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Introduction Headache is a frequent cause of consultation; it is important to detect patients with secondary headache, particularly high-risk secondary headache. Such systems as the Manchester Triage System (MTS) are used for this purpose. This study aims to evaluate the frequency of sub-triage in patients attending the Emergency Department due to headache. Material and methods We studied a series of consecutive patients who came to the Emergency Department with headache and presenting some warning sign, defined as the presence of signs leading the physician to request an emergency neuroimaging study and/or assessment by the on-call neurologist. The reference diagnosis was established by neurologists. We evaluated the MTS triage level assigned and the presence of warning signs that may imply a higher level than that assigned. Results We registered a total of 1,120 emergency department visits due to headache, and 248 patients (22.8%) were eligible for study inclusion. Secondary headache was diagnosed in 126 cases (50.8% of the sample; 11.2% of the total), with 60 cases presenting high-risk secondary headache (24.2%; 5.4%). According to the MTS, two patients were classified as immediate (0.8%), 26 as very urgent (10.5%), 147 as urgent (59.3%), 68 as normal (27.4%), and five as not urgent (2%). The percentage of patients under-triaged was 85.1% in the very urgent classification level and 23.3% in the urgent level. Conclusion During the study period, at least one in 10 patients attending the Emergency Department due to headache had secondary headache; one in 20 had high-risk secondary headache. The MTS under-triaged most patients with warning signs suggesting a potential emergency.

Herpes zoster infection (HZ) is an important public health problem due to its high incidence and frequent complications, especially post-herpetic neuropathy . The incidence of HZ increases with age and is more frequent in immunocompromised patients. It is estimated that at least 60,000 people develop HZ each year in Spain. The usual forms of HZ are so clinically characteristic that they do not usually require microbiological confirmation, which is reserved for cases without cutaneous manifestations or with atypical presentation. There are currently two vaccines approved by the regulatory agencies and marketed in Spain to prevent the onset of HZ and its complications. The first (Zostavax®) was marketed by the company MSD and licensed in Europe in 2006 and is a live attenuated virus vaccine that is administered in a single dose, while the second (Shingrix®) is a recombinant vaccine, marketed in 2017 and requires two doses. While the former cannot be administered to immunocompromised persons, the latter can be prescribed to any group of adults. The criteria for the indication and financing of these vaccines have not been uniform in the various autonomous communities of Spain. These and other aspects of HZ have been discussed by a group of experts from the Illustrious Official College of Physicians of Madrid (ICOMEM) whose criteria and opinions are included in this paper.

Predictions for a near end of the pandemic by the World Health Organization should be interpreted with caution. Current evidence indicates that the efficacy of a fourth dose of classical mRNA vaccines (BT162b2 or mRNA-1273) is low and short-lived in preventing SARS-CoV-2 infection in its predominant variant (Omicron). However, its efficacy is high against severe symptomatic infection, hospitalization and death. The new vaccines being introduced are bivalent and active against the Omicron variants. Potential new vaccines to be introduced in the coming year include a vaccine based on a recombinant protein that emulates the receptor binding domain of the Spike protein under development by the Spanish company Hipra, as well as vaccines for nasal or oral administration. Available information suggests that vaccines against COVID-19 can be administered in association with influenza vaccination without particular complications. New drugs against COVID-19, both antiviral and anti-inflammatory, are under investigation, but this does not seem to be the case with monoclonal antibodies. The indication to use masks in some circumstances will be maintained next year in view of the accumulation of scientific data on their efficacy. Finally, the long COVID or Post-COVID syndrome may continue to affect a very high proportion of patients who have had the disease, requiring combined diagnostic and therapeutic resources.

Aim To evaluate the diagnostic accuracy of the SNNOOP10 list in the detection of high-risk headaches. Methods Patients that visited the Hospital Clínico San Carlos (Madrid) emergency department due to headache that were allocated to a Manchester Triage System level between critical and urgent were prospectively included but retrospectively analysed. A researcher blind to the patients’ diagnosis administered a standardised questionnaire and afterwards a neurologist blind to the questionnaire results diagnosed the patient according to the International Classification of Headache Disorders. The primary endpoint was to assess the sensitivity of the SNNOOP10 list in the detection of high-risk headaches. Secondary endpoints included the evaluation of the sensitivity, specificity, positive predictive value, negative predictive value and area under the curve of each SNNOOP10 item. Results Between April 2015 and October 2021, 100 patients were included. Patients were 44 years old (inter-quartile range: 33.6–64.7) and 57% were female. We identified 37 different diagnoses. Final diagnosis was a primary headache in 33%, secondary headache in 65% and cranial neuralgia in 2%. There were 46 patients that were considered as having high-risk headache. Patients from the primary headache group were younger and more frequently female. Sensitivity of SNNOOP10 list was 100% (95% confidence interval: 90.2%–100%). The items with higher sensitivity were neurologic deficit or disfunction (75.5%), pattern change or recent onset of the headache (64.4%), onset after 50 years (64.4%). The most specific items were posttraumatic onset of headache (94.5%), neoplasm in history (89.1%) and systemic symptoms (89%). The area under the curve of the SNNOOP10 list was 0.66 (95% CI: 0.55–0.76). Conclusion The red flags from the SNNOOP10 list showed a 100% sensitivity in the detection of high-risk headache disorders.

Heart failure with preserved ejection fraction (HFpEF) is a disorder related to patient comorbidities and aging. Whether mitochondrial dysfunction is present during HFpEF decompensation versus the stable phase is largely unknown. The aim of the present study was to identify mitochondrial and cell metabolism blood biomarkers in older patients with acute and stable HFpEF.Peripheral blood biomarkers were investigated in a group of eight to 12 patients aged 80-96 years and diagnosed with HFpEF first when they were in decompensated phase and then at least three months later in stable phase. Their data were compared to two control groups with an equal number of participants and sex proportions. One group was age matched and the other included individuals aged between 22 and 44 years.Decompensated patients experienced an increased mitochondrial superoxide production and mitochondrial mass, lower mitochondrial DNA copy number and LDHB expression, and higher lactate level compared to the stable stage. The stable phase was characterized by a sharp reduction in formate level. Multivariate analysis indicated that formate, lactate, and histidine can distinguish both of the HFpEF phases. Many of these parameters, including LDHB, lactate, formate, and mitochondrial mass, followed an age-related pattern, with acute HFpEF at its apex or nadir, suggesting that it represents an exacerbation of an aging-related process.We identified distinct blood biomarkers of chronic and decompensated HFpEF phases. The data underlined the relationship between HFpEF and aging. These findings could be used to monitor patients and might be therapeutically targeted.

A progressively increasing percentage of the elderly live during the last years of their lives in nursing homes. Although these institutions are intended to mimic life at home as much as possible, they have characteristics that make them quite similar to a “nosocomiun”, i.e. an establishment for the treatment of the sick. The very coexistence among the elderly, the fact of sharing caregivers and the very significant exposure to third parties, together with the frequent predisposing diseases to infection in this population, make infection frequent among residents and also easily transmissible. This leads us to ask what can be done to prevent infection in this environment and more specifically what is the state of the art of the matter in a Western European nation such as ours. The Board of Trustees of the Health Sciences Foundation has asked itself a series of questions on the subject of infection prevention in Nursing Homes, the structure of procedures, the legislation available, compliance with the measures indicated, the best indicators of the processes and therefore, the need to promote in Spain a document of recommendations to avoid infections in this poplation whose morbidity and mortality need not be highlighted. To this end, a multidisciplinary group of experts in different aspects of this problem has been convened and asked the proposed questions. The questions were discussed by the group as a whole and led to a series of conclusions agreed upon by the participants. The results of the meeting are reported below.

