Programa de intervención en pacientes mayores frágiles dados de alta desde urgencias / Intervention programme for elderly frail patients discharged from the emergency department

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Intervención multidimensional que mejora el pronóstico a corto plazo entre los ancianos frágiles dados de alta desde una unidad de corta estancia: estudio cuasiexperimental / Multidimensional intervention to improve the short-term prognosis of frail elderly patients discharged from a short-stay unit: A quasiexperimental study

Objetivo. Estudiar el efecto de una intervención multidimensional en el pronóstico a 30 días en los ancianos frágiles dados de alta desde una unidad de corta estancia. Material y método. Estudio cuasiexperimental con una cohorte de control histórica. Se incluyeron pacientes frágiles (Identification of Senior at Risk≥2), de≥75 años, dados de alta desde la unidad de corta estancia durante 2 meses en 2013 (grupo control) y un año (2016; grupo de intervención). Se realizó una intervención basada en la activación de recursos, en función de los déficits detectados tras una valoración geriátrica abreviada, más la coordinación con Atención Primaria. La variable de resultado principal fue la presencia de algún resultado adverso (muerte o reingreso por cualquier causa o deterioro funcional grave) a los 30 días del alta. Resultados. Se incluyeron 137 (62,8%) pacientes en el grupo de intervención y 81 (37,2%) en el control. Dieciocho (13,1%) pacientes en el grupo de intervención y 29 (35,8%) en el control presentaron algún evento adverso a los 30 días. Tras un análisis multivariable, se demostró que la realización de una intervención multidimensional fue un factor de protección para la presentación de algún evento adverso a los 30 días tras el alta (RR ajustado 0,40; IC 95% 0,23-0,68; p=0,001). Conclusiones. La realización de un plan de atención individualizado, basado en la activación de recursos, en función de los déficits detectados tras una valoración geriátrica abreviada, y la coordinación con Atención Primaria, entre los pacientes ancianos frágiles podría mejorar los resultados a los 30 días tras el alta desde una UCE

Objective. To study the effect of a multidimensional intervention on the prognosis at 30 days for frail elderly patients discharged from a short-stay unit. Material and method. A quasiexperimental study was conducted with a historical control cohort. We included frail patients (Identification of Seniors at Risk score≥2) 75 years of age or older, discharged from an short-stay unit over 2 months in 2013 (control group) and in 2016 (intervention group). An intervention was conducted based on the activation of resources, based on the deficiencies detected after an abbreviated geriatric assessment, in conjunction with Primary Care. The main endpoint was the presence of an adverse result (death or readmission for any cause or severe functional impairment) at 30 days of discharge. Results. We included 137 (62.8%) patients in the intervention group and 81 (37.2%) in the control group. Eighteen (13.1%) patients in the intervention group and 29 (35.8%) in the control group presented an adverse event at 30 days. A multivariate analysis showed that the implementation of a multidimensional intervention was a protective factor for presenting an adverse event at 30 days of discharge (adjusted RR 0.40; 95% CI 0.23-0.68; P=.001). Conclusions. The implementation of an individual care plan for frail elderly patients, based on the activation of resources according to the deficiencies detected after an abbreviated geriatric assessment and in conjunction with Primary Care, could improve the results at 30 days of discharge from an short-stay unit

Multidimensional intervention to improve the short-term prognosis of frail elderly patients discharged from a short-stay unit: A quasiexperimental study. / Intervención multidimensional que mejora el pronóstico a corto plazo entre los ancianos frágiles dados de alta desde una unidad de corta estancia: estudio cuasiexperimental.

OBJECTIVE: To study the effect of a multidimensional intervention on the prognosis at 30 days for frail elderly patients discharged from a short-stay unit. MATERIAL AND METHOD: A quasiexperimental study was conducted with a historical control cohort. We included frail patients (Identification of Seniors at Risk score≥2) 75 years of age or older, discharged from an short-stay unit over 2 months in 2013 (control group) and in 2016 (intervention group). An intervention was conducted based on the activation of resources, based on the deficiencies detected after an abbreviated geriatric assessment, in conjunction with Primary Care. The main endpoint was the presence of an adverse result (death or readmission for any cause or severe functional impairment) at 30 days of discharge. RESULTS: We included 137 (62.8%) patients in the intervention group and 81 (37.2%) in the control group. Eighteen (13.1%) patients in the intervention group and 29 (35.8%) in the control group presented an adverse event at 30 days. A multivariate analysis showed that the implementation of a multidimensional intervention was a protective factor for presenting an adverse event at 30 days of discharge (adjusted RR 0.40; 95% CI 0.23-0.68; P=.001). CONCLUSIONS: The implementation of an individual care plan for frail elderly patients, based on the activation of resources according to the deficiencies detected after an abbreviated geriatric assessment and in conjunction with Primary Care, could improve the results at 30 days of discharge from an short-stay unit.

