Stress-induced hyperglycemia on complications in non-critically elderly hospitalized patients. / Hiperglucemia inducida por estrés en pacientes ancianos hospitalizados no críticos.

AIMS: Hospital complications and hyperglycemia are common in elderly patients during hospitalization. Our aim was to analyze the relationship between hyperglycemia and hospital complications in an ageing population. METHODS: We conducted an observational study to evaluate the association between maximum blood glucose (MBG) levels and hospital complications. Patients were stratified according to the quartiles of MBG levels. Diabetes mellitus (DM) was determined by patient history and/or admission glycated hemoglobin (HbA1c) level ≥6.5%. Hyperglycemia in patients without DM was defined as stress-induced hyperglycemia (SH). The composite primary end-point included frequent complications and/or all-cause hospital mortality. RESULTS: Among 461 patients, mean age 80±7.5years, 238 (51.6%) patients had DM, 20 had undiagnosed DM, and 162 (35.1%) developed hospital complications. Patients with complications had higher mean daily BG levels (215±84 vs 195±85mg/dl, P<.01). The incidence of complications was directly associated with severity of hyperglycemia according to the quartiles of MBG levels in patients without DM, namely SH (<140 mg/dl, 22.2%; 140-185mg/dl, 40%; 186-250mg/dl, 47%; >250mg/dl, 60%; P=.002), but not in patients with DM (<140mg/dl, 26.3%; 140-185mg/dl, 40.4%; 186-250mg/dl, 35.6%; >250mg/dl, 37.4%; P=.748). In the multivariate analyses, SH was independently associated with complications: OR 2.60 (CI95%: 1.2-5.6), 2.82 (CI95%: 1.2-6.5), 5.50 (CI95%: 1.4-20.8) for the second, third and fourth quartile respectively (P=.01), as compared to the first quartile. We found no association with readmissions and all-cause mortality. CONCLUSIONS: SH in elderly patients is associated with hospital complications, but not with all-cause mortality, compared to patients with diabetes or normoglycemia.

[Prevalence of potentially inappropriate medication in hospitalized elderly patients by using explicit criteria]. / Prevalencia de medicación potencialmente inapropiada en pacientes ancianos hospitalizados utilizando criterios explícitos.

INTRODUCTION: Potentially inappropriate medication (PIM) prescribing in older adults is quite prevalent and is associated with an increased risk for adverse drug events, morbidity, and utilization of health care resources. The aim of this study was to determine the prevalence and type of PIM in polypharmacy elderly patients on admission and discharge and the factors associated with their prescription. Just as the applicability of various explicit criteria selected from the literature and adapted to our area. METHODS: We performed a cross-sectional study for 12 months (March 2010-February 2011) on 179 polypharmacy elderly patients admitted to an Internal Medicine Department. We created a list of 50 PIM using a Delphi approach based on previous published criteria (Beers, Stopp, BMC and Priscus). Through patient interviews, review of medical records and discharge reconciliation report, we identified the prevalence of PIM in the patients. We also analyzed the relationship between different factors and the prescription of PIM. RESULTS: The prevalence of patients with PIM on admission and discharge were 71% and 48%, respectively. Out of the 50 selected PIM, 27 and 26 were detected on admission and discharge, respectively (55.5% and 57.69% included on STOPP criteria). We detected two factors associated with PIM prescription at discharge: severe-total dependence (OR = 1.8) and prescription of more than 11 drugs (OR = 2). CONCLUSIONS: PIM prevalence in our population is very high (70%), especially at hospital admission. These findings support the need for measures aimed at improving the quality of prescriptions, especially on dependent patients with polypharmacy.

