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Doppler radar data are increasingly used in rainfall-runoff synthesis studies, perhaps due to radar data availability, among other factors. However, the veracity of the radar data are often a topic of concern. In this paper, three Doppler radar outcomes developed by the United States National Weather Service at three radar sites are examined and compared to actual rain gage data for two separate severe storm events in order to assess accuracy in the published radar estimates of rainfall. Because the subject storms were very intense rainfall events lasting approximately one hour in duration, direct comparisons between the three radar gages themselves can be made, as well as a comparison to rain gage data at a rain gage location subjected to the same storm cells. It is shown that topographic interference with the radar outcomes can be a significant factor leading to differences between radar and rain gage readings, and that care is needed in calibrating radar outcomes using available rain gage data in order to interpolate rainfall estimates between rain gages using the spatial variation observed in the radar readings. The paper establishes and describes• the need for “ground-truthing” of radar data, and • possible errors due to topographic interference.

Introduction and Objectives: Liver diseases have gained importance due to their prevalence, incidence and because most chronic liver diseases have no cure, except for hepatitis C. Liver damage induced by drugs such as valproic acid (VPA) has been used to study therapeutic alternatives. Jatropha dioica may be one of these alternatives as it has metabolites with potential antioxidant activity. The objetive of this study was to evaluate the hepatoprotective effect of a hydroalcoholic extract of J. dioica against VPA-induced damage in Wistar rats. Materials and Patients: 24 Wistar rats of both sexes were used. Groups: Sham (SH), Non-Toxicity(JdTox), VPA and J. dioica+VPA(JdVPA) (n=6). J. dioica (300 mg/kg, p.o) was administered for 7 days, followed by VPA (500 mg/kg, i.p, for four days) injected concomitantly. Biochemical markers, oxidative stress, and histological analysis were determined. Ethics Committee approval under HI22-00003 registry and PAICYT 143-CS-2022 financing. The research group declares no conflict of interest. Results: VPA group showed a significant increase in ALT and AST against Sham, JdVPA group showed a significant decrease in these parameters vs. VPA (Figure 1), and the remaining biochemical markers showed no statistically significant differences between the groups. The VPA group presented statistically significant alterations in the concentrations of malondialdehyde (MDA), reduced glutathione (GSH), and superoxide dismutase (SOD) vs. SH. The JdVPA group significantly improved the damage caused by VPA, decreasing MDA and increasing GSH and SOD (Figure 2). Histologically, VPA presented an inflammatory infiltrate, which decreased in the JdVPA group. However, this difference was not statistically significant. Conclusions: In murine models, VPA has been able to induce alterations in transaminase levels and oxidative stress markers, both of which may indicate the presence of liver damage. Plants of the Jatropha genus have been shown to possess phenolic and flavonoid compounds with antioxidant capacity, which may be responsible for the hepatoprotective effect observed in this study using J. dioica at the evaluated dose without showing toxicity.

The addition of Ladle Furnace Slag (LFS) to concrete modifies its compressive strength and modulus of elasticity and consequently impacts their relationship. This research evaluated both properties at 28, 90, and 180 days in concrete mixes produced with 5%, 10%, and 20% of two LFS types, both stabilized and non-stabilized. The relationship between them was then analyzed through these experimental results by adopting a statistical approach. A three-way analysis of variance revealed that both properties were affected by LFS differently. Thus, the effect of each LFS content on both features varied depending on its composition and pre-treatment. Furthermore, the effect of the LFS content on the compressive strength was also influenced by the age of the concrete. These facets implied that when analyzing the relationship between both mechanical properties, the monotonic correlations were stronger than the linear ones, reaching values between 0.90 and 1.00. Therefore, the double reciprocal regression models were the most precise ones for expressing the modulus of elasticity as a function of compressive strength. The model accuracy was further enhanced when discriminating based on the LFS type and introducing concrete age as a predictive variable. With all these considerations, the average deviations between the estimated and experimental values of 1–3% and the maximum deviations of 4–7% were reached, as well as R2 coefficients of up to 97%. These aspects are central to the further development of LFS concrete models.

Any variation in temperature alters the dimensions of a concrete structure and provokes thermal stress. Moreover, the propagation of micro-cracking decreases the strength of concrete that is exposed to sub-zero temperatures (freezing), to heat phenomena (heating), or to cyclical thermal variations, especially when prepared using Recycled Concrete Aggregate (RCA). A reference self-compacting concrete (SCC) mix made with 100% coarse and fine natural aggregate and three SCC mixes containing 100% coarse and/or fine RCA in replacement of natural aggregate were tested in this study of the thermal performance of SCC and the related effects of RCA. The mixtures were subjected to five thermal tests designed with positive and negative, and both constant and cyclical, extreme-ambient temperature variations, reaching temperatures of − 15 °C and 70 °C. Stiffness, weight, compressive strength, thermal deformability, and internal damage of the SCC mixtures were monitored throughout suitable testing. Internal damage, hygroscopicity, and loss of strength increased at temperatures below 0 °C, especially in the mixtures containing 100% coarse RCA, although the SCC manufactured with simultaneous additions of fine and coarse RCA fractions showed the worst performance. Overall, RCA performed better under positive temperature variations. The test results lead to the recommendation of a linear thermal expansion coefficient of 1.2·10−5 °C−1 in calculations for SCC containing RCA under those extreme environmental conditions.

The COVID-19 lockdown in Spain caused abrupt changes for students following the Bachelor's Degree in Civil Engineering at the University of Burgos when face-to-face classes switched to online teaching. The recovery of face-to-face teaching after lockdown meant that classes were taught with obligatory social distancing and the use of masks. Teachers were therefore unable to interact with students closely, to perceive their facial expressions during class, or to conduct group work. The changes to civil-engineering teaching linked to the COVID-19 pandemic and the lessons that civil-engineering teachers learnt from the new teaching scenarios are studied in this paper. The reflections of teachers throughout all three stages of the pandemic (pre-pandemic and lockdown, during lockdown, and post-lockdown), and the qualitative and mixed analysis of their responses to a survey of open-ended questions contributed to the identification of six major lessons: (1) asking questions and using real-time quiz tools enliven classes and help to determine which concepts to emphasize for proper student understanding; (2) autonomous student learning can be promoted through the provision of supplementary documentation and the digitalization of solutions to classroom exercises; (3) virtual site visits and real visual examples interspersed with explanations bring concepts closer to their real applications; (4) the delivery of projects in the form of audio-recorded presentations enable their distribution, so that other students can also learn from them as well as the students who created them; (5) online videoconferences, adapted to the concepts that are addressed, facilitate fast and flexible communication with students; and (6) online continuous-assessment exams can promote better student learning patterns and final-exam preparation. Nevertheless, these six lessons were drawn from the experience of teachers at a small Spanish university where the period of solely online teaching during the COVID-19 pandemic lasted only four months. Thus, it would be interesting to analyze the experience of civil-engineering teachers at larger universities and universities that had longer periods of solely online teaching. A study of the level of implementation of the six aspects when the pandemic is declared over might also be worthwhile.

Ultrasonic pulse velocity (UPV) is a non-destructive measurement technique with which the quality of any concrete element can be evaluated. It provides information on concrete health and for assessing the need for repair in a straightforward manner. In this paper, the relationship is studied between UPV readings and the mechanical behavior of self-compacting concrete (SCC) containing coarse, fine, and/or powdery RA. To do so, correlations and simple- and multiple-regression relationships between compressive strength, modulus of elasticity, splitting tensile strength, flexural strength, and UPV readings of nine SCC mixes were assessed. The correlations showed that the relationship of UPV with any mechanical property was fundamentally monotonic. The inverse square-root model was therefore the best-fitting simple-regression model for all the mechanical properties, although for bending-tensile-behavior-related properties (splitting tensile strength and flexural strength) the estimation accuracy was much lower than for compressive-behavior-related properties (compressive strength and modulus of elasticity). Linear-combination multiple-regression models showed that the properties related to bending-tensile behavior had a minimal influence on the UPV value, and that their introduction resulted in a decreased estimation accuracy. Thus, the multiple-regression models with the best fits were those that linked the compressive-behavior-related properties to the UPV readings. This therefore enables the estimation of the modulus of elasticity when the UPV and compressive strength are known with a deviation of less than ±20% in 87% of the SCC mixes reported in other studies available in the literature.

