The authors investigated the incidence, risk factors, clinical characteristics, and outcomes of upper gastrointestinal bleeding (UGB) in patients with coronavirus disease 2019 (COVID-19), who were ...attending the emergency department (ED), before hospitalization.
We retrospectively reviewed all COVID-19 patients diagnosed with UGB in 62 Spanish EDs (20% of Spanish EDs, case group) during the first 2 months of the COVID-19 outbreak. We formed 2 control groups: COVID-19 patients without UGB (control group A) and non-COVID-19 patients with UGB (control group B). Fifty-three independent variables and 4 outcomes were compared between cases and controls.
We identified 83 UGB in 74,814 patients with COVID-19 who were attending EDs (1.11%, 95% CI=0.88-1.38). This incidence was lower compared with non-COVID-19 patients 2474/1,388,879, 1.78%, 95% confidence interval (CI)=1.71-1.85; odds ratio (OR)=0.62; 95% CI=0.50-0.77. Clinical characteristics associated with a higher risk of COVID-19 patients presenting with UGB were abdominal pain, vomiting, hematemesis, dyspnea, expectoration, melena, fever, cough, chest pain, and dysgeusia. Compared with non-COVID-19 patients with UGB, COVID-19 patients with UGB more frequently had fever, cough, expectoration, dyspnea, abdominal pain, diarrhea, interstitial lung infiltrates, and ground-glass lung opacities. They underwent fewer endoscopies in the ED (although diagnoses did not differ between cases and control group B) and less endoscopic treatment. After adjustment for age and sex, cases showed a higher in-hospital all-cause mortality than control group B (OR=2.05, 95% CI=1.09-3.86) but not control group A (OR=1.14, 95% CI=0.59-2.19) patients.
The incidence of UGB in COVID-19 patients attending EDs was lower compared with non-COVID-19 patients. Digestive symptoms predominated over respiratory symptoms, and COVID-19 patients with UGB underwent fewer gastroscopies and endoscopic treatments than the general population with UGB. In-hospital mortality in COVID-19 patients with UGB was increased compared with non-COVID patients with UGB, but not compared with the remaining COVID-19 patients.
To assess whether dementia is an independent predictor of death after a hospital emergency department (ED) visit by older adults with or without a COVID-19 diagnosis during the first pandemic wave.
...We used data from the EDEN-Covid (Emergency Department and Elderly Needs during Covid) cohort formed by all patients ≥65 years seen in 52 Spanish EDs from March 30 to April 5, 2020. The association of prior history of dementia with mortality at 30, 180 and 365 d was evaluated in the overall sample and according to a COVID-19 or non COVID diagnosis.
We included 9,770 patients aged 78.7 ± 8.3 years, 51.1% men, 1513 (15.5%) subjects with prior history of dementia and 3055 (31.3%) with COVID-19 diagnosis. 1399 patients (14.3%) died at 30 d, 2008 (20.6%) at 180 days and 2456 (25.1%) at 365 d. The adjusted Hazard Ratio (aHR) for age, sex, comorbidity, disability and diagnosis for death associated with dementia were 1.16 (95% CI 1.01-1.34) at 30 d; 1.15 at 180 d (95% CI 1.03-1.30) and 1.19 at 365 d (95% CI 1.07-1.32), p < .001. In patients with COVID-19, the aHR were 1.26 (95% CI: 1.04-1.52) at 30 days; 1.29 at 180 d (95% CI: 1.09-1.53) and 1.35 at 365 d (95% CI: 1.15-1.58).
Dementia in older adults attending Spanish EDs during the first pandemic wave was independently associated with 30-, 180- and 365-day mortality. This impact was lower when adjusted for age, sex, comorbidity and disability, and was greater in patients diagnosed with COVID-19.
Summary
Background
Eosinophilic oesophagitis (EoE) is characterized by oesophageal dysfunction and, histologically, by eosinophilic inflammation. There is no a clear aetiologic treatment. EoE ...exacerbations are often seasonal. We hypothesized that the inflammatory response of the oesophageal mucosa in patients with high levels of antibodies to pollen allergens and worsened seasonal EoE might be due to swallowing airborne pollen and the intrusion into the oesophageal mucosa of pollen allergens and pollen tubes, which encounter a pH and humidity resembling the stigma at pollination.
