Nephrocalcinosis fortuitously discovered: the role of surreptitious self administration of diuretics.

Background: Furosemide is a drug widely used for several medical conditions and could be used without medical prescription. Furosemide-related nephrocalcinosis can occur regardless of age, although the risk is higher in premature infants. The defining characteristic of nephrocalcinosis is generalized calcium deposition in the kidney. The most useful imaging studies for evaluation are ultrasonography and computed tomography (more effective in detecting calcification). Case Presentation: A 32-year-old woman with a history of depressive syndrome was admitted for evaluation of fortuitously discovered nephrocalcinosis and hypokalemia. The studies performed revealed the presence of a metabolic alkalosis with discrete hyperreninism/hyperaldosteronism but normal ratio, normotension and urinary study showed elevated sodium, chloride, potassium and calcium fluctuating in different determinations. Surreptitious diuretic intake was suspected and urine analysis revealed doses equivalent to 80-120 mg. The patient was advised to discontinue all diuretic treatment; she was adequately supplemented with potassium and she was followed-up in outpatient clinics. During the follow-up, clinical and analytical improvement was noted, which led to the discontinuation of supplementation. Conclusion: Surreptitious diuretic intake is a clinical condition to rule out in patients with chronic hypokalemia, metabolic alkalosis with elevated urinary sodium and chloride. The relation between surreptitious diuretic intake and nephrocalcinosis has not been fully elucidated in adults.

Prognosis of acute heart failure in patients followed up in nursing homes in Spain: Results from the RICA registry / Impacto pronóstico en la supervivencia de los pacientes en residencias de ancianos con insuficiencia cardiaca en España: Resultados del Registro RICA

Background: Patients with chronic diseases such as heart failure (HF) are at risk of hospital admission. We evaluated the impact of living in nursing homes (NH) on readmissions and all-cause mortality of HF patients during a one-year follow up. Methods: An observational and multicenter study from the Spanish National Registry of Heart Failure (RICA) was performed. We compared clinical and prognostic characteristics between both groups. Bivariate analyses were performed using Student's t-test and Tukey's method and a Kaplan–Meier survival at one-year follow up. A multivariate proportional hazards analysis of [Cox] regression by the conditional backward method was conducted for the variables being statistically significant related to the probability of death in the univariate. Results: There were 5644 patients included, 462 (8.2%) of whom were nursing home residents. There were 52.7% women and mean age was 79.7±8.8 years. NH residents had lower Barthel (74.07), Charlson (3.27), and Pfeiffer index (2.2), p<0.001). Mean pro-BNP was 6686pg/ml without statistical significance differences between groups. After 1-year follow-up, crude analysis showed no differences in readmissions 74.7% vs. 72.3%, p=0.292, or mortality 63.9% vs. 61.1%, p=0.239 between groups. However, after controlling for confounding variables, NH residents had a higher 1-year all-cause mortality (HR 1.153; 95% CI 1.011–1.317; p=0.034). Kaplan–Meier analysis showed worse survival in nursing home residents (log-rank of 7.12, p=0.008). Conclusions: Nursing home residents with heart failure showed higher one-year mortality which could be due to worse functional status, higher comorbidity, and cognitive deterioration.(AU)

Introducción: Los pacientes con enfermedades crónicas como la insuficiencia cardiaca (IC) presentan mayor riesgo de ingreso. Se evaluó el impacto sobre los reingresos y la mortalidad por todas las causas de los pacientes con IC respecto a vivir o no en residencias de ancianos durante un año de seguimiento. Métodos: Estudio observacional y multicéntrico a partir del Registro Nacional de Insuficiencia Cardiaca (RICA). Se compararon las características clínicas y pronósticas entre ambos grupos. Se realizó un análisis bivariante mediante el método de t de Student y Tukey y un análisis de supervivencia mediante Kaplan-Meier al año de seguimiento, así como un análisis multivariante de riesgos proporcionales de regresión (Cox) por el método de retroceso condicional para las variables que se relacionaban de forma estadísticamente significativa con la probabilidad de muerte en el univariante. Resultados: Fueron incluidos 5.644 pacientes; 462 (8,2%) de ellos estaban en residencias, el 52,7% eran mujeres y la edad media era de 79,7±8,8 años. Los pacientes en residencias tenían menor Barthel (74,07), Charlson (3,27) y Pfeiffer (2,2) (p<0,001). El pro-BNP medio era de 6.686 pg/ml sin diferencias significativas. Tras un año de seguimiento, el análisis bruto no mostró diferencias en los reingresos (74,7 vs. 72,3%; p=0,292) ni en mortalidad (63,9 vs. 61,1%; p=0,239) entre ambos grupos. Tras controlar las variables de confusión, los pacientes en residencias presentaron una mayor mortalidad por todas las causas a un año (hazard ratio 1,153; IC 95%: 1,011-1,317; p=0,034) así como peor supervivencia en el análisis de Kaplan-Meier (log-rank 7,12; p=0,008). Conclusiones: Los pacientes con IC en residencias de ancianos mostraron una mayor mortalidad a un año, que podría deberse a un peor estado funcional, a mayor deterioro cognitivo y a más comorbilidad.(AU)

Prognosis of acute heart failure in patients followed up in nursing homes in Spain: Results from the RICA registry.

