This study analyzed the impact of a categorized approach, based on patients' prognosis, on major outcomes and explanators in patients hospitalized for COVID-19 pneumonia in an academic center in ...Spain.
Retrospective cohort study (March 3 to May 2, 2020). Patients were categorized according to the followed clinical management, as maximum care or limited therapeutic effort (LTE). Main outcomes were all-cause mortality and need for invasive mechanical ventilation (IMV). Baseline factors associated with outcomes were analyzed by multiple logistic regression, estimating odds ratios (OR; 95%CI).
Thirty-hundred and six patients were hospitalized, median age 65.0 years, 57.8% males, 53.3% Charlson index ≥3. The overall all-cause fatality rate was 15.0% (n = 46). Maximum care was provided in 238 (77.8%), IMV was used in 38 patients (16.0%), and 5.5% died. LTE was decided in 68 patients (22.2%), none received IMV and fatality was 48.5%. Independent risk factors of mortality under maximum care were lymphocytes <790/mm3, troponin T >15ng/L and hypotension. Advanced age, lymphocytes <790/mm3 and BNP >240pg/mL independently associated with IMV requirement.
Overall fatality in the cohort was 15% but markedly varied regarding the decided approach (maximum care versus LTE), translating into nine-fold higher mortality and different risk factors.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Multiple studies have evaluated copeptin, a surrogate for arginine vasopressin, in the diagnosis of acute myocardial infarction (AMI) with mixed results. A systematic review and collaborative ...meta-analysis were performed for diagnosis of AMI and assessment of prognosis in patients presenting to the emergency department with chest pain. MEDLINE/PubMed, Cochrane CENTRAL, and EMBASE were searched for studies assessing copeptin in such patients. Study investigators were contacted, and many provided previously unpublished data. Random-effects methods were used to compare the data for copeptin, troponin, and their combination. There were a total of 9,244 patients from the 14 included studies. Mean age was 62 years; 64% were men; and 18.4% were ultimately diagnosed with AMI. Patients with AMI had a higher presentation copeptin level than those without AMI (22.8 vs 8.3 pmol/L, respectively, p <0.001). Although troponin had better diagnostic accuracy than copeptin for AMI, the combination of copeptin and troponin significantly improved the sensitivity (0.905 0.888 to 0.921 vs 0.686 0.661 to 0.710, respectively, p <0.001) and negative predictive value (0.97 0.964 to 0.975 vs 0.93 0.924 to 0.936, respectively, p <0.001) compared with troponin alone. Elevation in copeptin carried a similar risk of all-cause mortality to an elevation in troponin (odds ratio 5.84 vs 6.74, respectively, p = 0.67). In conclusion, copeptin not only identifies patients at risk of all-cause mortality, but its addition to troponin improved the sensitivity and negative likelihood ratio for diagnosis of AMI compared with troponin alone. Thus, copeptin may help identify patients who may be safely discharged early from the emergency department.
The objectives were to determine the impact of frailty and disability on 30-day mortality and whether the addition of these variables to HFRSS EFFECT risk score (FBI-EFFECT model) improves the ...short-term mortality predictive capacity of both HFRSS EFFECT and BI-EFFECT models in older patients with acute decompensated heart failure (ADHF) atended in the emergency department. We performed a retrospective analysis of OAK Registry including all consecutive patients ≥65 years old with ADHF attended in 3 Spanish emergency departments over 4 months. FBI-EFFECT model was developed by adjusting probabilities of HFRSS EFFECT risk categories according to the 6 groups (G1: non frail, no or mildly dependent; G2: frail, no or mildly dependent; G3: non frail, moderately dependent; G4: frail, moderately dependent; G5: severely dependent; G6: very severely dependent).We included 596 patients (mean age: 83 SD7; 61.2% females). The 30-day mortality was 11.6% with statistically significant differences in the 6 groups (p < 0.001). After adjusting for HFRSS EFFECT risk categories, we observed a progressive increase in hazard ratios from groups G2 to G6 compared with G1 (reference). FBI-EFFECT had a better prognostic accuracy than did HFRSS EFFECT (log-rank p < 0.001; Net Reclassification Improvement NRI = 0.355; p < 0.001; Integrated Discrimination Improvement IDI = 0.052; p ;< 0.001) and BI-EFFECT (log-rank p = 0.067; NRI = 0.210; p = 0.033; IDI = 0.017; p = 0.026). In conclusion, severe disability and frailty in patients with moderate disability are associated with 30-day mortality in ADHF, providing additional value to HFRSS EFFECT model in predicting short-term prognosis and establishing a care plan.
