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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Early identification of the severity of SARS-CoV-2 pneumonia is a very important clinical challenge that primary care and emergency room physicians face daily<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a>&#46; The high mortality rate among these patients&#8212;50 times higher than that of community-acquired pneumonia<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;3</span></a>&#8212;and a lack of knowledge about the utility of scales such as the CURB-65 or the Pneumonia Severity Index&#44; which are commonly used in this clinical scenario to evaluate prognosis&#44; can increase the hospital admission rate&#44; even among patients with criteria of non-severe pneumonia<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a>&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">An appropriate risk stratification can be useful for safely discharging patients&#44; tailoring the level of care the patient needs&#44; or starting more intensive treatment&#46; For example&#44; in patients with hypoxia and signs of systemic inflammation&#44; early use of tocilizumab is associated with a better prognosis and a significant reduction in mortality<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a>&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">The absence of severity criteria can facilitate a rational use of hospital resources and allow for referring these patients to smaller hospitals&#44; reserving intensive care unit &#40;ICU&#41; beds&#44; and facilitating non-COVID healthcare activity&#46; This is especially important given the unprecedented overload this disease has entailed for healthcare systems&#46; Finally&#44; avoiding unnecessary admissions increases quality of care&#44; decreases the risks inherent to hospitalization&#44; and avoids cost overruns&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">In the initial weeks after the start of the pandemic&#44; studies were published that described variables related to increased mortality<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a>&#46; Later&#44; numerous risk stratification models were presented as support tools<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;8</span></a>&#46; Nevertheless&#44; to apply them in clinical practice&#44; three important factors must be considered&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">First&#44; the outcome variable that is going to be used is important&#46; Thirty-day mortality is a variable that has classically been used in research studies&#44; but we have observed very long hospital stays among patients with COVID-19&#44; especially among those who require ICU admission&#46; Therefore&#44; mortality may occur after 30 days&#46; Second&#44; a patient&#8217;s final survival does not imply that they have not had severe symptoms with a prolonged hospitalization or intensive treatment&#46; Therefore&#44; it must be observed whether this variable has been included&#46; Third&#44; a high risk of bias has been described due to a combination of use of retrospective data and reports with deficient methods<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a>&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">In this issue of Revista Cl&#237;nica Espa&#241;ola&#44; Carriel et al&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> analyze the ability of the CURB-65 scale to predict 30-day mortality in a series of 247 patients with COVID-19 in Ecuador during the first wave of the disease in March and April 2020&#46; The CURB-65 scale is simple and easy to complete at the patient&#8217;s bedside&#46; It is widely used to determine the need for hospitalization in patients with community-acquired pneumonia&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">This study has some important limitations&#44; including a lack of a microbiological diagnosis in more than 75&#37; of cases&#59; the absence of information on the usefulness of dexamethasone or remdesivir at that time&#59; the healthcare system overload experienced at the time the information was collected&#59; and the limited availability of ICU beds for many patients&#46; The authors found that a score higher than 2 on the CURB-65 scale was associated with a significantly higher mortality rate than that of patients with a score of 0&#8211;1 points&#46; These findings were expected&#44; given that more severe patients naturally have a greater risk of dying due to the disease&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">On the other hand&#44; it should be noted that in their series&#44; mortality among patients with lower scores &#40;0&#8211;1 points&#41; was not negligible&#46; This indicates that a low score on the CURB-65 scale is not able to identify a subgroup of patients that will progress poorly&#46; From a clinical point of view&#44; patients without dyspnea or tachypnea but with profound hypoxemia and extensive radiological infiltrates have been observed&#59; this has come to be called silent hypoxemia<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11&#8211;13</span></a>&#46; It is important to recall that the respiratory rate is one of the variables in the CURB-65&#46; This may in part explain why patients with these low scores have these mortality rates&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">In this disease&#44; the inflammatory component is very important and allows for more precisely stratifying severe patients&#46; Likewise&#44; hypoxia is a decisive prognostic factor associated with worse progress&#46; It is possible that the incorporation of these two factors would have improved the scale&#8217;s predictive capacity&#46; In any case&#44; in the absence of inflammatory biomarkers&#44; the