% vs 71%, P = .15, respectively). In SRS, sensitivity for 30d-MACE was lower with ACC/AHA/HRS (54%) vs ESC criteria (88%; P <.001). Similarly, specificity for cardiac syncope and 30d-MACE in BASEL IX was comparable for both guidelines, but in SRS the ACC/AHA/HRS guidelines showed a higher specificity for 30d-MACE than the ESC guidelines. CONCLUSION: ACC/AHA/HRS and ESC guidelines showed disagreement regarding admission for 1 in 4 patients and had only modest sensitivity, all indicating possible opportunities for improvements.

Tetracaine from urethral ointment causes false positive amphetamine results by immunoassay.

BACKGROUND: Amphetamine urine drug screening by immunoassay is prone to cross-react with other compounds leading to false positive results. Tetracaine is a local anesthetic drug used in the clinical setting as an ointment during urinary catheterization. In our laboratory, tetracaine is often detected by gas chromatography-mass spectrometry in the urine of patients admitted in the emergency department with false positive amphetamine results. The objectives of this study were to investigate if there was cross-reactivity to tetracaine in an amphetamine immunoassay and to retrospectively evaluate the potential contribution of tetracaine to false positive amphetamine results. METHODS: An interference study was conducted using negative urine samples spiked with increasing concentrations of tetracaine hydrochloride and analyzed with the CEDIA Amphetamine/Ecstasy immunoassay. Retrospectively, urine samples of patients which yielded positive amphetamine immunoassay results and were analyzed by gas chromatography-mass spectrometry were reviewed (n = 417). The presence of tetracaine and/or other drugs by gas chromatography-mass spectrometry were gathered. RESULTS: Tetracaine caused false positive amphetamine results by immunoassay (cut-off 1000 µg/L) with a concentration of above 40 mg/L. Retrospective analysis of all positive amphetamine immunoassay samples showed that in 45 out of the 417 (10.8%) urine samples no amphetamine-like derivative was identified by gas chromatography - mass spectrometry. In 37 out of 45 (82.2%) of these false positive cases tetracaine was detected, of whom 59.5% (22/37) had an estimated tetracaine concentration of ≥40 mg/L. CONCLUSIONS: This study confirmed the interference of tetracaine in the CEDIA Amphetamine/Ecstasy immunoassay and that tetracaine may have contributed to around 80% of the false positive amphetamine cases in the urine samples of patients admitted to the emergency department at our institution.

Poisoning cases in Catalonia: characteristics according to age groups in the Intox.28 study. / Características de las intoxicaciones agudas atendidas en Cataluña y diferencias según grupos de edad: Estudio Intox-28.

OBJECTIVES: The Toxicology Working Group of the Catalan Society of Emergency Medicine (SoCMUETox) began the Intox-28 study in 2013. The aim was to identify differences in poisoning cases between 3 age groups. MATERIAL AND METHODS: Descriptive observational study of poisoning cases managed in 8 hospital emergency departments on the 28th day of each month from 2013 to 2019. We gathered information on patient particulars, type of poison, clinical data, and discharge destination. The patient sample was distributed into 3 groups for comparison: minors under the age of 17 years, adults aged 17 to 65 years, and adults over the age of 65 years. RESULTS: The hospitals registered 1088 cases: 132, 859, and 97 in each age group. In comparisons between the minors and the adults aged 65 years or younger, the minors had more females (58.3% vs 46.1%), fewer recreational poisonings (22% vs 46.1%) more poisonings inside the home (67.4% vs 51.1%), more medication poisonings (49.2% vs 31.1%), and less often received treatment (43.2% vs 73%) (P .001, all comparisons). The proportion of older adults receiving treatment (73.2%) was similar to that of the younger adults. CONCLUSION: The characteristics of poisonings vary according to age. Differences lie in gender, intentionality, and type of poison.

