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Resumen: Objetivo: Estudiar la asociación entre prescripciones potencialmente inapropiadas (PPI) y eventos adversos a los 30 y 180 días tras el alta de una unidad de corta estancia (UCE). Material y método: Estudio analítico observacional de cohortes retrospectivo que incluyó pacientes ≥ 75 años al alta de una UCE. Se utilizó la versión 2 de los criterios STOPP-START. La variable resultado fue la presencia de algún evento adverso a 30 y 180 días. Resultados: Se incluyeron 179 pacientes con una media de 84 (DE: 5) años. La presencia de ≥ 1PPI al alta no se asoció con la aparición de algún evento adverso a los 30 ni a los 180 días de manera global. La presencia de ≥ 1PPI al alta de fármacos del proceso cardiovascular tuvo mayor riesgo de presentar algún evento adverso a los 30 días del alta (OR ajustada 2,1; IC 95%: 1,0-3,2; p = 0,045), los fármacos del proceso «neuropsiquiátrico y riesgo de caídas» se relacionaron con deterioro funcional a los 30 días del alta (OR ajustada 6,3; IC 95%: 1,7-22,5; p = 0,005), y la omisión de fármacos del sistema cardiovascular se asoció con el reingreso a los 180 días (OR ajustada 3,6; IC 95%: 1,5-8,3, p = 0,003). Conclusiones: La presencia de eventos adversos de pacientes ancianos dados de alta de una UCE podría relacionarse con PPI detectadas por algunos criterios STOPP-START, y concretamente con los fármacos de los procesos cardiovasculares, neuropsiquiátrico y relacionado con las caídas. Abstract: Objective: To study the association between the potential inappropriate prescriptions (PIP) and the 30 and 180-day adverse event rate after discharge from a Short Stay Unit (SSU). Methodology: A retrospective cohort observational study was conducted on patients aged ≥ 75 years discharged from an SSU from February to April, 2014. STOPP-START criteria version 2 was used. The main outcome was 30 and 180-day adverse event rate after being discharged. Results: A total of 179 patients, with a mean age of 84 (SD 5) years were included. The presence of ≥ 1PIP after being discharged was not associated with a 30 and 180-day composite adverse event. Patients with ≥ 1PIP related to a cerebro-cardiovascular process were at higher risk of an adverse event at 30 days after discharge (adjusted OR, 2.1; 95% CI: 1.0-3.2; P = .045), those with ≥ 1PIP related to neuropsychiatric process and risk of fall were at higher risk of increased 30-day functional impairment (adjusted OR, 6.3; 95% CI: 1.7-22.5; P = .005), and those with ≥ 1PIP related to omission of cardiovascular system were at higher risk of 180-day hospital readmission (adjusted OR, 3.6; 95% CI: 1.5-8.3; P = .003). Conclusions: The presence of adverse events in older patients discharged from SSU may be associated with PIP, identified by STOPP-START criteria, and more specifically with drugs related to cardiovascular, neuropsychiatric disorders, and falls. Palabras clave: Anciano, Prescripción inadecuada, Unidad de corta estancia, Keywords: Elderly, Inappropriate prescription, Emergency short-stay unit

Aims This study aimed to determine the frequency of detectable relaxin-2 concentrations and associated factors in patients with acute heart failure (AHF) and to establish relationships with short-term outcome and clinical and analytical parameters. Methods and results We performed a prospective, analytical, observational, multicentre study with cohort follow-up. We collected sociodemographic variables, previous history, basal status, previous treatment, vital signs, electrocardiographic and analytical data in the emergency department. Relaxin-2 was quantified by enzyme-linked immunosorbent assay (ELISA) (detection limit: 1.5 pg/mL). The primary event was 30-day all-cause mortality. We compared clinical characteristics and outcomes between patients with undetectable and detectable concentrations, and across concentration quartile groups in the latter. We analysed data for 522 patients (mean ± standard deviation age: 80.9 ± 9.1 years; 53.6% women). In 92 (17.6%) patients, relaxin-2 concentrations were undetectable. This finding was associated with male sex, absence of heart valve disease and treatment with aldosterone receptor antagonists. The incidence of 30-day mortality was significantly lower (2.2% vs. 9.1%; P = 0.03) in these patients even after adjustment for differences between groups (hazard ratio: 0.22, 95% confidence interval 0.05–0.92; P = 0.038). There were no associations with age or sex. Among the 430 (82.4%) patients with detectable relaxin-2 concentrations, values did not differ between subjects who remained alive [median: 30.9 pg/mL; interquartile range (IQR) 15.8–74.7 pg/mL] and those who had died (median: 30.9 pg/mL; IQR 15.6–85.2 pg/mL) (P = 0.89). Analysis of patients according to relaxin-2 concentration quartiles showed no differences in mortality. Relaxin-2 was correlated, albeit weakly, with haemoglobin values (R2 = 0.018, P = 0.005), but not with NT-proBNP, age or left ventricular ejection fraction (LVEF). Conclusions Patients with AHF and undetectable relaxin-2 concentrations have lower 30-day mortality. In contrast, there were no linear relationships between blood concentrations within the measurable range and mortality, NT-proBNP or LVEF.

To determine the validity of the classic sepsis criteria or systemic inflammatory response syndrome (heart rate, respiratory rate, temperature, and leukocyte count) and the modified sepsis criteria (systemic inflammatory response syndrome criteria plus glycemia and altered mental status), and the validity of each of these variables individually to predict 30-day mortality, as well as develop a predictive model of 30-day mortality in elderly patients attended for infection in emergency departments (ED).A prospective cohort study including patients at least 75 years old attended in three Spanish university ED for infection during 2013 was carried out. Demographic variables and data on comorbidities, functional status, hemodynamic sepsis diagnosis variables, site of infection, and 30-day mortality were collected.A total of 293 patients were finally included, mean age 84.0 (SD 5.5) years, and 158 (53.9%) were men. Overall, 185 patients (64%) fulfilled the classic sepsis criteria and 224 patients (76.5%) fulfilled the modified sepsis criteria. The all-cause 30-day mortality was 13.0%. The area under the curve of the classic sepsis criteria was 0.585 [95% confidence interval (CI) 0.488-0.681; P=0.106], 0.594 for modified sepsis criteria (95% CI: 0.502-0.685; P=0.075), and 0.751 (95% CI: 0.660-0.841; P0.001) for the GYM score (Glasgow15; tachYpnea20 bpm; Morbidity-Charlson index ≥3) to predict 30-day mortality, with statistically significant differences (P=0.004 and P0.001, respectively). The GYM score showed good calibration after bootstrap correction, with an area under the curve of 0.710 (95% CI: 0.605-0.815).The GYM score showed better capacity than the classic and the modified sepsis criteria to predict 30-day mortality in elderly patients attended for infection in the ED.

We tested the hypothesis that early measurement of galectin-3 at the emergency department (ED) during an episode of acute heart failure (AHF) allows predicting short- and long-term outcomes.We performed an exploratory study including 115 patients consecutively diagnosed with AHF in a single ED. Clinical and analytical variables were recorded. The primary endpoint was 30-day all-cause mortality, and secondary endpoints were 30-day composite outcome (death, rehospitalization or ED reconsultation, whichever first) and 1-year mortality.Seven patients (6.1%) died within 30 days and 43 (37.4%) within 1 year. The 30-day composite endpoint was observed in 21.1% of patients. Galectin-3 was correlated with NT-proBNP and the glomerular filtration rate but not with age and s-cTnI. Measured at time of ED arrival, galectin-3 showed good discriminatory capacity for 30-day mortality (AUC ROC: 0.732; 95% CI 0.512-0.953; p = 0.041) but not for 1-year mortality (0.521; 0.408-0.633; p = 0.722). Patients with galectin-3 concentrations 42 μg/L had an OR = 7.67(95%CI = 1.57-37.53; p = 0.012) for 30-day mortality. Conversely, NT-proBNP only showed predictive capacity for 1-year mortality (0.642; 0.537-0.748; p = 0.014). Patients with NT-proBNP concentrations 5400 ng/L had an OR = 4.34 (95%CI = 1.93-9.77; p 0.001) for 1-year mortality. These increased short- (galectin-3) and long-term (NT-proBNP) risks remained significant after adjustment for age or renal function. s-cTnI failed in both short- and long term death prediction. No biomarker predicted the short-term composite endpoint.These results suggest that galectin-3 could help to monitor the risk of short-term mortality in unselected patients with AHF attended in the ED.

Background Emergency Department (ED) overcrowding mainly due to the lack of access to inpatient beds negatively affects safety and quality of care. Implementation of ED short-stay units (EDSSUs) may help to mitigate this situation. Objectives To describe the general characteristics and evaluate the activity of EDSSUs in Spanish hospitals. Methods This is a cross-sectional study. A questionnaire was sent to coordinators responsible for the EDSSUs identified among Spanish hospitals appearing on the Ministry of Health Web page. Data regarding structure, caseloads, and clinical management practices were collected. Results Among the 591 hospitals surveyed, 35 EDSSUs (5.9%) were identified and 23 participated in the study. Admissions to EDSSUs over different periods in 2011 were assessed: 12-month activity in 17 EDSSUs and between 5 and 10.5 months in six EDSSUs. A total of 25,568 patients with a mean age of 67.2 ± 9.8 years were admitted, representing between 6% and 16.3% of hospital admissions from the ED. The most frequent diagnoses were acute heart failure, chronic obstructive pulmonary disease exacerbation, and urinary and respiratory tract infections. The average length of stay (LOS) was 2.6 ± 1.1 days (range 1.2–5.3), in-hospital mortality 0.59% (range 0–2.68), and the 30-day readmission rate after discharge was 6.7% (range 0–14.6). Conclusions To date, only a few Spanish hospitals have implemented EDSSUs. Prevalent infections and exacerbation of chronic conditions are the most frequent causes for admission. Considering LOS, 30-day readmission rate and mortality, EDSSUs appear to be safe and effective and might be considered a tool to alleviate ED overcrowding.

