COVID-19 as a risk factor for long-term mortality in patients managed by the emergency medical system: A prospective, multicenter, ambulance-based cohort study.

Introduction: COVID-19 has initially been studied in terms of an acute-phase disease, although recently more attention has been given to the long-term consequences. In this study, we examined COVID-19 as an independent risk factor for long-term mortality in patients with acute illness treated by EMS (emergency medical services) who have previously had the disease against those who have not had the disease. Methods: A prospective, multicenter, ambulance-based, ongoing study was performed with adult patients with acute disease managed by EMS and transferred with high priority to the emergency department (ED) as study subjects. The study involved six advanced life support units, 38 basic life support units, and five emergency departments from Spain. Sociodemographic inputs, baseline vital signs, pre-hospital blood tests, and comorbidities, including COVID-19, were collected. The main outcome was long-term mortality, which was classified into 1-year all-cause mortality and 1-year in- and out-of-hospital mortality. To compare both the patients with COVID-19 vs. patients without COVID-19 and to compare survival vs non-survival, two main statistical analyses were performed, namely, a longitudinal analysis (Cox regression) and a logistic regression analysis. Results: Between 12 March 2020 and 30 September 2021, a total of 3,107 patients were included in the study, with 2,594 patients without COVID-19 and 513 patients previously suffering from COVID-19. The mortality rate was higher in patients with COVID-19 than in patients without COVID-19 (31.8 vs. 17.9%). A logistic regression showed that patients previously diagnosed with COVID-19 presented higher rates of nursing home residency, a higher number of breaths per minute, and suffering from connective disease, dementia, and congestive heart failure. The longitudinal analysis showed that COVID-19 was a risk factor for mortality [hazard ratio 1.33 (1.10-1.61); p < 0.001]. Conclusion: The COVID-19 group presented an almost double mortality rate compared with the non-COVID-19 group. The final model adjusted for confusion factors suggested that COVID-19 was a risk factor for long-term mortality.

COVID-19 as a risk factor for long-term mortality in patients managed by the emergency medical system: A prospective, multicenter, ambulance-based cohort study

Introduction COVID-19 has initially been studied in terms of an acute-phase disease, although recently more attention has been given to the long-term consequences. In this study, we examined COVID-19 as an independent risk factor for long-term mortality in patients with acute illness treated by EMS (emergency medical services) who have previously had the disease against those who have not had the disease. Methods A prospective, multicenter, ambulance-based, ongoing study was performed with adult patients with acute disease managed by EMS and transferred with high priority to the emergency department (ED) as study subjects. The study involved six advanced life support units, 38 basic life support units, and five emergency departments from Spain. Sociodemographic inputs, baseline vital signs, pre-hospital blood tests, and comorbidities, including COVID-19, were collected. The main outcome was long-term mortality, which was classified into 1-year all-cause mortality and 1-year in- and out-of-hospital mortality. To compare both the patients with COVID-19 vs. patients without COVID-19 and to compare survival vs non-survival, two main statistical analyses were performed, namely, a longitudinal analysis (Cox regression) and a logistic regression analysis. Results Between 12 March 2020 and 30 September 2021, a total of 3,107 patients were included in the study, with 2,594 patients without COVID-19 and 513 patients previously suffering from COVID-19. The mortality rate was higher in patients with COVID-19 than in patients without COVID-19 (31.8 vs. 17.9%). A logistic regression showed that patients previously diagnosed with COVID-19 presented higher rates of nursing home residency, a higher number of breaths per minute, and suffering from connective disease, dementia, and congestive heart failure. The longitudinal analysis showed that COVID-19 was a risk factor for mortality [hazard ratio 1.33 (1.10–1.61);p < 0.001]. Conclusion The COVID-19 group presented an almost double mortality rate compared with the non-COVID-19 group. The final model adjusted for confusion factors suggested that COVID-19 was a risk factor for long-term mortality.

Prehospital Respiratory Early Warning Score for airway management in-ambulance: A score comparison.

