Factores pronósticos en adultos hospitalizados por neumonía causada por Legionella pneumophila / Prognostic factors in adult patients hospitalized for pneumonia caused by Legionella pneumophila

Introduction: Legionellosis is a multisystem bacterial disease, which causes pneumonia with high mortality in patients with comorbidity and admitted in intensive care units (ICU). Objective: Determine predictors of mortality or ICU admission. Methods: Retrospective follow-up of patients diagnosed with Legionella pneumophila pneumonia in Complexo Hospitalario Universitario de A Coruña. Period 2000-2013 (n = 240). Analysis of multivariate logistic regression was performed. Results: Mean age was 57.2 ± 15.4 years old, 88.3% were male. Average score of comorbidity (Charlson score) was 2.3 ± 2.3. There was a clear seasonal variation. Predominant symptoms were fever (92.5%), dry cough (38.1%) and dyspnea (33.9%). Creatinine clearance was lower than 60 mL/min/1.73 m² in 29.7% and sodium < 135 mEq/l in 58.3%. Admission to ICU rate was 16.3% and 10.8% needs mechanical ventilation. Inhospital mortality rate was 4.6%, rising to 23.1% in patients admitted to ICU. Variables associated to predict ICU admission were age (OR = 0.96), liver disease (OR = 7.13), dyspnea (OR = 4.33), delirium (OR = 5.86) and high levels of lactatedehydrogenase (OR = 1.002). Variables associated with inhospital mortality were Charlson index (OR = 1.70), mechanical ventilation (OR = 31.44) and high levels of lactatedehydrogenase (OR = 1.002). Discussion: Younger patients with liver disease, dyspnea and confusion are more likely to be admitted to ICU. Comorbidity, mechanical ventilation and elevated LDH levels are associated with higher mortality rate.

Introducción: La legionelosis es una enfermedad bacteriana multisistémica, causante de neumonías con mortalidad elevada en pacientes con comorbilidad e ingresos en Unidad de Cuidados Intensivos (UCI). Objetivo: Determinar factores pronósticos de mortalidad o ingreso en UCI. Material y Métodos: Estudio de seguimiento retrospectivo de pacientes diagnosticados de neumonía por Legionella pneumophila en Complexo Hospitalario Universitario de A Coruña (España). Período 2000-2013 (n = 240), con análisis de regresión logística multivariada. Resultados: La edad media fue 57,2 ± 15,4 años, 88,3% fueron hombres. La puntuación media de comorbilidad (score Charlson) fue 2,3 ± 2,3. Existe clara estacionalidad. La clínica predominante fue fiebre (92,5%), tos seca (38,1%) y disnea (33,9%). El 29,7% presentó aclaramiento de creatinina < 60 mL/min/1,73 m² y el 58,3% sodio < 135 mEq/l. Un 16,3% ingresó en UCI, precisando ventilación mecánica invasiva el 10,8%. La mortalidad global fue 4,6% y de 23,1% en ingresados en UCI. Variables asociadas para predecir ingreso en UCI fueron menor edad (OR = 0,96), hepatopatía (OR = 7,13), disnea (OR = 4,33), síndrome confusional (OR = 5,86) y lactato deshidrogenasa elevada (OR = 1,002). Las variables asociadas a mortalidad intrahospitalaria fueron índice de Charlson (OR = 1,70), ventilación mecánica invasiva (OR = 31,44) y cifras elevadas de lactato deshidrogenasa (OR = 1,002). Discusión: Pacientes jóvenes, con hepatopatía, disnea o confusión tienen más probabilidad de ingresar en UCI. Comorbilidad, ventilación mecánica y lactato deshidrogenasa elevada se asocian a mortalidad.

