Olga H. Torres

Outcome Predictors of Pneumonia in Elderly Patients: Importance of Functional Assessment

Objectives: To evaluate the outcome of elderly patients with community‐acquired pneumonia (CAP) seen at an acute‐care hospital, analyzing the importance of CAP severity, functional status, comorbidity, and frailty.

Infection caused by Nocardia farcinica: case report and review.

Abstract Nocardia farcinica is a rare Nocardia species causing localised and disseminated infections. A case of Nocardia farcinica infection is presented, and 52 cases previously reported in the literature are reviewed. The hosts usually had predisposing conditions (85%), and acquired the infection through the respiratory tract or skin; the infection then often spread to the brain, kidney, joints, bones and eyes. Pulmonary or pleural infections (43%), brain abscesses (30%) and wound infections (15%) which failed to respond to conventional antimicrobial therapy were the more frequent forms of infection. Nocardia farcinica was frequently isolated from pus (100% of samples), bronchial secretions (41%) and biopsy specimens (63%), but isolation from blood and urine, as in the case presented here, is rare. Antibiotic therapy was adequate in 61% of the patients in whom it was specified, the agents most frequently given being trimethoprim-sulfamethoxazole (54%), amikacin combined with imipenem (7%) and amoxicillin-clavulanate (7%). The high mortality (31%) can be attributed to the severe underlying diseases present, difficulties encountered in identifying the pathogen, inappropriate therapy and late initiation of therapy. Although an infrequent pathogen, Nocardia farcinica should be kept in mind as a cause of infection especially in immunosuppressed patients with indolent infections not responding to third-generation cephalosporins.

Herpes zoster as an immune reconstitution disease after initiation of combination antiretroviral therapy in patients with human immunodeficiency virus type-1 infection

BACKGROUND Initiation of combination antiretroviral therapy may be followed by inflammatory reactions. We studied the epidemiology of herpes zoster infection among patients with human immunodeficiency virus (HIV) infection who were treated with combination antiretroviral therapy. SUBJECTS AND METHODS Of 316 patients who initiated combination antiretroviral therapy, 24 (8%) were treated for herpes zoster within 17 weeks of starting therapy. The characteristics of these cases were compared with those of a control group of 96 HIV-1-infected patients, who were matched by age, sex, plasma HIV-1 RNA concentration and CD4 cell counts, and length of follow-up. RESULTS The incidence of herpes zoster associated with combination antiretroviral therapy was 9 episodes per 100 patient-years. There were no significant differences between cases and controls in age, sex, years of HIV infection, history of herpes zoster, previous acquired immune deficiency syndrome, or baseline mean CD4 and CD8 cell counts before beginning combination antiretroviral therapy. However, patients who developed herpes zoster had a significantly greater mean (+/- SD) increase in the number of CD8 cells than did controls (347 +/- 269 vs. 54 +/- 331 cells/mL, P = 0.0006). In a multivariate analysis, the only factor that was associated with the development of herpes zoster was the increase in CD8 cells from before initiation of combination antiretroviral therapy to 1 month before development of herpes zoster (odds ratio 1.3 per percentage increase; 95% confidence interval: 1.1 to 1.5; P = 0.0002). CONCLUSION The initiation of combination antiretroviral therapy in HIV-1-infected patients was often associated with the development of herpes zoster, especially in those in whom the number of CD8 cells increased after therapy.

Inappropriate prescribing to older patients admitted to hospital: A comparison of different tools of misprescribing and underprescribing

