Influencia de la renta económica en la mortalidad intrahospitalaria de las personas mayores durante la primera ola de la pandemia por COVID-19: resultados del estudio EDEN-33 / Influence of income on in-hospital mortality in older adults during the first wave of the COVID-19 pandemic: results from the EDEN-33 study

Objetivo: Determinar si el nivel económico durante la primera ola pandémica tuvo una influencia diferente a la esperable en la mortalidad intrahospitalaria de los pacientes mayores atendidos en los servicios de urgencias (SU) de los hospitales públicos españoles. Método: Cincuenta y un SU públicos españoles que participaron voluntariamente y que dan cobertura al 25% de la población incluyeron todos los registros de pacientes de edad $ 65 años atendidos durante una semana del periodo preCOVID (1-4-2019 a 7-4-2019) y una semana del periodo COVID (30-3-2020 a 5-4-2020). Se identificó la renta bruta (RB) asignada al código postal de residencia de cada paciente y se calculó la RB normalizada (RBN) dividiendo aquella por la RB media de su comunidad autónoma. La existencia y fuerza de la relación entre RBN y mortalidad intrahospitalaria se determinó mediante curvas spline cúbicas restringidas (SCR) ajustadas por 10 características basales del paciente. Las OR para cada situación económica se expresó en relación con una RBN de 1 (referencia, renta correspondiente a la media de la comunidad autónoma). La comparación entre periodo COVID y no COVID se realizó mediante el estudio de interacción de primer grado. (AU)

Objective: To determine whether income was associated with unexpected in-hospital mortality in older patients treated in Spanish public health system hospital emergency departments. Methods: Fifty-one public health system hospital emergency departments in Spain voluntarily participated in the study. Together the hospitals covered 25% of the population aged 65 years or older included in all patient registers during a week in the pre-pandemic period (April 1-7, 2019) and a week during the COVID-19 pandemic (March 30 to April 5, 2020). We estimated a patient’s gross income as the amount published for the postal code of the patient’s address. We then calculated the standardized gross income (SGI) by dividing the patient’s estimated income by the mean for the corresponding territory (Spanish autonomous community). The existence and strength of an association between the SGI and in-hospital mortality was evaluated by means of restricted cubic spline (RCS) curves adjusted for 10 patient characteristics at baseline. Odds ratios (ORs) for each income level were expressed in relation to a reference SGI of 1 (the mean income for the corresponding autonomous community). We compared the COVID-19 and pre-pandemic periods by means of first-order interactions. (AU)

Influence of income on in-hospital mortality in older adults during the first wave of the COVID-19 pandemic: results from the EDEN-33 study. / Influencia de la renta económica en la mortalidad intrahospitalaria de las personas mayores durante la primera ola de la pandemia por COVID-19: resultados del estudio EDEN-33.

OBJECTIVES: To determine whether income was associated with unexpected in-hospital mortality in older patients treated in Spanish public health system hospital emergency departments. MATERIAL AND METHODS: Fifty-one public health system hospital emergency departments in Spain voluntarily participated in the study. Together the hospitals covered 25% of the population aged 65 years or older included in all patient registers during a week in the pre-pandemic period (April 1-7, 2019) and a week during the COVID-19 pandemic (March 30 to April 5, 2020). We estimated a patient's gross income as the amount published for the postal code of the patient's address. We then calculated the standardized gross income (SGI) by dividing the patient's estimated income by the mean for the corresponding territory (Spanish autonomous community). The existence and strength of an association between the SGI and in-hospital mortality was evaluated by means of restricted cubic spline (RCS) curves adjusted for 10 patient characteristics at baseline. Odds ratios (ORs) for each income level were expressed in relation to a reference SGI of 1 (the mean income for the corresponding autonomous community). We compared the COVID-19 and pre-pandemic periods by means of first-order interactions. RESULTS: Of the 35 280 patients attended in the 2 periods, gross income could be ascertained for 21 180 (60%), 15437 in the pre-pandemic period and 5746 during the COVID-19 period. SGIs were slightly higher for patients included before the pandemic (1.006 vs 0.994; P = .012). In-hospital mortality was 5.6% overall and higher during the pandemic (2.8% pre-pandemic vs 13.1% during COVID-19; P .001). The adjusted RCS curves showed that associations between income and mortality differed between the 2 periods (interaction P = .004). Whereas there were no significant income-influenced differences in mortality before the pandemic, mortality increased during the pandemic in the lowest-income population (SGI 0.5 OR, 1.82; 95% CI, 1.32-3.37) and in higher-income populations (SGI 1.5 OR, 1.32; 95% CI, 1.04-1.68, and SGI 2 OR, 1.92; 95% CI, 1.14-3.23). We found no significant differences between patients with COVID-19 and those with other diagnoses (interaction P = .667). CONCLUSION: The gross income of patients attended in Spanish public health system hospital emergency departments, estimated according to a patient's address and postal code, was associated with in-hospital mortality, which was higher for patients with the lowest and 2 higher income levels. The reasons for these associations might be different for each income level and should be investigated in the future.

