Rapidly progressive interstitial lung disease due to anti-MDA5 antibodies without skin involvement: a case report and literature review.

Anti-MDA5 antibodies have been strongly associated with rapidly progressive interstitial lung disease (RP-ILD) in dermatomyositis (DM) patients, especially in the clinically amyopathic subset (CADM). We present a case of anti-MDA5 antibody-associated RP-ILD in a patient with arthritis but with no other clinical signs suggestive of DM or CADM successfully treated with a combination of cyclophosphamide, cyclosporine and corticoids. A review of the literature was also done. Despite its rarity, anti-MDA5 antibody-associated ILD should be suspected in cases of RP-ILD even without other signs of DM or CADM as prompt and aggressive treatment could improve prognosis.

Transthyretin familial amyloid polyneuropathy (TTR-FAP) in Mallorca: a comparison between late- and early-onset disease.

The age of onset (AO) of hereditary ATTR amyloidosis (hATTR) is known to vary between populations, with differing characteristics reported according to AO in endemic/non-endemic foci. This was a retrospective study of patients with early AO (<50 years) and late AO (≥50 years) hATTR at our center in Mallorca. Data were collected on patient demographics, clinical disease manifestation, and physical symptoms. A total of 95 patients were analyzed, with mean follow-up of 9 years from diagnosis. The early AO group included 53 patients (33 male) and the late AO group included 42 patients (21 male). Neurologic involvement was the most common initial symptom, although it was significantly more frequent in the late AO vs. early AO group (p = 0.015). Autonomic involvement was observed in 26% of patients in the early AO group, but was rarely observed in the late AO group (5%). During follow up, cardiologic symptoms, renal involvement, and ophthalmologic symptoms were significantly more common in the late AO group (p < 0.05). This retrospective study demonstrates the variation in disease presentation and progression according to AO of hATTR at our Mallorcan center.

[Skin and soft-tissue infections in hospitalized patients: epidemiology, microbiological, clinical and prognostic factors]. / Infecciones de piel y partes blandas en pacientes hospitalizados: factores epidemiológicos, microbiológicos, clínicos y pronósticos.

INTRODUCTION: Skin and soft-tissue infections (SSTIs) are a frequent cause of consultation in emergence services, and complicated cases require hospitalization. However there are few data in our setting about the clinical characteristics of these infections. MATERIAL AND METHODS: A retrospective review of hospital admitted patients with a diagnosis of folliculitis, cellulitis, erysipelas, abscesses, hidradenitis, furuncle, impetigo, fasciitis and Fournier's gangrene. Cases were extracted from the data base of diagnostic codes of the Archive and Clinical Documentation Department of Son Llàtzer Hospital from January 2002 to November 2011. RESULTS: We studied 996 episodes in 841 hospitalized patients with any diagnosis of SSTIs. Cellulitis/erysipelas (66.7%) was the most frequently diagnosed condition, with 77% of all SSTIs being community acquired, and the majority of patients had comorbidities, mainly diabetes (33%) and heart failure (17.7%). The most frequent isolated microorganism was S.aureus (35.1%), in 19 (12.9%) cases with methicillin-resistance (MRSA), 84.2% of them were nosocomial or health care acquired. Monotherapy with aminopenicillin with clavulanic acid was the empiric treatment most frequently used (35.5%). New antibiotics for Gram-positive cocci (linezolid, daptomycin, and tigecycline) were used in patients with comorbidities that presented more complications (P<.001) and more risk of mortality (P=.001). During admission 10.9% of patients died, but only in 2.7% of them mortality was related to the SSTIs. CONCLUSIONS: SSTIs attended most frequently in hospitalized patients are mainly cellulitis/erysipela, the majority community acquired. MRSA infections are mainly health care related. Use of new antibiotic for Gram-positive cocci was limited.

[Symptomatic acute Q fever: a series of 87 cases in an area of Mallorca]. / Fiebre Q aguda sintomática: 87 casos en un área de Mallorca.

