Máximo Bernabeu-Wittel

Incidencia y características clínicas de los pacientes con pluripatología ingresados en una unidad de medicina interna

Fundamento y objetivo: Analizar la incidencia y caracteristicas clinicas y evolutivas de pacientes con pluripatologia (PP), segun la definicion propuesta por una comision de expertos (2 o mas enfermedades cronicas distribuidas en 7 categorias). Pacientes y metodo: Estudio prospectivo observacional en areas de medicina interna de un hospital de tercer nivel durante junio de 2003. Se estratifico a los pacientes en PP, paliativo (PL) y general (GE) segun los criterios de una comision de expertos. Se analizo la incidencia de PP, procedencia, limitacion funcional basal, al ingreso y al alta, evolucion y consumo de recursos (atenciones urgentes, programadas, y hospitalizaciones) en los 12 meses previos. Se realizo un analisis multivariante de los factores asociados a la supervivencia y al deterioro funcional significativo (descenso en la escala de Barthel de 10 o mas puntos entre basal-alta) en la cohorte de PP. Resultados: Se incluyo a 339 pacientes (cohorte PP: 132; PL: 52; GE: 155). La incidencia global de PP fue 38,9/100 ingresos/mes. En comparacion con la cohorte GE, los PP tuvieron mayor edad (media [desviacion estandar] 75 [11] frente a 67 [16] anos); mayor mortalidad (un 19,3 frente al 6,1%; riesgo relativo [RR] = 3,66; [intervalo de confianza [IC] del 95%, 1,65-8,13]); mayor limitacion funcional basal (45 frente a 95), al ingreso (20 frente as 75) y al alta (20 frente a 95); mayor porcentaje de deterioro funcional significativo (un 16 frente al 7%; RR = 2,47 [IC del 95%, 1,15-5,35]); y mayor consumo de recursos en terminos de asistencia urgente (3,6 [3,4] episodios frente a 2,4 [1,9]) y hospitalizaciones (1,9 [1,3] frente a 1,5 [1]). La supervivencia se asocio con padecer enfermedad del aparato digestivo (odds ratio [OR] = 48,3 [IC del 95%, 2,4-980,9]) o arteriopatia periferica/diabetes con repercusion visceral (OR = 5,6 [IC del 95%, 1,1-28,6]) y una mayor puntuacion Barthel al ingreso. Se asociaron a un deterioro funcional significativo el sexo femenino (OR = 46,6 [IC del 95%, 4,5-486,9]) y padecer enfermedad pulmonar cronica (OR = 8,9 [IC del 95%, 1,2-64]) o enfermedad neurologica con discapacidad (OR = 8 [IC del 95%, 1,1-58,9]). Conclusiones: En areas de medicina interna la incidencia de PP es elevada. La definicion propuesta identifica a una poblacion con especial fragilidad clinica, con una mayor necesidad de recursos hospitalarios y un deterioro funcional importante. La escala de Barthel constituyo un buen identificador comun de grupo y un marcador pronostico independiente.

Development of a new predictive model for polypathological patients. The PROFUND index

BACKGROUND There is a concern about the accuracy of the available prognostic indexes when applying them to the emergent population of polypathological patients (PP). METHODS To develop a 1-year mortality predictive index on PP, we developed a multicenter prospective cohort-study recruiting 1.632 PP after hospital discharge, outpatient clinics, or home hospitalization, from 33 hospitals. Potential risk factors were obtained in the 1.525 PP who completed follow-up. Each factor independently associated with mortality in the derivation cohort (757 PP from western hospitals) was assigned a weight, and risk scores were calculated by adding the points of each factor. Accuracy was assessed in the validation cohort (768 PP from eastern hospitals) by risk quartiles calibration, and discrimination power, by ROC curves. Finally, accuracy of the index was compared with that of the Charlson index. RESULTS Mortality in the derivation/validation cohorts was 35%/39.5%, respectively. Nine independent mortality predictors were identified to create the index (age ≥85 years, 3 points; No caregiver or caregiver other than spouse, 2 points; active neoplasia, 6 points; dementia, 3 points; III-IV functional class on NYHA and/or MRC, 3 points; delirium during last hospital admission, 3 points; hemoglobinemia <10 g/dl, 3 points; Barthel index <60 points, 4 points; ≥4 hospital admissions in last 12 months, 3 points). Mortality in the derivation/validation cohorts was 12.1%/14.6% for patients with 0-2 points; 21.5%/31.5% for those with 3-6 points; 45%/50% for those with 7-10 points; and 68%/61.3% for those with ≥11 points, respectively. Calibration was good in derivation/validation cohorts, and discrimination power by area under the curve was 0.77/0.7. Calibration of the Charlson index was good, but discrimination power was suboptimal (area under the curve, 0.59). CONCLUSIONS This prognostic index provides an accurate and transportable method of stratifying 1-year death risk in PP.

