Form of presentation, natural history and course of postoperative venous thromboembolism in patients operated on for pelvic and abdominal cancer. Analysis of the RIETE registry. / Forma de presentación, historia natural y evolución de la enfermedad tromboembólica venosa postoperatoria en pacientes operados por cáncer abdominal y pélvico. Análisis del registro RIETE.

INTRODUCTION: Venous thromboembolism (VTE) represents a serious complication after oncologic surgery. Recent studies have shown that the risk of VTE persists several weeks after surgery. This study assesses the form of presentation and time course of VTE after abdominal and pelvic cancer surgery. METHODS: Prospective, multicenter, observational study that analyzes data from an international registry (RIETE) that includes consecutive patients with symptomatic VTE. Our study assesses the form and time of presentation of postoperative VTE, as well as main outcomes, in patients operated for abdominopelvic cancer 8 weeks prior to VTE diagnosis. Variables related to the presentation of VTE after hospital discharge are identified. RESULTS: Out of the 766 analyzed patients with VTE, 395 (52%) presented pulmonary embolism (PE). Most VTE cases (84%) were detected after the first postoperative week, and 38% after one month. Among patients with VTE in the first postoperative week, 70% presented PE. VTE presented after hospital discharge in 54% of cases. Colorectal, urologic, and gynecologic tumors, the use of radiotherapy, and blood hemoglobin levels were independently associated with VTE diagnosis after hospital discharge. Complications (thrombosis recurrence, bleeding, and death) occurred in 34% of patients with VTE detected before hospital discharge, compared to 24% in VTE after hospital discharge (P<0.01). CONCLUSIONS: VTE occurs after hospital discharge in most patients, particularly in those operated for colorectal, urologic, and gynecologic cancer. Pulmonary embolism is more frequent in patients who develop early VTE, who also have worse prognosis.

Risk of recurrence after discontinuing anticoagulation in patients with COVID-19- associated venous thromboembolism: a prospective multicentre cohort study.

Background: The clinical relevance of recurrent venous thromboembolism (VTE) after discontinuing anticoagulation in patients with COVID-19-associated VTE remains uncertain. We estimated the incidence rates and mortality of VTE recurrences developing after discontinuing anticoagulation in patients with COVID-19-associated VTE. Methods: A prospective, multicenter, non-interventional study was conducted between March 25, 2020, and July 26, 2023, including patients who had discontinued anticoagulation after at least 3 months of therapy. All patients from the registry were analyzed during the study period to verify inclusion criteria. Patients with superficial vein thrombosis, those who did not receive at least 3 months of anticoagulant therapy, and those who were followed for less than 15 days after discontinuing anticoagulation were excluded. Outcomes were: 1) Incidence rates of symptomatic VTE recurrences, and 2) fatal PE. The rate of VTE recurrences was defined as the number of patients with recurrent VTE divided by the patient-years at risk of recurrent VTE during the period when anticoagulation was discontinued. Findings: Among 1106 patients with COVID-19-associated VTE (age 62.3 ± 14.4 years; 62.9% male) followed-up for 12.5 months (p25-75, 6.3-20.1) after discontinuing anticoagulation, there were 38 VTE recurrences (3.5%, 95% confidence interval [CI]: 2.5-4.7%), with a rate of 3.1 per 100 patient-years (95% CI: 2.2-4.2). No patient died of recurrent PE (0%, 95% CI: 0-7.6%). Subgroup analyses showed that patients with diagnosis in 2021-2022 (vs. 2020) (Hazard ratio [HR] 2.86; 95% CI 1.45-5.68) or those with isolated deep vein thrombosis (vs. pulmonary embolism) (HR 2.31; 95% CI 1.19-4.49) had significantly higher rates of VTE recurrences. Interpretation: In patients with COVID-19-associated VTE who discontinued anticoagulation after at least 3 months of treatment, the incidence rate of recurrent VTE and the case-fatality rate was low. Therefore, it conceivable that long-term anticoagulation may not be required for many patients with COVID-19-associated VTE, although further research is needed to confirm these findings. Funding: Sanofi and Rovi, Sanofi Spain.

