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The incidence of severe manifestations of COVID-19 increases with age with older patients showing the highest mortality, suggesting that molecular pathways underlying aging contribute to the severity of COVID-19. One mechanism of aging is the progressive shortening of telomeres, which are protective structures at chromosome ends. Critically short telomeres impair the regenerative capacity of tissues and trigger loss of tissue homeostasis and disease. The SARS-CoV-2 virus infects many different cell types, forcing cell turn-over and regeneration to maintain tissue homeostasis. We hypothesize that presence of short telomeres in older patients limits the tissue response to SARS-CoV-2 infection. We measure telomere length in peripheral blood lymphocytes COVID-19 patients with ages between 29 and 85 years-old. We find that shorter telomeres are associated to increased severity of the disease. Individuals within the lower percentiles of telomere length and higher percentiles of short telomeres have higher risk of developing severe COVID-19 pathologies.

Introduction. The diagnosis of SARS-CoV-2 infection is crucial for medical and public health reasons, to allow the best treatment of cases and the best control of the pandemic. Serology testing allows for the detection of asymptomatic infections and 19-COVID cases once the virus has been cleared. We analyzed the usefulness of the SARS-CoV-2 rapid test of Autobio and tried to correlate its pattern with the severity of COVID19 infection. Material and methods. We analyzed the accuracy and clinical usefulness of a point-of-care IgM and/or IgG test for SARS-CoV-2 in 35 COVID-19 patients [12 (34.3%) mild-moderate and 23 (65.7%) severe-critical] admitted to a field hospital in Madrid, as well as in 5 controls. Results. The mean time from the first day of symptoms to the antibody test was 28 days (SD: 8.7), similar according to the severity of the disease. All patients with SARS-CoV-2 PCR+ showed the corresponding IgG positivity, while these results were negative in all control individuals. A total of 26 (74%) cases also presented with positive IgM, 19 (83%) were severe-critical cases and 7 (58%) were mild-moderate cases. The IgM response lasted longer in the severe critical cases (mean: 29.7 days; SD: 8.4) compared to the moderate cases (mean: 21.2 days; SD: 2.0). Conclusions. Rapid serology tests are useful for the diagnosis of patients with COVID-19 (mainly IgG detection) and may also be correlated with the severity of the infection (based on IgM detection).

Aim: There is growing evidence regarding the imaging findings of coronavirus disease 2019 (COVID-19) in lung ultrasound (LUS); however, its role in predicting the prognosis has yet to be explored. The aim of the study was to assess the relationship between lung ultrasound findings with the degree of respiratory failure measured by the PaO2/FiO2 ratio (PaFi) andthe prognosis of these patients: need for non-invasive mechanical ventilation (NIMV), admission to the Intensive Care Unit (ICU) and mortality.Material and method: Prospective, longitudinal and observational study performed in patients with confirmed COVID-19 underwent a LUS examination and laboratory tests.Results: A total of 107 patients were enrolled: 93.4% with bilateral involvement and 73.83% presented at least one consolidation. A good inverse correlation (Rho Spearman coefficient -0.897) between the ultrasound score and PaFi was obtained. The AUC for identification of patients with more severe respiratory failure, a moderate and severe ARDS, was 0.97 (CI 95%: 0.95-1) and a cut-off score of 34.5 showed a sensitivity of 0.94 and a specificity of 0.91. The Kappa index showed a high concordance (0.83) of the classification by ultrasound lunginvolvement and ARDS.Conclusions: The combination of the ultrasound score and the presence of respiratory failure can easily identify patients with a higher risk to present complications.

Background To analyze hospitalization episodes with an ICD-9 diagnosis code of influenza (codes 487 and 488) in any diagnostic position from 2009 to 2015 in the Spanish hospital surveillance system. Methods Information about age, length of stay in hospital, mortality, comorbidity with an influenza diagnosis code between 1 October 2009 and 30 September 2015 was obtained from the National Surveillance System for Hospital Data (Conjunto Mínimo Básico de Datos, CMBD). Results 52,884 hospital admissions were obtained. A total of 24,527 admissions corresponded to diagnoses ICD-9 code 487 (46.4%), and 28,357 (53.6%) corresponded to ICD-9 code 488. The global hospitalization rates were 8.7 and 10.6 per 100,000 people, respectively. Differences between the two diagnostic groups were found for each of the six analyzed seasons. The diagnostic ICD-9-CM 488, male gender, and high-risk patients classified by risk vaccination groups showed direct relationship with inpatient hospital death. Conclusions Influenza diagnosis was present in a significant number of hospital admissions. The code used for diagnosis (ICD-9-CM 488), male sex, age groups and associated risk clinical conditions showed a direct relationship with inpatient hospital fatality.

Prior to the appearance of any foot ulcer, there is an increase in the local temperature due to the presence of an underlying inflammatory process. The use of thermometry to identify inflammation could make patients increase preventive measures until the inflammation disappears. We carried out a meta-analysis to determine the effectiveness of the daily measurement of the foot temperature in 6 points to prevent the occurrence of foot ulcers in patients with diabetes. Patients with temperature differences >4 degrees F (2.2 degrees C) between left and right corresponding sites should reduce activity and increase preventive measures until temperature is normalized. We searched the literature in MEDLINE, EMBASE, Cochrane Library, Web of Knowledge, and clinicaltrials.gov. We have only included randomized clinical trials where individuals were assigned to receive enhanced care (temperature measurement and standard care) versus standard care (education, self-care practices, and periodic clinical visits). We found 4 trials comprising 462 patients from the United States and Norway that met our inclusion criteria. The duration of follow-up varied from 4.5 to 15 months. Overall, 18 (7.9%) subjects in the enhanced foot care group and 53 (22.6%) in the standard foot care group developed foot ulcers (pooled risk ratio = 0.37; 95% confidence interval = 0.21-0.66; P = .0008; percentage of heterogeneity [I-2], 25%; P = .26). The number needed to treat was 7 (95% confidence interval = 5-11). The results were robust after analysis by subgroups according to the potential risk of bias in the studies and the duration of follow-up.

