Evolución de la infección fúngica invasora en los últimos 30 años

Clinical mycology is in continuous development. The appearance of new clinical guidelines has made it possible to improve the approach to opportunistic fungal infections, especially in immunosuppressed patients (oncohematological and/or transplant recipients). At the same time, the development of new diagnostic tools and new antifungals with a greater spectrum of action and fewer side effects have led to faster diagnoses and treatments that are more effective. Along with these advances, there has been a change in the epidemiology of invasive fungal infection (IFI), with the appearance of new patients (e.g., COPD, liver cirrhosis, post-influenza) and new microorganisms (Candida auris, Lomentospora prolificans, mucorales), and resistant fungi (isolates of Aspergillus resistant to azoles) which the clinician must take into account when choosing the treatment of a patient with an IFI. In this paper we will briefly review the advances in recent decades and the emerging problems.     

Tinea capitis. Experiencia de 2 años en un hospital de pediatría de Buenos Aires,Argentina

Tinea capitis is an infection caused by dermatophytes of the genera Microsporum and Trichophyton, and constitutes a major health problem in Argentina. The aim of the present study was to find out the incidence of those etiological agents and the therapeutic response in patients attending a High-Complexity Paediatric Hospital within a two-year period. A total of 98 tinea capitis were diagnosed, 13 of which were Celsus kerion. Microsporum canis was isolated in 61.28%. The range of values for minimum inhibitory concentrations were >32, 0,06–4; <0,015–2; <0,015–0.25; 0.13–8; 0.06–128 μg/mL for fluconazole itraconazole, voriconazole, terbinafine, ketoconazole and griseofulvin, respectively.     

Prevalencia de sobrepeso y obesidad en niños y adolescentes de 2 a 16 años

ObjectivesTo estimate the prevalence of obesity and overweight in children and adolescents in our city and to investigate the associated factors.Subjects and methodsA cross-sectional study of 1317 children and adolescents aged 2-16 years. Multistage probability sampling was used to select three groups of subjects: 411 aged 12 to 16 years, 504 aged 6 to 12 years, and 402 aged 2 to 6 years. Body mass index was calculated, and obesity and overweight were diagnosed using the threshold levels of the International Obesity Task Force for children and adolescents. Parents were asked about eating habits, health, social, and demographic aspects. Results are given as percentages (95% confidence interval). The relationship between obesity and overweight and the different variables was studied using multiple logistic regression. The adjusted odds ratio (OR) was calculated.ResultsAmong children and adolescentes aged 2-16 years, 9.5% (8.0%-11.0%) were obese and 22.4% (23.3%-24.6%) were overweight. Of subjects aged 12-16 years, 8.5% (5.9%-11.2%) were obese and 20.5% (16.7%-24.3%) were overweight. In the groups aged 6-12 years and 2-6 years, rates of obesity and overweight were 11.6% (8.9% -14.3%) and 31.0% (27.0-35.0) and 8.0% (5.4%-10.6%) and 13.6% (10.3%-16.9%) respectively. Obesity or overweight was associated to age (OR 1.21; P< 0.001), maternal obesity (OR 10.99; P= 0.008), a birthweight higher than 4 kg (OR 2.91; p 0.002), and formula feeding (OR 1.82; P= 0.005).ConclusionObesity and overweight in children and adolescents are highly prevalent problems in our city.     

Autopercepción de la salud en ancianos y mortalidad a los 5 años. Estudio en una comunidad rural

IntroductionTo investigate the relationship between self-rated health and mortality at 5 years of follow-up among the elderly in a rural community.DesignSurvival study with a 5-year follow-up.ParticipantsRepresentative sample of 408 individuals aged more than 65 years living in a rural municipality in the north-west of Spain.ResultsSurvival was significantly lower among individuals who reported «poor» or «very poor» health (relative risk [RR] = 1.56; 95% confidence interval [95% CI], 1.04-2.33). However, after adjusting for other variables (age, sex, education, severe disease, toxic habits, and mobility) the probability of survival among these individuals reporting «poor» or «very poor» health was similar to that among participants who rated their health as «average», «good » or «very good» (RR = 1.15; 95% CI, 0.71-1.87). In the multivariate analysis, only age, regular smoking, and mobility remained as significant predictive factors of mortality.ConclusionsAfter adjusting for demographic and socioeconomic factors and for objective health status, self-rated health does not have a direct effect on mortality. The degree of mobility does seem to be useful in predicting mortality.     