Major gastrointestinal bleeding in patients receiving anticoagulant therapy for venous thromboembolism.

INTRODUCTION: The gastrointestinal (GI) tract is a frequent site of bleeding in patients receiving anticoagulant therapy for venous thromboembolism (VTE). At-risk patients have not been consistently identified yet. METHODS: We used the RIETE registry to assess the clinical characteristics of patients developing major GI bleeding during the course of anticoagulation. Then, we built a predictive score based on multivariable analysis, aiming to identify patients at increased risk for major GI bleeding. RESULTS: We included 87,431 patients with acute VTE. During the course of anticoagulation, 778 (0.89%) suffered major GI bleeding, 815 (0.93%) non-major GI bleeding and 1462 (1.67%) had major bleeding outside the GI tract. During the first 30 days after major GI bleeding, 7.6% of patients re-bled, 3.9% had VTE recurrences and 33% died. On multivariable analysis, male sex, age ≥70 years, initial VTE presentation as pulmonary embolism, active cancer, prior VTE, recent major bleeding in the GI tract, esophageal varicosities, anemia, abnormal prothrombin time, renal insufficiency and use of corticosteroids were associated to an increased risk for major GI bleeding. Using the predictive score, 39,591 patients (45%) were at low risk; 36,602 (42%) at intermediate-risk; 9315 (11%) at high-risk; and 1923 (2.2%) at very high risk. Their rates of major GI bleeding were: 0.21%, 0.96%, 2.41% and 6.08%, respectively. The c-statistics was 0.771 (95%CI. 0.755-0.786). CONCLUSIONS: We have developed a score which has the potential to identify patients at increased risk for GI bleeding, but needs to be externally validated."

Enoxaparin versus dalteparin or tinzaparin in patients with cancer and venous thromboembolism: The RIETECAT study.

Background: Venous thromboembolism (VTE) is a frequent complication in patients with cancer and a leading cause of morbidity and death. Objectives: The objective of the RIETECAT study was to compare the long-term effectiveness and safety of enoxaparin versus dalteparin or tinzaparin for the secondary prevention of VTE in adults with active cancer. Methods: We used the data from the multicenter, multinational RIETE registry to compare the rates of VTE recurrences, major bleeding, or death over 6 months in patients with active cancer and acute VTE using full doses of enoxaparin versus dalteparin or tinzaparin, and a multivariable Cox proportional hazard model was used to analyze the primary end point. Results: From January 2009 to June 2018, 4451 patients with active cancer received full doses of the study drugs: enoxaparin, 3526 patients; and dalteparin or tinzaparin, 925 (754 + 171) patients. There was limited difference in VTE recurrences (2.0% vs 2.5%) and mortality rate (19% vs 17%) between the enoxaparin and dalteparin or tinzaparin subgroups. However, there was a slight numerical increase in major bleeding (3.1% vs 1.9%). Propensity score matching confirmed that there were no differences in the risk for VTE recurrences (adjusted hazard ratio [aHR], 0.81; 95% confidence interval [CI], 0.48-1.38), major bleeding (aHR, 1.40; 95% CI, 0.80-2.46), or death (aHR, 1.07; 95% CI, 0.88-1.30) between subgroups. Conclusions: In RIETECAT, in patients with cancer and VTE receiving full-dose enoxaparin or dalteparin or tinzaparin, no statistically significant differences were observed regarding effectiveness and safety outcomes over a 6-month period.

Impact of dementia on hospitalization.

