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1.
Emergencias (Sant Vicenç dels Horts) ; 32(1): 9-18, feb. 2020. graf, tab
Artigo em Espanhol | IBECS-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

3.
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.

5.
Emergencias (Sant Vicenç dels Horts) ; 31(6): 377-384, dic. 2019. graf, tab
Artigo em Espanhol | IBECS | 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


Assuntos
Humanos , Feminino , Pessoa de Meia-Idade , Dor no Peito/epidemiologia , Serviços Médicos de Emergência , Síndrome Coronariana Aguda/epidemiologia , Métodos Epidemiológicos , Assistência Ambulatorial/organização & administração , Assistência Ambulatorial/estatística & dados numéricos , Infarto do Miocárdio sem Supradesnível do Segmento ST , Infarto do Miocárdio com Supradesnível do Segmento ST , Estudos Retrospectivos , Fatores de Risco , Análise de Variância
6.
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.

7.
J Am Coll Cardiol ; 74(6): 744-754, 2019 Aug 13.
Artigo em Inglês | MEDLINE | ID: mdl-31395124

RESUMO

BACKGROUND: The prevalence of pulmonary embolism (PE) in patients presenting with syncope to the emergency department (ED) is largely unknown. This information, however, is necessary to balance the potential medical benefit or harm of systematic PE screening in patients presenting with syncope to the ED. OBJECTIVES: This study sought to determine the prevalence of PE in patients with syncope. METHODS: Unselected patients presenting with syncope to the ED were prospectively enrolled in a diagnostic multicenter study. Pre-test clinical probability for PE was assessed using the 2-level Wells score and the results of D-dimer testing using age-adapted cutoffs. Presence of PE was evaluated by imaging modalities, when ordered as part of the clinical assessment by the treating ED physician or by long-term follow-up data. RESULTS: Long-term follow-up was complete in 1,380 patients (99%) at 360 days and 1,156 patients (83%) at 720 days. Among 1,397 patients presenting with syncope to the ED, PE was detected at presentation in 19 patients (1.4%; 95% confidence interval [CI]: 0.87% to 2.11%). The incidence of new PEs or cardiovascular death during 2-year follow-up was 0.9% (95% CI: 0.5% to 1.5%). In the subgroup of patients hospitalized (47%), PE was detected at presentation in 15 patients (2.3%; 95% CI: 1.4% to 3.7%). The incidence of new PEs or cardiovascular death during 2-year follow-up was 0.9% (95% CI: 0.4% to 2.0%). CONCLUSIONS: PE seems to be a rather uncommon cause of syncope among patients presenting to the ED. Therefore, systematic PE-screening in all patients with syncope does not seem warranted. (BAsel Syncope EvaLuation Study [BASEL IX]; NCT01548352).