OBJETIVO: El Grupo de Trabajo de Toxicología de la Societat Catalana de Medicina d'Urgències i Emergències (SoCMUETox) inició en 2013 el estudio Intox-28. El objetivo de este trabajo es evaluar las diferencias existentes en las características de las intoxicaciones según la edad de los pacientes. METODO: Estudio descriptivo observacional de las intoxicaciones atendidas en 8 servicios de urgencias hospitalarios (SUH) el día 28 de cada mes durante el periodo 2013-19. Se recogieron datos demográficos, tipo de tóxico, datos clínicos y destino al alta. Los pacientes se dividieron en 3 grupos: menores de 17 años, adultos (entre 17 y 65 años) y mayores de 65 años. RESULTADOS: Se registraron 1.088 intoxicaciones: 132 (12,1%), 859 (78,9%) y 97 (8,9%) en cada grupo de edad respectivamente. En comparación a los pacientes adultos, en los menores de 17 años hubo más mujeres (58,3% vs 46,1%; p 0,001), menos intoxicaciones de tipo recreativo (22% vs 46,1%; p 0,001) y acontecieron más frecuentemente en el domicilio (67,4% vs 51,1%; p 0,001). El tipo de tóxico más implicado fueron los fármacos (49,2% vs 31,1%; p 0,001) y precisaron tratamiento con menor frecuencia (43,2% vs 73%; p 0,001). Los mayores de 65 años precisaron tratamiento en porcentaje similar a los pacientes de 17 a 65 años (73,2%). CONCLUSIONES: Existen diferencias entre los grupos de edad, entre las que destacan el sexo predominante, la intencionalidad de la intoxicación y el tipo de tóxico implicado.

Development of an electrocardiogram-based risk calculator for a cardiac cause of syncope.

OBJECTIVE: To develop an ECG-based tool for rapid risk assessment of a cardiac cause of syncope in patients ≥40 years. METHODS: In a prospective international multicentre study, 2007 patients ≥40 years presenting with syncope were recruited in the emergency department (ED) of participating centres ranging from large university hospitals to smaller rural hospitals in eight countries from May 2010 to July 2017. 12-Lead ECG recordings were obtained at ED presentation following the syncopal event. The primary diagnostic outcome, a cardiac cause of syncope, was centrally adjudicated by two independent cardiologists using all available clinical information including 12-month follow-up. ECG predictors for a cardiac cause of syncope were identified using penalised backward selection and a continuous-scale likelihood was calculated based on regression analysis coefficients. Findings were validated in an independent US multicentre cohort including 2269 patients. RESULTS: In the derivation cohort, a cardiac cause of syncope was adjudicated in 267 patients (16%). Seven ECG criteria were identified as predictors for this outcome: heart rate and QTc-interval (continuous predictors), rhythm, atrioventricular block, ST-segment depression, bundle branch block and ventricular extrasystole/non-sustained ventricular tachycardia (categorical predictors). Diagnostic accuracy of these combined predictors for a cardiac cause of syncope was high (area under the curve 0.80, 95% CI 0.77 to 0.83). Overall, 138 patients (8%) were rapidly triaged towards rule-out and 181 patients (11%) towards rule-in of a cardiac cause of syncope. External validation showed similar performance. CONCLUSION: In patients ≥40 years with a syncopal event, a combination of seven ECG criteria enabled rapid assessment of the likelihood that syncope was due to a cardiac cause. TRIAL REGISTRATION NUMBER: NCT01548352 (BASEL IX), NCT01802398 (SRS study).

Mortality in patients treated for COVID-19 in the emergency department of a tertiary care hospital during the first phase of the pandemic: Derivation of a risk model for emergency departments. / Análisis de mortalidad de los pacientes atendidos por COVID-19 en el servicio de urgencias de un hospital de tercer nivel en la fase incial de la pandemia. Derivación de un modelo de riesgo para urgencias.

OBJECTIVES: To develop a risk model to predict 30-day mortality after emergency department treatment for COVID-19. MATERIAL AND METHODS: Observational retrospective cohort study including 2511 patients with COVID-19 who came to our emergency department between March 1 and April 30, 2020. We analyzed variables with Kaplan Meier survival and Cox regression analyses. RESULTS: All-cause mortality was 8% at 30 days. Independent variables associated with higher risk of mortality were age over 50 years, a Barthel index score less than 90, altered mental status, the ratio of arterial oxygen saturation to the fraction of inspired oxygen (SaO2/FIO2), abnormal lung sounds, platelet concentration less than 100 000/mm3, a C-reactive protein concentration of 5 mg/dL or higher, and a glomerular filtration rate less than 45 mL/min. Each independent predictor was assigned 1 point in the score except age, which was assigned 2 points. Risk was distributed in 3 levels: low risk (score of 4 points or less), intermediate risk (5 to 6 points), and high risk (7 points or above). Thirty-day risk of mortality was 1.7% for patients who scored in the low-risk category, 28.2% for patients with an intermediate risk score, and 67.3% for those with a high risk score. CONCLUSION: This mortality risk stratification tool for patients with COVID-19 could be useful for managing the course of disease and assigning health care resources in the emergency department.

