[Analysis of the evolution of patients attended in Spanish emergency departments during the first wave of the pandemic]

BACKGROUND

To describe the number of visits (total and per COVID-19) attended by the Spanish hospital emergency departments (EDs) during the first wave of the pandemic (March-April 2020) compared to the same period in 2019, and to calculate the quantitative changes in healthcare activity and investigate the possible influence of hospital size and COVID-19 seroprevalence.

METHOD

Cross-sectional study that analyzes the number of visits to Spanish public EDs, reported through a survey of ED chiefs during the study periods. Changes in healthcare activity were described in each autonomous community and com-pared according to hospital size and the provincial impact of the pandemic.

RESULTS

A total of 187 (66?%) of the 283 Spanish EDs participated in the study. The total number of patients attended de-creased to 49.2?% (<?30?% in the Castilla-La Mancha region), with a 60?% reduction in non-COVID-19 patients (reduction <?50?% in the regions of Asturias and Extremadura). While there were no differences in changes of healthcare activity according to the size of the hospital, there were differences in relation to the provincial impact of the pandemic, with a direct correla-tion related to the decrease in non-COVID-19 activity (the greater the impact, the greater the decrease; R2?=?0.05; p?=?0.002) and an inverse correlation to the overall activity (the greater the impact, the lesser the decrease; R2?=?0.05; p?=?0.002).

CONCLUSION

There was a very significant decrease in the number of ED visits during the first pandemic wave, although this decrease cannot be explained solely by the local incidence of the pandemic.

Abstract 2025: Characterization of cancer cell lines made senescent by exposure to ribociclib, doxorubicin, or TGFβ1, and identification of genes required for entry into senescence and senescent cell survival

Cellular senescence is a stress-induced state of stable growth arrest characterized by high expression of cell cycle inhibitors; a dramatic change in cell morphology, including an increase in lysosomal content; and secretion of large numbers of proteins involved in immune signaling and extracellular matrix remodeling. The physiological importance of cellular senescence has been attributed to prevention of carcinogenesis, aging, development, and tissue repair, and tumor cells can undergo senescence in response to therapeutic agents. In this work, we sought to validate the senescence-inducing activity of two known inducers (doxorubicin and TGFβ1) and a CDK4/6 inhibitor (ribociclib) and to identify proteins that can kill senescent tumor cells (senolytic targets) if knocked out and to identify downstream components of the tumor cell senescence pathway. Huh7 hepatocellular carcinoma cells and SK-MEL-28 melanoma cells were induced to senescence by treatment with three different agents: ribociclib, low doses of doxorubicin, or TGFβ1. The induction of senescence was confirmed by observing growth arrest, an increase in SA-β-gal staining, dramatic cell morphology changes, loss of c-Myc protein, increased expression of p15, and increased expression of senescence-associated secretory phenotype (SASP) proteins. Induction of SASP components was measured by RNAseq and SOMAscan. All three agents induced a senescent state, with blockage at different stages of the cell cycle observed. Induction of known immune factors, including IL-8 and IL-11, were identified in senescent cells (Huh7). A whole-genome CRISPR screen identified proteins required to enter senescence and those that were incompatible with the senescent state if knocked out. Expected hits were observed (eg, TGFBR1/TGFBR2 for TGFβ1, RB for ribociclib, and TOP2A for doxorubicin) for guide DNAs (gDNAs) that blocked entry into the senescent state. No gDNA candidates for common downstream senescence pathway components were observed, suggesting that these components are essential genes or that they do not exist. gDNA-induced knockouts that were incompatible with the senescent state dropped out of the screen and represent potential senolytic targets. The screen identified BCL2L1 as the only common senolytic hit across multiple senescence-inducing reagents, confirming published reports suggesting it is a senolytic target. These data show that ribociclib, doxorubicin, and TGFβ1 induced senescence in cancer cell lines. Whole-genome CRISPR screens identified senescence pathway components for each of these agents, as well as a common senolytic target.

Citation Format: Pasupuleti Rao, Jennifer Tullai, Peter Aspesi, Felipa Mapa, Nadire Cochran, Frederic Sigoillot, Guglielmo Roma, Scott Gleim, Jaison Jacob, Jason Marchese, Jonathan Solomon. Characterization of cancer cell lines made senescent by exposure to ribociclib, doxorubicin, or TGFβ1, and identification of genes required for entry into senescence and senescent cell survival [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2021; 2021 Apr 10-15 and May 17-21. Philadelphia (PA): AACR; Cancer Res 2021;81(13_Suppl):Abstract nr 2025.