The use of devices that provide continuous positive pressure in the airway has shown improvement in various pathologies that cause respiratory failure. In the COVID 19 pandemic episode the use of these devices has become widespread, but, due to the shortage of conventional CPAP devices, alternative devices have been manufactured. The objective of this study is to describe the use of these devices, as well as their efficacy.Data are collected from patients admitted for Pneumonia due to COVID 19 at the IFEMA Field Hospital. Data are collected from 23 patients with respiratory failure and need for ventilatory support.Study carried out on a total of 23 patients, dated admission to IFEMA. Alternative CPAP was used in five patients (21.7%), while ventilatory support with a reservoir mask or Ventimask Venturi effect was used in the remaining 18 patients (78.3%). A progressive increase in saturation is observed in those patients in whom alternative CPAP was used (from 94% on average to 98% and 99% on average after 30 and 60 min with the mask, respectively), although this change was not significant (p = 0.058 and p = 0.122 respectively). No significant change in RF was observed at the beginning and end of the measurement in patients who used alternative CPAP (p = 0.423), but among those who did not use alternative CPAP (p = 0.001). A statistically significant improvement in the variable oxygen saturation / fraction inspired by oxygen is observed in patients who used alternative CPAP (p = 0.040).The use of these devices has helped the ventilatory work of several patients by improving their oxygenation parameters. To better observe the evolution of patients undergoing this therapy and compare them with patients with other types of ventilatory support, further studies are necessary.El uso de dispositivos que aportan presión positiva continua en la vía aérea ha demostrado mejoría en diversas patologías que producen insuficiencia respiratoria. En el episodio de pandemia por COVID 19 el uso de estos dispositivos se ha generalizado, pero, debido a la escasez de dispositivos convencionales de CPAP, se han fabricado dispositivos alternativos. El objetivo de este estudio es describir el uso de estos dispositivos, así como su eficacia.Se recogen datos de pacientes ingresados por Neumonía por COVID 19 en el Hospital de campaña de IFEMA. Se recogen datos de pacientes con insuficiencia respiratoria y necesidad de soporte ventilatorio.Estudio realizado sobre un total de 23 pacientes, con fecha ingreso en IFEMA. Se empleó CPAP alternativa en cinco pacientes (21,7%), mientras que en los 18 pacientes restantes (78,3%) se usó soporte ventilatorio con mascarilla reservorio o Ventimask efecto Venturi. Se observa un aumento progresivo de la saturación en aquellos pacientes en los que se empleó CPAP alternativa (de 94% de promedio a 98% y 99% de promedio tras 30 y 60 minutos con la máscara, respectivamente), aunque este cambio no resultó significativo (p = 0,058 y p = 0,122 respectivamente). No se observó un cambio significativo de frecuencia respiratoria al inicio y final de la medición en pacientes que usaron CPAP alternativa (p = 0,423) pero si entre los que no la usaron (p = 0,001). Se observa una mejoría estadísticamente significativa en la variable Saturación de oxigeno / Fracción inspirado de oxígeno en los pacientes que usaron CPAP alternativa (p = 0,040).El uso de estos dispositivos ha ayudado al trabajo ventilatorio de varios pacientes mejorando sus parámetros de oxigenación. Para observar mejor la evolución de los pacientes sometidos a esta terapia y compararlos con pacientes con otro tipo de soporte ventilatorio, son necesarios más estudios en los que se aleatorice su uso.

espanolIntroduccion El uso de dispositivos que aportan presion positiva continua en la via aerea ha demostrado mejoria en diversas patologias que producen insuficiencia respiratoria. En el episodio de pandemia por COVID-19, el uso de estos dispositivos se ha generalizado, pero, debido a la escasez de dispositivos convencionales de presion positiva continua en la via aerea (CPAP), se han fabricado dispositivos alternativos. El objetivo de este estudio es describir el uso de estos, asi como su eficacia. Material y metodos Se recogen datos de pacientes ingresados por neumonia por COVID-19 en el Hospital de Campana de IFEMA, asi como datos de pacientes con insuficiencia respiratoria y necesidad de soporte ventilatorio. Resultados Estudio realizado sobre un total de 23 pacientes, con fecha de ingreso de entre el 24 de marzo y el 28 de abril en IFEMA. Se empleo CPAP alternativa en cinco pacientes (21,7%), mientras que, en los 18 restantes (78,3%) se uso un soporte ventilatorio con mascarilla reservorio o Ventimask efecto Venturi. Se observo un aumento progresivo de la saturacion en aquellos pacientes en los que se empleo CPAP alternativa (de 94% de promedio a 98 y 99% de promedio, tras 30 y 60 minutos con la mascara, respectivamente), aunque este cambio no resulto significativo (p = 0,058 y p = 0,122, respectivamente). De igual manera, no se observo un cambio significativo de frecuencia respiratoria al inicio y al final de la medicion en pacientes que usaron CPAP alternativa (p = 0,423) pero si entre los que no la usaron (p = 0,001). Se observo una mejoria estadisticamente significativa en la variable de saturacion de oxigeno/fraccion inspirado de oxigeno en los pacientes que usaron CPAP alternativa (p = 0,040). Conclusion El uso de estos dispositivos ha ayudado al trabajo ventilatorio de varios pacientes, mejorando sus parametros de oxigenacion. Para observar mejor la evolucion de los pacientes sometidos a esta terapia y compararlos con pacientes con otro tipo de soporte ventilatorio, son necesarios mas estudios en los que se aleatorice su uso. EnglishIntroduction The use of devices that provide continuous positive pressure in the airway has shown improvement in various pathologies that cause respiratory failure. In the COVID-19 pandemic episode the use of these devices has become widespread, but, due to the shortage of conventional continuous positive airway pressure (CPAP) devices, alternative devices have been manufactured. The objective of this study is to describe the use of these devices, as well as their efficacy. Material and methods Data are collected from patients admitted for pneumonia due to COVID-19 at the IFEMA Field Hospital. Data are collected from 23 patients with respiratory failure and need for ventilatory support. Results Study carried out on a total of 23 patients, dated admission to IFEMA. Alternative CPAP was used in five patients (21.7%), while ventilatory support with a reservoir mask or Ventimask Venturi effect was used in the remaining 18 patients (78.3%). A progressive increase in saturation is observed in those patients in whom alternative CPAP was used (from 94% on average to 98 and 99% on average after 30 and 60 minutes with the mask, respectively), although this change was not significant (p = 0.058 and p = 0.122, respectively). No significant change in RF was observed at the beginning and end of the measurement in patients who used alternative CPAP (p = 0.423), but among those who did not use alternative CPAP (p = 0.001). A statistically significant improvement in the variable oxygen saturation / fraction inspired by oxygen is observed in patients who used alternative CPAP (p = 0.040) Conclusion The use of these devices has helped the ventilatory work of several patients by improving their oxygenation parameters. To better observe the evolution of patients undergoing this therapy and compare them with patients with other types of ventilatory support, further studies are necessary.

