Procalcitonin concentration in the emergency department predicts 30-day mortality in COVID-19 better than the lymphocyte count, the neutrophil-tolymphocyte ratio, or the C-reactive protein level. / Procalcitonina es superior a recuento linfocitario, índice neutrófilo/linfocito y proteína C reactiva para la predicción de mortalidad a 30 días de pacientes con COVID-19 en el servicio de urgencias.

OBJECTIVES: Although many demographic and clinical predictors of mortality have been studied in relation to COVID-19, little has been reported about the prognostic utility of inflammatory biomarkers. MATERIAL AND METHODS: Retrospective cohort study. All patients with laboratory-confirmed COVID-19 treated in a hospital emergency department were included consecutively if baseline measurements of the following biomarkers were on record: lymphocyte counts, neutrophil-to-lymphocyte ratio NRL, and C-reactive protein (CRP) and procalcitonin (PCT) levels. We analyzed associations between the biomarkers and all-cause 30-day mortality using Cox regression models and dose-response curves. RESULTS: We included 896 patients, 151 (17%) of whom died within 30 days. The median (interquartile range) age was 63 (51-78) years, and 494 (55%) were men. NLR, CRP and PCT levels at ED presentation were higher, while lymphocyte counts were lower, in patients who died compared to those who survived (P .001). The areas under the receiver operating characteristic curves revealed the PCT concentration (0.79; 95% CI, 0.75-0.83) to be a better predictor of 30-day mortality than the lymphocyte count (0.70; 95% CI, 0.65-0.74; P .001), the NLR (0.74; 95% CI, 0.69-0.78; P = .03), or the CRP level (0.72; 95% CI, 0.68-0.76; P .001). The proposed PCT concentration decision points for use in emergency department case management were 0.06 ng/L (negative) and 0.72 ng/L (positive). These cutoffs helped classify risk in 357 patients (40%). Multivariable analysis demonstrated that the PCT concentration had the strongest association with mortality. CONCLUSION: PCT concentration in the emergency department predicts all-cause 30-day mortality in patients with COVID-19 better than other inflammatory biomarkers.

OBJETIVO: Existen múltiples variables demográficas y clínicas predictivas de mortalidad en pacientes con COVID-19. Sin embargo, hay menos información sobre el valor pronóstico de los biomarcadores inflamatorios. METODO: Estudio de cohorte retrospectivo. Se incluyeron de forma consecutiva todos los pacientes con COVID-19, confirmado por laboratorio, atendidos en un servicio de urgencias hospitalario (SUH) y con valor basal de los siguientes biomarcadores: recuento linfocitario, índice neutrófilo/linfocito (INL), proteína C reactiva (PCR) y procalcitonina (PCT). La relación entre los biomarcadores y la mortalidad total a 30 días se analizó mediante una regresión de Cox y gráficos de dosis-respuesta. RESULTADOS: Se incluyeron 896 pacientes, 151 (17%) fallecieron en los primeros 30 días. La mediana de edad fue de 63 años (51-78) y 494 (55%) eran hombres. El valor de INL, PCR y PCT fue mayor, mientras que el recuento linfocitario fue menor, en los pacientes que fallecieron respecto a los que sobrevivieron (p 0,001). La PCT fue superior al recuento linfocitario, INL y PCR en la predicción de mortalidad a 30 días (ABC 0,79 [IC 95%: 0,75-0,83] vs 0,70 [IC 95%: 0,65-0,74], p 0,001; 0,74 [IC 95%: 0,69-0,78], p = 0,03; y 0,72 [IC 95%: 0,68-0,76], p 0,001). Los puntos de decisión de PCT propuestos, 0,06 ng/l para exclusión y 0,72 ng/l para inclusión de muerte a 30 días, podrían facilitar la toma de decisiones en urgencias. Hubo 357 pacientes (40%) con valores de PCT en estas categorías. El análisis multivariable mostró una mayor asociación con la mortalidad para PCT que en los otros biomarcadores estudiados. CONCLUSIONES: PCT es el biomarcador con mejor capacidad para predecir mortalidad a 30 días por cualquier causa en pacientes con COVID-19 valorados en un SUH.

Optic nerve and macular optical coherence tomography in recovered COVID-19 patients.

PURPOSE: To investigate the peripapillary retinal nerve fiber layer thickness (RNFLT), macular RNFLT, ganglion cell layer (GCL), and inner plexiform layer (IPL) thickness in recovered COVID-19 patients compared to controls. METHODS: Patients previously diagnosed with COVID-19 were included, while healthy patients formed the historic control group. All patients underwent an ophthalmological examination, including macular and optic nerve optical coherence tomography. In the case group, socio-demographic data, medical history, and neurological symptoms were collected. RESULTS: One hundred sixty patients were included; 90 recovered COVID-19 patients and 70 controls. COVID-19 patients presented increases in global RNFLT (mean difference 4.3; CI95% 0.8 to 7.7), nasal superior (mean difference 6.9; CI95% 0.4 to 13.4), and nasal inferior (mean difference 10.2; CI95% 2.4 to 18.1) sectors of peripapillary RNFLT. Macular RNFL showed decreases in COVID-19 patients in volume (mean difference -0.05; CI95% -0.08 to -0.02), superior inner (mean difference -1.4; CI95% -2.5 to -0.4), nasal inner (mean difference -1.1; CI95% -1.8 to -0.3), and nasal outer (mean difference -4.7; CI95% -7.0 to -2.4) quadrants. COVID-19 patients presented increased GCL thickness in volume (mean difference 0.04; CI95% 0.01 to 0.07), superior outer (mean difference 2.1; CI95% 0.8 to 3.3), nasal outer (mean difference 2.5; CI95% 1.1 to 4.0), and inferior outer (mean difference1.2; CI95% 0.1 to 2.4) quadrants. COVID-19 patients with anosmia and ageusia presented an increase in peripapillary RNFLT and macular GCL compared to patients without these symptoms. CONCLUSIONS: SARS-CoV-2 may affect the optic nerve and cause changes in the retinal layers once the infection has resolved.