OBJETIVO: Determinar si el nivel económico durante la primera ola pandémica tuvo una influencia diferente a la esperable en la mortalidad intrahospitalaria de los pacientes mayores atendidos en los servicios de urgencias (SU) de los hospitales públicos españoles. METODO: Cincuenta y un SU públicos españoles que participaron voluntariamente y que dan cobertura al 25% de la población incluyeron todos los registros de pacientes de edad 65 años atendidos durante una semana del periodo preCOVID (1-4-2019 a 7-4-2019) y una semana del periodo COVID (30-3-2020 a 5-4-2020). Se identificó la renta bruta (RB) asignada al código postal de residencia de cada paciente y se calculó la RB normalizada (RBN) dividiendo aquella por la RB media de su comunidad autónoma. La existencia y fuerza de la relación entre RBN y mortalidad intrahospitalaria se determinó mediante curvas spline cúbicas restringidas (SCR) ajustadas por 10 características basales del paciente. Las OR para cada situación económica se expresó en relación con una RBN de 1 (referencia, renta correspondiente a la media de la comunidad autónoma). La comparación entre periodo COVID y no COVID se realizó mediante el estudio de interacción de primer grado. RESULTADOS: De los 35.280 registros de pacientes atendidos en ambos periodos, se disponía de la RB en 21.180 (60%): 15.437 del periodo preCOVID y 5.746 del periodo COVID. La RBN de los pacientes incluidos fue discretamente superior en el periodo preCOVID (1,006 versus 0,994; p = 0,012). La mortalidad intrahospitalaria fue del 5,6%, y fue superior durante el periodo COVID (2,8% versus 13,1%; p 0,001). Las curvas SCR ajustadas mostraron una asociación entre nivel económico y mortalidad diferente entre ambos periodos (p interacción = 0,004): en el periodo preCOVID no hubo diferencias significativas de mortalidad en función de la RBN, mientras que en el periodo COVID la mortalidad se incrementó en rentas bajas (OR = 1,82, IC 95% = 1,32-3,37 para RBN de 0,5) y en rentas altas (OR = 1,32, IC 95% = 1,04-1,68 y OR = 1,92, IC 95% = 1,14-3,23 para RBN de 1,5 y 2, respectivamente), sin diferencias significativas entre pacientes con COVID y con otros diagnósticos (p interacción = 0,667). CONCLUSIONES: Durante la primera ola de la pandemia COVID, la RB asignada al código postal de residencia de los pacientes atendidos en los SU públicos españoles se asoció con la mortalidad intrahospitalaria, que aumentó en pacientes de rentas bajas y altas. Las razones de estas asociaciones pueden ser distintas para cada segmento económico y deben ser investigadas en el fututo.

Sex differences in mortality of older adults with falls after emergency department consultation: FALL-ER registry.

BACKGROUND: To investigate if sex is a risk factor for mortality in patients consulting at the emergency department (ED) for an unintentional fall. METHODS: This was a secondary analysis of the FALL-ER registry, a cohort of patients ≥65 years with an unintentional fall presenting to one of 5 Spanish EDs during 52 predefined days (one per week during one year). We collected 18 independent patient baseline and fall-related variables. Patients were followed for 6 months and all-cause mortality recorded. The association between biological sex and mortality was expressed as unadjusted and adjusted hazard ratios (HR) with the 95% confidence interval (95% CI), and subgroup analyses were performed by assessing the interaction of sex with all baseline and fall-related mortality risk variables. RESULTS: Of 1315 enrolled patients (median age 81 years), 411 were men (31%) and 904 women (69%). The 6-month mortality was higher in men (12.4% vs. 5.2%, HR = 2.48, 95% CI = 1.65-3.71), although age was similar between sexes. Men had more comorbidity, previous hospitalizations, loss of consciousness, and an intrinsic cause for falling. Women more frequently lived alone, with self-reported depression, and the fall results in a fracture and immobilization. Nonetheless, after adjustment for age and these eight divergent variables, older men aged 65 and over still showed a significantly higher mortality (HR = 2.19, 95% CI = 1.39-3.45), with the highest risk observed during the first month after ED presentation (HR = 4.18, 95% CI = 1.31-13.3). We found no interaction between sex and any patient-related or fall-related variables with respect to mortality (p > 0.05 in all comparisons). CONCLUSIONS: Male sex is a risk factor for death following ED presentation for a fall in the older population adults aged 65 and over. The causes for this risk should be investigated in future studies.

Pacientes ancianos atendidos en urgencias por caídas (Registro FALL-ER): probabilidad de nuevas caídas y factores asociados / Probability of new falls and factors associated with them in aged patients treated in emergency departments after falling: data from the FALL-ER registry

Objetivo: Investigar las características asociadas a una nueva caída tras la atención en urgencias por una caída no intencionada y desarrollar un modelo de riesgo para predecirla.Método: El registro FALL-ER incluye pacientes de 65 años o más atendidos por una caída no intencionada en cinco servicios de urgencias españoles. Las variables independientes incluyeron características basales del paciente, de la caída, consecuencias inmediatas y situación funcional al alta. Se realizó seguimiento telefónico para saber si habían existidonuevas caídas en los 6 meses posteriores. Mediante un análisis ajustado se identificaron las variables independientes asociadas a nueva caída y se desarrolló un modelo de riesgo.Resultados: Se incluyeron 1.313 pacientes y 147 presentaron una nueva caída (11,2%). Las variables asociadas a nueva caída fueron: caída en los 12 meses anteriores, enfermedad neurológica, anemia, toma de analgésicos no opiáceos, caída en domicilio y durante la noche, traumatismo craneoencefálico y necesidad de ayuda para levantarse de la silla. El modelo predictivo mostró una capacidad discriminativa moderada con un área bajo la curva de la característica operativa del receptor de 0,688 (IC 95%: 0,640-0,736). La probabilidad de sufrir una nueva caída fue de 3,5%, 10,5% y 23,3% en los pacientes clasificados como de riesgo bajo, intermedio y alto respectivamente.Conclusión: Uno de cada nueve adultos mayores que consultan a urgencias por caídas no intencionadas volverán a caer durante los 6 meses siguientes. Es posible identificar un subgrupo de pacientes con riesgo incrementado en los que deberían ponerse en marcha acciones preventivas. (AU)

Objective: To identify characteristics associated with a new fall in a patient who received emergency department care after an accidental fall and to develop a risk model to predict repeated falls. Method: The FALL-ER registry included accidental falls in patients over the age of 65 years treated in 5 Spanish emergency departments. Independent variables analyzed were patient characteristics at baseline, fall characteristics, immediate consequences, and functional status on discharge. Patients were followed with telephone interviews for 6 months to record the occurrence of new falls. Multivariate regression analysis was used to identify variables associated with falling again and to develop a risk model. We identified 3 levels of risk for new falls (low, intermediate, and high). Results: A total of 1313 patients were studied; 147 patients (11.2%) reported having another fall. Variables associated with risk of falling again were having had a fall in the 12 months before the index fall, neurological disease, anemia, use of non-opioid analgesics, falling at home, falling at night, head injury on falling, and need for help when rising from a chair. The probability of falling again was 3.5%, 10.5%, and 23.3%, respectively, in patients at low, intermediate, and high risk. The model’s ability to discriminate was moderate: the area under the receiver operating characteristic curve was 0.688 (95% CI, 0.640-0.736). Conclusion: One in 9 older adults treated in an emergency department for an accidental fall will fall again within 6 months. It is possible to identify patients at higher risk for whom preventive measures should be implemented. (AU)

New approaches in the nutritional treatment of advanced chronic kidney disease.

