Factores predictivos de mortalidad en los pacientes con sepsis y un valor del indicador 'Quick Sequential Organ Failure Assessment' (qSOFA) de 2 o 3 puntos atendidos en un servicio de urgencias / Predictors of mortality in emergency department patients with sepsisscored 2 or 3 on the Quick Sequential Organ Failure Assessment scale

OBJETIVO. Determinar los factores predictivos de mortalidad de los pacientes que acuden a urgencias con sepsis y tiene un qSOFA de 2 o 3 puntos tras la implementación de un paquete de medidas a cumplimentar en las primeras 3 horas. MÉTODO: De septiembre de 2018 a marzo de 2019 el equipo investigador identificó a los pacientes adultos que se encontraban en urgencias en el inicio del turno de mañana con el diagnóstico de sepsis. De estos pacientes se seleccionaron los que en el momento de su llegada tenían un qSOFA de 2 o 3 puntos. Se realizó análisis estadístico para establecer los factores relacionados con mortalidad. RESULTADOS: Se incluyeron 90 pacientes con una edad media de 72 (DE 16) años. La mortalidad global fue de 33 pacientes (37%). En el análisis univariado de mortalidad, el único indicador del qSOFA con significación estadística fue el nivel de consciencia (79% vs 54%, p = 0,02). Otras variables relacionadas con mayor mortalidad fueron: edad igual o mayor de 70 años, orden de limitación del esfuerzo terapéutico en urgencias y valor de la primera y de la segunda determinación de lactato. El cumplimiento del paquete de medidas fue del 42% y se asoció a una menor mortalidad (21% vs 54%, p = 0,003). En el análisis multivariado mediante regresión de Cox, los pacientes en los que no se cumplimentó el paquete de medidas en las primeras 3 horas tuvieron mayor riesgo de mortalidad al final del episodio (HR = 2,67; IC95% = 1,15-6,21; p = 0,02). CONCLUSIÓN: En los pacientes con sepsis y un qSOFA de 2-3 puntos a su llegada a urgencias el cumplimiento del paquete de medidas en las primeras 3 horas mejora la supervivencia. Es recomendable hacer los esfuerzos organizativos y docentes necesarios para mejorar el cumplimiento

OBJECTIVE: To identify predictors of mortality after implementation of a treatment protocol in the first 3 hours for patients who come to our emergency department with sepsis scored 2 or 3 on the Quick Sequential Organ Failure Assessment (qSOFA) scale. METHODS: Our team identified adult emergency department patients with a diagnosis of sepsis on starting the morning shift between September 2018 and March 2019. We selected patients whose qSOFA score on arrival was 2 or 3. Variables were explored statistically to identify factors associated with mortality. RESULTS: A total of 90 patients with a mean (SD) age of 72 (16) years were included. Thirty-three (37%) died. Univariate analysis detected that the only qSOFA indicator that was significantly associated with mortality was altered mentation (level of consciousness), which was noted in 79% of patients who died versus 54% of survivors (P=.02). Other variables associated with higher mortality were age 70 years or older, an order to limit therapeutic interventions in emergencies, and lactic acid levels on first and second extractions. The treatment protocol was completed in 42% of the cases and compliance was associated with a lower mortality rate of 21% versus 54% when the protocol was not fully implemented (P=.003). Multivariate Cox regression analysis showed that risk for death was higher when the full protocol was not implemented within 3 hours of arrival (hazard ratio, 2.67; 95% CI, 1.15-6.21; P=.02). CONCLUSIONS: Full implementation of the protocol within 3 hours of hospital arrival favors survival in patients with sepsis and qSOFA scores of 2 or 3 on arrival. We recommend that emergency departments organize ways to train staff in the use of a sepsis treatment protocol and improve compliance

Predictors of mortality in emergency department patients with sepsis scored 2 or 3 on the Quick Sequential Organ Failure Assessment scale. / Factores predictivos de mortalidad en los pacientes con sepsis y un valor del indicador 'Quick Sequential Organ Failure Assessment' (qSOFA) de 2 o 3 puntos atendidos en un servicio de urgencias.

