[Results following the implementation of a clinical pathway in the process of care to elderly patients with osteoporotic hip fracture in a second level hospital]. / Resultados tras la aplicación de una vía clínica en el proceso de atención al paciente geriátrico con fractura de cadera osteoporótica en un hospital de segundo nivel.

PURPOSE: To evaluate the efficiency of a clinical pathway in the management of elderly patients with fragility hip fracture in a second level hospital in terms of length of stay time to surgery, morbidity, hospital mortality, and improved functional outcome. MATERIAL AND METHODS: A comparative and prospective study was carried out between two groups of patients with hip fracture aged 75 and older prior to 2010 (n=216), and after a quality improvement intervention in 2013 (n=196). A clinical pathway based on recent scientific evidence was implemented. The degree of compliance with the implemented measures was quantified. RESULTS: The characteristics of the patients in both groups were similar in age, gender, functional status (Barthel Index) and comorbidity (Charlson Index). Median length of stay was reduced by more than 45% in 2013 (16.61 vs. 9.08 days, p=.000). Also, time to surgery decreased 29.4% in the multidisciplinary intervention group (6.23 vs. 4.4 days, p=.000). Patients assigned to the clinical pathway group showed higher medical complications rate (delirium, malnutrition, anaemia and electrolyte disorders), but a lower hospital mortality (5.10 vs. 2.87%, p>.005). The incidence of surgical wound infection (p=.031) and functional efficiency (p=.001) also improved in 2013. An increased number of patients started treatment for osteoporosis (14.80 vs. 76.09%, p=.001) after implementing the clinical pathway. CONCLUSION: The implementation of a clinical pathway in the care process of elderly patients with hip fracture reduced length of stay and time to surgery, without a negative impact on associated clinical and functional outcomes.

Temporal arteritis and polymyalgia rheumatica in north-eastern Spain: clinical spectrum and relationship over a 15 year period.

OBJECTIVE: To examine the clinical spectrum of polymyalgia rheumatica (PMR) and temporal arteritis (TA) and their relationship over a period of 15 years in an area of north-eastern Spain. METHODS: We undertook a descriptive study of an unselected population of 163 patients with PMR and/or TA diagnosed from 1985 to 1999. RESULTS: Of the 163 patients included, 90 had isolated PMR, 41 had PMR associated with TA, and 32 had isolated TA. The clinical spectrum of both conditions in our area was similar to that reported in other populations, including a marked female predominance. However, in our series, no patient developed permanent blindness or other major ischemic complications. PMR was observed in 56% of patients with TA. Conversely, 7% of patients originally suffering from PMR without clinical evidence of arteritis at presentation developed later symptoms of TA, and there were no predictive features for this. Interestingly, none of these patients suffered visual loss or other ischemic complications. The low risk of major complications in these cases does not support the need for systematic arterial biopsy in all patients with symptoms of PMR alone. On comparing patients with isolated TA with patients with PMR associated with TA, no differences were observed, thus discarding the possibility that the second constitutes a distinct and independent subgroup of TA. In contrast, when comparing patients with isolated PMR with patients with PMR associated with TA, we found significant differences between both the groups, with greater abnormality of clinical and laboratory markers of inflammation in patients with PMR associated with TA. These differences seem to reflect a greater degree of systemic inflammation linked to the presence of TA. CONCLUSION: In our area, TA appears nowadays as a benign disease which infrequently presents blindness or other major complications. Our experience confirms that even after a good clinical response with normalization of a high ESR in PMR, the patient is at risk for clinical development of TA. Finally, our study also shows that isolated TA and PMR associated with TA seem to be the same condition, different from isolated PMR.

Musculoskeletal manifestations in polymyalgia rheumatica and temporal arteritis.

