Persistent Q fever and ischaemic stroke in elderly patients.

Whether persistent or chronic Q fever may act as a risk factor for stroke is unknown. A case-control study was conducted in the Hospital Universitario de Burgos (Spain) between February 2011 and December 2012. A total of 803 samples from 634 consecutive hospitalized patients ≥65 years old were tested, of whom 111 were cases (patients with prevalent or incident ischaemic stroke and/or transient ischaemic attack) and 523 were controls (patients without ischaemic stroke and/or transient ischaemic attack). Immunoglobulin G (IgG) antibody titres phase I and II against Q fever, and IgG antibodies levels against Chlamydia pneumoniae and cytomegalovirus (CMV), were determined using immunofluorescence assay and ELISA methods, respectively. Phase I IgG titres against Coxiella burnetii ≥1:256 (compatible with chronic or persistent Q fever) were detected in 16 of 110 (14.5%) cases and in 32 of 524 (6.1%) controls; P = .004, odds ratio (OR) 2.6, 95% confidence interval (CI) 1.3 to 4.9. This ratio was maintained after adjusting for age, sex, hypertension, dyslipidaemia, cardioembolic focus, smoking, diabetes, other cardiovascular diseases, C-reactive protein, and leukocyte count (OR 2.6, 95% CI 1.3 to 5.3). High-titre IgG antibodies (top quartile) against CMV (OR 2.1, 95% CI 1.3 to 3.5), but not against C. pneumoniae (OR 0.9, 95% CI 0.5 to 1.6), also were associated with ischaemic stroke after adjustment for risk factors. In conclusion, serology compatible with persistent or chronic Q fever is associated with ischaemic stroke in elderly patients. High levels of IgG antibodies against CMV, but not against C. pneumoniae, also are associated with ischaemic stroke in these patients.

Association between serological evidence of past Coxiella burnetii infection and atherosclerotic cardiovascular disease in elderly patients.

Q fever, caused by Coxiella burnetii, may cause vascular complications, but the role that this infection may play in the development of atherosclerotic cardiovascular disease remains unknown. This study examined the association between Q fever serology and cardiovascular disease in a region where Q fever is endemic. A case-control study was conducted in the Hospital Universitario de Burgos (Spain) between February 2011 and June 2012. A total of 513 samples were tested, from 454 hospitalized patients ≥65 years old, of whom 164 were cases (patients with prevalent or incident coronary heart, cerebrovascular or peripheral artery, disease) and 290 controls (patients without cardiovascular disease). Serum IgG antibody phase II titres against Q fever were determined by immunofluorescence assay. Seropositivity (titres ≥1:256) was detected in 84/164 (51.2%) cases and in 109/290 (37.6%) controls (p = 0.005; OR, 1.7; 95% CI, 1.1-2.5). This ratio increases when adjusted for sex, hypertension, dyslipidaemia, smoking, diabetes and atrial fibrillation (OR, 2.6; 95% CI, 1.5-4.7). The geometric mean titre (GMT) for C. burnetii phase II assay was higher in cases than in controls (p = 0.004). We found no significant relationship between cardiovascular disease and C. pneumoniae, and Cytomegalovirus seropositivity (both determined by the IgG ELISA method). In conclusion, serological evidence of past Q fever is associated with atherosclerotic cardiovascular disease in elderly patients in an endemic region.

[Anisakiasis gastrointestinal manifestations: description of 42 cases]. / Manifestaciones digestivas de la anisakiasis: descripción de 42 casos.

BASIS: Anisakiasis is an emerging parasitosis in our environment, although still scarcely known, mainly its gastrointestinal manifestations. PATIENTS AND METHODS: In this paper 42 cases of anisakiasis with gastrointestinal symptoms (with or without cutaneous allergic manifestations) are described; all cases were studied in our hospital between 1995 and May 2004. RESULTS: Thirty seven cases showed a gastric or gastroallergic form (6 confirmed with gastroscopy) and 5 suffered intestinal symptoms. In those in which endoscopy was not carried out, the diagnosis was done after clinical and biological findings. All patients were sensitized in the presence of Anisakis simplex. The 69% (29 cases) described raw anchovies ingestion or anchovies seasoned in vinegar ingestion some hours before the beginning of the clinical picture. The 59% showed allergic symptoms (gastroallergic anisakiasis); no patient with intestinal affectation showed allergic symptoms. Nausea (67%), vomiting (51%), and epigastralgia (50%) were the dominant symptoms in the group with gastric or gastroallergic anisakiasis without endoscopic confirmation; on the other hand, pain in right ileac fossa was the dominant symptom in the intestinal form. Fever was seen in two of the later patients (40%), but in no patient with gastric or gastroallergic anisakiasis. CONCLUSIONS: Gastrointestinal symptomatology after ingestion of fish suspiciously prepared should suggest anisakiasis, regardless if clinical picture includes allergic manifestations. In our study, pain in right ileac fossa, fever, and absence of allergic manifestations were typical of intestinal form.

