Predictive Factors of the Use of Rituximab and Belimumab in Spanish Lupus Patients.

Objectives: To analyze the characteristics and the predictive factors of the use of rituximab and belimumab in daily practice in patients from the inception cohort Registro Español de Lupus (RELES). Material and methods: The study included 518 patients. We considered patients treated with biologics who received at least one dose of rituximab or belimumab, and possible indications of those manifestations registered at the same time or in the previous 2 months of the start of the therapy. Results: In our cohort, 37 (7%) patients received at least one biological treatment. Rituximab was prescribed in 26 patients and belimumab in 11. Rituximab was mainly prescribed for hemolytic anemia or thrombocytopenia (11 patients, 42%), lupus nephritis and neuropsychiatric lupus (5 patients each, 19%). Belimumab was mostly used for arthritis (8 patients, 73%). In the univariate analysis, the predictive factors at diagnosis for the use of biologic therapy were younger age (p = 0.022), a higher SLEDAI (p = 0.001) and the presence of psychosis (p = 0.011), organic mental syndrome (SOCA) (p = 0.006), hemolytic anemia (p = 0.001), or thrombocytopenia (p = 0.01). In the multivariant model, only younger age, psychosis, and hemolytic anemia were independent predictors of the use of biologics. Conclusions: Rituximab is usually given to patients with hematological, neuropsychiatric and renal involvement and belimumab for arthritis. Psychosis, hemolytic anemia and age at the diagnosis of lupus were independent predictive factors of the use of biological agents. Their global effects are beneficial, with a significant reduction in SLE activity and a low rate of side effects.

Malnutrition and obesity: influence in mortality and readmissions in chronic obstructive pulmonary disease patients.

BACKGROUND: The present study aimed to assess the association of obesity and malnutrition with the mortality of hospitalised patients with acute exacerbation of chronic obstructive pulmonary disease (COPD) and the risk of readmission in <30 days. METHODS: A retrospective chart review of consecutive patients admitted with COPD as the primary reason for discharge in Spain between 1 January 2006 and 31 December 2007 was performed. Patients with a diagnosis of obesity or malnutrition in the hospital discharge clinical report were identified. The in-hospital mortality and re-admittance 30 days after discharge indices of obese and malnourished patients were compared against the subpopulation without these diagnoses. RESULTS: Of the 313 233 COPD admittances analysed, there were 22 582 (7.2%) diagnoses of obesity and 6354 (2.0%) diagnoses of malnutrition. In-hospital global mortality and the re-admittance risk were 12.0% and 16.7%, respectively. Obese patients showed a lower in-hospital mortality risk [odds ratio (OR) = 0.52; 95% confidence interval (CI) = 0.49-0.55] and early re-admittance risk (OR = 0.87; 95% CI = 0.85-0.92) compared to non-obese patients. Malnourished patients had a much higher risk of death when in hospital (OR = 1.73; 95% CI = 1.62-1.85) or of being re-admitted within 30 days after discharge (OR = 1.29; 95% CI = 1.22-1.38), even after adjusting for possible confounding factors. CONCLUSIONS: Obesity in patients hospitalised for COPD substantially reduces in-hospital mortality risk and the possibility of early re-admittance. Malnutrition is associated with an important increase in in-hospital mortality and risk of re-admittance in the 30 days following discharge.

The impact of weekends on outcome for acute exacerbations of COPD.

Differences in hospital staffing may influence outcomes for patients with acute conditions, including acute exacerbations of chronic obstructive pulmonary disease (COPD), depending on which day of the week the patients are admitted. This study was conducted to determine whether weekend admission increases the risk of dying in hospital. We analysed the clinical data of 289,077 adults with acute exacerbations of COPD admitted to the hospital at any public centre in Spain, during 2006 and 2007. We analysed the following factors for their association with death rate: day of admission, demographics, medical history and comorbidity. During the study period, there were 35,544 (12.4%) deaths during admission in COPD patients. Weekend admissions were associated with a significantly higher in-hospital mortality (12.9%) than weekday admissions (12.1%) among COPD patients (OR 1.07 (95% CI 1.04-1.10)). The differences in mortality persisted after adjustment for age, sex and coexisting disorders (OR 1.05 (95% CI 1.02-1.08)). Analyses of deaths within 2 days after admission showed larger relative differences in mortality between the weekend and weekday admissions (OR 1.17 (95% CI 1.11-1.23)). We conclude that patients with acute exacerbations of COPD are more likely to die in the hospital if they are admitted on a weekend compared with a weekday.

[Invasive procedures in patients hospitalized in Spanish internal medicine departments]. / Procedimientos invasivos en pacientes ingresados en los servicios de Medicina Interna españoles.