INTRODUCTION: Q fever is a widespread zoonotic infection caused by Coxiella burnetii (C. burnetii). Acute infection varies from a self-limited flu-like illness to pneumonia or hepatitis. METHODS: A retrospective case study from March 2003 to December 2011 was conducted in the Hospital Son Llàtzer in Palma de Mallorca. Acute Q-fever was diagnosed in a patient with clinical suspicion and IgM in phase ii positive (≥ 1/40), with a positive IgG (≥1/80), or when IgG seroconversion was observed during convalescence. A total of 87 cases of acute Q fever were diagnosed. The median age was 50 years (range 21-89), and 69 (79.3%) were male. Fever and headache were the most common symptoms. Pneumonia was diagnosed in 39 (44.8%) patients, febrile episode in 21 (24.1%), and acute hepatitis in 23 (25.6%). Increased serum transaminases were observed in 19 (21.8%). Doxycycline was prescribed in 29 cases (33.4%). There were 30 (34.5%) patients lost to follow up after hospital discharge. A favorable outcome was observed in all other cases. Only one new case progressed to chronic Q fever. RESULTS: A total of 87 cases of acute Q fever were diagnosed. The median age was 50 years (range 21-89), and 69 (79.3%) were male. Fever and headache were the most common symptoms. Pneumonia was diagnosed in 39 (44.8%) patients, febrile episode in 21 (24.1%), and acute hepatitis in 23 (25.6%). Increased serum transaminases were observed in 19 (21.8%). Doxycycline was prescribed in 29 cases (33.4%). There were 30 (34.5%) patients lost to follow up after hospital discharge. A favorable outcome was observed in all other cases. Only one new case progressed to chronic Q fever. CONCLUSION: Acute Q fever acute is common our environment. Pneumonia was the most common clinical presentation. Even although doxycycline was prescribed in a small number of patients, a favorable outcome was observed in all cases.

Residual cardiovascular risk: When should we treat it?

Cardiovascular disease (CVD) still being the most common cause of death in worldwide. In spite of development of new lipid-lowering therapies which optimize low-density lipoprotein cholesterol (LDL-c) levels, recurrence of CVD events implies addressing factors related with residual cardiovascular (CV) risk. The key determinants of residual CV risk include triglyceride-rich lipoproteins (TRLs) and remnant cholesterol (RC), lipoprotein(a) [Lp(a)] and inflammation including its biochemical markers such as high sensitivity C reactive protein (hs-CRP). On the other hand, unhealthy lifestyle habits, environmental pollution, residual thrombotic risk and the residual metabolic risk determined by obesity and type 2 diabetes (T2D) have a specific weight in the residual CV risk. New pharmacologic therapies and pathways are being explored such as inhibition of apolipoprotein C-III (apoC-III) and angiopoietin-related protein 3 (ANGPTL3) in order to explore if a reduction in TRLs and RC reduce CVD events. Therapeutic target of inflammation plays an attractive way to reduce the atherosclerotic process and to date, approved therapies as colchicine plays a beneficial effect in chronic inflammation and residual CV risk. Lp(a) constitutes one of the most residual CV risk factor due to linkage with CVD and aortic valve stenosis. New and hopeful treatments including antisense oligonucleotides (ASO) and small-interfering ribonucleic acid (siRNA) which interfere in LP(a) codification have been developed to achieve an adequate control in Lp(a) levels. This review points out the paradigms of residual CV risk, discus how we should manage their features and summarize the different therapies targeting each residual CV risk factor.

Progress of patients hospitalized with acute heart failure treated with empagliflozin.

Aim: To describe the epidemiological, clinical and laboratory characteristics and clinical progress of patients hospitalized with heart failure (HF) who started treatment with empagliflozin before discharge. Methods: We performed a retrospective observational study of patients aged ≥18 years admitted to the Internal Medicine Department of University Hospital Jaen, Jaen, Spain with acute HF between 1 May 2022 and 31 May 2023. Patients had to have a life expectancy of ≥1 year and have started treatment with empagliflozin during admission. Results: We included 112 patients (mean age, 85.2 ± 6.5 years; 67.9% women; 35.7 and 31.3% in NYHA functional classes III and IV; 73.2% with HF and preserved ejection fraction). Before admission, 80.4% were taking loop diuretics, 70.6% renin-angiotensin-aldosterone system inhibitors, 49.1% betablockers and 25% mineralocorticoid receptor antagonists. At admission, 94.6% were taking furosemide (15.2% at high doses, 36.6% at intermediate doses). The dose of furosemide was reduced at initiation of empagliflozin. At the end of follow-up, 13.4% of patients had died, 93.8% of the survivors continued treatment with empagliflozin and 26.8% had attended the emergency department with signs and symptoms of HF. Conclusion: Introduction of empagliflozin before discharge from hospital in patients admitted with HF made it possible to reduce the dose of diuretics during admission. The frequency of complications was as expected, and treatment was largely maintained.

