Pulmonary embolism at the emergency department during the COVID-19 pandemic. A comparative cohort study from a tertiary level hospital in southern Spain

This work was supported by the ‘Artificial Intelligence for the diagnosis and prognosis of COVID-19’ project (CV20-29480), funded by the Consejería de Transformación Económica, In- dustria, Conocimiento y Universidades, Junta de Andalucía, and the FEDER funds.Several studies have been published showing a significant increase in thrombotic complications in coronavirus disease 2019 (COVID-19) patients, including acute pulmonary embolism (PE). However, there is significant variability regarding published data on the number of computed tomography pulmonary angiography (CTPA) orders to rule out PE, frequency and characteristics of PE, and other factors that could have magnified the actual incidence of PE. The aim of this work is to analyze these factors during the first year of the pandemic. A longitudinal retrospective observational study was designed comparing two cohorts (preCOVID and COVID) of patients for whom an emergency CTPA was requested to rule out PE at the emergency department of our institution. Information was collected regarding the number of CTPAs requested, patient demographics, presence and extension of PE, and radiological signs of right ventricle strain/pulmonary hypertension (RVS/PH). Univariate and bivariate analyses were performed, with stratification by time intervals according to different pandemic waves in the COVID cohort. A total of 1905 patients (530 in the pre-COVID cohort and 1375 in the COVID cohort), with a mean age of 68.3 years (standard deviation, 16.5) and 981 (51.5%) women were included. No significant differences were observed regarding the incidence of PE between both cohorts. In patients with PE, no significant differences regarding age or sex were found, but a significantly higher frequency of peripheral PE was observed in the COVID cohort (42.0% vs. 6.5%, p < 0.001). Regarding signs of RVS/PH, a lower degree of septal deviation and contrast reflux to the inferior vena cava was observed in the COVID cohort, but no significant differences were observed in the right-to-left ventricular ratio. For the COVID cohort, the distribution of central vs. peripheral PE was similar in patients without laboratory-confirmed COVID-19 infection. Finally, the analysis of signs of RVS/PH stratifying by pandemic waves showed a lower frequency of RVS/PH signs in the 2nd and 3rd pandemic waves. In conclusion, despite a significantly higher number of CTPAs were performed during the pandemic, the incidence of PE was similar to that of the pre-pandemic period. A higher number of peripheral PE and less radiological signs of RVS/PH were observed during the pandemic. These findings could be explained by an increased incidental detection of PE during the pandemic. Our study has some limitations, mainly derived from its retrospective and single-center nature, which should be overcome in future research.Consejeria de Transformacion Economica, Industria, Conocimiento y Universidades CV20-29480Junta de AndaluciaEuropean Commissio

Factors associated with readmission to the Emergency Department in a cohort of COVID-19 hospitalized patients

This work was supported by the 'Artificial Intelligence for the diagnosis and prognosis of COVID-19' project (CV20-29480), funded by the Consejeria de Transformacion Economica, Industria, Conocimiento y Universidades, Junta de Andalucia, and the FEDER funds. We acknowledge the Faculty of Medicine, University of Granada, for the successful organization of the final degree projects, since this work was designed and conducted during the project of Alvaro Romero-Duarte. We also acknowledge all the healthcare workers from the Department of Preventive Medicine and Public Health, San Cecilio University Hospital for their restless commitment during the pandemic of COVID-19 and their continuous efforts for investigating and communicating their results to the scientific community. Finally, we thank the SEMERGEN-UGR Chair of Teaching and Research in Family Medicine for being an example of support and encouragement in Primary Care research.Introduction: The aim of this study was to describe the symptomatology and main factors associated with readmission to the Emergency Department (ED) in COVID-19 patients discharged from hospital during the first wave of the pandemic at the San Cecilio University Hospital, Granada, Spain. Methods: An observational longitudinal study was conducted in a cohort of 441 patients admitted to our hospital with confirmed SARS-CoV-2 polymerase chain reaction (PCR) from 1 March to 15 April 2020. Patients were followed up through medical records 6 months after discharge. Sociodemographic, clinical and symptomatologic variables were collected. Descriptive, bivariate and multivariate logistic regression analyses were performed. Results: The mean age of patients in the cohort was 66.4 years (s = 15.3), with 55.1% men. In-hospital mortality was 18.1%. The presence of persistent symptomatology was high (64.5%), especially respiratory (53.2%), systemic (46.3%) and neurological (31.0%). A total of 75 (20.8%) patients were readmitted to the ED during the 6 months following hospital discharge. The main factors associated with readmission to the ED were polymedication (P = 0.031), living in a care home (P = 0.014), fever (P = 0.047), general malaise (P < 0.001), thoracic pain (P < 0.001), headache (P = 0.012), hematological symptoms (P = 0.011), nephrological symptoms (P = 0.047), depressive symptoms (P = 0.009), syncope or hypotension (P = 0.006) and superinfection (P = 0.018). After multivariate adjustment analysis, thoracic pain (OR: 4.45, 95% CI: 1.88– 10.52), general malaise and hematological symptoms (OR: 3.95, 95% CI: 1.12–13.89) remained as risk factors. Conclusions: The presence of persistent symptomatology after hospital discharge in our cohort was common and varied. Polymedication and living in a care home made up the most vulnerable profile of COVID-19 patients for returning to the ED. Thoracic pain, general malaise and hematological symptoms were identified as potential markers of severity, along with others predictors. These findings might be useful for optimizing follow-up strategies. Future studies conducted in other geographical areas are necessary to corroborate our results.'Artificial Intelligence for the diagnosis and prognosis of COVID-19' project - Consejeria de Transformacion Economica, Industria, Conocimiento y Universidades CV20-29480Junta de Andalucia European Commissio