OBJECTIVES: To identify predictors of mortality after implementation of a treatment protocol in the first 3 hours for patients who come to our emergency department with sepsis scored 2 or 3 on the Quick Sequential Organ Failure Assessment (qSOFA) scale. MATERIAL AND METHODS: Our team identified adult emergency department patients with a diagnosis of sepsis on starting the morning shift between September 2018 and March 2019. We selected patients whose qSOFA score on arrival was 2 or 3. Variables were explored statistically to identify factors associated with mortality. RESULTS: A total of 90 patients with a mean (SD) age of 72 (16) years were included. Thirty-three (37%) died. Univariate analysis detected that the only qSOFA indicator that was significantly associated with mortality was altered mentation (level of consciousness), which was noted in 79% of patients who died versus 54% of survivors (P=.02). Other variables associated with higher mortality were age 70 years or older, an order to limit therapeutic interventions in emergencies, and lactic acid levels on first and second extractions. The treatment protocol was completed in 42% of the cases and compliance was associated with a lower mortality rate of 21% versus 54% when the protocol was not fully implemented (P=.003). Multivariate Cox regression analysis showed that risk for death was higher when the full protocol was not implemented within 3 hours of arrival (hazard ratio, 2.67; 95% CI, 1.15-6.21; P=.02). CONCLUSION: Full implementation of the protocol within 3 hours of hospital arrival favors survival in patients with sepsis and qSOFA scores of 2 or 3 on arrival. We recommend that emergency departments organize ways to train staff in the use of a sepsis treatment protocol and improve compliance.

OBJETIVO: Determinar los factores predictivos de mortalidad de los pacientes que acuden a urgencias con sepsis y tiene un qSOFA de 2 o 3 puntos tras la implementación de un paquete de medidas a cumplimentar en las primeras 3 horas. METODO: De septiembre de 2018 a marzo de 2019 el equipo investigador identificó a los pacientes adultos que se encontraban en urgencias en el inicio del turno de mañana con el diagnóstico de sepsis. De estos pacientes se seleccionaron los que en el momento de su llegada tenían un qSOFA de 2 o 3 puntos. Se realizó análisis estadístico para establecer los factores relacionados con mortalidad. RESULTADOS: Se incluyeron 90 pacientes con una edad media de 72 (DE 16) años. La mortalidad global fue de 33 pacientes (37%). En el análisis univariado de mortalidad, el único indicador del qSOFA con significación estadística fue el nivel de consciencia (79% vs 54%, p = 0,02). Otras variables relacionadas con mayor mortalidad fueron: edad igual o mayor de 70 años, orden de limitación del esfuerzo terapéutico en urgencias y valor de la primera y de la segunda determinación de lactato. El cumplimiento del paquete de medidas fue del 42% y se asoció a una menor mortalidad (21% vs 54%, p = 0,003). En el análisis multivariado mediante regresión de Cox, los pacientes en los que no se cumplimentó el paquete de medidas en las primeras 3 horas tuvieron mayor riesgo de mortalidad al final del episodio (HR = 2,67; IC95% = 1,15-6,21; p = 0,02). CONCLUSIONES: En los pacientes con sepsis y un qSOFA de 2-3 puntos a su llegada a urgencias el cumplimiento del paquete de medidas en las primeras 3 horas mejora la supervivencia. Es recomendable hacer los esfuerzos organizativos y docentes necesarios para mejorar el cumplimiento.

Adecuación del uso de antibióticos de "Categoría Especial" en el Servicio de Urgencias de un hospital de tercer nivel / Adequacy of the special category antibiotics prescriptions in the Emergency Department of a third level urban Hospital

OBJETIVO: Analizar la adecuación de las prescripciones de antibióticos de categoría especial (ATB de CE) en el Servicio de Urgencias Hospitalario (SUH) de un centro urbano de tercer nivel. MATERIAL Y MÉTODOS: Se seleccionó una muestra aleatoria de 100 pacientes diferentes a los que se les inició un ATB de CE en Urgencias durante el año 2018. El equipo investigador revisó la historia clínica del episodio de urgencias y de ingreso. Se determinó mediante regresión logística los factores independientes asociados con el grado de adecuación del tratamiento. RESULTADOS: Se analizaron 97 prescripciones de las cuales 66 (68%) cumplían los criterios de prescripción adecuada. El grado de adecuación fue del 70% si la infección estaba relacionada con la asistencia sanitaria y del 75% si el paciente tenía factores de riesgo de infección por microorganismos multirresistentes (MMR). El porcentaje de adecuación fue mayor en los casos en los que se especificó el foco de la infección (72%) y la gravedad del episodio (73%). Las variables independientes que se asociaron a una prescripción adecuada fueron: la presencia de factores de riesgo de infección por MMR (OR: 2,35 IC 95%: 1,65 - 3,17 p: 0,01), el especificar el foco de la infección (OR: 3,79 IC 95%: 1,72 - 4,22 p: 0,02) y señalar la gravedad del episodio (OR: 3,09 IC 95%: 1,12 - 3,09 p: 0,03). CONCLUSIONES: La prescripción de los ATB de CE en el SUH es adecuada en la medida que se tenga en cuenta el ámbito de adquisición de la infección, los factores de riesgo de MMR, el foco de infección y la gravedad del cuadro clínico

