Respiratory syncytial virus: A new era / Virus respiratorio sincitial: un nuevo tiempo

Respiratory syncytial virus (RSV) is a major public health problem that has undergone significant changes in recent years. First of all, it has become easier to diagnose with highly reliable and rapidly available confirmatory tests. This has led to a better understanding of its epidemiology and RSV has gone from being a disease of the pediatric age group, severe only in infants and immunosuppressed children, to being a common disease in people of all ages, particularly important in patients of advanced age or with immunosuppressive diseases. Recent therapeutic and prophylactic advances, both with long-lasting monoclonal antibodies and vaccines, are another reason for satisfaction. For these reasons, the COVID and Emerging Pathogens Committee of the Illustrious Official College of Physicians of Madrid (ICOMEM) has considered it pertinent to review this subject in the light of new knowledge and new resources for dealing with this infection. We have formulated a series of questions that we believe will be of interest not only to members of the College but also to any non-expert in this subject, with a particular focus on the situation of RSV infection in Spain. (AU)

El Virus Respiratorio Sincitial (VRS), es un problema de salud pública de primera magnitud que en años recientes ha experimentado cambios muy importantes. En primer lugar, se ha producido una mayor facilidad diagnóstica con pruebas confirmatorias altamente fiables y rápidamente disponibles. Esto ha permitido conocer mejor su epidemiología y VRS ha pasado de ser una enfermedad de la edad pediátrica, grave sólo en lactantes y niños inmunodeprimidos, a ser una enfermedad común en personas de toda edad, particularmente importante en pacientes de edades avanzadas o con enfermedades que inmunodeprimen. Los avances terapéuticos y profilácticos, recientes, tanto con anticuerpos monoclonales de larga duración como con vacunas, constituyen otro motivo de satisfacción. Por estos motivos, el Comité de COVID y de patógenos emergentes del Ilustre Colegio Oficial de Médicos de Madrid (ICOMEM) ha considerado pertinente revisar este tema, a la luz de los nuevos conocimientos y de los nuevos recursos para afrontar esta infección. Hemos formulado una serie de preguntas que creemos de interés no sólo para los colegiados si no para cualquier persona no experta en este tema, con una vista particular en la situación de la infección por VRS en España. (AU)

[Negative stereotypes of old age in new resident medical interns]. / Estereotipos negativos de la vejez en los nuevos médicos internos residentes.

OBJECTIVES: To determine the presence of negative stereotypes of old age in new medical intern residents (MIR) of the Community of Madrid. MATERIAL AND METHODS: A descriptive cross-sectional survey study of first year MIRs was carried out anonymously during the process of registration at the Madrid College of Physicians between 25/03 and 26/05 of 2023. The Questionnaire of Negative Stereotypes towards Old Age (CENVE) and the Let's Fight All Together Against Ageism (LTJCE) survey were used. RESULTS: A total of 829 new MIRs were included, with a mean age of 26.0 (standard deviation [SD]=3.5) years. According to the LTJCE survey, 29.1% consider that in general older people are similar to each other; 47.5%, that deterioration of health in old age is inevitable, 26.8% that old age begins at 60 years; 30.5%, that age per se is a determinant when making clinical decisions and 31.0%, that aging is an obstacle that we must overcome in order to lead a healthy life. The mean total score of the CENVE scale (range 15-60) was 28.3 (SD=7.0) and the means of the different factors (range 5-20) were 8.6 (SD=2.8) for health; 9.8 (SD=2.6) for motivational-social; 10.0 (SD=2.7) for character-personality. CONCLUSIONS: Most new MIRs do not present old age-related stereotypes.

Utilidad de la combinación de biomarcadores de respuesta inflamatoria y escalas clínicas para la estratificación del riesgo en pacientes atendidos en urgencias por sospecha de infección / Usefulness of combining inflammatory biomarkers and clinical scales in an emergency department to stratify risk in patients with infections

Objetivo. Investigar si la combinación de biomarcadores de respuesta inflamatoria (BMRI) y escalas clínicas mejora la estratificación pronóstica de pacientes atendidos en servicios de urgencias hospitalarios (SUH) por sospecha de infección. Método. Estudio analítico, observacional y prospectivo que incluyó pacientes con sospecha de infección atendidos en un SUH. Se recogieron variables demográficas, comorbilidades, datos clínicos a la llegada al SUH, foco de infección y los siguientes BMRI: leucocitos, proteína C reactiva, procalcitonina, lactato y región medial de la proadrenomodulina (MR-proADM). Se calcularon los valores de las escalas SIRS (síndrome de respuesta inflamatoria sistémica), qSOFA (quick Sequential Organ Failure Assessment) y NEWS (National Early Warning Score). La variable de resultado principal fue una compuesta que incluía mortalidad a 30 días o necesidad de ingreso en la unidad de cuidados intensivos (UCI). Resultados. Se incluyeron 473 pacientes, con una edad media de 70 (DE 19) años y el 54,3% (257). Hubo 31 fallecimientos (6,6%) y 16 (3,4%) ingresos en UCI. La variable de resultado se produjo en 45 (9,5%) pacientes. La MR-proADM mostró la mejor área bajo la curva de la característica operativa del receptor (ABC-COR) en comparación con el resto de biomarcadores y escalas clínicas [0,739 (IC 95% 0,671-0,809)], aunque sin diferencias respecto a lactato (p = 0,144) ni a la escala NEWS (p = 0,064). Al combinar MR-proADM con los diferentes biomarcadores y escalas clínicas, no se obtuvo ninguna combinación que mejore significativamente la precisión pronóstica individual del MR-proADM. Conclusiones. La estratificación del riesgo de los pacientes con infección es una cuestión clave para la toma de decisiones en los SUH. La determinación de MR-proADM supera a otros BMRI y escalas clínicas para la estratificación pronóstica de los pacientes a corto plazo en los SUH... (AU)