OBJECTIVE: To evaluate the use of therapy with cardiovascular benefit in patients with type 2 diabetes mellitus admitted to internal medicine departments. METHODS: One day, cross-sectional study of patients with type 2 diabetes mellitus hospitalised in internal medicine departments. We recorded demographic and anthropometric variables, laboratory data and use of antihyperglycaemic drugs. The endpoint was the proportion and determinants of the use of sodium-glucose cotransporter-2 inhibitors (SGLT2i) and glucagon-like peptide-1 receptor agonists (GLP1-RA). RESULTS: We included 928 patients belonging to 74 hospitals, with a mean age of 78.9 years (SD, 10.86 years), 50% of whom were men. A total of 557 (60%) patients had ischaemic heart disease, 189 (20.4%) had cerebrovascular disease, 293 (31.6%) had heart failure, 274 (29.5%) had chronic kidney disease, and 129 (13.9%) had peripheral arterial disease. Prior to their hospital admission, the patients were taking sulfonylureas (5.7%), biguanides (49.1%), alpha-glucosidase inhibitors (0.2%), pioglitazone (0%), dipeptidyl peptidase 4 inhibitors (39%), SGLT2i (5.8%), GLP1-RA (2.6%) and basal insulin analogues (24%). An age over 75 years was the main determinant for not taking SGLT2i (adjusted OR, 0.28; 95% CI 0.10-0.74; P=.039) or GLP1-RA (adjusted OR, 0.09; 95% CI 0.02-0.46; P=.006). DISCUSSION: A large proportion of elderly patients with type 2 diabetes mellitus at very high cardiovascular risk are not treated with antihyperglycemic drugs with proven cardiovascular benefit. The most commonly used drugs were metformin and DPP4i. There is room for improvement in the treatment of this very high-risk population.

Resumen En el presente documento se sintetizan el concepto de ecocardioscopia, los aspectos tecnicos fundamentales relacionados con esta tecnica y sus objetivos diagnosticos. Ademas, se define como deben ser la formacion y la capacitacion en ecocardioscopia. Todo ello, avalado por la Sociedad Espanola de Medicina Interna (SEMI), la Sociedad Espanola de Medicina Familiar y Comunitaria (semFYC), la Sociedad Espanola de Neurologia (SEN) y la Sociedad Espanola de Cardiologia (SEC).

This positioning document describes the most important aspects of clinical ultrasonography in the internal medicine setting, from its fundamental indications to the recommended training period. There is no question as to the considerable usefulness of this tool in the standard clinical practice of internists in numerous clinical scenarios and settings (emergencies, hospital ward, general and specific consultations and home care). Ultrasonography has a relevant impact on the practitioner's ability to resolve issues, increasing diagnostic reliability and safety and providing important information on the prognosis and progression. In recent years, ultrasonography has been incorporated as a tool in undergraduate teaching, with excellent results. The use of ultrasonography needs to be widespread. To accomplish this, we must encourage structured training and the acquisition of equipment. This document was developed by the Clinical Ultrasonography Workgroup and endorsed by the Spanish Society of Internal Medicine. (C) 2018 Elsevier Espana, S.L.U. and Sociedad Espanola de Medicina Interna (SEMI). All rights reserved.