[Metabolic profile and end-organ damage in essential hypertensive patients according to the control of blood pressure in primary care centres]. / Perfil metabólico y deterioro de órganos diana en hipertensos esenciales según el control de la presión arterial en la consulta.

BACKGROUND AND OBJECTIVE: To evaluate the degree of metabolic control and end-organ damage in a group of hypertensive patients with poor and good blood pressure (BP) control in primary health care centers. PATIENTS AND METHODS: Observational study with diagnostic intervention, performed in 16 primary care centers of Burgos (Spain). 207 patients (120 with good BP control and 87 with poor BP control) with pharmacological treatment were included in the study. The following parameters were determined: clinic history, casual BP, 24-h ambulatory blood pressure monitoring (ABPM), electrocardiography, and clinic analysis in plasma and 24-hour urine. RESULTS: The 32% and 31% of patients respectively were receiving combined pharmacological treatment. No significant differences were detected between the two groups for the levels of c-HDL > 130 mg/dl (62% vs. 62%), microalbuminuria (5% vs. 10%) and basal glucose levels > 126 mg/dl (105 vs. 15%). There was a significant proportion of patients with poor clinical BP control with left ventricular hypertrophy (13% vs. 34%; p < 0,001), impaired renal function (3% vs. 11%; p < 0,05), mean hematocrit value (41,9 +/- 4,5 vs. 43,7 +/- 3,5; p < 0,01) and different degree on BP control by ABPM (1,6% vs. 16%: p < 0,01). CONCLUSIONS: Our hypertensive patients with poor BP clinical control showed more end-organ damage than those with good control, although they have a similar metabolic profile. The access to ABPM by primary health care centers could modify the therapeutic management in a significant subgroup of hypertensive patients with poor BP control.

[Clinical analysis of 91 cases of median and small vessel vasculitis in adults]. / Análisis clínico de 91 casos de vasculitis de mediano y pequeño vaso en adultos.

OBJECTIVE: To evaluate the clinical and biological differences between medium sized vessel vasculitis and small vessel vasculitis. PATIENTS AND METHODS: descriptive and retrospective study of 91 patients with vasculitis attended in our hospital from January 1991 to mars 2001. We describe the characteristics of clinical and analytic features. RESULTS: 57% were males. The mean age was 61.9 +/- 18.6 years (17 to 90 years). The symptoms and affected organs were: palpable purpura (89%), fever (36%), asthenia (20%), arthromyalgias (19%), nephropathy (18%), arthritis (16%), abdominal pain (16%), neuropathy (8.7%), pulmonary involvement (6.5%). 25% had several episodes, lasting clinical, chronic disease, 42% had evidence of two or more involve organs. The patients with pauci-inmune vasculitis presented more asthenia, nephritis, pulmonary involvement, multi-organic involvement and mortality related to the process. We did not found significant differences respect to the others clinical manifestations analysed. CONCLUSIONS: There is a substantial overlap among different vasculitis, the presence or absence of some clinical and biological features can help in the differentiation and characterization of the different entitles.

[Cardiovascular and hormonal factors associated with the lack of nocturnal fall in blood pressure among individuals aged over 55]. / Factores cardiovasculares y hormonales asociados a la falta de descenso nocturno de la presión arterial en sujetos mayores de 55 años.