Seroepidemiological study of Rickettsia felis, Rickettsia typhi, and Rickettsia conorii infection among the population of southern Spain

Rickettsia typhi and Rickettsia conorii, the etiologic agents of, respectively, murine typhus and Mediterranean spotted fever, are recognized as frequent causes of fever of intermediate duration in southern Spain; in addition, in recent years Rickettsia felis has been detected in potential vectors in this area. Nevertheless, limited data exist regarding the actual prevalence of past infection due to these three pathogens. In the present study, the prevalence of past infection due to R. felis, R. typhi, and R. conorii was determined in a representative population of southern Spain during 2002. In addition, the possible risk factors associated with exposure to these pathogens were investigated. An epidemiological survey was completed by all subjects included in the study. Serum samples were tested by indirect immunofluorescence assay. The prevalence of past infection due to R. felis, R. typhi, and R. conorii among the 504 total subjects was 6.5, 3.8 and 8.7%, respectively. In multivariate analysis, infection due to R. felis was independently associated with a high-risk occupation (one that required working outdoors in nature, close contact with domestic animals, or potential contact with rodents) (OR=5.8; 95%CI 2.1–15.6), while infection due to R. typhi was associated with older age (factor of 1.04 [95%CI 1.008–1.068]) and frequent insect bites (OR=10.3; 95%CI 2.3–45.5). Two factors were associated with infection due to R. conorii: a high-risk occupation (OR=9.3; 95%CI 3.7–23.2), and participation in outdoor activities (OR=7.2; 95%CI 1.4–38.5). The results confirm the widespread prevalence of past infection due to R. felis, R. typhi, and R. conorii in the population of southern Spain.

Peeking through the cracks: An assessment of the prevalence, clinical characteristics and health-related quality of life (HRQoL) of people with polypathology in a hospital setting

Little is known about the prevalence of the recently defined polypathology notion in hospital populations. Patients admitted to medical wards were assessed using established criteria of polypathology. Prevalence of polypathology, interobserver reliability, clinical features, nutritional status, and HRQoL were assessed using clinical data and interview, mini-nutritional assessment (MNA), and the 12-item short-form health survey (SF-12) scales. Of a total of 812 patients studied, 196 (24%) met polypathology criteria (65% men, of mean age 71.3+/-11.6 years, mean defining chronic diseases 2.4+/-0.046, and other comorbidities 2.6+/-0.094). Interobserver reliability for the detection of cases was good (kappa=0.628). Their mean Charlson index/prescribed drugs were 3.3/6, respectively. Severe dyspnea, delirium, or active neoplasia were present in 44, 15, and 11%. A bad nutritional status/risk of malnutrition was evident in 10.3/52.6%, and correlated with the number of previous hospitalizations (p=0.041), and the presence of active neoplasia (p=0.037). Mean physical/mental summaries of HRQoL were 33.9+/-10, and 42+/-13, and correlated with a better nutritional status (p=0.011, and p=0.001, respectively). Polypathology affects one quarter of inpatients in a hospital setting, and can be easily and reliably identified. The diversity and complexity of patient needs underscore the need for continuity of care between community and hospital, crossing sub-speciality lines and institutional boundaries.