Neumoperitoneo y COVID-19. ¿Una asociación causal?

En conclusión, casos clínicos como los expuestos (1,2) refuerzan el interés por indagar en la fisiopatología de la afectación abdominal de la COVID-19 pese a la existencia de potenciales factores confusores

Abscess of the pontine dorsolateral tegmentum due to E. coli and influenza A(H1N1)pdm09 virus co-infection

Los abscesos del tronco del encéfalo son entidades raras que suelen afectar a la protuberancia. Los microorganismos implicados son muy variados en función del foco de diseminación. Presentamos el caso de una paciente pluripatológica que desarrolló una neumonía multilobar secundaria a virus de la gripe A (H1N1)pdm09 en el postoperatorio de una colecistectomía urgente, requiriendo ventilación mecánica. Tras mejorar clínicamente y proceder a la desintubación, la paciente no recuperó el nivel de conciencia. Posteriormente, mediante pruebas de imagen se halló un absceso en el tegmento dorsolateral pontino izquierdo, región recientemente asociada al coma. Pese a administrar cobertura antibiótica amplia, la paciente falleció cinco días después. Este caso ilustra la importancia de considerar el absceso pontino como causa de mala evolución neurológica en pacientes críticos y la necesidad de realizar pruebas de imagen para descartar lesiones intracraneales, especialmente en regiones asociadas a coma.Brain stem abscesses are rare entities that predominantly affect the pons. A wide variety of microorganisms may be implied, depending on the focus of dissemination. We present the case of a female patient with multiple comorbidities who developed multi-lobar pneumonia due to influenza A(H1N1)pdm09 virus during the postoperative period after an emergent cholecystectomy, requiring mechanical ventilation (MV). Following clinical improvement and withdrawal of MV, the patient did not recover consciousness. Forty-eight hours later, imaging exams showed an abscess in the left pontine dorsolateral tegmentum –a region recently associated with coma-. Despite the administration of broad-spectrum antibiotics, the patient died five days later. This case illustrates the importance of considering pontine abscesses as a cause of poor neurological course in critically ill patients, as well as the need for doing imaging exams to rule out intracranial lesions, particularly in coma-associated areas

The value of magnetic resonance imaging and computed tomography in the study of spinal disorders

Computed tomography (CT) and magnetic resonance imaging (MRI) have replaced conventional radiography in the study of many spinal conditions, it is essential to know when these techniques are indicated instead of or as complementary tests to radiography, which findings can be expected in different clinical settings, and their significance in the diagnosis of different spinal conditions. Proper use of CT and MRI in spinal disorders may facilitate diagnosis and management of spinal conditions. An adequate clinical approach, a good understanding of the pathological manifestations demonstrated by these imaging techniques and a comprehensive report based on a universally accepted nomenclature represent the indispensable tools to improve the diagnostic approach and the decision-making process in patients with spinal pain. Several guidelines are available to assist clinicians in ordering appropriate imaging techniques to achieve an accurate diagnosis and to ensure appropriate medical care that meets the efficacy and safety needs of patients. This article reviews the clinical indications of CT and MRI in different pathologic conditions affecting the spine, including congenital, traumatic, degenerative, inflammatory, infectious and tumor disorders, as well as their main imaging features. It is intended to be a pictorial guide to clinicians involved in the diagnosis and treatment of spinal disorders

