•The prognosis of patients with acute coronary syndrome (ACS) depends on early diagnosis and treatment.•Chest pain onset presents more than 6 h prior to ED arrival in up to 38.5% of patients with ...chest pain and a final diagnosis of ACS.•Chest pain aggravated by exercise and recurrent chest pain were associated with both late presentation and a final diagnosis of ACS.•Educational initiatives should highlight these features as potential warnings for ACS and thereby encourage patients to seek prompt medical advice.
We investigated which factors predict late presentation (LP) to the emergency department (ED) in patients with non-traumatic chest pain (CP).
All CP cases attended at a single ED (2008–2017) were included. LP was considered if time from CP onset to ED arrival was>6 h. We analyzed associations between 42 patient/CP-related characteristics and LP in the whole cohort and in patients with CP due to acute coronary syndrome (ACS).
The cohort included 25,693 cases (LP=50.6%; ACS=19.0%). Twenty factors were associated with LP, and 8 were also found in patients with ACS: CP of short-duration, aggravated by exertion or breathing/movement, undulating or recurrent CP increased the risk of LP, whereas CP accompanied by diaphoresis, irradiated to the throat, and chronic treatment with nitrates decreased the risk of LP. Exertional and recurrent CP were associated with both, LP and ACS.
Some characteristics, mainly CP-related, may lead to LP to the ED. CP aggravated by exercise and recurrent CP were associated with both LP and a final diagnosis of ACS.
Patient educational initiatives should consider these two features as potential warnings for ACS and thereby encourage patients to seek early medical consultation.
Autoimmune polyglandular syndrome type 1 (APS-1, OMIM 240300) is a rare autosomal recessive disorder, characterized by the presence of at least two of three major diseases: hypoparathyroidism, ...Addison's disease, and chronic mucocutaneous candidiasis. We aim to identify the molecular defects and investigate the clinical and mutational characteristics in an index case and other members of a consanguineous family. We identified a novel homozygous mutation in the splice site acceptor (SSA) of intron 5 (c.653-1G>A) in two siblings with different clinical outcomes of APS-1. Coding DNA sequencing revealed that this AIRE mutation potentially compromised the recognition of the constitutive SSA of intron 5, splicing upstream onto a nearby cryptic SSA in intron 5. Surprisingly, the use of an alternative SSA entails the uncovering of a cryptic donor splice site in exon 5. This new transcript generates a truncated protein (p.A214fs67X) containing the first 213 amino acids and followed by 68 aberrant amino acids. The mutation affects the proper splicing, not only at the acceptor but also at the donor splice site, highlighting the complexity of recognizing suitable splicing sites and the importance of sequencing the intron-exon junctions for a more precise molecular diagnosis and correct genetic counseling. As both siblings were carrying the same mutation but exhibited a different APS-1 onset, and one of the brothers was not clinically diagnosed, our finding highlights the possibility to suspect mutations in the AIRE gene in cases of childhood chronic candidiasis and/or hypoparathyroidism otherwise unexplained, especially when the phenotype is associated with other autoimmune diseases.
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DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Abstract Background During the first wave of the COVID‐19 pandemic, the availability of mechanical ventilators was very limited and ad hoc recommendations establishing age to be used for patient ...triage for having access to intensive care beds (ICBs) were proposed. No reports have evaluated how this policy impacted ICB admission in Western countries. Aims We analyzed the age‐related probability of ICB admission during first COVID‐19 pandemic wave. Materials and Methods We included all patients ≥65 years attended in 42 Spanish emergency departments (EDs) covering around 22% of the Spanish population during 1‐week of the first wave of the COVID‐19 pandemic (9128 ED visits) and compared the probability of ICB admission respect to patients coming to these EDs 1‐week of 1‐year earlier (24,128 ED visits). Results We found that compared with patients aged 65, the probability of ICB admission was significantly reduced from 79 years and up during the pandemic period (odds ratio OR = 0.60 for patients aged 79, 95% confidence interval CI = 0.39–0.94), while a significant reduction of ICB admission probabilities was found from 88 years and up during the pre‐COVID‐19 period (OR = 0.66 for patients aged 88, 95% CI = 0.45–0.95) ( p < 0.001 for interaction). Similar results were found when analyses were limited to hospitalized or deceased patients and also after adjustment using sex and several baseline status covariates. Conclusion There was a real limitation in clinical practice of ICB admission based on age during the first wave of the COVID‐19 pandemic.