BACKGROUND: Patients with chronic diseases such as heart failure (HF) are at risk of hospital admission. We evaluated the impact of living in nursing homes (NH) on readmissions and all-cause mortality of HF patients during a one-year follow up. METHODS: An observational and multicenter study from the Spanish National Registry of Heart Failure (RICA) was performed. We compared clinical and prognostic characteristics between both groups. Bivariate analyses were performed using Student's t-test and Tukey's method and a Kaplan-Meier survival at one-year follow up. A multivariate proportional hazards analysis of [Cox] regression by the conditional backward method was conducted for the variables being statistically significant related to the probability of death in the univariate. RESULTS: There were 5644 patients included, 462 (8.2%) of whom were nursing home residents. There were 52.7% women and mean age was 79.7±8.8 years. NH residents had lower Barthel (74.07), Charlson (3.27), and Pfeiffer index (2.2), p<0.001). Mean pro-BNP was 6686pg/ml without statistical significance differences between groups. After 1-year follow-up, crude analysis showed no differences in readmissions 74.7% vs. 72.3%, p=0.292, or mortality 63.9% vs. 61.1%, p=0.239 between groups. However, after controlling for confounding variables, NH residents had a higher 1-year all-cause mortality (HR 1.153; 95% CI 1.011-1.317; p=0.034). Kaplan-Meier analysis showed worse survival in nursing home residents (log-rank of 7.12, p=0.008). CONCLUSIONS: Nursing home residents with heart failure showed higher one-year mortality which could be due to worse functional status, higher comorbidity, and cognitive deterioration.

Symptomatic Postoperative Compressive Pneumocephalus After Cholecystectomy.

A 75-year-old woman with a history of chronic hydrocephalus due to stenosis of the aqueduct of Sylvius was examined at the emergency department for altered mental status. There was placement of a ventriculoperitoneal shunt in 1970 complicated by meningitis, leading to removal of the material and ventriculociternostomy as definitive treatment in 2004. About one month previously, she had undergone a laparoscopic cholecystectomy complicated by an intra-abdominal collection. Clinical examination at the emergency department revealed a Glasgow score of 8 (E3 V1 M4). In the emergency department the patient presented a tonic-clonic seizure before a cerebral CT scan was performed showing a massive compressive pneumocephalus, then a second seizure. The patient was finally admitted to the neurosurgery department and underwent surgery. LEARNING POINTS: Changes in mental status in a patient with a history of chronic hydrocephalus should alert clinicians to a possible complication.This case reflects the delayed diagnosis of a critically ill patient in the emergency department.

Prognostic Impact of the UMIPIC Program in the Follow Up in Patients with Heart Failure and Cardiorenal Syndrome.

BACKGROUND: Individuals suffering from heart failure (HF) and cardiorenal syndrome (CRS) represent a special group of patients considering their age, multiple health issues, and treatment challenges. These factors make them more susceptible to frequent hospital stays and a higher mortality rate. UMIPIC is a multidisciplinary care model program for patients with heart failure follow up provided by internists and nurses who are experts in this entity. Our study delved into the effectiveness of this specialized care program (UMIPIC) in mitigating these risks for HF and CRS patients. METHODS: We analyzed the medical records of 3255 patients diagnosed with HF and CRS types 2 and 4, sourced from the RICA registry. These patients were divided into two distinct groups: those enrolled in the UMIPIC program (1205 patients) and those under standard care (2050 patients). Using propensity score matching, we ensured that both groups were comparable. The study focused on tracking hospital admissions and mortality rates for one year after an HF-related hospital stay. RESULTS: Patients in the UMIPIC group experienced fewer hospital readmissions due to HF compared to their counterparts (20% vs. 32%; Hazard Ratio [HR] = 0.48; 95% Confidence Interval [95% CI]: 0.40-0.57; p < 0.001). They also showed a lower mortality rate (24% vs. 36%; HR = 0.64; 95% CI: 0.54-0.75; p < 0.001). Furthermore, the UMIPIC group had fewer total hospital admissions (36% vs. 47%; HR = 0.58; 95% CI: 0.51-0.66; p < 0.001). CONCLUSIONS: The UMIPIC program, centered on holistic and ongoing care, effectively reduces both hospital admissions and mortality rates for HF and CRS patients after a one-year follow-up period.

