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Resumen Introduccion El diagnostico y el tratamiento precoces de la sepsis sigue siendo un reto en los servicios de urgencias hospitalarios. Objetivo El objetivo es evaluar el rendimiento de la escala quick Sequential related Organ Failure Assessment (qSOFA) para la activacion de un Codigo Sepsis en urgencias, respecto la aplicacion de los criterios previos basados en los parametros Systemic Inflammatory Response Syndrome (SIRS). Metodos Se incluyeron los pacientes ≥ 18 anos que consultaron en un servicio de urgencias de un hospital de tercer nivel durante dos periodos de tiempo (mayo-octubre de 2015) mediante criterios SIRS (grupo SIRS), y en los mismos meses de 2017 mediante criterios qSOFA (grupo qSOFA). Resultados Se analizaron 125 episodios: 70 correspondieron al grupo SIRS y 55 al grupo qSOFA. Los grupos fueron comparables respecto a antecedentes, con mayor presencia de enfermedad neoplasica en el grupo qSOFA. No se evidenciaron diferencias en la forma de presentacion, la actuacion realizada en urgencias, los ingresos en unidades de criticos, el uso de vasopresores o la estancia media hospitalaria entre los dos grupos. Si se objetivo una mayor tasa de mortalidad a 30 dias en el grupo qSOFA (21,81% vs 4,3%; p = 0,003). En el estudio multivariado destaca la enfermedad neoplasica como factor independiente de mal pronostico (OR: 5,36; p = 0,01), y la activacion mediante criterios SIRS como factor de buen pronostico (OR: 0,15; p = 0,021). Conclusiones La activacion del Codigo Sepsis mediante criterios qSOFA comporta una disminucion en la deteccion, con mayor mortalidad asociada. Es necesario buscar otras herramientas complementarias para la deteccion precoz de la sepsis en urgencias.

The early diagnosis and treatment of sepsis remains a challenge in hospital emergency departments.The objective was to evaluate the performance of the qSOFA (quick Sequential related Organ Failure Assessment) for activating a Sepsis Code in the emergency department, compared to applying previous criteria based on SIRS (Systemic Inflammatory Response Syndrome).Patients ≥18years were included who consulted an emergency department of a tertiary hospital over two periods of time (May-October 2015), using SIRS criteria (SIRS Group) and over the same months in 2017 using qSOFA criteria (qSOFA Group).One hundred and five episodes were analysed: 70 corresponded to the SIRS Group and 55 to the qSOFA Group. The groups were comparable in terms of history, with a greater presence of neoplastic disease in the qSOFA Group. No differences were observed in the form of presentation, the action taken in the emergency department, admissions to critical care units, use of vasopressors or mean hospital stay between the two groups. A higher 30-day mortality rate was observed in the qSOFA group (21.81% vs. 4.3%; P=.003). In the multivariate study, neoplastic disease was noteworthy as an independent factor of poor prognosis (OR 5.36; P=.01), and activation using the SIRS criteria as a factor of good prognosis (OR .15; P=.021).The activation of the Sepsis Code using qSOFA criteria results in a reduction in detection, with greater associated mortality. Other complementary tools need to be sought for the early detection of sepsis in the emergency department.

