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Ventilation/perfusion (V/Q) imaging and computed tomography pulmonary angiography (CTPA) are common tools for acute pulmonary embolism (PE) diagnosis. Limited contemporary data exist about the utilization of each modality, including the predictors of using V/Q versus CTPA. We used the data from patients diagnosed with PE using V/Q or CTPA from 2007 to 2019 in Registro Informatizado Enfermedad ThromboEmbolica, an international prospective registry of patients with venous thromboembolism. Outcomes was to determine the trends in utilization of V/Q vs. CTPA and, in a contemporary subgroup fitting with current practices, to evaluate predictors of V/Q use with multivariable logistic regression. Among 26,540 patients with PE, 89.2% were diagnosed with CTPA, 7.1% with V/Q and 3.7% with > 1 thoracic imaging modality. Over time, the proportional use of V/Q scanning declined (13.9 to 3.3%, P

Background Atrial fibrillation (AF) may exist before or occur early in the course of pulmonary embolism (PE). We determined the PE outcomes based on the presence and timing of AF. Methods and Results Using the data from a multicenter PE registry, we identified 3 groups: (1) those with preexisting AF, (2) patients with new AF within 2 days from acute PE (incident AF), and (3) patients without AF. We assessed the 90‐day and 1‐year risk of mortality and stroke in patients with AF, compared with those without AF (reference group). Among 16 497 patients with PE, 792 had preexisting AF. These patients had increased odds of 90‐day all‐cause (odds ratio [OR], 2.81; 95% CI, 2.33–3.38) and PE‐related mortality (OR, 2.38; 95% CI, 1.37–4.14) and increased 1‐year hazard for ischemic stroke (hazard ratio, 5.48; 95% CI, 3.10–9.69) compared with those without AF. After multivariable adjustment, preexisting AF was associated with significantly increased odds of all‐cause mortality (OR, 1.91; 95% CI, 1.57–2.32) but not PE‐related mortality (OR, 1.50; 95% CI, 0.85–2.66). Among 16 497 patients with PE, 445 developed new incident AF within 2 days of acute PE. Incident AF was associated with increased odds of 90‐day all‐cause (OR, 2.28; 95% CI, 1.75–2.97) and PE‐related (OR, 3.64; 95% CI, 2.01–6.59) mortality but not stroke. Findings were similar in multivariable analyses. Conclusions In patients with acute symptomatic PE, both preexisting AF and incident AF predict adverse clinical outcomes. The type of adverse outcomes may differ depending on the timing of AF onset.

Objetivo: evaluar la incidencia de eventos trombóticos, sangrado y mortalidad comparando diferentes regímenes de anticoagulación en pacientes ingresados en unidades de cuidados intensivos (UCI) por COVID-19. Diseño: Estudio de cohortes retrospectivo observacional y analítico. Ámbito: pacientes con COVID-19 ingresados en una UCI de un hospital terciario entre marzo y abril de 2020. Pacientes: se incluyeron un total de 201 pacientes de UCI ingresados por COVID-19. Los pacientes se categorizaron en 3 grupos en función de la dosis de anticoagulación más alta recibida durante el ingreso: profiláctica, intermedia y terapéutica. Intervenciones: se comparó la incidencia de eventos trombóticos, hemorragia y mortalidad entre los grupos. Se realizaron dos regresiones logísticas multivariables para comprobar la asociación entre los eventos trombóticos y el sangrado con el régimen anticoagulante. Principales variables de interés: eventos trombóticos, sangrado y mortalidad. Resultados: de los pacientes incluidos, 78 recibieron dosis profilácticas, 94 intermedias y 29 terapéuticas. No se encontraron diferencias en los eventos trombóticos y la mortalidad entre grupos, mientras que los sangrados fueron más frecuentes en el grupo de dosis terapéutica (31%) e intermedia (15%) que en el grupo de dosis profiláctica (5%) (p

