Factors related to bladder catheterization in older patients and its possible association with prognosis: results of the EDEN-30 study. / Factores relacionados con la práctica de sondaje vesical en urgencias en pacientes ancianos y su relación con el pronóstico: resultados del estudio EDEN-30.

OBJECTIVES: The aims of this study in the Emergency Department and Elder Needs (EDEN) series were to explore associations between clinical variables on arrival at the ED (baseline) and the insertion of a bladder catheter, and the relation between catheterization and deterioration to a more complex or serious clinical state. MATERIAL AND METHODS: Included were all patients aged 65 years or older attended during 1 week in 52 Spanish EDs. Patients were grouped according to whether a bladder catheter was or was not inserted in the ED. We used multivariable logistical regression to explore associations between catheterization and patient age, sex, 10 comorbidities, 7 baseline status variables, and 6 clinical variables. Progression was considered serious or complex if the patient died or required hospitalization, a prolonged hospital stay, or discharge to a care facility. We also explored the association between age and catheterization using adjusted restricted cubic spline (RCS) curves with a cutoff value of 65 years. RESULTS: Participating hospitals enrolled 24 573 patients; bladder catheters were inserted in 976 (4%). Of these, 44.3% were discharged from the ED. Fifteen of the 24 variables were independently associated with bladder catheterization. Factors with the strongest associations according to odds ratios (ORs) were impaired consciousness (OR, 2.50; 95% CI, 1.90-3.30), dehydration (OR, 2.24; 95% CI, 1.85-2.72), and male sex (OR, 2.12; 95% CI, 1.84- 2.44). Age 80 years or older was also associated with bladder catheterization (OR, 1.17; 95% CI, 1.01-1.358). The adjusted RCS curves showed a progressive linear increase in the probability of catheterization with age. The increase was constant in men and stabilized after the age of 85 years in women (P-interaction .001). Bladder catheterization was associated with hospitalization (OR, 2.31; 95% CI, 1.99-2.68), intensive care unit admission (OR, 4.64; 95% CI, 3.04-7.09), prolonged stay in the ED for discharged patients (OR, 2.28; 95% CI, 1.75-2.96), in-hospital death (OR, 1.99; 95% CI, 1.54-2.57), and 30-day death (OR, 1.66; 95% CI, 1.33-2.08). No associations were found between catheterization and prolonged hospital stay (OR, 1.11; 95% CI, 0.92-1.34) or need for a care facility on discharge (OR, 1.50; 95% CI, 0.98-2.29). CONCLUSION: Certain patient characteristics and baseline clinical conditions are associated with bladder catheterization in patients of advanced age. The main factors were decreased consciousness, dehydration, and male sex. Even after adjustment for related factors, catheterization is independently associated with progression to more complex or serious clinical states.

OBJETIVO: Estudiar las variables de estado basal y de situación clínica a la llegada a urgencias relacionadas con la práctica de sondaje vesical (SV) en pacientes mayores, y si el SV está asociado a una evolución más compleja o grave. METODO: Se incluyeron todos los pacientes de edad 65 años atendidos durante una semana en 52 servicios de urgencias (SU) españoles, que fueron clasificados en función de si se practicó o no SV en el SU. Se investigó la relación de SV con edad, sexo, 10 variables de comorbilidad, 7 de estado basal y 6 de situación clínica mediante un modelo de regresión logística multivariable. Se consideró la evolución como grave o compleja si existió necesidad de hospitalización, estancia prolongada, necesidad de residencia al alta o muerte. La relación entre edad y SV se exploró también mediante curvas spline cúbicas restringidas (SCR) ajustadas, tomando la edad de 65 años como referencia. RESULTADOS: Se incluyeron 24.573 pacientes, de los que 976 (4%) recibieron SV. De éstos, el 44,3% fueron dados de alta desde urgencias. De las 25 variables exploradas, 15 se relacionaron independientemente con el SV, y las más manifiestas fueron disminución de consciencia (OR = 2,50, IC 95% = 1,90-3,30), deshidratación (OR = 2,24, IC 95% = 1,85-2,72) y sexo masculino (OR = 2,12, IC 95% = 1,84-2,44). La edad 80 años también se asoció a SV (OR = 1,17, IC 95% = 1,01-1,358), y las curvas SCR ajustadas mostraron un incremento progresivo y lineal de la probabilidad de SV con la edad, constante en hombres y que se estabilizaba a partir de los 85 años en mujeres (p interacción 0,001). El SV se asoció a necesidad de hospitalización (OR = 2,31, IC 95% = 1,99-2,68), hospitalización en intensivos (OR = 4,64, IC 95% = 3,04-7,09), estancia prolongada en urgencias en los pacientes dados de alta (OR = 2,28, IC 95% = 1,75-2,96) y mortalidad intrahospitalaria (OR = 1,99, IC 95% = 1,54-2,57) y a 30 días (OR=1,66, IC 95% = 1,33-2,08), pero no con hospitalización prolongada (OR = 1,11, IC 95% = 0,92-1,34) ni con necesidad de residencia al alta (OR = 1,50, IC 95% = 0,98-2,29). CONCLUSIONES: Determinadas características del paciente mayor y de su estado clínico se asocian con realizar un SV en urgencias, entre las que destacan la disminución de consciencia, la deshidratación y el sexo masculino. Aun teniendo en cuenta los factores asociados a SV en urgencias, este procedimiento se asocia independientemente con evoluciones más complejas o graves.

Impact of the COVID-19 pandemic on demand for emergency department care for older patients: the EDEN-7 COVID cohort study. / Estudio EDEN-7: impacto de la pandemia COVID-19 sobre la demanda asistencial de personas mayores en los servicios de urgencias españoles.