ObjectiveTo estimate incidence, risk factors, clinical characteristics and outcomes of acute (myo)pericarditis (AMP) in patients with COVID-19.MethodsCase-control, retrospective review, consecutive case inclusion performed in 62 Spanish EDs. All COVID-19 patients with AMP (cases) were compared in clinical characteristics and outcomes with COVID-19 without AMP (control group A) and non-COVID patients with AMP (control group B). We estimated unadjusted standardised incidence (SI, not adjusted by population’s age/sex) of AMP in COVID-19 and non-COVID populations (per 100 000/year).ResultsWe identified 67 AMP in COVID-19 patients (SI=56.5, OR with respect to non-COVID patients=4.43, 95% CI=3.98 to 4.94). Remarkably, COVID-19 cases presented with chest pain less frequently than non-COVID patients and had less typical ECG changes, higher NT-proBNP (N-terminal prohormone of brain natriuretic peptide), more left and right ventricular dysfunction in echocardiography and more need of inotropic/vasopressor drugs. Admission to intensive care was higher than control group A (OR=3.22, 95% CI=1.43 to 7.23), and in-hospital mortality was higher than control group B (OR=7.75, 95% CI=2.77 to 21.7).ConclusionAMP is unusual as a form of COVID-19 presentation (about 1‰ cases), but SI is more than fourfold higher than non-COVID population, and it is less symptomatic, more severe and has higher in-hospital mortality; therefore, rapid recognition, echocardiographic assessment of myopericardial inflammation/dysfunction and treatment with vasoactive drugs when needed are recommended in AMP in patients with COVID-19.

Resumen Introduccion y objetivos Investigar si diferentes caracteristicas estructurales/organizativas del hospital y del servicio de urgencias (SU) impactan en los resultados de la insuficiencia cardiaca aguda (ICA). Metodos Analisis secundario del Registro EAHFE. Se recogieron 6 caracteristicas hospitalarias y del SU, y se relacionaron con 7 resultados tras el evento indice y tras el alta, ajustados por ano de inclusion, caracteristicas basales y del episodio de ICA y por dichas caracteristicas estructurales/organizativas. Tambien se relaciono el porcentaje de altas directas desde urgencias (ADU) y resultados, y si habia interaccion segun las caracteristicas hospitalarias o del SU. Resultados Cuarenta SU espanoles incluyeron 17.974 episodios de ICA. Hubo menos estancias prolongadas en hospitales de alta tecnologia, con hospitalizacion a domicilio y con SU con alta frecuentacion, y mas estancias prolongadas en hospitales con unidad de insuficiencia cardiaca y area de observacion en urgencias. Los hospitales de alta tecnologia presentaron menor mortalidad hospitalaria (OR = 0,78; IC95%, 0,65-0,94). Respecto a eventos 30 dias tras el alta, los hospitales con unidad de corta estancia (UCE) tuvieron mas hospitalizaciones (OR = 1,19; IC95%, 1,02-1,38); los SU con alta afluencia, menor mortalidad (OR = 0,73; IC95%, 0,56-0,96) y eventos combinados (OR = 0,87; IC95%, 0,76-0,99), y los hospitales con unidad de insuficiencia cardiaca, menos reconsultas a urgencias (OR = 0,83; IC95%, 0,76-0,91), hospitalizaciones (OR = 0,85; IC95%, 0,75-0,97) y eventos combinados (OR = 0,84; IC95%, 0,77-0,92). A mas ADU, menos estancias prolongadas. Entre otras interacciones, el incremento de ADU se asocio con mas reconsultas, hospitalizaciones y eventos combinados a los 30 dias del alta en hospitales sin UCE, pero no en hospitales con UCE. Conclusiones Las caracteristicas estructurales/organizativas de hospitales y SU y la agresividad en el tratamiento en urgencias influyen significativamente en los resultados en la ICA.

Introduction and objectives Intravenous iron is recommended to correct iron deficiency in heart failure (HF) patients, although not all patients had the same response. We evaluated the impact of ferric carboxymaltose (FCM) in analytical and clinical improvement and analyzed the response according to different parameters. Methods We included HF patients who received FCM in the daily hospital to correct iron deficiency. We recorded clinical and analytical parameters at baseline and 3 months follow-up. Results We included 236 patients (age 73.5 ± 10.7 years) with left ventricular ejection fraction 44.5 ± 15.3%. There were no adverse effects during the infusion. All ferric analytical parameters significantly increased at 3 months. 25.1% of patients improved functional class, and New York Heart Association (NYHA) III patients were more likely to improve. Mean corpuscular volume predicted NYHA improvement (OR, 0.97; 95%CI, 0.93–1.00; P = .05). Body mass index (OR, 0.86; 95%CI, 0.78–0.95; P = .002) and ferritin (OR, 1.00; 95%CI, 1.00–1.01; P = .042) were also predictors of N-terminal pro-B-type natriuretic peptide reduction of at least 30% from basal levels. 61.3% received lower doses of FCM than the theoretical ones, and those with the correct dose were more likely to improve NYHA and reduce natriuretic peptides. Conclusions FCM was useful to correct iron deficiency in clinical practice, independently to anemia, without relevant adverse effects. Clinical improvement was especially relevant in more symptomatic patients and those with absolute deficiency. Mean corpuscular volume, body mass index, ferritin, and dose of FCM were predictors of clinical improvement.

Design a risk model to predict bacteraemia in patients attended in emergency departments (ED) for an episode of infection. This was a national, prospective, multicentre, observational cohort study of blood cultures (BC) collected from adult patients (≥ 18 years) attended in 71 Spanish EDs from October 1 2019 to March 31, 2020. Variables with a p value

To define quality of care indicators and care process standards for treating patients with COVID-19 in hospital emergency departments (EDs), to determine the level of adherence to standards during the first wave in 2020, and to detect factors associated with different levels of adherence.We selected care indicators and standards by applying the Delphi method. We then analyzed the level of adherence in the SIESTA cohort (registered by the Spanish Investigators in Emergency Situations Team). This cohort was comprised of patients with COVID-19 treated in 62 Spanish hospitals in March and April 2020. Adherence was compared according to pandemic-related ED caseload pressure, time periods during the wave (earlier and later), and age groups.Fourteen quality indicators were identified. Three were adhered to in less than 50% of the patients. Polymerase chain reaction testing for SARS-CoV-2 infection was the indicator most often disregarded, in 29% of patients when the caseload was high vs 40% at other times (P .001) and in 30% of patients in the later period vs 37% in the earlier period (P = .04). Adherence to the following indicators was better in the later part of the wave: monitoring of oxygen saturation (100% vs 99%, P = .035), electrocardiogram monitoring in patients treated with hydroxychloroquine (87% vs 65%, P .001), and avoiding of lopinavir/ritonavir treatment in patients with diarrhea (79% vs 53%, P .001). No differences related to age groups were found.Adherence to certain quality indicators deteriorated during ED treatment of patients with COVID-19 during the first wave of the pandemic. Pressure from high caseloads may have exacerbated this deterioration. A learning effect led to improvement. No differences related to patient age were detected.Definir indicadores de calidad y sus estándares para el proceso asistencial del paciente con COVID-19 en servicios de urgencias hospitalarios (SUH), así como determinar su grado de cumplimiento durante el primer pico pandémico e investigar si existieron diferencias en relación con diferentes factores.Siguiendo la metodología del Delphi, los autores seleccionaron los indicadores y sus estándares. Posteriormente, se analizó el grado de cumplimiento en la cohorte SIESTA, formada por pacientes COVID-19 de 62 SUH españoles atendidos en marzo y abril de 2020. Se comparó el cumplimiento de los indicadores según la presión asistencial generada por la pandemia en el SUH, el periodo asistencial y el grupo etario.Se definieron 14 indicadores. Tres de ellos se cumplieron en 50% de los pacientes. La realización de la reacción en cadena de la polimerasa (PCR) para el SARS-CoV-2 tuvo peor cumplimiento en SUH con alta presión (29% frente a 40%, p 0,001) y durante el periodo tardío (30% frente a 37%, p = 0,04). Durante el periodo tardío, mejoró la medida de saturación de oxígeno (100% frente a 99%, p = 0,035), la realización de electrocardiograma en pacientes tratados con hidroxicloroquina (87% frente a 65%, p 0,001) y la no administración de lopinavir-ritonavir en pacientes con diarrea (79% frente a 53%, p 0,001). No hubo diferencias en relación con el grupo etario.Durante el primer pico pandémico, diversos aspectos de la calidad de la atención a pacientes COVID-19 en los SUH españoles se vieron deteriorados. La presión asistencial pudo incrementar este deterioro. Hubo un efecto de aprendizaje que condicionó una mejora, pero no se observaron diferencias según la edad de los pacientes.