Resumen Objetivo Analizar los cambios en la epidemiologia, en la atencion clinica ambulatoria y en urgencias, y la evolucion de los pacientes atendidos por insuficiencia cardiaca aguda (ICA) en los servicios de urgencias hospitalarios (SUH) espanoles entre 2007 y 2014. Metodo Estudio multicentrico, de cohortes, con inclusion consecutiva de pacientes con ICA diagnosticados en 9 SUH durante 4 periodos (2007, 2009, 2011 y 2014). Se analizaron los cambios observados en 20 variables correspondientes a datos basales, de atencion ambulatoria y urgente, y evolutivos. Resultados Se incluyeron 4.845 pacientes. Hubo cambios significativos en 13 variables: aumentaron los pacientes > 80 anos (2007/2014: 45,9/55,4%; p Conclusiones Se detectan cambios evolutivos durante un periodo de 7 anos en los pacientes con ICA atendidos en el SUH, con una asistencia mas ajustada a las guias clinicas, aunque todavia existen areas de mejora. Destaca un aumento del seguimiento ambulatorio sin ingreso, con una disminucion de las reconsultas al SUH.

Resumen Introduccion El objetivo principal fue determinar la frecuencia de pacientes que reciben terapia antibiotica inapropiada y evaluar los resultados en terminos de estancia media, reingreso y mortalidad a 30 dias. Metodos Estudio observacional de cohortes retrospectivo que incluyo a todos los pacientes ingresados por infeccion desde un Servicio de Urgencias (SU) durante un mes. Se recogieron variables demograficas, comorbilidad, factores de riesgo de multirresistencia, foco de infeccion, resultados microbiologicos y antibiotico prescrito en el SU. Las variables de resultado fueron el tiempo de estancia, y la mortalidad y el reingreso a 30 dias. Resultados Se incluyeron 376 pacientes con una edad media de 71,1 (DE 21) anos. Las infecciones mas frecuentes fueron respiratoria (45,7%) y urinaria (23,9%). El numero de pacientes con una estancia superior a la mediana (≥ 9 dias), reingreso y mortalidad a los 30 dias fue de 165 (46,1%), 74 (19,7%) y 44 (11,7%) pacientes, respectivamente. La prescripcion inapropiada del tratamiento antibiotico en el SU se produjo en 42 (11,2%) casos. Tras ajustar por los datos demograficos, la comorbilidad, los factores de riesgo para patogenos resistentes, la presencia de sepsis en el SU y el foco de infeccion, la prescripcion inapropiada se asocio a una estancia prolongada (OR 2,22; IC95% 1,07-4,60; p = 0,032), pero no a un aumento de la mortalidad (p = 0,271) o de los reingresos (p = 0,784) a los 30 dias. Conclusion La prescripcion inapropiada del tratamiento antibiotico empirico en los pacientes ingresados por un proceso infeccioso desde el SU provoca una estancia prolongada, pero no un incremento de la mortalidad o del reingreso.

Introduction The main objective of the study was to determine the frequency of patients receiving inappropriate empiric antibiotic therapy and to assess the impact in terms of increase length of hospital stay, 30-day re-admissions, and 30-day mortality. Methods An observational retrospective cohort study was conducted over a one-month period that included all patients hospitalised from an Emergency Department (ED) due to infection. Demographic variables, comorbidity, multi-resistance risk factors, site of infection, microbiological findings, and antibiotic prescribed in ED were collected. Outcomes were length of hospital stay, 30-day re-admissions, and 30-day mortality. Results A total of 376 patients were included, with a mean age of 71.1 (SD 21) years. The most frequent causes were respiratory (45.7%) and urine (23.9%) infections. The number of patients with length of stay over the median (≥9 days) was 165 (46.1%), with re-admissions 74 (19.7%), and mortality at 30 days 44 (11.7%). There was inappropriate antibiotic treatment in 42 (11.2%) cases. After adjusting for demographic data, comorbidity, risk factors for multidrug resistant organism, presence of sepsis criteria in ED, and site of infection, inappropriate treatment was associated with an extended length of hospital stay (OR 2.22; 95% CI; 1.07–4.60; p = 0.032), but did not to an increase in mortality (p = 0.271) or re-admission (p = 0.784) at 30 days. Conclusion The inappropriate empirical antibiotic therapy in patients admitted from the ED leads to an extended hospital stay, but did not increase mortality or readmission.

Objective: To analyse the changes in epidemiology, outpatient and emergency department clinical care, and outcomes of patients treated for acute heart failure (AHF) in Spanish hospital emergency departments (HEDs) between 2007 and 2014. Method: A multicentre cohort study was conducted that consecutively included patients with AHF diagnosed in 9 HEDs during 4 periods (2007, 2009, 2011 and 2014). The study analysed the changes observed in 20 variables corresponding to baseline data, outpatient care and emergency care data and outcome data. Results: A total of 4,845 patients were included. There were significant changes in 13 variables: there was an increase in patients older than 80 years (2007/2014: 45.9%/55.4%; P

The latest acute heart failure (AHF) consensus document from the Spanish Society of Cardiology (SEC, for its initials in Spanish), Spanish Society of Internal Medicine (SEMI), and Spanish Society of Emergency Medicine (SEMES) was published in 2015, which made an update covering the main novelties regarding AHF from the last few years necessary. These include publication of updated European guidelines on HF in 2016, new studies on the pharmacological treatment of patients during hospitalization, and other recent developments regarding AHF such as early treatment, intermittent treatment, advanced HF, and refractory congestion. This consensus document was drafted with the aim of updating all aspects related to AHF and to create a document that comprehensively describes the diagnosis, treatment, and management of this disease. (C) 2020 Elsevier Espana, S.L.U. and Sociedad Espanola de Medicina Interna (SEMI). All rights reserved.

To determine the impact of chronic obstructive pulmonary disease (COPD) on prognosis in patients diagnosed with venous thromboembolic disease (VTED) in Spanish emergency departments.Secondary analysis of data from the ESPHERIA (Spanish acronym for Risk Profile of Patients VTED Attended in Spanish Emergency Departments) registry.A total of 801 patients, 71 (9%) with COPD, were included. Pulmonary thromboembolism was recorded in 77.%% of the patients with COPD (vs in 47.1% of patients without COPD; P.001). Patients with COPD had evidence of right ventricular dysfunction on computed tomography angiography more often than other VTED patients (18.2% vs 13.1%; P.001) and more often required ventilatory support (7% vs 0.5%; P.001). VTED patients with COPD also had a higher rate of readmission or mortality at 180 days (hazard ratio, 1.52; 95% CI, 1.00-2.29; P = .048)] than patients without COPD.COPD affects the prognosis of patients diagnosed with VTED in Spanish emergency departments as evidenced by hospital readmission and mortality.Determinar el impacto pronóstico de la enfermedad pulmonar obstructiva crónica (EPOC) en los pacientes diagnosticados de enfermedad tromboembólica venosa (ETV) en servicios de urgencias (SU) españoles.Análisis secundario del registro ESPHERIA que incluyó pacientes consecutivos con ETV sintomática en 53 SU.Se incluyeron 801 pacientes de los que 71 (9%) tenían EPOC, siendo la tromboembolia pulmonar la forma de presentación más frecuente de ETV en este subgrupo de pacientes (77,5% vs 47,1%, p0,001). Los pacientes con EPOC tuvieron con más frecuencia disfunción de ventrículo derecho en la angiotomografía pulmonar (18,2% vs 13,1%; p0,001) y necesidad de soporte ventilatorio (7% vs 0,5%; p0,001). Los pacientes con ETV y EPOC tuvieron mayor incidencia de reingreso o mortalidad en el seguimiento a 180 días [HR 1,52 (IC 95% 1,00-2,29; p = 0,048)], comparados con los pacientes con ETV sin EPOC.La EPOC tiene impacto pronóstico en los pacientes diagnosticados de ETV en SU españoles, en términos de mortalidad y reingreso hospitalario.

