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This study tested the hypothesis that a more senescent immune system would predict a worse outcome in older patients hospitalized for community-acquired pneumonia (CAP). CAP has long been responsible for high rates of mortality and readmissions among older people. Although immunosenescence is a key factor in the increased susceptibility to infections, there are no related biomarkers currently available in clinical practice. In this context, the aim of this prospective study was to identify immunosenescence-related biomarkers to predict outcomes in patients older than 65 years hospitalized for CAP. We evaluated 97 patients admitted to our hospital for CAP in 2019 and 2020. All patients were followed for 1 year. Our findings showed that elevated levels of early differentiated CD28+ CD27+ T cells at admission were associated with better short (2 months) and long-term (1 year) outcomes in terms of mortality and readmissions. Early differentiated CD28+ CD27+ CD4+ T cell counts were even better long-term predictors. In conclusion, early differentiated CD28+ CD27+ T cells could be useful biomarkers to identify high-risk older patients with CAP, helping clinicians with risk stratification and follow-up.

This study tested the hypothesis that a more senescent immune system would predict a worse outcome in older patients hospitalized for community-acquired pneumonia (CAP). CAP has long been responsible for high rates of mortality and readmissions among older people. Although immunosenescence is a key factor in the increased susceptibility to infections, there are no related biomarkers currently available in clinical practice. In this context, the aim of this prospective study was to identify immunosenescence-related biomarkers to predict outcomes in patients older than 65 years hospitalized for CAP. We evaluated 97 patients admitted to our hospital for CAP in 2019 and 2020. All patients were followed for 1 year. Our findings showed that elevated levels of early differentiated CD28

The leading causes of mortality in our study were pneumonia, diseases of the circulatory system, and dementias. In patients with hip fractures, the emphasis should be placed not only on measures to prevent falls and osteoporosis, but also on preventing functional decline and pneumonia. Purpose: To describe the specific causes of death in patients who died up to 2 years after sustaining a hip fracture, how many of those deaths were directly related to the hip fracture, and the risk factors for mortality. Methods A retrospective review of the clinical data of all patients admitted with hip fractures between December 2009 and September 2015. Cause of death was classified according to the International Statistical Classification of Diseases and Related Health Problems (ICD10) Results In the first 2 years after hip fracture, 911 patients (32.7%) died. The leading causes of mortality were pneumonia 177 (19.4%), diseases of the circulatory system 146 (16%), and dementias 126 (13.9%). Thirty patients (3.2%) died from causes directly related to hip fracture or surgery. Mortality risk factors with a higher relative risk were advanced age, male sex, higher comorbidity, delirium, and medical complications during admission. Conclusions Pneumonia and circulatory system diseases were the commonest causes of death in our study. In patients with hip fractures, emphasis should be placed on preventing functional decline and pneumonia. In a few patients, death was directly related to the hip fracture, although decompensation of chronic illness as a result of hip fracture and fracture-related functional decline may have been indirect causes. Patients with worse conditions at admission had the highest risk of mortality.

Introduction: Centenarians and nonagenarians constitute a rapidly growing age group in Western countries and they are expected to be admitted to hospital with hip fractures. The aim of this study was to compare outcomes of centenarian and nonagenarian patients following a hip fracture and to identify risk factors related to in-hospital and post-discharge mortality in both groups. Patients and methods: A prospective evaluation of centenarian patients and nonagenarian controls admitted to a tertiary university hospital in Barcelona with hip fractures over a period of 5 years and 9 months. Baseline characteristics and outcomes in both patient groups were compared. Variables associated with in-hospital, 30-day, 3-month and 1-year mortality were also analyzed. Results: Thirty-three centenarians and 82 nonagenarians were included. The most relevant statistically significant differences found were: Barthel index at admission (61.90 vs. 75.22), number of drugs before admission (4.21 vs 5.55), in-hospital complication rates (97 vs. 78%), readmissions at 3 months and 1 year (0 vs 11.7% and 3.4 vs. 19.5% respectively) and mortality at 3 months and 1 year (41.4 vs. 20.8% and 62.1 vs. 29.9%, respectively). Mean number of complications, rapid atrial fibrillation, mean age, and urinary tract infection were risk factors associated with mortality. Conclusions: Centenarian patients had similar in-hospital outcomes to nonagenarians, but experienced more complications and twice the 3-month and 1-year mortality rate. The mean number of complications was the risk factor most consistently related to in-hospital and post-discharge mortality. These findings emphasize the need to improve care in very old patients to prevent complications. (C) 2018 Elsevier Ltd. All rights reserved.

