Factors associated with in-hospital and outpatient survival of patients with different types of stage IV cancer and venous thromboembolism.

OBJECTIVE: To identify factors associated with in-hospital and outpatient survival of patients with different types of stage IV cancer who present with venous thromboembolic disease (VTE). METHODS: In this prospective cohort, in-hospital and outpatient survival rates up to 180 days were analyzed using Kaplan-Meier curves. Cox regression was used to identify factors associated with different survival functions. RESULTS: One hundred patients were analyzed (median age, 67.5 years; 75% with Charlson index of <10; 69% with Eastern Cooperative Oncology Group (ECOG) score of 3-4). In-hospital mortality was 18%, and the median time from admission to death was 11 days (interquartile range, 1-61 days). Factors significantly associated with in-hospital mortality were the ECOG score and thrombocytopenia. The 180-day mortality rate was 52%, with deaths mainly occurring in the first 90 days since VTE diagnosis. Additional factors significantly associated with outpatient mortality included male sex and neoplasms with a high risk of thrombosis (lung, pancreas, stomach, uterus, bladder, and kidney neoplasms). CONCLUSION: Patients with stage IV cancer and acute VTE have short survival. Poor prognostic factors are thrombocytopenia, the ECOG score, and certain types of cancer. These results may help physicians individualize decisions regarding initiation and continuation of anticoagulant therapy.

Validation of the PESI Scale to Predict in-Hospital Mortality in Patients with Pulmonary Thromboembolism Secondary to SARS CoV - 2 Infection.

OBJECTIVE: To evaluate the discriminative ability and the calibration of the Pulmonary Embolism Severity Index (PESI) to predict in-hospital mortality in patients with Pulmonary Embolism (PE) secondary to COVID 19 in two hospitals in Bogotá. METHODS: External validation study of a prediction model based on a retrospective cohort of patients with PE secondary to COVID-19 treated at Hospital Universitario San Ignacio and Hospital universitario La Samaritana, between March 2020 and August 2021. Calibration of the scale was evaluated using the Hosmer-Lemeshow test and a calibration belt diagram. Discrimination ability was evaluated using a ROC curve. RESULTS: 272 patients were included (median age 61.5 years, male 58.8%). PE was diagnosed in 45.6% of the patients at the time of admission. Of the remaining 54.4%, 95.9% received thromboprophylaxis until the time of diagnosis.17.6% of the patients died. Regarding calibration, the scale systematically underestimates risk in all classes of PESI. For class I, the ratio of observed/expected events was 4.4 vs 0.8%, class II 4.8 vs 1.8%, class III 15.2 vs 4.2%, class IV 14.3 vs 5.9% and class V 46.7 vs 5.8%. The calibration test rejected the adequate calibration hypothesis (p < 0.001). The discriminatory ability was adequate (AUC = 0.7128, 95% CI 0.63-0.79). CONCLUSIONS: The PESI scale in patients with PE secondary to COVID 19 underestimates the risk of in-hospital mortality, while maintaining adequate discrimination. It is suggested not to use the PESI scale until it is recalibrated in this context.

Improving compliance to clinical practice guidelines with a multifaceted quality improvement program for the prevention of venous thromboembolic disease in nonsurgical patients.

OBJECTIVE: To evaluate the change in compliance to thromboprophylaxis guidelines before and after the implementation of a multifaceted patient safety program. DESIGN: Longitudinal before and after study. SETTING: Teaching hospital, Hospital Universitario San Ignacio, Bogotá (Colombia). PARTICIPANTS: Adult nonsurgical hospitalized patients. INTERVENTION: A multifaceted program for the prevention of venous thromboembolic (VTE) disease among adult nonsurgical hospitalized patients. The strategies of the program included (i) update and communication of thromboprophylaxis guidelines, (ii) the implementation of risk-assessment tools in electronic medical records, (iii) nursing staff activities and (iv) education to health personnel and patients for maintenance of the program. MAIN OUTCOME MEASURE: Appropriate use of thromboprophylaxis. RESULTS: 221 and 236 patients were evaluated in the pre- and postimplementation periods, respectively. Global appropriate thromboprophylaxis prescription went from 74.66 to 82.6% (P = 0.064). Adequate thromboprophylaxis in high-risk patients did not increase significantly (77.70 vs 80.62%, P = 0.528), but a significant reduction in inappropriate thromboprophylaxis formulation in low-risk patients was found, decreasing from 20.55 to 5.26% (P = 0.005). CONCLUSIONS: Implementing a quality improvement multifaceted program improves the formulation of adequate thromboprophylaxis. Reducing the inappropriate prescription of VTE prophylaxis in patients at low risk of thrombosis can lead to a reduction in bleeding complications and a better use of economic and human resources.

Colonization by Pneumocystis jirovecii in patients with chronic obstructive pulmonary disease: association with exacerbations and lung function status.

