La extracción de un hemograma antes de la valoración médica retrasa la administración de antibióticos en los pacientes con fiebre neutropénica en urgencias / Complete blood counts testing before physician assessment delays antibiotics in Emergency Febrile Neutropenia patients

Objetivo: La fiebre neutropénica (FN) se asocia a una alta mortalidad y requiere un tratamiento antibiótico precoz. Los procedimientos en urgencias, como las pautas preestablecidas de extracción de analíticas en el triaje, pueden disminuir los retrasos. Se evalua si el disponer de un hemograma con anterioridad a la primera valoración médica se asocia con una reducción del tiempo puerta-antibiótico. Método: Se revisaron los datos de 83 pacientes con FN ingresados en un hospital terciario durante 11 meses. El tiempo puerta-antibiótico se calculó como aquél correspondiente entre el momento del triaje y el de la administración del tratamiento. El principal factor de predicción fue la disponibilidad de los resultados del hemograma antes de la visita médica. Resultados: Se incluyó 72 pacientes [36% varones, edad de 58 (DE 14) años], todos clasificados con categorías altas de gravedad (I, II ó III) de triaje. El 50% tuvieron los resultados disponibles del hemograma cuando fueron valorados por primera vez por el urgenciólogo; y en ellos fue mayor el de tiempo puerta antibiótico que en los que no tuvieron un hemograma disponible (224 vs 83 minutos, p < 0,05). El 90% de los pacientes fueron diagnosticados de FN en urgencias y el 93% fueron tratados con antibióticos intravenosos. En un análisis de regresión logística, la valoración médica previa a los resultados del hemograma se asoció con un tiempo puerta-antibiótico más corto(-84 minutos; p = 0,051), mientras que los casos atendidos en fin de semana se asociaron con un mayor tiempo puerta-antibiótico (+151 minutos, p = 0,002).Conclusión: El tiempo puerta-antibiótico es un indicador factible de la calidad en la atención de los pacientes con FN. La mayoría de los pacientes son diagnosticados y tratados en urgencias. Los hallazgos del estudio no sugieren que disponer de los resultados de un hemograma en el momento de la primera valoración médica reduzca el tiempo puerta-antibiótico (AU)

Objective: Febrile neutropenia (FN) has high mortality and requires prompt antibiotic therapy. Emergency Department(ED) processes, such as standing orders for blood tests at triage, may reduce delays. We evaluated whether having complete blood counts (CBC) available prior to first physician assessment was associated with shorter door-to-antibiotic(DTA) time. Methods: Electronic and chart data was reviewed on 83 FN patients admitted to a tertiary care center over 11 months. DTA time was calculated from triage to delivery of drug. The main predictor was CBC result available before physician encounter. Results: Among 72 patients included, 36% were male, with a mean age of 58±14. All were given high acuity triagecodes, 50% had CBC results available when first assessed by the ED physician; their mean DTA time was longer than those who did not have a CBC available (224 min vs 83, p < 0.05). Although 90% of patients were diagnosed as “FN” in the ED, 93% were treated with IV antibiotics. In multivariable regression analysis, seeing a physician before CBC results was associated with shorter DTA time (–84 min, p = 0.0514), while weekend cases were associated with a longer DTAtime (+151 min, p = 0.0023).Conclusion: DTA time is a feasible measure of quality of care for FN patients. Most patients are diagnosed and treated inED. Our findings do not suggest that having a CBC result available at the first physician assessment reduces DTA time (AU)

Gender differences in carotid imaging and revascularization following stroke.

BACKGROUND: Carotid endarterectomy is performed less often in women than in men, but it is unknown whether this reflects differences in screening rates, disease prevalence, or other factors. METHODS: This was a cohort study of consecutive patients with acute stroke or TIA admitted to 11 Ontario stroke centers participating in the Registry of the Canadian Stroke Network between July 1, 2003, and September 30, 2007. We compared rates of carotid imaging, the severity of carotid stenosis, and rates of carotid endarterectomy or angioplasty within 6 months of the index event in women vs men. RESULTS: We studied 6,389 patients (48% women) with ischemic stroke or TIA. Women were less likely than men to undergo carotid imaging (81% vs 86%, p < 0.0001); however, when the analysis was limited to patients without apparent contraindications to surgery, 92% received carotid imaging, with no difference between women and men. Women were less likely than men to have severe carotid stenosis (7.4% vs 11.5%, p < 0.0001). Women were half as likely as men to undergo carotid revascularization within 6 months of the index event (odds ratio 0.51, 95% confidence interval 0.37 to 0.70), but this gender difference was no longer significant in the subgroup with severe carotid stenosis (odds ratio 0.75, 95% confidence interval 0.49 to 1.15). CONCLUSIONS: Although women with ischemic stroke or TIA are less likely than men to undergo carotid screening and revascularization, this difference is largely explained by potential contraindications to surgery and by sex differences in the severity of carotid disease.