8.
Circulation ; 2019 Feb 25.
Artigo em Inglês | MEDLINE | ID: mdl-30798615

RESUMO

BACKGROUND: The utility of B-type Natriuretic Peptide (BNP), N-terminal proBNP (NT-proBNP), and high-sensitivity cardiac troponin (hs-cTn) concentrations for diagnosis and risk-stratification of syncope is incompletely understood. METHODS: We evaluated the diagnostic and prognostic accuracy of BNP, NT-proBNP, hs-cTnT, and hs-cTnI concentrations, alone and against the ones of clinical assessments, in patients >45years presenting with syncope to the emergency department (ED) in a prospective diagnostic multicenter study. BNP, NT-proBNP, hs-cTnT and hs-cTnI concentrations were measured in a blinded fashion. Cardiac syncope, as adjudicated by two physicians based on all information available including cardiac work-up and 1-year follow-up, was the diagnostic endpoint. The EGSYS, a syncope-specific diagnostic score, served as the diagnostic comparator. Death and MACE at 30 and 720 days were the prognostic endpoints. MACE were defined as death, cardiopulmonary resuscitation, life-threatening arrhythmia, implantation of pacemaker/implantable cardioverter defibrillator, acute myocardial infarction, pulmonary embolism, stroke/transient ischemic attack, intracranial bleeding or valvular surgery. The ROSE, OESIL, San Fransisco Syncope Rule (SFSR) and Canadian Syncope Risk Score (CSRS) served as the prognostic comparators. RESULTS: Among 1538 patients eligible for diagnostic assessment, cardiac syncope was the adjudicated diagnosis in 234 patients (15.2%). BNP, NT-proBNP, hs-cTnT, and hs-cTnI were significantly higher in cardiac syncope vs. other causes (p<0.01). The diagnostic accuracy for cardiac syncope, as quantified by the area under the curve (AUC), was 0.77-0.78 (95% confidence interval (CI) 0.74-0.81) for all four biomarkers, and superior to the one of EGSYS (AUC 0.68 [95%-CI 0.65-0.71], p<0.001). Combining BNP/NT-proBNP with hs-cTnT/hs-cTnI further improved diagnostic accuracy to an AUC of 0.81 (p<0.01). BNP, NT-proBNP, hs-cTnT, and hs-cTnI cut-offs, achieving pre-defined thresholds for sensitivity and specificity (95%), allowed for rule-in or rule-out of ~30% of all patients. A total of 450 MACE occurred during follow-up. The prognostic accuracy of BNP, NT-proBNP, hs-cTnI, and hs-cTnT for MACE was moderate-to-good (AUC 0.75-0.79), superior to ROSE, OESIL and SFSR, and inferior to the CSRS. CONCLUSIONS: BNP, NT-proBNP, hs-cTnT, and hs-cTnI concentrations provide useful diagnostic and prognostic information in ED patients with syncope. CLINICAL TRIAL REGISTRATION: URL: https://clinicaltrials.gov Unique Identifier: NCT01548352.

9.
Europace ; 21(3): 511-521, 2019 Mar 01.
Artigo em Inglês | MEDLINE | ID: mdl-30137300

RESUMO

AIMS: It is unknown whether cardiac syncope, and possibly also other syncope aetiologies exhibit circadian, weekly, seasonal, and temperature-dependent patterns. METHODS AND RESULTS: We prospectively recorded the exact time, date, and outside temperature of syncope of patients >40 years old presenting with syncope to the emergency department in a diagnostic multicentre study. Two independent cardiologists/emergency physicians adjudicated the final diagnosis based on all information becoming available during clinical work-up including 1-year follow-up. Among 1230 patients, the adjudicated aetiology was cardiac in 14.6%, reflex in 39.2%, orthostatic in 25.7%, other non-cardiac in 9.7%, and unknown in 10.8% of patients. All syncope aetiologies occurred much more frequently during the day when compared with the night (P < 0.01). While reflex and orthostatic syncope showed a broad peak of prevalence with 80.9% of these events occurring between 4 am and 4 pm, cardiac syncope showed a narrow peak of prevalence with 70.1% of all events occurring between 8 am and 2 pm. A weekly pattern was present for most syncope aetiologies, with events occurring mainly from Monday to Friday (P < 0.01). Reflex syncope displayed a seasonal rhythm and was more common in winter (P < 0.01), while cardiac syncope stayed constant over the year. Syncope occurred most often when the outside temperature was coldest. Overall the patterns observed for cardiac syncope were similar to the patterns observed for its differential diagnosis. CONCLUSION: Syncope aetiologies in patients >40 years old display circadian, weekly, seasonal, and temperature-dependent patterns. Unfortunately, these patterns do not allow to reliably differentiate cardiac syncope from other aetiologies.

