Perfil de riesgo y valoración del tratamiento anticoagulante en pacientes con fibrilación auricular atendidos en un servicio de urgencias hospitalario

Los pacientes con FA consultan en los SUH por motivos relacionados con su arritmia así como de otra índole. Sus características clínicas, sociales y funcionales deben ser representativas de la población general de enfermos con FA. Caracterizar el perfil de riesgo de estos pacientes permitirá valorar la adecuación de la prescripción del tratamiento antitrombótico considerando escalas de riesgo embólico y de sangrado aplicables en la práctica diaria. Asumiendo que los AVK siguen siendo la terapia anticoagulante más común puede resultar útil determinar la efectividad de los mismos mediante el TTR. Los pacientes que visitan el SUH pueden ser una población en riesgo de tener un TTR inadecuado frente a un grupo control. Uno de los factores más evidentes de la inestabilidad del INR es la interacción farmacológica entre los AVK y otros fármacos. Características específicas de estos fármacos pueden afectar a la efectividad del tratamiento con AVK. de anticoagulación.Departamento de Medicina, Dermatología y Toxicologí

Derivation and validation of a blood biomarker score for 2-day mortality prediction from prehospital care: a multicenter, cohort, EMS-based study

Producción CientíficaIdentifying potentially life-threatening diseases is a key challenge for emergency medical services. This study aims at examining the role of different prehospital biomarkers from point-of-care testing to derive and validate a score to detect 2-day in-hospital mortality. We conducted a prospective, observational, prehospital, ongoing, and derivation—validation study in three Spanish provinces, in adults evacuated by ambulance and admitted to the emergency department. A total of 23 ambulance-based biomarkers were collected from each patient. A biomarker score based on logistic regression was fitted to predict 2-day mortality from an optimum subset of variables from prehospital blood analysis, obtained through an automated feature selection stage. 2806 cases were analyzed, with a median age of 68 (interquartile range 51–81), 42.3% of women, and a 2-day mortality rate of 5.5% (154 non-survivors). The blood biomarker score was constituted by the partial pressure of carbon dioxide, lactate, and creatinine. The score fitted with logistic regression using these biomarkers reached a high performance to predict 2-day mortality, with an AUC of 0.933 (95% CI 0.841–0.973). The following risk levels for 2-day mortality were identified from the score: low risk (score < 1), where only 8.2% of non-survivors were assigned to; medium risk (1 ≤ score < 4); and high risk (score ≥ 4), where the 2-day mortality rate was 57.6%. The novel blood biomarker score provides an excellent association with 2-day in-hospital mortality, as well as real-time feedback on the metabolic-respiratory patient status. Thus, this score can help in the decision-making process at critical moments in life-threatening situations.Junta de Castilla y León (Gerencia Regional de Salud - grant number GRS 1903/A/19 and GRS 2131/A/20)Ministerio de Ciencia e Innovación/Agencia Estatal de Investigación/10.13039/501100011033/’, ERDF A way of making Europe, and Next GenerationEU/PRTR (under projects PID2020-115468RB-I00 and PDC2021-120775-I00)CIBER -Consorcio Centro de Investigación Biomédica en Red (Instituto de Salud Carlos III) (CB19/01/00012)Publicación en abierto financiada por el Consorcio de Bibliotecas Universitarias de Castilla y León (BUCLE), con cargo al Programa Operativo 2014ES16RFOP009 FEDER 2014-2020 DE CASTILLA Y LEÓN, Actuación:20007-CL - Apoyo Consorcio BUCL

Prehospital point-of-care lactate increases the prognostic accuracy of national early warning score 2 for early risk stratification of mortality: results of a multicenter, observational study