SARS-CoV-2 infection may predispose to thrombotic complications. Most frequently Pulmonary Embolism (PE). The aim of this study was to identify predictive biomarkers for developing PE in patients with COVID-19. Methods: This study analysed retrospectively the data of patients with COVID-19 admitted to our institution that underwent CTPA scan due to suspected PE. Relevant laboratory data and radiology images were collected for each patient. Results: 100 patients with COVID-19 were included. 75 (75%) were male with a mean age of 65±15.3 years-old. Among 33 (33%) patients with confirmed PE, 22 (67%) had peripheral PE (subsegmental or segmental PE). There were no demographic or major clinical differences between patients with and without PE. Only systemic arterial hypertension was more frequent among non-PE patients. D-dimer levels were higher and ferritin levels were lower at the time of CTPA in the PE group compared to the non-PE group (9400ng/ml vs 4000ng/ ml; P

Background: The choice of the imaging modality for diagnosis of pulmonary embolism (PE) could be influenced by provider, patient or hospital characteristics, or over time. However, little is known about the choice of the diagnostic modalities in practice. The aim of this study was to evaluate the variations in the use of imaging modalities for patients with acute PE. Methods: Using the data from Registro Informatizado Enfermedad TromboEmbolica (RIETE), a prospective international registry of patients with venous thromboembolism (March 2001–January 2019), we explored the imaging modalities used in patients with acute PE. The imaging modalities included computed tomography pulmonary angiography, ventilation/perfusion scanning, pulmonary angiography, a combination of these tests, or PE signs and symptoms plus imaging-confirmed proximal deep vein thrombosis but no chest imaging. Results: Among 38 025 patients with confirmed PE (53.1% female, age: 67.3±17 years), computed tomography pulmonary angiography was the dominant modality of diagnosis in all RIETE enrollees (78.2% [99% CI, 77.6–78.7]); including pregnant patients (58.9% [99% CI, 47.7%–69.4%]) and patients with severe renal insufficiency (62.5% [99% CI, 59.9–65.0]). A greater proportion of patients underwent ventilation/perfusion scanning in larger hospitals compared with smaller hospitals (13.1% versus 7.3%, P P Conclusions: In a large multinational PE registry, variations were observed in the use of imaging modalities according to patient or institutional factors and over time. However, computed tomography pulmonary angiography was the dominant modality of diagnosis, even in pregnancy and severe renal insufficiency. The safety, costs, and downstream effects of these tests on PE-related and non-PE-related outcomes warrant further investigation.

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Prescription of antibiotics is wide and generalised in COPD exacerbated patients requiring hospitalisation. Previous data showed that sputum purulence-guided antibiotic treatment strategy might be useful in severe exacerbations. The aim of this study was to investigate the non-inferiority of placebo compared to antibiotic treatment in non-purulent severe exacerbations of COPD. Methods: In this RCT, we recruited a cohort of patients with non-purulent severe exacerbation of COPD. We randomly assigned them to a 5-day course of oral moxifloxacin (400 mg daily) or placebo. The primary outcome was the rate of treatment failure on day 3. Findings: We randomly allocated 73 (25%) patients from the total cohort of 287 evaluated patients with non-purulent exacerbations, and 72 were included in the ITT analysis (35 in the placebo arm and 37 in the moxifloxacin arm). For the primary outcome, 4 patients (11%) in the placebo group and 3 patients (8%) in the moxifloxacin group presented treatment failure (difference 3%, p =0.71; 2-sided 95% CI -0.10-0.17) not reaching the pre-specified non-inferiority failure limit of 15%. We did not observe significant differences between groups in length of stay (LOS) median 6 days (IQR 4-7) in placebo group vs 5 days (IQR 4-7) in moxifloxacin group. Interpretation: In patients with COPD requiring hospitalisation for non-purulent exacerbation, treatment without antibiotic was not inferior to antibiotics in treatment failure or LOS.

