Search

Background A description of individuals with SARS-CoV-2 infection comparing the first and second waves could help adapt health services to manage this highly transmissible infection. Objective We aimed to describe the epidemiology of individuals with suspected SARS-CoV-2 infection, and the characteristics of patients with a positive test comparing the first and second waves in Catalonia, Spain. Methods This study had 2 stages. First, we analyzed daily updated data on SARS-CoV-2 infection in individuals from Girona (Catalonia). Second, we compared 2 retrospective cohorts of patients with a positive reverse-transcription polymerase chain reaction or rapid antigen test for SARS-CoV-2. The severity of patients with a positive test was defined by their admission to hospital, admission to intermediate respiratory care, admission to the intensive care unit, or death. The first wave was from March 1, 2020, to June 24, 2020, and the second wave was from June 25, 2020, to December 8, 2020. Results The numbers of tests and cases were lower in the first wave than in the second wave (26,096 tests and 3140 cases in the first wave versus 140,332 tests and 11,800 cases in the second wave), but the percentage of positive results was higher in the first wave than in the second wave (12.0% versus 8.4%). Among individuals with a positive diagnostic test, 818 needed hospitalization in the first wave and 680 in the second; however, the percentage of hospitalized individuals was higher in the first wave than in the second wave (26.1% versus 5.8%). The group that was not admitted to hospital included older people and those with a higher percentage of comorbidities in the first wave, whereas the characteristics of the groups admitted to hospital were more alike. Conclusions Screening systems for SARS-CoV-2 infection were scarce during the first wave, but were more adequate during the second wave, reflecting the usefulness of surveillance systems to detect a high number of asymptomatic infected individuals and their contacts, to help control this pandemic. The characteristics of individuals with SARS-CoV-2 infection in the first and second waves differed substantially; individuals in the first wave were older and had a worse health condition.

Coronavirus SARS-CoV-2; COVID-19; 2019-nCoV; Epidemiologia; Cronologia Coronavirus SARS-CoV-2; COVID-19; 2019-nCoV; Epidemiología; Cronología Coronavirus SARS-CoV-2; COVID-19; 2019-nCoV; Epidemiology; Timeline Description of persons with infection by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) comparing the first and second waves could help adapt the health services to manage this highly transmissible disease. We aimed to describe the epidemiology of persons with suspected SARS-CoV-2 infection, and the characteristics of patients with a positive test comparing first and second waves in Catalonia, Spain. This study had two stages. First, we analysed daily updated data on SARS-CoV-2 infection of persons from Girona (Catalonia); second, we compared two retrospective cohorts of patients with a positive reverse-transcription polymerase chain reaction or rapid antigenic test for SARS-CoV-2. Severity of patients with a positive test was defined by their admission to hospital; intermediate respiratory care; intensive care; or by decease. The first wave was from 01/03/2020 to 24/06/2020, and the second from 25/06/2020 to 08/12/2020.A higher percentage of persons with a positive test for SARS-CoV-2 infection was found in the first wave, despite being a less numerous group, likely due to improvement in the surveillance systems during the second wave. The characteristics of persons with the infection in the first and second waves differed substantially; persons in the first wave were older and in worse health condition.

El síndrome de Evans es una enfermedad autoinmunitaria frecuente en pacientes con inmunodeficiencia común variable (IDCV), mientras que la endocarditis trombótica no bacteriana (ETNB) no está descrita asociada a la IDCV. Presentamos el caso de un varón de 60 años de edad con IDCV sin complicaciones asociadas a la enfermedad que, tras un cuadro de gastroenteritis de etiología no filiada, presentó un Síndrome de Evans y una ETNB, complicado con ictus de la arteria cerebral media derecha de causa cardioembólica. Dada la ausencia de respuesta al tratamiento con dosis elevadas de corticosteroides e inmunoglobulina intravenosa, se administraron dos bolos de ciclofosfamida y posteriormente se inició micofenolato de mofetilo con resolución del cuadro. Revisamos las principales enfermedades autoinmunes asociadas a la IDCV así como las complicaciones trombóticas asociadas al tratamiento con inmunoglobulinas endovenosa. Describimos la ETNB y sus principales asociaciones así como su posible fisiopatología. Finalmente concluimos con la hipótesis planteada que relacionaría la ETNB y la IDCV en el contexto de un síndrome de Evans.

