Comanejo de la fractura de cadera del anciano en un hospital de tercer nivel: un estudio de cohortes / Hip fracture co-management in the elderly in a tertiary referral hospital: a cohorts study

INTRODUCCIÓN: La fractura de cadera del anciano es de los diagnósticos más prevalentes en los servicios de Traumatología, con gran impacto en términos clínicos, económicos y sociales. Nuestro objetivo es analizar el impacto clínico de un modelo de comanejo entre Traumatología y Medicina Interna para pacientes ancianos ingresados por fractura de cadera en un hospital de tercer nivel. MATERIAL Y MÉTODOS: Cohortes retrospectivas de pacientes mayores de 65 años ingresados por fractura de cadera entre enero de 2005 y agosto de 2006 (cohorte HIST) sin modelo de comanejo, y entre enero de 2008 y agosto de 2010 (cohorte COFRAC) con dicho modelo. Se analizaron características demográficas, clínicas y quirúrgicas, incidencia de complicaciones, mortalidad y reingreso a los 30 días. RESULTADOS: Se incluyó a 701 pacientes (471 HIST, 230 COFRAC). No hubo diferencias en edad, género, demora quirúrgica, tiempo y tipo de cirugía e intervención, estancia, deambulación al alta, consulta en urgencias ni reingreso o mortalidad a 30 días. Hubo diferencias en identificación de pluripatológicos (16,8 vs. 24,4%; p = 0,02), osteoporosis (3,9 vs. 7,6%; p = 0,03) o déficit motor (3,5 vs. 8,8%; p = 0,03), fármacos del tratamiento (3,7+/-2,5 vs. 4,3+/-3,2; p < 0,01), aparición de delirium (15,6 vs. 20,9%, p = 0,048) e hipomotilidad intestinal (80,3 vs. 74,7%; p < 0,001), seguimiento de anemia (83,3 vs. 97,1%; p > 0,01) y de función renal (44,5 vs. 97,3%; p < 0,01) y mortalidad intrahospitalaria (4,6 vs. 1,3%; p = 0,02). CONCLUSIONES: El comanejo de pacientes ancianos ingresados por fractura de cadera permite mejorar la documentación de los problemas crónicos previos y el control de complicaciones hospitalarias y disminuye la mortalidad intrahospitalaria

INTRODUCTION: Hip fracture in the elderly is one of the most prevalent diagnoses in Orthopedic Surgery Departments. It has a great impact in medical, economic and social terms. Our objective is to analyze clinical impact of a co-management care model between orthopedic surgery and internal medicine departments for elderly patients admitted with hip fracture in a tertiary referral hospital. MATERIAL AND METHODS: Retrospective cohort study of patients older than 65 years old admitted with hip fracture between January 2005-August 2006 (HIST cohort) without a co-management care model, and between January 2008-August 2010 (COFRAC cohort) with a co-manEdadment care model. Analysis of demographic, clinical and surgery characteristics, complications incidence and mortality and re-admissions at 30 days was made. RESULTS: A total of 701 patients were included (471 HIST, 230 COFRAC). There were no differences in sex, gender, time to surgery, type of anesthesia and surgery, length of stay, ambulation at discharge and 30-days emergency room consultation, readmissions or mortality at 30 days. There were differences in identification of polypatological patients (16.8 vs. 24.4%, P=0.02), presence of osteoporosis (3.9 vs. 7.6%, P=0.03), motor deficit (3.5 vs. 8.8%, P=0.03), number of chronic drugs (3.7+/-2.5 vs. 4.3+/-3.2, P<0.01), diagnosis of delirium (15.6 vs. 20.9%, P=0.048), constipation (80.3 vs. 74.7%, p < 0.001), monitoring of anemia (83.3 vs. 97.1%, P>0.01) and renal failure at discharge (44.5 vs. 97.3%, P<0.01) and hospital mortality (4.6 vs. 1.3%, P=0.02). CONCLUSIONS: Co-management for elderly patients admitted with hip fracture provides a better information about previously chronic conditions, a higher control of hospital complications and decreases hospital mortality

Hip fracture co-management in the elderly in a tertiary referral hospital: A cohorts study. / Comanejo de la fractura de cadera del anciano en un hospital de tercer nivel: un estudio de cohortes.

