Social determinants of health and metabolic syndrome in Colombian older adults.

BACKGROUND AND AIMS: Social determinants of health (SDH) are critical in health outcomes. More insight is needed on the correlation between SDH and metabolic syndrome (MetS) in the aging population. This study assessed the association between SDH and MetS scores among older adults in Colombia. METHODS AND RESULTS: This cross-sectional country-wide study includes a sample of 4085 adults aged ≥60 from the SABE Colombia Survey. MetS measurements were central obesity, hyperglycemia or diabetes, hypertriglyceridemia, arterial hypertension, and low HDL cholesterol (MetS score 0-5). SDH includes four levels: 1- general socioeconomic and environmental conditions; 2-social and community networks; 3- individual lifestyle; and 4-constitutional factors. In multivariate linear regression analysis, the SDH factors with greater effect sizes, calculated by Eta Squared, predicting higher MetS mean scores were women followed by low education, no alcohol intake, urban origin, and residing in unsafe neighborhoods. Two interactions: men, but not women, have lower MetS in safe neighborhoods compared to unsafe, and men, but not women, have lower MetS when having low education (0-5 years) compared to high (≥6). CONCLUSION: Gender, education, alcohol intake, and origin have the greatest effect sizes on MetS. Education level and neighborhood safety modified the relationship between gender and MetS. Low-educated men or those residing in safe neighborhoods have lower MetS. Neighborhood environments and educational differences influencing MetS should be considered in future studies.

Manganese Associated with Non-Wilsonian Hepatolenticular Degeneration as a Rare Cause of Encephalopathy: Case Report

Aim: To describe the clinical picture, diagnosis, and treatment of a patient with encephalopathy as a manifestation of manganese-induced non-Wilsonian hepatolenticular degeneration (NWHD) in a high-complexity care center in a Latin American country. Case description: A 55-year-old male patient from the United States with a history of liver disease associated with alcohol consumption was admitted to the emergency department due to diarrhea, hematemesis, and psychomotor agitation. During his stay, his state of consciousness deteriorated, requiring orotracheal intubation. In his diagnostic study, cerebrospinal fluid tests were negative for infectious etiologies; the endoscopic examinations showed no marks of portal hypertension bleeding, while ammonium and tests for metabolic causes were normal. However, areas of hyperintensity in the basal ganglia were documented on brain MRI, with normal ceruloplasmin serum and urine copper levels, which ruled out Wilson's disease and determined the diagnosis of manganese-induced NWHD. Conclusion: NWHD is a rare cause of chronic encephalopathy with clinical manifestations of extrapyramidal symptoms secondary to basal ganglia dysfunction due to severe liver disease. Its diagnosis becomes a challenge, given that manganese deposits produce it, and no biomarkers can establish the level of exposure to this metal. Brain MRI is indispensable in reflecting these deposits in the basal ganglia.

Objetivo: Describir la presentación clínica, el diagnóstico y el tratamiento de un paciente con encefalopatía como manifestación de degeneración hepatolenticular no wilsoniana producida por manganeso, en un centro de alta complejidad de un país latinoamericano. Descripción del caso: Paciente masculino de 55 años, procedente de Estados Unidos, con antecedente de enfermedad hepática asociada con consumo de alcohol, quien ingresó al servicio de urgencias por un cuadro de diarrea, hematemesis y agitación psicomotora. Durante la estancia presentó deterioro en el estado de consciencia, por lo que requirió intubación orotraqueal. En su estudio diagnóstico, las pruebas de líquido cefalorraquídeo fueron negativas para etiologías infecciosas, en los estudios endoscópicos no tenía estigmas de sangrado portal hipertensivo y el amonio y los estudios para causas metabólicas fueron normales. Sin embargo, se documentaron áreas de hiperintensidad en los ganglios de la base en la resonancia magnética cerebral, con niveles de ceruloplasmina sérica y cobre urinario normales, lo que descartó enfermedad de Wilson y definió el diagnóstico de degeneración hepatolenticular no wilsoniana por depósitos de manganeso. Conclusión: La degeneración hepatolenticular no wilsoniana es una causa infrecuente de encefalopatía crónica con manifestaciones clínicas de extrapiramidalismo, secundaria a disfunción de los ganglios de la base por enfermedad hepática grave. Su diagnóstico se convierte en un reto, dado que se produce por depósitos de manganeso y no existen biomarcadores que puedan establecer el nivel de exposición a este metal. La resonancia magnética cerebral juega, por tanto, un papel indispensable al reflejar esos depósitos en los ganglios de la base.

Racial Discrimination and Multimorbidity Among Older Adults in Colombia: A National Data Analysis.

