Elaboración de modelos predictivos de la gravedad y la mortalidad en pacientes con COVID-19 que acuden al servicio de urgencias,incluida la radiografía torácica

ObjectivesTo develop prognosis prediction models for COVID-19 patients attending an emergency department (ED) based on initial chest X-ray (CXR), demographics, clinical and laboratory parameters.MethodsAll symptomatic confirmed COVID-19 patients admitted to our hospital ED between February 24th and April 24th 2020 were recruited. CXR features, clinical and laboratory variables and CXR abnormality indices extracted by a convolutional neural network (CNN) diagnostic tool were considered potential predictors on this first visit. The most serious individual outcome defined the three severity level: 0) home discharge or hospitalization ≤ 3 days, 1) hospital stay >3 days and 2) intensive care requirement or death. Severity and in-hospital mortality multivariable prediction models were developed and internally validated. The Youden index was used for the optimal threshold selection of the classification model.ResultsA total of 440 patients were enrolled (median 64 years; 55.9% male); 13.6% patients were discharged, 64% hospitalized, 6.6% required intensive care and 15.7% died. The severity prediction model included oxygen saturation/inspired oxygen fraction (SatO2/FiO2), age, C-reactive protein (CRP), lymphocyte count, extent score of lung involvement on CXR (ExtScoreCXR), lactate dehydrogenase (LDH), D-dimer level and platelets count, with AUC-ROC = 0.94 and AUC-PRC = 0.88. The mortality prediction model included age, SatO2/FiO2, CRP, LDH, CXR extent score, lymphocyte count and D-dimer level, with AUC-ROC = 0.97 and AUC-PRC = 0.78. The addition of CXR CNN-based indices did not improve significantly the predictive metrics.ConclusionThe developed and internally validated severity and mortality prediction models could be useful as triage tools in ED for patients with COVID-19 or other virus infections with similar behaviour.     

Chest pain on questionnaire and prediction of major ischaemic heart disease events in men

Objective To examine the prediction of major ischaemic heartdisease events by questionnaire-assessed chest pain and othersymptoms. Design Population-based prospective study. Subjects 7735 randomly selected men, aged 40–59 yearsat entry. Methods Symptoms and history of diagnosed ischaemic heart diseasewere ascertained by administered questionnaire at baseline.Follow-up was for an average of 14·7 years, for firstmajor ischaemic heart disease event. Results During follow-up, 969 men had a major ischaemic heartdisease event. ‘Definite’ angina (chest pain fulfillingall WHO criteria) and ‘possible’ angina (exertionalchest pain without all other WHO criteria) were associated withsimilar ischaemic heart disease outcome, and a single combinedangina category was used. In the whole cohort, the relativerisks (95% CI) of a major ischaemic heart disease event were2·03 (1·61, 2·57) for angina only, 2·13(1·72, 2·63) for possible myocardial infarctiononly and 4·50 (3·57, 5·66) for angina pluspossible myocardial infarction, compared to no chest pain. Therelative risk for recall of an ischaemic heart disease diagnosiswas 3·98 (3·36, 4·71). Only 33% of menwith angina or possible myocardial infarction symptoms recalleda previous ischaemic heart disease diagnosis. In men withoutrecall of an ischaemic heart disease diagnosis (in whom 82%of events during follow-up occurred), chest pain symptoms remainedpredictive of major ischaemic heart disease events with relativerisks (95% CI) of 1·69 (1·27, 2·24) forangina only, 1·49 (1·12, 1·97) for possiblemyocardial infarction only and 2·55 (1·44, 4·53)for angina plus possible myocardial infarction. ‘Otherchest pain’ increased risk of a major ischaemic heartdisease event by 1·19 (1·01, 1·40) comparedto no chest pain. Symptoms of breathlessness or calf pain onwalking increased ischaemic heart disease risk in men with ‘otherchest pain’ and in men without chest pain, but had nofurther effect on ischaemic heart disease risk in men with symptomsof angina or possible myocardial infarction. Conclusions In defining angina by chest pain questionnaire,the exertional component is the crucial criterion. When usingquestionnaire-assessed symptoms to determine ischaemic heartdisease risk, information on previous ischaemic heart diseasediagnoses should be taken into account. The majority of menwith angina or possible myocardial infarction symptoms do nothave a diagnosis of ischaemic heart disease, but they remainat significantly increased risk of a major ischaemic heart diseaseevent. The value of breathlessness and calf pain on walkingin stratifying ischaemic heart disease risk is restricted tomen with ‘other chest pain’ or no chest pain.     

