The significance of metabolic alkalosis on acute decompensated heart failure: the ALCALOTIC study.

AIMS: To determine the prevalence and the impact on prognosis of metabolic alkalosis (MA) in patients admitted for acute heart failure (AHF). METHODS AND RESULTS: The ALCALOTIC is a multicenter, observational cohort study that prospectively included patients admitted for AHF. Patients were classified into four groups according to their acid-base status on admission: acidosis, MA, respiratory alkalosis, and normal pH (reference group for comparison). Primary endpoint was all-cause in-hospital mortality, and secondary endpoints included 30/90-day all-cause mortality, all-cause readmission, and readmission for HF. Associations between endpoints and acid-base alterations were estimated in a multivariate Cox regression model including sex, age, comorbidities, and Barthel index and expressed as hazard ratio (HR) with 95% confidence interval (95% CI). Six hundred sixty-five patients were included (84 years and 57% women), and 40% had acid-base alterations on admission: 188 (28%) acidosis and 78 (12%) alkalosis. The prevalence (95% CI) of MA was 9% (6.8-11.2%). Patients with MA were more women; had fewer comorbidities, better renal function, and higher left ventricle ejection fraction values; and received more treatment with oral acetazolamide during hospitalization and at discharge. MA was not associated with a higher risk of in-hospital mortality and 30/90-day all-cause mortality or readmissions but was associated with a significant increase in readmissions for HF at 30 and 90 days (adjusted HR [95% CI] 3.294 [1.397-7.767], p = 0.006 and 2.314 [1.075-4.978], p = 0.032). CONCLUSION: The prevalence of MA in patients admitted for AHF was 9%, and its presence was associated with more readmissions for HF but not with all-cause mortality.

Situación inmune en el anciano con neumonía durante el episodio agudo y tras el alta / Immune status in the elderly with pneumonia during the acute episode and after discharge

Objetivo: analizar la situación inmunológica básica de la neumonía en el anciano (NEA) durante el ingreso y a los 6 meses tras el alta, y su relación con la mortalidad. Material y métodos: estudio prospectivo en pacientes mayores de 65 años con NEA que ingresaron en el Servicio de Medicina Interna en el Hospital Virgen del Camino (Pamplona) en 2 años. Se estudian los datos epidemiológicos, clínicos, etiológicos, analíticos y antropométricos en el ingreso, y la evolución de la NEA al año del alta. Se determinan linfocitos totales, linfocitos T CD4, CD8, CD4/CD8, inmunoglobulinas, complemento (C3, C4, CH50), anticuerpos antinucleares (ANA), factor reumatoide e interleucina 6 (IL-6) en sangre periférica, así como multitest durante el ingreso. A los 6 meses del alta se estudian: linfocitos totales, linfocitos T, CD4, CD8, CD4/CD8 e IL-6. Para realizar las comparaciones entre los diversos parámetros, se aplica un nivel de significación de p < 0,05. Resultados: en el período estudiado se admitió a 125 pacientes con una edad media de 77,9 años (65-95). Fallecieron 11 pacientes (8,8%) durante el ingreso. En el seguimiento ambulatorio durante un año falleció un 30%. Los pacientes que fallecieron tuvieron menos linfocitos totales (p = 0,01), linfocitos T (p = 0,005), CD4 (p = 0,002), C3 (p = 0,001) y C4 (p = 0,001) que los que sobrevivieron. Los ANA estaban presentes en mayor proporción entre los fallecidos (p = 0,017). No se encontraron relaciones evidentes entre los parámetros inmunológicos estudiados y la mortalidad ambulatoria. Los linfocitos totales, linfocitos T, CD4 y los CD8 se recuperan significativamente a los 6 meses tras el alta. En cambio, los valores de IL-6 disminuyen a los 6 meses respecto al ingreso (p = 0,009). Conclusiones: las variables relacionadas con mayor mortalidad durante la NEA fueron: linfocitos totales, linfocitos T, CD4, CD8, C3, C4 y ANA. Se describe un aumento significativo de los valores de inmunidad celular a los 6 meses del alta

