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),
< .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.
To validate a simple risk score to predict bacteremia (MPB5-Toledo) in patients seen in the emergency departments (ED) due to infections.
Prospective and multicenter observational cohort study of the ...blood cultures (BC) ordered in 74 Spanish ED for adults (aged 18 or older) seen from from October 1, 2019, to February 29, 2020. The predictive ability of the model was analyzed with the area under the Receiver Operating Characteristic curve (AUC-ROC). The prognostic performance for true bacteremia was calculated with the cut-off values chosen for getting the sensitivity, specificity, positive predictive value and negative predictive value.
A total of 3.843 blood samples wered cultured. True cases of bacteremia were confirmed in 839 (21.83%). The remaining 3.004 cultures (78.17%) were negative. Among the negative, 172 (4.47%) were judged to be contaminated. Low risk for bacteremia was indicated by a score of 0 to 2 points, intermediate risk by 3 to 5 points, and high risk by 6 to 8 points. Bacteremia in these 3 risk groups was predicted for 1.5%, 16.8%, and 81.6%, respectively. The model's area under the receiver operating characteristic curve was 0.930 (95% CI, 0.916-0.948). The prognostic performance with a model's cut-off value of ≥ 5 points achieved 94.76% (95% CI: 92.97-96.12) sensitivity, 81.56% (95% CI: 80.11-82.92) specificity, and negative predictive value of 98.24% (95% CI: 97.62-98.70).
The 5MPB-Toledo score is useful for predicting bacteremia in patients attended in hospital emergency departments for infection.
FUNDAMENTOS // La valoración funcional forma parte de la valoración geriátrica. No se conoce bien cómo se realiza en los servicios de Urgencias
hospitalarios (SUH) y menos aún su valor pronóstico. El ...objetivo de este trabajo fue investigar si la dependencia funcional basal para realizar las actividades
básicas de la vida diaria (ABVD) era un factor pronóstico independiente de muerte tras la visita índice al SUH durante la primera ola pandémica de la
COVID-19 y si tuvo un impacto diferente en pacientes con y sin diagnóstico de COVID-19.
MÉTODOS // Se realizó un estudio observacional retrospectivo de la cohorte EDEN-Covid (Emergency Department and Elder Needs during COVID) formada
por todos los pacientes de edad mayor o igual a 65 años atendidos en 52 SUH españoles, seleccionados por oportunidad durante siete días consecutivos
(del 30 de marzo al 5 de abril de 2020). Se analizaron variables demográficas, clínicas, funcionales, mentales y sociales. La dependencia se categorizó con
el índice de Barthel (IB) en independiente (IB=100), dependencia leve-moderada (100>IB>60) y dependencia grave-total (IB<60), y se evaluó su asociación
cruda y ajustada con la mortalidad a 30, 180 y 365 días mediante modelos de riesgos proporcionales de COX.
RESULTADOS // De 9.770 pacientes incluidos con una media de edad de 79 años, un 51% eran hombres, 6.305 (64,53%) eran independientes, 2.340 (24%)
tenían dependencia leve-moderada y 1.125 (11,5%) dependencia grave-total. El número de fallecidos a 30 días en estos tres grupos fue 500 (7,9%), 521 (22,3%) y 378 (33,6%), respectivamente; a 180 días fue 757 (12%), 725 (30,9%) y 526 (46,8%); y a 365 días 954 (15,1%), 891 (38,1%) y 611 (54,3%). En relación a los pacientes independientes, los riesgos (hazard ratio) ajustados de fallecer a 30 días, asociados a dependencia leve-moderada y grave-total, fueron 1,91 (IC 95%: 1,66-2,19) y 2,51 (2,11-2,98); a 180 días fueron de 1,88 (1,68-2,11) y 2,64 (2,28-3,05); y a 365 días fueron 1,82 (1,64-2,02) y 2,47 (2,17-2,82). Este impacto negativo de la dependenciasobre la mortalidad fue mayor en pacientes diagnosticados de COVID-19 que en los no COVID-19 (p interacción a 30, 180 y 365 días de 0,36, 0,05 y 0,04).
