Abordaje de la violencia doméstica (VD) en los servicios de urgencias (SUH)

Los servicios de urgencias son a veces los lugares más accesibles que encuentran las mujeres víctimas de malos tratos para solicitar ayuda y así, se detectan cifras altas de violencia doméstica (VD) entre las usuarias de estos centros. Según las cifras publicadas en diferentes trabajos realizados en los Servicios de Urgencias Hospitalarias (SUH) de los Estados Unidos, de un 11.7% - 35% de las mujeres que acuden a dichos servicios lo hacen como consecuencia de la violencia doméstica, Estos estudios reflejan que el 2% de las lesiones agudas en mujeres que se presentan en un SUH son atribuidas a la VD y muestran que el 14% de las mujeres que busca atención médica por diversos motivos, en los SUH, tienen antecedentes de haber sufrido abusos físicos o sexuales durante el último año. Diferentes fuentes nos indican que del 25% al 81% de las mujeres con intento de suicidio han sufrido en algún momento de su vida violencia doméstica. Aparte de las implicaciones sociales, las consecuencias derivadas de la VD, tanto en la víctima como en sus familias, son muy variadas y van desde las lesiones físicas de distinta gravedad, hasta depresión, ansiedad, abuso de sustancias tóxicas e intentos autolíticos. Todas estas consecuencias justifican nuestro papel en el abordaje multidisciplinar del maltrato. Para muchas mujeres maltratadas el servicio de urgencias hospitalario es el primer o único contacto que tienen con los sanitarios, por tanto, los objetivos prioritarios del abordaje de situaciones de violencia doméstica en los servicios de urgencias son: la detección precoz de violencia doméstica , la valoración en el momento del acto médico de la existencia del riesgo vital inmediato (físico, psíquico y social) a que puede estar expuesta la mujer tras su , la actitud urgente que debemos tomar si se confirma la existencia del mismo y la información que debemos conocer y facilitar a la posible víctima de VD. Aunque la presentación más común de violencia doméstica en el servicio de urgencias puede parecer no urgente, la falta de diagnóstico podría conducir a un aumento importante de la morbilidad, con un aumento de la frecuentación a los mismos, incremento de los ingresos y aumento del uso de los recursos de salud ambulatorios; o incluso llegar a la consecuencia más extrema y letal de la violencia de género. Parece que el realizar una historia clínica y un examen físico rutinario, no es suficiente para el diagnóstico de violencia doméstica. Aunque por el momento no existen suficientes evidencias científicas que recomienden el cribado sistemático del maltrato, a la población general, en los servicios de urgencias, la controversia acerca de la realización o no de dichos test es aún mayor. En dicho medio, son recomendables los cuestionarios cortos que aborden dos cuestiones fundamentales: por una parte la existencia de violencia doméstica y por otra la seguridad de la paciente. Uno de los posibles cuestionarios a utilizar para el cribado es el test "Detección Violencia de Pareja" (The Partner Violence Screen: PVS) que incorpora 3 simples preguntas: Ha sido usted golpeada, recibido alguna patada o puñetazo o alguna otra lesión por alguien durante el pasado ultimo año? De ser así por quién? ¿Se siente usted segura en su relación actual? ¿Se siente usted actualmente insegura por alguna relación previa? A pesar de todo lo mencionado anteriormente, los profesionales de salud tienen barreras a la hora de diagnosticar este tipo de problema de salud: falta de formación, desmotivación, no conciencia de problema de salud, prejuicios, miedo a ofender o invadir la intimidad de la víctima, desconocimiento de los recursos y ayudas sociales, presión asistencial. Sólo la tercera parte de ellos se plantean de manera rutinaria la agresión o los malos tratos como un diagnostico diferencial más ante las pacientes que acuden con lesiones físicas. Un 55 al 68 % de los médicos nunca o raramente preguntan por violencia domestica. Así, se estima que sólo se diagnostican en 5-15 % de todos los casos. Cuando detectamos una situación de maltrato, es importante realizar una Valoración del Riesgo Vital Inmediato: Riesgo Vital Inmediato Físico, Psíquico y Social. En el caso de la existencia de Riesgo Vital Inmediato Físico y psíquico deberemos proceder al tratamiento de las posibles lesiones e ingresar a la paciente (Hospital o Salud Mental) o mantener en observación según la necesidad. En el caso de Riesgo Vital Inmediato Social deberemos comunicarlo de manera inmediata al Juez o a los Servicios competentes. Ante el diagnóstico o sospecha que las lesiones, que estamos valorando, son resultado de una situación de maltrato, tenemos la obligación legal de comunicarlo al juez mediante la emisión de un parte judicial. Si se trata de un caso de derivación diferida, también deberemos realizar parte Judicial, es preferible la existencia de duplicidad de partes a la no existencia de ninguno. Es de vital importancia el registro claro y pormenorizado de: las lesiones (descripción, localización), las causas (según las refiere la paciente), los antecedentes, métodos diagnósticos y tratamiento realizado, diagnóstico final y el facultativo responsable, en la historia clínica de urgencias y/o en el parte de lesiones del consejo Interterritorial. Debemos informar de manera adecuada a la paciente de los recursos con los que cuenta y facilitarla los teléfonos de contactos de los mismos. No debemos olvidar ofrecer a la paciente nuestra ayuda continuada por ser un Servicio de Atención las 24 horas del día

