Comprehensive geriatric assessment: Influence on clinical results after colorectal surgery in advanced age patients. / Valoración geriátrica integral: influencia en los resultados clínicos de la cirugía colorrectal en pacientes de edad muy avanzada.

INTRODUCTION: The objective of this work was to analyse the postoperative clinical results of patients surgically treated for colorectal cancer in relation to the results of the preoperative comprehensive geriatric evaluation. METHODS: Observational study in which postoperative morbidity and mortality at 30 and 90 days were analysed in a cohort of patients surgically treated for colorectal cancer according to age groups: group 1) between 75 and 79 years old; group 2) between 80 and 84 years old, and group 3) ≥85 years old. In addition to the anaesthetic risk assessment, patients were assessed with the Karnofsky, Barthel and Pfeiffer indexes. Mortality at 30 and 90 days after surgery was analysed in relation to the results of the comprehensive evaluation. RESULTS: A total of 227 patients with colorectal cancer were included in the study period: 91 in group 1, 89 in group 2 and 47 in group 3. There were statistically significant differences in mortality at 30 days (p=0,029) but not at 90 days after surgery, according to age groups. Mortality at 90 days was significantly higher in patients with worse scores on the Karnofsky and Barthel scales. CONCLUSIONS: Comprehensive geriatric assessment using different scales is a good tool to assess postoperative mortality in the mid-term postoperative period.

Predictive biomarkers for death and rehospitalization in comorbid frail elderly heart failure patients.

BACKGROUND: Heart failure (HF) is associated with a high rate of readmissions within 30 days post-discharge and in the following year, especially in frail elderly patients. Biomarker data are scarce in this high-risk population. This study assessed the value of early post-discharge circulating levels of ST2, NT-proBNP, CA125, and hs-TnI for predicting 30-day and 1-year outcomes in comorbid frail elderly patients with HF with mainly preserved ejection fraction (HFpEF). METHODS: Blood samples were obtained at the first visit shortly after discharge (4.9 ± 2 days). The primary endpoint was the composite of all-cause mortality or HF-related rehospitalization at 30 days and at 1 year. All-cause mortality alone at one year was also a major endpoint. HF-related rehospitalizations alone were secondary end-points. RESULTS: From February 2014 to November 2016, 522 consecutive patients attending the STOP-HF Clinic were included (57.1% women, age 82 ± 8.7 years, mean Barthel index 70 ± 25, mean Charlson comorbidity index 5.6 ± 2.2). The composite endpoint occurred in 8.6% patients at 30 days and in 38.5% at 1 year. In multivariable analysis, ST2 [hazard ratio (HR) 1.53; 95% CI 1.19-1.97; p = 0.001] was the only predictive biomarker at 30 days; at 1 year, both ST2 (HR 1.34; 95% CI 1.15-1.56; p < 0.001) and NT-proBNP (HR 1.19; 95% CI 1.02-1.40; p = 0.03) remained significant. The addition of ST2 and NT-proBNP into a clinical predictive model increased the AUC from 0.70 to 0.75 at 30 days (p = 0.02) and from 0.71 to 0.74 at 1 year (p < 0.05). For all-cause death at 1 year, ST2 (HR 1.50; 95% CI 1.26-1.80; p < 0.001), and CA125 (HR 1.41; 95% CI 1.21-1.63; p < 0.001) remained independent predictors in multivariable analysis. The addition of ST2 and CA125 into a clinical predictive model increased the AUC from 0.74 to 0.78 (p = 0.03). For HF-related hospitalizations, ST2 was the only predictive biomarker in multivariable analyses, both at 30 days and at 1 year. CONCLUSIONS: In a comorbid frail elderly population with HFpEF, ST2 outperformed NT-proBNP for predicting the risk of all-cause mortality or HF-related rehospitalization. ST2, a surrogate marker of inflammation and fibrosis, may be a better predictive marker in high-risk HFpEF.

[Predictors of drug-resistant pathogens in community-onset pneumonia: Are factors considered in health-care-associated pneumonia useful in the emergency department?] / Predictores de patógenos resistentes en las neumonías procedentes de la comunidad: ¿es útil en urgencias el concepto de neumonía asociada a cuidados sanitarios?