INTRODUCTION: Hip fracture in the elderly is one of the most prevalent diagnoses in Orthopedic Surgery Departments. It has a great impact in medical, economic and social terms. Our objective is to analyze clinical impact of a co-management care model between orthopedic surgery and internal medicine departments for elderly patients admitted with hip fracture in a tertiary referral hospital. MATERIAL AND METHODS: Retrospective cohort study of patients older than 65 years old admitted with hip fracture between January 2005-August 2006 (HIST cohort) without a co-management care model, and between January 2008-August 2010 (COFRAC cohort) with a co-manEdadment care model. Analysis of demographic, clinical and surgery characteristics, complications incidence and mortality and re-admissions at 30 days was made. RESULTS: A total of 701 patients were included (471 HIST, 230 COFRAC). There were no differences in sex, gender, time to surgery, type of anesthesia and surgery, length of stay, ambulation at discharge and 30-days emergency room consultation, readmissions or mortality at 30 days. There were differences in identification of polypatological patients (16.8 vs. 24.4%, P=0.02), presence of osteoporosis (3.9 vs. 7.6%, P=0.03), motor deficit (3.5 vs. 8.8%, P=0.03), number of chronic drugs (3.7±2.5 vs. 4.3±3.2, P<0.01), diagnosis of delirium (15.6 vs. 20.9%, P=0.048), constipation (80.3 vs. 74.7%, p<0.001), monitoring of anemia (83.3 vs. 97.1%, P>0.01) and renal failure at discharge (44.5 vs. 97.3%, P<0.01) and hospital mortality (4.6 vs. 1.3%, P=0.02). CONCLUSIONS: Co-management for elderly patients admitted with hip fracture provides a better information about previously chronic conditions, a higher control of hospital complications and decreases hospital mortality.

Home management of acute medical complications in cancer patients: a prospective pilot study.

BACKGROUND: The development of reliable alternatives to conventional hospitalization in patients with cancer would have great clinical and economical value. The aim of the present study was to assess the feasibility of a home-based nursing intervention model as a safe alternative for the management of acute medical complications in cancer patients who would otherwise require conventional hospitalization. PATIENTS AND METHODS: From October 2013 to October 2014, we prospectively evaluated the outcomes of consecutive acute medical episodes treated at home under the home-based intervention program named the Bridge Project (BP). Episodes were classified as "avoided hospitalization in outpatients" (AHO) vs. "reduced hospitalization in inpatients" (RHI). The primary end-point was to assess the rate and causes of BP intervention failure (unplanned hospital readmission or death). RESULTS: Two hundred and forty-six consecutive episodes (52 % AHO and 48 % RHI) involving 203 patients (55 % male; mean age 63 years) were enrolled. The main conditions managed at home were non-neutropenic infections (40 %), febrile neutropenia (20 %), and cancer-related complications (28 %). The median duration of the BP intervention was 5 days (range 1-16 days). No deaths were reported at home. Unplanned hospital readmissions occurred in 9 % of episodes (14 % in AHO vs. 4 % in RHI; p = 0.001). Five of the 22 readmitted patients (22.7 % of the BP failures; 2.5 % of the whole series) died during hospitalization. The BP intervention burden was 1353 days, representing a potential saving of 14 % of days of hospitalization during the study period. CONCLUSIONS: The BP is a safe intervention which can potentially avoid or reduce the length of hospitalization in selected cancer patients with acute medical complications. Our findings support further development of innovative home-based clinical approaches to promote potentially avoidable hospitalization in this setting.

Impact of prompt catheter withdrawal and adequate antimicrobial therapy on the prognosis of hospital-acquired parenteral nutrition catheter-related bacteraemia.

