The EPICTER score: a bedside and easy tool to predict mortality at 6 months in acute heart failure

Aims: Estimating the prognosis in heart failure (HF) is important to decide when to refer to palliative care (PC). Our objective was to develop a tool to identify the probability of death within 6 months in patients admitted with acute HF. Methods and results: A total of 2848 patients admitted with HF in 74 Spanish hospitals were prospectively included and followed for 6 months. Each factor independently associated with death in the derivation cohort (60% of the sample) was assigned a prognostic weight, and a risk score was calculated. The accuracy of the score was verified in the validation cohort. The characteristics of the population were as follows: advanced age (mean 78 years), equal representation of men and women, significant comorbidity, and predominance of HF with preserved ejection fraction. During follow-up, 753 patients (26%) died. Seven independent predictors of mortality were identified: age, chronic obstructive pulmonary disease, cognitive impairment, New York Heart Association class III-IV, chronic kidney disease, estimated survival of the patient less than 6 months, and acceptance of a palliative approach by the family or the patient. The area under the ROC curve for 6 month death was 0.74 for the derivation and 0.68 for the validation cohort. The model showed good calibration (Hosmer and Lemeshow test, P value 0.11). The 6 month death rates in the score groups ranged from 6% (low risk) to 54% (very high risk). Conclusions: The EPICTER score, developed from a prospective and unselected cohort, is a bedside and easy-to-use tool that could help to identify high-risk patients requiring PC

Clinical and Ecological Impact of an Educational Program to Optimize Antibiotic Treatments in Nursing Homes (PROA-SENIOR): A Cluster, Randomized, Controlled Trial and Interrupted Time-Series Analysis

[Background] Antimicrobial stewardship programs (ASPs) are recommended in nursing homes (NHs), although data are limited. We aimed to determine the clinical and ecological impact of an ASP for NHs.[Methods] We performed a cluster, randomized, controlled trial and a before–after study with interrupted time-series analyses in 14 NHs for 30 consecutive months from July 2018 to December 2020 in Andalusia, Spain. Seven facilities implemented an ASP with a bundle of 5 educational measures (general ASP) and 7 added 1-to-1 educational interviews (experimental ASP). The primary outcome was the overall use of antimicrobials, calculated monthly as defined daily doses (DDD) per 1000 resident days (DRD).[Results] The total mean antimicrobial consumption decreased by 31.2% (−16.72 DRD; P = .045) with respect to the preintervention period; the overall use of quinolones and amoxicillin–clavulanic acid dropped by 52.2% (P = .001) and 42.5% (P = .006), respectively; and the overall prevalence of multidrug-resistant organisms (MDROs) decreased from 24.7% to 17.4% (P = .012). During the intervention period, 12.5 educational interviews per doctor were performed in the experimental ASP group; no differences were found in the total mean antimicrobial use between groups (−14.62 DRD; P = .25). Two unexpected coronavirus disease 2019 waves affected the centers increasing the overall mean use of antimicrobials by 40% (51.56 DRD; P < .0001).[Conclusions] This study suggests that an ASP for NHs appears to be associated with a decrease in total consumption of antimicrobials and prevalence of MDROs. This trial did not find benefits associated with educational interviews, probably due to the coronavirus disease 2019 pandemic.[Clinical Trials Registration] NCT03543605.Peer reviewe

Clonal chromosomal mosaicism and loss of chromosome Y in elderly men increase vulnerability for SARS-CoV-2

The pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2, COVID-19) had an estimated overall case fatality ratio of 1.38% (pre-vaccination), being 53% higher in males and increasing exponentially with age. Among 9578 individuals diagnosed with COVID-19 in the SCOURGE study, we found 133 cases (1.42%) with detectable clonal mosaicism for chromosome alterations (mCA) and 226 males (5.08%) with acquired loss of chromosome Y (LOY). Individuals with clonal mosaic events (mCA and/or LOY) showed a 54% increase in the risk of COVID-19 lethality. LOY is associated with transcriptomic biomarkers of immune dysfunction, pro-coagulation activity and cardiovascular risk. Interferon-induced genes involved in the initial immune response to SARS-CoV-2 are also down-regulated in LOY. Thus, mCA and LOY underlie at least part of the sex-biased severity and mortality of COVID-19 in aging patients. Given its potential therapeutic and prognostic relevance, evaluation of clonal mosaicism should be implemented as biomarker of COVID-19 severity in elderly people. Among 9578 individuals diagnosed with COVID-19 in the SCOURGE study, individuals with clonal mosaic events (clonal mosaicism for chromosome alterations and/or loss of chromosome Y) showed an increased risk of COVID-19 lethality