Salmonella Osteomyelitis of Unknown Origin: An Underestimated Infection.

Salmonella osteomyelitis is an underdiagnosed pathology with unusual clinical presentations. The patient was a 24-year-old female with no previous medical history who presented to the emergency department with progressive pain in the left arm for several months. She was initially treated unsuccessful with augmentin for 7 days for suspicious cellulites. Standard elbow X-rays described a lesion initially considered as metastatic. Investigations were completed with magnetic resonance imaging (MRI) compatible with osteomyelitis. Following surgical sampling, salmonella enterica infection was diagnosed. The patient recovered full use of her limb after 8 days of IV antibiotic therapy with third-generation cephalosporin, and she completed 11 weeks of antibiogram-targeted PO fluoroquinolone therapy. Salmonella osteomyelitis could mimic other diseases, making diagnosis difficult. LEARNING POINTS: A poor response to treatment should raise questions about the initial diagnosis.Isolated metastatic lesions in the upper limbs are rare and require proper clinical and radiological evaluation to arrive at a correct diagnosis.

Malignant hypercalcemia revealing a diffuse large B-cell lymphoma in a patient with a previous diagnosis of chronic myelomonocytic leukemia: An uncommon hematological coexistence.

A 76-year-old patient previously admitted to the cardiology department for replacement of a right ventricular lead on a double-chamber pacemaker was admitted to the internal medicine department 15 days after for bronchopneumopathy. His past medical history was relevant for Type 2 diabetes mellitus, heart failure due to dilated hypokinetic heart disease, transcatheter aortic valve implantation (TAVI), and chronic myelomonocytic leukemia (CMML-0) diagnosed in 2021. Twenty-four hours after admission, the patient's general condition deteriorated abruptly, with the onset of drowsiness and psychomotor retardation. Laboratory exams revealed hypercalcemia at 4.18 mmol/L. Intensive hydration, calcitonin, and zoledronic acid were initiated and the patient was transferred to the nephrology intensive care unit where he underwent two sessions of hemodialysis to normalize serum calcium levels before readmission to internal medicine. Laboratory exams revealed low parathyroid hormone, normal 1-25-OH vitamin D, and increased parathyroid hormone-related peptide. Thoracoabdominal and positron emission tomography (PET) scan showed diffuse abdominopelvic peritoneal carcinosis associated with low-grade pleural effusion and multiple supra- and sub-diaphragmatic adenopathies, leading to a search for a solid tumor. The patient's clinical condition worsened leading to a transfer to the intensive care unit. The biopsy of a peritoneal carcinosis nodule confirmed the diagnosis of diffuse large B-cell lymphoma. Specific treatments were unsuccessful and the patient expired.

[Long COVID, diagnosis and management : a survey among general practitioners in the Bas Rhin in France]. / Face à la COVID-19. COVID long, diagnostic et prise en charge : enquête auprès de médecins généralistes du Bas Rhin en France.

The long COVID includes non-specific symptoms affecting patients of all ages. METHODS: Monocentric, prospective, quantitative and descriptive study interested in comparing the knowledge of general practitioners in Alsace (France) with the positioning and recommendations of the World Health Organisation (WHO) on long COVID in the period November 2022-February 2023. A multiple-choice questionnaire was elaborated based on the WHO positioning and recommendations on the long COVID. RESULTS: 126 questionnaires were received, 65 (51.6 %) women, 42 % aged between 25-35 years. 84.9 % had knowledge about long COVID. The need for an impact on daily life, unexplained symptomatology and symptoms persisting at two months were criteria retained (84.9 %, 91.3 % and 82.5 %, respectively). A history of anxiety disorders (86.5 %) and severe acute forms of COVID-19 (57.9 %) were considered as risk factors. Fatigue, dyspnea, joint pain, headache and cough were associated with long COVID in 65.9 % of responders. About 74,6 % performed a complete blood test, 96.03 % recommended rehabilitation, 76.2 % referred to the pulmonologist and 71.4 % were in favour of a consensus document. CONCLUSIONS: General practitioners are aware of the existence of long COVID as a pathology and agree with the recommendations of scientific societies, among which those of WHO. However, this study has some limitations so that this topic deserves further dedicated investigations.