To evaluate the effectiveness of an integrated emergency department (ED)/hospital at home (HH) medical care model in mild COVID-19 pneumonia and evaluate baseline predictors of major outcomes and ...potential savings. Retrospective cohort study with patients evaluated for COVID-19 pneumonia in the ED, from March 3 to April 30, 2020. All of them were discharged home and controlled by HH. The main outcomes were ED revisit and the need for deferred hospital admission (protocol failure). Outcome predictors were analyzed by simple logistic regression model (OR; 95% CI). Potential savings of this medical care model were estimated. Of the 377 patients attended in the ED, 109 were identified as having mild pneumonia and were included in the ED/HH medical care model. Median age was 50.0 years, 52.3% were males and 57.8% had Charlson index ≥ 1. The median HH stay was 8 (IQR 3.7–11) days. COVID-19-related ED revisit was 19.2% (
n
= 21) within 6 days (IQR 3–12.5) after discharge from ED. Overall protocol failure (deferred hospital admission) was 6.4% (
n
= 7), without ICU admission. The ED/HH model provided potential cost savings of 77% compared to traditional stay, due to the costs of home care entails 23% of the expenses generated by a conventional hospital stay. 789 days of hospital stay were avoided by HH, rather than hospital admission. An innovative ED/HH model for selected patients with mild COVID-19 pneumonia is feasible, safe and effective. Less than 6.5% of patients requiring deferred hospital admission and potential savings were generated due to hospitalization.
Aims
The current study explores whether degree of inflammation, reflected by C‐reactive protein (CRP) level, modifies the effect of intravenous (IV) corticosteroid administered in the emergency ...department (ED) on clinical outcomes in patients with acute heart failure (AHF).
Methods and results
We selected patients diagnosed with AHF in the ED, with confirmed N‐terminal pro‐B‐type natriuretic peptide > 300 pg/mL and CRP > 5 mg/L in the ED from the Epidemiology of Acute Heart Failure in the Emergency Departments (EAHFE) registry. In these 1109 patients, 121 were treated by corticosteroid. The corticosteroid therapy hazard ratio (HR) for 30 day all‐cause mortality was 1.26 95% confidence interval (CI) 0.75–2.09, P = 0.38. Although not statistically significant, HRs tended to decrease with increasing CRP level, with point estimates favouring corticosteroid at CRP levels above 20. In patients with CRP > 40 mg/L, with adjusted HRs of 0.56 (95% CI 0.20–1.55, P = 0.27) for 30 day all‐cause mortality, 0.92 (95% CI 0.52–1.62, P = 0.78) for 30 day post‐discharge ED revisit, hospitalization, or death, and adjusted odds ratio of 0.61 (95% CI 0.17–2.14, P = 0.44) for in‐hospital all‐cause mortality.
Conclusions
The present analysis suggests that corticosteroids might have the potential to improve outcomes in AHF patients with inflammatory activation. Larger, prospective studies of anti‐inflammatory therapy should be considered to assess potential benefit in patients with the highest degree of inflammation.