OBJECTIVE: The aim of the study was to analyze the adequacy of the special category antibiotics prescriptions in the Emergency Department (ED) of a third level urban Hospital. MATERIAL AND METHODS: A random sample of 100 different patients who were started with a special category antibiotic along 2018 in the ED was selected. The research team reviewed the medical history of the emergency and admission episode. The independent factors associated with the degree of adequacy of the treatment were determined by logistic regression. RESULTS: A total of 97 prescriptions were analyzed of which 66 (68%) met the criteria of adequate prescription, 23 (24%) adequate prescription, but with equally recommended alternatives and 8 (8%) were inappropriate prescriptions. The degree of adequacy was 70% if the infection was related to healthcare and 75% if the patient had risk factors for multiresistant (MR) microorganisms' infection. The percentage of adequacy was higher in the cases in which the focus of the infection (72%) and the severity of the episode (73%) were specified. The independent variables that were associated with an adequate prescription were: the presence of risk factors for MR microorganisms' infection (OR: 2.35 95% CI: 1.65 - 3.17 p: 0.01), if the focus of the infection (OR: 3.79 95% CI: 1.72 - 4.22 p: 0.02) and the severity of the episode (OR: 3.09 95% CI: 1.12 - 3.09 p: 0.03) were specified. CONCLUSIONS: The prescription of special category antibiotics in ED is appropriate if the clinical guidelines are followed and if the setting of infection acquisition, the risk factors of MR microorganisms, the focus and the severity of infection are taken into account in clinical picture

HHV8-related lymphoid proliferations: a broad spectrum of lesions from reactive lymphoid hyperplasia to overt lymphoma.

Human herpesvirus 8 (HHV8)-associated lymphoid proliferations are uncommon and poorly characterized disorders mainly affecting immunosuppressed patients, especially with HIV infection. They encompass different diseases with overlapping features that complicate their classification. In addition, the role of HHV8 in reactive lymphoid hyperplasia is not well known. To analyze the clinicopathological spectrum of these lesions, we have reviewed 66 biopsies of 61 patients with HHV8 infection. All cases were also investigated for Epstein-Barr virus (EBV) and HIV infection. We identified 13 (20%) cases of HHV8-related reactive lymphoid hyperplasia, 2 (3%) HHV8 plasmablastic proliferations of the splenic red pulp, 28 (42%) multicentric Castleman disease, 6 (9%) germinotropic lymphoproliferative disorders, and 17 (26%) HHV8-related lymphomas. As expected, the pathologic subtype was predictive of overall survival (P<0.05). Forty-seven of our cases were HIV positive (77%). In addition to the classical presentation of the different entities, we identified novel and overlapping features. Reactive HHV8 proliferations were frequently associated with systemic symptoms but never progressed to overt HHV8-positive lymphoma. Two cases had a plasmablastic proliferation limited to spleen. Eight cases of multicentric Castleman disease had a previously unrecognized presentation shortly after the diagnosis of HIV infection, six cases had cavity effusions, and three showed plasmablast enriched proliferations. One germinotropic lymphoproliferative disorder was EBV negative and three occurred in HIV-positive patients, who had distinctive clinical and morphological features. Two of the HHV8-related lymphomas did not fulfill the criteria for previously recognized entities. All these findings expand the clinical and pathological spectrum of HHV8-related lymphoid proliferations, which is broader than current recognized.

Infection is the major trigger of hemophagocytic syndrome in adult patients treated with biological therapies.

INTRODUCTION: Hemophagocytic syndromes (hemophagocytic lymphohistiocytosis, HLH) are characterized by a wide range of etiologies, symptoms, and outcomes, but have a common etiopathogenic pathway leading to organ damage: an excessive inflammatory response. Biological therapies have been proposed as a therapeutic option for refractory HLH, but have also been related to the development of HLH in severe immunosuppressed patients. OBJECTIVES AND METHODS: The purpose of this study was to analyze the clinical characteristics and outcomes of adult patients who developed HLH after receiving biological therapies. RESULTS: We identified 30 patients (29 from the PubMed search and one unpublished case), including 19 women and 11 men, with a mean age of 46.5 years. Underlying diseases consisted of rheumatologic/autoimmune diseases in 24 patients and hematological neoplasia in the remaining 6. Biological agents received before the development of HLH were mainly anti-TNF agents (n = 19). Search for microorganisms confirmed systemic infection in 20 (67%) patients, including Mycobacterium tuberculosis (n = 5), cytomegalovirus (CMV) (n = 4), Epstein-Barr virus (EBV) (n = 3), Histoplasma capsulatum (n = 3), Escherichia coli (n = 2), Staphylococcus aureus, Leishmania amastigotes and Brucella melitensis (n = 1, respectively); viral infections were mainly reported in inflammatory bowel disease (IBD) patients. Patients with infections had more frequently received previous immunosuppressive therapies (p = 0.036) and had lower leukocyte counts (p = 0.020) in comparison with patients without associated infections. The outcome was described in 29 patients. After a mean follow-up of 6.3 months, 8 patients died (28%) and 6 had received anti-TNF agents. There was a high mortality rate in patients aged >65 years and those with tuberculosis (62% and 60%, respectively). CONCLUSIONS: In patients receiving biological therapies who develop HLH, searching for a concomitant infectious process is mandatory, and specific surveillance for EBV/CMV infections (in patients with IBD) and for bacteria, including mycobacteria (in elderly patients receiving anti-TNF therapy), is recommended.