Objective. To determine whether combining biomarkers of inflammatory response and clinical scales can improve risk stratification of patients with suspected infection in a hospital emergency department (ED). Methods. Prospective observational study of ED patients treated for infections. We collected the following information on arrival: demographic and baseline clinical data, comorbidities, the focus of infection, and values for the following inflammatory biomarkers: leukocyte counts, and C-reactive protein, procalcitonin, and midregional proadrenomedullin (MR-proADM) concentrations. Scores on the following clinical scales were recorded based on the variables gathered: the SIRS (Systemic Inflammatory Response Syndrome) criteria, the qSOFA (Quick Sequential Organ Failure Assessment), and the NEWS (National Early Warning Score). The main outcome was a composite measure that included 30-day death or need for intensive care unit (ICU) admission. Results. A total of 473 patients with a mean (SD) age of 70.3 (19.2) years were included. The majority were men (257, 54.3%). Thirty-one (6.6%) died within 30 days and 16 (3.4%) were admitted to the ICU. The composite outcome (death or ICU admission) occurred in 45 patients (9.5%). The MR-proADM concentration, with an area under the receiver operating characteristic curve of 0.739 (95% CI, 0671-0.809) was a better predictor than the other biomarkers or clinical scales, although the differences between MR-proADM and either lactate concentration or the NEWS were not significant in the comparisons (P = .064). Combining the MR-proADM concentration with any of the scales did not significantly improve risk prediction. Conclusions. Risk stratification of patients with infection is a key part of ED decision-making. MR-proADM concentration is superior to other biomarkers and clinical prediction scales for predicting short-term prognosis in the ED... (AU)

Utilidad de la región medial de la pro-adrenomodulina para la detección de bacteriemia verdadera en pacientes mayores atendidos en urgencias por sospecha de infección / Utility of the medial region of pro-adrenomodulin for the detection of true bacteremia in elderly patients treated in the emergency department for suspected infection

Introducción. La predicción de bacteriemia en urgencias es importante para la toma de decisiones iniciales. La población mayor un reto diagnóstico. El objetivo fue evaluar la capacidad de la región medial de la pro-adrenomodulina (MR-proADM) para identificar bacteriemia verdadera (BV) en pacientes mayores atendidos en tres servicios de urgencias. Metodología. Estudio observacional incluyendo pacientes ≥75 años atendidos por sospecha de infección en los que se extrajo un hemocultivo (HC). Se recogieron variables sociodemográficas, comorbilidad, hemodinámicas, analíticas y biomarcadores [MR-proADM, procalcitonina (PCT), proteína C reactiva (PCR) y lactato]. La variable de resultado fue un verdadero positivo en el hemocultivo. Resultados. Se incluyeron 109 pacientes con edad media de 83 (DE 5,5) años. En 22 pacientes (20,2%) se obtuvo un diagnóstico final de BV. Las variables independientes para predecirla fueron PCT (OR13,9; IC95%: 2,702-71,703; p=0,002), MR-proADM (OR4,081; IC95%: 1,026-16,225; p=0,046) y temperatura (OR 2,171; IC95%: 1,109-4,248; p=0,024). Considerando el punto de corte con mayor rendimiento diagnóstico para el MR-proADM (2,13 mg/dl), se obtuvo una sensibilidad (Se) de 73%, una especificidad (E) de 71%, un valor predictivo positivo (VPP) de 39%, un valor predictivo negativo (VPN) de 91%, un coeficiente de verosimilitud positivo (LHR+) de 2,53 y un coeficiente de verosimilitud negativo (LHR-) de 0,38; para PCT (0,76 mg/dl) se obtuvo una Se de 90%, E de 65%, VPP de 40%, VPN de 96%, LHR+ 2,64 y un LHR– de 0,14. Al combinar ambos, se observó una Se de 69%, E de 84%, VPP de 52%, VPN de 91%, LHR+ de 4,24 y un LHR- de 0,38. Conclusión. Niveles elevados de PCT y MR-proADM se asocian a un riesgo incrementado de BV y la combinación de ambos mejora la capacidad para identificar estos pacientes. (AU)

Background. The prediction of bacteremia in the emergency department (ER) is important for initial decision-making. The elderly population is a diagnosis challenge. The objective was to evaluate the accuracy of mid regional pro-adrenomedullin (MR-proADM) to identify true bacteremia (BV) in elderly patients attended in 3 hospital emergency departments. Methods. Observational study including patients ≥75 years of age or older attended in the ER for suspected infection in whom a blood culture (BC) was extracted. Sociodemographic, comorbidity, hemodynamic and analytical variables, biomarkers [MR-proADM, procalcitonin (PCT), C-reactive protein (CRP) and lactate] and final diagnosis were collected. The primary outcome was a true positive on a blood culture. Results. A total of 109 patients with a mean age of 83 (SD: 5.5) years were included. A final diagnosis of BV was obtained in 22 patients (20.2%). The independent variables to predict it were PCT (OR: 13.9; CI95%: 2.702-71.703; p=0.002), MR-proADM (OR: 4.081; CI95%: 1.026-16.225; p=0.046) and temperature (OR: 2.171; CI95%: 1.109-4.248; p=0.024). Considering the cut-off point for MR-proADM (2.13 mg/dl), a sensitivity (Se) of 73%, specificity (E) of 71%, a positive predictive value (PPV) of 39%, a negative predictive value (NPV) of 91%, a positive likelihood ratio (LHR+) of 2.53 and a negative likelihood ratio (LHR-) of 0.38; for PCT (0.76 mg/dl) a Se of 90%, E of 65%, PPV of 40%, NPV of 96%, LHR+ 2,64 and a LHR- of 0.14 were obtained. When combining both, a Se of 69%, E of 84%, PPV of 52%, NPV of 91%, LHR+ of 4.24 and LHR- of 0.38 were observed. Conclusions. Elevated levels of PCT and MR-proADM were independently associated with an increased risk of BV and the combination of both improves the accuracy to identify these patients. (AU)

Usefulness of combining inflammatory biomarkers and clinical scales in an emergency department to stratify risk in patients with infections. / Utilidad de la combinación de biomarcadores de respuesta inflamatoria y escalas clínicas para la estratificación del riesgo en pacientes atendidos en urgencias por sospecha de infección.

