[Utilisation of atypical antipsychotic drugs in institutionalised elderly persons and prevalence of metabolic alterations]. / Utilización de fármacos antipsicóticos atípicos en ancianos institucionalizados y prevalencia de alteraciones metabólicas.

OBJECTIVES: Describe and evaluate atypical antipsychotics utilisation on the institutionalized elderly population of the Valencian Community and prevalence of associated metabolic alterations. MATERIAL AND METHODS: Multicentre transversal descriptive study on medication utilisation and prevalence case-control of alterations of glycaemia, cholesterol and triglycerides. The statistical analysis of metabolic alterations is performed from the difference in prevalence and its statistical signification between the control group and the study group. RESULTS: 681 patients were included (study group, 344; control group, 337) from 20 social-health-care centres. 18.5% of the institutionalised patients are being treated with atypical antipsychotics. The most frequent diagnoses are: behavioural alterations associated with dementia (63.6%) and schizophrenia (18.4%). Risperidone is the most frequently used antipsychotic (66.0%). For all the drugs in general the doses used adjust to those recommended for elderly patients. The prevalence of alterations in glycaemia, cholesterol and triglycerides metabolism in the group under study is 23.96%, 34.83%, and 26.29%, respectively, with no statistically significant differences against the control group. The analysis by type of drug did not show significant differences. CONCLUSIONS: The results obtained show that utilisation of atypical antipsychotics in elderly patients complies with the established general recommendations. The doses used in elderly patients with behavioural alterations associated with dementia, mostly treated with risperidone, do not have a significant impact over prevalence increase of metabolic alterations.

[Assessment of a follow-up programme for institutionalised elderly patients on oral anticoagulant treatment]. / Evaluación de un programa de seguimiento de pacientes ancianos institucionalizados en tratamiento con anticoagulantes orales.

OBJECTIVE: To assess an interdisciplinary follow-up programme for institutionalised elderly people on oral anticoagulant treatment. METHOD: The proposed follow-up treatment is of an interdisciplinary nature and includes INR, an interview with the patient and/or carer and an assessment of the treatment plan every week. The quality of drug treatment is assessed by the percentage of time and the percentage of measurements falling within the therapeutic range. The suitability of the programme in comparison to the traditional follow-up was studied in terms of the different proportions for the first variable and by analysing contingency tables for the second. RESULTS: Nine patients were recruited. Six patients (67%) showed a significant increase in the percentage of time they remained within the therapeutic range. 68.5% of INR measurements during the follow-up programme were within therapeutic range. The percentage of INR measurements below the therapeutic range was significantly reduced when compared to the traditional follow up. Thirteen pharmaceutical interventions were documented per patient. CONCLUSIONS: The complexity of oral anticoagulant treatment, the large number of interventions carried out together with elderly patients poor treatment compliance are evidence of the need to introduce follow-up programmes which include the professionals responsible for the patients care.

Evaluation of once daily tobramycin dosing in critically ill patients through Bayesian simulation.

OBJECTIVE: To evaluate if once-daily dose (ODD) regimens of tobramycin attain pharmacodynamic goals using individualized pharmacokinetic monitoring of critically ill patients with creatinine clearance (Clcr) over 60 mL/min. METHODS: Fifty-one adult critically ill patients treated with intravenous tobramycin with ODD were included in the study. The effect of dosing using the proposed method was compared with a weight-based (7 mg/kg) dosing method. Pharmacokinetics parameters, peak concentration (Cpeak), minimum concentration (Cmin) and the time below the minimum inhibitory concentration (MIC) were estimated using Bayesian analysis. Pharmacodynamic parameters used to evaluate both dosing regimens were Cpeak/MIC ratio and, secondly, time below MIC (T< MIC). RESULTS: The median dose of tobramycin administrated in our hospital was too low for achieving pharmacodynamic goals. In contrast, the weight-based (7 mg/kg) method produced an adequate Cpeak/MIC ratio but an increase of the dose would not reduce the secondary pharmacodynamic index T60 mL/min achieved the Cpeak/MIC target values of 10. However in critically ill patients with Clcr>80 mL/min, T

[Therapeutic interchange between angiotensin II receptor blockers in institutionalized elderly patients. Implimenting a protocol]. / Intercambio terapéutico de antagonistas del receptor de la angiotensina-II en pacientes ancianos institucionalizados. Aplicación de un protocolo.

