Modelo de riesgo de crisis en acúmulos o estado epiléptico e intervención en servicios de urgencias / Risk model of seizure cluster or status epilepticus and intervention in the emergency department

Objetivos Identificar posibles factores predictores de crisis epilépticas en acúmulos o estado epiléptico (EE) y evaluar si estos pacientes reciben una mayor intervención en urgencias. Metodología Análisis secundario del Registro ACESUR el cual es un registro observacional de cohortes multipropósito, prospectivo y multicéntrico de pacientes adultos con crisis epilépticas en 18 servicios de urgencias. Se recogen variables clínico-asistenciales. Se identifican factores y modelo de riesgo de presentar crisis en acúmulos o EE y se evalúa el efecto de intervención en servicios de urgencias extrahospitalarios y hospitalarios. Resultados Del registro ACESUR se analizan 186 (28%) con crisis en acúmulos (126; 19%) o EE (60; 9%) frente a 478 (72%) pacientes con crisis aislada. El modelo de riesgo de crisis en acúmulo o EE en urgencias incluyó la presencia de alta comorbilidad según índice de Charlson > 3 (OR: 1,60; IC95%: 1,05-2,46; p = 0,030), > 2 fármacos antiepilépticos habituales (OR: 2,29; IC95%: 1,49-3,51; p < 0,001) y crisis focal (OR: 1,56; IC95%: 1,05-2,32; p = 0,027). El ABC del modelo fue de 0,735 (IC95%: 0,693-0,777; p = 0,021). La intervención en pacientes con crisis en acúmulos y EE fue mayor en los servicios de urgencias extrahospitalarios (OR: 2,89; IC95%: 1,91-4,36; p < 0,001) y en los servicios de urgencias hospitalarios (OR: 4,41; IC95%: 2,69-7,22; p < 0,001). Conclusiones El modelo presentado podría ser una herramienta con valor predictivo de utilidad para identificar al paciente adulto con riesgo de presentar crisis en acúmulos o EE en urgencias. Estos pacientes recibieron una mayor intervención frente a pacientes con crisis epiléptica aislada por parte de los servicios de urgencias extrahospitalarios y más aún por los servicios de urgencias hospitalarios en nuestra muestra. (AU)

Objectives To identify possible predictors of seizure cluster or status epilepticus (SE) and to evaluate whether these patients receive greater interventions in emergency departments. Methodology We conducted a secondary analysis of the ACESUR Registry, a multipurpose, observational, prospective, multicentre registry of adult patients with seizures from 18 emergency departments. Clinical and care-related variables were collected. We identified risk factors and risk models for seizure cluster or SE and assessed the effect of interventions by prehospital emergency services and the hospital emergency department. Results We identified a total of 186 (28%) patients from the ACESUR registry with seizure cluster (126 [19%]) or SE (60 [9%]); the remaining 478 patients (72%) had isolated seizures. The risk model for seizure cluster or SE in the emergency department included Charlson Comorbidity Index scores ≥ 3 (OR: 1.60; 95% CI, 1.05-2.46; P = .030), ≥ 2 habitual antiepileptic drugs (OR: 2.29; 95% CI, 1.49-3.51; P < .001), and focal seizures (OR: 1.56; 95% CI, 1.05-2.32; P = .027). The area under the curve of the model was 0.735 (95% CI, 0.693-0.777; P = .021). Patients with seizure cluster and SE received more aggressive interventions both by prehospital emergency services (OR: 2.89; 95% CI, 1.91-4.36; P < .001) and at the emergency department (OR: 4.41; 95% CI, 2.69-7.22; P < .001). Conclusions This risk model may be of prognostic value in identifying adult patients at risk of presenting seizure cluster or SE in the emergency department. In our sample, these patients received more aggressive treatment than adult patients with isolated seizures before arriving at hospital, and even more so in the emergency department. (AU)

Modelo de riesgo de crisis en acúmulos o estado epiléptico e intervención en servicios de urgencias / Risk model of seizure cluster or status epilepticus and intervention in the emergency department