BACKGROUND: Prehospital Respiratory Early Warning Scores to estimate the requirement for advanced respiratory support is needed. To develop a prehospital Respiratory Early Warning Score to estimate the requirement for advanced respiratory support. METHODS: Multicentre, prospective, emergency medical services (EMS)-delivered, longitudinal cohort derivationvalidation study carried out in 59 ambulances and five hospitals across five Spanish provinces. Adults with acute diseases evaluated, supported and discharged to the Emergency Department with high priority were eligible. The primary outcome was the need for invasive or non-invasive respiratory support (NIRS or IRS) in the prehospital scope at the first contact with the patient. The measures included the following: epidemiological endpoints, prehospital vital signs (respiratory rate, pulse oximetry saturation, fraction of inspired oxygen, systolic and diastolic mean blood pressure, heart rate, tympanic temperature and consciousness level by the GCS). RESULTS: Between 26 Oct 2018 and 26 Oct 2021, we enrolled 5793 cases. For NIRS prediction, the final model of the logistic regression included respiratory rate and pulse oximetry saturation/fraction of inspired oxygen ratio. For the IRS case, the motor response from the Glasgow Coma Scale was also included. The REWS showed an AUC of 0.938 (95% CI: 0.918-0.958), a calibration-in-large of 0.026 and a higher net benefit as compared with the other scores. CONCLUSIONS: Our results showed that REWS is a remarkably aid for the decision-making process in the management of advanced respiratory support in prehospital care. Including this score in the prehospital scenario could improve patients' care and optimise the resources' management.

SARS-CoV-2 Viremia Precedes an IL6 Response in Severe COVID-19 Patients: Results of a Longitudinal Prospective Cohort.

Background: Interleukin 6 (IL6) levels and SARS-CoV-2 viremia have been correlated with COVID-19 severity. The association over time between them has not been assessed in a prospective cohort. Our aim was to evaluate the relationship between SARS-CoV-2 viremia and time evolution of IL6 levels in a COVID-19 prospective cohort. Methods: Secondary analysis from a prospective cohort including COVID-19 hospitalized patients from Hospital Universitario La Princesa between November 2020 and January 2021. Serial plasma samples were collected from admission until discharge. Viral load was quantified by Real-Time Polymerase Chain Reaction and IL6 levels with an enzyme immunoassay. To represent the evolution over time of both variables we used the graphic command twoway of Stata. Results: A total of 57 patients were recruited, with median age of 63 years (IQR [53-81]), 61.4% male and 68.4% Caucasian. The peak of viremia appeared shortly after symptom onset in patients with persistent viremia (more than 1 sample with > 1.3 log10 copies/ml) and also in those with at least one IL6 > 30 pg/ml, followed by a progressive increase in IL6 around 10 days later. Persistent viremia in the first week of hospitalization was associated with higher levels of IL6. Both IL6 and SARS-CoV-2 viral load were higher in males, with a quicker increase with age. Conclusion: In those patients with worse outcomes, an early peak of SARS-CoV-2 viral load precedes an increase in IL6 levels. Monitoring SARS-CoV-2 viral load during the first week after symptom onset may be helpful to predict disease severity in COVID-19 patients.

Derivación y validación de nuevos fenotipos prehospitalarios en pacientes adultos con enfermedad por COVID-19