OBJECTIVE: To assess the effectiveness of a therapeutic interchange protocol for angiotensin II receptor blockers (ARB's) in the maintenance of blood pressure levels for institutionalized elderly patients diagnosed with hypertension. METHODS: A new protocol was discussed by the Pharmacy and Therapeutics Committee, and its implementation by the Pharmacy Department was authorized. The protocol specifies equivalent doses between drugs and the patients' clinical follow-up. Criteria used in the assessment includes: need to change dosage for an ARB included in the Pharmacotherapeutic Guide, and blood pressure changes after drug interchange. RESULTS: In the absence of hepatic insufficiency, the protocol may replace the standard doses of any drugs within this group with losartan 50 mg daily. If needed, the dose of losartan may be increased to 100 mg daily divided into two doses. Eighteen patients, which represent 10% of all interchange operations carried out by the Pharmacy Department, were included in this study. Blood pressures both before and after the interchange process show no major differences between them. Only two patients required an increase in the dose of losartan. CONCLUSION: The implementation of a therapeutic interchange protocol as agreed upon by the Pharmacy and Therapeutics Committee allows the clinical follow-up of patients and therefore facilitates an evaluation of the process. This ARB interchange protocol, as suggested for the institutionalized elderly population setting, has proven effective in maintaining anti-hypertensive activity.

[Urinary tract infection in institutionalized elderly patients. Incidence of bacterial resistance and risk factors]. / Infecciones de tracto urinario en pacientes ancianos institucionalizados. Incidencia y factores de riesgo de resistencias bacterianas.

INTRODUCTION: The goal of the present work was to study urinary tract infections (UTI) in a sociosanitary center in order to characterize etiology, define sensitivity profiles, and study associations between these profiles and various clinical parameters. MATERIAL AND METHODS: A prospective study of all urinary tract infections at the caring unit of a geriatric sociosanitary center was carried out. Antibiograms were performed on all patients in which a UTI was suspected, and the association between the isolated organism or E. coli resistance with various clinical parameters (gender, bed confinement, recurrence, incontinence, neural impairment, basic daily life activities and drug use) was studied using a multivariate logistic regression analysis. RESULTS: Escherichia coli and Proteus mirabilis are the most commonly isolated organisms (51% and 15%, respectively). The former is associated with bed confinement and the female gender. The latter shows an inverse relation with recurrence in 90 days. Resistance to the antibiotics studied correlates with a number of clinical parameters, although associations vary for each antimicrobial agent. Previous use of antibiotics and recurrence of infection have no influence on resistance. DISCUSSION: Geriatric patients' characteristics may well account for some of the results encountered. However, the development of resistance in the center may be related to spreading from direct contact between patients. The relationship between resistance and drug use may be affected by the external administration, rather than in-center administration, of drugs.

Radioimmunometric assay of B-type natriuretic peptide (BNP) in heart transplantation: correlation between BNP determinations and biopsy grading of rejection.

The aim of this study was to determine whether elevated brain natriuretic peptide (BNP) levels after heart transplantation are correlated with the severity of rejection by using endomyocardial biopsy (EMB) and echocardiographic parameters indicative of ventricular function of the transplanted heart. This was an observational study of 80 orthotopic heart transplant recipients (11 women and 69 men; mean age 53+/-11 years). BNP determinations were performed within 48 h of endomyocardial biopsy. The echocardiographic study and BNP determination were also performed in a group of healthy volunteers. We found significantly higher BNP mean levels in heart transplant patients than in healthy volunteers (volunteers, 16.7+/-16.2 pg.ml-1; transplant, 213.4+/-268.6 pg.ml-1; P<0.001). Transplant recipients with rejection grades 2, 3 and 4 on EMB had significantly higher BNP levels than those with rejection grades 0 and 1 (higher rejection grade, 162.5+/-168.4 pg.ml-1; lower rejection grade, 292+/-361.8 pg.ml-1; P<0.01). BNP values of patients with good left ventricular function (LVF) were significantly lower than in patients with mildly and moderately impaired LVF and patients with severely impaired LVF (good function, 199.76+/-233.6 pg.ml-1; mildly/moderately impaired LVF, 937+/-644.5 pg.ml-1; severely impaired LVF, 1038+/-491.2 pg.ml-1; P<0.001). It is concluded that BNP plasma levels are elevated in heart transplant patients compared to the normal population. The distribution of BNP levels in heart transplanted patients show a wide range. BNP elevation is greater in patients with higher rejection grades on EMB and greater impairment of left ventricular function.