INTRODUCTION: Multimorbidity is a prevalent worldwide problem among older adults. Our objective was to assess the association between life-course racial discrimination and multimorbidity among older adults in Colombia. METHODS: We used data from the SABE (Salud, Bienestar y Envejecimiento) Colombia Study in 2015 (N = 18,873), a national cross-sectional survey among adults aged 60 years or older. The outcome was multimorbidity, defined as having 2 or more chronic conditions. The main independent variables were 3 racial discrimination measures: 1) everyday racial discrimination (yes or no), 2) childhood racial discrimination score (scored from 0 [never] to 3 [many times]), and 3) situations of racial discrimination in the last 5 years (scored from 0 to 4 as a sum of the number of situations [group activities, public places, inside the family, health centers]). Other variables were sociodemographic characteristics, diseases, economic or health adversity during childhood, and functional status. We used weighted logistic regression analyses to adjust for differences between groups. RESULTS: Multivariate logistic regression models showed that multimorbidity was significantly associated with experiencing everyday racial discrimination (OR, 2.21; 95% CI, 1.62-3.02), childhood racial discrimination (OR, 1.27; 95% CI, 1.10-1.47), and the number of situations of racial discrimination (OR= 1.56; 95% CI, 1.22-2.00). Multimorbidity was also independently associated with multimorbidity during childhood. CONCLUSION: Racial discrimination experiences were associated with higher odds of multimorbidity among older adults in Colombia. Strategies to decrease life course experiences of racial discrimination may improve the health of older adults.

Síndrome de Anton-Babinsky / Anton-Babinski Syndrome

Introducción: El síndrome de Anton-Babinsky es un trastorno neuropsiquiátrico poco frecuente, que se manifiesta por anosognosia y ceguera cortical, debido a lesiones en las áreas visuales asociativas de la corteza occipital sin presentar afectación en la vía visual. En adultos mayores sus manifestaciones clínicas suelen ser atípicas y la valoración geriátrica integral permite orientar el diagnóstico, que se puede asociar con síndromes geriátricos. Objetivo: Describir las manifestaciones clínicas, síndromes geriátricos, paraclínicos y tratamiento de un paciente con Síndrome de Anton-Babinsky. Caso clínico: Paciente de 85 años, quien durante un postoperatorio inmediato de cirugía ocular (pterigión) presentó alteración fluctuante del estado de conciencia, alucinaciones visuales, disminución de la agudeza visual bilateral y anosognosia. La analítica sanguínea no reportó alteraciones y la tomografía computarizada de cráneo documentó isquemia occipital bilateral, se le diagnosticó síndrome de Anton-Babinsky. Conclusiones: El síndrome de Anton-Babinsky puede tener presentación atípica a través de síndromes geriátricos. La valoración geriátrica integral permite realizar un diagnóstico y manejo multicomponente oportuno con el objetivo de influir en el pronóstico tanto a corto como a largo plazo(AU)

Introduction: Anton-Babinski syndrome is a rare neuropsychiatric disorder, with a manifestation of anosognosia and cortical blindness, due to lesions in the associative visual areas of the occipital cortex without presenting visual pathway impairment. In elderly adults, its clinical manifestations are usually atypical and a comprehensive geriatric assessment allows to guide the diagnosis, which can be associated with geriatric syndromes. Objective: To describe the clinical manifestations, geriatric syndromes, paraclinical findings and treatment of a patient with Anton-Babinski syndrome. Clinical case: This is the case of an 85-year-old patient who, during the immediate postoperative period after ocular surgery (pterygium), presented a fluctuating alteration of consciousness, visual hallucinations, decreased bilateral visual acuity and anosognosia. Blood analysis reported no alterations and cranial computed tomography documented bilateral occipital ischemia; the patient was diagnosed with Anton-Babinski syndrome. Conclusions: Anton-Babinski syndrome may have an atypical presentation through geriatric syndromes. Comprehensive geriatric assessment allows for timely multicomponent diagnosis and management with the aim of influencing both short- and long-term prognosis(AU)

Cerebral amyloid angiopathy in an octogenarian

Cerebral amyloid angiopathy presents with lobar intracerebral hemorrhage, dementia or tran sient neurological events. It occurs due to P-amyloid deposits in the media and adventitia of small arteries, leptomeningeal capillaries and the cerebral cortex. Its prevalence increases with age, and its association with cognitive impairment is well established. We present the case of an 80-year-old previously independent woman with no disabilities or cognitive impairment, and a history of well-controlled systemic arterial hypertension who consulted due to a de novo seizure and focal neurological deficits. On imaging follow up, two bilateral parietal-occipital macrohemorrhages were found, which occurred at two different times during the development of the clinical condition. These findings were attributed to cerebral amyloid angiopathy, and the patient ultimately died during this hospitalization. In this case presentation, we discuss the diagnostic criteria for considering the presence of cerebral amyloid angiopathy, its prognosis, and the reason it led to death. (Acta Med Colomb 2022; 47. DOI:https://doi.org/10.36104/amc.2022.2567).