Aims This study aimed to systematically identify and summarise all risk scores evaluated in the emergency department setting to stratify acute heart failure patients. Methods and results A systematic review of PubMed and Web of Science was conducted including all multicentre studies reporting the use of risk predictive models in emergency department acute heart failure patients. Exclusion criteria were: (a) non-original articles; (b) prognostic models without predictive purposes; and (c) risk models without consecutive patient inclusion or exclusively tested in patients admitted to a hospital ward. We identified 28 studies reporting findings on 19 scores: 13 were originally derived in the emergency department (eight exclusively using acute heart failure patients), and six in emergency department and hospitalised patients. The outcome most frequently predicted was 30-day mortality. The performance of the scores tended to be higher for outcomes occurring closer to the index acute heart failure event. The eight scores developed using acute heart failure patients only in the emergency department contained between 4–13 predictors (age, oxygen saturation and creatinine/urea included in six scores). Five scores (Emergency Heart Failure Mortality Risk Grade, Emergency Heart Failure Mortality Risk Grade 30 Day mortality ST depression, Epidemiology of Acute Heart Failure in Emergency department 3 Day, Acute Heart Failure Risk Score, and Multiple Estimation of risk based on Emergency department Spanish Score In patients with Acute Heart Failure) have been externally validated in the same country, and two (Emergency Heart Failure Mortality Risk Grade and Multiple Estimation of risk based on Emergency department Spanish Score In patients with Acute Heart Failure) further internationally validated. The c-statistic for Emergency Heart Failure Mortality Risk Grade to predict seven-day mortality was between 0.74–0.81 and for Multiple Estimation of risk based on Emergency department Spanish Score In patients with Acute Heart Failure to predict 30-day mortality was 0.80–0.84. Conclusions There are several scales for risk stratification of emergency department acute heart failure patients. Two of them are accurate, have been adequately validated and may be useful in clinical decision-making in the emergency department i.e. about whether to admit or discharge.

Phonon polaritons—light coupled to lattice vibrations—in polar van der Waals crystals are promising candidates for controlling the flow of energy on the nanoscale due to their strong field confinement, anisotropic propagation and ultra-long lifetime in the picosecond range1,2,3,4,5. However, the lack of tunability of their narrow and material-specific spectral range—the Reststrahlen band—severely limits their technological implementation. Here, we demonstrate that intercalation of Na atoms in the van der Waals semiconductor α-V2O5 enables a broad spectral shift of Reststrahlen bands, and that the phonon polaritons excited show ultra-low losses (lifetime of 4 ± 1 ps), similar to phonon polaritons in a non-intercalated crystal (lifetime of 6 ± 1 ps). We expect our intercalation method to be applicable to other van der Waals crystals, opening the door for the use of phonon polaritons in broad spectral bands in the mid-infrared domain., J.T.-G. and G.Á.-P. acknowledge support through the Severo Ochoa Program from the Government of the Principality of Asturias (nos. PA-18-PF-BP17-126 and PA-20-PF-BP19-053, respectively). J.M.-S. acknowledges finantial support from the Clarín Programme from the Government of the Principality of Asturias and a Marie Curie-COFUND grant (PA-18-ACB17-29) and the Ramón y Cajal Program from the Government of Spain (RYC2018-026196-I). K.C., X.P.A.G., H.V. and M.H.B. acknowledge the Air Force Office of Scientific Research (AFOSR) grant no. FA 9550-18-1-0030 for funding support. I.E. acknowledges financial support from the Spanish Ministry of Economy and Competitiveness (grant no. FIS2016-76617-P). A.Y.N. acknowledges the Spanish Ministry of Science, Innovation and Universities (national project no. MAT2017-88358-C3-3-R) and the Basque Government (grant no. IT1164-19). Q.B. acknowledges the support from Australian Research Council (grant nos. FT150100450, IH150100006 and CE170100039). R.H. acknowledges support from the Spanish Ministry of Economy, Industry, and Competitiveness (national project RTI2018-094830-B-100 and the Project MDM-2016-0618 of the María de Maeztu Units of Excellence Program) and the Basque Goverment (grant no. IT1164-19). P.A.-G. acknowledges support from the European Research Council under starting grant no. 715496, 2DNANOPTICA.

Objective: To investigate whether patients with an acute heart failure (AHF) episode triggered by infection present different outcomes compared to patients with no trigger and the effects of early antibiotic administration (EAA) and hospitalisation. Methods: Two groups were made according to the AHF trigger: infection (G1) or none identified (G2). The primary outcome was 13-week (91-days) all-cause mortality, and secondary outcomes were 13-week post-discharge mortality, readmission or combined endpoint. Comparisons are presented as unadjusted and adjusted (MEESSI risk score) hazard ratios (uHR/aHR) for G1 compared to G2 patients, also estimated by weeks. Stratified analysis by EAA (provided/not provided) and patient disposition (discharged/hospitalised) was performed. Results: We included 6727 patients (G1 = 3973; G2 = 2754). The 13-week mortality uHR was 1.11 (0.99-1.25; p = 0.06; with significant increases in the first 3 weeks), and the aHR was 0.91 (0.81-1.02; p = 0.11). There were no differences in unadjusted secondary post-discharge outcomes; however, G1 outcomes significantly improved after adjustment: aHR 0.83 (0.71-0.96; p = 0.01) for mortality, 0.92 (0.84-0.99; p = 0.04) for readmission, and 0.92 (0.85-0.99; p = 0.04) for the combined endpoint. We found a differentiated effect of hospitalisation (p < 0.05 for interaction; better post-discharge readmission and combined outcomes in G1), and a trend (p = 0.06) to lower mortality in G1 patients with EAA. Additionally, there were some differences between groups in baseline and acute episode characteristics. Conclusion: AHF triggered by infection is not associated with a higher mid-term mortality and has better post-discharge outcomes; however, the first 3 weeks are an extremely vulnerable period. Since hospitalisation could have a role in limiting adverse post-discharge events, and EAA in reducing mortality, these relationships should be prospectively explored in further studies.

Despite SARS-CoV-19 infection has a stereotypical clinical picture, isolated cases with unusual manifestations have been reported, some of them being well-known to be triggered by viral infections. However, the real frequency in COVID-19 is unknown. Analysing data of 63 822 COVID patients attending 50 Spanish emergency department (ED) during the COVID outbreak, before hospitalisation, we report frequencies of (myo)pericarditis (0.71‰), meningoencephalitis (0.25‰), Guillain–Barré syndrome (0.13‰), acute pancreatitis (0.71‰) and spontaneous pneumothorax (0.57‰). Compared with general ED population, COVID patients developed more frequently Guillain–Barré syndrome (odds ratio (OR) 4.55, 95% confidence interval (CI) 2.09–9.90), spontaneous pneumothorax (OR 1.98, 95% CI 1.40–2.79) and (myo)pericarditis (OR 1.45, 95% CI 1.07–1.97), but less frequently pancreatitis (OR 0.44, 95% CI 0.33–0.60).

Background: coronavirus disease 2019 (COVID-19) can induce an exaggerated inflammatory response. Vitamin D is a key modulator of the immune system. We hypothesized that vitamin D deficiency (VDD) could increase the risk of developing severe COVID-19 infection. Methods: patients with confirmed COVID-19 seen at the emergency department of our hospital with recent measurements of 25(OH)D were recruited. We explored the association of vitamin D deficiency (VDD), defined as 25-hydroxyvitamin D20 ng/mL, with a composite of adverse clinical outcomes. Results: we included 80 patients, of which 31 (39 %) presented the endpoint. VDD tended to predict an increased risk of developing severe COVID-19 after adjusting for age, gender, obesity, cardiac disease, and kidney disease [OR 3.2 (95 % CI: 0.9-11.4), p = 0.07]. Age had a negative interaction with the effect of VDD on the composite outcome (p = 0.03), indicating that the effect was more noticeable at younger ages. Furthermore, male gender was associated with VDD and with severe COVID-19 at younger ages. Conclusions: in this retrospective study, vitamin D deficiency showed a signal of association with severe COVID-19 infection. A significant interaction with age was noted, suggesting VDD may have a greater impact in younger patients. These findings should be confirmed in larger, prospective, adequately powered studies.Antecedentes: la enfermedad por coronavirus 2019 (COVID-19) puede inducir una respuesta inflamatoria exagerada. La vitamina D es un modulador clave del sistema inmune. Planteamos que la deficiencia de vitamina D (VDD) podría aumentar el riesgo de desarrollar infección grave por COVID-19. Métodos: se reclutaron pacientes consecutivos que acudieron al servicio de urgencias de nuestro centro con diagnóstico de COVID-19 confirmado (PCR-COVID-19 positiva) y mediciones recientes de 25(OH)D. Exploramos la asociación de la deficiencia de vitamina D (VDD), definida como una 25-hidroxivitamina D20 ng/ml, con un compuesto de resultados clínicos adversos. Resultados: se incluyeron 80 pacientes, de los cuales 31 (39 %) presentaron el criterio de valoración primario. El VDD tendió a predecir un mayor riesgo de desarrollar COVID-19 grave después de ajustar edad, sexo, obesidad, enfermedad cardíaca y enfermedad renal [OR: 3,2 (IC 95 %: 0,9-11,4), p = 0,07]. La edad tuvo una interacción negativa con el efecto de la VDD en el resultado compuesto (p = 0,03), lo que indica que el efecto fue más notable a edades más tempranas. Además, el género masculino se asoció con la VDD y con la COVID-19 grave en las edades más jóvenes. Conclusiones: en este estudio retrospectivo, la deficiencia de vitamina D mostró una tendencia de asociación con la infección grave por COVID-19. Se observó una interacción significativa con la edad, lo que sugiere que la VDD puede tener un mayor impacto en los pacientes más jóvenes. Estos hallazgos deben confirmarse en estudios más grandes, prospectivos y con potencia adecuada.