Catheter-related bacteraemia (CRB) is a cause of death in hospitalized patients, and parenteral nutrition (PN) is a risk factor. We aim to describe the prognosis of PN-CRB and the impact of catheter extraction within 48 h from bacteraemia. All consecutive hospitalized adult patients with CRB (2007-2012) were prospectively enrolled. Factors associated with 30-day mortality were determined by logistic regression analysis. Among 847 episodes of CRB identified, 291 (34%) episodes were associated with short-term catheter use for PN. Cure was achieved in 236 (81%) episodes, 42 (14.5%) patients died within the first 30 days, 7 (2.5%) relapsed, and 6 (2%) had re-infection. On multivariate analysis, previous immunosuppressive therapy (OR 5.62; 95% CI 1.69-18.68; p 0.0048) and patient age (OR 1.05; 95% CI 1.02-1.07; p 0.0009) were predictors of 30-day mortality, whereas catheter removal within 48 h of bacteraemia onset (OR 0.26; 95% CI 0.12-0.58; p 0.0010) and adequate empirical antibiotic treatment (OR 0.36; 95% CI 0.17-0.77; p 0.0081) were protective factors. Incidence of PN-CRB decreased from 5.36 episodes/1000 days of PN in 2007 to 2.9 in 2012, yielding a 46.1% rate reduction (95% CI 15.7-65.5%), which may be attributable to implementation of a multifaceted prevention strategy. In conclusion, short-term PN-CRB accounted for one-third of all episodes of CRB in our setting, and 14.5% of patients died within 30 days following bacteraemia. Our findings suggest that prompt catheter removal and adequate empirical antibiotic treatment could be protective factors for 30-day mortality. Concomitantly with implementation of a multifaceted prevention strategy, PN-CRB incidence was reduced by half.

Comparative assessment of nonlinear metrics to quantify organization-related events in surface electrocardiograms of atrial fibrillation.

Atrial fibrillation (AF) is today the most common sustained arrhythmia, its treatment being not completely satisfactory. Electrical activity organization analysis within the atria could play a key role in the improvement of current AF therapies. The application of a nonlinear regularity index, such as sample entropy (SampEn), to the atrial activity (AA) fundamental waveform has proven to be a successful noninvasive AF organization estimator. However, the use of alternative nonlinear metrics within this context is a pending issue. The present work analyzes the ability of several nonlinear indices to assess regularity of patterns and, thus, organization, in the AA signal and its fundamental waveform, defined as the main atrial wave (MAW). Precisely, Fuzzy Entropy, Spectral Entropy, Lempel-Ziv Complexity and Hurst Exponents were studied, achieving more robust and accurate AF organization estimates than SampEn. Results also provided better AF organization estimates from the MAW than from the AA signal for all the tested nonlinear metrics, which agrees with previous works only focused on SampEn. Furthermore, some of these indices reported a discriminant ability close to 95% in the classification of AF organization-dependent events, thus outperforming the diagnostic accuracy of SampEn and other widely used noninvasive estimators, such as the dominant atrial frequency (DAF). As a conclusion, these nonlinear metrics could be considered as promising estimators of noninvasive AF organization and could be helpful in making appropriate decisions on the patients' management.

Surface ECG organization analysis to predict paroxysmal atrial fibrillation termination.

The aim of this work is to predict non-invasively if an AF episode terminates spontaneously or not by analyzing the increase of atrial activity organization prior to paroxysmal atrial fibrillation (PAF) termination. Sample entropy was selected as non-linear organization index. Synthetic PAF signals were used to evaluate the notable impact of noise in AA organization estimation. Three strategies to reduce noise, ventricular residues and enhance the atrial activity main features were proposed. The best prediction results were obtained through main atrial wave (MAW) organization estimation. The MAW can be considered as the fundamental waveform associated to the AA. The 92% of the terminating and non-terminating analyzed PAF episodes were correctly classified. Thereby, it can be concluded that the MAW non-linear analysis from the surface ECG is a reliable and useful tool to predict spontaneous PAF termination.

Nuisance odours produced by benthic cyanobacteria in a Mediterranean river.

