Neumonía intersticial aguda: varón de 75 años con neumonía no resuelta de fatal desenlace

We report a case of a 75-year-old man who came to the emergency room complaining of fever, cough and dyspnea of ten days duration. Patient developed severe respiratory failure and diffuse pulmonary infiltrates in chest film. Evolution of symptoms was poor and the diagnosis of non-resolving pneumonia was made. Micro- biological test and a bronchoscopy were negative. Steroid therapy was initiated promptly. He finally died of respiratory failure 15 days after the hospitalization. After exclusion of secondary etiologies including collagen diseases, we concluded this case as a probable acute (idiopathic) interstitial pneumonia, or Hamman-Rich syndrome. The poor prognosis associated with this entity has been confirmed.Presentamos el caso de un varón de 75 años que acudió a Urgencias por un cuadro de fiebre, tos y disnea de 10 días de evolución. Desarrolló una insuficiencia respiratoria severa con infiltrados pulmonares en la radio- grafía de tórax. Presentó una tórpida evolución, estableciéndose el diagnóstico de neumonía no resuelta. Los análisis microbiológicos y una broncoscopia fueron negativos. Se inició tratamiento esteroide de forma precoz. El paciente finalmente falleció por insuficiencia respiratoria tras 15 días de hospitalización. Se excluyeron otras etiologías y se estableció el caso como una probable neumonía intersticial aguda idiopática, o síndrome de Hamman-Rich, confirmándose el pobre pronóstico de esta entidad

Uso de pulsos de metilprednisolona de repetición en adultos hospitalizados por neumonía y síndrome de distrés respiratorio agudo por COVID-19: un estudio preliminar de tipo antes-después (estudio CortiCOVID)

[EN] Introduction: The use of systemic corticosteroids in severely ill patients with coronavirus disease 2019 (COVID-19) is controversial. We aimed to evaluate the efficacy and safety of corticosteroid pulses in patients with COVID-19 pneumonia. Methods: A quasi-experimental study, before and after, was performed in a tertiary referral hospital, including admitted patients showing COVID-19-associated pneumonia. The standard treatment protocol included targeted COVID-19 antiviral therapy from 23rd March 2020, and additionally pulses of methylprednisolone from 30th March 2020. The primary outcome was a composite endpoint combining oro-tracheal intubation (OTI) and death within 7 days. Results: A total of 24 patients were included. Standard of care (SOC) (before intervention) was prescribed in 14 patients, while 10 received SOC plus pulses of methylprednisolone (after intervention). The median age of patients was 64.5 years and 83.3% of the patients were men. The primary composite endpoint occurred in 13 patients (92.9%) who received SOC vs. 2 patients (20%) that received pulses of methylprednisolone (odds ratio, 0.02; 95% confidence interval, 0.001 to 0.25; p = 0.019). Length of hospitalization in survivors was shorter in the corticosteroids group (median, 14.5 [8.5–21.8] days vs. 29 [23–31] days, p = 0.003). There were no differences in the development of infections between both groups. There were 3 deaths, none of them in the corticosteroids group. Conclusions: In patients with severe pneumonia due to COVID-19, the administration of methylprednisolone pulses was associated with a lower rate of OTI and/or death and a shorter hospitalization episode.[ES] Introducción: El uso de corticosteroides sistémicos en pacientes gravemente enfermos por enfermedad coronavírica de 2019 (covid-19) es controvertido. Nuestro objetivo fue evaluar la eficacia y la seguridad de los pulsos de corticoesteroides en los pacientes con neumonía por covid-19. Métodos: Se realizó un ensayo cuasiexperimental, tipo antes y después, en un hospital terciario de referencia que incluyó a pacientes ingresados por neumonía asociada a covid-19. El protocolo de tratamiento estándar incluía un tratamiento antiviral dirigido contra el virus de la covid-19 desde el 23 de marzo de 2020 y añadió pulsos de metilprednisolona desde el 30 de marzo de 2020. El resultado primario fue un criterio combinado compuesto por la intubación orotraqueal y el fallecimiento durante los siguientes siete días. Resultados: Se incluyó un total de 24 pacientes. El protocolo de tratamiento (antes de la intervención) se prescribió en 14 pacientes, mientras que 10 recibieron el protocolo de tratamiento además de los pulsos de metilprednisolona (después de la intervención). La edad media de los pacientes fue de 64,5 años y el 83,3% de los pacientes eran hombres. El resultado combinado primario tuvo lugar en 13 pacientes (92,9%) que recibieron el protocolo de tratamiento frente a 2 pacientes (20%) que recibieron los pulsos de metilprednisolona (odds ratio = 0,02; intervalo de confianza del 95% = 0,001-0,25; p = 0,019). La duración de la hospitalización en los supervivientes fue más corta en el grupo que recibió corticoesteroides (media = 14,5 [8,5-21,8] días frente a 29 [23-31] días, p = 0,003). No hubo diferencias en el desarrollo de infecciones entre ambos grupos. Hubo tres fallecimientos, ninguno de ellos en el grupo que recibió corticoesteroides. Conclusiones: En los pacientes con neumonía grave por covid-19, la administración de pulsos de metilprednisolona se asoció a unas tasas menores de intubación orotraqueal y/o muerte y a episodios de hospitalización más cortos

