Intra-hospital mortality for community-acquired pneumonia in mainland Portugal between 2000 and 2009.

INTRODUCTION: Community-acquired pneumonia (CAP) remains a common and serious infection with wide variability in intra-hospital mortality. METHODS: We performed a retrospective analysis of adult patients admitted with CAP in mainland Portugal between the years 2000 and 2009. RESULTS: The intra-hospital mortality rate was 20.4% with deaths in all age groups. The average age of deceased patients was 79.8 years, significantly higher than surviving patients with 71.3 years. Patients aged 50 or more presented a relative risk of death 4.4 times the risk of patients under this age group. Likewise, in patients aged 65 or more the risk of death was 3.2 times the risk of patients <65 years. Men died more at a younger age than women, the men who died were, on average, 4 years younger than women, 78.1 vs 82.1 years old. Relative risk of death in men was 17% higher than women after adjustment for year of admission and age. CONCLUSION: CAP remains an important cause of hospital mortality in all age groups.

Chronic respiratory failure in patients with chronic obstructive pulmonary disease under home noninvasive ventilation: Real-life study.

BACKGROUND: Home noninvasive ventilation (NIV) has been increasingly used in stable chronic obstructive pulmonary disease (COPD) with chronic hypercapnic respiratory failure (CHRF). However its effectiveness remains debatable. AIM: To describe a follow-up of COPD patients under home NIV. METHODS: Retrospective descriptive study based on a prospective 3-year database that included COPD patients under home NIV between August 2011 and July 2014. RESULTS: Within the 334 patients initially screened, 109 (32.6%) had COPD with a mean±SD post-bronchodilator FEV1 of 38.6±14.9% predicted; age of 65.6±9.6 years. The mean±SD duration of ventilation was 63.4±51.1 months. Heterogeneous comorbidities that can contribute to CHRF were not excluded: obstructive sleep apnea and obesity were the most prevalent. Sixty-two (56.9%) patients started NIV during admission with acute respiratory failure. During follow-up there was a significant increase in mean inspiratory positive airway pressure (IPAP) and respiratory rate (19.5±4.4 vs. 23.6±5.3cmH2O and 10.7±5.2 vs. 15.2±1.4 breaths/min, respectively, p<0.0001), with a significant improvement in hypercapnia (PaCO2: 52.9±7.7 vs. 49.5±7.5mmHg, p<0.0001), with 93.3% of patients compliant to NIV. Admissions and days spent in hospital for respiratory illness significantly decreased after institution of NIV (respectively, 1.2±1.1 vs. 0.7±1.8 and 15.0±16.8 vs. 8.8±19.4, p<0.001). At final evaluation, patients with severe hypercapnia (n=47; PaCO2 ≥50mmHg) performing NIV at higher pressures (n=30; IPAP ≥25cmH2O) were more compliant (10.1±3.3 vs. 6.1±3.6h/day). Three-year mortality was 24.8% (27 of 109 patients). CONCLUSIONS: This is a real-life retrospective study in COPD patients with CHRF which results suggest benefit from home NIV. For most, NIV was effective and tolerable even at high pressures.

The typical presentation of an atypical pathogen during an outbreak of Legionnaires' disease in Vila Franca de Xira, Portugal, 2014.

BACKGROUND: An outbreak of Legionella pneumophila serogroup 1, with 403 cases was identified on the 7th November 2014 in Vila Franca de Xira, Portugal. Outbreak source was the wet cooling system of a local factory. Hospital Pulido Valente was one of the hospitals receiving patients with Legionnaires' disease (LD). METHODS: We describe the clinical findings and diagnostic methods used among the 43 confirmed or probable cases admitted to our department. RESULTS: 60.5% were male, mean age was 56.1±13.5 years and tobacco smoking was the most frequent risk factor (76.7%). All patients had fever, 62.8% ≥39.5°C, 72.1% had chills and myalgia/arthralgia and 62.8% had dry cough. Extra pulmonary symptoms were frequent: confusion and headache occurred in 34.9% and gastrointestinal symptoms in 20.9%. High C-Reactive Protein (55.8% ≥30mg/dL) and hyponatremia (62.8%) were the laboratorial abnormalities most commonly found. Hypoxemia occurred in 55.8% and hypocapnia in 93%. Urinary Antigen Test (UAT) was positive in 83.7% of the cases. CONCLUSIONS: Although not specific, a combination of risk factors, symptoms and laboratory findings can be highly suggestive of LD, even in an outbreak. This should prompt diagnosis confirmation. Routine use of UAT in less severe cases of community acquired pneumonia might contribute to earlier diagnosis.