10.
Emergencias (Sant Vicenç dels Horts) ; 30(6): 405-407, dic. 2018. tab
Artigo em Espanhol | IBECS | ID: ibc-179710

RESUMO

Objetivo. Identificar la principales drogas de abuso que producen intoxicación aguda en el paciente VIH. Método. Estudio retrospectivo de 1 año evolución de los episodios de intoxicación por drogas de abuso en el paciente VIH en un servicio de urgencias. Se definió chemsex como el consumo de metanfetamina, GHB/GBL o mefedrona para mantener relaciones sexuales prolongadas. Resultados. Se incluyeron 101 pacientes, 93 (92%) eran varones. La principal droga fue la cocaína en 52 (51%) pacientes, seguida del GHB y anfetaminas. La prevalencia de chemsex fue del 87%. La mortalidad de la serie fue del 2%. El consumo de anfetaminas predijo ingreso en cuidados intensivos: OR 9,2 (IC 95% 1,6-52,2); p = 0,012. Conclusión. La cocaína fue la principal causa de intoxicación aguda. El chemsex tuvieron una elevada prevalencia


Objective. To identify the drugs usually abused in cases of acute poisoning in human immunodeficiency virus (HIV) infected patients. Methods. Retrospective study of episodes of acute street drug poisoning in HIV-infected patients in our emergency department over a period of 1 year. Chemsex was defined as the use of methamphetamines, gamma-hydroxybutyrate (GHB), gamma-butyrolactone (GBL), and/or mephedrone in order to prolong sexual activity. Results. We included 101 patients, 93 (92%) of whom were men. The drug that caused the most cases of acute poisoning was cocaine, detected in 52 patients (51%). GHB and amphetamines were the next most frequently implicated street drugs. The prevalence of chemsex in this series was 87%. Mortality was 2%. Amphetamine poisoning was related to intensive care unit admission (odds ratio, 9,2 [95% CI, 1.6–52.2], P=.012). Conclusion. Cocaine use was the main cause of acute poisoning in this series. The prevalence of chemsex was high


Assuntos
Humanos , Masculino , Feminino , Adulto Jovem , Adulto , Pessoa de Meia-Idade , HIV , Drogas Ilícitas/envenenamento , Envenenamento/etiologia , Cocaína/envenenamento , Transtornos Relacionados ao Uso de Cocaína/mortalidade , Estudos Retrospectivos , Transtornos Relacionados ao Uso de Substâncias/epidemiologia , Metanfetamina/envenenamento , Psicotrópicos/farmacocinética , Oxibato de Sódio/envenenamento
11.
Int J Cardiol ; 269: 114-121, 2018 Oct 15.
Artigo em Inglês | MEDLINE | ID: mdl-30224031

RESUMO

BACKGROUND: Various scores have been derived for the assessment of syncope patients in the emergency department (ED) but stay inconsistently validated. We aim to compare their performance to the one of a common, easy-to-use CHADS2 score. METHODS: We prospectively enrolled patients ≥ 40 years old presenting with syncope to the ED in a multicenter study. Early clinical judgment (ECJ) of the treating ED-physician regarding the probability of cardiac syncope was quantified. Two independent physicians adjudicated the final diagnosis after 1-year follow-up. Major cardiovascular events (MACE) and death were recorded during 2 years of follow-up. Nine scores were compared by their area under the receiver-operator characteristics curve (AUC) for death, MACE or the diagnosis of cardiac syncope. RESULTS: 1490 patients were available for score validation. The CHADS2-score presented a higher or equally high accuracy for death in the long- and short-term follow-up than other syncope-specific risk scores. This score also performed well for the prediction of MACE in the long- and short-term evaluation and stratified patients with accuracy comparative to OESIL, one of the best performing syncope-specific risk score. All scores performed poorly for diagnosing cardiac syncope when compared to the ECJ. CONCLUSIONS: The CHADS2-score performed comparably to more complicated syncope-specific risk scores in the prediction of death and MACE in ED syncope patients. While better tools incorporating biochemical and electrocardiographic markers are needed, this study suggests that the CHADS2-score is currently a good option to stratify risk in syncope patients in the ED. TRIAL REGISTRATION: NCT01548352.