Objetivos Identificar posibles factores predictores de crisis epilépticas en acúmulos o estado epiléptico (EE) y evaluar si estos pacientes reciben una mayor intervención en urgencias. Metodología Análisis secundario del Registro ACESUR el cual es un registro observacional de cohortes multipropósito, prospectivo y multicéntrico de pacientes adultos con crisis epilépticas en 18 servicios de urgencias. Se recogen variables clínico-asistenciales. Se identifican factores y modelo de riesgo de presentar crisis en acúmulos o EE y se evalúa el efecto de intervención en servicios de urgencias extrahospitalarios y hospitalarios. Resultados Del registro ACESUR se analizan 186 (28%) con crisis en acúmulos (126; 19%) o EE (60; 9%) frente a 478 (72%) pacientes con crisis aislada. El modelo de riesgo de crisis en acúmulo o EE en urgencias incluyó la presencia de alta comorbilidad según índice de Charlson > 3 (OR: 1,60; IC95%: 1,05-2,46; p = 0,030), > 2 fármacos antiepilépticos habituales (OR: 2,29; IC95%: 1,49-3,51; p < 0,001) y crisis focal (OR: 1,56; IC95%: 1,05-2,32; p = 0,027). El ABC del modelo fue de 0,735 (IC95%: 0,693-0,777; p = 0,021). La intervención en pacientes con crisis en acúmulos y EE fue mayor en los servicios de urgencias extrahospitalarios (OR: 2,89; IC95%: 1,91-4,36; p < 0,001) y en los servicios de urgencias hospitalarios (OR: 4,41; IC95%: 2,69-7,22; p < 0,001). Conclusiones El modelo presentado podría ser una herramienta con valor predictivo de utilidad para identificar al paciente adulto con riesgo de presentar crisis en acúmulos o EE en urgencias. Estos pacientes recibieron una mayor intervención frente a pacientes con crisis epiléptica aislada por parte de los servicios de urgencias extrahospitalarios y más aún por los servicios de urgencias hospitalarios en nuestra muestra. (AU)

Objectives To identify possible predictors of seizure cluster or status epilepticus (SE) and to evaluate whether these patients receive greater interventions in emergency departments. Methodology We conducted a secondary analysis of the ACESUR Registry, a multipurpose, observational, prospective, multicentre registry of adult patients with seizures from 18 emergency departments. Clinical and care-related variables were collected. We identified risk factors and risk models for seizure cluster or SE and assessed the effect of interventions by prehospital emergency services and the hospital emergency department. Results We identified a total of 186 (28%) patients from the ACESUR registry with seizure cluster (126 [19%]) or SE (60 [9%]); the remaining 478 patients (72%) had isolated seizures. The risk model for seizure cluster or SE in the emergency department included Charlson Comorbidity Index scores ≥ 3 (OR: 1.60; 95% CI, 1.05-2.46; P = .030), ≥ 2 habitual antiepileptic drugs (OR: 2.29; 95% CI, 1.49-3.51; P < .001), and focal seizures (OR: 1.56; 95% CI, 1.05-2.32; P = .027). The area under the curve of the model was 0.735 (95% CI, 0.693-0.777; P = .021). Patients with seizure cluster and SE received more aggressive interventions both by prehospital emergency services (OR: 2.89; 95% CI, 1.91-4.36; P < .001) and at the emergency department (OR: 4.41; 95% CI, 2.69-7.22; P < .001). Conclusions This risk model may be of prognostic value in identifying adult patients at risk of presenting seizure cluster or SE in the emergency department. In our sample, these patients received more aggressive treatment than adult patients with isolated seizures before arriving at hospital, and even more so in the emergency department. (AU)

Risk model of seizure cluster or status epilepticus and intervention in the emergency department.

OBJECTIVES: To identify possible predictors of seizure cluster or status epilepticus (SE) and to evaluate whether these patients receive greater interventions in emergency departments. METHODOLOGY: We conducted a secondary analysis of the ACESUR Registry, a multipurpose, observational, prospective, multicentre registry of adult patients with seizures from 18 emergency departments. Clinical and care-related variables were collected. We identified risk factors and risk models for seizure cluster or SE and assessed the effect of interventions by prehospital emergency services and the hospital emergency department. RESULTS: We identified a total of 186 (28%) patients from the ACESUR registry with seizure cluster (126 [19%]) or SE (60 [9%]); the remaining 478 patients (72%) had isolated seizures. The risk model for seizure cluster or SE in the emergency department included Charlson Comorbidity Index scores ≥ 3 (OR: 1.60; 95% CI, 1.05-2.46; P=.030), ≥ 2 habitual antiepileptic drugs (OR: 2.29; 95% CI, 1.49-3.51; P<.001), and focal seizures (OR: 1.56; 95% CI, 1.05-2.32; P=.027). The area under the curve of the model was 0.735 (95% CI, 0.693-0.777; P=.021). Patients with seizure cluster and SE received more aggressive interventions both by prehospital emergency services (OR: 2.89; 95% CI, 1.91-4.36; P<.001) and at the emergency department (OR: 4.41; 95% CI, 2.69-7.22; P<.001). CONCLUSIONS: This risk model may be of prognostic value in identifying adult patients at risk of presenting seizure cluster or SE in the emergency department. In our sample, these patients received more aggressive treatment than adult patients with isolated seizures before arriving at hospital, and even more so in the emergency department.