Raman spectroscopy is one of the most extended experimental techniques to investigate thin-layered 2D materials. For a complete understanding and modeling of the Raman spectrum of a novel 2D material, it is often necessary to combine the experimental investigation to density functional theory calculations. We provide the experimental proof of the fundamentally different behavior of polar 2D vs 3D systems regarding the effect of the dipole − dipole interactions, which in 2D systems ultimately lead to the absence of optical phonons splitting, otherwise present in 3D materials. We demonstrate that non-analytical corrections (NACs) should not be applied to properly model the Raman spectra of few-layered 2D materials, such as WSe2 and h-BN, corroborating recent theoretical predictions (Sohier et al 2017 Nano Lett. 17 3758–63). Our findings are supported by measurements performed on tilted samples that allow increasing the component of photon momenta in the plane of the flake, thus unambiguously setting the direction of an eventual NAC. We also investigate the influence of the parity of the number of layers and of the type of layer-by-layer stacking on the effect of NACs on the Raman spectra., I Z acknowledges the Swiss National Science Foundation research grant (Project Grant No. 200021_165784). M D L acknowledges support from the Swiss National Science Foundation Ambizione grant (Grant No. PZ00P2_179801). R R acknowledges support from the Ministerio de Economía, Industria y Competitividad (MINECO) under grant FEDER-MAT2017-90024-P and the Severo Ochoa Centres of Excellence Program under grant SEV-2015-0496 and by the Generalitat de Catalunya under Grant Nos. 2017 SGR 1506. X C acknowledges financial support by the Ministerio de Economía, Industria y Competitividad under grant TEC2015-67462-C2-1-R (MINECO/FEDER), the Ministerio de Ciencia, Innovación y Universidades under Grant No. RTI2018-097876-B-C21 (MCIU/AEI/FEDER, UE), and the EU Horizon2020 research and innovation program under Grant No. GrapheneCore2: 785219. C S and D I acknowledge support by the Swiss Nanoscience Institute (SNI), the ERC project TopSupra (787414), the European Union Horizon 2020 research and innovation program under grant agreement No. 785219 (Graphene Flagship), the Swiss National Science Foundation and the Swiss NCCR QSIT. J.M.-S. acknowledges support through a Clarín Marie Curie-COFUND grant from the Government of the Principality of Asturias and the EU (PA-18-ACB17-29), and the Ramón y Cajal Program (RYC2018-026196-I) from the Government of Spain. R T acknowledges support by European Union's Horizon 2020 research and innovation programme (SPQRel grant agreement no. 679183). K W and T T acknowledge support from the Elemental Strategy Initiative conducted by the MEXT, Japan and the CREST(JPMJCR15F3), JST.

Objective: We investigated the incidence, risk factors, clinical characteristics and outcome of spontaneous pneumothorax (SP) in COVID-19 patients attended in emergency departments (ED) before hospitalization. Methods: We retrospectively reviewed all COVID patients diagnosed with SP (case group) in 61 Spanish EDs (20% of Spanish EDs), during the first two months of the COVID outbreak and compared them with two control groups: COVID patients without SP (control group A) and non-COVID patients with SP (control group B). Relative frequencies of SP were estimated in cases and control group B. Unadjusted comparisons between cases and controls included 52 clinical, analytical and radiological characteristics and 4 outcomes. Results: We identified 40 SP in 71,904 patients with COVID-19 attending EDs (0.56‰, 95%CI=0.40-0.76‰). This incidence was higher than that observed in non-COVID patients (387/1,358,134, 0.28‰, 95%CI=0.26-0.32; OR=1.93, 95%CI=1.41-2.71). In COVID patients the characteristics associated with a higher risk of SP were: male sex, shorter symptom length, less fever, greater dyspnea, tachycardia, tachypnea and hypoxia, higher hemoglobin, leukocyte count, D-dimer and LDH, and lower lymphocyte count. Compared to control group B, case group patients were older, more frequently had obesity, asthma, dyspnea, tachycardia, tachypnea, hypoxia and analytical disturbances, and less frequently diabetes mellitus, hypertension, smoker habit, and chest pain. All the outcomes measured, including in-hospital death, were worse in cases than in control groups A and B. Conclusions: SP as a form of COVID presentation is unusual (

Recent discoveries have shown that, when two layers of van der Waals (vdW) materials are superimposed with a relative twist angle between them, the electronic properties of the coupled system can be dramatically altered. Here, we demonstrate that a similar concept can be extended to the optics realm, particularly to propagating phonon polaritons–hybrid light-matter interactions. To do this, we fabricate stacks composed of two twisted slabs of a vdW crystal (α-MoO3) supporting anisotropic phonon polaritons (PhPs), and image the propagation of the latter when launched by localized sources. Our images reveal that, under a critical angle, the PhPs isofrequency curve undergoes a topological transition, in which the propagation of PhPs is strongly guided (canalization regime) along predetermined directions without geometric spreading. These results demonstrate a new degree of freedom (twist angle) for controlling the propagation of polaritons at the nanoscale with potential for nanoimaging, (bio)-sensing, or heat management., J.T.-G. and G.Á.-P. acknowledge support through the Severo Ochoa Program from the Government of the Principality of Asturias (Nos. PA-18-PF-BP17-126 and PA-20-PF-BP19-053, respectively). J.M.-S. acknowledges financial support through the Ramón y Cajal Program from the Government of Spain (RYC2018-026196-I). A.Y.N. acknowledges the Spanish Ministry of Science, Innovation and Universities (national Project No. MAT2017-88358-C3-3-R). P.A.-G. acknowledges support from the European Research Council under starting Grant No. 715496, 2DNANOPTICA.

Strain tuning emerged as an appealing tool for tuning of fundamental optical properties of solid-state quantum emitters. In particular, the wavelength and fine structure of quantum dot states can be tuned using hybrid semiconductor-piezoelectric devices. Here, we show how an applied external stress can directly impact the polarization properties of coupled InAs quantum dot-micropillar cavity systems. In our experiment, we find that we can reversibly tune the anisotropic polarization splitting of the fundamental microcavity mode by approximately 60 μeV. We discuss the origin of this tuning mechanism, which arises from an interplay between elastic deformation and the photoelastic effect in our micropillar. Finally, we exploit this effect to tune the quantum dot polarization optomechanically via the polarization-anisotropic Purcell effect. Our work paves the way for optomechanical and reversible tuning of the polarization and spin properties of light-matter-coupled solid-state systems., We acknowledge funding by the DFG within the Projects No. SCHN1376-5.1 and No. PR1749/1-1. Further, we acknowledge financial support by the State of Bavaria and the German Ministry of Education and Research (BMBF) within the project Q.Link.X (FKZ 16KIS0871). Project HYPER-U-P-S has received funding from the QuantERA ERA-NET Cofund in Quantum Technologies implemented within the European Union’s Horizon 2020 Programme. A.P. would like to thank the Swedish Research Council and Carl Tryggers Stiftelse. J.M.-S. acknowledges financial support from the Ramón y Cajal Program from the Government of Spain (RYC2018-026196-I) and the ClarínProgramme from the Government of the Principality of Asturias and a Marie Curie-COFUND Grant (PA-18-ACB17-29).

Among the most common few-layers transition metal dichalcogenides (TMDs), WSe2 is the most challenging material from the lattice dynamics point of view. Indeed, for a long time the main two phonon modes (A1g and ) have been wrongly assigned. In the last few years, these two modes have been properly interpreted, and their quasi-degeneracy in the monolayer has been used for its identification. In this work, we show that this approach has a limited validity and we propose an alternative, more general approach, based on multi-phonon bands. Moreover, we show and interpret all the peaks (about 40) appearing in the Raman spectra of monolayers, bilayers, and trilayers of WSe2 by combining experimental wavelength- and polarization-dependent Raman studies with density-functional theory calculations providing the phonon dispersions, the polarization-resolved first-order Raman spectra, and the two-phonon density of states. This complete study not only offers a method to distinguish between monolayers, bilayers, and trilayers with no need of optical images and atomic force microscopy, but it also sheds light on the interpretation of single and multi-phonon bands appearing in the inelastic light scattering experiments of layered WSe2; some of these bands were never observed before, and some were observed and uncertainly assigned. We promote the full understanding of the lattice dynamics of this material that is crucial for the realization of optoelectronics devices and of novel phononic metamaterials, such as TMDs superlattices., This project has received funding from the Swiss National Science Foundation research grant (Project Grant No. 200021_165784). MDL acknowledges support from the Swiss National Science Foundation Ambizione grant (Grant No. PZ00P2_179801). RR acknowledges financial support by the Ministerio de Economía, Industria y Competitividad (MINECO) under grant FEDER-MAT2017-90024-P and the Severo Ochoa Centres of Excellence Program under grant SEV-2015-0496 and by the Generalitat de Catalunya under Grant No. 2017 SGR 1506. XC acknowledges financial support by the Ministerio de Economía, Industria y Competitividad under grant TEC2015-67462-C2-1-R (MINECO/FEDER), the Ministerio de Ciencia, Innovación y Universidades under Grant No. RTI2018-097876-B-C21 (MCIU/AEI/FEDER, UE), and the EU Horizon2020 research and innovation program under Grant No. GrapheneCore2 785219. MLS is funded through a Juan de la Cierva fellowship. JM-S acknowledges support through the Clarín Programme from the Government of the Principality of Asturias and a Marie Curie-COFUND European Grant (PA-18-ACB17-29). RT Acknowledges support by European Union's Horizon 2020 research and innovation programme (SPQRel Grant Agreement No. 679183).

