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Vaittinada Ayar P, Motiejūnaitė J, Čerlinskaitė K, Deniau B, Blet A, Kavoliūnienė A, Mebazaa A, Čelutkienė J, Azibani F. The association of biological sex and long-term outcomes in patients with acute dyspnea at the emergency department. Eur J Emerg Med 2022; 29:195-203. [PMID: 34954724 DOI: 10.1097/mej.0000000000000899] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND AND IMPORTANCE Marked differences have been described between women and men in disease prevalence, clinical presentation, response to treatment and outcomes. However, such data are scarce in the acutely ill. An awareness of differences related to biological sex is essential for the success of clinical care and outcomes in patients presenting with acute dyspnea, the most frequent cause of emergency department (ED) admission. OBJECTIVES The aim of the present study was to assess the effect of biological sex on 1-year all-cause mortality in patients presenting with acute dyspnea to the ED. DESIGN, SETTINGS AND PARTICIPANTS Consecutive adult patients presenting with acute dyspnea in two Lithuanian EDs were included. Clinical characteristics, laboratory data and medication use at discharge were collected. Follow-up at 1 year was performed via national data registries. OUTCOMES MEASURE AND ANALYSIS The primary outcome of the study was 1-year all-cause mortality. Hazard ratios (HRs) for 1-year mortality according to biological sex were calculated using a Cox proportional hazards regression model, with and without adjustment for the following confounders: age, systolic blood pressure, creatinine, sodium and hemoglobin. MAIN RESULTS A total of 1455 patients were included. Women represented 43% of the study population. Compared to men, women were older [median (interquartile range [IQR]) age 74 (65-80) vs. 68 (59-77) years, P < 0.0001]. The duration of clinical signs before admission was shorter for women [median (IQR) duration 4 (1-14) vs. 7(2-14) days, P = 0.006]. Unadjusted 1-year all-cause mortality was significantly lower in women (21 vs. 28%, P = 0.001). Adjusted HR of 1-year all-cause mortality was lower in women when compared to men [HR 0.68 (0.53-0.88), P = 0.0028]. Additional sensitivity analyses confirmed the survival benefit for women in subgroups including age greater and lower than 75 years, the presence of comorbidities and causes of dyspnea (cardiac or noncardiac). CONCLUSION Women have better 1-year survival than men after the initial ED presentation for acute dyspnea. Understanding the biological sex-related differences should lead toward precision medicine, and improve clinical decision-making to promote gender equality in health.
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Affiliation(s)
- Prabakar Vaittinada Ayar
- Inserm UMR-S 942 MASCOT, Lariboisière Hospital, Paris
- Emergency Department, University Hospital of Beaujon, AP-HP, Clichy
- Université de Paris, Paris
| | - Justina Motiejūnaitė
- Inserm UMR-S 942 MASCOT, Lariboisière Hospital, Paris
- Université de Paris, Paris
- Department of Clinical Physiology-Functional Explorations, University Hospital Bichat-Claude Bernard, AP-HP, Paris, France
- Department of Cardiology, Hospital of Lithuanian Health Science University Kaunas Clinics, Kaunas
| | - Kamilė Čerlinskaitė
- Clinic of Cardiac and Vascular Diseases, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Benjamin Deniau
- Inserm UMR-S 942 MASCOT, Lariboisière Hospital, Paris
- Université de Paris, Paris
- Department of Anesthesiology and Critical Care, Department of Anesthesia, Burn and Critical Care, University Hospitals Saint-Louis-Lariboisière, AP-HP, Paris, France
| | - Alice Blet
- Inserm UMR-S 942 MASCOT, Lariboisière Hospital, Paris
- Université de Paris, Paris
- Department of Anesthesiology and Critical Care, Department of Anesthesia, Burn and Critical Care, University Hospitals Saint-Louis-Lariboisière, AP-HP, Paris, France
| | - Aušra Kavoliūnienė
- Department of Cardiology, Hospital of Lithuanian Health Science University Kaunas Clinics, Kaunas
| | - Alexandre Mebazaa
- Inserm UMR-S 942 MASCOT, Lariboisière Hospital, Paris
- Université de Paris, Paris
- Department of Anesthesiology and Critical Care, Department of Anesthesia, Burn and Critical Care, University Hospitals Saint-Louis-Lariboisière, AP-HP, Paris, France
| | - Jelena Čelutkienė
- Clinic of Cardiac and Vascular Diseases, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Feriel Azibani
- Inserm UMR-S 942 MASCOT, Lariboisière Hospital, Paris
- Université de Paris, Paris
