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BACKGROUND: The risk of future cardiovascular events in patients with peripheral artery disease (PAD) is often underestimated. PATIENTS AND METHODS: FRENA is an ongoing, observational registry of consecutive outpatients with symptomatic PAD, coronary artery disease (CAD) or cerebrovascular disease (CVD). We compared the incidence of major cardiovascular events (i.e., myocardial infarction, ischemic stroke, critical limb ischemia, or cardiovascular death) during a 12-month follow-up period in a series of consecutive outpatients with PAD, CAD or CVD. RESULTS: As of December 2006, 1265 patients had been enrolled in FRENA who completed the 12-month follow-up. Of these, 417 patients (33%) had PAD, 474 (37%) had CAD, 374 (30%) had CVD. Patients with PAD had an increased incidence of major cardiovascular events per 100 patient-years: 17 (95% CI: 13-22) vs. 7.9 (5.5-11) in those with CAD, or 8.9 (6.1-13) in those with CVD. Compared to patients with CAD or CVD those with PAD had a similar incidence of myocardial infarction or stroke, but a higher incidence of critical limb ischemia, limb amputation and death. This incidence increased with the severity of the symptoms: 8.7 (95% CI: 5.3-13) in patients in Fontaine stage IIa; 25 (95% CI: 16-38) in stage IIb; 26 (95% CI: 13-47) in stage III; 42 (95% CI: 24-67) in stage IV. CONCLUSIONS: Our data confirm a higher incidence of major cardiovascular events for patients with PAD, as well as a correlation of these events with the severity of PAD.

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BACKGROUND AND OBJECTIVE: To know the incidence of bacteremia in outpatients (BO), their clinical and epidemiological characteristics and evolution. PATIENTS AND METHOD: We have analyzed the percentage of positive blood cultures and BO in a 10 year period. We have collected year, month, age, gender, first diagnosis, risk factors for bacteremia, microrganism, final diagnosis and diagnosis concordance. The bacteremia was classified by origin in: urinary tract infection, respiratory, abdominal, venous catheter (IVC), skin, endocarditis, bacteremia without an apparent focus (BWAF) and miscellaneous. We have compared the characteristics of the patients with and without diagnosis concordance. RESULTS: We have collected 283 episodes. The percentage of positive blood culture remained wi-thout changes and the percentage of BO tended to decrease. The most prevalent bacteria was Escherichia coli (56.5%) and the most frequent origin was urinary (59.7%) and BWAF (19.7%). There was no concordance between diagnoses in 37.1%. 30.3% of patients were admitted. Urinary tract infection was detected in 93.5% of the cases, IVC in 6.2% and BWAF in 0%. With regard to the risk factors of bacteremia, human immunodeficiency infection tended to decrease and neoplasm to increase during the study period. CONCLUSIONS: In our experience, BO tends to decrease. The management of urinary infection seems adequate, and IVC could be improved. The main challenge is the cases of BWAF.

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Fundamento y objetivo: Conocer la incidencia anual de bacteriemia en pacientes no hospitalizados (BPNH), analizar sus características clínicas y epidemiológicas, así como sus tendencias evolutivas. Pacientes y método: Se analizó un período de 10 años, durante el cual se contabilizaron el porcentaje de hemocultivos positivos y, de éstos, el porcentaje de BPNH. Se recogieron los siguientes parámetros: año, mes, edad, sexo, diagnóstico inicial, factores de riesgo para la bacteriemia, microorganismo, diagnóstico final, concordancia entre ambos y necesidad de ingreso. Se clasificaron en: infección urinaria, respiratoria, abdominal, de catéter venoso (ICV), cutánea, endocarditis, bacteriemia sin focalidad aparente (BSFA) y un grupo miscelánea. Se compararon las variables edad, sexo, año y mes entre los grupos con y sin diagnóstico concordante. Resultados: Se registraron 283 episodios. El porcentaje de hemocultivos positivos se mantuvo constante, mientras que el de BPNH tendió a descender. El microorganismo más frecuente fue Escherichia coli (56,5%), y los principales focos, el urinario (59,7%) y la BSFA (19,7%). Los diagnósticos inicial y final no eran concordantes en el 37,1% de los casos. Precisó ingreso el 30,3%. Se detectó infección urinaria en el 93,5% de los casos, ICV sólo en el 6,2% y ninguna BSFA. La presencia de los principales factores de riesgo para la bacteriemia a lo largo de los años mostró un descenso de la infección por el virus de la inmunodeficiencia humana, mientras que se advertía un ascenso de las enfermedades neoplásicas. Conclusiones: La BPNH, en nuestra experiencia, tiende a un descenso progresivo. La de origen urinario no parece preocupante, mientras que es mejorable la sospecha de ICV. La BSFA constituye el grupo más preocupante y supone un reto diagnóstico para el futuro