Características clínicas, funcionales, mentales y sociales de pacientes pluripatológicos. Estudio prospectivo durante un año en Atención Primaria

OBJECTIVES: To analyze clinical, functional, mental, sociofamiliar, and evolutional characteristics of pluripathological patients (PP) in Primary Health Care setting. PATIENTS AND METHOD: Prospective, multiinstitutional cohort study in four Primary Health Care Institutions by active identification of PP from a computerized registry using the Spanish Andalusian Health Care Council criteria. A clinical interview was proposed to all identified patients. The clinical data, Barthel index (BI), Pfeiffer scale, clinical vulnerability (CV), sociofamiliar features by the Gijon scale, and 1-year admissions and mortality were analyzed. An univariant and multivariant analysis was performed in order to know the risk factors associated to previously described variables. RESULTS: Overall, 806 PP were detected (1.38% of the population). Cardiovascular categories were the most prevalent. A total of 662 patients (69%) were eligible for the interview. Median BI was 90 (0-100), and 24% of patients had severe functional impairment (BI < 60). Twenty-nine percent of them had been admitted to hospital at least once in the last 3 months. Patients with more functional impairment and CV were older, having more defining categories, especially E category. A total of 174 patients (37.75%) had cognitive impairment. This group was older, with more functional impairment, and worse sociofamiliar support. One-year mortality was 6.1%, and was correlated with CV and older age. CONCLUSIONS: The definition of PP used selects in the Primary Care setting a population with a high level of multidimensional frailty having a high prevalence of functional, cognitive deterioration, sociofamiliar problems, CV and consumption of health care resources. Due to this multidimensional deterioration, it is recommendable to make an integral evaluation in the health care practice of these patients.

Infections in Renal Transplant Recipients Receiving Mycophenolate Versus Azathioprine-Based Immunosuppression

Differences in the incidence, etiology, type, and outcome of infections occurring during the first 6 months after transplantation were evaluated in two consecutive cohorts of kidney recipients who received immunosuppressive regimens based on either azathioprine (plus antilymphocyte globulin, cyclosporine A, and prednisone) (ATG-AZA cohort) or mycophenolate-mofetil (plus cyclosporine A and prednisone) (MMF cohort). The overall incidence of infections in the two cohorts was similar (0.99±1.06 infections/patient in the MMF cohort and 1.04±0.99 in the ATG-AZA cohort, P=0.3), as was the incidence of bacterial and fungal infections. In patients who received mycophenolate, cytomegalovirus disease occurred at a higher incidence (0.3±0.54 vs. 0.1±0.34 episodes/patient, P=0.005) and affected the upper gastrointestinal tract more frequently (0.21±0.48 vs. 0.025±0.16 episodes of cytomegalovirus ulcerative esophagitis, gastritis, or duodenitis per patient; P=0.001). A nonsignificant trend toward a higher recipient survival for patients receiving mycophenolate was noted (100% vs. 95%, P=0.07). In multivariate analysis, the following factors were independently associated with a higher risk of cytomegalovirus disease: the serostatus R–/D+ (seronegative recipients who received a kidney from a seropositive donor) (RR=35.7 [95%CI, 7.4–166.7]), treatment with mycophenolate (RR=10.4 [95%CI, 2.7–38.4]), and the development of any episodes of acute rejection (RR=10.1 [95%CI, 2.5–41.6]). These data show that kidney recipients receiving mycophenolate have a higher incidence of cytomegalovirus disease, mainly affecting the upper gastrointestinal tract, compared to those receiving azathioprine-based immunosuppression.

Enfermedades producidas por Rickettsia

El genero Rickettsia esta constituido por diferentes especies de bacterias gramnegativas, parasitos intracelulares obligados, muchos de los cuales constituyen actualmente paradigmas de patogenos emergentes. A excepcion de R. prowazekii, su ciclo vital se mantiene al infectar especies de hospedadores (en general mamiferos), y vectores (en general garrapatas y pulgas), siendo el ser humano un huesped accidental. La patogenia comun a todas consiste en una vasculitis de pequenos vasos por infeccion directa de las celulas endoteliales, produciendose una pleyade de focos de vasculitis multisistemica. Segun la distribucion de las rickettsias se puede producir neumonitis intersticial, miopericarditis, lesiones vasculiticas cutaneas, meningitis linfocitaria, asi como afectacion hepatica, renal y gastrointestinal. La clasificacion mas utilizada es la que divide a las rickettsiosis en dos grupos: el de las fiebres manchadas, y el de las fiebres tificas. En nuestro entorno las dos entidades mas frecuentes de ambos grupos son la fiebre botonosa mediterranea (producida por R. conorii) y el tifus murino (producido por R. typhi), respectivamente. El presente capitulo revisa estas entidades, asi como otras rickettsiosis de interes por emergentes (R. slovaca, R. africae, R. prowazekii, R. felis), o por su alta incidencia en otras areas (R. rickettsii, Orientia tsutsugamushi).

