Monitorización avanzada en el posoperatorio de las cardiopatías congénitas : motorización hemodinámica avanzada en el posoperatorio de cardiopatías congénitas mediante termodilución transpulmonar y espectroscopia cercana al infrarrojo

196 p. : graf.

Subtypes of Patients Experiencing Exacerbations of COPD and Associations with Outcomes

Chronic obstructive pulmonary disease (COPD) is a complex and heterogeneous condition characterized by occasional exacerbations. Identifying clinical subtypes among patients experiencing COPD exacerbations (ECOPD) could help better understand the pathophysiologic mechanisms involved in exacerbations, establish different strategies of treatment, and improve the process of care and patient prognosis. The objective of this study was to identify subtypes of ECOPD patients attending emergency departments using clinical variables and to validate the results using several outcomes. We evaluated data collected as part of the IRYSS-COPD prospective cohort study conducted in 16 hospitals in Spain. Variables collected from ECOPD patients attending one of the emergency departments included arterial blood gases, presence of comorbidities, previous COPD treatment, baseline severity of COPD, and previous hospitalizations for ECOPD. Patient subtypes were identified by combining results from multiple correspondence analysis and cluster analysis. Results were validated using key outcomes of ECOPD evolution. Four ECOPD subtypes were identified based on the severity of the current exacerbation and general health status (largely a function of comorbidities): subtype A (n = 934), neither high comorbidity nor severe exacerbation; subtype B (n = 682), moderate comorbidities; subtype C (n = 562), severe comorbidities related to mortality; and subtype D (n = 309), very severe process of exacerbation, significantly related to mortality and admission to an intensive care unit. Subtype D experienced the highest rate of mortality, admission to an intensive care unit and need for noninvasive mechanical ventilation, followed by subtype C. Subtypes A and B were primarily related to other serious complications. Hospitalization rate was more than 50% for all the subtypes, although significantly higher for subtypes C and D than for subtypes A and B. These results could help identify characteristics to categorize ECOPD patients for more appropriate care, and help test interventions and treatments in subgroups with poor evolution and outcomes.

Predictive score for mortality in patients with COPD exacerbations attending hospital emergency departments

Background: Limited information is available about predictors of short-term outcomes in patients with exacerbation of chronic obstructive pulmonary disease (eCOPD) attending an emergency department (ED). Such information could help stratify these patients and guide medical decision-making. The aim of this study was to develop a clinical prediction rule for short-term mortality during hospital admission or within a week after the index ED visit. Methods: This was a prospective cohort study of patients with eCOPD attending the EDs of 16 participating hospitals. Recruitment started in June 2008 and ended in September 2010. Information on possible predictor variables was recorded during the time the patient was evaluated in the ED, at the time a decision was made to admit the patient to the hospital or discharge home, and during follow-up. Main short-term outcomes were death during hospital admission or within 1 week of discharge to home from the ED, as well as at death within 1 month of the index ED visit. Multivariate logistic regression models were developed in a derivation sample and validated in a validation sample. The score was compared with other published prediction rules for patients with stable COPD. Results: In total, 2,487 patients were included in the study. Predictors of death during hospital admission, or within 1 week of discharge to home from the ED were patient age, baseline dyspnea, previous need for long-term home oxygen therapy or non-invasive mechanical ventilation, altered mental status, and use of inspiratory accessory muscles or paradoxical breathing upon ED arrival (area under the curve (AUC) = 0.85). Addition of arterial blood gas parameters (oxygen and carbon dioxide partial pressures (PO2 and PCO2)) and pH) did not improve the model. The same variables were predictors of death at 1 month (AUC = 0.85). Compared with other commonly used tools for predicting the severity of COPD in stable patients, our rule was significantly better. Conclusions: Five clinical predictors easily available in the ED, and also in the primary care setting, can be used to create a simple and easily obtained score that allows clinicians to stratify patients with eCOPD upon ED arrival and guide the medical decision-making process.

Energy Audit for an Old Industrial Building in Gävle

(English)The Swedish industrial sector has overcome the oil crisis and has maintained the energy use constant even though the production has grown. This has been achieved thanks to the development of several energy policies, by the Swedish government, towards the 2020 goals. This thesis carries on this path and performs an energy audit for an old industrial building in Gävle (Sweden) in order to propose different energy efficiency measures to use less energy while maintaining the thermal comfort. The building is in quite a bad shape and some of the areas are unused making them a waste of money. By means of the invoices provided by different companies, the information from the staff and some measures that have been carried out in-situ, the energy balance has been calculated from where conclusions have been drawn. Although it is an industrial building, the study is not going to be focused in the industrial process but in the building’s envelope and support processes, since the unit combines both production and office areas. Therefore, the energy balance is divided in energy supplies (district heating, free heating and sun irradiation) and energy losses (transmission, ventilation hot tap water and infiltrations). The results show that the most important supply is that of the DH whereas the most important losses are the transmission and infiltration. Thus, the measures proposed are focused on the reduction of this relevant parameters. The most important measures are the renovation of the windows, heating systems valves and the ventilation. The glazing of the dwelling is old and some of it is broken accounting for quite a large amount of the losses. The radiator valves are not properly working and there does not exist any temperature control. Therefore the installation of thermostatic valves turns out to be a must. Moreover, some part of the building has no mechanical ventilation but conserves the ducts. These could be utilized if they are connected to the workshop’s ventilation which is capable of generating sufficient flow for the entire building. Finally, although other measures could also be carried out, the ones proposed appear to be the essential ones. A further analysis should be carried out in order to analyze the payback time or investment capability of the company so as to decide between one measure or another. A market study for possible new tenants for the unused parts of the building is also advisable.