Le COVID long regroupe des symptômes non spécifiques affectant des patients de tous âges. Méthodes : Étude mono-centrique, prospective, quantitative et descriptive ayant pour but de confronter les connaissances des médecins généralistes d'Alsace (France) au positionnement et aux recommandations de l'Organisation Mondiale de la Santé (OMS) sur le COVID long. La période d'étude s'étend du 15 novembre 2022 au 15 février 2023. Un questionnaire à choix multiples est élaboré à partir des recommandations de l'OMS sur le COVID long. Résultats : 126 questionnaires analysés, 65 (51,6 %) femmes, 42 % des répondants âgés entre 25-35 ans. Globalement, 84,9 % des répondants disent connaître le COVID long. La nécessité d'un impact sur la vie quotidienne, la symptomatologie non expliquée et symptômes persistants à 2 mois étaient des critères retenus (84,9 %, 91,3 % et 82,5 %, respectivement). Les antécédents de troubles anxio-dépressifs (86,5 %) et les formes aiguës sévères (57,9 %) étaient considérés comme des facteurs de risque. La fatigue, la dyspnée, les douleurs articulaires, les céphalées et la toux sont associées au COVID long dans 65,9 % des cas. Dans l'ensemble, 74,6 % réalisent un bilan biologique complet, 96,03 % préconisent la rééducation, 76,2 % orientent vers le pneumologue et 71,4 % étaient favorables à l'élaboration d'un document de consensus. Conclusions : Les médecins généralistes interrogés connaissent l'existence de cette pathologie et les démarches des répondants sont en accord avec les recommandations des sociétés savantes, dont celles de l'OMS. Cette étude comporte cependant diverses limitations et ce sujet mérite certainement des enquêtes supplémentaires.

Clinical Characteristics and Prognostic Impact of Short Physical Performance Battery in Hospitalized Patients with Acute Heart Failure-Results of the PROFUND-IC Registry.

BACKGROUND: Most patients diagnosed with heart failure (HF) are older adults with multiple comorbidities. Multipathological patients constitute a population with common characteristics: greater clinical complexity and vulnerability, frailty, mortality, functional deterioration, polypharmacy, and poorer health-related quality of life with more dependency. OBJECTIVES: To evaluate the clinical characteristics of hospitalized patients with acute heart failure and to determine the prognosis of patients with acute heart failure according to the Short Physical Performance Battery (SPPB) scale. METHODS: Observational, prospective, and multicenter cohort study conducted from September 2020 to May 2022 in patients with acute heart failure as the main diagnosis and NT-ProBNP > 300 pg. The cohort included patients admitted to internal medicine departments in 18 hospitals in Spain. Epidemiological variables, comorbidities, cardiovascular risk factors, cardiovascular history, analytical parameters, and treatment during admission and discharge of the patients were collected. Level of frailty was assessed by the SPPB scale, and dependence, through the Barthel index. A descriptive analysis of all the variables was carried out, expressed as frequencies and percentages. A bivariate analysis of the SPPB was performed based on the score obtained (SPPB ≤ 5 and SPPB > 5). For the overall analysis of mortality, HF mortality, and readmission of patients at 30 days, 6 months, and 1 year, Kaplan-Meier survival curves were used, in which the survival experience among patients with an SPPB > 5 and SPPB ≤ 5 was compared. RESULTS: A total of 482 patients were divided into two groups according to the SPPB with a cut-off point of an SPPB < 5. In the sample, 349 patients (77.7%) had an SPPB ≤ 5 and 100 patients (22.30%) had an SPPB > 5. Females (61%) predominated in the group with an SPPB ≤ 5 and males (61%) in those with an SPPB > 5. The mean age was higher in patients with an SPPB ≤ 5 (85.63 years). Anemia was more frequent in patients with an SPPB ≤ 5 (39.5%) than in patients with an SPPB ≥ 5 (29%). This was also seen with osteoarthritis (32.7%, p = 0.000), diabetes (49.6%, p = 0.001), and dyslipidemia (69.6%, p = 0.011). Patients with an SPPB score > 5 had a Barthel index < 60 in only 4% (n = 4) of cases; the remainder of the patients (96%, n = 96) had a Barthel index > 60. Patients with an SPPB > 5 showed a higher probability of survival at 30 days (p = 0.029), 6 months (p = 0.031), and 1 year (p = 0.007) with (OR = 7.07; 95%CI (1.60-29.80); OR: 3.9; 95%CI (1.30-11.60); OR: 6.01; 95%CI (1.90-18.30)), respectively. No statistically significant differences were obtained in the probability of readmission at 30 days, 6 months, and 1 year (p > 0.05). CONCLUSIONS: Patients admitted with acute heart failure showed a high frequency of frailty as assessed by the SPPB. Patients with an SPPB ≤ 5 had greater comorbidities and greater functional limitations than patients with an SPPB > 5. Patients with heart failure and a Barthel index > 60 frequently presented an SPPB < 5. In daily clinical practice, priority should be given to performing the SPPB in patients with a Barthel index > 60 to assess frailty. Patients with an SPPB ≤ 5 had a higher risk of mortality at 30 days, 6 months, and 1 year than patients with an SPPB ≤ 5. The SPPB is a valid tool for identifying frailty in acute heart failure patients and predicting 30-day, 6-month, and 1-year mortality.

