Five-year survival and prognostic factors in a cohort of hospitalized nonagenarians.

BACKGROUND: The number of hospitalized nonagenarians is increasing. Only a few studies have evaluated long-term predictors of survival in these patients. The aim of this study was to determine the 5-year outcome of a cohort of hospitalized nonagenarians, and to identify predictors of long-term survival. METHODS: In 124 consecutive medical hospitalized patients older than 89 years, and followed up during 5 years, the following variables were prospectively recorded: sociodemographic characteristics, main diagnoses, Charlson comorbidity index, Barthel index, Lawton-Brody test, Mini-Mental State Examination, Short Portable Mental Status Questionnaire of Pfeiffer, Mini Nutritional Assessment, albumin levels, and the 5-year survival. RESULTS: Out of the 124 patients, 109 died (87.9%) during the follow-up. The probability of being alive at 1, 3 and 5 years was 45%, 22% and 12%, respectively. A worse 5-year survival was significantly related to the diagnoses of pneumonia (p=0.037), heart failure (p=0.045), higher Charlson index (p=0.026), poorer functional status measured by the Barthel index (p=0.003), and the Lawton-Brody test (p=0.007), cognitive impairment measured by the Pfeiffer test (p=0.011), and lower levels of albumin (p=0.028). In the multivariate analysis, the Charlson index (p<0.001), and the Barthel index (p=0.003) were independently related to 5-year survival. These two variables were also 5-year survival prognostic factors in the subgroup of discharged patients. A prognostic index using these two variables was created: PI=(0.2 × Charlson index + 0.6 × Barthel index) × 0.92. CONCLUSIONS: In hospitalized nonagenarian patients, poor scores in the Barthel Index and a higher comorbidity evaluated by the Charlson index are independently related to 5-year survival.

A 69-year-old man with excessive sweating of the right hemithorax.

The pure autonomic failure is a rare entity, with only a few cases reported in the literature. The authors describe a case with compensatory excessive sweating of the right hemithorax as an initial manifestation of a pure autonomic failure, and the authors review the clinical characteristics of this disease. A 69-year-old man presented excessive sweating of the right hemithorax. Physical examination revealed orthostatic hypotension. No other neurological features were present. The autonomic study showed a low heart rate response to the Valsalva maneuver and reduced supine plasma norepinephrine levels. A pure autonomic failure was diagnosed. Treatment did not improve patient's symptoms. Anhidrosis with asymmetrical compensatory hyperhidrosis can be the only symptom of a pure autonomic failure. The authors highlight an unusual form of presentation of a rare disease, difficult to diagnose if it is not taken into consideration.

HDL cholesterol levels in children with mild hypercholesterolemia: effect of consuming skim milk enriched with olive oil and modulation by the TAQ 1B polymorphism in the CETP gene.

BACKGROUND: This study aimed to examine the changes in serum lipids in children with mild hypercholesterolemia after the use of skim milk or olive-oil-enriched skim milk in their diet and the modulation of lipid levels by the Taq 1B polymorphism in the cholesteryl-ester transfer protein gene. METHODS: Thirty-six prepubertal children with mild hypercholesterolemia were randomly assigned in a crossover design into 2 groups of 16 and 20 individuals. Both groups received, in sequential inverse order, the 2 types of milk for 2 periods of 6 weeks. RESULTS: Carriers of at least 1 B2 allele had an adjusted basal HDL cholesterol level significantly higher than children with the B1B1 genotype (1.291 mmol/l, 95% CI: 1.184-1.397, vs. 1.082 mmol/l, 95% CI: 0.931-1.233; p = 0.027). In contrast, there were no significant differences in the adjusted basal levels of apolipoprotein A-I (B2 carriers: 1.292 g/l, 95% CI: 1.218-1.367; B1B1 genotype: 1.215 g/l, 95% CI: 1.109-1.320; p = 0.223). The intake of olive-oil-enriched skim milk caused significant increases in HDL cholesterol and apolipoprotein A-I, both in B2 (0.089 mmol/l, 95% CI: 0.032-0.146, p = 0.005; 0.55 g/l, 95% CI: 0.012-0.098; p = 0.018) and in B1B1 carriers (0.179 mmol/l, 95% CI: 0.096-0.262; p < 0.001; and 0.095 g/l, 95% CI: 0.032-0.157; p = 0.003). This increase in HDL cholesterol was significantly higher in the B1B1 group (p = 0.049). CONCLUSION: The consumption of skim milk enriched with olive oil increases the HDL cholesterol and apolipoprotein A-I levels in children with hypercholesterolemia, this effect being more intense in carriers of the B1B1 genotype.