The compressive strength of recycled concrete is acknowledged to be largely conditioned by the incorporation ratio of Recycled Concrete Aggregate (RCA), although that ratio needs to be carefully assessed to optimize the design of structural applications. In this study, Self-Compacting Concrete (SCC) mixes containing 100% coarse RCA and variable amounts, between 0% and 100%, of fine RCA were manufactured and their compressive strengths were tested in the laboratory for a statistical analysis of their strength variations, which exhibited robustness and normality according to the common statistical procedures. The results of the confidence intervals, the one-factor ANalysis Of VAriance (ANOVA), and the Kruskal–Wallis test showed that an increase in fine RCA content did not necessarily result in a significant decrease in strength, although the addition of fine RCA delayed the development of the final strength. The statistical models presented in this research can be used to define the optimum incorporation ratio that would produce the highest compressive strength. Furthermore, the multiple regression models offered accurate estimations of compressive strength, considering the interaction between the incorporation ratio of fine RCA and the curing age of concrete that the two-factor ANOVA revealed. Lastly, the probability distribution predictions, obtained through a log-likelihood analysis, fitted the results better than the predictions based on current standards, which clearly underestimated the compressive strength of SCC manufactured with fine RCA and require adjustment to take full advantage of these recycled materials. This analysis could be carried out on any type of waste and concrete, which would allow one to evaluate the same aspects as in this research and ensure that the use of recycled concrete maximizes both sustainability and strength.

La fotografía juega un papel decisivo en la formación del imaginario colectivo y la memoria cultural. A través de las fotografías publicadas en la prensa gráfica se analizan los mecanismos de connotación de las imágenes para que estas puedan ser interpretadas por los lectores en claves de memoria cultural aplicada a un grupo humano concreto: lo judíos. Se analizan los mecanismos que visualizan y definen al grupo y el de los estereotipos que los definen en la memoria cultural occidental.

BACKGROUND Germ cell number during ovarian organogenesis is regulated through programmed cell death. We investigated the expression of germ-cell-specific VASA protein, apoptosis-related proteins BAX and BCL-2 and DNA fragmentation in developing human ovaries from gestation week 12 to term. METHODS Human fetal ovaries from 13 women undergoing spontaneous abortion were fixed, paraffin-embedded and processed for immunohistochemistry to analyse temporal and cellular localization of VASA, BCL-2 and BAX, and to detect apoptosis by TUNEL assay. RESULTS VASA showed a differential pattern of expression throughout the differentiation and proliferative phase and prophase I to finally associate with Balbianis body in primordial and primary follicles. BCL-2 was detected from week 12 to 17 and became undetectable thereafter. Strong BAX signal was detected in oogonia and oocytes from week 12 to term. Low levels (≤10%) of TUNEL positive germ cells were detectable throughout gestation with a higher incidence (around 20%) at 18–20 weeks. CONCLUSIONS VASA was specifically expressed in germ cells and displayed a stage-specific intracellular localization enabling one to follow oogenesis throughout gestation. Apoptosis-inhibiting BCL-2 was associated with the germ cell proliferative phase and prophase I, whereas BAX remained positive throughout gestation. The highest incidence of apoptotic germ cells was coincident with the lack of detectable BCL-2 protein, and when primordial follicle formation became widespread. [ABSTRACT FROM AUTHOR]

To investigate if worsening renal function (WRF) appearing in some patients with acute heart failure (AHF) after intravenous furosemide initiation is influenced by severity of congestion. We conducted a retrospective secondary analysis of consecutive patients diagnosed with AHF and prospectively included in 10 Spanish emergency departments (EDs) for whom serum creatinine at ED arrival and after 2-7 days of intravenous furosemide initiation were available. Congestion was clinically evaluated by identification of 7 signs/symptoms and by chest X-ray. The outcome was WRF, defined as a delta-creatinine ≥ 0.3 mg/dL. Risk of WRF according to congestion was estimated in models adjusted by patient baseline characteristics and vitals at ED arrival, and interaction was also investigated. We included 3027 patients (median age 82 years, 56% women), and 657 (21.7%) presented WRF after intravenous furosemide initiation. When signs/symptoms were individually considered, only lower limbs edema was associated with decreased risk of WRF (20.1% vs. 24.8%; OR = 0.76, 95%CI = 0.64-0.91). After adjustment, lower limbs edema persisted inversely associated with WRF (aOR = 0.78, 95%CI = 0.65-0.94), with significant lower risk for patients ≤ 80 years and without chronic kidney disease, functional limitation, and hypoxemia (p for interaction 0.01, 0.04, 0.02 and 0.03, respectively). Neither degree of clinical congestion (number of signs/symptoms of congestion) nor radiological congestion in chest X-ray were related to WRF. Worsening renal function was associated with a higher 1-year all-cause mortality (40.1% vs 34.6%; HR = 1.27, 1.10-1.46; aHR = 1.331, 1.151-1.540). In patients with WRF, liver cirrhosis, chronic treatment with loop diuretics and renin-angiotensin system inhibitors, age (> 80 years), dementia, heart valve disease and NYHA class III-IV were associated with higher mortality. Intravenous furosemide initiation in patients with AHF without lower limbs edema must be cautious, as they are at increasing risk of developing WRF during the next following days, which in turn is associated with a higher 1-year mortality., (© 2024. The Author(s), under exclusive licence to Società Italiana di Medicina Interna (SIMI).)

Objectives: The aim of the present study was to evaluate the impact of chronic treatment with angiotensin-converting enzyme inhibitors (ACEI) or angiotensin receptor blockers (ARB) on short-term clinical outcomes after an episode of AHF., Methods: A secondary analysis of patients included in the EAHFE (Epidemiology of Acute Heart Failure in Emergency Departments) cohort, which includes patients diagnosed with AHF in 45 Spanish Emergency Departments (EDs). The primary outcome was all-cause in-hospital mortality. The secondary outcomes were all-cause death within 7 days, need for hospital admission and prolonged hospitalisation defined as a stay longer than or equal to 7 days. Multiple regression and propensity-matching was used for multivariate adjustment., Results: Of the 17,920 patients, 10,041 (56 %) were receiving chronic treatment with ACEI/ARB. The mean age was 80.4 years and 55.7 % were women. Adjusted odds ratios (aOR) were 0.76 (95 % CI 0.71-0.82) for in-hospital mortality witch multiple regression and 0.74 (95 %CI 0.63-0.88) with propensity-matching. aOR were 0.72; (95 %CI 0.65-0.79) and 0.70 (95 %CI 0.57-0.87) for mortality at the 7-day follow-up, respectively. The sensitivity analysis ACEI/ARB were associated with few all-cause deaths in patients with elevated natriuretic peptides in the EDs (aOR 0.74; 95 % CI 0.68-0.80), patients requiring hospital admission (aOR 0.78; 95 % CI 0.73-0.84) and patients with a history of HF (aOR 0.72; 95 % CI 0.66-0.78)., Conclusions: Chronic use of ACEI/ARB was associated with better short-term outcomes in terms of all-cause in-hospital mortality in patients with AHF who attend an EDs., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier B.V. All rights reserved.)