INTRODUCTION: Patients with advanced chronic kidney disease (ACKD) have a high prevalence of malnutrition. The dietary restrictions that we usually apply in terms of macro and micronutrients force our patients to follow dietary guidelines that deviate from healthy patterns. OBJETIVES: To determine if a personalized nutritional intervention program, minimizing the usual restrictions would be justified in case it improved the evolution of kidney disease compared to standard treatment. SECUNDARY OBJETIVES: To determine changes in nutrient intakes and in anthropometric and biochemical parameters, as well as quantify episodes of hyperkalemia. MATERIAL AND METHODS: A single-center, randomized and controlled educational intervention clinical trial was conduct in patients from the ERCA outpatients clinic at the Complejo Hospitalario Universitario de Albacete. 75 patients were included, assigning 35 to a Control group and 40 to the Intervention group with 1-year follow-up. The nutritional status was determined using anthropometric data, body composition by Bioimpedance, blood and urine biochemical parameters and a 24-h recall questionnaire. The nutritional intervention was carried out in three different ways: individual, collective and telephone recall. RESULTS: At the beginning of the study, the BMI showed a situation of weight excess with a mean of 28.83 kg/m2 (5.4) in men and 26.96 kg/m2 (4.09) in women. 70% of our patients had overweight. The abdominal circumference was 105.3 cm (10.2) and 92.3 cm (13.7) for men and women respectively without significant changes throughout the study. The percentage of fat mass (FM) was high in both groups for men and women throughout the study. We did not find biochemical parameters of malnutrition and only significant differences were observed in glomerular filtration rate (GFR), which increased in the intervention group. No patient presented any episodes of hyperkalemia during the study. The energy intake in both groups showed an inadequate distribution of macronutrients with a poor intake of carbohydrates (CH) that was supplemented with an excess of fat. In the case of micronutrients, we did observe an increase in potassium and fiber intakes with a decrease in sodium and phosphorus in the intervention group. CONCLUSIONS: Malnutrition is not exclusively an intake defficit and encompasses both the problems derived from a deficit and an excess of nutrients intake. Un to 70% of our patients showed weight excess and a fat mass higher than desirable. The implementation of an individualized nutritional education program, including a vegetables and fiber rich diet, less atherogenic, not only did not cause electrolyte alterations but also slowed the progression of kidney disease.

Thermography as a Non-Ionizing Quantitative Tool for Diagnosing Burning Mouth Syndrome: Case-Control Study.

OBJECTIVES: Thermography is an imaging technique based on the acquisition and analysis of thermal data. The present study evaluates the use of tongue infrared thermography (IRT) as a tool for the diagnosis of burning mouth syndrome (BMS). MATERIAL AND METHODS: An IRT study was carried out in patients diagnosed with BMS according to the criteria of the International Association for the Study of Pain (n = 32) and in healthy controls (n = 35). Burning sensations, dry mouth and taste disturbances were assessed, and three temperature values were recorded for each tongue surface (dorsal, right lateral, left lateral and tip), along with body temperature and environmental temperature. RESULTS: A statistically significant difference was recorded in the temperature of the dorsal surface of the tongue between the BMS group and the controls (p = 0.01). The area under the curve (AUC) was 0.731 (95% CI: 0.402-0.657; p = 0.003). The sensitivity and specificity obtained was 62% and 77%, respectively. CONCLUSIONS: Infrared thermography appears to be useful as a complementary tool for the diagnosis of BMS, though further studies are needed in this field.

Intervención educativa de enfermería en pacientes con cateterismo cardiaco / Nursing educational intervention in patients with cardiac catheterization

Introducción: la intervención de enfermería en pacientes sometidos a cateterismo cardiaco constituye el eje articular de las acciones de planeación, desarrollo y evaluación; lo que permite atender el proceso de aprendizaje. Objetivo: evaluar la relación entre el nivel de conocimiento y ansiedad de los pacientes sometido a cateterismo cardiaco, antes y después de aplicar una intervención educativa. Metodología: investigación con enfoque cuantitativo, descriptivo, transversal y exploratorio a 70 pacientes sometidos a cateterismo cardiaco por primera vez, se aplicaron dos instrumentos validados para medir el nivel de conocimiento y ansiedad con un Alfa de Cronbach de 0.90; la recolección fue en dos fases, pretest y postest, la primera antes de la cirugia; la segunda posterior al procedimiento y se compararon los resultados de ambos test en búsqueda de mejores resultados. Resultados: media de edad de 60 - 79 años; 68.6% hombres y 31.4% mujeres; el nivel de conocimientos del pretest fue de 52.9% regular y postest, excelente con un 50%; en cuanto a la ansiedad el pretest el 97.1% reportó grave, mientras que en el postest, el 80% reportó moderado. Conclusiones: el aporte de conocimientos por parte del personal de enfermería a través del rol educador, favorece a los pacientes que son sometidos a un cateterismo cardiaco, que se refleja en disminución de ansiedad e incremento de calidad de vida.

Introduction:The nursing intervention in patients undergoing cardiac catheterization constitutes the articular axis of planning, development and evaluation actions; which allows to attend the learning process. Objective: To evaluate the relationship between the level of knowledge and anxiety of the patient undergoing cardiac catheterization, before and after applying an educational intervention. Methodology: Investigation with a quantitative, descriptive, cross-sectional and exploratory approach to 70 patients undergoing cardiac catheterization for the first time. Two validated instruments were applied to measure the level of knowledge and anxiety with a Cronbach's Alpha of 0.90; the collection was in two phases, pre and post test, the first before surgery; the second after the procedure, the results of both tests were compared in search of better results. Results: Average age of 60-79 years, 68.6% men and 31.4% women; the level of knowledge of the pre-test was 52.9% regular and post-test, excellent with 50%; regarding anxiety, the pre-test 97.1% serious, post-test, 80% moderate. Conclusions: The contribution of knowledges by the nursing staff through the educator role, favors patients who undergo cardiac catheterization, which is reflected in the reduction of seniority and the increase in the quality of life.