The Glittre Activities of Daily Living Test (ADL-Test) is a reliable functional status measurement for stable chronic obstructive pulmonary disease (COPD) patients in a laboratory setting. We aimed to adapt the test to the home setting (mADL-Test) and to follow-up the functional status recovery of post-exacerbation COPD patients included in a home hospitalization (HH) program.We assessed 17 exacerbated moderate-to-very-severe COPD patients in 3 home visits: at discharge to HH (V0), 10days (V10post) and 1month after discharge (V30post). Patients completed the mADL-Test (laps, VO2 and VE), COPD assessment test (CAT), London Chest ADL Test (LCADL), modified Medical Research Council (mMRC) and upper limb strength (handgrip).The number of laps of the mADL-Test (4, 5 and 5, P.05), CAT (19, 12 and 12, P.01), mMRC (2, 1.5 and 1, P.01) and the self-care domain of the LCADL (6, 5 and 5, P.01) improved during follow-up (V0, V10post and V30post, respectively). No significant changes were evidenced in VO2, VE or handgrip.Our results suggest that the mADL-test can be performed in the home setting after a COPD exacerbation, and that functional status continues to improve 10days after discharge to HH.

Soluble forms of CD5 and CD6 lymphocyte surface receptors (sCD5 and sCD6) are molecules that seem to prevent experimental sepsis when exogenously administered. The aim of this study was to assess sCD5 and sCD6 levels in patients with septic syndromes.The study population consisted of 218 patients admitted to the medical intensive care unit (ICU) presenting either septic syndromes or noninfectious systemic inflammatory response syndrome at admission or within the first 48 hours. The sCD5 and sCD6 levels were analyzed by sandwich enzyme-linked immunosorbent assay.Almost 50% of the patients had undetectable levels of sCD5 or sCD6, with no differences in clinical or biological variables with detectable patients. There was a correlation between the delta Sequential Organ Failure Assessment score and both sCD6 and sCD5 levels in all groups. Patients with sCD5 or sCD6 levels greater than 1500 ng/mL presented a higher in-ICU mortality (P.05). Logistic regression analysis showed that increased sCD6 levels were associated with an increased risk of in-ICU mortality.Levels of sCD5 and sCD6 in critically ill patients with systemic inflammatory response syndrome present a high variation and an elevated proportion of undetectability. Levels of sCD6 are associated with an increased risk of mortality in these patients.

Background Because the current economic crisis has led to austerity in health policies, with severe restrictions on public health care, avoiding unnecessary admissions and shortening hospital stays is rapidly becoming an urgent priority. Alternatives to hospitalisation replace or shorten hospital processes, including diagnosis, monitoring, treatment and follow-up. This review aims to present the available evidence on alternatives to conventional hospitalisation for medical disorders; options for surgery, psychiatry and palliative care are largely excluded. Materials and methods Narrative review. Results The main alternatives to conventional hospitalisation include day centres (DC), quick diagnosis units (QDU), hospital at home (HaH) and, in some circumstances, telemonitoring. DC increase patient comfort, reduce costs and can improve efficiency. In generally healthy patients with suspected severe disease, QDU may be a good alternative to hospitalisation for diagnostic procedures. However, their cost-effectiveness remains to be clearly proven. Randomised controlled trials have shown that hospital-at-home (HaH) can lead to earlier hospital discharges, improve outcomes and reduce costs in patients with prevalent chronic diseases. Although telemonitoring seems to be promising and its use is increasing, methodologically sounder studies with a higher level of evidence are needed to assess its clinical effectiveness. Conclusions Factors such as ageing, the need for an earlier diagnosis of suspected severe disease, the increasing complexity of medical care and the increasing costs of hospitalisation mean that, whenever possible, giving priority to less expensive alternatives to hospital admission, such as QDU, DC, HaH and telemedicine, is an urgent task in the current economic crisis.

COPD exacerbations worsen quality of life and increase cost. There is evidence of the impact of non-pharmacological treatment in the prevention of exacerbations. Therapeutic Education Programs (TEP) is a key component in the Integrated Care Models (ICM). To evaluate the effectiveness of TEP in preventing exacerbations after discharge. RCT (1:1), 6-m follow-up. Two hospitals: a) exclusively TEP and b) TEP as part of ICM. Recruitment: 12 m. Assessment using 5 domains (WHO). At 6 m we evaluated hospital admissions, emergency room visits and mortality. Intervention: 5 TEP group sessions. Material: “Controlling COPD”. 223 p (FEV 1 (44.7% (17) pred, 121 controls (CG) and 112 intervention (IG)). Age 73.3 (9.3), 17% smokers. Charlson index 5.2 (7.9), 45% LTOT. No differences between groups and centres at baseline. At 3 m (Hospital admission (23.5%), Emergency room visits (25.5%) exitus (6.2%)). The joint analysis of both centres showed a decrease in emergency room visits and hospital admissions, in comparison with the CG group, although it was not significant. When the two groups were analyzed separately, the patients in the IG with exclusive TEP showed no differences in emergency room visits and hospital admissions. Patients in the IG with TEP as part of an ICM showed a decrease in the number of emergency room visits (p=0.001) compared to the CG. The number of hospital admissions did not decrease but we observed a change in the management and type of admission, with 80% of the admissions being programmed (directly from home to ward). TEP by itself has no impact on the use of health resources. The assessment proposed by the WHO, is useful for COPD.Partially supported by SEPAR (191/2013).

