Alfons Aguirre

Predicting length of hospitalisation of elderly patients, using the Barthel Index

Key points • TDI is a powerful echocardiographic tool for assessing the functions of both ventricles. It shows that systolic and diastolic functions of both ventricles decline with normal ageing. • With ageing, there is an increase of plasma NT-proBNP levels and a decline of exercise capacity. Both are correlated with left ventricular diastolic dysfunction that reaches the degree found in patients with mild chronic heart failure. • Normal ageing can be considered as early-stage heart failure.

Multicenter assessment of the revisit risk for a further drug-related problem in the emergency department in cocaine users (MARRIED-cocaine study).

Introduction and objectives. Emergency departments (EDs) in Spanish hospitals daily attend a large number of patients for adverse reactions or clinical complications resulting from cocaine use. After discharge, some of these patients revisit the ED for the same reason within a year. The objective of the present study was to quantify the rate of such revisits and identify the factors associated with them. Method. We performed a retrospective, multicenter study with cohort follow-up and without a control group, conducted in the EDs of six Spanish hospitals during 12 months (January–December 2009). We included all ED patients attended for cocaine-related symptoms who reported recent cocaine use and those with cocaine-positive urine analysis by immunoassay without declared consumption. Twelve independent variables assessed for each hospital ED were collected: sex, age, place of consumption, month, day, and time of consumption, mode of arrival at the ED, discharge diagnosis, psychiatric assessment on the ED episode, concomitant drugs, destination on discharge, and history of previous ED visits related with drug use and alcohol use. The dependent variable was a subsequent visit to the ED associated with drug use, identified using the computerized hospital admissions system. Results. The study included 807 patients, of whom 6.7% revisited the ED within 30 days, 11.9% within 3 months and 18.9% within 1 year. The variables significantly associated with ED revisits were: presence of clinical manifestations directly related to cocaine (p < 0.05), ED attendance on a working day (p < 0.05), history of ED visits related with the consumption of alcohol (p < 0.001) or drugs (p < 0.001), and the need for urgent consultation with a psychiatrist (p < 0.001), although only the last four were independent predictors in multivariate analysis. We derived a score based on these variables to predict risk of revisits (MARRIED-score, ranging from 0 to 400 points), which had a reasonably good predictive value for revisit (area under ROC of 0.75; 95% CI 0.71–0.79).

Impact of Frailty and Disability on 30-Day Mortality in Older Patients With Acute Heart Failure

The objectives were to determine the impact of frailty and disability on 30-day mortality and whether the addition of these variables to HFRSS EFFECT risk score (FBI-EFFECT model) improves the short-term mortality predictive capacity of both HFRSS EFFECT and BI-EFFECT models in older patients with acute decompensated heart failure (ADHF) atended in the emergency department. We performed a retrospective analysis of OAK Registry including all consecutive patients ≥65 years old with ADHF attended in 3 Spanish emergency departments over 4 months. FBI-EFFECT model was developed by adjusting probabilities of HFRSS EFFECT risk categories according to the 6 groups (G1: non frail, no or mildly dependent; G2: frail, no or mildly dependent; G3: non frail, moderately dependent; G4: frail, moderately dependent; G5: severely dependent; G6: very severely dependent).We included 596 patients (mean age: 83 [SD7]; 61.2% females). The 30-day mortality was 11.6% with statistically significant differences in the 6 groups (p < 0.001). After adjusting for HFRSS EFFECT risk categories, we observed a progressive increase in hazard ratios from groups G2 to G6 compared with G1 (reference). FBI-EFFECT had a better prognostic accuracy than did HFRSS EFFECT (log-rank p < 0.001; Net Reclassification Improvement [NRI] = 0.355; p < 0.001; Integrated Discrimination Improvement [IDI] = 0.052; p ;< 0.001) and BI-EFFECT (log-rank p = 0.067; NRI = 0.210; p = 0.033; IDI = 0.017; p = 0.026). In conclusion, severe disability and frailty in patients with moderate disability are associated with 30-day mortality in ADHF, providing additional value to HFRSS EFFECT model in predicting short-term prognosis and establishing a care plan.

Morphine Use in the ED and Outcomes of Patients With Acute Heart Failure: A Propensity Score-Matching Analysis Based on the EAHFE Registry

OBJECTIVE: The objective was to determine the relationship between short‐term mortality and intravenous morphine use in ED patients who received a diagnosis of acute heart failure (AHF). METHODS: Consecutive patients with AHF presenting to 34 Spanish EDs from 2011 to 2014 were eligible for inclusion. The subjects were divided into those with (M) or without IV morphine treatment (WOM) groups during ED stay. The primary outcome was 30‐day all‐cause mortality, and secondary outcomes were mortality at different intermediate time points, in‐hospital mortality, and length of hospital stay. We generated a propensity score to match the M and WOM groups that were 1:1 according to 46 different epidemiological, baseline, clinical, and therapeutic factors. We investigated independent risk factors for 30‐day mortality in patients receiving morphine. RESULTS: We included 6,516 patients (mean age, 81 [SD, 10] years; 56% women): 416 (6.4%) in the M and 6,100 (93.6%) in the WOM group. Overall, 635 (9.7%; M, 26.7%; WOM, 8.6%) died by day 30. After propensity score matching, 275 paired patients constituted each group. Patients receiving morphine had a higher 30‐day mortality (55 [20.0%] vs 35 [12.7%] deaths; hazard ratio, 1.66; 95% CI, 1.09–2.54; P = .017). In patients receiving morphine, death was directly related to glycemia (P = .013) and inversely related to the baseline Barthel index and systolic BP (P = .021) at ED arrival (P = .021). Mortality was increased at every intermediate time point, although the greatest risk was at the shortest time (at 3 days: 22 [8.0%] vs 7 [2.5%] deaths; OR, 3.33; 95% CI, 1.40–7.93; P = .014). In‐hospital mortality did not increase (39 [14.2%] vs 26 [9.1%] deaths; OR, 1.65; 95% CI, 0.97–2.82; P = .083) and LOS did not differ between groups (median [interquartile range] in M, 8 [7]; WOM, 8 [6]; P = .79). CONCLUSIONS: This propensity score‐matched analysis suggests that the use of IV morphine in AHF could be associated with increased 30‐day mortality.