COVID-19 pneumonia: Relationship between initial chest X-rays and laboratory findings.

OBJECTIVE: To analyze the initial findings in chest X-rays of patients with RT-PCR positive for SARS-CoV-2, and to determine whether there is a relationship between the severity of these findings and the clinical and laboratory findings. MATERIALS AND METHODS: This retrospective study analyzed the relationship between initial chest X-rays and initial laboratory tests in symptomatic adults with nasopharyngeal RT-PCR results positive for SARS-CoV-2 seen at our center between February 29 and March 23, 2020. Among other radiologic findings, we analyzed ground-glass opacities, consolidations, linear opacities, and pleural effusion. We also used a scale of radiologic severity to assess the distribution and extent of these findings. Among initial laboratory findings, we analyzed leukocytes, lymphocytes, platelets, neutrophil-to-lymphocyte ratio, and C-reactive protein. RESULTS: Of 761 symptomatic patients, 639 (84%) required hospitalization and 122 were discharged to their homes. The need for admission increased with increasing scores on the scale of radiologic severity. The extent of initial lung involvement was significantly associated with the laboratory parameters analyzed (P<.05 for platelets, P<.01 for lymphocytes, and P<.001 for the remaining parameters), as well as with the time from the onset of symptoms (P<.001). CONCLUSION: It can be useful to use a scale of radiologic severity to classify chest X-ray findings in diagnosing patients with COVID-19, because the greater the radiologic severity, the greater the need for hospitalization and the greater the alteration in laboratory parameters.

COVID-19 pneumonia: relationship between initial chest X-rays and laboratory findings. / Neumonía COVID-19: relación entre la radiografía de tórax inicial y los datos analíticos.

OBJECTIVE: To analyze the initial findings in chest X-rays of patients with RT-PCR positive for SARS-CoV-2, and to determine whether there is a relationship between the severity of these findings and the clinical and laboratory findings. MATERIALS AND METHODS: This retrospective study analyzed the relationship between initial chest X-rays and initial laboratory tests in symptomatic adults with nasopharyngeal RT-PCR results positive for SARS-CoV-2 seen at our center between February 29 and March 23, 2020. Among other radiologic findings, we analyzed ground-glass opacities, consolidations, linear opacities, and pleural effusion. We also used a scale of radiologic severity to assess the distribution and extent of these findings. Among initial laboratory findings, we analyzed leukocytes, lymphocytes, platelets, neutrophil-to-lymphocyte ratio, and C-reactive protein. RESULTS: Of 761 symptomatic patients, 639 (84%) required hospitalization and 122 were discharged to their homes. The need for admission increased with increasing scores on the scale of radiologic severity. The extent of initial lung involvement was significantly associated with the laboratory parameters analyzed (p<0.05 for platelets, p<0.01 for lymphocytes, and p<0.001 for the remaining parameters), as well as with the time from the onset of symptoms (p<0.001). CONCLUSION: It can be useful to use a scale of radiologic severity to classify chest X-ray findings in diagnosing patients with COVID-19, because the greater the radiologic severity, the greater the need for hospitalization and the greater the alteration in laboratory parameters.

Risk model of seizure cluster or status epilepticus and intervention in the emergency department. / Modelo de riesgo de crisis en acúmulos o estado epiléptico e intervención en servicios de urgencias.

OBJECTIVES: To identify possible predictors of seizure cluster or status epilepticus (SE) and to evaluate whether these patients receive greater interventions in emergency departments. METHODOLOGY: We conducted a secondary analysis of the ACESUR Registry, a multipurpose, observational, prospective, multicentre registry of adult patients with seizures from 18 emergency departments. Clinical and care-related variables were collected. We identified risk factors and risk models for seizure cluster or SE and assessed the effect of interventions by prehospital emergency services and the hospital emergency department. RESULTS: We identified a total of 186 (28%) patients from the ACESUR registry with seizure cluster (126 [19%]) or SE (60 [9%]); the remaining 478 patients (72%) had isolated seizures. The risk model for seizure cluster or SE in the emergency department included Charlson Comorbidity Index scores≥3 (OR: 1.60; 95% CI, 1.05-2.46; P=.030), ≥2 habitual antiepileptic drugs (OR: 2.29; 95% CI, 1.49-3.51; P<.001), and focal seizures (OR: 1.56; 95% CI, 1.05-2.32; P=.027). The area under the curve of the model was 0.735 (95% CI, 0.693-0.777; P=.021). Patients with seizure cluster and SE received more aggressive interventions both by prehospital emergency services (OR: 2.89; 95% CI, 1.91-4.36; P<.001) and at the emergency department (OR: 4.41; 95% CI, 2.69-7.22; P<.001). CONCLUSIONS: This risk model may be of prognostic value in identifying adult patients at risk of presenting seizure cluster or SE in the emergency department. In our sample, these patients received more aggressive treatment than adult patients with isolated seizures before arriving at hospital, and even more so in the emergency department.

