Severity of COVID-19 cases in the months of predominance of the Alpha and Delta variants.

New SARS-CoV-2 may pose problems in controlling the COVID-19 pandemic for public health. We aimed to assess and compare the symptoms and severity of cases due to the Alpha and Delta variant dominance periods, taking into account the effect of COVID-19 vaccination. A prospective epidemiological study of SARS-CoV-2 in Lleida was made to determine differences between Alpha and Delta variants periods. We assessed symptoms, specific comorbidities, sociodemographic information and vaccination status. Bivariate and logistic regression analyses were used to estimate the adjusted odds ratio (aOR) and 95% confidence intervals (CI) to investigate the relationship between symptoms and severity and the variants. Alpha variant period compared to the Delta showed an increased risk of ICU admission (aOR 2.0; 95% CI 1.2-2.3) and death (aOR 2.6; 95% CI 1.8-3.9) and cases were associated with people aged > 85 years (aOR 2.1; 95% CI 1.7-2.6) and partially vaccinated (aOR 5.6; 95% CI 3.2-9.9) and unvaccinated people (aOR 27.8; 95% CI 19.7-40.5). Fever, cough and vomiting were significantly associated with the Alpha variant compared to the Delta (aOR 1.6 (95% CI 1.5-1.7), 2.0 (95% CI 1.9-2.2) and 2.5 (95% CI 2.2-2.9, respectively). Our results show that the severity and profile of clinical symptoms varied according to the variant. The risk of ICU admission and death was higher in the Alpha period compared to the Delta as it affected the elderly and cases were less vaccinated.

Perceptions from nurses, surgeons, and anesthetists about the use and benefits of the surgical checklist in a teaching hospital.

OBJECTIVE: To assess attitudes and perceptions from nursing staff, surgeons and anesthetists about compliance, utility, and impact on patient's safety of the surgical checklist in a teaching hospital. We also aimed to identify improvement opportunities for strengthening the usefulness of the checklist in the operating theater. METHODS: We carried out a questionnaire-based an observational cross-sectional study. A questionnaire was distributed to operating room staff, including nursing staff, surgeons, and anesthetists. In addition to the information about surgical checklist, We also collected information regarding years of experience in the operating theater. Fisher's exact was used to compare proportions in each statement. Group discussion meetings with key professionals were held to jointly assess the results, propose improvement actions, and evaluate their feasibility. RESULTS: The overall response rate was 36.2% (131/362). Nursing staff was perceived as the most supportive group in the use of surgical checklist. A 64.3% of surgeons considered that using the checklist prevented adverse events vs 84.2% and 85.7% among anesthetists and nurses, respectively; p=0.028. Junior staff showed a supportive attitude toward the use of surgical checklist, considering it as a tool that gives them confidence. We ended up with a list of improvement actions aiming at strengthening the surgical checklist reliability and compliance. CONCLUSIONS: The perception of the surgical checklist usefulness as a tool to prevent adverse events was moderate among surgeons, but well appreciated by junior staff. Nursing staff were especially critical regarding compliance and support by other professionals. To reinforce the usefulness perception of the surgical checklist it is needed to increase the involvement of all professionals, especially senior staff and surgical leaders.

[Factors that influence compliance with hand hygiene in healthcare professionals: A concept mapping study]. / Factores que influyen en el cumplimiento de la higiene de manos en profesionales sanitarios: un estudio de mapeo de conceptos.

