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INTRODUCTION: The clinical presentation of coronavirus disease 2019 (COVID-19) overlaps with many other common cold and influenza viruses. Identifying patients with a higher probability of infection becomes crucial in settings with limited access to testing. We developed a prediction instrument to assess the likelihood of a positive polymerase chain reaction (PCR) test, based solely on clinical variables that can be determined within the time frame of an emergency department (ED) patient encounter. METHODS: We derived and prospectively validated a model to predict SARS-CoV-2 PCR positivity in patients visiting the ED with symptoms consistent with the disease. RESULTS: Our model was based on 617 ED visits. In the derivation cohort, the median age was 36 years, 43% were men, and 9% had a positive result. The median time to testing from the onset of initial symptoms was four days (interquartile range [IQR]: 2-5 days, range 0-23 days), and 91% of all patients were discharged home. The final model based on a multivariable logistic regression included a history of close contact (adjusted odds ratio [AOR] 2.47, 95% confidence interval [CI], 1.29-4.7); fever (AOR 3.63, 95% CI, 1.931-6.85); anosmia or dysgeusia (AOR 9.7, 95% CI, 2.72-34.5); headache (AOR 1.95, 95% CI, 1.06-3.58), myalgia (AOR 2.6, 95% CI, 1.39-4.89); and dry cough (AOR 1.93, 95% CI, 1.02-3.64). The area under the curve (AUC) from the derivation cohort was 0.79 (95% CI, 0.73-0.85) and AUC 0.7 (95% CI, 0.61-0.75) in the validation cohort (N = 379). CONCLUSION: We developed and validated a clinical tool to predict SARS-CoV-2 PCR positivity in patients presenting to the ED to assist with patient disposition in environments where COVID-19 tests or timely results are not readily available.
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COVID-19/diagnóstico , Técnicas de Apoio para a Decisão , Adulto , COVID-19/fisiopatologia , Serviço Hospitalar de Emergência/estatística & dados numéricos , Feminino , Humanos , Masculino , Razão de Chances , Reação em Cadeia da Polimerase , Estudos Prospectivos , Curva ROC , SARS-CoV-2 , Fatores de TempoAssuntos
Doença Pulmonar Obstrutiva Crônica/mortalidade , Doença Pulmonar Obstrutiva Crônica/fisiopatologia , Fumar/fisiopatologia , Adulto , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Dispneia/mortalidade , Dispneia/fisiopatologia , Teste de Esforço , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Estudos Prospectivos , Doença Pulmonar Obstrutiva Crônica/sangue , Testes de Função Respiratória , Fatores de Risco , Fumar/mortalidade , Análise de Sobrevida , Exacerbação dos SintomasRESUMO
Background: Identifying risk factors for long-term mortality in patients with chronic obstructive pulmonary disease (COPD) could improve their clinical management. Aim: To examine the clinical variables associated to long-term mortality in a cohort of COPD patients. Patients and Methods: A clinical and respiratory functional assessment, chest computed tomography and clinical follow up for five years was carried out in 202 COPD patients aged 66 ± 9 years (59% males), active or former smokers of 10 or more pack-years. Results: Thirty four percent of patients were active smokers, consuming 46 ± 23 packs/year, 86% had comorbidities, especially chronic cardiovascular and metabolic diseases. Forty-six patients died in the five years follow-up (5-year mortality was therefore 22.8%). In the univariate analysis, the main risk factors associated to long-term mortality were an older age, male sex, dyspnea severity, severe exacerbation risk, chronic respiratory failure, magnitude of lung emphysema, airflow obstruction and lung hyperinflation, reduction of thigh muscle cross-sectional area and physical activity limitation. In the multivariate analysis, the three independent risk factors for long-term mortality were dyspnea severity, chronic hypoxemia and exercise limitation measured with the six minutes' walk test. Conclusions: Systematic clinical assessment allowed to identify the main risk factors associated with long-term mortality in patients with COPD, which could be used in planning preventive and management programs aimed at the high-risk population.