Assuntos
Eletrocardiografia/normas , Serviço Hospitalar de Emergência/normas , Síncope/diagnóstico , Síncope/fisiopatologia , Idoso , Idoso de 80 Anos ou mais , Eletrocardiografia/métodos , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos
12.
Emergencias ; 30(6): 405-407, 2018.
Artigo em Inglês, Espanhol | MEDLINE | ID: mdl-30638344

RESUMO

OBJECTIVES: To identify the drugs usually abused in cases of acute poisoning in human immunodeficiency virus (HIV) infected patients. MATERIAL AND METHODS: Retrospective study of episodes of acute street drug poisoning in HIV-infected patients in our emergency department over a period of 1 year. Chemsex was defined as the use of methamphetamines, -hydroxybutyrate (GHB), -butyrolactone (GBL), and/or mephedrone in order to prolong sexual activity. RESULTS: We included 101 patients, 93 (92%) of whom were men. The drug that caused the most cases of acute poisoning was cocaine, detected in 52 patients (51%). GHB and amphetamines were the next most frequently implicated street drugs. The prevalence of chemsex in this series was 87%. Mortality was 2%. Amphetamine poisoning was related to intensive care unit admission (odds ratio, 9,2 [95% CI, 1.6-52.2], P=.012). CONCLUSION: Cocaine use was the main cause of acute poisoning in this series. The prevalence of chemsex was high.


Assuntos
Overdose de Drogas/etiologia , Infecções por HIV/psicologia , Comportamento Sexual , Doença Aguda , Adulto , Overdose de Drogas/diagnóstico , Overdose de Drogas/epidemiologia , Serviço Hospitalar de Emergência , Feminino , Infecções por HIV/complicações , Humanos , Modelos Logísticos , Masculino , Estudos Retrospectivos , Fatores de Risco , Espanha
13.
JAMA Cardiol ; 1(8): 912-920, 2016 11 01.
Artigo em Inglês | MEDLINE | ID: mdl-27653005

RESUMO

Importance: It is currently unknown whether the uniform (universal clinical practice for more than 2 decades) or 2 sex-specific cutoff levels are preferable when using high-sensitivity cardiac troponin T (hs-cTnT) levels in the diagnosis of acute myocardial infarction (AMI). Objective: To improve the management of suspected AMI in women by exploring sex-specific vs uniform cutoff levels for hs-cTnT. Design, Setting, and Participants: In an ongoing prospective, diagnostic, multicenter study conducted at 9 emergency departments, the present study evaluated patients enrolled from April 21, 2006, through June 5, 2013. The participants included 2734 adults presenting with suspected AMI. Duration of follow-up was 2 years, and data analysis occurred from June 5 to December 21, 2015. Interventions: The final diagnosis was centrally adjudicated by 2 independent cardiologists using all available information, including measurements of serial hs-cTnT blood concentrations twice: once using the uniform 99th percentile cutoff value level of 14 ng/L and once using sex-specific 99th percentile levels of hs-cTnT (women, 9 ng/L; men, 15.5 ng/L). Main Outcomes and Measures: Diagnostic reclassification in women and men using sex-specific vs the uniform cutoff level in the diagnosis of AMI. Results: Of the 2734 participants, 876 women (32%) and 1858 men (68%) were included. Median (interquartile range) age was 68 (55-77) and 59 (48-71) years, respectively. With the use of the uniform cutoff value, 127 women (14.5%) and 345 men (18.6%) received a final diagnosis of AMI. Among these, at emergency department presentation, levels of hs-cTnT were already above the uniform cutoff value in 427 patients (sensitivity, 91.3% [95% CI, 85%-95.6%] in women vs 90.7% [95% CI, 87.1%-93.5% in men]; specificity, 79.2% [95% CI, 76.1%-82.1%] in women vs 78.5% [95% CI, 76.4%-80.6%] in men). After readjudication using sex-specific 99th percentile levels, diagnostic reclassification regarding AMI occurred in only 3 patients: 0.11% (95% CI, 0.02-0.32) of all patients and 0.6% (95% CI, 0.13-1.85) of patients with AMI. The diagnosis in 2 women was upgraded from unstable angina to AMI, and the diagnosis in 1 man was downgraded from AMI to unstable angina. These diagnostic results were confirmed when using 2 alternative pairs of uniform and sex-specific cutoff values. Conclusions and Relevance: The uniform 99th percentile should remain the standard of care when using hs-cTnT levels for the diagnosis of AMI.