[Donation after cardiac death: cardiac arrest during donor maintenance after brain death]. / Donación tras la muerte cardíaca. Parada cardíaca en el mantenimiento del donante en muerte encefálica.

Brain death implies the complete cessation of activity in both cerebral hemispheres and in the brainstem; this leads to severe physiopathological disorders that make donor maintenance complex and involve the concomitant risk of rapid organ deterioration. The heart is one of the target organs in this process of multiple organ failure. Myocardial stunning occurs due to a "catecholamine storm" and subsequent release of many proinflammatory mediators, free oxygen radicals, and electrolyte imbalance secondary to insipid diabetes and hypothermia. Cardiac arrest during the maintenance of a donor after brain death is relatively frequent. The shortage of organs for transplantation has led to the broadening of the criteria for organ donation to include donation after cardiac death or non heart beating donation, among others.

Donación tras la muerte cardíaca. Parada cardíaca en el mantenimiento del donante en muerte encefálica / Donation after cardiac death: Cardiac arrest during donor maintenance after brain death

La muerte encefálica comporta el cese completo e irreversible de las funciones de ambos hemisferios cerebrales y del tronco encefálico. Esto conlleva trastornos fisiopatológicos muy graves que hacen que el mantenimiento del donante sea complejo y el riesgo de deterioro orgánico aumente de forma muy rápida. El corazón es uno de los órganos diana en este proceso evolutivo de fracaso multiorgánico. Sobre él actúan el propio aturdimiento miocárdico producido por la tormenta catecolamínica y posteriormente la liberación de multitud de mediadores proinflamatorios, radicales oxígeno libres y el desequilibrio hidroelectrolítico secundario a la diabetes insípida e hipotermia. La parada cardíaca en el mantenimiento del donante en muerte encefálica es una situación aún relativamente frecuente. La carencia de órganos para el trasplante ha llevado a desarrollar programas de donación con criterios expandidos, entre los que se incluye la donación tras la muerte cardíaca o donación a corazón parado (AU)

Brain death implies the complete cessation of activity in both cerebral hemispheres and in the brainstem; this leads to severe physiopathological disorders that make donor maintenance complex and involve the concomitant risk of rapid organ deterioration. The heart is one of the target organs in this process of multiple organ failure. Myocardial stunning occurs due to a «catecholamine storm» and subsequent release of many proinflammatory mediators, free oxygen radicals, and electrolyte imbalance secondary to insipid diabetes and hypothermia. Cardiac arrest during the maintenance of a donor after brain death is relatively frequent. The shortage of organs for transplantation has led to the broadening of the criteria for organ donation to include donation after cardiac death or non heart beating donation, among others (AU)

Relaciones de la facultad de medicina con el hospital universitario. La enseñanza de la medicina clínica / Relationships between the medical school and the university hospital. The teaching of clinical medicine

Las nuevas necesidades en la formación de los futuros médicos, particularmente aquellas relacionadas con la definición, adquisición y evaluación de competencias, necesitan una potente estructura hospitalaria que soporte la docencia práctica en habilidades clínicas. El trascendente papel reservado a los hospitales universitarios significa que la institución sanitaria debe adaptarse para facilitar la implantación de una enseñanza de calidad, en aspectos estructurales y en el proceso de definición de objetivos y de evaluación de resultados a través de pruebas objetivas. Ellos implica cambios en la estructura, en la organización y en la gestión (AU)

The training of future doctors entails a series of new needs, especially in relation to the definition, acquisition and evaluation of abilities, and this requires the backing of a powerful hospital structure that ist capable of offering the practical teaching and learning of clinical skills. The fundamental role played by university hospitals means that the health care institution must adapt itself to facilitate the implementation of high quality teaching, both as regards structural aspects and in the process of defining aims and evaluationg results by means of objective testing. This involves changes in the structure, the organisation and management (AU)

Hypersensitivity to Vespula and Polistes: can we tell the primary sensitization from the clinical history?