Objective
The aim of our study was to demonstrate the possible pathogenic role of environmental allergens in EoE through molecular and anatomopathological studies
Methods
One hundred and twenty‐nine patients with EoE were tested for environmental and food allergens. Component resolved diagnosis (CRD), histological and botanical analysis was performed. Microscopic examination of oesophageal biopsies of 129 adults patients with EoE, 82 of them with seasonal exacerbation, and 100 controls, with gastroesophageal reflux without eosinophilic infiltrate, were made to verify the presence of callose (polysaccharide abundant in pollen tubes but absent in animal tissues) in the oesophagus.
Results
Component resolved diagnosis detected pollen allergens in 87.6% of patients with EoE. The predominant allergens were group 1 grass (55%), Art v 3 (11.3%) and lipid transfer proteins (LTPs) (19.4%) of common Mediterranean foods such as peach, hazelnuts, walnuts and wheat. Callose from pollen tubes was found in 65.6% of biopsies.
Conclusion
Alteration of the mucosal barrier in EoE might cause the penetration of pollen grains into the oesophageal tissues. In EoE patients, anatomopathological studies searching for intrusion to plant foods and pollen, and specific‐guided diet and immunotherapy after plant structures detection in biopsies, might be effective.
Clinical relevance
It is possible to see the intrusion into animal tissues (oesophagus mucosa) of plant structures (pollen grains or pollen tubes) using an adecuate histologic botanical analysis. Molecular and anatomopathological studies can help to demonstrate a possible pathogenic role of environmental allergens in EoE.
Mortality in emergency departments (EDs) is not well known. This study aimed to assess the impact of the first-wave pandemic on deaths accounted in the ED of older patients with COVID and non-COVID ...diseases.
We used data from the Emergency Department and Elderly Needs (EDEN) cohort (pre-COVID period) and from the EDEN-COVID cohort (COVID period) that included all patients ≥65 years seen in 52 Spanish EDs from April 1 to 7, 2019, and March 30 to April 5, 2020, respectively. We recorded patient characteristics and final destination at ED. We compared older patients in the pre-COVID period, with older patients with non-COVID and with COVID-19. ED-mortality (before discharge or hospitalization) is the prior outcome and is expressed as an adjusted odds ratio (aOR) with 95% interval confidence.
We included 23,338 older patients from the pre-COVID period (aged 78.3 8.1 years), 6,715 patients with non-COVID conditions (aged 78.9 8.2 years) and 3,055 with COVID (aged 78.3 8.3 years) from the COVID period. Compared to the older patients, pre-COVID period, patients with non-COVID and with COVID-19 were more often male, referred by a doctor and by ambulance, with more comorbidity and disability, dementia, nursing home, and more risk according to qSOFA, respectively (p < 0.001). Compared to the pre-COVID period, patients with non-COVID and with COVID-19 were more often to be hospitalized from ED (24.8% vs. 44.3% vs. 79.1%) and were more often to die in ED (0.6% vs. 1.2% vs. 2.2%), respectively (p < 0.001). Compared to the pre-COVID period, aOR for age, sex, comorbidity and disability, ED mortality in elderly patients cared in ED during the COVID period was 2.31 (95% confidence interval CI: 1.76-3.06), and 3.75 (95% CI: 2.77-5.07) for patients with COVID. By adding the variable qSOFA to the model, such OR were 1.59 (95% CI: 1.11-2.30) and 2.16 (95% CI: 1.47-3.17), respectively.
During the early first pandemic wave of COVID-19, more complex and life-threatening older with COVID and non-COVID diseases were seen compared to the pre-COVID period. In addition, the need for hospitalization and the ED mortality doubled in non-COVID and tripled in COVID diagnosis. This increase in ED mortality is not only explained by the complexity or severity of the elderly patients but also because of the system's overload.