The evolution of the ventilatory ratio is a prognostic factor in mechanically ventilated COVID-19 ARDS patients

Background: Mortality due to COVID-19 is high, especially in patients requiring mechanical ventilation. The purpose of the study is to investigate associations between mortality and variables measured during the first three days of mechanical ventilation in patients with COVID-19 intubated at ICU admission. Methods: Multicenter, observational, cohort study includes consecutive patients with COVID-19 admitted to 44 Spanish ICUs between February 25 and July 31, 2020, who required intubation at ICU admission and mechanical ventilation for more than three days. We collected demographic and clinical data prior to admission; information about clinical evolution at days 1 and 3 of mechanical ventilation; and outcomes. Results: Of the 2,095 patients with COVID-19 admitted to the ICU, 1,118 (53.3%) were intubated at day 1 and remained under mechanical ventilation at day three. From days 1 to 3, PaO2/FiO2 increased from 115.6 [80.0-171.2] to 180.0 [135.4-227.9] mmHg and the ventilatory ratio from 1.73 [1.33-2.25] to 1.96 [1.61-2.40]. In-hospital mortality was 38.7%. A higher increase between ICU admission and day 3 in the ventilatory ratio (OR 1.04 [CI 1.01-1.07], p = 0.030) and creatinine levels (OR 1.05 [CI 1.01-1.09], p = 0.005) and a lower increase in platelet counts (OR 0.96 [CI 0.93-1.00], p = 0.037) were independently associated with a higher risk of death. No association between mortality and the PaO2/FiO2 variation was observed (OR 0.99 [CI 0.95 to 1.02], p = 0.47). Conclusions: Higher ventilatory ratio and its increase at day 3 is associated with mortality in patients with COVID-19 receiving mechanical ventilation at ICU admission. No association was found in the PaO2/FiO2 variation

Clustering COVID-19 ARDS patients through the first days of ICU admission. An analysis of the CIBERESUCICOVID Cohort

