MEESSI-AHF score to estimate short-term prognosis of acute heart failure patients in the Emergency Department: a prospective and multicenter study.

BACKGROUND: The assessment of acute heart failure (AHF) prognosis is primordial in emergency setting. Although AHF management is exhaustively codified using mortality predictors, there is currently no recommended scoring system for assessing prognosis. The European Society of Cardiology (ESC) recommends a comprehensive assessment of global AHF prognosis, considering in-hospital mortality, early rehospitalization rates and the length of hospital stay. OBJECTIVE: We aimed to prospectively evaluate the performance of the Multiple Estimation of risk based on the Emergency department Spanish Score In patients with AHF (MEESSI-AHF) score in estimating short prognosis according to the ESC guidelines. DESIGN, SETTINGS AND PATIENTS: A multicenter study was conducted between November 2020, and June 2021. Adult patients who presented to eleven French hospitals for AHF were prospectively included. OUTCOME MEASURES AND ANALYSIS: According to MEESSI-AHF score, patients were stratified in four categories corresponding to mortality risk: low-, intermediate-, high- and very high-risk groups. The primary outcome was the number of days alive and out of the hospital during the 30-day period following admission to the Emergency Department (ED). RESULTS: In total, 390 patients were included. The number of days alive and out of the hospital decreased significatively with increasing MEESSI-AHF risk groups, ranging from 21.2 days (20.3-22.3 days) for the low-risk, 20 days (19.3-20.5 days) for intermediate risk,18.6 days (17.6-19.6 days) for the high-risk and 17.9 days (16.9-18.9 days) very high-risk category. CONCLUSION: Among patients admitted to ED for an episode of AHF, the MEESSI-AHF score estimates with good performance the number of days alive and out of the hospital.

Silent Hypoxemia in the Emergency Department: A Retrospective Cohort of Two Clinical Phenotypes in Critical COVID-19.

Introduction: Understanding hypoxemia, with and without the clinical signs of acute respiratory failure (ARF) in COVID-19, is key for management. Hence, from a population of critical patients admitted to the emergency department (ED), we aimed to study silent hypoxemia (Phenotype I) in comparison to symptomatic hypoxemia with clinical signs of ARF (Phenotype II). Methods: This multicenter study was conducted between 1 March and 30 April 2020. Adult patients who were presented to the EDs of nine Great-Eastern French hospitals for confirmed severe or critical COVID-19, who were then directly admitted to the intensive care unit (ICU), were retrospectively included. Results: A total of 423 critical COVID-19 patients were included, out of whom 56.1% presented symptomatic hypoxemia with clinical signs of ARF, whereas 43.9% presented silent hypoxemia. Patients with clinical phenotype II were primarily intubated, initially, in the ED (46%, p < 0.001), whereas those with silent hypoxemia (56.5%, p < 0.001) were primarily intubated in the ICU. Initial univariate analysis revealed higher ICU mortality (29.2% versus 18.8%, p < 0.014) and in-hospital mortality (32.5% versus 18.8%, p < 0.002) in phenotype II. However, multivariate analysis showed no significant differences between the two phenotypes regarding mortality and hospital or ICU length of stay. Conclusions: Silent hypoxemia is explained by various mechanisms, most physiological and unspecific to COVID-19. Survival was found to be comparable in both phenotypes, with decreased survival in favor of Phenotype II. However, the spectrum of silent to symptomatic hypoxemia appears to include a continuum of disease progression, which can brutally evolve into fatal ARF.

The Impact of Age on In-Hospital Mortality in Critically Ill COVID-19 Patients: A Retrospective and Multicenter Study.

Introduction: For the past two years, healthcare systems worldwide have been battling the ongoing COVID-19 pandemic. Several studies tried to find predictive factors of mortality in COVID-19 patients. We aimed to research age as a predictive factor associated with in-hospital mortality in severe and critical SARS-CoV-2 infection. Methods: Between 1 March and 20 April 2020, we conducted a multicenter and retrospective study on a cohort of severe COVID-19 patients who were all hospitalized in the Intensive Care Unit (ICU). We led our study in nine hospitals of northeast France, one of the pandemic's epicenters in Europe. Results: The median age of our study population was 66 years (58−72 years). Mortality was 24.6% (CI 95%: 20.6−29%) in the ICU and 26.5% (CI 95%: 22.3−31%) in the hospital. Non-survivors were significantly older (69 versus 64 years, p < 0.001) than the survivors. Although a history of cardio-vascular diseases was more frequent in the non-survivor group (p = 0.015), other underlying conditions and prior level of autonomy did not differ between the two groups. On multivariable analysis, age appeared to be an interesting predictive factor of in-hospital mortality. Thus, age ranges of 65 to 74 years (OR = 2.962, CI 95%: 1.231−7.132, p = 0.015) were predictive of mortality, whereas the group of patients aged over 75 years was not (OR = 3.084, CI 95%: 0.952−9.992, p = 0.06). Similarly, all comorbidities except for immunodeficiency (OR = 4.207, CI 95%: 1.006−17.586, p = 0.049) were not predictive of mortality. Finally, survival follow-up was obtained for the study population. Conclusion: Age appears to be a relevant predictive factor of in-hospital mortality in cases of severe or critical SARS-CoV-2 infection.

Prognostic Value of C-Reactive Protein to Lymphocyte Ratio (CLR) in Emergency Department Patients with SARS-CoV-2 Infection.