Implementing Point-of-Care Troponin Testing in the Emergency Department: Impact on Time to Result

IntroductionIn the emergency department, troponin assays are commonly used and essential in the evaluation of chest pain and diagnosis of acute coronary syndrome. This study was designed to assess the potential impact of implementing point-of-care troponin testing by comparing the time to point-of-care laboratory result and time to conventional laboratory result.MethodsThe study enrolled 60 ED patients deemed to need a troponin test in the evaluation of low-risk chest pain (HEART score <4 based on history, electrocardiogram, age, risk factors). Point-of-care troponin testing was performed with the same blood sample obtained for a conventional troponin assay. If the provider determined that the patient required 2 troponin tests, the second laboratory draw was used in the data collection. This was to correlate the time of laboratory result to time of disposition.ResultsOf the 60 subjects enrolled, 2 subjects were excluded because of user errors with the point-of-care testing equipment and 2 others for not meeting inclusion criteria on later review. The median times for the point-of-care troponin and conventional troponin assays were 11:00 minutes (interquartile range 10:00-15:30) and 40:00 minutes (interquartile range 31:30-52:30), respectively; P < 0.001. There were 3 extreme outliers from the conventional troponin assay that significantly skewed the distribution of the mean, making the median the more accurate assessment of the central tendency.DiscussionPoint-of-care troponin testing provided results in a median time 29 minutes quicker than the conventional troponin assay. This result is statistically significant and has the potential to greatly improve time to disposition in all patients with chest pain requiring a troponin assay.     

Cardiopulmonary Resuscitation Feedback: A Comparison of Device-Measured and Self-Assessed Chest Compression Quality

BackgroundHigh-quality cardiopulmonary resuscitation is the foundation of cardiac arrest care. Guidelines specify chest compression depth, recoil, and rate, but providers often fail to achieve these targets. Furthermore, providers are largely unable assess the quality of their own or other peoples’ chest compressions. Chest compression feedback devices can improve chest compression quality; their use is endorsed internationally, but they remain largely absent in clinical care.This article analyzes preclinical data collected during a quality improvement project. It describes provider demographics and perceptions about their chest compression quality and correlates them to measured chest compression quality, compares clinician perception of chest compressions to objective measures, and describes the effect of feedback on compression quality.MethodsClinicians were recruited from 2 metropolitan emergency departments. A questionnaire was used to assess participants’ levels of training and experience. A before-and-after assessment of chest compression quality was performed using a Laerdal CPRmeter 2 and a CPR mannequin. Pretest measures of chest compression quality were made by covering the device screen thereby blinding providers to feedback; repeat measures were then collected from the same participants but unblinded to feedback. Provider charecteristic were collected by survey. Correlations between blinded chest compression quality and provider charecteristics; the reliability of providers estimated compared to measured quality; and the effects of feedback on chest compression quality were assessed using Pearsons correlations, Cohens κ, and paired t testing.Results84 participants were assessed. The mean years of certification were 11.74. Ninty-five percent of the providers self-assessed as more experienced than novice and 81% reported performing cardiopulmonary resuscitation at least occasionally. The frequency of performing chest compressions was correlated with self-assessed skill (r = 0.58, P < .001). However, self-assessed skill was only weakly correlated with chest compression quality (r = 0.29, P = .01) and not at all with the frequency of performing chest compressions or years of certification. There was no agreement between self-assessed and device-measured chest compression depth (κ = ?0.10, P = 0.11), recoil (κ = ?0.14, P = .03), or rate (κ = 0.06, P =.30). The overall quality of compressions improved by 16.9%; the percentage of chest compressions achieving target depth by 3.58%; recoil by 22.82%; and rate by 23.66% with feedback. A total of 97.6% of the staff rated chest compression feedback helpful.ConclusionsOur findings suggest that participants’ demographics were not correlated with chest compression quality and that providers cannot reliably assess chest compression quality. The data also demonstrate that with minimal training, feedback can significantly improve chest compression quality.     