OBJECTIVES: To determine whether combining biomarkers of inflammatory response and clinical scales can improve risk stratification of patients with suspected infection in a hospital emergency department (ED). MATERIAL AND METHODS: Prospective observational study of ED patients treated for infections. We collected the following information on arrival: demographic and baseline clinical data, comorbidities, the focus of infection, and values for the following inflammatory biomarkers: leukocyte counts, and C-reactive protein, procalcitonin, and midregional proadrenomedullin (MR-proADM) concentrations. Scores on the following clinical scales were recorded based on the variables gathered: the SIRS (Systemic Inflammatory Response Syndrome) criteria, the qSOFA (Quick Sequential Organ Failure Assessment), and the NEWS (National Early Warning Score). The main outcome was a composite measure that included 30-day death or need for intensive care unit (ICU) admission. RESULTS: A total of 473 patients with a mean (SD) age of 70.3 (19.2) years were included. The majority were men (257, 54.3%). Thirty-one (6.6%) died within 30 days and 16 (3.4%) were admitted to the ICU. The composite outcome (death or ICU admission) occurred in 45 patients (9.5%). The MR-proADM concentration, with an area under the receiver operating characteristic curve of 0.739 (95% CI, 0671-0.809) was a better predictor than the other biomarkers or clinical scales, although the differences between MR-proADM and either lactate concentration or the NEWS were not significant in the comparisons (P = .064). Combining the MR-proADM concentration with any of the scales did not significantly improve risk prediction. CONCLUSION: Risk stratification of patients with infection is a key part of ED decision-making. MR-proADM concentration is superior to other biomarkers and clinical prediction scales for predicting short-term prognosis in the ED. Combining MR-proADM measurement with other scales or measures does not improve the yield.

OBJETIVO: Investigar si la combinación de biomarcadores de respuesta inflamatoria (BMRI) y escalas clínicas mejora la estratificación pronóstica de pacientes atendidos en servicios de urgencias hospitalarios (SUH) por sospecha de infección. METODO: Estudio analítico, observacional y prospectivo que incluyó pacientes con sospecha de infección atendidos en un SUH. Se recogieron variables demográficas, comorbilidades, datos clínicos a la llegada al SUH, foco de infección y los siguientes BMRI: leucocitos, proteína C reactiva, procalcitonina, lactato y región medial de la proadrenomodulina (MR-proADM). Se calcularon los valores de las escalas SIRS (síndrome de respuesta inflamatoria sistémica), qSOFA (quick Sequential Organ Failure Assessment) y NEWS (National Early Warning Score). La variable de resultado principal fue una compuesta que incluía mortalidad a 30 días o necesidad de ingreso en la unidad de cuidados intensivos (UCI). RESULTADOS: Se incluyeron 473 pacientes, con una edad media de 70 (DE 19) años y el 54,3% (257). Hubo 31 fallecimientos (6,6%) y 16 (3,4%) ingresos en UCI. La variable de resultado se produjo en 45 (9,5%) pacientes. La MR-proADM mostró la mejor área bajo la curva de la característica operativa del receptor (ABC-COR) en comparación con el resto de biomarcadores y escalas clínicas [0,739 (IC 95% 0,671-0,809)], aunque sin diferencias respecto a lactato (p = 0,144) ni a la escala NEWS (p = 0,064). Al combinar MR-proADM con los diferentes biomarcadores y escalas clínicas, no se obtuvo ninguna combinación que mejore significativamente la precisión pronóstica individual del MR-proADM. CONCLUSIONES: La estratificación del riesgo de los pacientes con infección es una cuestión clave para la toma de decisiones en los SUH. La determinación de MR-proADM supera a otros BMRI y escalas clínicas para la estratificación pronóstica de los pacientes a corto plazo en los SUH. La combinación con otros biomarcadores o escalas clínicas no mejora su capacidad pronóstica.

Utilidad de la combinación de biomarcadores de respuesta inflamatoria y escalas clínicas para la estratificación del riesgo en pacientes atendidos en urgencias por sospecha de infección / Usefulness of combining inflammatory biomarkers and clinical scales in an emergency department to stratify risk in patients with infections

Objetivo. Investigar si la combinación de biomarcadores de respuesta inflamatoria (BMRI) y escalas clínicas mejora la estratificación pronóstica de pacientes atendidos en servicios de urgencias hospitalarios (SUH) por sospecha de infección. Método. Estudio analítico, observacional y prospectivo que incluyó pacientes con sospecha de infección atendidos en un SUH. Se recogieron variables demográficas, comorbilidades, datos clínicos a la llegada al SUH, foco de infección y los siguientes BMRI: leucocitos, proteína C reactiva, procalcitonina, lactato y región medial de la proadrenomodulina (MR-proADM). Se calcularon los valores de las escalas SIRS (síndrome de respuesta inflamatoria sistémica), qSOFA (quick Sequential Organ Failure Assessment) y NEWS (National Early Warning Score). La variable de resultado principal fue una compuesta que incluía mortalidad a 30 días o necesidad de ingreso en la unidad de cuidados intensivos (UCI). Resultados. Se incluyeron 473 pacientes, con una edad media de 70 (DE 19) años y el 54,3% (257). Hubo 31 fallecimientos (6,6%) y 16 (3,4%) ingresos en UCI. La variable de resultado se produjo en 45 (9,5%) pacientes. La MR-proADM mostró la mejor área bajo la curva de la característica operativa del receptor (ABC-COR) en comparación con el resto de biomarcadores y escalas clínicas [0,739 (IC 95% 0,671-0,809)], aunque sin diferencias respecto a lactato (p = 0,144) ni a la escala NEWS (p = 0,064). Al combinar MR-proADM con los diferentes biomarcadores y escalas clínicas, no se obtuvo ninguna combinación que mejore significativamente la precisión pronóstica individual del MR-proADM. Conclusiones. La estratificación del riesgo de los pacientes con infección es una cuestión clave para la toma de decisiones en los SUH. La determinación de MR-proADM supera a otros BMRI y escalas clínicas para la estratificación pronóstica de los pacientes a corto plazo en los SUH... (AU)