Asociación entre la enfermedad Inflamatoria intestinal y las infecciones crónicas orales de origen endodóncico

Introducción: La posible conexión entre los procesos inflamatorios crónicos de origen infeccioso a nivel de la cavidad oral y el estado de salud sistémico es un área de creciente interés para la comunidad científica médica y odontológica. Aunque la enfermedad inflamatoria intestinal ha sido relacionada con la enfermedad periodontal y, más recientemente, con la periodontitis apical, hasta el momento la posible asociación entre la enfermedad inflamatoria intestinal y la endodoncia ha sido poco estudiada, existiendo pocos datos relativos a la posible interrelación entre la patología inflamatoria periapical de origen endodóncico y la enfermedad inflamatoria intestinal. Material y método: Se tomó una muestra de 108 pacientes divididos en un grupo de 54 casos (pacientes con diagnóstico de enfermedad inflamatoria intestinal tipo enfermedad de Crohn o Colitis ulcerosa atendidos en el Hospital San Juan de Dios del Aljarafe) y otro de 54 controles (atendidos en la facultad de odontología de Sevilla). A todos los pacientes del estudio se les realizó estudio radiológico mediante radiografía oral panorámica (PANOREX). Se analizó el número de dientes presentes y ausentes, número total de dientes con periodontitis apical (PAI > 2), número de dientes endodonciados y número de dientes endodonciados con periodontitis apical (PAI > 2). Resultados: Se ha analizado la relación entre la enfermedad inflamatoria intestinal con el estado apical, así como con el estado endodóncico. La prevalencia de lesiones periapicales fue casi 6 veces superior en los enfermos con enfermedad inflamatoria intestinal respecto a los controles siendo estos resultados estadísticamente significativos. En el análisis por tipos de enfermedad inflamatoria intestinal los resultados no mostraron diferencias estadísticamente significativas a favor de uno u otro. Asimismo, se ha objetivado que en los pacientes con enfermedad inflamatoria intestinal la prevalencia de periodontitis apical se asoció al número de dientes endodonciados de forma estadísticamente significativa, es decir, cuantos más dientes endodonciados presentaban los pacientes con enfermedad inflamatoria intestinal, mayor prevalencia de periodontitis apical tenían. En el análisis por tipos de enfermedad inflamatoria intestinal no se encontraron diferencias estadísticamente significativas, es decir, no se encontró asociación significativa entre el número de dientes endodonciados y el tipo de enfermedad inflamatoria intestinal. Conclusiones: Los pacientes con enfermedad inflamatoria intestinal tienen el doble de prevalencia de periodontitis apical que los controles sanos siendo dicha diferencia estadísticamente significativa. Podemos concluir que existe asociación significativa entre la enfermedad inflamatoria intestinal y padecer lesiones radiolúcidas periapicales. No existe asociación significativa entre la prevalencia de dientes endodonciados y tener enfermedad inflamatoria intestinal. De los tipos de enfermedad inflamatoria intestinal (enfermedad de Crohn o Colitis ulcerosa) podemos confirmar que no se asocian ni a la prevalencia de periodontitis apical ni a la de tratamiento endodóncico

High Prevalence of Apical Periodontitis in Patients With Inflammatory Bowel Disease: An Age- and Gender- matched Case-control Study