To analyze whether short-term outcomes are affected when patients diagnosed with acute heart failure (AHF) spend time in an emergency department observation unit (EDOU) before hospital admission.Baseline and emergency episode data were collected for patients diagnosed with AHF in the EDs of 15 Spanish hospitals. We analyzed crude and adjusted associations between EDOU stay and 30-day mortality (primary outcome) and in-hospital mortality and a prolonged hospital stay of more than 7 days (secondary outcomes).A total of 6597 patients with a median (interquartile range) age of 83 (76-88 years) were studied. Fifty-five percent were women. All were hospitalized for AHF (50% in internal medicine wards, 23% in cardiology, 11% in geriatrics, and 16 in other specialties. Of these patients, 3241 (49%) had had EDOU stays and 3350 (51%) had been admitted immediately, with no EDOU stay. Having an EDOU stay was associated with female sex, dementia or chronic obstructive pulmonary disease, long-term treatment with certain drugs for heart failure, greater baseline deterioration in function, and a higher degree of decompensation. Patients in the EDOU group were more often admitted to an internal medicine ward and had shorter stays; cardiology, geriatric, and intensive care admissions were less likely to have had an EDOU stay. Overall, 30-day mortality was 12.6% (13.7% in the EDOU group and 11.4% in the no-EDOU group; P = .004). In-hospital mortality was 10.4% overall (EDOU, 11.1% and no-EDOU, 9.6%; P = .044). Prolonged hospitalization occurred in 50.0% (EDOU, 48.7% and no-EDOU, 51.2%; P = .046). After adjusting for between-group differences, the EDOU stay was not associated with 30-day mortality (hazard ratio, 1.14; 95% CI, 0.99-1.31). Odds ratios for associations between EDOU stay and in-hospital mortality and prolonged hospital stay, respectively, were 1.09 (95% CI, 0.92-1.29) and 0.91 (95% CI, 0.82-1.01).Although mortality higher in patients hospitalized for AHF who spend time in an EDO, the association seems to be accounted for by their worse baseline situation and the greater seriousness of the decompensation episode, not by time spent in the EDOU.Analizar si la estancia en el área de observación de urgencias (AOU) de pacientes que han sido diagnosticados de insuficiencia cardiaca aguda (ICA) y que deben ingresar está asociada con algún cambio en la evolución a corto plazo.Se recogieron datos basales y clínicos de pacientes diagnosticados de ICA en el servicio de urgencias de 15 hospitales españoles. Se analizó la asociación cruda y ajustada de la estancia en el AOU previa a la hospitalización con mortalidad a 30 días (objetivo primario) y con mortalidad intrahospitalaria e ingreso prolongado (7 días) (objetivos secundarios).Se incluyeron 6.597 pacientes (mediana = 83 años, RIC = 76-88; mujeres = 55%) hospitalizados por ICA (50% en medicina interna, 23% en cardiología, 11% en geriatría y 16% en otros servicios); de ellos, 3.241 (49%) permanecieron en observación en urgencias (grupo AOU) y 3.350 (51%) hospitalizaron sin observación previa (grupo no-AOU). La observación en urgencias se asoció con ser mujer, tener demencia o enfermedad pulmonar obstructiva crónica, recibir crónicamente fármacos específicos para insuficiencia cardiaca, mayor deterioro funcional basal y mayor gravedad de la descompensación. El grupo AOU más frecuentemente hospitalizó en medicina interna y corta estancia, y menos frecuentemente en cardiología, geriatría y cuidados intensivos. La mortalidad a 30 días fue del 12,6% (AOU = 13,7%, no-AOU = 11,4%, p = 0,004); la mortalidad intrahospitalaria fue del 10,4% (AOU = 11,1%, no-AOU = 9,6%, p = 0,044) y el ingreso prolongado del 50,0% (AOU = 48,7%, no-AOU = 51,2%, p = 0,046). Tras ajustar por las diferencias entre grupos, la estancia en observación en urgencias no se asoció con mortalidad a 30 días (HR = 1,14, IC 95% = 0,99-1,31), mortalidad intrahospitalaria (OR = 1,09, IC 95% = 0,92-1,29) o estancia prolongada (OR = 0,91, IC 95% = 0,82-1,01).Aunque los pacientes hospitalizados por ICA que permanecen en observación en urgencias presentan mayor mortalidad, esta asociación parece explicarse por su peor situación de base y la mayor gravedad del episodio de descompensación y no por su paso por el AOU.

Aims We investigated the incidence, risk factors, clinical characteristics, and outcomes of pulmonary embolism (PE) in patients with COVID-19 attending emergency departments (EDs), before hospitalization. Methods and Results We retrospectively reviewed all COVID-19 patients diagnosed with PE in 62 Spanish EDs (20% of Spanish EDs, case group) during the first COVID-19 outbreak. COVID-19 patients without PE and non-COVID-19 patients with PE were included as control groups. Adjusted comparisons for baseline characteristics, acute episode characteristics, and outcomes were made between cases and randomly selected controls (1:1 ratio). We identified 368 PE in 74 814 patients with COVID-19 attending EDs (4.92‰). The standardized incidence of PE in the COVID-19 population resulted in 310 per 100 000 person-years, significantly higher than that observed in the non-COVID-19 population [35 per 100 000 person-years; odds ratio (OR) 8.95 for PE in the COVID-19 population, 95% confidence interval (CI) 8.51–9.41]. Several characteristics in COVID-19 patients were independently associated with PE, the strongest being D-dimer >1000 ng/mL, and chest pain (direct association) and chronic heart failure (inverse association). COVID-19 patients with PE differed from non-COVID-19 patients with PE in 16 characteristics, most directly related to COVID-19 infection; remarkably, D-dimer >1000 ng/mL, leg swelling/pain, and PE risk factors were significantly less present. PE in COVID-19 patients affected smaller pulmonary arteries than in non-COVID-19 patients, although right ventricular dysfunction was similar in both groups. In-hospital mortality in cases (16.0%) was similar to COVID-19 patients without PE (16.6%; OR 0.96, 95% CI 0.65–1.42; and 11.4% in a subgroup of COVID-19 patients with PE ruled out by scanner, OR 1.48, 95% CI 0.97–2.27), but higher than in non-COVID-19 patients with PE (6.5%; OR 2.74, 95% CI 1.66–4.51). Adjustment for differences in baseline and acute episode characteristics and sensitivity analysis reported very similar associations. Conclusions PE in COVID-19 patients at ED presentation is unusual (about 0.5%), but incidence is approximately ninefold higher than in the general (non-COVID-19) population. Moreover, risk factors and leg symptoms are less frequent, D-dimer increase is lower and emboli involve smaller pulmonary arteries. While PE probably does not increase the mortality of COVID-19 patients, mortality is higher in COVID-19 than in non-COVID-19 patients with PE.