Background: Intravenous digoxin is still used in emergency departments (EDs) to treat patients with acute heart failure (AHF), especially in those with rapid atrial fibrillation. Nonetheless, many emergency physicians are reluctant to use intravenous digoxin in patients with advanced age, impaired renal function, and potassium disturbances due to its potential capacity to increase adverse outcomes., Objective: We investigated whether intravenous digoxin used to treat rapid atrial fibrillation in patients with AHF may influence mortality in patients with specific age, estimated glomerular filtration rate (eGFR), and serum potassium classes., Design: A secondary analysis of patients included in in the Spanish EAHFE cohort, which includes patients diagnosed with AHF in the ED., Setting: 45 Spanish EDs., Participants: Two thousand one hundred ninety-four patients with AHF and rapid atrial fibrillation (heart rate ≥100 bpm) not receiving digoxin at home, divided according to whether they were or were not treated with intravenous digoxin in the ED., Outcome: The relationships between age, eGFR, and potassium with 30-day mortality were investigated using restricted cubic spline (RCS) models adjusted for relevant patient and episode variables. The impact of digoxin use on such relationships was assessed by checking interaction., Main Results: The median age of the patients was 82 years [interquartile range (IQR) = 76-87], 61.4% were women, 65.2% had previous episodes of atrial fibrillation, and the median heart rate at ED arrival was 120 bpm (IQR = 109-135). Digoxin and no digoxin groups were formed by 864 (39.4%) and 1330 (60.6%) patients, respectively. There were 191 deaths within the 30-day follow-up period (8.9%), with no differences between patients receiving or not receiving digoxin (8.5 vs. 9.1%, P  = 0.636). Although analysis of RCS curves showed that death was associated with advanced age, worse renal function, and hypo- and hyperkalemia, use of intravenous digoxin did not interact with any of these relationships ( P  = 0.156 for age, P  = 0.156 for eGFR; P  = 0.429 for potassium)., Conclusion: The use of intravenous digoxin in the ED was not associated with significant changes in 30-day mortality, which was confirmed irrespective of patient age or the existence of renal dysfunction or serum potassium disturbances., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Aims: To investigate whether seasonal influenza and COVID-19 vaccinations influence the severity of decompensations and long-term outcomes of patients with acute heart failure (AHF)., Methods and Results: We included consecutive AHF patients attended at 40 Spanish emergency departments during November and December 2022. They were grouped according to whether they had received seasonal influenza and COVID-19 vaccination. The severity of heart failure (HF) decompensation was assessed with the MEESSI scale, need for hospitalization, intensive care unit (ICU) admission, and in-hospital mortality. Long-term outcomes were 90-day and 1-year all-cause mortality. Associations between vaccination, HF decompensation severity, and long-term outcomes were investigated. Subgroup analyses were executed for 16 patient characteristics and their relationship with vaccination and 1-year mortality. We analysed 4243 patients (median age 85 years; interquartile range 77-90; 57% female): 1841 (43%) had received influenza vaccination, 3139 (74%) COVID-19 vaccination, 1773 (41.8%) received both vaccines (full vaccination) and 1036 (24.4%) none. Previous episodes of AHF, chronic obstructive pulmonary disease and chronic treatment with diuretics were associated with vaccination (either influenza, COVID-19 and full vaccination). High or very-high risk decompensation occurred in 18.6%; hospitalization in 72.3%, ICU admission in 1.1%, and in-hospital mortality in 8.4%. Influenza vaccination was associated with lower hospitalization rates (adjusted odds ratio [OR] 0.746, 95% confidence interval [CI] 0.636-0.876) and in-hospital mortality (OR 0.761, 95% CI 0.583-0.992), while COVID-19 vaccination was associated with increased hospitalizations (OR 1.215, 95% CI 1.016-1.454). Overall, 90-day and 1-year mortality were 20.3% and 34.4%. Both were decreased in influenza-vaccinated patients (adjusted hazard ratio [HR] 0.831, 95% CI 0.709-0.973; and HR 0.885, 95% CI 0.785-0.999, respectively) but only at 90 days in COVID-19 vaccinated patients (HR 0.829, 95% CI 0.702-0.980). Full vaccination achieved even greater reductions in in-hospital, 90-day, and 1-year mortality (HR 0.638, 95% CI 0.479-0.851; HR 0.702, 95% CI 0.592-0.833; and HR 0.815, 95% CI 0.713-0.931, respectively). Subgroup analysis based on patient-related characteristics demonstrated the consistence of vaccination with long-term survival., Conclusion: In HF patients, seasonal influenza vaccination appears to be associated with less severe decompensation and lower 1-year mortality, while no firm conclusions can be drawn from the results of the present study regarding the benefits of COVID-19 vaccination. Full vaccination is associated with the greatest reduction in short- and long-term mortality., (© 2024 European Society of Cardiology.)

Objective: To investigate the association of the addition of thiazide diuretic on top of loop diuretic and standard of care with short-term outcomes of patients discharged after surviving an acute heart failure (AHF) episode., Methods: This is a secondary analysis of 14,403 patients from three independent cohorts representing the main departments involved in AHF treatment for whom treatment at discharge was recorded and included loop diuretics. Patients were divided according to whether treatment included or not thiazide diuretics. Short-term outcomes consisted of 30-day all-cause mortality, hospitalization (with a separate analysis for hospitalization due to AHF or to other causes) and the combination of death and hospitalization. The association between thiazide diuretics on short-term outcomes was explored by Cox regression and expressed as hazard ratios (HR) with 95 % confidence intervals, which were adjusted for 18 patient-related variables and 9 additional drugs (aside from loop and thiazide diuretics) prescribed at discharge., Results: The median age was 81 (interquartile range=73-86) years, 53 % were women, and patients were mainly discharged from the cardiology (42 %), internal medicine or geriatric department (29 %) and emergency department (19 %). There were 1,367 patients (9.5 %) discharged with thiazide and loop diuretics, while the rest (13,036; 90.5 %) were discharged with only loop diuretics on top of the remaining standard of care treatments. The combination of thiazide and loop diuretics showed a neutral effect on all outcomes: death (adjusted HR 1.149, 0.850-1.552), hospitalization (0.898, 0.770-1.048; hospitalization due to AHF 0.799, 0.599-1.065; hospitalization due to other causes 1.136, 0.756-1.708) and combined event (0.934, 0.811-1.076)., Conclusion: The combination of thiazide and loop diuretics was not associated with changes in risk of death, hospitalization or a combination of both., Competing Interests: Declaration of competing interest None declared, (Copyright © 2024 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved.)

Digoxin is commonly used to treat acute heart failure (AHF), especially in patients with concurrent atrial fibrillation (AF). Nonetheless, there is little consensus about in which patients digoxin should be given, the proper time for digoxin initiation, and whether digoxin initiation is associated with improved outcomes. We investigated factors related to digoxin initiation after an episode of AHF and whether patients receiving digoxin presented better short-term outcomes. We analyzed digoxin-naïve AHF patients from a Spanish and Swiss database, who were dichotomized into cohorts based on their receipt of digoxin treatment at discharge. The relationship between digoxin initiation and 23 additional patient covariates, including chronic treatment, was investigated, as well as its association with 90-day combined adverse events (defined as all-cause death or AHF hospitalization). Of 13,105 patients (10,600/2505 from the Spanish/Swiss cohorts, respectively), the median (interquartile range) age was 83 (74.87) years, and 51% were women. Of these, 484 (3.7%) received digoxin at discharge, which was associated with AF, female sex, left ventricular ejection fraction (LVEF) < 50%, and coming from the Spanish cohort. Parameters inversely associated with receiving digoxin at discharge included some chronic treatments, diabetes mellitus (DM), and chronic kidney disease (CKD). Digoxin initiation was not association with 90-day adverse events, adjusted hazard ratio (aHR) = 0.939 (0.769-1.146), but there was an interaction for CKD, aHR = 1.390 (0.831-2.325) vs. 0.854 (0.682-1.183), p = 0.039, and for cohort pertinence, with higher risk in the Swiss cohort; aHR = 1.405 (0.827-2.386) vs. 0.862 (0.689-1.077), p = 0.046. Digoxin initiation after an AHF episode was more frequent in the Spanish cohort and was associated with certain patient characteristics (AF, female sex, reduced LVEF, no DM, no CKD), but had no effect on 90-day outcomes., (© 2024. The Author(s), under exclusive licence to Società Italiana di Medicina Interna (SIMI).)

Objectives: To quantify and analyze mortality in patients who die within 30 days of discharge home from a hospital emergency department (ED)., Material and Methods: All patients older than 14 years of age who were discharged home from the ED of a tertiary care hospital over a 5-year period were included. We collected age, sex, and other demographic variables, as well as the Charlson Comorbidity Index (CCI). The outcome variables of interest were 7-day and 30-day mortality and cause of death. Deaths were classified as expected and directly related to the emergency, expected but not directly related, unexpected and directly related, and unexpected and not directly related. A death was classified as an adverse event if it was directly related to a problem of diagnosis or management in the ED, underestimation of severity, or complications of a procedure., Results: Of 519312 patients attended in the ED, 453 599 were discharged home. Of those discharged, 148 died at home within 7 days (32.63 deaths/100 000 discharges) and 355 died within 30 days (78.48 deaths/100 000 discharges). One hundred thirteen deaths (31.8%) were expected and related to the emergency 24.91/100 000), 169 (47.6%) were expected but unrelated 37.26/100 000), 4 (1.1%) were unexpected and related 1.10/100000), and 69 (19.4%) were unexpected and unrelated 15.21/100000). Deaths were considered adverse events related to ED care in 24.2% of the cases. Underestimation of severity was responsible for the highest proportion (10.7%) of such deaths. The median age of patients who died was 83 years, and the median Charlson comorbidity index (CCI) was 6. The most common cause of death was a malignant tumor (23.0%), followed by congestive heart failure (20.2%) and atherosclerotic cardiovascular disease (13.2%). Unexpected deaths related to ED care were significantly related to a higher proportion of adverse events related to diagnosis (P = .001), management (P = .004), and underestimation of severity (P .001)., Conclusion: Early deaths after discharge home from a hospital ED occured in patients of advanced age with concomitant conditions. The main clinical settings were neoplastic and cardiovascular disease. Seven-day and 30-day mortality rates directly related to the emergency visit were low. Adverse events related to ED care played a role in about a quarter of the deaths after discharge.