OBJECTIVE: To study the relationship between the primary sensitization to wasp venoms and the geographical and seasonal circumstances of the anaphylaxis-induced sting. METHODS: We performed a retrospective review of 115 patients (age 10-80) who suffered a systemic reaction to a wasp sting. Season and type of locality (urban or rural) at the moment of the sting were recorded. Serum specific IgE levels to venoms from Vespula and Polistes were measured, and a primary sensitization was determined to whichever genus of wasp for which the highest class of specific IgE was observed. The primary sensitization in relation to the type of locality and the season was assessed using the chi-square test. RESULTS: Most reactions occurred in urban areas (67.8 %), and in the summer season (63.4 %). Most patients were sensitized to Vespula venom (94.8 %). Primary sensitization was to Vespula in 56.5 %, to Polistes in 10.4 %, and undetermined in 33 %. The distribution of geographical areas did not show significant differences in relation to primary sensitization (p > 0.05). Most patients with primary sensitization to Vespula suffered the anaphylaxis-induced sting after the spring season, with a statistically significant result (p < 0.05). CONCLUSION: In our population, the probability of Vespula sting is higher than Polistes sting when the reaction occurs after spring. This finding can help us to identify the responsible vespid when the diagnostic tests do not provide an accurate result.

Hypersensitivity to Vespula and Polistes: can we tell the primary sensitization from the clinical history? / Hipersensibilidad a vespula y polistes: ¿se puede determinar la sensibilización predominante a partir de la historia clínica?

Objective: To study the relationship between theprimary sensitization to wasp venoms and the geographicaland seasonal circumstances of the anaphylaxis-induced sting.Methods: We performed a retrospective review of115 patients (age 10-80) who suffered a systemicreaction to a wasp sting. Season and type of locality(urban or rural) at the moment of the sting wererecorded. Serum specific IgE levels to venoms fromVespula and Polistes were measured, and a primarysensitization was determined to whichever genus ofwasp for which the highest class of specific IgE wasobserved. The primary sensitization in relation to thetype of locality and the season was assessed usingthe chi-square test.Results: Most reactions occurred in urban areas(67.8 %), and in the summer season (63.4 %). Mostpatients were sensitized to Vespula venom (94.8 %).Primary sensitization was to Vespula in 56.5 %, toPolistes in 10.4 %, and undetermined in 33 %. Thedistribution of geographical areas did not show significantdifferences in relation to primary sensitization(p > 0.05). Most patients with primary sensitization toVespula suffered the anaphylaxis-induced sting afterthe spring season, with a statistically significant result(p < 0.05).Conclusion: In our population, the probability ofVespula sting is higher than Polistes sting when thereaction occurs after spring. This finding can help usto identify the responsible vespid when the diagnostictests do not provide an accurate result

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Systemic reactions to wasp sting: is the clinical pattern related to age, sex and atopy?

BACKGROUND: The aim of this study was to analyze the frequency of clinical features and the severity of systemic reactions to wasp stings, and to establish their relationship with mean age, sex, and atopy. METHODS: We studied 115 patients who suffered an anaphylactic reaction to wasp sting and showed specific IgE to venoms from Vespula and/or Polistes. In all patients, age, sex and personal history of atopy were registered. Cutaneous, respiratory, cardiovascular and gastrointestinal involvement during the course of the reaction was investigated. Each patient was assigned a severity grade according to a simple two-grade classification based on Müller's criteria. Bivariable analysis was performed to analyze the associations among mean age, sex and atopy and the symptoms and severity of the reaction. RESULTS: The mean age was 40.2 years. There were 60 males (52.2 %) and 55 females (47.8 %). Twenty-six patients (22.6 %) were atopic. The percentages of involved systems were as follows: skin 90.4 %, respiratory 54.8 %, cardiovascular 33.9 %, and gastrointestinal 21.7 %. Reactions were mild in 40.8 %, and severe in 59.1 %. The mean age was higher in patients without cutaneous symptoms (p < 0.05). Cardiovascular involvement was more frequent in males (p < 0.05). No other significant differences were found. CONCLUSION: The symptoms of systemic reactions to wasp venom most frequently involved the skin, while reactions without cutaneous involvement were more frequent in older patients. Cardiovascular involvement was more common in males. The clinical pattern was not determined by atopy and the variables studied were not related to severity.