Infection caused by Monkeypox Virus (MPVX) has small rodents as its natural reservoir and both monkeys and humans are occasional hosts. The causative agent is an Orthopoxvirus (MPVX) that was isolated in monkeys in 1958 and proved capable of passing to humans in 1970. It remained contained in Africa, causing isolated episodes of infection, until 2003 when an outbreak occurred in the United States following importation of animals from that continent. Since then, anecdotal cases have continued to be reported outside Africa, usually very clearly linked to travelers to those countries, but in May 2022, a broad outbreak of this disease has begun, now affecting several continents, with the emergence of human cases of MPVX (H-MPVX) infection mainly among Men that have Sex with Men (MSM). The disease has an incubation time ranging from 5 to 15 days and is characterized by the presence of pustules, fever, malaise and headache. The presence of significant regional lymphadenopathy is a differential feature with episodes of classical smallpox. Proctitis and pharyngitis, with minimal skin lesions, may be another form of presentation. Diagnosis can be confirmed by PCR testing of lesions or by demonstration of MPVX in other body fluids or tissues, although in the appropriate epidemiologic setting the clinical picture is highly suggestive of the disease. Effective drug treatment has been developed as part of programs to protect against potential bioterrorist agents and smallpox vaccinees are known to have high protection against monkeypox. New vaccines are available, but neither the drugs nor the vaccines are yet freely available on the market. The prognosis of the disease appears, at least in adults in developed countries, to be good, with very low mortality figures and much less aggressive behavior than that described in classical smallpox. Isolation measures, essential for the control of the outbreak, have been published by the health authorities.

Purpose Thrombotic events (TE) represent one of the major complications of SARS-CoV-2 infection. The objective is to evaluate vessel density (VD) and perfusion density (PD) by optical coherence tomography angiography (OCTA) in COVID-19 patients, and compare the findings with healthy controls. The secondary objective is to evaluate if there are differences in OCTA parameters between COVID-19 patients with and without associated TE. Methods Cross-sectional case–control study that included patients with laboratory-confirmed diagnosis of COVID-19 with and without TE related to the infection and age-matched healthy controls. Ophthalmological examination and OCTA were performed 12 weeks after diagnosis. Demographic data and medical history were collected. Macular OCTA parameters in the superficial retinal plexus were analyzed according to ETDRS sectors. Results Ninety patients were included, 19 (20%) COVID-19 patients with associated TE, 47 (49.5%) COVID-19 patients without TE, and 29 (30.5%) healthy controls. Fifty-three (55.7%) were male, mean age 54.4 (SD 10.2) years. COVID-19 patients presented significantly lower VD than healthy controls: central (p = 0.003), inner ring (p = 0.026), outer ring (p = 0.001). PD was also significantly decreased: outer ring (p = 0.003), full area (p = 0.001). No differences in OCTA parameters were found between COVID-19 patients with and without TE. Conclusions OCTA represents a promising tool for the in vivo assessment of microvascular changes in COVID-19. Patients with SARS-CoV-2 infection show lower VD and PD compared to healthy controls. However, no differences were found between COVID-19 when considering TE. Prospective studies are required to further evaluate the retinal microvascular involvement of SARS-CoV-2 and its impact on the vasculature of other organs. Supplementary Information The online version contains supplementary material available at 10.1007/s00417-021-05186-0.

• Several cardiovascular/hemostatic disturbances haves been reported in patients with COVID-19, but the real frequency and their potential association with the pathogenic mechanisms of SARS-CoV-19 still remain to be defined. • We investigated the relative frequency of acute coronary syndrome, deep venous thrombosis, pulmonary embolism, stroke and upper gastrointestinal bleeding in COVID patents attending emergency departments (EDs), before hospitalization and compared them with frequencies in the general ED population attending 50 Spanish EDs. • We found that the risk of pulmonary embolism is clearly increased in COVID patients, with an OR of 4.53 with respect to non-COVID patients (95% confidence interval 4.03- 5.10). Additionally, the diagnosis of pulmonary embolism was 2 fold more frequent among ED comers in 2020 compared to 2019, suggesting a SARS-CoV-2 role in such increment of cases.. The remaining entities studied were not found to be unequivocally increased in the present study and need further investigation.

Precis Vascular diseases have been linked to alterations in optic nerve head perfusion. Purpose The main objective was to investigate the changes in peripapillary vessel density (VD) in post coronavirus disease (COVID-19) patients. Methods In this prospective pilot exploratory study, patients with COVID-19 that were attended in the Emergency Department of Hospital Clinico San Carlos (Madrid) were included. All patients underwent optic nerve head optical coherence tomography angiography using the Cirrus HD-OCT 500 with AngioPlex OCTA (Zeiss, Dublin, CA) 4 and 12 weeks after diagnosis by positive reverse transcriptase-polymerase chain reaction test from nasopharyngeal swab at the Emergency Department. Sociodemographic data, medical history, disease severity, and laboratory work-up were collected. Results One hundred and eighty eyes of 90 patients with severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) infection were included. None of the patients reported visual changes. Severe patients were older, more frequently hispanic, dyslipidemic, and presented lower lymphocytes counts, as well as increased ferritin, D-dimer, fibrinogen, and international normalized ratio levels. No changes in optic nerve head vascularization were observed when both visits were compared. No correlation was found between VD and clinical parameters, disease severity and laboratory work-up. Conclusions Changes to peripapillary VD were not observed in patients with COVID-19 in the early months following diagnosis.

Objective: Experts recommended that direct discharge without hospitalization (DDWH) for emergency departments (EDs) able to observe acute heart failure (AHF) patients should be 40%, and these discharged patients should fulfil the following outcome standards: 30-day all-cause mortality 40%. Considering DDWH patients altogether, outcomes A/C were above the recommended standards (4.3%/29.4%), while outcome B was nearly met (B = 10.1%). When analyzing individual EDs, 58.1% of them achieved the outcome B standard, while outcomes A/C standards were barely achieved (19.3%/9.7%). We observed clinically relevant linear/quadratic relationships between higher DDWH and worse outcomes B (weighted R-2 = 0.184/0.322) and C (weighted R-2 = 0.430/0.624), but not with outcome A (weighted R-2 = 0.002/0.022). Conclusions: The EDs of this nationwide cohort do not fulfil the standards for AHF patients with DDWH. High DDWH rates negatively impact ED revisit or hospitalization but not mortality. This may represent an opportunity for improvement in better selecting patients for early ED discharge and in ensuring early follow-up after ED discharge. (c) 2020 Published by Elsevier Ltd on behalf of Japanese College of Cardiology.

OBJECTIVE To describe the frequency, clinical characteristics and outcomes of patients with acute heart failure (AHF) transferred directly from emergency departments to home hospitalisation (HH) and to compare them with those hospitalised in internal medicine (IM) or short-stay units (SSU). METHOD We included patients with AHF transferred to HH by hospitals that considered this option during the Epidemiology of Acute Heart Failure in Spanish Emergency Departments (EAHFE) 4-5-6 Registries and compared them with patients admitted to IM or SSU in these centres. We compared the adjusted all-cause mortality at 1 year and adverse events 30 days after discharge. RESULTS The study included 1473 patients (HH/IM/SSU: 68/979/384). The HH rate was 4.7% (95% CI, 3.8-6.0%). The patients in HH had few differences compared with those hospitalised in IM and SSUs. The HH mortality was 1.5%, and the HH median stay was 7.5 days (IQR, 4.5-12), similar to that of IM (median stay, 8 days; IQR, 5-13; p=.106) and longer than that of SSU (median stay, 4 days; IQR, 3-7; p

Resumen Objetivo Describir frecuencia, caracteristicas clinicas y evolucion de los pacientes con insuficiencia cardiaca aguda (ICA) ingresados directamente desde urgencias en hospitalizacion a domicilio (HaD) asi como compararlos con los ingresados en medicina interna (MI) o unidad de corta estancia (UCE). Metodo Se incluyeron los pacientes con ICA ingresados en HaD por parte de los hospitales que contemplaban esta opcion durante los Registros EAHFE 4-5-6 y se compararon con los casos que ingresaron en MI o UCE en estos centros. Se compararon la mortalidad por cualquier causa al ano y los eventos adversos a los 30 dias tras el alta de forma ajustada. Resultados Se incluyeron 1.473 pacientes (HaD/MI/UCE: 68/979/384). La frecuencia de HaD fue del 4,7% (IC95% = 3,8-6,0%). Los pacientes en HaD tuvieron escasas diferencias respecto a los ingresados en MI y UCE. Su mortalidad durante el ingreso fue del 1,5% y la duracion de la estancia mediana fue de 7,5 dias (RIC = 4,5-12), parecida a MI (mediana = 8; RIC = 5-13; p = 0,106) y superior a UCE (mediana = 4; RIC = 3-7; p Conclusiones El ingreso directo desde urgencias en HaD es poco frecuente a pesar de ser una opcion segura en un determinado perfil de pacientes con ICA.