Análisis de los factores implicados en la evolución de los pacientes mayores de 80 años,ingresados en la unidad de cuidados intensivos: ¿debemos cambiar nuestro proceder?

Background and objectivesThe care of older patients in intensive care units (ICU) is becoming more frequent.To describe characteristics of elderly patients admitted to the ICU and to analyze the factors associated with mortality.Patients and methodsRetrospective cross-sectional study, with patients ≥80 years, admitted to the ICU of the Rey Juan Carlos University Hospital, from March 2012 to December 2018. Demographic variables, comorbidities and mortality in the ICU, in hospital and at one year were collected, analyzed by univariate analysis and binary logistic regression.ResultsSix hundred twenty patients, mean age 83.6 years (SD: 3.25), 31% required invasive mechanical ventilation (IMV), 25% vasopressors and 29% renal replacement therapy (RRT) due to acute renal failure (ARF). The 60% were admissions of medical origin. In-hospital mortality was 156 patients (25%), 91 died in the ICU and 65 on the ward, with shorter ICU stays for the survivors (2.72; SD: 0.22) compared to the deceased (3.74; SD: 0.38), with statistically significant differences. 63% remained alive one year after ICU discharge.An explanatory model of ICU mortality was obtained by logistic regression that included the following factors: IMV (OR: 5.78, 95% CI 2.73-12.22), vasopressors (OR: 2.54, 95% CI 1.24-5.19), AKI/TRS (OR: 2.69, 95% CI 1.35-5.35), medical admission (OR: 2.88, 95% CI 1.40-5.92), urgent admission (OR: 2.33, 95% CI 1.30-4.18) and limitation of life support (LTSV) (OR: 47.35, 95% CI 22.96-97.68). The days in the ICU (OR: 0.93, 95% CI 0.87-0.99) would be inversely related to mortality.ConclusionsIn older patients, there is no increase in mortality, with a 1-year survival >63%. The need for IMV, the use of vasopressor drugs and ARF/RTS were factors associated with mortality in the multivariate analysis.     

Adenoma adrenal como etiología de síndrome de Cushing: veinte años de experiencia en un centro mexicano de tercer nivel

IntroductionCushing's syndrome (CS) includes a wide range of clinical and laboratory abnormalities and is the final outcome of chronic glucocorticoid exposure. Adrenal adenomas are an uncommon cause of adult CS.ObjectiveTo describe the characteristics and outcome of patients with CS caused by adrenal adenomas in a referral center.MethodsWe performed a retrospective cross-sectional observational study of patients with a diagnosis of CS caused by adrenal adenomas managed in our center over a 20-year period. Our clinical experience in the diagnosis and treatment of this entity was analyzed.ResultsThere were a total of 20 patients, 19 women and one man. The mean age was 25.9 years (14 to 52). The most frequently recorded clinical data were hirsutism and moon face. The mean morning cortisol level was 26.9±10.7 mcg/dl, the mean afternoon level was 24.4±8.5 mcg/dl and the mean corticotropin (ACTH) concentration was 24±19.4 pg/ml. Only four patients (20%) had ACTH levels below 5 pg/ml. The results of dynamic testing with dexamethasone suggested adrenal adenoma in 100% of the patients. Seventy percent of adenomas were found in the left gland. The mean size of the lesion was 2.8±0.47 cm.ConclusionsIn dynamic testing, the criteria of non-suppression with high doses of dexamethasone were evident in almost all patients. ACTH measurement in our center was not reliable in identifying adrenal adenoma as a cause of CS.     

Prevalencia de los trastornos de ansiedad en las personas mayores de 65 años: una revisión sistemática

Anxiety is an emotional problem that causes discomfort and suffering to those that suffer from it. Anxiety disorders can affect the functioning in different facets of a person's life. Studies on the prevalence of anxiety disorders in people over 65 years show variable results, ranging between 0.1% and 17.2%. Most of these studies include samples of the general population, in which the population of people over 65 years is under-represented. These studies evaluate older people with the same diagnostic tools used to assess anxiety disorders in people under 65 years, and collect data from people between 65 and 75 years old, leaving out people aged 75 and over. A systematic review of the prevalence studies of anxiety disorders in elderly people is presented. It is concluded that when representative samples of people over 65 years are used and evaluated with suitable tools, the prevalence rate of these disorders in the elderly is much higher than previously thought, reaching an annual prevalence rate of 20.8%.     