BACKGROUND A description of individuals with SARS-CoV-2 infection comparing the first and second waves could help adapt health services to manage this highly transmissible infection. OBJECTIVE We aimed to describe the epidemiology of individuals with suspected SARS-CoV-2 infection, and the characteristics of patients with a positive test comparing the first and second waves in Catalonia, Spain. METHODS This study had 2 stages. First, we analyzed daily updated data on SARS-CoV-2 infection in individuals from Girona (Catalonia). Second, we compared 2 retrospective cohorts of patients with a positive reverse-transcription polymerase chain reaction or rapid antigen test for SARS-CoV-2. The severity of patients with a positive test was defined by their admission to hospital, admission to intermediate respiratory care, admission to the intensive care unit, or death. The first wave was from March 1, 2020, to June 24, 2020, and the second wave was from June 25, 2020, to December 8, 2020. RESULTS The numbers of tests and cases were lower in the first wave than in the second wave (26,096 tests and 3140 cases in the first wave versus 140,332 tests and 11,800 cases in the second wave), but the percentage of positive results was higher in the first wave than in the second wave (12.0% versus 8.4%). Among individuals with a positive diagnostic test, 818 needed hospitalization in the first wave and 680 in the second; however, the percentage of hospitalized individuals was higher in the first wave than in the second wave (26.1% versus 5.8%). The group that was not admitted to hospital included older people and those with a higher percentage of comorbidities in the first wave, whereas the characteristics of the groups admitted to hospital were more alike. CONCLUSIONS Screening systems for SARS-CoV-2 infection were scarce during the first wave, but were more adequate during the second wave, reflecting the usefulness of surveillance systems to detect a high number of asymptomatic infected individuals and their contacts, to help control this pandemic. The characteristics of individuals with SARS-CoV-2 infection in the first and second waves differed substantially; individuals in the first wave were older and had a worse health condition.

Background:Biological therapies have marked a difference in the treatment of many autoimmune conditions. As all treatments, they have their side effects although little evidence of long-term effects has been reported.Objectives:Analyze retrospectively the appearance of infections that required hospitalization and other side effects in patients treated with biological therapies over the past 10 years.Methods:Biological drugs dispensed in our center to non-cancer patients from 2008 to 2018 were reviewed. Health records were collected from our database and all statistical analyzes were performed with the SPSS program.Results:24 different biological drugs applied to 34 medical conditions; 847 treatments were dispensed over a total of 555 patients. The median age was 44 years with a mean duration of 3.6 years of treatment. The most commonly used drug were adalimumab (n = 280, 33%), infliximab (n = 119, 12%), etanercept (n = 97.13%), rituximab (n = 63, 7%), vedolizumab (n = 47, 5.5%) and omalizumab (n = 43.5%). The rest of the drugs were administered The underlying conditions included Crohn’s Disease (n = 262, 31%), rheumatoid arthritis (n = 133, 16%), ulcerative colitis (n = 118, 14%), spondyloarthropathies (n = 86, 10%), psoriatic arthritis (n = 56, 7%), psoriasis (n = 49, 6%), asthma (n = 34, 4%), nephropathies (n = 19, 2%) and vasculitis (n = 13, 1.5%). The rest were pathologies with During treatment, infection requiring hospitalization occurred in 10.2% (n = 86). The most frequent focus of infection was respiratory (n = 23, 27%), abdominal (n = 19, 22%), soft tissue-bone (n = 17 cases, 20%), urinary (n = 7, 8%) and tuberculosis (n = 4, 5%). No case of hepatitis reactivation was observed. At the time of hospital admission, 46% of patients were only under biological therapy, 21% had another non-corticosteroid immunosuppressant, 17% were associated with corticosteroid, and 15% had triple therapy (corticosteroids, another immunosuppressant and the biological drug). The drugs associated with more infections were: abatacept 20%, rituximab 16% and adalimumab 13%.During the study period, 14 deaths (1.7%) were observed; being the cause cancer-related (n=5), infection (n=5), the disease itself for which was receiving biological treatment (n=2), and endocrine metabolic causes (n=2).At the end of the review, 48% of the treatments were still in use, while 52% had stopped for various reasons: 20% ineffectiveness, 12% side effects, 12% maintained complete remission. The remaining low percentage was due to death, pregnancy, or study entry.The side effects that led to a change in treatment was: non-immune hematological disorders in 4.1% (14% of tocilizumab, 7% of rituximab and 6% of vedolizumab), immune disorders in 3.8% (6% of secukinumab, 5% of tocilizumab and 4.5% of certolizumab), nervous system involvement in 2.4% (11.5% of golimumab,10% of abatacept, 5% of tocilizumab), debut or worsening of heart failure in 1.4% (9, 5% of tocilizumab, 2.5% of etanercept and 1.4% of adalimumab) and cancer-related in 0.7% (2% of infliximab, 1.7% of etanercept).Conclusion:In these 10 years of follow-up and and evaluating 847 treatments, there were 10% hospitalizations due to infections (n = 86) causing death in 5 patients. In light of these results, and pending an exhaustive statistical analysis, we did not find high frequencies of serious side effects in our series. Very little long-term evidence exists on the safety of these drugs.References:[1]Singh JA, Wells GA, Christensen R, et al. Adverse effects of biologics: a network meta-analysis and Cochrane overview. Cochrane Database Syst Rev. 2011;2011(2):CD008794. Published 2011 Feb 16.Disclosure of Interests:None declared.

