Effectiveness of a On-site Medicalization Program for Nursing Homes With COVID-19 Outbreaks.

BACKGROUND: Nursing homes are highly vulnerable to the occurrence of COVID-19 outbreaks, which result in high lethality rates. Most of them are not prepared to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic. METHOD: A coordinated on-site medicalization program (MP) in response to a sizeable COVID-19 outbreak in 4 nursing homes was organized, with the objectives of improving survival, offering humanistic palliative care to residents in their natural environment, and reducing hospital referrals. Ten key processes and interventions were established (provision of informatics infrastructure, medical equipment, and human resources, universal testing, separation of "clean" and "contaminated" areas, epidemiological surveys, and unified protocols stratifying for active or palliative care approach, among others). Main outcomes were a composite endpoint of survival or optimal palliative care (SOPC), survival, and referral to hospital. RESULTS: Two hundred and seventy-two of 457 (59.5%) residents and 85 of 320 (26.5%) staff members were affected. The SOPC, survival, and referrals to hospital occurred in 77%, 72.5%, and 29% of patients diagnosed before the start of MP, with respect to 97%, 83.7%, and 17% of those diagnosed during the program, respectively. The SOPC was independently associated to MP (OR = 15 [3-81]); and survival in patients stratified to active approach, to the use of any antiviral treatment (OR = 28 [5-160]). All outbreaks were controlled in 39 [37-42] days. CONCLUSIONS: A coordinated on-site MP of nursing homes with COVID-19 outbreaks achieved a higher SOPC rate, and a reduction in referrals to hospital, thus ensuring rigorous but also humanistic and gentle care to residents.

Death risk stratification in elderly patients with covid-19. A comparative cohort study in nursing homes outbreaks.

Elderly people are more severely affected by COVID-19. Nevertheless scarce information about specific prognostic scores for this population is available. The main objective was to compare the accuracy of recently developed COVID-19 prognostic scores to that of CURB-65, Charlson and PROFUND indices in a cohort of 272 elderly patients from four nursing homes, affected by COVID-19. Accuracy was measured by calibration (calibration curves and Hosmer-Lemeshov (H-L) test), and discriminative power (area under the receiver operation curve (AUC-ROC). Negative and positive predictive values (NPV and PPV) were also obtained. Overall mortality rate was 22.4 %. Only ACP and Shi et al. out of 10 specific COVID-19 indices could be assessed. All indices but CURB-65 showed a good calibration by H-L test, whilst PROFUND, ACP and CURB-65 showed best results in calibration curves. Only CURB-65 (AUC-ROC = 0.81 [0.75-0.87])) and PROFUND (AUC-ROC = 0.67 [0.6-0.75])) showed good discrimination power. The highest NPV was obtained by CURB-65 (95 % [90-98%]), PROFUND (93 % [77-98%]), and their combination (100 % [82-100%]); whereas CURB-65 (74 % [51-88%]), and its combination with PROFUND (80 % [50-94%]) showed highest PPV. PROFUND and CURB-65 indices showed the highest accuracy in predicting death-risk of elderly patients affected by COVID-19, whereas Charlson and recent developed COVID-19 specific tools lacked it, or were not available to assess. A comprehensive clinical stratification on two-level basis (basal death risk due to chronic conditions by PROFUND index, plus current death risk due to COVID-19 by CURB-65), could be an appropriate approach.

¿Es la obesidad un factor de riesgo de complicaciones, ingresos y suspensiones quirúrgicas en cirugía mayor ambulatoria? / Is obesity a risk factor for complications, hospital admissions, and surgical cancellations in ambulatory surgery?