La angiopatía amiloide cerebral se presenta con hemorragia intracerebral lobular, demencia o eventos neurológicos transitorios. Ocurre como resultado del depósito de (3-amiloide en la media y la adventicia de las arterias pequeñas, los capilares de las leptomeninges y la corteza cerebral. Su prevalencia aumenta con la edad y su asociación con deterioro cognitivo está bien establecido. Se presenta el caso de una mujer de 80 años, previamente independiente, sin discapacidad ni deterioro cognitivo, con antecedente de hipertensión arterial sistémica bien controlada, quien consultó por episodio convulsivo de novo y focalización neurológica. Durante el seguimiento imagenológico se documentó presencia de dos macrohemorragias parietooccipitales bilaterales, acontecidas en dos momentos diferentes durante la evolución del cuadro clínico, hallazgos que fueron atribuidos a la presencia de angiopatía amiloide cerebral, finalmente la paciente falleció durante dicha hospitaliza ción. En esta presentación de caso se discuten los criterios diagnósticos para considerar la presencia de angiopatía amiloide cerebral, el pronóstico y la razón que llevó a la muerte. (Acta Med Colomb 2022; 47. DOI:https://doi.org/10.36104/amc.2022.2567).

Abordaje de hipertensión secundaria en adultos mayores: reporte de caso / Secondary hypertension approach in older adults: a case report

Resumen La hipertensión arterial secundaria es poco frecuente y está asociada con una causa que puede ser tratable, por lo cual su diagnóstico y tratamiento oportuno son importantes. La orientación diagnóstica se hace con base en los datos obtenidos en la anamnesis y examen físico del paciente buscando posibles etiologías. Se presenta el caso de un hombre de 63 años, con hipertensión arterial resistente, sin otra sintomatología ni antecedentes personales o familiares. Se realizaron estudios iniciales que documentaron hipopotasemia, lo que hizo sospechar hiperaldosteronismo primario, se solicitaron pruebas complementarias con aldosterona plasmática elevada, actividad de la renina plasmática baja, además con imagen diagnóstica por resonancia nuclear magnética que mostró nódulo suprarrenal derecho. Se considero llevar a adrenalectomía derecha, con reporte de patología compatible con adenoma cortical adrenal. Durante el seguimiento en atención primaria presento adecuado control en cifras de presión arterial con disminución del número de medicamentos antihipertensivos requeridos.

Abstract Secondary arterial hypertension is rare, it is associated with a cause that can be treatable, for which its diagnosis and treatment are not important.The diagnostic orientation is made based on the data obtained in the anamnesis and physical examination of the patient, looking for possible etiologies.We present the case of a 63-year-old man with resistant hypertension, without other symptoms or personal or family history. Initial studies were performed that documented hypokalemia, which led to the suspicion of primary hyperaldosteronism. Complementary tests were requested with high plasma aldosterone, low plasma renin activity, in addition to a diagnostic magnetic resonance imaging that showed an adrenal nodule. A right adrenalectomy was considered, with a report of pathology compatible with adrenal cortical adenoma.During the follow-up in primary care, patient presented adequate control in blood pressure figures with a decrease in the number of antihypertensive drugs required.

Sarcopenic Dysphagia Is Associated With Mortality in Institutionalized Older Adults.

OBJECTIVE: To estimate mortality associated with sarcopenic dysphagia. DESIGN: A 3-year follow-up cohort. SETTING AND PARTICIPANTS: Ninety-five nursing home residents were evaluated to determine the baseline presence or absence of oropharyngeal dysphagia and followed up for 3 years. METHODS: The primary outcome was the risk of death. Dysphagia was assessed using a volume-viscosity swallow test. We used an algorithm to determine sarcopenic dysphagia based on grip strength, walking speed, calf circumference, and exclusion of neurologic or structural causes of dysphagia. We constructed 3 subgroups: without dysphagia, nonsarcopenic dysphagia, and sarcopenic dysphagia. Cox proportional regression analyses were used to predict the risk of death. RESULTS: Thirty-five percent of participants had no dysphagia, 20% nonsarcopenic dysphagia, and 45% sarcopenic dysphagia. Sarcopenic dysphagia was independently associated with a higher risk of death [hazard ratio (HR) 2.44, 95% CI 1.02-5.80, P = .043] than without dysphagia. In addition, a higher Charlson Comorbidity Index score was associated with a higher risk of death (HR 1.33, 95% CI 1.01-1.75, P = .040). CONCLUSIONS AND IMPLICATIONS: This study shows that sarcopenic dysphagia was associated with increased mortality among institutionalized older adults. These deaths could be potentially preventable.

