Predictor of enhanced mortality in patients with multimorbidity and atrial fibrillation in an acute hospital setting.

BACKGROUND: Patients with atrial fibrillation (AF) admitted to hospital commonly have comorbidities. Few studies have attempted to determine factors prognostic of mortality in hospitalized AF patients with multimorbidity. AIM: To identify factors associated with mortality in hospitalized AF patients. DESIGN: Retrospective cohort study. METHODS: Patients with multimorbidity (≥2 chronic diseases), with or without AF, discharged from Lugo hospital (Spain) between 1 January 2000 and 31 December 2015. Data were extracted from hospital medical records. RESULTS: Of 74 220 patients (170 978 hospitalizations), 52 939 had multimorbidity (14 181 had AF; 38 758 no AF) and were included in our study. Patients with AF were older (mean ± standard deviation 78.6 ± 10.0 vs. 71.9 ± 14.2 years) and had a higher mortality rate (27.1 vs. 20.5%) than those without AF. Gender (female), age, stroke and congestive heart failure (CHF), but not AF, were independently associated with mortality. AF significantly increased the mortality risk in women [relative risk (RR) 1.091; 95% confidence interval (CI) 1.021-1.165; P = 0.010] and in those aged >80 years (RR 1.153; 95% CI, 1.1-1.2; P < 0.001). CHF independently increased the risk of mortality across all age groups (RR 1.496; 95% CI 1.422-1.574; P < 0.001). CONCLUSIONS: Hospitalized patients with AF have a higher mortality rate than those without AF. The prognostic significance of AF changes with age and gender while CHF is associated with the greatest risk of death.

Collaborative hospital models for shared care and on-demand interconsultations. Which offer the best results for Orthopaedic Surgery and Trauma? / Modelos colaborativos hospitalarios de asistencia compartida e interconsultas a demanda. ¿Cuál ofrece mejores resultados en Cirugía Ortopédica y Traumatología?

BACKGROUND AND OBJECTIVES: Hospitalized surgical patients are increasing in medical complexity, thereby increasing the need for support by internal medicine departments. This support is provided through interconsultations, which present problems that have resulted in the development of shared care (SC). Our objective was to compare the healthcare results achieved by the SC and interconsultation models in Orthopaedic Surgery and Trauma. MATERIALS AND METHODS: We conducted an observational, prospective, multicentre study of patients hospitalized for emergency Orthopaedic Surgery and Trauma recorded in the REINA-SEMI registry, treated by internal medicine departments through interconsultation or SC. We recorded the demographic characteristics, comorbidity, medical complications, hospital stay and mortality. RESULTS: The study included 697 patients, 415 with SC and 282 with interconsultations. The SC patients were older (78.9 vs. 74.3; P<.001) underwent more operations (89.9 vs. 78.7%; P<.001), had fewer medical complications (50.4 vs. 62.8%; P<.001) and had shorter hospital stays (10 vs. 18 days; P<.001), with no differences in comorbidity or mortality. The following independent factors were associated with stays longer than 15 days: heart failure (OR 3.4; 95% CI 1.8-6.1; P<.001), the male sex (OR 1.9; 95% CI 1.2-3.1; P=.004), electrolyte disorder (OR 2.4; 95% CI 1.3-4.4; P=.003), respiratory infection (OR 1.9; 95% CI 1.04-3.7; P=.035), surgical delay (OR 1.1; 95% CI 1.08-1.2; P<.001) and treatment using the interconsultation on demand model (OR 3.5; 95% CI 2.3-5.4; P<.001). CONCLUSIONS: SC offers better healthcare results than interconsultations for patients hospitalized for emergency Orthopaedic Surgery and Trauma.

Analysis of the activity of interconsultations conducted by the departments of internal medicine. REINA-SEMI study: Registry of Interconsultations and Shared Care of the Spanish Society of Internal Medicine. / Análisis de la actividad de interconsulta realizada por los servicios de medicina interna. Estudio REINA-SEMI: Registro de Interconsultas y Asistencia Compartida de la Sociedad Española de Medicina Interna.