Objective. To characterize phenotypes of prehospital patients with COVID-19 to facilitate early identification of at-risk groups. Methods. Multicenter observational noninterventional study of a retrospective cohort of 3789 patients, analyzing 52 prehospital variables. The main outcomes were 4 clusters of prehospital variables describing the phenotypes. Secondary outcomes were hospitalization, mechanical ventilation, admission to an intensive care unit, and cumulative mortality inside or outside the hospital on days 1, 2, 3, 7, 14, 21, and 28 after hospitalization and after start of prehospital care. Results. We used a principal components multiple correspondence analysis (factor analysis) followed by decomposition into 4 clusters as follows: cluster 1, 1090 patients (28.7%);cluster 2, 1420 (37.4%);cluster 3, 250 (6.6%), and cluster 4, 1029 (27.1%). Cluster 4 was comprised of the oldest patients and had the highest frequencies of residence in group facilities and low arterial oxygen saturation. This group also had the highest mortality (44.8% at 28 days). Cluster 1 was comprised of the youngest patients and had the highest frequencies of smoking, fever, and requirement for mechanical ventilation. This group had the most favorable prognosis and the lowest mortality. Conclusions. Patients with COVID-19 evaluated by emergency medical responders and transferred to hospital emergency departments can be classified into 4 phenotypes with different clinical, therapeutic, and prognostic characteristics. The phenotypes can help health care professionals to quickly assess a patient's future risk, thus informing clinical decisions. Objetivos. Desarrollar un fenotipado prehospitalario de pacientes con COVID-19 que permita una identificación temprana de los grupos de riesgo. Método. Estudio observacional de cohorte retrospectivo multicéntrico, sin intervención con 3.789 pacientes y 52 variables prehospitalarias. Las variables de resultado principal fueron las cuatro agrupaciones prehospitalarios obtenidos, #1, #2, #3 y #4. Los resultados secundarios fueron: ingreso hospitalario, ventilación mecánica, ingreso en unidad de cuidados intensivos y mortalidad acumulada a los 1, 2, 3, 7, 14, 21 y 28 días desde el ingreso hospitalario (hospitalaria y extrahospitalaria). Resultados. Por medio de una descomposición en componentes principales/correspondencia múltiple de datos mixtos (continuos y categóricos), seguido de una descomposición en agrupaciones, se obtuvo cuatro agrupaciones/fenotipos #1, #2, #3 y #4 de 1.090 (28,7%), 1.420 (37,4%), 250 (6,6%) y 1.029 (27,1%) pacientes, respectivamente. El grupo #4, compuesto por los pacientes de mayor edad, baja saturación de oxígeno e institucionalización es el que presenta la mayor mortalidad (44,8% de mortalidad a 28 días). El grupo #1, compuesto de pacientes de menor edad, con mayor porcentaje de tabaquismo, fiebre y necesidades de ventilación mecánica, es el de pronóstico más favorable con la menor tasa de mortalidad. Conclusiones. Los pacientes con COVID-19 valorados por los servicios médicos de emergencias y transferidos al servicio de urgencias hospitalario se pueden clasificar en 4 fenotipos con diferentes consideraciones clínicas, terapéuticas y de pronóstico, y permite a los profesionales sanitarios discriminar rápidamente el nivel de riesgo futuro del paciente y ayuda por lo tanto en el proceso de toma de decisiones.

Relevant SARS-CoV-2 viremia is associated with COVID-19 severity: Prospective cohort study and validation cohort.

Early kinetics of SARS-CoV-2 viral load (VL) in plasma determined by quantitative reverse-transcription polymerase chain reaction (RT-PCR) was evaluated as a predictor of poor clinical outcome in a prospective study and assessed in a retrospective validation cohort. Prospective observational single-center study including consecutive adult patients hospitalized with COVID-19 between November 2020 and January 2021. Serial plasma samples were obtained until discharge. Quantitative RT-PCR was performed to assess SARS-CoV-2 VL. The main outcomes were in-hospital mortality, admission to the Intensive Care Unit (ICU), and their combination (Poor Outcome). Relevant viremia (RV), established in the prospective study, was assessed in a retrospective cohort including hospitalized COVID-19 patients from April 2021 to May 2022, in which plasma samples were collected according to clinical criteria. Prospective cohort: 57 patients were included. RV was defined as at least a twofold increase in VL within ≤2 days or a VL > 300 copies/ml, in the first week. Patients with RV (N = 14; 24.6%) were more likely to die than those without RV (35.7% vs. 0%), needed ICU admission (57% vs. 0%) or had Poor Outcome (71.4% vs. 0%), (p < 0.001 for the three variables). Retrospective cohort: 326 patients were included, 18.7% presented RV. Patients with RV compared with patients without RV had higher rates of ICU-admission (odds ratio [OR]: 5.6 [95% confidence interval [CI]: 2.1-15.1); p = 0.001), mortality (OR: 13.5 [95% CI: 6.3-28.7]; p < 0.0001) and Poor Outcome (OR: 11.2 [95% CI: 5.8-22]; p < 0.0001). Relevant SARS-CoV-2 viremia in the first week of hospitalization was associated with higher in-hospital mortality, ICU admission, and Poor Outcome. Findings observed in the prospective cohort were confirmed in a larger validation cohort.