Objetivo: Registrar la incidencia de complicaciones postoperatorias, ingresos inesperados y suspensiones quirúrgicas en pacientes intervenidos en una Unidad de Cirugía mayor ambulatoria estableciendo su relación con los índices de masa corporal (IMC) de los mismos.
Material y métodos: Se realizó un trabajo observacional descriptivo prospectivo en la Unidad de Cirugía mayor ambulatoria del Hospital Universitario Virgen del Rocío en Sevilla. Se incluyó a todos los pacientes adultos ASA I o II propuestos para intervención quirúrgica en régimen de cirugía mayor ambulatoria que precisaban anestesia general o locorregional, con o sin sedación. Se seleccionó a 1.088 pacientes que se clasificaron según su IMC en 4 grupos: no obesidad (IMC < 30), obesidad tipo i (IMC 30-34,9), obesidad tipo ii (IMC 35-39,9) y obesidad tipo iii mórbida (IMC 40-49,9). se analizaron las complicaciones en las 48h posteriores a la intervención, los ingresos inesperados y las suspensiones quirúrgicas en cada grupo de estudio. Resultados: El grupo obesidad tipo ii (IMC 35-39,9) registró la mayor incidencia de complicaciones postoperatorias (7,69%), ingresos (7,69%) y suspensiones quirúrgicas (4,87%), duplicando en el mejor de los casos el registro de estos eventos en el resto de grupos, aunque no se encontró asociación estadísticamente significativa entre la incidencia de estas variables y el grupo de estudio. El tipo de eventos registrados fue similar en todos los grupos de estudio. Conclusiones: Grados de obesidad moderados y severos podrían estar asociados a un aumento de la incidencia de complicaciones postoperatorias, especialmente dolor y náuseas y/o vómitos postoperatorios, ingresos inesperados y suspensiones en los programas de cirugía mayor ambulatoria. Una adecuada selección y preparación preoperatoria por parte de profesionales especializados en programas de cirugía mayor ambulatoria y estrategias encaminadas a la prevención y el control de las complicaciones más prevalentes en este colectivo son las claves para la integración de pacientes con IMC altos en las unidades de cirugía mayor ambulatoria (AU)

Objectives: To determine the incidence of outcomes, unanticipated admissions and cancella- tions in patients operated in an Ambulatory surgery unit, and to establish the relationships with their body mass index (BMI).
Subjects and methods: An observational descriptive prospective study was conducted in the Ambulatory surgery unit of the University Hospital Virgen del Rocío of Seville, on ASA I or II adult patients proposed for day case surgery with loco-regional or general anesthesia. A cohort of 1,088 patients was classified according to their body mass index into four groups: no obesity (BMI < 30), obesity i (BMI 30-34.9), obesity ii (BMI 35-39.9), and morbid obesity iii (BMI 40-49.9). Postoperative outcomes (48 h), inpatient admissions, and cancellations where calculated. Results: The obesity ii (BMI 35-39.9) group showed a higher incidence of postoperative complications (7.69%), unplanned admissions (7.69%), and surgical cancellations (4.87%), dou- bling, at least, the incidence of adverse events of the other study groups, even when no significant difference was found. Outcomes where similar in all study groups. Conclusions: The results of this study suggest that moderate and severe obesity should be a risk factor for postoperative complications, unplanned admissions, and cancellations in outpatient surgery. Adequate patient selection and preoperative evaluation, as well as strategies for the prevention and control of the most frequents complications in obese patients are the key factors for their integration in major ambulatory surgery programs (AU)

[Is obesity a risk factor for complications, hospital admissions, and surgical cancellations in ambulatory surgery?]. / ¿Es la obesidad un factor de riesgo de complicaciones, ingresos y suspensiones quirúrgicas en cirugía mayor ambulatoria?