Introduction The presence of iron deficiency (ID) in patients with acute heart failure (AHF) is high. There are few studies on the characteristics of these patients and the safety of ferric carboxymaltose administration (FCM). Objective Study the differences among patients with AHF based on the presence and type of ID as well as the safety of FCM administration in these patients. Method The AHF-ID study is a multicentre, analytical, prospective follow-up cohort including patients admitted to six Spanish hospitals for AHF. ID was defined as serum ferritin

The biaxial van der Waals semiconductor α-phase molybdenum trioxide (α-MoO

To describe the pattern of care usually given to patients with acute heart failure (AHF) who are taking sacubitril/valsartan (SV) and to explore the effects of care characteristics on clinical outcomes.Exploratory study of AHF cases in patients taking SV who were included in the register for the Epidemiology of Acute Heart Failure in Emergency Departments during the sixth period of data collection (EAHFE-6). We extracted baseline and episode variables and information related to SV treatment. We also analyzed associations between the discontinuation of SV therapy and adverse events within 180 days (all-cause mortality) and after discharge (emergency revisits, admission for AHF, death from any cause, or a composite event).. Fifty patients on SV were included. The median time on SV therapy was 81 days (interquartile range, 43-284 days). SV was discontinued in 19 cases (38%; 5 in the emergency department and 14 on the ward). Sixteen records specified the reason for discontinuing SV: renal insufficiency, 4 cases; arterial hypotension, 3; weakness/dizziness, 3; and exacerbated AHF, 3. SV discontinuation was associated with older age, absence of treatment with a betablocker, and hyperkalemia. The EAHFE-6 cases did not reveal significant differences related to SV discontinuation with respect to the rates of adverse events within 180 days or on discharge after the index event.Long-term SV therapy is discontinued in over a third of patients who present with exacerbated AHF even though no association with clinical outcomes could be identified.Identificar el patrón de práctica clínica habitual respecto al tratamiento crónico con sacubitrilo-valsartán (SV) durante los episodios de insuficiencia cardiaca aguda (ICA), sus determinantes y su efecto sobre la evolución.Estudio exploratorio de pacientes con ICA incluidos en el Registro EAHFE-6 en tratamiento crónico con SV. Se recogieron características basales, del episodio y del tratamiento con SV, y se identificaron factores relacionados con la interrupción de SV y su asociación con eventos adversos 180 días postevento índice (mortalidad por cualquier causa) y postalta (reconsulta a urgencias u hospitalización por ICA, muerte o evento combinado).Se incluyeron 50 pacientes (mediana desde inicio de SV: 81 días; RIC: 43-284) y SV se interrumpió en 19 casos (38%; 5 en urgencias, 14 en hospitalización). Se identificó un motivo de retirada en 16 casos (4 por insuficiencia renal; y 3 por hipotensión arterial, hiperpotasemia, debilidad/mareo y empeoramiento de ICA, respectivamente). La retirada de SV se asoció con edad avanzada, no estar en tratamiento con betabloqueantes e hiperpotasemia. No hubo diferencias significativas entre grupos en eventos adversos a los 180 días postevento índice o postalta.En los pacientes en tratamiento crónico con SV que presentan ICA, este es suspendido en más de un tercio de casos, si bien ello no se asocia con cambios evolutivos.

Phonon polaritons-light coupled to lattice vibrations-in polar van der Waals crystals are promising candidates for controlling the flow of energy on the nanoscale due to their strong field confinement, anisotropic propagation and ultra-long lifetime in the picosecond range

Increasing numbers of older persons are being treated by specialties other than Geriatric Medicine. Specialists turn to Geriatric Teams when they need to accurately stratify their patients' risk and prognosis, predict the potential impact of their, often, invasive interventions, optimise their clinical status, and contribute to discharge planning. Oncology and Haematology, Cardiology, General Surgery, and other surgical departments are examples where such collaborative working is already established, to a varying extent. The use of the term "Cross-speciality Geriatrics" is suggested when geriatric care is provided in clinical areas traditionally outside the reach of Geriatric Teams. The core principles of Geriatric Medicine (comprehensive geriatric assessment, patient-centred multidisciplinary targeted interventions, and input at point-of-care) are adapted to the specifics of each specialty and applied to frail older patients in order to deliver a holistic assessment/treatment, better patient/carer experience, and improved clinical outcomes. Using Comprehensive Geriatric Assessment methodology and Frailty scoring in such patients provides invaluable prognostic information, helps in decision making, and enables personalised treatment strategies. There is evidence that such an approach improves the efficiency of health care systems and patient outcomes. This article includes a review of these concepts, describes existing models of care, presents the most commonly used clinical tools, and offers examples of excellence in this new era of geriatric care. In an ever ageing population it is likely that teams will be asked to provide Cross-specialty Geriatrics across different Health Care systems. The fundamentals for its implementation are in place, but further evidence is required to guide future development and consolidation, making it one of the most important challenges for Geriatrics in the coming years.

Until now, high-sensitivity cardiac troponin (hs-cTn) assays were mainly developed for large central laboratory platforms.This study aimed to assess the clinical performance of a point-of-care (POC)-hs-cTnI assay in patients with suspected myocardial infarction (MI).This study enrolled patients presenting to the emergency department with symptoms suggestive of MI. Two cardiologists centrally adjudicated the final diagnosis using all clinical data including cardiac imaging. The primary objective was to directly compare diagnostic accuracy of POC-hs-cTnI-TriageTrue versus best-validated central laboratory assays. Secondary objectives included the derivation and validation of a POC-hs-cTnI-TriageTrue-specific 0/1-h algorithm.MI was the adjudicated final diagnosis in 178 of 1,261 patients (14%). The area under the curve (AUC) for POC-hs-cTnI-TriageTrue at presentation was 0.95 (95% confidence interval [CI]: 0.93 to 0.96) and was at least comparable to hs-cTnT-Elecsys (AUC: 0.94; 95% CI: 0.93 to 0.96; p = 0.213) and hs-cTnI-Architect (AUC: 0.92; 95% CI: 0.90 to 0.93; p 0.001). A single cutoff concentration 3 ng/l at presentation identified 45% of patients at low risk with a negative predictive value (NPV) of 100% (95% CI: 99.4% to 100%). A single cutoff concentration60 ng/l identified patients at high risk with a positive predictive value (PPV) of 76.8% (95% CI: 68.9% to 83.6%). The 0/1-h algorithm ruled out 55% of patients (NPV: 100%; 95% CI: 98.8% to 100%), and ruled in 18% of patients (PPV: 76.8%; 95% CI: 67.2% to 84.7%). Ruled-out patients had cumulative event rates of 0% at 30 days and 1.6% at 2 years. This study confirmed these findings in a secondary analysis including hs-cTnI-Architect for central adjudication.The POC-hs-cTnI-TriageTrue assay provides high diagnostic accuracy in patients with suspected MI with a clinical performance that is at least comparable to that of best-validated central laboratory assays. (Advantageous Predictors of Acute Coronary Syndromes Evaluation Study [APACE]; NCT00470587).

The appearance of single photon sources in atomically thin semiconductors holds great promises for the development of a flexible and ultracompact quantum technology in which elastic strain engineering can be used to tailor their emission properties. Here, we show a compact and hybrid two-dimensional semiconductor-piezoelectric device that allows for controlling the energy of single photons emitted by quantum emitters localized in wrinkled WSe2 monolayers. We demonstrate that strain fields exerted by the piezoelectric device can be used to tune the energy of localized excitons in WSe2 up to 18 meV in a reversible manner while leaving the single photon purity unaffected over a wide range. Interestingly, we find that the magnitude and, in particular, the sign of the energy shift as a function of stress is emitter dependent. With the help of finite element simulations we suggest a simple model that explains our experimental observations and, furthermore, discloses that the type of strain (tensile or compressive) experienced by the quantum emitters strongly depends on their localization across the wrinkles. Our findings are of strong relevance for the practical implementation of single photon devices based on two-dimensional materials as well as for understanding the effects of strain on their emission properties., J.M.-S. acknowledges support through the Cların Programme from the Government of the Principality of Asturias and a Marie Curie-COFUND European grant (PA-18-ACB17-29). J.T.-G. acknowledges support through the Severo Ochoa Program from the Goverment of the Principality of Asturias (PA-18-PF-BP17-126). P.A.-G. acknowledges support from the European Research Council under Starting Grant 715496, 2DNANOPTICA. R.T., D.T., and M.S. acknowledge support by the European Research council (ERC) under the European Union’s Horizon 2020 Research and Innovation Programme (SPQRel, Grant agreement No. 679183). C.S. acknowledges support by the European Research council (ERC) under the European Union’s Horizon 2020 Research and Innovation Programme (UnLiMIt-2D, Grant agreement No. 679288). A.R. acknowledges support from the Linz Institute of Technology (LIT). The Würzburg group acknowledges support by the State of Bavaria. S.T. acknowledges support from NSF DMR-1552220, NSF CMMI-1933214 and NSF DMR-1838443.