OBJECTIVE: To identify factors that may influence hand hygiene compliance by professional category and clinical department. MATERIALS AND METHODS: Use was made of concept mapping methodology, a tool that combines a qualitative analysis with a quantitative statistical analysis, in order to identify the most influential and important factors for the fulfilment of hand hygiene in 2 clinical departments (Infectious and General Surgery) of the Hospital del Mar. RESULTS: The study included a total of 42 volunteer professionals from General Surgery (6 doctors and 10 nurses) and from Infectious Diseases (11 doctors and 10 nurses) clinical departments, as well as 5 hospital porters. High correlations of influential and important factors for hand hygiene compliance were observed between nurses and doctors in the Infectious Diseases Department (r=0.93 vs. r=0.69, respectively). In contrast, the correlation was lower among surgical professionals (r=-0.17 for influence and r=0.51 for importance). Professionals identified the most influential factors in compliance as training and adequate resources, taking into account professional category and clinical department. CONCLUSION: The design of interventions to improve compliance with hand hygiene should take into account the perceptions of different professionals in order to adapt actions to each professional group.

[The professional in emergency care: aggressiveness and burnout]. / El profesional en urgencias y emergencias: agresividad y burnout.

Violence against professionals and the syndrome of burnout, or the professional exhaustion of health personnel, has acquired enormous significance in recent years, especially in emergency care. Only a small proportion of the aggressions against the health personnel come to light, but there is a great volume of submerged violent incidents that are not recorded anywhere. Protocols and registers of aggressions have been created in different autonomous communities to make precise data available so that more suitable and opportune decisions can be taken. The aggressions suffered by the workers fall within a wide range of risks that affect the safety and health of health workers, who are already subjected to high stress that lead to high levels of professional exhaustion (burnout). On the other hand, "burnt-out professionals", with their attitudes at work, increase the risk of aggressions against themselves and against their colleagues. The priorities of the health authorities include not only offering a quality service to all the users of the health system, but also ensuring that every health professional can work in optimum working conditions, with suitable levels of satisfaction, motivation and safety.

El profesional en urgencias y emergencias: agresividad y burnout / The professional in emergency care: aggressiveness and burnout

La violencia contra profesionales y el síndrome deburnout, o desgaste profesional del personal sanitario,ha adquirido una enorme importancia en los últimosaños, especialmente en los servicios de urgencias. Sólouna pequeña proporción de las agresiones al personalsanitario sale a la luz, pero hay un gran volumende incidentes violentos sumergidos que no constan enninguna parte. Se han creado protocolos y registros deagresiones en diversas comunidades para contar condatos precisos y poder tomar las decisiones más adecuadasy oportunas.Las agresiones sufridas por los trabajadores seencuentran dentro del amplio abanico de riesgos queafectan a la seguridad y salud de los trabajadores sanitarios,ya de por sí sometidos a factores de estrés laboralelevados que conducen a altos niveles de desgasteprofesional (burnout).Por otra parte, los «profesionales quemados» incrementan,con sus actitudes en el trabajo, el riesgo deagresiones contra sí mismos y contra sus compañeros.Las autoridades sanitarias tienen entre sus prioridadesno sólo ofrecer un servicio de calidad a todas las personasusuarias del sistema sanitario, sino también quetodo profesional sanitario pueda trabajar en las mejorescondiciones laborales y con unos niveles de satisfacción,motivación y seguridad adecuados(AU)

Violence against professionals and the syndrome ofburnout, or the professional exhaustion of health personnel,has acquired enormous significance in recentyears, especially in emergency care. Only a small proportionof the aggressions against the health personnelcome to light, but there is a great volume of submergedviolent incidents that are not recorded anywhere. Protocolsand registers of aggressions have been createdin different autonomous communities to make precisedata available so that more suitable and opportune decisionscan be taken. The aggressions suffered by theworkers fall within a wide range of risks that affect thesafety and health of health workers, who are alreadysubjected to high stress that lead to high levels of professionalexhaustion (burnout). On the other hand,“burnt-out professionals”, with their attitudes at work,increase the risk of aggressions against themselves andagainst their colleagues. The priorities of the health authoritiesinclude not only offering a quality service toall the users of the health system, but also ensuring thatevery health professional can work in optimum workingconditions, with suitable levels of satisfaction, motivationand safety(AU)

