The Effect of the Drug-Related Problems Prevention Bundle on Early Readmissions in Patients From the Emergency Department: A Randomized Clinical Trial

BACKGROUND

Drug-related problems (DRPs) are prevalent and avoidable disease that patients experience due to drug use or nonuse. However, secondary prevention policies have not yet been systematized.

OBJECTIVE

To assess the clinical impact of a secondary prevention bundle for DRPs in patients who visited the emergency department (ED) for medicine-related problems.

METHODS

A single-center randomized clinical trial was conducted from August 28, 2019, to January 28, 2021, with 1-month follow-up. We included 769 adult patients who visited ED with a DRP associated with cardiovascular, alimentary tract, and metabolic system medications. For the intervention group, a DRP prevention bundle, consisting of a combined strategy initiated in the ED was applied. Patients in the control group received standard pharmaceutical care. Intervention was evaluated in terms of 30-day hospital readmission due to any cause.

RESULTS

Final analysis included 769 patients, of which 68 (8.8%) were readmitted within 30 days (control group, 40 of 386 [cumulative incidence: 10.4%]; intervention group, 28 of 383 [cumulative incidence, 7.3%]). After adjustment of the model for chronic heart failure, there was a lower incidence of hospital readmission among patients in the intervention group compared with those in the control group, odds ratio: 0.59 [95% confidence interval: 0.37-0.97]; number needed to treat (NNT) = 32. No significant differences in other outcomes were observed.

CONCLUSION AND RELEVANCE

In this clinical trial, DRP prevention bundle in adjusted analysis decreased the rate of 30-day hospital readmission for any cause in patients who visited ED for a DRP.

TRIAL REGISTRATION

ClinicalTrials.gov (Identifier: NCT03607097).

Risk factors for emergency department revisit in elderly patients with gastrointestinal bleeding secondary to anticoagulant therapy

OBJECTIVE

To evaluate the frequency of emergency department (ED) revisits among elderly patients with gastrointestinal bleeding secondary to anticoagulant treatment and identify factors associated with an increased risk of ED revisits.

METHODS

A 3-year retrospective observational study was designed, including elderly patients (≥65 years) with atrial fibrillation and undergoing oral anticoagulation therapy who visited the ED for gastrointestinal bleeding. To evaluate the risk factors for 30-day revisit, a multivariate analysis was designed including comorbidities, concomitant treatment, change in anticoagulant treatment and prescription of direct-acting oral anticoagulants.

RESULTS

80 patients were included. At discharge, anticoagulation therapy was modified in 21 (26.2%) patients; and changed from an oral anticoagulant to heparin in 17 (21.2%) patients and to another oral anticoagulant in 4 (5.0%) patients. Anticoagulant treatment was withdrawn in 5 (6.3%) patients at discharge. Eleven (13.7%) patients revisited the ED 30 days after hospital discharge for bleeding episodes. No differences in the frequency of revisit to the ED were observed in the patients who changed their anticoagulant treatment at discharge. In the multivariate analysis, chronic kidney disease was the only factor significantly associated with revisits at 30 days.

CONCLUSIONS

Elderly patients who experience a first episode of gastrointestinal bleeding have a high risk of revisiting the ED for a bleeding episode, with no particular differences between the types of anticoagulant prescribed at discharge.

Prehospital emergency services in Catalonia: the SEPHCAT analysis

OBJECTIVES

To describe the main characteristics of all prehospital emergency services (SEPHs, the Catalan acronym) in Catalonia (the SEPHCAT study).

MATERIAL AND METHODS

A professional survey researcher interviewed the medical directors of all services in Catalonia, using a questionnaire prepared by the authors. Questions covered aspects related to organization, professional staffing and employment conditions, as well as the staff's training, instructional activity and research. Only closed answers were collected. The survey reflected the situation in 2015.

RESULTS

We identified 13 SEPHs (11 in the public health service and 2 private companies). Together they received 2 482 627 calls (16.4% to private services) and attended 943 849 emergencies (11.8% attended by private companies). Three hundred thirty-six basic life support units and 73 advanced life support units were reported. They were mostly considered to be of sufficient size and quality. The SEPHs contracted 1374845 person-hours/y (753995 physician-hours and 620 850 nurse-hours; 23.4% in private companies). These figures correspond to 815 full-time staff positions (447 for physicians and 368 for nurses). The numbers of physicians and nurses working were relatively stable during the morning, afternoon and evening shifts but decreased during the midnight-to-early-morning shift (physicians, by 31%; nurses, by 9%). A majority of the physicians employed were trained in family and community medicine (56.8%), but 21.3% had no specialized training; 6.5% had PhD degrees. SEPH physicians (61.5%) and nurses (46.2%) also taught undergraduate medical students; 46.2% of physicians and 84.6% of nurses taught postgraduate medical courses. Both undergraduate medical and nursing students were received in the same measure for practical training by 15.4% of the SEPHs; 69.2% also offered practical training for physicians at the postgraduate level and 76.9% trained postgraduate nurses.