BACKGROUND: The purpose of this study was to analyze and determine the prevalence and clinical characteristics of hospitalized dementia patients compared with nondemented patients. METHODS: We examined hospital discharge database records dated 1998-2003 from public hospitals in Andalusia, Spain. We used ICD-9-CM codes to identify patients with dementia. The variables examined included age, length of stay, discharge diagnosis, diagnostic-related groups, and mortality of both dementia and nondementia patients over 65 years of age. RESULTS: A diagnosis of dementia was documented for 40,482 cases. The prevalence of dementia increased from 3.43% to 4.64% between 1998 and 2003 and was higher among older patients and women. Dementia was the reason for admission in 5.6% of cases. Medical reasons constituted 82.4% of admittances. Dementia patients had hip surgery more frequently than patients without dementia, and other procedures (orthopedic surgery, cataracts, or hernia repair) were less frequent (p < 0.001). The mean duration of the hospital stay was longer (13.4 vs. 10.7 days) and the intra-hospital mortality rate was greater (19.3% vs. 8.7%) for patients with dementia compared to those without dementia. Dementia was an independent predictor of mortality (OR 1.77; 95% CI 1.72-1.82). CONCLUSIONS: Dementia is increasing among hospitalized patients. Dementia patients have different reasons for hospitalization and higher mortality. It is necessary to identify these differences and to improve the hospital care of dementia patients.

Efficient removal of azo-dye Orange II by fungal biomass absorption and laccase enzymatic treatment.

In this study, the exact contribution of T. versicolor fungal biomass and laccase in the removal of the Orange II dye from liquid culture was determined. Biomass and laccase were produced with three different carbon sources [bran flakes (BF), wheat bran (WB) and wheat flour (WF)]. The contribution of the biomass and the laccase enzyme in the removal of the Orange II dye was assessed as follows: (A) in vivo treatment with fungal biomass; in vivo treatment with fungal biomass and inhibited laccase (using 0.6 mM sodium azide); and (B) in vitro treatment with crude laccase. The results of fungal biomass production were similar for all the carbon sources evaluated, while laccase volumetric activities were different. The highest enzyme production was obtained with WB, followed by BF and WF. In the in vivo treatment with fungal biomass-laccase, dye removal was over 84% for all the carbon sources. Dye adsorption by fungal biomass varied from 1.5-2%, presenting enzymatic activities ranging from 62 to 163 U L-1. In the in vivo treatment with fungal biomass-inhibited laccase, the removal of the dye varied from 30 to 72%. In this case, the percentage of dye adsorption by fungal biomass was significantly increased and ranged from 18 to 53%. In the in vitro treatment with laccase, the removal ranged from 80 to 84%. The best treatment for dye removal involved the use of both fungal biomass and laccase. The carbon source for biomass and laccase production had an impact on dye removal.

Outcome of Electronic Order Alert Intervention Relative to Toxigenic Clostridium difficile PCR Analysis and Hospital-Onset C difficile Infection in a Multihospital Health Care System.

OBJECTIVES: Concern exists regarding overdiagnosis of Clostridium difficile infection (CDI) via molecular modalities. We determined effects of a preanalytic order intervention on laboratory and CDI prevention measures in a multihospital system. METHODS: Intervals before and following implementation of a CDI electronic order alert (relative to appropriate testing scenario) were assessed for C difficile test volume and positivity rate, hospital-onset CDI frequency, and hospital-onset C difficile standardized infection ratio (SIR). C difficile detection occurred by PCR throughout the study. RESULTS: During the first half of 2015, testing volume was 1,578, with 88 hospital-onset CDIs. Following implementation, 18.9% and 56.8% reductions in volume and hospital-onset CDIs were realized, respectively, in the first half of 2017. Regression analysis revealed decreasing trends in PCR volume, positivity rate, hospital-onset CDI frequency, and SIR in larger facilities. CONCLUSIONS: Preanalytic considerations affect not only the microbiology laboratory but also hospital infection prevention in the context of CDI.

Frequency and prognostic impact of acute kidney injury in patients with acute pulmonary embolism. Data from the RIETE registry.

