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1.
Emergencias (Sant Vicenç dels Horts) ; 32(1): 9-18, feb. 2020. graf, tab
Artigo em Espanhol | LILACS-Express | ID: ibc-ET2-3431

RESUMO

Objetivos. Analizar qué características clínicas y del ECG de la primera valoración de pacientes con dolor torácico no traumático (DNT) se asocian con una clasificación inicial de sospecha de síndrome coronario agudo (SCA) y con el diagnóstico final de SCA, e identificar cuáles resultan sobre o infravaloradas durante la clasificación inicial. Método. Se incluyeron las consultas consecutivas por DTNT en una unidad de dolor torácico durante 10 años (2008-2017) en las que se disponía de los diagnósticos inicial de sospecha (SCA/no SCA) y final de alta de urgencias (SCA/no SCA). Se incluyeron 33 variables independientes (2 demográficas, 5 comorbilidad cardiovascular, 22 dolor torácico, 4 datos ECG). Se calcularon las odds ratio (OR) para la clasificación (inicial y final) como SCA para cada variable independiente, crudas y ajustadas en modelos globales que incluían todas ellas. En estos modelos ajustados se comparó si las OR para la clasificación inicial y final como SCA eran significativamente diferentes. Resultados. Se incluyeron 34.552 visitas. Las 33 variables analizadas mostraron asociación significativa para la clasificación inicial y final del DTNT como SCA, y en muchos casos esta asociación se mantuvo en el modelo ajustado. Diecinueve variables mostraron OR significativamente diferentes para la sospecha inicial de SCA que para el diagnóstico final de SCA: 10 sobrestimaban la asociación final y 9 la subestimaban. Conclusión. Los datos clínicos iniciales clásicamente utilizados para sospechar SCA pacientes con DTNT en urgencias identifican todos ellos individualmente a pacientes con riesgo incrementado de ser clasificado inicial y finalmente como SCA; sin embargo, algunos de ellos sobreestiman y otros subestiman inicialmente el riesgo final. Los urgenciólogos debieran sensibilizarse más con estos datos subestimados


Objectives. To analyze clinical data and electrocardiographic (ECG) findings obtained during the initial evaluation of patients with nontraumatic chest pain (NTCP). To explore associations between these findings and the initial and final diagnoses of acute coronary syndrome (ACS). To assess which variables initially over- or underestimate risk ACS. Methods. Consecutive patients with NTCP attended in a chest pain unit during the 10-year period of 2008–2017 were included if the suspected and discharge diagnoses of interest (ACS or non-ACS) had been recorded. Thirtythree independent variables (demographic, 2; cardiovascular, 5; chest pain, 22; ECG, 4). We included all variables in models to calculate crude and adjusted odds ratios (ORs) between each independent variable and the initial and final diagnoses. The adjusted ORs were compared to determine whether the initial and final diagnoses of ACS differed significantly in relation to the variables. Results. A total of 34 552 patient visits were attended. The ORs for the 33 variables were significantly associated with initial and final NTCP classification as ACS or non-ACS, and in many cases the association was confirmed by the adjusted ORs. The adjusted ORs for 19 variables were significantly different in their relation to the initial and final diagnoses of ACS: 10 overpredicted the probability of the diagnosis and 9 underpredicted it. Conclusions. The variables traditionally used to warn of ACS in emergency patients with NTCP identify individuals likely to be initially and finally diagnosed with ACS. However, some of these variables overestimate or underestimate the risk of a final ACS diagnosis. Emergency medicine physicians should be aware of variables associated with underestimation of risk

2.
Emergencias ; 32(1): 9-18, 2020 Feb.
Artigo em Espanhol, Inglês | MEDLINE | ID: mdl-31909907

RESUMO

OBJECTIVES: To analyze clinical data and electrocardiographic (ECG) findings obtained during the initial evaluation of patients with nontraumatic chest pain (NTCP). To explore associations between these findings and the initial and final diagnoses of acute coronary syndrome (ACS). To assess which variables initially over- or underestimate risk ACS. MATERIAL AND METHODS: Consecutive patients with NTCP attended in a chest pain unit during the 10-year period of 2008-2017 were included if the suspected and discharge diagnoses of interest (ACS or non-ACS) had been recorded. Thirtythree independent variables (demographic, 2; cardiovascular, 5; chest pain, 22; ECG, 4). We included all variables in models to calculate crude and adjusted odds ratios (ORs) between each independent variable and the initial and final diagnoses. The adjusted ORs were compared to determine whether the initial and final diagnoses of ACS differed significantly in relation to the variables. RESULTS: A total of 34 552 patient visits were attended. The ORs for the 33 variables were significantly associated with initial and final NTCP classification as ACS or non-ACS, and in many cases the association was confirmed by the adjusted ORs. The adjusted ORs for 19 variables were significantly different in their relation to the initial and final diagnoses of ACS: 10 overpredicted the probability of the diagnosis and 9 underpredicted it. CONCLUSION: The variables traditionally used to warn of ACS in emergency patients with NTCP identify individuals likely to be initially and finally diagnosed with ACS. However, some of these variables overestimate or underestimate the risk of a final ACS diagnosis. Emergency medicine physicians should be aware of variables associated with underestimation of risk.

