Eficacia de una vía de alta resolución en la evaluación del cólico renoureteral no complicado en un servicio de urgencias hospitalario: un ensayo clínico aleatorizado (Estudio STONE).

Objetivo. Evaluar una vía de alta resolución (vía POC) que utiliza análisis en el punto de atención (point-of-care testing –POCT–) y ecografía en el punto de atención (point-of-care ultrasonography –POCUS–) en la sospecha del cólico renoureteral (CRU) no complicado y compararla con la vía estándar (vía STD). Método. Ensayo clínico aleatorizado, controlado, no ciego, realizado en un servicio de urgencias hospitalario (SUH). Incluyó pacientes con sospecha clínica de CRU agudo y se aleatorizaron 1:1 a seguir vía POC o vía STD. Se analizó el tiempo de estancia en el SUH, el tratamiento administrado, la proporción de diagnósticos alternativos a CRU y las complicaciones a 30 días. Resultados. Entre noviembre de 2018 y octubre de 2019, se reclutaron 140 pacientes de los que se analizaron 124. El tiempo de estancia total en el SUH de la vía POC fue de 112 minutos (DE 45) y en la vía STD 244 minutos (DE 102) (p < 0,001). No hubo diferencias en el tratamiento administrado en urgencias, en el número de diagnósticos alternativos, ni en las complicaciones a 30 días. Conclusiones. La utilización de una vía de alta resolución del manejo del CRU en un SUH es eficaz, segura y reduce el tiempo de estancia en urgencias.post-print225 K

Inhaled Methoxyflurane Provides Greater Analgesia and Faster Onset of Action Versus Standard Analgesia in Patients With Trauma Pain: InMEDIATE: A Randomized Controlled Trial in Emergency Departments

Study objective: The objective of the InMEDIATE study was to evaluate the change in intensity of traumatic pain over the first 20 min in adult patients treated with methoxyflurane versus standard analgesic treatment in Spain. This the first randomized, active-controlled, multicenter trial of methoxyflurane in the emergency setting in Europe. Methods: This was a randomized, controlled study that enrolled adult patients with acute moderate to severe (score >= 4 on the 11-point Numeric Rating Scale) trauma-associated pain in 14 Spanish emergency departments. Patients were randomized 1:1 to methoxyflurane (up to 2x3 mL) or standard analgesic treatment. Coprimary endpoints were the change from baseline in Numeric Rating Scale pain intensity score during the first 20 minutes of treatment and time to first pain relief. Results: Three hundred five patients were randomized (methoxyflurane 156; standard analgesic treatment 149). Most patients in the standard analgesic treatment group (70%) received intravenous first-step analgesics and 9.4% of patients were treated with opioids. Mean decrease from baseline in Numeric Rating Scale pain intensity score was greater for methoxyflurane than standard analgesic treatment at all points, with a significant treatment difference overall up to 20 minutes (repeated-measures model 2.47 versus 1.39; treatment difference 1.00; 95% confidence interval 0.84 to 1.32). Median time to first pain relief was significantly shorter for methoxyflurane than standard analgesic treatment (3 versus 10 minutes). Methoxyflurane achieved better patient and clinician ratings for pain control and comfort of treatment than standard analgesic treatment and exceeded patient and clinician expectations of treatment in, respectively, 77% and 72% of cases compared with 38% and 19% for standard analgesic treatment. Conclusion: These results support consideration of methoxyflurane as a nonnarcotic, easy-to-administer, rapid-acting, first-line alternative to currently available analgesic treatments for trauma pain

Oxygen Saturation on Admission Is a Predictive Biomarker for PD-L1 Expression on Circulating Monocytes and Impaired Immune Response in Patients With Sepsis

Sepsis is a pathology in which patients suffer from a proinflammatory response and a dysregulated immune response, including T cell exhaustion. A number of therapeutic strategies to treat human sepsis, which are different from antimicrobial and fluid resuscitation treatments, have failed in clinical trials, and solid biomarkers for sepsis are still lacking. Herein, we classified 85 patients with sepsis into two groups according to their blood oxygen saturation (SaO2): group I (SaO2 ≤ 92%, n = 42) and group II (SaO2 &gt; 92%, n = 43). Blood samples were taken before any treatment, and the immune response after ex vivo LPS challenge was analyzed, as well as basal expression of PD-L1 on monocytes and levels of sPD-L1 in sera. The patients were followed up for 1 month. Taking into account reinfection and exitus frequency, a significantly poorer evolution was observed in patients from group I. The analysis of HLA-DR expression on monocytes, T cell proliferation and cytokine profile after ex vivo LPS stimulation confirmed an impaired immune response in group I. In addition, these patients showed both, high levels of PD-L1 on monocytes and sPD-L1 in serum, resulting in a down-regulation of the adaptive response. A blocking assay using an anti-PD-1 antibody reverted the impaired response. Our data indicated that SaO2 levels on admission have emerged as a potential signature for immune status, including PD-L1 expression. An anti-PD-1 therapy could restore the T cell response in hypoxemic sepsis patients with SaO2 ≤ 92% and high PD-L1 levels

