Análisis de la seguridad y la eficacia de una unidad de corta estancia en el tratamiento de la neumonía adquirida en la comunidad / Community-acquired pneumonia management in a short-stay unit: analysis of safety and efficacy

Introducción: La neumonía adquirida en la comunidad (NAC) es una patología de alta prevalencia que a menudo requiere ingreso hospitalario. El objetivo de nuestro estudio es evaluar la eficacia y seguridad en el tratamiento de la NAC de una unidad de corta estancia (UCE) como alternativa a las unidades de hospitalización convencional (UHC). Método: Estudio retrospectivo comparativo de pacientes ingresados en un hospital terciario con diagnóstico al alta de NAC entre noviembre del 2005 y abril del 2007. Se comparan dos grupos: pacientes ingresados en UCE frente a pacientes ingresados en UHC (se excluyen pacientes que requieren terapia intensiva). Variables analizadas: edady sexo, índice de Charlson, peso según el grupo relacionado de diagnóstico (GRD),CURB 65 y Pneumonia Severity Index (PSI), hallazgos microbiológicos, tasas de readmisión y de mortalidad. Resultados: Un total de 606 pacientes fueron reclutados, 187 ingresados en el UCE(grupo 1) y 419 en UHC (grupo 2 o grupo control). Las diferencias más significativas entre los dos grupos fueron el promedio de edad (77,3 vs 67,9 p < 0,001) y la estancia promedio (3,48 vs 7,89 p < 0,001). Estas diferencias se objetivan en el comparativo general y por subgrupos según la escala de riesgo (PSI). No se observaron diferencias significativas en la tasa de mortalidad ni en la de reingreso entre las dos formas de hospitalización. Conclusiones: La UCE es eficaz y segura en el manejo de los pacientes con NAC, con una estancia media significativamente inferior respecto a las UHC, y sin diferencias enl as tasas de mortalidad y reingreso (AU)

Background and objective: Community-acquired pneumonia (CAP) is a highly prevalent disease that often requires hospital admission. We aimed to assess the safety and efficacy of treating CAP in a short-stay unit as an alternative to conventional hospitalization. Methods: Retrospective comparison of patients admitted to a tertiary care hospital with a diagnosis of CAP between November 2005 and April 2007. We compared outcomes for cases managed in the 2 locations (short-stay unit vs conventional hospital ward), excluding patients who required intensive care. Variables and outcomes analyzed were age,sex, Charlson index, mean weight in the diagnosis-related group, scores on the CURB-65 criteria and the Pneumonia Severity Index (PSI), findings of microbiology, and readmission and mortality rates. Results: A total of 606 patients were studied; 187 were treated in the short-stay unit and 419 were admitted to the conventional ward. The main significant differences between the 2 groups were mean age (77.3 vs 67.9 years,respectively; P<.0001) and mean stay (3.48 vs 7.89 days; P<.0001). These differences were also reflected in thecomparison between severity subgroups (by PSI). Mortality rates did not differ. Conclusions: Our experience with the short-stay unit suggests it offers a safe and effective way to manage CAP andleads to a significantly shorter hospital stay in comparison with conventional hospitalization, without increasing readmission and mortality rates (AU)

Evaluación de la utilidad de la tinción de Gramdel esputo para el manejo de la neumonía en urgencias / Is sputum Gram staining useful in the emergency department’s management of pneumonia?

Objetivo: Evaluar la utilidad de la tinción de Gram del esputo (TGE) en el manejo de la neumonía adquirida en la comunidad (NAC) en el servicio de urgencias (SU).Método: Estudio descriptivo y retrospectivo entre octubre 2005 y noviembre 2007 de pacientes con NAC ingresados en el hospital tras su valoración en el SU. Se han analizado las variables demográficas, índice de Fine, TGE, antigenuria, cultivos y antibioterapia inicial. Se ha calculado la sensibilidad, la especificidad y los valores predictivos positivo y negativo de la TGE. Resultados: Se ha revisado 608 casos de neumonía (edad media 70,7, 64,3% hombres).Se obtuvo muestras de esputo en 168 pacientes (27,6%). La TGE mostró diplococos Gram positivos en 74 casos (DCGP), cocobacilos Gram negativos (CBGN) en 26, bacilos Gram negativos en 15, cocos Gram positivos en racimo o cadenas en 11 y presencia de polimorfonucleares sin predominio de microorganismos en 42. Se aisló Streptococcus pneumoniae en 57 casos y Haemophilus influenzae en 19. El hallazgo de DCGP o CBGN mostró una sensibilidad del 47,1% y 73% y una especificidad del 94,2%y 95% para la infección neumocócica y por Haemophilus respectivamente. Ceftriaxona fue el tratamiento más frecuente en pacientes con DGCP y levofloxacino en CBGN. Conclusiones: La TGE tiene un valor limitado en el manejo de la NAC del adulto en el SU con resultados variables según la infecciones por lo que resulta poco útil para orientarla antibioterapia inicial (AU)