Cistitis enfisematosa: una causa poco frecuente de dolor abdominal / Emphysematous cystitis: An uncommon cause of ab dominal pain

Resumen Una mujer de 82 años con antecedentes de hiperten sión arterial e hipotiroidismo acudió al servicio de urgencias por dolor abdominal, diarrea, confusión y deterioro de su estado general de varios días de evolu ción. A su admisión, la paciente se encontraba febril y la analítica mostró una elevación de la proteína C reac tiva sin leucocitosis (8.9 × 10[PRESERVECIRC]9/L). En ese contexto se realizó exudado nasofaríngeo para SARS-CoV-2 que fue negativo. Con estos resultados, la sospecha inicial era la de un cuadro infeccioso de origen digestivo. La muestra de orina era maloliente con presencia de leucocitos y nitritos enviándose a cultivo microbiológico. Se inició tratamiento antibiótico empírico con una cefalosporina de tercera generación ante la sospecha de une posible infección urinaria. Se decidió la realización de una tomografía tóraco-abdomino-pélvica con el objetivo de evaluar la presencia de otros focos infecciosos en una paciente de edad avanzada. Este estudio mostró una cistitis enfisematosa, una enfermedad poco fre cuente en una paciente sin ninguno de los factores de riesgo clásicos para esta entidad. Los cultivos de orina y sangre fueron positivos para Escherichia coli sensible al antibiótico empírico por lo que se continuó para completar 7 días de tratamiento. La evolución clínica fue favorable.

Abstract An 82-year-old woman with a previous medical his tory of hypertension and hypothyroidism was admitted to the emergency department for abdominal pain, dia rrhea, confusion and changes in her overall condition over several days. At the emergency department, the patient was febrile and her blood tests showed elevated C-reactive protein without leukocytosis (8.9 × 10[PRESERVECIRC]9/L). In the current context, a nasopharyngeal swab for SARS was performed and was negative. With these results, the initial suspicion was that of an infectious condi tion of gastrointestinal origin. The urine sample was foul-smelling with presence of leukocytes and nitrites and was sent out for culture. In the setting of probable urinary tract infection, empirical antibiotic treatment was started with a third generation cephalosporin. It was decided to perform a total body scanner in order to evaluate the presence of other infectious foci. The study described the presence of emphysematous cystitis, a rare pathology in a patient without any of the classic risk factors for this entity. Urine and blood cultures were positive for Escherichia coli sensitive to the empiric antibiotic which was continued to complete 7 days. The clinical course was favorable.

Prognostic Factors Associated with Acute Heart Failure in Patients Admitted for COVID-19: Analysis of the SEMI-COVID-19 Registry.

INTRODUCTION: Since the beginning of the COVID-19 pandemic in March 2020, an intimate relationship between this disease and cardiovascular diseases has been seen. However, few studies assess the development of heart failure during this infection. This study aims to determine the predisposing factors for the development of heart failure (HF) during hospital admission of COVID-19 patients. METHODOLOGY: A retrospective and multicenter study of patients with HF admitted for COVID-19 in 150 Spanish hospitals (SEMI-COVID-19 Registry). A bivariate analysis was performed to relate the different variables evaluated in patients developing heart failure during hospital admission. A multivariate analysis including the most relevant clinical variables obtained in bivariate analyses to predict the outcome of heart failure was performed. RESULTS: A total of 16.474 patients hospitalized for COVID-19 were included (57.5% men, mean age 67 years), 958 of them (5.8%) developed HF during hospitalization. The risk factors for HF development were: age (odds ratio [OR]): 1.042; confidence interval 95% (CI 95%): 1.035-1.050; p < 0.001), atrial fibrillation (OR: 2.022; CI 95%: 1.697-2.410; p < 0.001), BMI > 30 kg/m2 (OR: 1.460 CI 95%: 1.230-1.733; p < 0001), and peripheral vascular disease (OR: 1.564; CI 95%: 1.217-2.201; p < 0.001). Patients who developed HF had a higher rate of mortality (54.1% vs. 19.1%, p < 0.001), intubation rate (OR: 2,36; p < 0.001), and ICU admissions (OR: 2.38; p < 0001). CONCLUSIONS: Patients who presented a higher risk of developing HF were older with cardiovascular risk factors. The risk factors for HF development were age, atrial fibrillation, obesity, and peripheral vascular disease. In addition, patients who developed HF more frequently required to be intubated or admitted to the ICU.