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.

Predictors of good visual outcomes in patients with neovascular age-related macular degeneration in daily practice.

PURPOSE: To report predictive factors for therapeutic response to anti-VEGF in patients with neovascular age-related macular degeneration (nAMD) in daily clinical practice in our patient population. METHODS: Retrospective cohort study including 56 patients (69 eyes) with nAMD treated with anti-VEGF, followed for at least two years between February 2012 and April 2018. Patients received three intravitreal anti-VEGF (bevacizumab) injections (loading dose) and were monitored and treated according to a PRN regimen. We analysed whether a gain in visual acuity of 15 or more ETDRS letters at the final visit was associated with demographic characteristics, presence of systemic comorbidities, fundus lesions or measurable improvement on Cirrus optical coherence tomography (OCT) between the first and last visit. RESULTS: After a mean follow-up of 15.5 months (4.7-27.8 interquartile range), central retinal thickness (CRT) (RR: 1.004; IC 95%: 1.001-1.007; P=0.011) and macular hemorrhage (RR: 0.30; IC 95%: 0.10-0.90, P=0.032) at baseline were found to be useful predictive factors for visual acuity improvement (≥15 letters) in patients treated for nAMD by anti-VEGF in a real world clinical setting. CONCLUSION: In the present series of patients with nAMD receiving a loading dose of bevacizumab and followed according to a PRN regimen for 24 months, the only predictable factors for a ≥15 letter gain in visual acuity were anatomical response as measured by OCT and macular hemorrhage at baseline.

Early markers of endocrinometabolic disease in newborns with delayed intrauterine growth.

INTRODUCTION: The adjustments to malnutrition in growth restricted fetus (GRF) that lead to obesity, insulin resistance, diabetes and cardiovascular disease in adulthood are not well known. The most feasible explanation for this association is the hypothesis of catch up. Some studies postulate a greater influence of catch up growth than the low birth weight itself in developing metabolic and cardiovascular disease. MATERIAL AND METHODS: This is a prospective cohort study of newborns with intrauterine growth restriction (defined as weight percentile at birth less than 10th) born during a one-year period. Clinical data of patients were recorded (gender, gestational age, data about breastfeeding and anthropometry during follow-up every 3 months). Some details of pregnancy and characteristics of the mother were also registered. Serum biochemical parameters (IGF-1, IGF-BP3, insulin, glucose, total cholesterol, HDL cholesterol, DLD cholesterol, triglycerides, HOMA) were collected at birth from cord blood, 9 and 12 months. Two main comparative groups were established: those GRF who made a catch-up growth (increase in weight Z score higher than 0,67) during the follow-up and those who did not get it. RESULTS: 126 GRF children were born in the study period. 125 accepted the inclusion in the study and 67 of them completed the full monitoring for a year; 47 of them made recovery growth and 20 did not. A significant difference between both groups was found in glucose in umbilical cord and triglycerides at 12 months: GRF children with catch up growth showed lower glucose levels (p = 0.03) and higher levels of triglycerides (p = 0.03). There were no statistically significant differences in the rest of laboratory parameters analyzed (IGF-1, IGF-BP3, insulin, glucose, total cholesterol, HDL cholesterol, DLD cholesterol, HOMA at 9 and 12 months or triglycerides at 9 months). CONCLUSIONS: Those GRF with catch up growth during the first year of life have early changes in the triglycerides at the end of that period with higher levels than those GRF children without catch up growth. This finding could be useful to develop a tool for early detection of GRF children with higher metabolic risk in order to prevent future pathology.

[Adequacy and effect of preventive antiepileptic treatment after a first epileptic seizure 30 days after discharge from hospital emergency departments: the ACESUR registry]. / Adecuacion y efecto del tratamiento antiepileptico preventivo tras una primera crisis epileptica a los 30 dias del alta de servicios de urgencias hospitalarios: registro ACESUR.

