An alternative model in the provision of CPAP in sleep apnea: a comparative cost analysis.

BACKGROUND: To conduct a pilot study on an alternative model for the provision of respiratory therapies in sleep apnea-hypopnea syndrome (SAHS) by internalizing the service with the purchase, monitoring and control of continuous positive airway pressure (CPAP) equipment by the hospital. METHODS: An observational, prospective pilot study of comparative cost analysis by internalizing the service to include all patients up to a budget limit of 5000 euros. The cost of internalizing the service included the acquisition of CPAP equipment and all the necessary accessories in addition to the nursing days necessary to track the patients. Patient satisfaction was assessed by a survey of the hospital service. RESULTS: Twenty-one patients with 23,046 patient-days of follow-up were included. The cost of the internalized system was 6825.11 €. The cost of the outsourced system over the same period would have been 22,781.18 €; thus, the direct saving was 15,956.07 €. The cost per device per day of the internalized system was 0.30 € versus the 0.99 € that the outsourced system would have cost during the study period. In the satisfaction survey, 12 (70.6%) patients indicated that they preferred the service of the hospital over that of the external company. No patient preferred the outsourced system. CONCLUSIONS: The internalization of CPAP service represents significant cost savings from a hospital perspective and an improvement in patients' perceptions of the quality of service.

Repeated Pulses of Methyl-Prednisolone in Adults Hospitalized With COVID-19 Pneumonia and Acute Respiratory Distress Syndrome: A Preliminary Before-After Study (CortiCOVID Study).

Introduction: The use of systemic corticosteroids in severely ill patients with coronavirus disease 2019 (COVID-19) is controversial. We aimed to evaluate the efficacy and safety of corticosteroid pulses in patients with COVID-19 pneumonia. Methods: A quasi-experimental study, before and after, was performed in a tertiary referral hospital, including admitted patients showing COVID-19-associated pneumonia. The standard treatment protocol included targeted COVID-19 antiviral therapy from 23rd March 2020, and additionally pulses of methylprednisolone from 30th March 2020. The primary outcome was a composite endpoint combining oro-tracheal intubation (OTI) and death within 7 days. Results: A total of 24 patients were included. Standard of care (SOC) (before intervention) was prescribed in 14 patients, while 10 received SOC plus pulses of methylprednisolone (after intervention). The median age of patients was 64.5 years and 83.3% of the patients were men. The primary composite endpoint occurred in 13 patients (92.9%) who received SOC vs. 2 patients (20%) that received pulses of methylprednisolone (odds ratio, 0.02; 95% confidence interval, 0.001 to 0.25; p = 0.019). Length of hospitalization in survivors was shorter in the corticosteroids group (median, 14.5 [8.5-21.8] days vs. 29 [23-31] days, p = 0.003). There were no differences in the development of infections between both groups. There were 3 deaths, none of them in the corticosteroids group. Conclusions: In patients with severe pneumonia due to COVID-19, the administration of methylprednisolone pulses was associated with a lower rate of OTI and/or death and a shorter hospitalization episode.

Introducción: El uso de corticosteroides sistémicos en pacientes gravemente enfermos por enfermedad coronavírica de 2019 (covid-19) es controvertido. Nuestro objetivo fue evaluar la eficacia y la seguridad de los pulsos de corticoesteroides en los pacientes con neumonía por covid-19. Métodos: Se realizó un ensayo cuasiexperimental, tipo antes y después, en un hospital terciario de referencia que incluyó a pacientes ingresados por neumonía asociada a covid-19. El protocolo de tratamiento estándar incluía un tratamiento antiviral dirigido contra el virus de la covid-19 desde el 23 de marzo de 2020 y añadió pulsos de metilprednisolona desde el 30 de marzo de 2020. El resultado primario fue un criterio combinado compuesto por la intubación orotraqueal y el fallecimiento durante los siguientes siete días. Resultados: Se incluyó un total de 24 pacientes. El protocolo de tratamiento (antes de la intervención) se prescribió en 14 pacientes, mientras que 10 recibieron el protocolo de tratamiento además de los pulsos de metilprednisolona (después de la intervención). La edad media de los pacientes fue de 64,5 años y el 83,3% de los pacientes eran hombres. El resultado combinado primario tuvo lugar en 13 pacientes (92,9%) que recibieron el protocolo de tratamiento frente a 2 pacientes (20%) que recibieron los pulsos de metilprednisolona (odds ratio = 0,02; intervalo de confianza del 95% = 0,001-0,25; p = 0,019). La duración de la hospitalización en los supervivientes fue más corta en el grupo que recibió corticoesteroides (media = 14,5 [8,5-21,8] días frente a 29 [23-31] días, p = 0,003). No hubo diferencias en el desarrollo de infecciones entre ambos grupos. Hubo tres fallecimientos, ninguno de ellos en el grupo que recibió corticoesteroides. Conclusiones: En los pacientes con neumonía grave por covid-19, la administración de pulsos de metilprednisolona se asoció a unas tasas menores de intubación orotraqueal y/o muerte y a episodios de hospitalización más cortos.