West Nile virus past infections in the general population of Southern Spain

OBJECTIVE To analyze the prevalence of past and recent infections by West Nile virus (WNV) and the risk factors associated with WNV exposure in a representative population from southern Spain. METHODS Sample size was established for an estimated prevalence of past WNV infections of 5 +/- 2.5% in 504 subjects. A pre-stratification was performed according to age distribution and place of residence. After random telephone solicitation and acquisition of informed consent, a serum sample was collected and an epidemiologic survey performed on all participating subjects. Samples were tested with ELISA-IgG and MAC-ELISA to detect specific IgG and IgM antibodies; results were confirmed by the plaque reduction neutralization test (PRNT). Multivariate analysis using a forward stepwise logistic regression model was performed to assess potential risk factors associated with WNV exposure. RESULTS Prevalence of past WNV infections confirmed by PRNT in the 504 participants was 0.6%, affecting mainly older persons (mean age 65 +/- 23 vs. 34 +/- 22 years; P = 0.018), those living in rural areas (5.4% vs. 0% in urban areas; P = 0.01), and individuals with risk professions (prevalence 2.8% vs. 0%; P = 0.048). None of the five recent infections detected by MAC-ELISA was confirmed by PRNT. CONCLUSIONS These results strongly suggest past circulation and exposure of the human population to WNV in southern Spain.

Spotted fever group Rickettsia in brown dog ticks Rhipicephalus sanguineus in southwestern Spain

A total of 2,229 adults ticks (1,428 males and 801 females) belonging to the brown dog tick, Rhipicephalus sanguineus Latreille, 1806, collected from dogs in Seville province (Andalusia), distributed in 500 lots ranging from one to eight specimens per lot, were examined for the presence of rickettsiae by molecular techniques. Specific rickettsiae DNA were detected in 90 lots (18%) of ticks tested. Sequence analysis of amplicons revealed that R. sanguineus ticks were infected exclusively with Rickettsia massiliae (including the strain Bar-29). The results of this study extend the knowledge of the geographic distribution and prevalence of these spotted fever group (SFG) rickettsiae and indicate that at least two of them, with yet uncertain pathogenicity to humans, are present in brown dog ticks in south western Spain. Although Mediterranean spotted fever (MSF) is an endemic disease in Andalusia, Rickettsia conorii was not found, whereas R. massiliae, recently described as a pathogenic species, was highly prevalent in this area. Our data suggest that in Andalusia a number of MSF or MSF-like cases attributed to R. conorii could have been actually caused by other SFG rickettsia present in R. sanguineus, particularly, R. massiliae.

A multi-institutional, hospital-based assessment of clinical, functional, sociofamilial and health-care characteristics of polypathological patients (PP)

Little is known about the main features of the emergent population of PP. Our objective was to determine the clinical, care and social characteristics of a multi-institutional population of PP, by means of a cross-sectional study including a reference population of hospital-based PP from 36 hospitals. The main clinical, functional, mental and social features and their associated factors were assessed: 1632 PP (53% males, mean age 77.9±9.8 years) were included. An informal caregiver was required by 52% (78% of caregivers were close female relatives). The mean inclusion criteria (Cat): were 2.7±0.8 (49.5% presented ≥3 Cat). The most frequent inclusion Cat were heart (77.5%), lung (45.6%), neurological (38.2%), and kidney diseases (32.2%), whereas the mean of other comorbidities was 4.5±2.7 per PP. The mean Charlson comorbidity index (CCI) was 4; 47.6%, and 52.4% presented dyspnea ≥3 on the NYHA, and on the MRC, respectively; nearly 19% required home oxygen therapy, 19% had suffered >1 fall in previous year, and 11% suffered an active neoplasia. The mean hospital admissions in last 12/3 months, and chronically prescribed drugs were 2/1, and 8±3, respectively. More than 70% presented obesity, while 60% had hypoalbuminemia. The basal/inclusion Barthel index (BI) score was 69±31/58±34 (BI score<60 was present in 31.5%/44%, respectively); and the mean Pfeiffer score was 2.94±3.2 (43% answered with ≥3 errors). More than half of the subjects were at risk or already had established social problems. This emergent population is considerably homogeneous, highly complex, clinically vulnerable, functionally impaired, dependent on caregivers and socially fragile. They need to receive more attention in clinical research and more support in health interventions based on comprehensive attention and continuity of care.