Background Acute respiratory distress syndrome (ARDS) can be classified into sub-phenotypes according to different inflammatory/clinical status. Prognostic enrichment was achieved by grouping patients into hypoinflammatory or hyperinflammatory sub-phenotypes, even though the time of analysis may change the classification according to treatment response or disease evolution. We aimed to evaluate when patients can be clustered in more than 1 group, and how they may change the clustering of patients using data of baseline or day 3, and the prognosis of patients according to their evolution by changing or not the cluster.Methods Multicenter, observational prospective, and retrospective study of patients admitted due to ARDS related to COVID-19 infection in Spain. Patients were grouped according to a clustering mixed-type data algorithm (k-prototypes) using continuous and categorical readily available variables at baseline and day 3.Results Of 6205 patients, 3743 (60%) were included in the study. According to silhouette analysis, patients were grouped in two clusters. At baseline, 1402 (37%) patients were included in cluster 1 and 2341(63%) in cluster 2. On day 3, 1557(42%) patients were included in cluster 1 and 2086 (57%) in cluster 2. The patients included in cluster 2 were older and more frequently hypertensive and had a higher prevalence of shock, organ dysfunction, inflammatory biomarkers, and worst respiratory indexes at both time points. The 90-day mortality was higher in cluster 2 at both clustering processes (43.8% [n = 1025] versus 27.3% [n = 383] at baseline, and 49% [n = 1023] versus 20.6% [n = 321] on day 3). Four hundred and fifty-eight (33%) patients clustered in the first group were clustered in the second group on day 3. In contrast, 638 (27%) patients clustered in the second group were clustered in the first group on day 3.Conclusions During the first days, patients can be clustered into two groups and the process of clustering patients may change as they continue to evolve. This means that despite a vast majority of patients remaining in the same cluster, a minority reaching 33% of patients analyzed may be re-categorized into different clusters based on their progress. Such changes can significantly impact their prognosis

New insights into the genetic etiology of Alzheimer's disease and related dementias

Characterization of the genetic landscape of Alzheimer's disease (AD) and related dementias (ADD) provides a unique opportunity for a better understanding of the associated pathophysiological processes. We performed a two-stage genome-wide association study totaling 111,326 clinically diagnosed/'proxy' AD cases and 677,663 controls. We found 75 risk loci, of which 42 were new at the time of analysis. Pathway enrichment analyses confirmed the involvement of amyloid/tau pathways and highlighted microglia implication. Gene prioritization in the new loci identified 31 genes that were suggestive of new genetically associated processes, including the tumor necrosis factor alpha pathway through the linear ubiquitin chain assembly complex. We also built a new genetic risk score associated with the risk of future AD/dementia or progression from mild cognitive impairment to AD/dementia. The improvement in prediction led to a 1.6- to 1.9-fold increase in AD risk from the lowest to the highest decile, in addition to effects of age and the APOE ε4 allele

Prevalence, associated factors and outcomes of pressure injuries in adult intensive care unit patients: the DecubICUs study

Funder: European Society of Intensive Care Medicine; doi: http://dx.doi.org/10.13039/501100013347Funder: Flemish Society for Critical Care NursesAbstract: Purpose: Intensive care unit (ICU) patients are particularly susceptible to developing pressure injuries. Epidemiologic data is however unavailable. We aimed to provide an international picture of the extent of pressure injuries and factors associated with ICU-acquired pressure injuries in adult ICU patients. Methods: International 1-day point-prevalence study; follow-up for outcome assessment until hospital discharge (maximum 12 weeks). Factors associated with ICU-acquired pressure injury and hospital mortality were assessed by generalised linear mixed-effects regression analysis. Results: Data from 13,254 patients in 1117 ICUs (90 countries) revealed 6747 pressure injuries; 3997 (59.2%) were ICU-acquired. Overall prevalence was 26.6% (95% confidence interval [CI] 25.9–27.3). ICU-acquired prevalence was 16.2% (95% CI 15.6–16.8). Sacrum (37%) and heels (19.5%) were most affected. Factors independently associated with ICU-acquired pressure injuries were older age, male sex, being underweight, emergency surgery, higher Simplified Acute Physiology Score II, Braden score 3 days, comorbidities (chronic obstructive pulmonary disease, immunodeficiency), organ support (renal replacement, mechanical ventilation on ICU admission), and being in a low or lower-middle income-economy. Gradually increasing associations with mortality were identified for increasing severity of pressure injury: stage I (odds ratio [OR] 1.5; 95% CI 1.2–1.8), stage II (OR 1.6; 95% CI 1.4–1.9), and stage III or worse (OR 2.8; 95% CI 2.3–3.3). Conclusion: Pressure injuries are common in adult ICU patients. ICU-acquired pressure injuries are associated with mainly intrinsic factors and mortality. Optimal care standards, increased awareness, appropriate resource allocation, and further research into optimal prevention are pivotal to tackle this important patient safety threat

Correction to: Prevalence, associated factors and outcomes of pressure injuries in adult intensive care unit patients: the DecubICUs study