3.
Emergencias (Sant Vicenç dels Horts) ; 31(6): 377-384, dic. 2019. graf, tab
Artigo em Espanhol | LILACS-Express | ID: ibc-ET2-3122

RESUMO

Objetivo. Analizar la evolución de las características epidemiológicas de las visitas atendidas de forma consecutiva en una unidad de dolor torácico (UDT) de un servicio de urgencias hospitalario (SUH) durante un periodo de 10 años. Método. Se incluyeron todas las visitas por dolor torácico no traumático (DTNT), analizándose la evolución temporal de las características epidemiológicas, de la clasificación diagnóstica inicial (evaluación clínica inicial y electrocardiograma) y final (al alta de la UDT), y los tiempos necesarios para alcanzar las mismas. Resultados. Se incluyeron 34.552 pacientes consecutivos con una edad media 59 (DE: 13) años, el 42% mujeres. Se observó un incrementó en el número anual de visitas a la UDT (p < 0,001), menor afluencia los meses de verano (p < 0,001), y mayor los días laborables (p < 0,001) y de 8-16 horas (p < 0,001). Se comprobó que progresivamente más pacientes eran mujeres (+0,29% anual, p < 0,05), menores de 50 años (+0,92%, p < 0,001), con más factores de riesgo cardiovascular, menos antecedentes de cardiopatía isquémica y con DTNT menos sugestivo de síndrome coronario agudo (SCA). La clasificación diagnóstica inicial y final descartó SCA en un 52,2% y un 80,4% de pacientes, respectivamente, hecho que aumentó progresivamente durante el periodo evaluado (+1,86%, p < 0,001; y +0,56%, p = 0,04; respectivamente). El tiempo de clasificación inicial no se modificó, pero se incrementó el necesario para la clasificación final (p < 0,001), que resultó superior en pacientes con diagnostico final de SCA (p < 0,001). Conclusión. Se observa un mayor uso de la UDT tras su creación, causado por un incremento de pacientes con DTNT de características no típicamente coronarias, disminuyendo el porcentaje de clasificados inicial y finalmente como debidos a SCA


Objective. To analyze changes in the characteristics of consecutively treated patients attended in the chest pain unit of a hospital emergency department over a 10-year period. Methods. All patients presenting with nontraumatic chest pain (NTCP) were included. We analyzed changes over time in epidemiologic characteristics, initial diagnostic classification (on clinical and electrocardiographic evaluation), final diagnosis (on discharge), and time until these diagnoses. Results. A total of 34 552 consecutive patients with a mean (SD) age of 59 (13) years were included; 42% were women. The annual number of visits rose over time. Visits were fewer in summer and more numerous on workdays and between the hours of 8 AM and 4 PM (P<.001, both comparisons). The number of women increased over time (up 0.29% annually, P<.05) as did the number of patients under the age of 50 years (up 0.92% annually, P<.001). With time, patients had fewer cardiovascular risk factors and less often had a history of ischemic heart disease. Fewer cases of NTCP had signs suggestive of acute coronary syndrome (ACS). ACS was ruled out at the time of initial and final diagnoses in 52.2% and 80.4%, respectively, and these percentages which rose over the 10-year period by 1.86% (P<.001) and 0.56% (P=.04). Time to initial diagnosis did not change. However, time to final diagnosis did increase (P<.001), and the delay was longer in patients diagnosed with ACS (P<.001). Conclusions. The chest pain unit was more active at the end of the period, in keeping with the increase in patients with NTCP whose characteristics were not typical of coronary disease. The percentages of patients initially and finally diagnosed with ACS decreased with time

4.
Emergencias ; 31(6): 377-384, 2019.
Artigo em Espanhol, Inglês | MEDLINE | ID: mdl-31777208

RESUMO

OBJECTIVES: To analyze changes in the characteristics of consecutively treated patients attended in the chest pain unit of a hospital emergency department over a 10-year period. MATERIAL AND METHODS: All patients presenting with nontraumatic chest pain (NTCP) were included. We analyzed changes over time in epidemiologic characteristics, initial diagnostic classification (on clinical and electrocardiographic evaluation), final diagnosis (on discharge), and time until these diagnoses. RESULTS: A total of 34 552 consecutive patients with a mean (SD) age of 59 (13) years were included; 42% were women. The annual number of visits rose over time. Visits were fewer in summer and more numerous on workdays and between the hours of 8 AM and 4 PM (P<.001, both comparisons). The number of women increased over time (up 0.29% annually, P<.05) as did the number of patients under the age of 50 years (up 0.92% annually, P<.001). With time, patients had fewer cardiovascular risk factors and less often had a history of ischemic heart disease. Fewer cases of NTCP had signs suggestive of acute coronary syndrome (ACS). ACS was ruled out at the time of initial and final diagnoses in 52.2% and 80.4%, respectively, and these percentages which rose over the 10-year period by 1.86% (P<.001) and 0.56% (P=.04). Time to initial diagnosis did not change. However, time to final diagnosis did increase (P<.001), and the delay was longer in patients diagnosed with ACS (P<.001). CONCLUSION: The chest pain unit was more active at the end of the period, in keeping with the increase in patients with NTCP whose characteristics were not typical of coronary disease. The percentages of patients initially and finally diagnosed with ACS decreased with time.