The objective of this study was to assess whether the use of prehospital lactate (pLA) can increase the prognostic accuracy of the National Early Warning Score 2 (NEWS2) to detect the risk of death within 48 h. A prospective, multicenter study in adults treated consecutively by the emergency medical services (EMS) included six advanced life support (ALS) services and five hospitals. Patients were assigned to one of four groups according to their risk of mortality (low, low-medium, medium, and high), as determined by the NEWS2 score. For each group, the validity of pLA in our cohort was assessed by the area under the curve (AUC) of the receiver operating characteristic (ROC) curve. In this study, 3081 participants with a median age of 69 years (Interquartile range (IQR): 54–81) were included. The two-day mortality was 4.4% (137 cases). The scale derived from the implementation of the pLA improved the capacity of the NEWS2 to discriminate low risk of mortality, with an AUC of 0.910 (95% CI: 0.87–0.94; p < 0.001). The risk stratification provided by the NEWS2 can be improved by incorporating pLA measurement to more accurately predict the risk of mortality in patients with low risk.Fil: Martín Rodríguez, Francisco. Universidad de Valladolid; España. Emergency Medical Services; EspañaFil: López Izquierdo, Raul. Hospital Universitario Rio Hortega; EspañaFil: Delgado Benito, Juan F.. Emergency Medical Services; EspañaFil: Sanz García, Ancor. Universidad Autonoma de Madrid. Hospital Universitario de la Princesa; EspañaFil: Pozo Vegas, Carlos del. Hospital Clínico Universitario de Valladolid; EspañaFil: Castro Villamor, Miguel Ángel. Universidad de Valladolid; EspañaFil: Martín Conty, José Luis. Universidad de Castilla-La Mancha; EspañaFil: Ortega, Guillermo José. Consejo Nacional de Investigaciones Científicas y Técnicas; Argentina. Universidad Autonoma de Madrid. Hospital Universitario de la Princesa; Españ

Time for a prehospital-modified sequential organ failure assessment score: An ambulance–Based cohort study

Producción CientíficaBackground: To adapt the Sequential Organ Failure Assessment (SOFA) score to fit the prehospital care needs; to do that, the SOFA was modified by replacing platelets and bilirubin, by lactate, and tested this modified SOFA (mSOFA) score in its prognostic capacity to assess the mortality-risk at 2 days since the first Emergency Medical Service (EMS) contact. Methods: Prospective, multicentric, EMS-delivery, ambulance-based, pragmatic cohort study of adults with acute diseases, referred to two tertiary care hospitals (Spain), between January 1st and December 31st, 2020. The discriminative power of the predictive variable was assessed through a prediction model trained using the derivation cohort and evaluated by the area under the curve (AUC) of the receiver operating characteristic (ROC) on the validation cohort. Results: A total of 1114 participants comprised two separated cohorts recruited from 15 ambulance stations. The 2-day mortality rate (from any cause) was 5.9% (66 cases). The predictive validity of the mSOFA score was assessed by the calculation of the AUC of ROC in the validation cohort, resulting in an AUC of 0.946 (95% CI, 0.913–0.978, p < .001), with a positive likelihood ratio was 23.3 (95% CI, 0.32–46.2). Conclusions: Scoring systems are now a reality in prehospital care, and the mSOFA score assesses multiorgan dysfunction in a simple and agile manner either bedside or en route. Patients with acute disease and an mSOFA score greater than 6 points transferred with high priority by EMS represent a high early mortality group.Gerencia Regional de Salud de Castilla y León (grants GRS 1678/A/18 and GRS 1903/A/19