Adecuacion de Ingresos Hospitalarios en un Servicio de Urgencias de un Hospital Terciario de la Comunidad de Madrid

At present, health expenditure should be regulated to ensure sustainability. With this intention, the emergency services must develop efficient behavior patterns. The appropriateness of hospital admissions is a determinant of good resource management. The purpose of this study is to determine the appropriateness of hospital admissions in our emergency department using internationally validated criteria. We note that 370 hospital admissions 95.1% (CI 92.4-96.9) were adequate while 4.8% (CI 3.1-7.5) were inadequate. No differences between adequacy ratio of hospital admissions depending on the age of the patients were identified. Conducting periodic surveys of its kind in the emergency services can contribute significantly to the sustainability of health systems.En la actualidad, el gasto sanitario debe regularse para asegurar la sostenibilidad. Con esa intención, los servicios de urgencias deben desarrollar patrones de conducta eficientes. La adecuación de los ingresos hospitalarios es un condicionante de la buena administración de recursos. El propósito del presente estudio es determinar el grado de adecuación de ingresos hospitalarios en nuestro servicio de urgencias aplicando criterios internacionalmente validados. Observamos que, de 370 ingresos hospitalarios el 95.1% (IC 92.4-96.9) fueron adecuados mientras que 4.8% (IC 3.1-7.5) fueron inadecuados. No se identificaron diferencias entre la proporción de adecuación de ingresos hospitalarios en función de la edad de los pacientes. La realización de estudios periódicos de este tipo en los servicios de urgencias, pueden contribuir de forma importante a la sostenibilidad de los sistemas sanitarios

Cost Analyses after a single intervention using a computer application (DIAGETHER) in the treatment of diabetic patients admitted to a third level hospital

Goals: To quantify the savings that could be made by the hospital implementation of a computer application (DIAGETHER®), which advises the treatment of hyperglycemia of the diabetic patient in the emergency department when this patient is admitted to a third level hospital. Methods: A multicenter interventional study was designed, including patients in two arms, one in the conventional treatment prescribed by the physician and the other applied the treatment indicated by the computer application DIAGETHER®. The days of hospitalization were collected in the two arms of intervention. Results: A total of 183 patients were included, 86 received treatment with the computer application, and 97 received conventional treatment. The mean blood glucose level on the first day of admission in the GLIKAL group was 178.56 (59.53), compared to 212.93 (62.23) in the conventional group (p <0.001) and on the second day 173.86 (58.86) versus 196.37 (66.60) (p = 0.017). There was no difference in the frequency of hypoglycemia reported in each group (p = 0.555). A reduction in mean stay was observed in patients treated with DIAGETHER. The days of admission were 7 (2-39) days for the GLIKAL group and 10 (2-53) days for the PCH group (p <0.001). Conclusions: The annual savings that could be generated with the use of the computer tool (DIAGETHER®), with the volume of diabetic patients admitted to the hospital, could decrease hospitalization days by 26,147 (14,134 patients for 1.85 days of stay reduction), this would generate a saving of 8,811,842 million euros per year (cost of stay / day of the diabetic patient, for the savings days generated)

Adherence of Emergency Physicians to clinical guidelines for hyperglycemia using a specific computing tool (GLIKAL©)