Background: Stroke is a morbid and potentially mortal complication among patients hospitalized with acute medical illness. The potential of extended-duration thromboprophylaxis with the factor Xa inhibitor betrixaban to reduce the risk of stroke compared with standard-dose enoxaparin in this population was assessed in this retrospective APEX trial substudy (Acute Medically Ill Venous Thromboembolism Prevention With Extended Duration Betrixaban). Methods: Hospitalized acutely medically ill subjects (n=7513) were randomized in a double-dummy double-blind fashion to either extended-duration oral betrixaban (80 mg once daily for 35–42 days) or standard-dose subcutaneous enoxaparin (40 mg once daily for 10±4 days) for venous thromboprophylaxis. Stroke events were adjudicated by an independent, blinded event adjudication committee. Results: The mean age of study participants was 76 years; 45% were male; 13% had had a stroke; and 45% had congestive heart failure. There were fewer all-cause strokes (0.54% versus 0.97%; relative risk [RR]=0.56; 95% confidence interval, 0.32–0.96; P =0.032; adjusted RR=0.43%; number needed to treat=233) and ischemic strokes (0.48% versus 0.91%; RR=0.53; 95% confidence interval, 0.30–0.94; P =0.026; adjusted RR=0.43%; number needed to treat=233) among patients treated with betrixaban versus enoxaparin through 77 days of follow-up. Among high-risk subjects, those with congestive heart failure or ischemic stroke as their index event, betrixaban reduced the risk of all-cause stroke (0.72% versus 1.48%; RR=0.49; 95% confidence interval, 0.26–0.90; P =0.019; adjusted RR=0.76%; number needed to treat=132) and ischemic stroke (0.63% versus 1.38%; RR=0.45; 95% confidence interval, 0.24–0.87; P =0.014; adjusted RR=0.75%; number needed to treat=134) compared with enoxaparin. Conclusions: Among hospitalized medically ill patients, extended-duration betrixaban significantly reduced all-cause stroke and ischemic stroke through 77 days of follow-up Clinical Trial Registration: URL: http://www.clinicaltrials.gov . Unique identifier: NCT01583218.