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Humanos , Masculino , Feminino , Adulto , Pessoa de Meia-Idade , Idoso , Idoso de 80 Anos ou mais , Fumar/fisiopatologia , Doença Pulmonar Obstrutiva Crônica/fisiopatologia , Doença Pulmonar Obstrutiva Crônica/mortalidade , Testes de Função Respiratória , Fumar/mortalidade , Análise de Sobrevida , Valor Preditivo dos Testes , Estudos Prospectivos , Fatores de Risco , Seguimentos , Fatores Etários , Doença Pulmonar Obstrutiva Crônica/sangue , Dispneia/fisiopatologia , Dispneia/mortalidade , Teste de Esforço , Exacerbação dos SintomasRESUMO
INTRODUCTION: Clinical onset of chronic obstructive pulmonary disease (COPD) is the point at which the disease is first identifiable by physicians. It is a poorly defined stage which seems to include both mild spirometric and non-spirometric disease, and could be described as early grade COPD, for practical purposes. While dyspnoea; chronic bronchitis and CT imaging evidence of emphysema and airway disease may be present very early, the lone significance of dyspnoea, the most relevant symptom in COPD in identifying these individuals, has been scarcely assessed.The Searching Clinical COPD Onset (SOON) Study was designed primarily to detect clinical, physiological and structural differences between dyspnoeic and non-dyspnoeic individuals with early grade COPD. It is hypothesised that presence of dyspnoea in early disease may identify a subtype of individuals with reduced exercise capacity, notwithstanding of their spirometry results. In addition, dyspnoeic individuals will share worse quality of life, lower physical activity, greater lung hyperinflation greater emphysema and airway thickness and reduced peripheral muscle mass than their non-dyspnoeic counterpart. METHODS AND ANALYSIS: SOON is a monocentric study, with a cross sectional design aimed at obtaining representative samples of current or ex-smoker-adults aged ≥45 and ≤80 years. Two hundred and forty participants will be enrolled into four strata, according to normal spirometry or mild spirometric obstruction and presence or not of dyspnoea modified Medical Research Council score ≥1. The primary outcome will be the difference between dyspnoeic and non-dyspnoeic individuals on the 6-min walk test performance, regardless of their spirometry results. To account for the confounding effect of heart failure on dyspnoea, stress echocardiography will be also performed. Secondary outcomes will include clinical (quality of life, physical activity), physiological (exercise testing) and structural characteristics (emphysema, airway disease and peripheral muscle mass by CT imaging). ETHICS AND DISSEMINATION: The Institutional Ethics Committee from Pontificia Universidad Católica de Chile has approved the study protocol and signed informed consent will be obtained from all participants. The findings of the trial will be disseminated through relevant peer-reviewed journals and international conference presentations. TRIAL REGISTRATION NUMBER: NCT03026439.
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Doença Pulmonar Obstrutiva Crônica/diagnóstico , Doença Pulmonar Obstrutiva Crônica/fisiopatologia , Enfisema Pulmonar/diagnóstico por imagem , Espirometria , Idoso , Idoso de 80 Anos ou mais , Estudos de Casos e Controles , Chile , Estudos Transversais , Ecocardiografia , Feminino , Testes de Função Cardíaca , Humanos , Masculino , Pessoa de Meia-Idade , Qualidade de Vida , Projetos de Pesquisa , Testes de Função Respiratória , Tomografia Computadorizada por Raios XRESUMO
INTRODUCTION: While a nationwide poison control registry exists in Chile, reporting to the center is sporadic and happens at the discretion of the treating physician or by patients' self-report. Moreover, individual hospitals do not monitor accidental or intentional poisoning in a systematic manner. The goal of this study was to identify all cases of intentional medication overdose (MO) that occurred over two years at a large public hospital in Santiago, Chile, and examine its epidemiologic profile. METHODS: This study is a retrospective, explicit chart review conducted at Hospital Sótero del Rio from July 2008 until June 2010. We included all cases of identified intentional MO. Alcohol and recreational drugs were included only when they were ingested with other medications. RESULTS: We identified 1,557 cases of intentional MO and analyzed a total of 1,197 cases, corresponding to 0.51% of all emergency department (ED) presentations between July 2008 and June 2010. The median patient age was 25 years. The majority was female (67.6%). Two peaks were identified, corresponding to the spring of each year sampled. The rate of hospital admission was 22.2%. Benzodiazepines, selective serotonin reuptake inhibitors, and tricyclic antidepressants (TCA) were the causative agents most commonly found, comprising 1,044 (87.2%) of all analyzed cases. Acetaminophen was involved in 81 (6.8%) cases. More than one active substance was involved in 35% of cases. In 7.3% there was ethanol co-ingestion and in 1.0% co-ingestion of some other recreational drug (primarily cocaine). Of 1,557 cases, six (0.39%) patients died. TCA were involved in two of these deaths. CONCLUSION: Similar to other developed and developing nations, intentional MO accounts for a significant number of ED presentations in Chile. Chile is unique in the region, however, in that its spectrum of intentional overdoses includes an excess burden of tricyclic antidepressant and benzodiazepine overdoses, a relatively low rate of alcohol and recreational drug co-ingestion, and a relatively low rate of acetaminophen ingestion.