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Safety of diuretic administration during the early management of dyspnea patients who are not finally diagnosed with acute heart failure. Eur J Emerg Med 2021; 27:422-428. [PMID: 32301800 DOI: 10.1097/mej.0000000000000695] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Investigating whether it is safe or not to administrate diuretics to patients arriving at emergency departments in a stage of acute dyspnea but without a final diagnosis of acute heart failure. METHODS We analyzed an unselected multinational sample of patients with dyspnea without a final diagnosis of acute heart failure from Global Research on Acute Conditions Team (France, Lithuania, Tunisia) and Basics in Acute Shortness of Breath Evaluation (Switzerland) registries. Thirty-day all-cause mortality and 30-day postdischarge all-cause readmission rate of treated patients with diuretics at emergency departments were compared with untreated patients by unadjusted and adjusted hazard and odds ratios. Interaction and stratified analyses were performed. RESULTS We included 2505 patients. Among them, 365 (14.6%) received diuretics in emergency departments. Thirty-day mortality was 4.5% (treated/untreated = 5.2%/4.3%, hazard ratio: 1.22; 95% confidence interval, 0.75-2.00) and 30-day readmission rate was 11.3% (14.7%/10.8%, odds ratio: 1.41; 95% confidence interval, 0.95-2.11). After adjustment, no differences were found between two groups in mortality (hazard ratio: 0.86; 95% confidence interval, 0.51-1.44) and readmission (odds ratio: 1.15; 95% confidence interval, 0.72-1.82). Age significantly interacted with the use of diuretics and readmission (P = 0.03), with better prognosis when used in patients >80 years (odds ratio: 0.27; 95% confidence interval, 0.07-1.03) than in patients ≤80 years (odds ratio: 1.56; 95% confidence interval, 0.94-2.63). CONCLUSIONS Diuretic administration to patients presenting to emergency departments with dyspnea while they were undiagnosed and in whom acute heart failure was finally excluded was not associated with 30-day all-cause mortality and 30-day postdischarge all-cause readmission rate.
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Berezin L, Zhabokritsky A, Andany N, Chan AK, Estrada-Codecido J, Gershon A, Lam PW, Leis JA, MacPhee S, Mubareka S, Simor AE, Daneman N. Diagnostic accuracy of subjective dyspnoea in detecting hypoxaemia among outpatients with COVID-19: a retrospective cohort study. BMJ Open 2021; 11:e046282. [PMID: 34006036 PMCID: PMC7941675 DOI: 10.1136/bmjopen-2020-046282] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVES The majority of patients with mild-to-moderate COVID-19 can be managed using virtual care. Dyspnoea is challenging to assess remotely, and the accuracy of subjective dyspnoea measures in capturing hypoxaemia have not been formally evaluated for COVID-19. We explored the accuracy of subjective dyspnoea in diagnosing hypoxaemia in COVID-19 patients. METHODS This is a retrospective cohort study of consecutive outpatients with COVID-19 who met criteria for home oxygen saturation monitoring at a university-affiliated acute care hospital in Toronto, Canada from 3 April 2020 to 13 September 2020. Dyspnoea measures were treated as diagnostic tests, and we determined their sensitivity (SN), specificity (SP), negative/positive predictive value (NPV/PPV) and positive/negative likelihood ratios (+LR/-LR) for detecting hypoxaemia. In the primary analysis, hypoxaemia was defined by oxygen saturation <95%; the diagnostic accuracy of subjective dyspnoea was also assessed across a range of oxygen saturation cutoffs from 92% to 97%. RESULTS During the study period, 89/501 (17.8%) of patients met criteria for home oxygen saturation monitoring, and of these 17/89 (19.1%) were diagnosed with hypoxaemia. The presence/absence of dyspnoea had limited accuracy for diagnosing hypoxaemia, with SN 47% (95% CI 24% to 72%), SP 80% (95% CI 68% to 88%), NPV 86% (95% CI 75% to 93%), PPV 36% (95% CI 18% to 59%), +LR 2.4 (95% CI 1.2 to 4.7) and -LR 0.7 (95% CI 0.4 to 1.1). The SN of dyspnoea was 50% (95% CI 19% to 81%) when a cut-off of <92% was used to define hypoxaemia. A modified Medical Research Council dyspnoea score >1 (SP 98%, 95% CI 88% to 100%), Roth maximal count <12 (SP 100%, 95% CI 75% to 100%) and Roth counting time <8 s (SP 93%, 95% CI 66% to 100%) had high SP that could be used to rule in hypoxaemia, but displayed low SN (≤50%). CONCLUSIONS Subjective dyspnoea measures have inadequate accuracy for ruling out hypoxaemia in high-risk patients with COVID-19. Safe home management of patients with COVID-19 should incorporate home oxygenation saturation monitoring.