Tendencias en las hospitalizaciones psiquiátricas de personas mayores de 65 años

BackgroundThe aim of this study was to analyse the trend in the percentages of elderly patients admitted to hospital for psychiatric reasons. An additional aim was to analyse the characteristics of the elderly population admitted to a psychiatric hospitalisation unit.Material an MethodsAn analysis was made of the trends in the percentages of discharges in elderly population at the national level and in the Mental Health Hospitalisation Unit (MHHU) of the Regional University Hospital of Malaga for a period of at least 18 years using segmented regression. For the study of the characteristics of the elderly population, all patients (N = 5,925) and consecutive episodes of admission (N = 15,418) were compared between 1999 and 2017 in the MHHU.ResultsAt the national level, there was an increase in hospital discharges in elderly patients with a significant mean annual percent change of 2.0%. In the study unit, the elderly population were more frequently female, involuntarily admitted, and had a longer hospital stay. They had been diagnosed more frequently with organic and depressive mental disorders, and less frequently with schizophrenia, substance use, and personality disorders.ConclusionsThere was a growing trend in the percentage of elderly psychiatric patients admitted to hospitals during the study period. These results point to the increase in elderly psychiatric admissions and thus the need to adapt psychiatric units to the characteristics of this population.     

Factores de riesgo de mortalidad en pacientes mayores de 65 años hospitalizados por COVID-19

Background and objectiveCOVID-19 is a disease caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and has caused a global pandemic that we are currently suffering from.Objectiveto identify factors associated with the death of patients aged 65 years or older hospitalized for COVID-19.Materials and methodsRetrospective cohort study. We included patients aged 65 years or older who were hospitalized for COVID-19 and dead o discharged between March 5 and 25, 2020. We used univariable and multivariable logistic regression methods to explore the risk factors associated with in-hospital death.Results277 patients were included in this study. The bivariate analysis showed significant differences (p < 0.05) between survivors and non survivors: age, increased dependence and comorbidity, history of ischemic heart disease, renal failure and non-hematological neoplasms, heart failure during admission, leukocytosis, elevated creatinine, PCR, GOT and troponin Ic values, lymphopenia, and decreased blood pH and SatO2. Multivariate logistic regression revealed that age ≥ 65 years (OR: 4.23 (95% CI: 1.43-12.52; p = 0.009), lymphopenia < 1000/μL (OR: 2.36 (95% CI: 1.07-5.20; p = 0.033), creatinine > 1.2 mg/dL (OR: 3.08 (95% CI: 1.37-6.92; p = 0.006), SatO₂ < 90% (OR: 2.29 (95% CI: 1.01-5.21; p = 0.049) and troponin Ic > 11 ng/mL (OR: 2.32 (95% CI: 1.04-5.16; p = 0.040) were independently associated with higher hospital mortality.ConclusionsOlder age, lymphopenia, SatO₂ < 90%, elevated creatinine and troponin Ic values were independently associated with higher mortality in hospitalized patients with COVID-19, these factors could help clinicians to identify patients with poor prognosis.     

Efectividad de la vacuna antigripal en la prevención de la gripe en personas mayores de 65 años

IntroductionInfluenza is one of the diseases with the greatest epidemiological impact and of maximum relevance in the management of health services. The flu vaccine can have great variability each season, so our objective was to find out the effectiveness of the flu vaccine for the 2017/2018 season for the prevention of severe cases of flu in people over 65 years of age in a 385-bed acute general hospital.Material and methodStudy of cases and controls. All hospitalized patients with laboratory-confirmed influenza older than 65 years during the 2017/2018 season were included. Those who met the criteria for a severe case of influenza were considered cases. Those who did not meet the severity criteria were considered controls. Factors associated with the development of severe influenza were calculated.ResultsThe median age was 68 years (SD 91.87). The attack rate was 0.23 per hundred inhabitants and the vaccine effectiveness was 38%. The vaccinated and unvaccinated groups were different in terms of age (p < 0.0481). Vaccination status against severe influenza was found to be an independent protective factor (OR = 0.840; 0.746-0.913).ConclusionsThe effectiveness of influenza vaccination provided greater protection against infection and reduced the severity of influenza in older hospitalized patients. These findings should be taken into account to improve vaccination strategies and achieve better vaccination coverage in the population at risk.     

Desarrollo de los estudios micológicos en la Argentina en el último decenio

(Director del Centro de Micología de la Facultad de Ciencias Médicas de Buenos Aires. Profesor de Micología en la Universidad Nacional de la Plata)