BACKGROUND: Usually, there is a physiological fall in nocturnal blood pressure among all individuals, both hypertensive and normotensive individuals. The lack of nocturnal blood pressure (BP) fall may be associated with the risk of developing cardiovascular complications in hypertensive patients. Cardiovascular and hormonal factors associated with the lack of nocturnal blood pressure fall was studied in individuals aged over 55, those most exposed to this kind of complications. METHODS: A total of 108 individuals aged over 55 and with a wide range of BP (59 normotensive and 49 light-moderate hypertensive with no previous treatment) were studied. Two groups were established: dipper and non-dipper, with a fall over 10% in nocturnal SBP and DBP or not, respectively. Patients included in the study underwent serum hormonal measurements (renin, aldosterone, endoteline-1, atrial natriuretic peptide, free epinephrine and norepinephrine), continuous blood pressure monitoring for 24 hours (CBPM) and echocardiography with measurement of left ventricular mass (LVM), cardiac output, and peripheral vascular resistances (PVR) (determined in function of mean blood pressure and cardiac output). RESULTS: Fifty-one individuals were dipper and 57 were non-dipper. Significantly higher cholesterol (p < 0.05) and free norepinephrine (p < 0.001) levels among dipper compared with non-dipper individuals were observed. Non-dipper individuals had PVR significantly higher than dipper individuals (p < 0.05). Values of diurnal BP, other hormonal measurements, and CBPM did not differ significantly between the two groups. CONCLUSIONS: Non-dipper individuals aged over 55 have lower circulating free norepinephrine values and higher peripheral vascular resistances than dipper individuals, irrespective of diurnal blood pressure values. The left ventricular mass does not differ significantly between the two groups.

[Pneumonia in the aged patient: is the clinical presentation atypical?]. / Neumonía en el anciano: es atípica su presentación clínica?

OBJECTIVE: Some new studies have questioned the often atypical character of pneumonia in aged patients. Therefore to study the different clinical presentation of this pathology is our aim. MATERIAL AND METHODS: Retrospective analysis of 179 cases of pneumonia in patients aged older than 65 years who were admitted in our hospital during 1992. RESULTS: The average age of the patients was 78 years, being 65.9% of them men. 91% presented pneumonias acquired in the community. 73.1% showed a typical dominant clinical presentation (febrile-respiratory); respiratory (47.4%), febrile (25.7%). The rest presented atypical patterns; mental-neurologic or "cerebral dysfunction" (10.6%), perambulation-general state (6.15%) and digestive-abdominal (9.5%). The respiratory pattern was associated to the presence of respiratory antecedents (p < 0.001); the febrile pattern to the absence of cardiovascular antecedents (p < 0.05); the mental-neurologic to the presence of neurologic antecedents (p < 0.001) and the alteration of perambulation-general state to an evolution of more than 7 days (p < 0.05). CONCLUSIONS: The greatest number of our pneumonia patients older than 65 years follows a typical clinical pattern febrile-respiratory). The patient's prior pathology conditions the clinical presentation.

[Attitudes to smoking and characteristics of the habit among a group of young asthmatics compared to a group of non-asthmatics]. / Actitudes ante el tabaquismo y características del hábito de un grupo de asmáticos jóvenes comparado con un grupo sin asma.

OBJECTIVE: To compare the attitudes toward smoking and smoking patterns of young male asthmatics with the attitudes and habits of a group previously studied non-asthmatic men. POPULATION AND METHODS: Volunteers responded individually to as anonymous questionnaire. RESULTS: Responses were received from 488 asthmatics men (55.83%) of the sample, with 11 not responding) and 386 non-asthmatics (44.16%, with 27 not responding). The mean age of subjects was 19.91 +/- 2.76 yr. Smoking asthmatics numbered 154 (31.56%) non-asthmatic smokers numbered 207 (53.6%) (p < 0.001). Eighteen asthmatics (3.68%) and 6 (1.55%) non-asthmatics were ex-smokers. The mean age of initiation was 15.20 +/- 2.42 for asthmatics and 15.08 +/- 2.41 for non-asthmatics. Smoking was established at a mean age of 16.56 +/- 2.04 yr for asthmatics and 16.47 +/- 2.18 yr for non-asthmatics. Sixty-two percent of asthmatics smoked fewer than 10 cigarettes/day whereas 55% of non-asthmatics smoked between 11 and 20 cigarettes/day. The mean Fagerström score were 2.59 +/- 2.2 for asthmatics and 4.66 +/- 2.2 for non-asthmatics (p < 0.001). Fifty-four percent of asthmatics and 47% non-asthmatics were considering quitting. Sixty-five percent of asthmatics and 44% of non-asthmatics had previously tried to quit (p < 0.01) and mean duration of abstinence was 4.6 +/- 3.8 months and 3.8 +/- 4.6, respectively (p < 0.05). No differences were found in the reason for starting to smoke. We found that the companions and friends of asthmatics smoked less than did the friend and acquaintances of non-asthmatics (p < 0.001), although that differences was not found for relatives, the friends, relatives and companions of smoking asthmatics smoked more than did those of non-smoking asthmatics. CONCLUSIONS: The prevalence of smoking is lower among asthmatics than among non-asthmatics and asthmatics smoke fewer cigarettes/day and have a lower level of addiction. There are no differences in age of or reasons for starting to smoke. Asthmatics have fewer smoking friends than do non-asthmatics and non-smoking asthmatics have fever still. the desire to quit smoking is high in both groups.