Two years after the COVID-19 pandemic, many uncertainties persist about the causal agent, the disease and its future. This document contains the reflection of the COVID-19 working group of the Official College of Physicians of Madrid (ICOMEM) in relation to some questions that remain unresolved. The document includes considerations on the origin of the virus, the current indication for diagnostic tests, the value of severity scores in the onset of the disease and the added risk posed by hypertension or dementia. We also discuss the possibility of deducing viral behavior from the examination of the structure of the complete viral genome, the future of some drug associations and the current role of therapeutic resources such as corticosteroids or extracorporeal oxygenation (ECMO). We review the scarce existing information on the reality of COVID 19 in Africa, the uncertainties about the future of the pandemic and the status of vaccines, and the data and uncertainties about the long-term pulmonary sequelae of those who suffered severe pneumonia. post-print 462 KB

COVID-19 pneumonia is a manifestation of SARS-CoV-2 infection and in most cases involves hospital admission. There are recommendations according to which these patients can be discharged without hospital admission, but there is no evidence regarding the revisit and the most appropriate type of follow-up. The objective of the RESALSEVID study was to investigate the variables associated with the 30-day revisit (Rev30d) in a group of patients discharged directly from 4 emergency departments (ED) with COVID-19 pneumonia, and analyze whether there were differences based on 4 different tracking devices.Analysis of a prospective cohort of patients discharged directly from the ED with COVID-19 pneumonia in 4 hospital with different models of follow-up at discharge (primary care, hospitalization at home [HaH] phone and in person, HaH phone, hospital phone).Five hundred twenty patients were included, with a mean age of 50.1 years and 51% men. Rev30d was 18.3% and was related only to immunosuppression, odds ratio 4.49 (95% confidence interval 1.10-18.24); p=0.022. There was no difference in Rev30d based on the follow-up model used at discharge from the ED.There are some recommendations that allow the safe discharge of patients with COVID-19 pneumonia, with no differences in Rev30d depending on the type of follow-up.

Platelets are the blood cells in charge of maintaining the body hemostasis, recognising the damaged vessel wall, and providing the appropriate cellular surface for the coagulation cascade to act locally. Additionally, platelets are active immunomodulators. At the crossroads of hemostasis and inflammation, platelets may exert either beneficial actions or participate in pathological manifestations, and have been associated with the prothrombotic nature of multi-organ failure in systemic inflammation. Platelet number alterations have been reported in septis, and platelet transfusions are given to thrombocytopenic patients. However, the risk to develop transfusion related acute lung injury (TRALI) is higher in sepsis patients. In this manuscript we show that platelets produced during inflammation in preclinical mouse models of sterile inflammation display lower aggregation capacity when stimulating certain receptors, while responses through other receptors remain intact, and we name them "inflammation-conditioned" platelets. In a cohort of sepsis patients, we observed, as previously reported, alterations in the number of platelets and platelet hyperreactivity. Furthermore, we identified a receptor-wise platelet aggregation response disbalance in these patients, although not similar to platelets from preclinical models of sterile inflammation. Interestingly, we generated evidence supporting the notion that platelet aggregation capacity disbalance was partially triggered by plasma components from sepsis patients. Our findings have implications in the indication of platelet transfusions in sepsis patients: Are fully functional platelets suitable for transfusion in sepsis patients? Current Clinical Trials (RESCUE) will answer whether platelet production stimulation with thrombopoietin receptor agonists (TPO-RAs) could be a substitute of platelet transfusions., This study was partially supported by an RYC fellowship (RYC-2013-12587, Ministerio de Economía y Competitividad, Spain) and I+D Excelencia 2017 and 2020 project grants (SAF2017-85489-P and PID2020-117265GB-I00, Ministerio de Ciencia e Innovaci´on -Spain- and Fondos Feder) to L.G and a Severo Ochoa Grant (PA-20-PF-BP19-014, Consejería de Ciencia, Innovación y Universidades del Principado de Asturias) to PMB.

Objective: The authors investigated the incidence, risk factors, clinical characteristics, and outcomes of upper gastrointestinal bleeding (UGB) in patients with coronavirus disease 2019 (COVID-19), who were attending the emergency department (ED), before hospitalization. Methods: We retrospectively reviewed all COVID-19 patients diagnosed with UGB in 62 Spanish EDs (20% of Spanish EDs, case group) during the first 2 months of the COVID-19 outbreak. We formed 2 control groups: COVID-19 patients without UGB (control group A) and non-COVID-19 patients with UGB (control group B). Fifty-three independent variables and 4 outcomes were compared between cases and controls. Results: We identified 83 UGB in 74,814 patients with COVID-19 who were attending EDs (1.11%, 95% CI=0.88-1.38). This incidence was lower compared with non-COVID-19 patients [2474/1,388,879, 1.78%, 95% confidence interval (CI)=1.71-1.85; odds ratio (OR)=0.62; 95% CI=0.50-0.77]. Clinical characteristics associated with a higher risk of COVID-19 patients presenting with UGB were abdominal pain, vomiting, hematemesis, dyspnea, expectoration, melena, fever, cough, chest pain, and dysgeusia. Compared with non-COVID-19 patients with UGB, COVID-19 patients with UGB more frequently had fever, cough, expectoration, dyspnea, abdominal pain, diarrhea, interstitial lung infiltrates, and ground-glass lung opacities. They underwent fewer endoscopies in the ED (although diagnoses did not differ between cases and control group B) and less endoscopic treatment. After adjustment for age and sex, cases showed a higher in-hospital all-cause mortality than control group B (OR=2.05, 95% CI=1.09-3.86) but not control group A (OR=1.14, 95% CI=0.59-2.19) patients. Conclusions: The incidence of UGB in COVID-19 patients attending EDs was lower compared with non-COVID-19 patients. Digestive symptoms predominated over respiratory symptoms, and COVID-19 patients with UGB underwent fewer gastroscopies and endoscopic treatments than the general population with UGB. Inhospital mortality in COVID-19 patients with UGB was increased compared with non-COVID patients with UGB, but not compared with the remaining COVID-19 patients.

Background The multiple estimation of risk based on the emergency department Spanish score in patients with acute heart failure (MEESSI-AHF) is a risk score designed to predict 30-day mortality in acute heart failure patients admitted to the emergency department. Using a derivation cohort, we evaluated the performance of the MEESSI-AHF risk score to predict 11 different short-term outcomes. Methods Patients with acute heart failure from 41 Spanish emergency departments (n=7755) were recruited consecutively in two time periods (2014 and 2016). Logistic regression models based on the MEESSI-AHF risk score were used to obtain c-statistics for 11 outcomes: three with follow-up from emergency department admission (inhospital, 7-day and 30-day mortality) and eight with follow-up from discharge (7-day mortality, emergency department revisit and their combination; and 30-day mortality, hospital admission, emergency department revisit and their two combinations with mortality). Results The MEESSI-AHF risk score strongly predicted mortality outcomes with follow-up starting at emergency department admission (c-statistic 0.83 for 30-day mortality; 0.82 for inhospital death, P=0.121; and 0.85 for 7-day mortality, P=0.001). Overall, mortality outcomes with follow-up starting at hospital discharge predicted slightly less well (c-statistic 0.80 for 7-day mortality, P=0.011; and 0.75 for 30-day mortality, P Conclusions The MEESSI-AHF risk score strongly predicts mortality outcomes in acute heart failure patients admitted to the emergency department, but the model performs poorly for outcomes involving hospital admission or emergency department revisit. There is a need to optimise this risk score to predict non-fatal events more effectively.