Hepatitis colestática grave por fiebre Q: presentación de un caso / Severe cholestatic hepatitis due to Q fever: Report of a case

La hepatitis colestática grave por Coxiella burnetii es una forma rara de presentación clínica de la fiebre Q aguda, que se detecta muy ocasionalmente en relación con esta enfermedad infecciosa. Se presenta un caso de hepatitis colestática grave por fiebre Q aguda, con clínica de insuficiencia hepática, marcada colestasis e insuficiencia renal. El estudio serológico inicial por fijación de complemento fue negativo en 2 ocasiones, y se precisó de la ayuda de la biopsia transyugular y de la serología por inmunofluorescencia indirecta para el diagnóstico. A pesar del tratamiento con doxiciclina y ciprofloxacino empeoró progresivamente la colestasis y aparecieron insuficiencia hepática y renal, que desaparecieron rápidamente tras tratamiento esteroideo (AU)

Severe cholestatic hepatitis due to Coxiella burnetii is a rare form of clinical presentation of acute Q fever that is only occasionally detected in association with this infectious disease. We report a case of severe cholestatic hepatitis due to acute Q fever, with clinical signs of hepatic insufficiency, marked cholestasis, and renal insufficiency. The results of the initial serologic study using a complement fixation test were negative on two occasions, and transjugular biopsy and serological analysis with indirect immunofluorescence were required to establish the diagnosis. Despite treatment with doxycycline and ciprofloxacin, the cholestasis progressively worsened, with the development of hepatic and renal insufficiency, which rapidly disappeared after corticosteroid treatment (AU)

[Severe cholestatic hepatitis due to Q fever: report of a case]. / Hepatitis colestática grave por fiebre Q: presentación de un caso.

Severe cholestatic hepatitis due to Coxiella burnetii is a rare form of clinical presentation of acute Q fever that is only occasionally detected in association with this infectious disease. We report a case of severe cholestatic hepatitis due to acute Q fever, with clinical signs of hepatic insufficiency, marked cholestasis, and renal insufficiency. The results of the initial serologic study using a complement fixation test were negative on two occasions, and transjugular biopsy and serological analysis with indirect immunofluorescence were required to establish the diagnosis. Despite treatment with doxycycline and ciprofloxacin, the cholestasis progressively worsened, with the development of hepatic and renal insufficiency, which rapidly disappeared after corticosteroid treatment.

[Contributions of the ambulatory blood pressure monitoring to the values measured at the medical office]. / Aportaciones de la monitorización ambulatoria a la presión arterial casual.

OBJECTIVE: To communicate our experience with this technique centred in the definition of the patterns and the peculiar characteristics of the rising pattern. METHODS: During a four year period, the ambulatory blood pressure monitoring was obtained in 500 hypertensive patients with difficult to control blood pressure or of recent detection, following the guide of the Cardiorisk project. RESULTS: The most frequent pattern observed was non-dipper (46.6%). The pulse pressures obtained by ambulatory and office blood pressure monitoring kept a correlation that serve as guide to the office blood pressure measurements. The level of control by ambulatory monitoring blood pressure is only discretely superior to the office blood pressure if the cases of white coat and masked hypertension are considered. The rising pattern is associated to a major vascular risk. CONCLUSIONS: An increased vascular risk is noticed in the rising pattern with respect to other patterns. The morphology of different atypical patterns was also presented. The help of the ambulatory blood pressure monitoring along with one taken in the office determined a great aid to interpret the huge variability of the arterial pressure.

Pyogenic liver abscesses: mortality-related factors.