[Background]: Deep carious lesions cause pulpitis, pulpal necrosis and, finally, apical periodontitis (AP). Root canal treatment (RCT) is the treatment of choice for AP, changing the tooth into a root-filled tooth (RFT). Several studies have linked AP and RFT to systemic diseases. Likewise, previous studies have also found an association among inflammatory bowel disease (IBD) and periodontal disease. This study aims to analyze the frequency of AP and RCT in IBD patients and healthy control subjects.[Methods]: An age- and gender-matched case-control study design was used. The study group (SG) included 54 IBD patients (28 with Crohn´s disease, 26 with ulcerative colitis). Another 54 healthy subjects without IBD and age- and gender-matched were included in the control group (CG). The radiographic records were analyzed, and periapical radiolucencies were diagnosed as AP, using the periapical index (PAI). The statistical analysis was carried out using the Student t test, χ 2 test, and multivariate logistic regression.[Results]: The presence of 1 or more teeth with radiolucent periapical lesions (RPLs) was found in 19 patients (35.2%) in the study group and in 9 subjects (16.7%) in the control group (P = 0.03). No differences were found among the 2 groups neither in the amount of teeth with AP nor in the number of RFTs (P > 0.05). However, multivariate logistic regression analysis adjusting for number of teeth and number of RFTs showed that patients with IBD have RPLs with higher likelihood than control patients (odds ratio, 5.7; confidence interval 95%, 1.7–19.1; P = 0.0048).[Conclusions]: Subjects with inflammatory bowel disease have higher prevalence of apical periodontitis. An oral health protocol should be established to address the higher prevalence of inflammatory oral processes

Prevalence of endodontic infection in patients with Crohn ́s disease and ulcerative colitis

[Background] Previous studies have linked apical periodontitis (AP) to inflammatory bowel disease (IBD). The aim of this study was to compare the prevalence of AP and root canal treatment (RCT) in patients with ulcerative colitis (UC) and Crohn ́s disease (CD).[Material and methods] A cross-sectional study, including 28 patients with Crohn ́s disease and 26 with ulcerative colitis, was conducted. AP was diagnosed as radiolucent periapical lesions (RPLs), using the periapical index score (PAI). Student’s t test, χ2 test and multivariate logistic regression were used in the statistical analysis.[Results] Multivariate logistic regression run with age, gender, number of teeth, number of RFT, periodontal disease and the type of IBD as covariates, taking as dependent variable and outcome “periapical status” (0 = no tooth with RPL; 1 = at least one tooth with RPL), showed that both UC and CD patients had the prevalence apical periodontitis (OR = 1.03; C.I. 95% = 0.25 – 4.31; p = 0.97). The multivariate analysis, including all the above covariates, shows that both in UC and CD patients the prevalence of RCT was similar (OR = 0.76; C.I. 95% =0.17 – 7.31; p = 0.73). Periapical status was significantly associated with endodontic status (OR = 42.72; C.I. 95% = 3.87 – 472.15; p = 0.002), regardless of IBD type.[Conclusions] The results of the present study show similar frequency of AP and RFT in both UC and CD patients. The type of IBD does not appear to affect the prevalence of radiographically detectable periapical lesions or the prevalence of root canal treatment.Daniel Cabanillas-Balsera is research fellow supported by Spanish Ministerio de Educación, Cultura y Deporte (Programa Nacional de Formación de Profesorado Universitario, FPU); Victoria Areal-Quecuty are research fellows supported by the University of Sevilla (Beca de Personal Investigador en Formación, PIF).Peer reviewe

Impact of the COVID-19 pandemic on antimicrobial consumption and hospital-acquired candidemia and multidrug-resistant bloodstream infections

During the COVID-19 pandemic, the implementation of antimicrobial stewardship strategies has been recommended. This study aimed to assess the impact of the COVID-19 pandemic in a tertiary care Spanish hospital with an active ongoing antimicrobial stewardship programme (ASP). For a 20-week period, we weekly assessed antimicrobial consumption, incidence density, and crude death rate per 1000 occupied bed days of candidemia and multidrug-resistant (MDR) bacterial bloodstream infections (BSI). We conducted a segmented regression analysis of time series. Antimicrobial consumption increased +3.5% per week (p = 0.016) for six weeks after the national lockdown, followed by a sustained weekly reduction of −6.4% (p = 0.001). The global trend for the whole period was stable. The frequency of empirical treatment of patients with COVID-19 was 33.7%. No change in the global trend of incidence of hospital-acquired candidemia and MDR bacterial BSI was observed (+0.5% weekly; p = 0.816), nor differences in 14 and 30-day crude death rates (p = 0.653 and p = 0.732, respectively). Our work provides quantitative data about the pandemic effect on antimicrobial consumption and clinical outcomes in a centre with an active ongoing institutional and education-based ASP. However, assessing the long-term impact of the COVID-19 pandemic on antimicrobial resistance is required

Impact of the COVID-19 Pandemic on Antimicrobial Consumption and Hospital-Acquired Candidemia and Multidrug-Resistant Bloodstream Infections