CONCLUSIONES // La dependencia funcional de los pacientes mayores que acuden a SUH españoles durante la primera ola pandémica se asocia a
mortalidad a 30, 180 y 365 días, y este riesgo es significativamente mayor en los pacientes atendidos por COVID-19.
BACKGROUND // Functional assessment is part of geriatric assessment. How it is performed in hospital Emergency Departments (ED) is poorly understood,
let alone its prognostic value. The aim of this paper was to investigate whether baseline disability to perform basic activities of daily living (BADL) was
an independent prognostic factor for death after the index visit to the ED during the first wave of the COVID-19 pandemic and whether it had a different
impact on patients with and without diagnosis of COVID-19.
METHODS // A retrospective observational study of the EDEN-Covid (Emergency Department and Elder Needs during COVID) cohort was carried out, consisting
of all patients aged ≥65 years seen in 52 Spanish EDs selected by chance during 7 consecutive days (30/3/2020 to 5/4/2020). Demographic, clinical, functional,
mental and social variables were analyzed. Dependence was categorized with the Barthel index (BI) as independent (BI=100), mild-moderate dependence
(100>BI>60) and severe-total dependence (BI<60), and their crude and adjusted association was evaluated with mortality at 30, 180 and 365 days using COX
proportional hazards models.
RESULTS // Of 9,770 enrolled patients with a mean age of 79 years, 51% were men, 6,305 (64.53%) were independent, 2,340 (24%) had mild-moderate
dependence, and 1,125 (11.5%) severe-total dependence. The number of deaths at 30 days in these three groups was 500 (7.9%), 521 (22.3%) and 378 (33.6%),
respectively; at 180 days it was 757 (12%), 725 (30.9%) and 526 (46.8%); and at 365 days 954 (15.1%), 891 (38.1%) and 611 (54.3%). In relation to independent
patients, the adjusted risks (hazard ratio) of dying within 30 days associated with mild-moderate and severe-total dependency were 1.91 (95% CI: 1.66-2.19) and
2.51. (2.11-2.98); at 180 days they were 1.88 (1.68-2.11) and 2.64 (2.28-3.05); and at 365 days they were 1.82 (1.64-2.02) and 2.47 (2.17-2.82). This negative impact of dependency on mortality was greater in patients diagnosed with COVID-19 than in non-COVID-19 (p interaction at 30, 180 and 365 days of 0.36, 0.05 and 0.04).
CONCLUSIONS // The functional dependence of older patients who attend Spanish EDs during the first wave of the pandemic is associated with mortality
at 30, 180 and 365 days, and this risk is significantly higher in patients treated for COVID-19.
Aims
Benzodiazepines have been used as safe anxiolytic drugs for decades and some authors have suggested they could be an alternative for morphine for treating acute cardiogenic pulmonary oedema ...(ACPE). We compared the efficacy and safety of midazolam and morphine in patients with ACPE.
Methods and results
A randomized, multicentre, open‐label, blinded endpoint clinical trial was performed in seven Spanish emergency departments (EDs). Patients >18 years old clinically diagnosed with ACPE and with dyspnoea and anxiety were randomized (1:1) at ED arrival to receive either intravenous midazolam or morphine. Efficacy was assessed by in‐hospital all‐cause mortality (primary endpoint). Safety was assessed through serious adverse event (SAE) reporting, and the composite endpoint included 30‐day mortality and SAE. Analyses were made on an intention‐to‐treat basis. The trial was stopped early after a planned interim analysis by the safety monitoring committee. At that time, 111 patients had been randomized: 55 to midazolam and 56 to morphine. There were no significant differences in the primary endpoint (in‐hospital mortality for midazolam vs. morphine 12.7% vs. 17.9%; risk ratioRR 0.71, 95% confidence interval CI 0.29–1.74; p = 0.60). SAE were less common with midazolam versus morphine (18.2% vs. 42.9%; RR 0.42, 95% CI 0.22–0.80; p = 0.007), as were the composite endpoint (23.6% vs. 44.6%; RR 0.53, 95% CI 0.30–0.92; p = 0.03).