There is growing evidence regarding the imaging findings of coronavirus disease 2019 (COVID-19) in lung ultrasounds, however, their role in predicting the prognosis has yet to be explored. Our objective was to assess the usefulness of lung ultrasound in the short-term follow-up (1 and 3 months) of patients with SARS-CoV-2 pneumonia, and to describe the progression of the most relevant lung ultrasound findings. We conducted a prospective, longitudinal and observational study performed in patients with confirmed COVID-19 who underwent a lung ultrasound examination during hospitalization and repeated it 1 and 3 months after hospital discharge. A total of 96 patients were enrolled. In the initial ultrasound, bilateral involvement was present in 100% of the patients with mild, moderate or severe ARDS. The most affected lung area was the posteroinferior (93.8%) followed by the lateral (88.7%). Subpleural consolidations were present in 68% of the patients and consolidations larger than 1 cm in 24%. One month after the initial study, only 20.8% had complete resolution on lung ultrasound. This percentage rose to 68.7% at 3 months. Residual lesions were observed in a significant percentage of patients who recovered from moderate or severe ARDS (32.4% and 61.5%, respectively). In conclusion, lung injury associated with COVID-19 might take time to resolve. The findings in this report support the use of lung ultrasound in the short-term follow-up of patients recovered from COVID-19, as a radiation-sparing, easy to use, novel care path worth exploring.

Objective: To report our experience in treating 10 consecutive patients with recalcitrant subcutaneous emphysema (SE) using two different types of subcutaneous drains. Methods: A retrospective review of our experience in managing 10 cases of recalcitrant SE. The method that we employed consisted of creating a subcutaneous tunnelization of the pre-pectoral space, under previous local anesthesia, and inserting three Penrose drains (small rubber tubes) or a multifenestrated Argyle drain in the tunnels. Results: The placement of the subcutaneous drains resolved SE in all 10 cases within a mean time of 5.3 days. No local or systemic complications were observed, but patients with the Argyle drain showed worse tolerance, presenting local pain that required treatment with additional analgesics. Conclusion: The subcutaneous drain treatment of the recalcitrant SE is a simple, safe, and effective method that should be used in clinical practice for the better comfort of patients. In our series, Penrose drains were better tolerated than the multifenestrated Argyle drains.

Objective To investigate the association between management of Internal Medical Units (IMUs) with outcomes (mortality and length of stay) within the Spanish National Health Service. Design Data on management were obtained from a descriptive transversal study performed among IMUs of the acute hospitals. Outcome indicators were taken from an administrative database of all hospital discharges from the IMUs. Setting Spanish National Health Service. Participants One hundred and twenty-four acute general hospitals with available data of management and outcomes (401 424 discharges). Main Outcome Measures IMU risk standardized mortality rates were calculated using a multilevel model adjusted by Charlson Index. Risk standardized myocardial infarction and heart failure mortality rates were calculated using specific multilevel models. Length of stay was adjusted by complexity. Results Greater hospital complexity was associated with longer average length of stays (r: 0.42; P < 0.001). Crude in-hospital mortality rates were higher at larger hospitals, but no significant differences were found when mortality was risk adjusted. There was an association between nurse workload with mortality rate for selected conditions (r: 0.25; P = 0.009). Safety committee and multidisciplinary ward rounds were also associated with outcomes. Conclusions We have not found any association between complexity and intra-hospital mortality. There is an association between some management indicators with intra-hospital mortality and the length of stay. Better disease-specific outcomes adjustments and a larger number of IMUs in the sample may provide more insights about the association between management of IMUs with healthcare outcomes.

Objective: To evaluate the use of therapy with cardiovascular benefit in patients with type 2 diabetes mellitus admitted to internal medicine departments. Methods: One day, cross-sectional study of patients with type 2 diabetes mellitus hospitalised in internal medicine departments. We recorded demographic and anthropometric variables, laboratory data and use of antihyperglycaemic drugs. The endpoint was the proportion and determinants of the use of sodium-glucose cotransporter-2 inhibitors (SGLT2i) and glucagon-like peptide-1 receptor agonists (GLP1-RA). Results: We included 928 patients belonging to 74 hospitals, with a mean age of 78.9 years (SD, 10.86 years), 50% of whom were men. A total of 557 (60%) patients had ischaemic heart disease, 189 (20.4%) had cerebrovascular disease, 293 (31.6%) had heart failure, 274 (29.5%) had chronic kidney disease, and 129 (13.9%) had peripheral arterial disease. Prior to their hospital admission, the patients were taking sulfonylureas (5.7%), biguanides (49.1%), alpha-glucosidase inhibitors (0.2%), pioglitazone (0%), dipeptidyl peptidase 4 inhibitors (39%), SGLT2i (5.8%), GLP1-RA (2.6%) and basal insulin analogues (24%). An age over 75 years was the main determinant for not taking SGLT2i (adjusted OR, 0.28; 95% CI 0.10-0.74; P = .039) or GLP1-RA (adjusted OR, 0.09; 95% CI 0.020.46; P = .006). Discussion: A large proportion of elderly patients with type 2 diabetes mellitus at very highcardiovascular risk are not treated with antihyperglycemic drugs with proven cardiovascular benefit. The most commonly used drugs were metformin and DPP4i. There is room forimprovement in the treatment of this very high-risk population. (C) 2020 Elsevier Espana, S.L.U. and Sociedad Espanola de Medicina Interna (SEMI). All rights reserved.

