Ébola en zonas rurales: lecciones aprendidas en la epidemia de África Occidental y últimas novedades

Un brote de Ébola en un área rural (con pocos pacientes dispersos en una zona aislada o remota)presenta ciertas peculiaridades que afectan a su manejo y lo diferencian del que se realiza en zonas urbanas (con mayor número de pacientes,más accesibles y con gran densidad poblacional). En una zona rural se deben diseñar estrategias para que los 6 pilares fundamentales para la erradicación del brote sean llevados a cabo de forma efectiva hasta en las zona más remotas y aisladas. Hay que sacar a los casos sospechosos fuera de los centros médicos habituales y crear centros de aislamiento diseñados de forma que cumplan escrupulosamente las normas de seguridad. El manejo de los pacientes debe hacerse en dichos centros de aislamiento donde se les puedan tomar muestras,aislar y tratar hasta que se confirma o se descarta el diagnóstico En el primer caso serán trasladados a un Centro de tratamiento de Ébola para su manejo. Las diferentes estrategias de vacunación suponen un nuevo campo muy interesante para evitar la diseminación del brote en zonas aisladas. Nuevos dispositivos como el CUBE también suponen un gran avance para el manejo de pacientes en zonas rurales.An Ébola outbreak in a rural area (with few patients dispersed in an isolated or remote zone) presents certain peculiarities that affect its management and make it different from an Ébola outbreak in urban areas (with a greater number of patients and with high population density). In a rural area is necessary to design strategies so that the 6 fundamental pillars for the eradication of the outbreak are carried out effectively,even in the most remote and isolatedareas. Suspicious cases must be taken outside of regular medical centers and isolated at holding centersthatmust be builtin a manner that scrupulously complies with safety regulations. The management of suspicious cases (isolation, sampling and treatment)should be done in these holding centers until the diagnosis is confirmed or discarded. In the first case,they will be transferred to an ÉbolaTreatment Center for management. The different vaccination strategies represent a very interesting new field to prevent the spread of the outbreak in specific areas. New devices such as CUBE also represent a great advance for the management of patients in rural areas

Comparing tuberculosis in children aged under 5 versus 5 to 14 years old in a rural hospital in southern Ethiopia: an 18-year retrospective cross-sectional study

Background: There are few data available about childhood tuberculosis (TB) in rural hospitals in low-income countries. We assessed differences in epidemiological characteristics and treatment outcomes in children with TB aged 0–4 versus 5–14 years in rural Ethiopia. Methods: For this retrospective cross-sectional study, we analyzed childhood TB registers from a rural Ethiopian hospital. We collected data on the number of cases, type of TB, and treatment outcomes using standard definitions. By means of binary and logistic regression analyses, data were compared from 1998 to 2015 in children aged under 5 versus those aged 5–14 years. Results: We included 1282 TB patients: 583 (45.5%) were under 5 years old, and 699 (54.5%) were aged 5–14 years. More than half (67.2%, n = 862) had pulmonary TB (PTB), which was more common in younger children (82.5%, 481/583) than in older ones (54.5%, 381/699; p < 0.001). Most cases of PTB (87.5%, 754/862) were smear negative, including virtually all (99.6%, 479/481) younger children and most older ones (72.2%, n = 275/381; p < 0.001). The most common types of extrapulmonary TB (EPTB) were TB adenitis (54.5%, 229/420) and bone TB (20%, 84/420). Children under five showed a lower prevalence of adenitis TB (9.9% [58/583] versus 24.5% [171/699], p < 0.001), bone TB (2.9% [17/583] versus 9.6% [69/699], p < 0.001), and abdominal TB (0.9% [5/583] versus 6.3% [44/699], p < 0.001). Most diagnoses were new cases of TB (98.2%, 1259/1282). Overall, 63.5% (n = 814) of the children successfully completed treatment (< 5 years: 56.6%, 330/583; 5–14 years: 69.2%, 489/699; p < 0.001). In total, 16.3% (n = 209) transferred to another center (< 5 years: 19.4%, 113/583; 5–14 years: 13.7%, 96/699; p = 0.006). Thirteen percent of patients (n = 167) were lost to follow-up (< 5 years: 16.0%, 93/583; 5–14 years: 10.4%, 74/699; p = 0.004). Fifty-two (4.1%) children died (no age differences). Being aged 5–14 years was independently associated with successful treatment outcomes (adjusted odds ratio 1.59; 95% confidence interval: 1.16, 1.94, p = 0.002). Conclusions: We observed a very low diagnostic yield for spontaneous sputum smear in children with TB. In this rural setting in Ethiopia, very young children tend to present with new cases of smear-negative PTB. They have less EPTB than older children but more TB meningitis and show lower rates of treatment succes

