Estudio del consumo de fármacos inadecuados o no indicados en el anciano que ingresa en un Servicio de Medicina Interna / Study of the consumption of innapropiate medicaments in elder hospitalized in the internal medicine service

Introducción: Los pacientes ancianos se caracterizan por el alto grado de polimedicación. Este factor se ha mostrado el más importante en la aparición de efectos adversos (EAF). El estudio de los fármacos ayuda a establecer cuales son inapropiados y por lo tanto se deben retirar, disminuyendo de esta forma la posibilidad de EAF. Material y Métodos: Estudio prospectivo y observacional. Criterio de inclusión: pacientes de > 64 años que ingresan en Medicina Interna. Se definió como fármaco inapropiado los medicamentos de baja utilidad terapéutica (UTB), los no indicados, y los inadecuados para el anciano. Mediante el programa informático SPSS 11.5 se analizaron las posibles variables relacionadas con el consumo. Resultados: Se incluyeron en el estudio 172 ancianos. La media de medicamentos por persona y día fue de 5,34 (0-15). El 52,5% consumían un fármaco inapropiado (36,6% inadecuado para el anciano, 15% noindicado y 12% UTBs). El análisis multivariante asocia el consumo de estos fármacos a un mayor número de patologías (p < 0,012), a un mayor consumo de medicamentos (p < 0,001) y a la procedencia de residencias de ancianos (p < 0,001). Sólo el consumo de fármacos no adecuados para el anciano se asocia a aumento de EAF. Conclusión: La mitad de los ancianos toma al menos un fármaco deforma innecesaria, y la mayoría de estos fármacos favorece la aparición de EAF

Background: The elderly patients are characterized by the high degree of polymedication. This factor is the most important in the appearance of adverse effects (EAD). The study of the medicaments helps to establish which are inappropriate and therefore they must move back, diminishing of this form EAD’s possibility. Patients and Method: Prospective and observacional Study. Criterion of incorporation: patients of > 64 years old, hospitalized in an Internal Medicine Service. There were defined as inappropriate medicament the medicines of low therapeutic utility, them not indicated, and the inadequate ones for the elder. By means of the SPSS 11.5 program the possible variables related with the consumption were analyzed. Results: 172 elders were included in the study. The average of medicines for person and day belonged to 5.34 (0-15). 52.5% was consuming an inappropriate medicament (36.6% inadequate for the elder, 15% not indicated, and 12% UTBs). The analysis multivariant associates the consumption of these medicaments with a major number of diseases (p <0.012), to a major consumption of medicines (p < 0.001) and to the origin of the nursing residences (p < 0.001). Only the consumption of medicaments not adapted for the elder is associated with increase of EAD. Conclusion: The half of the elders takes at least a medicament of unnecessary form, and the majority of these medicaments favors appearance of EAD

[Study of the conpsumption of innapropiate medicaments in elder hospitalized in the Internal Medicine Service]. / Estudio del consumo de fármacos inadecuados o no indicados en el anciano que ingresa en un Servicio de Medicina Interna.

BACKGROUND: The elderly patients are characterized by the high degree of polymedication. This factor is the most important in the appearance of adverse effects (EAD). The study of the medicaments helps to establish which are inappropriate and therefore they must move back, diminishing of this form EAD's possibility. PATIENTS AND METHOD: Prospective and observacional Study. Criterion of incorporation: patients of > 64 years old, hospitalized in an Internal Medicine Service. There were defined as inappropriate medicament the medicines of low therapeutic utility, them not indicated, and the inadequate ones for the elder. By means of the SPSS 11.5 program the possible variables related with the consumption were analyzed. RESULTS: 172 elders were included in the study. The average of medicines for person and day belonged to 5.34 (0-15). 52.5% was consuming an inappropriate medicament (36.6% inadequate for the elder, 15% not indicated, and 12% UTBs). The analysis multivariant associates the consumption of these medicaments with a major number of diseases (p < 0.012), to a major consumption of medicines (p < 0.001) and to the origin of the nursing residences (p < 0.001). Only the consumption of medicaments not adapted for the elder is associated with increase of EAD. CONCLUSION: The half of the elders takes at least a medicament of unnecessary form, and the majority of these medicaments favors appearance of EAD.

