Juan González del Castillo

Modifications by Olmesartan medoxomil treatment of the platelet protein profile of moderate hypertensive patients.

Olmesartan medoxomil is a new angiotensin II receptor blockers (ARB) which exhibits pleiotropic effects that are not fully understood. Our aims were: i) to determine the effect of Olmesartan medoxomil on blood pressure, lipid profile and renal functionality in moderately hypertensive patients with non‐controlled blood pressure, ii) to determine if Olmesartan medoxomil may exert anti‐inflammatory effects and modify the expression profile of platelet proteins. Thirteen moderate hypertensive patients with non‐controlled systolic blood pressure (SBP) and renal function classified as Kidney Disease Outcome Quality Initiative stage 2–3 were included. Patients were treated with Olmesartan medoxomil (20 mg/day) for 6 months. SBP, proteinuria and the plasma levels of cholesterol and low density lipoprotein (LDL)‐cholesterol were reduced after the treatment. Olmesartan medoxomil did not modify the circulating plasma levels of a number of proteins associated with inflammation, but reduced the expression level of different platelet proteins including tropomyosin‐β chain isotypes 3 and 4, serotransferrin isotypes 1 to 5, the leukocyte elastase inhibitor and the chloride intracellular channel‐protein isotype 1. The expression of the gelsolin precursor isotype 4 was increased in the platelets after the treatment. In summary, Olmesartan medoxomil reduced SBP, total and LDL‐cholesterol plasma levels and urinary protein excretion and induced changes in the expression of platelet proteins which may be related to some action of the drug at the megakaryocyte level.

Valor pronóstico de la valoración funcional al ingreso en una unidad de corta estancia de Urgencias

INTRODUCTION To determine the prognostic value of functional impairment on the final destination of elders admitted for acute medical illness to an emergency short-stay unit (ESSU). MATERIAL AND METHODS We performed a prospective analysis of patients aged more than 65 years old admitted to the ESSU of Hospital Clínico San Carlos in Madrid in April 2008. A protocol was designed that included epidemiologic variables (age and gender), clinical variables (reason for admission, comorbidity measured by the Charlson Index [CI]) and functional variables (previous, admission and functional decline [FD] measured with the Barthel [BI] and Lawton Indexes [LI]). The prognostic value of FD on the decision to admit patients was analyzed through ROC curves and the cut points that maximized sensitivity and specificity were determined. RESULTS Sixty patients were included with a mean age of 80.7 (SD 8.2) years and 71.7% were women. The reasons for admission were acute infections in 31.7%, heart failure in 23.3%, syncope in 15.0%, intestinal obstruction in 11.7%, gastrointestinal bleeding in 10.0%, and arrhythmias in 8.3%. The mean CI was 2.27 (1.45). Functional assessment was as follows: mean previous BI score: 79.25 (SD 25) and at admission: 62.92 (SD 28.19). Mean previous LI score: 4.85 (SD 2.45) and at admission: 2.98 (SD 2.42).): BI-FD: 20% (1.25-38.23), LI-FD 37.5% (16.7-70.2%). FD was found in 100% of the patients. The mean length of stay was 1.70 (SD 0.62) days. Discharge destination was home discharge in 46.7% and hospitalization unit in 53.3%. Multivariate analysis according to discharge destination (home vs hospitalization) provided the following results : BI-FI > or = 16% (OR=7.99 [1.1-60.5], p=0.037), LI-FI > or =35% (OR=19.6 [0.04-0.52], p <0.0001). CONCLUSIONS Patients with significant FD in the emergency room should not be admitted to an ESSU since significant FD is a prognostic factor for transfer to a conventional ward.

Conocimiento de la enfermedad y del testamento vital en pacientes con insuficiencia cardiaca