SARS-CoV-2 Viremia Precedes an IL6 Response in Severe COVID-19 Patients: Results of a Longitudinal Prospective Cohort

Background Interleukin 6 (IL6) levels and SARS-CoV-2 viremia have been correlated with COVID-19 severity. The association over time between them has not been assessed in a prospective cohort. Our aim was to evaluate the relationship between SARS-CoV-2 viremia and time evolution of IL6 levels in a COVID-19 prospective cohort. Methods Secondary analysis from a prospective cohort including COVID-19 hospitalized patients from Hospital Universitario La Princesa between November 2020 and January 2021. Serial plasma samples were collected from admission until discharge. Viral load was quantified by Real-Time Polymerase Chain Reaction and IL6 levels with an enzyme immunoassay. To represent the evolution over time of both variables we used the graphic command twoway of Stata. Results A total of 57 patients were recruited, with median age of 63 years (IQR [53–81]), 61.4% male and 68.4% Caucasian. The peak of viremia appeared shortly after symptom onset in patients with persistent viremia (more than 1 sample with > 1.3 log10 copies/ml) and also in those with at least one IL6 > 30 pg/ml, followed by a progressive increase in IL6 around 10 days later. Persistent viremia in the first week of hospitalization was associated with higher levels of IL6. Both IL6 and SARS-CoV-2 viral load were higher in males, with a quicker increase with age. Conclusion In those patients with worse outcomes, an early peak of SARS-CoV-2 viral load precedes an increase in IL6 levels. Monitoring SARS-CoV-2 viral load during the first week after symptom onset may be helpful to predict disease severity in COVID-19 patients.

Efficacy of short-course colchicine treatment in hospitalized patients with moderate to severe COVID-19 pneumonia and hyperinflammation: a randomized clinical trial.

Some patients with COVID-19 pneumonia develop an associated cytokine storm syndrome that aggravates the pulmonary disease. These patients may benefit of anti-inflammatory treatment. The role of colchicine in hospitalized patients with COVID-19 pneumonia and established hyperinflammation remains unexplored. In a prospective, randomized controlled, observer-blinded endpoint, investigator-initiated trial, 240 hospitalized patients with COVID-19 pneumonia and established hyperinflammation were randomly allocated to receive oral colchicine or not. The primary efficacy outcome measure was a composite of non-invasive mechanical ventilation (CPAP or BiPAP), admission to the intensive care unit, invasive mechanical ventilation requirement or death. The composite primary outcome occurred in 19.3% of the total study population. The composite primary outcome was similar in the two arms (17% in colchicine group vs. 20.8% in the control group; p = 0.533) and the same applied to each of its individual components. Most patients received steroids (98%) and heparin (99%), with similar doses in both groups. In this trial, including adult patients with COVID-19 pneumonia and associated hyperinflammation, no clinical benefit was observed with short-course colchicine treatment beyond standard care regarding the combined outcome measurement of CPAP/BiPAP use, ICU admission, invasive mechanical ventilation or death (Funded by the Community of Madrid, EudraCT Number: 2020-001841-38; 26/04/2020).

One-on-one comparison between qCSI and NEWS scores for mortality risk assessment in patients with COVID-19.