OBJECTIVES: To analyze the impact of the COVID-19 pandemic on Spanish emergency department (ED) care for patients aged 65 years or older during the first wave vs. a pre-pandemic period. MATERIAL AND METHODS: Retrospective cross-sectional study of a COVID-19 portion of the EDEN project (Emergency Department and Elder Needs). The EDEN-COVID cohort included all patients aged 65 years or more who were treated in 52 EDs on 7 consecutive days early in the pandemic. We analyzed care variables, discharge diagnoses, use of diagnostic and therapeutic resources, use of observation units, need for hospitalization, rehospitalization, and mortality. These data were compared with data for an EDEN cohort in the same age group recruited during a similar period the year before the pandemic. RESULTS: The 52 participating hospital EDs attended 33 711 emergencies during the pandemic vs. 96 173 emergencies in the pre-COVID period, representing a 61.7% reduction during the pandemic. Patients aged 65 years or older accounted for 28.8% of the caseload during the COVID-19 period and 26.4% of the earlier cohort (P .001). The COVID-19 caseload included more men (51.0%). Comorbidity and polypharmacy were more prevalent in the pandemic cohort than in the earlier one (comorbidity, 92.6% vs. 91.6%; polypharmacy, 65.2% vs. 63.6%). More esturesources (analgesics, antibiotics, heparins, bronchodilators, and corticosteroids) were applied in the pandemic period, and common diagnoses were made less often. Observation wards were used more often (for 37.8% vs. 26.2% in the earlier period), and hospital admissions were more frequent (in 56.0% vs. 25.3% before the pandemic). Mortality was higher during the pandemic than in the earlier cohort either in ED (1.8% vs 0.5%) and during hospitalization (11.5 vs 2.9%). CONCLUSION: The proportion of patients aged 65 years or older decreased in the participating Spanish EDs. However, more resources were required and the pattern of diagnoses changed. Observation ward stays were longer, and admissions and mortality increased over the numbers seen in the reference period.

OBJETIVO: Analizar el impacto de la pandemia COVID-19 sobre la asistencia a las personas mayores ($ 65 años) en los servicios de urgencias hospitalarios (SUH) españoles durante la primera oleada pandémica, comparándola con un periodo previo. METODO: Estudio transversal retrospectivo de la cohorte EDEN-COVID (Emergency Department and Elder Needs during COVID), que incluyó a todos los pacientes $ 65 años atendidos en 52 SUH españoles durante 7 días consecutivos de un periodo pandémico. Se analizaron variables asistenciales, diagnósticos de alta, consumo de recursos diagnósticos y terapéuticos, utilización de las unidades de observación, necesidad de ingreso, rehospitalización y mortalidad. Estos datos se compararon con la cohorte EDEN (Emergency Department and Elder Needs), que reclutó a pacientes del mismogrupo de edad durante un periodo similar del año anterior. RESULTADOS: Durante el periodo COVID-19 se atendieron 33.711 episodios en los 52 SUH participantes, frente a 96.173 del periodo pre-COVID, lo que supone una disminución de la demanda de 61,7%. La proporción de asistencias a pacientes de 65 o más años fue de 28,8% en el periodo COVID-19 y 26,4% en el periodo previo (p 0,001). Durante el periodo COVID hubo mayor proporción de hombres (51,0% vs 44,9%), mayor comorbilidad (92,6% vs 91,6%) y polifarmacia (65,2% vs 63,6%), mayor uso de recursos, de analgésicos, antibióticos, heparinas, broncodilatadores y corticoides, menor proporción de los diagnósticos más habituales, mayor utilización de las unidades de observación (37,8% vs 26,2%) y un incremento de la proporción de ingresos (56,0% vs 25,3%), y de mortalidad en urgencias (1,8% vs 0,5%) y durante la hospitalización (11,5% vs 2,9%). CONCLUSIONES: La primera ola de la pandemia COVID-19 ha provocado una disminución global de las asistencias a personas mayores ($ 65 años) en los SUH españoles analizados, mayor consumo de recursos, un mapa diferente de procesos diagnósticos asistidos y un aumento proporcional de estancias en observación, de ingresos y de mortalidad, respecto al periodo de referencia.

Impact of emergency department management of isolated superficial vein thrombosis of the lower limbs: a secondary analysis of data from the ALTAMIRA study. / Impacto del manejo en urgencias en la evolución de los pacientes con trombosis venosa superficial aislada de miembros inferiores: subanálisis del estudio ALTAMIRA.

OBJECTIVES: To describe the management of superficial vein thrombosis (SVT) of the lower limbs in patients treated in Spanish hospital emergency departments (EDs). To evaluate the impact of ED management of venous thromboembolic complications on outcomes and to determine the characteristics of patients who develop complications. MATERIAL AND METHODS: The retrospective multicenter ALTAMIRA study (Spanish acronym for risk factors, complications, and assessment of Spanish ED management of SVT) used recorded data for consecutive patients with a diagnosis of isolated SVT treated in 18 EDs. We gathered data on symptomatic venous thromboembolic disease (deep vein thrombosis, pulmonary embolism, or the extension or recurrence of SVT), clinically significant bleeding, and 180-day mortality. Cox regression analysis was used to explore variables associated with complications. RESULTS: A total of 703 patients were included. Anticoagulation was prescribed for 84.1% of the patients for a median of 30 days (interquartile range, 15-42 days); 81.3% were treated with low molecular weight heparin. A prophylactic dose was prescribed for 48% and an intermediate therapeutic dose for 52%. Sixty-four patients (9.2%) developed symptomatic thromboembolic disease within 180 days, 12 (1.7%) experienced clinically significant bleeding, and 4 (0.6%) died. Complications developed later in patients receiving anticoagulant therapy than in those not taking an anticoagulant (66 vs 11 days , P=.009), and 76.6% of those developing complications were not on anticoagulant when symptoms appeared. A history of thromboembolic disease was associated with developing complications (adjusted hazard ratio, 2.20; 95% confidence interval, 1.34-3.62). CONCLUSION: ED treatment of SVT varies and is often suboptimal. The incidence of thromboembolic complications after SVT is high. Starting anticoagulation in the ED delays the development of complications. Patients with a history of thromboembolic disease are more at risk of complications.