Background The MEESSI-acute heart failure (AHF) risk score has high accuracy in the prediction of 30-day mortality in patients presenting with AHF and may be considered the current gold standard for this indication. Purpose As the original MEESSI model does not include measurements of inflammatory biomarkers, the impact of interleukin-6 or C-reactive protein (CRP) on the model's goodness of fit is unknown. Methods In a prospective multicenter diagnostic study the presence of AHF was centrally adjudicated by two independent cardiologists among patients presenting with acute dyspnea to the ED. The MEESSI-AHF risk score was calculated using a recalibrated model containing 12 independent risk factors. The incremental value of interleukin-6 and CRP was examined by the use of logistic regression analysis and enter method variable selection with an entry criterion of p Results In 1247 patients with adjudicated AHF, the MEESSI-AHF risk score was calculated. Of these, 1113 patients (89.3%) had available measurements of interleukin-6 and CRP. In the logistic regression analysis both biomarkers had a highly significant impact on the MEESSI model (p Discrimination original_updated Conclusion There is significant incremental value of interleukin-6 and CRP to the MEESSI score as indicated by the improved goodness of fit compared to the original model. Acknowledgement/Funding European Union, the Swiss National Science Foundation, the Swiss Heart Foundation, the Cardiovascular Research Foundation Basel

Background Lately, the novel high-sensitivity cardiac troponin I (hs-cTnI) Access assay was developed. Its clinical performance in patients presenting with chest pain to the emergency department (ED) is unknown. Purpose To clinically validate the novel hs-cTnI-Access assay and to derive and validate an assay specific 0/1h-algorithm accordingly to the European Society of Cardiology (ESC) recommendations. Methods In a prospective international multicentre study we enrolled patients presenting to the emergency department with symptoms suggestive of acute myocardial infarction (AMI). Final diagnoses were centrally adjudicated by two independent cardiologists including all clinical information including cardiac imaging twice: first, using serial hs-cTnT (Elecsys, primary analysis) and second, using hs-cTnI (Architect, secondary analysis) measurements in addition to the clinically used (hs)-cTn. Hs-cTnI-Access was measured at presentation and at 1h. Primary objective was a direct comparison of diagnostic accuracy as quantified by the area under the receiver-operating-characteristic curve (AUC) of hs-cTnI-Access versus the two established hs-cTn assays (hs-cTnT-Elecsys, hs-cTnI-Architect). Secondary objectives included the derivation and internal validation of an hs-cTnI-Access specific 0/1h-algorithm. Results AMI was the adjudicated final diagnosis in 243/1579 (15.4%) patients. The AUC at presentation for hs-cTnI-Access was 0.95 (95% CI, 0.94–0.96), significantly higher as hs-cTnI-Architect (0.92 [95% CI, 0.91–0.94; p Performance of the 0/1h-algorithm Conclusions Diagnostic accuracy of the novel hs-cTnI-Access assay is excellent and at least comparable to the two established hs-cTn assays. The assay-specific 0/1h-algorithm allows a safe rule-out and accurate rule-in of MI in about 75% of patients within 1-hour after presentation to the ED. Survival of patients ruled-out by the 0/1h-algorithm was very high. Acknowledgement/Funding Swiss National Science Foundation, the Swiss Heart Foundation, the KTI, the European Union, the Stiftung für kardiovaskuläre Forschung Basel

Background The novel high-sensitivity cardiac troponin I (hs-cTnI)-Vitros assay was developed recently. Before its possible implementation into routine clinical care for triage of chest pain patients, its performance needs clinical validation. Purpose To clinically validate hs-cTnI-Vitros and to derive and validate an assay-specific 0/1h-algorithm following the European Society of Cardiology (ESC) recommendations. Methods In a prospective international multicentre study (12 centres in 5 European countries) we enrolled patients presenting to the emergency department with symptoms suggestive of acute myocardial infarction (AMI). Final diagnoses were centrally adjudicated by two independent cardiologists including all clinical information including cardiac imaging twice: first, using serial hs-cTnT (Elecsys, primary analysis) and second, using hs-cTnI (Architect, secondary analysis) measurements in addition to the clinically used (hs)-cTn. Hs-cTnI-Vitros was measured at presentation and at 1h in a blinded fashion. Primary objective was direct comparison of diagnostic accuracy as quantified by the area under the receiver-operating-characteristic curve (AUC) of hs-cTnI-Vitros versus the two established hs-cTn assays (hs-cTnT-Elecsys, hs-cTnI-Architect). Secondary objectives included the derivation and validation of a hs-cTnI-Vitros specific 0/1h-algorithm. Results AMI was the adjudicated final diagnosis in 158/1231 (13%) patients. The AUC at presentation for hs-cTnI-Vitros was 0.95 (95% CI, 0.93–0.96), and significantly higher as hs-cTnT-Elecsys (0.94 [95% CI, 0.92–0.95; p=0.01]) and hs-cTnI-Architect (0.92 [95% CI, 0.90–0.94; p ROC Curves for the 3 hs-cTn assays at 0h Conclusions The novel hs-cTnI-Vitros assay has even higher diagnostic accuracy as the current gold-standards hs-cTnT and hs-cTnI. The hs-cTnI-Vitros specific 0/1h-algorithms allows a safe rule-out and accurate rule-in of AMI in about 70% of patients within 1h after presentation to the ED. Acknowledgement/Funding Swiss National Science Foundation, the Swiss Heart Foundation, the KTI, the European Union, the Stiftung für kardiovaskuläre Forschung Basel

Release kinetics of high-sensitivity cardiac troponin (hs-cTn) T and I in patients with acute myocardial infarction (AMI) are incompletely understood. We aimed to assess whether hs-cTnT/I release in early AMI is near linear.In a prospective diagnostic multicenter study the acute release of hs-cTnT and hs-cTnI within 1 and 2hours from presentation to the emergency department was quantified using 3 hs-cTnT/I assays in patients with suspected AMI. The primary endpoint was correlation between hs-cTn changes from presentation to 1 hour vs changes from presentation to 2hours, among all AMI patients and different prespecified subgroups. The final diagnosis was adjudicated by 2 independent cardiologists, based on serial hs-cTnT from the serial study blood samples and additional locally measured hs-cTn values.Among 2437 patients with complete hs-cTnT data, AMI was the adjudicated diagnosis in 376 patients (15%). For hs-cTnT, the correlation coefficient between 0- to 1-hour change and 0- to 2 hour change was 0.931 (95%CI, 0.916-0.944), P.001. Similar findings were obtained with hs-cTnI (Architect) with correlation coefficients between 0- to 1-hour change and 0- to 2 hour change of 0.969 and hs-cTnI (Centaur) of 0.934 (P.001 for both). Findings were consistent among type 1 and type 2 AMI and in the subgroup of patients presenting very early after chest pain onset.Patients presenting with early AMI showed a near linear release of hs-cTnT and hs-cTnI. This near linearity provides the pathophysiological basis for rapid diagnostic algorithms using 0- to 1-hour changes as surrogates for 0- to 2 hour or 0- to 3 hour changes. Registered at ClinicalTrials.gov (Identifier: NCT00470587).

The appearance of single photon sources in atomically thin semiconductors holds great promises for the development of a flexible and ultracompact quantum technology in which elastic strain engineering can be used to tailor their emission properties. Here, we show a compact and hybrid two-dimensional semiconductor-piezoelectric device that allows for controlling the energy of single photons emitted by quantum emitters localized in wrinkled WSe

Early and accurate detection of short-term major adverse cardiac events (MACE) in patients with suspected acute myocardial infarction (AMI) is an unmet clinical need.; The goal of this study was to test the hypothesis that adding clinical judgment and electrocardiogram findings to the European Society of Cardiology (ESC) high-sensitivity cardiac troponin (hs-cTn) measurement at presentation and after 1 h (ESC hs-cTn 0/1 h algorithm) would further improve its performance to predict MACE.; Patients presenting to an emergency department with suspected AMI were enrolled in a prospective, multicenter diagnostic study. The primary endpoint was MACE, including all-cause death, cardiac arrest, AMI, cardiogenic shock, sustained ventricular arrhythmia, and high-grade atrioventricular block within 30 days including index events. The secondary endpoint was MACE + unstable angina (UA) receiving early (≤24 h) revascularization.; Among 3,123 patients, the ESC hs-cTnT 0/1 h algorithm triaged significantly more patients toward rule-out compared with the extended algorithm (60%; 95% CI: 59% to 62% vs. 45%; 95% CI: 43% to 46%; p < 0.001), while maintaining similar 30-day MACE rates (0.6%; 95% CI: 0.3% to 1.1% vs. 0.4%; 95% CI: 0.1% to 0.9%; p = 0.429), resulting in a similar negative predictive value (99.4%; 95% CI: 98.9% to 99.6% vs. 99.6%; 95% CI: 99.2% to 99.8%; p = 0.097). The ESC hs-cTnT 0/1 h algorithm ruled-in fewer patients (16%; 95% CI: 14.9% to 17.5% vs. 26%; 95% CI: 24.2% to 27.2%; p < 0.001) compared with the extended algorithm, albeit with a higher positive predictive value (76.6%; 95% CI: 72.8% to 80.1% vs. 59%; 95% CI: 55.5% to 62.3%; p < 0.001). For 30-day MACE + UA, the ESC hs-cTnT 0/1 h algorithm had a higher positive predictive value for rule-in, whereas the extended algorithm had a higher negative predictive value for the rule-out. Similar findings emerged when using hs-cTnI.; The ESC hs-cTn 0/1 h algorithm better balanced efficacy and safety in the prediction of MACE, whereas the extended algorithm is the preferred option for the rule-out of 30-day MACE + UA. (Advantageous Predictors of Acute Coronary Syndromes Evaluation [APACE]; NCT00470587).