Thoracic imaging outcomes in COVID-19 survivors

The coronavirus disease 2019 (COVID-19) pandemic presents a significant global public health challenge. One in five individuals with COVID-19 presents with symptoms that last for weeks after hospital discharge, a condition termed “long COVID”. Thus, efficient follow-up of patients is needed to assess the resolution of lung pathologies and systemic involvement. Thoracic imaging is multimodal and involves using different forms of waves to produce images of the organs within the thorax. In general, it includes chest X-ray, computed tomography, lung ultrasound and magnetic resonance imaging techniques. Such modalities have been useful in the diagnosis and prognosis of COVID-19. These tools have also allowed for the follow-up and assessment of long COVID. This review provides insights on the effectiveness of thoracic imaging techniques in the follow-up of COVID-19 survivors who had long COVID.     

Hallazgos iniciales en la radiografía de tórax como predictores de empeoramiento en la infección pulmonar por SARS-CoV-2. Correlación en 265 pacientes

Background and aimsWe aimed to analyze the relationship between the initial chest X-ray findings in patients with severe acute respiratory syndrome due to infection with SARS-CoV-2 and eventual clinical worsening and to compare three systems of quantifying these findings.Material and methodsThis retrospective study reviewed the clinical and radiological evolution of 265 adult patients with COVID-19 attended at our center between March 2020 and April 2020. We recorded data related to patients’ comorbidities, hospital stay, and clinical worsening (admission to the ICU, intubation, and death). We used three scoring systems taking into consideration 6 or 8 lung fields (designated 6 A, 6 B, and 8) to quantify lung involvement in each patient's initial abnormal chest X-ray and to classify its severity as mild, moderate, or severe, and we compared these three systems. We also recorded the presence of alveolar opacities and linear opacities (fundamentally linear atelectasis) in the first chest X-ray with pathologic findings.ResultsIn the χ2 analysis, moderate or severe involvement in the three classification systems correlated with hospital admission (p = 0.009 in 6 A, p = 0.001 in 6 B, and p = 0.001 in 8) and with death (p = 0.02 in 6 A, p = 0.01 in 6 B, and p = 0.006 in 8). In the regression analysis, the most significant associations were 6 B with alveolar involvement (OR 2.3; 95%CI 1.1.–4.7; p = 0.025;) and 8 with alveolar involvement (OR 2.07; 95% CI 1.01.–4.25; p = 0.046). No differences were observed in the ability of the three systems to predict clinical worsening by classifications of involvement in chest X-rays as moderate or severe.ConclusionModerate/severe extension in the three chest X-ray scoring systems evaluating the extent of involvement over 6 or 8 lung fields and the finding of alveolar opacities in the first abnormal X-ray correlated with mortality and the rate of hospitalization in the patients studied. No significant difference was found in the predictive ability of the three classification systems proposed.     

心脏骤停患者心肺复苏抢救中的影响因素分析

目的 探讨心脏骤停患者心肺复苏抢救中的影响因素。方法 回顾性收集2015年9月-2018年9月急救中心收治的304例成年心脏骤停患者的临床数据,包括患者基本人口学信息、现场心肺复苏(cardio-pulmonary resuscitaion,CPR)情况[包括是否有目击者、目击者是否实施CPR、胸部按压分数(chest compression fraction,CCF)、到达急救中心时间等],患者24 h的存活率,采用单因素分析和Logistic回归分析研究心脏骤停患者CPR后24 h存活率的影响因素。结果 单因素分析发现,目击者是否进行CPR及接受不同CCF的患者,其24 h存活率比较,差异有统计学意义(P＜0.05);Logistic回归分析显示,CCF≤80%为24 h存活率的危险因素(P＜0.05),目击者进行CPR为24 h存活率的保护因素(P＜0.05)。结论 对心脏骤停患者,目击者尽早实施CPR及增加有效持续胸部按压时间,能够提高心脏骤停患者心肺复苏后的24 h存活率。