Assuntos
Biomarcadores/análise , Infarto do Miocárdio/diagnóstico , Troponina T/análise , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Sensibilidade e Especificidade
14.
Int J Cardiol ; 207: 238-45, 2016 Mar 15.
Artigo em Inglês | MEDLINE | ID: mdl-26808985

RESUMO

OBJECTIVE: The novel high-sensitivity cardiac troponin (hs-cTn) 0h/1h-algorithm substantially improves the early triage of patient's assigned "rule-out" or "rule-in" of acute myocardial infarction (AMI), while diagnostic uncertainty remains in that 25-30% of patients assigned to "observe". We aimed to better characterize these patients. METHODS: In a prospective multicenter diagnostic study, we applied the hs-cTnT 0h/1h-algorithm in 2213 unselected patients presenting with symptoms suggestive of AMI to the emergency department. The final diagnosis was adjudicated by two independent cardiologists using all available information. Survival at 720-days was the prognostic endpoint. Findings were validated using a hs-cTnI 0h/1h-algorithm. RESULTS: Twenty-four percent (n=523) of patients were assigned to "observe" by the hs-cTnT 0h/1h-algorithm. These patients differed significantly in multiple characteristics from "rule-out" and "rule-in" patients: they were older, in 75% male, and very often (57%) had pre-existing coronary artery disease (CAD). Diagnostic uncertainty for the presence of an AMI/UA was high. Only 39% of patients were suitable for coronary computed tomography angiography (CCTA). The most common final adjudicated diagnoses were non-cardiac disease (38%), non-coronary cardiac disease (24%), unstable angina (UA, 21%), and AMI (15%). Absolute hs-cTnT-changes within 3h had the highest diagnostic accuracy for AMI (AUC 0.86). Cumulative 720-day survival rate was 86%, which was significantly lower as compared to "rule-out" (p<0.001) and comparable to "rule-in" (p=ns). Findings were similar for the hs-cTnI "observe" zone. CONCLUSION: "Observe" patients are typically elderly men with pre-existing CAD and high long-term mortality. Absolute hs-cTn-changes within 3h, functional stress imaging and coronary angiography are the key diagnostic modalities.


Assuntos
Algoritmos , Internacionalidade , Infarto do Miocárdio/sangue , Infarto do Miocárdio/diagnóstico , Troponina T/sangue , Idoso , Biomarcadores/sangue , Diagnóstico Precoce , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Fatores de Tempo
15.
Biochim Biophys Acta ; 1850(9): 1685-93, 2015 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-25960389

RESUMO

BACKGROUND: Recombinant erythropoietin (EPO) has been marketed as biopharmaceutical for anemia and chronic renal failure. Long-acting EPO variants that aimed at achieving less frequent dosing have been generated, either by the addition of glycosylation sites or increasing its molecular weight. METHODS: The hEPO cDNA linked to the human IgG Fc fragment was cloned as a single codifying gene on the pAdtrack-CMV vector, yielding the recombinant adenoviral genome. For in vitro and in vivo expression assays cervical cancer cell line (SiHa) and nulliparous goats were used, respectively. The hematopoietic activity of EPO-Fc, expressed as the differential increment of hematocrit was evaluated in B6D2F1 mice. NP-HPLC of the 2AB-labeled N-glycan was carried out to profile analysis. RESULTS: The direct transduction of mammary secretory cells with adenoviral vector is a robust methodology to obtain high levels of EPO of up to 3.5mg/mL in goat's milk. SiHa-derived EPO-Fc showed significant improvement in hematopoietic activity compared to the commercial hEPO counterpart or with the homologous milk-derived EPO-Fc. The role of the molecular weight seemed to be important in enhancing the hematopoietic activity of SiHa-derived EPO-Fc. However, the lack of sialylated multi-antennary glycosylation profile in milk-derived EPO-Fc resulted in lower biological activity. CONCLUSIONS: The low content of tri- or tetra-antennary sialylated N-glycans linked to the chimeric EPO-Fc hormone, expressed in the goat mammary gland epithelial cells, defined its in vivo hematopoietic activity. GENERAL SIGNIFICANCE: The sialylated N-glycan content plays a more significant role in the in vivo biological activity of hEPO than its increased molecular weight.


