Mónica Rodríguez-Carballeira

Risk factors for opportunistic infections in infliximab-treated patients: the importance of screening in prevention

We sought to determine factors associated with opportunistic infections (OI) in infliximab-treated patients. A retrospective study cohort (1999–2004) was examined. Nine OI were diagnosed in 94 infliximab-treated patients: tuberculosis (four), visceral leishmaniasis (one), pyogenic muscular abscess (one Salmonella spp. and one Streptococcus pneumoniae), and two viral infections (hepatitis B virus [HBV] and zoster ophthalmicus). The risk for OI was significantly higher in the first year of treatment (odds ratio [OR] 8; 95% confidence interval [CI] 2–50). Previous treatment with more than two immunosuppressive drugs was the only factor related to OI (OR 8.686; 95% CI 1.889–39.943). We identified the subset of patients treated with infliximab who had a higher risk for OI. The screening of latent infections is key to diminishing the incidence of these infections.

Recent improvement in long-term survival after a COPD hospitalisation

Background Evidence-based international guidelines on chronic obstructive pulmonary disease (COPD), and their corresponding recommendations, were established to improve individual COPD prognosis, and ultimately to improve survival. The aim of this study was to determine whether the long-term mortality after discharge from a COPD hospitalisation has improved recently, and the effect of co-morbidity treatment in improving COPD prognosis. Methods In a prospective cohort study design of two cohorts 7 years apart, patients discharged from the same university hospital after a COPD exacerbation were followed-up, and their outcomes compared. Demographic and clinical variables, as well as lung function, were collected with the same protocol by the same investigators. Comprehensive assessments of co-morbidities and treatments were undertaken. Kaplan–Meier survival curves were estimated, and outcomes were compared by means of Cox regression methods. Results Overall, 135 participants in the 1996–7 cohort and 181 participants in the 2003–4 cohort were studied. Both cohorts were comparable in their baseline demographic and clinical variables, and median follow-up was 439 days. The 3-year mortality was lower in the 2003–4 cohort (38.7%) than in the 1996–7 cohort (47.4%) (p=0.017), and the RR of death after adjustment for gender, age, body mass index, co-morbidities, lung function and mMRC (modified Medical Research Council scale) dyspnoea was 0.66 (95% CI 0.45 to 0.97). Long-term survival improved in the second cohort for patients with COPD with heart failure or cancer (p<0.001). Conclusions A recent trend towards better prognosis of patients with COPD after hospital discharge is described and is likely to be associated with better management and treatment of COPD and co-morbidities.

Pseudomonas aeruginosa and Mortality after Hospital Admission for Chronic Obstructive Pulmonary Disease

Background:Pseudomonas aeruginosa (PA) is isolated in advanced stages of chronic obstructive pulmonary disease (COPD). Objectives: The aim of our study was to determine whether PA isolation during hospitalization for COPD exacerbation was associated with a poorer prognosis after discharge. Methods: We prospectively studied all patients with COPD exacerbation admitted between June 2003 and September 2004. A sputum culture was obtained at admission. Comorbidity, functional dependence, hospitalizations during the previous year, dyspnea, quality of life and other variables previously associated with mortality in COPD were studied. Spirometry and a 6-min walking test were performed 1 month after discharge. Mortality was evaluated 3 years after discharge. Results: A total of 181 patients were included in the study. Of these, 29 (16%) had PA in the sputum. The mean age was 72 years, and mean basal postbronchodilator forced expiratory volume in 1 s was 45.2% predicted (SD 14.4). The mean point value on the BODE index was 5.1 (SD 2.5). At 3 years, 17 of 29 patients (58.6%) in the PA group had died, compared to 53 of the 152 non-PA patients [34.9%; p < 0.004; hazard ratio (HR) 2.23, 95% confidence interval (CI) 1.29–3.86]. In the multivariate analysis, PA remained statistically related to posthospital mortality (p = 0.02; HR 2.2, 95% CI 1.2–4.2) after adjustment for age (p < 0.02; HR 1.04, 95% CI 1.007–1.07), BODE index (p < 0.02; HR 1.15, 95% CI 1.02–1.3) and comorbidity (p < 0.02; HR 1.24, 95% CI 1.03–1.5). Conclusions: PA isolation in sputum in patients hospitalized for acute exacerbation of COPD is a prognostic marker of 3-year mortality. Poor prognosis is independent of other significant predictors of mortality such as BODE index, age and comorbidity, as measured by the Charlson index.

Seven-year review of bacteremia caused by Streptococcus milleri and other viridans streptococci.