The original version of this article unfortunately contained a mistake

Prevalence, associated factors and outcomes of pressure injuries in adult intensive care unit patients: the DecubICUs study

Funder: European Society of Intensive Care Medicine; doi: http://dx.doi.org/10.13039/501100013347Funder: Flemish Society for Critical Care NursesAbstract: Purpose: Intensive care unit (ICU) patients are particularly susceptible to developing pressure injuries. Epidemiologic data is however unavailable. We aimed to provide an international picture of the extent of pressure injuries and factors associated with ICU-acquired pressure injuries in adult ICU patients. Methods: International 1-day point-prevalence study; follow-up for outcome assessment until hospital discharge (maximum 12 weeks). Factors associated with ICU-acquired pressure injury and hospital mortality were assessed by generalised linear mixed-effects regression analysis. Results: Data from 13,254 patients in 1117 ICUs (90 countries) revealed 6747 pressure injuries; 3997 (59.2%) were ICU-acquired. Overall prevalence was 26.6% (95% confidence interval [CI] 25.9–27.3). ICU-acquired prevalence was 16.2% (95% CI 15.6–16.8). Sacrum (37%) and heels (19.5%) were most affected. Factors independently associated with ICU-acquired pressure injuries were older age, male sex, being underweight, emergency surgery, higher Simplified Acute Physiology Score II, Braden score 3 days, comorbidities (chronic obstructive pulmonary disease, immunodeficiency), organ support (renal replacement, mechanical ventilation on ICU admission), and being in a low or lower-middle income-economy. Gradually increasing associations with mortality were identified for increasing severity of pressure injury: stage I (odds ratio [OR] 1.5; 95% CI 1.2–1.8), stage II (OR 1.6; 95% CI 1.4–1.9), and stage III or worse (OR 2.8; 95% CI 2.3–3.3). Conclusion: Pressure injuries are common in adult ICU patients. ICU-acquired pressure injuries are associated with mainly intrinsic factors and mortality. Optimal care standards, increased awareness, appropriate resource allocation, and further research into optimal prevention are pivotal to tackle this important patient safety threat

New insights into the genetic etiology of Alzheimer’s disease and related dementias

Characterization of the genetic landscape of Alzheimer’s disease (AD) and related dementias (ADD) provides a unique opportunity for a better understanding of the associated pathophysiological processes. We performed a two-stage genome-wide association study totaling 111,326 clinically diagnosed/‘proxy’ AD cases and 677,663 controls. We found 75 risk loci, of which 42 were new at the time of analysis. Pathway enrichment analyses confirmed the involvement of amyloid/tau pathways and highlighted microglia implication. Gene prioritization in the new loci identified 31 genes that were suggestive of new genetically associated processes, including the tumor necrosis factor alpha pathway through the linear ubiquitin chain assembly complex. We also built a new genetic risk score associated with the risk of future AD/dementia or progression from mild cognitive impairment to AD/dementia. The improvement in prediction led to a 1.6- to 1.9-fold increase in AD risk from the lowest to the highest decile, in addition to effects of age and the APOE ε4 allele

New insights into the genetic etiology of Alzheimer’s disease and related dementias

Characterization of the genetic landscape of Alzheimer’s disease (AD) and related dementias (ADD) provides a unique opportunity for a better understanding of the associated pathophysiological processes. We performed a two-stage genome-wide association study totaling 111,326 clinically diagnosed/‘proxy’ AD cases and 677,663 controls. We found 75 risk loci, of which 42 were new at the time of analysis. Pathway enrichment analyses confirmed the involvement of amyloid/tau pathways and highlighted microglia implication. Gene prioritization in the new loci identified 31 genes that were suggestive of new genetically associated processes, including the tumor necrosis factor alpha pathway through the linear ubiquitin chain assembly complex. We also built a new genetic risk score associated with the risk of future AD/dementia or progression from mild cognitive impairment to AD/dementia. The improvement in prediction led to a 1.6- to 1.9-fold increase in AD risk from the lowest to the highest decile, in addition to effects of age and the APOE ε4 allele