OBJETIVO: Describir el manejo terapéutico de los pacientes con trombosis venosa superficial (TVS) aislada de miembros inferiores en servicios de urgencias hospitalarios (SUH) españoles. Evaluar el impacto del tratamiento instaurado en urgencias en la evolución, en términos de complicaciones de enfermedad tromboembólica venosa (ETV), y conocer las características de los pacientes que sufren complicaciones. METODO: El estudio multicentrico (18 SUH) ALTAMIRA (fActores de riesgo, compLicaciones y evaluación del manejo de la TVS de Miembros Inferiores en hospitales españoles atendidos en los seRvicios de urgenciAs) creó un cohorte retrospectivo de pacientes consecutivos con diagnóstico objetivo de TVS aislada. Se recogieron las complicaciones de ETV sintomáticas (trombosis venosa profunda, tromboembolia pulmonar y extensión o recurrencia de TVS), sangrados clínicamente relevantes y defunciones a 180 días. Se evaluaron las variables asociadas a las complicaciones mediante una regresión de Cox. RESULTADOS: Se incluyeron 703 pacientes. El 84,1% recibieron anticoagulación durante 30 días (rango intercuartil 15-42), 81,3% con heparina de bajo peso molecular (48% dosis profilácticas, 52% intermedias-terapéuticas). En 180 días, 64 pacientes (9,1%) tuvieron complicación de ETV, 12 (1,7%) tuvieron sangrado clínicamente relevante, y 4 fallecieron (0,6%). Los pacientes en que se instauró anticoagulación en urgencias tardaron más tiempo en desarrollar complicaciones (66 vs 11 días, p = 0,009). El 76,6% de los que se complicaron no estaban anticoagulados en ese momento. La ETV previa se asoció de forma independiente con el desarrollo de complicaciones (hazard ratio ajustada 2,20; intervalo de confianza del 95%: 1,34-3,62). CONCLUSIONES: El tratamiento en urgencias de la TVS aislada es heterogéneo y con frecuencia subóptimo. La incidencia de complicaciones de ETV es elevada. El tratamiento anticoagulante iniciado en urgencias supone un retraso en el desarrollo de complicaciones. Los pacientes con ETV previa tienen más riesgo de complicaciones.

Impacto del manejo en urgencias en la evolución de los pacientes con trombosis venosa superficial aislada de miembros inferiores: subanálisis del estudio ALTAMIRA / Impact of emergency department management of isolated superficial vein thrombosis of the lower limbs: a secondary analysis of data from the ALTAMIRA study

Objetivos: Describir el manejo terapéutico de los pacientes con trombosis venosa superficial (TVS) aislada de miembros inferiores en servicios de urgencias hospitalarios (SUH) españoles. Evaluar el impacto del tratamiento instaurado en urgencias en la evolución, en términos de complicaciones de enfermedad tromboembólica venosa (ETV), y conocer las características de los pacientes que sufren complicaciones. Métodos: Estudio de cohorte retrospectivo, multicéntrico (18 SUH), que incluyó pacientes consecutivos con diagnóstico objetivo de TVS aislada. Se recogieron las complicaciones de ETV sintomáticas (trombosis venosa profunda, tromboembolia pulmonar y extensión o recurrencia de TVS), sangrados clínicamente relevantes y defunciones a 180 días. Se evaluaron las variables asociadas a las complicaciones mediante una regresión de Cox. Resultados: Se incluyeron 703 pacientes. El 84,1% recibieron anticoagulación durante 30 días (rango intercuartil 15-42), 81,3% con heparina de bajo peso molecular (48% dosis profilácticas, 52% intermedias-terapéuticas). En 180 días, 64 pacientes (9,1 %) tuvieron complicación de ETV, 12 (1,7%) tuvieron sangrado clínicamente relevante, y 4 fallecieron (0,6 %). Los pacientes en que se instauró anticoagulación en urgencias tardaron más tiempo en desarrollar complicaciones (66 vs 11 días, p = 0,009). El 76,6% de los que se complicaron no estaban anticoagulados en ese momento. La ETV previa se asoció de forma independiente con el desarrollo de complicaciones (hazard ratio ajustada 2,20; intervalo de confianza del 95%: 1,34-3,62). (AU)

Objectives: To describe the management of superficial vein thrombosis (SVT) of the lower limbs in patients treated in Spanish hospital emergency departments (EDs). To evaluate the impact of ED management of venous thromboembolic complications on outcomes and to determine the characteristics of patients who develop complications.Methods: The retrospective multicenter ALTAMIRA study (Spanish acronym for risk factors, complications, and assessment of Spanish ED management of SVT) used recorded data for consecutive patients with a diagnosis of isolated SVT treated in 18 EDs. We gathered data on symptomatic venous thromboembolic disease (deep vein thrombosis, pulmonary embolism, or the extension or recurrence of SVT), clinically significant bleeding, and 180-day mortality. Cox regression analysis was used to explore variables associated with complications. Results: A total of 703 patients were included. Anticoagulation was prescribed for 84.1% of the patients for a median of 30 days (interquartile range, 15-42 days); 81.3% were treated with low molecular weight heparin. A prophylactic dose was prescribed for 48% and an intermediate therapeutic dose for 52%. Sixty-four patients (9.2%) developed symptomatic thromboembolic disease within 180 days, 12 (1.7%) experienced clinically significant bleeding, and 4 (0.6%) died. Complications developed later in patients receiving anticoagulant therapy than in those not taking an anticoagulant (66 vs 11 days , P=.009), and 76.6% of those developing complications were not on anticoagulant when symptoms appeared. A history of thromboembolic disease was associated with developing complications (adjusted hazard ratio, 2.20; 95% confidence interval, 1.34-3.62). (AU)

Convalescent Plasma Therapy, Therapeutic Formulations of Repurposed Drugs in 20th Century Epidemics against COVID-19: A Systematic Review.