Goal: to evaluate the adherence of Emergency Physicians to clinical guidelines for medical treatment in in-hospital patients, evaluated by using a specific computing tool (GLIKAL©) in patients with hyperglycemia and/or diabetes mellitus. Methodology: An observational study with descriptive cases was designed, with no intervention, including patients from an urban, tertiary university hospital. Patients pending admittance were recruited, starting at the very first hours of the day, any day of the week. Inclusion criteria were age above 18 years old, with glycaemia >150 mg/dl upon admittance to hospital (with a known diabetes or not) who were admitted to hospital from the Emergency Department. The study period included was from June to October 2012. The independent variables were age, sex, previous treatment for diabetes, type of diet prescribed upon admittance, corticosteroid treatment, serum creatinine and glycaemia upon admittance to the Emergency Department. The outcome variable was the treatment suggested by the software program, which was evaluated with 11 items gathered by the specific computing tool (GLIKAL©). Results: 125 patients were gathered, amongst which eight were discarded due to mistakes in the initial data collected. Of the remaining 117 patients, the mean age was of 78.1 years old, with 61% males. Among these 117 patients, 74 of them (63.4%) were being treated with oral antidiabetic drugs alone or in combination with insulin, of which 13 cases (17.5%) continued having it prescribed by the physician even when it was not suitable, while no mistake was detected in the treatment specified by GLIKAL© (p<0.001). The following percentages of correct prescriptions by the physicians were found: basal insulin treatment adjusted to weight (22.6%), basal treatment adjusted to nil per os diet (0%), treatment adjusted according to newly prescribed treatment with corticosteroids (10%), adjusted to deteriorated kidney function (14.2%) or if the corrective treatment was adjusted to weight (17.9%), in comparison with 100% accomplished by GLIKAL©. The investigators concluded that of the 117 analyzed patients, the treatment suggested by GLIKAL© was correct in all of them, as opposed to 17 (14.52%) of the treatments suggested by the physician, which constitutes a 85.4% of incorrect treatments, with 4 patients in which the treatment was considered “unclear”. Conclusion: the adherence of the physicians from the Emergency Department to the guidelines for treating patients with hyperglycemia or diabetes mellitus, as gathered in the GLIKAL© program, was inadequate

Adherencia de los Urgenciólogos al protocolo de Control Glucémico de la Herramienta GLIKAL

Goal: to evaluate the adherence of Emergency Physicians to clinical guidelines for medical treatment in in-hospital patients, evaluated by using a specific computing tool (GLIKAL© ) in patients with hyperglycemia and/or diabetes mellitus. Methodology: An observational study with descriptive cases was designed, with no intervention, including patients from an urban, tertiary university hospital. Patients pending admittance were recruited, starting at the very first hours of the day, any day of the week. Inclusion criteria were age above 18 years old, with glycaemia >150 mg/dl upon admittance to hospital (with a known diabetes or not) who were admitted to hospital from the Emergency Department. The study period included was from June to October 2012. The independent variables were age, sex, previous treatment for diabetes, type of diet prescribed upon admittance, corticosteroid treatment, serum creatinine and glycaemia upon admittance to the Emergency Department. The outcome variable was the treatment suggested by the software program, which was evaluated with 11 items gathered by the specific computing tool (GLIKAL© ). Results: 125 patients were gathered, amongst which eight were discarded due to mistakes in the initial data collected. Of the remaining 117 patients, the mean age was of 78.1 years old, with 61% males. Among these 117 patients, 74 of them (63.4%) were being treated with oral antidiabetic drugs alone or in combination with insulin, of which 13 cases (17.5%) continued having it prescribed by the physician even when it was not suitable, while no mistake was detected in the treatment specified by GLIKAL© (p<0.001). The following percentages of correct prescriptions by the physicians were found: basal insulin treatment adjusted to weight (22.6%), basal treatment adjusted to nil per os diet (0%), treatment adjusted according to newly prescribed treatment with corticosteroids (10%), adjusted to deteriorated kidney function (14.2%) or if the corrective treatment was adjusted to weight (17.9%), in comparison with 100% accomplished by GLIKAL© . The investigators concluded that of the 117 analyzed patients, the treatment suggested by GLIKAL© was correct in all of them, as opposed to 17 (14.52%) of the treatments suggested by the physician, which constitutes a 85.4% of incorrect treatments, with 4 patients in which the treatment was considered “unclear”. Conclusion: the adherence of the physicians from the Emergency Department to the guidelines for treating patients with hyperglycemia or diabetes mellitus, as gathered in the GLIKAL© program, was inadequate.Objetivo: Evaluar la adherencia a las guías clínicas del tratamiento médico pautado por el urgenciólogo, al ingreso en el hospital, evaluado a través de una herramienta informática específica (GLIKAL© ) en los pacientes con hiperglucemia y/o diabetes mellitus. Metodología: Se diseño un estudio observacional de serie de casos descriptivo, de no intervención, con inclusión de pacientes de un hospital urbano, terciario y universitario. Los pacientes se reclutaron de los pendientes de ingreso, a partir de un muestreo de oportunidad en la primera hora de la mañana de cualquier día de la semana. Los criterios de inclusión fueron pacientes mayores de 18 años, con glucemia analítica a la entrada en urgencias > 150 mg/dl (diabéticos o no) que ingresaron en el hospital desde el SU. El periodo del estudio fue entre junio y octubre de 2012. Las variables independientes edad, peso, sexo, tratamiento previo para la diabetes, tipo de dieta pautada al ingreso, tratamiento con corticoides, creatinina sérica al ingreso, y glucemia analítica a la entrada en urgencias. La variable de resultado fue el tratamiento sugerido por el programa que fue valorado en 11 ítems recogidos en la herramienta informática específica (GLIKAL© ). Resultados: Se recogieron 125 pacientes, de los cuales se descartaron 8 por errores en la recogida de datos. De 117 pacientes, la edad media fue de 78,1 años, recogiendo un 61% de varones. De estos 117 pacientes, 74 (63,4%) tomaban ADOS solos o en combinación con insulina, de estos, en 13 (17,5%) casos el tratamiento convencional por el médico no suprimió los ADOS a pesar de estar indicado, no se apreció ningún fallo en el tratamiento indicado por GLIKAL© (p < 0,001). Se encontraron los siguientes porcentajes de ajustes correctos en la pauta de tratamiento indicada por el urgenciólogo: pauta basal estaba ajustada al peso (22,6%), pauta basal ajustada a dieta absoluta (0%), ajuste si al paciente se le han pautado corticoides (10%), si tiene deterioro de función renal (14,2%), o si la pauta correctora estaba ajustada al peso (17,9%), respecto al 100% encontrados en la aplicación GLIKAL© . Los investigadores concluyeron que de los 117 pacientes analizados, el tratamiento indicado por GLIKAL© era correcto en todos ellos (100%), frente a 17 (14,52%), de los tratamientos indicados por el médico, lo que constituye un porcentaje de tratamientos considerados no correctos del 85,4%, con 4 pacientes en los que el tratamiento fue considerado por los investigadores como “dudoso” (Figura 1). Conclusión: La adherencia por parte de los urgenciólogos a las guías de practica clínica, recogidas en el programa GLIKAL© , en los pacientes con hiperglucemia y/o diabetes mellitus fue deficiente