Conclusion
Although the number of patients was too small to draw final conclusions and there were no significant differences in mortality between midazolam and morphine, a significantly higher rate of SAEs was found in the morphine group.
There were no significant differences in mortality between morphine and midazolam but the rate of serious adverse events was significantly higher in the morphine group, although the number of patients was too small to draw final conclusions.
Abstract
Aims
We investigated the incidence, risk factors, clinical characteristics, and outcomes of pulmonary embolism (PE) in patients with COVID-19 attending emergency departments (EDs), before ...hospitalization.
Methods and Results
We retrospectively reviewed all COVID-19 patients diagnosed with PE in 62 Spanish EDs (20% of Spanish EDs, case group) during the first COVID-19 outbreak. COVID-19 patients without PE and non-COVID-19 patients with PE were included as control groups. Adjusted comparisons for baseline characteristics, acute episode characteristics, and outcomes were made between cases and randomly selected controls (1:1 ratio). We identified 368 PE in 74 814 patients with COVID-19 attending EDs (4.92‰). The standardized incidence of PE in the COVID-19 population resulted in 310 per 100 000 person-years, significantly higher than that observed in the non-COVID-19 population 35 per 100 000 person-years; odds ratio (OR) 8.95 for PE in the COVID-19 population, 95% confidence interval (CI) 8.51–9.41. Several characteristics in COVID-19 patients were independently associated with PE, the strongest being D-dimer >1000 ng/mL, and chest pain (direct association) and chronic heart failure (inverse association). COVID-19 patients with PE differed from non-COVID-19 patients with PE in 16 characteristics, most directly related to COVID-19 infection; remarkably, D-dimer >1000 ng/mL, leg swelling/pain, and PE risk factors were significantly less present. PE in COVID-19 patients affected smaller pulmonary arteries than in non-COVID-19 patients, although right ventricular dysfunction was similar in both groups. In-hospital mortality in cases (16.0%) was similar to COVID-19 patients without PE (16.6%; OR 0.96, 95% CI 0.65–1.42; and 11.4% in a subgroup of COVID-19 patients with PE ruled out by scanner, OR 1.48, 95% CI 0.97–2.27), but higher than in non-COVID-19 patients with PE (6.5%; OR 2.74, 95% CI 1.66–4.51). Adjustment for differences in baseline and acute episode characteristics and sensitivity analysis reported very similar associations.
Conclusions
PE in COVID-19 patients at ED presentation is unusual (about 0.5%), but incidence is approximately ninefold higher than in the general (non-COVID-19) population. Moreover, risk factors and leg symptoms are less frequent, D-dimer increase is lower and emboli involve smaller pulmonary arteries. While PE probably does not increase the mortality of COVID-19 patients, mortality is higher in COVID-19 than in non-COVID-19 patients with PE.
To analyse factors associated with short-term mortality in elderly patients seen in emergency departments (ED) for an episode of infectious disease.
A prospective, observational, multicentre, ...analytical study was carried out on patients aged 75years and older who were treated in the ED of one of the eight participating hospitals. An assessment was made of 26 independent variables that could influence mortality at 30days. They covered epidemiological, comorbidity, functional, clinical and analytical factors. Multivariate logistic regression analysis was performed.
The study included 488 consecutive patients, 92 (18.9%) of whom died within 30days of visiting the ED. Three variables were significantly associated with higher mortality: severe functional dependence, with Barthel index≤60 odds ratio (OR) 8.92; 95% confidence interval (CI): 4.98–15.98, p=0.003, systolic blood pressure <90mmHg OR 7.34; 95% CI: 4.39–12.26, p=0.005 and serum lactate >4mmol/l OR 21.14; 95% CI: 8.94–49.97, p=0.001. The area under the curve for the model was 0.971 (95% CI: 0.951–0.991; p<0.001).