OBJETIVO: Derivar un modelo de riesgo para estimar la probabilidad de mortalidad a los 30 días de la visita a urgencias de pacientes con COVID-19. METODO: Estudio observacional de cohortes retrospectivo de 2.511 pacientes con COVID-19 atendidos en el servicio de urgencias hospitalario (SUH) del 1 de marzo al 30 de abril de 2020. Se realizó análisis de supervivencia mediante Kaplan Meier y regresión de Cox. RESULTADOS: La mortalidad por cualquier causa a los 30 días fue de un 8%. Los factores asociados de forma independiente a mayor mortalidad fueron: edad 50 años, índice de Barthel 90 puntos, alteración del nivel de consciencia, índice de SaO2/FIO2 400, auscultación respiratoria anómala, cifra de plaquetas 100.000/mm3, PCR 5 mg/dL y filtrado glomerular 45 mL/min. A estos factores se les asignó una puntuación de 1, excepto a la edad, que se le asignó un valor de 2 puntos. Se dividió el modelo de riesgo en 3 categorías: riesgo bajo (menor o igual a 4 puntos), riesgo intermedio (5-6 puntos) y riesgo alto (igual o superior a 7 puntos). Para los pacientes clasificados como de bajo riesgo la probabilidad de mortalidad a los 30 días fue del 1,7%, en los casos de riesgo intermedio fue del 28,2% y para los de alto riesgo fue del 67,3%. CONCLUSIONES: Disponer de una herramienta para estratificar el riesgo de mortalidad de los pacientes con COVID-19 que consultan a un SUH podría ser de utilidad para la gestión de los recursos sanitarios disponibles.

Nontraumatic chest pain and suspicion of acute coronary syndrome: associated clinical and electrocardiographic findings on initial evaluation. / Asociación entre los datos clínicos y electrocardiográficos iniciales en pacientes con dolor torácico no traumático y la sospecha inicial y el diagnóstico final de síndrome coronario agudo.

OBJECTIVES: To analyze clinical data and electrocardiographic (ECG) findings obtained during the initial evaluation of patients with nontraumatic chest pain (NTCP). To explore associations between these findings and the initial and final diagnoses of acute coronary syndrome (ACS). To assess which variables initially over- or underestimate risk ACS. MATERIAL AND METHODS: Consecutive patients with NTCP attended in a chest pain unit during the 10-year period of 2008-2017 were included if the suspected and discharge diagnoses of interest (ACS or non-ACS) had been recorded. Thirtythree independent variables (demographic, 2; cardiovascular, 5; chest pain, 22; ECG, 4). We included all variables in models to calculate crude and adjusted odds ratios (ORs) between each independent variable and the initial and final diagnoses. The adjusted ORs were compared to determine whether the initial and final diagnoses of ACS differed significantly in relation to the variables. RESULTS: A total of 34 552 patient visits were attended. The ORs for the 33 variables were significantly associated with initial and final NTCP classification as ACS or non-ACS, and in many cases the association was confirmed by the adjusted ORs. The adjusted ORs for 19 variables were significantly different in their relation to the initial and final diagnoses of ACS: 10 overpredicted the probability of the diagnosis and 9 underpredicted it. CONCLUSION: The variables traditionally used to warn of ACS in emergency patients with NTCP identify individuals likely to be initially and finally diagnosed with ACS. However, some of these variables overestimate or underestimate the risk of a final ACS diagnosis. Emergency medicine physicians should be aware of variables associated with underestimation of risk.