Objective: to analyze immune status in elderly patients with pneumonia during admission and at 6 months after discharge, as well as its association with mortality. Material and methods: we performed a prospective study in patients aged > 65 years old with pneumonia admitted to the Internal Medicine Department of the Hospital Virgen del Camino (Pamplona) over a 2-year period. Epidemiological, etiological, laboratory and anthropometric data were studied at admission and 1 year after discharge. Total lymphocytes, T lymphocytes, CD4, CD8, CD4/CD8, immunoglobulins, complement (C3, C4, CH50), antinuclear antibodies (ANA), rheumatoid factor and interleukin-6 (IL-6) in peripheral blood, as well as the multitest during admission, were studied. The following variables were studied 6 months after discharge: total lymphocytes, T lymphocytes, CD4, CD8, CD4/CD8, and IL-6. For the comparison of variables, a significance level of p < 0.05 was set. Results: during the study period, 125 patients with a mean age of 77.9 years (65-95) were admitted. Eleven patients (8.8%) died during admission. During the 1-year outpatient follow-up, 30% died. Patients who died had lower total lymphocyte (p = 0.01), T lymphocyte (p = 0.005), CD4 (p = 0.002), C3 (p = 0.001) and C4 (p = 0.001) levels than those who survived. Higher ANA concentrations were found among patients who died (p = 0.017). No clear associations were found between the immunological parameters studied and outpatient mortality. Levels of total lymphocytes, T lymphocytes, CD4 and CD8 were significantly increased at 6 months after discharge. In contrast, IL-6 levels were lower at 6 months after discharge than on admission (p = 0.009). Conclusions: the variables related to higher mortality in pneumonia in the elderly were total lymphocytes, T-lymphocytes, CD4, CD8, C3, C4 and ANA. Values of cellular immunity were significantly increased 6 months after discharge

[Home intravenous antibiotic treatment: a study in 515 patients]. / Antibioterapia intravenosa en domicilio. Estudio de 515 casos.

OBJECTIVE: To assess the effectiveness of therapy, type of infection, hospital department of origin and outcome of 515 cases of infection requiring home intravenous antibiotic therapy treated by the home care service. METHODS: The clinical records of patients undergoing intravenous antibiotic therapy through the home care service over a 6-year period were retrospectively reviewed. RESULTS: A total of 439 patients (244M/195F; mean age, 55.9 years, range 7-96) requiring 515 courses of home intravenous antibiotic therapy were reviewed. Mean duration of antibiotic therapy was 7.9 days (1-58). Urinary (42.3%) and respiratory infections (25.8%) were the most frequent indications for home treatment. Most patients were referred from the emergency room (50.5%) followed by the Internal Medicine Department (11.5%) and Oncology Department (11.1%). Ceftriaxone was the most widely prescribed antibiotic (41.8%) followed by aminoglycosides (35.3%) and glycopeptides (11.7%). In 49 cases electronic infusion pumps were used, with ceftazidime being the predominant antibiotic (32.7%) in these cases. Hospitalization was required in 7% of patients due to infectious disease-related complications. Clinical outcome was positive in 79% of the patients, with improvement in 90% of patients from the emergency room CONCLUSIONS: The advantages of home care services to provide home intravenous antibiotic therapy are evident. More than half of the patients were referred from the emergency room and 90% of these progressed well. The presence of medical and nursing staff qualified to handle infectious diseases is necessary, as well as continuing home care.