Assuntos
Eritropoetina/farmacologia , Hematopoese/efeitos dos fármacos , Fragmentos Fc das Imunoglobulinas/farmacologia , Processamento de Proteína Pós-Traducional , Proteínas Recombinantes de Fusão/farmacologia , Animais , Relação Dose-Resposta a Droga , Células HEK293 , Humanos , Camundongos , Polissacarídeos/farmacologia
17.
Med Clin (Barc) ; 130(8): 286-91, 2008 Mar 08.
Artigo em Espanhol | MEDLINE | ID: mdl-18358119

RESUMO

BACKGROUND AND OBJECTIVE: We aimed: a) to determine changes in patient flow, and in emergency department (ED) effectiveness and quality that may happen depending on the season (winter/non-winter), and b) to analyze effects on those changes when a special winter programme (SWP) of the Pla Integral d'Urgències de Catalunya (PIUC) is applied. MATERIAL AND METHOD: We studied 4 weeks of each period: non-winter period, winter control period (without SWP), winter period with SWP. Within the 3 periods, the daily census was taken as a proxy of external pressure, and the number of patients admitted to the hospital from the ED as a proxy of internal pressure. In each period, effectiveness markers--ED occupancy rate, rate of ED patients waiting for a bed, waiting time (WT) and number of patients waiting to be seen (PW), length of stay-- objective quality markers -revisit rate, rate of patients left without being seen, rate of patients left against medical advise (LAMA), and mortality rate-, and subjective quality markers -patient satisfaction with the physician, the nurse, the general ED organization, and level of complaint solution- were recorded. RESULTS: Compared to the non-winter period, in the winter period without SWP the daily census rose by 6% (p = 0.07), and the number of patients admitted 10.8% (p = 0.16). These increases went along with a worsening of almost all effectiveness and quality markers, although only PW (+63%; p < 0.01), WT (+130%; p < 0.001), length of stay (+28%; p < 0.05), rate of patients left without being seen (+97%; p < 0.001) and LAMA (+218%; p < 0.05) reached statistical significance. In the winter period with SWP, the daily census kept stable but the number of patients admitted grew by 18% (p < 0.01). The SWP improved some subjective quality markers (patient satisfaction with the physician and the nurse), but failed to improve any effectiveness or objective quality marker. Some of them got even worse within the SWP period: ED occupancy rate, +20% (p = 0.001); PW, +42% (p < 0.05), and WT, +56% (p < 0.05). CONCLUSIONS: In winter, a worsening of ED effectiveness and quality can be expected. Measures from the SWP prepared by the Administration are unable to correct such deterioration. A profound analysis of the SWP is suggested.


Assuntos
Serviço Hospitalar de Emergência/normas , Número de Leitos em Hospital/estatística & dados numéricos , Admissão do Paciente/estatística & dados numéricos , Qualidade da Assistência à Saúde , Estações do Ano , Ocupação de Leitos , Interpretação Estatística de Dados , Serviço Hospitalar de Emergência/estatística & dados numéricos , Política de Saúde , Mortalidade Hospitalar , Hospitais Universitários , Humanos , Tempo de Internação , Satisfação do Paciente , Indicadores de Qualidade em Assistência à Saúde , Espanha , Fatores de Tempo
18.
Med. clín (Ed. impr.) ; 130(8): 286-291, mar. 2008. ilus, tab
Artigo em Espanhol | IBECS | ID: ibc-63535