(1) Introduction: According to recent studies, the ratio of C-reactive-protein to lymphocyte is more sensitive and specific than other biomarkers associated to systemic inflammatory processes. This study aimed to determine the prognostic value of CLR on COVID-19 severity and mortality at emergency department (ED) admission. (2) Methods: Between 1 March and 30 April 2020, we carried out a multicenter and retrospective study in six major hospitals of northeast France. The cohort was composed of patients hospitalized for a confirmed diagnosis of moderate to severe COVID-19. (3) Results: A total of 1,035 patients were included in this study. Factors associated with infection severity were the CLR (OR: 1.001, CI 95%: (1.000-1.002), p = 0.012), and the lymphocyte level (OR: 1.951, CI 95%: (1.024-3.717), p = 0.042). In multivariate analysis, the only biochemical factor significantly associated with mortality was lymphocyte rate (OR: 2.308, CI 95%: (1.286-4.141), p = 0.005). The best threshold of CLR to predict the severity of infection was 78.3 (sensitivity 79%; specificity 47%), and to predict mortality, was 159.5 (sensitivity 48%; specificity 70%). (4) Conclusion: The CLR at admission to the ED could be a helpful prognostic biomarker in the early screening and prediction of the severity and mortality associated with SARS-CoV-2 infection.

Neutrophil-to-Lymphocyte Ratio and Early Variation of NLR to Predict In-Hospital Mortality and Severity in ED Patients with SARS-CoV-2 Infection.

(1) Introduction: The neutrophil-to lymphocyte ratio is valued as a predictive marker in several inflammatory diseases. For example, an increasing NLR is a risk factor of mortality in sepsis. It also appears to be helpful in other settings such as cancer. The aim of our work was to study the prognostic value of NLR for disease severity and mortality in patients infected with SARS-CoV-2 upon their admission to the Emergency Department (ED) and its early variation (ΔNLR) in the first 24 h of management (H-24). (2) Methods: Between 1 March and 30 April 2020, we conducted a multicenter and retrospective cohort study of patients with moderate or severe coronavirus disease 19 (COVID-19), who were all hospitalized after presenting to the ED. (3) Results: A total of 1035 patients were included in our study. Factors associated with infection severity were C-reactive protein level (OR: 1.007, CI 95%: [1.005-1.010], p < 0.001), NLR at H-24 (OR: 1.117, CI 95%: [1.060-1.176], p < 0.001), and ΔNLR (OR: 1.877, CI 95%: [1.160-3.036], p: 0.01). The best threshold of ΔNLR to predict the severity of infection was 0.222 (sensitivity 56.1%, specificity 68.3%). In multivariate analysis, the only biochemical factor significantly associated with mortality was again ΔNLR (OR: 2.142, CI 95%: ([1.132-4.056], p: 0.019). The best threshold of ΔNLR to predict mortality was 0.411 (sensitivity 53.3%; specificity 67.3%). (4) Conclusion: The NLR and its early variation (ΔNLR) could help physicians predict both severity and mortality associated with SARS-CoV-2 infection, hence contributing to optimized patient management (accurate triage and treatment).

Do Blood Eosinophils Predict in-Hospital Mortality or Severity of Disease in SARS-CoV-2 Infection? A Retrospective Multicenter Study.

INTRODUCTION: Healthcare systems worldwide have been battling the ongoing COVID-19 pandemic. Eosinophils are multifunctional leukocytes implicated in the pathogenesis of several inflammatory processes including viral infections. We focus our study on the prognostic value of eosinopenia as a marker of disease severity and mortality in COVID-19 patients. METHODS: Between 1 March and 30 April 2020, we conducted a multicenter and retrospective study on a cohort of COVID-19 patients (moderate or severe disease) who were hospitalized after presenting to the emergency department (ED). We led our study in six major hospitals of northeast France, one of the outbreak's epicenters in Europe. RESULTS: We have collected data from 1035 patients, with a confirmed diagnosis of COVID-19. More than three quarters of them (76.2%) presented a moderate form of the disease, while the remaining quarter (23.8%) presented a severe form requiring admission to the intensive care unit (ICU). Mean circulating eosinophils rate, at admission, varied according to disease severity (p < 0.001), yet it did not differ between survivors and non-survivors (p = 0.306). Extreme eosinopenia (=0/mm3) was predictive of severity (aOR = 1.77, p = 0.009); however, it was not predictive of mortality (aOR = 0.892, p = 0.696). The areas under the Receiver operating characteristics (ROC) curve were, respectively, 58.5% (CI95%: 55.3-61.7%) and 51.4% (CI95%: 46.8-56.1%) for the ability of circulating eosinophil rates to predict disease severity and mortality. CONCLUSION: Eosinopenia is very common and often profound in cases of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Eosinopenia was not a useful predictor of mortality; however, undetectable eosinophils (=0/mm3) were predictive of disease severity during the initial ED management.

[French national emergency department's crisis: The outcome of a growing gap between health resources and needs?] / Crise nationale des urgences : le résultat d'un déséquilibre croissant entre offre et demande de soins ?

Overcrowding in Emergency Departments is often considered as an outcome of insufficient access to hospital beds or primary care, therefore a potential lack of health resources. We sought to describe the quantitative evolution of health resources in the French health care system, in comparison with demographic and epidemiologic parameters that reflect health needs. Overall, in the last decade, parameters of capacity and human resources stagnated while activity and spending increased jointly, stimulated by ageing of the population and chronic diseases mostly. Nevertheless, recent official previsions have again recommended to proceed with hospital bed reduction until 2030. This has led to a dangerous saturation of emergency care and to the ongoing systemic health crisis. This situation will require ambitious health resources reinforcement plans in both hospital and primary care. Furthermore, ageing of the population and chronic diseases must lead society to deliberate on the fundamental goals and funding of our health care system.