OBJECTIVE: To analyse the activity of interconsultations conducted by internal medicine (IM) departments, their formal aspects and the profile of clinical care required and to quantify the workload they represent. MATERIAL AND METHOD: A multicentre, observational prospective study was conducted with consecutive hospitalised patients treated by IM departments using interconsultations between May 15 and June 15, 2016. We estimated the workload related to this activity (1time unit [TU]=10min). RESULTS: We recorded 1,141 interconsultations from 43 hospitals. The mean age of the patients involved was 69.4 years (SD: 16.2), and 51.2% were men. The mean Charlson index was 2.3 (SD: 2.2). The most common reasons for the consultations were general assessments (27.4%), fever (18.1%), dyspnoea (13.6%), metabolic disorder (9.6%), arterial hypertension (6.3%) and delirium (5.3%). The duration of the first visit was 4 TUs (SD: 5.9) and 7.3 (SD: 21.5) for the sum of all subsequent visits. The surgical patients were older (70.6 [SD, 15.9] vs. 64.4 [SD, 16.3] years; P=.0001) and required more follow-up time (5 [SD, 7.3] vs. 3.5 [SD, 4.2] days; P=.009). The following issues were more common in the interconsultation format performed by medical services: number of regular interconsultations (response >24h), specification of the reason for the interconsultation, minimal data regarding the medical history and agreement on the appropriateness of the time spent with the consultant. CONCLUSION: The patients treated through interconsultations by the IM departments represented a significant workload. The interconsultations from the medical departments were more in line with the request format.

Paralysis of the external popliteal sciatic nerve associated with daptomycin administration.

WHAT IS KNOWN AND OBJECTIVE: Peripheral neuropathy has been associated with the administration of certain drugs. Few reports have described the association of daptomycin with the development of peripheral neuropathy, none of them with peroneal nerve involvement. CASE SUMMARY: We report a case of a 62-year-old man who developed external popliteal sciatic nerve paralysis after 22 days of therapy with daptomycin. WHAT IS NEW AND CONCLUSION: We present an uncommon and not previously reported adverse event. We have also analysed a possible alteration in a metabolic pathway (ABCB1 gene polymorphisms) that, in some patients, could explain certain drug adverse events. WHAT IS NEW AND CONCLUSION: We present an uncommon and not previously reported adverse event. We have also analysed a possible alteration in a metabolic pathway (ABCB1 gene polymorphisms) that, in some patients, could explain certain drug adverse events.

Epidemiological and sociodemographic factors associated with complicated alcohol withdrawal syndrome. / Factores epidemiológicos y sociodemográficos asociados al síndrome de abstinencia alcohólica complicado.

OBJECTIVES: To analyse the influence of epidemiological and sociodemographic factors in complicated alcohol withdrawal syndrome (AWS). MATERIAL AND METHODS: A multicentre, observational prospective study was conducted on consecutively added patients with AWS hospitalised in internal medicine departments. We recorded sociodemographic, epidemiological, clinical and progression data. Complicated AWS was defined as that which progressed with seizures or delirium tremens. RESULTS: We studied 228 episodes of AWS in 219 patients. The mean age was 54.5 years (SD, 11.5), and 90.8% were men. AWS was the cause for hospitalisation in 39.9% of the patients. Some 27.1% of the cases presented seizures, and 32.4% presented delirium tremens. The daily quantity of alcohol ingested was 17.8 standard drink units (SD, 21.4), with 16.6 years of dependence (SD, 11.3). The pattern of alcohol abuse was regular in 82.8% of the patients. Some 38.4% of the patients were married or had a partner, and 45.6% had children. Some 72.7% of the patients were unemployed or retired. Some 68.5% had only completed primary studies. Some 4.8% consumed cannabis, 5.2% consumed cocaine and 3% consumed opioids. The independent variables related to complicated AWS were consumption of a drug other than alcohol (OR, 5.3; 95% CI 1.5-18.7), low education level (OR, 3.4; 95% CI 1.6-7.3) and hospitalisation for AWS (OR, 2.9; 95% CI 1.5-5.6). The model's receiver operating characteristic area was 0.718 (95% CI 0.643-0.793). CONCLUSIONS: Concomitant drug abuse and a low educational level could help identify patients at risk of complicated AWS.

Characteristics and temporal pattern of readmissions of patients with atrial fibrillation hospitalized in medical departments. / Características y patrón temporal de reingresos de los pacientes con fibrilación auricular hospitalizados en servicios médicos.

