La vuelta de los sonidos casi a los 100 años. ¿Cuál va a ser el límite?

Resumen El implante coclear (IC) es el tratamiento estándar para las sorderas profundas en niños y adultos. En adultos mayores esta indicación ha pasado a ser cada día más común. Se describe un abordaje para implantes cocleares en adultos mayores usando como hilo conductor el caso clínico de una mujer de 98 años y 9 meses con hipoacusia neurosensorial severa que ya no se beneficiaba de sus audífonos. Las evaluaciones fueron conducidas por las áreas de otología, cardiología, neurología y anestesiología. Con las aprobaciones de las áreas médicas, la cirugía de implante coclear en el oído izquierdo fue realizada con anestesia local y sedación. No hubo complicaciones intra ni postoperatorias. La rápida recuperación permitió el alta al segundo día posoperatorio. El implante fue activado al mes de operada con todos los electrodos estando activos. Se lograron umbrales para tonos puros de 25 dB HL en campo libre y discriminación en silencio con IC en oído izquierdo y audífono en oído derecho para frases del 76% y para palabras familiares del 100%. El implante coclear fue una alternativa adecuada para esta paciente, posiblemente la implantada de mayor edad en el mundo, y debe ser considerado una alternativa razonable para el adulto mayor con sordera profunda. La decisión quirúrgica debe estar enfocada en las condiciones generales de salud más que en la edad cronológica.

Abstract Cochlear implant (IC) is the standard treatment for profound deafness in children and adults. In the elderly this indication is becoming more common every day. An approach to cochlear implants in the elderly is described, using as a common thread the case of a 98 years and 9 months old woman with severe bilateral gradually progressive sensorineural hearing loss who did not benefit from her hearing aids. She underwent comprehensive multispecialty medical evaluation including otolaryngology, neurology, cardiology and anesthesiology. She underwent cochlear implantation under local anesthesia and sedation. No intra or postoperative complications occurred. Recovery was quick and she was discharged on the second postoperative day. The device was activated at 1-month post-surgery and all electrodes were active. Free field thresholds for pure tones were 25 dB HL and discrimination in silence with IC in left ear and hearing aid in right ear for sentences were 76% and for familiar words 100%. Cochlear implantation resulted in an adequate alternative for this elderly patient, possibly the oldest implanted individual in the world. Cochlear implantation should be considered a reasonable alternative for elderly patients with profound hearing loss. The surgical decision should focus more on the general health conditions than on the chronological age.

[Development and validation of a clinical predictive model for delirium in hospitalized older people]. / Riesgo de delirium durante la hospitalización en personas mayores: desarrollo y validación de un modelo de predicción clínica.

BACKGROUND: Delirium is a prevalent problem among older patients and it is frequently underdiagnosed. AIM: To develop and validate a clinical predictive model to identify patients at high risk of delirium. MATERIAL AND METHODS: Two consecutive prospective cohort studies were used to develop and validate the model. The development cohort included 542 consecutive medical inpatients, 65 years or older. The validation cohort included 85 comparable patients. A predictive score was constructed with a multivariate analysis, using variables independently associated with delirium and subsequently tested in the new cohort. Patients were assessed within the first 48 hours of admission, and every 48 hours thereafter, using the Confusion Assessment Method to diagnose delirium, evaluating also the severity of underlying disease, comorbidities, functionality, and laboratory data. RESULTS: Delirium occurred in 192 patients (35.4%) of the development cohort and was independently associated with age and functional status assessed using the Barthel Index. With these two variables, the predictive score for delirium was developed and tested rendering an area under the receiver operating characteristic (ROC) of 0.80 (confidence intervals 0.77-0.85). Cut-off points were chosen to establish low, intermediate, and high-risk groups for delirium. According to these cut-off points, delirium frequencies in the development cohort were 8%, 23%, and 69%, and in the validation cohort 5%, 34%, and 66%, respectively (c² p<0.05). CONCLUSIONS: This simple predictive model based on age and functional status may be a useful tool for identifying older patients risking delirium.