RESUMO

Fundamento y objetivo: Estimar si se producen cambios en los parámetros de flujo de pacientes, eficacia y calidad en un servicio de urgencias hospitalario (SUH) en función de la época del año (invierno-no invierno), así como los efectos que sobre estos parámetros tienen las medidas extraordinarias del Plan Especial de Invierno (PEI) del Pla Integral d'Urgències de Catalunya (PIUC). Material y método: Se estudiaron 4 semanas de cada período: período no invernal; período control invernal (sin PEI), y período invernal con PEI. La presión asistencial externa sobre el SUH durante los 3 períodos se estimó mediante el número de visitas diarias, y la presión asistencial interna mediante el número de pacientes atendidos en el SUH que precisaron ingreso. En cada período se midieron parámetros de efectividad ­porcentaje de ocupación de urgencias y de pacientes pendientes de ingresar, tiempo (Tesp) y número de pacientes (Pesp) en espera para iniciar la visita, y duración total de ésta­, de calidad objetiva ­índices de revisita, de pacientes no visitados, de altas voluntarias (IAV) y de fallecidos­ y de calidad subjetiva ­satisfacción respecto al trato médico y de enfermería, organización del servicio y resolución del problema­. Resultados: En comparación con el período no invernal, durante el invierno la presión asistencial externa sobre urgencias aumentó un 6,0% (p = 0,07) y la interna un 10,8% (p = 0,16). Estos incrementos durante el invierno se acompañaron de un empeoramiento de casi todos índices de efectividad y de calidad tanto objetiva como subjetiva, entre los que resultaron significativos los cambios en el Pesp (+63%; p < 0,01), el Tesp (+130%; p < 0,001), la duración total de la visita (+28%; p < 0,05), el IAV (+218%; p < 0,05) y el índice de pacientes no visitados (+97%; p < 0,001). Durante el período invernal con el PEI del PIUC en funcionamiento, la presión externa sobre el SUH se mantuvo prácticamente constante en comparación con el período invernal control (sin PIE) y la presión interna creció un 18% (p < 0,01). Las medidas del PIE del PIUC consiguieron mejoras en algún parámetro de calidad subjetiva (satisfacción respecto al trato médico y de enfermería), pero no lograron mejorar los de efectividad ni los de calidad objetiva, y algunos de ellos incluso empeoraron significativamente: un +20% en la ocupación global de urgencias (p = 0,001); un +42% en Pesp (p < 0,05), y un +56% en Tesp (p < 0,05). Conclusiones: Durante el período invernal se deterioran tanto la efectividad como la calidad objetiva y subjetiva del SUH. Las medidas extraordinarias del PIE del PIUC sólo consiguen mejorar alguno de estos aspectos, por lo que deben revisarse y ajustarse a los resultados conseguidos


Background and objective: We aimed: a) to determine changes in patient flow, and in emergency department (ED) effectiveness and quality that may happen depending on the season (winter/non-winter), and b) to analyze effects on those changes when a special winter programme (SWP) of the Pla Integral d'Urgències de Catalunya (PIUC) is applied. Material and method: We studied 4 weeks of each period: non-winter period, winter control period (without SWP), winter period with SWP. Within the 3 periods, the daily census was taken as a proxy of external pressure, and the number of patients admitted to the hospital from the ED as a proxy of internal pressure. In each period, effectiveness markers ­ED occupancy rate, rate of ED patients waiting for a bed, waiting time (WT) and number of patients waiting to be seen (PW), length of stay­, objective quality markers ­revisit rate, rate of patients left without being seen, rate of patients left against medical advise (LAMA), and mortality rate­, and subjective quality markers ­patient satisfaction with the physician, the nurse, the general ED organization, and level of complaint solution­ were recorded. Results: Compared to the non-winter period, in the winter period without SWP the daily census rose by 6% (p = 0.07), and the number of patients admitted 10.8% (p = 0.16). These increases went along with a worsening of almost all effectiveness and quality markers, although only PW (+63%; p < 0.01), WT (+130%; p < 0.001), length of stay (+28%; p < 0.05), rate of patients left without being seen (+97%; p < 0.001) and LAMA (+218%; p < 0.05) reached statistical significance. In the winter period with SWP, the daily census kept stable but the number of patients admitted grew by 18% (p < 0.01). The SWP improved some subjective quality markers (patient satisfaction with the physician and the nurse), but failed to improve any effectiveness or objective quality marker. Some of them got even worse within the SWP period: ED occupancy rate, +20% (p = 0.001); PW, +42% (p < 0.05), and WT, +56% (p < 0.05). Conclusions: In winter, a worsening of ED effectiveness and quality can be expected. Measures from the SWP prepared by the Administration are unable to correct such deterioration. A profound analysis of the SWP is suggested