Influencia del modelo organizativo en los Servicios de Urgencias sobre la eficiencia de la atención de procesos críticos / Influence of the organisational model on the efficiency of critical care in the Emergency Department

El objetivo de este estudio es el de comparar la eficiencia de los diferentes modelos organizativos y gestión de la atención en Servicios de urgencias existentes en diversos hospitales de la provincia de Barcelona. El trabajo está diseñado como un estudio multicéntrico observacional de cohortes. El ámbito fue el de los Servicios de Urgencias de Hospitales de segundo y tercer niel, con distintos modelos organizativos de atención al paciente crítico: modelo de atención integrada: coordinación y atención de los pacientes que acuden a Urgencias por médico polivalentes; el médico especialista interviene en las técnicas diagnósticas y terapéuticas específicas. Modelo de atención especializada: intervención del especialista en primera línea sobre los pacientes que acuden a Urgencias. Modelo de atención en centro no especializado: servicios de Urgencias de Hospitales sin disponibilidad de recursos especializados y que requiere la colaboración de un centro de referencia para completar el diagnóstico y tratamiento. Se estudiaron todos los pacientes que llegan al Servicio de Urgencias y que reunían los siguientes criterios de inclusión: Síndrome coronario agudo con o sin elevación del ST. Accidente vascular cerebral isquémico o hemorragia subaracnoidea. Traumatismo craneoencefálico con GCS < 13. Enfermedad pulmonar obstructiva crónica agudizada que requerirá soporte ventilatorio mecánico.

The objective of this article is to compare the efficiency according to different organisational and management models of the existing care provided in Emergency Services in different hospitals of the provence of Barcelona. It presents a comparative analysis model which makes it possible to obtain certified conclusions and possibilities for improvement (AU)

Relationship of oncogenes (sFas, Bcl-2) and cytokines (IL-10, alfa-TNF) with the activity of systemic lupus erythematosus.

BACKGROUND: Different oncogenes (Fas and bcl-2) and diverse cytokines (IL-10 and alfa-TNF) may have an effect on the regulation of apoptosis. The majority of studies to date have evaluated only one or two of these elements independently and it is difficult to obtain a global view of apoptosis disregulation in the pathogenesis of systemic lupus erythematosus (SLE) and their role in disease activity. The aim of this study was to evaluate serum levels of sFas, bcl-2, IL-10 and alfa-TNF in human SLE patients and to analyze their relationship with disease activity and with regulation of the apoptotic process. PATIENTS AND METHODS: Serum levels of sFas and cytokines IL-10 and alfa-TNF were studied by enzyme-linked immunoabsorbent assay. Bcl-2 antigen expression was analyzed in lysated lymphocytes from 51 SLE patients. The disease activity was analyzed according to the SLE disease activity index (SLEDAI). RESULTS: SLE patients had higher levels of sFas (p=0.0006) and alfa-TNF (p<0.0001) than the control group. No relationship was found between the levels of bcl-2 and IL-10 from SLE patients and the control group. However, there was a significant correlation between SLEDAI and bcl-2 (p<0.001) and IL-10 levels (p=0.004). In contrast, we found that sFas and alfa-TNF were not related with disease activity. A significant correlation of sFas with alfa-TNF serum levels (p=0.003, R= +0.41) and bcl-2 antigen expression (p=0.02, R=+0.32) was observed. CONCLUSION: sFas and alfa-TNF serum levels are increased in SLE patients. sFas levels seems to be secondary to alfa-TNF action, which is enhanced in inflammatory conditions such as SLE. Bcl-2 antigen expression and IL-10 serum levels are related to the maintenance of SLE activity. These alterations may interfere with the apoptotic process, promoting lymphocyte hyperactivity secondary to increased cytokine levels, and causing the characteristic features of SLE.

Bcl-2 oncogene (B cell lymphoma/leukemia-2) levels correlate with systemic lupus erythematosus disease activity.

