Albert Salazar

Effectiveness and safety of an emergency department short-stay unit as an alternative to standard inpatient hospitalisation

Background: Emergency department short-stay units (EDSSUs) are currently emerging worldwide as an alternative to standard inpatient hospitalisation. In our hospital, a 960-bed teaching tertiary institution in Barcelona, Spain, an EDSSU has been in operation during winter periods (November–March) since 1997. Aim: To determine the efficacy and safety of our EDSSU. Methods: Retrospective analysis of activity and quality outcomes, assessment of patient satisfaction levels and determination of the diagnostic-related groups that were mainly responsible for admissions to the EDSSU, comparing the clinical characteristics of those patients with the characteristics of patients with similar clinical diagnoses admitted to standard hospitalisation units. Results: 5666 patients were treated in the EDSSU, with a progressive increase in the number of patients admitted per period, ranging from 707 in 1997–8 to 1227 in 2003–4 (73.5% increase). The mean length of stay ranged from 3.1 to 2.8 days, mortality from 2.5% to 5.1%, home discharge rate from 84% to 90%, and hospital readmission rate within the first week after discharge from 3.9% to 6.2%. In all, 98% of patients were satisfied with their stay at the EDSSU. The main diagnostic-related groups were chronic obstructive pulmonary disease (COPD = 50%) and acute heart failure (28%). Patients with COPD admitted at the EDSSU (n = 545) showed significantly (p = 0.05) lower mean length of stay (3.4 v 12 days) and mortality (1.7% v 8.1%), but a higher hospital readmission rate (9.9% v 7%) than those admitted to standard inpatient units (n = 1961). Conclusions: In our experience, the EDSSU proved to be an effective and safe alternative to standard inpatient hospitalisation.

Clinical Factors Predicting Persistence of Activity in Sarcoidosis: A Multivariate Analysis of 193 Cases

The prognosis of sarcoidosis is difficult to establish and it depends mainly on the persistence of activity over time and the degree of functional impairment of the involved organs. The aim of this study was to identify factors predicting persistence of disease activity at diagnosis. In a 14-year period (1974-1987), 209 patients were diagnosed with sarcoidosis at Bellvitge Hospital, a 1,000-bed teaching institution in Barcelona, Spain. One hundred ninety-three patients were followed up and included in the study. Clinical and radiological data were collected at diagnosis and a definition of disease activity was established. A Cox proportional-hazards regression model identified the following variables as independently influencing the persistence of activity: absence of erythema nodosum (risk ratio, RR = 2.37; 95% confidence interval, CI: 1.54-3.66), pulmonary infiltrates in chest x-ray (RR = 1.89, 95% CI: 1.28-2.8), splenomegaly (RR = 3.67, 95% CI: 1.46-9.23), age > or = 40 years (RR = 1.01, 95% CI: 1.006-1.03), and absence of lymphadenopathy in chest x-ray (RR = 2.26, 95% CI: 1.08-4.77). We suggest that the identification of factors predicting persistence of sarcoidosis activity at diagnosis may help to establish the prognosis of the disease and therefore improve the therapeutic approach.

Are the Pulmonary Function Tests and the Markers of Activity Helpful to Establish the Prognosis of Sarcoidosis

The prognosis of sarcoidosis is difficult to establish. It depends mainly on the persistence of activity over time and the degree of functional impairment of the involved organs. The aim of this study was to analyze whether the pulmonary function tests and the more commonly used markers of activity, such as serum angiotensin-converting enzyme (SACE) and gallium-67 scan, are helpful to evaluate the prognosis of sarcoidosis, besides the clinical data. Over a 14-year period (1974-1987), 209 patients were diagnosed as having sarcoidosis at the Bellvitge Hospital, a 1,000-bed teaching hospital in Barcelona, Spain. Clinical, radiological, pulmonary function tests, and activity markers (SACE and gallium-67 scan) data at diagnosis were collected and classified as variables, and a definition of disease activity was established. One hundred sixteen patients were on follow-up, had all the variables available and were included in the statistical analysis. A Cox proportional-hazard regression model identified the following variables as independently influencing the persistence of activity over time: absence of erythema nodosum [risk ratio (RR) = 2.78; 95% confidence interval (CI): 1.48-5.18], age > or = 40 years (RR = 1.67; 95% CI: 1.008-1.04), SACE level > or = mean + 2 SD U/ml (RR = 1.45; CI: 0.99-1.07), hyperglobulinemia (RR = 2.47; CI: 0.98-6.24), forced vital capacity < 80% predicted (RR = 2.17; CI: 0.97-4.85), and male sex (RR = 1.8; CI: 0.95-3.45). We conclude that the pulmonary function tests and the SACE level but not the gallium scan are helpful to identify the factors predicting persistence of activity in sarcoidosis. Therefore, we recommend to add these tests to the initial clinical evaluation of patients with sarcoidosis in order to establish the prognosis and improve the therapeutic approach.