AIMS: Invasive procedures (IP) have become routine techniques that benefit an important number of patients on improving their quality of life or avoiding more aggressive treatments. We have conducted a study on the IPs performed in Spanish Internal Medicine (IM) Departments between 2005 and 2009. PATIENTS AND METHODS: IP performed to patients admitted to Spanish Internal Medicine departments were analyzed based on the information obtained from the Minimum Basis Data Set (CMBD). IP was defined as the following: filter placement in the inferior vena cava, chest tube placement, biliary, esophageal and colon prosthesis placement, pleurodesis, nephrostomy, external biliary drain placement, gastrostomy tube placement, thoracocentesis and peritoneal catheter placement. RESULTS: During the study period, a total of 75,853 invasive procedures on 70,239 admittances were performed in 2,766,673 patients (2.5%). IP subjects were younger (68.1 vs 71.4; P<.001), predominantly male (61.9 vs 53.2%; P<.001), with higher mortality (14.6 vs 9.9%; P<.001) and longer stay (18.4 vs 9.6 days; P<0.001). Cost of admittance was clearly higher than the rest of the patients (5,600€ vs 3,835€; P<.001). CONCLUSIONS: IPs are performed on a low percentage of IM Department hospitalized patients. They are costly, entail high mortality and a longer stay period compared to the mean population admitted to IM. A considerable proportion of the patients receiving IP suffer from neoplastic diseases, frequently in advances stages, which justifies the high inhospital mortality of this population.

[Survey of Spanish Society of Internal Medicine on health care provision by internists in the public health system]. / Encuesta SEMI sobre la oferta asistencial de los internistas en los hospitales del Sistema Público de Salud.

AIMS: To know the organization of internal medicine departments (IMD) and the opinion of their heads of department. METHODS: In 2008, a survey was mailed to 410 heads of department of the IMD of 313 Spanish public hospitals. It included a standardized structured questionnaire on staff, hospitalization, outpatients, consultation, research and teaching. The heads of departments were also asked for their opinion and suggestions on management, projects and future. RESULTS: Sixty-eight surveys (22%) were filled out. Internists are on call an average of 3 times a month and perform 200 discharges, 500 outpatient visits and 40 consultations in a year. The average IMD consists of 10 internists with one-fifth of the hospital beds. One third of hospitals have alternatives to inpatient care, the most frequent being palliative care. Infectious diseases accounts for the most common monographic outpatient visit, one-third of IMD lack a structured relationship with primary care and the emergency department is independent of IMD. Half of the IMD have at least one IM resident and 6 residents in other specialties; half are involved in at least two clinical trials and one-third train medical students. The heads of the IMD identify problems in their relationship with hospital managers, other specialties and local population. Excessive workload, aging and discouragement of staff and patients' social problems have negative effects. Even so, they want to initiate projects, are optimistic about the future and take an interest in clinical epidemiology research. CONCLUSIONS: Although the sample is small and heterogeneous, it permits a valuable panoramic view of the structure and standard operation of a Spanish IMD as well as their expectations and areas of improvement.

Approach to COVID-19 pandemic management in Madrid. Chronic of a year.

After more than a year of pandemic, the international medical community has changed the perception of fear to one of respect for SARS-COV-2. This has been the consequence of the integral study of all the dimensions of the disease, from viral recombinant capacity to transmissibility, diagnosis, care and prevention. This document summarizes the main strategic lines of study and approach to the pandemic in Madrid.

Temporary hospitals in times of the COVID pandemic. An example and a practical view.

We describe the most widely used temporary hospital in Europe during the first pandemic wave, its structure, function, and achievements. Other models of care developed during the pandemic around the world were reviewed including their capacity, total bed/ICU bed ratio and time of use. We particularly analyzed the common and differential characteristics of this type of facilities. IFEMA Exhibition Center was transformed into a temporary 1,300-bed hospital, which was in continuous operation for 42 days. A total of 3,817 people were treated, generally patients with mild to moderate COVID-19, 91% of whom had pneumonia. The average length of stay was 5 to 36 days. The most frequent comorbidities were hypertension (16.5%), diabetes mellitus (9.1%), COPD (6%), asthma (4.6%), obesity (2.9%) and dementia (1.6%). A total of 113 patients (3%) were transferred to another centers for aggravation, 19 (0.5%) were admitted to ICU and 16 patients (0.4%) died. An element of great help to reducing the overload of care in large hospitals during peaks of health emergencies could be these flexible structures capable of absorbing the excess of patients. These must be safe, breaking domestic transmission and guarantee social and emotional needs of patients. The success of these structures depends on delimitation in admission criteria taking into account the proportion of patients who may require, during admission, assistance in the critical care area.