AIM: To evaluate the adequacy and effect of preventive antiepileptic treatment in adult patients with the first epileptic seizure in adverse outcomes at 30 days after discharge from the hospital emergency department (HED). PATIENTS AND METHODS: ACESUR was an observational registry of multipurpose, prospective and multicentric cohorts with a systematic sampling. Phone follow-up was done at 30 days. Clinical variables were collected in the index visit and the follow-up result. The main variable was «adequate preventive treatment according to indications¼ and the result of «some adverse outcome¼ (recurrence of epileptic seizure, revisits to HED, hospitalization or death) 30 days after discharge from HED. A logistic regression model was used to isolate the effect of adequate preventive treatment. RESULTS: 151 (22.7%) patients with a mean age of 55 years old were included with first epileptic seizure discharged from 18 HED with follow-up data. Preventive treatment was considered adequate in 128 (84.8%) patients. 41 (27.2%) patients presented some adverse outcome 30 days after discharge. After the logistic regression, the appropriate preventive treatment to the discharge of the HED exerts a protective effect on the variable «some adverse outcome to 30 days¼. CONCLUSIONS: In the ACESUR registry, preventive treatment was adequate for most patients and its effect was independent protective at 30 days. Therefore, adequate preventive treatment could improve the short-term results of adult patients discharged with the first epileptic seizure of the HED.

TITLE: Adecuacion y efecto del tratamiento antiepileptico preventivo tras una primera crisis epileptica a los 30 dias del alta de servicios de urgencias hospitalarios: registro ACESUR.Objetivo. Evaluar la adecuacion y el efecto del tratamiento antiepileptico preventivo en pacientes adultos con una primera crisis epileptica en cuanto a resultados adversos a los 30 dias del alta del servicio de urgencias hospitalario (SUH). Pacientes y metodos. ACESUR fue un registro observacional de cohortes multiproposito, prospectivo y multicentrico con un muestreo sistematico. Se realizo seguimiento telefonico a los 30 dias. Se recogieron variables clinicas en la visita indice y de resultado en seguimiento. La variable principal fue «tratamiento preventivo adecuado segun indicaciones¼, y la de resultado, «algun resultado adverso¼ (recurrencia de crisis epileptica, revisita a SUH, hospitalizacion o muerte) a los 30 dias del alta de urgencias. Se realizo un modelo de regresion logistica para aislar el efecto del tratamiento preventivo adecuado. Resultados. Se incluyo a 151 (22,7%) pacientes con una media de 55 años con primera crisis epileptica, dados de alta de 18 SUH con datos de seguimiento. El tratamiento preventivo se considero adecuado en 128 (84,8%) pacientes. Cuarenta y un (27,2%) pacientes presentaron algun resultado adverso a los 30 dias del alta. Tras la regresion logistica, el tratamiento preventivo adecuado al alta del SUH ejerce un efecto protector sobre la variable «algun resultado adverso a 30 dias¼. Conclusiones. En el registro ACESUR, el tratamiento preventivo fue adecuado en la mayoria de los pacientes y su efecto resulto, de forma independiente, protector a los 30 dias. Por tanto, el tratamiento preventivo adecuado podria mejorar los resultados a corto plazo de pacientes adultos dados de alta con una primera crisis epileptica del SUH.

[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.

Intervención multidimensional que mejora el pronóstico a corto plazo entre los ancianos frágiles dados de alta desde una unidad de corta estancia: estudio cuasiexperimental / Multidimensional intervention to improve the short-term prognosis of frail elderly patients discharged from a short-stay unit: A quasiexperimental study

Objetivo. Estudiar el efecto de una intervención multidimensional en el pronóstico a 30 días en los ancianos frágiles dados de alta desde una unidad de corta estancia. Material y método. Estudio cuasiexperimental con una cohorte de control histórica. Se incluyeron pacientes frágiles (Identification of Senior at Risk≥2), de≥75 años, dados de alta desde la unidad de corta estancia durante 2 meses en 2013 (grupo control) y un año (2016; grupo de intervención). Se realizó una intervención basada en la activación de recursos, en función de los déficits detectados tras una valoración geriátrica abreviada, más la coordinación con Atención Primaria. La variable de resultado principal fue la presencia de algún resultado adverso (muerte o reingreso por cualquier causa o deterioro funcional grave) a los 30 días del alta. Resultados. Se incluyeron 137 (62,8%) pacientes en el grupo de intervención y 81 (37,2%) en el control. Dieciocho (13,1%) pacientes en el grupo de intervención y 29 (35,8%) en el control presentaron algún evento adverso a los 30 días. Tras un análisis multivariable, se demostró que la realización de una intervención multidimensional fue un factor de protección para la presentación de algún evento adverso a los 30 días tras el alta (RR ajustado 0,40; IC 95% 0,23-0,68; p=0,001). Conclusiones. La realización de un plan de atención individualizado, basado en la activación de recursos, en función de los déficits detectados tras una valoración geriátrica abreviada, y la coordinación con Atención Primaria, entre los pacientes ancianos frágiles podría mejorar los resultados a los 30 días tras el alta desde una UCE