CONCLUSION

SEPHs in Catalonia are very active, and private companies account for nearly 12% of the activity. Together the public and private sectors employ a large number of physicians and nurses. Staff members are involved in training others but are less involved in research.

[Prevalence of microbiologically-confirmed influenza in patients with influenza-like illness in primary care and clinical and epidemiological characteristics]

OBJECTIVE

We evaluated the prevalence of microbiologically-confirmed influenza infection among patients with influenza-like symptoms and compared the clinical and epidemiological characteristics of patients with and without influenza infection.

METHODS

Retrospective study of a cohort of patients with influenza-like symptoms from 2016 to 2018 who participated in a clinical trial in thirteen urban primary centres in Catalonia. Different epidemiological data were collected. Patients rated the different symptoms and signs on a Likert scale (absent, little problem, moderate problem and severe problem) and self-reported the measure of health status with the EuroQol visual analogue scale. A nasopharyngeal swab was taken for microbiological isolation of influenza and other microorganisms.

RESULTS

A total of 427 patients were included. Microbiologically confirmed influenza was found in 240 patients (56.2%). The percentage of patients with moderate-to-severe cough, muscle aches, tiredness and dizziness was greater among patients with microbiologically confirmed influenza. The self-reported health status was significantly lower among patients with true flu infection (mean of 36.3 ± 18.2 vs 41.7 ± 17.8 in patients without influenza; p<0.001).

CONCLUSIONS

Clinical findings are not particularly useful for confirming or excluding the diagnosis of influenza when intensity is not considered. However, the presence of moderate-to-severe cough, myalgias, tiredness and dizziness along with a poor health status is more common in patients with confirmed flu infection.

Epidemiology of hypertriglyceridaemia

Based on the most recent scientific evidence, in this chapter we describe the relation of levels of triglycerides and risk of cardiovascular diseases. Particularly, we describe the prevalence of hypertriglyceridemia based on studies published at national and international reports; the relation between hypertriglyceridemia and cardiovascular diseases according to results of cohort studies; and finally, we describe the most recent evidence from clinical trials, meta-analysis and systematic reviews that have shown data on the efficacy of lowering triglyceride levels and reducing cardiovascular diseases.

Community seroprevalence of COVID-19 in probable and possible cases at primary health care centres in Spain

BACKGROUND

There is a scarcity of information about patients with mild or moderate symptoms during the coronavirus disease 2019 (COVID-19). This is especially true for those who attended and were followed up at primary care settings.

OBJECTIVES

We aim to measure the seroprevalence of antibodies against SARS-CoV-2 infection in a community sample of possible cases and among probable cases followed in primary care.

METHODS

We selected a random sample of 600 individuals stratified by age groups from a total population of 19 899 individuals from a community area in Barcelona. We also invited all the patients that had been followed by General Practitioners (GPs). For both populations, we used COVID-19 rapid lateral flow immunoassays, which qualitatively assess the presence of patient-generated Immunoglobulins G (IgG) and Immunoglobulin M (IgM).

RESULTS

Three hundred and eleven asymptomatic individuals from the randomly selected sample participated in the study. The mean age was 43.7 years [standard deviation (SD) = 21.79] and 55% were women. Seventeen individuals were seropositive for IgM and/or IgG, resulting in an overall prevalence of 5.47% (95% confidence interval = 3.44-8.58). Six hundred and thirty-four symptomatic patients were followed up by GPs. The mean age was 46.97 years (SD = 20.05) and 57.73% were women. Of these, 244 patients (38.49%) were seropositive. Results of the multivariate logistic regression analysis showed that the odds ratio for a positive test was significantly increased in patients who had fever, ageusia and contact with a patient diagnosed with COVID-19.

CONCLUSIONS

The seroprevalence of antibodies against SARS-CoV-2 among possible cases was lower than expected. Approximately, 40% of the symptomatic patients followed up by GPs during the peak months of the pandemic were positive.

