Prehospital emergency care of patients with acute heart failure in Spain: the SEMICA study (Emergency Medical Response Systems for Patients with Acute Heart Failure)

Objectives. To study the means of emergency transport used to bring patients with acute heart failure (AHF) to hospital emergency departments (EDs) and explore associations between factors, type of transport, and prehospital care received. Methods. We gathered the following information on patients treated for AHF at 34 Spanish hospital EDs: means of transport used (medicalized ambulance [MA], nonmedicalized ambulance [NMA], or private vehicle) and treatments administered before arrival at the hospital. Twenty-seven independent variables potentially related to type of transport used were also studied. Indicators of AHF severity were triage level assigned in the ED, need for admission, need for intensive care, in-hospital mortality, and 30-day mortality. Results. A total of 6106 patients with a mean (SD) age of 80 years were included; 56.5% were women, 47.2% arrived in PVs, 37.8% in NMAs, and 15.0% in MAs. Use of an ambulance was associated with female sex, age over 80 years, chronic obstructive pulmonary disease, a history of AHF, functional dependency, New York Heart Association class III-IV, sphincteral incontinence, labored breathing, orthopnea, cold skin, and sensory depression or restlessness. Assignment of a MA was directly associated with living alone, a history of ischemic heart disease, cold skin, sensory depression or restlessness, and high temperature; it was inversely associated with a history of falls. The rates of receipt of prehospital treatments and AHF severity level increased with use of MAs vs. NMAs vs. PV. Seventy-three percent of patients transported in MAs received oxygen, 29% received a diuretic, 13.5% a vasodilator, and 4.7% noninvasive ventilation. Conclusions. Characteristics of the patient with AHF are associated with the assignment of type of transport to a hospital ED. Assignment appears to be related to severity. Treatment given during MA transport could be increased

New Splice Site Acceptor Mutation in AIRE Gene in Autoimmune Polyendocrine Syndrome Type 1

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

Thirty-day outcomes in frail older patients discharged home from the emergency department with acute heart failure: effects of high-risk criteria identified by the DEED FRAIL-AHF trial

Objectives: To study the effect of high-risk criteria on 30-day outcomes in frail older patients with acute heart failure (AHF) discharged from an emergency department (ED) or an ED's observation and short-stay areas. Material and methods: Secondary analysis of discharge records in the Older AHF Key Data registry. We selected frail patients (aged > 70 years) discharged with AHF from EDs. Risk factors were categorized as modifiable or nonmodifiable. The outcomes were a composite endpoint for a cardiovascular event (revisits for AHF, hospitalization for AHF, or cardiovascular death) and the number of days alive out-of-hospital (DAOH) within 30 days of discharge. Results: We included 380 patients with a mean (SD) age of 86 (5.5) years (61.2% women). Modifiable risk factors were identified in 65.1%, nonmodifiable ones in 47.8%, and both types in 81.6%. The 30-day cardiovascular composite endpoint occurred in 83 patients (21.8%). The mean 30-day DAOH observed was 27.6 (6.1) days. Highrisk factors were present more often in patients who developed the cardiovascular event composite endpoint: the rates for patients with modifiable, nonmodifiable, or both types of risk were, respectively, as follows in comparison with patients not at high risk: 25.0% vs 17.2%, P = .092; 27.6% vs 16.7%, P = .010; and 24.7% vs 15.2%, P = .098). The 30-day DAOH outcome was also lower for at-risk patients, according to type of risk factor present: modifiable, 26.9 (7.0) vs 28.4 (4.4) days, P = .011; nonmodifiable, 27.1 (7.0) vs 28.0 (5.0) days, P = .127; and both, 27.1 (6.7) vs 28.8 (3.4) days, P = .005). After multivariate analysis, modifiable risk remained independently associated with fewer days alive (adjusted absolute difference in 30-day DAOH, -1.3 days (95% CI, -2.7 to -0.1 days). Nonmodifiable factors were associated with increased risk for the 30-day cardiovascular composite endpoint (adjusted absolute difference, 10.4%; 95% CI, -2.1% to 18.7%). Conclusion: Risk factors are common in frail elderly patients with AHF discharged home from hospital ED areas. Their presence is associated with a worse 30-day prognosis