Introduccion y objetivos Investigar en pacientes con insuficiencia cardiaca atendidos en urgencias su conocimiento de las posibilidades evolutivas y del testamento vital (TV) y su predisposicion a redactarlo. Metodos Estudio transversal con inclusion prospectiva y consecutiva, multicentrico, sin intervencion. Se consignaron caracteristicas clinico-demograficas de cada paciente y, tras el control de sus sintomas, se realizo una encuesta acerca de aspectos de conocimiento y opinion de su enfermedad. Como variables dependientes, se consideraron tener buen conocimiento objetivo de su enfermedad y la predisposicion a redactar un TV. Se investigaron los factores asociados. Resultados Se incluyo a 309 pacientes: el 79% se consideraba subjetivamente bien informado, el 51,5% lo estaba realmente, el 39,8% desearia mas informacion y el 54,7%, participar mas en la toma de decisiones; el 13,3% sabia en que consistia un TV; al 4,9% su medico le habia informado y el 28,8% se mostraba partidario de redactarlo. Estar objetivamente bien informado y estar dispuesto a redactar un TV se asociaron de forma reciproca e independiente; ademas, con la primera variable se asociaron el ingreso en intensivos, considerarse bien informado y haber participado suficientemente en la toma de decisiones, y con la segunda, tener menos de 75 anos, desear mas informacion, saber en que consiste el TV y el centro de procedencia. Conclusiones El conocimiento de los pacientes con insuficiencia cardiaca respecto a sus posibilidades evolutivas es suboptimo, como tambien lo es su conocimiento del TV y su predisposicion a redactarlo. Debe mejorarse la informacion de estos aspectos como parte esencial de la relacion medico-paciente.

Gym score: 30-day mortality predictive model in elderly patients attended in the emergency department with infection

Objective To determine the validity of the classic sepsis criteria or systemic inflammatory response syndrome (heart rate, respiratory rate, temperature, and leukocyte count) and the modified sepsis criteria (systemic inflammatory response syndrome criteria plus glycemia and altered mental status), and the validity of each of these variables individually to predict 30-day mortality, as well as develop a predictive model of 30-day mortality in elderly patients attended for infection in emergency departments (ED). Methods A prospective cohort study including patients at least 75 years old attended in three Spanish university ED for infection during 2013 was carried out. Demographic variables and data on comorbidities, functional status, hemodynamic sepsis diagnosis variables, site of infection, and 30-day mortality were collected. Results A total of 293 patients were finally included, mean age 84.0 (SD 5.5) years, and 158 (53.9%) were men. Overall, 185 patients (64%) fulfilled the classic sepsis criteria and 224 patients (76.5%) fulfilled the modified sepsis criteria. The all-cause 30-day mortality was 13.0%. The area under the curve of the classic sepsis criteria was 0.585 [95% confidence interval (CI) 0.488–0.681; P=0.106], 0.594 for modified sepsis criteria (95% CI: 0.502–0.685; P=0.075), and 0.751 (95% CI: 0.660–0.841; P<0.001) for the GYM score (Glasgow <15; tachYpnea>20 bpm; Morbidity–Charlson index ≥3) to predict 30-day mortality, with statistically significant differences (P=0.004 and P<0.001, respectively). The GYM score showed good calibration after bootstrap correction, with an area under the curve of 0.710 (95% CI: 0.605–0.815). Conclusion The GYM score showed better capacity than the classic and the modified sepsis criteria to predict 30-day mortality in elderly patients attended for infection in the ED.

Impact of Frailty and Disability on 30-Day Mortality in Older Patients With Acute Heart Failure

The objectives were to determine the impact of frailty and disability on 30-day mortality and whether the addition of these variables to HFRSS EFFECT risk score (FBI-EFFECT model) improves the short-term mortality predictive capacity of both HFRSS EFFECT and BI-EFFECT models in older patients with acute decompensated heart failure (ADHF) atended in the emergency department. We performed a retrospective analysis of OAK Registry including all consecutive patients ≥65 years old with ADHF attended in 3 Spanish emergency departments over 4 months. FBI-EFFECT model was developed by adjusting probabilities of HFRSS EFFECT risk categories according to the 6 groups (G1: non frail, no or mildly dependent; G2: frail, no or mildly dependent; G3: non frail, moderately dependent; G4: frail, moderately dependent; G5: severely dependent; G6: very severely dependent).We included 596 patients (mean age: 83 [SD7]; 61.2% females). The 30-day mortality was 11.6% with statistically significant differences in the 6 groups (p < 0.001). After adjusting for HFRSS EFFECT risk categories, we observed a progressive increase in hazard ratios from groups G2 to G6 compared with G1 (reference). FBI-EFFECT had a better prognostic accuracy than did HFRSS EFFECT (log-rank p < 0.001; Net Reclassification Improvement [NRI] = 0.355; p < 0.001; Integrated Discrimination Improvement [IDI] = 0.052; p ;< 0.001) and BI-EFFECT (log-rank p = 0.067; NRI = 0.210; p = 0.033; IDI = 0.017; p = 0.026). In conclusion, severe disability and frailty in patients with moderate disability are associated with 30-day mortality in ADHF, providing additional value to HFRSS EFFECT model in predicting short-term prognosis and establishing a care plan.