RATIONALE: Acute kidney injury (AKI) is associated with a poor outcome. Although pulmonary embolism (PE) may promote AKI through renal congestion and/or hemodynamic instability, its frequency and influence on outcome in patients with acute PE have been poorly studied. METHODS: The frequency of AKI (defined according to the "Kidney Disease: Improving Global Outcomes" definition) at baseline and its influence on the 30-day mortality was evaluated in patients with acute PE from the RIETE (Registro Informatizado Enfermedad TromboEmbolica) registry. We used multivariate analysis to assess whether the presence of AKI influenced the risk for 30-day death. RESULTS: The study included 21,131 patients, of whom 6222 (29.5%) had AKI at baseline: 4385 patients (21%) in stage 1, 1385 (6.5%) in stage 2 and 452 (2%) in stage 3. The proportion of patients with high-risk PE in those with no AKI, AKI stage 1, AKI stage 2 or AKI stage 3 was: 2.8%, 5.3%, 8.8% and 12%, respectively (p < 0.001). After 30 days, 1236 patients (5.9%) died. Overall mortality was 4% in patients with no AKI, 8.4% in AKI stage 1, 14% in AKI stage 2 and 17% in AKI stage 3 (all p < 0.001). AKI was independently associated with an increased risk of all-cause death at 30 days (odds ratio = 1.25; 95%CI: 1.02-1.54). CONCLUSIONS: One in every 3-4 patients with acute PE had AKI at baseline. The presence of AKI independently predicted 30-day mortality. This study suggests that AKI may deserve to be evaluated as a prognostic factor in patients with acute PE.

Clinical findings, diagnostic approach, and outcome of Brucella melitensis epididymo-orchitis.

We have studied 912 patients with brucellosis. Of these, 631 (69.2%) were male and 48 had epididymo-orchitis, giving an incidence of epididymo-orchitis of 7.6%. The duration of symptoms before diagnosis was 52.5 +/- 70 days. All the patients had fever, swelling, and scrotal pain, but only 2 (4.2%) reported urinary symptoms. Seven patients (14.5%) had leukocyte figures above 11 x 10(9)/L, and urine analysis was normal in 69% of the patients. Blood cultures were positive in 65.8% of cases. A total of 33 patients (68.8%) received a combination of doxycycline plus streptomycin and 13 (27.1%) doxycycline plus rifampin. The overall percentage of failure or relapse was 8.8%: 7.1% in the doxycycline plus streptomycin group and 20% in the doxycycline plus rifampin group. None of the patients required surgery. Pending clinical trials to confirm the results, conservative management with a combination of doxycycline for 2 months and streptomycin for 14 to 21 days appears to be adequate and could avoid unnecessary orchiectomy.

Gender-related differences in the outcome of patients with venous thromboembolism and thrombophilia.

BACKGROUND: In patients with venous thromboembolism (VTE) and factor V Leiden (FVL) or prothrombin 20210G-A mutation (PTM), the influence of gender on outcome has not been consistently studied. METHODS: We used the RIETE (Registro Informatizado Enfermedad TromboEmbolica) database to assess the existence of gender differences in the rate of VTE recurrences (deep vein thrombosis [DVT] or pulmonary embolism [PE]) or major bleeding during the course of anticoagulation and after its discontinuation in FVL and PTM carriers. RESULTS: From March 2001 to September 2016, 11,224 VTE patients underwent thrombophilia testing. Of these, 1,563 were FVL carriers (863 men and 700 women) and 1,231 were PTM carriers (659 men and 572 women). During the course of anticoagulant therapy, men with FVL had a 6-fold higher rate of VTE recurrences than major bleeds (31 vs. 5 events). In women with FVL, the rate of VTE recurrences was 2-fold higher (16 vs. 8), as was in men (17 vs. 8) or women (17 vs. 9) with PTM. After discontinuing anticoagulation, men with FVL had a 3-fold higher rate of DVT recurrences than women (hazard ratio [HR]: 3.13; 95% CI: 1.79-5.67), with no differences in PE recurrences. Among patients with PTM, there were no gender differences in the rate of DVT (HR: 1.89; 95% CI: 1.00-3.65) or PE recurrences (HR: 1.82; 95% CI: 0.83-4.12). CONCLUSIONS: During the anticoagulation course, men with FVL are at a much higher risk for VTE recurrences than bleeding. After discontinuing anticoagulation, men with FVL are at an increased risk for DVT recurrences.