The aim was to develop a predictive model of infection by multidrug-resistant microorganisms (MDRO). A national, retrospective cohort study was carried out including all patients attended for an infectious disease in 54 Spanish Emergency Departments (ED), in whom a microbiological isolation was available from a culture obtained during their attention in the ED. A MDRO infection prediction model was created in a derivation cohort using backward logistic regression. Those variables significant at p0.05 assigned an integer score proportional to the regression coefficient. The model was then internally validated by k-fold cross-validation and in the validation cohort. A total of 5460 patients were included; 1345 (24.6%) were considered to have a MDRO infection. Twelve independent risk factors were identified in the derivation cohort and were combined into an overall score, the ATM (assessment of threat for MDRO) score. The model achieved an area under the curve-receiver operating curve of 0.76 (CI 95% 0.74-0.78) in the derivation cohort and 0.72 (CI 95% 0.70-0.75) in the validation cohort (p = 0.0584). Patients were then split into 6 risk categories and had the following rates of risk: 7% (0-2 points), 16% (3-5 points), 24% (6-9 points), 33% (10-14 points), 47% (15-21 points), and 71% (21 points). Findings were similar in the validation cohort. Several patient-specific factors were independently associated with MDRO infection risk. When integrated into a clinical prediction rule, higher risk scores and risk classes were related to an increased risk for MDRO infection. This clinical prediction rule could be used by providers to identify patients at high risk and help to guide antibiotic strategy decisions, while accounting for clinical judgment.

Pulmonary congestion (PC) is associated with an increased risk of hospitalization and death in patients with heart failure (HF). Lung ultrasound has shown to be highly sensitive for detecting PC in HF. The aim of this study is to evaluate whether lung ultrasound–guided therapy improves 6-month outcomes in patients with HF compared with conventional treatment. Randomized, multicenter, single-blind clinical trial in patients discharged from Internal Medicine Departments after hospitalization for decompensated HF. Participants will be assigned 1:1 to receive treatment guided according to the presence of lung ultrasound signs of congestion (semi-quantitative evaluation of B lines and the presence of pleural effusion) versus clinical assessment of congestion. The primary outcome is the combination of cardiovascular death and readmission for HF at 6 months. The results of this study will provide more evidence about the impact of lung ultrasound on treatment monitoring in patients with chronic HF.

Objective: To study the outcomes of patients with acute heart failure (AHF) presenting renal dysfunction (RD) or hyperkalaemia (Hk) alone or in combination. Method: We analysed the data of the EAHFE registry, a multicentre, non interventionist cohort with prospective follow-up of patients with AHF. Four groups were defined based on the presence or not of RD or Hk alone or in combination. The primary endpoint was 30-day all-cause mortality. Results: A total of 11,935 of the 13,791 patients included in the EAHFE registry were analysed. Of these, 5088 (42.6%) did not have RD or Hk (NoRD-NoHk), 150 (1.3%) had no RD but had Hk (NoRD-Hk), 6012 (50.4%) had RD but not Hk (RD-NoHk) and 685 (5.7%) had both RD and Hk (RD-Hk). Thirty-day all-cause mortality was greatest in the RD-Hk group with an adjusted Hazard Ratio (HR) of 2.44 (confidence interval 95% [CI95%] 1.67-3.55; p < 0.001) and in the RD-NoHk group with an adjusted HR of 1.34 (CI95% 1.04-1.71; p = 0.022). There were no significant differences in in-hospital mortality and reconsultation at 30 days for HF. For the combined endpoint of 30-day all-cause mortality the adjusted HR was 1.33 (CI95% 1.04-1.70); (p = 0.021) for the RD-Hk group. Conclusions: The association of 30-day all-cause mortality with the presence of RD and Hk in patients presenting AHF at admission is greater than in those without this combination.

Lung ultrasound is a useful tool for the assessment of patients with both acute and chronic heart failure, but the use of different image acquisition methods, inconsistent reporting of the technique employed and variable quantification of 'B-lines,' have all made it difficult to compare published reports. We therefore need to ensure that future studies utilizing lung ultrasound in the assessment of heart failure adopt a standardized approach to reporting the quantification of pulmonary congestion. Strategies to improve patient care by use of lung ultrasound in the assessment of heart failure have been difficult to develop. In the present document, key aspects of standardization are discussed, including equipment used, number of chest zones assessed, the method of quantifying B-lines, the presence and timing of additional investigations (e.g. natriuretic peptides and echocardiography) and the impact of therapy. This consensus report includes a checklist to provide standardization in the preparation, review and analysis of manuscripts. This will serve as a guide for investigators and clinicians and enhance the quality and transparency of lung ultrasound research.

BACKGROUND We desired to determine cardiac troponin (cTn) concentrations necessary to achieve a positive predictive value (PPV) of ≥75% for acute myocardial infarction (AMI) to justify immediate admission of patients to a monitored unit and, in general, early coronary angiography. METHODS In a prospective multicenter diagnostic study enrolling patients presenting to the emergency department with symptoms suggestive of AMI, final diagnoses were adjudicated by 2 independent cardiologists based on clinical information including cardiac imaging. cTn concentrations were measured using 5 different sensitive and high-sensitivity cTn (hs-cTn) assays in a blinded fashion at presentation and serially thereafter. The diagnostic end point was PPV for rule-in of AMI of initial cTn concentrations alone and in combination with early changes. RESULTS Among 3828 patients, 616 (16%) had an AMI. At presentation, 7% to 14% of patients had cTnT/I concentrations associated with a PPV of ≥75%. Adding absolute or relative changes did not significantly further increase the PPV. PPVs increased from 46.5% (95% CI, 43.6–49.4) for hs-cTnT at presentation >14 ng/L to 78.9% (95% CI, 74.7–82.5) for >52 ng/L (P < 0.001), whereas PPVs in higher hs-cTnT strata remained largely unchanged [e.g., 82.4% (95% CI, 77.5–86.7) for >80 ng/L vs 83.9% (95% CI, 76.0–90.1) for >200 ng/L (P = 0.72)]. The addition of early changes in hs-cTnT further increased the PPV up to 60 ng/L, but not for higher concentrations. CONCLUSIONS Serial sampling does not seem necessary for predicting AMI and concurrent decision-making in about 10% of patients, as it only marginally increases the PPV for AMI and not in a statistically or clinically significant way. ClinicalTrials.gov Identifier NCT00470587.

Background The prevalence of pulmonary embolism (PE) in patients presenting with syncope to the emergency department (ED) is largely unknown. This information, however, is necessary to balance the potential medical benefit or harm of systematic PE screening in patients presenting with syncope to the ED. Objectives This study sought to determine the prevalence of PE in patients with syncope. Methods Unselected patients presenting with syncope to the ED were prospectively enrolled in a diagnostic multicenter study. Pre-test clinical probability for PE was assessed using the 2-level Wells score and the results of D-dimer testing using age-adapted cutoffs. Presence of PE was evaluated by imaging modalities, when ordered as part of the clinical assessment by the treating ED physician or by long-term follow-up data. Results Long-term follow-up was complete in 1,380 patients (99%) at 360 days and 1,156 patients (83%) at 720 days. Among 1,397 patients presenting with syncope to the ED, PE was detected at presentation in 19 patients (1.4%; 95% confidence interval [CI]: 0.87% to 2.11%). The incidence of new PEs or cardiovascular death during 2-year follow-up was 0.9% (95% CI: 0.5% to 1.5%). In the subgroup of patients hospitalized (47%), PE was detected at presentation in 15 patients (2.3%; 95% CI: 1.4% to 3.7%). The incidence of new PEs or cardiovascular death during 2-year follow-up was 0.9% (95% CI: 0.4% to 2.0%). Conclusions PE seems to be a rather uncommon cause of syncope among patients presenting to the ED. Therefore, systematic PE-screening in all patients with syncope does not seem warranted. (BAsel Syncope EvaLuation Study [BASEL IX]; NCT01548352)

Importance Rapid and accurate noninvasive discrimination of type 2 myocardial infarction (T2MI), which is because of a supply-demand mismatch, from type 1 myocardial infarction (T1MI), which arises via plaque rupture, is essential, because treatment differs substantially. Unfortunately, this is a major unmet clinical need, because even high-sensitivity cardiac troponin (hs-cTn) measurement provides only modest accuracy. Objective To test the hypothesis that novel cardiovascular biomarkers quantifying different pathophysiological pathways involved in T2MI and/or T1MI may aid physicians in the rapid discrimination of T2MI vs T1MI. Design, Setting, and Participants This international, multicenter prospective diagnostic study was conducted in 12 emergency departments in 5 countries (Switzerland, Spain, Italy, Poland, and the Czech Republic) with patients presenting with acute chest discomfort to the emergency departments. The study quantified the discrimination of hs-cTn T, hs-cTn I, and 17 novel cardiovascular biomarkers measured in subsets of consecutively enrolled patients against a reference standard (final diagnosis), centrally adjudicated by 2 independent cardiologists according to the fourth universal definition of MI, using all information, including cardiac imaging and serial measurements of hs-cTnT or hs-cTnI. Results Among 5887 patients, 1106 (18.8%) had an adjudicated final diagnosis of MI; of these, 860 patients (77.8%) had T1MI, and 246 patients (22.2%) had T2MI. Patients with T2MI vs those with T1MI had lower concentrations of biomarkers quantifying cardiomyocyte injury hs-cTnT (median [interquartile range (IQR)], 30 (17-55) ng/L vs 58 (28-150) ng/L), hs-cTnI (median [IQR], 23 [10-83] ng/L vs 115 [28-576] ng/L;P Conclusions and Relevance In this study, biomarkers quantifying myocardial injury, endothelial dysfunction, microvascular dysfunction, and/or hemodynamic stress provided modest discrimination in early, noninvasive diagnosis of T2MI.