Systemic reactions to wasp sting: is the clinical pattern related to age, sex and atopy?

Background: The aim of this study was to analyze the frequency of clinical features and the severity of systemic reactions to wasp stings, and to establish their relationship with mean age, sex, and atopy. Methods: We studied 115 patients who suffered an anaphylactic reaction to wasp sting and showed specific IgE to venoms from Vespula and/or Polistes. In all patients, age, sex and personal history of atopy were registered. Cutaneous, respiratory, cardiovascular and gastrointestinal involvement during the course of the reaction was investigated. Each patient was assigned a severity grade according to a simple two-grade classification based on Müller's criteria. Bivariable analysis was performed to analyze the associations among mean age, sex and atopy and the symptoms and severity of the reaction. Results: The mean age was 40.2 years. There were 60 males (52.2 %) and 55 females (47.8 %). Twenty-six patients (22.6 %) were atopic. The percentages of involved systems were as follows: skin 90.4 %, respiratory 54.8 %, cardiovascular 33.9 %, and gastrointestinal 21.7 %. Reactions were mild in 40.8 %, and severe in 59.1 %. The mean age was higher in patients without cutaneous symptoms (p < 0.05). Cardiovascular involvement was more frequent in males (p < 0.05). No other significant differences were found. Conclusion: The symptoms of systemic reactions to wasp venom most frequently involved the skin, while reactions without cutaneous involvement were more frequent in older patients. Cardiovascular involvement was more common in males. The clinical pattern was not determined by atopy and the variables studied were not related to severity

Fundamento: El propósito de este estudio es analizar la frecuencia de manifestaciones clínicas y la gravedad de las reacciones sistémicas a picadura de avispa, así como establecer su relación con la edad media, el sexo y la atopia. Métodos: Estudiamos 115 pacientes que han sufrido una reacción anafiláctica a picadura de avispa y que muestran IgE específica frente a venenos de Vespula y/o Polistes. En cada caso re registra la edad, el sexo y los antecedentes personales de atopia. Se investigó la presencia de afectación cutánea, respiratoria, cardiovascular y gastrointestinal en el curso de la reacción, y se asignó un grado de severidad mediante un sistema de clasificación en dos grados a partir de los criterios de Müller. Se realizó un análisis bivariante para relacionar la edad, el sexo y la atopia con los síntomas y la gravedad de la reacción. Resultados: La edad media fue de 40,2 años. Los varones eran 60 (52,2%) y las mujeres 55 (47,8%). Veintiséis pacientes (22,6%) eran atópicos. El porcentaje de afectación por sistemas fue como sigue: cutánea 90,4%; respiratoria 54,8%; cardiovascular 33,9%; gastrointestinal 21,7%. Las reacciones fueron leves en un 40,8% y graves en un 59,1%. La edad media fue superior en pacientes sin síntomas cutáneos (p>0,05) y la afectación cardiovascular resultó mas frecuente en varones (p>0,05). No se observaron otros hallazgos significativos. Conclusión: Se concluye que los síntomas más frecuentes de las reacciones sistémicas a veneno de avispa son los cutáneos, siendo las reacciones sin afectación cutánea más típicas de personas de edad avanzada. La presencia de síntomas cardiovasculares es más común en varones. La atopia no determina el cuadro clínico y la gravedad no se relaciona con las variables estudiadas

[Clinical and therapeutic characteristics in patients with heart failure cared in a tertiary hospital]. / Características clínicas y terapéuticas de los pacientes con insuficiencia cardíaca en un hospital de tercer nivel.