Introduction Previous studies of antihypertensive treatment of older patients have focused on blood pressure control, cardiovascular risk or adherence, whereas data on inappropriate antihypertensive prescriptions to older patients are scarce. Objectives The aim of the study was to assess inappropriate antihypertensive prescriptions to older patients. Methods An observational, prospective multicentric study was conducted to assess potentially inappropriate prescription of antihypertensive drugs, in patients aged 75 years and older with arterial hypertension (HTN), in the month prior to hospital admission, using four instruments: Beers, Screening Tool of Older Person's Prescriptions (STOPP), Screening Tool to Alert Doctors to the Right Treatment (START) and Assessing Care of Vulnerable Elders 3 (ACOVE-3). Primary care and hospital electronic records were reviewed for HTN diagnoses, antihypertensive treatment and blood pressure readings. Results Of 672 patients, 532 (median age 85 years, 56% female) had HTN. 21.6% received antihypertensive monotherapy, 4.7% received no hypertensive treatment, and the remainder received a combination of antihypertensive therapies. The most frequently prescribed antihypertensive drugs were diuretics (53.5%), angiotensin-converting enzyme inhibitors (ACEIs) (41%), calcium antagonists (32.2%), angiotensin receptor blockers (29.7%) and beta-blockers (29.7%). Potentially inappropriate prescription was observed in 51.3% of patients (27.8% overprescription and 35% underprescription). The most frequent inappropriately prescribed drugs were calcium antagonists (overprescribed), ACEIs and beta-blockers (underprescribed). ACEI and beta-blocker underprescriptions were independently associated with heart failure admissions [ beta-blockers odds ratio (OR) 0.53, 95% confidence interval (CI) 0.39-0.71, p < 0.001; ACEIs OR 0.50, 95% CI 0.36-0.70, p < 0.001]. Conclusion Potentially inappropriate prescription was detected in more than half of patients receiving antihypertensive treatment. Underprescription was more frequent than overprescription. ACEIs and beta-blockers were frequently underprescribed and were associated with heart failure admissions.

The purpose of this study is to describe the characteristics of older patients treated with psychotropic medicines and the associated factors and to assess their inappropriate use. An observational, prospective study was carried out in 672 elderly patients admitted to seven hospitals for a year. A comparison of sociodemographic characteristics, geriatric variables, multimorbidity and the number of prescribed medicines taken in the preceding month before hospitalization between patients treated with psychotropics and those not treated was performed. To assess factors associated with psychotropics, multivariate logistic regression analyses were performed. Inappropriate use was assessed using the Beers and the STOPP criteria. A total of 57.5 % patients (median [Q1-Q3] age 81.7 [78.2-86.1], 65.7 % female) were treated with psychotropics (44.2 % anxiolytics, 22.6 % antidepressants and 10.8 % antipsychotics). Independent factors associated with the use of psychotropics were female gender (OR = 2.3; CI 95 %,1.6-3.5), some degree of disability on admission (slight [OR = 2.2; 1.2-4.2], moderate [OR = 3.2, 1.6-6.6], severe [OR = 3.4; 1.4-8] and very severe [OR = 5.1; 2.0-12.8]) and polypharmacy (5-9 medicines [OR = 3.0; 1.3-6.9] and a parts per thousand yen10 medicines [OR = 6.0; 2.7-13.6]). The associated factors varied depending on the different types of psychotropics. In patients treated with psychotropics, the percentage of those with at least one Beers (61.6 %) or at least one STOPP (71.4 %) criteria was significantly higher in comparison with those not treated with psychotropics (30.7 and 47.7 %, respectively, p < 0.001). Psychotropics are widely used in the elderly population and often their use is inappropriate. Female gender, a poor functional status and polypharmacy, are the characteristics linked to their use. Interventional strategies should be focused on patients with these characteristics.