5.
Int J Qual Health Care ; 30(4): 250-256, 2018 May 01.
Artigo em Inglês | MEDLINE | ID: mdl-29447352

RESUMO

Objective: To apply lean thinking in triage acuity level-3 patients in order to improve emergency department (ED) throughtput and waiting time. Design: A prospective interventional study. Setting: An ED of a tertiary care hospital. Participants: Triage acuity level-3 patients. Intervention(s): To apply lean techniques such as value stream mapping, workplace organization, reduction of wastes and standardization by the frontline staff. Main Outcome Measure(s): Two periods were compared: (i) pre-lean: April-September, 2015; and (ii) post-lean: April-September, 2016. Variables included: median process time (time from beginning of nurse preparation to the end of nurse finalization after doctor disposition) of both discharged and transferred to observation patients; median length of stay; median waiting time; left without being seen, 72-h revisit and mortality rates, and daily number of visits. There was no additional staff or bed after lean implementation. Results: Despite an increment in the daily number of visits (+8.3%, P < 0.001), significant reductions in process time of discharged (182 vs 160 min, P < 0.001) and transferred to observation (186 vs 176 min, P < 0.001) patients, in length of stay (389 vs 329 min, P < 0.001), and in waiting time (71 vs 48 min, P < 0.001) were achieved after lean implementation. No significant differences were registered in left without being seen rate (5.23% vs 4.95%), 72-h revisit rate (3.41% vs 3.93%), and mortality rate (0.23% vs 0.15%). Conclusion: Lean thinking is a methodology that can improve triage acuity level-3 patient flow in the ED, resulting in better throughput along with reduced waiting time.


Assuntos
Eficiência Organizacional , Serviço Hospitalar de Emergência/organização & administração , Triagem/organização & administração , Hospitais de Ensino , Humanos , Tempo de Internação/estatística & dados numéricos , Alta do Paciente/estatística & dados numéricos , Estudos Prospectivos , Espanha , Fatores de Tempo
8.
Rev. esp. cardiol. (Ed. impr.) ; 64(3): 233-236, mar. 2011. tab, ilus
Artigo em Espanhol | IBECS | ID: ibc-86038

RESUMO

Se analizan las diferencias en el manejo de la fibrilación auricular en varones y mujeres tomando como referencia de base poblacional un área sanitaria. Se incluyeron 668 pacientes (359 mujeres) que consultaron por fibrilación auricular. Las mujeres presentaban más edad, insuficiencia cardiaca y dependencia funcional que los varones. Respecto al manejo de la fibrilación auricular, ellas recibían más frecuentemente digoxina y menos frecuentemente cardioversión eléctrica y valoración por un cardiólogo, y su conocimiento del tratamiento era menor. Tras estratificar los resultados por edad y ajustarlos por insuficiencia cardiaca y grado de dependencia, las mujeres de 85 o más años recibían más frecuentemente digoxina y las menores de 65 años, menos frecuentemente cardioversión. Se concluye que existen diferencias de género en el manejo de la fibrilación auricular, las cuales no pueden ser totalmente atribuidas a diferencias de las características clínicas poblacionales entre mujeres y varones(AU)


Differences in the treatment of atrial fibrillation between men and women were investigated by using patients in a local health district as a reference population. The study included 688 patients (359 female) who presented with atrial fibrillation. Women were older, more frequently had heart failure, and were more often functionally dependent than men. With regards to the management of atrial fibrillation, women were prescribed digoxin more frequently than men, but underwent electrical cardioversion less often, were less frequently seen by a cardiologist, and understood less about their treatment. After stratifying the findings by age and adjusting for heart failure and the degree of functional dependence, it was observed that women aged over 85 years were prescribed digoxin more often than men, while women aged under 65 years underwent cardioversion less often than men. In conclusion, gender differences observed in the treatment of atrial fibrillation cannot be fully explained by differences in clinical characteristics between men and women in the population(AU)


Assuntos
Humanos , Masculino , Feminino , Pessoa de Meia-Idade , Idoso , Fibrilação Atrial/diagnóstico , Fibrilação Atrial/terapia , Gênero e Saúde , Insuficiência Cardíaca/complicações , Insuficiência Cardíaca/diagnóstico , Fibrilação Atrial/epidemiologia , Fibrilação Atrial/fisiopatologia , Insuficiência Cardíaca/epidemiologia , Estudos Retrospectivos , Estudos Transversais , Atenção Primária à Saúde
9.
Rev Esp Cardiol ; 64(3): 233-6, 2011 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-21324575

RESUMO

Differences in the treatment of atrial fibrillation between men and women were investigated by using patients in a local health district as a reference population. The study included 688 patients (359 female) who presented with atrial fibrillation. Women were older, more frequently had heart failure, and were more often functionally dependent than men. With regards to the management of atrial fibrillation, women were prescribed digoxin more frequently than men, but underwent electrical cardioversion less often, were less frequently seen by a cardiologist, and understood less about their treatment. After stratifying the findings by age and adjusting for heart failure and the degree of functional dependence, it was observed that women aged over 85 years were prescribed digoxin more often than men, while women aged under 65 years underwent cardioversion less often than men. In conclusion, gender differences observed in the treatment of atrial fibrillation cannot be fully explained by differences in clinical characteristics between men and women in the population.