•The type of household is associated with elderly patients' prognosis at one year.•Living in a nursing home is associated with higher mortality.•Living at home but not alone is associated with a ...lower rate of rehospitalization/revisit.
To investigate whether the type of household is associated with prognosis at one year in patients ≥65 years of age discharged after medical consultation requiring emergency department care.
Data from the Emergency Department and Elder Needs (EDEN) cohort were used. This retrospective cohort included all patients ≥65 years of age seen in 52 Spanish emergency departments over one week (April 1–7, 2019) in whom the type of household was recorded and categorized as living at home alone, with relatives, with professional caregivers, or in a nursing home. Patient demographic and other baseline characteristics and management during the index emergency department episode were recorded and used to adjust the following 1-year outcomes: all-cause mortality, hospitalization and emergency department revisit. Associations between type of household and outcomes are expressed as adjusted hazard ratios with 95% confidence intervals using living alone as the reference category.
13,442 patients with a median age of 79 years (interquartile range 72–86) were included; 56% were women, 12.2% of patients lived alone, 74.9% with relatives, 3.9% with a professional caregiver, and 9.1% in a nursing home. During the year following discharge, the mortality rate was 14.0%, the hospitalization rate 29.7%, and the emergency department revisit rate 59.3%. In the fully adjusted model, the risk of death was associated only with living in a nursing home (hazard ratio 1.366 (1.101–1.695)). On the other hand, the risk of hospitalization was lower in individuals living in nursing homes (hazard ratio 0.783 0.676–0.907) and at home with relatives (hazard ratio 0.897 0.810–0.992), while the risk of emergency department revisit was lower in individuals living in nursing homes (hazard ratio 0.826 0.742–0.920) or at home with caregivers (hazard ratio 0.856 0.750–0.976).
The type of household was modestly associated with the one-year prognosis of patients ≥65 years of age discharged after attendance at an emergency department. Living in a nursing home is associated with an increased risk of death but a decreased risk of rehospitalization or emergency department revisit, while living at home with relatives or professional caregivers is associated only with a decreased risk of hospitalization and emergency department revisit, respectively.
The Covid-19 pandemic continues challenging health systems globally, exposing healthcare workers to constant physical and psychological stressors. To date, several studies have already shown the ...catastrophic impact on the mental health of medical personnel during the early period of the pandemic. Nevertheless, literature evidences the dearth of works that evaluate the effect over time, understanding the pandemic as a sustained extreme stressor. The present study examines the effect of the pandemic on the mental health of Covid-19 frontline healthcare workers at six months follow-up.
A total of 141 frontline healthcare workers from two tertiary hospitals were recruited between July and November 2020. Healthcare workers were evaluated psychologically at baseline and six months follow-up (January to May 2021) using psychometric tests for the assessment of acute stress (VASS, PSS-10, PCL-5), anxiety (STAI) and depression (PHQ-2)
Overall, there was a general worsening of the mental health between the two psychological assessments, especially regarding depression and predisposition to perceiving the situations as a threat. Nurses and nurse aides showed poorer mental health while physicians improved over time. Reduced working hours and higher physical exercise resulted in better mental health among healthcare workers. Women and nursing staff were the most affected by psychological distress at baseline and six months follow-up.
Reduced working hours, adequate resting periods, physical exercise, and efficient intervention strategies are of utmost importance in preventing, controlling, and reducing psychological distress among healthcare workers when coping with critical scenarios such as the current pandemic.
La pandemia Covid-19 sigue desafiando a los sistemas sanitarios, exponiendo al personal asistencial a estresores físicos y psicológicos. Actualmente, varios estudios han demostrado el impacto catastrófico en la salud mental del personal asistencial durante la primera etapa de la pandemia, pero pocos han considerado el seguimiento de los síntomas. El presente estudio examina el efecto de la pandemia en la salud mental del personal sanitario de primera línea a los 6 meses de seguimiento.