Acidosis metabólica y topiramato. Utilidad de la fórmula de Winters

Topiramate is a drug introduced in Europe in 1995 for the treatment of hard-to-control epilepsy. The drug is also effective in the treatment of bipolar disorder, migraines, neuropathic pain, alcohol dependence, essential tremor, obesity and eating disorders. One of its side effects is hyperchloremic metabolic acidosis without anion gap,1,2 which can appear in up to 40% of the patients who receive topiramate at therapeutic doses; it is more frequent and severe in the case of acute poisoning.1 However, in the cases of acute intoxication, it is usually associated with other drugs, which can also influence acid--base balance. We report the case of a patient who presented with metabolic acidosis after an overdose of 2 drugs, one of them being topiramate. This was a 38-year-old woman with a history of gastric reduction due to obesity and cluster B personality disorder. She was on treatment with venlafaxine, mirtazapine, topiramate and lorazepam. She came to emergency treatment for autolytic-intention medicine overdose with topiramate and lorazepam of uncertain dosage and time. Upon arrival the patient was found to be Glasgow 14, tending to somnolence, with the rest of the examination being normal. She was given activated charcoal. The analytical analyses showed hyperchloremic metabolic acidosis with normal anion gap: pH 7.29, pCO2 41 mm Hg, bicarbonate 19.7 mmol/l, excess of bases 6.9, chlorine 113.4 mmol/l, and anion gap 14.6. After 18 h her level of consciousness improved, being in Glasgow 15, and the pH was normal, although low levels of bicarbonate (18.2 mmol/l) and hyperchloremia (117 mmol/l) persisted. Nevertheless, given her clinical stability, the patient was discharged after psychiatric assessment. Topiramate, besides potentially causing metabolic acidosis, can also produce central neurogenic hyperventilation. This is probably due to its inhibitory effect on the carbonic anhydrase in the brain and to the subsequent LCR acidosis.2 In such a situation, the clinical picture develops with hyperventilation, arterial hypotension and different degrees of altered consciousness and cognitive functions.1

Ritmo nodal secundario a descarga eléctrica de alto voltaje: Report of one case

Electrical shock can cause a direct myocardial damage and different types of arrhythmias, which are uncommon and occur more often when there is a high voltage exposure. We report a 19-year-old male that received a high voltage shock, falling thereafter from an altitude of four meters. On admission to the emergency room, he had second and third degree burns in the right hand and the left thigh. The electrocardiogram showed a nodal rhythm of 72 beats per minute. After four hours of monitoring, sinus rhythm returned spontaneously.Introduccion: Las descargas electricas pueden producir dano miocardico directo y diferentes tipos de arritmias, desde taquicardia y fibrilacion ventricular hasta extrasistolia aislada. Suelen ser poco frecuentes y se presentan mas a menudo cuando la descarga es de alto voltaje. Caso clinico: Se presenta el caso de un varon de 19 anos, que tras una descarga electrica de alto voltaje presento un ritmo nodal acelerado autolimitado. Discusion y conclusiones: Se discuten los posibles mecanismos por los que una descarga electrica puede generar arritmias. Los pacientes que han sufrido una descarga electrica de alto voltaje deben ser sometidos a monitorizacion.

Ritmo nodal secundario a descarga eléctrica de alto voltaje

Electrical shock can cause a direct myocardial damage and different types of arrhythmias, which are uncommon and occur more often when there is a high voltage exposure. We report a 19-year-old male that received a high voltage shock, falling thereafter from an altitude of four meters. On admission to the emergency room, he had second and third degree burns in the right hand and the left thigh. The electrocardiogram showed a nodal rhythm of 72 beats per minute. After four hours of monitoring, sinus rhythm returned spontaneously.Introduccion: Las descargas electricas pueden producir dano miocardico directo y diferentes tipos de arritmias, desde taquicardia y fibrilacion ventricular hasta extrasistolia aislada. Suelen ser poco frecuentes y se presentan mas a menudo cuando la descarga es de alto voltaje. Caso clinico: Se presenta el caso de un varon de 19 anos, que tras una descarga electrica de alto voltaje presento un ritmo nodal acelerado autolimitado. Discusion y conclusiones: Se discuten los posibles mecanismos por los que una descarga electrica puede generar arritmias. Los pacientes que han sufrido una descarga electrica de alto voltaje deben ser sometidos a monitorizacion.