Background Extended‐duration betrixaban showed a significant reduction in venous thromboembolism in the APEX trial (Acute Medically Ill VTE Prevention With Extended Duration Betrixaban Study). Given the variable clinical impact of different efficacy and safety events, one approach to assess net clinical outcomes is to include only those events that are either fatal or cause irreversible harm. Methods and Results This was a post hoc analysis of the APEX trial—a multicenter, double‐blind, randomized controlled trial comparing extended‐duration betrixaban versus standard‐of‐care enoxaparin. A composite of all fatal or irreversible safety (fatal bleeding or intracranial hemorrhage) and efficacy events (cardiopulmonary death, myocardial infarction, pulmonary embolism, and ischemic stroke) was evaluated in a time‐to‐first event analysis. In patients with positive D‐dimer results, betrixaban reduced fatal or irreversible events at 35 to 42 days (4.80% versus 3.54%; hazard ratio, 0.73; absolute risk reduction, 1.26%; number needed to treat, 79 [ P =0.033]) and at study end at 77 days (6.27% versus 4.36%; hazard ratio, 0.70; absolute risk reduction, 1.91%; number needed to treat, 52 [ P =0.005]) versus enoxaparin. In all patients, betrixaban reduced fatal or irreversible events at 35 to 42 days (4.08% versus 2.90%; hazard ratio, 0.71; absolute risk reduction, 1.18%; number needed to treat, 86 [ P =0.006]) and 77 days (5.17% versus 3.64%; hazard ratio, 0.70; absolute risk reduction, 1.53%; number needed to treat, 65 [ P =0.002]). Conclusions Among hospitalized medically ill patients, extended‐duration betrixaban demonstrated an ≈30% reduction in fatal or irreversible ischemic or bleeding events compared with standard‐duration enoxaparin. A total of 65 patients would require treatment with betrixaban to prevent 1 fatal or irreversible event versus enoxaparin. Clinical Trial Registration URL : http://www.ClinicalTrials.gov . Unique identifier: NCT 01583218.

The APEX trial assessed the safety and efficacy of extended-duration thromboprophylaxis using betrixaban versus standard dosing of enoxaparin among hospitalized, acutely ill medical patients. The 80-mg betrixaban dose was halved to 40 mg among subjects with severe renal insufficiency and those receiving a concomitant strong P-glycoprotein inhibitor.This analysis assessed the pharmacokinetics, efficacy, and safety of full- (80 mg) and reduced-dose (40 mg) betrixaban relative to enoxaparin in the APEX trial.The median concentration of betrixaban among subjects administered the 80-mg dose was higher than that of the 40-mg dose (19 ng/mL vs 11 ng/mL, P.001). In the primary analysis cohort 1 (d-dimer ≥2× upper limit of normal), the primary efficacy outcome (asymptomatic proximal deep vein thrombosis, symptomatic proximal or distal deep vein thrombosis, symptomatic nonfatal pulmonary embolism, or venous thromboembolism-related death) was significantly reduced among subjects treated with 80 mg of extended-duration betrixaban versus enoxaparin (6.27% [95/1516] vs 8.39% [130/1549], relative risk reduction=0.26 [0.04-0.42], P=.023), and similarly in the entire primary efficacy outcome population (4.87% [122/2506] vs 7.06% [181/2562], relative risk reduction=0.30 [0.13-0.44], P=.001). There was no difference in the primary outcome for subjects treated with 40 mg betrixaban vs enoxaparin across cohorts. In addition, there was no excess of major bleeding associated with either betrixaban dose compared with enoxaparin.The 80-mg betrixaban dose achieves higher plasma concentrations than the 40-mg dose and, in contrast to the 40-mg dose, is associated with improved efficacy across all cohorts relative to standard-dose enoxaparin without an excess risk of major bleeding in the management of medically ill subjects.

Rationale Immunoglobulin G4-related disease (IgG4-RD) is an inflammatory condition of unknown cause. Cancer might be related to the development of certain IgG4-RD but to date, little literature documents it. Patient concerns A 78-year old man presented with unilateral proptosis responsive to steroids, initially attributed to nonspecific orbital inflammation. Diagnosis Right hemicolectomy was performed because of a suspicious lesion which turned out to be tubulovillous adenoma on histological analysis. Eight months after the surgery, a mass infiltrating the mesentery was found and biopsy revealed IgG4-RD. Interventions Both the orbital inflammation and abdominal mass infiltrating the mesentery were responsive to steroids and rituximab administered to treat IgG4-RD. Outcomes In the course of IgG4-RD, the patient developed bilateral optic perineuritis, causing bilateral visual loss. Colon cancer with synchronous multiple liver metastases was found 1 year after rituximab treatment. Lessons This case raises the possibility of IgG4-RD being a paraneoplastic syndrome in some patients. Cancer screening should probably be performed in some elderly patients diagnosed with IgG4-RD.