Se evaluó psicológicamente a 141 trabajadores sanitarios de primera línea de 2 hospitales terciarios al inicio del estudio (julio-noviembre, 2020) y a los 6 meses (enero-mayo, 2021) mediante pruebas psicométricas para el estrés agudo (VASS, PSS-10, PCL-5), la ansiedad (STAI) y la depresión (PHQ-2).
En general, se observó un empeoramiento de la salud mental entre las 2 evaluaciones psicológicas, especialmente en depresión y predisposición a percibir las situaciones como una amenaza. La salud mental del personal de enfermería empeoró con el tiempo, mientras que los médicos mejoraron. La reducción de la jornada laboral y el aumento del ejercicio físico mejoraron la salud mental. Las mujeres y el personal de enfermería fueron los más afectados por el malestar psicológico al inicio y a los 6 meses de seguimiento.
Jornadas laborales reducidas, períodos de descanso adecuados, ejercicio físico y estrategias de intervención eficientes son de suma importancia para prevenir, controlar y reducir el malestar psicológico entre el personal sanitario ante escenarios críticos como la pandemia actual.
•Functional outcomes of older adults after a fall-related ED visit are less well understood.•Three out of 4 older patients attended for a fall in EDs had some degree of functional impairment before ...the event.•One out of 3 cases had a clinically significant functional decline at 180 days.•Age ≥85 years, fall-related fracture, hospitalization and post-fall syndrome were associated with 180-day poor outcome.
To determine functional changes and factors affecting 180-day functional prognosis among older patients attending a hospital emergency department (ED) after a fall.
Retrospective analysis from a prospective cohort study (FALL-ER Registry) spanning one year that included individuals aged ≥65 years attending four Spanish EDs after a fall. We collected 9 baseline and 6 fall-related factors.
Barthel Index (BI) was measured at baseline, discharge and 30, 90 and 180 days after the index fall. Absolute and relative BI changes were calculated. Absolute difference of ≥10 points between BI at baseline and at 180 days was considered a clinically significant functional decline.
452 patients (mean age 80 ± 8 years; 70.8% women) were included. Baseline BI was 79.3 ± 23.1 points. Compared with baseline, functional status was significantly lower at the 4 follow-up time points (-8.7% at discharge; and −6.9%, −7.9% and −9.5% at 30, 90 and 180 days; p < 0.001 for all comparisons in relation to baseline; p = 0.001 for change over time). One hundred and thirty-three (29.6%) patients had a clinically significant functional decline at 180 days. Age ≥85 years (OR = 2.24, 95%CI 1.23–4.08; p = 0.008), fall-related fracture (OR = 2.45, 95%CI 1.43–4.28; p = 0.001), hospitalization (OR = 1.91; 95%CI 1.11–3.29; p = 0.019) and post-fall syndrome (OR = 1.77, 95%CI 1.13-2.77; p = 0.013) were independently associated with 180-day clinically significant functional decline.
Patients ≥65 years attending EDs after a fall experience a consistent and persistent negative impact on their functional status. Several factors may help identify patients at increased risk of functional impairment.
Objective
To define the short- and mid-term outcomes of patients discharged after an episode of acute-decompensated heart failure (ADHF) and evaluate the differences between patients discharged ...directly from the emergency department (ED) and those discharged after hospitalization.
Methods
We performed a prospective, multicenter, cohort-designed study, including consecutive patients diagnosed with ADHF in 27 Spanish EDs. Thirty-four variables on epidemiology, comorbidity, baseline status, vital signs, signs of congestion, laboratory tests, and treatment were collected in every patient. The primary outcome was a combined endpoint of ED revisit (without hospitalization) or hospitalization due to ADHF, or all-cause death. Secondary outcomes were each of these three events individually. Outcomes were obtained by survival analysis at different timepoints in the entire cohort, and crude and adjusted comparisons were carried out between patients discharged directly from the ED and after hospitalization.