Age-Adjusted Endothelial Activation and Stress Index for Coronavirus Disease 2019 at Admission Is a Reliable Predictor for 28-Day Mortality in Hospitalized Patients With Coronavirus Disease 2019

Background: Endothelial Activation and Stress Index (EASIX) predict death in patients undergoing allogeneic hematopoietic stem cell transplantation who develop endothelial complications. Because coronavirus disease 2019 (COVID-19) patients also have coagulopathy and endotheliitis, we aimed to assess whether EASIX predicts death within 28 days in hospitalized COVID-19 patients. Methods: We performed a retrospective study on COVID-19 patients from two different cohorts [derivation (n = 1,200 patients) and validation (n = 1,830 patients)]. The endpoint was death within 28 days. The main factors were EASIX [(lactate dehydrogenase * creatinine)/thrombocytes] and aEASIX-COVID (EASIX * age), which were log2-transformed for analysis. Results: Log2-EASIX and log2-aEASIX-COVID were independently associated with an increased risk of death in both cohorts (p 7) of 47.6% (95% CI = 44.2-50.9%). The cutoff of log2 aEASIX-COVID = 6 showed a positive predictive value of 31.7% and negative predictive value of 94.7%, and log2 aEASIX-COVID = 7 showed a positive predictive value of 47.6% and negative predictive value of 89.8%. Conclusion: Both EASIX and aEASIX-COVID were associated with death within 28 days in hospitalized COVID-19 patients. However, aEASIX-COVID had significantly better predictive performance than EASIX, particularly for discarding death. Thus, aEASIX-COVID could be a reliable predictor of death that could help to manage COVID-19 patients.This study was supported by grants from Instituto de Salud Carlos III [grant number COV20/1144 [MPY224/20) to AF-R/MÁJ-S]. MÁJ-S and AF-R are supported by Instituto de Salud Carlos III (grant numbers CP17CIII/00007 and CP14CIII/00010, respectively).S

Treatment with tocilizumab or corticosteroids for COVID-19 patients with hyperinflammatory state: a multicentre cohort study (SAM-COVID-19)

Objectives: The objective of this study was to estimate the association between tocilizumab or corticosteroids and the risk of intubation or death in patients with coronavirus disease 19 (COVID-19) with a hyperinflammatory state according to clinical and laboratory parameters. Methods: A cohort study was performed in 60 Spanish hospitals including 778 patients with COVID-19 and clinical and laboratory data indicative of a hyperinflammatory state. Treatment was mainly with tocilizumab, an intermediate-high dose of corticosteroids (IHDC), a pulse dose of corticosteroids (PDC), combination therapy, or no treatment. Primary outcome was intubation or death; follow-up was 21 days. Propensity score-adjusted estimations using Cox regression (logistic regression if needed) were calculated. Propensity scores were used as confounders, matching variables and for the inverse probability of treatment weights (IPTWs). Results: In all, 88, 117, 78 and 151 patients treated with tocilizumab, IHDC, PDC, and combination therapy, respectively, were compared with 344 untreated patients. The primary endpoint occurred in 10 (11.4%), 27 (23.1%), 12 (15.4%), 40 (25.6%) and 69 (21.1%), respectively. The IPTW-based hazard ratios (odds ratio for combination therapy) for the primary endpoint were 0.32 (95%CI 0.22-0.47; p < 0.001) for tocilizumab, 0.82 (0.71-1.30; p 0.82) for IHDC, 0.61 (0.43-0.86; p 0.006) for PDC, and 1.17 (0.86-1.58; p 0.30) for combination therapy. Other applications of the propensity score provided similar results, but were not significant for PDC. Tocilizumab was also associated with lower hazard of death alone in IPTW analysis (0.07; 0.02-0.17; p < 0.001). Conclusions: Tocilizumab might be useful in COVID-19 patients with a hyperinflammatory state and should be prioritized for randomized trials in this situatio