Coronavirus 2019 disease (COVID-19) represents one of the largest pandemics the world has faced, and it is producing a global health crisis. To date, the availability of drugs to treat COVID-19 infections remains limited to supportive care although therapeutic options are being explored. Some of them are old strategies for treating infectious diseases. convalescent plasma (CP) therapy has been used successfully in other viral outbreaks in the 20th century. In this study, we systematically evaluated the effect and safety of CP therapy on hospitalized COVID-19 patients. A structured search was conducted following the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines using Medline (PubMed), SciELO, Cochrane Library Plus, Web of Science, and Scopus. The search included articles published up to January 2022 and was restricted to English- and Spanish-language publications. As such, investigators identified six randomized controlled trials that met the search criteria. The results determined that in hospitalized COVID-19 patients the administration of CP therapy with a volume between 200-500 mL and a single transfusion performed in 1-2 h, compared to the control group, decreased viral load, symptomatology, the period of infection, and mortality, without serious adverse effects. CP did influence clinical outcomes and may be a possible treatment option, although further studies will be necessary.

Sociodemographic characteristics, functional status, and health resource use of older patients treated in Spanish emergency departments: a description of the EDEN cohort. / Características sociodemográficas, funcionales y consumo de recursos de la población mayor atendida en los servicios de urgencias españoles: una aproximación desde la cohorte EDEN.

OBJECTIVES: To describe the sociodemographic characteristics of and the health care resources used to treat patients aged 65 years or older who come to hospital emergency departments (EDs) in Spain, according to age groups. MATERIAL AND METHODS: We studied the phase-1 data for the EDEN cohort (Emergency Department and Elder Needs). Forty Spanish EDs collected data on all patients aged 65 years or older who were treated on the first 7 days in April 2019. We registered information on 6 sociodemographic and 5 function variables for all patients. For health resource use we used 6 diagnostic, 13 therapeutic, and 5 physical structural variables, for a total of 24 variables. Differences were analyzed according to age in blocks of 5 years. RESULTS: A total of 18 374 patients with a median age of 78 years were included; 55% were women. Twenty-seven percent arrived by ambulance, 71% had not previously been seen by a physician, and 13% lived alone without assistance. Ten percent had a high level of functional dependence, and 14% had serious comorbidity. Resources used most often were blood analysis (in 60%) and radiology (59%), analgesics (25%), intravenous fluids (21%), antibiotics (14%), oxygen (13%), and bronchodilators (11%). Twenty-six percent were kept under observation in the ED, 26% were admitted to wards, and 2% were admitted to intensive care units (ICUs). The median stay in the ED was 3.5 hours, and the median hospital stay was 7 days. Sociodemographic characteristics changed according to age. Functional dependence worsened with age, and resource requirements increased in general. However, benzodiazepine use was unaffected, while the use of nonsteroidal anti-inflammatory drugs and ICU admission decreased. CONCLUSION: The functional dependence of older patients coming to EDs increases with age and is associated with a high level of health care resource use, which also increases with age. Planners should take into consideration the characteristics of the older patients and the proportion of the caseload they represent when arranging physical spaces and designing processes for a specific ED.

OBJETIVO: Investigar las características sociodemográficas y consumo de recursos de los pacientes de 65 o más años que consultan en servicios de urgencias hospitalarios (SUH) en España, y su modificación por grupos etarios. METODO: Se utilizaron datos de la cohorte EDEN obtenidos en fase 1 (Emergency Department and Elder Needs). Cuarenta SUH españoles incluyeron todos los pacientes de $ 65 años atendidos del 1-4-2019 al 7-4-2019 (7 días). Se analizaron 6 características sociodemográficas, 5 funcionales y 24 referidas a consumo de recursos (6 diagnósticos, 13 terapéuticos, 5 estructurales) y sus cambios a medida que avanza la edad (agrupada en bloques de 5 años). RESULTADOS: Se analizaron 18.374 pacientes (mediana edad: 78 años; 55% mujeres). El 27% acude a urgencias en ambulancia, el 71% sin consulta médica previa y el 13% vive solo sin cuidadores. Funcionalmente, el 10% tiene dependencia grave y el 14% comorbilidad grave. La solicitud de analítica sanguínea (60% de casos) y radiología (59%) destaca entre el consumo de recursos diagnósticos, y el uso de analgésicos (25%), sueroterapia (21%), antibioticoterapia (14%), oxigenoterapia (13%) y broncodilatadores (11%), entre los terapéuticos. El 26% requiere observación en urgencias, el 26% hospitalización y el 2% cuidados intensivos. La mediana de estancia en urgencias es de 3:30 horas y la de hospitalización es de 7 días. Las características sociodemográficas se modifican con la edad, las funcionales empeoran y el consumo de recursos aumenta (excepto benzodiacepinas, que no se modifica, y antinflamatorios no esteroideos y cuidados intensivos, que disminuye). CONCLUSIONES: Las características funcionales de la población mayor que consulta en los SUH empeora a medida que su edad avanza, y se asocia a un consumo de recursos alto que también se incrementa con la edad. Las características de esta población y su proporción en un determinado SUH deben tenerse en cuenta en su planificación estructural y funcional.