OBJECTIVE: To determine the characteristics of patients with auricular fibrillation (AF) in the hospital setting and their successive hospitalisations. METHOD: A retrospective cohort study was conducted on all hospital admissions in the medical area of hospital of Lugo between January 1, 2000 and December 31, 2013. The data source was the centre's minimum basic data set. RESULTS: A total of 149,271 hospital admissions corresponding to 66,286 patients were recorded. Of the total, the percentage of admissions and patients with AF was 17.3% (25,870) and 18.9% (12,512), respectively. The patients with AF were characterized by a larger proportion of women (49.7 vs. 44.3%; P<.0001), advanced age (78.3 [DE 10.2] vs. 67.1 years [DE 17.9]; P<.0001), more chronic diseases (4.2 [DE 2.1] vs. 2.9 [DE 1.9]; P<.001), longer hospital stays (12.5 [DE 12.5] vs. 10.6 [DE 19.9] days; P<.0001) and a high rate of readmissions (3.0 [DE 2.75] vs. 2.1 [DE 2.28]; P<.001), with a progressive shortening of the time between hospitalisations. The department of internal medicine was responsible for the care of more than half of the patients with AF. The most common associated secondary diagnoses were chronic obstructive pulmonary disease, stroke, heart failure, ischemic heart disease, other respiratory system diseases and arterial hypertension. CONCLUSIONS: AF occurs in highly complex patients, who are mostly hospitalized in internal medicine departments, and is associated with a high rate of readmissions. We need to consider the diseases associated with AF for an overall approach to these patients.

General principles of medical interconsultation for hospitalised patients.

Medical interconsultation for hospitalised patients is a regular activity among internal medicine specialists. However, despite its growing impact and importance, a model that defines its characteristics, objectives and information has not been established. This study, conducted by the Shared Care and Interconsultations Group of the Spanish Society of Internal Medicine, proposes a number of general recommendations concerning the method for requesting and responding to hospital medical interconsultations, as well as a format for these interconsultations.

Inpatient alcohol withdrawal syndrome. / Síndrome de abstinencia alcohólica en pacientes hospitalizados.

A 55-year-old man was admitted for a femur fracture; an alcohol fetor was noted on admission. The following day, the patient began to experience tremors and nervousness. Intravenous haloperidol was administered. Shortly afterwards, the patient experienced two generalized seizures and then began to experience delirium and uncontrollable agitation. The patient was diagnosed with alcohol withdrawal syndrome; high doses of intravenous midazolam were prescribed and infused. A few hours later, the patient presented signs of respiratory depression, requiring a transfer to the intensive care unit. After a review of the medical history, it was determined that the patient had been admitted on 3 previous occasions due to alcohol withdrawal and had progressed to delirium tremens after experiencing seizures. Can the risk of alcohol withdrawal syndrome and the need for prophylactic treatment be assessed on admission? Were appropriate monitoring and treatment measures employed? Would it have been possible to change his outcome?

Definitions of Internal Medicine activities outside of the im department. / Definiciones de la actividad de Medicina Interna fuera de su propio servicio.

The inpatient profile is changing towards patients with multiple diseases, the elderly and those with high comorbidity. The growing complexity of their care, the progressive medical superspecialization and the organizational problems that often hinder daily patient follow-up by the same physician have contributed to a progressive increase in the participation of medical departments, especially Internal Medicine, in the care of patients hospitalized in other medical and surgical specialties. The hospital activities that the departments of internal medicine perform outside of their own department do not have well-established definitions and criteria at the organizational level; their assessment and accountability are different in each hospital. In this document, we establish the definitions for shared care, advisory medicine, perioperative medicine and interconsultation, as well as their types in terms of priority, formality, care setting, timeliness, relationship with surgery and other circumstances.

[Risk factors for the development of medical complications in patients with hip fracture]. / Factores de riesgo para la presentación de complicaciones médicas en enfermos con fractura de cadera.

OBJECTIVE: To evaluate the clinical features and outcome of inpatients with hip fracture and to investigate the clinical variables associated with the risk of medical complications. METHODS: Prospective study of hip fracture patients aged 65 or more, admitted to the Department of Orthopaedic Surgery of the Xeral-Calde Hospital, in Lugo, Spain, in 2008. The different clinical and biochemical variables as regards the baseline health status and presentation features of the hip fracture and its complications were all recorded. The factors associated with the development of medical inpatient complications, including death, were determined, using univariate and multivariate analyses. RESULTS: A total of 258 patients were studied. The mean age was 82.2 (9.5) years, and 76% were women. The fracture was osteoporotic in 96.8%, and 92.6% were treated surgically. The mean Barthel index was 72.9 (25.7) and the age adjusted Charlson comorbidity index was 5.2 (1.5). A total of 63.9% patients had a major medical complication during their hospital stay. Mortality was 5.8%. The following variables were associated with the development of medical inpatient complications: Barthel index (OR=2.21; 95% CI, 1.1-4.25; p=0,01), age (OR=1.09; 95% CI, 1.02-1.12; p=0.006), haemoglobin at admission (OR=0.76; 95% CI, 0.62-0.93; p=0.01). CONCLUSIONS: Patients with hip fracture are fragile elderly with a high degree of functional dependence and comorbidity. Those with a high risk of developing medical inpatient complications can be identified at admission.