Impacto de los resultados a medio plazo de la prescripción inadecuada en los pacientes ancianos dados de alta desde una unidad de corta estancia

Resumen Objetivo Estudiar la asociación entre prescripciones potencialmente inapropiadas (PPI) y eventos adversos a los 30 y 180 días tras el alta de una unidad de corta estancia (UCE). Material y método Estudio analítico observacional de cohortes retrospectivo que incluyó pacientes ≥ 75 años al alta de una UCE. Se utilizó la versión 2 de los criterios STOPP-START. La variable resultado fue la presencia de algún evento adverso a 30 y 180 días. Resultados Se incluyeron 179 pacientes con una media de 84 (DE: 5) años. La presencia de ≥ 1PPI al alta no se asoció con la aparición de algún evento adverso a los 30 ni a los 180 días de manera global. La presencia de ≥ 1PPI al alta de fármacos del proceso cardiovascular tuvo mayor riesgo de presentar algún evento adverso a los 30 días del alta (OR ajustada 2,1; IC 95%: 1,0-3,2; p = 0,045), los fármacos del proceso «neuropsiquiátrico y riesgo de caídas» se relacionaron con deterioro funcional a los 30 días del alta (OR ajustada 6,3; IC 95%: 1,7-22,5; p = 0,005), y la omisión de fármacos del sistema cardiovascular se asoció con el reingreso a los 180 días (OR ajustada 3,6; IC 95%: 1,5-8,3, p = 0,003). Conclusiones La presencia de eventos adversos de pacientes ancianos dados de alta de una UCE podría relacionarse con PPI detectadas por algunos criterios STOPP-START, y concretamente con los fármacos de los procesos cardiovasculares, neuropsiquiátrico y relacionado con las caídas.

Guía de consenso para el abordaje de la neumonía adquirida en la comunidad en el paciente anciano

Resumen La incidencia de la neumonía adquirida en la comunidad se incrementa con la edad y se asocia a una elevada morbimortalidad debido a los cambios fisiológicos asociados al envejecimiento y a una mayor presencia de enfermedades crónicas. Debido a la importancia que tiene desde un punto de epidemiológico y pronóstico, y a la enorme heterogeneidad descrita en el manejo clínico, creemos que existía la necesidad de realizar un documento de consenso específico para este perfil de paciente. El propósito de este fue realizar una revisión de las evidencias en relación con los factores de riesgo para la etiología, la presentación clínica, el manejo y el tratamiento de la neumonía adquirida en la comunidad en los ancianos con el fin de elaborar una serie de recomendaciones específicas basadas en el análisis crítico de la literatura. Este documento es fruto de la colaboración de diferentes especialistas en representación de la Sociedad Española de Medicina de Urgencias y Emergencias (SEMES), Sociedad Española de Geriatría y Gerontología (SEGG), Sociedad Española de Quimioterapia (SEQ), Sociedad Española de Medicina Interna (SEMI), Sociedad Española de Neumología y Cirugía Torácica (SEPAR), Sociedad Española de Hospitalización a Domicilio (SEHAD) y Sociedad Española de Enfermedades Infecciosas y Microbiología Clínica (SEIMC). Abstract The incidence of community-acquired pneumonia increases with age and is associated with an elevated morbidity and mortality due to the physiological changes associated with aging and a greater presence of chronic disease. Taking into account the importance of this disease from an epidemiological and prognostic point of view, and the enormous heterogeneity described in the clinical management of the elderly, we believe a specific consensus document regarding this patient profile is necessary. The purpose of the present work was to perform a review of the evidence related to the risk factors for the etiology, the clinical presentation, the management and the treatment of community-acquired pneumonia in elderly patients with the aim of producing a series of specific recommendations based on critical analysis of the literature. This document is the result of the collaboration of different specialists representing the Spanish Society of Emergency Medicine and Emergency Care (SEMES), the Spanish Society of Geriatrics and Gerontology (SEGG), the Spanish Society of Chemotherapy (SEQ), the Spanish Society of Internal Medicine (SEMI), the Spanish Society of Respiratory Medicine and Thoracic Surgery (SEPAR), Spanish Society of Home Hospitalization (SEHAD) and the Spanish Society of Infectious Disease and Clinical Microbiology (SEIMC).