Resumen Introduccion El objetivo principal del estudio es evaluar si una intervencion multidimensional en los ancianos que han sido ingresados por neumonia disminuye los reingresos hospitalarios y el numero de consultas a urgencias durante el ano siguiente a la intervencion. Metodologia Ensayo clinico no farmacologico unicentrico con 2 grupos de estudio paralelos en los que los pacientes son asignados aleatoriamente. Se incluiran 314 pacientes (157 en cada grupo). Seran sujetos del estudio los pacientes ≥ 65 anos con indice de Barthel ≥ 60 que ingresen por neumonia. El grupo intervencion recibira a los 2 meses del ingreso por neumonia una intervencion geriatrica realizada por un medico y una enfermera en la que se incluyen los siguientes componentes: vacunacion, nutricion, estado funcional, estado cognitivo y comorbilidades. El grupo control realizara el seguimiento convencional. Se evaluara al ano de la intervencion el numero de ingresos, consultas a urgencias, estado funcional, supervivencia e institucionalizacion. Si esta intervencion demostrara mejorar las variables estudiadas, dispondriamos de una intervencion estandarizada y relativamente sencilla que nos permitiria mejorar los resultados de salud a nivel individual e indirectamente disminuir los costes relacionados con la asistencia a estos pacientes.

To analyze factors related to drug-resistant pathogens (DRPs) in community-onset pneumonia (COP) and whether previously suggested criteria are useful in our emergency-department.Prospective 1-year study of adults coming to the emergency department for COP. We assessed the usefulness of criteria used in health-care-associated pneumonia (HCAP), as well the Shorr index, the Barthel index, and clinical suspicion of resistant pathogens. Data were analyzed by multiple logistic regression and the area under the receiver operating characteristic curve (AUC).We included 139 patients with a mean (SD) age of 75.9 (15.3) years; 63.3% were men. Forty-nine COP patients (35.2%) were at risk for DRP-caused pneumonia according to HCAP criteria; 43 (30.9%) according to the Shorr index, and 56 (40.3%) according to the Aliberti index. A score of less than 60 derived from the Barthel index was recorded for 25 patients (18%). Clinical suspicion of a DRP was recorded for 11 (7.9%). A DRP was isolated in 5 patients (3.6%) (3, Pseudomonas aeruginosa; 2, methicillin-resistant Staphylococcus aureus). Multiple logistic regression analysis identified 2 predictors of DRP-caused COP: hospital admission within the last 90 days (odds ratio [OR], 8.92; 95% CI, 1.92-41.45) and initial arterial blood oxygen saturation (OR, 0.85; 95% CI, 0.74-0.98). The AUC was 0.91 (95% CI, 0.85-0.98). The model identified 22 patients (16.8%) at risk for DRP-caused pneumonia. The positive and negative predictive values were 20% and 99.1%, respectively, for the model 90-day period (vs 8.7% and 98.9%, respectively, for criteria used in HCAP).Hospitalization within the 90-day period before a COP emergency and arterial blood oxygen saturation were good predictors of DRP in our setting. Criteria of DRP in HCAP, on the other hand, had lower ability to identify patients at risk in COP.Analizar en las neumonías de la comunidad diagnosticados en nuestro centro los predictores de etiología por patógenos resistentes (PR) y evaluar la utilidad de distintos criterios de riesgo de PR previamente sugeridos.Se estudiaron prospectivamente durante 1 año los pacientes adultos procedentes de la comunidad atendidos en el servicio de urgencias (SU) por neumonía. Se evaluaron los criterios definitorios de neumonía asociada al cuidado sanitario (NACS), así como los índices de Shorr, Aliberti y Barthel y el juicio clínico de PR. Se realizó regresión logística múltiple y se calculó el área bajo la curva receptor-operador (ABC-ROC).Se incluyeron 139 pacientes con una edad media de 75 (DE: 15,3) años, el 63,3% varones. Tenían riesgo de PR según los criterios de NACS 49 (35,2%), según el índice de Shorr 43 (30,9%) y según índice de Aliberti 56 (40,3%). Se encontró un I. Barthel60 en 25 enfermos (18%) y juicio clínico de PR en 11 (7,9%). Se aisló PR en el 3,6% (3 Pseudomonas aeruginosa y 2 Staphylococcus aureus meticilin resistentes). En el análisis multivariado fueron predictores de PR el haber ingresado en los 90 días previos, con una odds ratio (OR) de 8,92 [intervalo de confianza (IC) 95%: 1,92-41,45], y la saturación inicial de oxígeno, con una OR de 0,85 [IC 95%: 0,74-0,98] con ABC-ROC de 0,91 (IC 95%: 0,85-0,98). Nuestro modelo identificó 22 pacientes (16,8%) con riesgo de PR, con valor predictivo positivo y negativo del 20% y 99,1%, respectivamente, frente a un 8,7% y 98,9%, respectivamente para NACS.En las neumonías de nuestro centro el antecedente de ingreso en los 90 días previos junto con la saturación de oxígeno fueron buenos predictores de PR, mientras que los criterios de NACS tuvieron menor capacidad de discriminación.