Background\ud Patients with acute medical illnesses are at prolonged risk for venous thrombosis. However, the appropriate duration of thromboprophylaxis remains unknown.\ud \ud Methods\ud Patients who were hospitalized for acute medical illnesses were randomly assigned to receive subcutaneous enoxaparin (at a dose of 40 mg once daily) for 10±4 days plus oral betrixaban placebo for 35 to 42 days or subcutaneous enoxaparin placebo for 10±4 days plus oral betrixaban (at a dose of 80 mg once daily) for 35 to 42 days. We performed sequential analyses in three prespecified, progressively inclusive cohorts: patients with an elevated d-dimer level (cohort 1), patients with an elevated d-dimer level or an age of at least 75 years (cohort 2), and all the enrolled patients (overall population cohort). The statistical analysis plan specified that if the between-group difference in any analysis in this sequence was not significant, the other analyses would be considered exploratory. The primary efficacy outcome was a composite of asymptomatic proximal deep-vein thrombosis and symptomatic venous thromboembolism. The principal safety outcome was major bleeding.\ud \ud Results\ud A total of 7513 patients underwent randomization. In cohort 1, the primary efficacy outcome occurred in 6.9% of patients receiving betrixaban and 8.5% receiving enoxaparin (relative risk in the betrixaban group, 0.81; 95% confidence interval [CI], 0.65 to 1.00; P=0.054). The rates were 5.6% and 7.1%, respectively (relative risk, 0.80; 95% CI, 0.66 to 0.98; P=0.03) in cohort 2 and 5.3% and 7.0% (relative risk, 0.76; 95% CI, 0.63 to 0.92; P=0.006) in the overall population. (The last two analyses were considered to be exploratory owing to the result in cohort 1.) In the overall population, major bleeding occurred in 0.7% of the betrixaban group and 0.6% of the enoxaparin group (relative risk, 1.19; 95% CI, 0.67 to 2.12; P=0.55).\ud \ud Conclusions\ud Among acutely ill medical patients with an elevated d-dimer level, there was no significant difference between extended-duration betrixaban and a standard regimen of enoxaparin in the prespecified primary efficacy outcome. However, prespecified exploratory analyses provided evidence suggesting a benefit for betrixaban in the two larger cohorts. (Funded by Portola Pharmaceuticals; APEX ClinicalTrials.gov number, NCT01583218. opens in new tab.)

ObjetivosIdentificar los aspectos que valoran los pacientes en los centros de salud. Ponderar la importancia relativa de cada uno de ellos.DiseñoFase cualitativa (4 grupos focales) para identificar los aspectos que se valoran. Fase cuantitativa (encuesta a 225 ciudadanos) para ponderar su importancia relativa.EmplazamientoAtención primariaParticipantesCiudadanos de clase social media-alta, media-baja, urbanos, rurales y mayores de 65 años, seleccionados a través de informantes clave por su interés en los servicios sanitarios. Se reclutaron con la colaboración de diferentes asociaciones de vecinos y ayuntamientos.MétodoMediante grupos focales se identificaron los aspectos que se valoran, y se clasificaron en categorías. Mediante encuesta se ponderó la importancia relativa de los mismos y se realizó un análisis factorial para identificar los componentes principales.ResultadosSe identificaron 60 aspectos valorables por los pacientes. De ellos, 8 se referían al centro y eran tangibles, 9 a organización y accesibilidad, 18 a relación con los profesionales y 25 a servicios disponibles. El aspecto más valorado fue: «el centro dispone de suficiente material para curas, pequeña cirugía, vendajes, etc.». El análisis factorial confirmó las categorías que se habían establecido. La organización y accesibilidad y las relaciones con los profesionales parecen ser las dimensiones más valoradas.ConclusionesLa combinación de métodos cualitativos y cuantitativos parece muy adecuada para este tipo de estudios. Aunque muchos de los aspectos eran de esperar, aparecen otros poco previsibles. Además, los clientes parecen valorar ciertos aspectos de manera distinta a como lo harían los profesionales.ObjectivesTo identify the factors valued by users of health centres; to weigh the relative importance of each factor.DesignQualitative stage (4 focus groups) to identify the factors valued. Quantitative stage (questionnaire to 225 people) to weigh their relative importance.Setting. Primary care.ParticipantsCitizens from middle-high and middle-low social classes, urban, rural and over 65, were chosen through key informants for their interest in the health services. They were recruited with the assistance of various residents´ associations and town councilsMethodThe factors valued were identified through focus groups and classified in categories. Their relative importance was weighed through a questionnaire and a factorial analysis to identify the main components was run.Results60 factors that could be valued by patients were identified. Eight of these referred to the centre and concrete assets, nine to organisation and acessibility, 18 to relationship with the health professionals, and 25 to the services available. The most highly valued factor was: «The centre has sufficient material available for cures, minor surgery, bandages, etc.» The factorial analysis confirmed the categories established. Organisation and accessibility, and relationship with professionals were the most highly valued dimensions.ConclusionsThe combination of qualitative and quantitative methods seems very fitting for this kind of study. Although many of the factors were to be expected, other little-expected ones emerged. In addition, users seem to value certain factors in a different way from how the professionals do.