Diagnostic accuracy of the APPY1 Test in patients aged 2–20 years with suspected acute appendicitis presenting to emergency departments

Objective Evaluate the diagnostic accuracy of the APPY1 Test alone and in combination with the Alvarado score (AS) to rule out acute appendicitis (AA) in patients presenting to EDs with abdominal pain suspicious for AA. Methodology Observational study in a prospective consecutive cohort including all patients from 2 to 20 years with abdominal pain suggestive of AA in four EDs. The APPY1 Test was performed and AS was calculated to determine risk stratification for each patient. Results 321 patients enrolled (mean age 11.8 (SD 3.8) years, 52.0% male), with 32.4% low risk, 23.7% intermediate risk and 43.9% high risk according to the AS. 111 (34.6%) had AA, of whom 1 (0.9%) had a false-negative APPY1 Test result. The APPY1 Test had a sensitivity (Se) of 99.1% (95% CI 94.4% to 99.9%), specificity (Sp) of 32.9% (95% CI 26.6% to 39.7%), negative predictive value (NPV) of 98.6% (95% CI 91.2% to 99.9%) and negative likelihood ratio (LHR−) of 0.03 (0.00 to 0.19) in this population. For patients at low risk by AS, the APPY1 Test had a Se of 100% (95% CI 62.9% to 100%), NPV of 100% (95% CI 91.1% to 100%) and LHR− of 0.0 (not calculable), and for patients at intermediate risk by AS, the APPY1 Test had a Se of 94.4% (95% CI 70.6% to 99.7%), NPV of 94.7% (95% CI 71.9% to 99.7%) and LHR− of 0.18 (0.0 to 1.2), respectively. Conclusions APPY1 Test is a potentially useful diagnostic tool to rule out AA in this population, with clinical utility primarily in those patients classified as having low clinical risk of appendicitis according to the AS.

Approach for Initial Treatment of Skin and Soft Tissue Infection

TO THE EDITOR—Recently the Infectious Diseases Society of America (IDSA) Guideline for the Management of Skin and Soft Tissue Infections (SSTIs) [1] were published. Understanding that the best approach to the management of this condition is included in this guideline, we would like to discuss a first approximation algorithm in the emergency department to this disease [2], implemented this year by Infection Group of the Spanish Society of Emergency Medicine (INFURG-SEMES). In recent studies by this group, it was determined that the SSTI constituted 11% of infections treated by Spanish emergency departments [3], and that only 1 in 3 cases of infections by methicillin-resistant Staphylococcus aureus (MRSA), the initial empirical treatment was appropriate [4]. The significance in terms of survival of the initial

Nonagenarians: Questions and answers

Wehave read the interesting article published by Ramos et al. which concluded that nonagenariansweremost frequently admitted to general internal medicine wards (GIMW) followed by short stay units (SSU) and that intra-hospital mortality was observed in nearly one out of each five cases and was three times higher in GIMW compared to SSU [1]. We would like to make some comments about these findings and decision making regarding the hospitalization to GIMW or SSU of very elderly patients. Firstly, we would like to highlight the differences in intra-hospital mortality rates between these services taking into account that the most common diagnosis-related groups were respiratory and circulatory systems in both units [2]. In our opinion it would have been better to compare the intra-hospital mortality and, especially, the 30-day mortality in each diagnosis-related group between both units. Along this line, we would like to comment on some important variables not collected that could be associated with decisionmaking regarding admission placement and intra-hospital mortality. These include clinical data or that of the management of the acute episode, the clinical, functional and cognitive baseline profile of the nonagenarians, or complications during hospitalization [3,4]. Previous studies have shown that severe comorbidity was nearly 20% in nonagenarians admitted to medical wards [5]. Comorbidities and adverse events during hospitalization were strongly correlated with a longer hospital stay and higher mortality risk [6]. Other authors have suggested an association between functional, cognitive status and hypoalbuminemia with worse outcomes in cardio-respiratory diseases in elderly patients [7,8]. There is a high probability that great differences in these fields may lead to an important bias in the selection of patients to one department or another. Secondly, another interesting finding was that nonagenarians admitted to SSU had a lower mean hospital stay and were more frequently discharged to home hospitalization compared to the GIMW. In conjunction with the results described above, these results formulate the hypothesis regarding the best care plan in nonagenarians requiring admission for an exacerbation of chronic cardiorespiratory conditions, that is, either short length stay in hospital followed by home hospitalization or conventional hospitalization. Prolonged hospital stay is associated with complications secondary to immobility such as pressure sores or functional decline. These factors have been described as the main predictors for in-hospital death in admitted nonagenarians [9]. Finally, we agree with the authors that nonagenarians are a frail and complex population and hospital admission is associated with