Assuntos
Fibrilação Atrial/terapia , Idoso , Idoso de 80 Anos ou mais , Estudos Transversais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores Sexuais , Espanha
10.
Emerg Med J ; 28(10): 841-6, 2011 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-20961935

RESUMO

OBJECTIVE: To validate a triage flowchart to rule out acute coronary syndrome (ACS) in chest pain patients attending the emergency department (ED). METHODS: An observational cohort study of consecutive patients. In all cases, a previously derived five-step triage flowchart (age ≤ 40 years, absence of diabetes, not previously known coronary artery disease, non-oppressive and non-retrosternal pain) was applied. Patients meeting all five discriminators were grouped as 'five-step triage non-ACS', the rest as 'five-step triage ACS'. The same strategy was used with a four-step model (without age ≤ 40 years). After ED study and 1-month follow-up, patients were definitively classified as 'true ACS' or 'true non-ACS'. Validity indexes and receiver operating characteristics curves were calculated. RESULTS: 4231 patients were included: 918 (21.7%) were 'true ACS', 3303 (78.1%) 'true non-ACS'; 10 (0.2%) were lost to follow-up. The five-step triage flowchart classified 4000 (94.8%) as 'triage ACS' and 221 (5.2%) as 'triage non-ACS'; none of the latter was 'true ACS'. The four-step model classified 3194 (75.6%) as 'triage ACS' and 1027 (24.4%) as 'triage non-ACS'. A 'true ACS' was seen in 26 patients from the latter group. Accordingly, five-step triage flowchart specificity and positive predictive value (PPV) to rule out ACS were 100% (95% CI 100% to 100%). For the four-step model specificity and PPV were 97% (95% CI 96% to 98%). CONCLUSION: The five-step triage flowchart identifies chest pain patients without an ACS. However, only 5% of these patients meet these five criteria. A simpler model allows greater patient inclusion but a higher risk of misclassification of true ACS.


Assuntos
Síndrome Coronariana Aguda/diagnóstico , Dor no Peito/diagnóstico , Árvores de Decisões , Triagem/métodos , Adulto , Idoso , Estudos de Coortes , Serviço Hospitalar de Emergência/organização & administração , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Estudos Prospectivos , Curva ROC , Reprodutibilidade dos Testes , Sensibilidade e Especificidade
11.
Gac. sanit. (Barc., Ed. impr.) ; 24(4): 303-308, jul.-ago. 2010. tab
Artigo em Espanhol | IBECS | ID: ibc-85690

RESUMO

ObjetivoIdentificar los factores asociados a la aceptación por parte del paciente de la hospitalización a domicilio directamente desde el servicio de urgencias.Pacientes y métodosEstudio de cohortes prospectivo observacional de pacientes que, una vez visitados en urgencias, reunían criterios de ingreso en sala convencional, podían responder a una entrevista y disponían de un posible cuidador. Se tomó como variable dependiente la predisposición a aceptar o no un ingreso en hospitalización a domicilio. De cada paciente, como variables independientes se recogieron aspectos demográficos, factores de su estado de salud-comorbilidad y de su enfermedad actual, y percepciones psicosociales relacionadas con la hospitalización a domicilio. La relación entre variables se estableció por análisis de regresión logística múltiple.ResultadosSe realizaron 129 entrevistas. La predisposición a aceptar un ingreso en hospitalización a domicilio fue del 71%. Sólo las percepciones psicosociales del paciente, con independencia de sus aspectos demográficos e incluso de su estado de salud actual y comorbilidad, se relacionaron con la predisposición a aceptar un ingreso en hospitalización a domicilio, en concreto las adecuadas condiciones físicas del domicilio (odds ratio [OR]: 4,31; intervalo de confianza del 95% [IC95%]: 1,18–15,78), la ausencia de miedo por tener que manejar el oxígeno (OR: 5,99; IC95%: 2,05–17,52), la ausencia de miedo a una mala evolución clínica (OR: 6,07; IC95%: 1,94–18,96) y la percepción de una mayor libertad de horarios (OR: 12,61; IC95%: 3,31–48,01).ConclusionesLa hospitalización a domicilio tendría una buena aceptación si se ofreciera directamente en el Servicio de Urgencias como alternativa a la hospitalización convencional. Esta aceptación se asocia a percepciones psicosociales, que deberían tenerse en cuenta al ofrecer esta modalidad asistencial (AU)


AimTo identify the factors associated with patients’ acceptance of emergency department discharge directly to hospital-at-home care.Patients and methodsWe performed a prospective observational cohort study of patients seen at the emergency department who met the following inclusion criteria: need for hospital admission, ability to be interviewed, and availability of an informal caregiver. The dependent variable was defined as the predisposition to accept or refuse hospital-at-home care. For each patient, the following independent variables were recorded: demographic characteristics, health-related factors, comorbidities, current illness and psychosocial perceptions related to hospital-at-home care. The associations among the variables were tested by means of logistic regression analysis.ResultsWe included 129 patients. Seventy-one percent would have accepted hospital-at-home care. Acceptance of hospital-at-home care was associated with psychosocial perceptions only, independently of demographic characteristics, current illness severity and comorbidities. These psychosocial perceptions included adequate conditions at home (OR: 4.31; 95% CI: 1.18–15.78), not being afraid of oxygen manipulation (OR: 5.99; 95% CI: 2.05–17.52), lack of fear of a poor outcome (OR: 6.07; 95% CI: 1.94–18.96) and the possibility of enjoying a more flexible schedule (OR: 12.61; 95% CI: 3.31–48.01).ConclusionsHospital-at-home care would be well accepted by patients if offered in the emergency department as an alternative to conventional hospitalization. Acceptance depends on patients’ psychosocial perceptions, which should be assessed before this mode of care is proposed (AU)