Splanchnic vein thrombosis as a manifestation of latent myeloproliferative neoplasm associated with sticky platelet syndrome / Trombosis esplácnica como presentación de neoplasia mieloproliferativa latente asociada con síndrome de plaqueta pegajosa

Abstract Vein thrombosis of unusual sites such as the splanchnic region continues to be not only a diagnostic but also a therapeutic challenge for the clinician due to its manifestation and associated pathologies. Latent JAK2 (Janus kinase 2) positive myeloproliferative neoplasm associated with sticky platelet syndrome is unusual. We present a clinical case of a 38-year-old female patient who presented with sudden onset abdominal pain of a possible vascular origin. Splanchnic thrombosis was diagnosed in latent myeloproliferative neoplasm by identifying the JAK2V617F mutation and sticky platelet syndrome via platelet aggregometry. Off-label anticoagulation with rivaroxaban 20 mg/day was administered. During her outpatient follow-up, she did not suffer any new thrombotic episodes.

Resumen La trombosis venosa de sitios inusuales como la esplácnica continúa siendo un reto no solo diagnóstico sino también terapéutico para el clínico debido a su forma de presentación y las patologías asociadas. La neoplasia mieloproliferativa latente JAK2 (cinasa de Janus 2) positiva asociada con síndrome de plaqueta pegajosa es inusual. Se presenta un caso clínico de una paciente de 38 años de edad que debutó con dolor abdominal de inicio súbito que sugirió un posible origen vascular. Se diagnosticó trombosis esplácnica en relación con neoplasia mieloproliferativa latente por la identificación de la mutación de la JAK2V617F y síndrome de plaqueta pegajosa mediante agregometría plaquetaria. Se administró de manera off-label anticoagulación con rivaroxabán 20 mg/día. Durante su seguimiento ambulatorio no ha presentado nuevos episodios trombóticos.

The Association Between Discrimination and Falling. A National Sample of Older Adults.

OBJECTIVE: To assess the relationship between discrimination and falling among older people. METHODS: A cross-sectional nationwide population-based face-to-face survey, 2015. The SABE (Salud, Bienestar y Envejecimiento) Colombia Study, 19,004 community-dwelling adults aged ≥60 years. Recurrent falling was defined as ≥2 falls during the prior year. Main independent variable was discrimination. RESULTS: Multivariate logistic regression models showed that recurrent falling was significantly associated with a number of reasons for experiences of everyday discrimination (due to racial, socioeconomic status, gender, age, religion, sexual orientation, or disability) (OR = 1.27, 95% CI 1.21-1.33), childhood discrimination score (never = 0 to many times = 3) (OR = 1.23, 95% CI 1.13-1.33), and number of situations for discrimination during the last 5 years due to skin color (group activities, public places, inside the family, or health centers) (OR = 1.12, 95% CI 1.08-1.17). DISCUSSION: Discrimination experiences were associated with higher odds of recurrent falling.

Gitelman syndrome, a rare cause of refractory hypokalemia. A case report / Símdrome de Gitelman, causa rara de hipopotasemia refractaria. Reporte de caso

Abstract Introduction: Gitelman syndrome is a rare hereditary primary renal tubular disorder, with a prevalence of approximately 1 to 10 cases per 40 000 people. It does not have specific symptoms, so its diagnosis depends on high clinical suspicion by the treating physical and a sequential approach to hypokalemia, especially in young patients. Thus, a diagnostic algorithm is proposed at the end of this report. Case presentation: A 23-year-old woman with a history of hospitalization due to hypokalemia presented to the emergency service with intermittent cramping in her lower limbs, which was exacerbated by gastrointestinal symptoms. Laboratory tests reported the following findings: metabolic alkalosis, elevated levels of potassium, magnesium, chloride and sodium in urine, and reduced levels of calcium in urine. Thus, potassium supplementation and eplerenone administration were started, obtaining the complete resolution of symptoms. At her last follow-up appointment, the patient was asymptomatic, and her serum electrolyte levels were normal. In addition, during her hospital stay and due to the high suspicion of Gitelman syndrome, a genetic study was performed, which reported a mutation of the SCL12A3 gene, confirming the diagnosis. Conclusion: The sequential approach to a patient with recurrent hypokalemia is very important to reach an accurate diagnosis among a wide range of differential diagnoses.

Resumen Introducción. El síndrome de Gitelman es un trastorno tubular renal primario hereditario poco frecuente, con una prevalencia aproximada de 1 a 10 casos por cada 40 000 personas; su sintomatologia es inespecífica, por lo que su diagnóstico depende de la alta sospecha clínica por parte del médico tratante y de un abordaje secuencial de la hipopotasemia, sobre todo en pacientes jóvenes, para lo cual se propone un algoritmo diagnóstico al final de este reporte. Presentación de caso. Mujer de 23 años con antecedente de hospitalización por hipopotasemia, quien consultó por calambres musculares intermitentes en miembros inferiores, los cuales se agudizaron debido a síntomas gastrointestinales. En los exámenes de laboratorio se reportaron los siguientes hallazgos: alcalosis metabólica, niveles elevados de potasio, magnesio, cloro y sodio en orina, y niveles reducidos de calcio en orina, por lo que se inició suplementación de potasio y manejo con eplerenona, obteniéndose resolución completa de los síntomas. En su último control, la paciente se encontraba asintomática y sus niveles séricos de electrolitos eran normales. Además, durante la hospitalización, y debido a la alta sospecha de síndrome de Gitelman, se solicitó estudio genético que reportó mutación del gen SCL12A3, confirmándose el diagnóstico. Conclusión. El abordaje secuencial de un paciente con hipopotasemia recurrente es de gran importancia para realizar un diagnóstico certero ante una amplia gama de diagnósticos diferenciales.