To investigate whether the timing of a previous hospital admission for acute heart failure (AHF) is a prognostic factor for AHF patients revisiting the emergency department (ED) in the subsequent 12-month follow-up. All ED AHF patients enrolled in the previously described EAHFE registry were stratified by the presence or absence of an AHF hospitalization admission in the prior 12 months. The primary outcome was 12-month all-cause mortality post ED visit. Secondary end points were hospital admission, prolonged hospitalization (> 7 days), mortality during hospitalization and a 90-day post-discharge adverse composite event (ACE) rate, defined as ED revisits due to AHF, hospitalizations due to AHF, or all-cause mortality. Outcomes were adjusted for baseline and AHF episode characteristics.Of 5,757 patients included, the median age was 84 years (IQR 77-88); 57% were women, and 3,759 (65.3%) had an AHF hospitalization in the previous 12 months. The 12-month mortality was 37% (41.7% vs. 28.3% p < 0.001), hospital admission was 76.1% (78.8% vs. 71.1% p < 0.001) ACE was 60.2% (65.1% vs. 50.5% p < 0.001). In the adjusted analysis, patients with AHF hospitalization in the prior 12 months had a higher mortality (HR = 1.41; 95% CI 1.27-1.56), 90-day ACE rate (HR = 1.45: 95% CI 1.32-1.59), and more hospital admissions (OR = 1.32; 95% CI 1.16-1.51), with shorter times since the previous hospitalization being related to the outcomes analyzed. One-year mortality, adverse events at 90 days, and readmission rates are increased in ED AHF patients previously admitted within the last 12 months., (© 2024. The Author(s), under exclusive licence to Società Italiana di Medicina Interna (SIMI).)

Summary: COVID-19 continues to pose a significant threat: mortality stands at nearly twice that of influenza, and the incidence rate is growing as the population's vaccination rate decreases, particularly in Spain and other areas of Europe. Given this situation, it is vitally important know whether medical protocols are consistent and appropriately implemented by health care staff in the interest of preventing possible inefficiency or inequity. Physicians from hospital emergency departments met to study their hospitals' usual clinical practices for managing SARS-CoV-2 infection and to determine their expert opinions on the use of antiviral agents. The participating physicians then reached consensus on evidencebased recommendations for strategies that would optimize emergency treatment.

Early diagnosis of HIV is still a challenge. Emergency Departments (EDs) suppose ideal settings for the early detection of HIV, since patients with high prevalence of hidden HIV infection are frequently attending those services. In 2020, the Spanish Society of Emergency and Emergency Medicine (SEMES) published a series of recommendations for the early diagnosis of patients with suspected HIV infection and their referral and follow-up in the EDs as part of its "Deja tu huella" program. However, the application of these recommendations has been very heterogeneous in our country. Considering this, the working group of the HIV hospital network led by the SEMES has motivated the drafting of a decalogue, with the aim of promoting the implementation and improvement of protocols for the early diagnosis of HIV in Spanish EDs., (Copyright © 2023 Sociedad Española de Enfermedades Infecciosas y Microbiología Clínica. Published by Elsevier España, S.L.U. All rights reserved.)

Objectives: To study differences in the emergency department treatment of acute poisoning according to biological sex of patients and to assess adherence to care quality indicators., Material and Methods: Retrospective observational study including all cases of acute poisoning diagnosed in patients over the age of 14 years treated in a tertiary care hospital emergency department over a period of 4 years. We analyzed demographic variables, substance type and reason for acute poisoning, degree of adherence to quality indicators, and discharge destination., Results: A total of 1144 cases were included; 710 patients (62.1%) were female and 434 (37.9%) were male. The proportion of deliberate self-poisoning was higher in females (52.3% vs 41.4% in males; P .001); unintentional poisoning was less frequent in females (in 24.9% vs in 30.3% of males; P = .047). Benzodiazepine poisoning was more frequent in females (in 49.6% vs 41.2%; P = .007). Street drug and alcohol poisoning was less common in females. Adherence to quality indicators was high (> 85%) for both sexes., Conclusion: The epidemiologic profile of poisoning is different in females and males. General emergency department adherence to quality indicators can be considered optimal. We detected no qualitative sex-related differences in the care of patients with acute poisoning.

One of the phytopathogens that cause severe damage to jalapeño pepper is Leveillula taurica (Lév.) Arnaud, the causative agent of powdery mildew. Synthetic fungicides are currently employed for its control, contributing to adverse effects on human health and the environment. The main objective of this research was to identify the causal agent of powdery mildew and assess the efficacy of chitosan in powdery mildew control on jalapeño pepper. The following treatments were evaluated in laboratory and greenhouse conditions: T1 = 0.0125% chitosan, T2 = 0.0025% chitosan, T3 = 0.05% chitosan, T4 = 0.1% chitosan, T5 = 0.2% chitosan, T6 = tebuconazole 25% (1.8 mL/L water), and T7 = control (water). Symptomatology results indicated that L. taurica is indeed the causative agent of powdery mildew. Treatments T4 and T5 exhibited the lowest percentages of incidences and severity, hence achieving higher control efficacy in the laboratory (57.70 ± 3.85 and 65.39 ± 3.85) and greenhouse (56.67 ± 4.08 and 70 ± 8.16%) compared to T6 (control efficacy, 38.46 ± 0.00% in the laboratory and 50 ± 0.00% in the greenhouse). The chitosan derived from shrimp had a significant impact on the cell walls of L . taurica spores and mycelium. Consequently, chitosan emerges as a viable organic alternative to fungicides for controlling powdery mildew in jalapeño pepper.

Background and Importance: The rates of hidden infection and late diagnosis of HIV still remain high in Western countries. Missed diagnostic opportunities represent the key point in changing the course of the epidemic., Objective: To evaluate the feasibility and results of implementation of a selective strategy to test for HIV in the emergency department (ED) in patients with six pre-defined medical situations: sexually transmitted infections, herpes zoster, community-acquired pneumonia, mononucleosis syndrome, practice of chemsex (CS) or request of post-exposure prophylaxis., Design: This quasi-experimental longitudinal study evaluated the pre- and post-implementation results of HIV testing in the six aforementioned clinical scenarios., Settings and Participants: Patients attended 34 Spanish EDs., Intervention or Exposure: The intervention was an intensive educational program and pathways to facilitate and track orders and results were designed. We collected and compared pre- and post-implementation ED census and diagnoses, and HIV tests requested and results., Outcome Measures and Analysis: The main outcome was adherence to the recommendations. Secondary outcomes were to evaluate the effectiveness of the program by the rate of positive test and the new HIV diagnoses. Differences between first and second periods were assessed. The magnitude of changes (absolute and relative) was expressed with the 95% confidence interval (CI)., Main Results: HIV tests increasing from 7080 (0.42% of ED visits) to 13 436 (relative increase of 75%, 95% CI from 70 to 80%). The six conditions were diagnosed in 15 879 and 16 618 patients, and HIV testing was ordered in 3393 (21%) and 7002 (42%) patients (increase: 97%; 95% CI: 90-104%). HIV testing significantly increased for all conditions except for CS. The positive HIV test rates increased from 0.92 to 1.67%. Detection of persons with undiagnosed HIV increased from 65 to 224, which implied a 220% (95% CI: 143-322%) increase of HIV diagnosis among all ED comers and a 71% (95% CI: 30-125%) increase of positive HIV tests., Conclusion: Implementation of a strategy to test for HIV in selective clinical situations in the ED is feasible and may lead to a substantial increase in HIV testing and diagnoses., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Objectives: To determine the prevalence, characteristics, timing of implementation and prognosis of patients with left bundle branch block (LBBB) and acute heart failure (AHF) treated with cardiac resynchronization therapy (CRT) in a real-life registry., Methods: We analysed the characteristics of patients with AHF and LBBB at the time of inclusion in the EAHFE (Epidemiology Acute Heart Failure Emergency) cohort to determine the indication for CRT, the timing of implementation and its impact on 10-year all-cause mortality., Results: 729 patients with a median age of 82 years and there was a high burden of comorbidities and functional dependence. The median left-ventricle ejection fraction (LVEF) was 40%. Forty-six (6%) patients were treated with CRT at some point during follow-up, with a median time of delay for CRT implementation of 960 (IQR=1,147 days) and at least 108 more untreated patients fulfilled criteria for CRT. Patients receiving CRT were younger, had different comorbidities, less functional dependence (higher Barthel index) and lower LVEF values. The median follow-up was 5.7 years (95% CI: 5.6-5.8) and CRT was not associated with changes in 10-year mortality (adjusted HR 1.33, 95% CI: 0.72-2.48; p-value 0.4). When compared with untreated patients fulfilling criteria for CRT, very similar results were observed (adjusted HR 1.34, 95% CI: 0.67-2.68). , Conclusions: CRT implementation was delayed and underused in patients with AHF and LBBB. Under these circumstances, CRT is not associated with a reduction in all-cause mortality in the long term., Competing Interests: Conflicts of interest: The authors declare that they have no conflict of interest., (Copyright © 2023 Colombia Medica.)