Clinical outcomes during anticoagulant therapy in fragile patients with venous thromboembolism.

BACKGROUND: Subgroup analyses from randomized trials suggested favorable results for the direct oral anticoagulants in fragile patients with venous thromboembolism (VTE). The frequency and natural history of fragile patients with VTE have not been studied yet. OBJECTIVES: To compare the clinical characteristics, treatment and outcomes during the first 3 months of anticoagulation in fragile vs non-fragile patients with VTE. METHODS: Retrospective study using consecutive patients enrolled in the RIETE (Registro Informatizado Enfermedad TromboEmbolica) registry. Fragile patients were defined as those having age ≥75 years, creatinine clearance (CrCl) levels ≤50 mL/min, and/or body weight ≤50 kg. RESULTS: From January 2013 to October 2016, 15 079 patients were recruited. Of these, 6260 (42%) were fragile: 37% were aged ≥75 years, 20% had CrCl levels ≤50 mL/min, and 3.6% weighed ≤50 kg. During the first 3 months of anticoagulant therapy, fragile patients had a lower risk of VTE recurrences (0.78% vs 1.4%; adjusted odds ratio [OR]: 0.52; 95% confidence intervals [CI]: 0.37-0.74) and a higher risk of major bleeding (2.6% vs 1.4%; adjusted OR: 1.41; 95% CI: 1.10-1.80), gastrointestinal bleeding (0.86% vs 0.35%; adjusted OR: 1.84; 95% CI: 1.16-2.92), haematoma (0.51% vs 0.07%; adjusted OR: 5.05; 95% CI: 2.05-12.4), all-cause death (9.2% vs 3.5%; adjusted OR: 2.02; 95% CI: 1.75-2.33), or fatal PE (0.85% vs 0.35%; adjusted OR: 1.77; 95% CI: 1.10-2.85) than the non-fragile. CONCLUSIONS: In real life, 42% of VTE patients were fragile. During anticoagulation, they had fewer VTE recurrences and more major bleeding events than the non-fragile.

Prevalence of metabolically discordant phenotypes in a mediterranean population-The IMAP study.

OBJECTIVE: To study the prevalence and correlates of body size phenotypes in an adult Spanish population. METHODS: We undertook a cross-sectional analysis in a random sample of 2,270 individuals. We defined six body size phenotypes based on body mass index category (normal-weight, 18.5 to 24.9 kg/m2; overweight, 25 to 29.9 kg/m2; obese, ≥30.0 kg/m2) and the presence of ≤1 (metabolically healthy) or ≥2 (metabolically abnormal) cardiometabolic abnormalities: metabolically healthy normal-weight (MHNW), metabolically abnormal normal-weight (MANW), metabolically healthy overweight (MHOW), metabolically abnormal overweight (MAOW), metabolically healthy obese (MHO), and metabolically abnormal obese (MAO). We considered four cardiometabolic abnormalities: systolic and/or diastolic blood pressure ≥130/85 mm Hg, triglycerides ≥150 mg/dL, high-density-lipoprotein cholesterol levels <40/<50 mg/dL in men/women, and elevated glucose (fasting plasma glucose ≥100 mg/dL or previous diabetes). RESULTS: The prevalence of the MHO, MHOW, and MANW phenotypes was 2.2, 13.9, and 7.9%, respectively. Whereas 9.6% of obese and 32.6% of overweight individuals were metabolically healthy, 21.3% of the normal-weight subjects were metabolically abnormal. A multivariate regression model (adjusted for age, sex, and waist circumference) showed that age >40 years, male sex, and higher waist circumference were independently associated with the metabolically abnormal phenotype MANW, whereas younger age, female sex, and lower waist circumference were independently associated with the metabolically healthy phenotypes. CONCLUSION: The prevalence of MHO in our population is low and is more common in women and younger people. In contrast, a high proportion of normal-weight individuals (mainly over 40 years of age) in our population show cardiometabolic abnormalities.