Prehospital troponin as a predictor of early clinical deterioration

Producción CientíficaAntecedentes y objetivos Los valores elevados de la troponina T (cTnT) se asocian a comorbilidades y a mortalidad temprana, en enfermedades cardiovasculares y noncardiovascular. El objetivo de este estudio es evaluar la exactitud pronóstica de la utilización única de la troponina cardíaca T del punto de atención prehospital para identificar el riesgo de deterioro prehospital del hospital, incluyendo mortalidad en el plazo de 28 días. Métodos Se realizó un estudio prospectivo, multicéntrico, controlado, basado en ambulancias, observacional en adultos con enfermedades agudas transferidos con alta prioridad en ambulancia a los departamentos de emergencia, entre el 1 de enero y el 30 de septiembre de 2020. Excluyeron a los pacientes con diagnosis del hospital del síndrome coronario agudo. El poder discriminativo de la cTnT predictiva fue evaluado a través de un modelo de discriminación entrenado utilizando una cohorte de derivación y evaluado por el área bajo la curva de la característica operativa del receptor en una cohorte de validación. Resultados Un total de 848 pacientes fueron incluidos en nuestro estudio. La edad media era de 68 años (percentiles 25º-75º: 50-81 años), y 385 (45,4%) eran mujeres. La tasa de mortalidad en 28 días fue del 12,4% (156 casos). La capacidad predictiva de la cTnT para predecir la mortalidad presentó un área por debajo de la curva de 0,903 (IC95%: 0,85-0,954; P < .001). Se realizó estratificación del riesgo, resultando en tres categorías con los siguientes puntos de corte óptimos de cTnT: alto riesgo mayor o igual a 100, riesgo intermedio 40-100 y bajo riesgo menor a 40 ng/L. En el grupo de alto riesgo, la tasa de mortalidad fue de 61,7%, y por el contrario, el grupo de bajo riesgo presentó una mortalidad de 2,3%. Conclusiones La implementación de una determinación rutinaria de cTnT en la ambulancia en pacientes transferidos con alta prioridad al servicio de urgencias puede ayudar a estratificar el riesgo de estos pacientes y a detectar un deterioro clínico temprano desconocido.Background and Objectives: Elevated troponin T (cTnT) values are associated with comorbidities and early mortality, in both cardiovascular and noncardiovascular diseases. The objective of this study is to evaluate the prognostic accuracy of the sole utilization of prehospital point-of-care cardiac troponin T to identify the risk of early in-hospital deterioration, including mortality within 28 days. Methods: We conducted a prospective, multicentric, controlled, ambulance-based, observational study in adults with acute diseases transferred with high priority by ambulance to emergency departments, between 1 January and 30 September 2020. Patients with hospital diagnosis of acute coronary syndrome were excluded. The discriminative power of the predictive cTnT was assessed through a discrimination model trained using a derivation cohort and evaluated by the area under the curve of the receiver operating characteristic on a validation cohort. Results: A total of 848 patients were included in our study. The median age was 68 years (25th-75th percentiles: 50-81 years), and 385 (45.4%) were women. The mortality rate within 28 days was 12.4% (156 cases). The predictive ability of cTnT to predict mortality presented an area under the curve of 0.903 (95% CI: 0.85-0.954; P < .001). Risk stratification was performed, resulting in three categories with the following optimal cTnT cut-off points: high risk greater than or equal to 100, interme diate risk 40-100 and low risk less than 40 ng/L. In the high-risk group, the mortality rate was 61.7%, and on the contrary, the low-risk group presented a mortality of 2.3%. Conclusions: The implementation of a routine determination of cTnT on the am bulance in patients transferred with high priority to the emergency department can help to stratify the risk of these patients and to detect unknown early clinical deterioration.Gerencia Regional de Salud de Castilla y León (España), Grant Number [GRS 1678/A/18] and Grant Number [GRS 1903/A/19

Re-use of construction and demolition residues and industrial wastes for the elaboration or recycled eco-efficient concretes

Production of residues from industries and construction and demolition sectors has increased during last years. The total amount of debris produced according to different estimations reaches values close to 42 million tonnes yr1. Much of this waste has been thrown to landfill, without considering its potential for reuse, recycling or valuation. The aim of this research is to describe some of the physical and mechanical properties of different laboratory-mixed concretes, using various proportions of additional materials recovered from industrial waste and demolition rubble. The added materials are included either as admixtures (forestry residues, cork dust, steel fibre) or in partial substitution of natural aggregates (wire from electrical residues, tyre rubber, white ceramic, sanitary porcelain or shale). The laboratory tests have followed the standard EN protocols. Assay results were variable according to the nature of the material added to the mix: organic materials and shale, despite the steel fibre reinforcement, reduce the compression strength, but are suitable for the manufacture of lightweight concrete for agricultural pavements, with certain flexion resistance and a relatively good behaviour to impact. The substitution of natural aggregates with ceramic and porcelain wastes produces a significant increase in compression resistance, making them suitable for the manufacture of concrete with characteristic resistances above 40 MPa, which can be used both for structures or other agricultural elements: separators, feeders, slat floors. As a conclusion can be stated the possibility of reuse these wastes for the production of structural or non-structural concrete, with different applications in agricultural engineering.La producción de residuos industriales y los procedentes del sector de la construcción y demolición se han incrementado en los últimos años, hasta alcanzar valores cercanos a los 42 millones de toneladas año1. Gran parte de estos residuos han ido a parar a vertedero, sin considerar sus posibilidades de reutilización. Los trabajos desarrollados en este artículo tienen por objeto conocer las propiedades físicas y mecánicas de varios hormigones elaborados en laboratorio, añadiéndoles diversas proporciones de residuos industriales y escombros. Estos materiales son incluidos bien como adiciones (residuos forestales, polvo de corcho, polvo de corcho+fibra de acero) o bien en sustitución parcial de los áridos naturales utilizados en la dosificación (residuo de cable eléctrico, restos de neumáticos, cerámica blanca y sanitaria o pizarra). Para la elaboración de hormigones se han seguido los protocolos de la normativa EN. Los resultados de los ensayos son variables en función del material incorporado: los materiales orgánicos y la pizarra, a pesar del refuerzo de fibra de acero reducen la resistencia a compresión, pero son adecuados para la elaboración de hormigones ligeros para pavimentos agropecuarios, ya que mantienen cierta resistencia a la flexión y un buen comportamiento al impacto. La inclusión de cerámica y residuos de porcelana produce aumentos apreciables de la resistencia a la compresión, lo que les hace adecuados para la elaboración de hormigones con resistencias superiores a los 40 MPa, que pueden ser utilizados tanto para estructuras como para otros elementos del ámbito agropecuario: separadores, comederos, suelos, enrejillados, etc