Short-term prognosis of polypharmacy in elderly patients treated in emergency departments: results from the EDEN project

Background: 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. Methods: 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. Results: 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. Conclusion: Polypharmacy was common among the elderly treated in EDs and associated with increased risks of ED revisits and hospital readmissions 10 drugs. In these patients comorbidities were associated with an increase in the number of drugs. In the patients with severe polypharmacy (>10 drugs), diuretics were the most frequently drugs prescribed, followed by antihypertensives and statins. The results obtained indicate that polypharmacy is a frequent phenomenon among the elderly population treated in Emergency departments, being antihypertensives the most frequently used drugs in this population. Those patients who takes >10 drugs have a higher risk of new visits to the emergency room and hospital readmissions in short term period

Mental health assessment of spanish healthcare workers during the SARS-CoV-2 pandemic: a cross-sectional study

Introduction: The SARS-CoV-2 outbreak is posing unprecedented care scenarios, increasing the psychological distress among healthcare workers while reducing the efficiency of health systems. This work evaluated the psychological impact of the Covid-19 pandemic on Spanish frontline healthcare workers of two tertiary hospitals. Material and methods: Healthcare workers were recruited from the medical units designated for the care of Covid-19 patients. The psychological assessment consisted of an individual, face-to-face session where gold-standard psychometric tests were administered to assess stress (VASS & PSS-10), anxiety (STAI), depression (PHQ-2) and posttraumatic stress disorder (PCL-5). Regression models were also fitted to identify predictors of psychological distress. Results: Overall, almost 13% of healthcare workers showed severe anxiety, while more than 26% had high levels of perceived stress. More than 23% presented severe posttraumatic stress symptoms, and another 13% had PHQ-2 scores equal to or above 3, compatible with Major Depressive Disorder (MDD) diagnosis, respectively. Women, stress-related medication, overworking, performing in Covid-19 wards, and substance abuse were risk factors for increased psychological distress. Instead, practising exercise reduced the burden. Conclusion: This study outlines the severe psychological impact of the Covid-19 pandemic on Spanish frontline healthcare workers. The stress, depression and anxiety levels found were similar to those reported in similar works but much higher than in Wuhan healthcare workers. Knowledge of risk factors for increased psychological distress may help to develop comprehensive intervention strategies to prevent, control and reduce the mental health exacerbation of healthcare workers, thereby maintaining the effectiveness of health systems in critical scenarios

Análisis de la salud mental de trabajadores sanitarios españoles de primera línea durante la pandemia por SARS-CoV-2

Background and objective: 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. Material and methods: 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) RESULTS: 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. Conclusion: 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.Antecedentes y objetivo: 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. Material y métodos: 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). Resultados: 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. Conclusión: 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

Importancia de la consulta ambulatoria previa a la visita a las urgencias hospitalarias en pacientes mayores: impacto sobre resultados de hospitalización