Prevalence and Risk Factors Associated with Tumors and Other Structural Anomalies in Brain MRI Performed to Rule out Secondary Headache: A Multicenter Observational Study

This research was funded by MCIN/AEI/10.13039/501100011033, grant number PID2020118224RB-I00.Headache disorders (HDs) are among the most common conditions of the central nervous system, with an estimated prevalence of 50% in adult population. The aim of this work is to analyze the prevalence of structural anomalies that may explain HDs in MRI exams performed to rule out secondary headache in real-world practice, as well as risk factors associated with these lesions. We conducted a retrospective observational study based on a consecutive case series of all patients that underwent brain MRI due to headache from 1 January 2019 to 31 May 2019. We included patients from six MRI diagnostic centers accounting for four provinces of Andalusia (southern Spain). Bivariate and multivariate logistical regression models were performed to identify risk factors associated with the outcomes (1) presence of a structural finding potentially explaining headache, (2) presence of intracranial space-occupying lesions (SOLs), and (3) presence of intracranial tumors (ITs). Of the analyzed sample (1041 patients), a structural finding that could explain headache was found in 224 (21.5%) patients. SOLs were found in 50 (6.8%) patients and ITs in 12 (1.5%) patients. The main factors associated with structural abnormalities were female sex (OR, 1.35; 95% CI, 1.02–1.85), accompanying symptoms (OR, 1.34; 95% CI, 1.05–1.89), use of gadolinium-based contrast agents (OR, 1.89; 95% CI, 1.31–2.72) and previously known conditions potentially explaining headache (OR, 2.44; 95% CI, 1.55–3.84). Female sex (p = 0.048) and accompanying symptoms (p = 0.033) were also associated with ITs in bivariate analyses. Our results may be relevant for different medical specialists involved in the diagnosis, management and prevention of headache. Moreover, the risk factors identified in our study might help the development of public health strategies aimed at early diagnosis of brain tumors. Future studies are warranted to corroborate our findings.MCIN/AEI/10.13039/501100011033 PID2020118224RB-I0

COVID-19-associated lung weakness (CALW): Systematic review and meta-analysis

Anexo. Material adicional Se puede consultar material adicional a este artículo en su versión electrónica disponible en doi:10.1016/j.medin.2023.04.010.Objetivo: Evaluar la mortalidad y diversos factores clínicos derivados del desarrollo de neumotórax (NTX) y/o neumomediastino (NMD) atraumáticos en pacientes críticos como consecuencia de la debilidad pulmonar asociada a la COVID-19 (DPAC). Diseño: Revisión sistemática con metaanálisis. Ámbito: Unidad de cuidados intensivos (UCI). Participantes: Investigaciones originales en las que se evaluase a pacientes, con o sin necesidad de ventilación mecánica invasiva (VMI), con diagnóstico de COVID-19 que hubiesen desarrollado NTX o NMD atraumáticos al ingreso o durante su estancia hospitalaria. Intervenciones: Se obtuvieron los datos de interés de cada artículo que fueron analizados y evaluados por la Escala Newcastle-Ottawa. El riesgo de las variables de interés principales se evaluó por los datos derivados de los estudios que incluyeron a pacientes que desarrollaron NTX o NMD atraumáticos. Variables de interés principales: Mortalidad, estancia media en la UCI y PaO2/FiO2 media en el momento diagnóstico. Resultados: Se recogieron datos de 12 estudios longitudinales. En el metaanálisis se incluyeron datos de un total de 4.901 pacientes, entre los cuales 1.629 presentaron un episodio de NTX y 253 de NMD atraumáticos. A pesar de encontrar asociaciones significativamente fuertes, la alta heterogeneidad entre los estudios hace que la interpretación de los resultados deba hacerse con cautela. Conclusiones: La mortalidad de los pacientes con COVID-19 fue mayor en los que desarrollaron NTX y/o NMD atraumáticos con respecto a los que no lo hicieron. La media del índice PaO2/FiO2 fue menor en los pacientes que desarrollaron NTX y/o NMD atraumáticos. Proponemos agrupar bajo el término DPAC estos casos.Objectives: To assess mortality and different clinical factors derived from the development of atraumatic pneumothorax (PNX) and/or pneumomediastinum (PNMD) in critically ill patients as a consequence of COVID-19-associated lung weakness (CALW). Design: Systematic review with meta-analysis. Setting: Intensive care unit (ICU). Participants: Original research evaluating patients, with or without the need for protective invasive mechanical ventilation (IMV), with a diagnosis of COVID-19 who had developed atraumatic PNX or PNMD on admission or during their hospital stay. Interventions: Data of interest were obtained from each article and analysed and assessed by the Newcastle-Ottawa Scale. The risk of the variables of interest was assessed by data derived from studies including patients who developed atraumatic PNX or PNMD. Main variables of interest: Mortality, mean ICU length of stay and mean PaO2/FiO2 at diagnosis. Results: Data were collected from 12 longitudinal studies. Data from a total of 4,901 patients were included in the meta-analysis. A total of 1,629 patients had an episode of atraumatic PNX and 253 patients had an episode of atraumatic PNMD. Despite finding significantly strong associations, the high heterogeneity between studies means that interpretation of the results should be made with caution. Conclusions: Mortality of COVID-19 patients was higher in those who developed atraumatic PNX and/or PNMD compared to those who did not. The mean PaO2/FiO2 index was lower in patients who developed atraumatic PNX and/or PNMD. We propose to group these cases under the term CAPD.Universidad de Granada/CBU