OBJECTIVE: To evaluate the incidence and characteristics of musculoskeletal manifestations in polymyalgia rheumatica (PMR) and temporal arteritis (TA). METHODS: The records of 163 cases of PMR or TA diagnosed over a 15 year period in one area of Spain were reviewed for the presence and type of musculoskeletal manifestations. RESULTS: Of 163 patients, 90 had isolated PMR and 73 had TA. Eighteen of the 90 patients (20%) with isolated PMR developed distal peripheral arthritis either at diagnosis or during the course of the disease. When it occurred, synovitis was mild, monoarticular or pauci-articular, asymmetrical, transient, and not destructive. Other distal manifestations observed in these patients were carpal tunnel syndrome and distal extremity swelling with pitting oedema. In all cases these manifestations occurred in conjunction with active PMR. As expected, PMR was the most frequent musculoskeletal manifestation in patients with TA, occurring in 56% of cases. On the contrary, only 11% of patients with TA developed peripheral arthritis. An important finding was that peripheral arthritis in these patients appears to be linked only temporally to the presence of simultaneous PMR and is not observed in its absence. Distal extremity swelling or defined polyarthritis were not observed. CONCLUSION: The spectrum of distal musculoskeletal manifestations of PMR in our series is similar to that reported in other populations. By contrast, distal musculoskeletal symptoms are uncommon in TA. The almost complete absence of distal musculoskeletal manifestations in patients with pure TA suggests different mechanisms of disease in PMR and TA, supporting the view of two separate conditions or one common disease in which host susceptibility influences the clinical expression.

Lack of association between infection and onset of polymyalgia rheumatica.

OBJECTIVE: The etiology of giant cell arteritis (GCA) is unknown, but its sudden onset and the wide variation in incidence reported from various parts of the world suggest a genetic predisposition and/or the influence of environmental factors, such as infectious agents or a seasonal effect. We analyzed the influence of season on GCA in our area over the period 1985-97, as well as the possible association between infection and onset. METHODS: Retrospective study of 143 cases of GCA diagnosed from 1985 to 1997. To evaluate seasonal variation in disease onset, the month of onset of the first symptoms related to GCA was used to calculate season-specific incidence rates. Differences between season incidence rates were assessed by chi-square test. To test for an association between infection and GCA onset, we considered only infections that occurred within 2 months before the onset of disease. Because of the difficulty in determining whether an infection was present using only the clinical and laboratory data recorded in patients' medical charts, we categorized the likelihood of patients having infection into 3 groups: no infection, probable infection, and definite infection. RESULTS: Between 1985 and 1997 (both years included), a total of 143 patients (88 women, 55 men) were diagnosed with GCA. Of these, 85 had isolated polymyalgia rheumatica (PMR), 22 had temporal arteritis (TA) without PMR, and 36 had PMR associated with TA. The main clinical features in our population were similar to those reported in other studies. We found no seasonal variation in disease onset during the 13 year period. Moreover, only one (0.7%) of 143 patients was categorized as a probable infection, whereas definite infection was not observed in any case. From these results, the hypothesis of an infectious cause for GCA seems highly improbable. CONCLUSION: We were unable to observe a seasonal pattern or an association between infection and the onset of GCA.

Longterm therapy in polymyalgia rheumatica: effect of coexistent temporal arteritis.

OBJECTIVE: To analyze the clinical course and duration of therapy in a series of 104 patients with polymyalgia rheumatica (PMR), identifying factors that influence prolonged steroid use and relapses. METHODS: Retrospective study of 104 cases of PMR diagnosed from 1985 to 1995. Patients were followed from time of diagnosis until either their death or December 31, 1995. To assess the effects of the coexistence of temporal arteritis (TA) on outcome in PMR, patients were grouped according to the absence or presence of arteritis. Kaplan-Meier survival analysis was performed to evaluate the duration of therapy, the incidence of prolonged remissions and relapses, and the average time to relapse. The log-rank test was used to test for significant differences between groups. Multivariate Cox proportional hazards regression models were used to identify variables associated with the occurrence of these events. RESULTS: Of 104 patients, 69 had pure PMR and 35 had both PMR and TA. Although some patients had limited disease requiring limited corticosteroid (CS) therapy (usually about 2 years), a significant number of patients had sustained disease requiring longterm treatment. Patients with simultaneous arteritis tended to have a longer duration of therapy, but no increased risk of relapse. By multivariate analysis, increasing age at diagnosis, female sex, higher baseline erythrocyte sedimentation rate, and lower daily CS dose were significant risk factors associated with long duration of therapy. No clinical feature predicted patients who were more likely to relapse. CONCLUSION: Although there was great individual patient variation, we found that typically CS therapy lasted at least 2 years. Our findings allow the identification of patients who are particularly predisposed to need prolonged and higher dose cumulative steroid therapy and merit preventive strategies to decrease the incidence of steroid related adverse events.

Giant cell tumor of the foot phalanges in children: a case report.