Probability of new falls and factors associated with them in aged patients treated in emergency departments after falling: data from the FALL-ER registry. / Pacientes ancianos atendidos en urgencias por caídas (Registro FALL-ER): probabilidad de nuevas caídas y factores asociados.

OBJECTIVES: To identify characteristics associated with a new fall in a patient who received emergency department care after an accidental fall and to develop a risk model to predict repeated falls. MATERIAL AND METHODS: The FALL-ER registry included accidental falls in patients over the age of 65 years treated in 5 Spanish emergency departments. Independent variables analyzed were patient characteristics at baseline, fall characteristics, immediate consequences, and functional status on discharge. Patients were followed with telephone interviews for 6 months to record the occurrence of new falls. Multivariate regression analysis was used to identify variables associated with falling again and to develop a risk model. We identified 3 levels of risk for new falls (low, intermediate, and high). RESULTS: A total of 1313 patients were studied; 147 patients (11.2%) reported having another fall. Variables associated with risk of falling again were having had a fall in the 12 months before the index fall, neurological disease, anemia, use of non-opioid analgesics, falling at home, falling at night, head injury on falling, and need for help when rising from a chair. The probability of falling again was 3.5%, 10.5%, and 23.3%, respectively, in patients at low, intermediate, and high risk. The model's ability to discriminate was moderate: the area under the receiver operating characteristic curve was 0.688 (95% CI, 0.640-0.736). CONCLUSION: One in 9 older adults treated in an emergency department for an accidental fall will fall again within 6 months. It is possible to identify patients at higher risk for whom preventive measures should be implemented.

OBJETIVO: Investigar las características asociadas a una nueva caída tras la atención en urgencias por una caída no intencionada y desarrollar un modelo de riesgo para predecirla. METODO: El registro FALL-ER incluye pacientes de 65 años o más atendidos por una caída no intencionada en cinco servicios de urgencias españoles. Las variables independientes incluyeron características basales del paciente, de la caída, consecuencias inmediatas y situación funcional al alta. Se realizó seguimiento telefónico para saber si habían existido nuevas caídas en los 6 meses posteriores. Mediante un análisis ajustado se identificaron las variables independientes asociadas a nueva caída y se desarrolló un modelo de riesgo.. RESULTADOS: Se incluyeron 1.313 pacientes y 147 presentaron una nueva caída (11,2%). Las variables asociadas a nueva caída fueron: caída en los 12 meses anteriores, enfermedad neurológica, anemia, toma de analgésicos no opiáceos, caída en domicilio y durante la noche, traumatismo craneoencefálico y necesidad de ayuda para levantarse de la silla. El modelo predictivo mostró una capacidad discriminativa moderada con un área bajo la curva de la característica operativa del receptor de 0,688 (IC 95%: 0,640-0,736). La probabilidad de sufrir una nueva caída fue de 3,5%, 10,5% y 23,3% en los pacientes clasificados como de riesgo bajo, intermedio y alto respectivamente. CONCLUSIONES: Uno de cada nueve adultos mayores que consultan a urgencias por caídas no intencionadas volverán a caer durante los 6 meses siguientes. Es posible identificar un subgrupo de pacientes con riesgo incrementado en los que deberían ponerse en marcha acciones preventivas.

Factors associated with late presentation to the emergency department in patients complaining of chest pain.

OBJECTIVE: We investigated which factors predict late presentation (LP) to the emergency department (ED) in patients with non-traumatic chest pain (CP). METHODS: All CP cases attended at a single ED (2008-2017) were included. LP was considered if time from CP onset to ED arrival was>6 h. We analyzed associations between 42 patient/CP-related characteristics and LP in the whole cohort and in patients with CP due to acute coronary syndrome (ACS). RESULTS: The cohort included 25,693 cases (LP=50.6%; ACS=19.0%). Twenty factors were associated with LP, and 8 were also found in patients with ACS: CP of short-duration, aggravated by exertion or breathing/movement, undulating or recurrent CP increased the risk of LP, whereas CP accompanied by diaphoresis, irradiated to the throat, and chronic treatment with nitrates decreased the risk of LP. Exertional and recurrent CP were associated with both, LP and ACS. CONCLUSION: Some characteristics, mainly CP-related, may lead to LP to the ED. CP aggravated by exercise and recurrent CP were associated with both LP and a final diagnosis of ACS. PRACTICE IMPLICATIONS: Patient educational initiatives should consider these two features as potential warnings for ACS and thereby encourage patients to seek early medical consultation.

Infratriaje en urgencias de pacientes que precisan ingreso directo en cuidados intensivos por enfermedades médicas: impacto en el pronóstico y factores asociados / Undertriage of patients requiring direct admission to intensive care from the emergency department for medical conditions: impact on prognosis and associated factors