[Emphysematous cystitis: an uncommon cause of abdominal pain]. / Cistitis enfisematosa: una causa poco frecuente de dolor abdominal.

An 82-year-old woman with a previous medical history of hypertension and hypothyroidism was admitted to the emergency department for abdominal pain, diarrhea, confusion and changes in her overall condition over several days. At the emergency department, the patient was febrile and her blood tests showed elevated C-reactive protein without leukocytosis (8.9 × 10^9/L). In the current context, a nasopharyngeal swab for SARS was performed and was negative. With these results, the initial suspicion was that of an infectious condition of gastrointestinal origin. The urine sample was oul-smelling with presence of leukocytes and nitrites and was sent out for culture. In the setting of probable urinary tract infection, empirical antibiotic treatment was started with a third generation cephalosporin. It was decided to perform a total body scanner in order to evaluate the presence of other infectious foci. The study described the presence of emphysematous cystitis, a rare pathology in a patient without any of the classic risk factors for this entity. Urine and blood cultures were positive for Escherichia coli sensitive to the empiric antibiotic which was continued to complete 7 days. The clinical course was favorable.

Una mujer de 82 años con antecedentes de hipertensión arterial e hipotiroidismo acudió al servicio de urgencias por dolor abdominal, diarrea, confusión y deterioro de su estado general de varios días de evolución. A su admisión, la paciente se encontraba febril y la analítica mostró una elevación de la proteína C reactiva sin leucocitosis (8.9 × 10

Focal Myositis of the Sternocleidomastoid Muscle: A Rare and Uncommon Cause of Cervical Mass.

We report on a 70-year-old male patient admitted to the internal medicine department for evaluation of a right cervical mass. He had been treated with antibiotics as an outpatient by his primary care doctor. Upon admission the patient was asymptomatic, but within a few hours his cervical mass enlarged; this enlargement was confined to the right sternocleidomastoid muscle. Complete blood investigations including serology and autoimmunity were negative. The neck scan and MRI were in favour of myositis. No other lesions were found either in the nasal fibre-optic exam or in the thoracic-abdominal-pelvic scan. The biopsy of the muscle showed a lymphoplasmacytic inflammatory infiltrate of the perimysium. The diagnosis of focal myositis was made. The patient clinically improved during hospitalisation with complete resolution of symptoms without any specific intervention. LEARNING POINTS: A thorough clinical examination is essential in the evaluation and characterisation of cervical masses.The diagnostic approach must be rigorous in order not to ignore potentially serious diseases.A high level of clinical suspicion is needed in the diagnosis of focal myositis.

Trombo flotante en el arco aórtico, una causa poco frecuente de isquemia de miembros inferiores / Floating thrombus in the aortic arch, a rare cause of lower limb ischemia

Resumen La oclusión arterial aguda de los miembros inferio res es una urgencia médica y quirúrgica por su morbi mortalidad. Presentamos el caso de un hombre de 59 años que ingresó al servicio de urgencias por un dolor agudo y difuso del miembro inferior izquierdo causado por extensos coágulos obstructivos en las arterias del miembro inferior izquierdo. Siendo improbable la cau sa ateromatosa tras realización de la angioscopia de miembros inferiores, se sospechó un origen cardíaco. La ecografía cardiaca no mostró anomalías, sin embargo, la angiotomografía torácica reveló un trombo flotante en el arco aórtico. El paciente fue tratado quirúrgica mente con colocación de una endoprótesis aórtica sin complicaciones.

Abstract Acute arterial occlusion of the lower limbs is a medi cal and surgical emergency due to its morbi-mortality. We present the case of a 59-year-old man admitted to the emergency department for acute and diffuse pain in the left lower limb caused by extensive obstructive clots in the arteries of this limb. Since atheromatous cause was unlikely after angioscopy of the lower limbs, a car diac origin was suspected. Echocardiogram was normal, however, thoracic angiotomography revealed a floating thrombus in the aortic arch. The patient was treated surgically with placement of an aortic endoprosthesis without complications.

[Floating thrombus in the aortic arch, a rare cause of lower limb ischemia]. / Trombo flotante en el arco aórtico, una causa poco frecuente de isquemia de miembros inferiores.

Acute arterial occlusion of the lower limbs is a medical and surgical emergency due to its morbi-mortality. We present the case of a 59-year-old man admitted to the emergency department for acute and diffuse pain in the left lower limb caused by extensive obstructive clots in the arteries of this limb. Since atheromatous cause was unlikely after angioscopy of the lower limbs, a cardiac origin was suspected. Echocardiogram was normal, however, thoracic angiotomography revealed a floating thrombus in the aortic arch. The patient was treated surgically with placement of an aortic endoprosthesis without complications.