Factors Associated with Hospitalization among Emergency Department Patients Referred for Quick Investigation of Iron-Deficiency Anemia.

BACKGROUND: Although patients with anemia are frequently seen in emergency departments (EDs), studies on patients presenting there with symptomatic chronic anemia--usually iron-deficiency anemia (IDA) caused by occult gastrointestinal bleeding--are lacking. Awareness of predictors of hospitalization could direct the ED triage to the appropriate diagnostic setting. OBJECTIVE: Based on initial observations that some patients with IDA were hospitalized after ED referral and initial evaluation at a quick diagnosis unit (QDU), a new cost-effective alternative to hospitalization for diagnostic workup, this study aimed to determine the patient factors associated with hospitalization after the first QDU visit. METHODS: An 8-year prospective cohort study of patients with IDA referred from the ED to the QDU of a third-level university hospital was conducted. Patients with a baseline hemoglobin level of <9 g/dL in the ED, proven iron deficiency, and no overt bleeding were included. The primary outcome was hospitalization after the initial QDU assessment. RESULTS: Two hundred eighty-four (7.7%) of 3692 patients were hospitalized. Inter-rater agreement of appropriateness of admissions was 90.6% (κ = 0.82). Overall, 90% of study patients presented to the ED with symptomatic anemia, and 87% were transfused there. On multivariate analysis, age ≥ 65 years, living alone, a post-transfusion hemoglobin level of <9 g/dL, higher age-adjusted overall comorbidity, heart failure, and poor physical health-related quality of life at first QDU visit independently predicted hospitalization. CONCLUSION: While these predictors do not necessarily reflect the need for hospitalization, they are easily evaluated during the initial ED visit and can guide the triage of similar IDA patients to the suitable setting for timely investigation.

Características de la prescripción de antibióticos en un servicio de urgencias de un hospital de tercer nivel / Antibiotic prescription in the emergency department of a tertiary level hospital

Objetivos: Analizar la prescripción de antibióticos en un servicio de urgencias hospitalario (SUH) mediante la evaluación del tiempo hasta la primera dosis, el ajuste a función renal, la adecuación según resultados microbiológicos y el paso precoz a vía oral. Método: Se identificaron los pacientes que recibieron una primera dosis de antibiótico por vía intravenosa con intención terapéutica en el SUH. Los pacientes fueron seguidos de manera prospectiva mientras duró el tratamiento antibiótico. Resultados: Se incluyeron 98 pacientes. La mediana del tiempo hasta la primera dosis de antibiótico fue de 180 minutos (media 215 min, DE: 127 min) desde la llegada a urgencias y de 120 minutos (media 132 min, DE: 80 min) desde la visita médica. Doce pacientes cumplieron criterios de sepsis grave y 7 de shock séptico, y en ellos la mediana entre la valoración médica y la primera dosis de antibiótico fue de 93 y 60 minutos respectivamente. El ajuste a la función renal fue realizado en el 95% de pacientes, y en el 97% se ajustó el tratamiento a los aislamientos microbiológicos. El paso a vía oral fue realizado en el 98% de los casos elegibles, con un retraso medio de 1,7 días. Conclusiones: El tiempo hasta la administración de la primera dosis de antibiótico en el SUH es mayor a lo recomendado incluso en los pacientes con sepsis grave y shock séptico

Objectives: To analyze the prescription of antibiotics in a hospital emergency department (ED) by assessing time elapsed until the first antibiotic dose, adjustment of renal function, adjustment according to the findings for microbiology, and early switch to oral route of administration. Methods: Patients were included consecutively on receiving a first intravenous dose of an antibiotic in the ED. The patients were followed prospectively while they were on antibiotic treatment. Results: We included 98 patients. The median time until the first dose was 180 minutes from the time of arrival in the department; the mean (SD) time was 215 (127) minutes. The median time from first medical evaluation until the first dose was 120 minutes; the mean time was 132 (80) minutes. Twelve of the 98 patients had severe sepsis and 7 were in septic shock. In these patients the median time between physician evaluation and first antibiotic dose was 93 minutes (severe sepsis) and 60 minutes (septic shock). In 95% of the patients, the dosage was adjusted based on renal function; in 97% treatment was adjusted based on results of microbiology. Ninety-eight percent of patients were switched to oral antibiotics after a mean of 1.7 days. Conclusions: Time elapsed until the first antibiotic dose administered in the ED is longer than recommended even for patients with severe sepsis or in septic shock