Resumen: Objetivo: Investigar los factores asociados a una consulta ambulatoria previa (CAP), al acudir a un servicio de urgencias hospitalario (SUH), en los pacientes mayores de 65 años y su impacto sobre los resultados. Emplazamiento: Cincuenta y dos SUH españoles. Participantes: Pacientes mayores de 65 años que consultan a un SUH. Medidas principales y metodología: Se utilizó una cohorte (n = 24.645) de pacientes mayores e 65 años atendidos en 52 SUH durante una semana. Se consignaron 5 variables sociodemográficas, 6 funcionales y 3 de gravedad y se analizó su asociación cruda y ajustada con la existencia o no de una CAP a la consulta al SUH. La variable de resultado primaria fue la necesidad de ingreso y secundarias la realización de exploraciones complementarias y tiempo de estancia en el SUH. Se analizó si la CAP influenció en los resultados. Resultados: El 28,5% de los pacientes tenía una CAP previa a su visita al SUH. Vivir en residencia, NEWS2 ≥ 5, edad ≥ 80 años, dependencia funcional, comorbilidad grave, vivir solo, deterioro cognitivo, sexo masculino y depresión se asociaron de forma independiente con la CAP. La CAP se asoció a mayor necesidad de hospitalización y menor tiempo de estancia en el SUH, pero no se observó un menor consumo de recursos diagnósticos. Conclusiones: Los pacientes que acuden al SUH tras una CAP tienen más necesidad de hospitalización, sugiriendo que son debidamente derivados, y las urgencias menores son solucionadas de forma efectiva en la CAP. Su estancia en el SUH previa a la hospitalización es menor, por lo que la CAP facilitaría su resolución clínica. Abstract: Objective: Investigate factors associated with a previous outpatient medical consultation (POMC), to the health center or another physician, before attending a hospital emergency department (ED), in patients aged >65 and its impact on the hospitalization rate and variables related to ED stay. Site: Fifty-two Spanish EDs. Participants: Patients over 65 years consulting an ED. Main measurements and design: A cohort (n=24645) of patients aged >65 attended for one week in 52 ED. We recorded five sociodemographic variables, six functional, three episode-related severity and analyzed their crude and adjusted association with the existence of a POMC at ED consultation. The primary outcome variable was the need for admission and the secondary variables were complementary examinations and ED stay length. We analyzed whether the POMC influenced these outcomes. Results: 28.5% of the patients had performed a POMC prior to their visit to the ED. Living in a residence, NEWS-2 score ≥5, aged ≥80, dependency functions, severe comorbidity, living alone, cognitive impairment, male gender and depression were independently associated with a POMC. Also was associated with a greater need for hospitalization and shorter length of stay in the ED. No minor consumption of diagnostic resources in patients with POMC. Conclusion: Patients presenting to the ED following POMC are admitted more frequently, suggesting that they are appropriately referred and that minor emergencies are probably effectively resolved in the POMC. Their stay in the ED prior to hospitalization is shorter, so the POMC would facilitate clinical resolution in the ED

Short-term outcomes of heart failure patients with reduced and preserved ejection fraction after acute decompensation according to the final destination after emergency department care

To compare short-term outcomes after an episode of acute heart failure (AHF) in patients with reduced and preserved ejection fractions (HFrEF,  49%; respectively) according to their destinations after emergency department (ED) care. Methods and results: This secondary analysis of the EAHFE Registry (consecutive AHF patients diagnosed in 41 Spanish EDs) investigated 30-day all-cause mortality, in-hospital all-cause mortality, prolonged hospitalisation (> 7 days), and 30-day post-discharge ED revisit due to AHF, all-cause death, and combined endpoint (ED revisit/death) in 5829 patients with echocardiographically documented HFrEF and HfpEF (HFrEF/HFpEF: 1,442/4,387). Adjusted ratios were calculated for patients admitted to internal medicine (IM), short stay unit (SSU), and discharged from the ED without hospitalisation (DEDWH) and compared with those admitted to cardiology. For HFrEF, the only significant differences were lower in-hospital mortality (OR = 0.26; 95% CI 0.08-0.81; p = 0.021) and prolonged hospitalisation (OR = 0.07; 95% CI 0.04-0.13; p < 0.001) related to SSU admission. For HFpEF, IM admission had a higher post-discharge 30-day mortality (HR = 1.85; 95% CI 1.05-3.25; p = 0.033) and combined endpoint (HR = 1.24; 95% CI 1.01-1.64; p = 0.044); SSU admission had a lower in-hospital mortality (OR = 0.43; 95% CI 0.23-0.80; p = 0.008) and prolonged hospitalisation (OR = 0.17; 95% CI 0.13-0.23; p < 0.001) but a higher post-discharge 30-day combined endpoint (HR = 1.29; 95% CI 1.01-1.64; p = 0.041); and DEDDWH had a lower 30-day mortality (HR = 0.46; 95% CI 0.28-0.75; p = 0.002) but higher post-discharge ED revisit (HR = 1.62; 95% CI 1.31-2.00; p < 0.001). Conclusion: While HFrEF patients have similar short-term outcomes irrespective of the destination after ED care for an AHF episode, HFpEF patients present worse short-term outcomes when managed by non-cardiology departments, despite adjustment for different clinical patient profiles. Reasons for this heterogeneous specialty-related performance should be investigated.Sin financiación4.907 JCR (2018) Q1, 32/136 Cardiac & Cardiovascular Systems2.206 SJR (2018) Q1, 34/365 Cardiology and Cardiovascular Medicine, 131/2844 Medicine (miscellaneous)No data IDR 2018UE

