Sira Aguiló

Circulating auto-antibodies against nuclear and non-nuclear antigens in primary Sjögren's syndrome : Prevalence and clinical significance in 335 patients

The aim of this study was to analyze the prevalence and clinical significance of circulating auto-antibodies against nuclear and non-nuclear antigens in a large cohort of Spanish patients with primary Sjögrens syndrome (SS). We studied 335 patients diagnosed with primary SS seen consecutively in our department since 1994 and tested for anti-nuclear antibodies (ANA), anti-Ro/SS-A, anti-La/SS-B, anti-Sm, anti-ribonucleoprotein (anti-RNP), anti-smooth muscle antibodies (anti-SMA), anti-parietal cell antibodies (anti-PCA), anti-liver–kidney microsome type-1 (anti-LKM-1) antibodies and anti-mitochondrial antibodies (AMA). ANA were detected in 278 (83%) patients. The association of positive ANA with the presence of anti-Ro/SS-A and anti-La/SS-B antibodies reached statistical significance at a titre of ANA >1/80 (p<0.001), while the presence of anti-Sm and anti-RNP was associated with positive ANA at a titre ≥1/320 (p=0.037 for Sm and p=0.016 for RNP). ANA titres correlated with the number of positive antibodies against specific nuclear antigens (p<0.001) but not with the number of positive antibodies against non-nuclear antigens. We found positive anti-Ro/SS-A antibodies in 111 (33%) patients, anti-La/SS-B in 78 (23%), anti-RNP in 8 (2%) and anti-Sm in 4 (1%). Anti-SMA antibodies were detected in 208 (62%) patients, with no significant associations with clinical or analytical SS features, while anti-PCA antibodies were found in 90 (27%) patients and were associated with a higher prevalence of thyroiditis and liver involvement. AMA were detected in 28 (8%) patients, although only 14 presented clinical and/or analytical evidence of liver involvement. No patient presented anti-LKM antibodies. ANA play a central role in the immunological expression of primary SS, due to their frequency and close association with the underlying presence of one or more anti-ENA antibodies. Positivity for antibodies against non-nuclear antigens such as anti-PCA and AMA suggests an association with some organ-specific autoimmune diseases (thyroiditis and primary biliary cirrhosis), while the presence of anti-SMA, in spite of their high prevalence, has no clinical significance in primary SS.

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.

Short-term outcomes of heart failure patients with reduced and preserved ejection fraction after acute decompensation according to the final destination after emergency department care

AimsTo compare short-term outcomes after an episode of acute heart failure (AHF) in patients with reduced and preserved ejection fractions (HFrEF, < 40%; and HFpEF, > 49%; respectively) according to their destinations after emergency department (ED) care.Methods and resultsThis secondary analysis of the EAHFE Registry (consecutive AHF patients diagnosed in 41 Spanish EDs) investigated 30-day all-cause mortality, in-hospital all-cause mortality, prolonged hospitalisation (> 7 days), and 30-day post-discharge ED revisit due to AHF, all-cause death, and combined endpoint (ED revisit/death) in 5829 patients with echocardiographically documented HFrEF and HfpEF (HFrEF/HFpEF: 1,442/4,387). Adjusted ratios were calculated for patients admitted to internal medicine (IM), short stay unit (SSU), and discharged from the ED without hospitalisation (DEDWH) and compared with those admitted to cardiology. For HFrEF, the only significant differences were lower in-hospital mortality (OR = 0.26; 95% CI 0.08–0.81; p = 0.021) and prolonged hospitalisation (OR = 0.07; 95% CI 0.04–0.13; p < 0.001) related to SSU admission. For HFpEF, IM admission had a higher post-discharge 30-day mortality (HR = 1.85; 95% CI 1.05–3.25; p = 0.033) and combined endpoint (HR = 1.24; 95% CI 1.01–1.64; p = 0.044); SSU admission had a lower in-hospital mortality (OR = 0.43; 95% CI 0.23–0.80; p = 0.008) and prolonged hospitalisation (OR = 0.17; 95% CI 0.13–0.23; p < 0.001) but a higher post-discharge 30-day combined endpoint (HR = 1.29; 95% CI 1.01–1.64; p = 0.041); and DEDDWH had a lower 30-day mortality (HR = 0.46; 95% CI 0.28–0.75; p = 0.002) but higher post-discharge ED revisit (HR = 1.62; 95% CI 1.31–2.00; p < 0.001).ConclusionWhile HFrEF patients have similar short-term outcomes irrespective of the destination after ED care for an AHF episode, HFpEF patients present worse short-term outcomes when managed by non-cardiology departments, despite adjustment for different clinical patient profiles. Reasons for this heterogeneous specialty-related performance should be investigated.