Objetivo: Determinar si el infratriaje tiene impacto pronóstico en pacientes que requieren ingreso desde urgencias en cuidados intensivos por enfermedad médica e identificar factores asociados. Método: Revisión retrospectiva de pacientes atendidos durante 2018 por enfermedades médicas con ingreso directo en cuidados intensivos desde urgencias. Se clasificaron en dos grupos en función del nivel de triaje asignado y se consideró infratriaje un nivel de triaje $ III. Las variables independientes incluyeron datos demográficos, epidemiológicos e indicadores de gravedad en urgencias. Se registró la mortalidad a los 30 días (objetivo primario), así como la mortalidad hospitalaria, el ingreso prolongado en cuidados intensivos o el ingreso prolongado hospitalario (objetivos secundarios). Resultados: Se incluyeron 470 pacientes [edad 68 años (rango 57-78), 61,1% hombres] de los que 151 (32,1%) formaban el grupo con infratriaje. Los factores relacionados con el infratriaje fueron la edad (OR = 1,017; IC 95% 1,003-1,032), indicador qSOFA 0-1 (OR = 1,761; IC 95% 1,038-2,988), índice SpO2/FiO2 > 300 (OR = 2,447; IC 95% 1,418-4,223) y el diagnóstico de infección (OR = 5,003; IC 95% 2,727-9,188), respiratorio (OR = 3,993; IC 95% 1,919-8,310) u otro (OR = 1,980; IC 95% 1,036-3,785) respecto al diagnóstico cardiovascular, mientras que la admisión en horario de tarde (OR = 0,512; IC 95% 0,306-0,856) o el traslado en ambulancia (OR = 0,373; IC 95% 0,232-0,600) se relacionaron de forma inversa con el infratriaje. El evento mortalidad a 30 días tuvo lugar en 90 pacientes (19,1%). El infratriaje no se relacionó con la mortalidad a 30 días ni con el resto de los objetivos analizados. (AU)

Objectives: To determine whether undertriage affects the outcome for patients requiring direct admission to the intensive care unit (ICU) from the emergency department due to a medical condition. To identify factors associated with undertriage. Material and methods: Retrospective review of patients treated in 2018 for medical emergencies requiring direct admission to the ICU from the emergency department. The cases were classified in 2 groups according to the assigned triage level. Underestimation was defined as a triage level of III or more. Independent variables were demographic and epidemiologic data and indicators of severity recorded in the emergency department. The main outcome was 30-day mortality. Secondary outcomes were in-hospital mortality, prolonged ICU stay, and prolonged hospital stay. Results: We included 470 patients with a median age of 68 years (first-third quartile range, 57-78 years); 61.1% were men, and 151 (32.1%) were undertriaged. Factors directly related to undertriage according to odds ratios (ORs) were age (OR = 1.017; 95% CI, 1.003-1.032), Quick Sequential Organ Failure Assessment score of 0 or 1 (OR = 1.761; 95% CI, 1.038-2.988), ratio of oxygen saturation to fraction of inspired oxygen greater than 300 (OR = 2.447; 95% CI, 1.418-4.223), a diagnosis of infection (OR = 5.003, 95% CI 2.727-9.188) whether respiratory (OR = 3.993, 95% CI 1.919-8.310) or other (OR = 1.980, 95% CI, 1.036-3.785) versus a diagnosis of cardiovascular disease. Factors inversely related to undertriage were admission during the afternoon (OR = 0.512, 95% CI, 0.306-0.856) and ambulance transfer (OR = 0.373; 95% CI, 0.232-0.600). Ninety patients (19.1%) died within 30 days. Undertriage was not related to 30-day mortality or the other outcomes analyzed. (AU)

Undertriage of patients requiring direct admission to intensive care from the emergency department for medical conditions: impact on prognosis and associated factors. / Infratriaje en urgencias de pacientes que precisan ingreso directo en cuidados intensivos por enfermedades médicas: impacto en el pronóstico y factores asociados.

OBJECTIVES: To determine whether undertriage affects the outcome for patients requiring direct admission to the intensive care unit (ICU) from the emergency department due to a medical condition. To identify factors associated with undertriage. MATERIAL AND METHODS: Retrospective review of patients treated in 2018 for medical emergencies requiring direct admission to the ICU from the emergency department. The cases were classified in 2 groups according to the assigned triage level. Underestimation was defined as a triage level of III or more. Independent variables were demographic and epidemiologic data and indicators of severity recorded in the emergency department. The main outcome was 30-day mortality. Secondary outcomes were in-hospital mortality, prolonged ICU stay, and prolonged hospital stay. RESULTS: We included 470 patients with a median age of 68 years (first-third quartile range, 57-78 years); 61.1% were men, and 151 (32.1%) were undertriaged. Factors directly related to undertriage according to odds ratios (ORs) were age (OR = 1.017; 95% CI, 1.003-1.032), Quick Sequential Organ Failure Assessment score of 0 or 1 (OR = 1.761; 95% CI, 1.038-2.988), ratio of oxygen saturation to fraction of inspired oxygen greater than 300 (OR = 2.447; 95% CI, 1.418-4.223), a diagnosis of infection (OR = 5.003, 95% CI 2.727-9.188) whether respiratory (OR = 3.993, 95% CI 1.919-8.310) or other (OR = 1.980, 95% CI, 1.036-3.785) versus a diagnosis of cardiovascular disease. Factors inversely related to undertriage were admission during the afternoon (OR = 0.512, 95% CI, 0.306-0.856) and ambulance transfer (OR = 0.373; 95% CI, 0.232-0.600). Ninety patients (19.1%) died within 30 days. Undertriage was not related to 30-day mortality or the other outcomes analyzed. CONCLUSION: Undertriage was not associated with a worse outcome in patients requiring direct admission to the ICU for a medical emergency. The factors we found to be associated with undertriage, such as patient age and time of day admitted, merit special attention given that these factors should not be affecting the triage process.