Utilización de TICS en medicina de urgencias: valoración de un software de ayuda a la prescripción del paciente con hiperglucemia (DIAGETHER®), por parte de médicos residentes

Introduction. Permissiveness to hyperglycemia is harmful to admitted patients. DIAGETHER is an application that helps the doctor in the treatment of the diabetic patient. Objectives. Determine degree of usability, level of confidence and overall assessment of DIAGETHER used by physicians resident in different clinical settings. Method. Multicenter descriptive study, based on a DIAGETHER assessment survey, of 42 residents of two hospitals, assessing decision-making regarding the therapeutics of patients with glycemic disorders in different clinical settings. Results. DIAGETHER was positively assessed regarding usability, confidence in case resolution, and time spent. The overall assessment of the tool was 87.5. On the negative side, it is necessary to conduct real-field studies to know the real adaptation of the tool to medical work. Conclusions. The DIAGETHER® application is an easy-to-use, quick decision-making tool and gives the doctor safety in the treatment of patients with hyperglycemia, which makes their overall assessment high. On the negative side, the study was conducted under “non-real” conditions, it would be interesting to develop future studies in several emergency departments.  Introducción. La permisividad ante la hiperglucemia es nociva para los pacientes ingresados. DIAGETHER es una aplicación que ayuda al médico en el tratamiento del paciente diabético. Objetivos. Determinar grado de usabilidad, nivel de confianza y valoración global de DIAGETHER empleada por médicos residentes en distintos escenarios clínicos. Método. Estudio descriptivo multicéntrico, basado en una encuesta de valoración sobre DIAGETHER, a 42 residentes de dos hospitales, valorando la toma de decisiones con respecto a la terapéutica de pacientes con alteraciones glucémicas en distintos escenarios clínicos. Resultados. DIAGETHER fue valorado positivamente respecto a usabilidad, confianza en resolución de casos, y tiempo empleado. La valoración global de la herramienta fue del 87,5. En el lado negativo, es necesario realizar estudios en terreno real para saber la adaptación real de la herramienta al trabajo médico. Conclusiones. La aplicación DIAGETHER® es una herramienta fácil de usar, rápida en la toma de decisiones y le da al médico seguridad en el tratamiento de pacientes con hiperglucemia, lo que hace que su valoración global sea alta. En el lado negativo, el estudio fue realizado en condiciones “no reales”, sería interesante desarrollar futuros estudio en varios servicios de urgencias.