OBJETIVO: Evaluar la utilidad del cuestionario COPD Asessment Test (CAT) para valorar la recuperación de la exacerbación de la enfermedad pulmonar obstructiva crónica (EA-EPOC). Evaluar si la puntuación CAT aumenta la capacidad predictiva de mala evolución de una escala de gravedad para EA-EPOC. METODO: Se incluyeron las consultas consecutivas por DTNT en una unidad de dolor torácico durante 10 años (2008-2017) en las que se disponía de los diagnósticos inicial de sospecha (SCA/no SCA) y final de alta de urgencias (SCA/no SCA). Se incluyeron 33 variables independientes (2 demográficas, 5 comorbilidad cardiovascular, 22 dolor torácico, 4 datos ECG). Se calcularon las odds ratio (OR) para la clasificación (inicial y final) como SCA para cada variable independiente, crudas y ajustadas en modelos globales que incluían todas ellas. En estos modelos ajustados se comparó si las OR para la clasificación inicial y final como SCA eran significativamente diferentes. RESULTADOS: Se incluyeron 34.552 visitas. Las 33 variables analizadas mostraron asociación significativa para la clasificación inicial y final del DTNT como SCA, y en muchos casos esta asociación se mantuvo en el modelo ajustado. Diecinueve variables mostraron OR significativamente diferentes para la sospecha inicial de SCA que para el diagnóstico final de SCA: 10 sobrestimaban la asociación final y 9 la subestimaban. CONCLUSIONES: Los datos clínicos iniciales clásicamente utilizados para sospechar SCA pacientes con DTNT en urgencias identifican todos ellos individualmente a pacientes con riesgo incrementado de ser clasificado inicial y finalmente como SCA; sin embargo, algunos de ellos sobreestiman y otros subestiman inicialmente el riesgo final. Los urgenciólogos debieran sensibilizarse más con estos datos subestimados.

Factors associated with revisits by patients with SARS-CoV-2 infection discharged from a hospital emergency department. / Factores asociados a revisita en pacientes con diagnóstico de infección por SARS-CoV-2 dados de alta de un servicio de urgencias hospitalario.

OBJECTIVES: To analyze emergency department (ED) revisits from patients discharged with possible coronavirus disease 2019 (COVID-19). MATERIAL AND METHODS: Retrospective observational study of consecutive patients who came to the ED over a period of 2 months and were diagnosed with possible COVID-19. We analyzed clinical and epidemiologic variables, treatments given in the ED, discharge destination, need to revisit, and reasons for revisits. Patients who did or did not revisit were compared, and factors associated with revisits were explored. RESULTS: The 2378 patients included had a mean age of 57 years; 49% were women. Of the 925 patients (39%) discharged, 170 (20.5%) revisited the ED, mainly for persistence or progression of symptoms. Sixty-six (38.8%) were hospitalized. Odds ratios (ORs) for the following factors showed an association with revisits: history of rheumatologic disease (OR, 2.97; 95% CI, 1.10-7.99; P = .03), digestive symptoms (OR, 1.73; 95% CI, 1.14-2.63; P = .01), respiratory rate over 20 breaths per minute (OR, 1.03; 95% CI, 1.0-1.06; P = .05), and corticosteroid therapy given in the ED (OR, 7.78; 95% CI, 1.77-14.21, P = .01). Factors associated with hospitalization after revisits were age over 48 years (OR, 2.57; 95% CI, 1 42-4.67; P = .002) and fever (OR, 4.73; 95% CI, 1.99-11.27; P = .001). CONCLUSION: Patients under the age of 48 years without comorbidity and with normal vitals can be discharged from the ED without fear of complications. A history of rheumatologic disease, fever, digestive symptoms, and a respiratory rate over 20 breaths per minute, or a need for corticosteroid therapy were independently associated with revisits. Fever and age over 48 years were associated with a need for hospitalization.

OBJETIVO: Analizar las revisitas y los factores asociados a la misma en pacientes con diagnóstico de posible COVID-19 dados de alta de un servicio de urgencias hospitalario (SUH). METODO: Estudio observacional, retrospectivo que incluyó pacientes consecutivos que consultaron al SUH en un periodo de 2 meses y fueron diagnosticados de posible de COVID-19. Se analizaron variables clínico-epidemiológicas, tratamiento administrado en urgencias, destino final, revisita al SUH y motivo de esta. Se hizo un análisis comparativo entre ambos grupos (revisita sí/no) y se identificaron factores asociados a la revisita. RESULTADOS: Se incluyeron 2.378 pacientes (edad media 57 años; 49% mujeres). De los pacientes dados de alta (39% del total; n = 925), 170 (20,5%) reconsultaron al SUH, principalmente por persistencia o progresión de síntomas, y 66 (38,8%) precisaron ingreso. Los factores relacionados con la revisita fueron: antecedentes de enfermedad reumatológica [OR: 2,97 (IC 95%: 1,10-7,99, p = 0,03)], síntomas digestivos [OR: 1,73 (IC 95%: 1,14-2,63, p = 0,01)], frecuencia respiratoria $ 20 [OR: 1,03 (IC 95%: 1,0-1,06, p = 0,05)] y haber recibido tratamiento con esteroides en urgencias [OR: 7,78 (IC 95%: 1,77-14,21, p = 0,01)]. Los factores asociados al ingreso en la revisita fueron la edad $ 48 años [OR: 2,57 (IC 95%: 1,42-4,67, p = 0,002)] y presentar fiebre [OR: 4,73 (IC 95%: 1,99-11,27, p = 0,001)]. CONCLUSIONES: Los pacientes con posible COVID-19 menores de 48 años, sin comorbilidad y con signos vitales normales podrían ser dados de alta desde urgencias sin temor a sufrir complicaciones. Los antecedentes de enfermedad reumatológica, fiebre, sintomas digestivos, frecuencia respiratoria $ 20/min o necesidad de tratamiento con esteroides fueron factores independientes de revisita, y la fiebre y edad $ 48 años de necesidad de ingreso.