INTRODUCTION: Heart failure shows high incidence and prevalence in our population. Objectives of our study are to describe the profile of patients cared in the Internal Medicine Department of our hospital, in order to analyze the therapeutic characteristics and to know the degree of utilization of different pharmacological groups. PATIENTS AND METHODS: A cross-sectional study with collection of data from clinical records of patients admitted to 2002 with the diagnosis of heart failure in Internal Medicine Department of San Carlos Hospital in Madrid. Total patients with heart failure was 1,338. Calculating the sample size with a precision of 5% and a confidence interval of 95%, the number of randomly selected clinical records was 130. Data were obtained with a questionnaire for analysis of different clinical and therapeutic parameters. RESULTS: The average age was 80.3 (SD: 9.64) years, and most patients were women. Most frequent associated pathology was hypertension, and in 70.2% patients a diagnosis of some disease was established. Diuretics were the drugs most utilized and its prescription increased at discharge (p < 0.0001). Furthermore, the higher the functional class the more diuretics were prescribed. Beta-blockers were prescribed in 7.1% patients, more frequently in patients with an ejection fraction higher than 35% (p = 0.042). DISCUSSION AND CONCLUSIONS: Patients with heart failure in our environment have advanced age, shows important comorbidities, and suffer an advanced functional class heart failure, being the diuretics their essential treatment. We observed that there is no uniformity concerning the treatment with regard to the last recommendations, and that there is a limited utilization of drugs as beta-blockers that have demonstrated increase the survival of patients with heart failure.

Características clínicas y terapéuticas de los pacientes con insuficiencia cardíaca en un hospital de tercer nivel / Clinical and therapeutic characteristics in patients with heart failure cared in a tertiary hospital

Introducción. La insuficiencia cardíaca tiene una elevada incidencia y prevalencia en nuestra población. Los objetivos marcados en nuestro estudio son describir el perfil del paciente que ingresa en los servicios de Medicina Interna de nuestro hospital con objeto de analizar los aspectos terapéuticos y conocer el grado de utilización de los distintos grupos farmacológicos. Material y métodos. Se realiza un estudio transversal recogiendo datos de las historias clínicas de los pacientes ingresados en el año 2002 en los sevicios de Medicina Interna del Hospital Clínico San Carlos de Madrid con el diagnóstico de insuficiencia cardíaca. El total de pacientes con dichas características es de 1.338. Calculando el tamaño muestral con una precisión del 5% y un intervalo de confianza del 95%, el número de historias analizadas es de 130 escogidas de un modo aleatorio. Los datos se recogen mediante un cuestionario que analiza diferentes variables clínicas y terapéuticas. Resultados. La media de edad es de 80,3 (desviación estándar: 9,64) años, siendo en su mayoría mujeres. La patología asociada más frecuente es la hipertensión arterial, existiendo en un 70,2% de los pacientes alguna enfermedad. Los diuréticos son los fármacos más utlizados y su prescripción aumenta al alta (p < 0,0001). Además se prescriben más cuanto peor es la clase funcional. Los bloqueadores beta se prescriben en el 7,1% de los pacientes, más en pacientes con fracciones de eyección superiores al 35% (p = 0,042). Discusión y conclusiones. En nuestro medio los pacientes con IC tienen una edad avanzada, presentan una importante comorbilidad y una clase funcional avanzada, siendo los diuréticos su tratamiento de base. Observamos que no existe homogeneización en cuanto al tratamiento con respecto a las últimas recomendaciones y que hay una escasa utilización de los fármacos que, como los bloqueadores beta, han demostrado un aumento de la supervivencia en la insuficiencia cardíaca

Introduction. Heart failure shows high incidence and prevalence in our population. Objectives of our study are to describe the profile of patients cared in the Internal Medicine Department of our hospital, in order to analyze the therapeutic characteristics and to know the degree of utilization of different pharmacological groups. Patients and methods. A cross-sectional study with collection of data from clinical records of patients admitted to 2002 with the diagnosis of heart failure in Internal Medicine Department of San Carlos Hospital in Madrid. Total patients with heart failure was 1,338. Calculating the sample size with a precision of 5% and a confidence interval of 95%, the number of randomly selected clinical records was 130. Data were obtained with a questionnaire for analysis of different clinical and therapeutic parameters. Results. The average age was 80.3 (SD: 9.64) years, and most patients were women. Most frequent associated pathology was hypertension, and in 70.2% patients a diagnosis of some disease was established. Diuretics were the drugs most utilized and its prescription increased at discharge (p < 0.0001). Furthermore, the higher the functional class the more diuretics were prescribed. Beta-blockers were prescribed in 7.1% patients, more frequently in patients with an ejection fraction higher than 35% (p = 0.042). Discussion and conclusions. Patients with heart failure in our environment have advanced age, shows important comorbidities, and suffer an advanced functional class heart failure, being the diuretics their essential treatment. We observed that there is no uniformity concerning the treatment with regard to the last recommendations, and that there is a limited utilization of drugs as beta-blockers that have demonstrated increase the survival of patients with heart failure

[Kikuchi's disease: a case report and literature review]. / Enfermedad de Kikuchi: a propósito de un caso y revisión de la literatura.