PURPOSE This study aims to assess inappropriate prescribing (IP) to elderly patients during the month prior to hospitalization and to compare different IP criteria. METHODS An observational, prospective and multicentric study was carried out in the internal medicine services of seven Spanish hospitals. Patients aged 75years and older were randomly selected after hospital admission for a year. To assess potentially inappropriate medicines (PIMs), the Beers and STOPP criteria were used and to assess potentially prescribing omissions (PPOs), the START criteria and ACOVE-3 medicine quality indicators were used. An analysis to assess factors associated with IP was performed. RESULTS 672 patients [median age (Q1-Q3) 82 (79-86) years, 55.9% female] were included. Median prescribed medicines in the month prior to hospitalization were 10(Q1-Q3 7-13). The prevalence of IP was 87.6%, and 54.3% of patients had PIMs and PPOs concurrently. A higher prevalence rate of PIMs was predicted using the STOPP criteria than with the Beers criteria (p<0.001) and a higher prevalence of PPOs using the ACOVE-3 criteria than using the START criteria (p<0.001) was observed. Polypharmacy (≥ 10 medicines) was the strongest predictor of IP [OR=11.34 95% confidence interval (CI) 4.96-25.94], PIMs [OR=14.16, 95% CI 6.44-31.12], Beers-listed PIMs [OR=8.19, 95% CI 3.01-22.28] and STOPP-listed PIMs [OR=8.21, 95% CI 3.47-19.44]. PIMs was the strongest predictor of PPOs [OR=2.79, 95% CI 1.81-4.28]. CONCLUSIONS A high prevalence of polypharmacy and PIMs and PPOs were reported. More than half the patients had simultaneous PIMs and PPOs. The related factors to PIMs and PPOs were different.

Effect of prophylactic treatment with low-molecular-weight heparin bemiparin sodium on serum potassium levels: a prospective observational study.

BackgroundHyperkalaemia is a serious adverse effect of unfractionated heparin, but the effect of low-molecular-weight heparins (LMWHs) on potassium levels is not clear. Previous studies have shown a disparity of results depending on the dose and type of LMWH used.ObjectiveTo analyse potassium level variations in medical and surgical inpatients receiving the LMWH bemiparin sodium at prophylactic doses and assess the consequent effective risk of hyperkalaemia in a real-life setting.MethodsThis was a prospective observational study conducted over a 9-month period in a university teaching hospital. Patients consecutively admitted to internal medicine wards for general medical conditions (n = 145) or to traumatology wards for hip fractures (n = 98) and who received prophylactic bemiparin sodium were enrolled in the study. The intervention consisted of daily dosages of bemiparin sodium (Hibor®) 3500IU (56%)or2500IU (44%) for a minimum of 5 days. The mean age of participants was 80.5 years, with 91.8% being aged ≥65 years. Eighty-six percent of patients had co-morbidities and 79.4% were taking medication affecting potassium homeostasis. The main outcome measures were variations in serum potassium levels observed within 4–8 days of starting bemiparin sodium and the presence of hyperkalaemia (serum potassium >5.1 mmol/L) while on bemiparin sodium treatment.ResultsAfter patients had received bemiparin sodium for a median 6-day period, the mean (±SD) serum potassium level increased from 4.1 ± 0.5 to 4.3 ± 0.5mmol/L(p < 0.001). Hyperkalaemia >5.1 mmol/L developed in ten patients (4.1%), but serum potassium levels >5.5 mmol/L related to bemiparin sodium were present in only two (0.8%). Laboratory tests between the fourth and eighth days identified all but one case of hyperkalaemia. Patients were not symptomatic and discontinuation of bemiparin sodium treatment was not required. There were no statistically significant differences in potassium disturbances between older (aged ≥65 years) and younger (aged <65 years) patients. The maximum serum potassium level showed a significant inverse correlation with bodyweight (R = −0.731; p = 0.016) and creatinine clearance (R = −0.640; p = 0.046), and a positive correlation with the individual variation in serum potassium levels (R = 0.692; p = 0.027) and with serum potassium levels after 4–8 days on bemiparin sodium treatment (R = 0.741; p = 0.014). Baseline potassium level (odds ratio [OR] 26.5, 95% CI 4.7, 150.3; p < 0.001) and treatment with ACE inhibitors (OR 10.5, 95% CI 1.9, 57.8; p = 0.007) were the only predictors of hyperkalaemia at admission (c-statistic 0.88,95% CI 0.78, 0.99). For patients not receiving ACE inhibitors, a baseline serum potassium >4.6 mmol/L was considered the cut-off value for predicting hyperkalaemia (sensitivity 90% and specificity 70%).ConclusionsSerum potassium levels in in-hospital traumatology and medical patients increased significantly with bemiparin sodium prophylaxis but the incidence of relevant hyperkalaemia was low. Patients taking bemiparin sodium who are treated with ACE inhibitors or who have a baseline potassium level >4.6 mmol/L should be monitored for serum potassium levels between days 4 and 8 of hospital admission.