The incidence of pneumonia increases with age and contributes to morbidity and mortality in the elderly. In our setting, pneumonia is the sixth leading cause of death and the fourth most common diagnosis at discharge from acute hospitals. This article reviews current concepts in management of pneumonia in the elderly: healthcare-associated pneumonia, aspiration and oropharyngeal dysphagia, risk stratification, and indications of radiological, microbiological and biological markers. We present current evidence on antibiotic treatment (when to start, empirical coverage, duration, new drugs and combinations) and adjuvant treatment (steroids, early mobilization, oral hygiene, prevention and treatment of aspiration and cardiac complications). We emphasize preventive aspects and considerations regarding palliative treatment.

To analyse potentially inappropriate prescribing (PIP) in elderly polypathological patients (PP).Multicentre observational, prospective study of 672 patients aged 75 years and older hospitalised in Internal Medicine between April 2011 and March 2012. The Beers, STOPP-START and ACOVE criteria were used to detect potentially inappropriate prescribing and the results of PP and non-PP patients were compared.Of the 672 patients included, 419 (62%) were polypathological, of which 89.3% met PIP criteria versus 79.4% of non-polypathological patients (p0.01). 40.3% of polypathological patients met at least one Beers criteria, 62.8% at least one STOPP criteria, 62.3% at least one START criteria and 65.6% at least one ACOVE criteria. The rate of potentially inappropriate prescribing was higher in polypathological patients regardless of the tool used.Given the high rate of potentially inappropriate prescribing in polypathological patients, strategies to improve prescribing adequacy must be developed.

Background: Hyperkalaemia is a serious adverse effect of unfractionated heparin, but the effect of low-molecular-weight heparins (LMWHs) on potassium levels is not clear. Previous studies have shown a disparity of results depending on the dose and type of LMWH used. Objective: To analyse potassium level variations in medical and surgical inpatients receiving the LMWH bemiparin sodium at prophylactic doses and assess the consequent effective risk of hyperkalaemia in a real-life setting. Methods: This was a prospective observational study conducted over a 9-month period in a university teaching hospital. Patients consecutively admitted to internal medicine wards for general medical conditions (n = 145) or to traumatology wards for hip fractures (n = 98) and who received prophylactic bemiparin sodium were enrolled in the study. The intervention consisted of daily dosages of bemiparin sodium (Hibor (R)) 3500IU (56%) or 2500IU (44%) for a minimum of 5 days. The mean age of participants was 80.5 years, with 91.8% being aged >= 65 years. Eighty-six percent of patients had co-morbidities and 79.4% were taking medication affecting potassium homeostasis. The main outcome measures were variations in serum potassium levels observed within 4-8 days of starting bemiparin sodium and the presence of hyperkalaemia (serum potassium >5.1 mmol/L) while on bemiparin sodium treatment. Results: After patients had received bemiparin sodium for a median 6-day period, the mean (+/- SD) serum potassium level increased from 4.1 +/- 0.5 to 4.3 +/- 0.5 mmol/L (p < 0.001). Hyperkalaemia >5.1 mmol/L developed in ten patients (4.1%), but serum potassium levels >5.5 mmol/L related to bemiparin sodium were present in only two (0.8%). Laboratory tests between the fourth and eighth days identified all but one case of hyperkalaemia. Patients were not symptomatic and discontinuation of bemiparin sodium treatment was not required. There were no statistically significant differences in potassium disturbances between older (aged >= 65 years) and younger (aged 4.6 mmol/L was considered the cut-off value for predicting hyperkalaemia (sensitivity 90% and specificity 70%). Conclusions: Serum potassium levels in in-hospital traumatology and medical patients increased significantly with bemiparin sodium prophylaxis but the incidence of relevant hyperkalaemia was low. Patients taking bemiparin sodium who are treated with ACE inhibitors or who have a baseline potassium level >4.6 mmol/L should be monitored for serum potassium levels between days 4 and 8 of hospital admission.