Exposure to Pneumocystis jirovecii (P. jirovecii) can lead to a wide variety of presenting features ranging from colonization in immunocompetent patients with lung disease, to invasive infections in immunocompromised hosts. Colonization by this fungus in patients with chronic obstructive pulmonary disease (COPD) could be associated with higher rates of exacerbations and impaired lung function in these patients. Our objective was to determine whether colonization by P. jirovecii in patients with COPD is associated with increased exacerbations and deterioration of lung function. This was a prospective cohort study on patients with COPD. All participants meeting selection criteria underwent clinical and microbiological assessments and were then classified as colonized vs. non-colonized patients. Chi-squared tests were performed and multivariate logistic models were fitted in order to obtain risk ratios (RR) with 95% confidence intervals (CI). We documented a frequency of colonization by P. jirovecii of 32.3%. Most patients were categorized as having GOLD B and D COPD. The history of significant exacerbations in the last year, health status impairment (COPD Assesment Tool ≥10), airflow limitation (percent of post-bronchodilator FEV1), and BODEx score (≥5) were similar between groups. After a 52-week follow-up period, the rate of adjusted significant exacerbations did not differ between groups. However, a decrease in FEVI was found in both groups.

Leiomiomatosis intravascular gigante con extensión a cavidades cardíacas / Giant intravascular leiomyomatosis intravascular with extension to the cardiac cavities

Resumen Se presenta el caso de inusual crecimiento intracardíaco de leiomiomatosis intravascular gigante en una mujer de 38 años, en quien durante evaluación prequirúrgica de cirugía abdominal se documentó de manera incidental una masa en cavidades cardiacas derechas. Dada su presentación infrecuente y las dificultades en el abordaje diagnóstico y terapéutico, se realiza posterior revisión de la literatura.

Abstract The case is presented of an unusual intracardiac growth of a giant intravascular leiomyomatosis in a 38 year-old woman. During a pre-surgical evaluation for abdominal surgery, the incidental finding of a mass in the right cardiac cavities was noted. Given its uncommon presentation and the difficulties in the diagnostic and therapeutic approach, a subsequent review of the literature was performed.

FRECUENCIA DE LA COLONIZACIÓN POR PNEUMOCYSTIS JIROVECII EN PACIENTES CON ENFERMEDAD PULMONAR OBSTRUCTIVA CRÓNICA EN BOGOTÁ, COLOMBIA / Pneumocystis jirovecii colonization frequency in Chronic Obstructive Pulmonary Disease (COPD) patients in Bogota, Colombia

Antecedentes: la colonización por Pneumocystis jirovecci (P. jirovecii) se ha postulado como causa de deterioro de la función pulmonar en pacientes con Enfermedad Pulmonar Obstructiva Crónica (EPOC). Se desconocía la frecuencia de aparición de la colonización por P. jirovencii en esa población en Colombia. Objetivo: documentar la frecuencia de colonización por P. jirovecii en mayores de 40 años con EPOC excluyendo a los pacientes que requirieran manejo inmunosupresor y a las personas infectadas por el Virus de la Inmunodeficiencia Humana (VIH). Materiales y métodos: se trató de un estudio de corte transversal, que contó con muestreo no probabilístico por conveniencia y selección continua de pacientes. Se realizó PCR (reacción en cadena de polimerasa) en tiempo real (rt-PCR) del esputo inducido con el Kit LighMix de P. jirovecii (Roche®-Suiza) amplificándose un fragmento de 244 pares de bases a partir del gen de la glicoproteína de superficie del hongo. Resultados: para una muestra de 52 pacientes en total, se documentó una frecuencia de colonización del 15,4% en todos los participantes mayores de 65 años, quienes además presentaron altos índices de sintomatología según la escala modificada Medical Research Council (MR Cm) y el cuestionario de evaluación de la EPOC (CAT). La mayoría de pacientes analizados se clasificó como GOLD D (63%) en la clasificación por la Iniciativa Global para la EPOC. Conclusiones: la frecuencia de colonización por P. jirovecii en pacientes con EPOC detectada por rt-PCR en el esputo inducido fue del 15,4%. Este constituye el primer estudio colombiano que evalúa la frecuencia de colonización del hongo.

Background: Pneumocystis jirovecii colonization has been proposed as the explanation for lung function decline in patients with Chronic Obstructive Pulmonary Disease (COPD). The colonization frequency due to Pneumocystis jirovecii in this group of patients was yet unknown in Colombia. Objective: To document the frequency of colonization in patients over 40 years old with COPD diagnosis. The study excludes patients who require immunosuppressive treatment and who are infected with Human Immunodeficiency Virus (HIV). Materials and methods: A cross-sectional study was held, using non-probabilistic convenience sampling with continuous patient selection. Real time PCR (rt-PCR) of P. jirovecii was performed in an induced sputum sample, the fragment of 244 base pairs from the major surface glycoprotein gene of the fungus was amplified using the LighMix Kit (Roche®-Switzerland). Results: From the sample of 52 patients, we found a frequency of colonization of 15.4%. All colonized patients were over 65 years old with high symptomatology levels according to the modified Medical Research Council scale (MRCm), and the COPD Evaluation Test (CAT). Most of the colonized patients were classified as GOLD D (63%), as rated by the Global Initiative for COPD. Conclusions: The colonization frequency due to P. jirovecii in COPD patients detected by rt-PCR in induced sputum was 15.4%. This is the first study to assess the frequency of P. jirovecii colonization in Colombia.