Abstract Objective To determine whether the presence of a short-stay unit(SSU) in a hospital influences the percentage of admissions, length of hospital stay(LOS) and outcomes in emergency ...department(ED) patients with acute heart failure(AHF). Method Retrospective analysis of AHF patients presenting to one of 34 Spanish ED included in EAHFE registry. Baseline and ED data of patients were collected. Patients were classified into two groups in function of being attended at hospitals with or without a SSU. Main outcome variables were the percentage of admissions from ED, and LOS for admitted patients. Secondary variables were all-cause death and ED revisits for worsening heart failure within 30 days following discharge. Results Of 9078 patients presenting to the ED (SSU 5191; no SSU 3887), 6796 (74.8%) were admitted. Compared to hospitals without a SSU, the admission rate in hospitals with a SSU was 8.9% higher (95%CI 6.5%–11.4%), but 30-day ED revisit and mortality rates were lower among patients discharged directly from the ED (− 10.3%, 95%CI − 16,9% to − 3.7%; and − 10.0%, 95%CI − 16.6 to − 3.4%, respectively). For admitted patients, the overall LOS was 9.3 ± 9.5 days, being 2.2 days shorter (95%CI − 2.7 to − 1.7) in hospitals with a SSU, with no significant differences in in-hospital, 30-day mortality or 30-day ED revisit rates. Conclusions The data suggest that SSU may improve the safety of emergency care of patients with AHF, but at the cost of a higher rate of hospital admissions, and it may also reduce the LOS for admitted patients without affecting post discharge safety.
Desde el inicio de la pandemia de la COVID-19 en marzo de 2020, el uso de la mascarilla ha constituido un pilar fundamental para el control de la transmisión del SARS-CoV-2 en diferentes ámbitos. Su ...obligatoriedad ha sido regulada por diferentes normativas, y la efectividad de la misma para la reducción de la transmisión del SARS-CoV-2 y de otros virus respiratorios ha sido fuertemente probada. Al respecto, destaca el impacto beneficioso en los centros sanitarios en los que ha demostrado reducir la transmisión de las infecciones respiratorias, tanto en pacientes como en profesionales sanitarios. Este documento plantea una propuesta de recomendaciones para el uso de la mascarilla en los centros sanitarios en el momento actual en el que nos encontramos con un cese de la obligatoriedad de su uso en España. Están dirigidas a profesionales sanitarios, pacientes y acompañantes/visitantes y pretenden protegerles de adquirir infecciones respiratorias agudas como consecuencia de las complejas relaciones establecidas en el ámbito sanitario.
Objective
To investigate whether patients with an acute heart failure (AHF) episode triggered by infection present different outcomes compared to patients with no trigger and the effects of early ...antibiotic administration (EAA) and hospitalisation.
Methods
Two groups were made according to the AHF trigger: infection (G1) or none identified (G2). The primary outcome was 13-week (91-days) all-cause mortality, and secondary outcomes were 13-week post-discharge mortality, readmission or combined endpoint. Comparisons are presented as unadjusted and adjusted (MEESSI risk score) hazard ratios (uHR/aHR) for G1 compared to G2 patients, also estimated by weeks. Stratified analysis by EAA (provided/not provided) and patient disposition (discharged/hospitalised) was performed.
Results
We included 6727 patients (G1 = 3973; G2 = 2754). The 13-week mortality uHR was 1.11 (0.99–1.25;
p
= 0.06; with significant increases in the first 3 weeks), and the aHR was 0.91 (0.81–1.02;
p
= 0.11). There were no differences in unadjusted secondary post-discharge outcomes; however, G1 outcomes significantly improved after adjustment: aHR 0.83 (0.71–0.96;
p
= 0.01) for mortality, 0.92 (0.84–0.99;
p
= 0.04) for readmission, and 0.92 (0.85–0.99;
p
= 0.04) for the combined endpoint. We found a differentiated effect of hospitalisation (
p
< 0.05 for interaction; better post-discharge readmission and combined outcomes in G1), and a trend (
p
= 0.06) to lower mortality in G1 patients with EAA. Additionally, there were some differences between groups in baseline and acute episode characteristics.
Conclusion
AHF triggered by infection is not associated with a higher mid-term mortality and has better post-discharge outcomes; however, the first 3 weeks are an extremely vulnerable period. Since hospitalisation could have a role in limiting adverse post-discharge events, and EAA in reducing mortality, these relationships should be prospectively explored in further studies.
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