Objectives: To analyze factors related to the use of digoxin to treat patients with acute heart failure (AHF) in emergency departments (EDs) and the impact of digoxin treatment on short-term outcomes., Material and Methods: We included patients diagnosed with AHF in 45 Spanish EDs. The patients, who were not undergoing long-term treatment for heart failure, were classified according to whether or not they were given intravenous digoxin in the ED. Fifty-one patient or cardiac decompensation episode variables were recorded to profile ED patients treated with digoxin. Outcome variables studied were the need for hospital admission, prolonged stay in the ED (> 24 hours) for discharged patients, prolonged hospitalization (> 7 days) for admitted patients, and all-cause in-hospital or 30-day mortality. The associations between digoxin treatment and the outcomes were studied with odds ratios (ORs) adjusted for patient and AHF episode characteristics., Results: Data for 15 549 patients (median age, 83 years; 55% women) were analyzed; 1430 (9.2%) were treated with digoxin. Digoxin was used more often in women, young patients, and those with better New York Heart Association (NYHA) classifications but more severe cardiac decompensation, especially if the trigger was atrial fibrillation with rapid ventricular response. Admissions were ordered for 75.4% of the patients overall (81.6% of digoxin-treated patients vs 74.8% of nontreated patients; P .001). The ED stay was prolonged in 38.3% of patients discharged from the ED (52.9% of digoxin-treated patients vs 37.2% of nontreated patients; P .001). The duration of hospital stay was prolonged in 48.1% (digoxin-treated, 49.3% vs 47.9%; P = .385). In-hospital mortality was 7.2% overall (6.9% vs 7.2%, P= .712), and 30-day mortality was 9.7% (9.3% vs 9.7%, P = .625). ED use of digoxin was associated with a prolonged stay in the department (adjusted OR, 1.883; 95% CI, 1.359-2.608) but not with hospitalization or mortality., Conclusion: Digoxin continues to be used in one out of ten ED patients who are not already on long-term treatment with the drug. Digoxin use is associated with cardiac decompensation triggered by atrial fibrillation with rapid ventricular response, younger age, women, and patients with better initial NYHA function status but possibly more severe decompensation. Digoxin use leads to a longer ED stay but is safe, as it is not associated with need for admission, prolonged hospitalization, or short-term mortality.

Objective: To investigate the association of corrected QT (QTc) interval duration and short-term outcomes in patients with acute heart failure (AHF)., Methods: We analyzed AHF patients enrolled in 11 Spanish emergency departments (ED) for whom an ECG with QTc measurement was available. Patients with pace-maker rhythm were excluded. Primary outcome was 30-day all-cause mortality and secondary outcomes were need of hospitalization, in-hospital mortality and prolonged hospitalization (> 7 days). Association between QTc and outcomes was explored by restricted cubic spline (RCS) curves. Results were expressed as odds ratios (OR) and 95%CI adjusted by patients baseline and decompensation characteristics, using a QTc = 450 ms as reference., Results: Of 1800 patients meeting entry criteria (median age 84 years (IQR = 77-89), 56% female), their median QTc was 453 ms (IQR = 422-483). The 30-day mortality was 9.7%, while need of hospitalization, in-hospital mortality and prolonged hospitalization were 77.8%, 9.0% and 50.0%, respectively. RCS curves found longer QTc was associated with 30-day mortality if > 561 ms, OR = 1.86 (1.00-3.45), and increased up to OR = 10.5 (2.25-49.1), for QTc = 674 ms. A similar pattern was observed for in-hospital mortality; OR = 2.64 (1.04-6.69), for QTc = 588 ms, and increasing up to OR = 8.02 (1.30-49.3), for QTc = 674 ms. Conversely, the need of hospitalization had a U-shaped relationship: being increased in patients with shorter QTc [OR = 1.45 (1.00-2.09) for QTc = 381 ms, OR = 5.88 (1.25-27.6) for the shortest QTc of 200 ms], and also increasing for prolonged QTc [OR = 1.06 (1.00-1.13), for QTc = 459 ms, and reaching OR = 2.15 (1.00-4.62) for QTc = 588 ms]. QTc was not associated with prolonged hospitalization., Conclusion: In ED AHF patients, initial QTc provides independent short-term prognostic information, with increasing QTc associated with increasing mortality, while both, shortened and prolonged QTc are associated with need of hospitalization., (© 2023. The Author(s).)

Objective: To investigate whether the type of household is associated with prognosis at one year in patients ≥65 years of age discharged after medical consultation requiring emergency department care., Methods: Data from the Emergency Department and Elder Needs (EDEN) cohort were used. This retrospective cohort included all patients ≥65 years of age seen in 52 Spanish emergency departments over one week (April 1-7, 2019) in whom the type of household was recorded and categorized as living at home alone, with relatives, with professional caregivers, or in a nursing home. Patient demographic and other baseline characteristics and management during the index emergency department episode were recorded and used to adjust the following 1-year outcomes: all-cause mortality, hospitalization and emergency department revisit. Associations between type of household and outcomes are expressed as adjusted hazard ratios with 95% confidence intervals using living alone as the reference category., Results: 13,442 patients with a median age of 79 years (interquartile range 72-86) were included; 56% were women, 12.2% of patients lived alone, 74.9% with relatives, 3.9% with a professional caregiver, and 9.1% in a nursing home. During the year following discharge, the mortality rate was 14.0%, the hospitalization rate 29.7%, and the emergency department revisit rate 59.3%. In the fully adjusted model, the risk of death was associated only with living in a nursing home (hazard ratio 1.366 (1.101-1.695)). On the other hand, the risk of hospitalization was lower in individuals living in nursing homes (hazard ratio 0.783 [0.676-0.907]) and at home with relatives (hazard ratio 0.897 [0.810-0.992]), while the risk of emergency department revisit was lower in individuals living in nursing homes (hazard ratio 0.826 [0.742-0.920]) or at home with caregivers (hazard ratio 0.856 [0.750-0.976])., Conclusion: The type of household was modestly associated with the one-year prognosis of patients ≥65 years of age discharged after attendance at an emergency department. Living in a nursing home is associated with an increased risk of death but a decreased risk of rehospitalization or emergency department revisit, while living at home with relatives or professional caregivers is associated only with a decreased risk of hospitalization and emergency department revisit, respectively., Competing Interests: Declaration of competing interest The authors declare that they have no competing interest., (Copyright © 2023 Elsevier B.V. All rights reserved.)

Objectives: To determine whether income was associated with unexpected in-hospital mortality in older patients treated in Spanish public health system hospital emergency departments., Material and Methods: Fifty-one public health system hospital emergency departments in Spain voluntarily participated in the study. Together the hospitals covered 25% of the population aged 65 years or older included in all patient registers during a week in the pre-pandemic period (April 1-7, 2019) and a week during the COVID-19 pandemic (March 30 to April 5, 2020). We estimated a patient's gross income as the amount published for the postal code of the patient's address. We then calculated the standardized gross income (SGI) by dividing the patient's estimated income by the mean for the corresponding territory (Spanish autonomous community). The existence and strength of an association between the SGI and in-hospital mortality was evaluated by means of restricted cubic spline (RCS) curves adjusted for 10 patient characteristics at baseline. Odds ratios (ORs) for each income level were expressed in relation to a reference SGI of 1 (the mean income for the corresponding autonomous community). We compared the COVID-19 and pre-pandemic periods by means of first-order interactions., Results: Of the 35 280 patients attended in the 2 periods, gross income could be ascertained for 21 180 (60%), 15437 in the pre-pandemic period and 5746 during the COVID-19 period. SGIs were slightly higher for patients included before the pandemic (1.006 vs 0.994; P = .012). In-hospital mortality was 5.6% overall and higher during the pandemic (2.8% pre-pandemic vs 13.1% during COVID-19; P .001). The adjusted RCS curves showed that associations between income and mortality differed between the 2 periods (interaction P = .004). Whereas there were no significant income-influenced differences in mortality before the pandemic, mortality increased during the pandemic in the lowest-income population (SGI 0.5 OR, 1.82; 95% CI, 1.32-3.37) and in higher-income populations (SGI 1.5 OR, 1.32; 95% CI, 1.04-1.68, and SGI 2 OR, 1.92; 95% CI, 1.14-3.23). We found no significant differences between patients with COVID-19 and those with other diagnoses (interaction P = .667)., Conclusion: The gross income of patients attended in Spanish public health system hospital emergency departments, estimated according to a patient's address and postal code, was associated with in-hospital mortality, which was higher for patients with the lowest and 2 higher income levels. The reasons for these associations might be different for each income level and should be investigated in the future.