POS1449 SEGMENTED SHORT-FORMAT ONLINE EDUCATION SIGNIFICANTLY INCREASES PREDICTION, PROGNOSIS, AND MANAGEMENT OF FIBROSING INTERSTITIAL LUNG DISEASE ASSOCIATED WITH CONNECTIVE TISSUE DISEASE

Background:

Identifying fibrosing interstitial lung disease (ILD) at the earliest opportunity remains one of the most urgent challenges for the effective management of this potentially rapidly progressive and burdensome condition, which is frequently associated with several connective tissue diseases (CTDs). However, knowledge on how to identify early hallmarks and predictors of fibrosing ILD, as well as knowing which steps to take next is frequently lacking in clinical practice.

Objectives:

This study was conducted to determine whether online independent medical education could improve rheumatologists’ and pulmonologists’ knowledge and competence in identifying and managing progressive fibrosing ILDs earlier in the disease course.

Methods:

Rheumatologists and pulmonologists participated in five ~10-min presentations about the early identification of fibrosing ILD in patients with or without CTDs and completed all pre- and post-questions.1 The effects of the education on knowledge and competence were assessed using a 3-question, repeated pairs, pre-assessment/post-assessment study design. For all questions combined, the chi-square test assessed differences from pre- to post-assessment. P values <.05 are statistically significant. The activity launched on October 9, 2020, and data were collected through December 18, 2020.

Results:

Overall significant improvements were seen after participation for both rheumatologists (average correct response rate of 28% at pre-assessment vs 74% at post-assessment; P<.001, representing a 165% relative percentage change [RPC]; N=39), and pulmonologists (average correct response rate of 39% at pre-assessment vs 67% at post-assessment; P<.001, representing a 72% RPC; N=102). Specifically, significant improvements were observed in clinicians’ knowledge of predictors of fibrosing ILD in patients with CTD, as well as competence in selecting the right HRCT parameters to assess prognosis and select a treatment approach to reduce the risk of disease progression (Figure 1).

Figure 1.

After participating in the activity, 59% of rheumatologists and 50% of pulmonologists had measurable improved confidence related to identifying early disease progression in patients with progressive fibrosing ILDs.

Given the very low rates of correct responses at baseline regarding predictors of fibrosing ILD and assessing prognosis, it will be important to continue to reinforce these learnings in ongoing educational programs.

Conclusion:

This study demonstrates the success of segmented online education in improving rheumatologists’ and pulmonologists’ knowledge and competence in evaluating risk and prognosis of fibrosing ILD and managing patients with CTD-ILDs. This could lead to earlier changes in therapeutic approach for those with signs of progression and result in improved overall outcomes for these patients.

References:

[1]Kolb M, Maher T, Smith V, Jacob J, Rimekasten G. Catching and Managing Progressive Fibrosing Interstitial Lung Disease Progression Earlier. Launched: Oct 9, 2020. Data as of Dec 18, 2020. Available at www.medscape.org/viewarticle/938826

Disclosure of Interests:

Christy Rohani-Montez: None declared, Marinella Calle: None declared, Chris Allen: None declared, Toby Maher Speakers bureau: Astra Zeneca, Bayer, Blade Therapeutics, Boehringer Ingelheim, Bristol-Myers Squibb, Galapagos, Galecto, GlaxoSmithKline R&D, Indalo, IQVIA, Pliant, Respivant, Roche and Theravance, Consultant of: Astra Zeneca, Bayer, Blade Therapeutics, Boehringer Ingelheim, Bristol-Myers Squibb, Galapagos, Galecto, GlaxoSmithKline R&D, Indalo, IQVIA, Pliant, Respivant, Roche and Theravance, Grant/research support from: Astra Zeneca and GlaxoSmithKline R&D, Vanessa Smith Speakers bureau: Boehringer-Ingelheim Pharma GmbH&Co and Janssen-Cilag NV, Consultant of: Boehringer-Ingelheim Pharma GmbH&Co, Grant/research support from: Research Foundation - Flanders (FWO), Belgian Fund for Scientific Research in Rheumatic diseases (FWRO), Boehringer-Ingelheim, Pharma GmbH&Co, and Janssen-Cilag NV, Joseph Jacob Speakers bureau: Boehringer-Ingelheim; Roche, Consultant of: Boehringer-Ingelheim, Grant/research support from: GlaxoSmithKline, Gabriela Riemekasten Speakers bureau: AbbVie; Actelion; Boehringer-Ingelheim, Consultant of: Actelion; CellTrend; Janssen, Grant/research support from: AbbVie; Actelion, Martin Kolb Speakers bureau: AstraZeneca; Boehringer-Ingelheim; Novartis; Roche, Consultant of: AbbVie Inc.; Algernon Pharma; AstraZeneca;, Boehringer-Ingelheim; Cipla; Covance; EPG Health; Galapagos NV; Gilead; GlaxoSmithKline; Indalo; MitoImmune Therapeutics Inc; Novartis; Pieris; Prometic (now Liminal Biosciences); Roche; Third Pole Inc.; TwoXAR Inc., Grant/research support from: Boehringer-Ingelheim; GlaxoSmithKline; Novartis; Prometic; Roche; Avalyn

Determinants of Willingness for COVID-19 Vaccine: Implications for Enhancing the Proportion of Vaccination Among Indians

Objective

To assess willingness for the coronavirus disease 2019 (COVID-19) vaccine and identify the factors attributing to the willingness.