Metabolic syndrome and vascular risk estimation in a Mediterranean non-diabetic population without cardiovascular disease.

AIMS: Vascular risk equations are tools used to help prevent cardiovascular events. Our aim was to compare the REGICOR and SCORE equations in a general population and in persons with the metabolic syndrome (MS) according to the criteria of the International Diabetes Federation. METHODS AND RESULTS: We calculated the cardiovascular risk with both equations in a random sample of 838 non-diabetic persons aged 40-65years without a history of cardiovascular disease, of whom 251 had the MS. Of the 838 persons, 3.6% had a high risk according to SCORE and 1.5% according to REGICOR, and of these, 53.3% and 61.5%, respectively, had the MS. The mean risk was greater in the persons with the MS than those without (REGICOR 4.6% vs. 2.6% and SCORE 1.7% vs. 1%; p<0.01 for each). In comparison with the group without the MS, the percentage of persons with the MS who had a high risk was greater with both scales: REGICOR (3.2% vs. 0.8%, p=0.027) and SCORE (6.4% vs. 2.4%, p=0.004). The agreement (kappa index) classifying the subjects with a high risk, was 0.453 in the overall sample and 0.391 in the subgroup with the MS. CONCLUSIONS: The percentage of persons classified as having a high cardiovascular risk differed between REGICOR and SCORE. Using these scales only a small percentage of non-diabetic persons with the MS have a high risk. The presence of the MS multiplies the percentage of non-diabetic persons with a high vascular risk two-fold with SCORE and four-fold with REGICOR.

Comunicación preliminar sobre un año de uso de la doble Tcu 500, Modelo "Córdoba" / Preliminar comunication on 1 year of use of double Tcu 500, \"Cordoba\" style

Se presenta experiencia en el Servicio de Planificación Familiar de la Maternidad "Concepción Palacios", con un nuevo dispositivo intrauterino de la Casa Limoro (Argentina), modelo "Córdoba","Doble Tcu 500", sobre un total de 263 casos con un año de seguimiento. Las caracteristicas de las usuarias fueron; edad 16-48 años, promedio 28,5 años; gestación de 0 a 12, con promedio de 2,2; y paridad de 0 a 9, con promedio de 2,1. Los meses de uso promedio fueron 8,9 con 2.005 meses mujer uso. Se encontró porcentaje alto (50,45%) de casos con problemas, siendo los más comunes el dolor con 42,96% y dificultades debidas al grosor del insertor, 14,82%. Los motivos de descontinuación fueron: expulsión 2,67%, perforación 0,44%, embarazo accidental 0%. Retiros 21 casos (9,38%), por causa médica 13 casos (5,80%). Se concluye con la Doble Tcu 500, tuvo un desempeño satisfactorio en cuanto al embarazo accidental y expulsión que debe prestarse atención al seleccionar un DIU, a la geometría uterina y diseño del dispositivo intrauterino para lograr reducir al mínimo los eventos negativos

Evaluación del embarazo con DIU / Evaluation of pregnancy with DIU

Se puede decir que el embarazo que se presenta con DIU in situ, se comporta al igual que cualquier embarazo, aparte de una incidencia mayor de abortos, los recién nacidos de estos embarazos con el DIU in situ, son tan normales como los que nacen de mujeres sin anticoncepción

Síndrome de hipotensión intracraneal espontánea: comunicación de dos observaciones / Spontanous intracraneal hypotensión syndrome: communication of two case histories

Los autores describen los casos de dos pacientes con síndrome de hipotensión espontánea o síndrome de Schaltenbrand, caracterizado por cefalea ortostática aliviada o suprimida con el clinostatismo, nauseas, vomitos, vértigos, tinnitus y rigidez de nuca, en los cuales pudo precisarse un antecedente traumático menor posiblemente relacionado, donde la resonancia magnética cerebral fue más informativa para el diagnóstico que la punción lumbar y cuyas manifestaciones clínicas revirtieron con el reposo en cama. Se hace una revisión de la literatura nacional e internacional relacionada