[Translated article] Evaluation of the antibiotic prescription in a hospital emergency department: Pilot study.

OBJECTIVE: A study about the adherence of the antimicrobial prescriptions to the local guidelines of treatment of infections was conducted in a hospital emergency department to study the clinical and epidemiological characteristics of the patients who received these treatments. Conducting a feasibility study for supporting the design and execution of future studies, addressing specific aspects of the appropriateness of the antimicrobial prescription. METHOD: Observational, descriptive and cross-sectional pilot study, with retrospective data collection about the antimicrobial prescription in a hospital emergency department. Seven cross sections were made, corresponding to seven different days of the week, in seven consecutive weeks. INCLUSION CRITERIA: patient over 14 years of age, with at least one first dose of antimicrobial treatment prescribed on the day of recruitment. The main variable was the inappropriate antimicrobial prescription according to the local guidelines. Epidemiological and clinical parameters of the patients were collected as secondary variables. In order to determine inappropriate prescription a revision was carried out by two specialists in emergencies, two pharmacists and one specialist in infectious diseases, all unrelated to prescriptions. RESULTS: 168 patients with 192 prescriptions were evaluated. Seventy-six (39.6%) of the prescriptions were not conformed to the local treatment guidelines. Of these, 55% were with active antimicrobial coverage against the microorganism but not recommended, 23.5% with inactive drugs, 13.7% presented an inappropriate dose and 7.8% were unnecessary treatment. The strength of agreement in the evaluation of the adequacy of treatment between doctors and pharmacists was high (kappa = 0.71). CONCLUSIONS: A high rate of inappropriate antimicrobial prescriptions was obtained in a hospital emergency department according to local guidelines. The hospital pharmacist has an opportunity to improve the use of antimicrobials in this area.

Evaluation of the antibiotic prescription in a hospital emergency department: Pilot study. / Evaluación de la prescripción de antibióticos en un servicio de urgencias hospitalarias: estudio piloto.

OBJECTIVE: A study about the adherence of the antimicrobial prescriptions to the local guidelines of treatment of infections was conducted in a hospital emergency department to study the clinical and epidemiological characteristics of the patients who received these treatments. Conducting a feasibility study for supporting the design and execution of future studies, addressing specific aspects of the appropriateness of the antimicrobial prescription. METHOD: Observational, descriptive and cross-sectional pilot study, with retrospective data collection about the antimicrobial prescription in a hospital emergency department. Seven cross sections were made, corresponding to 7 different days of the week, in 7 consecutive weeks. INCLUSION CRITERIA: patient over 14 years of age, with at least one first dose of antimicrobial treatment prescribed on the day of recruitment. The main variable was the inappropriate antimicrobial prescription according to the local guidelines. Epidemiological and clinical parameters of the patients were collected as secondary variables. In order to determine inappropriate prescription a revision was carried out by 2 specialists in emergencies, 2 pharmacists and one specialist in infectious diseases, all unrelated to prescriptions. RESULTS: One hundred sixty eight patients with 192 prescriptions were evaluated. 76 (39.6%) of the prescriptions were not conformed to the local treatment guidelines. Of these, 55% were with active antimicrobial coverage against the microorganism but not recommended, 23.5% with inactive drugs, 13.7% presented an inappropriate dose and 7.8% were unnecessary treatment. The strength of agreement in the evaluation of the adequacy of treatment between doctors and pharmacists was high (kappa=0.71). CONCLUSIONS: A high rate of inappropriate antimicrobial prescriptions was obtained in a hospital emergency department according to local guidelines. The hospital pharmacist has an opportunity to improve the use of antimicrobials in this area.

Exposure to valproic acid is associated with less pulmonary infiltrates and improvements in diverse clinical outcomes and laboratory parameters in patients hospitalized with COVID-19.