OBJECTIVES: To analyze factors related to drug-resistant pathogens (DRPs) in community-onset pneumonia (COP) and whether previously suggested criteria are useful in our emergency-department. MATERIAL AND METHODS: Prospective 1-year study of adults coming to the emergency department for COP. We assessed the usefulness of criteria used in health-care-associated pneumonia (HCAP), as well the Shorr index, the Barthel index, and clinical suspicion of resistant pathogens. Data were analyzed by multiple logistic regression and the area under the receiver operating characteristic curve (AUC). RESULTS: We included 139 patients with a mean (SD) age of 75.9 (15.3) years; 63.3% were men. Forty-nine COP patients (35.2%) were at risk for DRP-caused pneumonia according to HCAP criteria; 43 (30.9%) according to the Shorr index, and 56 (40.3%) according to the Aliberti index. A score of less than 60 derived from the Barthel index was recorded for 25 patients (18%). Clinical suspicion of a DRP was recorded for 11 (7.9%). A DRP was isolated in 5 patients (3.6%) (3, Pseudomonas aeruginosa; 2, methicillin-resistant Staphylococcus aureus). Multiple logistic regression analysis identified 2 predictors of DRP-caused COP: hospital admission within the last 90 days (odds ratio [OR], 8.92; 95% CI, 1.92-41.45) and initial arterial blood oxygen saturation (OR, 0.85; 95% CI, 0.74-0.98). The AUC was 0.91 (95% CI, 0.85-0.98). The model identified 22 patients (16.8%) at risk for DRP-caused pneumonia. The positive and negative predictive values were 20% and 99.1%, respectively, for the model 90-day period (vs 8.7% and 98.9%, respectively, for criteria used in HCAP). CONCLUSION: Hospitalization within the 90-day period before a COP emergency and arterial blood oxygen saturation were good predictors of DRP in our setting. Criteria of DRP in HCAP, on the other hand, had lower ability to identify patients at risk in COP.

OBJETIVO: Analizar en las neumonías de la comunidad diagnosticados en nuestro centro los predictores de etiología por patógenos resistentes (PR) y evaluar la utilidad de distintos criterios de riesgo de PR previamente sugeridos. METODO: Se estudiaron prospectivamente durante 1 año los pacientes adultos procedentes de la comunidad atendidos en el servicio de urgencias (SU) por neumonía. Se evaluaron los criterios definitorios de neumonía asociada al cuidado sanitario (NACS), así como los índices de Shorr, Aliberti y Barthel y el juicio clínico de PR. Se realizó regresión logística múltiple y se calculó el área bajo la curva receptor-operador (ABC-ROC). RESULTADOS: Se incluyeron 139 pacientes con una edad media de 75 (DE: 15,3) años, el 63,3% varones. Tenían riesgo de PR según los criterios de NACS 49 (35,2%), según el índice de Shorr 43 (30,9%) y según índice de Aliberti 56 (40,3%). Se encontró un I. Barthel < 60 en 25 enfermos (18%) y juicio clínico de PR en 11 (7,9%). Se aisló PR en el 3,6% (3 Pseudomonas aeruginosa y 2 Staphylococcus aureus meticilin resistentes). En el análisis multivariado fueron predictores de PR el haber ingresado en los 90 días previos, con una odds ratio (OR) de 8,92 [intervalo de confianza (IC) 95%: 1,92-41,45], y la saturación inicial de oxígeno, con una OR de 0,85 [IC 95%: 0,74-0,98] con ABC-ROC de 0,91 (IC 95%: 0,85-0,98). Nuestro modelo identificó 22 pacientes (16,8%) con riesgo de PR, con valor predictivo positivo y negativo del 20% y 99,1%, respectivamente, frente a un 8,7% y 98,9%, respectivamente para NACS. CONCLUSIONES: En las neumonías de nuestro centro el antecedente de ingreso en los 90 días previos junto con la saturación de oxígeno fueron buenos predictores de PR, mientras que los criterios de NACS tuvieron menor capacidad de discriminación.

Early Postdischarge STOP-HF-Clinic Reduces 30-day Readmissions in Old and Frail Patients With Heart Failure.