An inter-rater reliability study of the prescribing indicated medications quality indicators of the Assessing Care Of Vulnerable Elders (ACOVE) 3 criteria as a potentially inappropriate prescribing tool.

PURPOSE There are limited tools to assess potential prescribing omissions (PPOs) or underprescribing in the elderly. The ACOVE project defines comprehensive quality care indicators for older people and some of these indicators focused on appropriate use of medicines. The aim of the present study was to assess the inter-rater reliability between observers using the ACOVE 3 prescribing indicated medications indicators and compare it with the inter-rater reliability obtained for the Screening Tool of Older Persons Prescriptions (STOPP)/Screening Tool to Alert Doctors to Right Treatment (START) criteria. METHODS In the context of an observational and multicentric study of a cohort of 672 patients 75 years and older who were hospitalized in Internal Medicine services of seven Spanish hospitals, an inter-rater reliability study using the ACOVE selected indicators and the STOPP/START criteria was carried out between April 2011 and March 2012. Three patients were randomly selected in each participating hospital, one for each four months of study. RESULTS A total of 21 patients (mean (SD) age of 84.3 (5.6) years, 57.1% female) were included in the inter-rater reliability study. For the STOPP, START and ACOVE criteria, the median kappa coefficient for the seven hospital analyses was 0.97, 0.92 and 0.95, respectively. Out of 123 total indicators in only 7 (5.7%) was the kappa coefficient value below 0.75. Only for 2 (5.6%) of the 37 studies selected ACOVE quality indicators was the kappa coefficient value less than 0.75. CONCLUSIONS A high inter-rater reliability was obtained for the selected underprescribing quality indicators of ACOVE 3. These quality indicators may be considered a useful tool in detecting underprescribing to the elderly patients.

Actualización de la neumonía en el anciano

The incidence of pneumonia increases with age and contributes to morbidity and mortality in the elderly. In our setting, pneumonia is the sixth leading cause of death and the fourth most common diagnosis at discharge from acute hospitals. This article reviews current concepts in management of pneumonia in the elderly: healthcare-associated pneumonia, aspiration and oropharyngeal dysphagia, risk stratification, and indications of radiological, microbiological and biological markers. We present current evidence on antibiotic treatment (when to start, empirical coverage, duration, new drugs and combinations) and adjuvant treatment (steroids, early mobilization, oral hygiene, prevention and treatment of aspiration and cardiac complications). We emphasize preventive aspects and considerations regarding palliative treatment.

99mTc-HMPAO SPET: a method to study visual loss in cryptococcal meningitis.