Introduction: Inflammation is a fundamental phenomenon in heart failure, but the prognostic or therapeutic role of markers such as interleukin-6 (IL-6) has not yet been clarified. The objective of this study is to describe the clinical profile of patients with elevated IL-6 and determine if they have worse clinical outcomes. Methods: A retrospective c.ohort observational study including 78 patients with heart failure followed up at the Heart Failure Outpatient Clinic of the Internal Medicine Department. IL-6 was determined in all patients, who were then assigned into two groups according to IL-6 level (normal or high). Clinical and prognostic data were collected to determine the differences in both groups. Results: The average age was 79 years, 60% female. A total of 53.8% of the patients had elevated IL-6 (group 2). Patients with elevated IL-6 presented more frequently with anemia mellitus (64.3% vs. 41.7%, p = 0.046), atrial fibrillation (83.3% vs. 61.9% p = 0.036), dyslipidemia (76.2% vs. 58.2%, p = 0.03), higher creatinine levels (1.35 mg/dL vs. 1.08 mg/dL, p = 0.024), lower glomerular filtration rate (43.6 mL/min/m2 vs. 59.9 mL/min/m2, p = 0.007), and anemia 25% vs. 52.4% p = 0.014. The factors independently associated with the increase in IL-6 were anemia 3.513 (1.163–10.607) and renal failure 0.963 (0.936–0.991), p &lt, 0.05. Mortality was higher in the group with elevated IL-6 levels (16% vs. 2%, p = 0.044) with a log-rank p = 0.027 in the Kaplan–Meier curve. Conclusion: Patients with heart failure and elevated IL-6 most often have atrial fibrillation, diabetes mellitus, dyslipidemia, anemia, and renal failure. In addition, mortality was higher and a tendency of higher hospital admission was observed in stable HF patients with elevated IL-6.

Evaluate the use of different cardiac troponin (cTn) immunoassays and the prognostic value of increased cTn values in patients diagnosed with acute heart failure (AHF) in the emergency department (ED).The epidemiology acute heart failure emergency-TROPonin in acute heart failure2 (EAHFE-TROPICA2) is a retrospective study including patients with AHF admitted in 34 Spanish EDs with cTn values determined in the ED. We studied the prevalence of elevated troponin (value above the established reference limit) for the different types of troponin. We also assessed crude and adjusted primary (1-year all-cause death) and secondary (30 d ED revisit due to AHF) outcomes for every type of cTn and different magnitudes of troponin elevation.We analysed 4705 episodes of AHF. Troponin was elevated in 48.4% of the cases (25.3% in cTnI, 37.9% in cTnT and 82.2% in hs-cTnT). Mortality at one year was higher in patients with elevated troponin (adjusted HR 1.61; CI 95% 1.38-1.88) regardless of the type of cTn determined. Elevated troponin was not related to ED revisit within 30 d after discharge (1.01; 0.87-1.19).The use of conventional troponin in the ED is useful to predict one-year mortality in patients with AHF. Highly sensitive cTnT (hs-cTnT) elevations less than double the reference value have no impact on patient outcome.

Resumen Objetivo Determinar el perfil clinico y el manejo inicial de los pacientes ancianos atendidos por infeccion aguda en los servicios de Urgencias hospitalarios espanoles y estudiar si existen diferencias en relacion con los adultos mas jovenes. Metodologia Estudio descriptivo transversal multicentrico a partir de los datos del registro INFURG-SEMES, que incluye a 79.654 pacientes de 15 anos o mas atendidos por una infeccion aguda en 49 servicios de Urgencias hospitalarios espanoles entre el 10 octubre del 2010 y el 20 de septiembre del 2011. Se recogieron variables demograficas, del perfil clinico y de la atencion en Urgencias. La variable clasificadora fue tener 65 anos o mas. Resultados Del total de 11.399 casos, 4.255 (37,3%) tenian 65 anos o mas. Al comparar a los ancianos con los adultos mas jovenes, se encontraron diferencias estadisticamente significativas en cuanto a la presencia de alta comorbilidad (p Conclusiones Existen importantes diferencias en el perfil y el manejo de los pacientes con infeccion aguda atendidos en los SUH espanoles en funcion de la edad, que deben ser tenidas en cuenta de cara a desarrollar estrategias de mejora de la calidad y posibles lineas de investigacion futura.

Fundamento: Investigar el comportamiento de varios indicadores de producción y repercusión científicos en un grupo de investigadores clínicos españoles y valorar su utilidad para interpretar trayectorias individuales o colectivas. Material y método: Estudio piloto ecológico unicéntrico en un grupo de médicos con trayectoria investigadora consolidada. A través de Science Citation Index Expanded se obtuvo el número de trabajos publicados por cada autor (indicador de producción) y el número de citas, el factor de impacto y el índice h (indicadores de repercusión). Los indicadores se calcularon para cada año de la trayectoria investigadora. Se relacionó la experiencia del investigador y el valor del indicador alcanzado, la relación entre indicadores y la evolución temporal, tanto individual como colectivamente. Resultados: Se analizaron 35 investigadores, con experiencia de 28,4 (9,6) años. El índice h fue el indicador con coeficiente de variación más bajo. La relación entre indicadores y experiencia investigadora es significativa pero discreta (R² entre 0,15-0,22). Los cuatro indicadores mostraron buenas correlaciones entre ellos. La evolución temporal de los indicadores, tanto individual como colectiva, se ajustó mejor a una función polinómica de segundo grado que a una lineal: individualmente, todos los autores obtuvieron R²>0,90 en todos los indicadores; el mejor ajuste se produjo con el índice h (R²=0,61). En función del indicador utilizado, pueden producirse variaciones sustanciales en la ordenación de los investigadores. Conclusiones: Es posible describir, en una muestra relativamente homogénea de investigadores, un modelo de evolución temporal de los indicadores de producción y repercusión, y el índice h parece mostrar ciertas ventajas respecto al resto. Este análisis podría convertirse en una herramienta predictiva del rendimiento a alcanzar por investigadores individuales y para grupos homogéneos de investigadores correspondientes a un mismo nicho científico. Background: To study the behaviour of several indicators of scientific production and repercussion in a group of Spanish clinical researchers and to evaluate their possible utility for interpreting individual or collective scientific pathways. Method: We performed a unicentric, ecological pilot study involving a group of physicians with consolidated research experience. From the Science Citation Index Expanded (SCI-Expanded) database, we obtained the number of publications of each author (indicator of production) and the number of citations, impact factor and h index (indicators of repercussion). These indicators were calculated individually for each of the years of research experience and we assessed the relationship between the experience of the researcher and the value of the indicator achieved, the relationship between these indicators themselves, and their temporal evolution, both individually and for the entire group. Results: We analysed 35 researchers with a research experience of 28.4 (9.6) years. The h index showed the lowest coefficient of variance. The relationship between the indicators and research experience was significant, albeit modest (R² between 0.15-0.22). The 4 indicators showed good correlations. The temporal evolution of the indicators, both individual and collective, adjusted better to a second grade polynomial than a linear function: individually, all the authors obtained R²>0.90 in all the indicators; together the best adjustment was produced with the h index (R²=0.61). Based on the indicator used, substantial variations may be produced in the researchers' ranking. Conclusions: A model of the temporal evolution of the indicators of production and repercussion can be described in a relatively homogeneous sample of researchers and the h index seems to demonstrate certain advantages compared to the remaining indicators. This type of analysis could become a predictive tool of performance to be achieved not only for a particular researcher, but also for a homogeneous group of researchers corresponding to a specific scientific niche.

Objective To explore bibliometric markers in a worldwide sample of emergency physician investigators to define global, continental and individual patterns over time. Methods We evaluated the number of papers published, citations received, cumulative impact factor and h-index of editorial board members of six international emergency medicine journals. We calculated the individual values for every year of each author9s career to evaluate their dynamic evolution. We analysed the results by researcher world area and growth rate. Results We included 107 researchers (76 American, 21 European and 10 Australasian; 46 slow-rate -group C-, 43 medium-rate -group B- and 18 fast-rate growth -group A-). The median experience was 18 (IQR: 12) years, without subgroups differences. Dynamic analysis over time showed good fit with quadratic function in all individual researchers and for all bibliometric markers (R 2 : 0.505–0.997), with the h-index achieving the best R 2 . The combined analysis of the h-index of the 107 investigators also fit the quadratic model (R 2 =0.49). Analysis by predefined continental and growth-rate subgroups allowed defining specific patterns (R 2 between 0.46–0.54 and 0.80–0.86, respectively): by continents, American researchers9 h-index increased 0.632 points per year, European 0.417 and Australasian 0.341; by growth rate, researchers from group A, B and C increased 1.239, 0.683 and 0.320, respectively. Conclusions Dynamic analysis of every individual author indicator over time has a very good fit with a quadratic model, with the h-index achieving the best R 2 . It is also possible to construct models based on continent and rate of growth that could help to predict future expected outcomes of researchers in a particular subgroup and to classify new emerging researchers by growth rate.