Validación del euroSCORE en la valoración del riesgo quirúrgico en un centro de referencia cardiovascular en Colombia / Validation of the EuroSCORE in assessing surgical risk in a Cardiovascular referral center in Colombia

Introducción y objetivos: El euroSCORE es el modelo predictivo de mortalidad en cirugía cardiovascular de mayor aceptación en todo el mundo. El objetivo del presente estudio fue validar estadísticamente este modelo tanto en sus variantes logística como aditiva, en un centro de referencia para cirugía cardiovascular en Colombia. Métodos: Estudio retrospectivo; se incluyeron a los pacientes de cirugía cardiaca mayor intervenidos durante los años 2007 a 2009 en el centro. Se determinó para cada paciente el riesgo de muerte tanto con el euroSCORE aditivo como con el logístico; se validó a partir de su capacidad de calibración y discriminación para comparar la mortalidad predicha con la observada, de manera global y para cada grupo de riesgo. Resultados: Se incluyeron 498 pacientes, 226 (45%) correspondientes a cirugía de revascularización miocárdica aislada y el resto a otras cirugías cardiovasculares mayores. La calibración del modelo fue de p = 0.8 para el aditivo y de 0.2 para el logístico. Las áreas bajo la curva receiver operating characteristic fueron de 0.85 para ambos modelos. La mortalidad global observada alcanzó el 7.03% mientras que la estimada fue 5.34% por el modelo logístico y 4.47% con el aditivo. Conclusiones: La predicción fue buena con los dos modelos, tanto de manera global como dentro de cada categoría de riesgo; el modelo logístico fue el más aproximado a la mortalidad observada. El euroSCORE ha sido validado satisfactoriamente en este centro de referencia en Colombia y los resultados permiten calificar bien el desempeño del programa de cirugía cardiovascular en este centro.

Introduction and objectives: The euroSCORE is the predictive model of mortality in cardiovascular surgery more accepted worldwide. The objective of the present study was to statistically validate this model in both its logistic and additive variants in a cardiovascular referral center in Colombia. Methods: We included patients undergoing major cardiac surgery consecutively during the period of years 2007 and 2009 in the center. The risk of death was determined separately for each patient for both the additive euroSCORE and the logistic model. The capacity calibration of the model and its discrimination were calculated by comparing the observed with the predicted mortality, both overall and for each risk group. Results: Were included 498 patients, 226 (45%) of isolated CABG, and the rest other major cardiovascular surgical procedures. The calibration of the model was satisfactory (p = 0.8 and 0.2 additive and logistic). The discrimination was calculated with an area under the curve AUC of 0.85 for both models. The overall mortality reached 7.03% while 5.34% was estimated by the logistic model, and 4.47% with the additive one. The prediction was good with the two models both for overall and within each risk category, but it was more accurate in the logistic model. Conclusions: The euroSCORE has been successfully validated in this cardiovascular referral center. The results allow us to properly qualify the performance of this cardiovascular surgery program of Colombia.

Delirium en ancianos hospitalizados: Seguimiento de 18 meses / Delirium in elderly inpatients: An 18 month follow-up

El objetivo de este trabajo fue describir la prevalencia de síndrome confusional agudo en ancianos hospitalizados, la evolución durante la internación y a los 18 meses. Se evaluó en forma prospectiva a pacientes de 70 años de edad o mayores, internados en el Servicio de Clínica Médica de nuestro hospital, entre septiembre de 2005 y mayo de 2006. Se utilizó una versión validada en español del Confussion Assessment Method para diagnosticar delirium. A los 18 meses se evaluó el estado vital, lugar de residencia, actividades de la vida diaria, dependencia de cuidadores y reinternaciones. Se evaluaron 194 pacientes y 74 fueron excluidos. De los 120 casos incluidos, 52 (43.3%) presentaron delirium. La edad media fue de 82.6 años (DS: 7.4) en el grupo de pacientes con síndrome confusional agudo y de 80.4 años (DS: 5.6) en el grupo de pacientes sin delirium. Al comparar estos dos grupos encontramos diferencias significativas en las características, siendo más frecuentes en el grupo con delirium la residencia previa en un centro de tercer nivel (17.3% vs. 1.5%; p < 0.002), la demencia (40.4% vs. 8.8%; p < 0.001), menor puntaje en la evaluación de las actividades de la vida diaria (5 vs. 6; p < 0.001), más días de internación (7 vs. 5; p = 0.04) y mayor mortalidad intrahospitalaria (21.2% vs. 1.5%; p < 0.001). A los 18 meses de seguimiento después del alta, el desarrollo de delirium durante la internación se asoció a mayor grado de dependencia evidenciado por el peor puntaje en las actividades de la vida diaria (mediana 1/6 vs. 5/6) y a menor sobrevida actuarial 35.3% (CI 95%: 24-49%) a los 569 días y 49% (CI 95%: 32.9-65.4%) a los 644 días (p=0.027).