OBJETIVO: Determinar si el infratriaje tiene impacto pronóstico en pacientes que requieren ingreso desde urgencias en cuidados intensivos por enfermedad médica e identificar factores asociados. METODO: Revisión retrospectiva de pacientes atendidos durante 2018 por enfermedades médicas con ingreso directo en cuidados intensivos desde urgencias. Se clasificaron en dos grupos en función del nivel de triaje asignado y se consideró infratriaje un nivel de triaje III. Las variables independientes incluyeron datos demográficos, epidemiológicos e indicadores de gravedad en urgencias. Se registró la mortalidad a los 30 días (objetivo primario), así como la mortalidad hospitalaria, el ingreso prolongado en cuidados intensivos o el ingreso prolongado hospitalario (objetivos secundarios). RESULTADOS: Se incluyeron 470 pacientes [edad 68 años (rango 57-78), 61,1% hombres] de los que 151 (32,1%) formaban el grupo con infratriaje. Los factores relacionados con el infratriaje fueron la edad (OR = 1,017; IC 95% 1,003- 1,032), indicador qSOFA 0-1 (OR = 1,761; IC 95% 1,038-2,988), índice SpO2/FiO2 > 300 (OR = 2,447; IC 95% 1,418- 4,223) y el diagnóstico de infección (OR = 5,003; IC 95% 2,727-9,188), respiratorio (OR = 3,993; IC 95% 1,919-8,310) u otro (OR = 1,980; IC 95% 1,036-3,785) respecto al diagnóstico cardiovascular, mientras que la admisión en horario de tarde (OR = 0,512; IC 95% 0,306-0,856) o el traslado en ambulancia (OR = 0,373; IC 95% 0,232- 0,600) se relacionaron de forma inversa con el infratriaje. El evento mortalidad a 30 días tuvo lugar en 90 pacientes (19,1%). El infratriaje no se relacionó con la mortalidad a 30 días ni con el resto de los objetivos analizados. CONCLUSIONES: El infratriaje no se relacionó con un peor pronóstico en pacientes con ingreso directo en intensivos por enfermedad médica. Se han identificado factores relacionados con el infratriaje, como la edad o el horario de admisión que merecen una atención especial, ya que no deberían afectar el proceso de triaje.

New approaches in the nutritional treatment of advanced chronic kidney disease. / Nuevo enfoque en el tratamiento nutricional de la enfermedad renal crónica avanzada.

INTRODUCTION: Patients with advanced chronic kidney disease (ACKD) have a high prevalence of malnutrition. The dietary restrictions that we usually apply in terms of macro and micronutrients force our patients to follow dietary guidelines that deviate from healthy patterns. OBJECTIVES: To determine if a personalized nutritional intervention program, minimizing the usual restrictions would be justified in case it improved the evolution of kidney disease compared to standard treatment. SECONDARY OBJECTIVES: To determine changes in nutrient intakes and in anthropometric and biochemical parameters, as well as quantify episodes of hyperkalemia. MATERIAL AND METHODS: A single-center, randomized and controlled educational intervention clinical trial was conduct in patients from the ERCA outpatients clinic at the Complejo Hospitalario Universitario de Albacete. 75 patients were included, assigning 35 to a Control group and 40 to the Intervention group with 1-year follow-up. The nutritional status was determined using anthropometric data, body composition by Bioimpedance, blood and urine biochemical parameters and a 24-h recall questionnaire. The nutritional intervention was carried out in three different ways: individual, collective and telephone recall. RESULTS: At the beginning of the study, the BMI showed a situation of weight excess with a mean of 28.83 kg/m2 (5.4) in men and 26.96 kg/m2 (4.09) in women. 70% of our patients had overweight. The abdominal circumference was 105.3 cm (10.2) and 92.3 cm (13.7) for men and women respectively without significant changes throughout the study. The percentage of fat mass (FM) was high in both groups for men and women throughout the study. We did not find biochemical parameters of malnutrition and only significant differences were observed in glomerular filtration rate (GFR), which increased in the intervention group. No patient presented any episodes of hyperkalemia during the study. The energy intake in both groups showed an inadequate distribution of macronutrients with a poor intake of carbohydrates (CH) that was supplemented with an excess of fat. In the case of micronutrients, we did observe an increase in potassium and fiber intakes with a decrease in sodium and phosphorus in the intervention group. CONCLUSIONS: Malnutrition is not exclusively an intake deficit and encompasses both the problems derived from a deficit and an excess of nutrients intake. Un to 70% of our patients showed weight excess and a fat mass higher than desirable. The implementation of an individualized nutritional education program, including a vegetables and fiber rich diet, less atherogenic, not only did not cause electrolyte alterations but also slowed the progression of kidney disease.

Análisis de mortalidad de los pacientes atendidos por COVID-19 en el servicio de urgencias de un hospital de tercer nivel en la fase incial de la pandemia. Derivación de un modelo de riesgo para urgencias / Mortality in patients treated for COVID-19 in the emergency department of a tertiary care hospital during the first phase of the pandemic: Derivation of a risk model for emergency departments

Objetivo. Derivar un modelo de riesgo para estimar la probabilidad de mortalidad a los 30 días de la visita a urgencias de pacientes con COVID-19. Método. Estudio observacional de cohortes retrospectivo de 2.511 pacientes con COVID-19 atendidos en el servicio de urgencias hospitalario (SUH) del 1 de marzo al 30 de abril de 2020. Se realizó análisis de supervivencia mediante Kaplan Meier y regresión de Cox. Resultados. La mortalidad por cualquier causa a los 30 días fue de un 8%. Los factores asociados de forma independiente a mayor mortalidad fueron: edad $ 50 años, índice de Barthel < 90 puntos, alteración del nivel de consciencia, índice de SaO2/FIO2 < 400, auscultación respiratoria anómala, cifra de plaquetas < 100.000/mm3, PCR $ 5 mg/dL y filtrado glomerular < 45 mL/min. A estos factores se les asignó una puntuación de 1, excepto a la edad, que se le asignó un valor de 2 puntos. Se dividió el modelo de riesgo en 3 categorías: riesgo bajo (menor o igual a 4 puntos), riesgo intermedio (5-6 puntos) y riesgo alto (igual o superior a 7 puntos). Para los pacientes clasificados como de bajo riesgo la probabilidad de mortalidad a los 30 días fue del 1,7%, en los casos de riesgo intermedio fue del 28,2% y para los de alto riesgo fue del 67,3%. Conclusión. Disponer de una herramienta para estratificar el riesgo de mortalidad de los pacientes con COVID-19 que consultan a un SUH podría ser de utilidad para la gestión de los recursos sanitarios disponibles. (AU)