Objective. To determine whether combining biomarkers of inflammatory response and clinical scales can improve risk stratification of patients with suspected infection in a hospital emergency department (ED). Methods. Prospective observational study of ED patients treated for infections. We collected the following information on arrival: demographic and baseline clinical data, comorbidities, the focus of infection, and values for the following inflammatory biomarkers: leukocyte counts, and C-reactive protein, procalcitonin, and midregional proadrenomedullin (MR-proADM) concentrations. Scores on the following clinical scales were recorded based on the variables gathered: the SIRS (Systemic Inflammatory Response Syndrome) criteria, the qSOFA (Quick Sequential Organ Failure Assessment), and the NEWS (National Early Warning Score). The main outcome was a composite measure that included 30-day death or need for intensive care unit (ICU) admission. Results. A total of 473 patients with a mean (SD) age of 70.3 (19.2) years were included. The majority were men (257, 54.3%). Thirty-one (6.6%) died within 30 days and 16 (3.4%) were admitted to the ICU. The composite outcome (death or ICU admission) occurred in 45 patients (9.5%). The MR-proADM concentration, with an area under the receiver operating characteristic curve of 0.739 (95% CI, 0671-0.809) was a better predictor than the other biomarkers or clinical scales, although the differences between MR-proADM and either lactate concentration or the NEWS were not significant in the comparisons (P = .064). Combining the MR-proADM concentration with any of the scales did not significantly improve risk prediction. Conclusions. Risk stratification of patients with infection is a key part of ED decision-making. MR-proADM concentration is superior to other biomarkers and clinical prediction scales for predicting short-term prognosis in the ED... (AU)

Ten Issues for Updating in Community-Acquired Pneumonia: An Expert Review.

Community-acquired pneumonia represents the third-highest cause of mortality in industrialized countries and the first due to infection. Although guidelines for the approach to this infection model are widely implemented in international health schemes, information continually emerges that generates controversy or requires updating its management. This paper reviews the most important issues in the approach to this process, such as an aetiologic update using new molecular platforms or imaging techniques, including the diagnostic stewardship in different clinical settings. It also reviews both the Intensive Care Unit admission criteria and those of clinical stability to discharge. An update in antibiotic, in oxygen, or steroidal therapy is presented. It also analyzes the management out-of-hospital in CAP requiring hospitalization, the main factors for readmission, and an approach to therapeutic failure or rescue. Finally, the main strategies for prevention and vaccination in both immunocompetent and immunocompromised hosts are reviewed.

Elderly patients in the Emergency Department: Which patients should be selected for a different approach?

Background: While multidimensional and interdisciplinary assessment of older adult patients improves their short-term outcomes after evaluation in the emergency department (ED), this assessment is time-consuming and ill-suited for the busy environment. Thus, identifying patients who will benefit from this strategy is challenging. Therefore, this study aimed to identify older adult patients suitable for a different ED approach as well as independent variables associated with poor short-term clinical outcomes. Methods: We included all patients ≥65 years attending 52 EDs in Spain over 7 d. Sociodemographic, comorbidity, and baseline functional status data were collected. The outcomes were 30-day mortality, re-presentation, hospital readmission, and the composite of all outcomes. Results: During the study among 96,014 patients evaluated in the ED, we included 23,338 patients ≥65 years (mean age 78.4 [SD 8.1] years, 12,626 (54.1%) women). During follow-up, 5,776 (24.75) patients had poor outcomes after evaluation in the ED: 1,140 (4.88%) died, 4,640 (20.51) returned to the ED, and 1,739 (7.69) were readmitted 30 d after discharge following the index visit. A model including male sex, age ≥75 years, arrival by ambulance, Charlson Cormorbidity Index ≥3, and functional impairment had a C-index of 0.81 (0.80-0.82) for 30-day mortality. Conclusion: Male sex, age ≥75 years, arrival by ambulance, functional impairment, or severe comorbidity are features of patients who could benefit from approaches in the ED different from the common triage to improve the poor short-term outcomes of this population.

Impact of the MEESSI-AHF tool to guide disposition decision-making in patients with acute heart failure in the emergency department: a before-and-after study.

OBJECTIVES: To determine the impact of risk stratification using the MEESSI-AHF (Multiple Estimation of risk based on the Emergency department Spanish Score In patients with acute heart failure) scale to guide disposition decision-making on the outcomes of ED patients with acute heart failure (AHF), and assess the adherence of emergency physicians to risk stratification recommendations. METHODS: This was a prospective quasi-experimental study (before/after design) conducted in eight Spanish EDs which consecutively enrolled adult patients with AHF. In the pre-implementation stage, the admit/discharge decision was performed entirely based on emergency physician judgement. During the post-implementation phase, emergency physicians were advised to 'discharge' patients classified by the MEESSI-AHF scale as low risk and 'admit' patients classified as increased risk. Nonetheless, the final decision was left to treating emergency physicians. The primary outcome was 30-day all-cause mortality. Secondary outcomes were days alive and out of hospital, in-hospital mortality and 30-day post-discharge combined adverse event (ED revisit, hospitalisation or death). RESULTS: The pre-implementation and post-implementation cohorts included 1589 and 1575 patients, respectively (median age 85 years, 56% females) with similar characteristics, and 30-day all-cause mortality was 9.4% and 9.7%, respectively (post-implementation HR=1.03, 95% CI=0.82 to 1.29). There were no differences in secondary outcomes or in the percentage of patients entirely managed in the ED without hospitalisation (direct discharge from the ED, 23.5% vs 24.4%, OR=1.05, 95% CI=0.89 to 1.24). Adjusted models did not change these results. Emergency physicians followed the MEESSI-AHF-based recommendation on patient disposition in 70.9% of cases (recommendation over-ruling: 29.1%). Physicians were more likely to over-rule the recommendation when 'discharge' was recommended (56.4%; main reason: need for hospitalisation for a second diagnosis) than when 'admit' was recommended (12.8%; main reason: no appreciation of severity of AHF decompensation by emergency physician), with an OR for over-ruling the 'discharge' compared with the 'admit' recommendation of 8.78 (95% CI=6.84 to 11.3). CONCLUSIONS: Implementing the MEESSI-AHF risk stratification tool in the ED to guide disposition decision-making did not improve patient outcomes.

Advantages and disadvantages of maintaining the mandatory use of masks in health centers and nursing homes in Spain. How and when is it justified to maintain it? / Ventajas e inconvenientes de mantener la obligatoriedad del uso de las mascarillas en centros sanitarios y sociosanitarios en España. ¿Cómo y cuándo está justificado mantenerla?