use of the CURB-65 scale along with oxygen saturation measurement are tools within the reach of any physician that can help in deciding whether to admit the patient or recommend outpatient monitoring&#46; In an ideal predictive scale&#44; it is probable that in addition to the factors included in the CURB-65 scale&#44; it would be necessary to include the presence of hypoxia and some inflammatory markers&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">In this issue&#44; Ena et al&#46; also describe the development and validation of a scale for predicting ICU admission<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a>&#46; The information comes from an extensive database &#40;SEMI-COVID Registry&#44; with more than 16&#44;000 cases&#44; of which 8&#37; were admitted to the ICU&#41;&#46; The authors identify a series of variables with great predictive power&#44; among which the severity of the patient&#39;s comorbidities&#44; age&#44; neutrophil-lymphocyte ratio&#44; LDH levels&#44; and presence of diffuse infiltrates on a chest X-ray are of note&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">ICU admission could be conditioned by other factors&#44; such as the general occupancy of beds in that unit&#44; the patient&#8217;s characteristics&#44; or the possibility of administering noninvasive mechanical ventilation &#40;high-flow nasal cannula&#41; in other units apart from the ICU&#59; this information could be highly valuable&#46; Knowing what patients may need ventilatory support at the time of admission can guide physicians toward different treatment&#46; This information can also help scale each center&#39;s capacity to offer better treatment to their patients&#44; which in the case of Ena et al&#46;&#8217;s series&#44; included ICU admission in 8&#37; of cases<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a>&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Vaccination against SARS-CoV-2 is an extraordinary useful tool that decisively influences the control of this disease&#44; reducing its severity and risk of complications&#44; though not preventing them entirely&#46; However&#44; we cannot expect that the vaccine will make the incidence of SARS-CoV-2 pneumonia totally disappear&#46; There will be unvaccinated patients and cases of vaccine failure in&#44; for example&#44; immunosuppressed patients who are not able to develop an adequate immune response&#46; This variable may add complexity to the prognosis and it will be necessary to continue working to perfect prediction scales&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Estrada V&#44; Gonz&#225;lez del Castillo J&#46; Predicci&#243;n con escalas cl&#237;nicas de la evoluci&#243;n de la COVID-19&#46; Rev Clin Esp&#46; 2022&#59;222&#58;42&#8211;43&#46;</p>"
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Editorial
Predicting COVID-19 progress with clinical scales
Predicción con escalas clínicas de la evolución de la COVID-19
V. Estradaa,
Corresponding author
, J. González del Castillob
a Servicio de Medicina Interna/Infecciosas, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, Spain
b Servicio de Urgencias, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Early identification of the severity of SARS-CoV-2 pneumonia is a very important clinical challenge that primary care and emergency room physicians face daily<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a>&#46; The high mortality rate among these patients&#8212;50 times higher than that of community-acquired pneumonia<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;3</span></a>&#8212;and a lack of knowledge about the utility of scales such as the CURB-65 or the Pneumonia Severity Index&#44; which are commonly used in this clinical scenario to evaluate prognosis&#44; can increase the hospital admission rate&#44; even among patients with criteria of non-severe pneumonia<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a>&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">An appropriate risk stratification can be useful for safely discharging patients&#44; tailoring the level of care the patient needs&#44; or starting more intensive treatment&#46; For example&#44; in patients with hypoxia and signs of systemic inflammation&#44; early use of tocilizumab is associated with a better prognosis and a significant reduction in mortality<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a>&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">The absence of severity criteria can facilitate a rational use of hospital resources and allow for referring these patients to smaller hospitals&#44; reserving intensive care unit &#40;ICU&#41; beds&#44; and facilitating non-COVID healthcare activity&#46; This is especially important given the unprecedented overload this disease has entailed for healthcare systems&#46; Finally&#44; avoiding unnecessary admissions increases quality of care&#44; decreases the risks inherent to hospitalization&#44; and avoids cost overruns&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">In the initial weeks after the start of the pandemic&#44; studies were published that described variables related to increased mortality<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a>&#46; Later&#44; numerous risk stratification models were presented as support tools<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;8</span></a>&#46; Nevertheless&#44; to apply them in clinical practice&#44; three important factors must be considered&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">First&#44; the outcome variable that is going to be used is important&#46; Thirty-day mortality is a variable that has classically been used in research studies&#44; but we have observed very long hospital stays among patients with COVID-19&#44; especially