INTRODUCCIÓN: En personas mayores la prescripción de medicamentos potencialmente inapropiados (PIM) es muy elevada y se asocia con mayor riesgo de eventos adversos, morbilidad y utilización de recursos sanitarios. El objetivo del presente estudio es conocer la prevalencia y tipo de PIM en pacientes ancianos polimedicados al ingreso y alta hospitalaria, los factores asociados a su prescripción y la aplicabilidad de distintos criterios explícitos seleccionados de la bibliografía y adaptados a nuestro ámbito. MÉTODO: Se realiza estudio observacional transversal durante 12 meses (marzo 2010-febrero 2011), sobre 179 pacientes ancianos polimedicados, ingresados en un servicio de Medicina Interna. Como herramienta para detectar la prescripción inadecuada se seleccionaron 50 PIM a partir de la bibliografía (criterios Beers, Stopp, BMC y Priscus) utilizando una técnica Delphi. A través de entrevista con el paciente, revisión de historias clínicas e informe de conciliación se identificaron los PIM previamente seleccionados. Posteriormente se analizó la relación entre distintos factores y la prescripción de PIM. RESULTADOS: La prevalencia de pacientes con PIM al ingreso fue de 71% y al alta de 48%. De 50 PIM seleccionados, sólo se detectaron 27 y 26 tipos (55,5% y 57,69% criterios STOPP) al ingreso y al alta respectivamente. Los factores asociados a la prescripción de PIM al alta fueron: dependencia severa-total (OR = 1,8; IC 95% 1,0-3,4) y nº de medicamentos mayor de 11 (OR = 2; IC 95% 1,1-3,7). CONCLUSIONES: La prevalencia de PIM en nuestra población es muy elevada (70%) especialmente al ingreso hospitalario, estos resultados apoyan la necesidad de adoptar medidas enfocadas a mejorar la calidad de la prescripción prioritariamente en pacientes dependientes y polimedicados.

[Constitutional syndrome as a presentation of a cerebellopontine meningioma]. / Síndrome constitucional como presentación de meningioma pontocerebeloso.

Meningiomas are basically benign tumours arising in the meninges and account for 15-25% of intracranial tumours in adults. It is clinically signs are due to compression of the neighbouring structures, with the main symptoms being migraine, behavioural changes, and neurological deficits. We present a case where constitutional syndrome was the first and principal manifestation of an intracranial cerebellopontine meningioma.

[Persistent fever syndrome secondary to brain abscesses: a rare complication of the meningococcemia]. / Síndrome febril persistente secundario a abscesos cerebrales: una rara complicación de la meningococemia.

Meningococcal disease is caused by hematogenous spreading of Neisseria meningitidis. Meningococcal sepsis occurs in around 20% of cases of meningococcal disease, meningitis in 50% and, to a lesser extent, other conditions such as pneumonia, arthritis, urethritis, conjunctivitis or pericarditis. Brain abscesses are a rare complication.

[Palpebral ptosis, a rare ocular manifestation of Crohn's disease]. / Ptosis palpebral: manifestación ocular inusual de la enfermedad de Crohn.

CLINICAL CASE: An 18 year-old-woman presented with abdominal pain, diarrhea, and ptosis in her left eye. Nuclear magnetic resonance imaging (NMRI) and the study of cerebrospinal fluid detected no abnormalities. Colonoscopy revealed a Crohn's disease (CD) confirmed by histological examination of biopsies. Ocular symptoms improved after appropriate treatment of the underlying CD. DISCUSSION: Inflammatory bowel disease (IBD) is associated with a wide variety of extra-intestinal manifestations, in fact it may be considered a systemic disorder with predominantly gastrointestinal tract manifestations. Extra-intestinal manifestations of inflammatory bowel disease (IBD) occur in one third of patients. Ocular complications are infrequent, occurring in less than 10% of cases, but can be associated with significant morbidity, including blindness. Ocular symptoms may precede a diagnosis of IBD. We report the first case of palpebral ptosis associated with Crohn's disease.

Prevalence of thoracic vertebral fractures in Spanish patients hospitalized in Internal Medicine Departments. Assessment of the clinical inertia. (PREFRAMI study).