Aims To assess inappropriate prescribing in older people with diabetes mellitus during the month prior to a hospitalization, using tools on potentially inappropriate medicines (PIMs) and potential prescribing omissions (PPOs) and comparing inappropriate prescribing in patients with without diabetes. Methods In an observational, prospective multicentric study, we assessed inappropriate prescribing in 672 patients aged 75 years and older during hospital admission. The Beers, Screening Tool of Older Person's Prescriptions (STOPP) and Screening Tool to Alert Doctors to Right Treatment (START) criteria and Assessing Care of Vulnerable Elders (ACOVE-3) medicine quality indicators were used. We analysed demographic and clinical factors associated with inappropriate prescribing. Results Of 672 patients, 249 (mean age 82.4 years, 62.9% female) had a diagnosis of diabetes mellitus. The mean number of prescribing drugs per patient with diabetes was 12.6 (4.5) vs. 9.4 (4.3) in patients without diabetes (P < 0.001). Of those patients with diabetes, 74.2% used 10 or more medications; 54.5% of patients with diabetes had at least one Beers-listed PIM, 68.1% had at least one STOPP-listed PIM, 64.6% had at least one START-listed PPO and 62.8% had at least one ACOVE-3-listed PPO. Except for the Beers criteria, these prevalences were significantly higher in patients with diabetes than in those without. After excluding diabetes-related items from these tools, only STOPP-listed PIMs remained significantly higher among patients with diabetes (P = 0.04). Conclusions Polypharmacy is common among older patients with diabetes mellitus. Inappropriate prescribing is higher in older patients with diabetes, even when diabetes-related treatment is excluded from the inappropriate prescribing evaluation.

Objective: Patients with heart failure (HF) seen at the emergency department (ED) are increasingly older and more likely to present delirium. Little is known, however, about the impact of this syndrome on outcome in these patients. We aimed to investigate the prognostic value and risk factors of delirium at admission (prevalent delirium) in ED patients with decompensated HF. Methods and Results: We performed a prospective, observational study, analyzing the presence of prevalent delirium in decompensated HF patients attended at the ED in 2 hospitals in Spain in the context of the Epidemiology Acute Heart Failure Emergency project. We used the brief Confusion Assessment Method to assess the presence of delirium. Patients were followed for 1 month after discharge. Of 239 enrolled patients (81.7 +/- 9.4 years, women 61.1%, long-term care [LTC] 11%), 35 (14.6%) had prevalent delirium (20% LTC vs 9.4% in-home, P = .078). The factors associated with delirium in the multivariate analysis were functional dependence (P = .001) and dementia (P = .005). Prevalent delirium was an independent risk factor of death within 30 days (OR 3.532; 95% CI 1.422-8.769, P = .007) whereas autonomy in basic activities of daily living was a protective factor (OR 0.971; 95% CI 0.956-0.986, P = .001). The area under the ROC curve for our 30-day mortality model was 0.802 (95% CI 0.721-0.883, P = .001). Conclusion: Prevalent delirium in patients with decompensated HF was a predictor of short-term mortality. Routine identification of delirium in patients at risk, particularly those with greater functional dependence, can help emergency physicians in decision-making and enhance care in patients with decompensated HF. (C) 2015 AMDA - The Society for Post-Acute and Long-Term Care Medicine.

Objective To evaluate short- and long-term outcomes of elderly patients (≥ 65 years) treated at an intermediate care unit (IMCU) and to identify outcome predictors.