Objectives: To develop a risk model to predict 30-day mortality after emergency department treatment for COVID-19. Material and methods: Observational retrospective cohort study including 2511 patients with COVID-19 who came to our emergency department between March 1 and April 30, 2020. We analyzed variables with Kaplan Meier survival and Cox regression analyses. Results: All-cause mortality was 8% at 30 days. Independent variables associated with higher risk of mortality were age over 50 years, a Barthel index score less than 90, altered mental status, the ratio of arterial oxygen saturation to the fraction of inspired oxygen (SaO2/FIO2), abnormal lung sounds, platelet concentration less than 100 000/mm3, a C-reactive protein concentration of 5 mg/dL or higher, and a glomerular filtration rate less than 45 mL/min. Each independent predictor was assigned 1 point in the score except age, which was assigned 2 points. Risk was distributed in 3 levels: low risk (score of 4 points or less), intermediate risk (5 to 6 points), and high risk (7 points or above). Thirty-day risk of mortality was 1.7% for patients who scored in the low-risk category, 28.2% for patients with an intermediate risk score, and 67.3% for those with a high risk score. Conclusion: This mortality risk stratification tool for patients with COVID-19 could be useful for managing the course of disease and assigning health care resources in the emergency department. (AU)

Mortality in patients treated for COVID-19 in the emergency department of a tertiary care hospital during the first phase of the pandemic: Derivation of a risk model for emergency departments. / Análisis de mortalidad de los pacientes atendidos por COVID-19 en el servicio de urgencias de un hospital de tercer nivel en la fase incial de la pandemia. Derivación de un modelo de riesgo para urgencias.

OBJECTIVES: To develop a risk model to predict 30-day mortality after emergency department treatment for COVID-19. MATERIAL AND METHODS: Observational retrospective cohort study including 2511 patients with COVID-19 who came to our emergency department between March 1 and April 30, 2020. We analyzed variables with Kaplan Meier survival and Cox regression analyses. RESULTS: All-cause mortality was 8% at 30 days. Independent variables associated with higher risk of mortality were age over 50 years, a Barthel index score less than 90, altered mental status, the ratio of arterial oxygen saturation to the fraction of inspired oxygen (SaO2/FIO2), abnormal lung sounds, platelet concentration less than 100 000/mm3, a C-reactive protein concentration of 5 mg/dL or higher, and a glomerular filtration rate less than 45 mL/min. Each independent predictor was assigned 1 point in the score except age, which was assigned 2 points. Risk was distributed in 3 levels: low risk (score of 4 points or less), intermediate risk (5 to 6 points), and high risk (7 points or above). Thirty-day risk of mortality was 1.7% for patients who scored in the low-risk category, 28.2% for patients with an intermediate risk score, and 67.3% for those with a high risk score. CONCLUSION: This mortality risk stratification tool for patients with COVID-19 could be useful for managing the course of disease and assigning health care resources in the emergency department.

OBJETIVO: Derivar un modelo de riesgo para estimar la probabilidad de mortalidad a los 30 días de la visita a urgencias de pacientes con COVID-19. METODO: Estudio observacional de cohortes retrospectivo de 2.511 pacientes con COVID-19 atendidos en el servicio de urgencias hospitalario (SUH) del 1 de marzo al 30 de abril de 2020. Se realizó análisis de supervivencia mediante Kaplan Meier y regresión de Cox. RESULTADOS: La mortalidad por cualquier causa a los 30 días fue de un 8%. Los factores asociados de forma independiente a mayor mortalidad fueron: edad 50 años, índice de Barthel 90 puntos, alteración del nivel de consciencia, índice de SaO2/FIO2 400, auscultación respiratoria anómala, cifra de plaquetas 100.000/mm3, PCR 5 mg/dL y filtrado glomerular 45 mL/min. A estos factores se les asignó una puntuación de 1, excepto a la edad, que se le asignó un valor de 2 puntos. Se dividió el modelo de riesgo en 3 categorías: riesgo bajo (menor o igual a 4 puntos), riesgo intermedio (5-6 puntos) y riesgo alto (igual o superior a 7 puntos). Para los pacientes clasificados como de bajo riesgo la probabilidad de mortalidad a los 30 días fue del 1,7%, en los casos de riesgo intermedio fue del 28,2% y para los de alto riesgo fue del 67,3%. CONCLUSIONES: Disponer de una herramienta para estratificar el riesgo de mortalidad de los pacientes con COVID-19 que consultan a un SUH podría ser de utilidad para la gestión de los recursos sanitarios disponibles.

Influencia del teletrabajo en la seroprevalencia de COVID-19 en trabajadores de la administración sanitaria / Teleworking does not influence the prevalence of Covid infection in a cohort of health administration workers without exposure to Covid patients

Debido a la pandemia, el teletrabajo se contempló como opción para continuar el ritmo laboral. Objetivos: Valorar la influencia de la presencialidad laboral en la prevalencia de infección por SARS-CoV-2. Conocer las variables relacionadas con la presencialidad en el trabajo. Material y Métodos: Estudio descriptivo, transversal de prevalencia. Variables: edad, sexo, peso, talla, tabaco, comorbilidades, vacunación gripe, síntomas COVID-19, contacto, modalidad de trabajo. Realización de prueba rápida anticuerpos SARS-CoV-2. Resultados: La prevalencia de los trabajadores se relaciona significativamente con: edad, no fumador, vacuna gripe, síntomas sospechosos, convivencia con enfermos. La presencialidad en el trabajo se ha relacionado significativamente con: sexo y fumador. La seroprevalencia fue superior en trabajadores que no acudieron a su puesto respecto a los que acudieron siempre u ocasionalmente. Conclusiones: El teletrabajo parece no influir en la reducción de la seroprevalencia por Covid-19, luego no hay motivos para pensar que el riesgo de contagio sea distinto en el trabajo que en el domicilio del paciente (AU)

Due to the pandemic, teleworking was considered as an option to continue the work rhythm. Objectives: To assess the influence of presence at work on the prevalence of SARS-CoV-2 infection. Know the variables related to presence at work. Material and Methods: Prospective, descriptive, cross-sectional prevalence study. Variables: age, sex, weight, height, tobacco, comorbidities, flu vaccination, COVID-19 symptoms, contact, work modality. Carrying out rapid SARS-CoV-2 antibody test Results: The prevalence of workers is significantly related to: age, non-smoker, flu vaccine, suspicious symptoms, living with patients. Presence at work has been significantly related to: sex and smoker. The seroprevalence was higher in workers who did not go to their position compared to those who did always or occasionally. Conclusions: Teleworking does not seem to influence the reduction of seroprevalence due to Covid-19. The risk of contagion is lower at work than at the worker's home (AU)

Influence of previous coronary artery bypass grafting in the difficulty of acute coronary syndrome diagnosis.