Incidence, Clinical Characteristics, Risk Factors, and Outcomes of Upper Gastrointestinal Bleeding in Patients With COVID-19: Results of the UMC-19-S12.

OBJECTIVE: The authors investigated the incidence, risk factors, clinical characteristics, and outcomes of upper gastrointestinal bleeding (UGB) in patients with coronavirus disease 2019 (COVID-19), who were attending the emergency department (ED), before hospitalization. METHODS: We retrospectively reviewed all COVID-19 patients diagnosed with UGB in 62 Spanish EDs (20% of Spanish EDs, case group) during the first 2 months of the COVID-19 outbreak. We formed 2 control groups: COVID-19 patients without UGB (control group A) and non-COVID-19 patients with UGB (control group B). Fifty-three independent variables and 4 outcomes were compared between cases and controls. RESULTS: We identified 83 UGB in 74,814 patients with COVID-19 who were attending EDs (1.11%, 95% CI=0.88-1.38). This incidence was lower compared with non-COVID-19 patients [2474/1,388,879, 1.78%, 95% confidence interval (CI)=1.71-1.85; odds ratio (OR)=0.62; 95% CI=0.50-0.77]. Clinical characteristics associated with a higher risk of COVID-19 patients presenting with UGB were abdominal pain, vomiting, hematemesis, dyspnea, expectoration, melena, fever, cough, chest pain, and dysgeusia. Compared with non-COVID-19 patients with UGB, COVID-19 patients with UGB more frequently had fever, cough, expectoration, dyspnea, abdominal pain, diarrhea, interstitial lung infiltrates, and ground-glass lung opacities. They underwent fewer endoscopies in the ED (although diagnoses did not differ between cases and control group B) and less endoscopic treatment. After adjustment for age and sex, cases showed a higher in-hospital all-cause mortality than control group B (OR=2.05, 95% CI=1.09-3.86) but not control group A (OR=1.14, 95% CI=0.59-2.19) patients. CONCLUSIONS: The incidence of UGB in COVID-19 patients attending EDs was lower compared with non-COVID-19 patients. Digestive symptoms predominated over respiratory symptoms, and COVID-19 patients with UGB underwent fewer gastroscopies and endoscopic treatments than the general population with UGB. In-hospital mortality in COVID-19 patients with UGB was increased compared with non-COVID patients with UGB, but not compared with the remaining COVID-19 patients.

Características y manejo diagnóstico-terapéutico de los pacientes con trombosis venosa superficial aislada en los servicios de urgencias hospitalarios españoles. Estudio ALTAMIRA / Characteristics of isolated superficial vein thrombosis and diagnostic-therapeutic management in Spanish hospital emergency departments: the ALTAMIRA study

Objetivo: Describir las características de los pacientes diagnosticados de trombosis venosa superficial (TVS) aislada de miembros inferiores en servicios de urgencias hospitalarios (SUH), y evaluar la adherencia a las guías de práctica clínica en el manejo diagnóstico y terapéutico (realización de ecografía venosa e instauración de tratamiento anticoagulante). Método: Estudio de cohortes retrospectivo en 18 SUH españoles. Se incluyeron todos los pacientes atendidos en los SUH con diagnóstico final de TVS en miembros inferiores, con edad $ 18 años, de enero de 2016 a mayo de 2017. Para evaluar la no adherencia a las recomendaciones de las guías de práctica clínica (realización de ecografía venosa, e instauración de tratamiento anticoagulante) se ajustó un modelo de regresión logística múltiple por pasos hacia atrás. Resultados: Mil ciento sesenta y seis pacientes fueron incluidos. La edad media fue de 59,6 años, el 67,9% eran mujeres. El 24,4% tenían antecedentes de enfermedad tromboembólica venosa (ETV). El 8,9% tuvieron alguna complicación a 180 días [4,6% recurrencia y 3,6% progresión de TVS, 1,8% trombosis venosa profunda (TVP) y 0,9% tromboembolia pulmonar (TEP)]. Hubo 17 pacientes (1,5%) con hemorragia y 16 (1,4%) muertes. Se realizó ecografía venosa a 703 (60,3%) pacientes. Recibieron tratamiento anticoagulante 898 (77%), con una mediana de 22 días. Las variables asociadas con la decisión de anticoagular fueron: antecedentes ETV (OR 1,60; IC 95%: 1,12-2,30), varices (OR 1,40; IC 95%: 1,12-2,30), dolor de la extremidad (OR 1,44; IC 95%: 1,08-191), presencia de cordón doloroso (OR 1,30; IC 95%: 0,97-1,73) y realización de ecografía venosa (OR 1,60; IC 95%: 1,94-3,45). (AU)