Geosmin dynamics in the Llobregat waters were related to the waxing and waning of benthic cyanobacterial mats developing in the river. Geosmin concentration in the water during 2002 reached a maximum of 204 ng L(-1), and coincided with an abundance of cyanobacteria in the river. Cyanobacterial mats were favoured by the high nutrient content of the waters. The cyanobacterial mats experienced a process of growth in thickness (attached forms), until they became unattached and drifted downstream (free-floating forms), accumulating in shallow areas of the river. Geosmin in the biofilm ranged from 0.55 +/- 0.97 ng geosmin per mg DW(-1) in the attached biofilms and 5.25 +/- 4.96 ng geosmin per mg DW(-1) in the free-floating biofilms. While the attached mats could be responsible for the local occurrence of geosmin at a given site, the free-floating mats became a relevant agent for the dispersion of the metabolite downstream. This impression was reinforced by the extremely high correlation between the geosmin content in the free-floating biofilm and in the water (r = 0.917, p = 0.00001). In order to reduce the geosmin concentration and accumulation of the cyanobacterial mats in shallow river waters, the nutrient content should be controlled and the natural flow conditions restored, to prevent the growth and accumulation of the geosmin-producing cyanobacterial mats.

Sarcoidosis extrapulmonar como causa de fiebre de origen desconocido / Extrapulmonary sarcoidosis as the etiology in a patient with fever of unknown origin

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[Sudden unexpected death in epilepsy in children and adolescents]. / Muerte súbita inesperada en epilepsia en niños y jóvenes.

INTRODUCTION: Sudden unexpected death in epilepsy (SUDEP) is an important cause of death in young epileptic patients. However, it is relatively unknown to neurologists. OBJECTIVE: To analyze the frequency and clinicopathological characteristics of SUDEP as a cause of sudden death (SD) in young persons. PATIENTS AND METHODS: An observational study of all SD due to SUDEP in persons aged 1 35 years occurring between 1991 and 1998 in Bizkaia, in whom medico legal autopsy was done. In all cases a full autopsy was done and the previous clinical history was investigated. RESULTS: Eight of the 107 cases of SD (7.5%) were due to SUDEP. Five were aged between 25 and 29 years and in this age group it was the commonest cause of death (22%). Six had been diagnosed as having idiopathic epilepsy and two as having posttraumatic epilepsy. Generalized convulsions occurred in 75%. Four patients died when they were alone. Two patients had epileptic seizures hours before their death. At necropsy no structural changes were seen in the brain except in the two patients with posttraumatic epilepsy. Pulmonary oedema was a frequent finding. In 50% of the dead patients, chemico toxicological study showed there to be no trace of the drugs they had been prescribed. CONCLUSIONS: Although SD is rare, SUDEP is an important cause of mortality in young epileptics. Violent death in relation to epilepsy causes problems in forensic medicine. Although the mechanisms of SUDEP are not clear, it would seem necessary to increase medical control of this disorder, especially in young people.

Muerte súbita inesperada en epilepsia en niños y jóvenes / Sudden unexpected death in epilepsy in children and adolescents

Introducción. La muerte súbita inesperada en la epilepsia (MSIEP) es una causa importante de mortalidad en pacientes epilépticos jóvenes. Sin embargo, su existencia es escasamente conocida por los neurólogos. Objetivo. Analizar la frecuencia y características clinicopatológicas de la MSIEP como causa de muerte súbita (MS) en jóvenes. Pacientes y métodos. Estudio observacional de todas las MS ocurridas por MSIEP en personas de 135 años desde 1991 a 1998 en Bizkaia que fueron objeto de autopsia médico-legal. En cada caso se efectuó una autopsia completa y se investigaron los antecedentes patológicos. Resultados. Ocho de los 107 casos de MS (7,5 por ciento) fueron debidos a MSIEP. Cinco tenían entre 25 y 29 años, siendo en este grupo quinquenal la causa más frecuente (22 por ciento). Seis estaban diagnosticados de epilepsia idiopática, y 2 de postraumática. Un 75 por ciento tenían crisis generalizadas. En 4 la muerte no fue presenciada. Dos pacientes sufrieron una crisis epiléptica horas antes del fallecimiento. El estudio necrópsico no mostró alteraciones estructurales del encéfalo, salvo en los 2 pacientes con epilepsia postraumática. Hubo una alta frecuencia de edema pulmonar. En el 50 por ciento el estudio químico-toxicológico fue negativo para los fármacos antiepilépticos prescritos. Conclusiones. Dentro de la rareza de la MS, la MSIEP constituye una causa importante de mortalidad en epilépticos jóvenes. Para la Medicina Forense la muerte de carácter violento relacionada con la epilepsia plantea mayor conflictividad. Aunque los mecanismos de la MSIEP no son bien conocidos, parece necesario reforzar el control médico de esta enfermedad especialmente en la juventud (AU)