BACKGROUND: Convalescent plasma has been proposed as an early treatment to interrupt the progression of early COVID-19 to severe disease, but there is little definitive evidence. We aimed to assess whether early treatment with convalescent plasma reduces the risk of hospitalisation and reduces SARS-CoV-2 viral load among outpatients with COVID-19. METHODS: We did a multicentre, double-blind, randomised, placebo-controlled trial in four health-care centres in Catalonia, Spain. Adult outpatients aged 50 years or older with the onset of mild COVID-19 symptoms 7 days or less before randomisation were eligible for enrolment. Participants were randomly assigned (1:1) to receive one intravenous infusion of either 250-300 mL of ABO-compatible high anti-SARS-CoV-2 IgG titres (EUROIMMUN ratio =6) methylene blue-treated convalescent plasma (experimental group) or 250 mL of sterile 0·9% saline solution (control). Randomisation was done with the use of a central web-based system with concealment of the trial group assignment and no stratification. To preserve masking, we used opaque tubular bags that covered the investigational product and the infusion catheter. The coprimary endpoints were the incidence of hospitalisation within 28 days from baseline and the mean change in viral load (in log(10) copies per mL) in nasopharyngeal swabs from baseline to day 7. The trial was stopped early following a data safety monitoring board recommendation because more than 85% of the target population had received a COVID-19 vaccine. Primary efficacy analyses were done in the intention-to-treat population, safety was assessed in all patients who received the investigational product. This study is registered with ClinicalTrials.gov, NCT04621123. FINDINGS: Between Nov 10, 2020, and July 28, 2021, we assessed 909 patients with confirmed COVID-19 for inclusion in the trial, 376 of whom were eligible and were randomly assigned to treatment (convalescent plasma n=188 [serum antibody-negative n=160]; placebo n=188 [serum antibody-negative n=166]). Median age was 56 years (IQR 52-62) and the mean symptom duration was 4·4 days (SD 1·4) before random assignment. In the intention-to-treat population, hospitalisation within 28 days from baseline occurred in 22 (12%) participants who received convalescent plasma versus 21 (11%) who received placebo (relative risk 1·05 [95% CI 0·78 to 1·41]). The mean change in viral load from baseline to day 7 was -2·41 log(10) copies per mL (SD 1·32) with convalescent plasma and -2·32 log(10) copies per mL (1·43) with placebo (crude difference -0·10 log(10) copies per mL [95% CI -0·35 to 0·15]). One participant with mild COVID-19 developed a thromboembolic event 7 days after convalescent plasma infusion, which was reported as a serious adverse event possibly related to COVID-19 or to the experimental intervention. INTERPRETATION: Methylene blue-treated convalescent plasma did not prevent progression from mild to severe illness and did not reduce viral load in outpatients with COVID-19. Therefore, formal recommendations to support the use of convalescent plasma in outpatients with COVID-19 cannot be concluded. FUNDING: Grifols, Crowdfunding campaign YoMeCorono.

There is a high rate of occult infection and late diagnosis in HIV. Hospital emergency departments (ED) are an important point of health care. The present work aims to know the number of missed opportunities for HIV diagnosis occurring in the ED.Retrospective multicenter cohort study that included all patients diagnosed with HIV infection in 2019 in 27 Spanish hospitals in 7 different autonomous communities. All ED consultation episodes in the 5 years prior to diagnosis were reviewed to find out the reason for consultation and whether this represented a missed opportunity for HIV diagnosis.Seven hundred twenty-three patients were included, and 352 (48.7%, 95%CI: 45.1%-52.3%) had at least one ED visit during the 5 years prior to diagnosis (median 2, p25-p75: 1-4). One hundred and eighteen patients (16.3%, 95%CI: 13.8%-19.2%) had a missed diagnostic opportunity. The main consultations were drug use [145 (15%)], sexually transmitted infections [91 (9.4%)] and request for post-exposure HIV prophylaxis [39 (4%)]. One hundred and fifty-five (42.9%) of the 352 had less than 350 CD4/mmSixteen percent of patients diagnosed with HIV missed the opportunity to be diagnosed in the 5 years prior to diagnosis, highlighting the need to implement ED screening measures different from current ones to improve these outcomes.

Background Early sepsis diagnosis has emerged as one of the main challenges in the emergency room. Measurement of sepsis biomarkers is largely used in current practice to improve the diagnosis accuracy. Monocyte distribution width (MDW) is a recent new sepsis biomarker, available as part of the complete blood count with differential. The objective was to evaluate the performance of MDW for the detection of sepsis in the emergency department (ED) and to compare to procalcitonin (PCT) and C-reactive protein (CRP). Methods Subjects whose initial evaluation included a complete blood count were enrolled consecutively in 2 EDs in France and Spain and categorized per Sepsis-2 and Sepsis-3 criteria. The performance of MDW for sepsis detection was compared to that of procalcitonin (PCT) and C-reactive protein (CRP). Results A total of 1,517 patients were analyzed: 837 men and 680 women, mean age 61 ± 19 years, 260 (17.1%) categorized as Sepsis-2 and 144 patients (9.5%) as Sepsis-3. The AUCs [95% confidence interval] for the diagnosis of Sepsis-2 were 0.81 [0.78–0.84] and 0.86 [0.84–0.88] for MDW and MDW combined with WBC, respectively. For Sepsis-3, MDW performance was 0.82 [0.79–0.85]. The performance of MDW combined with WBC for Sepsis-2 in a subgroup of patients with low sepsis pretest probability was 0.90 [0.84–0.95]. The AUC for sepsis detection using MDW combined with WBC was similar to CRP alone (0.85 [0.83–0.87]) and exceeded that of PCT. Combining the biomarkers did not improve the AUC. Compared to normal MDW, abnormal MDW increased the odds of Sepsis-2 by factor of 5.5 [4.2–7.1, 95% CI] and Sepsis-3 by 7.6 [5.1–11.3, 95% CI]. Conclusions MDW in combination with WBC has the diagnostic accuracy to detect sepsis, particularly when assessed in patients with lower pretest sepsis probability. We suggest the use of MDW as a systematic screening test, used together with qSOFA score to improve the accuracy of sepsis diagnosis in the emergency department. Trial Registration ClinicalTrials.gov (NCT03588325).