Background and objetive: To know the incidence of bacteremia in outpatients (BO), their clinical and epidemiological characteristics and evolution. Patients and method: We have analyzed the percentage of positive blood cultures and BO in a 10 year period. We have collected year, month, age, gender, first diagnosis, risk factors for bacteremia, microrganism, final diagnosis and diagnosis concordance. The bacteremia was classified by origin in: urinary tract infection, respiratory, abdominal, venous catheter (IVC), skin, endocarditis, bacteremia without an apparent focus (BWAF) and miscellaneous. We have compared the characteristics of the patients with and without diagnosis concordance. Results: We have collected 283 episodes. The percentage of positive blood culture remained wi-thout changes and the percentage of BO tended to decrease. The most prevalent bacteria was Escherichia coli (56.5%) and the most frequent origin was urinary (59.7%) and BWAF (19.7%). There was no concordance between diagnoses in 37.1%. 30.3% of patients were admitted. Urinary tract infection was detected in 93.5% of the cases, IVC in 6.2% and BWAF in 0%. With regard to the risk factors of bacteremia, human immunodeficiency infection tended to decrease and neoplasm to increase during the study period. Conclusions: In our experience, BO tends to decrease. The management of urinary infection seems adequate, and IVC could be improved. The main challenge is the cases of BWAF

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BACKGROUND: Erythromycin has been the treatment of choice for Legionnaires disease (LD). However, treatment failure and experimental evidence of its bacteriostatic effect have led to evaluation of new drugs such as fluoroquinolones. This study compared the evolution of patients with LD treated with macrolides and fluoroquinolones. METHODS: A prospective observational study was performed, and 130 patients from three centers were included. Diagnoses were made using Legionella urinary antigen assay in all patients. Patients receiving any antibiotic > 36 h before starting the study therapy were excluded. Group 1 included 76 patients who received macrolides (33 patients with erythromycin and 43 patients with clarithromycin), and group 2 included 54 patients treated with fluoroquinolones (50 patients with levofloxacin and 4 patients with ofloxacin). RESULTS: No significant differences were seen between the two groups regarding age, sex, smoking, alcohol intake, underlying diseases, or community/hospital acquisition. The time from onset of LD symptoms until the initiation of antibiotic treatment was 78.5 h and 92.7 h in groups 1 and 2, respectively (p = 0.1). Time to apyrexia was significantly longer in the macrolide group (77.1 h vs 48 h for groups 1 and 2, respectively; p = 0.000). There were no differences according to radiology, clinical complications, or mortality. Nevertheless, a trend to a longer hospital stay was observed in the macrolide group (9.9 days vs 7.6 days in groups 1 and 2, respectively; p = 0.09). CONCLUSIONS: Fluoroquinolones were as effective as erythromycin in the treatment of LD. It is of note that time to apyrexia was significantly shorter and hospital stay tended to be shorter in patients receiving fluoroquinolones.