Characterization of bacteriophage lambda excisionase mutants defective in DNA binding.

The bacteriophage lambda excisionase (Xis) is a sequence-specific DNA binding protein required for excisive recombination. Xis binds cooperatively to two DNA sites arranged as direct repeats on the phage DNA. Efficient excision is achieved through a cooperative interaction between Xis and the host-encoded factor for inversion stimulation as well as a cooperative interaction between Xis and integrase. The secondary structure of the Xis protein was predicted to contain a typical amphipathic helix that spans residues 18 to 28. Several mutants, defective in promoting excision in vivo, were isolated with mutations at positions encoding polar amino acids in the putative helix (T. E. Numrych, R. I. Gumport, and J. F. Gardner, EMBO J. 11:3797-3806, 1992). We substituted alanines for the polar amino acids in this region. Mutant proteins with substitutions for polar amino acids in the amino-terminal region of the putative helix exhibited decreased excision in vivo and were defective in DNA binding. In addition, an alanine substitution at glutamic acid 40 also resulted in altered DNA binding. This indicates that the hydrophilic face of the alpha-helix and the region containing glutamic acid 40 may form the DNA binding surfaces of the Xis protein.

Specificity determinants for bacteriophage Hong Kong 022 integrase: analysis of mutants with relaxed core-binding specificities.

The integrase (Int) proteins encoded by bacteriophages HK022 and lambda catalyse similar site-specific integration and excision reactions between specific DNA regions known as attachment (att) sites. However, the Int proteins of HK022 and lambda are unable to catalyse recombination between non-cognate att sites. The att sites of both phages contain weak binding sites for Int, known as 'core-type' sites. Negatively acting nucleotide determinants associated with specific core sites (lambda B', HK022 B', HK022 C) are responsible for the barrier to non-cognate recombination. In this study, we used challenge phages to demonstrate that the lambda and HK022 Ints cannot bind to core sites containing non-cognate specificity determinants in vivo. We isolated mutants of the HK022 Int, which bind the lambda B' core site. Two mutants, D99N and D99A, have changed a residue in the core-binding (CB) domain, which may be directly contacting the core site DNA. We suggest that binding to the lambda B' site was accomplished by removing the negatively charged aspartate residue, which normally participates in a conflicting interaction with the G4 nucleotide of the lambda B' site. We showed that, although our mutants retain the ability to recombine their cognate att sites, they are unable to recombine lambda att sites.

Necrosis intestinal asociada a la administración de sulfonato de poliestireno sódico: presentación de un caso / Intestinal necrosis associated with the administration of sodium polystyrene sulfonate: a case representation

Varias son las complicaciones gastrointestinales observadas en pacientes urémicos, que pueden aparecer además en relación a las medidas terapeúticas usadas. Se presenta el caso de un anciano en diálisis peritoneal durante varios años, con múltiples episodios de rectorragia. Se le diagnosticó angiodisplasia de ciego y se trató con láser y Resin sodio oral. A las 24 horas del posoperatorio presenta perforación ileal, con presencia de cristales de Resin sodio en la zona de necrosis intestinal (AU)

Site-specific recombination of bacteriophage P22 does not require integration host factor.