Design

A cross-sectional study was conducted, adopting an exponential, non-discriminative snowball sampling technique. The questionnaire collected the socio-demographic profile, history of COVID-19 infection, presence of co-morbidities (diabetes mellitus, hypertension, chronic obstructive pulmonary disease (COPD), asthma, cancer), willingness, and preference of vaccine among participants. An online platform (Google Forms) was used to collect data from all over India. A total of 2032 Indian adults aged above 18 years were included in the study.

Results

Around 1598 (78.6%) expressed willingness to receive the COVID vaccine, and among the healthcare providers (HCPs), 579 (80.3%) were willing for COVID vaccination. Factors like the belief that the vaccine is necessary (aOR=1.68, 95% CI =1.34 to 2.11), respondents having no history of COVID infection (aOR=0.71, 95% CI: 0.52 to 0.97), having trust in the government (aOR=6.09, CI: 4.59 to 7.98), people who felt the cost of the vaccine didn’t matter (aOR=4.92, CI: 3.80 to 6.37), and respondents with no perceived risk of COVID infection (aOR=0.63; CI: 0.47 to 0.83) were more associated with willingness for COVID vaccination.

Conclusions

An effective vaccine should be well-received by the public. The responsibility lies with the government, health authorities, and manufacturers to take appropriate steps to dispel rumors in order to ensure people’s understanding and acceptance.

The safety and efficacy of day-case total joint arthroplasty

INTRODUCTION

The popularity of day-case arthroplasty has been fuelled by focus on its cost effectiveness for the healthcare system. Safety concerns still remain. The aim of this review was to compare readmission rates after total joint arthroplasty for patients undergoing day-case surgery and for inpatients.

METHODS

A comprehensive online search of databases was performed for all published articles in the English language evaluating readmission rates after total hip arthroplasty (THA) and total knee arthroplasty (TKA). Seventeen studies were deemed eligible and included in the meta-analysis.

RESULTS

All studies included in the meta-analysis described readmission rates following THA/TKA. The readmission rate for day-case patients was 1.9% (n=124) whereas for inpatients, it was 2.0% (n=12,399). Compared with inpatient arthroplasty, day-case arthroplasty was associated with lower total readmission rates (odds ratio [OR]: 0.77, 95% confidence interval [CI]: 0.63-0.94, p=0.01). Furthermore, day-case surgery conferred a decrease in readmission rates for both THA (1.3% vs 7.0%) and TKA (2.7% vs 4.3%). Moreover, day-case THA and TKA were both associated with a decreased chance of readmission (OR: 0.27, 95% CI: 0.17-0.42, p<0.00001; and OR: 0.55, 95% CI: 0.42-0.72, p<0.00001 respectively).

CONCLUSIONS

This review emphasises that with a thoughtful, designated protocol and with careful patient selection, day-case arthroplasty is a safe and effective option.

Prognostic implications of Anemia in patients with acute heart failure in emergency departments. ANEM-AHF Study

INTRODUCTION

The presence of anaemia leads to a worse prognosis in patients with heart failure (HF). There are few data on the impact of anaemia on mortality in patients with acute heart failure (AHF), and the studies available are mainly retrospective, and include hospitalised patients.

OBJECTIVE

Evaluate the role of anaemia on 30-day and 1-year mortality in patients with AHF attended in hospital emergency departments (HEDs).

METHODS

We performed a multicentre, observational study of prospective cohorts of patients with AHF. The study variables were: Anaemia (haemoglobin < 12g/dL in women and <13g/dL in men), mortality at 30 days and at 1 year, risk factors, comorbidity, functional impairment, basal functional grade for dyspnoea, chronic and acute treatment, clinical and analytical data of the episode, and patient destination.

STATISTICAL ANALYSIS

Bivariate analysis and survival analyses using Cox regression.

RESULTS

A total of 13 454 patients were included, 7662 (56.9%) of whom had anaemia. Those with anaemia were older, had more comorbidity, a worse functional status and New York Heart Association class, greater renal function impairment, and more hyponatraemia. The mortality was higher in patients with anaemia at 30 days and 1 year: 7.5% vs 10.7% (P < .001) and 21.2% vs 31.4% (P < .001), respectively. The crude and adjusted hazard ratios of anaemia for 30-day mortality were: 1.46 (confidence interval [CI] 95% 1.30-1.64); P < .001 and 1.20 (CI 95% 1.05-1.38); P = .009, respectively, and 1.57 (CI 95% 1.47-1.68) and 1.30 (CI 95% 1.20-1.40) for mortality at 1 year. The weight of anaemia on mortality was different in each follow-up period.