espanolIntroduccion. Los cambios en las recomendaciones de Salud Publica pueden haber modificado la cantidad de visitas y los casos diagnosticados por COVID-19 en un servicio de urgencias de Madrid. Material y metodos. Estudio retrospectivo de series de casos que incluyo a todos los pacientes atendidos de manera consecutiva en un servicio de urgencias terciario y urbano en Madrid, del 1 al 31 de marzo. La muestra se dividio: no COVID-19, COVID-19 no investigado, COVID-19 posible, COVID-19 probable, COVID-19 confirmado. Las diferencias entre los diferentes periodos establecidos por Salud Publica se evaluaron por el test de ANOVA para cada cohorte, incluyendo el numero porcentual de test de PCR como covariable. Resultados. Se incluyeron un total de 7.163 casos (4.071 no COVID-19, 563 COVID-19 no investigados, 870 posibles, 648 probables y 1.011 confirmados COVID-19). Las medidas de Salud Publica aplicadas durante cada periodo mostraron un claro efecto en la proporcion de casos para las cinco cohortes. Conclusion. La variabilidad de las definiciones de casos y los criterios de las pruebas de diagnostico pueden tener un impacto en la cantidad de visitas a urgencias y en los casos diagnosticados de COVID-19 en el servicio de Urgencias. EnglishIntroduction. Changes in Public Health recommendations may have changed the number of emergency visits and COVID-19 diagnosed cases in an Emergency Department in Madrid. Material and methods. This retrospective case series study included all consecutive patients in a tertiary and urban ED in Madrid from 1st to 31st March. The sample was divided: NonCOVID-19, Non-investigated COVID-19, Possible COVID-19, Probable COVID-19, Confirmed COVID-19. Differences between public health periods were tested by ANOVA for each cohort, and by ANCOVA including the number of PCR tests (%) as covariate. Results. A total of 7,163 (4,071 Non-COVID-19, 563 Non-investigated COVID-19, 870 Possible, 648 Probable and 1,011 Confirmed COVID-19) cases were included. Public Health measurements applied during each period showed a clear effect on the case proportion for the five cohorts. Conclusion. The variability of case definitions and diagnostic test criteria may have impact on the number of emergency visits and COVID-19 diagnosed cases in Emergency Department.

Resumen Cada vez es mayor el numero de pacientes de edad avanzada que esta siendo tratado por especialidades diferentes a la geriatria, las cuales, por las caracteristicas de sus tratamientos, necesitan conocer el pronostico que tiene su indicacion en los pacientes ancianos fragiles y optimizar la situacion de estos pacientes para mejorar dicho pronostico. Las mas frecuentes, actualmente, son oncologia y hematologia, cardiologia, cirugia general y otros servicios quirurgicos. Se entiende por geriatria transversal la ampliacion del area de conocimiento y atencion de la geriatria en sentido horizontal, fuera de sus unidades habituales, aplicando los principios de la medicina geriatrica con un enfoque multidisciplinar al terreno de otros servicios que atienden a pacientes muy mayores y fragiles con enfermedades graves, con el objetivo de ofrecer una atencion centrada en la persona y mejorar su manejo integral. La valoracion geriatrica y la deteccion de la fragilidad en estos casos aportan informacion pronostica y ayudan en la toma de decisiones y en la seleccion de un tratamiento individualizado. En algunos casos es posible mejorar la evolucion de los pacientes y la eficiencia del sistema sanitario. En este articulo se revisan estos conceptos, se describen algunos modelos existentes, se mencionan los instrumentos mas empleados para esta funcion y se resumen algunas actividades de esta nueva area de la asistencia geriatrica. Es previsible que cada vez en mas hospitales se solicite a los servicios de geriatria la implementacion de este tipo de valoraciones e intervenciones. Existe informacion basica para su puesta en marcha, pero no la suficiente como para considerar que estan respondidas todas las preguntas que se plantean. Sera, pues, en los proximos anos un nuevo reto para esta especialidad.

Antecedentes y objetivos La insuficiencia cardiaca (IC) es una enfermedad crónica frecuentemente asociada al envejecimiento. Disponemos de modelos predictivos basados en variables que asocian mal pronóstico y que sin embargo no incluyen condiciones habituales en el paciente mayor, como la fragilidad o la comorbilidad. Nuestro objetivo es conocer las características clínicas y epidemiológicas de una cohorte de pacientes mayores con IC ambulatoria seguidos por cardiología, la prevalencia de la fragilidad y otros síndromes geriátricos, así como su impacto pronóstico, y conocer si su consideración mejora la capacidad predictiva de los modelos de riesgo utilizados. Material y métodos Estudio observacional, prospectivo y multicéntrico que incluirá 400 pacientes ≥ 75 años con IC crónica seguidos en hospital de día y consultas de IC de cardiología de hospitales terciarios españoles, a los que se realizará una valoración geriátrica integral y una predicción de eventos basada en los scores MAGGIC y BCN-Bio HF calculator. La variable de resultado principal es la mortalidad por cualquier causa y de origen cardiovascular a 1 y 3 años. Resultados Este estudio permitirá conocer las características y el pronóstico de pacientes ancianos con IC seguidos por cardiología en nuestro medio y la utilidad en población anciana de scores utilizados en la población general con IC crónica. Conclusión Nuestro trabajo es el primer estudio prospectivo que valorará la fragilidad y otros síndromes geriátricos de forma sistemática en el paciente anciano ambulatorio con IC en España seguido por cardiología, contribuyendo a mejorar el conocimiento de su prevalencia e impacto en nuestros pacientes. Background and objectives Heart failure (HF) is a chronic disease that is often associated with ageing. There are predictive models based on variables that associate it with a poor prognosis, although those do not include common conditions in the elderly, such as frailty or comorbidity. The aim of this study is to determine the clinical and epidemiological characteristics of a cohort of elderly outpatients with HF followed-up by cardiologists. This will include a study of the prevalence of frailty and other geriatric syndromes, as well as their impact on the prognosis, and to evaluate whether these may improve predictive ability of such predictive models. Material and methods Observational, prospective, and multicentre study that will include 400 patients ≥ 75 years old with chronic HF followed-up in Spanish tertiary hospitals by cardiology specialists in HF. Patients will undergo a comprehensive geriatric assessment, and prediction of events will be performed based on MAGGIC (Meta-Analysis Global Group in Chronic Heart Failure) and Barcelona-Bio HF calculator scores. The primary endpoint is cardiovascular and overall mortality at 1 and 3 years follow-up. Results This study will assess both the characteristics and prognosis of elderly patients with HF followed-up by cardiologists in Spain and the applicability in the elderly population of scores used in the general population with chronic HF. Conclusion This is the first prospective study that will systematically assess frailty and other geriatric syndromes in the elderly outpatient with HF in Spain and followed-up by cardiologists, thus contributing to improve knowledge about both its prevalence and impact on our patients. Sin financiación No data JCR 2020 0.206 SJR (2020) Q4, 31/35 Aging No data IDR 2020 UEM

A “Pandemic/Disaster Law” is needed to condense and organize the current dispersed and multiple legislation. The State must exercise a single power and command appropriate to each situation, with national validity. The production of plans for the use of land and real estate as potential centers for health care, shelter or refuge is recommended. There should be specific disaster plans at least for Primary Health Care, Hospitals and Socio-sanitary Centers. The guarantee of the maintenance of communication and supply routes is essential, as well as the guarantee of the autochthonous production of basic goods. The pandemic has highlighted the need to redefine the training plans for physicians who, in their different specialties, have to undertake reforms that allow a more versatile and transversal training. National research must have plans to be able to respond quickly to questions posed by the various crises, using all the nation’s resources and in particular, all the data and capabilities of the health sector. Contingency plans must consider ethical aspects, and meet the needs of patients and families with a humanized approach. In circumstances of catastrophe, conflicts increase and require a bioethical response that allows the best decisions to be made, with the utmost respect for people’s values. Rapid, efficient and truthful communication systems must be contained in a special project for this sector in critic circumstances. Finally, we believe that the creation of National Coordination Centers for major disasters and Public Health can contribute to better face the crises of the future. post-print 176 KB