Multimorbilidad y síndromes geriátricos. Su efecto sobre la mortalidad en adultos mayores con sepsis / Multimorbidity and geriatric syndromes. Their effect on mortality in older adults with sepsis

Resumen Introducción: la sepsis se diagnostica en más de 60% de los adultos mayores (AM) en el mundo. Estos AM con frecuencia presentan multimorbilidad y alguno de los síndromes geriátricos, llevando a discapacidad física, cognitiva y psicosocial, lo cual produce altos costos para los sistemas de salud, resultando en un problema grave de salud pública. Objetivo: identificar el impacto de la multimorbilidad y los síndromes geriátricos en la morta lidad de AM hospitalizados por sepsis en una unidad geriátrica de agudos a 30 días de su ingreso. Material y métodos: estudio observacional, analítico de casos y controles anidado en una cohorte. Resultados: se analizaron 238 pacientes con edad media de 83.15±7.12 años, 52.1% fueron mujeres y el 99% tenían al menos una comorbilidad, la mortalidad a 30 días fue 34%. La infección urinaria fue la causa principal de hospitalización (42.9%), obteniendo un aislamiento microbio-lógico en 43.3% de los casos, siendo la Escherichia coli el agente causal más frecuente (46.6%). La regresión logística múltiple mostró que la enfermedad renal crónica (OR 2.1 IC 95% 1.1-4.8; p=0.037), el delirium (OR 3.1 IC 95% 1.6-5.8; p=0.001) y la discapacidad (índice de Barthel <60; OR 3.4 IC 95% 1.5-7.5; p=0.002) se asociaron de manera significativa con la mortalidad a 30 días desde el ingreso a la unidad geriátrica de agudos en paciente con sepsis. Conclusión: en los AM hospitalizados por sepsis, la multimorbilidad, la enfermedad re nal crónica y los síndromes geriátricos representados por delirium y discapacidad fueron los predictores de mortalidad a 30 días. (Acta Med Colomb 2022; 47. DOI:https://doi.org/10.36104/amc.2022.2125).

Abstract Introduction: sepsis is diagnosed in more than 60% of older adults (OAs) worldwide. These OAs often have multimorbidity and one of the geriatric syndromes, leading to physical, cognitive and psychosocial disability with consequently high healthcare costs, resulting in a serious public health problem. Objective: to determine the impact of multimorbidity and geriatric syndromes on the 30-day mortality rate of OAs hospitalized for sepsis in an acute geriatric unit Materials and methods: an observational, analytical, nested case-control study. Results: 238 patients with a mean age of 83.15±7.12 were analyzed; 52.1% were women and 99% had at least one comorbidity; the 30-day mortality was 34%. Urinary tract infection was the main cause of hospitalization (42.9%), with microbiological isolation achieved in 43.3% of cases and Escherichia coli being the most common causal agent (46.6%). Multiple logistic regression showed that chronic kidney disease (OR 2.1 95% CI 1.1-4.8; p=0.037), delirium (OR 3.1 95% CI 1.6-5.8; p=0.001) and disability (Barthel index <60; OR 3.4 95% CI 1.5-7.5; p=0.002) were significantly related to 30-day mortality in patients with sepsis admitted to an acute geriatric unit. Conclusion: in OAs hospitalized for sepsis, multimorbidity, chronic kidney disease and geriatric syndromes (represented by delirium and disability) were the predictors of 30-day mortality. (Acta Med Colomb 2022; 47. DOI:https://doi.org/10.36104/amc.2022.2125).

Paracoccidioidomicosis diseminada en paciente inmunocompetente: reporte de caso / Disseminated Paracoccidioidomycosis in immunocompetent patient: case report