OBJECTIVES: To investigate whether the diagnosis of acute coronary syndrome (ACS) in coronary artery bypass grafting (CABG) patients with chest pain (CP) is more difficult based on the initial clinical and electrocardiogram (ECG) findings. METHODS: We included consecutive CP patients attended at a single emergency department (ED) during a 10-year period. CABG status and the final diagnosis of ACS were considered as stated in the ED discharge report. We evaluated the frequency of 21 CP characteristics (CPC) and four ECG signatures, their individual and collective association with ACS, and ED length of stay (LOS) in CABG and non-CABG patients. RESULTS: We included 34 429 patients [median age: 61 years; female: 41.8%; CABG: 2204 patients (6.4%)], and ACS was diagnosed in 6727 (19.5%; CABG/non-CABG 37.2%/18.3%; P < 0.001). CABG patients more frequently had CPC and ECG findings typically associated with ACS, but their final association with ACS was weaker than in non-CABG patients (only significant after adjustment for attendant diaphoresis, throat irradiation, ST-segment elevation and T-wave inversion). The collective discriminative capacity was significantly lower in CABG patients (area under the curve 0.710 vs. 0.793; P < 0.001), even after adjustment (0.708 vs. 0.790; P < 0.001). ED LOS was longer for CABG patients, overall (P < 0.001) and for patients diagnosed with ACS (P = 0.008) and non-ACS (P < 0.001), but these differences disappeared after adjustment. CONCLUSION: CABG substantially reduces the diagnostic performance of CPC and ECG findings to suggest ACS. A longer LOS in the ED in CABG patients is more related to their baseline characteristics than to CABG itself.

Factors associated with revisits by patients with SARS-CoV-2 infection discharged from a hospital emergency department. / Factores asociados a revisita en pacientes con diagnóstico de infección por SARS-CoV-2 dados de alta de un servicio de urgencias hospitalario.

OBJECTIVES: To analyze emergency department (ED) revisits from patients discharged with possible coronavirus disease 2019 (COVID-19). MATERIAL AND METHODS: Retrospective observational study of consecutive patients who came to the ED over a period of 2 months and were diagnosed with possible COVID-19. We analyzed clinical and epidemiologic variables, treatments given in the ED, discharge destination, need to revisit, and reasons for revisits. Patients who did or did not revisit were compared, and factors associated with revisits were explored. RESULTS: The 2378 patients included had a mean age of 57 years; 49% were women. Of the 925 patients (39%) discharged, 170 (20.5%) revisited the ED, mainly for persistence or progression of symptoms. Sixty-six (38.8%) were hospitalized. Odds ratios (ORs) for the following factors showed an association with revisits: history of rheumatologic disease (OR, 2.97; 95% CI, 1.10-7.99; P = .03), digestive symptoms (OR, 1.73; 95% CI, 1.14-2.63; P = .01), respiratory rate over 20 breaths per minute (OR, 1.03; 95% CI, 1.0-1.06; P = .05), and corticosteroid therapy given in the ED (OR, 7.78; 95% CI, 1.77-14.21, P = .01). Factors associated with hospitalization after revisits were age over 48 years (OR, 2.57; 95% CI, 1 42-4.67; P = .002) and fever (OR, 4.73; 95% CI, 1.99-11.27; P = .001). CONCLUSION: Patients under the age of 48 years without comorbidity and with normal vitals can be discharged from the ED without fear of complications. A history of rheumatologic disease, fever, digestive symptoms, and a respiratory rate over 20 breaths per minute, or a need for corticosteroid therapy were independently associated with revisits. Fever and age over 48 years were associated with a need for hospitalization.

OBJETIVO: Analizar las revisitas y los factores asociados a la misma en pacientes con diagnóstico de posible COVID-19 dados de alta de un servicio de urgencias hospitalario (SUH). METODO: Estudio observacional, retrospectivo que incluyó pacientes consecutivos que consultaron al SUH en un periodo de 2 meses y fueron diagnosticados de posible de COVID-19. Se analizaron variables clínico-epidemiológicas, tratamiento administrado en urgencias, destino final, revisita al SUH y motivo de esta. Se hizo un análisis comparativo entre ambos grupos (revisita sí/no) y se identificaron factores asociados a la revisita. RESULTADOS: Se incluyeron 2.378 pacientes (edad media 57 años; 49% mujeres). De los pacientes dados de alta (39% del total; n = 925), 170 (20,5%) reconsultaron al SUH, principalmente por persistencia o progresión de síntomas, y 66 (38,8%) precisaron ingreso. Los factores relacionados con la revisita fueron: antecedentes de enfermedad reumatológica [OR: 2,97 (IC 95%: 1,10-7,99, p = 0,03)], síntomas digestivos [OR: 1,73 (IC 95%: 1,14-2,63, p = 0,01)], frecuencia respiratoria $ 20 [OR: 1,03 (IC 95%: 1,0-1,06, p = 0,05)] y haber recibido tratamiento con esteroides en urgencias [OR: 7,78 (IC 95%: 1,77-14,21, p = 0,01)]. Los factores asociados al ingreso en la revisita fueron la edad $ 48 años [OR: 2,57 (IC 95%: 1,42-4,67, p = 0,002)] y presentar fiebre [OR: 4,73 (IC 95%: 1,99-11,27, p = 0,001)]. CONCLUSIONES: Los pacientes con posible COVID-19 menores de 48 años, sin comorbilidad y con signos vitales normales podrían ser dados de alta desde urgencias sin temor a sufrir complicaciones. Los antecedentes de enfermedad reumatológica, fiebre, sintomas digestivos, frecuencia respiratoria $ 20/min o necesidad de tratamiento con esteroides fueron factores independientes de revisita, y la fiebre y edad $ 48 años de necesidad de ingreso.