Aims To evaluate the association between chronic treatment with betablockers (BB) and the severity of decompensation and short-term outcomes of patients with acute heart failure (AHF). Methods and results We consecutively included all patients presenting with AHF to 45 Spanish emergency departments (ED) during six different time-periods between 2007 and 2018. Patients were stratified according to whether they were on chronic treatment with BB at the time of ED consultation. Those receiving BB were compared (adjusted odds ratio—OR—with 95% confidence interval—CI—) with those not receiving BB group in terms of in-hospital and 7-day all-cause mortality, need for hospitalization, and prolonged length of stay (≥7 days). Among the 17 923 recruited patients (median age: 80 years; 56% women), 7795 (43%) were on chronic treatment with BB. Based on the MEESSI-AHF risk score, those on BB were at lower risk. In-hospital mortality was observed in 1310 patients (7.4%), 7-day mortality in 765 (4.3%), need for hospitalization in 13 428 (75.0%), and prolonged length of stay (43.3%). After adjustment for confounding, those on chronic BB were at lower risk for in-hospital all-cause mortality (OR = 0.85, 95% CI = 0.79–0.92, P < 0.001); 7-day all-cause mortality (OR = 0.77, 95% CI = 0.70–0.85, P < 0.001); need for hospitalization (OR = 0.89, 95% CI = 0.85–0.94, P < 0.001); prolonged length of stay (OR = 0.90, 95% CI = 0.86–0.94, P < 0.001). A propensity matching approach yielded consistent findings. Conclusion In patients presenting to ED with AHF, those on BB had better short-term outcomes than those not receiving BB.

Resumen Antecedentes y objetivos Describir las caracteristicas clinicas y el pronostico–mortalidad intrahospitalaria, a 30 dias y a 12 meses y reconsulta en urgencias a 30 dias por insuficiencia cardiaca aguda– de pacientes atendidos en servicios de urgencias hospitalarios por insuficiencia cardiaca aguda de nueva aparicion o de novo (ICAN) y compararlas con los que consultan por insuficiencia cardiaca cronica descompensada (ICAD). Pacientes NOVICA es un analisis secundario del registro Epidemiology of Acute Heart Failure in Emergency Departments. Se compararon variables demograficas, caracteristicas basales, datos del episodio agudo y seguimiento a 30 dias y al ano de pacientes con ICAN e ICAD. Resultados Se analizaron 8647 pacientes, 3288 ICAN (38%) y 5359 ICAD (62%). Las ICAN asociaron menor comorbilidad, mejor estado basal, datos de menor gravedad del episodio agudo: menor uso de diureticos en perfusion intravenosa y de oxigenoterapia, menor tasa de hospitalizacion. Las ICAN ingresaron mas frecuentemente en cardiologia o unidades de cuidados intensivos y las ICAD en unidades de corta estancia. La mortalidad cruda a 30 dias y a 12 meses y la reconsulta a 30 dias fueron inferiores en pacientes con ICAN. No obstante, en el analisis ajustado solo la reconsulta a 30 dias fue inferior en las ICAN (p Conclusiones Los pacientes que consultan en servicios de urgencias hospitalarios por ICAN muestran un perfil clinico diferente a los pacientes con ICAD. En los analisis ajustados, no hay diferencias entre los dos grupos en relacion a mortalidad intrahospitalaria, a 30 dias ni a 12 meses.

Functional decline and frailty are common in older adults and influence the risk of adverse outcomes. We aimed to assess the value of a Barthel index at the Emergency Department (ED-BI) score in predicting 30-day mortality and ED reconsultation among older patients with acute infection.We performed a prospective multicentre cohort study of older patients (≥75 years) diagnosed with acute infection in 69 Spanish EDs. Demographic, comorbidities, functional status, clinical and analytical data were collected. Unadjusted and adjusted logistic regression models were used to assess the association between ED-BI score, mortality and ED reconsultation.In total 1596 patients with a mean age of 84.7 years were included in the study and 51.7% female. The most frequent focus of infection was respiratory in 918 patients (57.5%). Patients with an ED-BI 60 points were significantly older, predominantly female, more likely institutionalized and more urinary infections. When comparing patients with an ED-BI score ≥ 60 points with those 60 points no differences were found in ED reconsultation but in the latter group mortality at 30-days was higher (p 0.001).An ED-BI score 60 points appears to be a strong predictor of mortality at the 30-day follow up in older patients with acute infection.The data used to support the findings of this study are included within the article.

The precocity and efficacy of the vaccines developed so far against COVID-19 has been the most significant and saving advance against the pandemic. The development of vaccines has not prevented, during the whole period of the pandemic, the constant search for therapeutic medicines, both among existing drugs with different indications and in the development of new drugs. The Scientific Committee of the COVID-19 of the Illustrious College of Physicians of Madrid wanted to offer an early, simplified and critical approach to these new drugs, to new developments in immunotherapy and to what has been learned from the immune response modulators already known and which have proven effective against the virus, in order to help understand the current situation. pre-print 258 KB

To determine whether there are differences in the clinical characteristics, management, and outcome of episodes of acute heart failure (AHF) in residents of the Canary Islands, where the climate is subtropical, and episodes in continental Spain.Cases were identified in the registry for Epidemiology of Acute Heart Failure in Emergency Departments and categorized as in the Canary Islands or continental Spain. Data for 38 demographic, baseline, clinical, and therapeutic variables were extracted. We analyzed statistics for in-hospital and 30-day mortality, long hospital stay (more than 7 days), and a composite outcome after discharge (revisits or death within 30 days). The results for island and continental patients were compared and adjusted for between-group differences.A total of 18 390 patients were studied, 697 islanders (3.8%) and 17 673 continental patients (96.2%). Comparisons showed that the islanders were younger; more often women; and more likely to have hypertension, diabetes, and a prior AHF episode. Their New York Heart Association functional class was also likely to be higher. However, their rates of dyslipidemia, valve disease, and functional dependence were lower, and they were also less likely to be on reninangiotensin system blockers. Although the severity of cardiac decompensation was similar in island and continental patients, the islanders received more intravenous treatments in the emergency department and were admitted less often. The adjusted risk of a long hospital stay was higher for the islanders (odds ratio [OR], 2.36; 95% CI, 1.52-3.02) but their risk for mortality and the composite outcome did not differ: in-hospital mortality, OR 0.97 (95% CI, 0.68-1.37); 30-day mortality, OR, 0.9 (95% CI, 0.67-1.27); and the post-discharge composite, OR, 1.19 (95% CI, 0.93-1.53).Baseline patient characteristics and clinical management of AHF episodes differ between the subtropical region and those in southern continental Europe. Hospitalization was required less often, but hospital stays were longer.Investigar si existen diferencias clínicas, asistenciales y evolutivas entre los episodios de insuficiencia cardiaca aguda (ICA) desarrollados en residentes en las Islas Canarias (CAN), de clima subtropical, y en los del territorio español continental (CON).. Los pacientes con ICA incluidos en el registro EAHFE se dividieron en CAN o CON. Se recogieron 38 variables demográficas, de estado clínico basal, clínicas y terapéuticas. Se analizó la mortalidad intrahospitalaria y a los 30 días, la hospitalización prolongada (7 días) y el evento combinado post-alta (reconsulta o muerte a 30 días). Se compararon los pacientes CAN y CON, ajustando los resultados por las diferencias entre grupos.Se incluyeron 18.390 pacientes: CAN = 697 (3,8%), CON = 17.673 (96,2%). Tras el ajuste, los CAN eran más jóvenes, más frecuentemente mujeres, tenían más antecedentes de hipertensión, diabetes e ICA previa, y estaban en clase funcional más avanzada, pero tenían menos dislipemia, valvulopatías y dependencia funcional, y recibían menos frecuentemente inhibidores del eje renina-angiotensina. Aunque la gravedad del episodio de descompensación fue similar, los CAN recibían más tratamientos endovenosos en urgencias y se hospitalizaban menos. El riesgo ajustado de hospitalización prolongada en los CAN resultó incrementado (OR 2,36; IC 95%:1,52-3,02), pero no hubo diferencias en la mortalidad intrahospitalaria (OR 0,97; IC 95%: 0,68-1,37), a 30 días (OR 0,9; IC 95%: 0,67-1,27) o en los eventos combinados post-alta a los 30 días (OR 1,19; IC 95%: 0,93-1,53).Existen diferencias tanto en las características basales como en el manejo clínico de los episodios de insuficiencia cardiaca en los residentes de una región subtropical respecto a los de una zona meridional europea. Además, tienen menor necesidad de hospitalización, aunque estas son más prolongadas.