OBJECTIVE: Bcl-2 translocation or overexpression is found in many types of malignancy, possibly through alteration of the apoptosis mechanism. It has also been suggested that similar apoptotic alterations may be important in the pathogenesis of systemic lupus erythematosus (SLE). It is believed that a process of apoptosis at the stage of maturation or differentiation of lymphocytes may be related to the beginning of an autoimmune event, due to the non-elimination of autoreactive lymphocytes. The aim of this study is to test bcl-2 antigen expression in human SLE peripheral blood and to analyze its relationship with disease activity. MATERIALS AND METHODS: Serum levels of bcl-2 were studied by enzyme-linked immunoabsorbent assay in whole blood samples in 68 patients with SLE and its correlation with disease activity according to SLE disease activity index (SLEDAI). RESULTS: No significant differences were found in bcl-2 levels between all SLE patients and controls. We observed increased levels of bcl-2 in active SLE patients in relation to inactive (p = 0.0003) and controls (p = 0.02). Our results show a significant correlation between bcl-2 levels and SLEDAI values (R = 0.46, P < 0.001). CONCLUSIONS: These results suggest that bcl-2 levels are related to disease activity and that this protein may play a role in the pathogenesis of SLE.

Lack of correlation between tumor markers (CA 125 and SCC) and systemic lupus erythematosus activity.

BACKGROUND: Recently, tumor markers (CA 125 and SCC) have been suggested as possible activity markers of systemic lupus erythematosus (SLE), but study results have been contradictory. OBJECTIVE: The aim of this study was to evaluate the possible relationship between CA 125 and SCC serum levels and SLE activity. PATIENTS AND METHODS: Serum levels of CA 125 from 59 patients and levels of SCC from 53 patients with SLE were analyzed. Both tumor markers were determined by ELISA, considering 35 U/ml (CA 125) and 2.5 ng/ml (SCC) respectively as the upper limit of normality. The serum levels of these tumor markers were correlated with the SLE disease activity index (SLEDAI). RESULTS: The CA 125 concentrations in active SLE (mean 13.8 + 15.3) were similar to those in inactive patients (mean 13.1 + 11.7 U/ml). Significantly high CA 125 serum levels were found only in SLE patients with nephrotic syndrome (p = 0.001). No significant differences were found in SCC serum levels in SLE patients with (mean 0.9 +/- 0.8 ng/ml) or without activity (mean 1.1 +/- 1.3 ng/ml). Likewise, no relationship between SCC serum levels and parameters related to SLE activity were found, excluding slight increases associated with renal failure. CONCLUSIONS: The correlation that some authors have found between elevated serum levels of CA 125 and SLE activity is only associated with the presence of nephrotic syndrome. Likewise, SCC is not related with SLE activity and the increases found may be due to renal failure.

Antiphospholipid syndrome without antiphospholipid antibodies at the time of the thrombotic event: transient 'seronegative' antiphospholipid syndrome?

The antiphospholipid syndrome (APS) is characterized by the presence of venous and arterial thrombosis, recurrent fetal losses and thrombocytopenia, associated with the presence of antiphospholipid antibodies (aPL). This syndrome may be "primary" or may be associated with other diseases, mainly systemic lupus erythematosus (SLE). However, some patients present the clinical picture of this syndrome but without evidence of aPL in their serum. The term "seronegative" APS has been proposed to categorize these patients. Here with we present two patients with seronegativity for aPL at the time of a thrombotic event, but in whom these antibodies were detected 2 and 7 months later.

Antiphospholipid antibodies in primary Sjögren's syndrome: prevalence and clinical significance in a series of 80 patients.