CONCLUSIONS

Anaemia is an independent predictor of mortality at 30 days and 1 year in patients with AHF attended in HEDs. It is important to study the aetiology of AHF since adequate treatment would reduce mortality.

Massive left upper abdominal cyst: how to diagnose and what to do

We present a case of a large splenic pseudocyst in a 16-year-old female, who presented with a left upper quadrant mass and features of gastric outlet obstruction. We discuss the difficulties in diagnosis, the management options and why the definitive treatment of distal pancreatectomy and splenectomy was necessary.

Consensus on improving the comprehensive care of patients with acute heart failure

The latest acute heart failure consensus document from the Spanish Society of Cardiology, Spanish Society of Internal Medicine, and Spanish Society of Emergency Medicine was published in 2015, which made an update covering the main novelties regarding acute heart failure from the last few years necessary. These include publication of updated European guidelines on heart failure in 2016, new studies on the pharmacological treatment of patients during hospitalization, and other recent developments regarding acute heart failure such as early treatment, intermittent treatment, advanced heart failure, and refractory congestion. This consensus document was drafted with the aim of updating all aspects related to acute heart failure and to create a document that comprehensively describes the diagnosis, treatment, and management of this disease.

Consensus on improving the comprehensive care of patients with acute heart failure

The latest acute heart failure (AHF) consensus document from the Spanish Society of Cardiology (SEC, for its initials in Spanish), Spanish Society of Internal Medicine (SEMI), and Spanish Society of Emergency Medicine (SEMES) was published in 2015, which made an update covering the main novelties regarding AHF from the last few years necessary. These include publication of updated European guidelines on HF in 2016, new studies on the pharmacological treatment of patients during hospitalization, and other recent developments regarding AHF such as early treatment, intermittent treatment, advanced HF, and refractory congestion. This consensus document was drafted with the aim of updating all aspects related to AHF and to create a document that comprehensively describes the diagnosis, treatment, and management of this disease.

Multiscale three-dimensional imaging of intact human organs down to the cellular scale using hierarchical phase-contrast tomography

Human organs are complex, three-dimensional and multiscale systems. Spatially mapping the human body down through its hierarchy, from entire organs to their individual functional units and specialised cells, is a major obstacle to fully understanding health and disease. To meet this challenge, we developed hierarchical phase-contrast tomography (HiP-CT), an X-ray phase propagation technique utilising the European Synchrotron Radiation Facility's Extremely Brilliant Source: the world's first high-energy 4 th generation X-ray source. HiP-CT enabled three-dimensional and non-destructive imaging at near-micron resolution in soft tissues at one hundred thousand times the voxel size whilst maintaining the organ's structure. We applied HiP-CT to image five intact human parenchymal organs: brain, lung, heart, kidney and spleen. These were hierarchically assessed with HiP-CT, providing a structural overview of the whole organ alongside detail of the organ's individual functional units and cells. The potential applications of HiP-CT were demonstrated through quantification and morphometry of glomeruli in an intact human kidney, and identification of regional changes to the architecture of the air-tissue interface and alveolar morphology in the lung of a deceased COVID-19 patient. Overall, we show that HiP-CT is a powerful tool which can provide a comprehensive picture of structural information for whole intact human organs, encompassing precise details on functional units and their constituent cells to better understand human health and disease.

COVID-19: looking beyond the peak. Challenges and tips for radiologists in follow-up of a novel patient cohort

As the coronavirus pandemic evolves, the focus of radiology departments has begun to change. The acute phase of imaging a new disease entity whilst rationalising radiology services in the face of lockdown has passed. Radiologists are now becoming familiar with the complications of COVID-19, particularly the lung parenchymal and pulmonary vascular sequelae and are considering the impact follow-up imaging may have on departments already struggling with a backlog of suspended imaging in the face of reduced capacity. This review from the British Society of Thoracic Imaging explores both the thoracic and extra-thoracic complications of COVID-19, recognising the importance of a holistic approach to patient follow-up. The British Thoracic Society guidelines for respiratory follow-up of COVID-19 will be discussed, together with newly developed reporting templates, which aim to provide consistency for clinicians as well as an opportunity for longer-term data collection.