OBJECTIVE: To compare the predictive value of the quick COVID-19 Severity Index (qCSI) and the National Early Warning Score (NEWS) for 90-day mortality amongst COVID-19 patients. METHODS: Multicenter retrospective cohort study conducted in adult patients transferred by ambulance to an emergency department (ED) with suspected COVID-19 infection subsequently confirmed by a SARS-CoV-2 test (polymerase chain reaction). We collected epidemiological data, clinical covariates (respiratory rate, oxygen saturation, systolic blood pressure, heart rate, temperature, level of consciousness and use of supplemental oxygen) and hospital variables. The primary outcome was cumulative all-cause mortality during a 90-day follow-up, with mortality assessment monitoring time points at 1, 2, 7, 14, 30 and 90 days from ED attendance. Comparison of performances for 90-day mortality between both scores was carried out by univariate analysis. RESULTS: From March to November 2020, we included 2,961 SARS-CoV-2 positive patients (median age 79 years, IQR 66-88), with 49.2% females. The qCSI score provided an AUC ranging from 0.769 (1-day mortality) to 0.749 (90-day mortality), whereas AUCs for NEWS ranging from 0.825 for 1-day mortality to 0.777 for 90-day mortality. At all-time points studied, differences between both scores were statistically significant (p < .001). CONCLUSION: Patients with SARS-CoV-2 can rapidly develop bilateral pneumonias with multiorgan disease; in these cases, in which an evacuation by the EMS is required, reliable scores for an early identification of patients with risk of clinical deterioration are critical. The NEWS score provides not only better prognostic results than those offered by qCSI at all the analyzed time points, but it is also better suited for COVID-19 patients.KEY MESSAGESThis work aims to determine whether NEWS is the best score for mortality risk assessment in patients with COVID-19.AUCs for NEWS ranged from 0.825 for 1-day mortality to 0.777 for 90-day mortality and were significantly higher than those for qCSI in these same outcomes.NEWS provides a better prognostic capacity than the qCSI score and allows for long-term (90 days) mortality risk assessment of COVID-19 patients.

A Differential Signature of Circulating miRNAs and Cytokines Between COVID-19 and Community-Acquired Pneumonia Uncovers Novel Physiopathological Mechanisms of COVID-19

Coronavirus Disease 2019 (COVID-19) pneumonia is a life-threatening infectious disease, especially for elderly patients with multiple comorbidities. Despite enormous efforts to understand its underlying etiopathogenic mechanisms, most of them remain elusive. In this study, we compared differential plasma miRNAs and cytokines profiles between COVID-19 and other community-acquired pneumonias (CAP). A first screening and subsequent validation assays in an independent cohort of patients revealed a signature of 15 dysregulated miRNAs between COVID-19 and CAP patients. Additionally, multivariate analysis displayed a combination of 4 miRNAs (miR-106b-5p, miR-221-3p, miR-25-3p and miR-30a-5p) that significantly discriminated between both pathologies. Search for targets of these miRNAs, combined with plasma protein measurements, identified a differential cytokine signature between COVID-19 and CAP that included EGFR, CXCL12 and IL-10. Significant differences were also detected in plasma levels of CXCL12, IL-17, TIMP-2 and IL-21R between mild and severe COVID-19 patients. These findings provide new insights into the etiopathological mechanisms underlying COVID-19.

Usefulness of the CONUT index upon hospital admission as a potential prognostic indicator of COVID-19 health outcomes.