Recommendations for use of antigenic tests in the diagnosis of acute SARS-CoV-2 infection in the second pandemic wave: attitude in different clinical settings.

The high transmissibility of SARS-CoV-2 before and shortly after the onset of symptoms suggests that only diagnosing and isolating symptomatic patients may not be sufficient to interrupt the spread of infection; therefore, public health measures such as personal distancing are also necessary. Additionally, it will be important to detect the newly infected individuals who remain asymptomatic, which may account for 50% or more of the cases. Molecular techniques are the "gold standard" for the diagnosis of SARS-CoV-2 infection. However, the massive use of these techniques has generated some problems. On the one hand, the scarcity of resources (analyzers, fungibles and reagents), and on the other the delay in the notification of results. These two facts translate into a lag in the application of isolation measures among cases and contacts, which favors the spread of the infection. Antigen detection tests are also direct diagnostic methods, with the advantage of obtaining the result in a few minutes and at the very "pointof-care". Furthermore, the simplicity and low cost of these tests allow them to be repeated on successive days in certain clinical settings. The sensitivity of antigen tests is generally lower than that of nucleic acid tests, although their specificity is comparable. Antigenic tests have been shown to be more valid in the days around the onset of symptoms, when the viral load in the nasopharynx is higher. Having a rapid and real-time viral detection assay such as the antigen test has been shown to be more useful to control the spread of the infection than more sensitive tests, but with greater cost and response time, such as in case of molecular tests. The main health institutions such as the WHO, the CDC and the Ministry of Health of the Government of Spain propose the use of antigenic tests in a wide variety of strategies to respond to the pandemic. This document aims to support physicians involved in the care of patients with suspected SC2 infection, in the context of a growing incidence in Spain since September 2020, which already represents the second pandemic wave of COVID-19.

Clinical characteristics and prognosis for delirium in Spanish internal medicine departments: An analysis from a large clinical-administrative database. / Características clínicas del delirio y sus implicaciones pronósticas en los servicios de medicina interna españoles: análisis de una gran base de datos clínico-administrativa.

OBJECTIVES: To investigate the prevalence of reported delirium and its associated factors and costs. DESIGN: Retrospective and descriptive analysis of a national clinical-administrative database that includes all patients hospitalised in Spain in internal medicine departments from January 2007 to December 2014. MATERIAL AND METHOD: The study included the patients' sociodemographic and clinical data (sex, age, diagnosis and procedures). RESULTS: The prevalence of reported delirium was 2.5% (114,343 of 4,628,397 discharge reports). Delirium was most common in the 81-90-year age group (48%) and in institutionalised patients (4.5% vs. 2.9%; P<.001). The diagnoses most associated with delirium were dementia (14% vs. 7% for patients without delirium), cerebrovascular disease (17% vs. 11%), malnutrition (4% vs. 2%), pressure ulcers (4% vs. 2%), dysphagia (2% vs. 0.2%) and hyponatraemia (5% vs. 2%) (P<.001 in all cases). Patients with delirium also had longer mean stays (11.85±13.15days vs. 9.49±11.17) and higher hospital mortality (OR: 1.41; 95%CI: 1.39-1.43; P=.0001). The costs attributable to delirium in 8years exceeded €100 million (almost €1,000 per hospitalisation/patient). We developed a predictive model for the risk of developing delirium, which has insufficient sensitivity but is useful for identifying low-risk patients. CONCLUSIONS: Patients who develop delirium during their hospitalisation in internal medicine have a longer stay, greater mortality and an increased risk of being institutionalised at discharge. Delirium is probably poorly reported in the discharge reports prepared by internists.

Venous thromboembolism in patients with liver diseases.

Essentials Emerging evidence shows that patients with liver disease are not protected from thrombotic events. We assessed the risk of venous thromboembolism (VTE) in patients with liver disease. The presence of VTE resulted in an increase in mortality for patients with liver disease. Hospitalized patients with moderate-severe liver disease had low risk of VTE during admission. SUMMARY: Background and Aims Patients with liver disease were traditionally believed to be protected against development of blood clots, but some studies have shown a potential increased risk of venous thrombotic complications. We assessed the risk of venous thromboembolism (VTE) in patients with liver disease. Methods Data in discharge reports of patients with liver disease and control patients without liver disease were analyzed from the national inpatient sample. Incidence of VTE was compared in patients with mild, moderate-severe or no liver disease, and the impact on in-hospital mortality and length of stay was calculated. Results The overall incidence of VTE for patients with no liver disease, mild liver disease and moderate-severe liver disease was 2.7, 2.4 and 0.9 per 100 patient discharges, respectively. In the presence of VTE, in-hospital mortality was 10.8%, 5.8%, and 21.7% for the no liver disease, mild disease and moderate-severe liver disease, respectively. The presence of VTE resulted in an increase in mortality for patients with no liver disease (OR, 1.16; 95% CI, 1.14-1.18) and moderate-severe liver disease (OR, 1.63; CI 95%, 1.42-1.88). Conclusions Patients with moderate-severe liver disease have a lower risk of VTE than those without liver disease. Development of thrombosis during admission increased the risk of in-hospital mortality.