Varón de 77 años con ictericia y prurito / 77 year old man with jaundice and pruritus

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[Mechanisms of disease in Mycoplasma pneumoniae infection. Clinical manifestations and complications]. / Mecanismos de enfermedad en la infección por Mycoplasma pneumoniae. Manifestaciones clínicas y complicaciones.

CONTEXT: Mycoplasma pneumonia has been related to several conditions. With this study we have tried to establish the condition more frequently associated and their physiopathological mechanism. METHOD: One-hundred and five patients admitted to Puerta de Hierro Hospital between March 1996 and July 2001, with IgM positive serology to Mycoplasma were evaluated. Thirty four cases were selected upon the basis of two criteria: patients which positivity was confirmed by seroconversion, elevation of the antibody titer, or confirmation by complement fixation were included, and patients with some intercurrent condition or with other diagnoses were ruled out. RESULTS: 26 patients (77%) showed a respiratory infection, and 20 of them showed a pneumonia. Two types of complications were observed. The first type were the complications due to an invasion of the tissue by Mycoplasma, with 5 cases of pleuropericarditis and three cases of pleuritis; in 5 of these there was simultaneously a respiratory process. The second type were the complications mediated by an autoimmune mechanism, with two cases of reactive arthritis, one case of vasculitis with cutaneous predominance, one case of urticaria a frigore, three cases of lymphocytic meningitis, one case of disseminated encephalitis, one patient with Guillain-Barré syndrome and one case of Adie's tonic pupil. Six of these patients showed a respiratory infection on the previous days with an average delay of 10 days between the beginning of the respiratory symptomatology and the appearance of one of these diseases. CONCLUSIONS: Mycoplasma pneumoniae can give rise to disease through a mechanism of direct invasion and through autoimmunity mechanisms. The second group of complications is seen by more frequency in young women.

[Preliminary study of the drug consumption in hospitalized elders]. / Estudio piloto sobre el consumo de fármacos en ancianos que ingresan en un hospital.

BACKGROUND: The absence of studies that evaluate the effect of the medical acts is an example of "mala praxis". The irrational use of medications is one of these cases. This study shows the characteristics of the drugs consumption in elders. MATERIAL AND METHODS: We include 53 elders hospitalized between 1/02/02 and the 31/05/02. RESULTS: The elders received an average of 6.45 medicaments/day. The factors of more consumption are the origin from nursing home residents and the number of previous surgeries. The adverse effects were related in 25% of the hospitalizations. CONCLUSIONS: The basis of this situation is in the loss of the global perspective of the patients and in the abuse of the sanitary resources. Each drug is the result of an isolated medical act, determining the appearance of iatrogenic disease.

Estudio piloto sobre el consumo de fármacos en ancianos que ingresan en un hospital / Preliminary study of the drug consumption in hospitalized elders

Fundamento: La ausencia de estudios sobre el resultado de actos médicos conlleva mala praxis. El uso irracional de fármacos es uno de estos casos. Este estudio muestra las características del consumo de medicamentos en mayores de 65 años. Material y métodos: Se incluyeron 53 pacientes mayores de 65 años ingresados desde el 1/02/02 al 31/05/02. Resultados: La media de fármacos es 6,45/día. Los factores de mayor consumo son la procedencia de residencia y la existencia previa de un mayor numero de cirugías. El 25 por ciento de ingresos está relacionado con efectos secundarios. Conclusiones: La perdida del enfoque global del enfermo y el abuso de los recursos sanitarios son la base de esta situación. Cada fármaco es el resultado de actos médicos aislados, condicionando el desarrollo de iatrogenia (AU)

Salmonella endocarditis presenting as cerebral hemorrhage.

The case of a 35-year-old male with cerebral hemorrhage as a presenting complication of infective endocarditis of the aortic valve, caused by Salmonella typhimurium, is described. We emphasize the infrequent etiology and review the mechanisms of intracranial hemorrhage in infective endocarditis.