Objectives: To evaluate the outcome of elderly patients with community-acquired pneumonia (CAP) seen at an acute-care hospital, analyzing the importance of CAP severity, functional status, comorbidity, and frailty. Design: Prospective observational study. Setting: Emergency department and geriatric medical day hospital of a university teaching hospital. Participants: Ninety-nine patients aged 65 and older seen for CAP over a 6-month recruitment period. Measurements: Clinical data were used to calculate Pneumonia Severity Index (PSI), Barthel Index (BI), Charlson Comorbidity Index, and Hospital Admission Risk Profile (HARP). Patients were then assessed 15 days later to determine functional decline and 30 days and 18 months later for mortality and readmission. Multiple logistic regression was used to analyze outcomes. Results: Functional decline was observed in 23% of the 93 survivors. Within the 30-day period, case-fatality rate was 6% and readmission rate 11%; 18-month rates were 24% and 59%, respectively. Higher BI was a protective factor for 30-day and 18-month mortality (odds ratio (OR)=0.96, 95% confidence interval (CI)=0.94–0.98 and OR=0.97, 95% CI=0.95–0.99, respectively; P

BACKGROUND: Initiation of combination antiretroviral therapy may be followed by inflammatory reactions. We studied the epidemiology of herpes zoster infection among patients with human immunodeficiency virus (HIV) infection who were treated with combination antiretroviral therapy. SUBJECTS AND METHODS: Of 316 patients who initiated combination antiretroviral therapy, 24 (8%) were treated for herpes zoster within 17 weeks of starting therapy. The characteristics of these cases were compared with those of a control group of 96 HIV-1–infected patients, who were matched by age, sex, plasma HIV-1 RNA concentration and CD4 cell counts, and length of follow-up. RESULTS: The incidence of herpes zoster associated with combination antiretroviral therapy was 9 episodes per 100 patient-years. There were no significant differences between cases and controls in age, sex, years of HIV infection, history of herpes zoster, previous acquired immune deficiency syndrome, or baseline mean CD4 and CD8 cell counts before beginning combination antiretroviral therapy. However, patients who developed herpes zoster had a significantly greater mean (± SD) increase in the number of CD8 cells than did controls (347 ± 269 vs. 54 ± 331 cells/mL, P = 0.0006). In a multivariate analysis, the only factor that was associated with the development of herpes zoster was the increase in CD8 cells from before initiation of combination antiretroviral therapy to 1 month before development of herpes zoster (odds ratio 1.3 per percentage increase; 95% confidence interval: 1.1 to 1.5; P = 0.0002). CONCLUSION: The initiation of combination antiretroviral therapy in HIV-1–infected patients was often associated with the development of herpes zoster, especially in those in whom the number of CD8 cells increased after therapy.

Purpose: This study aims to assess inappropriate prescribing (IP) to elderly patients during the month prior to hospitalization and to compare different IP criteria. Methods: An observational, prospective and multicentric study was carried out in the internal medicine services of seven Spanish hospitals. Patients aged 75 years and olderwere randomly selected after hospital admission for a year. To assess potentially inappropriate medicines (PIMs), the Beers and STOPP criteria were used and to assess potentially prescribing omissions (PPOs), the START criteria and ACOVE-3 medicine quality indicators were used. An analysis to assess factors associated with IP was performed. Results: 672 patients [median age (Q1-Q3) 82 (79-86) years, 55.9% female] were included. Median prescribed medicines in the month prior to hospitalization were 10(Q1-Q3 7-13). The prevalence of IP was 87.6%, and 54.3% of patients had PIMs and PPOs concurrently. A higher prevalence rate of PIMs was predicted using the STOPP criteria than with the Beers criteria (p < 0.001) and a higher prevalence of PPOs using the ACOVE-3 criteria than using the START criteria (p < 0.001) was observed. Polypharmacy (>= 10 medicines) was the strongest predictor of IP [OR = 11.34 95% confidence interval (CI) 4.96-25.94], PIMs [OR = 14.16, 95% CI 6.44-31.12], Beers-listed PIMs [OR = 8.19, 95% CI 3.01-22.28] and STOPP-listed PIMs [OR = 8.21, 95% CI 3.47-19.44]. PIMs was the strongest predictor of PPOs [OR = 2.79, 95% CI 1.81-4.28]. Conclusions: A high prevalence of polypharmacy and PIMs and PPOs were reported. More than half the patients had simultaneous PIMs and PPOs. The related factors to PIMs and PPOs were different. (c) 2014 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved.