BACKGROUND: In-hospital mortality in patients with coronavirus disease 2019 (COVID-19) is high. Simple prognostic indices are needed to identify patients at high-risk of COVID-19 health outcomes. We aimed to determine the usefulness of the CONtrolling NUTritional status (CONUT) index as a potential prognostic indicator of mortality in COVID-19 patients upon hospital admission. METHODS: Our study design is of a retrospective observational study in a large cohort of COVID-19 patients. In addition to descriptive statistics, a Kaplan-Meier mortality analysis and a Cox regression were performed, as well as receiver operating curve (ROC). RESULTS: From February 5, 2020 to January 21, 2021, there was a total of 2969 admissions for COVID-19 at our hospital, corresponding to 2844 patients. Overall, baseline (within 4 days of admission) CONUT index could be scored for 1627 (57.2%) patients. Patients' age was 67.3 ±â€Š16.5 years and 44.9% were women. The CONUT severity distribution was: 194 (11.9%) normal (0-1); 769 (47.2%) light (2-4); 585 (35.9%) moderate (5-8); and 79 (4.9%) severe (9-12). Mortality of 30 days after admission was 3.1% in patients with normal risk CONUT, 9.0% light, 22.7% moderate, and 40.5% in those with severe CONUT (P < 0.05). An increased risk of death associated with a greater baseline CONUT stage was sustained in a multivariable Cox regression model (P < 0.05). An increasing baseline CONUT stage was associated with a longer duration of admission, a greater requirement for the use of non-invasive and invasive mechanical ventilation, and other clinical outcomes (all P < 0.05). The ROC of CONUT for mortality had an area under the curve (AUC) and 95% confidence interval of 0.711 (0.676-0746). CONCLUSION: The CONUT index upon admission is potentially a reliable and independent prognostic indicator of mortality and length of hospitalization in COVID-19 patients.

Comorbidity-adjusted NEWS predicts mortality in suspected patients with COVID-19 from nursing homes: Multicentre retrospective cohort study.

AIMS: To assess the prognostic accuracy of comorbidity-adjusted National Early Warning Score in suspected Coronavirus disease 2019 patients transferred from nursing homes by the Emergency Department. DESIGN: Multicentre retrospective cohort study. METHODS: Patients transferred by high-priority ambulances from nursing homes to Emergency Departments with suspected severe acute respiratory syndrome coronavirus 2 infection, from March 12 to July 31 2020, were considered. Included variables were: clinical covariates (respiratory rate, oxygen saturation, systolic blood pressure, heart rate, temperature, level of consciousness and supplemental oxygen use), the presence of comorbidities and confirmatory analytical diagnosis of severe acute respiratory syndrome coronavirus 2 infection. The primary outcome was a 2-day mortality rate. The discriminatory capability of the National Early Warning Score was assessed by the area under the receiver operating characteristic curve in two different cohorts, the validation and the revalidation, which were randomly selected from the main cohort. RESULTS: A total of 337 nursing homes, 10 advanced life support units, 51 basic life support units and 8 hospitals in Spain entailing 1,324 patients (median age 87 years) was involved in this study. Two-day mortality was 11.5% (152 cases), with a positivity rate of severe acute respiratory syndrome coronavirus 2 of 51.2%, 77.7% of hospitalization from whom 1% was of intensive care unit admission. The National Early Warning Score results for the revalidation cohort presented an AUC of 0.771, and of 0.885, 0.778 and 0.730 for the low-, medium- and high-level groups of comorbidities. CONCLUSION: The comorbidity-adjusted National Early Warning Score provides a good short-term prognostic criterion, information that can help in the decision-making process to guide the best strategy for each older adult, under the current pandemic. IMPACT: What problem did the study address? Under the current coronavirus disease 2019 pandemic, targeting older adults at high risk of deterioration in nursing homes remains challenging. What were the main findings? Comorbidity-adjusted National Early Warning Score helps to forecast the risk of clinical deterioration more accurately. Where and on whom will the research have impact? A high NEWS, with a low level of comorbidity is associated with optimal predictive performance, making these older adults likely to benefit from continued follow up and potentially hospital referral under the current coronavirus disease 2019 pandemic.

Role of SpO2/FiO2 Ratio and ROX Index in Predicting Early Invasive Mechanical Ventilation in COVID-19. A Pragmatic, Retrospective, Multi-Center Study.