Kikuchi-Fujimoto disease, also known as hystiocytic necrotizing lymphadenitis, is an unusual entity which affects predominantely young Asiatic females, although its distribution is world-wide. Cardinal symptoms are fever and adenopathy, generally cervical, although generalized and extraganglionar cases have been described. Considered a self-limiting disease, it has to be differentiated by pathologic analysis from other less-benign disorders such as lymphoma or histiocytoma, which bear worse prognosis and may require specific treatment. Although the origin of this disease is unknown, a viral origin is postulated and the immune system is involved Kikuchi disease has been associated to other entities such as subcutaneous lupus erythematosus, Hashimoto thyroiditis, etc... requiring that patients be followed immunologically alter diagnosis of this disease. We present a case of Kikuchi disease associated with subacute lymphocytic thyroiditis.

Enfermedad de Kikuchi: a propósito de un caso y revisión de la literatura / Kikuchi´s disease: a case report and literature review

La enfermedad de Kikuchi-Fujimoto, también conocida como linfadenitis necrotizante histiocitaria no linfocítica, es una entidad clínica poco frecuente que afecta principalmente a mujeres jóvenes de procedencia asiática, aunque tiene una distribución universal. Es característica la aparición de fiebre y adenopatías, habitualmente localizadas a nivel cervical, aunque hay casos descritos de afectación generalizada o extraganglionar. Su interés estriba en que, aun siendo un proceso benigno y autolimitado, es necesario un diagnóstico anatomo-patológico de exclusión de otras entidades clínicas de peor pronóstico que precisan tratamiento más específico (linfoma, histiocitoma...).A pesar de que su etiopatogenia es desconocida, se postula un origen vírico y una mediación inmunológica en el desarrollo de la enfermedad. Se ha descrito asociación de la enfermedad de Kikuchi con procesos como el lupus eritematoso subcutáneo, tiroiditis/ Hashimoto, lo que obliga a un posterior seguimiento inmunológico de la enfermedad tras su diagnóstico, ante la posibilidad de aparición con el tiempo de un proceso autoinmune. Se presenta el caso de una enfermedad de Kikuchi asociada a tiroiditis subaguda linfocitaria (AU)

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Síndrome de hipersensibilidad retardada a fármacos / Drug-induced delayed hypersensitivity syndrome

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Tratamiento con interferón en la hepatitis crónica VCH e hipotiroidismo autoinmune / Interferon therapy in chronic hepatitis and autoinmune hypothyroidism

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[Alpha tumor necrosis factor in central nervous system disease associated with HIV infection]. / El factor de necrosis tumoral alfa en la afectación del sistema nervioso central asociada a la infección por el VIH.

The aim of the present study is to evaluate the relationship between the alpha tumor necrosis factor (TNF-alpha), interleukin 1 beta (IL-1 beta) and the neurological disease associated to the HIV-1 infection and different neurological manifestations (15 infections of the CNS and 11 AIDS-dementia complexes) and 14 from a control group. The mean value of TNF-alpha in CSF of patients with HIV-1 infection and AIDS-dementia complex was 19.8 +/- 30.6 pg/ml, superior to that of the control group (p < 0.05). The group of patients with HIV-1 and opportunistic CNS infection has a TNF-alpha value of 28.5 +/- 37.8 pg/ml, that is superior to that of the patients with the AIDS-dementia complex (TNF-alpha = 7.9 +/- 9.4 pg ml; p < 0.05). Within the group of patients with a CNS infection, the value of TNF-alpha was greater in those in the acute phase (44.2 +/- 42.4 pg/ml) than in those in the chronic phase (6.8 +/- 7.6 pg/ml; p < 0.05). The TNF-alpha in the CSF is a good marker of infection of the CNS in the HIV-1 infection.