Assuntos
Humanos , Masculino , Feminino , Idoso , Aceitação pelo Paciente de Cuidados de Saúde/psicologia , Alta do Paciente , Serviços Hospitalares de Assistência Domiciliar , Estudos Prospectivos
12.
Gac Sanit ; 24(4): 303-8, 2010.
Artigo em Espanhol | MEDLINE | ID: mdl-20663592

RESUMO

AIM: To identify the factors associated with patients' acceptance of emergency department discharge directly to hospital-at-home care. PATIENTS AND METHODS: We performed a prospective observational cohort study of patients seen at the emergency department who met the following inclusion criteria: need for hospital admission, ability to be interviewed, and availability of an informal caregiver. The dependent variable was defined as the predisposition to accept or refuse hospital-at-home care. For each patient, the following independent variables were recorded: demographic characteristics, health-related factors, comorbidities, current illness and psychosocial perceptions related to hospital-at-home care. The associations among the variables were tested by means of logistic regression analysis. RESULTS: We included 129 patients. Seventy-one percent would have accepted hospital-at-home care. Acceptance of hospital-at-home care was associated with psychosocial perceptions only, independently of demographic characteristics, current illness severity and comorbidities. These psychosocial perceptions included adequate conditions at home (OR: 4.31; 95% CI: 1.18-15.78), not being afraid of oxygen manipulation (OR: 5.99; 95% CI: 2.05-17.52), lack of fear of a poor outcome (OR: 6.07; 95% CI: 1.94-18.96) and the possibility of enjoying a more flexible schedule (OR: 12.61; 95% CI: 3.31-48.01). CONCLUSIONS: Hospital-at-home care would be well accepted by patients if offered in the emergency department as an alternative to conventional hospitalization. Acceptance depends on patients' psychosocial perceptions, which should be assessed before this mode of care is proposed.


Assuntos
Serviço Hospitalar de Emergência , Serviços Hospitalares de Assistência Domiciliar , Aceitação pelo Paciente de Cuidados de Saúde/psicologia , Alta do Paciente , Idoso , Feminino , Humanos , Masculino , Estudos Prospectivos
13.
Am J Emerg Med ; 28(4): 454-9, 2010 May.
Artigo em Inglês | MEDLINE | ID: mdl-20466225

RESUMO

INTRODUCTION: HIV-1-infected patients have higher incidence of community-acquired pneumonia (CAP) and risk of complications. Bacteremia has been associated with a higher risk of complications in such patients. We investigated factors associated with bacteremia in HIV-1-infected patients with CAP presenting at the emergency department. METHODS: We included HIV-1-infected patients with CAP for 3 years (March 2005-February 2008). Only patients in whom blood cultures were performed were finally included. Clinical data (age; sex; CD4(+) count; serum HIV viral load; previous or current intravenous drug use and antiretroviral treatment; systolic blood pressure; and cardiac and respiratory rates), analytical data (leukocyte count, arterial oxygen content, C-reactive protein value, and urgent Streptococcus pneumoniae and Legionella spp antigen urine detection), and APACHE-II (Acute Physiology and Chronic Health Evaluation) score were compiled. The need for intensive care unit admission, mechanical ventilation, mortality, and for patients finally discharged, duration of admission were retrospectively obtained from the clinical history. A multivariate analysis using logistic regression was performed to find independent predictors of bacteremia. RESULTS: We diagnosed 129 HIV-1-infected patients with CAP. Blood cultures were performed in 118 cases (91%). Bacteremia was present in 28 (24%). Independent predictors of bacteremia were the detection of S pneumoniae antigen in urine (odds ratio, 9.0; 95% confidence interval, 1.9-42.0) and the absence of current antiretroviral treatment (odds ratio, 7.1; 95% confidence interval, 1.4-33.3). In-hospital mortality was higher in patients with bacteremia (15% vs 0%). CONCLUSION: HIV-1-infected patients with CAP who are not on current antiretroviral therapy and have positive S pneumoniae antigenuria are at increased risk of having bacteremia. Bacteremic patients have a poor outcome.


Assuntos
Bacteriemia/diagnóstico , Infecções por HIV/complicações , Pneumonia Bacteriana/diagnóstico , APACHE , Adulto , Fármacos Anti-HIV/uso terapêutico , Antígenos de Bactérias/sangue , Bacteriemia/etiologia , Bacteriemia/microbiologia , Proteína C-Reativa/análise , Contagem de Linfócito CD4 , Infecções Comunitárias Adquiridas/diagnóstico , Infecções Comunitárias Adquiridas/etiologia , Infecções Comunitárias Adquiridas/microbiologia , Serviço Hospitalar de Emergência , Feminino , HIV-1 , Infecções por Haemophilus/diagnóstico , Infecções por Haemophilus/etiologia , Haemophilus influenzae/imunologia , Humanos , Contagem de Leucócitos , Masculino , Infecções Pneumocócicas/diagnóstico , Infecções Pneumocócicas/etiologia , Pneumonia Bacteriana/etiologia , Pneumonia Bacteriana/microbiologia , Fatores de Risco , Infecções Estreptocócicas/diagnóstico , Infecções Estreptocócicas/etiologia , Streptococcus pneumoniae/imunologia , Streptococcus pyogenes/imunologia , Resultado do Tratamento
14.
Med. clín (Ed. impr.) ; 134(15): 671-677, mayo 2010. tab
Artigo em Espanhol | IBECS | ID: ibc-83532