Effectiveness and safety of intravenous tocilizumab to treat COVID-19-associated hyperinflammatory syndrome: Covizumab-6 observational cohort

Although the starting event in COVID-19 is a viral infection some patients present with an over-exuberant inflammatory response, leading to acute lung injury (ALI) and adult respiratory distress syndrome (ARDS). Since IL-6 plays a critical role in the inflammatory response, we assessed the efficacy and safety of tocilizumab (TCZ) in this single-centre, observational study in all Covid-19 in-patient with a proven SARS-CoV-2 rapidly progressing infection to prevent ALI and ARDS. 104 patients with COVID-19 treated with TCZ had a lower mortality rate (5·8%) compared with the regional mortality rate (11%), hospitalized patient's mortality (10%), and slightly lower than hospitalized patients treated with our standard of care alone (6%). We found that TCZ rapidly decreased acute phase reactants, ferritin and liver release of proteins. D-Dimer decreased slowly. We did not observe specific safety concerns. Early administration of IL6-R antagonists in COVID-19 patients with impending hyperinflammatory response, may be safe and effective treatment to prevent, ICU admission and further complications.

Estimation of Lifetime Risk of Cardiovascular Disease (IBERLIFERISK): A New Tool for Cardiovascular Disease Prevention in Primary Care

INTRODUCTION AND OBJECTIVES

To develop a predictive function of lifetime cardiovascular risk, including morbidity and mortality, in a healthy working population in Spain.

METHODS

Retrospective cohort study. We selected healthy workers, aged 18 to 65 years, with no history of cardiovascular disease, who underwent a health assessment between 2004 and 2007. We used 70% of the cohort to develop the risk equation, and the remaining 30% to validate the equation. Four Cox proportional hazards models were constructed using cardiovascular events and competing events as dependent variables. The same models were replicated for men and women separately. Fatal and nonfatal events were assessed until 2014.

RESULTS

A total of 762 054 individuals were selected. The mean age was 35.48 years and 71.14% were men. Significant risk variables in the model included manual occupations, being a smoker or exsmoker, diabetes mellitus, antihypertensive treatment, systolic blood pressure, total cholesterol, high-density lipoprotein cholesterol, and lipid-lowering treatment; in men, the model also included alcohol consumption, body mass index, a family history of early coronary disease in first-degree relatives, renal failure, and diastolic blood pressure. The area under the curve receiver operating characteristic was 0.84 (95%CI, 0.82-0.85) in men and 0.73 (95%CI, 0.66-0.80) in women. Calibration showed underestimation in low-risk deciles and overestimation in high-risk deciles.

CONCLUSIONS

The new lifetime cardiovascular risk model has satisfactory discrimination and calibration, with better results in men than in women.

LB3. Daptomycin Plus Fosfomycin vs. Daptomycin Monotherapy for Methicillin-Resistant Staphylococcus aureus Bacteremia: A Multicenter, Randomized, Clinical Trial

Background

Daptomycin plus fosfomycin combination has demonstrated synergistic and bactericidal effect in animal models of methicillin-resistant Staphylococcus aureus bacteremia (MRSAB), but there is lack of data in humans.

Method

A randomized (1:1), open-label, clinical trial involving adults with MRSAB was conducted at 18 medical centers in Spain. Patients were assigned to receive daptomycin, 10 mg/kg IV daily plus fosfomycin, 2 g IV/6 hour (combination therapy) or to receive daptomycin 10 mg/kg/24 h IV (monotherapy) during 10 up to 14 days for uncomplicated bacteremia and 28 up to 42 days for complicated bacteremia. The primary efficacy endpoints were: (a) treatment success at Test-of-Cure visit (ToC: 6 weeks after end of therapy) and (b) treatment success at 7 days (defined as alive at day 7 and clearance of bacteremia without relapse from 8 to 90 days after randomization), according with the proposed primary endpoints for use in clinical trials in bloodstream infections in adults.

Result

Between December 2013 and November 2017, 674 patients with MRSAB were evaluated and 155 patients were randomized: 74 received combination therapy and 81 monotherapy. In intention-to-treat analysis, (a) at ToC visit successful outcome was achieved in 40 of 74 patients (54,1%) who received combination therapy as compared with 34 of 81 patients (42%) who were given monotherapy (54.1% vs. 42.0%; absolute difference, 12.1%; 95% confidence interval, 0%-27.0%); (b) at 7 days after starting the therapy: a successful outcome was achieved in 69 of 74 patients who received combination therapy as compared with 62 out of 81 patients who received monotherapy (93.2% vs. 76.5%; absolute difference, 16.7%; 95% confidence interval, 5.4%–27.7%). Combination therapy was associated with lower rates of microbiologic failure than monotherapy at ToC visit (0 vs. 9 patients, P = 0.009). Combination therapy, as compared with daptomycin monotherapy, was associated with a nonsignificantly higher rate of adverse events due to study medication leading to treatment failure and discontinuation of therapy: 6/74 (8.1%) vs. 3/81 (3.7%) (P = 0.31).

Conclusion

The combination of daptomycin plus fosfomycin was more effective than daptomycin alone for treating MRSAB (NCT01898338).

Disclosures

All authors: No reported disclosures.