TheStreptococcus milleri group is associated with a spectrum of serious suppurative infections that have not been well defined. The purposes of this study were to ascertain the clinical significance ofStreptococcus milleri bacteremia and to determine the epidemiological, clinical, and microbiological features of these infections compared to those caused by other viridans streptococci. All cases of streptococcal bacteremia observed in a Spanish hospital in the period from January 1988 to December 1994 were reviewed. Of 137 cases ofStreptococcus milleri infection, 33 (24%) were documented cases of bacteremia. Twenty-four patients were men (mean age 57.8 ± 17.4 years). The majority of infections were abdominal in origin (20/33), the most frequent diagnoses being cholangitis/cholecystitis (18%) and appendicitis (12%). The origin of infection could not be established in three cases. Nine cases of bacteremia (27%) were polymicrobial. Six patients (18%) had septic shock; in four the infection was polymicrobial, and in two the infection was of abdominal origin. Eighteen of the 33 patients (54%) required surgery. Five patients died. All 33Streptococcus milleri isolates were susceptible to penicillin. Twenty-two cases of bacteremia caused by other viridans streptococci were observed during the same period. There were no statistically significant differences between the two groups in terms of age, sex, mortality, rate of polymicrobial infection, rate of nosocomial acquisition of bacteremia, or the occurrence of shock. An abdominal origin of infection was more frequent inStreptococcus milleri bacteremia (p=0.0001); a cardiovascular origin was more frequent in the viridans group (p=0.01), as was a diagnosis of endocarditis (p=0.004). Four patients with viridans streptococci bacteremia required surgery versus 18 patients withStreptococcus milleri bacteremia (p=0.01). Viridans streptococci were notably less susceptible to penicillin (89%), clindamycin (79%), and erythromycin (79%).

Systemic Expression of Cytokine Production in Patients with Severe Pneumococcal Pneumonia: Effects of Treatment with a β-Lactam versus a Fluoroquinolone

ABSTRACT Bacterial alveolar invasion is followed by an inflammatory response. A systemic extension of the compartmentalized immune response has been described in patients with severe pneumonia. The data suggest that some antimicrobials may induce a differential release of cytokines. We conducted a prospective, randomized study in adult patients with severe pneumococcal pneumonia to measure the effects of ceftriaxone and levofloxacin in the systemic cytokine expression over time. Demographic, clinical characteristics, and severity scores were recorded. The serum concentrations of tumor necrosis factor alpha (TNF-α), interleukin-1β (IL-1β), IL-6, IL-8, IL-10, and IL-1 receptor agonist were measured at 0, 24, 72, and 120 h. A total of 32 patients were included in the study. Both groups were homogeneous in terms of age, comorbidities, severity of disease, and corticosteroid or statin use. With the single exception of IL-1β, all cytokines were detected in venous blood. All of the cytokines studied showed a similar pattern of progressive decrease over time. No significant differences in the concentrations of any of the cytokines studied were found, with the exception of TNF-α, for which lower concentrations were obtained at 120 h in the levofloxacin group (P = 0.014). Basal oxygen saturation (P = 0.034) and heart rate (P = 0.029) returned to normal values earlier in the levofloxacin arm. We demonstrated that in patients with severe pneumococcal pneumonia pro- and anti-inflammatory responses could be detected in venous blood, representing a systemic extension of the compartmentalized response. Treatment with a β-lactam agent or a fluoroquinolone has different effects on cytokine production and its systemic expression, impacting the clinical course of the disease.

Clinical manifestations and long-term outcome of anti-Jo1 antisynthetase patients in a large cohort of Spanish patients from the GEAS-IIM group

OBJECTIVE To evaluate the clinical manifestations, long-term clinical outcome and longitudinal pulmonary function in a large cohort of Spanish patients with anti-Jo1 antibodies. METHODS We retrospectively analyzed the clinical data and lung function parameters of 148 anti-Jo1 patients recruited from a multicentre registry including 18 Spanish hospitals. A composite endpoint was defined, comprising death due to respiratory failure directly related to antisynthetase syndrome (ASS), the need for long-term oxygen therapy or lung transplantation. RESULTS Median follow-up was 78.3 months. Clinical presentation patterns at onset are as follows: isolated interstitial lung disease (ILD) (32.4%), isolated myositis (26.9%), concomitant myositis and ILD (22.8%), and isolated polyarthritis (17.9%). Myositis with ILD was the most frequent final clinical phenotype (67.6%). In most ASS patients, ILD was a non-progressive disease, tending to stabilize with therapy. The endpoint was reached in a significantly larger number of ILD patients with dyspnea at onset than those with paucisymptomatic or asymptomatic forms (p = 0.01). A steady FVC decrease was the hallmark of patients with end-stage lung disease. Estimated survival rates were 87.7% and 75.4% at 5 and 10 years, respectively. Cancer (p = 0.02) and advanced age at ASS diagnosis (p < 0.0001) were related to poorer survival. Mortality was significantly higher than in the general Spanish population, with a standardised mortality ratio (95% CI) of 4.03 (2.79-5.64). CONCLUSIONS Anti-Jo1 ASS is a heterogeneous syndrome. ILD in ASS under immunosuppressive therapy is mainly a non-progressive disease. Dyspnea at ILD onset and a steady FVC decrease over time were related to a poorer respiratory prognosis.