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BACKGROUND AND OBJECTIVE: We intended to analyze the relation between the main symptom at hospital admission and the diagnosis mistake, assessing the reasons and clinical implications. PATIENTS AND METHOD: We analyzed hospitalized patients from the emergency room to the medical wards. We collected: age, sex, time, main symptom at admission, diagnosis at admission and final diagnosis, days of hospitalization and mortality. We established two groups: patients with a concordant diagnosis and patients with a wrong diagnosis, and we compared the characteristics of them. In each case of a wrong diagnosis, we analyzed the reason of the mistake and the clinical consequences. RESULTS: We found a wrong diagnosis in 42 (6.2%) cases. Fever, as main symptom at admission, had a significant higher rate of mistake than other symptoms. No differences were found in the other variables analyzed. Most frequently omitted diagnosis were infectious diseases, pulmonary embolism and heart failure. Main causes of mistake were a deficient clinical evaluation and X-ray interpretation. The mistake implied a delay in the specific treatment in 42.8% cases. CONCLUSIONS: Diagnostic mistakes in the emergency room are more frequent in patients attending with fever. They are mostly related to deficient clinical evaluation or wrong interpretation of X-ray findings. Although these mistakes usually lead to a delay in the treatment, no increase in the days of hospitalization or mortality is observed.

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Fundamento y objetivo: Analizar la relación entre motivo de consulta y error diagnóstico, los mecanismos clínicos de éste, y la trascendencia clínica del error, en pacientes atendidos en un área médica de urgencias. Pacientes y método: Se analizan los ingresos en el área médica comparando los diagnósticos en urgencias y al alta para detectar los casos con error. Se compararon las variables edad, sexo, horario y motivo de consulta, estancia y mortalidad, entre los grupos con y sin error. Los casos con error diagnóstico se analizaron para determinar los mecanismos del error y su trascendencia clínica. Resultados: Se detectaron 42 casos (6,2%) con error diagnóstico. No se encontraron diferencias significativas en cuanto a la distribución de edad, sexo, horario, días de estancia y mortalidad, pero sí en cuanto a los diferentes motivos de consulta, siendo la fiebre la que presentó una mayor y significativa frecuencia de error (p < 0,05). Entre los diagnósticos omitidos, los más frecuentes correspondían a enfermedades infecciosas, embolia pulmonar e insuficiencia cardíaca. Los mecanismos de error más frecuentes eran defectos en precisar los síntomas actuales, en la exploración física y en la interpretación de la radiografía de tórax. El error implicaba en el 42,8% de los casos un retraso en iniciar una medida terapéutica específica. Conclusiones: Los errores diagnósticos en urgencias son más frecuentes en los pacientes que consultan por fiebre. Se producen mayoritariamente en relación con una anamnesis sobre los síntomas actuales o exploración física insuficientes, o con una interpretación errónea de la radiología. Aunque a menudo implican retrasos en el inicio de tratamientos específicos, no incrementan la estancia hospitalaria ni la mortalidad

Background and objective: We intended to analyze the relation between the main symptom at hospital admission and the diagnosis mistake, assessing the reasons and clinical implications. Patients and method: We analyzed hospitalized patients from the emergency room to the medical wards. We collected: age, sex, time, main symptom at admission, diagnosis at admission and final diagnosis, days of hospitalization and mortality. We established two groups: patients with a concordant diagnosis and patients with a wrong diagnosis, and we compared the characteristics of them. In each case of a wrong diagnosis, we analyzed the reason of the mistake and the clinical consequences. Results: We found a wrong diagnosis in 42 (6.2%) cases. Fever, as main symptom at admission, had a significant higher rate of mistake than other symptoms. No differences were found in the other variables analyzed. Most frequently omitted diagnosis were infectious diseases, pulmonary embolism and heart failure. Main causes of mistake were a deficient clinical evaluation and X-ray interpretation. The mistake implied a delay in the specific treatment in 42.8% cases. Conclusions: Diagnostic mistakes in the emergency room are more frequent in patients attending with fever. They are mostly related to deficient clinical evaluation or wrong interpretation of X-ray findings. Although these mistakes usually lead to a delay in the treatment, no increase in the days of hospitalization or mortality is observed

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