Effect of Art Therapy on Cognitive and Psychological Well-being of Patients with Major Mental Disorders- An Experimental Study

Introduction: Psychological and recreational activities have been found to be useful in the field of psychiatry. ‘Art Therapy’ uses therapeutic use of art within the professional role in the personal development of the patient by creating art and finding meaning through them. People can improve their awareness of self and cope with symptoms of stress, anxiety, and traumatic experiences. They can also improve cognitive abilities and gain pleasure in making art. Aim: To evaluate the effectiveness of art therapy on cognitive functions and psychological well-being among mentally ill patients admitted with major mental disorders. Materials and Methods: An evaluative approach with a pre- experimental, one group pre and post-test design was adopted to select 60 patients admitted with major mental disorders in a selected psychiatric unit, Udupi, Karnataka, India through purposive sampling technique. Data collection was done from 1st December 2019 to 31st January 2020. Information was collected through Montreal Cognitive Assessment (MoCA) Scale and Psychological General Well-being Index (PGWBI) Scale. The pretest was conducted on the first day. Art therapy sessions were conducted for four consecutive days. Post-test assessments were done on the seventh and fourteenth day. Results: The mean baseline MoCA score was 16.70±4.04 which improved to 19.10±4.07 on 7th day and 21.28±4.33 on 14th day. Similarly, baseline score of PGWBI was 35.28±13.94 which improved to 53.58±13.88 on 7th day and further increased to 81.80±17.69. Conclusion: Art therapy has a strong effect on the psychological well-being of the patients with mental illnesses and is effective in improving cognitive functions and psychological well-being.

Frequency, profile and results of patients with acute heart failure transferred directly to home hospitalisation from emergency departments

OBJECTIVE

To describe the frequency, clinical characteristics and outcomes of patients with acute heart failure (AHF) transferred directly from emergency departments to home hospitalisation (HH) and to compare them with those hospitalised in internal medicine (IM) or short-stay units (SSU).

METHOD

We included patients with AHF transferred to HH by hospitals that considered this option during the Epidemiology of Acute Heart Failure in Spanish Emergency Departments (EAHFE) 4-5-6 Registries and compared them with patients admitted to IM or SSU in these centres. We compared the adjusted all-cause mortality at 1 year and adverse events 30 days after discharge.

RESULTS

The study included 1473 patients (HH/IM/SSU: 68/979/384). The HH rate was 4.7% (95% CI, 3.8-6.0%). The patients in HH had few differences compared with those hospitalised in IM and SSUs. The HH mortality was 1.5%, and the HH median stay was 7.5 days (IQR, 4.5-12), similar to that of IM (median stay, 8 days; IQR, 5-13; p=.106) and longer than that of SSU (median stay, 4 days; IQR, 3-7; p<.001). The all-cause mortality at 1 year for HH did not differ from that of IM (HR, 0.91; 95% CI, 0.73-1.14) or SSU (HR, 0.77; 95% CI, 0.46-1.27); however, the emergency department readmission rate during the 30 days postdischarge was lower than that of IM (HR, 0.50; 95% CI, 0.25-0.97) and SSU (HR, 0.37; 95% CI, 0.19-0.74). There were no differences in the need for new hospitalisations or in the 30-day mortality rate.

CONCLUSIONS

Direct transfer from the emergency department to HH is infrequent despite being a safe option for a certain patient profile with AHF.

Frequency, profile, and outcomes of patients with acute heart failure transferred directly to home hospitalization from emergency departments

OBJECTIVE

To describe the frequency, clinical characteristics and outcomes of patients with acute heart failure (AHF) transferred directly from emergency departments to home hospitalisation (HH) and to compare them with those hospitalised in internal medicine (IM) or short-stay units (SSU).

METHOD

We included patients with AHF transferred to HH by hospitals that considered this option during the Epidemiology of Acute Heart Failure in Spanish Emergency Departments (EAHFE) 4-5-6 Registries and compared them with patients admitted to IM or SSU in these centres. We compared the adjusted all-cause mortality at 1 year and adverse events 30 days after discharge.

RESULTS

The study included 1473 patients (HH/IM/SSU:68/979/384). The HH rate was 4.7% (95% CI 3.8-6.0%). The patients in HH had few differences compared with those hospitalised in IM and SSUs. The HH mortality was 1.5%, and the HH median stay was 7.5 days (IQR, 4.5-12), similar to that of IM (median stay, 8 days; IQR, 5-13; p = .106) and longer than that of SSU (median stay, 4 days; IQR, 3-7; p < .001). The all-cause mortality at 1 year for HH did not differ from that of IM (HR, 0.91; 95% CI 0.73-1.14) or SSU (HR, 0.77; 95% CI 0.46-1.27); however, the emergency department readmission rate during the 30 days postdischarge was lower than that of IM (HR, 0.50; 95% CI 0.25-0.97) and SSU (HR, 0.37; 95% CI 0.19-0.74). There were no differences in the need for new hospitalisations or in the 30-day mortality rate.