Several factors evaluated in an initial assessment in the ED, including the level of functional dependence, systolic blood pressure and, especially, serum lactate, were found to determine a poor short-term prognosis in the elderly patients who presented with an episode of an infectious disease.
Analizar los factores asociados a la mortalidad a corto plazo en los pacientes ancianos que acuden al servicio de urgencias (SU) por un episodio de infección.
Estudio observacional, prospectivo, multicéntrico y analítico. Se incluyó consecutivamente a pacientes de 75 o más años atendidos en 8 servicios de SU por un proceso infeccioso. Se analizaron 26 variables independientes (epidemiológicas, de comorbilidad, funcionales, clínicas y analíticas) que pudieran influir en la mortalidad a corto plazo (30días). Se realizó un estudio multivariable mediante regresión logística.
Se incluyó a 488 pacientes, de los que 92 (18,9%) habían fallecido a los 30días tras su consulta en el SU. Tres variables se asociaron de forma significativa con la mortalidad: la dependencia funcional basal grave con índice de Barthel ≤60 (odds ratio OR 8,92; intervalo de confianza IC del 95%: 4,98-15,98, p=0,003), la existencia de una presión arterial sistólica (PAS)<90mmHg (OR 7,34; IC95%: 4,39-12,26, p=0,005) y lactato sérico >4mmol/l (OR 21,14; IC 95%: 8,94-49,97, p=0,001). El área bajo la curva-ROC del modelo fue 0,971 (IC 95%: 0,951-0,991; p<0,001).
Existen varios factores disponibles tras una primera atención en el SU—entre ellos la valoración funcional, la PAS y, el más importante, el lactato sérico—que determinan un mal pronóstico a corto plazo del paciente anciano que consulta por un proceso infeccioso.
To analyze if the hypoglycemic therapy prescribed in the Emergency Department adapts to the consensus recommendations available, as well as to assess its clinical impact.
A descriptive observational ...study, which included patients awaiting hospital admission, who were in the Observation Ward of the Emergency Department and had been previously diagnosed with diabetes mellitus, and were receiving treatment with hypoglycemic drugs at home. The management of antidiabetic treatment and its clinical impact were assessed.
78 patients were included. At admission to the Emergency Department, treatment was modified for 91% of patients, and omitted for 9%. The most prescribed treatment was sliding scale insulin (68%). The treatments prescribed coincided in a 16.7% with the recommendations by the Spanish Society of Emergency Medicine. After intervention by the Pharmacist, the omission descended to 1.3%, and the adaptation to the recommendations increased to 20.5%. Comparing patients whose treatment coincided with the recommendations and those who did not, the clinical impact was respectively: mean glycemia at 24 hours: 138.3 ± 49.5 mg/dL versus 182.7 ± 97.1 mg/dL (p = 0.688); mean rescues with insulin lispro: ± 1.6 versus 1.5 ± 1.8 (p = 0.293); mean units of insulin lis-pro administered: 4.6 ± 12.7 IU versus 6.6 ± 11.3 IU (p = 0.155).
We found antidiabetic prescriptions to have a low adaptation to consensus recommendations. These results are in line with other studies, showing an abuse of sliding scale regimen as single hypoglycemic treatment.
Analizar la adecuación del tratamiento hipogluce-miante prescrito en el Servicio de Urgencias a las recomendaciones de consenso disponibles, así como evaluar su repercusión clínica.
Estudio observacional descriptivo. Se incluyeron pacientes que se encontraban en la sala de observación del Servicio de Urgencias pendientes de ingreso hospitalario, con diagnóstico previo de diabetes mellitus y en tratamiento domiciliario con fármacos hipoglucemiantes. Se evaluó el manejo del tratamiento antidiabético y su repercusión clínica.