Objectives: To describe the characteristics of patients with isolated lower-limb superficial vein thrombosis (SVT) treated in hospital emergency departments and to evaluate adherence to clinical practice guidelines on diagnosis (vein ultrasound imaging) and therapeutic management (start of anticoagulant therapy). Material and methods: Retrospective cohort study in 18 Spanish emergency departments. We included all patients with a final emergency department diagnosis of lower-limb SVT aged 18 years or older between January 2016 and May 2017. Backward stepwise multiple logistic regression analysis was used to evaluate adherence to clinical practice guidelines on ordering vein ultrasound imaging and starting anticoagulant therapy. Results: A total of 1166 patients were included. The mean patient age was 59.6 years, and 67.9% were women. About a quarter of the patients (24.4%) had a history of venous thromboembolic disease. Complications developed in 8.9% within 180 days: 4.6% experienced a recurrence and 3.6% progressed to SVT and 1.8% to deep vein thrombosis; pulmonary thromboembolism occurred in 0.9%. Hemorrhagic complications developed in 17 patients (1.5%). Sixteen patients (1.4%) died. Vein ultrasound imagine was ordered for 703 patients (60.3%). Anticoagulant agents were prescribed for 898 (77%) for a median period of 22 days. Variables associated with a decision to order anticoagulants were a history of venous thromboembolic disease (odds ratio [OR], 1.60; 95% CI, 1.12-2.30), varicose veins (OR, 1.40; 95% CI, 1.12-2.30); limb pain (OR, 1.44; 95% CI, 1.08-1.91); painful cord (OR, 1.30; 95% CI, 0.97-1.73); and availability of vein ultrasound images (OR, 1.60; 95% CI, 1.94-3.45). (AU)

Characteristics of isolated superficial vein thrombosis and diagnostictherapeutic management in Spanish hospital emergency departments: the ALTAMIRA study. / Características y manejo diagnóstico-terapéutico de los pacientes con trombosis venosa superficial aislada en los servicios de urgencias hospitalarios españoles. Estudio ALTAMIRA.

OBJECTIVES: To describe the characteristics of patients with isolated lower-limb superficial vein thrombosis (SVT) treated in hospital emergency departments and to evaluate adherence to clinical practice guidelines on diagnosis (vein ultrasound imaging) and therapeutic management (start of anticoagulant therapy). MATERIAL AND METHODS: Retrospective cohort study in 18 Spanish emergency departments. We included all patients with a final emergency department diagnosis of lower-limb SVT aged 18 years or older between January 2016 and May 2017. Backward stepwise multiple logistic regression analysis was used to evaluate adherence to clinical practice guidelines on ordering vein ultrasound imaging and starting anticoagulant therapy. RESULTS: A total of 1166 patients were included. The mean patient age was 59.6 years, and 67.9% were women. About a quarter of the patients (24.4%) had a history of venous thromboembolic disease. Complications developed in 8.9% within 180 days: 4.6% experienced a recurrence and 3.6% progressed to SVT and 1.8% to deep vein thrombosis; pulmonary thromboembolism occurred in 0.9%. Hemorrhagic complications developed in 17 patients (1.5%). Sixteen patients (1.4%) died. Vein ultrasound imagine was ordered for 703 patients (60.3%). Anticoagulant agents were prescribed for 898 (77%) for a median period of 22 days. Variables associated with a decision to order anticoagulants were a history of venous thromboembolic disease (odds ratio [OR], 1.60; 95% CI, 1.12-2.30), varicose veins (OR, 1.40; 95% CI, 1.12-2.30); limb pain (OR, 1.44; 95% CI, 1.08-1.91); painful cord (OR, 1.30; 95% CI, 0.97-1.73); and availability of vein ultrasound images (OR, 1.60; 95% CI, 1.94-3.45). CONCLUSION: Adherence to clinical practice guidelines for the diagnosis and treatment of isolated lower-limb SVT is low in Spanish emergency departments. Ultrasound imaging is not ordered for 1 out of every 2 to 3 patients, and anticoagulant treatment is not started in 1 out of 4 patients. There is great room for improvement.

OBJETIVO: Describir las características de los pacientes diagnosticados de trombosis venosa superficial (TVS) aislada de miembros inferiores en servicios de urgencias hospitalarios (SUH), y evaluar la adherencia a las guías de práctica clínica en el manejo diagnóstico y terapéutico (realización de ecografía venosa e instauración de tratamiento anticoagulante). METODO: . Estudio de cohortes retrospectivo en 18 SUH españoles. Se incluyeron todos los pacientes atendidos en los SUH con diagnóstico final de TVS en miembros inferiores, con edad $ 18 años, de enero de 2016 a mayo de 2017. Para evaluar la no adherencia a las recomendaciones de las guías de práctica clínica (realización de ecografía venosa, e instauración de tratamiento anticoagulante) se ajustó un modelo de regresión logística múltiple por pasos hacia atrás. RESULTADOS: . Mil ciento sesenta y seis pacientes fueron incluidos. La edad media fue de 59,6 años, el 67,9% eran mujeres. El 24,4% tenían antecedentes de enfermedad tromboembólica venosa (ETV). El 8,9% tuvieron alguna complicación a 180 días [4,6% recurrencia y 3,6% progresión de TVS, 1,8% trombosis venosa profunda (TVP) y 0,9% tromboembolia pulmonar (TEP)]. Hubo 17 pacientes (1,5%) con hemorragia y 16 (1,4%) muertes. Se realizó ecografía venosa a 703 (60,3%) pacientes. Recibieron tratamiento anticoagulante 898 (77%), con una mediana de 22 días. Las variables asociadas con la decisión de anticoagular fueron: antecedentes ETV (OR 1,60; IC 95%: 1,12-2,30), varices (OR 1,40; IC 95%: 1,12-2,30), dolor de la extremidad (OR 1,44; IC 95%: 1,08-191), presencia de cordón doloroso (OR 1,30; IC 95%: 0,97-1,73) y realización de ecografía venosa (OR 1,60; IC 95%: 1,94-3,45). CONCLUSIONES: Existe una baja adherencia a las recomendaciones de las guías de práctica clínica en el manejo diagnóstico y terapéutico de los pacientes con diagnóstico de TVS aislada de miembros inferiores en los SUH españoles: no se realiza ecografía venosa en uno de cada 2-3 pacientes, y no se instaura tratamiento anticoagulante en 1 de cada 4. Esto constituye un margen de mejora muy relevante.

Pulmonary embolism in patients with COVID-19: incidence, risk factors, clinical characteristics, and outcome.