Resumen La Paracoccidioidomicosis (PCM) es una infección micótica endémica en Latinoamérica que se caracteriza por compromiso multiorgánico. El diagnóstico tardío y la diseminación sistémica favorecen complicaciones como falla respiratoria e insuficiencia suprarrenal que condicionan el desenlace del paciente. Se presenta el caso de un paciente de 51 años de edad, procedente de la costa pacífica colombiana, inmunocompetente con PCM diseminada a sistema nervioso central (SNC), pulmones y glándulas suprarrenales con debut clínico de síndrome neurológico. Durante estancia hospitalaria presenta pico febril, colapso hemodinámico, aci dosis metabólica severa e hiperlactatemia. Se hemocultivó e inició tratamiento antimicrobiano de amplio espectro con piperacilina-tazobactam (4.5 gr/IV cada 8 horas), vancomicina (15 mg/kg) más anfotericina B desoxicolato (1 mg/kg/dia) y se trasladó a unidad de cuidado intensivo. En la muestras de tejido suprarrenal se identificaron levaduras multigemantes de Paracoccidioides spp e inflamacion crónica granulomatosa. A los seis días posteriores a su ingreso, el paciente continuó con deterioro hemodinámico, desequilibrio electrolítico, shock séptico e insuficiencia suprarrenal que conllevó a su deceso a pesar de las medidas terapéuticas establecidas. Se intenta exponer el desafío que representa el diagnóstico de PCM sistémica y promover su sospecha clínica para poder identificar la enfermedad de forma oportuna y evitar complicaciones que conduzcan a un desenlace fulminante.

Abstract Paracoccidioidomycosis (PCM) is an endemic fungal infection in Latin America characterized by multi-organ involvement. Late diagnosis and systemic dissemina tion favor complications such as respiratory failure and adrenal insufficiency, which determine the outcome of the patient. We present the case of a 51-year-old patient from the Colombian Pacific coast, immunocompetent with PCM spread to the central nervous system (CNS), lungs, and adrenal glands with a clinical debut of the neurological syndrome. During a hospital stay, he presented fever peak, hemodynamic collapse, severe metabolic acidosis, and hyperlactatemia. Blood culture and began broad-spectrum antimicrobial treatment with piperacillin-tazobactam (4.5 gr / IV every 8 hours), vancomycin (15 mg/kg) plus amphotericin B deoxycholate (1 mg/kg/day) and was transferred to the intensive care unit. Paracoccidioides spp multigene yeasts and chronic granulomatous inflammation were identified in adrenal tissue samples. Six days after admission, the patient continued with hemodynamic deterioration, electrolyte imbalance, septic shock, and adrenal insufficiency that led to death despite the established therapeutic measures. The aim is to expose the challenge posed by the diagnosis of systemic PCM and promote its clinical suspicion to identify the disease promptly and avoid complications that lead to a fulminant outcome.

Sarcopenic dysphagia in institutionalised older adults.

INTRODUCTION: Sarcopenic dysphagia, defined as dysphagia caused by sarcopenia, is a swallowing disorder of great interest to the medical community. The objective of our study was to evaluate the prevalence and factors associated with sarcopenic dysphagia in institutionalised older adults. MATERIAL AND METHODS: An observational, analytical, cross-sectional study was conducted in a nursing home between September and December 2017, with 100 participants. The presence of dysphagia was assessed using the volume-viscosity clinical examination method, and the diagnostic algorithm for sarcopenic dysphagia was followed. The participants' grip strength, gait speed, calf circumference, nutritional assessment (Mini Nutritional Assessment), Barthel Index, cognitive assessment (Mini-Mental State Examination) and Charlson Comorbidity Index were evaluated. Bivariate and multivariate logistic regression analyses were performed. RESULTS: The median age was 84 years, and 55% were women; 48% had functional dependence, 49% had positive screening for malnutrition and 64% had some degree of dysphagia. The prevalence of sarcopenic dysphagia was 45%, and the main factors related to less sarcopenic dysphagia were a good nutritional status (OR 0.85, 95% CI, 0.72-0.99) and a better functional performance status (OR 0.98, 95% CI 0.97-0.98). CONCLUSION: Sarcopenic dysphagia has a high prevalence in institutionalised older adults; and functional dependence and poor nutritional status were associated with sarcopenic dysphagia.

Centenaria institucionalizada recuperada por COVID-19 con generación de inmunidad: Un caso de estudio / A centenarian institutionalized patient who recovered from COVID-19 and developed immunity: A case study

Resumen Introducción: El virus SARS-CoV-2 y su enfermedad COVID-19, afecta con mayor severidad a personas adultas mayores, sobre todo aquellas con multimorbilidad y fragilidad; esto debido a mecanismos fisiológicos como la inmunosenescencia o un pobre control de la actividad inflamatoria en esta población. Los estudios sobre el diagnóstico y tratamiento en estos pacientes son escasos y muchos de ellos tienen niveles de evidencia bajos. Objetivo: Describir las características clínicas y paraclínicas de una adulta mayor centenaria institucionalizada, frágil, con multimorbilidad quien sobrevive a la infección y desarrolla inmunidad en una unidad geriátrica de agudos. Presentación del caso: Centenaria institucionalizada con multimorbilidad y fragilidad con criterios de severidad de la enfermedad, quien fue manejada tempranamente y recuperada, llegando a desarrollar inmunidad. Conclusiones: El diagnóstico temprano, un manejo precoz y el abordaje geriátrico integral e interdisciplinar son indispensables para un desenlace favorable en pacientes adultos mayores con alto riesgo de progresión de enfermedad con COVID-19.