We address the advantages and disadvantages of main taining the mandatory use of masks in health centers and nursing homes in the current epidemiological situation in Spain and after the declaration of the World Health Organiza tion on May 5, 2023 of the end of COVID-19 as public health emergency. We advocate for prudence and flexibility, respect ing the individual decision to wear a mask and emphasizing the need for its use when symptoms suggestive of a respira tory infection appear, in situations of special vulnerability (such as immunosuppression), or when caring for patients with those infections. At present, given the observed low risk of se vere COVID-19 and the low transmission of other respiratory infections, we believe that it is disproportionate to maintain the mandatory use of masks in a general way in health centers and nursing homes. However, this could change depending on the results of epidemiological surveillance and it would be necessary to reconsider returning to the obligation in periods with a high incidence of respiratory infections (AU)

Abordamos las ventajas e inconvenientes de mantener la obligatoriedad del uso de las mascarillas en centros sani tarios y sociosanitarios en la situación epidemiológica actual de España y tras la declaración de la Organización Mundial de la Salud el 5 de mayo de 2023 del fin de la COVID-19 como emergencia de salud pública. Propugnamos prudencia y flexi bilidad, respetando la decisión individual de usar mascarilla y enfatizando la necesidad de su uso ante la aparición de sín tomas sugestivos de infección respiratoria, en situaciones de especial vulnerabilidad (como inmunodepresión) o al attender pacientes con dichas infecciones. En la actualidad, dado el ba jo riesgo observado de COVID-19 grave y la baja transmisión de otras infecciones respiratorias, creemos que es despropor cionado mantener el uso obligatorio de mascarillas de forma generalizada en centros sanitarios y sociosanitarios. No obs tante, esto podría cambiar en función de los resultados de la vigilancia epidemiológica y habría que reconsiderar volver a la obligatoriedad en periodos con alta incidencia de infecciones respiratorias (AU)

Decisions to admit vs. discharge patients with acute heart failure from the emergency department: consistency with a measure of severity of decompensation and the impact on prognosis. / Decisión de hospitalización o alta en pacientes con insuficiencia cardiaca aguda en urgencias, su adecuación con la gravedad de la descompensación e impacto pronóstico.

OBJECTIVES: To analyze the consistency between decisions to discharge or admit patients with acute heart failure (AHF) treated in emergency departments (EDs) and the level of risk of adverse events, and to analyze the impact of decisions to discharge patients. MATERIAL AND METHODS: Prospective study of baseline clinical data collected from patients diagnosed with AHF in 16 Spanish emergency departments. Patients were stratified by severity of decompensated AHF based on MEESSI assessment (Multiple Estimation of Risk Based on the Spanish Emergency Department Score). The distribution of severity was described for patients who were hospitalized (overall and for departments receiving the largest number of admissions) and for discharged patients. We analyzed the data for discharged patients for associations with the following quality-of-care indicators: all-cause mortality of less than 2% at 30 days, revisits to the ED for AHF in less than 10% of patients within 7 days of discharge, and revisits to the ED or admission for AHF in less than 20% within 30 days of discharge. RESULTS: We included 2855 patients with a median (interquartile range) age of 84 (76-88) years. Fifty-four percent were women, 1042 (36.5%) were classified as low risk, 1239 (43.4%) as intermediate risk, 301 (10.5%) as high risk, and 273 (9.6%) as very high risk. Thirty-day mortality rates by level of low to very high risk were 1.9%, 9.3%, 15.3%, and 38.4%, respectively. One-year mortality rates by risk level were 15.4%, 35.6%, 52.0%, and 74.2%. Admission rates by risk level were 62.2%, 77.4%, 87.0%, and 88.3%. Overall, 47.1% o patients discharged from the ED were in the 3 higher-risk categories (intermediate to very high), and 30.7% were in the lowest risk category. The 5 hospital areas receiving the most admissions, in order of lowest-to-highest risk classification, were internal medicine, the short-stay unit, cardiology, intensive care, and geriatrics. Rates and 95% CIs for quality-of-care indicators in patients discharged from EDs were as follows: 30-day mortality, 4.3% (3.0%-6.1%); ED revisits within 7 days, 11.4% (9.2%-14.0%), and ED revisits or admissions within 30 days, 31.5% (28.0%-35.1%). In patients classified as low risk on ED discharge, these percentages were lower, as follows, respectively: 0.5% (0.1%-1.8%), 10.5% (7.6%-14.0%), and 29.5% (26.6%-32.6%). CONCLUSION: We detected disparity between severity of AHF decompensation and the decision to discharge or admit patients. Outcomes in patients discharged from EDs do not reach the recommended quality-of-care standards. Reducing inconsistencies between severity of decompensation and ED decisions could help to improve quality targets.

OBJETIVO: Analizar cómo se ajusta la decisión de ingreso o alta del paciente con insuficiencia cardiaca aguda (ICA) atendido en urgencias a su riesgo de evento adverso, así como su impacto en el pronóstico en aquellos dados de alta desde urgencias. METODO: Se recogieron datos basales y clínicos de pacientes diagnosticados de ICA en 16 servicios de urgencias españoles. Los pacientes se estratificaron según la gravedad de la descompensación mediante la escala MEESSI y se analizó la distribución de dicha gravedad en hospitalizados (en conjunto, e individualmente para los servicios con mayor número de hospitalizaciones) y dados de alta desde urgencias. En este último grupo, se analizó el cumplimiento de los siguientes indicadores de calidad: mortalidad por cualquier causa a 30 días ( 2%), reconsulta a urgencias por ICA a 7 días posalta ( 10%), y reconsulta a urgencias u hospitalización por ICA a 30 días posalta ( 20%). RESULTADOS: Se incluyeron 2.855 pacientes (edad mediana = 84 años, RIC = 76-88; mujeres = 54%): 1.042 pacientes (36,5%) de riesgo bajo, 1.239 (43,4%) intermedio, 301 (10,5%) alto y 273 (9,6%) muy alto. La mortalidad a 30 días por categorías de riesgo fue 1,9%, 9,3%, 15,3% y 38,4%, respectivamente; la mortalidad al año 15,4%, 35,6%, 52,0% y 74,2%; y la hospitalización 62,2%, 77,4%, 87,0% y 88,3%. El 47,1% de pacientes dados de alta de urgencias tenía un riesgo incrementado (intermedio, alto o muy alto) y el 30,7% de hospitalizados eran de bajo riesgo. La gravedad de la descompensación según el servicio de hospitalización se incrementaba en el siguiente orden: medicina interna, corta estancia, cardiología, intensivos y geriatría. El 4,3% de pacientes dados de alta de urgencias (IC 95%: 3,0-6,1) falleció a los 30 días, el 11,4% (9,2-14,0) reconsultó en urgencias a los 7 días, y el 31,5% (28,0-35,1) reconsultó en urgencias o se hospitalizó a los 30 días. Si sólo se consideran los pacientes dados de alta de bajo riesgo, estos porcentajes descienden al 0,5% (0,1-1,8), 10,5% (7,6-14,0) y 29,5% (26,6-32,6), respectivamente. CONCLUSIONES: Existe disparidad entre la gravedad de la descompensación y la decisión en urgencias de hospitalizar o dar de alta a los pacientes con ICA. Los resultados que se obtienen en los pacientes dados de alta desde urgencias no alcanzan los estándares de calidad recomendados. Disminuir las incongruencias entre gravedad de la descompensación y toma de decisión podría contribuir a cumplir con estos estándares.