Objective: To assess the utility of sputum Gram stains in the management of community-acquired pneumonia (CAP) in the emergency department. Methods: Descriptive, retrospective study of patients with CAP admitted to hospital after evaluation in the emergency department between October 2005 and November 2007. We analyzed patient variables; the Fine index; the results of Gram staining of sputum smears, urine antigen tests, and blood cultures; and the antibiotic therapy initially prescribed. The sensitivity, specificity, and positive and negative predictive values of the Gram stain results were calculated.Results: A total of 608 cases of CAP (mean age, 70.7 years; 64.3% men) were included. Sputum cultures were obtained for 168 patients (27.6%). Gram-negative diplococcal infection was demonstrated in 74 cases, gram-negative coccobacilliin 26, gram-negative stains in 15, gram-positive cocci in clusters or chains in 11, and polymorphonuclear cells with nopredominating microorganisms in 42. Streptococcus pneumoniae was isolated in 57 patients and Haemophilus influenza in 19. The sensitivity of a finding of gram-positive diplococci was 47.1% for pneumococcal infection, with a specificity of94.2%. The sensitivity of a finding of gram-negative coccobacilli was 73% for H. influenza e infection, with a specificity of95%. Ceftriaxone and levofloxacin were the most frequently assigned treatments in patients with diplococcal and H.influenzae infections, respectively. Conclusions: Gram staining of sputum is of limited value in the emergency department’s management of CAP in adult patients. As the results vary according to pathogen, they are of little use in choosing the antibiotic treatment (AU)

[Improvement of endothelial function in patients with hypercholesterolemia and normal coronary arteries with lipid-lowering therapy]. / Mejoría de la función endotelial al reducir las concentraciones lipídicas en pacientes con hipercolesterolemia y arterias coronarias normales.

INTRODUCTION AND AIMS: In patients with coronary risk factors the presence of endothelial dysfunction in epicardial arteries has been documented. The purpose of this study was to determine whether endothelial dysfunction, documented hypercholesterolemic patients and angiographically normal coronary arteries, improves by reduction and normalization of lipid levels. PATIENTS AND METHOD: In 10 patients with hypercholesterolemia and normal coronary angiography, the endothelium-dependent coronary vasomotion was studied by intracoronary infusion of acetylcholine into the left anterior descending coronary artery. Vasomotion changes in response to acetylcholine were analyzed by quantitative angiography. Five patients without coronary risk factors and normal coronary arteries formed the control group. Patients with hypercholesterolemia were treated with lipid-lowering therapy (diet and lovastatin) and endothelial function was reevaluated after 24 +/- 4 months. RESULTS: In the initial study, hypercholesterolemic patients compared with the control group showed a vasoconstrictor response to serial doses of acetylcholine(10(-6) M, 10(-5) M, 10(-4)M) indicative of endothelial dysfunction (study group: -0.3 +/- 10%, -6 +/- 4%, -18 +/- 10% vs control group: -0.6 +/- 6%, -2 +/- 6%, 3+/-6%; p < 0.01 to 10(-4) M acetylcholine dose. During follow-up hypercholesterolemic patients who a significant reduction in total cholesterol levels and LDL. Compared to first study, at follow-up, there was an improvement in the response to acetylcholine (-0.4 +/- 4%, -3 +/- 6%, -3 +/- 10%; p<0.001 vs basal values at 10(-4) M acetylcholine concentration). Reduction in total cholesterol during follow-up was related to the improvement in the vasoconstrictor response to acetylcholine (r=0.53; p< 0.05). CONCLUSION: In patients with hypercholesterolemia and angiographycally normal coronary arteries with documented endothelial dysfunction, the reduction and normalization of lipid levels during follow-up may improve endothelium-dependent coronary vasomotion.

[Spontaneous tendinous rupture in systemic lupus erythematosus. Presentation of 2 cases]. / Ruptura tendinosa espontánea en el lupus eritematoso sistémico. Presentación de dos casos.

Spontaneous tendinous breakage is a rare complication in patients with systemic erythematous lupus. Bilateral tendinous breakage is an exceptional phenomena. Two cases of bilateral spontaneous breakage are discussed, one achillea, the other patellar, its frequency is compared in the scientific literature with the one found in the patients at our center. Magnetic Resonance usefulness is underlined to confirm the diagnosis of tendinous breakage.