La oclusión arterial aguda de los miembros inferiores es una urgencia médica y quirúrgica por su morbimortalidad. Presentamos el caso de un hombre de 59 años que ingresó al servicio de urgencias por un dolor agudo y difuso del miembro inferior izquierdo causado por extensos coágulos obstructivos en las arterias del miembro inferior izquierdo. Siendo improbable la causa ateromatosa tras realización de la angioscopia de miembros inferiores, se sospechó un origen cardíaco. La ecografía cardiaca no mostró anomalías, sin embargo, la angiotomografía torácica reveló un trombo flotante en el arco aórtico. El paciente fue tratado quirúrgicamente con colocación de una endoprótesis aórtica sin complicaciones.

Effectiveness of sacubitril-varsartan versus angiotensin converting enzyme inhibitors in patients hospitalized for acute heart failure: a retrospective cohort study of the RICA registry.

BACKGROUND: Sacubitril-valsartan has been shown to reduce hospitalizations and mortality in patients with heart failure (HF) and reduced ejection fraction. The PIONEER-HF trial demonstrated that initiation of the drug during acute HF hospitalization reduced NT-proBNP levels and a post-hoc analysis of the trial found a reduction in HF hospitalizations and deaths. Real-life studies in the elderly population are scarce. The aim of our study was to assess the effectiveness of sacubitril-valsartan versus angiotensin converting enzyme inhibitors (ACEI) in elderly patients who initiate this treatment during hospitalization for acute HF. METHODS: We conducted a retrospective cohort study using the Spanish acute heart failure registry (RICA) comparing rehospitalizations and deaths at 3 months and 1 year among patients aged 70 years or older who had initiated treatment with sacubitril-valsartan during hospitalization for acute HF versus those treated with ACEI. RESULTS: One hundred and ninety-nine patients hospitalized between October 2016 and November 2020 were included, with a median age of 82 years and high rate of comorbidity. Of these, 107 were treated with sacubitril-valsartan and 92 with ACEI. The adjusted OR for readmission for HF at 3 months was 0.906 (95% CI: 0.241-3.404) and for the combined variable readmission for HF or death at 3 months was 0.696 (95% CI: 0.224-2.167). The adjusted OR for HF readmission at one year was 0.696 (95% CI: 0.224 -2.167). and for the combined variable HF readmission or death at one year 0.724 (95% CI: 0.325-1.612). CONCLUSION: Treatment with sacubitril-valsartan initiated early in hospitalization for HF in elderly patients with high comorbidity was associated with a trend towards a reduction in readmissions and death due to HF compared to treatment with ACEI, which did not reach statistical significance either at 3 months or 1 year of follow-up.

Recurrent Episodes of Hypokalaemia during Treatment with Inhaled Beta-2 Agonist Revealing Gitelman Syndrome, an Uncommon Clinical Entity.

A 28-year-old female patient was hospitalized for mild-moderate hypokalaemia which was persistent despite discontinuation of beta-2 agonist bronchodilator treatment. Her past medical history was relevant for two episodes of severe hypokalaemia after active inhaled beta-2 agonist treatment for asthma crisis. Investigations revealed increased potassium in spot urine with a transtubular potassium gradient <4. A 24-hour urine analysis showed hypophosphaturia, hypocalciuria, hypomagnesuria and normal urine prostaglandins in favour of Gitelman syndrome. Oral potassium supplementation was started and genetic studies were recommended. LEARNING POINTS: An exhaustive aetiological work-up should be performed in young patients with persistent hypokalaemia after withdrawal of bronchodilators.Gitelman syndrome should be suspected in any patient with unexplained hypokalaemia, metabolic alkalosis, and a normal or low blood pressure.

Haemothorax in a Pregnant Woman Secondary to Rupture of a Pulmonary Arteriovenous Malformation.

Pulmonary arteriovenous malformations (PAVMs) are abnormal communications between the arteries and veins of the pulmonary vasculature leading to a right-to-left shunt. We report the case of a pregnant patient who presented with chest pain revealing a haemothorax secondary to the rupture of an arteriovenous malformation. The diagnosis was made during arteriography after simultaneous performance of an urgent caesarean section and thoracic drainage. LEARNING POINTS: The rupture of a pulmonary arteriovenous malformation in a pregnant patient is a serious and potentially life-threatening event, especially if it is not diagnosed quickly.It is crucial to use whatever imaging test is available whether ionizing or non-ionizing, as no thoracic imaging has been shown to adversely affect the fetus beyond embryogenesis.It is important for emergency doctors to consider this life-threatening condition in the differential diagnosis of atypical chest pain in pregnant women.