Comparing the utility of clinical risk scores and integrated clinical judgement in patients with suspected acute coronary syndrome.

AIMS: The utility of clinical risk scores regarding the prediction of major adverse cardiac events (MACE) is uncertain. We aimed to directly compare the prognostic performance of five established clinical risk scores as well as an unstructured integrated clinical judgement (ICJ) of the treating emergency department (ED) physician. METHODS AND RESULTS: Thirty-day MACE including all-cause death, life-threatening arrhythmia, cardiogenic shock, acute myocardial infarction (including the index event), and unstable angina requiring urgent coronary revascularization were centrally adjudicated by two independent cardiologists in patients presenting to the ED with acute chest discomfort in an international multicentre study. We compared the prognostic performance of the HEART score, GRACE score, T-MACS, TIMI score, and EDACS, as well as the unstructured ICJ of the treating ED physician (visual analogue scale to estimate the probability of acute coronary syndrome, ranging from 0 to 100). Among 4551 eligible patients, 1110/4551 patients (24.4%) had at least one MACE within 30 days. Prognostic accuracy was high and comparable for the HEART score, GRACE score, T-MACS, and ICJ [area under the receiver operating characteristic curve (AUC) 0.85-0.87] but significantly lower and only moderate for the TIMI score (AUC 0.79, P < 0.001) and EDACS (AUC 0.74, P < 0.001), resulting in sensitivities for the rule-out of 30-day MACE of 93-96, 87 (P < 0.001), and 72% (P < 0.001), respectively. CONCLUSION: The HEART score, GRACE score, T-MACS, and unstructured ICJ of the treating physician, not the TIMI score or EDACS, performed well for the prediction of 30-day MACE and may be considered for routine clinical use. TRIAL REGISTRATION: ClinicalTrials.gov number NCT00470587.

Análisis de la relación entre la contaminación del aire ambiente y la gravedad de las descompensaciones por insuficiencia cardiaca en dos metrópolis españolas (Barcelona y Madrid) / Analysis of the relationship between ambient air pollution and the severity of heart failure decompensations in two Spanish metropolises (Barcelona and Madrid)

Se estudiaron pacientes con IC descompensada en urgencias de 4 hospitales de Barcelona y 3 de Madrid. Se recogieron datos clínicos (edad, sexo, comorbilidades, situación funcional basal), atmosféricos (temperatura, presión atmosférica) y de contaminantes (SO2, NO2, CO, O3, PM10, PM2,5) el día de atención en urgencias. La gravedad de la descompensación se estimó mediante la mortalidad a 7 días (indicador primario) y la necesidad de hospitalización, mortalidad intrahospitalaria y hospitalización prolongada (indicadores secundarios). Se investigó la asociación ajustada por datos clínicos, atmosféricos y ciudad entre concentración de contaminantes y gravedad, mediante regresión logística (asunción de linealidad) y curvas spline cúbicas restringidas (no asunción de linealidad). Resultados Se incluyeron 5.292 descompensaciones, con edad mediana de 83 años (RIC=76-88) y 56% mujeres. Las medianas (RIC) de los promedios diarios de contaminantes fueron: SO2=2,5μg/m3 (1,4-7,0), NO2=43μg/m3 (34-57), CO=0,48mg/m3 (0,35-0,63), O3=35μg/m3 (25-48), PM10=22μg/m3 (15-31) y PM2,5=12μg/m3 (8-17). La mortalidad a 7 días fue del 3,9%, y la hospitalización, la mortalidad intrahospitalaria y la hospitalización prolongada, del 78,9, 6,9 y 47,5%, respectivamente. El SO2 fue el único contaminante que mostró asociación lineal con la gravedad de la descompensación, ya que cada unidad de incremento supuso una OR para necesidad de hospitalización de 1,04 (IC 95% 1,01-1,08). El estudio mediante curvas spline cúbicas restringidas tampoco mostró asociaciones nítidas entre contaminantes y gravedad, excepto para SO2 y hospitalización, con OR de 1,55 (IC 95% 1,01-2,36) y de 2,71 (IC 95% 1,13-6,49) para concentraciones de 15 y 24μg/m3, respectivamente, en relación con una concentración de referencia de 5μg/m3 (AU)