Background Spine is a mechanical structure, in a young and healthy individual, under a radiological focus, disposes their vertebral bodies in harmony with their stature, and progressively increasing in magnitude from the cervical to the lumbar spine, in a range of vertical growth that it can exceed the horizontal (1). It is postulated that the important obesity in the early stages of life, could modify the vertebral parameters by skeletal overloads, but the problem is that the current vertebral indexes do not measure a relation of the person height with his vertebra (2). Objectives Thus, to check whether the childhood obesity could modify the vertebral parameters, or it is accepted that it entails a loss of equivalent stature, and in this case would be necessary a study comparative of average height, or whether the harmony of the individual is accepted, it would be necessary to create an index that combine these variables to objectify if its value is a constant, and thus, eliminate the ambiguity of the observer. Methods We selected a population of obese (BMI≥35), both sex, between 20 and 55 years old, in bariatric surgery protocol, with a significant obesity in their development. Was excluded any cause that could produce vertebral flattening. As a control group, was included any patient that went to outpatient visit of rheumatology, and which met the inclusion and exclusion criteria above, except obesity. As variables, sex, age, body mass index (BMI), and with a chest lateral plate, not rotated, and in the eighth dorsal vertebra, we calculate his length (LVD8) and his height (HVD8), measured in mm. Figure 1. Finally, we applied a comparative study of average of height and vertebral index (VI) results: VI = 10 x LVD8/(HVD8 x stature) Results 90 patients were analyzed. 20 patients in the study group (22.2%): 48.1% female, 48.6 years old, 38.2 BMI, and VI 11.6 Meters-1 And 70 patients in the control group (77.8%): 51.1% females 45.15 yers old, 26.2 BMI, and VI 11.2 Meters-1 The comparative analysis of averages does not show any significant differences in the index or in the stature of these patients. Conclusion It is a small study, and according to height or the created index, it does not seem that obesity in development modifies the overall height or the vertebral parameters. In addition, the index gives a stable value regarding the sex of both populations in the eighth dorsal vertebra. References [1] White AA, Panjabi MM. Clinical Biomechanics of the Spine. 2nd ed, Lippincott Williams & Wilkins, 1990. [2] Gooding CA, Neuhause EBD (1965) Growth and developedment of the vertebral body in the presence and absence of normal stress. AJR 93:388. [3] Veiga C RM. Vertebra plana. Revision de concepto y aproximacion diagnostica. Semin Fund Esp Reumatol. 2009;10(2):56-63. Disclosure of Interests None declared

Background Chronic pain analgesia is a concern in clinical practice in rheumatic patients, especially when the intensity is severe. In this case opioids are indicated but also contraindicated in cases of important respiratory depression and, therefore, must be administered with caution to patients with respiratory disease (1). Many of our patients are not in the condition of severe respiratory depression although they present plurypathologies, which could be triggered at the use of certain doses (2). For this reason, it is important the existence of a study that shows that tapentadol is safe in pluripathological patients when used at regular doses in clinical daily practice in Reumathology (3). Objectives Single site, non-postmarketing observational study. The main objective is to evaluate the safety of tapentadol prolonged release (TPR) 50 mg/12h, measured as tolerance (“good”, “bad” or “not too bad”) and by the comparative analysis of gradients between both groups of the study (control group and pathological group), the basal oxygen saturation, and after the dose of TPR (basal pulse oximetry minus the mean of the oxygen saturation after 30 days of study). Methods Inclusions criteria arepatients with severe chronic pain (Visual Analogical Scale, VAS>4) diagnosed from mild to severe chronic obstructive pulmonary disease (COPD) (spirometry after bronchodilatation with forced expiratory volume (FEV)/forced vital capacity (FVC) Results 29 patients; 12 in control group and 17 pathological group (obesity: 9, controlled asthma: 3; mild to moderate COPD: 7; other pathologies: 7). Overall, the type of pain was nociceptive 59%, neuropathic 21% and mixed 20%; mainly women (67%), caucasic race (92%), median age 60 years old, and with 93% good tolerability and 97% good treatment adherence. Concerning results per groups, at control group, VAS mean, arterial pressure (AP), oxygen saturation (SO2) and heart rate (HR) before and after treatment. 8,3 vs 5,8; 127/74 vs 124/73 (mmHg); 95,6 vs 95,7 (%); 76 vs 73 (bpm). In the pathological group: 7,5 vs 5,6; 131/82 vs 127/78 (mmHg); 96 vs 95,5 (%); 75 vs 76 bpm. Regarding the results as per gradients between groups, no statistically significant differences were found, except for VAS, (p=0,00008). There were no cases of decrease of the oxygen saturation below 92% along the study. Conclusion The results support the safety of tapentadol from the respiratory point of view, measured by oxygen saturation, since no statistically significant differences were found between both groups, and, due to the excellent tolerability, as no clinical data showed signs of hypercapnia. No statistically significant differences were found in the oxygen saturation between both groups with the intake of TPR, with excellent tolerability and treatment adherence. There were no cases of decrease of the oxygen saturation below 92% along the study. References [1] Carr DB, How prevalent is chronic pain?. Pain clinical updates 2003; (11) 2:1-4 [2] Breivik H, ColletB, Ventafridda V, Cohen R, Gallacher, D. Survey of chronic pain in Europa: Prevalence, impact on daily life, and treatment. Eur J Pain 2006; 10 (4) 287-333 [3] Ficha Tecnica Palexia® Retard. Disclosure of Interests None declared