GOAL: To analyse the characteristics and mortality-related factors in a series of patients hospitalized for pyogenic liver abscess (PLA). BACKGROUND: Pyogenic liver abscesses are infrequent but potentially life threatening. Factors related to mortality have been less studied. STUDY: The medical records of 84 patients, 56 men and 28 women, mean age of 64.4 years (SD: 14) who were hospitalized between 1992 and 2005 owing to a PLA were reviewed. The past medical history, clinical signs and symptoms, laboratory values, imaging studies, microbiological features, treatment, complications and mortality were recorded. Factors related to complications and mortality were analysed. RESULTS: One or more bacteria were isolated in 65 patients (77.4%), being Streptococcus spp. (40.5%), Escherichia coli (27.4%), Klebsiella spp. (14.3%) and anaerobics (17.9%) the most frequent isolates. Complications developed in 60.7% of the cases, the most common one being a right pleural effusion (34.5%). Mortality rate was 19% (95% confidence interval: 10-28%). Mortality was associated with age (P=0.005), a previous history of coronary heart disease (P=0.016), absence of fever (P=0.001), development of sepsis and/or septic shock (P<0.001), raise of bilirubin levels (P=0.004), a biliary (P=0.035), or cryptogenetic origin (P=0.039), infection owing to E. coli (P=0.01) or to Candida (P=0.009) and development of pneumonia (P<0.001). Logistic regression revealed sepsis and/or septic shock as an independent risk factor for mortality. CONCLUSIONS: Mortality associated with PLA is high. The main risk factor for mortality is the development of sepsis and/or septic shock.

Utilidad diagnóstica del cuestionario alcohol use disorders identification test (AUDIT) para detectar el consumo de alcohol de riesgo en atención primaria / Diagnostic usefulness of Alcohol Use Disorders Identification Test (AUDIT) for detecting hazardous alcohol consumption in primary care settings

FUNDAMENTO: Evaluar la utilidad diagnóstica del cuestionario AUDIT (Alcohol Use Disorders Identification Test) para detectar el consumo de alcohol de riesgo en atención primaria, valorar las posibles diferencias en función del sexo o la edad y comparar su utilidad con la de otros métodos utilizados habitualmente (CAGE y marcadores biológicos). PACIENTES Y MÉTODO: Estudio descriptivo transversal de evaluación de pruebas diagnósticas, en el que intervinieron 500 pacientes elegidos al azar de la consulta de un centro de salud. Se recogió el consumo de alcohol mediante una encuesta semiestructurada, considerándose consumo de riesgo la ingestión igual o superior a 35 UBE (unidades de bebida estándar) por semana en varones y 21 en mujeres. Se administraron los cuestionarios AUDIT y CAGE, y se determinaron los valores de GGT, VCM, AST, ALT, fosfatasa alcalina, plaquetas, triglicéridos y ácido úrico. Para cada uno de ellos se calcularon la sensibilidad, especificidad, valor global, valores predictivos y cocientes de probabilidad positivos y negativos, así como el área bajo la curva ROC de los cuestionarios. RESULTADOS: La sensibilidad del AUDIT para detectar a bebedores de riesgo fue del 89 por ciento; la especificidad, del 93 por ciento, y el área bajo la curva ROC, de 0,98 (intervalo de confianza [IC] del 95 por ciento, 0,96-0,99). Su sensibilidad fue menor en las mujeres (el 60 frente al 78 por ciento) y en los pacientes menores de 60 años (el 86 frente al 100 por ciento). El CAGE obtuvo una sensibilidad del 48 por ciento y una especificidad del 97 por ciento. Los marcadores biológicos tuvieron sensibilidades inferiores al 40 por ciento y especificidades superiores al 90 por ciento. CONCLUSIONES: El AUDIT es un cuestionario útil para detectar el consumo de alcohol de riesgo en atención primaria. Su sensibilidad es menor en mujeres y pacientes menores de 60 años, y su utilidad diagnóstica, claramente superior a la de otros métodos utilizados habitualmente (AU)

Demasiado riesgo cardiovascular y enfermedad poco frecuente / Too much cardiovascular risk and uncommon disease

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