Reduced retinal vessel density in COVID-19 patients and elevated D-dimer levels during the acute phase of the infection.

PURPOSE: To describe macular vessel density and perfusion in COVID-19 patients using coherence tomography angiography (OCTA) and to investigate whether there is a correlation between retinal vascular abnormalities and clinical and laboratory parameters. METHODS: Cross-sectional analysis conducted at the Hospital Clinico San Carlos in Madrid, Spain. Patients with laboratory-confirmed COVID-19 that were attended in the Emergency Department (ED) from March 23 to March 29, 2020 were included. Fundus examination and OCTA were performed 4 weeks after being attended in ED. Macular OCTA parameters were analyzed and correlated with clinical (severity and hypoxemia- oxygen saturation < 92%) and laboratory parameters during hospital stay (D-Dimer-DD, lactate dehydrogenase-LDH and C-reactive protein-CRP). RESULTS: 80 patients were included, mean age 55(SD9) years old; 46.3% male. We reported macular vessel density and perfusion measurements in COVID-19 patients. Those patients with D-Dimer ≥ 500 ng/ml during SARS-CoV-2 infection had a decrease of central vessel density (mean difference 2.2; 95%CI 0.4-3.9) and perfusion density (mean difference 4.9; 95%CI 0.9-8.9) after the acute phase of COVID-19. These variations of vessel density and perfusion density were not documented in patients with LDH ≥ 500 U/L, CRP ≥ 10 mg/L and hypoxemia. CONCLUSIONS: COVID-19 patients showed short-term retinal vasculature abnormalities which may be related to a prothrombotic state associated with SARS-CoV-2 infection. Since the retinal microvasculature shares many morphological and physiological properties with the vasculature of other vital organs, further research is needed to establish whether patients with increased D-Dimer levels require more careful assessment and follow-up after COVID-19.

OBJETIVO: Evaluar la densidad vascular (DV) y la perfusión vascular (PV) retiniana en pacientes con COVID-19 mediante una angiografía por tomografía de coherencia óptica (OCTA), e investigar si existe una correlación entre las anomalías vasculares de la retina y los parámetros clínicos y de laboratorio. MÉTODOS: Análisis transversal realizado en el Hospital Clínico San Carlos, Madrid. Se incluyeron pacientes con diagnóstico confirmado de COVID-19 atendidos en el Servicio de Urgencias (SU) del 23 al 29 de marzo del 2020. Se realizó una exploración oftalmológica y OCTA cuatro semanas después de acudir al SU. Se analizaron los parámetros maculares de OCTA y se correlacionaron con parámetros clínicos (gravedad e hipoxemia-saturación de oxígeno < 92%) y de laboratorio durante la estancia hospitalaria (dímero D [DD], lactato deshidrogenasa [LDH] y proteína C reactiva [CRP]. RESULTADOS: Se incluyeron 80 pacientes, edad media 55 (DE nueve) años; 46,3% hombres. Las personas con DD > 500 ng/mL durante la infección por SARS-CoV-2 tuvieron una disminución de la DV central (diferencia de medias 2,2; IC 95% 0,4 a 3,9) y PV central (diferencia de medias 4,9; IC 95% 0,9 a 8,9) después de la fase aguda de COVID-19. Estas variaciones no se documentaron en los pacientes con LDH > = 500 U/L, CRP > = 10 mg/L y con hipoxemia. CONCLUSIONES: Los pacientes con COVID-19 mostraron anomalías de la vasculatura retiniana a corto plazo que pueden estar relacionadas con un estado protrombótico asociado con la infección por SARS-CoV-2. Dado que la microvasculatura de la retina comparte muchas propiedades morfológicas y fisiológicas con la vasculatura de otros órganos vitales, es necesario seguir investigando para determinar si los pacientes con niveles elevados de DD requieren una evaluación y un seguimiento más cuidadoso.

Reduced retinal vessel density in COVID-19 patients and elevated D-dimer levels during the acute phase of the infection

Purpose: To describe macular vessel density and perfusion in COVID-19 patients using coherence tomography angiography (OCTA) and to investigate whether there is a correlation between retinal vascular abnormalities and clinical and laboratory parameters.MethodsCross-sectional analysis conducted at the Hospital Clinico San Carlos in Madrid, Spain. Patients with laboratory-confirmed COVID-19 that were attended in the Emergency Department (ED) from March 23 to March 29, 2020 were included. Fundus examination and OCTA were performed 4 weeks after being attended in ED. Macular OCTA parameters were analyzed and correlated with clinical (severity and hypoxemia- oxygen saturation<92%) and laboratory parameters during hospital stay (D-Dimer-DD, lactate dehydrogenase-LDH and C-reactive protein-CRP).Results80 patients were included, mean age 55(SD9) years old; 46.3% male. We reported macular vessel density and perfusion measurements in COVID-19 patients. Those patients with D-Dimer≥500ng/ml during SARS-CoV-2 infection had a decrease of central vessel density (mean difference 2.2; 95%CI 0.4–3.9) and perfusion density (mean difference 4.9; 95%CI 0.9–8.9) after the acute phase of COVID-19. These variations of vessel density and perfusion density were not documented in patients with LDH≥500U/L, CRP≥10mg/L and hypoxemia.ConclusionsCOVID-19 patients showed short-term retinal vasculature abnormalities which may be related to a prothrombotic state associated with SARS-CoV-2 infection. Since the retinal microvasculature shares many morphological and physiological properties with the vasculature of other vital organs, further research is needed to establish whether patients with increased D-Dimer levels require more careful assessment and follow-up after COVID-19. (AU)