CONCLUSIONS

Direct transfer from the emergency department to HH is infrequent despite being a safe option for a certain patient profile with AHF.

E-cigarette constituents propylene glycol and vegetable glycerin decrease glucose uptake and its metabolism in airway epithelial cells in vitro

Electronic nicotine delivery systems, or e-cigarettes, utilize a liquid solution that normally contains propylene glycol (PG) and vegetable glycerin (VG) to generate vapor and act as a carrier for nicotine and flavorings. Evidence indicated these "carriers" reduced growth and survival of epithelial cells including those of the airway. We hypothesized that 3% PG or PG mixed with VG (3% PG/VG, 55:45) inhibited glucose uptake in human airway epithelial cells as a first step to reducing airway cell survival. Exposure of H441 or human bronchiolar epithelial cells (HBECs) to PG and PG/VG (30-60 min) inhibited glucose uptake and mitochondrial ATP synthesis. PG/VG inhibited glycolysis. PG/VG and mannitol reduced cell volume and height of air-liquid interface cultures. Mannitol, but not PG/VG, increased phosphorylation of p38 MAPK. PG/VG reduced transepithelial electrical resistance, which was associated with increased transepithelial solute permeability. PG/VG decreased fluorescence recovery after photobleaching of green fluorescent protein-linked glucose transporters GLUT1 and GLUT10, indicating that glucose transport function was compromised. Puffing PG/VG vapor onto the apical surface of primary HBECs for 10 min to mimic the effect of e-cigarette smoking also reduced glucose transport. In conclusion, short-term exposure to PG/VG, key components of e-cigarettes, decreased glucose transport and metabolism in airway cells. We propose that this was a result of PG/VG reduced cell volume and membrane fluidity, with further consequences on epithelial barrier function. Taking these results together, we suggest these factors contribute to reduced defensive properties of the epithelium. We propose that repeated/chronic exposure to these agents are likely to contribute to airway damage in e-cigarette users.

[Comparison of the demographic characteristics and comorbidities of patients with COVID-19 who died in Spanish hospitals based on whether they were or were not admitted to an intensive care unit]

Objetivo

Describir las características demográficas y de comorbilidad de los pacientes con COVID-19 fallecidos en hospitales españoles durante el brote pandémico de 2020 y compararlas según si ingresaron o no en una Unidad de Cuidados Intensivos (UCI) antes del fallecimiento.

Métodos

Análisis secundario de los pacientes de la cohorte SIESTA (formada por pacientes COVID de 62 hospitales españoles) fallecidos durante la hospitalización. Se recogieron sus características demográficas y comorbilidades, individuales y globalmente, estimadas mediante el índice de comorbilidad de Charlson (ICC). Se identificaron los factores independientes relacionados con ingreso en UCI, y se realizaron diversos análisis de sensibilidad para contrastar la consistencia de los hallazgos del análisis principal.

Resultados

Se incluyeron los 338 pacientes de la cohorte SIESTA fallecidos; de ellos, 77 (22,8%) accedieron a una UCI previamente al fallecimiento. En el análisis multivariable, tres de las 20 características basales analizadas se asociaron independientemente con ingreso en UCI de los pacientes fallecidos: demencia (no hubo pacientes fallecidos con demencia que ingresasen en UCI; OR = 0, IC 95% = no calculable), cáncer activo (OR = 0,07, IC 95% = 0,02-0,21) y edad (< 70 años: OR = 1, referencia; 70-74 años: OR = 0,21, IC 95% = 0,08-0,54; 75-79 años: OR = 0,21, IC 95% = 0,08-0,54; ≥ 80 años: OR = 0,02, IC 95% = 0,01-0,05). La probabilidad de ingreso en UCI de los pacientes que fallecieron disminuyó significativamente al aumentar el ICC, incluso tras ajustarla por edad (ICC 0 puntos: OR = 1, referencia; ICC 1 punto: OR = 0,36, IC 95% = 0,16-0,83; ICC 2 puntos: OR = 0,36, IC 95% = 0,16-0,83; ICC > 2 puntos: OR = 0,09, IC 95% = 0,04-0,23). Los análisis de sensibilidad no mostraron diferencias destacables respecto al análisis principal.

Conclusiones

El perfil de los pacientes COVID fallecidos sin ingresar en UCI se ajustó a lo observado en la práctica médica habitual antes de la pandemia, y las características basales que limitaron su ingreso fueron la edad y la carga de comorbilidad global, especialmente la demencia y el cáncer activo.