INTRODUCTION AND OBJECTIVES: Heart failure (HF) is associated with a high rate of readmissions within 30 days postdischarge. Strategies to lower readmission rates generally show modest results. To reduce readmission rates, we developed a STructured multidisciplinary outpatient clinic for Old and frail Postdischarge patients hospitalized for HF (STOP-HF-Clinic). METHODS: This prospective all-comers study enrolled patients discharged from internal medicine or geriatric wards after HF hospitalization. The intervention involved a face-to-face early visit (within 7 days), HF nurse education, treatment titration, and intravenous medication when needed. Thirty-day readmission risk was calculated using the CORE-HF risk score. We also studied the impact of 30-day readmission burden on regional health care by comparing the readmission rate in the STOP-HF-Clinic Referral Area (∼250000 people) with that of the rest of the Catalan Health Service (CatSalut) (∼7.5 million people) during the pre-STOP-HF-Clinic (2012-2013) and post-STOP-HF-Clinic (2014-2015) time periods. RESULTS: From February 2014 to June 2016, 518 consecutive patients were included (age, 82 years; Barthel score, 70; Charlson index, 5.6, CORE-HF 30-day readmission risk, 26.5%). The observed all-cause 30-day readmission rate was 13.9% (47.5% relative risk reduction) and the observed HF-related 30-day readmission rate was 7.5%. The CatSalut registry included 65131 index HF admissions, with 9267 all-cause and 6686 HF-related 30-day readmissions. The 30-day readmission rate was significantly reduced in the STOP-HF-Clinic Referral Area in 2014-2015 compared with 2012-2013 (P < .001), mainly driven by fewer HF-related readmissions. CONCLUSIONS: The STOP-HF-Clinic, an approach that could be promptly implemented elsewhere, is a valuable intervention for reducing the global burden of early readmissions among elder and vulnerable patients with HF.

[Update of pneumonia in the elderly]. / Actualización de la neumonía en el anciano.

The incidence of pneumonia increases with age and contributes to morbidity and mortality in the elderly. In our setting, pneumonia is the sixth leading cause of death and the fourth most common diagnosis at discharge from acute hospitals. This article reviews current concepts in management of pneumonia in the elderly: healthcare-associated pneumonia, aspiration and oropharyngeal dysphagia, risk stratification, and indications of radiological, microbiological and biological markers. We present current evidence on antibiotic treatment (when to start, empirical coverage, duration, new drugs and combinations) and adjuvant treatment (steroids, early mobilization, oral hygiene, prevention and treatment of aspiration and cardiac complications). We emphasize preventive aspects and considerations regarding palliative treatment.

Association of ITPA gene polymorphisms and the risk of ribavirin-induced anemia in HIV/hepatitis C virus (HCV)-coinfected patients receiving HCV combination therapy.

Polymorphisms of the ITPA gene have been associated with anemia during combination therapy in hepatitis C virus (HCV)-monoinfected patients. Our aim was to confirm this association in HIV/HCV-coinfected patients. In this prospective, observational study, 73 HIV/HCV-coinfected patients treated with pegylated interferon plus ribavirin (RBV) were enrolled. Two single nucleotide polymorphisms within or adjacent to the ITPA gene (rs1127354 and rs7270101) were genotyped. The associations between the ITPA genotype and anemia or treatment outcome were examined. Fifty-nine patients (80.8%) had CC at rs1127354, whereas 14 (19.2%) had a CA/AA ITPA genotype. Percent decreases from baseline hemoglobin level were significantly greater in patients with the CC genotype than in those with the CA/AA genotype at week 4 (P = 0.0003), week 12 (P < 0.0001), and week 36 (P = 0.0102) but not at the end of treatment. RBV dose reduction was more often needed in patients with the CC genotype than in those with the CA/AA genotype (odds ratio [OR] = 11.81; 95% confidence interval [CI] = 1.45 to 256.17; P = 0.0039), as was erythropoietin therapy (OR = 8.28; 95% CI = 1.04 to 371.12; P = 0.0057). Risk factors independently associated with percent hemoglobin nadir decrease were RBV dose reduction (OR = 11.72; 95% CI = 6.82 to 16.63; P < 0.001), baseline hemoglobin (OR = 1.69; 95% CI = 0.23 to 3.15; P = 0.024), and body mass index (OR = -0.7; 95% CI = -1.43 to 0.03; P = 0.061). ITPA polymorphism was not an independent predictor of sustained virological response. Polymorphisms at rs1127354 in the ITPA gene influence hemoglobin levels during combination HCV therapy and the need for RBV dose reduction and erythropoietin use in HIV/HCV-coinfected patients.