Background: Fragility fractures (FF) represent a health problem and among them, the VFF. They have worse vital prognosis, are at greater risk of new FF, had higher comorbidity, with clinical manifestations in only 30%-40% of cases. One in 6 women and one in 12 adult males will have a VFF. Objectives: To analyze the clinical characteristics of FF patients attended in the FLS at Virgen Macarena University Hospital. Compare the sociodemographic and clinical characteristics of VFF patients with those with OFF. Methods: Design: Prospective cohort. Patients attended in the FLS from May 2018 to November 2019 in a protocolized manner (Openclinica®). Inclusion criteria: a clinical FF in the previous two years. Descriptive statistics: percentages and means with 25th and 75th percentile. Inferential statistic by parametric and nonparametric tests. The project was approved by the Ethics Committee and patients signed consent to participate. Results: Data from 414 patients with a first FF are analyzed, 101 (25%) with VFF and 313 (76%) with OFF [188 (45%) hip, 66 (16%) distal radius, 32 (8%) humerus and 27 (6%) miscellaneous (pelvis, ribs, tibia)]. All VFFs analyzed had clinical symptoms and the number of fractured vertebrae was 2 (1-3). In 28 (37%) were FF of dorsal vertebrae, at 25 (33%) lumbar and 23 (30%) dorsal and lumbar. Comparative analysis showed differences in age VFF 71 (62-77) vs OFF 76 (66 – 83) years, p=0.0003. It highlighted a bimodal distribution according to age, with a peak incidence of 55 to 68 years and another between 75-80 years (Graph). Referral unit to FLS: VFF Rheumatology (42%) and/or Traumatology Emergency Room (44%) vs OFF Internal Medicine (45%) and General Traumatology Unit (38%), p=0.0001. There were also differences in the treatment with teriparatide (VFF 20% vs OFF 4%); zoledronate (VFF 6% vs OFF 3%) and alendronate (VFF 44% vs OFF 63%, p=0001); days of immobilization (VFF 30 (0 - 60) vs OFF 10 (0 - 30), p-0.01); they have greater independence to carry out activities of daily life (Barthel Scale) VFF 95(81 – 100) vs OFF 80 (60 – 95), p=0.00001; increased clamping force of hands 18 (12 - 20) vs 12 (8 - 18) mmHg, p=0.001, and lower risk of falls (J D Downton Scale) (VFF 43% vs OFF 60%, p=0,01). While the number of relevant comorbidities was higher in VFF 3 (1 - 5) vs OFF 2 (1 - 4) it was no statistical, p=0.3. The use of GCC was risky for VFF (n=13, 13%) vs OFF (n=17, 5%), p=0.01 and RR (95%CI) 2.3 (1.01 – 5.3) and not for other drugs (GnRH inhibitors, aromatase inhibitors or chemotherapy). No differences in sex were found (VFF 80%- vs OFF 80% women, p=0.9), previous FF history (9% vs 12%, p=0.2), secondary OP (16% vs 21%, p=0.1); percentage of patients with OP by femoral neck DEXA (VFF 35% vs 42%, p=0.2) or by lumbar spine DEXA (VFF 36% vs OFF 34%, p=0.8). Conclusion: VFF have a bimodal age-based distribution, usually occurring in younger patients, with a higher degree of independence and muscle strength and lower risk of falls, although they are associated with longer duration of immobilization, compared to OFF. In our cohort, VFFs affect 2 or more vertebrae and they are commonly treated with parenteral osteoporotic drugs. The use of glucocorticoids doubled the risk of developing a VFF, these findings are similar to those of others published cohorts. This project received a grant of the Ministry Health of the Junta de Andalucia Ref.PIN-0092-2016. Bibliography: [1]Gerdhem P. Best Practice & Research Clinical Rheumatology 27 (2013) 743–755 [2]McCarty J,et al. Diagnosis and management for vertebral compression fractures. American Family of Physicians Jul1, 2016 Vol 94 No 1. Disclosure of Interests: Blanca Hernandez-Cruz Speakers bureau: Abbvie, Lilly, Sanofi, BMS, STADA, Francisco Jesus Olmo Montes: None declared, Maria Jose Miranda Garcia: None declared, Maria Dolores Jimenez Moreno: None declared, Maria Angeles Vazquez Gomez: None declared, Mercedes Giner Garcia: None declared, Miguel Angel Colmenero Camacho: None declared, Jose Javier Perez Venegas: None declared, Maria Jose Montoya Garcia: None declared

Objectives: Diabetes mellitus is associated with a marked increase in cardiovascular disease. In this study, we analysed the prevalence of diabetes mellitus in hospitalised patients in Spain in 2015 and the burden of associated cardiovascular disease. Methods: By analysing the 2015 minimum basic data set (MBDS) of the Spanish Ministry of Health, we included all patients discharged with a diagnosis of diabetes mellitus. We describe the epidemiological characteristics, distribution by the various hospital departments and the presence of cardiovascular disease. Results: In 2015, there was 3,727,583 hospital discharges in Spain, 619,188 of which involved patients with diabetes (16.7%), 56.8% of whom were men and with a mean age of 73.2 years. The prevalence of cardiovascular disease was 40.8%, distributed among congestive heart failure (20.1%), cerebrovascular disease (10.3%), coronary artery disease (9.4%) and peripheral arterial disease (9.1%). Most of the patients were admitted to internal medicine (34.2%), cardiology (9.5%) and general surgery (8.9%) departments. The mean overall stay was 8.2 days, the readmission rate at 30 days was 14%, and the mortality rate was 6.8%. The patients hospitalized in internal medicine had higher severity levels (3-4) than those hospitalized in other medical departments (41.9% vs. 31.6%, respectively; P