ObjetivosIdentificar los aspectos que los profesionales consideran positivos en un centro de salud, agruparlos en dimensiones y ponderar su importancia relativaDiseñoFase cualitativa: grupos focales y análisis de contenido de los mismos. Fase cuantitativa: encuesta mediante cuestionario elaborado a partir de los aspectos identificados en la fase cualitativaEmplazamientoDirecciones de Atención Primaria de Reus y Tarragona (Cataluña)ParticipantesDirectivos, profesionales asistenciales y de admisión. En los grupos focales participaron 33 profesionales. En la encuesta se distribuyeron 136 cuestionarios (tasa de respuesta del 78,6%)Mediciones principalesIdentificación de los aspectos a valorar mediante los grupos focales. Agrupación en dimensiones, con diferentes niveles de agrupamiento, mediante análisis de contenido. Encuesta para ponderar la importancia relativa de los aspectos identificadosResultadosSe identificaron 133 aspectos valorables por los profesionales: 36 se referían a estructura (arquitectura, dotación), 33 a organización (accesibilidad, funcionamiento del equipo), 23 a profesionales (conocimiento, actitudes), 20 a cartera de servicios (gestión de necesidades e información, servicios asistenciales) y 21 a gestión directiva. Las dimensiones más valoradas fueron las que se refieren a actitudes y a gestión directivConclusionesLas relaciones con los pacientes y los otros profesionales y cómo son gestionados son los campos más valoradospor los profesionales. Algunos aspectos problemáticos, como la toma de decisions compartida, el trabajo en equipo o las culturas minoritarias, ponen en evidencia las diferentes sensibilidades presentes en el ámbito sanitarioObjectivesTo identify features of health care centers valued by health care workers as positive, to group features into dimensions, and to determine their relative importanceDesignQualitative phase: focus groups and content analysis. Quantitative phase: survey with a questionnaire developed from the features identified in the qualitative phaseSettingPrimary care services in Reus and Tarragona (Catalonia, northeastern Spain)ParticipantsManagers, medical care providers and admissions staff. A total of 33 workers took part in focus groups, and 136 questionnaires were distributed for the survey, with a 78.6% response rateMain measuresIdentification by focus groups of the features to be evaluated. Features were grouped into dimensions at different levels by content analysis. Survey to determine the relative importance of different featuresResultsWe identified 133 features to be evaluated by workers: 36 related with structural features of the center (architecture, staffing and equipment), 33 with organization (accessibility, team functioning), 23 with workers (knowledge and attitudes) 20 with the services provided (needs and information management, care services provided) and 21 with management. The most highly valued dimensions were workers' attitudes and managementConclusionsRelations with patients and colleagues, and management issues, were valued most highly by workers. Some problematic features such as shared decision-making, team work and minority cultures revealed different levels of awareness and sensitivity within the health care system