Association of sarcoidosis, low-grade B-lymphoma and epidermoid carcinoma.

We report on a case of the so-called sarcoidosis-lymphoma syndrome in a 65-years-old man diagnosed as having sarcoidosis and, four years later, neurosarcoidosis. The diagnoses of epidermoid carcinoma of the skin and of stage IV monocytoid, small cell lymphocytic lymphoma were made five and seven years, respectively, after the initial diagnosis of sarcoidosis. It has been suggested that the increased mitotic activity of lymphocytes observed in sarcoidosis, favours their malignant transformation. Hypothetically, sarcoidosis might also influence the development of epidermoid carcinomas by depletion of circulating T4 lymphocytes and decreased resistance to oncogenic viruses that could lead to decreased tumour rejection in the epithelia exposed to carcinogenic stimuli.

[Comparative study of the protective role of the vaccine against Haemophilus influenzae type b and partial splenectomy in an experimental model]. / Estudio comparativo del papel protector de la vacuna frente a Haemophilus influenzae tipo b y de la esplenectomía parcial en un modelo experimental.

BACKGROUND: Although the vaccine against Haemophilus influenzae type b has demonstrated its efficacy in children, this bacteria continues to be a cause or overwhelming sepsis in splenetomized patients. METHODS: To compare the degree of protection provided by partial splenectomy and the conjugated diptheria toxoid vaccine against H. influenzae type b, the bacteremia generated 24, 48 and 96 hours after intravenous inoculation with this bacteria at concentrations of 5 x 10(14), 5 x 10(13) and 5 x 10(12) colony-forming units was assessed in rats subjected to total splenectomy, with and without previous vaccination, to partial splenectomy or to sham operation. RESULTS: With respect to both the proportion of positive blood cultures and the concentration of H. influenzae in the blood stream, the sham-operated control rats and those vaccinated prior to splenectomy presented similar behaviors; the widest differences with respect to the latter two groups were found in the nonvaccinated total splenectomy rats, and the results with the partial splenectomy group fell between these two extremes. CONCLUSIONS: The protection of H. influenzae type b vaccine against infection is equivalent to that provided by the intact spleen for inoculum concentrations of 5 x 10(13) colony-forming units and less. Thus, the possibility of its systematic use in asplenic patients should be considered. The protection provided by the remnant spleen following 50% splenectomy is intermediate between those observed with eusplenia and with asplenia. These results suggest that when partial splenectomy is to be performed in normal spleen, the attempt should be made to conserve as much of the organ as possible.

[Cerebral abscess. Clinical review of 26 cases]. / Abscesos cerebrales. Revisión clínica de 26 casos.

BACKGROUND: The introduction of new diagnostic and therapeutic techniques has changed the clinical attitude and consequences of brain abscesses (BA). OBJECTIVE: To analyse clinical-radiological features, therapy, prognostic factors and evolution of BA in our institution. MATERIALS AND METHODS: Retrospective study of all clinical records of patients diagnosed with BA from 1982 to 1992. RESULTS: Twenty-six patients with a mean age of 46.2 years were selected. The incidence was 2.6 patients/10,000 admission/year. Among 17 patients (65%) some extraprenchymatous infectious focus was found, which was located at the otorhynolaryngeal area in twelve patients. Mean duration of symptoms was 12.9 days, headache being the most common of them (69%). With CT 18 patients had a single mass, eight patients multiple masses, and 21 patients a ring enhancement when the contrast material was introduced. The causative organism was recovered from 15 patients. The organism recovered more frequently were Streptococcus spp, Enterobacteriaceae and Staphylococcus aureus. Twenty patients (77%) underwent surgical therapy, which consisted in ablation (12) or drainage (8). All patients received antibiotics for a mean of 37 days: the most frequent antibiotic combination used was penicillin+chloramphenicol. Six patients died (23%) and 7 remained with sequelae. Although statistically non-significant, the acute presentation was associated with a higher mortality rate, and the use of dexamethasone was associated with a lower mortality rate (p = 0.053 and 0.062, respectively). CONCLUSIONS: BA is associated with a high mortality rate and a high sequelae rate despite appropriate diagnostic and therapeutic measures. ORL infection is the most frequent predisposing factor. The use of dexamethasone is not associated with a higher mortality rate.