Radiotherapy of non-tumoral refractory neurological pathologies

Intracranial radiotherapy has been improved, primarily because of the development of stereotactic approaches. While intracranial stereotactic body radiotherapy is mainly indicated for treatment of benign or malignant tumors, this procedure is also effective in the management of other neurological pathologies; it is delivered using GammaKnife® and linear accelerators. Thus, brain arteriovenous malformations in patients who are likely to experience permanent neurological sequelae can be managed by single session intracranial stereotactic body radiotherapy, or radiosurgery, in specific situations, with an advantageous benefit/risk ratio. Radiosurgery can be recommended for patients with disabling symptoms, which are poorly controlled by medication, such as trigeminal neuralgia, and tremors, whether they are essential or secondary to Parkinson's disease. This literature review aims at defining the place of intracranial stereotactic body radiotherapy in the management of patients suffering from non-tumoral refractory neurological pathologies. It is clear that the multidisciplinary collaboration of experienced teams from Neurosurgery, Neurology, Neuroradiology, Radiation Oncology and Medical Physics is needed for the procedures using high precision radiotherapy techniques, which deliver high doses to locations near functional brain areas.

Metallic implants and CT artefacts in the CTV area: Where are we in 2020?

Radiation therapy (RT) is one of the main modalities of cancer treatment worldwide with computed tomography (CT), as the most commonly used imaging method for treatment planning system (TPS). Image reconstruction errors may greatly affect all the radiation therapy planning process, such as target delineation, dose calculation and delivery, particularly with particle therapy. Metallic implants, such as hip and spinal implants, and dental filling significantly deteriorate image quality. These hardware structures are often very complex in geometry leading to geometric complex artefacts in the clinical target volume (CTV) area, rendering the delineation of CTV challenging. In our review, we focus on the methods to overcome artefact consequences on CTV delineation: 1- medical approaches anticipating issues associated with imaging artefacts during preoperative multidisciplinary discussions while following standard recommendations; 2- common metal artefact reduction (MAR) methods such as manually override artefact regions, ballistics avoiding beam paths through implanted materials, megavoltage-CT (MVCT); 3- prospects with radiolucent implants, MAR algorithms and various methods of dual energy computed tomography (DECT). Despite substantial and broad evidence for their benefits, there is still no universal solution for cases involving implanted metallic devices. There is still a high need for research efforts to adapt technologies to our issue: "how do I accurately delineate the ideal CTV in a metal artefact area?"

COVID-19: Weighing the Endeavors of Nations, with Time to Event Analysis

The cataclysmic COVID-19 pandemic erupted silently causing colossal impact worldwide, the repercussions of which indicated a lackadaisical vigilance in preparation for such a pandemic. This review assessed the measures taken by nations to contain this pandemic. A literature review was conducted using Medline, Google Scholar, Science Direct, Scopus, and WHO website. There were 8 nations (selected from the GHS index list) appraised for containment strategies. This was achieved by using mortality rate (per million) as the primary endpoint. The nations which were proactive, initiated scientific strategies earlier with rigor, appeared to have succeeded in containing the pandemic, although it is still too early to arbitrate a verdict. The so called "pandemic war" mandates international, interdisciplinary, and interdepartmental collaboration. Furthermore, building trust and confidence between the government and the public, having transparent communication, information sharing, use of advanced research-technology, and plentiful resources are required in the fight against COVID-19.

Grid refinement in the three-dimensional hybrid recursive regularized lattice Boltzmann method for compressible aerodynamics

Grid refinement techniques are of paramount importance for computational fluid dynamics approaches relying on the use of Cartesian grids. This is especially true of solvers dedicated to aerodynamics, in which the capture of thin shear layers require the use of small cells. In this paper, a three-dimensional grid refinement technique is developed within the framework of hybrid recursive regularized lattice Boltzmann method (HRR-LBM) for compressible high-speed flows, which is an efficient collide-stream-type method on a compact D3Q19 stencil. The proposed method is successfully assessed considering several test cases, namely, an isentropic vortex propagating through transition interface, shock-vortex interaction with intersection between grid refinement interface and shock corrugation, and transonic flows over three-dimensional DLR-M6 wing with seven levels of grid refinement.

The Pandemic League of COVID-19: Korea Versus the United States, With Lessons for the Entire World

Coronavirus disease 2019 (COVID-19) is inflicting a brutal blow on humankind, and no corner of the world has been exempted from its wrath. This study analyzes the chief control measures and the distinctive features of the responses implemented by Korea and the United States to contain COVID-19 with the goal of extracting lessons that can be applied globally. Even though both nations reported their index cases on the same day, Korea succeeded in flattening the curve, with 10 752 cases as of April 28, 2020, whereas the outbreak skyrocketed in the United States, which had more than 1 million cases at the same time. The prudent and timely execution of control strategies enabled Korea to tame the spread of the virus, whereas the United States paid a major price for its delay, although it is too early to render a conclusive verdict. Information pertaining to the number of people infected with the virus and measures instituted by the government to control the spread of COVID-19 was retrieved from the United States Centers for Disease Control and Prevention and the Korea Centers for Disease Control and Prevention websites and press releases. Drawing lessons from both nations, it is evident that the resolution to the COVID-19 pandemic lies in the prudent usage of available resources, proactive strategic planning, public participation, transparency in information sharing, abiding by the regulations that are put into place, and how well the plan of action is implemented.