RESUMO

Fundamento y objetivos: Evaluar las diferencias por sexo en la forma de presentación clínica y el abordaje diagnóstico y terapéutico inicial de pacientes con insuficiencia cardíaca aguda (ICA) atendidos en los servicios de urgencias hospitalarios (SUH). Pacientes y métodos: Estudio prospectivo, evaluativo, transversal y multicéntrico, que incluye todos los pacientes atendidos por ICA en 10 SUH españoles entre el 15 de abril y el 15 de mayo de 2007 (n=944). Se registraron variables sociodemográficas, comorbilidad, cardiopatía previa, exploraciones complementarias, tratamiento domiciliario y medidas terapéuticas. Resultados: Las mujeres (n=501; 53%), con respecto a los varones, presentaron mayor edad (media [DE] de 79 [9] frente a 75 [10] años, respectivamente; p<0,001), hipertensión (el 83,4 frente al 74,9%; p<0,01), valvulopatía (el 23,1 frente al 17,8%; p<0,05) y obesidad (el 21,9 frente al 15,6%; p<0,05) y menor prevalencia de cardiopatía isquémica (el 26,5 frente al 43,3%; p<0,001) y tabaquismo (el 4,4 frente al 18,7%; p<0,001). En el tratamiento ambulatorio, las mujeres son tratadas con menos bloqueadores beta (el 19,6 frente al 30,2%; p<0,001) y antiagregantes (el 34,1 frente al 41,3%; p<0,05). El tratamiento en urgencias fue similar en ambos grupos, excepto que las mujeres recibieron más frecuentemente digoxina (el 25,7 frente al 17,4%; p<0,01). Las mujeres ingresaron menos en cardiología (el 8,0 frente al 13,8%; p<0,01). Conclusiones: En los SUH se realiza un abordaje diagnóstico y terapéutico de la ICA muy similar en ambos sexos y la mayoría de las diferencias encontradas pueden justificarse por el diferente perfil de paciente y el manejo ambulatorio distinto previo a su consulta en urgencias (AU)


Background and objective: To evaluate the differenith acute heart failure who are attended in emergency rooms. Patients and methods: Prospective, evaluated, descriptive, transverse and multicentric study, which includes all patients attended by acute heart failure in emergency rooms of 10 Spanish centers between April 15th and May 15th, 2007 (n=944). Data were recorded regarding socio-demographic, comorbidity, previous heart disease, complementary explorations, previous home treatment, and therapeutic measurements in emergency. Results: Regarding men, women (n=501; 53%) were older (79±9 and 75±10, P<.001), and had more hypertension (83,4% vs 74,9%, P<.01), valvular heart disease (23,1% vs 17,8%, P<.05) and obesity (21,9% vs 15,6%, P<.05); however, they also had less prevalence of coronary heart disease (26,5% vs 43,3%, P=.001) and smoking (4,4 % vs 18,7%, P<.001). According to outpatient treatment, women were less likely to be treated with beta blockers (19,6% vs 30,2%, P<.001) and antithrombotics (34,1% vs 41,3%, P<.05). Treatment administered in the emergency was similar in both groups, yet women received more frequently digoxin (25,7% vs 17,4%, P<.01). Moreover, women were admitted to the cardiology department less often (8,0% vs 13,8%, P<.01). Conclusions: In emergency, the diagnostic and therapeutic approach is very similar in both sexes and the most cases, differences can be justified due to the different patients′ profile and the ambulatory handling before their consultation to emergency (AU)


Assuntos
Humanos , Masculino , Feminino , Idoso , Insuficiência Cardíaca/diagnóstico , Fatores Sexuais , Tratamento de Emergência , Insuficiência Cardíaca/terapia , Estudos Transversais , Estudos Prospectivos , Insuficiência Cardíaca/complicações
15.
Am Heart J ; 159(2): 176-82, 2010 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-20152214

RESUMO

BACKGROUND: Exercise testing constitutes the usual tool for decision making in chest pain units. This policy implies logistical constrains. Our aim was to evaluate a new strategy, combining a clinical risk score and N-terminal pro-B-type natriuretic peptide (NT-proBNP), in patients presenting to the emergency department with chest pain, without ischemic electrocardiogram changes or troponin elevation. METHODS: A total of 320 patients were randomized to either usual management, involving exercise testing, or a new strategy combining a clinical risk score and NT-proBNP without exercise testing. In the usual management, discharge decision was guided by the result of exercise test. In the new strategy, those patients with low clinical risk score and NT-proBNP were directly discharged. The primary outcome was hospitalization at the index episode. Secondary outcomes were cardiac events at 1 year. RESULTS: A total of 110 patients (69%) were hospitalized using usual management in comparison with 90 (56%) in the new strategy (P = .03). There were no differences in death or myocardial infarction (n = 11, 6.9% vs n = 6, 3.8%, P = .3) or cardiac events (n = 38, 24% vs n = 28, 18%, P = .2). Revascularizations at the index episode were more frequent under usual management (18% vs 8%, P = .01), although the new strategy was associated with higher rate of planned postdischarge revascularizations (0.6% vs 5%, P = .04). CONCLUSIONS: A strategy combining clinical history and NT-proBNP is simpler and reduced initial emergency hospitalizations in patients with chest pain, in comparison with the usual strategy involving exercise testing. Larger studies to assess its impact on long-term hard end points are needed.