Antibioterapia intravenosa en domicilio. Estudio de 515 casos / Home intravenous antibiotic treatment: A study in 515 patients

Objetivo. Valorar la efectividad, tipo de infección, servicio de procedencia y pronóstico de 515 casos tratados con antibioterapia intravenosa en domicilio en una Unidad de Hospitalización a Domicilio (UHD). Métodos. Estudio retrospectivo de un período de 6 años de las historias clínicas de los pacientes ingresados en la UHAD que recibieron antibióticos intravenosos. Resultados. Se trataron 439 pacientes (244 hombres y 195 mujeres) que generaron 515 casos. La edad media fue de 55,9 (límites: 7-96 años). La duración media del tratamiento antibiótico intravenoso en domicilio fue de 7,9 días (límites: 1-58 días). La localización infecciosa más frecuente fue la urinaria (42,3%) seguida de la respiratoria (25,8%). El servicio de procedencia que más pacientes remitió fue urgencias (50,5%) seguido de medicina interna (11,5%) y oncología (11,1%). La ceftriaxona fue el antibiótico más utilizado (41,8%), seguido de los aminoglucósidos (35,3%) y glucopéptidos (11,7%). En 49 ocasiones se utilizaron bombas programables de perfusión, siendo el antibiótico más utilizado la ceftazidima (32,7%). El 7% reingresaron por causa infecciosa. El 79% fueron dados de alta por evolución favorable. El 90% de los pacientes procedentes de urgencias tuvieron una evolución favorable. Conclusiones. Las ventajas de la hospitalización a domicilio para desarrollar programas de antibioterapia intravenosa en domicilio son evidentes. Más de la mitad de los pacientes procedieron del servicio de urgencias con una evolución favorable del 90%. Es precisa la presencia de personal médico y de enfermería cualificado en el tratamiento de enfermedades infecciosas y una asistencia continuada en domicilio (AU)

Objective. To assess the effectiveness of therapy, type of infection, hospital department of origin and outcome of 515 cases of infection requiring home intravenous antibiotic therapy treated by the home care service. Methods. The clinical records of patients undergoing intravenous antibiotic therapy through the home care service over a 6-year period were retrospectively reviewed. Results. A total of 439 patients (244M/195F; mean age, 55.9 years, range 7-96) requiring 515 courses of home intravenous antibiotic therapy were reviewed. Mean duration of antibiotic therapy was 7.9 days (1-58). Urinary (42.3%) and respiratory infections (25.8%) were the most frequent indications for home treatment. Most patients were referred from the emergency room (50.5%) followed by the Internal Medicine Department (11.5%) and Oncology Department (11.1%). Ceftriaxone was the most widely prescribed antibiotic (41.8%) followed by aminoglycosides (35.3%) and glycopeptides (11.7%). In 49 cases electronic infusion pumps were used, with ceftazidime being the predominant antibiotic (32.7%) in these cases. Hospitalization was required in 7% of patients due to infectious disease-related complications. Clinical outcome was positive in 79% of the patients, with improvement in 90% of patients from the emergency room Conclusions. The advantages of home care services to provide home intravenous antibiotic therapy are evident. More than half of the patients were referred from the emergency room and 90% of these progressed well. The presence of medical and nursing staff qualified to handle infectious diseases is necessary, as well as continuing home care (AU)

[Pneumonia in the elderly. Factors related with the mortality during the episode and after the discharge]. / Neumonía en el anciano. Factores relacionados con la mortalidad durante el episodio y tras el alta hospitalaria.

BACKGROUND AND OBJECTIVE: Pneumonia in the elderly (PIE) is a growing disease that causes great morbidity and mortality with frequent admissions to hospital and increasing health costs. The objective of our study was yo analyze the characteristics of PIE in an internal medicine hospital ward, the influence of quality of life (Katz index and scale of Karnofsky) on its evolution and after the discharge and the factors of poor prognosis during the episode of PIE and throughout the ambulatory follow-up. PATIENTS AND METHOD: All the patients suffering from PIE admitted to the internal medicine ward of our hospital during a two years period were included in the study (125). Five of them were referred from geriatric centers. Mean age was 77.9 years (range = 65-95). The most frequent chronic disease was COPD (53.6%) and 10.4% were taking oral corticosteroids. We studied the association of several factors laboratory, clinical and radiological with the evolution of PIE and after discharge. RESULTS: Patients rated high on the indicators of quality of life used (78.4% scored 5 or greater on the Katz index and 76% scored 80 or greater on the scale of Karnofsky) and their comorbidity was low (44% lesser than or equal to 1 and 6.4% greater than or equal to 5). Fever above 38 C was recorded in 40% of cases. Mean APACHE score was 12.8. 21.6% patients had pleural effusion and 20% had multilobar involvement. Overall mortality was 8.8% (11 patients). Fifteen patients suffered major complications during admission. One hundred patients out of the 114 who survived the episode of PIE were followed up on an ambulatory basis. Thirty of those died within 12 months after discharge. CONCLUSIONS: In our study, a poorer quality of life and a higher APACHE score were related to a greater mortality during the episode of PIE. After hospital discharge, a greater mortality was associated with a poor quality of life, comorbidity and low concentrations of albumin.