Objetivo: Evaluar la densidad vascular (DV) y la perfusión vascular (PV) retiniana en pacientes con COVID-19 mediante una angiografía por tomografía de coherencia óptica (OCTA), e investigar si existe una correlación entre las anomalías vasculares de la retina y los parámetros clínicos y de laboratorio.MétodosAnálisis transversal realizado en el Hospital Clínico San Carlos, Madrid. Se incluyeron pacientes con diagnóstico confirmado de COVID-19 atendidos en el Servicio de Urgencias (SU) del 23 al 29 de marzo del 2020. Se realizó una exploración oftalmológica y OCTA cuatro semanas después de acudir al SU. Se analizaron los parámetros maculares de OCTA y se correlacionaron con parámetros clínicos (gravedad e hipoxemia-saturación de oxígeno < 92%) y de laboratorio durante la estancia hospitalaria (dímero D [DD], lactato deshidrogenasa [LDH] y proteína C reactiva [CRP].ResultadosSe incluyeron 80 pacientes, edad media 55 (DE nueve) años; 46,3% hombres. Las personas con DD > 500 ng/mL durante la infección por SARS-CoV-2 tuvieron una disminución de la DV central (diferencia de medias 2,2; IC 95% 0,4 a 3,9) y PV central (diferencia de medias 4,9; IC 95% 0,9 a 8,9) después de la fase aguda de COVID-19. Estas variaciones no se documentaron en los pacientes con LDH > = 500 U/L, CRP > = 10 mg/L y con hipoxemia.ConclusionesLos pacientes con COVID-19 mostraron anomalías de la vasculatura retiniana a corto plazo que pueden estar relacionadas con un estado protrombótico asociado con la infección por SARS-CoV-2. Dado que la microvasculatura de la retina comparte muchas propiedades morfológicas y fisiológicas con la vasculatura de otros órganos vitales, es necesario seguir investigando para determinar si los pacientes con niveles elevados de DD requieren una evaluación y un seguimiento más cuidadoso. (AU)

Reduced retinal vessel density in COVID-19 patients and elevated D-dimer levels during the acute phase of the infection.

PURPOSE: To describe macular vessel density and perfusion in COVID-19 patients using coherence tomography angiography (OCTA) and to investigate whether there is a correlation between retinal vascular abnormalities and clinical and laboratory parameters. METHODS: Cross-sectional analysis conducted at the Hospital Clinico San Carlos in Madrid, Spain. Patients with laboratory-confirmed COVID-19 that were attended in the Emergency Department (ED) from March 23 to March 29, 2020 were included. Fundus examination and OCTA were performed 4 weeks after being attended in ED. Macular OCTA parameters were analyzed and correlated with clinical (severity and hypoxemia- oxygen saturation<92%) and laboratory parameters during hospital stay (D-Dimer-DD, lactate dehydrogenase-LDH and C-reactive protein-CRP). RESULTS: 80 patients were included, mean age 55(SD9) years old; 46.3% male. We reported macular vessel density and perfusion measurements in COVID-19 patients. Those patients with D-Dimer≥500ng/ml during SARS-CoV-2 infection had a decrease of central vessel density (mean difference 2.2; 95%CI 0.4-3.9) and perfusion density (mean difference 4.9; 95%CI 0.9-8.9) after the acute phase of COVID-19. These variations of vessel density and perfusion density were not documented in patients with LDH≥500U/L, CRP≥10mg/L and hypoxemia. CONCLUSIONS: COVID-19 patients showed short-term retinal vasculature abnormalities which may be related to a prothrombotic state associated with SARS-CoV-2 infection. Since the retinal microvasculature shares many morphological and physiological properties with the vasculature of other vital organs, further research is needed to establish whether patients with increased D-Dimer levels require more careful assessment and follow-up after COVID-19.

Categorías diagnósticas y resultados a corto plazo en los pacientes con sospecha de COVID-19 atendidos en un servicio de urgencias / Diagnostic groups and short-term outcomes in suspected COVID-19 cases treated in an emergency department