Polypharmacy is a growing phenomenon among elderly individuals. However, there is little information about the frequency of polypharmacy among the elderly population treated in emergency departments ...(EDs) and its prognostic effect. This study aims to determine the prevalence and short-term prognostic effect of polypharmacy in elderly patients treated in EDs.
A retrospective analysis of the Emergency Department Elderly in Needs (EDEN) project's cohort was performed. This registry included all elderly patients who attended 52 Spanish EDs for any condition. Mild and severe polypharmacy was defined as the use of 5-9 drugs and ⩾10 drugs, respectively. The assessed outcomes were ED revisits, hospital readmissions, and mortality 30 days after discharge. Crude and adjusted logistic regression analyses, including the patient's comorbidities, were performed.
A total of 25,557 patients were evaluated mean age: 78 (IQR: 71-84) years; 10,534 (41.2%) and 5678 (22.2%) patients presented with mild and severe polypharmacy, respectively. In the adjusted analysis, mild polypharmacy and severe polypharmacy were associated with an increase in ED revisits odds ratio (OR) 1.13 (95% confidence interval (CI): 1.04-1.23) and 1.38 (95% CI: 1.24-1.51) and hospital readmissions OR 1.18 (95% CI: 1.04-1.35) and 1.36 (95% CI: 1.16-1.60), respectively, compared to non-polypharmacy. Mild and severe polypharmacy were not associated with increased 30-day mortality OR 1.05 (95% CI: 0.89-2.26) and OR 0.89 (95% CI: 0.72-1.12), respectively.
Polypharmacy was common among the elderly treated in EDs and associated with increased risks of ED revisits and hospital readmissions ⩽30 days but not with an increased risk of 30-day mortality. Patients with polypharmacy had a higher risk of ED revisits and hospital readmissions ⩽30 days after discharge.
Objective
We investigated the incidence, predictor variables, clinical characteristics, and stroke outcomes in patients with COVID‐19 seen in emergency departments (EDs) before hospitalization.
...Methods
We retrospectively reviewed all COVID‐19 patients diagnosed with stroke during the COVID‐19 outbreak in 62 Spanish EDs. We formed two control groups: COVID‐19 patients without stroke (control A) and non–COVID‐19 patients with stroke (control B). We compared disease characteristics and four outcomes between cases and controls.
Results
We identified 147 strokes in 74,814 patients with COVID‐19 seen in EDs (1.96‰, 95% confidence interval CI = 1.66‰ to 2.31‰), being lower than in non–COVID‐19 patients (6,541/1,388,879, 4.71‰, 95% CI = 4.60‰ to 4.83‰; odds ratio OR = 0.42, 95% CI = 0.35 to 0.49). The estimated that standardized incidences of stroke per 100,000 individuals per year were 124 and 133 for COVID‐19 and non–COVID‐19 individuals, respectively (OR = 0.93 for COVID patients, 95% CI = 0.87 to 0.99). Baseline characteristics associated with a higher risk of stroke in COVID‐19 patients were hypertension, diabetes mellitus, and previous cerebrovascular and coronary diseases. Clinically, these patients more frequently presented with confusion, decreased consciousness, and syncope and higher D‐dimer concentrations and leukocyte count at ED arrival. After adjustment for age and sex, the case group had higher hospitalization and intensive care unit (ICU) admission rates (but not mortality) than COVID‐19 controls without stroke (OR = 3.41, 95% CI = 1.27 to 9.16; and OR = 3.79, 95% CI = 1.69 to 8.50, respectively) and longer hospitalization and greater in‐hospital mortality than stroke controls without COVID‐19 (OR = 1.55, 95% CI = 1.24 to 1.94; and OR = 1.77, 95% CI = 1.37 to 2.30, respectively).
Conclusions
The incidence of stroke in COVID‐19 patients presenting to EDs was lower than that in the non–COVID‐19 reference sample. COVID‐19 patients with stroke had greater need for hospitalization and ICU admission than those without stroke and longer hospitalization and greater in‐hospital mortality than non–COVID‐19 patients with stroke.