Riesgo de delirium durante la hospitalización en personas mayores: desarrollo y validación de un modelo de predicción clínica / Development and validation of a clinical predictive model for delirium in hospitalized older people

Background: Delirium is a prevalent problem among older patients and it is frequently underdiagnosed. Aim: To develop and validate a clinical predictive model to identify patients at high risk of delirium. Material and Methods: Two consecutive prospective cohort studies were used to develop and validate the model. The development cohort included 542 consecutive medical inpatients, 65 years or older. The validation cohort included 85 comparable patients. A predictive score was constructed with a multivariate analysis, using variables independently associated with delirium and subsequently tested in the new cohort. Patients were assessed within the first 48 hours of admission, and every 48 hours thereafter, using the Confusion Assessment Method to diagnose delirium, evaluating also the severity of underlying disease, comorbidities, functionality, and laboratory data. Results: Delirium occurred in 192 patients (35.4%) of the development cohort and was independently associated with age and functional status assessed using the Barthel Index. With these two variables, the predictive score for delirium was developed and tested rendering an area under the receiver operating characteristic (ROC) of 0.80 (confidence intervals 0.77-0.85). Cut-off points were chosen to establish low, intermediate, and high-risk groups for delirium. According to these cut-off points, delirium frequencies in the development cohort were 8%, 23%, and 69%, and in the validation cohort 5%, 34%, and 66%, respectively (c² p < 0.05). Conclusions: This simple predictive model based on age and functional status may be a useful tool for identifying older patients risking delirium.

Púrpura trombótico trombocitopénico: revisión de la literatura a partir de 18 casos / Thrombotic thrombocytopenic purpura: experience in 18 cases and literature review

Background: Thrombotic thrombocytopenic purpura (TTP) is characterized by anemia, thrombocytopenia, neurological and renal involvement of variable severity and it has a dismal prognosis. Platelet-derived von Willebrand Factor-cleaving metalloprotease ADAMTS-13 activity may orient the diagnosis, but normal levels do not discard it. The most effective therapy thus known is plasmapheresis. Aim: To report the experience in 18 patients with TTP. Material and methods: Retrospective assessment of 11 patients and prospective assessment of seven subjects with TTP, aged 15 to 81 years. Results: All presented with anemia, thrombocytopenia and LDH elevation. Sixteen had neurological symptoms, five had fever, four had macroscopic urinary excretion of pigments, four had petechiae, and two had nosebleeds. Haptoglobin was low in 10 of 11 patients in whom it was measured. ADAMTS-13 had low activity in 15 of 17 patients (in 11, the inhibitor was found). Seventeen patients were treated with plasmapheresis and nine received steroids also. Seven patients died due to shock with respiratory involvement or múltiple organic failure. Conclusions: TTP has heterogeneous modes of presentation. If the diagnosis is strongly suspected, plasmapheresis can be started without laboratory confirmation. An ADAMTS-13 activity below 6 percent is almost exclusive of TTP .

Enfermedad por arañazo de gato: Características clínicas y de laboratorio en pacientes adultos hospitalizados por fiebre o adenopatías / Cat-scratch disease: Review of eight adult patients hospitalized for fever or adenopathy

Background: Cat-scratch disease is common among children. Among adults the disease is less often considered in the differential diagnosis of enlarged lymph nodes and fever. Aim: To report the clinical and laboratory features of eight patients with cat-scratch disease. Material and methods: Review of the medical records of eight patients (aged 22 to 57 years, six males) with a serological diagnosis of cat-scratch disease (an IgG titer over 1:256, by immunofluorescence). Results: Only five patients recalled having had contact with cats. Seven had fever and weight loss. Six had excessive sweating and five had chills. Seven had painfully enlarged lymph nodes mainly in submandibular and axillary regions. All had an increased C reactive protein and six had elevated erythrocyte sedimentation rate. Five had leukocytosis and four an elevated serum lactate dehydrogenase. The disease subsided in all, even in one patient that did not receive antimicrobials. Conclusions: Cat-scratch disease should be considered in the differential diagnosis of adult patients with lymph adenitis and fever.