OBJETIVO: EL objetivo principal fue describir el perfil clínico y la mortalidad a los 30 días de diferentes categorías diagnósticas en los casos de COVID-19 atendidos en un servicio de urgencias (SU). MÉTODO: Análisis secundario del registro COVID-19_URG-HCSC. Se seleccionaron los casos sospechosos de COVID-19 atendidos en un SU de Madrid desde el 28 de febrero hasta el 31 de marzo de 2020. La muestra se dividió: 1) sospecha con PCR no realizada (S/PCR NR); 2) sospecha con PCR negativa (S/PCR-); 3) sospecha con PCR positiva (S/PCR+); 4) alta sospecha con PCR negativa o no realizada (AS/PCR- o NR); y 5) alta sospecha con PCR positiva (AS/PCR+). Se recogieron variables clínicas, radiológicas y microbiológicas del episodio de urgencias. La variable de resultado principal fue la mortalidad por cualquier causa a los 30 días. Las variables secundarias fueron el ingreso y la gravedad del episodio. RESULTADOS: Se incluyeron 1.993 pacientes; 17,2% S/PCR NR, 11,4% S/PCR-, 22,1% S/PCR+, 11,7% AS/PCR- o NR y 37,6% AS/PCR+. Se hallaron diferencias estadísticamente significativas respecto a las variables demográficas, comorbilidad, clínicas, radiográficas, analíticas y terapéuticas y de resultados a corto plazo en función las categorías diagnósticas. La mortalidad global a los 30 días fue de un 11,5%, 56,5% casos fueron hospitalizados y 19,6% casos sufrieron un episodio grave. Las categorías de AS y de S/PCR+ tuvieron un incremento del riesgo ajustado de mortalidad a los 30 días y de sufrir un episodio grave durante el ingreso hospitalario respecto a S/PCR-. En relación al ingreso, solo las categorías de AS tuvieron un incremento del riesgo ajustado de hospitalización respecto a la categoría de S/PCR-. CONCLUSIONES: Existen diferentes categorías diagnósticas de la enfermedad COVID-19 en función del perfil clínico y microbiológico que tienen correlato con el pronóstico a 30 días

OBJECTIVE: The primary objective was to describe the clinical characteristics and 30-day mortality rates in emergency department patients with coronavirus disease 2019 (COVID-19) in different diagnostic groupings. METHODS: Secondary analysis of the COVID-19 registry compiled by the emergency department of Hospital Clínico San Carlos in Madrid, Spain. We selected suspected COVID-19 cases treated in the emergency department between February 28 and March 31, 2020. The cases were grouped as follows: 1) suspected, no polymerase chain reaction (PCR) test (S/no-PCR); 2) suspected, negative PCR (S/PCR-); 3) suspected, positive PCR (S/PCR+); 4) highly suspected, no PCR, or negative PCR (HS/no or PCR-); and 5) highly suspected, positive PCR (HS/PCR+). We collected clinical, radiologic, and microbiologic data related to the emergency visit. The main outcome was 30-day all-cause mortality. Secondary outcomes were hospitalization and clinical severity of the episode. RESULTS: A total of 1993 cases (90.9%) were included as follows: S/no-PCR, 17.2%; S/PCR-, 11.4%; S/PCR+, 22.1%; HS/no PCR or PCR-, 11.7%; and HS/PCR+, 37.6%. Short-term outcomes differed significantly in the different groups according to demographic characteristics; comorbidity and clinical, radiographic, analytical, and therapeutic variables. Thirty-day mortality was 11.5% (56.5% in hospitalized cases and 19.6% in cases classified as severe). The 2 HS categories and the S/PCR+ category had a greater adjusted risk for 30-day mortality and for having a clinically severe episode during hospitalization in comparison with S/PCR- cases. Only the 2 HS categories showed greater risk for hospitalization than the S/PCR- cases

Clinical presentation and outcome across age categories among patients with COVID-19 admitted to a Spanish Emergency Department.

PURPOSE: To determine the differences by age-dependent categories in the clinical profile, presentation, management, and short-term outcomes of patients with laboratory-confirmed COVID-19 admitted to a Spanish Emergency Department (ED). METHODS: Secondary analysis of COVID-19_URG-HCSC registry. We included all consecutive patients with laboratory-confirmed COVID-19 admitted to the ED of the University Hospital Clinico San Carlos (Madrid, Spain). The population was divided into six age groups. Demographic, baseline and acute clinical data, and in-hospital and 30-day outcomes were collected. RESULTS: 1379 confirmed COVID-19 cases (mean age 62 (SD 18) years old; 53.5% male) were included (18.1% < 45 years; 17.8% 45-54 years; 17.9% 55-64 years; 17.2% 65-74 years; 17.0% 75-84 years; and 11.9% ≥ 85 years). A statistically significant association was found between demographic, comorbidity, clinical, radiographic, analytical, and therapeutic variables and short-term results according to age-dependent categories. There were less COVID-specific symptoms and more atypical symptoms among older people. Age was a prognostic factor for hospital admission (aOR = 1.04; 95% CI 1.02-1.05) and in-hospital (aOR = 1.08; 95% CI 1.05-1.10) and 30-day mortality (aOR = 1.07; 95% CI 1.04-1.09), and was associated with not being admitted to intensive care (aOR = 0.95; 95% CI 0.93-0.98). CONCLUSIONS: Older age is associated with less COVID-specific symptoms and more atypical symptoms, and poor short-term outcomes. Age has independent prognostic value and may help in shared decision-making in patients with confirmed COVID-19 infection.

Diagnostic groups and short-term outcomes in suspected COVID-19 cases treated in an emergency department. / Categorías diagnósticas y resultados a corto plazo en los pacientes con sospecha de COVID-19 atendidos en un servicio de urgencias.