Radioimmunometric assay of natriuretic peptide type-B (BNP) in heart failure.

The aim of this study was to assess the value of the radioimmunometric determination of natriuretic peptide type-B (brain natriuretic peptide, BNP) in the diagnosis and prognosis of heart failure, and to study the association between BNP and the clinical, analytical and echocardiographic variables associated with the evolution of heart failure. The study group included 169 patients (74 women and 95 men; mean, 66 years) with heart failure of different causes, admitted consecutively to our hospital. BNP levels were measured with a radioimmunometric assay (Shionora BNP Cis ) after day 3 of admission. Patients were also studied by echocardiography. A significant association between the cause of heart failure and the BNP concentration was found (patients with ischaemic disease had the highest BNP values). Systolic function was worse in patients with ischaemic disease or dilated cardiomyopathy. High BNP values were also associated with advanced functional class and male sex. Plasma creatinine correlated positively with plasma BNP. However, we found no significant association with the other clinical variables evaluated. Of the echocardiographic variables analysed, BNP correlated positively with the ventricular diameter and pulmonary artery systolic pressure, and inversely with the shortening fraction; patients with severely impaired systolic function had the highest BNP values. It can be concluded that BNP levels (by radioimmunometric assay) are increased in patients with heart failure, and increase in relation to left ventricular dysfunction and the severity of heart failure. The strong independent association of plasma BNP with the left ventricular ejection fraction, its stability and the low cost of measurement suggest that plasma BNP assay could become a routine test. BNP assay could be included as an important factor in clinical and therapeutic decision making, as it complements the information provided by other variables used in the diagnosis of heart failure.

Is the depth correction using the geometric mean really necessary in a 99Tcm-DMSA scan in the paediatric population?

Determination of the left to right dimercaptosuccinic acid (DMSA) uptake ratio is theoretically one of the easiest quantitative procedures in nuclear medicine. The quantification can be performed on the posterior view, with or without the lateral view for correction of kidney depth. The geometric mean can also be determined using both the anterior and the posterior views. The aim of this study was to evaluate the occurrence of remarkable differences in the results from quantification of the relative renal function using the geometric mean and those obtained using the posterior counts only. Moreover, we evaluated to what extent the patient age influenced these differences. We reviewed 328 99Tcm-DMSA scans. The difference between the relative renal function obtained using the posterior view and that obtained using the geometric mean was calculated and analysed statistically. For the purpose of evaluating the value of performing the geometric mean calculation in patients of different ages, patients were divided into four age groups (group I, < or =2 years; group II, 3-9 years; group III, 10-18 years; group IV, >18 years). Using the Student's t test, no statistical differences were found in the relative renal function obtained by the two methods (posterior projection and geometric mean) in groups I (t = 0.01, P = 0.992) and II (t = 1.43, P = 0.155), which consisted of patients younger than 10 years (77% of the patients). In groups III and IV statistical differences were found (t = 2.27, P = 0.028 and t = 2.170, P = 0.038), respectively. We conclude that for children under 10 years it is unnecessary to perform depth correction using the geometric mean except in rare cases of major malformations and position anomalies.

[Transesophageal echocardiography diagnosis of perforation of the mitral valve secondary to infective endocarditis]. / Diagnóstico por ecocardiografía transesofágica de perforación de la válvula mitral secundaria a endocarditis infecciosa.

We report on a patient with infective endocarditis and severe mitral regurgitation secondary to perforation in the base of the posterior mitral leaflet. Transthoracic echocardiography was inconclusive. Only transesophageal echocardiography could confirm the presence of vegetations, their characteristics and the existence of valvular perforation. We also review the literature on the contribution of transesophageal echocardiography to the diagnosis of infective endocarditis and its complications.

Apraxia in a patient with lesion located in right sub-cortical area. Analysis of errors.

This report describes a case of apraxia caused by a right sided sub-cortical lesion. Performance on test for apraxia was impaired. A new type of error which involved demonstrating the use of objects on one's own body is reported. Some theoretical interpretations of the findings are discussed.