BACKGROUND: Valproic acid (VPA) has shown beneficial effects in vitro against SARS-CoV-2 infection, but no study has analyzed its efficacy in the clinical setting. METHODS: This multicenter, retrospective study included 165 adult patients receiving VPA at the time of admission to hospital, and 330 controls matched for sex, age and date of admission. A number of clinical, outcome and laboratory parameters were recorded to evaluate differences between the two groups. Four major clinical endpoints were considered: development of lung infiltrates, in-hospital respiratory worsening, ICU admissions and death. RESULTS: VPA-treated patients had higher lymphocyte (P<0.0001) and monocyte (P = 0.0002) counts, and lower levels of diverse inflammatory parameters, including a composite biochemical severity score (P = 0.016). VPA patients had shorter duration of symptoms (P<0.0001), were more commonly asymptomatic (P = 0.016), and developed less commonly lung infiltrates (65.8%/88.2%, P<0.0001), respiratory worsening (20.6%/30.6%, P = 0.019) and ICU admissions (6.1%/13.0%, P = 0.018). There was no difference in survival (84.8%/88.8%, P = 0.2), although death was more commonly related to non-COVID-19 causes in the VPA group (36.0%/10.8%, P = 0.017). The cumulative hazard for developing adverse clinical endpoints was higher in controls than in the VPA group for infiltrates (P<0.0001), respiratory worsening (P<0.0001), and ICU admissions (P = 0.001), but not for death (0.6). Multivariate analysis revealed that VPA treatment was independently protective for the development of the first three clinical endpoints (P = 0.0002, P = 0.03, and P = 0.025, respectively), but not for death (P = 0.2). CONCLUSIONS: VPA-treated patients seem to develop less serious COVID-19 than control patients, according to diverse clinical endpoints and laboratory markers.

Factors associated with readmission and mortality in adult patients with skin and soft tissue infections.

BACKGROUND: Skin and soft tissue infections (SSTIs) are a common cause of consultation, and complicated cases require hospitalization. We describe factors that are related to readmission and/or mortality of hospitalized patients diagnosed with SSTIs. METHODS: Retrospective review of hospital-admitted patients with a diagnosis of cellulitis, abscess, hidradenitis, fasciitis, and Fournier's gangrene. Cases from January 2002 to October 2015 were extracted from the diagnostic codification database of the Archives and Clinical Documentation Department. FINDINGS: We studied 1,482 episodes of hospitalized patients diagnosed with SSTIs. There were 187 (12.3%) readmissions, the most frequent diagnosis was cellulitis (72.7%), and the most commonly isolated microorganism was Staphylococcus aureus (25; 30.1%). Factors associated with readmissions were healthcare-related infections (P = 0.002), prior antibiotic therapy (P < 0.001), ischemic heart disease (P = 0.01), chronic liver disease (P = 0.001), and diabetes mellitus (DM) (P = 0.006). The number of patients who died as a result of an infection was 34 (2.2%) and, in these patients, the most common diagnosis was also cellulitis (79.4%), which in 52.9% (P = 0.001) was community acquired. DM (P = 0.01), heart failure (P = 0.001), and chronic liver disease (P = 0.003) were the most frequent comorbidities. This group presented more complications (P < 0.005) such as endocarditis (P < 0.005), amputation (P = 0.018), severe sepsis (P < 0.005), and septic shock (P < 0.001). CONCLUSIONS: Readmitted patients had healthcare-related S. aureus infection, had received prior antibiotic therapy, and presented comorbid conditions such as ischemic heart disease, peripheral vascular disease, chronic liver disease, or DM. Comorbidities such as advanced age, DM, heart failure, and chronic liver disease were associated with complications and higher infection-related mortality.

Early diagnosis in patients with transthyretin familial amyloid polyneuropathy: A comparative study. / Diagnóstico precoz en pacientes con polineuropatía amiloidótica familiar asociada a transtirretina. Estudio comparativo.

INTRODUCTION AND OBJECTIVE: Transthyretin-associated familial amyloid polyneuropathy (TTR-FAP) is a disease caused by the deposit of abnormal transthyretin on tissues, mainly nerves. Small nerve fibers are altered earlier during the course of the disease; hence, detection of their involvement may have serious consequences on the natural history of disease. METHODS: A cross-sectional, observational study, was carried out on symptomatic patients, involving the conduct of several tests for small nerve fibers: Vibration, Touch Pressure (TP) and Heat Pain (HP). Results were compared with those obtained during a conventional neurological examination carried out on a group of healthy individuals. RESULTS: Fifteen symptomatic patients were recruited at an early stage of the disease (60% stage 1), along with 13 healthy individuals, with both patient groups having similar epidemiological characteristics in terms of gender, age, weight, height or BMI. A comparison carried out between the neuropsychological tests performed revealed statistically significant differences: Vibration (P<.05), TP (P<.05) and HP (P<.05, except volar forearm). CONCLUSIONS: The neurophysiological tests performed revealed significant differences between both groups, allowing for an earlier detection of neurological injuries compared to conventional neurological examinations.