OBJECTIVES: The primary objective was to describe the clinical characteristics and 30-day mortality rates in emergency department patients with coronavirus disease 2019 (COVID-19) in different diagnostic groupings. MATERIAL AND METHODS: Secondary analysis of the COVID-19 registry compiled by the emergency department of Hospital Clínico San Carlos in Madrid, Spain. We selected suspected COVID-19 cases treated in the emergency department between February 28 and March 31, 2020. The cases were grouped as follows: 1) suspected, no polymerase chain reaction (PCR) test (S/no-PCR); 2) suspected, negative PCR (S/PCR-); 3) suspected, positive PCR (S/PCR+); 4) highly suspected, no PCR, or negative PCR (HS/no or PCR-); and 5) highly suspected, positive PCR (HS/PCR+). We collected clinical, radiologic, and microbiologic data related to the emergency visit. The main outcome was 30-day all-cause mortality. Secondary outcomes were hospitalization and clinical severity of the episode. RESULTS: A total of 1993 cases (90.9%) were included as follows: S/no-PCR, 17.2%; S/PCR-, 11.4%; S/PCR+, 22.1%; HS/no PCR or PCR-, 11.7%; and HS/PCR+, 37.6%. Short-term outcomes differed significantly in the different groups according to demographic characteristics; comorbidity and clinical, radiographic, analytical, and therapeutic variables. Thirty-day mortality was 11.5% (56.5% in hospitalized cases and 19.6% in cases classified as severe). The 2 HS categories and the S/PCR+ category had a greater adjusted risk for 30-day mortality and for having a clinically severe episode during hospitalization in comparison with S/PCR- cases. Only the 2 HS categories showed greater risk for hospitalization than the S/PCR- cases. CONCLUSION: COVID-19 diagnostic groups differ according to clinical and laboratory characteristics, and the differences are associated with the 30-day prognosis.

OBJETIVO: El objetivo principal fue describir el perfil clínico y la mortalidad a los 30 días de diferentes categorías diagnósticas en los casos de COVID-19 atendidos en un servicio de urgencias (SU). METODO: Análisis secundario del registro COVID-19_URG-HCSC. Se seleccionaron los casos sospechosos de COVID-19 atendidos en un SU de Madrid desde el 28 de febrero hasta el 31 de marzo de 2020. La muestra se dividió: 1) sospecha con PCR no realizada (S/PCR NR); 2) sospecha con PCR negativa (S/PCR­); 3) sospecha con PCR positiva (S/ PCR+); 4) alta sospecha con PCR negativa o no realizada (AS/PCR­ o NR); y 5) alta sospecha con PCR positiva (AS/ PCR+). Se recogieron variables clínicas, radiológicas y microbiológicas del episodio de urgencias. La variable de resultado principal fue la mortalidad por cualquier causa a los 30 días. Las variables secundarias fueron el ingreso y la gravedad del episodio. RESULTADOS: Se incluyeron 1.993 pacientes; 17,2% S/PCR NR, 11,4% S/PCR­, 22,1% S/PCR+, 11,7% AS/PCR­ o NR y 37,6% AS/PCR+. Se hallaron diferencias estadísticamente significativas respecto a las variables demográficas, comorbilidad, clínicas, radiográficas, analíticas y terapéuticas y de resultados a corto plazo en función las categorías diagnósticas. La mortalidad global a los 30 días fue de un 11,5%, 56,5% casos fueron hospitalizados y 19,6% casos sufrieron un episodio grave. Las categorías de AS y de S/PCR+ tuvieron un incremento del riesgo ajustado de mortalidad a los 30 días y de sufrir un episodio grave durante el ingreso hospitalario respecto a S/PCR­. En relación al ingreso, solo las categorías de AS tuvieron un incremento del riesgo ajustado de hospitalización respecto a la categoría de S/PCR­. CONCLUSIONES: Existen diferentes categorías diagnósticas de la enfermedad COVID-19 en función del perfil clínico y microbiológico que tienen correlato con el pronóstico a 30 días.

Planning to reduce 30-day adverse events after discharge of frail elderly patients with acute heart failure: design and rationale for the DEED FRAIL-AHF trial. / Planificación del alta desde urgencias para reducir eventos adversos a 30 días en pacientes mayores frágiles con insuficiencia cardiaca aguda: diseño y justificación del ensayo clínico DEED FRAIL-AHF.

OBJECTIVES: To demonstrate the efficacy of a system for comprehensive care transfer (Multilevel Guided Discharge Plan [MGDP]) for frail older patients diagnosed with acute heart failure (AHF) and to validate the results of MGDP implementation under real clinical conditions. The MGDP seeks to reduce the number of adverse outcomes within 30 days of emergency department (ED) discharge. MATERIAL AND METHODS: We will enroll frail patients over the age of 70 years discharged home from the ED with a main diagnosis of AHF. The MGDP includes the following components: 1) a checklist of clinical recommendations and resource activations, 2) scheduling of an early follow-up visit, 3) transfer of information to the primary care doctor, and 4) written instructions for the patient. Phase 1 of the study will be a matched-pair cluster-randomized controlled trial. Ten EDs will be randomly assigned to the intervention group and 10 to the control group. Each group will enroll 480 patients, and the outcomes will be compared between groups. Phase 2 will be a quasi-experimental study of the intervention in 300 new patients enrolled by the same 20 EDs. The outcomes will be compared to those for each Phase-1 group. The main endpoint at 30 days will be a composite of 2 outcomes: revisits to an ED and/for hospitalization for AHF or cardiovascular death. CONCLUSION: The study will assess the efficacy and feasibility of comprehensive MGDP transfer of care for frail older AHF patients discharged home.