among those who require ICU admission&#46; Therefore&#44; mortality may occur after 30 days&#46; Second&#44; a patient&#8217;s final survival does not imply that they have not had severe symptoms with a prolonged hospitalization or intensive treatment&#46; Therefore&#44; it must be observed whether this variable has been included&#46; Third&#44; a high risk of bias has been described due to a combination of use of retrospective data and reports with deficient methods<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a>&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">In this issue of Revista Cl&#237;nica Espa&#241;ola&#44; Carriel et al&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> analyze the ability of the CURB-65 scale to predict 30-day mortality in a series of 247 patients with COVID-19 in Ecuador during the first wave of the disease in March and April 2020&#46; The CURB-65 scale is simple and easy to complete at the patient&#8217;s bedside&#46; It is widely used to determine the need for hospitalization in patients with community-acquired pneumonia&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">This study has some important limitations&#44; including a lack of a microbiological diagnosis in more than 75&#37; of cases&#59; the absence of information on the usefulness of dexamethasone or remdesivir at that time&#59; the healthcare system overload experienced at the time the information was collected&#59; and the limited availability of ICU beds for many patients&#46; The authors found that a score higher than 2 on the CURB-65 scale was associated with a significantly higher mortality rate than that of patients with a score of 0&#8211;1 points&#46; These findings were expected&#44; given that more severe patients naturally have a greater risk of dying due to the disease&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">On the other hand&#44; it should be noted that in their series&#44; mortality among patients with lower scores &#40;0&#8211;1 points&#41; was not negligible&#46; This indicates that a low score on the CURB-65 scale is not able to identify a subgroup of patients that will progress poorly&#46; From a clinical point of view&#44; patients without dyspnea or tachypnea but with profound hypoxemia and extensive radiological infiltrates have been observed&#59; this has come to be called silent hypoxemia<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11&#8211;13</span></a>&#46; It is important to recall that the respiratory rate is one of the variables in the CURB-65&#46; This may in part explain why patients with these low scores have these mortality rates&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">In this disease&#44; the inflammatory component is very important and allows for more precisely stratifying severe patients&#46; Likewise&#44; hypoxia is a decisive prognostic factor associated with worse progress&#46; It is possible that the incorporation of these two factors would have improved the scale&#8217;s predictive capacity&#46; In any case&#44; in the absence of inflammatory biomarkers&#44; the use of the CURB-65 scale along with oxygen saturation measurement are tools within the reach of any physician that can help in deciding whether to admit the patient or recommend outpatient monitoring&#46; In an ideal predictive scale&#44; it is probable that in addition to the factors included in the CURB-65 scale&#44; it would be necessary to include the presence of hypoxia and some inflammatory markers&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">In this issue&#44; Ena et al&#46; also describe the development and validation of a scale for predicting ICU admission<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a>&#46; The information comes from an extensive database &#40;SEMI-COVID Registry&#44; with more than 16&#44;000 cases&#44; of which 8&#37; were admitted to the ICU&#41;&#46; The authors identify a series of variables with great predictive power&#44; among which the severity of the patient&#39;s comorbidities&#44; age&#44; neutrophil-lymphocyte ratio&#44; LDH levels&#44; and presence of diffuse infiltrates on a chest X-ray are of note&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">ICU admission could be conditioned by other factors&#44; such as the general occupancy of beds in that unit&#44; the patient&#8217;s characteristics&#44; or the possibility of administering noninvasive mechanical ventilation &#40;high-flow nasal cannula&#41; in other units apart from the ICU&#59; this information could be highly valuable&#46; Knowing what patients may need ventilatory support at the time of admission can guide physicians toward different treatment&#46; This information can also help scale each center&#39;s capacity to offer better treatment to their patients&#44; which in the case of Ena et al&#46;&#8217;s series&#44; included ICU admission in 8&#37; of cases<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a>&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Vaccination against SARS-CoV-2 is an extraordinary useful tool that decisively influences the control of this disease&#44; reducing its severity and risk of complications&#44; though not preventing them entirely&#46; However&#44; we cannot expect that the vaccine will make the incidence of SARS-CoV-2 pneumonia totally disappear&#46; There will be unvaccinated patients and cases of vaccine failure in&#44; for example&#44; immunosuppressed patients who are not able to develop an adequate immune response&#46; This variable may add complexity to the prognosis and it will be necessary to continue working to perfect prediction scales&#46;</p></span>"
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ISSN: 22548874
Original language: English
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