[Clinical course and features of the alcohol withdrawal syndrome in a general hospital]. / Manifestaciones y curso clínico del síndrome de abstinencia alcohólica en un hospital general.

INTRODUCTION: Despite its frequency and high clinical burden, few studies have analyzed the clinical features of the alcohol withdrawal syndrome in a hospital setting. Our purpose was to describe its manifestations and clinical course in a general hospital. PATIENTS AND METHODS: Patients with a diagnosis of alcohol withdrawal since January 1983 to December 2003, according to the revised fourth edition of the Diagnostic and Statistical Manual of Mental Disorders criteria, at the Xeral-Calde General Hospital in Lugo, were studied. Clinical and biochemical data at admission were collected, as well as those referred to the clinical course and complications. RESULTS: 539 episodes in 436 patients were included. Mean age was 45 (standard deviation: 12), and 91,3% were men. Abstinence was the reason for admission in 62,3%. 71,1% had a diagnosis of delirium tremens during their stay. Hallucinations were present in 59,7%, and convulsions (most of them generalized) in 41%. Patients with delirium tremens had greater elevations in temperature, heart rate and blood pressure, as well as more convulsions than minor withdrawal cases. Cirrhosis was present in 10%. The admission rate to the Intensive Care Unit (ICU) was 37,8% (95% confidence interval [95%IC]: 33,1-37,8). Of these, 69,9% needed mechanical ventilation. Mortality rate was 6,6% (95%IC: 4,2-9,1). 62% of patients died after admission in the ICU. CONCLUSION: The majority of complications related to the alcohol withdrawal syndrome in a hospital setting develop in patients with delirium tremens. They are especially related to the rate of admissions to the ICU and the use of mechanical ventilation.

[Analysis of the investigation activity of the internist from the Public Bid of Employment in Galicia]. / Análisis de la actividad investigadora de los internistas gallegos a partir de los resultados de la oferta pública de empleo.

OBJECTIVES: The aim of the present study was to assess the investigative activity of the internists. Data were collected from the Public Bid of Employment (PBE) performed in Galicia in 2005, and compared with the rest of medical subspecialities. METHODS: The results from the PBE related to internal medicine and medical subspecialities are available in the web page of the Galician Service of Health. The following data were studied: speciality, sex, method of attainment of the specialist degree, thesis, and scores obtained in Galician language exam, professional experience, professional report, postgraduate teaching and published scientific papers. RESULTS: Data from 355 specialists were analyzed: 118 (33.2%) were internists, and 237 (66.8%) were medical subspecialists. There were no differences between internal medicine and the rest of subspecialities in terms of sex, method of attainment of the specialist degree, thesis, and scores obtained in Galician language exam, professional experience and postgraduate teaching. Internists presented fewer scientific papers than subspecialists, even when they were classified according to different levels of professional experience. Degrees obtained by the MIR system were associated with more publications (p < 0.001). The attainment of the job was associated to scores obtained in the professional report, professional experience, and published scientific papers (p < 0.001). The obtaining of the job was associated to the accomplishment of the doctoral thesis in the university teaching hospitals (A Coruña, Santiago y Vigo, p < 0.005). CONCLUSIONS: The investigative activity of the internists in Galicia is inferior to the rest of the medical subspecialists. It seems necessary to stimulate the internists to developing scientific investigation and to improve those skills of the internal medicine residents.

[Should we use oral replacement for vitamin B12 deficiency as the first option of treatment?]. / 'Debemos utilizar la vía oral como primera opción para el tratamiento del déficit de vitamina B12?

OBJECTIVE: Analyze whether the tablets available in Spain are useful for oral replacement in the treatment of vitamin B12 deficiency. METHODS: From June 2003 to December 2005, patients with vitamin B12 deficiency attended at the Internal Medicine Clinic, were offered the possibility of starting or switching to oral therapy. Clinical and biochemical responses were monitored at baseline and at 2, 4, 6, 12, 18 y 24 months of follow-up. RESULTS: Twenty-eight patients were included (55.6% women), with a mean age of 74.96 +/- 9.98 years. Twenty-three cases (82.1%) had pernicious anemia, and 5 were gastrectomized. Patients who switched from intramuscular to oral therapy (16 cases) showed no decrease in the mean values of hemoglobin and B12 levels during the follow-up. Patients who started on oral therapy showed an increase in the values of hemoglobin (from 9.9 +/- 2.8 g/dl to 13.5 +/- 1.1, p = 0.003) and vitamin B12 (from 118 +/- 50 pg/ml to 496 +/- 229, p = 0.001) as early as two months after baseline, maintaining the response during the follow-up. No patient refused oral therapy and no toxic effect attributed to oral therapy was recorded. CONCLUSIONS: Oral replacement of vitamin B12 deficiency with the tablets available in Spain is safe, effective and acceptable to patients.