Hospitalización a domicilio directamente desde urgencias: una opción posible y eficiente

Leuconostoc spp. in a patient without immunological disorders. An Med Interna. 2006;23:77–9. 4. Cuervo S, Cortés J, Rodrı́guez E, Hormaza N, Vargas E. Leuconostoc sp. en pacientes con cáncer: Estudio descriptivo. Rev Chil Infect. 2008;25:184–8. 5. Bernaldo de Quirós JC, Muñoz P, Cercenado E, Hernández-Sampelayo T, Moreno S, Bouza E. Leuconostoc species as a cause of bacteremia: two case reports and a literature review. Eur J Clin Microbiol Infect Dis. 1991;10:505–9. 6. Vázquez E, Carazo I, Martı́n A, Lozano C, Cuesta I, Pagola C. Infectious endocarditis caused by Leuconostoc mesenteroides. Enferm Infecc Microbiol Clin. 1998;16:237–8. 7. Friedland IR, Snipelisky M, Khoosal M. Meningitis in a neonate caused by Leuconostoc sp. J Clin Microbiol. 1990;28:2125–6. 8. Del Nozal MI, Jiménez-Mejı́as ME, Suárez A, Viciana P. Sepsis por Leuconostoc cremoris, neutropenia e infección por el virus de la inmunodeficiencia humana. Med Clin (Barc). 1997;108:799. 9. Handwerger S, Horowitz H, Coburn K, Kololathis A, Wormser GP. Infectiondue to Leuconostoc sp. Six cases and review. Rev Infect Dis. 1990;4:602–10. M. de los Ángeles Ballesteros Sanz a, , Carlos Ruiz De Alegrı́aPuig , Carlos Fernández-Mazarrasa b y Manuel Gutiérrez-Cuadra c Servicio de Medicina Intensiva, Hospital Universitario Marqués de Valdecilla, Santander, Cantabria, España Servicio de Microbiologı́a, Hospital Universitario Marqués de Valdecilla, Santander, Cantabria, España Unidad de Enfermedades Infecciosas, Servicio de Medicina Interna, Hospital Universitario Marqués de Valdecilla, Santander, Cantabria, España

Tasas de reconsulta, hospitalización y muerte a corto plazo tras el alta directa desde Urgencias de pacientes con insuficiencia cardiaca aguda y análisis de los factores asociados. Estudio ALTUR-ICA

BACKGROUND AND OBJECTIVES The aim of this study was to define the following in patients with acute heart failure (AHF) discharged directly from accident and emergency (A&E): rates of reconsultation to A&E and hospitalisation for AHF, and all-cause death at 30 days, rate of combined event at 7 days and the factors associated with these rates. PATIENTS AND METHOD The study included patients consecutively diagnosed with AHF during 2 months in 27 Spanish A&E departments who were discharged from A&E without hospitalisation. We collected 43 independent variables, monitored patients for 30 days and evaluated predictive factors for adverse events using Cox regression analysis. RESULTS We evaluated 785 patients (78±9) years, 54.7% women). The rates of reconsultation, hospitalisation, and death at 30 days and the combined event at 7 days were: 26.1, 15.7, 1.7 and 10.6%, respectively. The independent factors associated with reconsultation were no endovenous diuretics administered in A&E (HR 2.86; 95% CI 2.01-4.04), glomerular filtration rate (GFR)<60ml/min/m2 (1.94; 1.37-2.76) and previous AHF episodes (1.48; 1.02-2.13); for hospitalisation these factors were no endovenous diuretics in A&E (2.97; 1.96-4.48), having heart valve disease (1.61; 1.04-2.48), blood oxygen saturation at arrival to A&E<95% (1.60; 1.06-2.42); and for the combined event no endovenous diuretics in A&E (3.65; 2.19-6.10), GFR<60ml/min/m2 (2.22; 1.31-3.25), previous AHF episodes (1.95; 1.04-3.25), and use of endovenous nitrates (0.13; 0.02-0.99). CONCLUSION This is the first study in Spain to describe the rates of adverse events in patients with AHF discharged directly from A&E and define the associated factors. These data should help establish the most adequate approaches to managing these patients.