Mejoría de la capacidad funcional tras tratamiento con levotiroxina en pacientes con insuficiencia cardíaca crónica e hipotiroidismo subclínico

AimTo assess whether levothyroxine treatment improves functional capacity in patients with chronic heart failure (New York Heart Association class i-iii) and subclinical hypothyroidism.MethodsOne hundred and sixty-three outpatients with stable chronic heart failure followed up for at least 6 months were enrolled. A physical examination was performed, and laboratory tests including thyroid hormone levels, Doppler echocardiogram, radionuclide ventriculography, and Holter monitoring were requested. Functional capacity was assessed by of the 6-min walk test. Patients with subclinical hypothyroidism were detected and, after undergoing the s6-min walk test, were given replacement therapy. When they reached normal thyrotropin (TSH) levels, the 6-min walk test was performed again. The distance walked in both tests was recorded, and the difference in meters covered by each patient was analyzed.ResultsPrevalence of subclinical hypothyroidism in patients with heart failure was 13%. These patients walked 292 ± 63 m while they were hypothyroid and 350 ± 76 m when TSH levels returned to normal, a difference of 58 ± 11 m (P < .011). Patients with normal baseline TSH levels showed no significant difference between the 2 6-min walk tests.ConclusionsPatients with chronic heart failure and subclinical hypothyroidism significantly improved their physical performance when normal TSH levels were reached.     

Características y factores asociados a caídas en pacientes con enfermedad cerebrovascular

Objectiveto asses the characteristics and factors associated with falls during hospitalisation among elderly stroke patients.Material and methodswe studied 1,410 subjects (60.1% female), aged 65 years and older (80.6 ± 6.9 years), admitted to a geriatric stroke unit between 2000 and 2003. We recorded demographic, clinical and functional variables and evaluated the characteristics and management of falls. The variables showing an association with falls in bivariate analyses were subsequently included in a multivariate logistic regression analysis.Resultsthe incidence rate of falls was 10.49% in 115 patients. The variables showing statistical association (p < 0.05) with falls were age (78.7 vs 80.8) and gender (10.5% male vs 6.6% female), arm strength (2.8 vs 2.3), leg strength (3.2 vs 2.6) and being classified in the group with moderate stroke (47.8%) compared with patients without falls (29.3%). Falls were more frequent in patients with depression (13% vs 7%) and delirium (27% vs 6%). The variables that remained significant in the multivariate logistic regression model for falls were: delirium (OR = 4.691 [2.930-7.511]), mild stroke (OR: 0.347 [0.154-0.782]), age (OR = 0.958 [0.929-0.987]), depression (OR = 1.760[1.095-2.828]), arm strength (OR = 1.233 [1.058-1.438]), and Barthel Index prior to the fall (OR = 1.013 [1.002-1.024]).Conclusionspatients with falls are younger, with a higher previous functional status and with lesser neurological severity on admission. The presence of depression and delirium are frequently associated.     

Particularidades clínicas del paciente crítico con infección fúngica invasora

BackgroundInvasive fungal infection (IFI) is an entity that encompasses different types of infections caused by different types of those fungi pathogenic for humans. In the setting of critically ill patients with multiple and oftenconcurrent risk factors and comorbidities the most common are those caused by the Candida and Aspergillus species. Among the characteristics of IFI in critically ill patients, three aspects can be highlighted: those related to the host (e.g.: risk factors, clinical severity), those related with the pathogen (sensitivity, virulence), or those concerning antifungal treatment (spectrum, features PK / PD, safety, interactions). The fungus that most often causes an IFI in critically ill patients is Candida; the most common type infections are candidemia, Candida peritonitis and catheter-related infections. In recent years new antifungal treatments have expanded the therapeutic options, with echinocandins as a clear choice, often the first in the latest guidelines in critically ill patients with IFI.Case reportWe report the case of a critically ill patient having the most common risk factors, multiple organ dysfunction and development of an IFI. The complexity of establishing an antifungal treatment from the moment of its inception, its setting, and the considerations of the different therapeutic possibilities according to organ dysfunction of the patient are discussed. The antifungal treatment options mentioned in the current guidelines and recommendations are also evaluated.ConclusionsThe most common fungal infection in critically ill patients is invasive candidiasis, with candidemia or candida peritonitis being the most frequent clinical presentations. Candins have brought new possibilities for treating these complex patients due to their good safety profile and clinical efficacy.     