Background Protozoan parasites of the genus Leishmania can cause opportunistic infections in patients using anti-tumour necrosis factor (anti-TNF) agents, and some authors recommend serological tests for leishmaniasis before using them. An outbreak of cutaneous and visceral leishmaniasis (CL,VL) occurred in the Fuenlabrada area (Spain) in 2010–2012. Some patients were on anti-TNF treatment. Objectives We aimed to explore leishmaniasis related to bilogical therapies in the literature, and to obtain data on leishmaniasis cases in patients using antiTNFs referred to our Department of Infectious Diseases Methods Literature search of leishmaniasis cases in patients using biological therapies, and to realise descriptive analysis of the clinical features of patients treated with anti-TNFs in our outbreak. Results Cases detected in the literature, included our cases, are listed in table 1. In our outbreak of Leishmaniasis, 127 VL and 194 CL cases were detected. Six patients were using anti-TNFs: 2 presented with VL and were using etanercept (33.3%) and 4 using other anti-TNFs had CL (66,6%). (table 2) These results do not coincide with the total data (table 1): CL 55.2%, VL 44.8%, 17 ADA (44,7%), 16 IFM (42,1%), 4 ETN (10.5%), 1 CTZ (2.7%). There are not more cases described with another biologic therapies at the present time. Conclusions This preliminary detection of leishmaniasis in patients using anti-TNFs is aimed at examining the safety of TNFα inhibitors in areas where Leishmania is endemic. This is a small series, but the largest described to date. Our preliminary results suggest that the use of either TNFα receptor or other anti-TNFs has the same probability of triggering the disease but etanercept seems to be associated with fewer, although more severe, cases of VL. Nevertheless, adding all the cases, Table number 1, ADA e IFM are the 86.8% of the Leishmaniasis, but perhaps will be due to this therapies are combinated and of the most prevalent use. On the other hand, no leishmaniasis cases related to IBD treatment have been described in the literature, suggesting possible involvement of therapies concomitant with the use of anti-TNF with MTX. We detected 3 additional cases of VL and 1 CL using MTX without anti-TNFs. Serological tests for leishmaniasis before using anti-TNFs might not be useful. References [1] Smith VM, Goulden V. Cutaneous leishmaniasis while taking adalimumab for psoriasis. Br J Dermatol [Internet]((Smith V.M.; Goulden V.) Dermatology Department, Leeds Teaching Hospitals, Leeds, United Kingdom)2014;171:100. [2] Guedes-Barbosa LS, Pereira da Costa I, Fernandes V, Henrique da Mota LM, de Menezes I, Aaron Scheinberg M. Leishmaniasis during anti-tumor necrosis factor therapy: report of 4 cases and review of the literature (additional 28 cases). Semin Arthritis Rheum. octubre de 2013;43(2):152–7. Acknowledgements To our families Disclosure of Interest None declared

This positioning document describes the most important aspects of clinical ultrasonography in the internal medicine setting, from its fundamental indications to the recommended training period. There is no question as to the considerable usefulness of this tool in the standard clinical practice of internists in numerous clinical scenarios and settings (emergencies, hospital ward, general and specific consultations and home care). Ultrasonography has a relevant impact on the practitioner's ability to resolve issues, increasing diagnostic reliability and safety and providing important information on the prognosis and progression. In recent years, ultrasonography has been incorporated as a tool in undergraduate teaching, with excellent results. The use of ultrasonography needs to be widespread. To accomplish this, we must encourage structured training and the acquisition of equipment. This document was developed by the Clinical Ultrasonography Workgroup and endorsed by the Spanish Society of Internal Medicine. (C) 2018 Elsevier Espana, S.L.U. and Sociedad Espanola de Medicina Interna (SEMI). All rights reserved.

To evaluate how chronic kidney disease (CKD) and diabetes mellitus (DM) influence in-hospital mortality in patients urgently admitted for acute heart failure (HF).We used data from the Spanish "Minimum Basic Data Set" for 2006-2007 to evaluate clinical differences and crude mortality rates for patients having versus non-having CKD or DM. We tested pre-specified predictive factors of in-hospital mortality in a multivariate logistic regression model, which included age, sex, CKD, DM, acute respiratory failure, a modified Charlson Comorbidity Index-excluding CKD/DM- and a CKD × DM-interaction variable. p Values 0.05 were considered significant.A total of 275,176 episodes of acute HF were analyzed (47.9% male, mean age 76.2 ± 12.8 years). CKD patients (N = 25,174, 9.1%) were older (78.4 ± 10.1 vs. 76.0 ± 13.1 years; p 0.001) and more frequently had coexisting medical conditions. DM patients (N = 88,994, 32.3%) more often had vascular risk factors and CKD (11.4% vs. 8.1%; p 0.001). Overall in-hospital mortality rate for admitted HF patients was 10.4%. Mortality was lower for DM versus non-DM patients (9.2% vs. 11.0%; p 0.001), but higher for CKD versus non-CKD patients (14.1% vs. 10.0%; p 0.001). No interaction effect was found between CKD and DM on survival for a HF episode (odds ratio; OR = 1.01, 95% CI: 0.91-1.10; p for interaction = 0.73). DM remained protective (OR = 0.85, 95% CI: 0.82-0.87; p 0.001), while CKD was associated with increased mortality (OR = 1.46, 95% CI: 1.39-1.53; p 0.001).In patients urgently admitted for HF, the association of CKD with higher in-hospital mortality was homogeneous irrespectively of the absence or presence of DM.

Objective. This study aimed to evaluate cardiovascular (CV) and atherothrombosis risk factors in patients with gout and hyperuricaemia with suspected sleep apnoeahypopnoea syndrome (SAHS) compared with a control group of subjects with knee OA and SAHS. Methods. Clinical information on CV risk factors and atherothrombosis was collected in a rheumatology department in patients with gout and hyperuricaemia and suspicion of SAHS. Confirmation polysomnography that registered apnoeahypopnoea index (AHI) and oxygen saturation during sleep (SaO2) was performed. The control group consisted of patients with OA and polysomnographically confirmed SAHS. Results. In the gout patient group (54 patients, 48 men), CV risk factors were found in 77.8% and evidence of atherothrombosis in 46.3%. In the OA group (36 patients, 27 men), CV risk factors were found in 66.7% and evidence of atherothrombosis in 0%. SAHS diagnosis was confirmed by polysomnography in 88.9% of patients. AHI showed mild, moderate and severe SAHS in 12%, 26% and 66% of the gout patients and 45%, 24% and 30% of the OA patients, respectively. SaO2 was 90.18% in the gout group and 91.26% in the OA group. Conclusion. Patients with gout and hyperuricaemia and suspicion of SAHS had polysomnographically confirmed SAHS in 88.9% of cases. These patients had more severe forms of SAHS and a greater prevalence of documented atherothrombotic disease compared with a control group with OA.