Objective: Both hyperkalemia (HK) and Acute Heart Failure (AHF) are associated with increased short-term mortality, and the management of either may exacerbate the other. As the relationship between HK and AHF is poorly described, our purpose was to determine the relationship between HK and short-term outcomes in Emergency Department (ED) AHF., Methods: The EAHFE Registry enrolls all ED AHF patients from 45 Spanish ED and records in-hospital and post-discharge outcomes. Our primary outcome was all-cause in-hospital death, with secondary outcomes of prolonged hospitalization (>7 days) and 7-day post-discharge adverse events (ED revisit, hospitalization, or death). Associations between serum potassium (sK) and outcomes were explored using logistic regression by restricted cubic spline (RCS) curves, with sK =4.0 mEq/L as the reference, adjusting by age, sex, comorbidities, patient baseline status and chronic treatments. Interaction analyses were performed for the primary outcome., Results: Of 13,606 ED AHF patients, the median (IQR) age was 83 (76-88) years, 54% were women, and the median (IQR) sK was 4.5 mEq/L (4.3-4.9) with a range of 4.0-9.9 mEq/L. In-hospital mortality was 7.7%, with prolonged hospitalization in 35.9%, and a 7-day post-discharge adverse event rate of 8.7%. Adjusted in-hospital mortality increased steadily from sK ≥4.8 (OR = 1.35, 95% CI = 1.01-1.80) to sK = 9.9 (8.41, 3.60-19.6). Non-diabetics with elevated sK had higher odds of death, while chronic treatment with mineralocorticoid-receptor antagonists exhibited a mixed effect. Neither prolonged hospitalization nor post-discharge adverse events was associated with sK., Conclusion: In ED AHF, initial sK >4.8 mEq/L was independently associated with in-hospital mortality, suggesting that this cohort may benefit from aggressive HK treatment., Competing Interests: Declaration of Competing Interest The authors state that they have no conflict of interests with the present work. The ICA-SEMES Research Group has received unrestricted support from Orion Pharma, Novartis and Boehringer. The present study has been designed, performed, analyzed and written exclusively by the authors independently of these pharmaceutical companies., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Objectives: To analyze the impact of the COVID-19 pandemic on Spanish emergency department (ED) care for patients aged 65 years or older during the first wave vs. a pre-pandemic period., Material and Methods: Retrospective cross-sectional study of a COVID-19 portion of the EDEN project (Emergency Department and Elder Needs). The EDEN-COVID cohort included all patients aged 65 years or more who were treated in 52 EDs on 7 consecutive days early in the pandemic. We analyzed care variables, discharge diagnoses, use of diagnostic and therapeutic resources, use of observation units, need for hospitalization, rehospitalization, and mortality. These data were compared with data for an EDEN cohort in the same age group recruited during a similar period the year before the pandemic., Results: The 52 participating hospital EDs attended 33 711 emergencies during the pandemic vs. 96 173 emergencies in the pre-COVID period, representing a 61.7% reduction during the pandemic. Patients aged 65 years or older accounted for 28.8% of the caseload during the COVID-19 period and 26.4% of the earlier cohort (P .001). The COVID-19 caseload included more men (51.0%). Comorbidity and polypharmacy were more prevalent in the pandemic cohort than in the earlier one (comorbidity, 92.6% vs. 91.6%; polypharmacy, 65.2% vs. 63.6%). More esturesources (analgesics, antibiotics, heparins, bronchodilators, and corticosteroids) were applied in the pandemic period, and common diagnoses were made less often. Observation wards were used more often (for 37.8% vs. 26.2% in the earlier period), and hospital admissions were more frequent (in 56.0% vs. 25.3% before the pandemic). Mortality was higher during the pandemic than in the earlier cohort either in ED (1.8% vs 0.5%) and during hospitalization (11.5 vs 2.9%)., Conclusion: The proportion of patients aged 65 years or older decreased in the participating Spanish EDs. However, more resources were required and the pattern of diagnoses changed. Observation ward stays were longer, and admissions and mortality increased over the numbers seen in the reference period.

Objectives: To study baseline factors associated with hypo- and hypernatremia in older patients attended in emergency departments (EDs) and explore the association between these dysnatremias and indicators of severity in an emergency., Material and Methods: We included patients attended in 52 Spanish hospital EDs aged 65 years or older during a designated week. All included patients had to have a plasma sodium concentration on record. Patients were distributed in 3 groups according to sodium levels: normal, 135-145 mmol/L; hyponatremia, 135 mmol/L; or hypernatremia > 145 mmol/L. We analyzed associations between sodium concentration and 24 variables (sociodemographic information, measures of comorbidity and baseline functional status, and ongoing treatment for hypo- or hypernatremia). Indicators of the severity in emergencies were need for hospitalization, in-hospital mortality, prolonged ED stay (> 12 hours) in discharged patients, and prolonged hospital stay (> 7 days) in admitted patients. We used restricted cubic spline curves to analyze the associations between sodium concentration and severity indicators, using 140 mmol/L as the reference., Results: A total of 13 368 patients were included. Hyponatremia was diagnosed in 13.5% and hypernatremia in 2.9%. Hyponatremia was associated with age ($ 80 years), hypertension, diabetes mellitus, an active neoplasm, chronic liver disease, dementia, chemotherapy, and needing help to walk. Hypernatremia was associated with needing help to walk and dementia. The percentages of cases with severity indicators were as follows: hospital admission, 40.8%; in-hospital mortality, 4.3%; prolonged ED stay, 15.9%; and prolonged hospital stay, 49.8%. Odds ratios revealed associations between lower sodium concentration cut points in patients with hyponatremia and increasing need for hospitalization (130 mmol/L, 2.24 [IC 95%, 2.00-2.52]; 120 mmol/L, 4.13 [3.08-5.56]; and 110 mmol/L, 7.61 [4.53-12.8]); risk for in-hospital death (130 mmol/L, 3.07 [2.40-3.92]; 120 mmol/L, 6.34 [4.22- 9.53]; and 110 mmol/L, 13.1 [6.53-26.3]); and risk for prolonged ED stay (130 mmol/L, 1.59 [1.30-1.95]; 120 mmol/L, 2.77 [1.69-4.56]; and 110 mmol/L, 4.83 [2.03-11.5]). Higher sodium levels in patients with hypernatremia were associated with increasing need for hospitalization (150 mmol/L, 1.94 [1.61-2.34]; 160 mmol/L, 4.45 [2.88-6.87]; 170 mmol/L, 10.2 [5.1-20.3]; and 180 mmol/L, 23.3 [9.03-60.3]); risk for in-hospital death (150 mmol/L, 2.77 [2.16-3.55]; 160 mmol/L, 6.33 [4.11-9.75]; 170 mmol/L, 14.5 [7.45-28.1]; and 180 mmol/L, 33.1 [13.3-82.3]); and risk for prolonged ED stay (150 mmol/L, 2.03 [1.48-2.79]; 160 mmol/L, 4.23 [2.03-8.84]; 170 mmol/L, 8.83 [2.74-28.4]; and 180 mmol/L, 18.4 [3.69-91.7]). We found no association between either type of dysnatremia and prolonged hospital stay., Conclusion: Measurement of sodium plasma concentration in older patients in the ED can identify hypo- and hypernatremia, which are associated with higher risk for hospitalization, death, and prolonged ED stays regardless of the condition that gave rise to the dysnatremia.

Objectives: To analyze whether discharge to home hospitalization (HHosp) directly from emergency departments (EDs) after care for acute heart failure (AHF) is efficient and if there are short-term differences in outcomes between patients in HHosp vs those admitted to a conventional hospital ward (CHosp)., Material and Methods: Secondary analysis of cases from the EAHFE registry (Epidemiology of Acute Heart Failure in Emergency Departments). The EAHFE is a multicenter, multipurpose, analytical, noninterventionist registry of consecutive AHF patients after treatment in EDs. Cases were included retrospectively and registered to facilitate prospective follow-up. Included were all patients diagnosed with AHF and discharged to HHosp from 2 EDs between March 2016 and February 2019 (3 years). Cases from 6 months were analyzed in 3 periods: March-April 2016 (corresponding to EAHFE-5), January-February 2018 (EAHFE-6), and January-February 2019 (EAHFE-7). The findings were adjusted for characteristics at baseline and during the AHF decompensation episode., Results: A total of 370 patients were discharged to HHosp and 646 to CHosp. Patients in the HHosp group were older and had more comorbidities and worse baseline functional status. However, the decompensation episode was less severe, triggered more often by anemia and less often by a hypertensive crisis or acute coronary syndrome. The HHosp patients were in care longer (median [interquartile range], 9 [7-14] days vs 7 [5-11] days for CHosp patients, P .001), but there were no differences in mortality during hospital care (7.0% vs. 8.0%, P = .56), 30-day adverse events after discharge from the ED (30.9% vs. 32.9%, P = .31), or 1-year mortality (41.6% vs. 41.4%, P = .84). Risks associated with HHosp care did not differ from those of CHosp. The odds ratios (ORs) for HHosp care were as follows for mortality while in care, OR 0.90 (95% CI, 0.41-1.97); adverse events within 30 days of ED discharge, OR 0.88 (95% CI, 0.62-1.26); and 1-year mortality, OR 1.03 (95% CI, 0.76-1.39). Direct costs of HHosp and CHosp averaged €1309 and €5433, respectively., Conclusion: After ED treatment of AHF, discharge to HHosp requires longer care than CHosp, but short- and longterm outcomes are the same and at a lower cost.