ObjectiveTo develop an ECG-based tool for rapid risk assessment of a cardiac cause of syncope in patients ≥40 years.MethodsIn a prospective international multicentre study, 2007 patients ≥40 years presenting with syncope were recruited in the emergency department (ED) of participating centres ranging from large university hospitals to smaller rural hospitals in eight countries from May 2010 to July 2017. 12-Lead ECG recordings were obtained at ED presentation following the syncopal event. The primary diagnostic outcome, a cardiac cause of syncope, was centrally adjudicated by two independent cardiologists using all available clinical information including 12-month follow-up. ECG predictors for a cardiac cause of syncope were identified using penalised backward selection and a continuous-scale likelihood was calculated based on regression analysis coefficients. Findings were validated in an independent US multicentre cohort including 2269 patients.ResultsIn the derivation cohort, a cardiac cause of syncope was adjudicated in 267 patients (16%). Seven ECG criteria were identified as predictors for this outcome: heart rate and QTc-interval (continuous predictors), rhythm, atrioventricular block, ST-segment depression, bundle branch block and ventricular extrasystole/non-sustained ventricular tachycardia (categorical predictors). Diagnostic accuracy of these combined predictors for a cardiac cause of syncope was high (area under the curve 0.80, 95% CI 0.77 to 0.83). Overall, 138 patients (8%) were rapidly triaged towards rule-out and 181 patients (11%) towards rule-in of a cardiac cause of syncope. External validation showed similar performance.ConclusionIn patients ≥40 years with a syncopal event, a combination of seven ECG criteria enabled rapid assessment of the likelihood that syncope was due to a cardiac cause.Trial registration numberNCT01548352 (BASEL IX), NCT01802398 (SRS study).

Background The latest non-ST elevation myocardial infarction (NSTEMI) guidelines from the European Society of Cardiology (ESC) recommend a 3h cardiac troponin determination in patients triaged to the observe-zone of the ESC 0/1h-algorithm; however, no specific cut-off for further triage is endorsed. Purpose To derive and internally, as well as externally, validate a novel 3-hour pathway for the observe-zone of the ESC 0/1h-algorithm. Methods In an ongoing multicentre international diagnostic study, we prospectively enrolled unselected patients presenting to the emergency department with symptoms suggestive of myocardial infarction (MI). Final diagnoses were centrally adjudicated by two independent cardiologists applying the 4th universal definition of MI, based on complete cardiac work-up including cardiac imaging, serial high sensitivity cardiac troponin T (hs-cTnT) sampling and 90-day follow-up information. High sensitivity-cTnT concentrations were measured at presentation and after 1 and 3 hours. The primary outcome was safety, quantified by the sensitivity and NPV for early rule out of NSTEMI. External validation was performed in an independent multicentre international study. Results Among 2076 eligible patients, application of the ESC 0/1h-algorithm triaged 1512 patients (72.8%) to either rule-out or rule-in of NSTEMI, remaining 564 patients (27.2%) in the observe-zone (adjudicated NSTEMI prevalence 120/564 patients, 21.3%). The novel derived 3h-pathway for the observe-zone patients ruled-out NSTEMI with a 3h hs-cTnT concentration Conclusions A novel derived pathway combining a 3h hs-cTnT concentration Funding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): The Swiss Heart FoundationThe Swiss National Science Foundation Figure 1

Objective We investigated the incidence, predictor variables, clinical characteristics, and stroke outcomes in patients with COVID-19 seen in emergency departments (EDs) before hospitalization. Methods We retrospectively reviewed all COVID-19 patients diagnosed with stroke during the COVID-19 outbreak in 62 Spanish EDs. We formed two control groups: COVID-19 patients without stroke (control A) and non-COVID-19 patients with stroke (control B). We compared disease characteristics and four outcomes between cases and controls. Results We identified 147 strokes in 74,814 patients with COVID-19 seen in EDs (1.96 parts per thousand, 95% confidence interval [CI] = 1.66 parts per thousand to 2.31 parts per thousand), being lower than in non-COVID-19 patients (6,541/1,388,879, 4.71 parts per thousand, 95% CI = 4.60 parts per thousand to 4.83 parts per thousand; odds ratio [OR] = 0.42, 95% CI = 0.35 to 0.49). The estimated that standardized incidences of stroke per 100,000 individuals per year were 124 and 133 for COVID-19 and non-COVID-19 individuals, respectively (OR = 0.93 for COVID patients, 95% CI = 0.87 to 0.99). Baseline characteristics associated with a higher risk of stroke in COVID-19 patients were hypertension, diabetes mellitus, and previous cerebrovascular and coronary diseases. Clinically, these patients more frequently presented with confusion, decreased consciousness, and syncope and higher D-dimer concentrations and leukocyte count at ED arrival. After adjustment for age and sex, the case group had higher hospitalization and intensive care unit (ICU) admission rates (but not mortality) than COVID-19 controls without stroke (OR = 3.41, 95% CI = 1.27 to 9.16; and OR = 3.79, 95% CI = 1.69 to 8.50, respectively) and longer hospitalization and greater in-hospital mortality than stroke controls without COVID-19 (OR = 1.55, 95% CI = 1.24 to 1.94; and OR = 1.77, 95% CI = 1.37 to 2.30, respectively). Conclusions The incidence of stroke in COVID-19 patients presenting to EDs was lower than that in the non-COVID-19 reference sample. COVID-19 patients with stroke had greater need for hospitalization and ICU admission than those without stroke and longer hospitalization and greater in-hospital mortality than non-COVID-19 patients with stroke.

Background: The non–ST-segment–elevation myocardial infarction (NSTEMI) guidelines of the European Society of Cardiology (ESC) recommend a 3h cardiac troponin determination in patients triaged to the observe-zone of the ESC 0/1h-algorithm; however, no specific cutoff for further triage is endorsed. Recently, a specific cutoff for 0/3h high-sensitivity cardiac troponin T (hs-cTnT) change (7 ng/L) was proposed, warranting external validation. Methods: Patients presenting with acute chest discomfort to the emergency department were prospectively enrolled into an international multicenter diagnostic study. Final diagnoses were centrally adjudicated by 2 independent cardiologists applying the fourth universal definition of myocardial infarction, on the basis of complete cardiac workup, cardiac imaging, and serial hs-cTnT. Hs-cTnT concentrations were measured at presentation, after 1 hour, and after 3 hours. The objective was to externally validate the proposed cutoff, and if necessary, derive and internally as well as externally validate novel 0/3h-criteria for the observe-zone of the ESC 0/1h-hs-cTnT-algorithm in an independent multicenter cohort. Results: Among 2076 eligible patients, application of the ESC 0/1h-hs-cTnT-algorithm triaged 1512 patients (72.8%) to either rule out or rule in NSTEMI, leaving 564 patients (27.2%) in the observe-zone (adjudicated NSTEMI prevalence, 120/564 patients, 21.3%). The suggested 0/3h-hs-cTnT-change of Conclusions: A combination of a 3h-hs-cTnT concentration ( Registration: URL: https://clinicaltrials.gov ; Unique identifier: NCT00470587.