Impact of a pharmaceutical care programme for patients with chronic disease initiated at the emergency department on drug-related negative outcomes: a randomised controlled trial

BACKGROUND

The resolution of potential drug-related problems is a priority of pharmaceutical care programmes.

OBJECTIVES

To assess the clinical impact on drug-related negative outcomes of a pharmaceutical care programme focusing on the resolution of potential drug-related problems, initiated in the emergency department for patients with heart failure (HF) and/or chronic obstructive pulmonary disease (COPD).

METHODS

Controlled trials, in which older adults (≥65 years) receiving four or more medications admitted to the emergency department for ≥12 hours for worsening of HF and/or COPD were randomised (1:1) to either a pharmaceutical care programme focusing on resolving potential drug-related problems initiated at the emergency department (intervention group (IG)) or standard care (control group). Comparisons between the groups were made for the proportion of patients with drug-related negative outcomes, number of drug-related negative outcomes per patient, mean stay, patients readmitted within 180 days and 180-day mortality.

RESULTS

118 patients were included, 59 in each group. Fewer patients in the IG had drug-related negative outcomes (37 (62.7%) vs 47 (79.7%) in the control group (p=0.042)). Fewer drug-related negative outcomes per patient occurred in the IG (56 (0.95 per patient) vs 85 (1.44 per patient) in the control group (p=0.01)). The mean stay was similar between groups (194.7 hours in the IG vs 242.5 hours in the control group (p=0.186)). No difference in revisits within 180 days was found (32 (54.24%) in the IG vs 22 (37.3%) in the control group (p=0.065)). 180-Day mortality was detected in 11 (18.6%) patients in the IG compared with 13 (22%) in the control group (p=0.647).

CONCLUSION

A pharmaceutical care programme focusing on resolving potential drug-related problems initiated at the emergency department has a favourable clinical impact, as it reduces the number and prevalence of drug-related negative outcomes. No difference was found in other outcome variables.Trial registration number NCT02368548.

Epidemiological Features and Trends of Brown Spot of Pear Disease Based on the Diversity of Pathogen Populations and Climate Change Effects

Brown spot of pear, caused by the fungus Stemphylium vesicarium, is an emerging disease of economic importance in several pear-growing areas in Europe. In recent years, new control strategies combining sanitation practices and fungicide applications according to developed forecasting models have been introduced to manage the disease. However, the pathogenic and saprophytic behavior of this pathogen makes it difficult to manage the disease. In addition, climate change can also result in variations in the severity and geographical distribution of the disease. In this study, ecological and epidemiological aspects of brown spot of pear disease related to inoculum characterization and climate change impact were elucidated. The pathogenic variation in S. vesicarium populations from pear orchards and its relationship to inoculum sources (air samples, leaf debris, and infected host and nonhost tissues) was determined using multivariate analysis. In total, six variables related to infection and disease development on cultivar Conference pear detached leaves of 110 S. vesicarium isolates were analyzed. A high proportion of isolates (42%) were nonpathogenic to pear; 85% of these nonpathogenic isolates were recovered from air samples. Most isolates recovered from lesions (93%) and pseudothecia (83%) were pathogenic to pear. A group of pathogenic isolates rapidly infected cultivar Conference pear leaves resulted in disease increase that followed a monomolecular model, whereas some S. vesicarium isolates required a period of time after inoculation to initiate infection and resulted in disease increase that followed a logistic model. The latter group was mainly composed of isolates recovered from pseudothecia on leaf debris, whereas the former group was mainly composed of isolates recovered from lesions on pear fruit and leaves. The relationship between the source of inoculum and pathogenic/aggressiveness profile was confirmed by principal component analysis. The effect of climate change on disease risk was analyzed in two pear-growing areas of Spain under two scenarios (A2 and B1) and for three periods (2005 to 2009, 2041 to 2060, and 2081 to 2100). Simulations showed that the level of risk predicted by BSPcast model increased to high or very high under the two scenarios and was differentially distributed in the two regions. This study is an example of how epidemiological models can be used to predict not only the onset of infections but also how climate change could affect brown spot of pear. [Formula: see text] Copyright © 2018 The Author(s). This is an open-access article distributed under the CC BY-NC-ND 4.0 International license .

Update on management of invasive candidiasis

Given the growing incidence of invasive candidiasis in critically ill and haemato-oncological patients and its poor outcomes, an early diagnosis and treatment are need for get a better prognosis. This document reviews the current ap-proaches that help in diagnosis of invasive candidiasis based on culture-independent microbiological tests. The combination of clinical prediction scores with fungal serological markers could facilitate the approach in antifungal therapy, optimiz-ing it. This article also reviews the epidemiology and primary risk factors for invasive candidiasis in these patients, updating the therapeutic approach algorithms in both clinical contexts based on the main evidence and international guidelines.