Objective. To study the effect of a multidimensional intervention on the prognosis at 30 days for frail elderly patients discharged from a short-stay unit. Material and method. A quasiexperimental study was conducted with a historical control cohort. We included frail patients (Identification of Seniors at Risk score≥2) 75 years of age or older, discharged from an short-stay unit over 2 months in 2013 (control group) and in 2016 (intervention group). An intervention was conducted based on the activation of resources, based on the deficiencies detected after an abbreviated geriatric assessment, in conjunction with Primary Care. The main endpoint was the presence of an adverse result (death or readmission for any cause or severe functional impairment) at 30 days of discharge. Results. We included 137 (62.8%) patients in the intervention group and 81 (37.2%) in the control group. Eighteen (13.1%) patients in the intervention group and 29 (35.8%) in the control group presented an adverse event at 30 days. A multivariate analysis showed that the implementation of a multidimensional intervention was a protective factor for presenting an adverse event at 30 days of discharge (adjusted RR 0.40; 95% CI 0.23-0.68; P=.001). Conclusions. The implementation of an individual care plan for frail elderly patients, based on the activation of resources according to the deficiencies detected after an abbreviated geriatric assessment and in conjunction with Primary Care, could improve the results at 30 days of discharge from an short-stay unit

Multidimensional intervention to improve the short-term prognosis of frail elderly patients discharged from a short-stay unit: A quasiexperimental study. / Intervención multidimensional que mejora el pronóstico a corto plazo entre los ancianos frágiles dados de alta desde una unidad de corta estancia: estudio cuasiexperimental.

OBJECTIVE: To study the effect of a multidimensional intervention on the prognosis at 30 days for frail elderly patients discharged from a short-stay unit. MATERIAL AND METHOD: A quasiexperimental study was conducted with a historical control cohort. We included frail patients (Identification of Seniors at Risk score≥2) 75 years of age or older, discharged from an short-stay unit over 2 months in 2013 (control group) and in 2016 (intervention group). An intervention was conducted based on the activation of resources, based on the deficiencies detected after an abbreviated geriatric assessment, in conjunction with Primary Care. The main endpoint was the presence of an adverse result (death or readmission for any cause or severe functional impairment) at 30 days of discharge. RESULTS: We included 137 (62.8%) patients in the intervention group and 81 (37.2%) in the control group. Eighteen (13.1%) patients in the intervention group and 29 (35.8%) in the control group presented an adverse event at 30 days. A multivariate analysis showed that the implementation of a multidimensional intervention was a protective factor for presenting an adverse event at 30 days of discharge (adjusted RR 0.40; 95% CI 0.23-0.68; P=.001). CONCLUSIONS: The implementation of an individual care plan for frail elderly patients, based on the activation of resources according to the deficiencies detected after an abbreviated geriatric assessment and in conjunction with Primary Care, could improve the results at 30 days of discharge from an short-stay unit.

In-hospital mortality risk score for very old patients hospitalized with decompensated chronic heart failure.

OBJECTIVE: To derive a risk score to predict in-hospital mortality for very old patients with decompensated chronic heart failure (DCHF). METHODOLOGY: Retrospective cohort study that included patients ≥ 80 years admitted to a Geriatric Acute Care Unit with DCHF between January 2012 and December 2014. We analyzed 70 candidate risk factors and in-hospital mortality. We derived a risk model using multivariate logistic regression model and constructed a scale for scoring risk. We used bootstrapping techniques for the internal validation. RESULTS: We included 629 patients with mean age of 90 (SD5) years, 470 (73.1%) being women. Eighty-six (13.7%) patients died during the hospitalization. Factors included in the final risk model were NYHA class III-IV, severe functional dependence (Katz activities of daily living index < 2), infection as cause of exacerbation of heart failure, number of medications ≥ 8, albumin < 3 mg/dL, glomerular filtration rate < 60 mL/min, level of potassium in blood > 5.5 mEq/L and red blood cell distribution width (RDW) > 17%. In-hospital mortality in risk groups was 3.0, 4.6, 9.5, 15.1 and 36.3%, respectively. The area under ROC curve risk for score after bootstrapping was 0.77 (95%: CI 0.70-0.83). CONCLUSION: This risk score could be useful for stratifying risk for in-hospital mortality among very old patients admitted to hospital for DCHF.

Prognostic value of metabolic tumour volume and total lesion glycolysis in 18F-FDG PET/CT scans in locally advanced breast cancer staging. / Papel pronóstico del volumen metabólico tumoral y de la glucólisis tumoral total en los estudios 18F-FDG PET/TC de estadificación del cáncer localmente avanzado de mama.