Purpose We sought to determine the safety, efficacy, and cost of oral therapy for patients with community-acquired pneumonia. In patients with nonsevere pneumonia, conventional (parenteral) treatment was compared with the oral route; in patients with severe pneumonia, conventional treatment was compared with early switch from parenteral to oral therapy. Subjects and methods We randomly assigned 85 hospitalized patients with nonsevere pneumonia to one of two groups: 41 received oral antimicrobials from admission, and 44 received parenteral antimicrobials until they had been afebrile for 72 hours before switching to oral treatment. We randomly assigned 103 patients with severe pneumonia who had initially been treated with parenteral antimicrobials to one of two groups: 48 were switched to oral therapy after 48 hours of treatment (early switch), and 55 received a full 10-day course of parenteral antibiotics. Results Among patients with nonsevere pneumonia, there were no deaths in the oral treatment group, and one death (2%) in the parenteral treatment group (95% confidence interval [CI] for between-group [oral minus parenteral] difference: −7% to 2%, P = 0.3). The time to resolution of morbidity was ≤5 days in 34 (83%) patients in the oral treatment group and 39 (88%) patients in the parenteral treatment group ( P = 0.5); there were treatment failures in 4 (10%) patients in the oral treatment group and 14 (32%) patients in the parenteral treatment group ( P = 0.02). Among patients with severe pneumonia, there was one (2%) death in the early-switch group and no deaths in the full course of parenteral antibiotics groups (95% CI for between-group [early switch vs. full course] difference: −2% to 6%, P=0.5). The time to resolution of morbidity was ≤5 days in 38 (79%) patients in the early-switch group and 41 (75%) in the full-course group ( P = 0.3). There were 12 (25%) treatment failures in the early-switch group and 13 (24%) in the full-course group ( P = 0.9). There were fewer adverse events in the oral and early-switch groups, primarily due to lower rates of infusion-related phlebitis. Significant cost savings, mainly due to a shorter hospitalization, occurred among patients with severe pneumonia in the early-switch group. Conclusion Inpatients with nonsevere community-acquired pneumonia can be effectively and safely treated with oral antimicrobials from the time of admission, whereas those with severe pneumonia can be treated with early-switch therapy.

OBJECTIVES: To identify features of health care centers valued by health care workers as positive, to group features into dimensions, and to determine their relative importance DESIGN: Qualitative phase: focus groups and content analysis. Quantitative phase: survey with a questionnaire developed from the features identified in the qualitative phase SETTING: Primary care services in Reus and Tarragona (Catalonia, northeastern Spain) PARTICIPANTS: Managers, medical care providers and admissions staff. A total of 33 workers took part in focus groups, and 136 questionnaires were distributed for the survey, with a 78.6% response rate MAIN MEASURES: Identification by focus groups of the features to be evaluated. Features were grouped into dimensions at different levels by content analysis. Survey to determine the relative importance of different features RESULTS: We identified 133 features to be evaluated by workers: 36 related with structural features of the center (architecture, staffing and equipment), 33 with organization (accessibility, team functioning), 23 with workers (knowledge and attitudes) 20 with the services provided (needs and information management, care services provided) and 21 with management. The most highly valued dimensions were workers' attitudes and management CONCLUSIONS: Relations with patients and colleagues, and management issues, were valued most highly by workers. Some problematic features such as shared decision-making, team work and minority cultures revealed different levels of awareness and sensitivity within the health care system

OBJECTIVES: To identify the factors valued by users of health centres; to weigh the relative importance of each factor. DESIGN: Qualitative stage (4 focus groups) to identify the factors valued. Quantitative stage (questionnaire to 225 people) to weigh their relative importance. Setting. Primary care. PARTICIPANTS: Citizens from middle-high and middle-low social classes, urban, rural and over 65, were chosen through key informants for their interest in the health services. They were recruited with the assistance of various residents´ associations and town councils METHOD: The factors valued were identified through focus groups and classified in categories. Their relative importance was weighed through a questionnaire and a factorial analysis to identify the main components was run. RESULTS: 60 factors that could be valued by patients were identified. Eight of these referred to the centre and concrete assets, nine to organisation and acessibility, 18 to relationship with the health professionals, and 25 to the services available. The most highly valued factor was: «The centre has sufficient material available for cures, minor surgery, bandages, etc.» The factorial analysis confirmed the categories established. Organisation and accessibility, and relationship with professionals were the most highly valued dimensions. CONCLUSIONS: The combination of qualitative and quantitative methods seems very fitting for this kind of study. Although many of the factors were to be expected, other little-expected ones emerged. In addition, users seem to value certain factors in a different way from how the professionals do.