Characteristics of prolonged noninvasive ventilation in emergency departments and impact upon effectiveness. Analysis of the VNICat registry

OBJECTIVE

To analyze the characteristics and variables associated with prolonged noninvasive ventilation performed completely in Emergency Departments (NIV-ED) and its influence upon effectiveness.

DESIGN

A prospective, multicenter, observational multipurpose cohort study was carried out.

SETTING

VNICat Registry.

SUBJECTS

Patients in which NIV-ED was performed in 11 Catalan hospitals in the months of February or March 2015.

INTERVENTION

No.

VARIABLES

The study variable was NIV-ED, which as a function of time was defined as prolonged or not prolonged. The efficacy variable was the success of the technique in terms of patient improvement.

RESULTS

A total of 125 patients were included, with a median NIV-ED duration of 12hours, which was the cut-off point for the comparator groups. In 60 cases (48%) NIV-ED was not prolonged (<12hours), while in 65 cases (52%) ventilation was prolonged (≥12hours). Non-prolonged NIV-ED was associated to the indication of acute heart failure and prolonged ventilation to the presence of diabetes. There were no differences between non-prolonged and prolonged NIV-ED in terms of efficacy, and the success rate in terms of improvement was 68.3% and 76.9%, respectively, with an adjusted odds ratio of 1.49 (95%CI 0.61-3.60).

CONCLUSIONS

Prolonged NIV-ED is a frequent situation, but few variables associated to it have been studied. The presence of prolonged ventilation did not influence the success rate of NIV.

P1653Admission high-sensitivity troponin T and NT-proBNP for outcome prediction in acute heart failure

Background

High-sensitivity troponin T (hs-TnT) reflects the severity of ongoing myocardial damage and holds independent prognostic significance in chronic heart failure (HF). In acute HF (AHF), its additive prognostic value over natriuretic peptides is unclear.

Methods

Individual data of 1571 AHF patients with admission hs-TnT were collected from 3 cohorts.

Results

Patients were aged 78±10 years, and 51% were men. Median hs-TnT and N-terminal fraction of pro-B-type natriuretic peptide (NT-proBNP) concentrations were 43 ng/L (interquartile interval 26–69) and 5660 (2693–12466), respectively. Patients experiencing in-hospital death (n=187, 13%) had significantly higher hs-TnT and NT-proBNP on admission (both p<0.001). The risk of in-hospital death increased by 45% per each doubling of hs-TnT (HR 1.45, 95% confidence interval - CI 1.31–1.59, p<0.001), and by 32% per each doubling of NT-proBNP (HR 1.32, 95% CI 1.17–1.50, p<0.001). Patients with hs-TnT ≥43 ng/L and NT-proBNP ≥5660 ng/L had a 2.7-fold higher risk of in-hospital death (relative risk - RR 2.7, 95% CI 1.7–4.5). Among the 1262 patients discharged, 1024 deaths occurred over a median 11-month follow-up (4–22). In a model including NT-proBNP, hs-TnT ≥43 ng/L was a strong, independent predictor of all-cause death at 6, 12 and 24 months, and the composite of cardiovascular death or HF hospitalization at 6 and 24 months. hs-TnT ≥43 ng/L also improved risk reclassification.

Conclusions

The risk of in-hospital death is almost 3 folds higher with admission hs-TnT ≥43 ng/L and NT-proBNP ≥5660 ng/L, and hs-TnT ≥43 ng/L holds strong independent prognostic significance for post-discharge outcome.

Unchecked immunity: a unique case of sequential immune-related adverse events with Pembrolizumab

BACKGROUND

Immune checkpoint inhibition has dramatically transformed the treatment of malignant melanoma. With increasing use, their unique spectrum of immune-mediated toxicity has become apparent.

CASE PRESENTATION

We describe a case of sequential immune-related adverse events (irAEs) in a patient with metastatic melanoma treated with single-agent anti-programmed cell death-1 (PD-1) therapy, pembrolizumab. Although numerous cases of irAEs have been reported, sequential multi-organ involvement, including progressive atopic dermatitis, vitiligo, autoimmune nephritis, autoimmune hepatitis, and autoimmune encephalitis after cessation of therapy, has not been previously documented.

CONCLUSIONS

Immunosuppression resulted in clinical remission of each irAE, highlighting the importance of vigilance for autoimmune complications in patients treated with checkpoint inhibition, even after immunotherapy cessation.