Plasma sodium concentration in older patients as an indicator of severity in emergencies: Results from the Emergency Department and Elder Needs-16 study

Objetivo. Estudiar los factores basales asociados a hiponatremia e hipernatremia en pacientes mayores atendidos en urgencias y la relación de estas disnatremias con eventos indicadores de gravedad. Método. Se incluyeron durante una semana a todos los pacientes atendidos en 52 servicios de urgencias hospitalarios españoles de edad $65 años con determinación de sodio plasmático. Se formaron tres grupos: sodio normal (135145 mmol/L), hiponatremia ( 145 mmol/L). Se investigó la relación de 24 factores sociodemográficos, de comorbilidad, estado funcional basal y tratamiento crónico con hipo e hipernatremia. Como eventos de gravedad se recogieron necesidad de hospitalización, mortalidad intrahospitalaria, estancia prolongada en urgencias (> 12 horas) en dados de alta y hospitalización prolongada (> 7 días) en hospitalizados, y se analizó su relación con la concentración de sodio mediante curvas spline cúbicas restringidas ajustadas, tomando el valor 140 mmol/L como referencia. Resultados. Se incluyeron 13.368 pacientes (13,5$ 80 años, hipertensión arterial, diabetes mellitus, neoplasia activa, hepatopatía crónica, demencia, tratamiento con quimioterápicos y ayuda para la deambulación, y la hipernatremia a dependencia, necesidad de ayuda para deambular y demencia. La hospitalización fue del 40,8%, la mortalidad intrahospitalaria del 4,3%, la estancia prolongada en urgencias del 15,9% y la hospitalización prolongada del 49,8%. A mayor hiponatremia, mayor necesidad de hospitalización (sodio 130 mmol/L: OR:2,24; IC 95%: 2,00-2,52; 120 mmol/L: 4,13, 3,08-5,56; 110 mmol/L: 7,61, 4,53-12,8), mortalidad intrahospitalaria (130 mmol/L: 3,07, 2,40-3,92; 120 mmol/L: 6,34, 4,22-9,53; 110 mmol/L: 13,1, 6,53-26,3) y estancia prolongada en urgencias (130 mmol/L: 1,59, 1,30-1,95; 120 mmol/L: 2,77, 1,69-4,56; 110 mmol/L: 4,83, 2,03-11,5), y a mayor hipernatremia mayor necesidad de hospitalización (150 mmol/L: 1,94, 1,61-2,34; 160 mmol/L: 4,45, 2,88-6,87; 170 mmol/L: 10,2, 5,1-20,3; 180 mmol/L: 23,3, 9,03-60,3), mortalidad intrahospitalaria (150 mmol/L: 2,77, 2,16-3,55; 160 mmol/L: 6,33, 4,11-9,75; 170 mmol/L: 14,5, 7,45-28,1; 180 mmol/L: 33,1, 13,3-82,3) y estancia prolongada en urgencias (150 mmol/L: 2,03, 1,48-2,79; 160 mmol/L: 4,23, 2,03-8,84; 170 mmol/L: 8,83, 2,74-28,4; 180 mmol/L: 18,4, 3,69-91,7). No hubo asociación entre estas disnatremias y hospitalización prolongada. Conclusiones. El sodio plasmático determinado en urgencias en pacientes mayores permite identificar hiponatremias e hipernatremias, las cuales se asocian a un riesgo incrementado de hospitalización, mortalidad y estancia prolongada en urgencias independientemente de la causa que haya generado la disnatremia.Objectives: To study baseline factors associated with hypo- and hypernatremia in older patients attended in emergency departments (EDs) and explore the association