[The association of hematocrit with blood pressure and left ventricular mass in subjects over 55]. / Asociación del hematocrito con la presión arterial y la masa ventricular izquierda en sujetos mayores de 55 años.

OBJECTIVE: To establish the association between hematocrit, blood pressure (BP), and left ventricular mass (LVM) in persons older than 55 years. PATIENTS AND METHODS: One hundred patients older than 55 years (46 males and 54 females) with a wide range in BP were studied on an ambulatory basis. The following parameters were determined: hematocrit, casual BP (CBP), 24-h ambulatory blood pressure monitoring (ABPM), left ventricular mass index (LVMI) determined by echocardiography (according to the Devereux's formula), cardiac output (CO) (determined by cardiac echocardiography), peripheral vascular resistances (PVR) (determined according to mean blood pressure and cardiac output), and levels of creatinine in plasma and sodium in 24-hour urine. RESULTS: Mean age of patients was 65 years (range 55 to 83 years). Twenty-two percent of patients were smokers (17 males and 5 females) with a mean of 13 +/- 6 cigarettes/day. Mean hematocrit value was 41.4 +/- 3.6% (43.3 +/- 3.5 for males and 39.7 +/- 2.7% for females) (p < 0.001). Thirty-five percent of males and 26% of females had mild-moderate hypertension with an hematocrit of 42.3 +/- 3.5% versus 40.8 +/- 3.6% (p < 0.05). The LVMI was 132 +/- 37 g/m2 (139 +/- 38 g/m2 for males and 127 +/- 36 g/m2 for females). A significant linear association was observed between hematocrit value and diastolic BP: casual (r = 0.25; p < 0.05, 24 h mean (r = 0.34; p < 0.001), mean from 7 to 23 hours (r = 0.32; p < 0.001), mean from 23 to 7 hours (r = 0.37; p < 0.001). For females, these relationships were: r = 0.41, 0.36; 0.34 and 0.41, respectively (p < 0.01). No significant association was observed between these parameters among males. Among hypertensive patients this association was observed 24-h mean diastolic BP and mean from 23 and 7 hours (r = 0.39; p < 0.05). Among normotensive patients the values for this association were: r = 0.25; p < 0.05 and r = 0.26; p < 0.05, respectively. No significant association was observed between hematocrit value and LVMI for the total group and for the established subgroups. CONCLUSIONS: Among patients older than 55 years a weak significant association was found between hematocrit value and diastolic BP (both casual and in that obtained with ambulatory monitoring), but not with the left ventricular mass. The mean hematocrit value was significantly higher for hypertensive than for normotensive patients.

[Smoking in young military men: attitudes and characteristics]. / Hábito tabáquico en jóvenes en edad militar: actitudes y características.

This study aimed to determine the attitudes toward smoking and the characteristics of smoking patterns in young men of military age. Individuals performing their military service were surveyed using a self-administered, anonymous, personal and voluntary questionnaire. Questions were included on smoking habits, social context, and desire to quit. Responses were received from 386 (93.46%) subjects, all male, whose mean age was 20.52 +/- 2.3 years. The sample included 207 smokers (53.62%), 173 non smokers (44.81%) and 6 ex-smokers (1.55%). Mean age of initiation was 15.07 +/- 2.4 years and mean age of start of habitual smoking was 16.46 +/- 2.2 years. The main reasons for starting to smoke were curiosity (39.73%) and peer pressure (29.45%). Between 11 and 20 cigarettes/day were smoked by 53.74%. Those who began before 18 years of age smoked more than those who began after age 19. Light tobacco was smoked by 90.87%. Non smokers had fewer friends and family members who smoked than did smokers (p < 0.05). The proportion of moderate smokers was 78.85%. Forty-three percent were found to be in a phase of thinking about quitting, and 48.19% had previously tried to quit. Anxiety is the most common cause of re-commencement. Stress was cited most often as the reason for increased smoking. We conclude that the prevalence of daily smoking is high among young men, who begin smoking regularly at 16 years of age. Those who begin later smoke less. The influence of friends and family members on initiation and maintenance of smoking is great. Half the smokers contemplated quitting and reported a high number of earlier attempts to stop. We believe that military quarters are an ideal place for health education and promotion, offering the possibility of designing special programs for decreasing the prevalence of smoking among adults.

