August Supervía

Predicting length of hospitalisation of elderly patients, using the Barthel Index

Key points • TDI is a powerful echocardiographic tool for assessing the functions of both ventricles. It shows that systolic and diastolic functions of both ventricles decline with normal ageing. • With ageing, there is an increase of plasma NT-proBNP levels and a decline of exercise capacity. Both are correlated with left ventricular diastolic dysfunction that reaches the degree found in patients with mild chronic heart failure. • Normal ageing can be considered as early-stage heart failure.

Multicenter assessment of the revisit risk for a further drug-related problem in the emergency department in cocaine users (MARRIED-cocaine study).

Introduction and objectives. Emergency departments (EDs) in Spanish hospitals daily attend a large number of patients for adverse reactions or clinical complications resulting from cocaine use. After discharge, some of these patients revisit the ED for the same reason within a year. The objective of the present study was to quantify the rate of such revisits and identify the factors associated with them. Method. We performed a retrospective, multicenter study with cohort follow-up and without a control group, conducted in the EDs of six Spanish hospitals during 12 months (January–December 2009). We included all ED patients attended for cocaine-related symptoms who reported recent cocaine use and those with cocaine-positive urine analysis by immunoassay without declared consumption. Twelve independent variables assessed for each hospital ED were collected: sex, age, place of consumption, month, day, and time of consumption, mode of arrival at the ED, discharge diagnosis, psychiatric assessment on the ED episode, concomitant drugs, destination on discharge, and history of previous ED visits related with drug use and alcohol use. The dependent variable was a subsequent visit to the ED associated with drug use, identified using the computerized hospital admissions system. Results. The study included 807 patients, of whom 6.7% revisited the ED within 30 days, 11.9% within 3 months and 18.9% within 1 year. The variables significantly associated with ED revisits were: presence of clinical manifestations directly related to cocaine (p < 0.05), ED attendance on a working day (p < 0.05), history of ED visits related with the consumption of alcohol (p < 0.001) or drugs (p < 0.001), and the need for urgent consultation with a psychiatrist (p < 0.001), although only the last four were independent predictors in multivariate analysis. We derived a score based on these variables to predict risk of revisits (MARRIED-score, ranging from 0 to 400 points), which had a reasonably good predictive value for revisit (area under ROC of 0.75; 95% CI 0.71–0.79).

Intrahepatic cholestasis without hepatitis induced by amoxycillin/clavulanic acid.

Amoxycillin/clavulanic acid liver injury is very rare. We describe an exceptional case of intrahepatic cholestasis without hepatitis induced by amoxycillin/clavulanic acid. Recognition of this benign cholestatic syndrome as a side-effect may obviate unnecessary complementary and costly procedures.

Acidosis metabólica y topiramato. Utilidad de la fórmula de Winters

Topiramate is a drug introduced in Europe in 1995 for the treatment of hard-to-control epilepsy. The drug is also effective in the treatment of bipolar disorder, migraines, neuropathic pain, alcohol dependence, essential tremor, obesity and eating disorders. One of its side effects is hyperchloremic metabolic acidosis without anion gap,1,2 which can appear in up to 40% of the patients who receive topiramate at therapeutic doses; it is more frequent and severe in the case of acute poisoning.1 However, in the cases of acute intoxication, it is usually associated with other drugs, which can also influence acid--base balance. We report the case of a patient who presented with metabolic acidosis after an overdose of 2 drugs, one of them being topiramate. This was a 38-year-old woman with a history of gastric reduction due to obesity and cluster B personality disorder. She was on treatment with venlafaxine, mirtazapine, topiramate and lorazepam. She came to emergency treatment for autolytic-intention medicine overdose with topiramate and lorazepam of uncertain dosage and time. Upon arrival the patient was found to be Glasgow 14, tending to somnolence, with the rest of the examination being normal. She was given activated charcoal. The analytical analyses showed hyperchloremic metabolic acidosis with normal anion gap: pH 7.29, pCO2 41 mm Hg, bicarbonate 19.7 mmol/l, excess of bases 6.9, chlorine 113.4 mmol/l, and anion gap 14.6. After 18 h her level of consciousness improved, being in Glasgow 15, and the pH was normal, although low levels of bicarbonate (18.2 mmol/l) and hyperchloremia (117 mmol/l) persisted. Nevertheless, given her clinical stability, the patient was discharged after psychiatric assessment. Topiramate, besides potentially causing metabolic acidosis, can also produce central neurogenic hyperventilation. This is probably due to its inhibitory effect on the carbonic anhydrase in the brain and to the subsequent LCR acidosis.2 In such a situation, the clinical picture develops with hyperventilation, arterial hypotension and different degrees of altered consciousness and cognitive functions.1