OBJECTIVE: To determine the prevalence and clinical significance of antiphospholipid antibodies (aPL) in a cohort of patients with primary Sjögren's syndrome (SS). METHODS: Eighty patients with primary SS were studied prospectively. The prevalence of aPL and characteristics of the clinical and laboratory features of these patients were compared with those of the following groups of patients: (i) 50 patients with SS associated with systemic lupus erythematosus (SLE); (ii) 100 patients with SLE without SS; and (iii) 100 healthy blood donors from the blood bank of our hospital. RESULTS: Only 11 (14%) patients with primary SS were found to have aPL (anticardiolipin antibodies or lupus anticoagulant, or both) in their sera, but anti beta 2-glycoprotein I antibodies were not detected in any patient. In contrast, aPL were detected in 12 (24%) patients with SS secondary to SLE and in 21 (21%) patients with SLE without SS. None of the healthy controls presented aPL in their sera. Patients with primary SS presented a lower prevalence of thrombocytopenia (p < 0.05) and livedo reticularis (p < 0.01) compared with the other two groups of patients. No patient with primary SS was diagnosed as having an antiphospholipid syndrome (APS), while 4 (8%) patients with secondary SS and 9 (9%) with SLE without SS were found to have APS (p < 0.05). CONCLUSION: In patients with primary SS, aPL are present in a lower percentage than in patients with SS secondary to SLE or in patients with SLE without SS. The presence of aPL in these primary SS patients is not associated with the clinical events of APS.

[Primary Sjögren's syndrome: clinical and immunologic study of 80 patients]. / Síndrome de Sjögren primario: estudio clínico e immunológico de 80 pacientes.

BACKGROUND: To determine the clinical and immunologic characteristics of a large cohort of patients with primary Sjörgen's syndrome (SS) and to asses if the sex, the age at onset, the time of evolution and the immunologic pattern define different subsets with specific characteristics. PATIENTS AND METHODS: We included 80 patients (76 female and 4 male) that were prospectively studied at our Unit. All patients fulfilled the European Community criteria proposed in 1993 for the diagnosis of SS. RESULTS: Mean age of patients was 62 years with a mean disease duration of 8 years. The most frequently observed clinical manifestations were xerostomia (96%), xerophthalmia (94%) and parotidomegaly (46%). The main extraglandular manifestations were arthritis (45%), Raynaud's phenomenon (20%) and liver involvement (19%). The immunologic study showed antinuclear antibodies in 82% of patients, rheumatoid factor in 45%, anti-Ro/SS-A in 40% and anti-La/SS-B in 20%. In patients with an onset of disease before the age of 40 years, a higher prevalence of parotidomegaly, peripheral neuropathy, cutaneous vasculitis, rheumatoid factor, anti-Ro/SS-A and anti-La/SS-B antibodies was observed. A disease duration longer than 10 years was associated with a higher prevalence of pulmonary involvement and more focus of mononuclear cells in the minor salivary glands. Clinical manifestations associated to any one or more immunologic marker (rheumatoid factor, anti-Ro/SS-A and/or anti-La/SS-B) were Raynaud's phenomenon, arthritis, thyroid disease, cutaneous vasculitis and peripheral neuropathy. CONCLUSIONS: Primary SS is an autoimmune disease characterized by a marked heterogeneity in the clinical presentation and evolution, thus allowing the definition of several subsets of patients with their own clinical and immunological characteristics.

Antibodies to thromboplastin in systemic lupus erythematosus: isotype distribution and clinical significance in a series of 92 patients.

We determined the prevalence and relationship with clinical manifestations of antibodies to thromboplastin (aTP) in 92 patients with systemic lupus erythematosus (SLE). Thirty-two (35%) patients had aTP: 13 (14%) were positive for IgG aTP, 13 (14%) for IgM aTP, and 6 (7%) for both. Patients with aTP had an increased incidence of thrombosis (p = 0.01), thrombocytopenia (p < 0.001), hemolytic anemia (p < 0.001), and fetal losses (p = 0.03). When the IgG and IgM aTP isotypes were analysed separately, the IgG aTP were found to be associated with thrombosis (p < 0.001), thrombocytopenia (p < 0.001), and fetal losses (p = 0.02). The IgM aTP were associated with hemolytic anemia (p < 0.001). A correlation was found between the titers of aTP and those of anticardiolipin antibodies, in both IgG (p < 0.01, r = 0.6) and IgM (p < 0.01, r = 0.64) isotypes, and between the titers of IgG aTP and the diluted Russell's viper venom time used to detect the lupus anticoagulant (p < 0.001, r = 0.42). This test is a reliable, reproducible and sensitive assay for the detection of antiphospholipid antibodies, specially in those patients under anticoagulant therapy.