Tratamiento domiciliario de la enfermedad tromboembólica venosa (ETV) / Outpatient treatment of venous throemboembolic disease

El desarrollo de la heparina de bajo peso molecular (HBPM) subcutánea ha supuesto un cambio cualitativamente positivo en el tratamiento de los pacientes con enfermedad tromboembólica venosa (ETV), sobre todo ante la posibilidad de poder realizarlo de forma ambulatoria. El tratamiento domiciliario de la trombosis venosa profunda (TVP) con HBPM es eficaz, seguro y reduce costes, y es preferible, siempre que sea posible, al tratamiento hospitalario. Sin embargo, el enfoque ambulatorio del tratamiento de la embolia pulmonar (EP) no está resuelto. Algunos ensayos han sugerido la posibilidad de altas tempranas o incluso tratamiento completo en el domicilio en la EP, pero todos han incurrido en serias limitaciones para sacar conclusiones definitivas. La estratificación pronóstica de la EP representa un punto esencial en el planteamiento de su manejo ambulatorio (AU)

The advent of subcutaneous treatment with low molecular-weight heparins (LMWH) and less intensive monitoring has made it possible for patients the treatment at home. Large, randomised, controlled trials have demonstrated that outpatient treatment of deep vein thrombosis (DVT) with LMWH is as safe as the hospital-based treatment with intravenous unfractionated heparin (UFH). However, the risk of death in patients with treatment at home is higher for pulmonary embolism (PE) than for DVT, and additional evidence is required before the results of outpatient treatment for DVT can be extrapolated to PE. The prognostic stratification of patients with acute PE has important management implications for the outpatient treatment (AU)

[Outpatient treatment of venous throemboembolic disease]. / Tratamiento domiciliario de la enfermedad tromboembólica venosa (ETV).

The advent of subcutaneous treatment with low -molecular-weight heparins (LMWH) and less intensive monitoring has made it possible for patients the treatment at home. Large, randomised, controlled trials have demonstrated that outpatient treatment of deep vein thrombosis (DVT) with LMWH is as safe as the hospital-based treatment with intravenous unfractionated heparin (UFH). However, the risk of death in patients with treatment at home is higher for pulmonary embolism (PE) than for DVT, and additional evidence is required before the results of outpatient treatment for DVT can be extrapolated to PE. The prognostic stratification of patients with acute PE has important management implications for the outpatient treatment.

El síndrome de apnea-hipopnea del sueño en 2009 / Sleep apnea-hypopnea syndrome 2009

El síndrome de apnea-hipopnea del sueño (SAHS) es una entidad con una elevada prevalencia en la poblacióngeneral que, debido a su repercusión sociosanitaria, se ha convertido en un problema de salud públicade primera magnitud. La defi nición del síndrome ha ido evolucionando, así como la defi nición de acontecimientorespiratorio. El papel de los mecanismos infl amatorios en el desarrollo de enfermedad cardiovascularse encuentra en plena investigación y es probable que en el futuro haya que añadir marcadores biológicostanto en la defi nición del síndrome como en la elección del tratamiento. Aunque la técnica de referenciaen el diagnóstico es la polisomnografía, la poligrafía respiratoria se ha convertido en una alternativa váliday complementaria al tratarse de un método simplifi cado, que puede realizarse en el domicilio, para descartaro confi rmar la enfermedad. Sistemas expertos como el monocanal quizá aporten nuevos datos en lasimplifi cación del diagnóstico. Actualmente el tratamiento con presión positiva continua de la vía aérea(CPAP) sigue siendo el método de referencia y su indicación principal en pacientes con SAHS moderado osevero en los cuales ha demostrado disminuir la mortalidad(AU)

Sleep apnea-hypopnea syndrome (SAHS) is a highly prevalent disease in the general population and, due toits social and health repercussions, has become a major public health problem. The defi nition of thissyndrome, as well as that of respiratory event, have been refi ned.The role of infl ammatory mechanisms in the development of cardiovascular disease is currently underinvestigation and biological markers will probably be added, both in the defi nition of SAHS and in thechoice of treatment. Although the gold standard in diagnosis is polysomnography, respiratory polygraphyhas become a valid and complementary alternative, since this technique is a simplifi ed method that can beperformed in the home to confi rm or exclude this disease. Expert systems such as single-channel devicesmay help to simplify diagnosis. Currently, the mainstay of treatment is still continuous positive airwaypressure (CPAP); this modality is mainly indicated in patients with moderate or severe SAHS and has beenshown to reduce mortality in this group(AU)