Assuntos
Dor no Peito/sangue , Dor no Peito/etiologia , Teste de Esforço , Peptídeo Natriurético Encefálico/sangue , Doença Aguda , Dor no Peito/diagnóstico , Feminino , Hospitalização/estatística & dados numéricos , Humanos , Masculino , Pessoa de Meia-Idade , Alta do Paciente , Estudos Prospectivos
16.
Med Clin (Barc) ; 134(15): 671-7, 2010 May 22.
Artigo em Espanhol | MEDLINE | ID: mdl-20181365

RESUMO

BACKGROUND AND OBJECTIVE: To evaluate the differences by sex in clinic presentation, diagnostic approach and initial treatment in patients with acute heart failure who are attended in emergency rooms. PATIENTS AND METHODS: Prospective, evaluated, descriptive, transverse and multicentric study, which includes all patients attended by acute heart failure in emergency rooms of 10 Spanish centers between April 15th and May 15th, 2007 (n=944). Data were recorded regarding socio-demographic, comorbidity, previous heart disease, complementary explorations, previous home treatment, and therapeutic measurements in emergency. RESULTS: Regarding men, women (n=501; 53%) were older (79+/-9 and 75+/-10, P<.001), and had more hypertension (83,4% vs 74,9%, P<.01), valvular heart disease (23,1% vs 17,8%, P<.05) and obesity (21,9% vs 15,6%, P<.05); however, they also had less prevalence of coronary heart disease (26,5% vs 43,3%, P=.001) and smoking (4,4 % vs 18,7%, P<.001). According to outpatient treatment, women were less likely to be treated with beta blockers (19,6% vs 30,2%, P<.001) and antithrombotics (34,1% vs 41,3%, P<.05). Treatment administered in the emergency was similar in both groups, yet women received more frequently digoxin (25,7% vs 17,4%, P<.01). Moreover, women were admitted to the cardiology department less often (8,0% vs 13,8%, P<.01). CONCLUSIONS: In emergency, the diagnostic and therapeutic approach is very similar in both sexes and the most cases, differences can be justified due to the different patients' profile and the ambulatory handling before their consultation to emergency.


Assuntos
Tratamento de Emergência , Insuficiência Cardíaca/diagnóstico , Insuficiência Cardíaca/terapia , Doença Aguda , Idoso , Estudos Transversais , Serviço Hospitalar de Emergência , Feminino , Humanos , Masculino , Estudos Prospectivos , Fatores Sexuais , Espanha
17.
Am J Emerg Med ; 27(6): 660-7, 2009 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-19751622

RESUMO

AIM: To determine predictors of frequent chest pain unit (CPU) users and to identify characteristics and outcomes of their CPU visits. PATIENTS AND METHODS: Observational prospective case-control study. Frequent CPU user was defined by 3 or more CPU visits within the study year. A control patient and a control visit were randomly selected for each case patient and case visit. Demographic, clinical, and outcome variables were collected from medical record and phone interview performed in a 30-day interval. A multivariate logistic regression analysis was used to identify frequent CPU users' predictors. RESULTS: Of 1934 patients presenting during the year, 80 (4.1%) met the definition for case patient. They accounted for 352 (13%) of 2709 CPU visits. Sixty-seven (83.7%) case patients and 71 (88.7%) control patients were contacted. The final predictors were the following: Karnofsky Performance Scale of 70 or lesser (odds ratio [OR], 5.24 [95% confidence interval {CI}, 1.71-16.06]), previous hospitalization (OR, 3.76 [95% CI, 1.49-9.49]), previously known coronary artery disease (OR, 3.72 [95% CI, 1.32-10.52]), and symptoms of depression (OR, 2.98 [95% CI, 1.14-7.78]). Case visits were more likely at night (OR, 2.41 [95% CI, 1.64- 3.52]), generated more diagnostic uncertainty (OR, 2.39 [95% CI, 1.71-3.35]), but did not increase the need of hospital admission. CONCLUSIONS: Frequent CPU user is associated with previously known coronary artery disease, previous hospitalization, impaired performance status, and presence of symptoms of depression. They are more likely to arrive on CPU at night and generate more diagnostic uncertainty.