[Treatment of congestive heart failure in the setting of hospital at home. Study of 158 patients]. / Tratamiento de la insuficiencia cardíaca en régimen de hospitalización a domicilio. Estudio de 158 pacientes.

BACKGROUND AND OBJECTIVE: Hospital at Home might become a suitable alternative to traditional hospital admissions for several exacerbated chronic diseases. Congestive heart failure represents an important workload at the hospital level. In this study we present the results of our experience with congestive heart failure patients attended in Hospital at Home regimen during the period 1999-2001. PATIENTS AND METHOD: In 1999 we initiated a program to refer patients with congestive heart failure to Hospital at Home care. The program was agreed by the departments of emergency, cardiology, internal medicine and hospital at home. During the period 1999-2001, 158 patients (mean age = 76) were attended. Ninety one (58%) were women. At the moment of admission, 103 patients (68%) were on functional status IV of the NYHA. RESULTS: On average, patient's stay on hospital at home was 12,8 days. One hundred and twenty three (78%) of them were discharged, 29 (18%) had to be referred back to conventional hospitalisation and six (4%) died. During the 90 days following the discharge from Hospital at Home, the number of visits to the emergency department and the rate of hospital admissions decreased significantly. CONCLUSIONS: Our data confirm Hospital at Home as a valid option to conventional hospital admission for the management of patients with congestive heart failure.

Tratamiento de la insuficiencia cardíaca en régimen de hospitalización a domicilio. Estudio de 158 pacientes / Treatment of congestive heart failure in the setting of hospital at home. Study of 158 patients

FUNDAMENTO Y OBJETIVO: La hospitalización a domicilio puede convertirse en una alternativa real a la hospitalización tradicional en enfermedades crónicas reagudizadas como la insuficiencia cardíaca, que representa una carga asistencial importante en el ámbito hospitalario. En este trabajo presentamos los resultados de nuestra experiencia en el período 1999-2001 en pacientes con insuficiencia cardíaca atendidos en régimen de hospitalización a domicilio. PACIENTES Y MÉTODO: En 1999 se inició un programa de derivación de los pacientes con insuficiencia cardíaca a un régimen de hospitalización a domicilio en el Hospital Txagorritxu de Vitoria-Gasteiz, consensuado entre los Servicios de Urgencias, Cardiología, Medicina Interna y Hospitalización a Domicilio. Durante el período 1999-2001 se atendió a 158 pacientes con una edad media de 75,8 años siendo 91 (57,6 por ciento) mujeres. En el momento de su ingreso 103 pacientes (65,2 por ciento) se encontraban en grado funcional IV de la New York Heart Association. RESULTADOS: La estancia media de los pacientes fue de 12,8 días. Se pudo dar de alta a 123 pacientes (77,9 por ciento), 29 (18,3 por ciento) reingresaron en el hospital y 6 (3,8 por ciento) fallecieron. Se objetivó un descenso significativo tanto del número de visitas a urgencias como de los ingresos hospitalarios en los 90 días siguientes al alta del Servicio de Hospitalización a Domicilio. CONCLUSIONES: Nuestros datos confirman la validez de la hospitalización a domicilio como alternativa al ingreso hospitalario de pacientes con insuficiencia cardíaca descompensada (AU)