Purpose: There are limited tools to assess potential prescribing omissions (PPOs) or underprescribing in the elderly. The ACOVE project defines comprehensive quality care indicators for older people and some of these indicators focused on appropriate use of medicines. The aim of the present study was to assess the inter-rater reliability between observers using the ACOVE 3 prescribing indicated medications indicators and compare it with the inter-rater reliability obtained for the Screening Tool of Older Person's Prescriptions (STOPP)/Screening Tool to Alert Doctors to Right Treatment (START) criteria. Methods: In the context of an observational and multicentric study of a cohort of 672 patients 75 years and older who were hospitalized in Internal Medicine services of seven Spanish hospitals, an inter-rater reliability study using the ACOVE selected indicators and the STOPP/START criteria was carried out between April 2011 and March 2012. Three patients were randomly selected in each participating hospital, one for each four months of study. Results: A total of 21 patients (mean (SD) age of 84.3 (5.6) years, 57.1% female) were included in the inter-rater reliability study. For the STOPP, START and ACOVE criteria, the median kappa coefficient for the seven hospital analyses was 0.97, 0.92 and 0.95, respectively. Out of 123 total indicators in only 7 (5.7%) was the kappa coefficient value below 0.75. Only for 2 (5.6%) of the 37 studies selected ACOVE quality indicators was the kappa coefficient value less than 0.75. Conclusions: A high inter-rater reliability was obtained for the selected underprescribing quality indicators of ACOVE 3. These quality indicators may be considered a useful tool in detecting underprescribing to the elderly patients. (C) 2014 Elsevier Ireland Ltd. All rights reserved.

The incidence of pneumonia increases with age and contributes to morbidity and mortality in the elderly. In our setting, pneumonia is the sixth leading cause of death and the fourth most common diagnosis at discharge from acute hospitals. This article reviews current concepts in management of pneumonia in the elderly: healthcare-associated pneumonia, aspiration and oropharyngeal dysphagia, risk stratification, and indications of radiological, microbiological and biological markers. We present current evidence on antibiotic treatment (when to start, empirical coverage, duration, new drugs and combinations) and adjuvant treatment (steroids, early mobilization, oral hygiene, prevention and treatment of aspiration and cardiac complications). We emphasize preventive aspects and considerations regarding palliative treatment.

Of the 316 patients who initiated combination antiretroviral therapy, 24 were treated for herpes zoster within 17 weeks of starting therapy. The characteristics of these cases were compared with those of a control group of 96 human immunodeficiency virus type-1 (HIV-1) infected patients, who were matched by age, sex, plasma, HIV-1 RNA concentration and CD4 cell counts, and length of follow-up. The incidence of herpes zoster associated with combination antiretroviral therapy was 9 episodes per 100 patient years. There were no significant differences between cases and controls in age, sex, years of HIV infection, history of herpes zoster, previous acquired immune deficiency syndrome, or baseline mean CD4 and CD8 cell counts before beginning combination antiretroviral therapy. However, patients who developed herpes zoster had a significantly greater mean increase in the number of CD8 cells than did controls. Conclude that the initiation of combination antiretroviral therapy in HIV-1 infected patients was often associated with the development of herpes zoster especially in those whom the number of CD8 cells increased after therapy.

Nocardia farcinica is a rare Nocardia species causing localised and disseminated infections. A case of Nocardia farcinica infection is presented, and 52 cases previously reported in the literature are reviewed. The hosts usually had predisposing conditions (85%), and acquired the infection through the respiratory tract or skin; the infection then often spread to the brain, kidney, joints, bones and eyes. Pulmonary or pleural infections (43%), brain abscesses (30%) and wound infections (15%) which failed to respond to conventional antimicrobial therapy were the more frequent forms of infection. Nocardia farcinica was frequently isolated from pus (100% of samples), bronchial secretions (41%) and biopsy specimens (63%), but isolation from blood and urine, as in the case presented here, is rare. Antibiotic therapy was adequate in 61% of the patients in whom it was specified, the agents most frequently given being trimethoprim-sulfamethoxazole (54%), amikacin combined with imipenem (7%) and amoxicillin-clavulanate (7%). The high mortality (31%) can be attributed to the severe underlying diseases present, difficulties encountered in identifying the pathogen, inappropriate therapy and late initiation of therapy. Although an infrequent pathogen, Nocardia farcinica should be kept in mind as a cause of infection especially in immunosuppressed patients with indolent infections not responding to third-generation cephalosporins.