PURPOSE: To study the prevalence of vertebral fractures (VF), the associated risk factors and the degree of diagnosis and prescription upon discharge in a series of hospitalized medical patients ≥50 years of age. METHODS: A cross-sectional, multicentre and observational study in which a prevalence cut-off was carried out concerning patients admitted to six Internal Medicine departments in Malaga (Spain). The main variables were the existence of a fracture in the spine lateral x-ray, the inclusion of the diagnosis of a fracture in the discharge report, and the establishment of anti-osteoporotic treatment at discharge. RESULTS: 254 patients were included (mean age 66.4±14.9 years). The prevalence of VF was of 14.2% (36 cases). Patients with VF presented with a higher mean age, compared to those without VF (70.14 vs. 65.7 years) (p=0.035). The means contrast for the FRAX index variable (major osteoporotic and hip fracture), grouping according to the presence of VF, did not show any statistical significance (p=0.369 and p=0.788, respectively). Only in 8.3% of the discharge reports of patients with VF had the diagnosis of VF and/or osteoporosis been recorded and the prescription of anti-osteoporotic drugs been included. CONCLUSIONS: A high prevalence of asymptomatic VF is verified in medical inpatients ≥50 years of age. The FRAX index did not turn out to be predictive of the presence of VF in this population. There is an underdiagnosis of osteoporotic VF in the coding at hospital discharge. Action protocols are necessary to avoid clinical inactivity regarding this entity.

Usefulness of a quantitative real-time PCR assay using serum samples to discriminate between inactive, serologically positive and active human brucellosis.

Diagnosis of brucellosis can be difficult in certain scenarios where conventional microbiological techniques have important limitations. The aim of this study was to develop a LightCycler Quantitative PCR assay in serum samples to discriminate between active and past brucellosis. In total, 110 serum samples from 46 brucellosis patients and 64 controls, including persons who had recently been treated for brucellosis, asymptomatic persons exposed to brucellosis, and patients with febrile syndromes involving a differential diagnosis with brucellosis, were studied. Brucella spp.-specific sequences of the PCR primers and probe were selected from the gene encoding an immunogenic membrane protein of 31 kDa (BCSP31). The analytical sensitivity was 1 x 10(1) fg of Brucella DNA. The mean threshold cycles for brucellosis patients and controls were 31.8 +/- 1.7 and 35.4 +/- 1.1, respectively (p <0.001). The best cut-off for bacterial DNA load was 5 x 10(3) copies/mL. At this cut-off, the area under the receiver operating characteristic curves was 0.963 (95% CI 0.920-1.005), with a sensitivity of 93.5% and a specificity of 98.4%. Under the assay conditions, the LightCycler Quantitative PCR in serum samples seems to be highly reproducible, rapid, sensitive and specific. It is therefore a useful method for both the initial diagnosis and the differentiation between past and active brucellosis.

[Fulminant pneumococcal pancarditis and acute myocardial infarction with cardiac failure]. / Pancarditis neumocócica con infarto agudo de miocardio y fracaso cardiaco de curso fulminante.

Streptococcus pneumoniae is an infrequent cause of endocarditis in adults. Typically occurs in individuals with debilitating illnesses as alcoholism. Frequently the course is aggressive, with rapid destruction of valves. It is associated with high mortality. We describe a young patient without underlying illnesses with pneumococcal endocarditis and meningitis of fulminant course diagnosed in postmorten examination.

[Epidemiological characteristics and mortality risk factors in patients admitted in hospitals with soft tissue infections. A multicentric STIMG (Soft Tissue Infections Malacitan Group) study results]. / Características clínicas, epidemiológicas y factores asociados a mortalidad en los pacientes hospitalizados por infecciones de piel y partes blandas. Resultados del estudio multicéntrico STIMG.