Estudio de la evolución del síndrome de temor a caerse entre pacientes mayores con mareos,caídas y síncopes

Aimsto study fear of falling (FOF) syndrome at 1 year in a population of elderly individuals referred to a specific outpatient clinic for dizziness, falls and syncope. To analyse which variables gathered at the beginning of the study were related with FOF at that time and 1 year later.Methodsa prospective cohort study was performed from April 2000 to December 2001. Sixty-six elderly individuals referred to a specific outpatient clinic for dizziness, falls and syncope were classified in a group with FOF (n = 31) or a group without FOF (n = 35). Patients without all the tests and those lost to follow-up were excluded. The protocol included medical history, physical examination, tilt test and routine or specific complementary tests, when deemed necessary. FOF was determined through the direct question: Are you afraid of falling?ResultsFOF disappeared in 14 patients (45.2%) who had this syndrome at the beginning of the study and developed in five patients (14.3%) who did not (p = 0.06). After multivariate analyses, the variables associated with FOF at the beginning of the study were: taking benzodiazepines, recurrent dizziness, higher blood urea levels and a drop in systolic blood pressure with upright position. The variables significantly associated with fear of falling 1 year later were: angiotensin-converting enzyme inhibitors, positive Hallpike's manoeuvre and a drop in diastolic blood pressure with the head-up-tilt test. The model also included taking benzodiazepines and symptom reproduction with movement of the neck.Conclusionsat 1 year, FOF syndrome decreased in nearly half the patients who had this syndrome at the beginning of the study but developed in other patients without this syndrome at that time. No association was found with falls at the beginning or end of the study. At 1 year of follow-up, FOF was associated with intake of certain medications and data from the tilt test.     

Uso de sujeciones físicas en relación con el riesgo de caídas en una residencia de ancianos

Backgrounds and objectivesThe use of physical restraints (PR) is common in the care of the elderly. However, their efficacy and safety are not supported by scientific evidence. The aim of this study was to determine the role of PR in preventing falls.Materials and methodsA retrospective cohort study design was used, in which each fall incident (n = 575) was examined in the residents over 65 years of age who resided at the one nursing homes from February 2009 to September 2013. An analysis was made of the association between the use of PR and risk of falls using a multivariate logistic regression, adjusting for the characteristics of residents that were associated with the use of PR according to a bivariate analysis.ResultsRisk factors for falls after accounting for PR use, include: risk of falling (Tinetti test) (OR 4.57; 95% CI 1.76-11.75); ability to walk (OR 6.40; 95% CI 2.78-14.74); hearing impairment (OR 2.12; 95% CI 1.05-4.29); and history of a previous fall (OR 17.81; 95% CI 8.83-35.93). The risk of falls was greater in restrained, ambulatory residents with cognitive impairment (OR 18.95; 95% CI 7.06-50.85). No differences were found in injuries between falls that occurred with and without PR.ConclusionsRestraint use was not significantly associated with fewer falls and injuries. The risk of falls could increase in ambulatory residents with cognitive impairment. The study results suggest the need to consider whether restraints provide adequate protection against the risk of falls.     

Especies de Aspergillus en ambientes hospitalarios con pacientes pediátricos en estado crítico

BackgroundAspergillus is a group of opportunistic fungi that cause infections, with high morbimortality in immunosuppressed patients. Aspergillus fumigatus is the most frequent species in these infections, although the incidence of other species has increased in the last few years.AimsTo evaluate the air fungal load and the diversity of Aspergillus species in hospitals with pediatric patients in critical condition.MethodsThe Intensive Care Unit and Burns Unit of a pediatric hospital were sampled every 15 days during the autumn and spring seasons. The air samples were collected with SAS Super 100^® and the surface samples were collected by swab method.ResultsThe UFC/m³ counts found exceeded the acceptable levels. The UFC/m³ and the diversity of Aspergillus species found in the Intensive Care Unit were higher than those found in the Burns Unit. The fungal load and the diversity of species within the units were higher than those in control environments. The use of both methods –SAS and swab– allowed the detection of a higher diversity of species, with 96 strains of Aspergillus being isolated and 12 species identified. The outstanding findings were Aspergillus sydowii, Aspergillus niger, Aspergillus flavus, Aspergillus terreus and Aspergillus parasiticus, due to their high frequency. Aspergillus fumigatus, considered unacceptable in indoor environments, was isolated in both units.ConclusionsAspergillus was present with high frequency in these units. Several species are of interest in public health for being potential pathogenic agents. Air control and monitoring are essential in the prevention of these infections.     

Mortalidad en pacientes con demencia que cursaron internación en unidades de cuidados críticos

ObjectiveTo determine the mortality and comorbidities associated of patients with dementia admitted to the Intensive Care Unit (ICU) on the hospitalization and at one year of follow-up.Materials and methodsA retrospective observational cohort study was carried out between 2012 and 2017 at the Hospital Italiano de San Justo, of patients who were admitted to the ICU, these were observed up to hospitalary death, out hospital death one year of hospitalization, the disenrollment from the institution's health plan or the end of the follow-up.ResultsA total of 163 patients were included for analysis. We recorded those 79 patients (48.47%) died one year after the hospitalization, of them 25 (15.34%) in ICU and 8 (4.91%) in general room. The most frequent causes of death were respiratory. The factors most associated with mortality were: orotracheal intubation (HR = 2.01; 95% CI: 1.11-3.65; P = .02), history of leukemia (HR = 8.55; 95% CI: 1.82-40.05; P ≤ .05), elevated Charlson (HR = 1.16, 95% CI: 1.04-1.41; P = .05), and elevated APACHE II at admission (HR = 1.07; 95% CI: 1.03-1.11; P ≤ .05).ConclusionsThe present study expresses the prognosis of patients with a diagnosis of dementia admitted to the ICU and that depends not only on their baseline neurological status but also on the severity at admission and comorbidities.