Objective: To investigate the relationship of seasonal flu vaccination with the severity of decompensation and long-term outcomes of patients with heart failure (HF)., Methods: We analyzed 6147 consecutively enrolled patients with decompensated HF who presented to 33 Spanish emergency departments (EDs) during January and February of 2018 and 2019, grouped according to seasonal flu vaccination status. The severity of HF decompensation was assessed by the Multiple Estimation of Risk Based on the Emergency Department Spanish Score in Patients With Acute Heart Failure (MEESSI-AHF) + MEESSI scale, need of hospitalization and in-hospital all-cause mortality. The long-term outcomes analyzed were 90-day postdischarge adverse events and 90-day all-cause death. Associations between vaccination, HF decompensation severity and long-term outcomes were explored by unadjusted and adjusted logistic and Cox regressions by using 14 covariables that could act as potential confounders., Results: Overall median (IQR) age was 84 (IQR = 77-89) years, and 56% were women. Vaccinated patients (n = 1139; 19%) were older, had more comorbidities and had worse baseline status, as assessed by New York Heart Association class and Barthel index, than did unvaccinated patients (n = 5008; 81%). Infection triggering decompensation was more common in vaccinated patients (50% vs 41%; P < 0.001). In vaccinated and unvaccinated patients, high or very-high risk decompensation was seen in 21.9% and 21.1%; hospitalization occurred in 72.5% and 73.7%; in-hospital mortality was 7.4% and 7.0%; 90-day postdischarge adverse events were 57.4% and 53.2%; and the 90-day mortality rate was 15.8% and 16.6%, respectively, with no significant differences between cohorts. After adjusting, vaccinated decompensated patients with HF had decreased odds for hospitalization (OR = 0.823, 95%CI = 0.709-0.955)., Conclusion: In patients with HF, seasonal flu vaccination is associated with less severe decompensations., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Aims: To assess whether symptoms/signs of congestion and perfusion in acute heart failure (AHF) evaluated at patient arrival to the emergency department (ED) can predict the severity of decompensation and short-term outcomes., Methods and Results: We included patients from the Epidemiology of AHF Emergency Registry (EAHFE Registry). We registered seven clinical surrogates of congestion and five of hypoperfusion. Patients were grouped according to severity of congestion/hypoperfusion. We assessed the need for hospitalization, in-hospital all-cause mortality for patients needing hospitalization, and prolonged hospitalization for patients surviving the decompensation episode. Outcomes were adjusted for patient characteristics and the coexistence of congestion and hypoperfusion. We analysed 18 120 patients (median = 83 years, interquartile range = 76-88; women = 55.7%). Seventy-two per cent presented >2 signs/symptoms of congestion and 18% had at least 1 sign/symptom of hypoperfusion. Seventy-five per cent were hospitalized with in-hospital death in 9% and prolonged hospitalization in 47% discharged alive. The presence of congestion/hypoperfusion was independently associated with poorer outcomes. An increase in the number of signs/symptoms of congestion was associated with increased risk of hospitalization (P < 0.001) and prolonged stay (P = 0.011), but not mortality (P = 0.06). Increased signs/symptoms of hypoperfusion were associated with hospitalization (P < 0.001) and mortality (P < 0.001), but not prolonged stay (P = 0.227). In the combined model, including congestion and hypoperfusion, both had additive effects on hospitalization, in-hospital mortality was driven by hypoperfusion and no differences were observed for prolonged hospitalization., Conclusion: The presence of congestion/hypoperfusion at ED arrival is a simple clinical marker associated with a higher risk of severity/adverse short-term outcomes., Competing Interests: Conflict of interest: We declare that no author has had or has a conflict of interest., (© The Author(s) 2022. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Background and Importance: Deterioration of renal function with respect to baseline during an acute heart failure (AHF) episode is frequent, but impact on outcomes is still a matter of debate., Objective: To investigate the association of creatinine deterioration detected at emergency department (ED) arrival and short-term outcomes in patients with AHF., Design: Secondary analysis of a large multipurpose registry., Settings and Participants: Patients with AHF were diagnosed in 10 Spanish ED for whom a previous baseline creatinine was available., Exposure: Difference between creatinine at ED arrival and at baseline was calculated (∂-creatinine)., Outcome Measures and Analysis: Primary outcome was 30-day all-cause death, and secondary outcomes were inhospital all-cause death, prolonged hospitalization (>7 days) and 7-day postdischarge adverse events. Associations between ∂-creatinine and outcomes were explored using logistic regression by restricted cubic spline (RCS) curves and expressed as odds ratio (OR) with 95% confidence interval (CI), taking ∂-creatinine = 0 mg/dl as reference. Curves were adjusted by age, sex, comorbidities, patient baseline status, chronic treatments, and vitals and laboratory results at ED arrival. Interactions for the primary outcome also were investigated., Main Results: We analyzed 3036 patients (median age = 82 years; IQR = 75-87; women = 55%), with ∂-creatinine ranged from -0.3 to 3 mg/dl. The 30-day mortality was 11.6%. Increments of ∂-creatinine were associated with progressive increase in risk of 30-day death, although adjustment attenuated this association: ∂-creatinine of 0.3/1/2/3 mg/dl were, respectively, associated with adjusted OR of 1.41 (1.02-1.95), 1.69 (1.02-2.80), 1.46 (0.56-3.80) and 1.27 (0.27-5.83). Distinctively significant higher risk was found for patients over 80 years old, female, nondiabetic, functionally disabled and on digoxin therapy. With respect to secondary outcomes, inhospital mortality was 8.1%, prolonged hospitalization was 33.6% and 7-day postdischarge adverse event was 9.7%. Inhospital death steadily increased with increments in ∂-creatinine [from 1.50 (1.04-2.17) with ∂-creatinine = 0.3 to 3.78 (0.78-18.3) with ∂-creatinine = 3], as well as prolonged hospitalization did [from 1.41 (1.11-1.77) to 2.24 (1.51-3.33), respectively]. Postdischarge adverse events were not associated with ∂-creatinine., Conclusion: WRF detected at ED arrival has prognostic value in AHF, being associated with increased risk of death and prolonged hospitalization. These associations showed different patterns of risk but, remarkably, risk started with increments as low as 0.3 mg/dl., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: To investigate the relationship between ambient temperature and atmospheric pressure (AP) and the severity of heart failure (HF) decompensations., Methods: We analysed patients coming from the Epidemioloy Acute Heart Failure Emergency (EAHFE) Registry, a multicentre prospective cohort study enrolling patients diagnosed with decompensated HF in 26 emergency departments (EDs) of 16 Spanish cities. We recorded patient and demographic data and maximum temperature (T max ) and AP (AP max ) the day before ED consultation. Associations between temperature and AP and severity endpoints were explored by logistic regression. We used restricted cubic splines to model continuous non-linear associations of temperature and AP with each endpoint., Results: We analysed 16,545 patients. Daily T max and AP max (anomaly) of the day before patient ED arrival ranged from 0.8 to 41.6° and from - 61.7 to 69.9 hPa, respectively. A total of 12,352 patients (75.2%) were hospitalised, with in-hospital mortality in 1171 (7.1%). The probability of hospitalisation by HF decompensation showed a U-shaped curve versus T max and an increasing trend versus AP max . Regarding temperature, hospitalisation significantly increased from 20 °C (reference) upwards (25 °C: OR = 1.12, 95% CI = 1.04-1.21; 40 °C: 1.65, 1.13-2.40) and below 5.4 °C (5 °C: 1.21, 1.01-1.46). Concerning the mean AP of the city (anomaly = 0 hPa), hospitalisation increased when AP max (anomaly) was above + 7.0 hPa (atmospheric anticyclone; + 10 hPa: 1.14, 1.05-1.24; + 30 hPa: 2.02. 1.35-3.03). The lowest probability of mortality also corresponded to cold-mild temperatures and low AP, with a significant increased risk only found for T max above 24.3 °C (25 °C: 1.13, 1.01-1.27; 40 °C: 2.05, 1.15-3.64) and AP max (anomaly) above + 3.4 hPa (+ 10 hPa: 1.21, 1.07-1.36; + 30 hPa: 1.73, 1.06-2.81). Sensitivity analysis confirmed the main analysis results., Conclusion: Temperature and AP are independently associated with the severity of HF decompensations, with possible different effects on the need for hospitalisation and in-hospital mortality., (© 2022. The Author(s), under exclusive licence to Society of General Internal Medicine.)