Results
Of the 3233 patients diagnosed with ADHF during a 2-month period, we analyzed 2986 patients discharged alive: 787 (26.4%) discharged from the ED and 2199 (73.6%) after hospitalization. The cumulative percentages of events for the whole cohort (at 7/30/180 days) for the combined endpoint were 7.8/24.7/57.8; for ED revisit 2.5/9.4/25.5; for hospitalization 4.6/15.3/40.7; and for death 0.9/4.3/16.8. After adjustment for patient profile and center, significant increases were found in the hazard ratios for ED- compared to hospital-discharged patients in the combined endpoint, ED revisit and hospitalization, being higher at short-term at 7 days, 2.373 (1.678–3.355), 2.069 (1.188–3.602), and 3.071 (1.915–4.922), respectively than at mid-term at 180 days, 1.368 (1.160–1.614), 1.642 (1.265–2.132), and 1.302 (1.044–1.623), respectively. No significant differences were found in death.
Conclusions
Patients with ADHF discharged from the ED have worse outcomes, especially at short term, than those discharged after hospitalization. The definition and implementation of effective strategies to improve patient selection for direct ED discharge are needed.
To assess whether older adults who spend a night in emergency departments (ED) awaiting admission are at increased risk of mortality. This was a retrospective review of a multipurpose cohort that ...recruited all patients ≥ 75 years who visited ED and were admitted to hospital on April 1 to 7, 2019, at 52 EDs across Spain. Study groups were: patients staying in ED from midnight until 8:00 a.m. (ED group) and patients admitted to a ward before midnight (ward group). The primary endpoint was in-hospital mortality, truncated at 30 days, and secondary outcomes assessed length of stay for the index episode. The sample comprised 3,243 patients (median IQR age, 85 81-90 years; 53% women), with 1,096 (34%) in the ED group and 2,147 (66%) in the ward group. In-hospital mortality for patients spending the night in the ED the ED group was 10.7% and 9.5% for patients transferred to a ward bed before midnight the ward group (adjusted OR: 1.12, 95%CI: 0.80-1.58). Sensitivity analyses rendered similar results (ORs ranged 1.06-1.13). Interaction was only detected for academic/non-academic hospitals (p < 0.001), with increased mortality risk for the latter (1.01, 0.33-3.09 vs 2.86, 1.30-6.28). There were no differences in prolonged hospitalization (> 7 days), with adjusted OR of 1.16 (0.94-1.43) and 1.15 (0.94-1.42) depending on whether time spent in the ED was or was not taken into consideration. No increased risk of in-hospital mortality or prolonged hospitalization was found in older patients waiting overnight in the ED for admission. Nonetheless, all estimations suggest a potential harmful effect of staying overnight, especially if a proper bedroom and hospitalist ward bed and hospitalized care are not provided.To assess whether older adults who spend a night in emergency departments (ED) awaiting admission are at increased risk of mortality. This was a retrospective review of a multipurpose cohort that recruited all patients ≥ 75 years who visited ED and were admitted to hospital on April 1 to 7, 2019, at 52 EDs across Spain. Study groups were: patients staying in ED from midnight until 8:00 a.m. (ED group) and patients admitted to a ward before midnight (ward group). The primary endpoint was in-hospital mortality, truncated at 30 days, and secondary outcomes assessed length of stay for the index episode. The sample comprised 3,243 patients (median IQR age, 85 81-90 years; 53% women), with 1,096 (34%) in the ED group and 2,147 (66%) in the ward group. In-hospital mortality for patients spending the night in the ED the ED group was 10.7% and 9.5% for patients transferred to a ward bed before midnight the ward group (adjusted OR: 1.12, 95%CI: 0.80-1.58). Sensitivity analyses rendered similar results (ORs ranged 1.06-1.13). Interaction was only detected for academic/non-academic hospitals (p < 0.001), with increased mortality risk for the latter (1.01, 0.33-3.09 vs 2.86, 1.30-6.28). There were no differences in prolonged hospitalization (> 7 days), with adjusted OR of 1.16 (0.94-1.43) and 1.15 (0.94-1.42) depending on whether time spent in the ED was or was not taken into consideration. No increased risk of in-hospital mortality or prolonged hospitalization was found in older patients waiting overnight in the ED for admission. Nonetheless, all estimations suggest a potential harmful effect of staying overnight, especially if a proper bedroom and hospitalist ward bed and hospitalized care are not provided.
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