Evaluation of Ziehl–Neelsen smear for diagnosis of pulmonary tuberculosis in childhood in a rural hospital in Ethiopia

The goal of this study is to describe the experience with smear microscopy examination for acid-fast bacilli (AFB) of spontaneous sputum from children in a district hospital located in a rural zone of Ethiopia. All sputum reports of children were retrospectively reviewed from July 2007 until June 2012. During the period of study, 875 children less than 15 years old were screened and 48 (5.5%, 95% confidence interval [CI]: 4.1–7.3%) were diagnosed with pulmonary tuberculosis sputum smear positive. The mean age of the children with sputum positive for AFB was significantly higher than children with sputum negative for AFB (11.4 versus 10.4) (p =0.001). Only 1 out of 47 (1.3%) children of 6 years or less had sputum positive for AFB. In 13- and 14-year-old children, 8.7% had sputum positive for AFB (20 of 229) (p = 0.03). Spontaneous sputum has a low diagnostic yield in childhood in low-income countries. Alternative methods should be implemented in rural areas to improve diagnosis of pulmonary TB, particularly in children less than 12 years old

The PANDEMYC Score. An Easily Applicable and Interpretable Model for Predicting Mortality Associated With COVID-19.

This study aimed to build an easily applicable prognostic model based on routine clinical, radiological, and laboratory data available at admission, to predict mortality in coronavirus 19 disease (COVID-19) hospitalized patients. We retrospectively collected clinical information from 1968 patients admitted to a hospital. We built a predictive score based on a logistic regression model in which explicative variables were discretized using classification trees that facilitated the identification of the optimal sections in order to predict inpatient mortality in patients admitted with COVID-19. These sections were translated into a score indicating the probability of a patient's death, thus making the results easy to interpret. Median age was 67 years, 1104 patients (56.4%) were male, and 325 (16.5%) died during hospitalization. Our final model identified nine key features: age, oxygen saturation, smoking, serum creatinine, lymphocytes, hemoglobin, platelets, C-reactive protein, and sodium at admission. The discrimination of the model was excellent in the training, validation, and test samples (AUC: 0.865, 0.808, and 0.883, respectively). We constructed a prognostic scale to determine the probability of death associated with each score. We designed an easily applicable predictive model for early identification of patients at high risk of death due to COVID-19 during hospitalization.S

Characteristics, complications and outcomes among 1549 patients hospitalised with COVID-19 in a secondary hospital in Madrid, Spain: a retrospective case series study

Objectives To describe demographic, clinical, radiological and laboratory characteristics, as well as outcomes, of patients admitted for COVID-19 in a secondary hospital.Design and setting Retrospective case series of sequentially hospitalised patients with confirmed SARS-CoV-2, at Infanta Leonor University Hospital (ILUH) in Madrid, Spain.Participants All patients attended at ILUH testing positive to reverse transcriptase-PCR on nasopharyngeal swabs and diagnosed with COVID-19 between 1 March 2020 and 28 May 2020.Results A total of 1549 COVID-19 cases were included (median age 69 years (IQR 55.0–81.0), 57.5% men). 78.2% had at least one underlying comorbidity, the most frequent was hypertension (55.8%). Most frequent symptoms at presentation were fever (75.3%), cough (65.7%) and dyspnoea (58.1%). 81 (5.8%) patients were admitted to the intensive care unit (ICU) (median age 62 years (IQR 51–71); 74.1% men; median length of stay 9 days (IQR 5–19)) 82.7% of them needed invasive ventilation support. 1393 patients had an outcome at the end of the study period (case fatality ratio: 21.2% (296/1393)). The independent factors associated with fatality (OR; 95% CI): age (1.07; 1.06 to 1.09), male sex (2.86; 1.85 to 4.50), neurological disease (1.93; 1.19 to 3.13), chronic kidney disease (2.83; 1.40 to 5.71) and neoplasia (4.29; 2.40 to 7.67). The percentage of hospital beds occupied with COVID-19 almost doubled (702/361), with the number of patients in ICU quadrupling its capacity (32/8). Median length of stay was 9 days (IQR 6–14).Conclusions This study provides clinical characteristics, complications and outcomes of patients with COVID-19 admitted to a European secondary hospital. Fatal outcomes were similar to those reported by hospitals with a higher level of complexity