Evolución clínica y factores pronóstico en el síndrome de abstinencia alcohólica

[Resumen] Introducción: el síndrome de abstinencia alcohólica es un estado de hiperexcitabilidad del sistema nervioso que aparece en individuos dependientes tras disminuir la ingesta alcohólica. La intensidad de sus manifestaciones es variable y no se conocen bien los factores que determinan su pronóstico. Objetivo: Describir las características y evolución clínica del síndrome de abstinencia alcohólica en un hospital general, individualizando los factores que determinan su pronóstico. Pacientes y método: pacientes ingresados con síndrome de abstinencia alcohólica (menor y delirium tremens), de acuerdo con los criterios del manual DSM IV, en el complexo hospitalario Xeral-Calde de Lugo, entre Enero de 1987 y Diciembre de 2003. Se recogieron sus características clínicas, evolución y complicaciones. Se realizó un estudio descriptivo y una análisis univariado y mutivariado de factores pronóstico de evolución a delirium tremens, ingreso en la UCI para control de los síntomas y de supervivencia. Resultados: 539 episodios en 436 pacientes. 45 años (DE 12), 91% hombres. 71% delirum tremens. 59% alucinaciones. El 41% cursó con crisis comiciales, que aparecieron a las 35 horas de abstinencia (DE 23). Los casos con síndrome menor que no progresaron a síndrome mayor se prolongaron 46 horas (DE 21). Cuando apareció delirium lo hizo a las 40 horas (DE 29) del diagnóstico, y se prolongó 74 horas (DE 41). La tasa de traslados a UCI fue 37,8% (IC 95% 33-38) y la mortalidad 6,6% (IC 95% 4-9). El 65% de los exitus se produjeron en pacientes ingresados en la UCI, la totalidad de estos últimos conectados a ventilaciónmecánica. No se apreciaron diferencias significativas en la evolución clínica en relación con el sexo. Los casos con síndrome de abstinencia en el curso de un ingreso por otro motivo, presentaron más ingresos en UCI y mayor mortalidad. Los factores predictores de evolución a delirium tremens fueron la presencia de crisis epilépticas y su nº, OR 2,7 (IC 95% 1,2-3,8), la temperatura >38ºC en las priimeras 24 horas, OR 1,9 (IC 95% 1.05-3,5) y la TA sistólica >150 mmHg al diagnóstico, OR 2,1 (1,1-3,8) (área bajo la curva ROC 0,679). Los factores predictores de ingreso en la UCI fueron la presencia de crisis epilépticas y su nº, OR 7,1 (IC 95% 3,3-15,6), ingresar por un motivo diferente a la abstinencia, OR 2 (IC 95% 1,2-3,4), tener delirium al diagnóstico, OR 3,3 (IC 95% 2,1-5,2), haber ingresado en la UCI previamente por abstinencia, OR 3,1 (IC 95% 1,4-6,8) y una albúmina <3,5mg/dl, OR 2,2 (IC 95% 1,4-3,5) (área bajo la curva ROC 0,743). Los factores determinantes de mortalidad fueron la presencia de cirrosis, OR 4,8 (IC 95% 0,9-5,6), la comorbilidad OR 3,5 (IC 95% 1,3-8,9), presentar delirium tremens al diagnóstico, OR 2,5 (IC 95% 1-6,1), ser conectado a ventilación mecánica en la UCI, OR 2,9 (IC 95% 1,1-7,9) y sufrir una neumonía intraUCI, OR 8 (IC 95% 3-21,3) (área bajo la curva ROC 0,818). Conclusión: El síndrome de abstinencia alcohólica en un hospital general sigue una pauta evolutiva reconocible. El desarrollo de delirium tremens depende de factores intrínsecos de la abstinencia, aunque no es facilmente predecible, mientras que la mortalidad depende de factores relacionados con el estado basal del enfermo y de las actitudes terapéuticas tomadas durante el episodio de abstinencia