Sociodemographic, clinical and laboratory factors on admission associated with COVID19 mortality in hospitalized patients: A retrospective observational study

Background To identify and quantify associations between baseline characteristics on hospital admission and mortality in patients with COVID-19 at a tertiary hospital in Spain. Methods and findings This retrospective case series included 238 patients hospitalized for COVID-19 at Hospital Universitario Clı´nico San Cecilio (Granada, Spain) who were discharged or who died. Electronic medical records were reviewed to obtain information on sex, age, personal antecedents, clinical features, findings on physical examination, and laboratory results for each patient. Associations between mortality and baseline characteristics were estimated as hazard ratios (HR) calculated with Cox regression models. Series mortality was 25.6%. Among patients with dependence for basic activities of daily living, 78.7% died, and among patients residing in retirement homes, 80.8% died. The variables most clearly associated with a greater hazard of death were age (3% HR increase per 1-year increase in age; 95%CI 1–6), diabetes mellitus (HR 2.42, 95%CI 1.43–4.09), SatO2/ FiO2 ratio (43% HR reduction per 1-point increase; 95%CI 23–57), SOFA score (19% HR increase per 1-point increase, 95%CI 5–34) and CURB-65 score (76% HR increase per 1- point increase, 95%CI 23–143). Conclusions The patients residing in retirement homes showed great vulnerability. The main baseline factors that were independently associated with mortality in patients hospitalized for COVID-19 were older age, diabetes mellitus, low SatO2/FiO2 ratio, and high SOFA and CURB-65 scores.Fondos Estructurales de la Union Europea (FEDER)Unit of Excellence on Exercise and Health (UCEES), University of Granad

&lsquo;Back-and-Forth Stomach&rsquo; CT Imaging Findings of a Pathophysiologic Entity Causing Acute Gastric Volvulus

Background: Gastric volvulus (GV) is a life-threatening emergency condition that prompts emergent surgical management. With the advent of high-resolution computed tomography (CT), the role of radiologists in its diagnosis has become essential. Although many cases of GV have been described in the literature, its pathophysiology is still poorly understood. In addition, there is substantial terminological confusion with associated entities such as paraesophageal hernia, upside-down stomach, organo-axial or chronic GV. Methods: We conducted a retrospective review of clinical, radiological findings and other relevant data for seven patients with previous radiological diagnoses of a large hiatus hernia who presented with acute GV to the emergency department of our institution. We report data on age, sex, medical history, clinical presentation, imaging, treatment and outcomes for each case. Results: The CT findings at acute presentation showed the antrum lying above the diaphragm and dilated fundus below the diaphragm. By comparing the position of the stomach at acute presentation with previous imaging examinations, we confirmed a hypothesis put forward by a few authors decades ago that re-herniation of the gastric fundus into the abdomen is a common pathophysiologic trigger leading to acute GV. This hypothesis has not been supported by modern imaging examinations. Conclusions: We have provided imaging evidence supporting that the pathophysiology of many GVs is based on caudal re-descent of hiatal hernia into the abdominal cavity. Given the terminological disparity used in the literature in this context, we believe it appropriate to introduce and extend the term &lsquo;back-and-forth stomach&rsquo; to refer to this type of GV

Diagnóstico y tratamiento de las fracturas vertebrales osteoporóticas: aportaciones desde la radiología