Association of Prehospital Oxygen Saturation to Inspired Oxygen Ratio with 1-, 2-, and 7-Day Mortality

Importance: The early identification of patients at high risk of clinical deterioration represents one of the greatest challenges for emergency medical services (EMS). Objective: To assess whether use of the ratio of prehospital oxygen saturation measured by pulse oximetry (Spo2) to fraction of inspired oxygen (Fio2) measured during initial contact by EMS with the patient (ie, the first Spo2to Fio2ratio) and 5 minutes before the patient's arrival at the hospital (ie, the second Spo2to Fio2ratio) can predict the risk of early in-hospital deterioration. Design, Setting, and Participants: A prospective, derivation-validation prognostic cohort study of 3606 adults with acute diseases referred to 5 tertiary care hospitals in Spain was conducted between October 26, 2018, and June 30, 2020. Eligible patients were recruited from among all telephone requests for EMS assistance for adults who were later evacuated with priority in advanced life support units to the referral hospitals during the study period. Main Outcomes and Measures: The primary outcome was hospital mortality from any cause within the first, second, third, or seventh day after EMS transport to the hospital. The main measure was the Spo2to Fio2ratio. Results: A total of 3606 participants comprised 2 separate cohorts: the derivation cohort (3081 patients) and the validation cohort (525 patients). The median age was 69 years (interquartile range, 54-81 years), and 2122 patients (58.8%) were men. The overall mortality rate of the patients in the study cohort ranged from 3.6% for 1-day mortality (131 patients) to 7.1% for 7-day mortality (256 patients). The best model performance was for 2-day mortality with the second Spo2to Fio2ratio with an area under the curve of 0.890 (95% CI, 0.829-0.950; P <001), although the other outcomes also presented good results. In addition, a risk-stratification model was generated. The optimal cutoff resulted in the following ranges of Spo2to Fio2ratios: 50 to 100 for high risk of mortality, 101 to 426 for intermediate risk, and 427 to 476 for low risk. Conclusions and Relevance: This study suggests that use of the prehospital Spo2to Fio2ratio was associated with improved management of patients with acute disease because it accurately predicts short-term mortality.Fil: Martín Rodríguez, Francisco. Universidad de Valladolid; España. Servicio de Urgencias Médicas; EspañaFil: López Izquierdo, Raúl. Universidad de Valladolid; España. Hospital Universitario Rio Hortega; EspañaFil: Del Pozo Vegas, Carlos. Universidad de Valladolid; España. Hospital Clínico Universitario de Valladolid; EspañaFil: Delgado Benito, Juan F.. Servicio de Urgencias Médicas; EspañaFil: Ortega, Guillermo José. Universidad Autonoma de Madrid. Hospital Universitario de la Princesa; España. Universidad Nacional de Quilmes. Departamento de Ciencia y Tecnología; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; ArgentinaFil: Castro Villamor, Miguel A.. Universidad de Valladolid; EspañaFil: Sanz García, Ancor. Universidad Autonoma de Madrid. Hospital Universitario de la Princesa; Españ