AIMS: We investigated the incidence, risk factors, clinical characteristics, and outcomes of pulmonary embolism (PE) in patients with COVID-19 attending emergency departments (EDs), before hospitalization. METHODS AND RESULTS: We retrospectively reviewed all COVID-19 patients diagnosed with PE in 62 Spanish EDs (20% of Spanish EDs, case group) during the first COVID-19 outbreak. COVID-19 patients without PE and non-COVID-19 patients with PE were included as control groups. Adjusted comparisons for baseline characteristics, acute episode characteristics, and outcomes were made between cases and randomly selected controls (1:1 ratio). We identified 368 PE in 74 814 patients with COVID-19 attending EDs (4.92‰). The standardized incidence of PE in the COVID-19 population resulted in 310 per 100 000 person-years, significantly higher than that observed in the non-COVID-19 population [35 per 100 000 person-years; odds ratio (OR) 8.95 for PE in the COVID-19 population, 95% confidence interval (CI) 8.51-9.41]. Several characteristics in COVID-19 patients were independently associated with PE, the strongest being D-dimer >1000 ng/mL, and chest pain (direct association) and chronic heart failure (inverse association). COVID-19 patients with PE differed from non-COVID-19 patients with PE in 16 characteristics, most directly related to COVID-19 infection; remarkably, D-dimer >1000 ng/mL, leg swelling/pain, and PE risk factors were significantly less present. PE in COVID-19 patients affected smaller pulmonary arteries than in non-COVID-19 patients, although right ventricular dysfunction was similar in both groups. In-hospital mortality in cases (16.0%) was similar to COVID-19 patients without PE (16.6%; OR 0.96, 95% CI 0.65-1.42; and 11.4% in a subgroup of COVID-19 patients with PE ruled out by scanner, OR 1.48, 95% CI 0.97-2.27), but higher than in non-COVID-19 patients with PE (6.5%; OR 2.74, 95% CI 1.66-4.51). Adjustment for differences in baseline and acute episode characteristics and sensitivity analysis reported very similar associations. CONCLUSIONS: PE in COVID-19 patients at ED presentation is unusual (about 0.5%), but incidence is approximately ninefold higher than in the general (non-COVID-19) population. Moreover, risk factors and leg symptoms are less frequent, D-dimer increase is lower and emboli involve smaller pulmonary arteries. While PE probably does not increase the mortality of COVID-19 patients, mortality is higher in COVID-19 than in non-COVID-19 patients with PE.

Registro ESPHERIA: perfiles de pacientes con enfermedad tromboembólica venosa en urgencias y su asociación con el pronóstico a medio plazo / Profiles of patients with venous thromboembolic disease in the emergency department and their medium-term prognosis: data from the ESPHERIA registry

Objetivos. Evaluar el pronóstico a 180 días de los pacientes diagnosticados de enfermedad tromboembólica venosa (ETV) en urgencias, en función de una clasificación por perfiles clínicos. Los objetivos secundarios fueron evaluar la mortalidad y el reingreso por todas las causas de manera individual, y describir las características clínicas y formas de presentación de trombosis venosa profunda (TVP) y tromboembolismo pulmonar (TEP), según dichos perfiles.Método. Análisis secundario del registro ESPHERIA que incluye pacientes consecutivos con ETV sintomática de 53 ser-vicios de urgencias (SU). Se dividió la muestra en 4 perfiles: ETV no provocada (perfil 1), ETV provocada por factores de riesgo transitorios (perfil 2), cáncer (perfil 3) y baja reserva cardiopulmonar (perfil 4). La variable de resultado primaria fue la compuesta mortalidad o reingreso por cualquier causa a 180 días.Resultados. Se incluyeron 773 pacientes de los cuales 450 (58,2%) fueron clasificados en el perfil 1, 128 (16,6%) en el perfil 2, 115 pacientes (14,9%) en el perfil 3 y 80 (10,3%) en el perfil 4. Se documentaron diferencias demográficas, de comorbilidad, presentación clínica, tipo de ETV, manejo, ubicación y resultados entre los perfiles clínicos. Ciento noventa y cinco pacientes (25,2%) presentaron un resultado adverso compuesto a los 180 días, de los cuales 69 (8,9%) fallecieron y 179 (23,2%) sufrieron un nuevo ingreso por cualquier causa. La ETV asociada a baja reserva cardiopulmonar (HR 1,73; IC 95% 1,12-2,68; p = 0,01) y la ETV asociada a cáncer (HR 3,10; IC 95% 2,22-4,34; p < 0,001) se asociaron de forma independiente con sufrir un resultado adverso en los primeros 180 días. (AU)

Objectives. To assess the 180-day prognosis for patients of different profiles diagnosed with venous thromboembolism (VTE) in emergency departments (EDs). Secondary aims were to assess all-cause mortality and readmission rates and to describe the clinical characteristics and forms of presentation of deep vein thrombosis (DVT) and pulmonary thromboembolism (PTE) in each patient profile.Method. Secondary analysis of data from the ESPHERIA registry (Spanish acronym for Risk Profile of Patients with VTE Attended in Spanish Emergency Departments), which includes consecutive patients with symptomatic VTE treated in 53 EDs. The cases were divided according to 4 profiles: 1) unprovoked DVT, 2) DVT provoked by transient risk factors, 3) patients with cancer, and 4) patients with low cardiopulmonary reserve. The primary outcome was a composite of 180-day all-cause mortality or readmission.Results. We studied 773 patients: 450 (58.2%) were classified as profile 1, 128 (16.6%) as profile 2, 115 (14.9%) as profile 3, and 80 (10.3%) as profile 4. We found differences between the 4 profiles in demographics, comorbidity, clinical presentation, type of DVT and location, management, and outcomes. One hundred ninety-five patients (25.2%) had at least one of the adverse events included in the composite within 180 days: 69 (8.9%) died and 179 (23.2%) were readmitted. Hazard ratios (HR) indicated that DVT with low cardiopulmonary reserve (HR, 1.73; 95% CI, 1.12–2.68; P = .01)) or DVT with cancer (HR, 3.10; 95% CI, 2.22–4.34; P < .001) were the profiles that were independently associated with the 180-day composite outcome. (AU)

Profiles of patients with venous thromboembolic disease in the emergency department and their medium-term prognosis: data from the ESPHERIA registry. / Registro ESPHERIA: perfiles de pacientes con enfermedad tromboembólica venosa en urgencias y su asociación con el pronóstico a medio plazo.