Heart failure and in-hospital mortality in elderly patients after elective noncardiac surgery in Spain

Background: Patients with heart failure (HF) undergoing noncardiac surgical procedures is rising worldwide. This study was aiming at analyzing the impact of heart failure (HF) on the outcomes (mortality, complications, readmissions, and length of stay) of elderly patients undergoing elective major noncardiac surgical procedures in Spain.MethodsA retrospective observational study of patients undergoing noncardiac surgery was conducted. The Minimum Basic Data Set (MBDS) was used to collect information about the demographic characteristics of patients discharged from hospitals of the Spanish National Health System (SNHS), variables related to patients’ medical conditions and surgeries conducted during the episode.ResultsA total of 996,986 selected procedures in the discharge record were identified in the period 2007–2015. HF was recorded as a secondary diagnosis in 22,367 discharges (2.24%). The mean age of patients was 76.6±7.27 years, with a difference in patients without and with HF: 76.5 (95% CI: 76.47–76.50) vs 82.8 (95% CI: 82.71–82.90). The number of selected surgical procedures increased by 13.2% (117,487 in 2015 vs. 103,744 in 2007), and the proportion of presence HF as a comorbidity increased by 24.4% (2.4% in 2015 v 1.9% in 2007). The proportion of women was higher in the HF group: 53.2% (95% CI: 53.18–53.22) vs 64.3% (95% CI: 64.20–64.44), with a longer average length of stay: 7.9 (95% CI: 7.9–7.9) vs 14.9 (95% CI 14.7–15.0) days, and women had a higher proportion of comorbidities. HF was found to be an independent risk factor in-hospital mortality in the multilevel risk adjustment model (OR=2.3; 95% CI: 2.2–2.4). (AU)

Antecedentes: El número de pacientes con insuficiencia cardíaca (IC) que se someten a procedimientos quirúrgicos no cardíacos está aumentando en todo el mundo. El objetivo de este estudio es analizar el impacto de la IC en los resultados (mortalidad, complicaciones, reingresos y duración de la estancia) de los pacientes de edad avanzada sometidos a procedimientos quirúrgicos mayores electivos no cardíacos en España.MétodosSe realizó un estudio observacional retrospectivo de pacientes sometidos a cirugía no cardíaca. Se utilizó el Conjunto Mínimo Básico de Datos (CMBD) para recoger información sobre las características demográficas de los pacientes dados de alta en los hospitales del Sistema Nacional de Salud (SNS), variables relacionadas con las condiciones médicas de los pacientes y las cirugías realizadas durante el episodio.ResultadosSe identificaron un total de 996.986 procedimientos seleccionados en el registro de altas en el periodo 2007-2015. La IC se registró como diagnóstico secundario en 22.367 altas (2,24%). La edad media de los pacientes fue de 76,6 ± 7,27 años, con una diferencia en los pacientes sin y con IC: 76,5 IC 95%: 76,47 - 76,50) vs. 82,8 (IC 95%: 82,71 – 82,90). El número de procedimientos quirúrgicos seleccionados aumentó un 13,2% (117.487 en 2015 vs. 103.744 en 2007), y la proporción de presencia de IC como comorbilidad aumentó un 24,4% (2,4% en 2015 vs. 1,9% en 2007). La proporción de mujeres fue mayor en el grupo de IC: 53,2% (IC 95%: 53,18 – 53,22) vs. 64,3% (IC 95%: 64,20 – 64,44), con una duración media de la estancia mayor 7,9 (IC 95%: 7,9 – 7,9) vs. 14,9 (IC 95%: 14,7 – 15,0), y las mujeres tenían una mayor proporción de comorbilidades. La IC resultó ser un factor de riesgo independiente de mortalidad intrahospitalaria en el modelo de ajuste de riesgo multinivel (OR = 2,3; IC 95%: 2,2-2,4). (AU)

Severe Hydrocephalus due to Obstructive Basilar Dolichoectasia of the Third Ventricle.

Vertebro-basilar dolichoectasia (VBD) is a rare pathology of unknown aetiology. Its clinical presentation is wide and prognosis is generally poor with a high mortality rate. Cerebral magnetic resonance imaging is the gold standard for diagnosis. We report an unusual case of intracranial dolichoectasia. VBD was revealed during investigation of a patient with altered mental status. CT brain imaging demonstrated severe obstructive hydrocephalus secondary to compression of the third ventricle. Management is always challenging and depends on the location and the mode of presentation. Our patient died despite surgical management with placement of an external ventricular shunt. LEARNING POINTS: Vertebro-basilar dolichoectasia is a little known cause of altered mental status in elderly patients.An atypical presentation of vertebro-basilar dolichoectasia can mimic extensive cerebrovascular haemorrhage.The prognosis is poor despite prompt diagnosis and the surgical treatment of choice.