Gene polymorphisms, giving rise to low serum levels of mannose-binding lectin (MBL) or MBL-associated protease 2 (MASP2), have been associated with an increased risk of infections. The objective of this study was to assess the outcome of intensive care unit (ICU) patients with systemic inflammatory response syndrome (SIRS) regarding the existence of functionally relevant MBL2 and MASP2 gene polymorphisms. The study included 243 ICU patients with SIRS admitted to our hospital, as well as 104 healthy control subjects. MBL2 and MASP2 single nucleotide polymorphisms were genotyped using a sequence-based typing technique. No differences were observed regarding the frequencies of low-MBL genotypes (O/O and XA/O) and MASP2 polymorphisms between patients with SIRS and healthy controls. Interestingly, ICU patients with a noninfectious SIRS had a lower frequency for low-MBL genotypes and a higher frequency for high-MBL genotypes (A/A and A/XA) than either ICU patients with an infectious SIRS or healthy controls. The existence of low- or / high-MBL genotypes or a MASP2 polymorphism had no impact on the mortality rates of the included patients. The presence of high-MBL-producing genotypes in patients with a noninfectious insult is a risk factor for SIRS and ICU admission. Sepsis is the main cause of death in intensive care units (ICU), with mortality rates above 50% in patients with septic shock (54). Increasing evidence suggests that variations in genes encoding different components of the immune system influence an individual’s capacity to respond adequately to infections. Genetic polymorphisms of several molecules of the innate immune system, such as tumor necrosis factor alpha (TNF-) (35), interleukin-1 receptor antagonist (IL-1RA) (2), and more recently plasminogen activator inhibitor 1 (PAI-1) (12), have been associated with increased mortality in patients with severe sepsis and septic shock. The mannose-binding lectin (MBL) is an important element of the innate immune defense system. The MBL is a circulating C-type plasma lectin, mainly produced by the liver, which binds to the specific carbohydrates present on the surface of different microorganisms (21, 38). In serum, MBL is present as oligomers (mainly trimers and tetramers) bound to the MBL-associated serine proteases (MASPs, which are also produced in the liver), mainly MASP2. Once bound to the carbohydrate residues, the MBL/MASP2 complex acts as an opsonin for phagocytosis for numerous pathogens and activates comple

Severe imported malaria is an important problem in many countries in which this disease is not endemic. This retrospective study describes the characteristics of 20 adults with severe imported malaria admitted to our intensive care unit from 1991 through 2007. All episodes were caused by Plasmodium falciparum and all patients had returned from sub-Saharan Africa, except for one transfusion recipient. All persons were considered non-immune, and none had taken appropriate chemoprophylaxis. The median time between the initiation of symptoms and the diagnosis was seven days. Five patients died (mortality rate = 25%). A higher frequency of unrousable coma and acidosis and a higher median Apache II score at admission was noted in the persons who died. Mortality by severe malaria remains high despite high quality management, which highlights the importance of chemoprophylaxis and early diagnosis and treatment.