[Guidelines and practice of evidence based medicine]. / Normas para orientação e a prática da medicina baseada na evidência científica.

This is a review paper with pedagogic goals in essence. The concept of guidelines is defined and the function and types of guidelines described. Different types of guidelines, such as normative, methodological and practice-motivated, are considered. The most common methods for the drafting of guidelines are presented. The difference between evidence-based guidelines and consensus-based guidelines is established and the importance of grading the strength of recommendations in guidelines, on basis of the validity of the evidence, is stressed. Finally, an update of the role of guidelines in the practice of EBM is put forward.

The effect of bromocriptine in benign prostatic hypertrophy and vesicosphincteric dynamics.

Four studies were carried out on 66 patients in order to examine the effect of bromocriptine in benign prostatic hypertrophy (BPH) and to clarify its mechanism of action. Two studies were clinical: the first was a double-blind, controlled trial (lasting 6 months) in which bromocriptine 5 mg/day was compared with placebo, and the second was an open study to evaluate the effect of bromocriptine 5 mg on patients with acute retention due to BPH. The other two studies were designed to investigate the action of the drug on vesicosphincteric dynamics. These were double-blind, controlled, parallel trials, one comparing bromocriptine at dosages of 2.5 and 5 mg with placebo 90 min after administration, and the other comparing bromocriptine 5 mg/day with placebo after 15 days' administration in post-prostatectomy patients. Bromocriptine had a favourable effect on patients with BPH but no effect on cases of acute retention. The urodynamic studies suggested that the drug affected urethral sphincteric mechanisms specifically. The weight and volume of the prostate remained unchanged after administration of the drug, so that any clinical response was not due to a direct effect on the gland itself.

Modification of antihypertensive effect of beta-adrenoceptor-blocking agents by inhibition of endogenous prostaglandin synthesis.

The effect of indomethacin-induced inhibition of endogenous prostaglandin synthesis on the antihypertensive activity of pindolol (15 mg daily) and propranolol (80--160 mg daily) was studied in 7 hypertensive patients. In four test phases of 10 days each, patients received beta-blocker alone, placebo, beta-blocker plus indomethacin (100 mg daily), and beta-blocker alone. Mean supine diastolic blood-pressure rose from 82 +/- 2 mm Hg in the first beta-blocker phase to 98 +/- 3 mm Hg in the placebo phase, remained elevated (96 +/- 3 mm Hg) in the beta-blocker-plus-indomethacin phase, and fell to 83 +/- 3 mm Hg in the last beta-blocker phase. Diastolic blood-pressure values obtained in the beta-blocker-plus-indomethacin phase were not significantly different from those obtained in the placebo phase but were significantly different from the values measured in both beta-blocker phases (P less than 0-01). The changes in systolic blood-pressure and pulse-rate were not significant. These preliminary results suggest that the antihypertensive effect of these two beta-blockers in some hypertensive patients may be related to the endogenous prostaglandin system.

Modification by indomethacin of the blood pressure lowering effect of pindolol and propranolol in conscious rabbits.

In conscious rabbits, the intravenous administration of pindolol (0.125 mg/kg) and propranolol (1 mg/kg) induced a highly significant (p less than 0.001) decrease of mean arterial blood pressure and with propranolol, a significant (p less than 0.01) bradycardia. In the same model the intravenous administrtion of saline (1 ml/kg) and of indomethacin (1 mg/kg) did not affect mean arterial blood pressure or heart rate (p greater than 0.3). Pretreatment of the animals with indomethacin (1 mg/kg) abolished the effect of both beta-blockers on mean arterial blood pressure (p greater than 0.05) and had no significant effect on heart rate.