OBJETIVO: Demostrar la eficacia de una intervención integral en la transición de cuidados (Plan de Alta Guiado Multinivel, PAGM) para disminuir eventos adversos a 30 días en ancianos frágiles con insuficiencia cardiaca aguda (ICA) dados de alta desde servicios de urgencias (SU) y validar los resultados de dicha intervención en condiciones reales. METODO: Se seleccionarán pacientes 70 años frágiles con diagnóstico principal de ICA dados del alta a su domicilio desde SU. La intervención consistirá en aplicar un PAGM: 1) lista de verificación sobre recomendaciones clínicas y activación de recursos; 2) programación de visita precoz; 3) transmisión de información a atención primaria; 4) hoja de instrucciones al paciente por escrito. Fase 1: ensayo clínico con asignación al azar por conglomerados emparejado. Se asignará de forma aleatoria 10 SU (N = 480) al grupo de intervención y 10 SU (N = 480) al grupo de control. Se compararán los resultados entre grupo de intervención y control. Fase 2: estudio cuasi-experimental. Se realizará la intervención en los 20 SU (N = 300). Se comparará los resultados entre la fase 1 y 2 del grupo de intervención y entre la fase 1 y 2 del grupo de control. La variable principal de resultado es compuesta (revisita a urgencias u hospitalización por ICA o mortalidad de origen cardiovascular) a los 30 días del alta. CONCLUSIONES: El estudio valorará la eficacia y factibilidad de una intervención integral en la transición de cuidados para reducir resultados adversos a 30 días en ancianos frágiles con ICA dados de alta desde los SU.

Podemos llamar hiperfrecuentadores a los pacientes con mayor número de atenciones en urgencias y atención primaria / We can call hiper frequent users to the patients with the highest number of attention in emergencies and primary care

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Mutaciones genéticas en los pacientes jóvenes atendidos en un servicio de urgencias por síncope durante la práctica de deporte / Genetic mutations in young patients admitted to an emergency department for syncope during sport practice

Fundamento y objetivos: Estudiar la frecuencia de mutaciones relacionadas con cardiopatías genéticas entre los pacientes jóvenes atendidos por un síncope durante la práctica de deporte. Pacientes y métodos: Estudio de una serie de casos que incluyó a pacientes≤45 años con un síncope relacionado con la práctica del deporte durante 2010-2011. Se recogieron variables demográficas, clínicas, mutaciones genéticas y diagnóstico clínico final. Resultados: Se realizó un test genético en 46 (76,7%) de los 60 pacientes evaluados. El test genético fue positivo en 12 (26%; IC 95% 15,6-40,3) pacientes, de los cuales 10 (21,7%) tuvieron una mutación para el gen PKP2 de displasia arritmogénica de ventrículo derecho, uno (2,2%) para el gen KCNQ1 y otro (2,2%) para el gen SCN5A, relacionados con canalopatías. El test genético fue positivo en 11 (35,5%) casos con síncope indeterminado y en un (50%) caso con síncope cardiogénico, siendo negativo en todos los casos de síncope neuromediado (p=0,037). Conclusiones: Las mutaciones genéticas son frecuentes en pacientes jóvenes que presentan un síncope durante la práctica deportiva, especialmente en aquellos con etiología cardiaca o indeterminada

Background and objectives: To study the frequency of genetic mutations related to genetic heart disease among young patients admitted for syncope during sport practice. Patients and methods: A case series study that included patients≤45 years admitted for syncope during sport practice during 2010-2011. We collected demographic and clinical variables, genetic tests mutations and final clinical diagnosis. Results: A genetic test was performed in 46 (76.7%) of 60 patients evaluated. The genetic test was positive in 12 (26%; 95% CI 15.6-40.3) patients; 10 (21.7%) had PKP2 mutation related to arrhythmogenic right ventricular dysplasia mutation, one (2.2%) KCNQ1 mutation and one (2.2%) SCN5A mutation related to channelopathies. The genetic test was positive in 11 (35.5%) cases of undetermined syncope and one (50%) case of cardiac syncope, being negative in all cases with neuromediated syncopes (P=.037). Conclusions: Gene mutations are common in young patients suffering from syncope during sports, especially in those with cardiac or undetermined aetiology

Presente y futuro de los Congresos de la Sociedad Española de Medicina de Urgencias y Emergencias / Present and future conferences of the Spanish Society of Emergency Medicine (SEMES)

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Genetic mutations in young patients admitted to an emergency department for syncope during sport practice. / Mutaciones genéticas en los pacientes jóvenes atendidos en un servicio de urgencias por síncope durante la práctica de deporte.

BACKGROUND AND OBJECTIVES: To study the frequency of genetic mutations related to genetic heart disease among young patients admitted for syncope during sport practice. PATIENTS AND METHODS: A case series study that included patients≤45 years admitted for syncope during sport practice during 2010-2011. We collected demographic and clinical variables, genetic tests mutations and final clinical diagnosis. RESULTS: A genetic test was performed in 46 (76.7%) of 60 patients evaluated. The genetic test was positive in 12 (26%; 95% CI 15.6-40.3) patients; 10 (21.7%) had PKP2 mutation related to arrhythmogenic right ventricular dysplasia mutation, one (2.2%) KCNQ1 mutation and one (2.2%) SCN5A mutation related to channelopathies. The genetic test was positive in 11 (35.5%) cases of undetermined syncope and one (50%) case of cardiac syncope, being negative in all cases with neuromediated syncopes (P=.037). CONCLUSIONS: Gene mutations are common in young patients suffering from syncope during sports, especially in those with cardiac or undetermined aetiology.