OBJECTIVE: To determine whether metabolic tumour volume (MTV) and total lesion glycolysis (TLG) are able to predict recurrence risk in locally advanced breast cancer (LABC) patients. MATERIAL AND METHODS: Retrospective study of LABC patients who undertook neoadjuvant, local and adjuvant treatment and follow up. A 18F-FDG PET/CT study for initial staging was performed analysing in this study different metabolic parameters (MTV, TLG, SUVmax and SUVmed) both in the primary tumour (T) as well as in axillary nodes (N) and whole-body (WB). RESULTS: Forty females were included between January 2010-2011; follow up until January 2015 was completed. The average follow-up was 46 months. Twenty percent presented recurrence: local disease (n=2) and distant metastasis (n=6); 3 patients died (38% of the patients which recurred and 7.5% from the total). SUVmax, MTV and TLG, in T, N and WB, were higher in those patients with recurrence. The MTV and TLG parameters in the tumour (T) were related to the recurrence rate (P=.020 and P=.028, respectively); whereas SUVmax in the lymph nodes (N) was significantly related (P=.008) to the recurrence rate. The best cut-off points to predict recurrence where: MTV T ≥19.3cm3, TLG T≥74.4g and SUVmax N≥13.8, being 10-12 times more likely to recidivate when these thresholds where exceeded. Tumour grade was the only clinical-pathological variable which was related to recurrence probability (p=.035). CONCLUSIONS: In this study of LABC patients the metabolic parameters which have a better relationship with recurrence rate are: MTV and TLG in the primary tumour, SUVmax in the regional lymph node disease and whole-body PET data.

Breslow thickness and (18)F-FDG PET-CT result in initial staging of cutaneous melanoma: Can a cut-off point be established?

AIM: To establish a Breslow Thickness (BT) cut-off point for indication of PET-CT of cutaneous melanoma in early stages and evaluate its prognostic value. MATERIAL AND METHODS: Retrospective analysis of 347 PET-CT studies with diagnosis of melanoma, of which 108 were performed for initial staging. Thirty-one patients were excluded, and a final sample of 77 patients remained. A ROC curve analysis was performed to establish an optimal cut-off point. A survival analysis was performed, considering death assignable to melanoma as the main event, for the evaluation of its prognostic value. RESULTS: Forty-seven (61.04%) of all 77 patients selected were men, and 11 (14.29%) had a positive PET-CT result. Mean age was 65.17±15.00 years. The median BT in patients with a negative PET-CT result was 2.75 mm (IQR 1.83-4.50) and in the positive group 6.25 mm (IQR 5.40-7.50) (P=.0013). In the ROC curve analysis (AUC 0.804, SE 0.054), an optimal value of 5 mm BT with the following values was obtained: sensitivity 90.91%, specificity 78.79%, negative predictive value (NPV) 98.1%, positive predictive value (PPV) 41.7%, diagnostic OR 37.1, and accuracy 80.52%. Mean follow-up was 18.66±14,35 months, detecting 2/53 (3.77%) deaths in the BT<5 mm group, and 7/24 (29.17%) in the BT≥5 mm group. Survival curves between both groups were significantly different (P=.0013). CONCLUSIONS: A 5 mm cut-off point correctly distinguishes those patients with positive PET-CT from those with negative results in the early stages of cutaneous melanoma; therefore it could be included in initial staging of this subgroup of patients.

[Axillary pathologic response after neoadjuvant chemotherapy in locally advanced breast cancer with axillary involvement]. / Respuesta patológica en la axila tras quimioterapia neoadyuvante en el cáncer de mama localmente avanzado con afectación axilar.

AIM: To compare axillary involvement (N+) at initial staging in locally advanced breast cancer (LABC) with axillary lymphadenectomy histologic results after neoadjuvant chemotherapy treatment (NeoChemo). MATERIAL AND METHODS: Retrospective study between November 2011 and September 2013 of LABC cases treated with neoadjuvant chemotherapy based on docetaxel (associated with trastuzumab in HER2 positive cases and carboplatin/adriamycin in HER2 negative cases). Those clinically or radiologically suspected cases of axillary involvement were histologically confirmed. When there was no suspicion of axillary involvement, sentinel lymph node radioguided biopsy (SLNRB) was performed using intradermal injection of (99m)Tc-nanocolloid albumin prior to neoadjuvant treatment. Axillary lymphadenectomy after NeoChemo was undertaken in all cases with positive axilla. Final pathologic response was classified as complete (pCR) when there was no evidence of tumoral disease and as non-pathologic complete response (no pCR) in the opposite case. RESULTS: A total of 346 patients treated with docetaxel were reviewed, identifying 105 LABC. Axillary involvement at initial staging was detected in 70 (67%) before starting NeoChemo. From these 70, 73% (n=51) were N+ (fine needle biopsy and/or biopsy) and the remaining 19 (27%) were occult N+ detected by SLNRB. Axillary lymphadenectomy detected pCR in 56% (39/70), increasing up to 84% pCR when initial N+ status was reached using SNLB. On the other hand, when N+ was detected using fine needle biopsy/lymph biopsy, pCR was only 45%. CONCLUSION: More than 50% of women affected by locally advanced breast cancer with tumoral axillary involvement at initial diagnosis present free metastatic axilla after therapeutic neoadjuvant chemotherapy effect. This increases up to almost 90% in case of occult metastatic axilla detected with sentinel node biopsy prior starting neoadjuvant chemotherapy.