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Acetaminofen/intoxicação , Analgésicos não Narcóticos/intoxicação , Antidepressivos Tricíclicos/intoxicação , Overdose de Drogas/epidemiologia , Serviço Hospitalar de Emergência/estatística & dados numéricos , Hospitalização/estatística & dados numéricos , Tentativa de Suicídio/estatística & dados numéricos , Adulto , Consumo de Bebidas Alcoólicas/epidemiologia , Assistência Ambulatorial , Chile/epidemiologia , Medicina Baseada em Evidências , Feminino , Humanos , Masculino , Estudos RetrospectivosRESUMO
BACKGROUND: Day hospitals can reduce health care costs without increasing the risks of patients with lower respiratory tract infection. AIM: To report the experience of a respiratory day hospital care delivered to adult patients with community-acquired pneumonia (CAP) in a public hospital. MATERIAL AND METHODS: During the fall and winter of 2011 and 2012, adult patients with CAP of intermediate risk categories were assessed in the emergency room, their severity was stratified according to confusion, respiratory rate, blood pressure, 65 years of age or older (CRB-65) score and the Chilean CAP Clinical Guidelines, and were admitted to the respiratory day hospital. RESULTS: One hundred seventeen patients aged 67 ± 16 years, (62% females) with CAP were attended in the respiratory day hospital. Ninety percent had comorbidities, especially chronic obstructive pulmonary disease in 58%, heart disease in 32%, diabetes in 16% and asthma in 13%. Their most important risk factors were age over 65 years in 60%, comorbidities in 88%, failure of antibiotic treatment in 17%, loss of autonomy in 21%, vital sign abnormalities in 60%, mental confusion in 5%, multilobar CAP in 23%, pleural effusion in 15%, hypoxemia in 41% and a serum urea nitrogen over 30 mg/dL in 16%. Patients stayed an average of seven days in the day hospital with oxygen, hydration, chest physiotherapy and third-generation cephalosporins (89%) associated with quinolones (52%) or macrolides (4%). Thirteen patients required noninvasive ventilation, eight patients were hospitalized because of clinical deterioration and three died in hospital. CONCLUSIONS: Day hospital care reduced hospital admission rates of patients with lower respiratory tract infections.