Purpose Decreased ADAMTS-13 (A Disintegrin and Metalloprotease with a ThromboSpondin type 1 motif, member 13) seems to be associated with a poor prognosis in sepsis. However, its role in different septic syndromes and other causes of systemic inflammatory response syndrome (SIRS) remains unclear. The aims of this study were to assess ADAMTS-13 levels in patients with septic syndromes or noninfectious SIRS and to determine their association with morbidity and mortality. Methods The study population consisted of 178 patients admitted to the medical intensive care unit presenting either septic syndromes or noninfectious SIRS. ADAMTS-13 levels were analyzed. Results Patients with septic syndromes showed significantly lower levels of ADAMTS-13 compared with those with noninfectious SIRS (P = 0.014). Patients with severe sepsis or septic shock presented lower levels than those of patients with sepsis (P = 0.086). A significant negative correlation was found between ADAMTS-13 levels and delta Sequential Organ Failure Assessment and Acute Physiology and Chronic Health Evaluation II scores at admission in the septic patients. Patients who died had significantly lower levels of ADAMTS-13 compared with survivors, both in the whole population and among the septic patients (P = 0.002 and P = 0.009, respectively). Logistic regression analysis showed that decreased ADAMTS-13 levels were associated with an increased risk of in-intensive care unit mortality (odds ratio, 0.985; 95% confidence interval, 0.973-0.998; P = 0.023). Conclusions Septic patients have lower levels of ADAMTS-13 than do patients with noninfectious SIRS. Levels of ADAMTS-13 are correlated with illness severity in patients with septic syndromes. ADAMTS-13 levels were associated with an increased risk of mortality in critically ill patients with SIRS especially those with septic syndromes.

To evaluate the effect of the 4G/5G PAI-1 gene polymorphism on the development of organ failure and outcome in critically ill patients with septic syndromes.Prospective, observational study in a medical intensive care unit of a university hospital.224 consecutively admitted patients.Epidemiological data, severity scores, and the primary site of infection were recorded. DNA genotyping of the PAI-1, TNF-beta, and IL1-ra genes, and measurement of plasma PAI-1 antigen and D-dimer were carried out.The primary outcome variables were organ dysfunction and mortality.Eighty-eight subjects had septic shock at ICU entry or within 48 h from admission. Homozygotes for the 4G allele exhibited higher plasma concentrations of PAI-1 antigen and D-dimer than 4G/5G and 5G/5G subjects). ICU mortality was 44.0% in patients with 4G/4G, 23.4% in 4G/5G and 12.5% in 5G/5G, mainly due to multiorgan failure. After adjusting for SAPS II at admission the genotypes independently associated with ICU mortality in septic shock were TNF-B2/B2 (OR 2.83, 1.04-7.67) and 4G/4G of PAI-1 (OR 2.23, 1.02-4.85). The PAI-1 genotype did not determine susceptibility to infection or the outcome in nonseptic systemic inflammatory response syndrome, sepsis, severe sepsis, and nosocomial septic shock.Homozygosity for 4G of the PAI-1 gene confers an increase in the risk of mortality in adult patients with septic shock due to a greater organ failure.

Home Hospitalization has proven efficacy, but its effectiveness and potential as an Integrated Care Service in a real world setting deserves to be explored. Objective: To evaluate implementation and 10 years follow-up of Home Hospitalization and Early Discharge as an Integrated Care Service in an urban healthcare district in Barcelona. Methods: Prospective study with pragmatic assessment. Patients: Surgical and medical acute and exacerbated chronic patients requiring admission into a highly specialized hospital, from 2006 to 2015. Intervention: Home-based individualized care plan, administered as a hospital-based outreach service, aiming at substituting hospitalization and implementing a transitional care strategy for optimal discharge. Main measurements: Emergency Department, readmissions and mortality. Patients' and professionals' perspectives, technologies and costs were evaluated. Results: 4,165 admissions (71 ± 15 yrs; Charlson Index 4 ± 3). In-hospital stay was 1 (0-3) days and the length of home-based stay was 6 (5-7) days. The 30-day readmission rate was 11% and mortality was 2%. Patients, careers and health professionals expressed high levels of satisfaction (98%). At the start, the service was reimbursed at a flat rate of 918€ per patient discharged, significantly lower than conventional hospitalization (2,879€) but still allowing the hospital to keep a balanced budget. At present, there is no difference in the payment schemes for both types of services. Conclusions: The service freed an average of 6 in-hospital days per patient. The program showed health value generation, as well as potential for synergies with community-based Integrated Care Services. The publication of the current work has been fully supported by CONNECARE (UE Grant n° 689802).