Accuracy of prehospital point-of-care lactate in early in-hospital mortality

Background: Emergency medical services (EMS) routinely face complex scenarios where decisions should be taken with limited clinical information. The development of fast, reliable and easy to perform warning biomarkers could help in such decision-making processes. The present study aims at characterizing the validity of point-of-care lactate (pLA) during prehospital tasks for predicting in-hospital mortality within two days after the EMS assistance. Materials and methods: Prospective, multicentric, ambulance-based and controlled observational study without intervention, including six advanced life support and five hospitals. The pLA levels were recorded during EMS assistance of adult patients. The validity of pLA to determine the in-hospital mortality was assessed by the area under the curve (AUC) of the receiver operating curve (ROC). Results: A total of 2997 patients were considered in the study, with a median of 69 years (IQR 54-81) and 41.4% of women. The median pLA value was 2.7 mmol/L (1.9-3.8) in survivors and 5.7 mmol/L (4.4-7.6) in nonsurvivors. The global discrimination level of pLA reached an AUC of 0.867, being 1.9 mmol/L and 4 mmol/L the cut-off point for low and high mortality. The discrimination value of pLA was not affected by sex, age or pathology. Conclusions: Our results highlight the clinical importance of prehospital pLA to determine the in-hospital risk of mortality. The incorporation of pLA into the EMS protocols could improve the early identification of risky patients, leading to a better care of such patients.Fil: Martín Rodríguez, Francisco. Universidad de Valladolid; España. Paseo Hospital Militar; EspañaFil: López Izquierdo, Raúl. Universidad de Valladolid; España. Hospital Universitario Rio Hortega; EspañaFil: Medina Lozano, Elena. Universidad de Valladolid; EspañaFil: Ortega, Guillermo José. Consejo Nacional de Investigaciones Científicas y Técnicas; Argentina. Universidad Autonoma de Madrid. Hospital Universitario de la Princesa; EspañaFil: del Pozo Vegas, Carlos. Hospital Clínico Universitario; EspañaFil: Carbajosa Rodríguez, Virginia. Hospital Universitario Rio Hortega; EspañaFil: Castro Villamor, Miguel Ángel. Universidad de Valladolid; EspañaFil: Sánchez Soberon, Irene. Paseo Hospital Militar; EspañaFil: Sanz García, Ancor. Universidad Autonoma de Madrid. Hospital Universitario de la Princesa; Españ

Modified Sequential Organ Failure Assessment Score vs. Early Warning Scores in Prehospital Care to Predict Major Adverse Cardiac Events in Acute Cardiovascular Disease

(1) Background: The Modified Sequential Organ Failure Assessment (mSOFA) is an Early Warning Score (EWS) that has proven to be useful in identifying patients at high risk of mortality in prehospital care. The main objective of this study was to evaluate the predictive validity of prehospital mSOFA in estimating 2- and 90-day mortality (all-cause) in patients with acute cardiovascular diseases (ACVD), and to compare this validity to that of four other widely-used EWS. (2) Methods: We conducted a prospective, observational, multicentric, ambulance-based study in adults with suspected ACVD who were transferred by ambulance to Emergency Departments (ED). The primary outcome was 2- and 90-day mortality (all-cause in- and out-hospital). The discriminative power of the predictive variable was assessed and evaluated by the area under the curve (AUC) of the receiver operating characteristic (ROC). (3) Results: A total of 1540 patients met the inclusion criteria. The 2- and 90-day mortality rates were 5.3% and 12.7%, respectively. The mSOFA showed the highest AUC of all the evaluated scores for both 2- and 90-day mortality, AUC = 0.943 (0.917–0.968) and AUC = 0.874 (0.847–0.902), respectively. (4) Conclusions: The mSOFA is a quick and easy-to-use EWS with an excellent ability to predict mortality at both 2 and 90 days in patients treated for ACVD, and has proved to be superior to the other EWS evaluated in this study

Libro blanco del eurotaxi. Un taxi para todos

Entre los diferentes ámbitos de colaboración entre la Fundación ONCE y otras instituciones se encuentra la promoción del transporte público accesible, que no debería, en ningún caso, quedar al margen de las políticas e iniciativas públicas y privadas favorecedoras del desplazamiento de las personas con discapacidad en condiciones de igualdad al resto de los ciudadanos. En esta ocasión, los resultados del trabajo contemplan la realidad del eurotaxi desde múltiples perspectivas técnicas y normativas, presentando un estudio evolutivo de la realidad del eurotaxi y un análisis de los usuarios como servicio público. El estudio trata de sintetizar las opiniones e informaciones presentadas en las entrevistas y en las posteriores discusiones con consumidores y representantes de la industria. Su pretensión es poder servir como instrumento de identificación y orientación de las actividades y líneas de actuación posibles para mejorar la situación en el futuro. Se realizan propuestas para mejorar la dotación, lograr incentivos económicos más eficaces y crear sistemas de seguimiento para la prestación de servicios de mayor calidad