Giant cell tumor of the bone is infrequent in the phalanges of the toes and is extremely rare in children. A case of giant cell tumor of the proximal phalanx of the big toe on the left foot in a 12-year-old boy is reported. The tumor was treated by partial resection of the phalanx and repair of the osseous defect with an autologous iliac crest graft. A literature review showed few cases of giant cell tumor at this site.

[Secondary amyloidosis in rheumatoid arthritis. A clinical study of 29 patients]. / Amiloidosis secundaria a la artritis reumatoide. Estudio clínico de una serie de 29 casos.

BACKGROUND: To study the clinical features, outcome and response to therapy in 29 cases of rheumatoid arthritis (RA) with secondary amyloidosis (AA). PATIENTS AND METHOD: Twenty-nine patients with RA and AA who were diagnosed during 11 years. RESULTS: The mean age and the mean duration of RA were 63 +/- 12 years and 15 +/- 7 years respectively. The most common initial clinical feature was renal involvement (83%). Nineteen patients were treated with methotrexate. The mean survival time was 42 +/- 8 months. Eleven patients (38%) have deceased. CONCLUSION: Our data confirms that AA in RA is a serious complication with a bleak prognosis. A normal renal function is a good prognosis indicator.

Sudden cochlear hearing loss in a patient with Behçet's disease.

A Behçet's disease patient developed sudden cochlear hearing loss during a flare of her disease. Prednisone and cyclosporin therapy was ineffective, probably because it was initiated late. Sensorineural hearing loss is a rare but underrecognized complication of various forms of vasculitis such as Wegener's granulomatosis, polyarteritis nodosa, giant cell arteritis and Behçet's disease. Its importance lies in the need for an early diagnosis, since prompt treatment with steroids and immunosuppressive agents may lead to restoration of hearing.

[Reactive arthritis. Prospective clinico-microbiologic study]. / Artritis reactivas. Estudio prospectivo clínico-microbiológico.

We study with a prospective design all reactive arthritis diagnosed at the Service of Rheumatology in Bellvitge Hospital during a thirty months period, from August 1985 to February 1988; in order to describe its clinical features, etiological factors and prognosis. Thirty patients who fulfilled the admission criteria were admitted to the study. A previously designed protocol of clinical, serological and microbiologic study was applied to all. A microorganism was identified in 21 patients. In 14 cases it was Yersinia enterocolitica, in 4 Chlamydia trachomatis, in 2 Salmonella enteritidis and in 1 a group A beta-hemolytic Streptococcus. The averaged length of the disease was 7.6 +/- 8 months.

Role of technetium-99m diphosphonate and gallium-67 citrate bone scanning in the early diagnosis of infectious spondylodiscitis. A comparative study.

A comparative study of the parts played by technetium-99m diphosphonate and gallium-67 citrate bone scanning in the early diagnosis of infectious spondylodiscitis is presented. Nineteen patients were included in the study. All patients (11 men aged 19-70 years and eight women aged 18-72 years) had a history of back pain varying in duration from one to 15 weeks. A 99mTc diphosphonate bone scan was positive in 17 patients. The two patients with negative results had less than two weeks of back pain. The 67Ga citrate bone scan showed uptake in all patients.

Infectious arthritis in patients with rheumatoid arthritis.

Eleven cases of infectious arthritis occurring in patients with rheumatoid arthritis are reported. Staphylococcus aureus was the causative organism in eight patients. Streptococcus anginosus and Streptococcus agalactiae in one patient each, and Mycobacterium tuberculosis in two patients. The mean duration of symptoms before diagnosis was 16 days in patients with pyogenic arthritis. The diagnosis of joint infection caused by Mycobacterium tuberculosis was especially delayed (57 days). Four patients died; they were found to have a longer time to diagnosis and two of them had multiple joint infection. Although Staphylococcus aureus is the microorganism most often affecting patients with rheumatoid arthritis, infection caused by Mycobacterium tuberculosis must also be considered in such patients.

Familial sarcoidosis: a case report.

The occurrence of sarcoidosis in more than one member in the same family is a fact that has been noted by many authors. It is now recognized as Familial Sarcoidosis, and nearly 450 cases have been reported in the world literature. Included in this figure are consaguineal cases as well as contacts without genetic relationship. The incidence of Familial Sarcoidosis (FS) is in striking contrast in the different series of recorded sarcoidosis cases. While some authors indicate 12% of the sarcoidosis total, others refer to up to 44.7% with an average of 7% in the literature. We report a new case of Familial Sarcoidosis that according to our knowledge of the literature is the first case referred to from Spain.