between these dysnatremias and indicators of severity in an emergency. Material and methods: We included patients attended in 52 Spanish hospital EDs aged 65 years or older during a designated week. All included patients had to have a plasma sodium concentration on record. Patients were distributed in 3 groups according to sodium levels: normal, 135-145 mmol/L; hyponatremia, 135 mmol/L; or hypernatremia > 145 mmol/L. We analyzed associations between sodium concentration and 24 variables (sociodemographic information, measures of comorbidity and baseline functional status, and ongoing treatment for hypo- or hypernatremia). Indicators of the severity in emergencies were need for hospitalization, in-hospital mortality, prolonged ED stay (> 12 hours) in discharged patients, and prolonged hospital stay (> 7 days) in admitted patients. We used restricted cubic spline curves to analyze the associations between sodium concentration and severity indicators, using 140 mmol/L as the reference. Results: A total of 13 368 patients were included. Hyponatremia was diagnosed in 13.5% and hypernatremia in 2.9%. Hyponatremia was associated with age ($ 80 years), hypertension, diabetes mellitus, an active neoplasm, chronic liver disease, dementia, chemotherapy, and needing help to walk. Hypernatremia was associated with needing help to walk and dementia. The percentages of cases with severity indicators were as follows: hospital admission, 40.8%; in-hospital mortality, 4.3%; prolonged ED stay, 15.9%; and prolonged hospital stay, 49.8%. Odds ratios revealed associations between lower sodium concentration cut points in patients with hyponatremia and increasing need for hospitalization (130 mmol/L, 2.24 [IC 95%, 2.00-2.52]; 120 mmol/L, 4.13 [3.08-5.56]; and 110 mmol/L, 7.61 [4.53-12.8]); risk for in-hospital death (130 mmol/L, 3.07 [2.40-3.92]; 120 mmol/L, 6.34 [4.22- 9.53]; and 110 mmol/L, 13.1 [6.53-26.3]); and risk for prolonged ED stay (130 mmol/L, 1.59 [1.30-1.95]; 120 mmol/L, 2.77 [1.69-4.56]; and 110 mmol/L, 4.83 [2.03-11.5]). Higher sodium levels in patients with hypernatremia were associated with increasing need for hospitalization (150 mmol/L, 1.94 [1.61-2.34]; 160 mmol/L, 4.45 [2.88-6.87]; 170 mmol/L, 10.2 [5.1-20.3]; and 180 mmol/L, 23.3 [9.03-60.3]); risk for in-hospital death (150 mmol/L, 2.77 [2.16-3.55]; 160 mmol/L, 6.33 [4.11-9.75]; 170 mmol/L, 14.5 [7.45-28.1]; and 180 mmol/L, 33.1 [13.3-82.3]); and risk for prolonged ED stay (150 mmol/L, 2.03 [1.48-2.79]; 160 mmol/L, 4.23 [2.03-8.84]; 170 mmol/L, 8.83 [2.74-28.4]; and 180 mmol/L, 18.4 [3.69-91.7]). We found no association between either type of dysnatremia and prolonged hospital stay. Conclusion: Measurement of sodium plasma concentration in older patients in the ED can identify hypo- and hypernatremia, which are associated with higher risk for hospitalization, death, and prolonged ED stays regardless of the condition that gave rise to the dysnatremia.Sin financiación5.5 Q1 JCR 20220.571 Q2 SJR 2022No data IDR 2022UE