The ability of COVID-19 to compromise the respiratory system has generated a substantial proportion of critically ill patients in need of invasive mechanical ventilation (IMV). The objective of this paper was to analyze the prognostic ability of the pulse oximetry saturation/fraction of inspired oxygen ratio (SpO2/FiO2) and the ratio of SpO2/FiO2 to the respiratory rate-ROX index-as predictors of IMV in an emergency department in confirmed COVID-19 patients. A multicenter, retrospective cohort study was carried out in four provinces of Spain between March and November 2020. The discriminative power of the predictive variable was assessed through a prediction model trained using a derivation sub-cohort and evaluated by the area under the curve (AUC) of the receiver operating characteristic (ROC) on the validation sub-cohort. A total of 2040 patients were included in the study. The IMV rate was 10.1%, with an in-hospital mortality rate of 35.3%. The performance of the SpO2/FiO2 ratio was better than the ROX index-AUC = 0.801 (95% CI 0.746-0.855) and AUC = 0.725 (95% CI 0.652-0.798), respectively. In fact, a direct comparison between AUCs resulted in significant differences (p = 0.001). SpO2 to FiO2 ratio is a simple and promising non-invasive tool for predicting risk of IMV in patients infected with COVID-19, and it is realizable in emergency departments.

Modelo de riesgo de mortalidad en pacientes con sospecha de enfermedad por COVID-19 basado en información del centro coordinador de urgencias

Objective. To develop and validate a scale to stratify risk of 2-day mortality based on data collected during calls to an emergency dispatch center from patients with suspected coronavirus disease 2019 (COVID-19). Methods. Retrospective multicenter study of consecutive patients over the age of 18 years with suspected COVID-19 who were transported from home over the course of 3 months after telephone interviews with dispatchers. We analyzed clinical and epidemiologic variables and comorbidities in relation to death within 2 days of the call. Using data from the development cohort, we built a risk model by means of logistic regression analysis of categorical variables that were independently associated with 2-day mortality. The scale was validated first in a validation cohort in the same province and then in a cohort in a different province. Results. A total of 2320 patients were included. The mean age was 79 years, and 49.8% were women. The overall 2-day mortality rate was 22.6% (376 deaths of patients with severe acute respiratory syndrome coronavirus 2 infection). The model included the following factors: age, location (rural location as a protective factor), institutionalization, desaturation, lung sounds (rhonchi), and altered mental status. The area under the receiver operating characteristic curve for death within 2 days was 0.763 (95% CI, 0.725-0.802;P < .001). Mortality in patients at high risk (more than 2.4 points on the scale) was 60%. Conclusions. This risk scale derived from information available to an emergency dispatch center is applicable to patients with suspected COVID-19. It can stratify patients by risk of early death (within 2 days), possibly helping with decision making regarding whether to transport from home or what means of transport to use, and destination. Objetivo. Derivar y validar una escala basada en variables recogidas durante la llamada a un centro coordinador de urgencias (CCU) que permita estratificar el riesgo de mortalidad a 2 días en pacientes con sospecha de enfermedad por COVID-19. Método. Estudio multicéntrico retrospectivo que incluyó a los pacientes consecutivos ≥ 18 años durante 3 meses, catalogados como caso sospechoso de COVID-19 después de la entrevista telefónica del CCU y que precisaron evacuación. Se analizaron variables clínico-epidemiológicas, comorbilidades y resultado de muerte a los 2 días. Se derivó una escala con las variables categóricas asociadas de forma independiente con la mortalidad a 2 días mediante regresión logística, en la cohorte de derivación. La escala se validó mediante una cohorte de validación y otra de revalidación obtenida en una provincia distinta. Resultados. Se incluyeron 2.320 pacientes (edad mediana 79 años, 49,8% mujeres). La mortalidad global fue del 22,6% (376 casos en pacientes con SARS-CoV-2). El modelo incluyó edad, localización (zona rural como variable protectora), institucionalización, desaturación, roncus, taquipnea y alteración del nivel de conciencia. El área bajo la curva (ABC) para la mortalidad a 2 días fue de 0,763 (IC 95%: 0,725-0,802;p < 0,001). La mortalidad en los pacientes de alto riesgo (> 2,4 puntos) fue del 60%. Conclusiones. La escala, derivada a través de información obtenida con datos del CCU, es aplicable a pacientes con sospecha de infección por COVID-19, estratifica el riesgo de mortalidad precoz (menos de 2 días) y puede ser una herramienta que ayude en la toma de decisiones, referidas a su evacuación, destino o vector de transporte.