Electrocardiographic abnormalities in centenarians: impact on survival

[Abstract] Background: The centenarian population is gradually increasing, so it is becoming more common to see centenarians in clinical practice. Electrocardiogram abnormalities in the elderly have been reported, but several methodological biases have been detected that limit the validity of their results. The aim of this study is to analyse the ECG abnormalities in a prospective study of the centenarian population and to assess their impact on survival. Method: We performed a domiciliary visit, where a medical history, an ECG and blood analysis were obtained. Barthel index (BI), cognitive mini-exam (CME) and Charlson index (ChI) were all determined. Patients were followed up by telephone up until their death. Results: A total of 80 centenarians were studied, 26 men and 64 women, mean age 100.8 (SD 1.3). Of these, 81% had been admitted to the hospital at least once in the past, 81.3% were taking drugs (mean 3.3, rank 0-11). ChI was 1.21 (SD 1.19). Men had higher scores both for BI (70 -SD 34.4- vs. 50.4 -SD 36.6-, P = .005) and CME (16.5 -SD 9.1- vs. 9.1 -SD 11.6-, P = .008); 40.3% of the centenarians had anaemia, 67.5% renal failure, 13% hyperglycaemia, 22.1% hypoalbuminaemia and 10.7% dyslipidaemia, without statistically significant differences regarding sex. Only 7% had a normal ECG; 21 (26.3%) had atrial fibrillation (AF), 30 (37.5%) conduction defects and 31 (38.8%) abnormalities suggestive of ischemia, without sex-related differences. A history of heart disease was significantly associated with the presence of AF (P = .002, OR 5.2, CI 95% 1.8 to 15.2) and changes suggestive of ischemia (P = .019, OR 3.2, CI 95% 1.2-8.7). Mean survival was 628 days (SD 578.5), median 481 days. Mortality risk was independently associated with the presence of AF (RR 2.0, P = .011), hyperglycaemia (RR 2.2, P = .032), hypoalbuminaemia (RR 3.5, P < .001) and functional dependence assessed by BI (RR 1.8, P = .024). Conclusion: Although ECG abnormalities are common in centenarians, they are not related to sex, functional capacity or cognitive impairment. The only abnormality that has an impact on survival is AF

Ferric carboxymaltose with or without erythropoietin for the prevention of red-cell transfusions in the perioperative period of osteoporotic hip fractures: a randomized contolled trial. The PAHFRAC-01 project

Background: Around one third to one half of patients with hip fractures require red-cell pack transfusion. The increasing incidence of hip fracture has also raised the need for this scarce resource. Additionally, red-cell pack transfusions are not without complications which may involve excessive morbidity and mortality. This makes it necessary to develop blood-saving strategies. Our objective was to assess safety, efficacy, and cost-effictveness of combined treatment of i.v. ferric carboxymaltose and erythropoietin (EPOFE arm) versus i.v. ferric carboxymaltose (FE arm) versus a placebo (PLACEBO arm) in reducing the percentage of patients who receive blood transfusions, as well as mortality in the perioperative period of hip fracture intervention. Methods/Design: Multicentric, phase III, randomized, controlled, double blinded, parallel groups clinical trial. Patients > 65 years admitted to hospital with a hip fracture will be eligible to participate. Patients will be treated with either a single dosage of i.v. ferric carboxymaltose of 1 g and subcutaneous erythropoietin (40.000 IU), or i.v. ferric carboxymaltose and subcutaneous placebo, or i.v. placebo and subcutaneous placebo. Follow-up will be performed until 60 days after discharge, assessing transfusion needs, morbidity, mortality, safety, costs, and health-related quality of life. Intention to treat, as well as per protocol, and incremental cost-effectiveness analysis will be performed. The number of recruited patients per arm is set at 102, a total of 306 patients. Discussion: We think that this trial will contribute to the knowledge about the safety and efficacy of ferric carboxymaltose with/without erythropoietin in preventing red-cell pack transfusions in patients with hip fracture. ClinicalTrials.gov identifier: NCT01154491

Treatment variability and its relationships to outcomes among patients with Wernicke's encephalopathy: A multicenter retrospective study

Background: Despite guidelines and recommendations, Wernicke's encephalopathy (WE) treatment lacks evidence, leading to clinical practice variability.Aims: Given the overall lack of information on thiamine use for WE treatment, we analyzed data from a large, well-characterized multicenter sample of patients with WE, examining thiamine dosages; factors associated with the use of different doses, frequencies, and routes; and the influence of differences in thiamine treatment on the outcome.Methods: This retrospective study was conducted with data from 443 patients from 21 centers obtained from a nationwide registry of the Spanish Society of Internal Medicine (from 2000 to 2012). Discharge codes and Caine criteria were applied for WE diagnosis, and treatment-related (thiamine dosage, frequency, and route of administration) demographic, clinical, and outcome variables were analyzed.Results: We found marked variability in WE treatment and a low rate of high-dose intravenous thiamine administration. Seventy-eight patients out of 373 (20.9%) received > 300 mg/day of thiamine as initial dose. Patients fulfilling the Caine criteria or presenting with the classic WE triad more frequently received parenteral treatment. Delayed diagnosis (after 24 h hospitalization), the fulfillment of more than two Caine criteria at diagnosis, mental status alterations, and folic acid deficiency were associated significantly with the lack of complete recovery. Malnutrition, reduced consciousness, folic acid deficiency, and the lack of timely thiamine treatment were risk factors for mortality.Conclusions: Our results clearly show extreme variability in thiamine dosages and routes used in the management of WE. Measures should be implemented to ensure adherence to current guidelines and to correct potential nutritional deficits in patients with alcohol use disorders or other risk factors for WE

Unidades de ortogeriatría

El aumento progresivo de la esperanza de vida ligada a la mejora de las condiciones higiénicas, socioeconómicas y de la asistencia sanitaria ha conducido a un incremento constante de la población anciana en los últimos años en nuestro país