Symptom-related screening programme for early detection of chronic thromboembolic pulmonary hypertension after acute pulmonary embolism: the SYSPPE study.

BACKGROUND: Chronic thromboembolic pulmonary hypertension (CTEPH) is the most severe long-term complication of acute pulmonary embolism (PE). We aimed to evaluate the impact of a symptom screening programme to detect CTEPH in PE survivors. METHODS: This was a multicentre cohort study of patients diagnosed with acute symptomatic PE between January 2017 and December 2018 in 16 centres in Spain. Patients were contacted by phone 2 years after the index PE diagnosis. Those with dyspnoea corresponding to a New York Heart Association (NYHA)/WHO scale≥II, visited the outpatient clinic for echocardiography and further diagnostic tests including right heart catheterisation (RHC). The primary outcome was the new diagnosis of CTEPH confirmed by RHC. RESULTS: Out of 1077 patients with acute PE, 646 were included in the symptom screening. At 2 years, 21.8% (n=141) reported dyspnoea NYHA/WHO scale≥II. Before symptom screening protocol, five patients were diagnosed with CTEPH following routine care. In patients with NYHA/WHO scale≥II, after symptom screening protocol, the echocardiographic probability of pulmonary hypertension (PH) was low, intermediate and high in 76.6% (n=95), 21.8% (n=27) and 1.6% (n=2), respectively. After performing additional diagnostic test in the latter 2 groups, 12 additional CTEPH cases were confirmed. CONCLUSIONS: The implementation of this simple strategy based on symptom evaluation by phone diagnosed more than doubled the number of CTEPH cases. Dedicated follow-up algorithms for PE survivors help diagnosing CTEPH earlier. TRIAL REGISTRATION NUMBER: NCT03953560.

Anemia and bleeding in patients receiving anticoagulant therapy for venous thromboembolism.

In patients receiving anticoagulant therapy for venous thromboembolism (VTE), the important issue of anemia influence on the risk of bleeding has not been consistently studied. We used the large registry data RIETE (Registro Informatizado Enfermedad Tromboembólica) to compare the rate of major bleeding in patients receiving anticoagulant therapy for VTE according to the presence or absence of anemia at baseline. Patients with or without cancer were separately studied. Until August 2016, 63492 patients had been enrolled. Of these, 21652 (34%) had anemia and 14312 (23%) had cancer. Anemia was found in 57% of the patients with cancer and in 28% without (odds ratio 3.46; 95% CI 3.33-3.60). During the course of anticoagulant therapy, 680 patients with cancer had a major bleeding event (gastrointestinal tract 43%, intracranial 14%, hematoma 12%). Cancer patients with anemia had a higher rate of major bleeding (rate ratio [RR]: 2.52; 95% CI 2.14-2.97) and fatal bleeding (RR 2.73; 95% CI 1.95-3.86) than those without anemia. During the course of anticoagulation, 1133 patients without cancer had major bleeding (gastrointestinal tract 32%, hematoma 24%, intracranial 21%). Patients with anemia had a higher rate of major bleeding (RR 2.84; 95% CI 2.52-2.39) and fatal bleeding (RR 2.76; 95% CI 2.07-3.67) than those without. On a multivariable analysis, anemia independently predicted the risk for major bleeding in patients with and without cancer (hazard ratios: 1.66; 95% CI 1.40-1.96 and 1.95; 95% CI 1.72-2.20, respectively). During anticoagulation for VTE, both cancer- and non-cancer anemic patients had a higher risk for major bleeding than those without anemia. In anemic patients (with or without cancer), the rate of major bleeding during the course of anticoagulant therapy exceeded the rate of VTE recurrences. In patients without anemia the rate of major bleeding was lower than the rate of VTE recurrences.

Effect of the administration of different forms of vitamin D on central blood pressure and aortic stiffness, and its implication in the reduction of albuminuria in chronic kidney disease. / Efecto de la administración de diferentes formas de vitamina D en la presión arterial y rigidez aórticas, y su implicación en la reducción de la albuminuria en la enfermedad renal crónica.