Diferencias en los hallazgos clínicos en dos grupos de población inmigrante afecta de tuberculosis

A study was performed to assess differences in the clinical presentation of tuberculosis between two groups of immigrants. Ninety-four patients seen in the emergency room for newly diagnosed tuberculosis between 2006 and 2012 were included. Forty-nine patients were from Asian countries and 45 from Latin America. Mean age [years (SD)] was 35.3 (13) in Asian patients and 33.9 (10) in Latin American patients. Asian subjects were predominantly male (40/49 vs 25/45; P=0.006). Patients from Latin American countries had a higher rate of pulmonary tuberculosis. A higher percentage of Asian patients lived in overcrowded conditions, whereas HIV infection was more frequent among Latin Americans. Most patients were treated with a quadruple regimen. Resistance to isoniazid was documented in two patients from Latin America.

Ritmo nodal secundario a descarga eléctrica de alto voltaje: Report of one case

Electrical shock can cause a direct myocardial damage and different types of arrhythmias, which are uncommon and occur more often when there is a high voltage exposure. We report a 19-year-old male that received a high voltage shock, falling thereafter from an altitude of four meters. On admission to the emergency room, he had second and third degree burns in the right hand and the left thigh. The electrocardiogram showed a nodal rhythm of 72 beats per minute. After four hours of monitoring, sinus rhythm returned spontaneously.Introduccion: Las descargas electricas pueden producir dano miocardico directo y diferentes tipos de arritmias, desde taquicardia y fibrilacion ventricular hasta extrasistolia aislada. Suelen ser poco frecuentes y se presentan mas a menudo cuando la descarga es de alto voltaje. Caso clinico: Se presenta el caso de un varon de 19 anos, que tras una descarga electrica de alto voltaje presento un ritmo nodal acelerado autolimitado. Discusion y conclusiones: Se discuten los posibles mecanismos por los que una descarga electrica puede generar arritmias. Los pacientes que han sufrido una descarga electrica de alto voltaje deben ser sometidos a monitorizacion.

Ritmo nodal secundario a descarga eléctrica de alto voltaje

Electrical shock can cause a direct myocardial damage and different types of arrhythmias, which are uncommon and occur more often when there is a high voltage exposure. We report a 19-year-old male that received a high voltage shock, falling thereafter from an altitude of four meters. On admission to the emergency room, he had second and third degree burns in the right hand and the left thigh. The electrocardiogram showed a nodal rhythm of 72 beats per minute. After four hours of monitoring, sinus rhythm returned spontaneously.Introduccion: Las descargas electricas pueden producir dano miocardico directo y diferentes tipos de arritmias, desde taquicardia y fibrilacion ventricular hasta extrasistolia aislada. Suelen ser poco frecuentes y se presentan mas a menudo cuando la descarga es de alto voltaje. Caso clinico: Se presenta el caso de un varon de 19 anos, que tras una descarga electrica de alto voltaje presento un ritmo nodal acelerado autolimitado. Discusion y conclusiones: Se discuten los posibles mecanismos por los que una descarga electrica puede generar arritmias. Los pacientes que han sufrido una descarga electrica de alto voltaje deben ser sometidos a monitorizacion.

Efectos del tabaquismo sobre los niveles plasmáticos de osteoprotegerina en adultos jóvenes sanos

El tabaco es un conocido factor de riesgo de osteoporosis, pero los mecanismos por los que se produce esta asociacion siguen siendo objeto de debate. Estudios previos han evaluado las variaciones de osteoprotegerina plasmatica, una citoquina que regula la osteoclastogenesis y la resorcion osea, en fumadores, con resultados dispares. En este estudio se analizaron los niveles de osteoprotegerina plasmatica en un grupo de 49 voluntarios jovenes sanos, pero no existieron diferencias entre fumadores y no fumadores. Tampoco se encontraron diferencias tras ajustar por las diferencias basales existentes en estrona en varones y en edad e ingesta de calcio en mujeres. En conclusion, fumar no parece influir en los niveles plasmaticos de osteoprotegerina en voluntarios jovenes sanos. PALABRAS CLAVE: osteoprotegerina, tabaco, jovenes. While tobacco smoke is a known risk factor for osteoporosis, the mechanisms that produce this association must still elucidated. Several previous studies have evaluated the variations in serum levels of osteoprotegerin, a cytokine that regulates osteoclastogenesis and bone resorption in smokers, however, the results have been inconclusive. This study, which makes an analysis of serum levels of osteoprotegerin in a group of 49 healthy young volunteers, did not find any influence of smoking on this parameter. There were also no differences following adjustment for baseline differences in estrone in men and for age and calcium intake in women. In conclusion, tobacco smoking does not seem to influence osteoprotegerin serum levels in healthy young volunteers.