Objectives: We investigated if the phenotypic classification of acute heart failure (AHF) based on the number of signs/symptoms of congestion and hypoperfusion at emergency department (ED) arrival identifies subgroups in which intravenous (IV) nitroglycerine (NTG) use improves short-term survival., Methods: We included consecutive AHF patients diagnosed in 45 Spanish EDs, who were grouped according to phenotype severity. The main outcome was 30-day all-cause death. Propensity scores (PS) for NTG use were generated using variables associated with death. Analysis of interaction was performed in subgroups of patients based on congestion, hypoperfusion, age, sex, coronary artery disease (CAD), left ventricular ejection fraction (LVEF) and SBP., Results: We analyzed 16 437 AHF patients (median = 83 years; women = 56%); 1882 received NTG (11.4%). In the whole cohort, the cumulative 30-day mortality in patients receiving NTG was higher (11.5% vs. 9.6%; unadjusted HR, 1.19; 95% CI, 1.04-1.36), but not in the PS-matched cohorts (1698 pairs of patients; 11.5% vs. 10.5%; HR, 1.10; 95% CI, 0.90-1.35). Mortality was increased in NTG-treated patients with mild congestion (HR, 2.09; 95% CI, 1.19-3.67), especially in those without hypoperfusion (HR, 2.51; 95% CI, 1.24-5.10). Interaction analysis of the PS-matched cohorts confirmed detrimental effects of NTG use in less congested patients, whereas beneficial effects were only observed in patients with decreased LVEF (<50% subgroup: HR, 0.59; 95% CI, 0.37-0.92; ≥50% subgroup: HR, 1.30; 95% CI, 0.66-2.56; P = 0.002)., Conclusion: Phenotypical classification of AHF based on congestion/hypoperfusion at ED arrival does not identify subgroups of patients in whom IV-NTG would decrease mortality, although it could potentially be beneficial in those with LVEF of less than 50%. This hypothesis will have to be confirmed in the future. Conversely, our results suggest that IV-NTG may be harmful in patients with only mild clinical congestion., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Objectives: To describe the sociodemographic characteristics, comorbidity, and baseline functional status of patients aged 65 or older who came to hospital emergency departments (EDs) during the first wave of the COVID-19 pandemic, and to compare them with the findings for an earlier period to analyze factors of the index episode that were related to mortality., Material and Methods: We studied data from the EDEN-COVID cohort (Emergency Department and Elder Needs During COVID-19) of patients aged 65 years or older treated in 40 Spanish EDs on 7 consecutive days. Nine sociodemographic variables, 18 comorbidities, and 7 function variables were registered and compared with the findings for the EDEN cohort of patients included with the same criteria and treated a year earlier in the same EDs. In-hospital mortality was calculated in the 2 cohorts and a multivariable logistic regression model was used to explore associated factors., Results: The EDEN-COVID cohort included 6806 patients with a median age of 78 years; 49% were women. The pandemic cohort had a higher proportion of men, patients covered by the national health care system, patients brought from residential facilities, and patients who arrived in an ambulance equipped for advanced life support. Pandemic-cohort patients more often had diabetes mellitus, chronic kidney disease, and dementia; they less often had connective tissue and thromboembolic diseases. The Barthel and Charlson indices were worse in this period, and cognitive decline was more common. Fewer patients had a history of depression or falls. Eight hundred ninety these patients (13.1%) died, 122 of them in the ED (1.8%); these percentages were lower in the earlier EDEN cohort, at 3.1% and 0.5%, respectively. Independent sociodemographic factors associated with higher mortality were transport by ambulance, older age, male sex, and living in a residential facility. Mortalityassociated comorbidities were neoplasms, chronic kidney disease, and heart failure. The only function variable associated with mortality was the inability to walk independently. A history of falls in the past 6 months was a protective factor., Conclusion: The sociodemographic characteristics, comorbidity, and functional status of patients aged 65 years or older who were treated in hospital EDs during the pandemic differed in many ways from those usually seen in this older-age population. Mortality was higher than in the prepandemic period. Certain sociodemographic, comorbidity, and function variables were associated with in-hospital mortality.

The HEFESTOS scale was developed in 14 Spanish primary care centres and validated in 9 primary care centres of other European countries. It showed good performance to predict death/hospitalisation during the first 30 days after an episode of acute heart failure (AHF), with c-statistics of 0.807/0.730 in the derivation/validation cohorts. We evaluated this scale in the emergency department (ED) setting, comparing it to the EHMRG and MEESSI scales in the ED and the EFFECT and GWTG scales in hospitalised patients, to predict 30-day outcomes, including death and hospitalisation. Consecutive AHF patients were enrolled in 34 Spanish EDs in January-February 2016, 2018, and 2019 with variables needed to calculate outcome scores. Thirty-day hospitalisation/death (together and separately) and post-discharge combined adverse event (ED revisit or hospitalisation for AHF or all-cause death) were determined for patients discharged home after ED care. Predictive capacity was assessed by c-statistic with 95% confidence intervals. Of 10,869 patients, 4,044 were included (median age: 83 years, 54% women). The performance of HEFESTOS was modest for 30-day hospitalisation/death, c-statistic=0.656 (0.637-0.675), hospitalisation, 0.650 (0.631-0.669), and death, 0.610 (0.576-0.644). Of 1,034 patients with scores for the 5 scales, HEFESTOS had the numerically highest c-statistic for hospitalisation/death at 30 days, 0.666 (0.627-0.704), vs. MEESSI= 0.650 (0.612-0.687, p=0.51), EFFECT=0.633 (0.595-0.672, p=0.21), GWTG=0.618 (0.578-0.657, p=0.06) and EHMRG=0.617 (0.577-0.704, p=0.07). Similar modest performances were observed for predicting hospitalisation [ranging from HEFESTOS=0.656 (0.618-0.695) to GWTG=0.603 (0.564-0.643)]. Conversely, prediction of 30-day death was good with the MEESSI=0.787 (0.728-845), EFFECT=0.754 (0.691-0.818) and GWTG=0.749 (0.689-0.809) scales, and modest with EHMRG=0.649 (0.581-0.717) and HEFESTOS=0.610 (0.538-0.683). Although the HEFESTOS scale was numerically better for predicting 30-day hospitalisation/death in ED AHF patients, its modest performance precludes routine use. Only 30-day mortality was adequately predicted by some scales, with the MEESSI achieving the best results., (© 2022. The Author(s), under exclusive licence to Società Italiana di Medicina Interna (SIMI).)

To investigate the relationship of ambient temperature and atmospheric pressure (AP) at patient discharge after an episode of acute heart failure (AHF) with very early post-discharge adverse outcomes. We analyzed 14,656 patients discharged after an AHF episode from 26 hospitals in 16 Spanish cities. The primary outcome was the 7-day post-discharge combined adverse event (emergency department -ED- revisit or hospitalization due to AHF, or all-cause death), and secondary outcomes were these three adverse events considered individually. Associations (adjusted for patient and demographic conditions, and length of stay -LOS- during the AHF index episode) of temperature and AP with the primary and secondary outcomes were investigated. We used restricted cubic splines to model the continuous non-linear association of temperature and AP with each endpoint. Some sensitivity analyses were performed. Patients were discharged after a median LOS of 5 days (IQR = 1-10). The highest temperature at discharge ranged from - 2 to 41.6 °C, and AP was from 892 to 1037 hPa. The 7-day post-discharge combined event occurred in 1242 patients (8.4%), with percentages of 7-day ED-revisit, hospitalization and death of 7.8%, 5.1% and 0.9%, respectively. We found no association between the maximal temperature and AP on the day of discharge and the primary or secondary outcomes. Similarly, there were no significant associations when the analyses were restricted to hospitalized patients (median LOS = 7 days, IQR = 4-11) during the index event, or when lag-1, lag-2 or the mean of the 3 post-discharge days (instead of point estimation) of ambient temperature and AP were considered. Temperature and AP on the day of patient discharge are not independently associated with the risk of very early adverse events during the vulnerable post-discharge period in patients discharged after an AHF episode., (© 2022. The Author(s), under exclusive licence to Società Italiana di Medicina Interna (SIMI).)

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) evolves rapidly under the pressure of host immunity, as evidenced by waves of emerging variants despite effective vaccinations, highlighting the need for complementing antivirals. We report that targeting a pyrimidine synthesis enzyme restores inflammatory response and depletes the nucleotide pool to impede SARS-CoV-2 infection. SARS-CoV-2 deploys Nsp9 to activate carbamoyl-phosphate synthetase, aspartate transcarbamoylase, and dihydroorotase (CAD) that catalyzes the rate-limiting steps of the de novo pyrimidine synthesis. Activated CAD not only fuels de novo nucleotide synthesis but also deamidates RelA. While RelA deamidation shuts down NF-κB activation and subsequent inflammatory response, it up-regulates key glycolytic enzymes to promote aerobic glycolysis that provides metabolites for de novo nucleotide synthesis. A newly synthesized small-molecule inhibitor of CAD restores antiviral inflammatory response and depletes the pyrimidine pool, thus effectively impeding SARS-CoV-2 replication. Targeting an essential cellular metabolic enzyme thus offers an antiviral strategy that would be more refractory to SARS-CoV-2 genetic changes.