[Salmonella ssp non-typhi focal infections]. / Infecciones focales por Salmonella spp no-typhi.

Provided here are the descriptions of 18 patients with focal infections caused by Salmonella spp no-typhi occurring in a period of seven years at the Puerta de Hierro Clinic. In all cases, there was at least one local factor, treatment, or underlying illness associated with decreased resistance to infection. Antecedents of severe gastroenteritis were found in seven cases (38 percent). Eighty-three percent had previous or concomitant bacteremia caused by the same serotype of Salmonella isolated in the focal infection. S. enteritidis was the most prevalent serotype (66 percent). The most common localizations were plueropulmonary (5), osteoarticular (5), and intravascular (3). Relapsing infection was demonstrated in five cases. There was 28 percent mortality. Statistically, age greater than 65 years and the absence of surgical intervention were associated with a worse prognosis.

Syndrome of inappropriate antidiuretic hormone secretion and herpes zoster infection: 1. Report of this association in a patient suffering from AIDS.

The syndrome of inappropriate secretion of antidiuretic hormone is a common consequence of neurologic and pulmonary infections as well as drug intake and many other clinical situations. Its association with herpes varicella-zoster virus infections is scarcely reported in the literature. It generally appears in immunosuppressed patients suffering from serious underlying diseases. There are also a few cases of syndrome of inappropriate secretion of antidiuretic hormone related to vidarabine use. We report the case of a man infected by human immunodeficiency virus who developed a disseminated herpes varicella-zoster virus infection and symptoms due to hyponatremia caused by antidiuretic hormone excess. The patient was cured with saline hypertonic infusion, water restriction, and intravenous administration of acyclovir. To the best of our knowledge, this is the first case of this association in a human immunodeficiency virus infected patient. We propose the use of acyclovir instead of vidarabine in the management of these situations.

[Auditory evoked potentials and magnetic resonance in the diagnosis and follow-up of central pontine myelinolysis]. / Potenciales evocados auditivos y resonancia magnética en el diagnóstico y seguimiento de la mielinolisis central pontina.

We report the case of a woman who developed central pontine myelinolysis in spite of gradual correction of hyponatremia. The good clinical evolution as well as the influence of rapid correction of serum sodium concentration in the unfolding of this rare condition are discussed. Several diagnostic procedures, mainly auditory-evoked responses and magnetic resonance imaging are also analysed. We remark the particular interest of the auditory-evoked responses in the attestation of an eventual remyelination.

[Abdominal tuberculosis today. A review of 46 cases]. / Tuberculosis abdominal en la época actual. Revisión de 46 casos.

The clinical features, radiological and therapeutic response of 46 cases of abdominal tuberculosis (AT) seen at a university hospital are presented. Diagnosis was anatomopathologic in 39 cases (85%) and clinical with response to tuberculostatic in 7 cases (15%). Most of the patients did not have history nor exposition to tuberculosis. Both sexes were similar affected, mean age 43 years old, between 11 and 79. Clinical manifestations were no specific, the most frequent fever (65%), abdominal pain (63%) and constitutional syndrome with asthenia, anorexia and weight loss (63%). Thorax radiograph was normal in 50% and PPD negative in 42%, so in 10% of patients both tests were negative. More than half of the patients had other disease. 82% of patients were cured with tuberculostatic. 18% of patients died. AT seen now is different from classic descriptions. Is not a complication of pulmonary tuberculosis (PT) as it was to be in the past. Thinking in AT only in patients with PT make most patients lead without diagnosis.

[Lupus induced by quinidine]. / Lupus inducido por quinidina.

The case is described of a 34 year old female who suffered quinidine induced lupus, which appeared 14 months after the administration of the drug, and it was necessary to substitute it. This secondary effect o quinidine, which is rarely described, can go unnoticed if it is no kept in mind. The diagnostic criteria for drug induced lupus ar discussed and the clinical and analytical manifestations of 27 cases o quinidine induced lupus described in the literature are reviewed.