OBJECTIVES: To describe the characteristics of patients admitted in hospitals with soft tissue infections, and analyse the variables whose died, in order to define risk groups. METHOD: retrospective analysis of medical reports of all patient admitted during 2002 year for soft tissue infections in public malacitans hospitals. We excluded the patient with soft tissue infections associated with burns, surgery, pressure ulcers, and orbit cellulitis. We analysed clinical, biochemical variables and indications for yields and imaging tests, so the empiric antibiotic treatment established and its correlations with practice guidelines. RESULTS: We analysed 391 admissions of 374 patients. Cellulitis was the most frequent diagnosis (69.3%). We did imaging tests in 51.6%. In 94.3% of cases were treated with empirics antibiotics. The most prescribed drug was amoxiciline plus clavulanate (39%). 27 patients died, 40.7% of them for septic cause. All deceased patients had chronic diseases. The only biochemical parameters associated with mortality were serum proteins and albumina (55 +/- 9 g/L vs. 63 +/- 8 g/L; p = 0.0231) and (22 +/- 7 g/L vs. 29 +/- 7 g/L; p = 0.0125) respectively. CONCLUSIONS: Cellullitis are the most frequent soft tissue infections that requires admissions in hospitals. We overuse imaging test and don t follow the practice guidelines recommendations in antibiotic therapy. Primary soft issue infection s mortality is low and it s restricted to people with chronic illness, deep infections and bad nutritional status.

[Epidemiological features of community- and nosocomial-acquired bacteremia in the hospitalized elderly patients]. / Características epidemiologías de la bacteriemia de origen comunitario y nosocomial en pacientes hospitalizados mayores de 65 años.

OBJECTIVES: To analyze the epidemiology and to identify associated factors for community- and nosocomial-acquired bacteremia in the elderly (BE). PATIENT AND METHODS: Elderly patients diagnosed of bacteremia were selected. Community- or acquired-bacteremia were defined according to standard criteria. The severity of underlying diseases was classified as non-fatal, ultimately fatal, or rapidly fatal, according to McCabe-Jackson criteria. Multivariate analysis by logistic regression was used to identify associated factors to bacteremia. RESULTS: Two hundred and forty-two cases of BE were selected. The mean age was 72.5 years, 50% occurred in males. One hundred and thirty cases (53.7%) were community-acquired and 112 (46.3%) cases were nosocomial-acquired BE. Most common underlying diseases were diabetes mellitus (30.6%%), chronic obstructive pulmonary disease (25.6%) and neoplasia (24%). Gram-negative bacteria were more frequently isolated in community-acquired BE, while gram-positive cocci were more common in nosocomial-acquired BE. Sources of infection were: vascular (19%), respiratory tract (18.6%), biliary tract (17.8%) and urinary tract (8.3%). The factors associated with nosocomial-acquired BE were (adjusted OR; 95%CI): underlying diseases (5.4; 2.7-10.8), neoplasia (2.5; 1.3-4.9) and vascular origin (2.2; 1.1-4.5). Fifty-two patients died (23.1%). CONCLUSIONS: BE occurs in elderly patients debilitated with well-defined underlying diseases. BE is associated to high mortality.

Rapid diagnosis of human brucellosis by SYBR Green I-based real-time PCR assay and melting curve analysis in serum samples.

The aim of this study was to develop a LightCycler-based real-time PCR (LC-PCR) assay and to evaluate its diagnostic use for the detection of Brucella DNA in serum samples. Following amplification of a 223-bp gene sequence encoding an immunogenetic membrane protein (BCSP31) specific for the Brucella genus, melting curve and DNA sequencing analysis was performed to verify the specificity of the PCR products. The intra- and inter-assay variation coefficients were 1.3% and 6.4%, respectively, and the detection limit was 5 fg of Brucella DNA (one genome equivalent). After optimisation of the PCR assay conditions, a standard curve was obtained with a linear range (correlation coefficient=0.99) over seven orders of magnitude from 10(7) to 10 fg of Brucella DNA. The LC-PCR assay was found to be 91.9% sensitive and 95.4% specific when tested with 65 negative control samples and 62 serum samples from 60 consecutive patients with active brucellosis. The assay is reproducible, easily standardised, minimises the risk of infection in laboratory workers, and has a total processing time of <2 h. It could therefore form a promising and practical approach for the rapid diagnosis of human brucellosis.