Delirium usually hardens care during hospitalization and increases morbidity during hospital stay and after discharge. The objective of this study was to describe the prevalence of delirium in elderly inpatients in a Buenos Aires hospital, its morbidity and mortality during hospital stay and the next 18 month follow-up. Patients aged 70 or older admitted to internal medicine unit between September 2005 and May 2006 were enrolled. Delirium was assessed with the Spanish version of Confusion Assessment Method. Demographic data, cause of admition and length of stay, destination after discharge and mortality were registered. A new evaluation was made 18 months after discharge. We evaluated 194 patients and 74 were excluded. Of the 120 included, 52 (43.3%) presented delirium. We found significant differences between patients with and without delirium in previous placement in nursing home (17.3% vs. 1.5%; p < 0.002), dementia (40.4% vs. 8.8%; p < 0.001), median activity of daily living (5 vs. 6; p < 0.001), length-of-stay (7 vs. 5; p = 0.04) and mortality rate (21.2% vs. 1.5%; p < 0.001). Evaluation 18 months later showed differences between patients with and without delirium in median of activity of daily living (1/6 vs. 5/6), patients living in nursing homes (27.5% vs. 7.9%), estimated survival 35.3% (CI 95%: 24-49%) at day 569 and 49% (CI 95%: 32.9-65.4%) at day 644. The difference between survival curves was statistically significant (p = 0.027). Delirium increases morbidity and mortality during hospital stay. Elderly with delirium are at risk of worsening disability and of becoming dependent after discharge and it is a risk factor for higher mortality during the following months after discharge.

Severity Measurement Methods and Comparing Hospital Death Rates for Coronary Artery Bypass Graft Surgery / 예방의학회지

OBJECTIVE: Health insurers and policy makers are increasingly examining the hospital mortality rate as an indicator of hospital quality and performance. To be meaningful, a risk-adjustment of the death rates must be implemented. This study reviewed 5 severity measurement methods and applied them to the same data set to determine whether judgments regarding the severity-adjusted hospital mortality rates were sensitive to the specific severity measure. METHODS: The medical records of 584 patients who underwent coronary artery bypass graft surgery in 6 general hospitals during 1996 and 1997 were reviewed by trained nurses. The MedisGroups, Disease Staging, Computerized Severity Index, APACHElll and KDRG were used to quantify severity of the patients. The predictive probability of death was calculated for each patient in the sample from a multivariate logistic regression model including the severity score, age and sex to evaluate the hospitals' performance, the ratio of the observed number of deaths to the expected number for each hospital was calculated. RESULTS: The overall in-hospital mortality rate was 7.0%, ranging from 2.7% to 15.7% depending on the particular hospital. After the severity adjustment, the mortality rates for each hospital showed little difference according to the severity measure. The 5 severity measurement methods varied in their statistical performance. All had a higher c statistic and R2 than the model containing only age and sex. There was a little difference in the relative hospital performance evaluation by the severity measure. CONCLUSION: These results suggest that judgments regarding a hospital's performance based on severity adjusted mortality can be sensitive to the severity measurement method. Although the 5 severity measures regarding hospital performance concurred, more often than would be expected by chance, the assessment of an individual hospital mortality rates varied by the different severity measurement method used.