Se incluyeron 78 pacientes. Al ingreso en el Servicio de Urgencias se modificó el tratamiento en el 91% de los pacientes, y se omitió en el 9%, siendo el tratamiento más pautado los rescates con insulina rápida (68%). Los tratamientos prescritos se ajustaron en un 16,7% a las recomendaciones de la Sociedad Española de Medicina de Urgencias y Emergencias. Tras la intervención del farmacéutico, la omisión descendió al 1,3% y la adecuación a las recomendaciones aumentó al 20,5%. Comparando los pacientes cuyo tratamiento se ajustó a las recomendaciones y los que no, la repercusión clínica fue, respectivamente: media de glucemia a las 24 horas 138,3 ± 49,5 mg/dL versus 182,7 ± 97,1 mg/dL (p = 0,688); media de rescates con insulina lispro 1± 1,6 versus 1,5 ± 1,8 (p = 0,293); media de unidades de insulina lispro administradas 4,6 ± 12,7 UI frentea6,6 ± 11,3 UI (p = 0,155).
Encontramos una baja adecuación de las prescripciones de antidiabéticos a las recomendaciones de consenso. Estos resultados van en línea con otros estudios, objetivándose un abuso de las pautas de rescate con insulina rápida como único tratamiento hipoglucemiante.
To quantify and to evaluate the reliability of Primary Care (PC) computerised medication records of as an information source of patient chronic medications, and to identify associated factors with ...the presence of discrepancies.
A descriptive cross-sectional study.
General Referral Hospital in Murcia.
Patients admitted to the cardiology-chest diseases unit, during the months of February to April 2013, on home treatment, who agreed to participate in the study.
Evaluation of the reliability of Primary Care computerised medication records by analysing the concordance, by identifying discrepancies, between the active medication in these records and that recorded in pharmacist interview with the patient/caregiver. Identification of associated factors with the presence of discrepancies was analysed using a multivariate logistic regression.
The study included a total of 308 patients with a mean of 70.9 years (13.0 SD). The concordance of active ingredients was 83.7%, and this decreased to 34.7% when taking the dosage into account. Discrepancies were found in 97.1% of patients. The most frequent discrepancy was omission of frequency (35.6%), commission (drug added unjustifiably) (14.6%), and drug omission (12.7%). Age older than 65 years (1.98 1.08 to 3.64), multiple chronic diseases (1.89 1.04 to 3.42), and have a narcotic or psychotropic drug prescribed (2.22 1.16 to 4.24), were the factors associated with the presence of discrepancies.
Primary Care computerised medication records, although of undoubted interest, are not be reliable enough to be used as the sole source of information on patient chronic medications when admitted to hospital.
Chronic obstructive pulmonary disease (COPD) is an important comorbidity in heart failure. The MIMO trial showed that patients with acute cardiogenic pulmonary edema (ACPE) treated with midazolam had ...fewer serious adverse events than those treated with morphine. In this post hoc analysis, we examined whether the presence/ absence of COPD modifies the reduced risk of midazolam over morphine.
Patients >18 years old clinically diagnosed with ACPE and with dyspnea and anxiety were randomized (1:1) at emergency department arrival to receive either intravenous midazolam or morphine. In this post hoc analysis, we calculated the relative risk (RR) of serious adverse events in patients with and without COPD. Calculating the CochranMantel-Haenszel interaction test, we evaluated if COPD modified the reduced risk of serious adverse events in the midazolam arm compared to morphine.
Overall, 25 (22.5%) of the 111 patients randomized had a history of COPD. Patients with COPD were more commonly men with a history of previous episodes of heart failure, than participants without COPD. In the COPD group, the RR for the incidence of serious adverse events in the midazolam versus morphine arm was 0.36 (95%CI, 0.1–1.46). In the group without COPD, the RR was 0.44 (95%CI, 0.22–0.91). The presence of COPD did not modify the reduced risk of serious adverse events in the midazolam arm compared to morphine (p for interaction =0.79).
The reduced risk of serious adverse events in the midazolam group compared with morphine is similar in patients with and without COPD.
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