Site-specific recombination by phages lambda and P22 is carried out by multiprotein-DNA complexes. Integration host factor (IHF) facilitates lambda site-specific recombination by inducing DNA bends necessary to form an active recombinogenic complex. Mutants lacking IHF are over 1,000-fold less proficient in supporting lambda site-specific recombination than wild-type cells. Although the attP region of P22 contains strong IHF binding sites, in vivo measurements of integration and excision frequencies showed that infecting P22 phages can perform site-specific recombination to its maximum efficiency in the absence of IHF. In addition, a plasmid integration assay showed that integrative recombination occurs equally well in wild-type and ihfA mutant cells. P22 integrative recombination is also efficient in Escherichia coli in the absence of functional IHF. These results suggest that nucleoprotein structures proficient for recombination can form in the absence of IHF or that another factor(s) can substitute for IHF in the formation of complexes.

Minors' access to single cigarettes in California.

OBJECTIVE: As the cost of a pack of cigarettes continues to increase, minors may resort to purchasing single cigarettes ("loosies"), but no clear data on their rate of access to singles are available. This study examined the availability of singles to minors by gender, age, and ethnicity. DESIGN: In a factorial experiment, 36 minors of different sexes, ages, and ethnic groups each attempted to purchase a single cigarette once in half of a group of 72 randomly selected stores in middle-class California communities, for a total of 1,271 single cigarette purchase attempts. RESULTS: Minors were able to purchase singles 7.9% of the time, with this access rate being significantly higher (16.2%) for older (16-year-old) minors. Minors were typically charged 15 cents for the single, and singles were sold by 28 of the 72 (38.9%) stores. CONCLUSIONS: Minors have considerable access to single cigarettes in middle-class, California communities, despite California laws banning their sale. Minors' rate of access to singles in poorer communities and in states that lack legislation against selling them is probably significantly higher. Because singles facilitate cigarette purchases by minors who lack money, any legislation that increases the cost of a pack of cigarettes must also explicitly ban the sale of singles.

An instrument for assessing the quality of tobacco-control policies: the ACT-L scale.

BACKGROUND: Efforts to prevent and decrease tobacco use and tobacco-related disease include improving the quality of tobacco-control laws to make them more stringent in controlling tobacco advertising, youth access, and exposure to environmental tobacco smoke (ETS). However, because there are no instruments to empirically evaluate the quality of such laws, it has been difficult to demonstrate that their quality is associated with decreased youth access or tobacco-related morbidity. We present the first instrument for empirically assessing the quality of tobacco-control policies. METHODS: Recommendations for the content of an ideal, comprehensive tobacco-control policy were used as the 55 items in the Assessment of the Comprehensiveness of Tobacco Laws Scale (ACT-L Scale). Raters evaluated 71 tobacco-control laws with the scale; 70 of these were actual California laws and 1 was a model law from Americans for Non-smokers' Rights (ANR). RESULTS: Interrater (r = 0.64-0.89) and internal-consistency (r = 0.63-0.88) reliability of the scale and subscales were high, and validity was established by demonstrating that the ANR model law received a significantly higher total score (mean = 18.75) than all actual laws (mean = 2.04). California tobacco-control laws were poor in all areas (youth access, ETS, tobacco advertising). CONCLUSIONS: The ACT-L scale can be used to compare and evaluate the quality of tobacco-control laws, highlight areas in which further policy efforts are needed, quantify improvement in such policies, and empirically demonstrate the positive health impact of high-quality tobacco-control laws.

An experimental analysis of sociocultural variables in sales of cigarettes to minors.

OBJECTIVES: This study assessed the role of age, racial/ethnic group, and gender, as well as that of other sociocultural variables, in minors' access to tobacco. METHODS: Thirty-six minors attempted to purchase cigarettes once in each of 72 stores (2592 purchase attempts). The minors represented equal numbers of girls and boys; 10-year-olds, 14-year-olds, and 16-year-olds; and Whites, Blacks, and Latinos. Equal numbers of stores were in Black, White, and Latino neighborhoods. RESULTS: Older children were more likely than younger ones to be sold cigarettes, and Latino children were more likely than Whites to be sold cigarettes. Older Black children (irrespective of gender) were the single most likely group to be sold cigarettes. Cigarettes were significantly more likely to be sold to children by male than female clerks and in specific sociocultural contexts. CONCLUSIONS: Interventions with retailers must address sociocultural variables to improve effectiveness in reducing minors' access to tobacco.