Visual loss, in the absence of direct ocular involvement, is an uncommon but severe complication of cryptococcal meningitis in patients with AIDS (1). To our knowledge, the use of TcHMPAO SPET (Tc-hexamethylpropylene amine oxime single photon emission tomography) for the study of visual loss in cryptococcal meningitis has not been previously reported. We report the use of this method in a 28-yearold HIV-infected woman with a severe cryptococcal meningitis who presented progressive visual loss, with ®nal visual acuity of no light perception in both eyes, pupils symmetrically sluggish to light and normal fundus exam. Tc-HMPAO SPET, showed a slight decrease in the supratentorial cerebral blood ̄ow and hypoperfusion of bilateral occipital and left temporal lobes (Fig. 1). Then, MRI did not show lesions in visual pathways, and evoked potentials were unrecordable in both eyes. One month later visual loss persisted; fundus exam remained normal and MRI showed bilateral lower-signal of optic nerves in a plane. Nine months later fundoscopy showed bilateral optic atrophy. Tc-HMPAO SPET has been used to determine changes in cerebral blood ̄ow. Particularly in the striate cortex, changes in regional cerebral perfusion have been related to visual stimulation, and Tc-HMPAO SPET has been proved as a successful method of diagnosis in cortical blindness (2). On the other hand, in cryptococcal meningitis only few case-reports have showed changes in cerebral blood ̄ow by SPECT, like increased perfusion in meningoencephalitis (3) and focal hypoperfusion in cryptococcomas (4). Although SPECT has not been previously used for the study of visual alterations in cryptococcal meningitis, it should be considered. In this disorder anatomical imaging studies are usually not conclusive. CT is useful to rule out focal lesions (1, 4) and, despite that MRI is the best method for radiological study, it may be normal (1). Pathogenesis of visual loss in cryptococcal meningitis is not well-known, either a direct lesion of the visual pathways and endocraneal hypertension have been described as the cause (1). In our patient SPECT-HMPAO showed bilateral occipital and left temporal lobes hypoperfusion. Although this could be due to visual deprivation, its association with other perfusion de®cits, especially in the temporal lobe, suggests a real cortical blindness, even in the absence of MRI alterations. In clinically documented cortical visual impairment, SPECT may detect focal brain dysfunction that correlates with clinical status whereas MRI can be normal or disclose only a smaller lesion. Moreover, SPECT is able to detect minor ̄uctuations in cerebral blood ̄ow such as those due to the connectivity of various regions of cerebral cortex (2). Bilateral occipital hypoperfusion observed in cortical blindness is often associated with other perfusion defects, specially in temporal or parietal lobes (2), which might re ̄ect direct central nervous system involvement due to neuronal degeneration or to impaired vascular function. Our case suggests a possible role of SPET-HMPAO for the study of Fig. 1. Tc HMPAO SPET images of the brain (oblique slices): The present case (A) is compared with the normal activity (B) and the normal MRI of the patient. The image from the present case (A) shows a slight decrease in the supratentorial cerebral blood ̄ow. Hypoperfusion of bilateral occipital and left temporal lobes is especially evident. Acta Neurol Scand 2000: 102: 340±341 Printed in UK. All rights reserved Copyright # Munksgaard 2000

Hip fractures in the oldest old. Comparative study of centenarians and nonagenarians and mortality risk factors

INTRODUCTION Centenarians and nonagenarians constitute a rapidly growing age group in Western countries and they are expected to be admitted to hospital with hip fractures. The aim of this study was to compare outcomes of centenarian and nonagenarian patients following a hip fracture and to identify risk factors related to in-hospital and post-discharge mortality in both groups. PATIENTS AND METHODS A prospective evaluation of centenarian patients and nonagenarian controls admitted to a tertiary university hospital in Barcelona with hip fractures over a period of 5 years and 9 months. Baseline characteristics and outcomes in both patient groups were compared. Variables associated with in-hospital, 30-day, 3-month and 1-year mortality were also analyzed. RESULTS Thirty-three centenarians and 82 nonagenarians were included. The most relevant statistically significant differences found were: Barthel index at admission (61.90 vs. 75.22), number of drugs before admission (4.21vs 5.55), in-hospital complication rates (97 vs. 78%), readmissions at 3 months and 1 year (0 vs 11.7% and 3.4 vs. 19.5% respectively) and mortality at 3 months and 1 year (41.4 vs. 20.8% and 62.1 vs. 29.9%, respectively). Mean number of complications, rapid atrial fibrillation, mean age, and urinary tract infection were risk factors associated with mortality. CONCLUSIONS Centenarian patients had similar in-hospital outcomes to nonagenarians, but experienced more complications and twice the 3-month and 1-year mortality rate. The mean number of complications was the risk factor most consistently related to in-hospital and post-discharge mortality. These findings emphasize the need to improve care in very old patients to prevent complications.