La Sociedad Española de Medicina Tropical y Salud Internacional (SEMTSI), la Sociedad Española de Enfermedades Infecciosas y Microbiología Clínica (SEIMC), la Sociedad Española de Medicina de ...Urgencias y Emergencias (SEMES), la Sociedad Española de Médicos de Atención Primaria (SEMERGEN) y la Sociedad Española de Medicina Familiar y Comunitaria (SEMFYC) han elaborado un documento de consenso sobre el diagnóstico y manejo de pacientes con enfermedades febriles importadas.
Veinte autores que representaban diferentes perspectivas de la atención médica (atención primaria ambulatoria, especialistas en medicina tropical y del viajero, urgencias, atención hospitalaria, microbiología y parasitología y salud pública), identificaron 39 preguntas clínicamente relevantes, que se organizaron en 7 bloques temáticos. Tras una revisión sistemática de la literatura, los autores elaboraron 125 recomendaciones, así como varias tablas e imágenes para ser utilizadas como herramientas de consulta. Este resumen ejecutivo muestra una selección de las preguntas y recomendaciones más relevantes incluidas en las presentes guías.
The Spanish Society of Tropical Medicine and International Health (SEMTSI), the Spanish Society of Infectious Diseases and Clinical Microbiology (SEIMC), the Spanish Society of Emergency Medicine (SEMES), the Spanish Society of Primary Care Physicians (SEMERGEN) and the Spanish Society of Family and Community Medicine (SEMFYC) have elaborated a consensus statement on the diagnosis and management of patients with imported febrile illnesses.
Twenty authors with different backgrounds and representing different healthcare perspectives (ambulatory primary care, travel and tropical medicine specialists, emergency medicine, hospital care, microbiology and parasitology and public health), identified 39 relevant questions, which were organized in 7 thematic blocks. After a systematic review of the literature and a thoughtful discussion, the authors elaborated 125 recommendations, as well as several tables and figures to be used as a consulting tool. The present executive summary shows a selection of some of the most relevant questions and recommendations included in the guidelines.
To describe the sociodemographic characteristics, comorbidity, and baseline functional status of patients aged 65 or older who came to hospital emergency departments (EDs) during the first wave of ...the COVID-19 pandemic, and to compare them with the findings for an earlier period to analyze factors of the index episode that were related to mortality.
We studied data from the EDEN-COVID cohort (Emergency Department and Elder Needs During COVID-19) of patients aged 65 years or older treated in 40 Spanish EDs on 7 consecutive days. Nine sociodemographic variables, 18 comorbidities, and 7 function variables were registered and compared with the findings for the EDEN cohort of patients included with the same criteria and treated a year earlier in the same EDs. In-hospital mortality was calculated in the 2 cohorts and a multivariable logistic regression model was used to explore associated factors.
The EDEN-COVID cohort included 6806 patients with a median age of 78 years; 49% were women. The pandemic cohort had a higher proportion of men, patients covered by the national health care system, patients brought from residential facilities, and patients who arrived in an ambulance equipped for advanced life support. Pandemic-cohort patients more often had diabetes mellitus, chronic kidney disease, and dementia; they less often had connective tissue and thromboembolic diseases. The Barthel and Charlson indices were worse in this period, and cognitive decline was more common. Fewer patients had a history of depression or falls. Eight hundred ninety these patients (13.1%) died, 122 of them in the ED (1.8%); these percentages were lower in the earlier EDEN cohort, at 3.1% and 0.5%, respectively. Independent sociodemographic factors associated with higher mortality were transport by ambulance, older age, male sex, and living in a residential facility. Mortalityassociated comorbidities were neoplasms, chronic kidney disease, and heart failure. The only function variable associated with mortality was the inability to walk independently. A history of falls in the past 6 months was a protective factor.
The sociodemographic characteristics, comorbidity, and functional status of patients aged 65 years or older who were treated in hospital EDs during the pandemic differed in many ways from those usually seen in this older-age population. Mortality was higher than in the prepandemic period. Certain sociodemographic, comorbidity, and function variables were associated with in-hospital mortality.
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