Assuntos
Dor no Peito/diagnóstico , Unidades Hospitalares/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Estudos de Casos e Controles , Dor no Peito/psicologia , Doença da Artéria Coronariana/diagnóstico , Depressão/epidemiologia , Feminino , Hospitais com mais de 500 Leitos , Hospitalização , Humanos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Recidiva , Espanha
20.
Emergencias (St. Vicenç dels Horts) ; 20(6): 399-404, nov.-dic. 2008. tab
Artigo em Espanhol | IBECS | ID: ibc-70069

RESUMO

Objetivo: Valorar si existen diferencias en la aproximación diagnóstica del dolor torácico en un servicio de urgencias hospitalario (SUH) en función del género. Método: Pacientes consecutivos visitados en la unidad de dolor torácico de un SUH durante16 meses. Tras la primera valoración y el electrocardiograma, los pacientes se clasificaron en cuatro protocolos diferentes: P1 (síndrome coronario agudo (SCA) con elevación del ST); P2 (SCA con descenso del ST); P3 (dolor torácico probablemente coronario con electrocardiograma (ECG) normal o no diagnóstico) y P4 (dolor torácico no coronario).La variable dependiente fue el género, y las independientes el tiempo puerta–ECG(t1) para cada protocolos; en P1 y P2 el lugar de ingreso del paciente; y en P3 los porcentajes de pacientes a los que se les hizo doble determinación de troponina y prueba de esfuerzo y los tiempos puerta-alta (t2) y puerta-prueba de esfuerzo (t3). En las variables en que se hallaron diferencias significativas, se estratificó por edad y TIMI. Resultados: Se visitaron 4.568 pacientes (5% P1, 8% P2, 46% P3, 41% P4). El 45%fueron mujeres, con una edad media de 74 ± 18 años (varones 58 ± 18 años ;p < 0,001) y un TIMI menor de 2 en el 63% de ellas (varones 47%; p < 0,001). El t1(mediana, en minutos) fue superior en las mujeres en todos los protocolos (P1: 7 vs 5,p = 0,06; P2: 12 vs 9, p = 0,15; P3: 15 vs 13, p < 0,01; P4: 21 vs 19, p = 0,25). Las mujeres ingresaron con menor frecuencia en las unidades de cuidados intensivos o intermedios(36% vs 62%, p < 0,001) y se les solicitaron menos pruebas de esfuerzo(33% vs 39%; p < 0,01). Al estratificar por edad, sólo se mantuvo significativo un menor porcentaje de ingresos en intensivos/intermedios en las mujeres entre 71 y 80 años y una menor cantidad de pruebas de esfuerzo en las mujeres entre 81-90 años. Al estratificar por TIMI, también desaparecieron gran parte de las diferencias y sólo se mantuvieron unos porcentajes inferiores de ingresos en intensivos/intermedios para las mujeres con TIMI <= 2 (15% vs 43%; p < 0,01) y de pruebas de esfuerzo en mujeres con TIMI entre 3 y 4 (23% vs 33%; p = 0,04).Conclusiones: La aproximación diagnóstica del dolor torácico en el SUH puede parecer menos intensa en las mujeres, pero muchas de las diferencias inicialmente observadas desaparecen al estratificar por la edad y el TIMI (AU)


Objective: To assess whether the diagnosis of chest pain is approached differently in men and women attending hospital emergency services. Method: Patients who were treated consecutively in the chest pain unit of a hospital emergency department over a period of 16 months were studied. After the preliminary examination and electrocardiogram (ECG), patient assessment followed 1 of 4 protocols: P1, acute coronary syndrome (ACS) with ST elevation; P2, ACS with ST depression; P3, chest pain with probable ACS but a normal or inconclusive ECG; and P4, chest pain unrelated to ACS. Gender was the dependent variable. The independent variables were time from arrival at the door of the emergency room until the first ECG (t1) for each protocol; the admitting department for P1 and P2 patients; and the percentage of patients in whomtroponin was measured twice and a stress test was ordered, door arrival to discharge time (t2), and door arrival to stress test time (t3) for P3 patients. Variables that were significantly different between genders were studied further with the population stratified by age and risk score for thrombosis in myocardial infarction (TIMI).Results: A total of 4568 patients were attended (5% P1, 8% P2, 46% P3, 41% P4). Forty-five percent were women. The mean (SD) ages were 74 (18) years for women and 58 (18) years for men (P<.001). Sixty-three percent of women and47% of men had a TIMI risk score less than 2 (P<.001). The median t1 was longer for women than men in all protocols(P1, 7 minutes vs 5 minutes, respectively, P=.06; P2, 12 vs 9 minutes, P=.15; P3, 15 vs 13 minutes, P<.01; P4, 21 vs 19minutes, P=.25). Women were admitted to intensive or intermediate care units less often than men (36% vs 62%,P<.001) and stress tests were less often ordered for them (33% vs 39%, P<.01). The only difference that remained after stratifying by age was a lower percentage of intensive or intermediate care unit admission for women between 71 and80 years of age and fewer stress tests for women between 81 and 90 years old. Many differences also disappeared after stratifying by TIMI risk score. Women with TIMI risk scores less than 2 were less often admitted to intensive or intermediate care units than men (15% vs 43%, P<.01); those with scores between 3 and 4 were less often scheduled for stress tests (23% vs 33%, P=.04).Conclusions: The diagnosis of chest pain in this hospital emergency department seems to be less energetically pursued in women; however, many of the differences initially observed disappear when the population is stratified by age and TIMI risk score (AU)


Assuntos
Humanos , Masculino , Feminino , Pessoa de Meia-Idade , Dor no Peito/diagnóstico , Emergências/epidemiologia , Identidade de Gênero , Cuidados Críticos/métodos , Prognóstico , Isquemia Miocárdica/complicações , Revascularização Miocárdica/métodos , Cuidados Críticos/tendências , Revascularização Miocárdica/instrumentação , Revascularização Miocárdica/tendências , Revascularização Miocárdica
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