Abstract Introduction: SARS-CoV-2 virus, and the disease it causes (COVID-19), severely affects older adults (OA), especially those with multimorbidity and frailty. This is due to physiological mechanisms such as immunosenescence or poor control of inflammatory activity in this population. Studies of the diagnoses and treatments in these patients are scarce and many of them have low levels of evidence. Objective: To describe the clinical and paraclinical characteristics of a frail institutionalized centenarian female patient with multimorbidity who survived COVID-19 infection, developed immunity, and was treated in an acute geriatric unit. Case presentation: Institutionalized centenarian patient with multimorbidity and frailty who fulfilled the criteria for severe COVID-19 disease, was managed early, recovered, and eventually developed immunity. Conclusion: early diagnosis, early management and a comprehensive and interdisciplinary geriatric approach are essential for a favorable outcome in OA patients at high risk of COVID-19 disease progression.

Efecto conjunto de deterioro cognitivo y condición sociofamiliar sobre el estado funcional en adultos mayores hospitalizados / Joint effect of cognitive impairment and socio-family status on functional status in hospitalized older adults

Resumen Introducción: El objetivo de este estudio fue evaluar el efecto conjunto de deterioro cognitivo y condición sociofamiliar sobre el estado funcional en adultos mayores hospitalizados. Método: Se usó una cohorte retrospectiva, que incluyó 399 adultos mayores entre 2014 hasta 2015. El desenlace primario fue el estado funcional evaluado con la Escala de Lawton y Brody en cuatro tiempos. El deterioro cognitivo se evaluó con el Examen Mínimo Mental y la condición sociofamiliar con la Escala Sociofamiliar de Gijón. Resultados: Se encontró que el 54% tenían deterioro social y el 86% presentaban deterioro cognitivo. En análisis multivariados, la edad avanzada, la estancia hospitalaria prolongada, la albúmina baja, el deterioro cognitivo, el delirium y el deterioro social se asociaron significativamente con peor estado funcional. Conclusiones: Este estudio sugiere que el efecto conjunto entre deterioro cognitivo y deterioro social comprometen más el estado funcional que cada factor por separado.

Abstract Introduction: The objective of this study was to evaluate the joint effect of cognitive impairment and socio-family condition on the functional status in hospitalized older adults. Method: A retrospective cohort included 399 older adults between 2014 and 2015. The primary outcome was functional status assessed by Lawton and Brody Scale in four times. Cognitive impairment was assessed with the MiniMental State examination and the socio-family condition with the Gijón Socio-family Scale. Results: It was found that 54% had social deterioration and 86% had cognitive impairment. In multivariate analyzes, advanced age, prolonged hospital stay, low albumin, cognitive impairment, delirium, and social deterioration were significantly associated with worse functional status. Conclusions: This study suggests that the joint effect between cognitive impairment and social deterioration compromises the functional status more than each factor separately.

Valoración geriátrica integral en cuidados paliativos: revisión bibliográfica / Comprehensive geriatric assessment in palliative care: a literature review

El progresivo envejecimiento de la población es explicado por el avance en el cuidado de la salud, y las transiciones demográficas y epidemiológicas presentes en el plano mundial. Este fenómeno implica cambios en el campo social y económico, en los sistemas de educación y salud y en la seguridad social. En consecuencia, es característico encontrar adultos mayores con multimorbilidad que presentan enfermedades crónicas con diferentes trayectorias al final de la vida y que van a requerir atención en el modelo de cuidados paliativos. La valoración geriátrica integral (VGI) es la tecnología disponible en la actualidad para abordar la compleja situación de los adultos mayores, en particular los que necesitan atención por cuidados paliativos. El proceso de la VGI ofrece un enfoque integral que se fundamenta en el modelo biopsicosocial y se operativiza mediante la actuación de un equipo interdisciplinario, quien brinda evaluación y cuidado paliativo de forma individualizada y continua, y adaptado a lo largo de la trayectoria de la enfermedad, ayudando a determinar un pronóstico y calidad de vida potencial en cada adulto mayor. En la VGI dentro de los cuidados paliativos, la planificación anticipada de cuidados y la toma de decisiones compartida son de especial importancia, desde el momento en el que los adultos mayores tienen indicación de ser atendidos hasta el final de sus vidas, y después de la muerte, dando soporte a sus familiares y cuidadores. (AU)

The progressive aging of the population may be explained by advances in health care, and by the demographic and epidemiological transitions present on a worldwide level. This phenomenon implies changes in the social and economic settings, in the education and health care systems, and in social security. As a consequence, older adults with multiple morbidities are typically encountered who develop chronic diseases with different trajectories at the end of life, and who will require care within the palliative model. Comprehensive geriatric assessment (CGA) is the technology currently available to address the complex situation of older adults, particularly of those who need palliative care. The CGA process offers a comprehensive approach that is based on the biopsychosocial model and made operational through the efforts of an interdisciplinary team that provides assessment and palliative care in an individualized, continuous, adaptive way throughout the course of the disease, helping to establish the prognosis and potential quality of life of each older adult. To implement CGA within the palliative care setting, advance care planning and shared decisionmaking are of special importance from the time palliative care is indicated to the end of life, as is providing support to relatives and caregivers after the patient’s demise.