Hiperfrecuentación en Atención Primaria e hiperfrecuentadores en Urgencias / Frequent attenders in Primary Health Care Centres and frequent attenders in Emergency Departments

OBJETIVO: Identificar factores predictores de hiperfrecuentación en Atención Primaria (AP) en una muestra de pacientes hiperfrecuentadores (HF) en servicios de urgencias hospitalarios (SUH). DISEÑO: Estudio observacional retrospectivo multicéntrico. PARTICIPANTES: Se seleccionaron pacientes mayores de 14 años HF en el SUH entre el 1 de enero y el 31 de diciembre de 2013. Emplazamiento: se reclutaron pacientes atendidos en los SUH de 17 hospitales públicos de la Comunidad de Madrid. MÉTODO: Se recogieron variables relativas a la visita índice del SUH. Se analizó la muestra en función de ser o no HF en AP. Se considera HF al paciente que realizó al menos 10 visitas en cada nivel asistencial durante un año. RESULTADOS: Se incluyeron 1.284 pacientes HF en SUH. Se analizaron 423 (32,9%) HF en AP con 16 visitas (RIC 12-25) frente a 861 (67,1%) pacientes no HF en AP con 4 visitas (RIC 2-6). Factores independientes predictores de HF en AP fueron la edad > 65 años (OR: 1,51; IC 95%: 1,07-2,13; p = 0,019), el deterioro cognitivo (OR: 1,63; IC 95%: 1,01-2,65; p = 0,049), el número de fármacos ≥3 (OR: 1,56; IC 95%: 1,06-2,30; p = 0,025) y vivir en la comunidad frente a vivir institucionalizado o en la calle (OR: 3,05; IC 95%: 1,14-8,16; p = 0,026). CONCLUSIONES: En una muestra de pacientes HF en los SUH, el hecho de ser mayor de 65 años, tomar 3 o más fármacos, presentar deterioro cognitivo y vivir en la comunidad se consideran factores predictores de ser HF también en AP

OBJECTIVE: To identify predictors of frequent attenders (HF) in Primary Health Care (PHC) centres in a sample of frequent attenders (HF) in Emergency Departments (ED). DESIGN: This was an observational, retrospective, multicentre cohort study. PARTICIPANTS: The HF patients were selected from patients seen in the ED between January 1 and December 31, 2013. Setting Patients were recruited from 17 public hospitals of the Community of Madrid, Spain. METHOD: Variables on the index visit to the ED were collected. The sample was analysed in terms of being or not being an HF user in PHC. An HF user is considered a patient who made at least 10 visits in each level of care for a year. RESULTS: A total of 1284 HF patients were included. An analysis was performed on 423 (32.9%) HF users in ED with 16 (12-25) visits to PHC vs. 861 (67.1%) non-HF users in ED, with 4 (2-6) visits to PHC. Independent predictors of HF in PHC: over 65 years (OR: 1.51; 95% CI: 1.07-2.13; P=.019), cognitive impairment (OR: 1.63; 95% CI: 1.01-2.65; P = .049), taking > 3 drugs (OR: 1.56; 95% CI: 1.06-2.30; P = .025), and living in the community vs. nursing home or homeless (OR: 3.05; 95% CI: 1.14-8.16; P = .026). CONCLUSIONS: Among HF patients in the ED, the fact that of being over 65 years, taking 3 or more drugs, suffering cognitive impairment, and living in the community, are also considered to be predictors of HF in PHC

Adjustment of antidiabetic treatment regimens on discharge from the emergency department: effect on 90-day outcomes in patients admitted to a short-stay unit. / Efecto de la adecuación al alta del tratamiento antidiabético en los resultados a 90 días en los pacientes ingresados en una unidad de corta estancia.

OBJECTIVES: To determine whether the adjustment of antidiabetic treatment of patients discharged from a short-stay unit (SSU) after a hyperglycemic crisis reduces the rate of adverse events in the next 90 days. MATERIAL AND METHODS: Retrospective study of patients admitted to an emergency SSU in June 2011. We gathered information on patient demographics, concurrent diseases, reason for admission, and appropriateness of antidiabetic treatment on discharge. Patients were classified as diabetic, nondiabetic, or newly hyperglycemic. Patients with altered carbohydrate metabolism were subclassified according to the appropriateness of the antidiabetic treatment prescribed on discharge. The main outcome variable was the occurrence of an adverse event within 90 days of discharge. RESULTS: We included 750 patients with a mean (SD) age of 68.1 (19.5) years; 357 (47.6%) were men. A new adverse event occurred in 262 (36%) patients within 90 days; 15.6 (31.5%) of these patients were not diabetic, 77 (41.8%) were diabetic, and 29 (59.2%) were newly hyperglycemic (P<.001). Failure to provide an appropriate antidiabetic regimen when discharging patients with altered carbohydrate metabolism was an independent risk factor for an adverse event within 90 days (adjusted odds ratio, 7.2; 95% CI, 3.9­13.3). CONCLUSION: Lack of appropriate antidiabetic treatment after discharge from an emergency SSU is a risk factor for adverse events within 90 days.

OBJETIVO: Determinar si el adecuado tratamiento al alta de la hiperglucemia en pacientes atendidos en una unidad de corta estancia (UCE) es un factor relacionado con la reducción de eventos adversos a tres meses tras el alta. METODO: Estudio de cohorte retrospectivo que incluyó los pacientes ingresados en una UCE durante el mes de junio de 2011. Se incluyeron variables demográficas, comorbilidad, causa de ingreso y congruencia del tratamiento antidiabético al alta. Se clasificó a los pacientes en diabéticos, no diabéticos y nuevos hiperglucémicos (NHG), y en aquellos con alteración del metabolismo hidrocarbonado, la variable clasificadora fue la congruencia del tratamiento antidiabético al alta. La variable de resultado principal fue la aparición de un evento adverso compuesto en los tres primeros meses tras el alta. RESULTADOS: Se incluyeron 750 pacientes con edad media de 68,1 años (DE 19,5), de los cuales 357 (47,6%) fueron varones, 262 (36%) pacientes sufrieron un evento adverso a los 3 meses. De ellos, 156 (31,5%) fueron no diabéticos, 77 (41,8%) diabéticos y 29 (59,2%) NHG (p < 0,001). En los pacientes con alteración hidrocarbonada, el tener un tratamiento antidiabético no congruente al alta de una UCE fue un factor de riesgo independiente de sufrir un eventoadverso a 3 meses del alta [OR ajustada 7,2 (IC 95%: 3,9-13,3)]. CONCLUSIONES: Un tratamiento antidiabético no adecuado al alta de una UCE se muestra como un factor independiente de sufrir un evento adverso en los tres primeros meses.