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Hospital Dia , Hospedeiro Imunocomprometido/imunologia , Pneumonia/mortalidade , Atenção Primária à Saúde , Doença Pulmonar Obstrutiva Crônica/mortalidade , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Antibacterianos/uso terapêutico , Pressão Sanguínea/fisiologia , Infecções Comunitárias Adquiridas/imunologia , Infecções Comunitárias Adquiridas/mortalidade , Infecções Comunitárias Adquiridas/terapia , Comorbidade , Feminino , Cardiopatias/mortalidade , Cardiopatias/terapia , Humanos , Masculino , Pessoa de Meia-Idade , Ventilação não Invasiva , Pneumonia/imunologia , Pneumonia/terapia , Estudos Prospectivos , Doença Pulmonar Obstrutiva Crônica/terapia , Taxa Respiratória/fisiologia , Fatores de Risco , Fatores de Tempo , Adulto JovemRESUMO
BACKGROUND: In addition to smoking, acute exacerbations are considered to be a contributing factor to progression of chronic obstructive pulmonary disease (COPD). However, these findings come from studies including active smokers, while results in ex-smokers are scarce and contradictory. The purpose of this study was to evaluate if frequent acute moderate exacerbations are associated with an accelerated decline in forced expiratory volume in one second (FEV1) and impairment of functional and clinical outcomes in ex-smoking COPD patients. METHODS: A cohort of 100 ex-smoking patients recruited for a 2-year follow-up study was evaluated at inclusion and at 6-monthly scheduled visits while in a stable condition. Evaluation included anthropometry, spirometry, inspiratory capacity, peripheral capillary oxygen saturation, severity of dyspnea, a 6-minute walking test, BODE (Body mass index, airflow Obstruction, Dyspnea, Exercise performance) index, and quality of life (St George's Respiratory Questionnaire and Chronic Respiratory Disease Questionnaire). Severity of exacerbation was graded as moderate or severe according to health care utilization. Patients were classified as infrequent exacerbators if they had no or one acute exacerbation/year and frequent exacerbators if they had two or more acute exacerbations/year. Random effects modeling, within hierarchical linear modeling, was used for analysis. RESULTS: During follow-up, 419 (96% moderate) acute exacerbations were registered. At baseline, frequent exacerbators had more severe disease than infrequent exacerbators according to their FEV1 and BODE index, and also showed greater impairment in inspiratory capacity, forced vital capacity, peripheral capillary oxygen saturation, 6-minute walking test, and quality of life. However, no significant difference in FEV1 decline over time was found between the two groups (54.7±13 mL/year versus 85.4±15.9 mL/year in frequent exacerbators and infrequent exacerbators, respectively). This was also the case for all other measurements. CONCLUSION: Our results suggest that frequent moderate exacerbations do not contribute to accelerated clinical and functional decline in COPD patients who are ex-smokers.
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Pulmão/fisiopatologia , Doença Pulmonar Obstrutiva Crônica/etiologia , Abandono do Hábito de Fumar , Prevenção do Hábito de Fumar , Idoso , Progressão da Doença , Feminino , Volume Expiratório Forçado , Nível de Saúde , Humanos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Estudos Prospectivos , Doença Pulmonar Obstrutiva Crônica/diagnóstico , Doença Pulmonar Obstrutiva Crônica/fisiopatologia , Testes de Função Respiratória , Fatores de Risco , Índice de Gravidade de Doença , Fumar/efeitos adversos , Fumar/fisiopatologia , Inquéritos e Questionários , Fatores de TempoRESUMO
BACKGROUND: Patients with chronic obstructive pulmonary disease (COPD) have elevated serum levels of ultrasensitive C reactive protein (CRPus). This raise may be related directly to COPD and its associated systemic inflammation or secondary to other factors such as smoking status, disease severity, acute exacerbations, or associated complications. AIM: To evaluate the potential causes of raised levels of CRPus in stable COPD patients. PATIENTS AND METHODS: Cohorts of 133 mild-to-very severe COPD patients (41 current smokers), 31 never-smokers, and 33 current smoker controls were compared. Clinical assessments included body mass index (BMI), fat (FM) and fat-free mass (FFM) measurement by DEXA, forced expiratory volume in one second (FEV1), arterial oxygen tension (PaO2), six-minute walking test (SMWT), emphysema (EMPH) and right thigh muscle cross-sectional area (TMCSA), both quantified by high resolution computed tomography. RESULTS: Serum CRPus levels were significantly higher in COPD patients than in controls (7 ± 4.2 and 3.7 ± 2.7 mg/L respectively; p < 0.0001). Being smoker did not influence CRPus levels. These levels were significantly correlated with FM (r = 0.30), BMI (r = 0.21), FEV1 (r = -0.21), number of acute exacerbations of the disease in the last year (r = 0.28), and PaO2 (r = -0.27). Using multivariate analysis FM, PaO2, and number of acute exacerbations of the disease in the last year had the strongest association with CRPus levels. CONCLUSIONS: CRPus is elevated in COPD patients, independent of smoking status. It is weakly associated with fat mass, arterial oxygen tension and frequency of exacerbations.