La presente tesis doctoral está dedicada al estudio de las fracturas vertebrales osteoporóticas (FVO) desde el punto de vista radiológico, y más concretamente en sus aportaciones diagnósticas y terapéuticas. Las FVO constituyen un problema de salud global de primer nivel por su alta prevalencia y morbimortalidad asociada. El diagnóstico por imagen de estas fracturas puede realizarse mediante diferentes pruebas radiológicas como la radiografía convencional (RC), la tomografía computarizada (TC) o la resonancia magnética (RM) y existen diversos abordajes terapéuticos, entre los cuales cabe destacar las técnicas de cementación vertebral como la vertebroplastia percutánea (VP) y su variantes posteriores (cifoplastia, vesselplastia, etc.). A pesar de las mejoras en el diagnóstico radiológico de las FVO, se han descrito limitaciones y controversias en la literatura sobre los criterios diagnósticos por imagen y los sistemas de clasificación más útiles. Además, existe un gran interés por determinar los factores pronósticos que permitan seleccionar a los pacientes con mayor riesgo de colapso vertebral con tratamiento conservador, con el fin de tomar decisiones que redunden en un mayor beneficio clínico para el paciente. Por otra parte, la eficacia de la VP se ha puesto en tela de juicio en la última década, a raíz de la publicación de algunos ensayos clínicos y metaanálisis que no mostraron beneficios clínicos en comparación con placebo o tratamiento conservador, pero los resultados en la literatura son inconsistentes. Finalmente, el desarrollo de nuevas tecnologías como la inteligencia artificial (IA) y la impresión 3D basada en imagen médica está abriendo nuevas posibilidades en radiología y su aplicación a las diferentes patologías de la columna vertebral, particularmente a las FVO, aún está por definirse. Con estos antecedentes, hemos llevado a cabo diversos trabajos con el objetivo general de revisar y profundizar en los avances radiológicos relativos al diagnóstico y tratamiento las FVO, y, de manera más concreta, con los objetivos específicos de: a) revisar los hallazgos de imagen en RC, TC y RM de las principales patologías de la columna vertebral, especialmente las que se incluyen en el diagnóstico diferencial de las FVO, y conocer el statu quo de la impresión 3D e IA en este ámbito; b) analizar qué alteraciones radiológicas tienen influencia en la evolución clínica y radiológica de las FVO; y c) determinar si la vertebroplastia percutánea en las FVO es superior al placebo y al tratamiento conservador, y las potenciales causas de las controversias sobre su eficacia existentes en la literatura científica. De los resultados obtenidos se concluyen los siguientes puntos. Primero: el conocimiento de los hallazgos radiológicos de la columna vertebral normal y patológica en RC, TC y RM resulta fundamental para realizar un correcto diagnóstico de las FVO. Deben considerarse las indicaciones, ventajas y limitaciones de estas pruebas de imagen en función de la patología que se sospeche (traumática, degenerativa, inflamatoria, infecciosa o tumoral). Segundo: es preciso conocer los diferentes sistemas de clasificación utilizados en el diagnóstico de las FVO, sus ventajas e inconvenientes, y su utilidad en la práctica clínica. La distinción entre sistemas de clasificación cualitativos, cuantitativos y semicuantitativos es útil para este propósito. Tercero: las tecnologías de impresión 3D y los sistemas basados en IA representan áreas emergentes con aplicaciones útiles en el diagnóstico y tratamiento de las FVO. Su implementación clínica se está instaurando progresivamente en los últimos años, por lo que el radiólogo debe familiarizarse con ellas y conocer sus ventajas y limitaciones. Cuarto: una diferencia significativa en la pérdida de altura vertebral posterior entre la RC en bipedestación y la TC en supino, un cociente elevado entre la densidad radiológica del cuerpo vertebral fracturado y el no fracturado, y una edad avanzada, se asocian con un mayor riesgo de colapso vertebral en las FVO, lo que permite orientar hacia la elección de un tratamiento alternativo al conservador. Es necesario validar estos hallazgos mediante series más amplias, idealmente prospectivas y multicéntricas. Quinto: La VP ofrece ventajas significativas en el alivio del dolor, mejora en la funcionalidad y calidad de vida en comparación con el placebo y con el tratamiento conservador. La adecuada selección de pacientes candidatos a este tratamiento es fundamental para obtener resultados óptimos. El conocimiento derivado de esta tesis doctoral permite profundizar en el estado actual del diagnóstico y tratamiento de las FVO desde la radiología, aporta recursos útiles para la práctica de radiólogos y otros especialistas, y sirve de punto de partida para nuevas investigaciones que redunden en beneficios clínicos significativos para los pacientes con este tipo de fracturas.Tesis Univ. Granada