During the COVID-19 pandemic, the implementation of antimicrobial stewardship strategies has been recommended. This study aimed to assess the impact of the COVID-19 pandemic in a tertiary care Spanish hospital with an active ongoing antimicrobial stewardship programme (ASP). For a 20-week period, we weekly assessed antimicrobial consumption, incidence density, and crude death rate per 1000 occupied bed days of candidemia and multidrug-resistant (MDR) bacterial bloodstream infections (BSI). We conducted a segmented regression analysis of time series. Antimicrobial consumption increased +3.5% per week (p = 0.016) for six weeks after the national lockdown, followed by a sustained weekly reduction of −6.4% (p = 0.001). The global trend for the whole period was stable. The frequency of empirical treatment of patients with COVID-19 was 33.7%. No change in the global trend of incidence of hospital-acquired candidemia and MDR bacterial BSI was observed (+0.5% weekly; p = 0.816), nor differences in 14 and 30-day crude death rates (p = 0.653 and p = 0.732, respectively). Our work provides quantitative data about the pandemic effect on antimicrobial consumption and clinical outcomes in a centre with an active ongoing institutional and education-based ASP. However, assessing the long-term impact of the COVID-19 pandemic on antimicrobial resistance is required.The programme received public funding from the Regional Health Ministry of Andalucía (grant PI0361-2010), which did not participate in the development of the programme or the analysis of its results.Peer reviewe

Appropriateness of antiplatelet therapy for primary and secondary cardio- and cerebrovascular prevention in acutely hospitalized older people

Aims: Antiplatelet therapy is recommended for the secondary prevention of cardio- and cerebrovascular disease, but for primary prevention it is advised only in patients at very high risk. With this background, this study aims to assess the appropriateness of antiplatelet therapy in acutely hospitalized older people according to their risk profile. Methods: Data were obtained from the REPOSI register held in Italian and Spanish internal medicine and geriatric wards in 2012 and 2014. Hospitalized patients aged ≥65 assessable at discharge were selected. Appropriateness of the antiplatelet therapy was evaluated according to their primary or secondary cardiovascular prevention profiles. Results: Of 2535 enrolled patients, 2199 were assessable at discharge. Overall 959 (43.6%, 95% CI 41.5–45.7) were prescribed an antiplatelet drug, aspirin being the most frequently chosen. Among patients prescribed for primary prevention, just over half were inappropriately prescribed (52.1%), being mainly overprescribed (155/209 patients, 74.2%). On the other hand, there was also a high rate of inappropriate underprescription in the context of secondary prevention (222/726 patients, 30.6%, 95% CI 27.3–34.0%). Conclusions: This study carried out in acutely hospitalized older people shows a high degree of inappropriate prescription among patients prescribed with antiplatelets for primary prevention, mainly due to overprescription. Further, a large proportion of patients who had had overt cardio- or cerebrovascular disease were underprescribed, in spite of the established benefits of antiplatelet drugs in the context of secondary prevention

Prognostic value of degree and types of anaemia on clinical outcomes for hospitalised older patients

Study objective This study investigated in a large sample of in-patients the impact of mild-moderate-severe anaemia on clinical outcomes such as in-hospital mortality, re-admission, and death within three months after discharge. Methods A prospective multicentre observational study, involving older people admitted to 87 internal medicine and geriatric wards, was done in Italy between 2010 and 2012. The main clinical/laboratory data were obtained on admission and discharge. Based on haemoglobin (Hb), subjects were classified in three groups: group 1 with normal Hb, (reference group), group 2 with mildly reduced Hb (10.0–11.9 g/dL in women; 10.0–12.9 g/dL in men) and group 3 with moderately-severely reduced Hb (<10 g/dL in women and men). Results Patients (2678; mean age 79.2 ± 7.4 y) with anaemia (54.7%) were older, with greater functional impairment and more comorbidity. Multivariable analysis showed that mild but not moderate-severe anaemia was associated with a higher risk of hospital re-admission within three months (group 2: OR = 1.62; 95%CI 1.21–2.17). Anaemia failed to predict in-hospital mortality, while a higher risk of dying within three months was associated with the degree of Hb reduction on admission (group 2: OR = 1.82;95%CI 1.25–2.67; group 3: OR = 2.78;95%CI 1.82–4.26) and discharge (group 2: OR = 2.37;95%CI 1.48–3.93; group 3: OR = 3.70;95%CI 2.14–6.52). Normocytic and macrocytic, but not microcytic anaemia, were associated with adverse clinical outcomes. Conclusions Mild anaemia predicted hospital re-admission of older in-patients, while three-month mortality risk increased proportionally with anaemia severity. Type and severity of anaemia affected hospital re-admission and mortality, the worst prognosis being associated with normocytic and macrocytic anaemia