Changes in cases of nontraumatic chest pain treated in a chest pain unit over the 10-year period of 2008-2017. / Evolución de las características de las visitas por dolor torácico no traumático en una unidad de dolor torácico durante un periodo de 10 años (2008-2017).

OBJECTIVES: To analyze changes in the characteristics of consecutively treated patients attended in the chest pain unit of a hospital emergency department over a 10-year period. MATERIAL AND METHODS: All patients presenting with nontraumatic chest pain (NTCP) were included. We analyzed changes over time in epidemiologic characteristics, initial diagnostic classification (on clinical and electrocardiographic evaluation), final diagnosis (on discharge), and time until these diagnoses. RESULTS: A total of 34 552 consecutive patients with a mean (SD) age of 59 (13) years were included; 42% were women. The annual number of visits rose over time. Visits were fewer in summer and more numerous on workdays and between the hours of 8 AM and 4 PM (P<.001, both comparisons). The number of women increased over time (up 0.29% annually, P<.05) as did the number of patients under the age of 50 years (up 0.92% annually, P<.001). With time, patients had fewer cardiovascular risk factors and less often had a history of ischemic heart disease. Fewer cases of NTCP had signs suggestive of acute coronary syndrome (ACS). ACS was ruled out at the time of initial and final diagnoses in 52.2% and 80.4%, respectively, and these percentages which rose over the 10-year period by 1.86% (P<.001) and 0.56% (P=.04). Time to initial diagnosis did not change. However, time to final diagnosis did increase (P<.001), and the delay was longer in patients diagnosed with ACS (P<.001). CONCLUSION: The chest pain unit was more active at the end of the period, in keeping with the increase in patients with NTCP whose characteristics were not typical of coronary disease. The percentages of patients initially and finally diagnosed with ACS decreased with time.

OBJETIVO: Analizar la evolución de las características epidemiológicas de las visitas atendidas de forma consecutiva en una unidad de dolor torácico (UDT) de un servicio de urgencias hospitalario (SUH) durante un periodo de 10 años. METODO: Se incluyeron todas las visitas por dolor torácico no traumático (DTNT), analizándose la evolución temporal de las características epidemiológicas, de la clasificación diagnóstica inicial (evaluación clínica inicial y electrocardiograma) y final (al alta de la UDT), y los tiempos necesarios para alcanzar las mismas. RESULTADOS: Se incluyeron 34.552 pacientes consecutivos con una edad media 59 (DE 13) años, el 42% mujeres. Se observó un incrementó en el número anual de visitas a la UDT (p < 0,001), menor afluencia los meses de verano (p < 0,001), y mayor los días laborables (p < 0,001) y de 8-16 horas (p < 0,001). Se comprobó que progresivamente más pacientes eran mujeres (+0,29% anual, p < 0,05), menores de 50 años (+0,92%, p < 0,001), con más factores de riesgo cardiovascular, menos antecedentes de cardiopatía isquémica y con DTNT menos sugestivo de síndrome coronario agudo (SCA). La clasificación diagnóstica inicial y final descartó SCA en un 52,2% y un 80,4% de pacientes, respectivamente, hecho que aumentó progresivamente durante el periodo evaluado (+1,86%, p < 0,001; y +0,56%, p = 0,04; respectivamente). El tiempo de clasificación inicial no se modificó, pero se incrementó el necesario para la clasificación final (p < 0,001), que resultó superior en pacientes con diagnóstico final de SCA (p < 0,001). CONCLUSIONES: Se observa un mayor uso de la UDT tras su creación, causado por un incremento de pacientes con DTNT de características no típicamente coronarias, disminuyendo el porcentaje de clasificados inicial y finalmente como debidos a SCA.