OBJECTIVES: To determine the incidence of outcomes, unanticipated admissions and cancellations in patients operated in an Ambulatory surgery unit, and to establish the relationships with their body mass index (BMI). SUBJECTS AND METHODS: An observational descriptive prospective study was conducted in the Ambulatory surgery unit of the University Hospital Virgen del Rocío of Seville, on ASA I or II adult patients proposed for day case surgery with loco-regional or general anesthesia. A cohort of 1,088 patients was classified according to their body mass index into four groups: no obesity (BMI<30), obesity i (BMI 30-34.9), obesity ii (BMI 35-39.9), and morbid obesity iii (BMI 40-49.9). Postoperative outcomes (48h), inpatient admissions, and cancellations where calculated. RESULTS: The obesity ii (BMI 35-39.9) group showed a higher incidence of postoperative complications (7.69%), unplanned admissions (7.69%), and surgical cancellations (4.87%), doubling, at least, the incidence of adverse events of the other study groups, even when no significant difference was found. Outcomes where similar in all study groups. CONCLUSIONS: The results of this study suggest that moderate and severe obesity should be a risk factor for postoperative complications, unplanned admissions, and cancellations in outpatient surgery. Adequate patient selection and preoperative evaluation, as well as strategies for the prevention and control of the most frequents complications in obese patients are the key factors for their integration in major ambulatory surgery programs.

Infiltrado pulmonar y fiebre tras la resolución de neumonía por Pneumocystis jirovecii en un paciente con infección por el VIH / Pulmonary infiltrates and fever in a HIV infected patient after pneumocystis jirovecii pneumonia

El diagnóstico de enfermedad por citomegalovirus (CMV) en el paciente con infección por VIH no resulta con frecuencia fácil y suele aparecer en el contexto de inmunosupresión severa por reactivación o reinfección del virus. Además, aunque tras la introducción de terapia antirretroviral de gran actividad (TARGA) la incidencia de enfermedad por CMV ha disminuido de forma drástica, es una entidad a tener en cuenta con considerable morbimortalidad. Presentamos el caso de un paciente con fiebre infiltrados pulmonares y dolor abdominal tras la resolución de una neumonía por P.jirovecii con aislamiento de CMV (shellvial positivo) en LBA y biopsia gástrica. Se plantea el posible diagnóstico de enfermedad digestiva y pulmonar por CMV iniciando tratamiento dirigido con respuesta clínica. En este paciente llama la atención la rápida progresión a SIDA desde el diagnóstico y resulta sugerente la hipótesis de que una confección simultánea de VIH y CMV fuese la responsable del rápido deterioro inmunológico (AU)

In HIV-infected patients, cytomegalovirus (CMV) disease diagnosis is usually difficult and disease results from reactivation of latent infection or reinfection in the context of severe immunosuppression. Although the introduction of highly active antiretroviral therapy (HAART) has resulted in an important decline of CMV disease, it has considerable morbidity and mortality rate. We present a case of a patient who presented fever, pulmonary infiltrates and abdominal pain after P.jirovecii pneumonia, with isolated of CMV (positive shell-vial) from LBA and gastric biopsy. We propose a possible diagnosis of digestive and pulmonary CMV disease and we initiated treatment for this with clinical response. It results surprising the rapid progression to SIDA of the patient and we can suggest that a co-infection HIV-CMV could be the cause for the rapid immunological damage (AU)

[Pulmonary infiltrates and fever in a HIV infected patient after Pneumocystis jirovecii pneumonia]. / Infiltrado pulmonar y fiebre tras la resolución de neumonía por Pneumocystis jirovecii en un paciente con infección por el VIH.

In HIV-infected patients, cytomegalovirus (CMV) disease diagnosis is usually difficult and disease results from reactivation of latent infection or reinfection in the context of severe immunosupression. Although the introduction of highly active antiretroviral therapy (HAART) has resulted in a important decline of CMV disease, it has considerable morbidity and mortality rate. We present a case of a patient who presented fever, pulmonary infiltrates and abdominal pain after P.jirovecii pneumonia, with isolated of CMV (positive shell-vial) from LBA and gastric biopsy. We propose a possible diagnosis of digestive and pulmonary CMV disease and we initiated treatment for this with clinical response. It results surprising the rapid progression to SIDA of the patient and we can suggest that a co-infection HIV-CMV could be the cause for the rapid immunological damage.