Influence of serum amyloid A on the decrease of high density lipoprotein-cholesterol in active sarcoidosis

OBJECTIVE We have previously observed low levels of high density lipoprotein (HDL) cholesterol in active sarcoidosis. The aim of this study was to analyze the role of serum amyloid A (SAA) on this lipid disorder. METHODS Eighty five untreated sarcoid patients, 40 with active disease and 45 with inactive disease, were recruited. Sarcoidosis activity was evaluated by means of clinical, chest X-ray, gallium-67 scan, serum angiotensin converting enzyme (peptidyl-dipeptidase A) values, and pulmonary function tests. Analysis of lipoprotein metabolism included: serum cholesterol, low density lipoprotein (LDL)-cholesterol, HDL-cholesterol, HDL(2)-cholesterol, HDL(3)-cholesterol, apolipoprotein A-I (apo A-I), apolipoprotein B (apo B), and triglyceride concentrations. Serum amyloid A protein and lecithin-cholesterol acyltransferase (LCAT) activity were measured. RESULTS In active sarcoidosis we found significantly reduced levels of HDL-cholesterol (1.17+/-0.36 vs. 1. 44+/-0.39 mmol/l, P=0.002), HDL(3)-cholesterol (0.78+/-0.23 vs. 1. 02+/-0.21 mmol/l, P<0.0001), and apo A-I (1.36+/-0.29 vs. 1.61+/-0. 27 g/l, P<0.0001) and significantly increased levels of triglyceride (1.51+/-0.64 vs. 1.03+/-0.46 mmol/l, P<0.0001), and apo B (1.14+/-0. 25 vs. 0.99+/-0.27 g/l, P=0.012) versus inactive sarcoidosis. Serum amyloid A concentrations were significantly increased in the patients with active disease (155.45+/-154.01 mg/ml) compared to the inactive sarcoid patients (89.70+/-65.36 mg/ml) (P=0.011). There were no significant differences in cholesterol, LDL-cholesterol, HDL(2)-cholesterol or LCAT values between groups. Multivariate logistic regression analysis showed that HDL-cholesterol (regression coefficient b=-1.96; S.E.=0.87; P=0.02) and SAA (regression coefficient b=0.01; S.E.=0.004; P=0.01) were the two variables independently associated with disease activity. Moreover, a significant negative correlation was observed between SAA levels and both HDL-cholesterol (r=-0.39; P=0.01) and apo A-I (r=-0.35; P=0.03) levels, in the active sarcoid group. Conversely, no correlation was found in the inactive sarcoid group. CONCLUSION The low HDL-cholesterol and apo A-I concentrations seen in active sarcoid patients are associated with a significant increase of SAA levels. We suggest that the displacement of apo A-I by SAA on HDL accounts for the lower level of HDL-cholesterol seen in active sarcoidosis.

High mortality rates from medical problems of frequent emergency department users at a university hospital tertiary care centre.

Background: Frequent emergency department (ED) users are a nebulous group of patients. A high degree of psychiatric problems and higher than expected mortality from medical illness have been reported in this population. Study objectives: We sought to examine the pattern of ED use by adult patients identified as being heavy users of the ED, to examine their demographic characteristics and describe their clinical profile during a one-year period at one institution. Methods: This was a descriptive, retrospective study that took place in the ED of a 1000-bed teaching hospital in Barcelona, Spain, with a population in the metropolitan area of 1.5 million, which attends approximately 110 000 emergency visits per year, excluding paediatrics and obstetrics. The ED computer registration database was used to identify all patients presenting to the hospital ED more than 10 times in a one-year period from 1 January to 31 December 2000. A cohort composed of 86 patients fitting these inclusion criteria was identified as making 1263 (1.1%) of the total 109 857 ED visits. All medical records for each patient were reviewed to determine the primary reason for repeated ED visits. Results: Of the 86 patients enrolled, 58 were men (67.4%). The mean age was 55 years (range 18–91), but only six patients (6.9%) were older than 80 years. The median number of ED visits per patient was 14 throughout the year. Forty-five of the patients (52.3%) were classified as having primarily medical reasons for presenting to the ED, with diagnoses such as shortness of breath and chest pain being the chief symptoms. Seventeen patients (19.7%) had a surgical problem as the cause of their ED visits, and eight (9.3%) had psychiatric problems contributing to the ED visits. Other major reasons for presentation to the ED were as follows: ophthalmic, eight patients (9.3%); otolaryngological, four patients (4.6%); and trauma, four patients (4.6%). A total of 982 (77.8%) of the total ED visits resulted in home discharge. Hospital emergency admissions and outpatient clinics diversions occurred in 106 (8.3%) and 71 (5.6%) ED visits, respectively. The mortality rate was as high as 18.6% (16 frequent ED users died). Conclusion: These data show that there is a high incidence of medical problems in frequent ED users and a high incidence of mortality in patients with heavy ED use.

Serum amyloid A and high‐density lipoprotein cholesterol: serum markers of inflammation in sarcoidosis and other systemic disorders

Hypocholesterolemia has been observed in several inflammatory diseases such as rheumatoid arthritis, myeloproliferative disorders, systemic lupus erythematosus and sarcoidosis. Serum amyloid A is an acute‐phase reactant that is related to the high‐density lipoprotein cholesterol. This review discusses the relationship between the activation of the cells of the monocyte‐macrophage system, determined by the serum amyloid A levels, and the lipid metabolism, measured as alterations in plasma lipoprotein concentrations. The mechanisms of this association during acute inflammation are also discussed in this review.