[Health status of the oldest old: functional and medical situation in centenarians]. / Estado de salud de los muy ancianos: situación clínica y funcional de la población centenaria.

OBJECTIVE: We planned a prospective and descriptive analysis of the centenarian population in Lugo sanitary area, establishing their social, functional and medical status as well as its relationship with their basic hematological and biochemical parameters. MATERIAL AND METHODS: During the study period between January 2001 and September 2003, participants were visited at home by a doctor and a nurse. The following variables were assessed: social status, past medical history, physical examination, functional status (Barthel index), blood analysis. RESULTS: 54 centenarians were interviewed, 16 men and 38 women. 75.9% were widows; 87% lived with their family and 57,4% in urban areas. 79.6% had followed studies. All of them had their own incomes. Regarding past medical history, 64.8% had some visual or auditive disturbances, 81.5% were taking medical drugs, 59.3% had some surgical intervention and 46.3% had been hospitalized for medical reasons. Their vaccination status was poor. Functional status, assessed by Barthel index, showed an average of 59 +/- 36.4, higher in men (82.7 +/- 28.7) than in women (49.6 +/- 35.1) (p<0.003). Blood samples were analyzed in 51 cases, there were not significant differences among them regarding sex or physical disability. CONCLUSION: The features of the centenarian population of Lugo are similar to other countries. It is an heterogeneous group. There are more women, but their clinical and functional status are significantly worse than in males. We have not founded a relationship between hematological and nutritional parameters and the degree of functional dependence in centenarians.

[The internist's role in the medical evaluation of surgical patients]. / Papel del internista como consultor de servicios quirúrgicos.

OBJECTIVE: To describe the characteristics of the consultations carried out by surgical services to an Internal Medicine service and to determine what factors influence the prognosis of these patients. METHODS: A prospective study of the consultations carried out by the surgical services of a 540-bed hospital to an Internal Medicine service. Analyzed variables were: age, sex, service of reference, reason for consultation, medical and admission diagnoses done during the admission, and clinical evolution. RESULTS: In the study 453 interconsultations were included, corresponding to 0.96 new interconsultations by working day and to 4.05 interconsultations per every 100 admissions in surgical services during the period study. The reasons for the more common consultations were dyspnea, fever, electrolytic and metabolic disorders, assessment of multiple conditions and acute confusional syndrome. Two or more diagnoses were carried out in 257 patients (56.7%). The average number of visits carried out by patient was 3.9 +/- 3.9. The average hospital stay in the study group was 28 +/- 33.05 days, while the average hospital stay of patients admitted in the surgical services during the same period was 11.6 days. Fifty patients (11%) had died at the time of the "medical discharge", and this percentage amounted to 20.5% (93 cases) upon considering the end of the hospital admission, compared with the global mortality of 3.7% registered during that period in the surgical services. The number of medical diagnoses and the age were independent predictors of mortality in the multivariate analysis. CONCLUSIONS: The interconsultations of the surgical services to an Internal Medicine service imply an important workload. The patients are complex from the medical standpoint. The average hospital stay and mortality of these patients are different from that of the patients cared in surgical services.

[Centenarian patients attended at a general hospital]. / Pacientes centenarios atendidos en un hospital general.

BACKGROUND: To report the social and medical situation of centenarian patients who required emergency hospital care during the last 8 years. METHOD: Retrospective study of patients aged over 100 years attended at the Emergency Department of a general hospital. The percentages of admissions and mortality rates were then compared with those among patients aged over 65. RESULTS: A total of 51 consultations from 41 patients were recorded, with a mean age of 101.2 years. The number of consultations increased gradually with time (p = 0.008). Ninety-three percent of patients lived with their families, predominantly in the rural setting. The most prevalent conditions included the prostatic syndrome (among males), heart failure and chronic obstruction to the airflow. Only 20% of patients had dementia. Sixty-four percent of consultations required hospital admission, with a mortality rate of 20.5% in this group of patients. The most common discharge diagnoses were heart failure and acute cerebrovascular accident. CONCLUSIONS: A gradual increase in hospital care is likely to be excepted among centenarians, who have an acceptable health status, although with a high risk of mortality during hospital admission.