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Affiliation(s)
- Linor Berezin
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | | | - Nisha Andany
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Division of Infectious Diseases, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Adrienne K Chan
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Division of Infectious Diseases, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Jose Estrada-Codecido
- Division of Infectious Diseases, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Andrea Gershon
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Division of Respirology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Philip W Lam
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Division of Infectious Diseases, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Jerome A Leis
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Division of Infectious Diseases, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Scott MacPhee
- Department of Nursing, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Samira Mubareka
- Division of Infectious Diseases, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
- Department of Laboratory Medicine and Pathology, University of Toronto, Toronto, Ontario, Canada
| | - Andrew E Simor
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Division of Infectious Diseases, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Nick Daneman
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Division of Infectious Diseases, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
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Karaman K, Sağlam Gürmen E. The role of peripheral perfusion index in differential diagnosis of cardiac and pulmonary-origin dyspnea in emergency service. HONG KONG J EMERG ME 2020. [DOI: 10.1177/1024907920944050] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Introduction: Pulmonary and cardiac disorders are diagnosed in most patients presenting to the emergency department with dyspnea. Discrimination of pulmonary and cardiac pathologies from each other and early intervention have vital importance. Various methods have been used for assessment of peripheral perfusion, and the peripheral perfusion index) has gained popularity in recent years. This study aimed to investigate the contribution of peripheral perfusion index to the evaluation process in patients presenting with the complaint of dyspnea and diagnosed with either a pulmonary or cardiac pathology. Materials and Methods: We retrospectively reviewed the charts of patients who presented to emergency department with dyspnea between 1 July 2018 and 1 July 2019. Patients in whom the cause of dsypnea was determined to be a cardiac or pulmonary pathology were included in the study. The age, gender, peripheral perfusion index value at admission, the diagnosis, and the hospitalization status were recorded. Results: One hundred and ninety patients consisting of 106 (55.8%) males and 84 (44.2%) females were included in our study. While a pulmonary pathology was determined in 141 (74.2%) patients and a cardiac pathology in 49 (25.8%) patients, 72 (37.9%) patients were decided to be hospitalized. No difference was determined between patients with pulmonary and cardiac pathologies regarding peripheral perfusion index. When the patients were compared regarding hospitalization status and discharge from the emergency department, no significant difference was found to be present between the groups. Conclusion: Since peripheral perfusion index is a noninvasive, easy-to-perform, rapid, and reproducible test, it has been promising as a prognostic and diagnostic parameter. However, it has been realized that PPI was unsuccessful in the evaluation of patients with dyspnea, in the differential diagnosis of cardiac and pulmonary pathologies and prediction of hospitalization status in the emergency department.
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Affiliation(s)
- Kıvanç Karaman
- Emergency Department, Faculty of Medicine, Suleyman Demirel University, Isparta, Turkey
| | - Ekim Sağlam Gürmen
- Emergency Department, Faculty of Medicine, Manisa Celal Bayar University, Manisa, Turkey
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