Resumen Objetivos Evaluar el impacto de la implantacion de un codigo sepsis (CS) en la evolucion de pacientes con sepsis grave (SG)/shock septico (SS). Determinar los factores independientes asociados a mortalidad. Metodo Estudio de cohortes de pacientes con diagnostico de SG/SS que consultaron en urgencias de un hospital terciario durante 6 meses. Se analiza el cumplimiento de las recomendaciones de la Surviving Sepsis Campaign, la estancia media, el ingreso en criticos y la mortalidad a 30 dias. Se comparan 2 grupos: activacion CS (A) y no activacion (NA). Resultados Se detectaron 114 episodios, 61,4% del grupo A y 38,6% del NA. El grupo A presenta con mayor frecuencia presion arterial sistolica 3 mmol/l (48,3% vs 80%; p = 0,01) y foco abdominal (34,3% vs 13%; p = 0,01). En el grupo A mas frecuentemente se cursaron hemocultivos en la primera hora (95% vs 41,7%; p Una determinacion de proteina C reactiva > 200 mg/l (odds ratio 33,7; p Conclusiones La implantacion de un CS mejora el cumplimiento de las recomendaciones y se asocia a una reduccion de los ingresos en unidades de criticos, estancia media y mortalidad. La elevacion de la proteina C reactiva y la no activacion del codigo son factores independientes asociados a mortalidad. Existe un gran margen de mejora en la deteccion de los pacientes con SG/SS, asi como en la optimizacion del tratamiento inicial en urgencias.

Objective: To evaluate the usefulness of YouTube videos as an educative tool for type 2 diabetes self-management. Design: Search terms were “diabetes diet” and “diabetes treatment.” Videos were jointly assessed by two reviewers. A third investigator evaluated a random sample to check for agreement. Main measures: Usefulness defined as making reference to AAD7 Self-Care Behaviors™ and presence of misleading information. Results: Of the 393 videos included, 42.2 percent (n = 166) classified as “alternative medicine.” 40.2 percent (n = 158) contained useful information. 25.7 percent (n = 101) videos contained misleading information. Videos displaying “alternative medicine” professionals (60 out of 200) were less useful (17% vs 57%; p Conclusion: The probability of finding videos that relate to AADE7™ self-care behaviors is below 50 percent. The odds of finding misleading information are high. Therefore, it is inadvisable for professionals to recommend the use of YouTube as an educating tool if specific videos are not suggested.

To evaluate the impact of a code sepsis (CS) activation, complying with recommendations, the evolution of patients with severe sepsis in the emergency room and determine independent factors associated to mortality.All patients attending the emergency room with severe sepsis during a 6-month period were included. Complying with Surviving Sepsis Campaign recommendations, patients' average stay, intensive care admissions and 30-day mortality were assessed. Two groups were compared: CS activation (A) and no activation (NA).A total of 114 episodes were found, 61.4% belonging to group A and 38.6% to NA. Patients in group A presented hypotension more frequently (61.5% vs 34.4%; P=.005). Patients in group NA more frequently had lactate levels of3mmol/L (48.3% vs 80%; P=.01), and abdominal focus of sepsis (34.3% vs 13%; P=.01). In group A, blood cultures were more frequently drawn in the first hour (95% vs 41.7%; P.001), early antibiotic was administered (76.9% vs 25%; p=.005) and fluid replacement carried out (54.5% vs 18.2%; P=.01). Global achievement of CS objectives was higher in group A (31.4% vs 9.1%; P=.006). In group NA more patients were admitted to the intensive care unit (10% vs 36.4%; P.001), had longer average stays (10.2 days SD 6.9 vs 14.4 days SD 5.8; P.001) and a higher mortality rate (4.3% vs 34.1%; P.001). CRP200mg/l (OR 33.7; P.001) and the no activation of CS (OR 13.3; p=.001) resulted in being independent factors associated with mortality.The implementation of a CS improves compliance with SSC recommendations and decreases intensive care admissions, average stays and mortality.