Isotype distribution and clinical significance of antibodies to cardiolipin, phosphatidic acid, phosphatidylinositol and phosphatidylserine in systemic lupus erythematosus: prospective analysis of a series of 92 patients.

OBJECTIVE: To determine the prevalence and correlation with clinical manifestations of the IgG and IgM isotypes of antibodies to cardiolipin (aCL), phosphatidic acid (aPA), phosphatidylinositol (aPI) and phosphatidylserine (aPS) in patients with systemic lupus erythematosus (SLE). METHODS: Clinical and laboratory features of 92 consecutive unselected patients with SLE were prospectively studied over two years. aCL, aPA, aPI and aPS were determined by ELISA. RESULTS: aCL were detected in 34 (37%) patients, aPA in 26 (28%), aPI in 22 (24%), and aPS in 29 (32%). A significant association was found between the appearance of thrombosis and the presence of IgG aCL (p < 0.001) and IgG aPS (p < 0.05). A significant association was also found between thrombocytopenia and the presence of IgG aCL (p < 0.001), IgG aPA (p < 0.01), IgG aPI (p < 0.05), and IgG aPS (p < 0.001). The development of hemolytic anemia was associated with the detection of IgM aCL (p < 0.001), IgM aPA (p < 0.05), IgM aPI (p < 0.001), and IgM aPS (p < 0.01). CONCLUSION: We found a relatively high prevalence of aCL, aPA, aPI and aPS in our SLE population and confirmed the presence of a correlation between the IgG isotype of these antibodies and thrombosis and thrombocytopenia, and also between the IgM isotype and hemolytic anemia. These results demonstrate the variety of antiphospholipid antibodies that can be detected in SLE patients, as well as their association with the clinical manifestations of the antiphospholipid syndrome.

Hepatitis C virus infection in 'primary' Sjögren's syndrome: prevalence and clinical significance in a series of 90 patients.

OBJECTIVES: To determine the prevalence and clinical significance of hepatitis C virus (HCV) infection in a large cohort of patients with "primary' Sjögren's syndrome (SS). METHODS: 90 consecutive patients (83 female and seven male) were included, with a mean age of 62 years (range 31-80) who prospectively visited our unit. All patients fulfilled the European Community criteria for SS and underwent a complete history, physical examination, as well as biochemical and immunological evaluation for liver disease. Serum from all patients was tested for antibodies to HCV by third generation enzyme linked immunoassay and positivity was confirmed by polymerase chain reaction. RESULTS: Antibodies to HCV were present in 13 (14%) patients with 'primary' SS. When compared with patients without HCV infection, patients with HCV infection presented a higher prevalence of hepatic involvement, (100% v 8%, p < 0.05). Transcutaneous liver biopsy was performed in five patients with HCV infection, and specimens obtained showed in all cases a chronic active hepatitis with varying degrees of portal inflammation. CONCLUSION: HCV infection is frequent in patients with "primary' SS and liver involvement is presented in all these patients. The possible pathogenic role of HCV infection in these patients is still unclear.

Shrinking lungs syndrome in systemic lupus erythematosus: improvement with inhaled beta-agonist therapy.

The pathogenesis and therapy of shrinking lungs syndrome in patients with systemic lupus erythematosus remains controversial. It has been previously reported that corticosteroid treatment can be effective. We report a patient with shrinking lungs syndrome who presented a good response to inhaled beta-agonist therapy. Therapeutic approach to this syndrome is discussed.