Combined portal and pulmonary hypertension in sarcoidosis.

A case is reported of a 48-year-old man previously diagnosed as having mitral valvular disease, who was admitted for evaluation of chronic cor pulmonale. Seven years before admission, an intraoperative liver biopsy had shown multiple noncaseating granulomas. The further course was characterized by progressive chronic intrahepatic cholestasis and portal hypertension. Right heart catheterization revealed a mean pulmonary artery pressure of 43 mm Hg and a normal wedge pressure (5 mm Hg). A perfusion lung scan was normal. Open lung biopsy demonstrated noncaseating granulomas and extensive pulmonary fibrosis. To our knowledge, only one case of sarcoidosis with combined portal and pulmonary hypertension has previously been described.

Cytomegalovirus ventriculoencephalitis in AIDS patients

We report 4 autopsy-proven cases of cytomegalovirus ventriculoencephalitis (CMV-VE) and a further case with dramatic clinical and radiological response to ganciclovir therapy. The diagnoses were based upon clinical features, cerebrospinal fluid (CSF) examination and either brain computerized tomography (CT) or magnetic resonance imaging (MRI), and confirmed by autopsy findings in 4 cases. All patients had previously had an AIDS-defining condition. CMV retinitis was diagnosed in 3 patients, 2 of them before the onset of encephalitis. CMV viremia was present in 4 patients. Examination of CSF demonstrated elevated protein and hypoglycorachia in all cases. CSF culture was negative for CMV in 3 of 3 patients. Periventricular enhancement was detected by MRI in 2 of 3 patients, but in only 1 of 5 patients by CT. Three patients received ganciclovir and 2 patients foscarnet therapy. All 4 patients died. Pathologic examination revealed periventriculitis with ependymal necrosis and CMV intranuclear inclusion bodies all 4 patients. One showed a marked neurological improvement and radiological resolution by MRI after 4 weeks of ganciclovir therapy. We conclude that CMV-VE should be suspected in HIV-infected patients who present with altered neurological status, CMV viremia or retinitis, hypoglycorachia and ventriculitis as demonstrated by MRI. Although more effective therapy is needed, ganciclovir may be beneficial, as shown in one of our patients.

How to manage the ED crisis when hospital and/or ED capacity is reaching its limits. Report about the implementation of particular interventions during the Christmas crisis.

Emergency admissions are continuing to rise. The massive use of the urban ED during winter is annually accentuated in the Christmas period, which includes the last week of the year and the first week of the new year. The causes of Christmas crisis are complex, but respiratory infections are definitely a major factor. Provision of acceptable patient care under such circumstances requires a fundamental reordering of ED priorities and procedures. Although acute responses have been described that include redesignating wards, redeploying staff, and boarding patients elsewhere in the hospital, few have been evaluated.

Corticosteroid therapy increases HDL-cholesterol concentrations in patients with active sarcoidosis and hypoalphalipoproteinemia

BACKGROUND We have previously reported that the decrease in high-density lipoprotein (HDL)-cholesterol that is observed in patients with untreated sarcoidosis is limited to those with active disease. AIM To determine the effect of corticosteroids, used in the treatment of active sarcoidosis, on the reported lipoprotein metabolism abnormalities. METHODS We studied 62 patients with biopsy-proven sarcoidosis, all of them with active disease. Sarcoidosis activity was evaluated by means of clinical, chest X-ray, gallium-67 scan, serum angiotensin-converting enzyme (peptidyl-dipeptidase A) values, and pulmonary function tests. A total of 40 patients were not treated with prednisone and 22 patients were treated with prednisone. The mean daily prednisone dosage in the treated patients with sarcoidosis was 20 mg and the mean duration of prednisone therapy was 6 months. Analysis of lipoprotein metabolism included: serum cholesterol, low-density lipoprotein (LDL)-cholesterol, HDL-cholesterol, HDL(2)-cholesterol, HDL(3)-cholesterol, apolipoprotein (apo) A-I, apo B, and triglyceride concentrations. RESULTS When patients with active sarcoidosis not treated with prednisone were compared to those treated with prednisone, the former had significantly lower HDL-cholesterol (1.17+/-0.36 vs. 1.42+/-0.42 mmol/l; P=0.01) and HDL(2)-cholesterol (0.37+/-0.18 vs. 0.53+/-0.25 mmol/l; P=0.009) levels. Multiple regression analysis demonstrated that the HDL-cholesterol (P=0.004), HDL(2)-cholesterol (P=0.002), HDL(3)-cholesterol (P=0.02), and apo A-I (P=0.02) levels were the variables independently and significantly associated with steroid therapy. CONCLUSIONS Corticosteroid therapy, used in the treatment of active sarcoidosis, increased HDL-cholesterol levels to those seen in inactive disease. These changes are manifestations of reducing disease activity.