Objectives To analyze whether the high levels of air pollutants are related to a greater severity of decompensated heart failure (HF). Method Patients diagnosed with decompensated HF in the emergency department of 4 hospitals in Barcelona and 3 in Madrid were included. Clinical data (age, sex, comorbidities, baseline functional status), atmospheric (temperature, atmospheric pressure) and pollutant data (SO2, NO2, CO, O3, PM10, PM2.5) were collected in the city on the day of emergency care. The severity of decompensation was estimated using 7-day mortality (primary indicator) and the need for hospitalization, in-hospital mortality, and prolonged hospitalization (secondary indicators). The association adjusted for clinical, atmospheric and city data between pollutant concentration and severity was investigated using linear regression (linearity assumption) and restricted cubic spline curves (no linearity assumption). Results A total of 5292 decompensations were included, with a median age of 83 years (IQR=76-88) and 56% women. The medians (IQR) of the daily pollutant averages were: SO2=2.5μg/m3 (1.4-7.0), NO2=43μg/m3 (34-57), CO=0.48mg/m3 (0.35-0.63), O3=35μg/m3 (25-48), PM10=22μg/m3 (15-31) and PM2.5=12μg/m3 (8-17). Mortality at 7 days was 3.9%, and hospitalization, in-hospital mortality, and prolonged hospitalization were 78.9, 6.9, and 47.5%, respectively. SO2 was the only pollutant that showed a linear association with the severity of decompensation, since each unit of increase implied an OR for the need for hospitalization of 1.04 (95% CI 1.01-1.08). The restricted cubic spline curves study also did not show clear associations between pollutants and severity, except for SO2 and hospitalization, with OR of 1.55 (95% CI 1.01-2.36) and 2.71 (95% CI 1.13-6.49) for concentrations of 15 and 24μg/m3, respectively, in relation to a reference concentration of 5μg/m3 (AU)

Performance of 3 frailty scales for predicting adverse outcomes at 30 days in older patients discharged from emergency departments. / Rendimiento de tres escalas de fragilidad para predecir resultados adversos a 30 días en los pacientes mayores dados de alta en los servicios de urgencias.

OBJECTIVES: To compare the ability of 3 frailty scales (the Clinical Frailty Scale [CFS], the Functional Index - eMergency [FIM], and the Identification of Seniors at Risk [ISAR] scale) to predict adverse outcomes at 30 days in older patients discharged from hospital emergency departments (EDs). MATERIAL AND METHODS: Secondary analysis of data from the FRAIL-Madrid registry of patients aged 75 years or older who were discharged from Madrid EDs over a period of 3 months in 2018 and 2019. Frailty was defined by a CFS score over 4, a FIM score over 2, or an ISAR score over 3. The outcome variables were revisits to an ED, hospitalization, functional decline, death, and a composite variable of finding any of the previously named variables within 30 days of discharge. RESULTS: A total of 619 patients were studied. The mean (SD) age was 84 (7) years, and 59.1% were women. The CFS identified as frail a total of 339 patients (54.8%), the FIM 386 (62.4%), and the ISAR 301 (48.6%). An adverse outcome occurred within 30 days in 226 patients (36.5%): 21.5% revisited, 12.6% were hospitalized, 18.4% experienced functional decline, and 3.6% died. The areas under the receiver operating characteristic curves were as follows: CFS, 0.66 (95% CI, 0.62-0.70; P = .022); FIM, 0.67 (95% CI, 0.62-0.71; P = .021), and ISAR, 0.64 (95% CI, 0.60-0.69; P = .023). Adjusted odds ratios (aOR) showed that frailty was an independent risk factor for presenting any of the named adverse outcomes: aOR for CFS >4, 3.18 (95% CI, 2.02-5.01), P .001; aOR for FIM > 2, 3.49 (95% CI, 2.15-5.66), P .001; and aOR for ISAR >3, 2.46 (95% CI, 1.60-3.79), P .001. CONCLUSION: All 3 scales studied - the CFS, the FIM and the ISAR - are useful for identifying frail older patients at high risk of developing an adverse outcome (death, functional decline, hospitalization, or revisiting the ED) within 30 days after discharge.

OBJETIVO: Comparar la capacidad de tres escalas de fragilidad, Clinical Frailty Scale (CFS), Functional Index ­ eMergency (FIM) e Identification Senior at Risk (ISAR), para predecir resultados adversos (RA) a 30 días en los pacientes mayores dados de alta desde el servicio de urgencias hospitalario (SUH). METODO: Análisis secundario del registro FRAIL-Madrid que incluyó pacientes 75 años dados de alta de 10 SUH de Madrid durante un periodo de 3 meses entre 2018 y 2019. Se definió fragilidad como CFS 4, FIM 2 e ISAR 3. Las variables de resultado fueron revisita en urgencias, hospitalización, deterioro funcional, muerte y la variable compuesta por algún RA de los anteriores en los 30 días posteriores al alta del SUH. RESULTADOS: Se incluyeron 619 pacientes, la edad media fue de 84 años (DE 7), 59,1% eran mujeres. Hubo 339 pacientes (54,8%) identificados como frágiles en el SUH según CFS 4, 386 (62,4%) según FIM 2 y 301 (48,6%) según ISAR 3. Hubo 226 pacientes (36,5%) que presentaron algún RA a los 30 días tras el alta (21,5% revisita, 12,6% hospitalización,18,4% deterioro funcional y 3,6% muerte). El área bajo la curva (ABC) de la escala CFS fue de 0,66 (0,62-0,70; p = 0,022), de FIM 0,67 (0,62-0,71; p = 0,021) y de ISAR 0,64 (0,60-0,69; p = 0,023). La presencia de fragilidad fue un factor independiente de presentar algún RA a los 30 días tras el alta (CFS 4 ORa 3,18 [IC 95% 2,02-5,01, p 0,001], FIM 2 ORa 3,49 [IC 95% 2,15-5,66, p 0,001] e ISAR 3 ORa 2,46 [IC 95% 1,60-3,79, p 0,001]). CONCLUSIONES: Las tres escalas estudiadas ­CFS, FIM, ISAR­ son útiles y tienen una capacidad similar para identificar al paciente mayor frágil dado de alta del SUH con alto riesgo de presentar RA (muerte, deterioro funcional, hospitalización o revisita al SUH) a los 30 días.

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.

[Analysis of the relationship between ambient air pollution and the severity of heart failure decompensations in two Spanish metropolises (Barcelona and Madrid)]. / Análisis de la relación entre la contaminación del aire ambiente y la gravedad de las descompensaciones por insuficiencia cardiaca en dos metrópolis españolas (Barcelona y Madrid).