Introduction Sjogren’s syndrome (SS) is a chronic autoimmune multisystemic disease. Respiratory manifestations of SS are polymorphic and vary in severity. Among the possible manifestations, organizing pneumonia (OP) is a rare entity. Reversed halo sign (RHS) is an unusual radiological finding classically related to OP but it is also reported in other forms of interstitial pneumonitis (IP). Case presentation We report a case of a 65-year-old woman with dyspnoea and persistent-cough of 2-month duration. She presented with RHS as an initial manifestation of IP related to SS. Chest radiography and computer tomography showed multiple well defined lesions with a central ground glass area and peripheral rim of consolidation. No pathological lymph nodes were found. After investigations, the associated diagnosis of SS was confirmed. The patient started steroids (0.5 mg/kg/day) and after 10 weeks of steroid tapering a significant clinical improvement was observed, with radiological resolution of lung lesions. We make some general considerations about differential diagnosis, conditions related to RHS and different patterns of lung involvement in SS. A report of the literature emphasizes this case as an exceptional way of presentation. Conclusion To the best of our knowledge this is the second reported OP case associated with SS manifesting as RHS. RSH as an expression of IP related to SS is exceptional, either in the pattern of OP or non-specific IP.

Small cell carcinoma (SCC) of the prostate is an uncommon condition; there are very few cases in which presenting symptoms are consistent with Cushing Syndrome (CS). We report a new case in which CS triggers the suspicion of an SCC of the prostate and a review of the published cases of SCC of the prostate presenting with CS. The origin of these neoplasms is still unclear. It may be suspected when laboratory features appear in patients diagnosed with prostatic adenocarcinoma which becomes resistant to specific therapy. SCC usually occurs after the 6th decade. Patients suffering SCC of the prostate presenting with CS usually present symptoms such as hypertension, hyperglycemia, alkalosis or hypokalemia; cushingoid phenotype is less frequent. Cortisol and ACTH levels are often high. Prostatic-specific antigen levels are usually normal. CT scan is the preferred imaging test to localize the lesion, but its performance may be improved by adding other tests, such as FDG-PET scan. All patients have metastatic disease at the time of diagnosis. Lymph nodes, liver and bone are the most frequent metastases sites. Surgery and Ketokonazole are the preferred treatments for CS. The prognosis is very poor: 2- and 5-year survival rates are 27.5 and 14.3%, respectively. Key messages When a patient presents with ectopic Cushing Syndrome but lungs are normal, an atypical localization should be suspected. We should suspect a prostatic origin if Cushing Syndrome is accompanied by obstructive inferior urinary tract symptoms or in the setting of a prostatic adenocarcinoma with rapid clinical and radiological progression with relatively low PSA levels. Although no imaging test is preferred to localize these tumors, FDG-PET-TC can be very useful. Hormone marker scintigraphy (e.g. somatostatin) could be used too. As Cushing Syndrome is a paraneoplastic phenomenon, treatment of the underlying disease may help control hypercortisolism manifestations. These tumors are usually metastatic by the time of diagnosis. They have very poor prognosis.

Objectives: We evaluated the effect of an intervention on certain quality indicators employed for improving the treatment of hospital hyperglycemia. Material and methods: A multicenter cross-sectional study was conducted on patients with hyperglycemia hospitalized in the internal medicine departments of 44 hospitals evaluated in 2 time periods: 2014 (baseline period) and 2015 (postintervention period). The intervention consisted of the dissemination of the indicators obtained in 2014 and the objectives for improvement. As indicators, we assessed the frequency of glucose monitoring adapted to the patient's dietary intake or medication, the use of basal-bolus or basal-bolus-correction insulin therapy as the preferred control method of hyperglycemia and the recent availability of HbA1c prior to hospital discharge. Results: A total of 506 and 562 patients were assessed in 2014 and 2015, respectively. The results of the indicators in the baseline and postintervention periods were as follows: blood glucose monitoring adapted to the dietary intake or the medication (71.5 vs. 74.1%, P=.33), use of insulin in basal-correction regimen (32 vs. 32.6%, P=.61) or basal-bolo-correction (20.7 vs. 24, P=.20) and recent HbA1c value (54.1 vs. 66.3%, P

Objectives: We evaluated the effect of an intervention on certain quality indicators employed for improving the treatment of hospital hyperglycemia. Material and methods: A multicenter cross-sectional study was conducted on patients with hyperglycemia hospitalized in the internal medicine departments of 44 hospitals evaluated in 2 time periods: 2014 (baseline period) and 2015 (postintervention period). The intervention consisted of the dissemination of the indicators obtained in 2014 and the objectives for improvement. As indicators, we assessed the frequency of glucose monitoring adapted to the patient's dietary intake or medication, the use of basal-bolus or basal-bolus-correction insulin therapy as the preferred control method of hyperglycemia and the recent availability of HbA1c prior to hospital discharge. Results: A total of 506 and 562 patients were assessed in 2014 and 2015, respectively. The results of the indicators in the baseline and postintervention periods were as follows: blood glucose monitoring adapted to the dietary intake or the medication (71.5 vs. 74.1%, P=.33), use of insulin in basal-correction regimen (32 vs. 32.6%, P=.61) or basal-bolo-correction (20.7 vs. 24, P=.20) and recent HbA1c value (54.1 vs. 66.3%, P