OBJECTIVES: To assess the 180-day prognosis for patients of different profiles diagnosed with venous thromboembolism (VTE) in emergency departments (EDs). Secondary aims were to assess all-cause mortality and readmission rates and to describe the clinical characteristics and forms of presentation of deep vein thrombosis (DVT) and pulmonary thromboembolism (PTE) in each patient profile. MATERIAL AND METHODS: Secondary analysis of data from the ESPHERIA registry (Spanish acronym for Risk Profile of Patients with VTE Attended in Spanish Emergency Departments), which includes consecutive patients with symptomatic VTE treated in 53 EDs. The cases were divided according to 4 profiles: 1) unprovoked DVT, 2) DVT provoked by transient risk factors, 3)patients with cancer, and 4) patients with low cardiopulmonary reserve. The primary outcome was a composite of 180-day all-cause mortality or readmission. RESULTS: We studied 773 patients: 450 (58.2%) were classified as profile 1, 128 (16.6%) as profile 2, 115 (14.9%) as profile 3 , a nd 8 0 ( 10.3%) a s p rofile 4. We fo und di fferences be tween th e 4 pr ofiles in demographics, com orbidity, clinical presentation, type of DVT and location, management, and outcomes. One hundred ninety-five p atients (25.2%) had at least one of the adverse events included in the composite within 180 days: 69 (8.9%) died and 179 (23.2%) were readmitted. Hazard ratios (HR) indicated that DVT with low cardiopulmonary reserve (HR, 1.73; 95% CI, 1.12-2.68; P = .01)) or DVT with cancer (HR, 3.10; 95% CI, 2.22-4.34; P .001) were the profiles t hat w ere independently associated with the 180-day composite outcome. CONCLUSION: Classifying patients with DVT according to 4 profiles ( unprovoked, provoked by t ransient r isk f actors, associated with cancer, and associated with low cardiopulmonary reserve) when making the diagnosis is useful for assessing prognosis for all-cause mortality or readmission within 180 days. This classification could be useful for establishing a care and follow-up plan when discharging patients with DVT from the ED.

OBJETIVO: Evaluar el pronóstico a 180 días de los pacientes diagnosticados de enfermedad tromboembólica venosa (ETV) en urgencias, en función de una clasificación por perfiles clínicos. Los objetivos secundarios fueron evaluar la mortalidad y el reingreso por todas las causas de manera individual, y describir las características clínicas y formas de presentación de trombosis venosa profunda (TVP) y tromboembolismo pulmonar (TEP), según dichos perfiles. METODO: Análisis secundario del registro ESPHERIA que incluye pacientes consecutivos con ETV sintomática de 53 servicios de urgencias (SU). Se dividió la muestra en 4 perfiles: ETV no provocada (perfil 1), ETV provocada por factores de riesgo transitorios (perfil 2), cáncer (perfil 3) y baja reserva cardiopulmonar (perfil 4). La variable de resultado primaria fue la compuesta mortalidad o reingreso por cualquier causa a 180 días. RESULTADOS: Se incluyeron 773 pacientes de los cuales 450 (58,2%) fueron clasificados en el perfil 1, 128 (16,6%) en el perfil 2, 115 pacientes (14,9%) en el perfil 3 y 80 (10,3%) en el perfil 4. Se documeô€‚˜taron diferencias demográficas, de comorbilidad, presentación clínica, tipo de ETV, manejo, ubicación y resultados entre los perfiles clínicos. Ciento noventa y cinco pacientes (25,2%) presentaron un resultado adverso compuesto a los 180 días, de los cuales 69 (8,9%) fallecieron y 179 (23,2%) sufrieron un nuevo ingreso por cualquier causa. La ETV asociada a baja reserva cardiopulmonar (HR 1,73; IC 95% 1,12-2,68; p = 0,01) y la ETV asociada a cáncer (HR 3,10; IC 95% 2,22-4,34; p 0,001) se asociaron de forma independiente con sufrir un resultado adverso en los primeros 180 días. CONCLUSIONES: Clasificar a los pacientes con ETV según factores de riesgo y comorbilidades en 4 perfiles (no provocada, provocada por factores transitorios, asociada a cáncer y asociada a baja reserva cardiopulmonar) resulta útil al momento del diagnóstico de la ETV para estimar el pronóstico en términos de mortalidad y reingreso a 180 días. Esta clasificación podría ayudar a establecer un plan de cuidados y seguimiento al alta en la ETV diagnosticada en urgencias.

Ictus criptogénico secundario a embolia paradójica: ¿entidad infrecuente o poco diagnosticada? / Cryptogenic stroke secondary to paradoxical embolism: Is this event rare or underdiagnosed?

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Ahorro de antibióticos prescritos en faringitis e infecciones del tracto respiratorio inferior en Atención Primaria / Saving antibiotics prescribed in pharyngitis and lower respiratory tract infections in Primary Care

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