BACKGROUND AND OBJECTIVES: Vitamin D(vitD) participates in phospho-calcium metabolism and exerts multiple pleiotropic effects. There is tissue 1-α (OH)ase that converts 25-OH cholecalciferol (25 (OH) D) in calcitriol that exerts autocrine and paracrine effects. 25 (OH)D deficiency could limit these tissue effects of vitD. The administration of nutritional vitD and the activator of the vitD receptor, paricalcitol, may promote beneficial effects on vascular and renal function. The objective of this work was to study in subjects with chronic kidney disease (CKD) the effect that the administration of different forms of vitD has on arterial function and albuminuria, and the possible relationship between the modifications of these variables. PATIENTS AND METHODS: We studied in 97 patients with CKD stages 3-4 the effect of the administration of cholecalciferol (group 2; n: 35) and paricalcitol (n: 31; group 3) on parameters derived from brachial blood pressure, aortic blood pressure and on aortic stiffness studied using carotid-femoral pulse velocity (Vpc-f), and on albuminuria. A group of patients with stages 3-4 CKD who did not receive vitD therapy served as a control group (n: 31; group 1). All parameters were studied at baseline and after the follow-up period which was 7 ± 2 months. RESULTS: In the baseline phase, no differences were observed between the groups in brachial systolic blood pressure (bSBP), central systolic blood pressure (SBP), brachial pulse pressure (bPP), and central pulse pressure (pCP) or in aortic stiffness that was increased in all groups with a baseline Vpc-f value of 10.5 (9.2-12.1) m/sec. The baseline albuminuria value in the grouped patients was 229 (43-876) mg / g (median (interquartile range)), with no differences between the groups. Serum calcium and phosphorus increased significantly in those treated with cholecal-ciferol (native vitD) and paricalcitol (active vitD). Parathormone (PTH) values decreased in those treated with paricalcitol.bPP and cPP decreased in all groups treated with native and active vitD. No significant changes in bPP and cPP were observed in the control group. Vpc-f did not change significantly in any of the groups, although the variation was quantitatively greater in group 3 (11.2±2 vs. 10.7±1.6 (P=.06)). No differences were observed in the changes in Vpc-f between the groups when adjusted to the baseline values of estimated glomerular filtration rate (eGFR), albuminuria, PTH, vitD, brachial and central blood pressure parameters, and their changes with treatment.Those who received treatment with native and active vitD presented a significant decrease in albuminuria of 17% (group 2) and 21% (group 3) compared to a 16% increase in the untreated group (group 1) (P=.01). A decrease in albuminuria ≥30% was observed more frequently in the groups treated with some form of vitD (group 2: 23%; group 3: 45%) than in the control group (13%) (P=.03). The decrease in albuminuria observed in the groups treated with any of the forms of vitD did not vary when the baseline values of the biochemical parameters of phosphorus-calcium metabolism, those of arterial function (PPb, PPc, Vpc-f) or its modifications were introduced as covariates. There was no significant correlation between changes in Vpc-f and albuminuria. In logistic regression, changes in arterial function parameters were also not explanatory for the ≥30% decrease in albuminuria. CONCLUSIONS: In patients with CKD stages 3-4, treated with RAS blockers and with residual albuminuria, the administration of or paricalcitol reduces brachial and aortic pulse pressures, and albuminuria. The decrease in albuminuria does not seem to be mediated, at least not decisively, by changes in central hemodynamics or aortic stiffness.

El reto de comenzar a impartir cuidados paliativos en una facultad de medicina. ¿Es útil esta materia para los futuros médicos? / The challenge of begining to teach palliative care in medical school. Will this be useful for future doctors?

INTRODUCCIÓN Y OBJETIVO: Impartir la materia de cuidados paliativos a nivel universitario se ha iniciado hace pocos años, con un progresivo aumento de las universidades donde este hecho está ocurriendo. En nuestro caso llevamos 2 cursos haciéndolo, con la sensación de ser algo positivo para nuestros alumnos. Quisimos valorar si nuestros alumnos adquirían los adecuados conocimientos científicos que se presuponen al impartir la asignatura, pero además conocer hasta qué punto llegaban a percibir esos otros aspectos que hacen peculiar a la medicina paliativa y que tanto ayudan en la relación médico-paciente-familia. Material y MÉTODO: Definimos la muestra como todos los alumnos de la facultad de medicina de quinto curso que cursan la materia de cuidados paliativos durante los cursos académicos 2013-2014 y 2014-2015. Antes de la intervención completaron un test de 8 ítems sobre conocimientos básicos de cuidados paliativos (preguntas cerradas). Posteriormente a la intervención se completó otro test con las mismas preguntas cerradas a las que se añadieron 6 cuestiones abiertas en las que se exploran también sus opiniones y actitudes respecto a los cuidados paliativos. RESULTADOS: De los alumnos matriculados en los 2 años en la asignatura acudieron a clases, y por tanto realizaron el test de preintervención, 102 y el test postintervención 105. La edad media fue de 23,16 años (±2,25). El 67% fueron mujeres y el 33% hombres. Sesenta y siete (65,6%) no conocían lo que son los cuidados paliativos al iniciar el curso. Las entidades clínicas que asociaban con más frecuencia a los cuidados paliativos antes de iniciar la materia fueron el cáncer de pulmón 95 (93%) y de colon 90 (88%), variando los resultados en el test al finalizar el curso. Los profesionales de medicina y enfermería (100%) son los más referidos, otros se incluyen o aumenta su número tras la intervención. Los conocimientos teóricos muestran un aumento en las respuestas afirmativas, así como las preguntas que hacen referencias a aspectos más generales. CONCLUSIONES: Existe una mejora en los conocimientos teóricos que deben asimilar los alumnos de esta área de la medicina. Además la mayoría de los alumnos participantes muestran actitudes de mejora tras impartir la materia en aspectos fundamentales de cuidados paliativos

INTRODUCTION AND OBJECTIVE: The teaching of palliative care has begun recently in certain universities. In our case, we have given two courses with positive outcome. We want to investigate if our students were able to acquire the necessary skills of basic palliative care and if they also appreciate the aspects of the bedside manner needed for our practice. Material and method: We prepared a survey to be taken by fifth year medical students undertaking our palliative care course during the academic years 2003-2014 and 2014-2015. The survey was carried out before the first class was taught (pre-intervention test) and after completing the course (post-intervention test). RESULTS: A total of 102 students undertook the pre-intervention test and 105 the post-intervention test. The average age of the students was 23.16 years (+/- 2.25). Sixty-seven percent were female and 33% male. A total of 67 (65.6%) had no idea of the meaning of palliative care when they started the course. They associated lung cancer 95 (93%) and colon cancer 90 (88%) as the most common diseases treated by palliative care at first, and changed their opinion after taking the course. They identified doctors and nurses (100%) as the only professionals that practiced palliative care; however, they identified other professionals involved after the course. The students also acquired more theoretical knowledge on concluding the course as well as acquiring more general knowledge of palliative care. CONCLUSIONS: We have seen an improvement in the medical knowledge that a medical student should have about palliative care. We have also seen that the students acquired a better bedside manner and better communication skills in talking to patients and their relatives