Background: The differential diagnosis of community-acquired pneumonia and some non-pneumonia diseases involving the chest may sometimes be cumbersome. Adding some objective variables to the diagnostic strategy may be helpful.We evaluated the main objective variables that are usually available in the emergency ward and that may be valuable in this differential diagnosis. Methods: We recorded epidemiological, clinical, and analytical data, as well as that obtained from physical examination, from 284 consecutive patients diagnosed in the emergency ward as having community-acquired pneumonia. The diagnosis was reviewed by the investigators applying pre-set diagnostic criteria. Statistical analysis was then performed comparing data from patients with a definitive diagnosis of community-acquired pneumonia with those with a final diagnosis of non-pneumonia disease excluding acute exacerbations of chronic bronchitis. Results: In the univariate analysis, C-reactive protein (difference of means 93 mg/l; 95% C.I. 47, 140), erythrocyte sedimentation rate (d.m. 19 mm/h; 95% C.I. 3, 35), leukocyte count (d.m. 3.5x10(9)/l; 95% C.I. 0.5, 6.4), and temperature (d.m. 0.5 degrees C; 95% C.I. 0.1, 0.9) discriminated between community-acquired pneumonia and non-pneumonia diseases. In the multivariate analysis, only C-reactive protein remained in the equation. Conclusions: C-reactive protein, erythrocyte sedimentation rate, leukocyte count, and temperature were measurable variables that proved to be useful in the differential diagnosis between community-acquired pneumonia and non-pneumonia diseases. C-reactive protein appears to be the most suitable for this purpose.

Pneumonia is a common medical problem with a significant mortality and morbidity. It is the leading infectious disease in hospital admissions. We conducted a one year prospective study of the patients over 14 years of age that had been diagnosed of community-acquired pneumonia in our institution. The objective was to determinate the clinical characteristics and the aetiological agents of pneumonia in our geographic area and to know which factors are related with the evolution and prognosis of this disease.A medical team evaluated and followed-up all the patients diagnosed of community-acquired pneumonia. Epidemiological, clinical, radiological and laboratory data were recorded. An attempt to obtain an aetiological diagnosis was done by means of sputum, blood cultures and serologic studies at admission and between third and fourth week later. In individualized patients invasive techniques were performed. We classified the patients in five groups according to previous criteria defined in the guidelines of our hospital based in age, the presence of an underlying disease and the severity in the initial presentation.274 patients received an initial diagnosis of pneumonia, in 76 (28%) this initial diagnosis was not confirmed. The mean age of the remaining 198 was 55 years. 62% were men. 40% had an identifiable microbiological etiology. The main causal microorganism was Streptococcus pneumoniae followed by Mycoplasma pneumoniae. Gram stain and sputum culture were the most useful laboratory tests for the aetiological diagnosis. Blood cultures and serological test had a lower efficiency. There was no relationship between the clinical presentation, typical or atypical pneumonia, and the causal microorganism. Complications developed in 11% of the patients and the mortality rate was of 3%.There was a high rate of initial erroneous diagnoses of pneumonia. The epidemiological, clinical and roentgenographic characteristics were similar to other studies conducted in our country with a lower number of microbiological agents identified. Patients who were admitted at hospital only because their age or the presence of chronic disease had a good evolution. In this series patients with severe presentation also had a good prognosis. It would be interesting to investigate about which parameters could be useful as indicators of prognosis and evolution at initial presentation of pneumonia.

Sixteen patients with AIDS (6% of the total AIDS patients) who had infection by Cryptococcus neoformans were studied. Most of these patients (94%) had cryptococcal meningitis. Only 50% of the cases showed clinical manifestations of neurological involvement. Blood cultures and antigen level measurement were the diagnostic techniques with best results due to their high percentage of positivity. Sixty nine percent of patients survived the acute phase of the infection and only 3 of those who died in this period showed evidence of active infection patients by the fungus.