Sarcopenic dysphagia in institutionalised older adults. / Disfagia sarcopénica en adultos mayores institucionalizados.

INTRODUCTION: Sarcopenic dysphagia, defined as dysphagia caused by sarcopenia, is a swallowing disorder of great interest to the medical community. The objective of our study was to evaluate the prevalence and factors associated with sarcopenic dysphagia in institutionalised older adults. MATERIAL AND METHODS: An observational, analytical, cross-sectional study was conducted in a nursing home between September and December 2017, with 100 participants. The presence of dysphagia was assessed using the volume-viscosity clinical examination method, and the diagnostic algorithm for sarcopenic dysphagia was followed. The participants' grip strength, gait speed, calf circumference, nutritional assessment (Mini Nutritional Assessment), Barthel Index, cognitive assessment (Mini-Mental State Examination) and Charlson Comorbidity Index were evaluated. Bivariate and multivariate logistic regression analyses were performed. RESULTS: The median age was 84 years, and 55% were women; 48% had functional dependence, 49% had positive screening for malnutrition and 64% had some degree of dysphagia. The prevalence of sarcopenic dysphagia was 45%, and the main factors related to less sarcopenic dysphagia were a good nutritional status (OR 0.85, 95% CI, 0.72-0.99) and a better functional performance status (OR 0.98, 95% CI 0.97-0.98). CONCLUSION: Sarcopenic dysphagia has a high prevalence in institutionalised older adults; and functional dependence and poor nutritional status were associated with sarcopenic dysphagia.

Factores asociados con estancia hospitalaria prolongada en una unidad geriátrica de agudos / Factors associated with prolonged hospital stay in an acute geriatric unit

Resumen Objetivo: analizar los factores asociados con estancia hospitalaria prolongada en una unidad geriátrica de agudos de un hospital general. Material y métodos: incluyó 2014 pacientes ≥60 años hospitalizados entre enero 2012 y septiembre 2015. La variable dependiente fue la estancia hospitalaria prolongada (>10 días vs ≤10 días). Variables independientes incluyeron las sociodemográficas, de laboratorio, comorbilidad, estado funcional y mental. Para análisis bivariado se empleó la prueba de chi 2 para variables categóricas y de Wilcoxon Two-Sample no-paramétrico para las cuantitativas. Se realizó un modelo multivariado de regresión logística. Resultados: el 51.1% fueron mujeres y la edad promedio fue 82.3 ± 7.2 años. El promedio de estancia fue 14.7 ± 14 días y la mediana fue de 10.6 días. El 50.6% tuvieron estancia prolongada. Aquellos con estancia hospitalaria prolongada se caracterizaron por presentar dependencia funcional, anemia, comorbilidad (Indice de Charlson ≥4), hipoalbuminemia, niveles elevados de reactantes de fase aguda (PCR), y ulceras por presión. Las mujeres tuvieron menos días de hospitalización. La estancia prolongada no se relacionó con las variables sociales. Conclusión: los principales factores independientes en aumentar la estancia hospitalaria son las ulceras por presión, la dependencia funcional, la hipoalbuminemia, la comorbilidad y los niveles elevados de PCR.

Abstract Objective: to analyze the factors associated with prolonged hospital stay in the Acute Geriatric Unit of a general hospital. Materials and methods: the study included 2,014 patients ≥60 years old who were hospitalized between January 2012 and September 2015. The dependent variable was prolonged hospital stay (>10 days vs ≤10 days). The independent variables included sociodemographic, laboratory, comorbidity, and functional and mental status variables. The Chi 2 test for categorical variables and the non-parametric two-sample Wilcoxon test for quantitative variables were employed for bivariate analysis. A multivariate logistic regression model was run. Results: 51.1% of the study subjects were women and the average age was 82.3 ± 7.2 years. The average length of stay was 14.7 ± 14 days, and the median was 10.6 days. Altogether, 50.6% had a prolonged stay. Those with prolonged hospital stay were characterized by having functional dependence, anemia, comorbidity (Charlson Index ≥4), hypoalbuminemia, high levels of acute phase reactants (CRP), and pressure sores. Women had fewer inpatient days. Prolonged length of stay was not related to the social variables. Conclusion: the main independent factors increasing hospital stay are pressure sores, functional dependence, hypoalbuminemia, comorbidity and elevated CRP levels.