[Differences in the management of epileptic seizures between the elderly and younger adults treated in an emergency department]. / Diferencias en el manejo de las crisis epilepticas entre los ancianos y los adultos mas jovenes atendidos en un servicio de urgencias.

AIM: To study the differences in the management and short-term outcomes of adult patients treated in an emergency service for epileptic seizures, depending on whether they are elderly or not. PATIENTS AND METHODS: This observational retrospective cohort study included all the patients over 15 years of age who were treated for epileptic seizures in the hospital emergency department of a tertiary and university hospital between 1 September and 31 December 2011. The variables collected were acute treatment and follow-up at 30 days after the index event in the emergency department. RESULTS: Altogether the sample included 114 patients with a mean age of 46.4 years (interquartile range: 32.6-74.3 years), of whom 34 (29.8%) were aged 65 years or over. The group of elderly persons presented a first epileptic episode (p = 0.001), with unknown precipitating factor (p = 0.02), structural causation (p < 0.001), a computerised tomography scan carried out in the emergency department (p < 0.001), establishment of preventive antiepileptic drug regime in the emergency department (p = 0.001) and a prolonged hospital stay (p = 0.002) more frequently than the younger adults. Following a multivariable analysis, being elderly was an independent factor associated to a greater need for specific complementary tests (odds ratio = 3.7; 95% confidence interval = 1.3-10.3) and pharmacological intervention in the emergency department (odds ratio = 3.3; 95% confidence interval = 1.4-8.1). There were no statistically significant differences in the results between the two groups at 30 days in terms of return visits (p = 0.316) and mortality (p = 0.087). CONCLUSIONS: The treatment of epileptic seizures in the elderly in the emergency department is complex, if compared with younger adults, thereby making it necessary to use a greater amount of hospital resources.

TITLE: Diferencias en el manejo de las crisis epilepticas entre los ancianos y los adultos mas jovenes atendidos en un servicio de urgencias.Objetivo. Estudiar las diferencias en el manejo y los resultados a corto plazo de los pacientes adultos atendidos en un servicio de urgencias por una crisis epileptica en funcion de ser anciano. Pacientes y metodos. Estudio observacional de cohorte retrospectivo que selecciono a todos los pacientes de 15 años o mas atendidos por una crisis epileptica en un servicio de urgencias de un hospital terciario y universitario desde el 1 de septiembre al 31 de diciembre de 2011. Se recogieron las variables de la atencion aguda y de seguimiento a los 30 dias del episodio indice de urgencias. Resultados. Se incluyeron 114 pacientes con una mediana de edad de 46,4 años (rango intercuartilico: 32,6-74,3 años), de los cuales 34 (29,8%) tenian 65 años o mas. El grupo de los mayores presento mas frecuentemente un primer episodio epileptico (p = 0,001), desencadenante desconocido (p = 0,02), etiologia estructural (p < 0,001), realizacion de tomografia computarizada en urgencias (p < 0,001), inicio de farmaco antiepileptico preventivo en urgencias (p = 0,001) y estancia prolongada (p = 0,002) que los adultos mas jovenes. Tras un analisis multivariable, el ser anciano fue un factor independiente asociado a un mayor requerimiento de pruebas complementarias especificas (Odds ratio = 3,7; intervalo de confianza al 95% = 1,3-10,3) e intervencion farmacologica en urgencias (odds ratio = 3,3; intervalo de confianza al 95% = 1,4-8,1). No hubo diferencias estadisticamente significativas en los resultados a 30 dias entre ambos grupos en terminos de revisita (p = 0,316) y mortalidad (p = 0,087). Conclusiones. La atencion de las crisis epilepticas del anciano en urgencias, en comparacion con adultos mas jovenes, es mas compleja, siendo necesario un mayor consumo de recursos hospitalarios.