Association of a non-synonymous functional variant of the ITGAM gene with systemic sclerosis

Systemic sclerosis (SSc) is a chronic fibrotic autoimmune disease of complex aetiology which shares genetic similarities with systemic lupus erythematosus (SLE).1 2 One of the novel risk loci that have been recently associated with SLE is the integrin α M ( ITGAM ) gene, which encodes the α subunit of the αMβ2-integrin.3 4 The most likely causal polymorphism that best explains this association is a non-synonymous single-nucleotide polymorphism (SNP) at the exon 3, rs1143679, which changes the 77th amino acid residue arginine to histidine (R77H). This functional SNP represents one of the highest associated signals with SLE and is predicted to alter the structure and function of the integrin.4 5 To determine whether ITGAM rs1143679 is also associated with SSc susceptibility and clinical manifestations, we genotyped a total of 3735 SSc patients and 3930 matched healthy individuals from seven independent European cohorts of Caucasian origin (Spain, Germany, The Netherlands, Italy, Norway, Sweden and UK) using a predesigned TaqMan® assay (ID: C\__\_|2847895\_1_) in an ABI 7900HT (both from Applied Biosystems, Foster City, California, USA). Case …

Bacteraemic pneumococcal pneumonia in COPD patients: better outcomes than expected

The purpose of the study was to compare the clinical characteristics and outcomes of bacteraemic pneumococcal pneumonia (BPP) in chronic obstructive pulmonary disease (COPD) and non-COPD patients. A case-control study was conducted. Cases were any adult with BPP and forced expiratory volume in 1 second (FEV1) <80% and FEV1/forced expiratory vital capacity (FVC) <70%. Controls were patients with BPP without clinical diagnosis of COPD matched 1:2 by age, gender and date of isolation. Variables included co-morbidities, serotypes, pneumonia severity index (PSI), treatment and mortality. There were 45 cases and 90 controls. No significant differences were found in Charlson scores, antibiotic treatment, serotype distribution and severity. Malignancy, shock and mechanical ventilation were less frequent in COPD patients. One patient died vs 14 controls (p = 0.02). In univariate analysis, shock, multilobar involvement, Charlson score, heart failure and absence of COPD were associated with mortality. After adjustment for the presence of shock there were no differences in mortality. BPP presents less frequently with shock and has a lower mortality rate in COPD patients than in non-COPD patients.

Mortality of Tuberculosis in Very Old People

OBJECTIVES: To describe the clinical characteristics and outcomes of tuberculosis (TB) in elderly people.

Ingresos, estancia y mortalidad de las neumonías adquiridas en la comunidad en un hospital de agudos. Correlación entre el índice pronóstico de severidad y los criterios clínicos tradicionales de valoración de la gravedad

Introduccion Nuestro objetivo fue evaluar el tratamiento de la neumonia adquirida en la comunidad (NAC) segun los criterios convencionales comunmente aplicados, comparandolos con el indice pronostico de severidad (IPS) y analizar los factores relacionados con la necesidad de ingreso en la categoria III del IPS Metodos Se incluyeron prospectivamente los pacientes adultos con NAC atendidos durante 1999. A su llegada se recopilaron los datos necesarios para el calculo del IPS; al alta, los dias de estancia, la ubicacion y la mortalidad Resultados Se recogieron 447 casos de NAC. El 55,7% pertenecia a las categorias IV o V. Se produjeron 27 muertos (6,1%), el 97% en categorias IV y V. Hubo 362 ingresos, 302 (83%) pertenecian a las categorias III, IV y V. Se trataron de forma ambulatoria 85 pacientes (el 60% eran de categoria I o II). Se ha observado un aumento en la tasa de reingresos de forma proporcional a la categoria de riesgo que oscila del 4% en la categoria I al 18% en la categoria IV. En la categoria III (con 80 enfermos) se produjeron 63 ingresos (79%), con una estancia media de 7,89 dias. En esta categoria, la presencia de alteraciones en la exploracion fisica o analitica fue un factor asociado al ingreso (OR, 7,62 [1,5-35,2]) Conclusion El IPS se ha mostrado util en nuestra cohorte en la estratificacion de enfermos por gravedad y como factor asociado a la necesidad de ingreso y de reingreso. En categoria III, la variable mejor relacionada con la hospitalizacion fue la gravedad de la NAC y no la presencia de comorbilidad