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Proteína C-Reativa/análise , Doença Pulmonar Obstrutiva Crônica/sangue , Fumar/efeitos adversos , Síndrome de Resposta Inflamatória Sistêmica/sangue , Idoso , Biomarcadores/sangue , Índice de Massa Corporal , Estudos de Casos e Controles , Feminino , Volume Expiratório Forçado , Humanos , Inflamação/sangue , Masculino , Pessoa de Meia-Idade , Doença Pulmonar Obstrutiva Crônica/fisiopatologia , Síndrome de Resposta Inflamatória Sistêmica/fisiopatologiaRESUMO
Background: Patients with chronic obstructive pulmonary disease (COPD) have elevated serum levels of ultrasensitive C reactive protein (CRPus). This raise may be related directly to COPD and its associated systemic inflammation or secondary to other factors such as smoking status, disease severity, acute exacerbations, or associated complications. Aim: To evaluate the potential causes of raised levels of CRPus in stable COPD patients. Patients and Methods: Cohorts of 133 mild-to-very severe COPD patients (41 current smokers), 31 never-smokers, and 33 current smoker controls were compared. Clinical assessments included body mass index (BMI), fat (FM) and fat-free mass (FFM) measurement by DEXA, forced expiratory volume in one second (FEV1), arterial oxygen tension (PaO2), six-minute walking test (SMWT), emphysema (EMPH) and right thigh muscle cross-sectional area (TMCSA), both quantified by high resolution computed tomography. Results: Serum CRPus levels were significantly higher in COPD patients than in controls (7 ± 4.2 and 3.7 ± 2.7 mg/L respectively; p < 0.0001). Being smoker did not influence CRPus levels. These levels were significantly correlated with FM (r = 0.30), BMI (r = 0.21), FEV1 (r = -0.21), number of acute exacerbations of the disease in the last year (r = 0.28), and PaO2 (r = -0.27). Using multivariate analysis FM, PaO2, and number of acute exacerbations of the disease in the last year had the strongest association with CRPus levels. Conclusions: CRPus is elevated in COPD patients, independent of smoking status. It is weakly associated with fat mass, arterial oxygen tension and frequency of exacerbations.
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Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Proteína C-Reativa/análise , Doença Pulmonar Obstrutiva Crônica/sangue , Fumar/efeitos adversos , Síndrome de Resposta Inflamatória Sistêmica/sangue , Biomarcadores/sangue , Índice de Massa Corporal , Estudos de Casos e Controles , Volume Expiratório Forçado , Inflamação/sangue , Doença Pulmonar Obstrutiva Crônica/fisiopatologia , Síndrome de Resposta Inflamatória Sistêmica/fisiopatologiaRESUMO
Background: Patients with chronic obstructive pulmonary disease (COPD) decrease their physical activity. However, it is unknown at which stage of the disease the reduction occurs and whether dyspnea is a limiting factor. Aim: To compare physical activity between patients with COPD and controls of similar age and to assess its association with disease severity. Material and Methods: We studied 112 patients with mild to very severe COPD and 55 controls. Lung function, six-minutes walking test (SMWT), and physical activity through the International Physical Activity Questionnaire (IPAQ) were measured. Results: Compared to controls, physical activity was significantly reduced in COPD patients (1823 ± 2598 vs. 2920 ± 3040 METs min/week; p = 0.001). Patients were more frequently sedentary (38 vs. 11%), while controls were more often very active (31 vs. 19%) or moderately active (58 vs. 43%). Physical activity was reduced from Global Initiative for Obstructive Chronic Lung Disease (GOLD) stage 2 and from Modified Medical Research Council (MMRC) dyspnea grade 1. Weak relationships were observed between lung function, SMWT and physical activity. Conclusions: Physical activity decreases early in the course of the disease and when dyspnea is still mild, among patients with COPD. (Rev Med Chile 2011; 139:1562-1572).