Somos jóvenes. Educamos a nuestros hijos / We're still young: let's educate the next generation

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Efecto de la adecuación al alta del tratamiento antidiabético en los resultados a 90 días en los pacientes ingresados en una unidad de corta estancia / Adjustment of antidiabetic treatment regimens on discharge from the emergency department: effect on 90-day outcomes in patients admitted to a short-stay unit

Objetivo. Determinar si el adecuado tratamiento al alta de la hiperglucemia en pacientes atendidos en una unidad de corta estancia (UCE) es un factor relacionado con la reducción de eventos adversos a tres meses tras el alta. Método. Estudio de cohorte retrospectivo que incluyó los pacientes ingresados en una UCE durante el mes de junio de 2011. Se incluyeron variables demográficas, comorbilidad, causa de ingreso y congruencia del tratamiento antidiabético al alta. Se clasificó a los pacientes en diabéticos, no diabéticos y nuevos hiperglucémicos (NHG), y en aquellos con alteración del metabolismo hidrocarbonado, la variable clasificadora fue la congruencia del tratamiento antidiabético al alta. La variable de resultado principal fue la aparición de un evento adverso compuesto en los tres primeros meses tras el alta. Resultados. Se incluyeron 750 pacientes con edad media de 68,1 años (DE 19,5), de los cuales 357 (47,6%) fueron varones, 262 (36%) pacientes sufrieron un evento adverso a los 3 meses. De ellos, 156 (31,5%) fueron no diabéticos, 77 (41,8%) diabéticos y 29 (59,2%) NHG (p < 0,001). En los pacientes con alteración hidrocarbonada, el tener un tratamiento antidiabético no congruente al alta de una UCE fue un factor de riesgo independiente de sufrir un evento adverso a 3 meses del alta [OR ajustada 7,2 (IC 95%: 3,9-13,3)]. Conclusiones. Un tratamiento antidiabético no adecuado al alta de una UCE se muestra como un factor independiente de sufrir un evento adverso en los tres primeros meses (AU)

Objective. To determine whether the adjustment of antidiabetic treatment of patients discharged from a short-stay unit (SSU) after a hyperglycemic crisis reduces the rate of adverse events in the next 90 days. Methods. Retrospective study of patients admitted to an emergency SSU in June 2011. We gathered information on patient demographics, concurrent diseases, reason for admission, and appropriateness of antidiabetic treatment on discharge. Patients were classified as diabetic, nondiabetic, or newly hyperglycemic. Patients with altered carbohydrate metabolism were subclassified according to the appropriateness of the antidiabetic treatment prescribed on discharge. The main outcome variable was the occurrence of an adverse event within 90 days of discharge. Results. We included 750 patients with a mean (SD) age of 68.1 (19.5) years; 357 (47.6%) were men. A new adverse event occurred in 262 (36%) patients within 90 days; 15.6 (31.5%) of these patients were not diabetic, 77 (41.8%) were diabetic, and 29 (59.2%) were newly hyperglycemic (P<.001). Failure to provide an appropriate antidiabetic regimen when discharging patients with altered carbohydrate metabolism was an independent risk factor for an adverse event within 90 days (adjusted odds ratio, 7.2; 95% CI, 3.9-13.3). Conclusion. Lack of appropriate antidiabetic treatment after discharge from an emergency SSU is a risk factor for adverse events within 90 days (AU)

[Frequent attenders in Primary Health Care Centres and frequent attenders in Emergency Departments]. / Hiperfrecuentación en Atención Primaria e hiperfrecuentadores en Urgencias.

OBJECTIVE: To identify predictors of frequent attenders (HF) in Primary Health Care (PHC) centres in a sample of frequent attenders (HF) in Emergency Departments (ED). DESIGN: This was an observational, retrospective, multicentre cohort study. PARTICIPANTS: The HF patients were selected from patients seen in the ED between January 1 and December 31, 2013. Setting Patients were recruited from 17 public hospitals of the Community of Madrid, Spain. METHOD: Variables on the index visit to the ED were collected. The sample was analysed in terms of being or not being an HF user in PHC. An HF user is considered a patient who made at least 10 visits in each level of care for a year. RESULTS: A total of 1284 HF patients were included. An analysis was performed on 423 (32.9%) HF users in ED with 16 (12-25) visits to PHC vs. 861 (67.1%) non-HF users in ED, with 4 (2-6) visits to PHC. Independent predictors of HF in PHC: over 65 years (OR: 1.51; 95% CI: 1.07-2.13; P=.019), cognitive impairment (OR: 1.63; 95% CI: 1.01-2.65; P=.049), taking >3 drugs (OR: 1.56; 95% CI: 1.06-2.30; P=.025), and living in the community vs. nursing home or homeless (OR: 3.05; 95% CI: 1.14-8.16; P=.026). CONCLUSIONS: Among HF patients in the ED, the fact that of being over 65 years, taking 3or more drugs, suffering cognitive impairment, and living in the community, are also considered to be predictors of HF in PHC.