Assuntos
Humanos , Avaliação de Processos e Resultados (Cuidados de Saúde) , Serviço Hospitalar de Emergência/organização & administração , Serviço Hospitalar de Emergência/estatística & dados numéricos , Estações do Ano , Necessidades e Demandas de Serviços de Saúde/estatística & dados numéricos , Resolução de Problemas
19.
Med Clin (Barc) ; 127(3): 86-9, 2006 Jun 17.
Artigo em Espanhol | MEDLINE | ID: mdl-16827997

RESUMO

BACKGROUND AND OBJECTIVE: To find out if the daily emergency department (ED) census and daily ED admittances can accurately be foreseen based on the number of visits arrived on ED within the first shift hours. PATIENTS AND METHOD: For 6 consecutively months, the number of ED visits from 6 AM to 10 AM (early visits), and from 10 AM to next day 6 AM (daily ED census) was recorded, along with the number of both daily hospital and ED admittances from 6 AM to 6 AM. The analysis was performed for the ED as a whole, and for each one of its sections. RESULTS: A significant direct correlation was seen between the early visits and daily ED census. This relationship was even greater as considered the ED as a whole (R2 = 0.25; p < 0.001). A direct correlation was also found between daily ED census and daily admittances (R2 = 0.19; p < 0.001). CONCLUSIONS: The number of early ED visits is an important tool to accurately predict the daily ED census and the number of in-hospital beds needed for ED patients.


Assuntos
Serviço Hospitalar de Emergência/estatística & dados numéricos , Determinação de Necessidades de Cuidados de Saúde , Admissão do Paciente/estatística & dados numéricos , Número de Leitos em Hospital , Humanos , Espanha
20.
Med Clin (Barc) ; 126(19): 736-9, 2006 May 20.
Artigo em Espanhol | MEDLINE | ID: mdl-16759588

RESUMO

BACKGROUND AND OBJECTIVE: To determine the effect that the lack of inhospital beds exerts on emergency department performance. MATERIAL AND METHOD: Two different time periods with comparable daily census, but significantly different bed availability. Variables assessed were general emergency department performance markers, emergency department effectiveness markers and objective and subjective quality markers. RESULTS: All variables got worse within lower bed availability period, and reached a change magnitude between 0% and 300% when compared with control period. However, a statistical difference was only achieved in emergency department occupation rate (+14%; p < 0.001), rate of patients waiting to be admitted (+100%; p < 0.001), patients waiting to be seen (+60%; p < 0.01), waiting time to be seen (+83%; p < 0.001), time to employed for first medical assessment and treatment (+44%; p < 0.01), and patients left without being seen (+90%; p < 0.05). CONCLUSIONS: The lack of inhospital beds for patients admitted from the emergency department leads to a remarkable worsening in its function and performance.


Assuntos
Serviço Hospitalar de Emergência/normas , Número de Leitos em Hospital/estatística & dados numéricos , Indicadores de Qualidade em Assistência à Saúde , Serviço Hospitalar de Emergência/estatística & dados numéricos , Humanos , Admissão do Paciente/estatística & dados numéricos , Espanha/epidemiologia , Fatores de Tempo
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