[Association between blood pressure and circulating hormonal factors with left ventricular mass in patients with essential hypertension older than 55 years of age]. / Asociación entre la presión arterial y factores hormonales circulantes con la masa ventricular izquierda en hipertensos esenciales mayores de 55 años.

BACKGROUND: The prevalence of left ventricular hypertrophy (LVH) is higher in elderly patients with hypertension than in normotensive patients. The factors relationed herewith are not well known. The first purpose was to analyse the relationship between the levels of blood pressure (BP) recorded by ambulatory blood pressure monitoring (ABPM) and the left ventricular mass index (LVMI) in a group of untreated patients older than 55 years with essential hypertension. Our second purpose was to observe the relationship between the concentration of several circulating hormones and the left ventricular mass index. SUBJECTS AND METHODS: The study included 31 untreated patients with mild to moderate essential hypertension and 37 healthy normotensives. Both groups were of similar age, sex and body mass index. We determined for both groups the casual arterial pressure (CAP), ambulatory BP monitoring (ABPM) throughout 24 h, daytime (07.00-23.00 h), nighttime (23.00-07.00 h), left ventricular mass index (LVMI) (following Devereux's formula) and circulating levels of endothelin-1, aldosterone, renine, free adrenaline and noradrenaline. RESULTS: The ILVM in hypertensive patients was 139.6 +/- 35.9 g/m2 and in 124.0 +/- 31.8 g/m2 in normotensive (p < 0.05). The percentage of patients with LVH was 63 and 43%, respectively (p < 0.05). The LVMI in hypertensive patients was correlated with the diastolic CAP (97 +/- 7 mmHg) (r = 0.41; p < 0.05), unlike with the systolic CAP (164 +/- 18 mmHg). The ILVM in normotense patients was not associated neither with the systolic CAP (126 +/- 10 mmHg) nor with the diastolic (79 +/- 6 mmHg). In hypertensive patients we found a slight association between the LVMI and the systolic ABPM (130 +/- 14 mmHg) during nighttime (r = 0.41; p < 0.05). The rest of average ambulatory BP and the hormonal values at study did not show a correlation with the LVMI in both groups. CONCLUSIONS: A slight correlation exists between BP (casual and determined with ambulatory blood pressure monitoring throughout 24 hours) and the left ventricular mass index in mild to moderate untrated hypertensive patients older than 55 years. We did not observe correlations between the circulating levels of endothelin-1, renin, aldosterone, free adrenaline and noradrenaline and the left ventricular mass. The average ventricular mass and the number of subjects with ventricular hypertrophy was significantly increased in hypertensives than in normotensives.

[Effort thrombosis of the subclavian-axillary vein: a report of 3 cases and the individualization of treatment]. / Trombosis de esfuerzo de la vena subclavioaxilar: descripción de tres casos e individualización del tratamiento.

The previous history, clinical evolution, diagnostic procedure and treatment in three cases of effort thrombosis of the subclavian-axillary vein are described. Only one patient presented on admittance signs compatible with thoracic outlet syndrome. We insist on the importance of individualizing treatment. A patient presented on admittance an advanced clinical picture and underwent anticoagulant treatment for six months, showing important clinical and phlebographic alterations during this time. The other two patients presented an acute picture of a few hours of evolution and initially underwent fibrinolytic treatment followed by anticoagulant treatment during three months. The clinical data as well as phlebography was normal in these patients six months after admission.

[Gastrointestinal involvement and the response to dapsone in a case of the urticarial vasculitis syndrome]. / Afección gastrointestinal y respuesta a dapsona en un caso de síndrome vasculitis urticaria.

A case of urticarial vasculitis syndrome is described in which the gastrointestinal disease was the main clinical manifestation. The gastroduodenal barium meal demonstrated signs compatible with intestinal ischemia which reversed upon medical treatment. The colonoscopy with biopsy showed changes compatible with unspecific colitis. The role of reversible acute vasculitis as a pathogenic factor implicated in the gastrointestinal manifestations in this entity is discussed. Although the response to treatment with corticoids and cochicine was not constant, there was good response to dapsone in successive relapses of the disease. Despite some antibodies becoming positive during the third year of follow up, the patient did not fulfill the clinical criteria for the diagnosis of systemic lupus erythematosus.