Early Warning Scores in Patients with Suspected COVID-19 Infection in Emergency Departments.

Early warning scores (EWSs) help prevent and recognize and thereby act as the first signs of clinical and physiological deterioration. The objective of this study is to evaluate different EWSs (National Early Warning Score 2 (NEWS2), quick sequential organ failure assessment score (qSOFA), Modified Rapid Emergency Medicine Score (MREMS) and Rapid Acute Physiology Score (RAPS)) to predict mortality within the first 48 h in patients suspected to have Coronavirus disease 2019 (COVID-19). We conducted a retrospective observational study in patients over 18 years of age who were treated by the advanced life support units and transferred to the emergency departments between March and July of 2020. Each patient was followed for two days registering their final diagnosis and mortality data. A total of 663 patients were included in our study. Early mortality within the first 48 h affected 53 patients (8.3%). The scale with the best capacity to predict early mortality was the National Early Warning Score 2 (NEWS2), with an area under the curve of 0.825 (95% CI: 0.75-0.89). The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) positive patients presented an area under the curve (AUC) of 0.804 (95% CI: 0.71-0.89), and the negative ones with an AUC of 0.863 (95% CI: 0.76-0.95). Among the EWSs, NEWS2 presented the best predictive power, even when it was separately applied to patients who tested positive and negative for SARS-CoV-2.

Blood Biomarkers for Assessing Headaches in Healthcare Workers after Wearing Biological Personal Protective Equipment in a COVID-19 Field Hospital.

The coronavirus disease 2019 (COVID-19) has led to a pandemic, which among other things, has highlighted biosafety as a key cornerstone in the management of disease transmission. The aim of this work was to analyze the role played by different blood biomarkers in predicting the appearance of headaches in healthcare workers wearing personal protective equipment (PPE) in a COVID-19 treatment unit. A prospective cohort study of 38 healthcare workers was performed during April 2020. Blood analysis, performed just before the start of a 4 hour shift, was carried out on all volunteers equipped with PPE. At the end of their shifts and after decontamination, they were asked if they had suffered from headache in order to obtain a binary outcome. The baseline creatinine value reflected a specific odds ratio of 241.36 (95% CI: 2.50-23,295.43; p = 0.019) and an area under the curve (AUC) value of 0.737 (95%CI: 0.57-0.90; p < 0.01). Blood creatinine is a good candidate for predicting the appearance of a de novo headache in healthcare workers after wearing PPE for four hours in a COVID-19 unit.

Predicting Health Care Workers' Tolerance of Personal Protective Equipment: An Observational Simulation Study.

BACKGROUND: More recently, due to the coronavirus disease 2019 pandemic, health care workers have to deal with clinical situations wearing personal protective equipment (PPE); however, there is a question of whether everybody will tolerate PPE equally. The main objective of this study was to develop a risk model to predict whether health care workers will tolerate wearing PPE, C category, 4B/5B/6B type, during a 30-minute simulation. METHODS: A nonexperimental simulation study was conducted at the Advanced Simulation Center, Faculty of Medicine, Valladolid University (Spain) from April 3rd to 28th, 2017. Health care students and professionals were equipped with PPE and performed a 30-minute simulation. Anthropometric, physiological, and analytical variables and anxiety levels were measured before and after simulation. A scoring model was constructed. RESULTS: Ninety-six volunteers participated in the study. Half the sample presented metabolic fatigue in the 20 minutes after finishing the simulation. The predictive model included female sex, height, muscle and bone mass, and moderate level of physical activity. The validity of the main model using all the variables presented an area under the curve of 0.86 (95% confidence interval: 0.786-0.935), and the validity of the model had an area under the curve of 0.725 (95% confidence interval: 0.559-0.89). CONCLUSIONS: Decision-making in biohazard incidents is a challenge for emergency team leaders. Knowledge of health care workers' physiological tolerance of PPE could improve their performance.