Prevalence of Pulmonary Embolism in Patients With Syncope.

BACKGROUND: The prevalence of pulmonary embolism (PE) in patients presenting with syncope to the emergency department (ED) is largely unknown. This information, however, is necessary to balance the potential medical benefit or harm of systematic PE screening in patients presenting with syncope to the ED. OBJECTIVES: This study sought to determine the prevalence of PE in patients with syncope. METHODS: Unselected patients presenting with syncope to the ED were prospectively enrolled in a diagnostic multicenter study. Pre-test clinical probability for PE was assessed using the 2-level Wells score and the results of D-dimer testing using age-adapted cutoffs. Presence of PE was evaluated by imaging modalities, when ordered as part of the clinical assessment by the treating ED physician or by long-term follow-up data. RESULTS: Long-term follow-up was complete in 1,380 patients (99%) at 360 days and 1,156 patients (83%) at 720 days. Among 1,397 patients presenting with syncope to the ED, PE was detected at presentation in 19 patients (1.4%; 95% confidence interval [CI]: 0.87% to 2.11%). The incidence of new PEs or cardiovascular death during 2-year follow-up was 0.9% (95% CI: 0.5% to 1.5%). In the subgroup of patients hospitalized (47%), PE was detected at presentation in 15 patients (2.3%; 95% CI: 1.4% to 3.7%). The incidence of new PEs or cardiovascular death during 2-year follow-up was 0.9% (95% CI: 0.4% to 2.0%). CONCLUSIONS: PE seems to be a rather uncommon cause of syncope among patients presenting to the ED. Therefore, systematic PE-screening in all patients with syncope does not seem warranted. (BAsel Syncope EvaLuation Study [BASEL IX]; NCT01548352).

[Failure of a special winter programme aimed to alleviate negative effects of winter overload on an emergency department]. / Cuantificación de los efectos negativos de la sobrecarga invernal en urgencias y de la efectividad de las medidas extraordinarias invernales para paliarlos.

BACKGROUND AND OBJECTIVE: We aimed: a) to determine changes in patient flow, and in emergency department (ED) effectiveness and quality that may happen depending on the season (winter/non-winter), and b) to analyze effects on those changes when a special winter programme (SWP) of the Pla Integral d'Urgències de Catalunya (PIUC) is applied. MATERIAL AND METHOD: We studied 4 weeks of each period: non-winter period, winter control period (without SWP), winter period with SWP. Within the 3 periods, the daily census was taken as a proxy of external pressure, and the number of patients admitted to the hospital from the ED as a proxy of internal pressure. In each period, effectiveness markers--ED occupancy rate, rate of ED patients waiting for a bed, waiting time (WT) and number of patients waiting to be seen (PW), length of stay-- objective quality markers -revisit rate, rate of patients left without being seen, rate of patients left against medical advise (LAMA), and mortality rate-, and subjective quality markers -patient satisfaction with the physician, the nurse, the general ED organization, and level of complaint solution- were recorded. RESULTS: Compared to the non-winter period, in the winter period without SWP the daily census rose by 6% (p = 0.07), and the number of patients admitted 10.8% (p = 0.16). These increases went along with a worsening of almost all effectiveness and quality markers, although only PW (+63%; p < 0.01), WT (+130%; p < 0.001), length of stay (+28%; p < 0.05), rate of patients left without being seen (+97%; p < 0.001) and LAMA (+218%; p < 0.05) reached statistical significance. In the winter period with SWP, the daily census kept stable but the number of patients admitted grew by 18% (p < 0.01). The SWP improved some subjective quality markers (patient satisfaction with the physician and the nurse), but failed to improve any effectiveness or objective quality marker. Some of them got even worse within the SWP period: ED occupancy rate, +20% (p = 0.001); PW, +42% (p < 0.05), and WT, +56% (p < 0.05). CONCLUSIONS: In winter, a worsening of ED effectiveness and quality can be expected. Measures from the SWP prepared by the Administration are unable to correct such deterioration. A profound analysis of the SWP is suggested.