OBJECTIVES: To analyze whether the high levels of air pollutants are related to a greater severity of decompensated heart failure (HF). METHOD: Patients diagnosed with decompensated HF in the emergency department of 4 hospitals in Barcelona and 3 in Madrid were included. Clinical data (age, sex, comorbidities, baseline functional status), atmospheric (temperature, atmospheric pressure) and pollutant data (SO2, NO2, CO, O3, PM10, PM2.5) were collected in the city on the day of emergency care. The severity of decompensation was estimated using 7-day mortality (primary indicator) and the need for hospitalization, in-hospital mortality, and prolonged hospitalization (secondary indicators). The association adjusted for clinical, atmospheric and city data between pollutant concentration and severity was investigated using linear regression (linearity assumption) and restricted cubic spline curves (no linearity assumption). RESULTS: A total of 5292 decompensations were included, with a median age of 83 years (IQR=76-88) and 56% women. The medians (IQR) of the daily pollutant averages were: SO2=2.5µg/m3 (1.4-7.0), NO2=43µg/m3 (34-57), CO=0.48mg/m3 (0.35-0.63), O3=35µg/m3 (25-48), PM10=22µg/m3 (15-31) and PM2.5=12µg/m3 (8-17). Mortality at 7 days was 3.9%, and hospitalization, in-hospital mortality, and prolonged hospitalization were 78.9, 6.9, and 47.5%, respectively. SO2 was the only pollutant that showed a linear association with the severity of decompensation, since each unit of increase implied an OR for the need for hospitalization of 1.04 (95% CI 1.01-1.08). The restricted cubic spline curves study also did not show clear associations between pollutants and severity, except for SO2 and hospitalization, with OR of 1.55 (95% CI 1.01-2.36) and 2.71 (95% CI 1.13-6.49) for concentrations of 15 and 24µg/m3, respectively, in relation to a reference concentration of 5µg/m3. CONCLUSION: Exposure to ambient air pollutants, in a medium to low concentration range, is generally not related to the severity of HF decompensations, and only SO2 may be associated with an increased need for hospitalization.

Insights for COVID-19 in 2023 / Perspectivas de COVID-19 para 2023

Predictions for a near end of the pandemic by the World Health Organization should be interpreted with caution. Current evidence indicates that the efficacy of a fourth dose of classical mRNA vaccines (BT162b2 or mRNA-1273) is low and short-lived in preventing SARS-CoV-2 infection in its predominant variant (Omicron). However, its efficacy is high against severe symptomatic infection, hospitalization and death. The new vaccines being introduced are bivalent and active against the Omicron variants. Potential new vaccines to be introduced in the coming year include a vaccine based on a recombinant protein that emulates the receptor binding domain of the Spike protein under development by the Spanish company Hipra, as well as vaccines for nasal or oral administration. Available information suggests that vaccines against COVID-19 can be administered in association with influenza vaccination without particular complications. New drugs against COVID-19, both antiviral and anti-inflammatory, are under investigation, but this does not seem to be the case with monoclonal antibodies. The indication to use masks in some circumstances will be maintained next year in view of the accumulation of scientific data on their efficacy. Finally, the long COVID or Post-COVID syndrome may continue to affect a very high proportion of patients who have had the disease, requiring combined diagnostic and therapeutic resources. (AU)

Las predicciones para un próximo fin de la pandemia de la Organización Mundial de la Salud deben interpretarse con precaución. La evidencia actual indica que la eficacia de una cuarta dosis de las vacunas clásicas ARNm (BNT162b2 o mRNA-1273) es baja y de corta duración para prevenir la infección de SARS-CoV-2 en su variante predominante (Omicron). No obstante, su eficacia es alta frente a la infección sintomática grave, hospitalización y muerte. Las nuevas vacunas que están siendo introducidas son bivalentes y activas frente a las variantes Omicron. Entre las potenciales nuevas vacunas que se introducirán en el próximo año, se encuentra una vacuna basada en una proteína recombinante que emula el dominio de unión al receptor de la proteína Spike en desarrollo por la compañía española Hipra, así como vacunas de administración nasal u oral. La información disponible apunta a que las vacunas frente al COVID-19 podrán administrarse asociadas a la vacunación antigripal sin particulares complicaciones. Se encuentran en investigación nuevos fármacos frente a COVID-19 tanto antivirales como anti-inflamatorios pero no parece ocurrir lo mismo con los anticuerpos monoclonales. La indicación de utilizar mascarillas en algunas circunstancias se mantendrá el próximo año en vista a la acumulación de datos científicos sobre su eficacia. Finalmente, el síndrome del COVID largo o Post-COVID puede que siga afectando a una proporción muy elevada de los pacientes que sufrieron la enfermedad, requiriendo recursos diagnósticos y terapéuticos combinados. (AU)

Hospital development of heart failure follow-up units and short-term prognosis after acute decompensation in Spain.

OBJECTIVE: To investigate whether the existence of heart failure units (HFU) and link nurse units (LNU) in the hospital improve short-term outcomes of acute heart failure (AHF) episodes. METHODS: Patients with AHF diagnosed in 45 Spanish emergency departments were analysed according to whether the hospital had a complete development of follow-up units (HFU + LNU), partial (HFU or LNU) or none. The outcomes were: 30-day mortality, hospitalization, in-hospital mortality, >7 days admission, and adverse event (death, rehospitalisation, or reconsultation to the emergency department) at 30 days post-discharge. Outcomes were adjusted for baseline and AHF episode characteristics. RESULTS: 19,947 patients were included, median age was 82 years (IQR 76--87), women were 55%. It was 20% of patients attended in hospitals with null development, 28% with partial development and 52% with complete development. Mortality at 30 days was 10.1% (null/partial/complete development: 10.5%/9.5%/10.4%; p=0.880), hospitalization 74.6% (72.7%/72.7%/75.7%; p<0.001), in-hospital mortality 7.4% (7.6%/7.0%/7.5%; p=0.995), prolonged hospitalization 47.4% (51.1%/52.4%/43.5%; p<0.001) and adverse events 30 days post-hospitalization 30.3% (36.2%/28.9%/30.3%; p < 0.001). In the adjusted analysis, hospital with complete development of follow-up units was not associated with mortality, but with increased hospitalization (OR= 1.172; 95%CI 1.069-1.285) and lower prolonged hospitalization (OR = 0.725; 95%CI 0.660-0.797) and adverse events at 30 days post-discharge (OR=0.831; 95%CI 0.755-0.916). Partial development was only associated with decreased post-discharge adverse events (OR= 0.782; 95%CI 0.702-0.871). CONCLUSION: The development of follow-up units is not associated with 30-day mortality, but is associated with less prolonged hospitalization and fewer post-discharge adverse events in patients with AHF.