Clinical characteristics during diagnosis of a prospective cohort of patients with systemic lupus erythematosus treated in Spanish Departments of Internal Medicine: The RELES study. / Características clínicas al diagnóstico de una cohorte prospectiva de pacientes con lupus eritematoso sistémico atendidos en servicios de Medicina Interna españoles: estudio RELES.

INTRODUCTION: Patient registries are useful tools for assessing rare diseases. Our objective is to present the Spanish registry of patients with systemic lupus erythematosus (Registro español de pacientes con lupus eritematoso sistémico, RELES). PATIENTS AND METHODS: RELES was started in 2008 as an observational, prospective, multicentre cohort registry that included patients from the time they were diagnosed. The registry's objective is to analyse the incidence and noninflammatory complications of systemic lupus erythematosus (SLE). The departments of internal medicine of 38 Spanish hospitals participate in this registry. RESULTS: A total of 298 patients with a mean age of 40.8±15.7 years were included, 88.9% of whom were women and 85.6% of whom were white. In the first visit, there was a predominance of joint manifestations (74.5%). One hundred and seventy-seven patients (59.4%) were positive for anti-native DNA. In these patients, there was a higher rate of lupus nephritis (26.7% vs. 14%, p=.009; relative risk [RR], 1.33), haemolytic anaemia (13.6% vs. 4.1%, p=.07; RR, 1.46) and lymphopenia (55.4% vs. 43.8%, p=.05; RR, 1.21). The median Systemic Lupus Erythematosus Disease Activity Index 2000 (SLEDAI 2K) score was 9.64 points (interquartile range, 4-13). The patients treated with antimalarial drugs before the diagnosis of SLE had a median SLEDAI score in the first visit of 5, compared with 8 for those who were not treated with these drugs (p=.02). CONCLUSIONS: RELES constitutes the first Spanish patient cohort with SLE recorded from the time of the diagnosis. The presence of anti-DNA has been related to severe manifestations such as nephritis and haemolytic anaemia. Treatment with antimalarial drugs before the diagnosis was associated with less active disease at the initial presentation.

First month prednisone dose predicts prednisone burden during the following 11†months: an observational study from the RELES cohort.

AIM: To study the influence of prednisone dose during the first month after systemic lupus erythematosus (SLE) diagnosis (prednisone-1) on glucocorticoid burden during the subsequent 11 months (prednisone-2-12). METHODS: 223 patients from the Registro Español de Lupus Eritematoso Sistémico inception cohort were studied. The cumulative dose of prednisone-1 and prednisone-2-12 were calculated and recoded into a four-level categorical variable: no prednisone, low dose (up to 7.5 mg/day), medium dose (up to 30 mg/day) and high dose (over 30 mg/day). The association between the cumulative prednisone-1 and prednisone-2-12 doses was tested. We analysed whether the four-level prednisone-1 categorical variable was an independent predictor of an average dose >7.5 mg/day of prednisone-2-12. Adjusting variables included age, immunosuppressives, antimalarials, methyl-prednisolone pulses, lupus nephritis and baseline SLE Disease Activity Index (SLEDAI). RESULTS: Within the first month, 113 patients (51%) did not receive any prednisone, 24 patients (11%) received average low doses, 46 patients (21%) received medium doses and 40 patients (18%) received high doses. There was a strong association between prednisone-1 and prednisone-2-12 dose categories (p<0.001). The cumulative prednisone-1 dose was directly associated with the cumulative prednisone-2-12 dose (p<0.001). Compared with patients on no prednisone, patients taking medium (adjusted OR 5.27, 95% CI 2.18 to 12.73) or high-dose prednisone-1 (adjusted OR 10.5, 95% CI 3.8 to 29.17) were more likely to receive prednisone-2-12 doses of >7.5 mg/day, while patients receiving low-dose prednisone-1 were not (adjusted OR 1.4, 95% CI 0. 0.38 to 5.2). If the analysis was restricted to the 158 patients with a baseline SLEDAI of ≥6, the model did not change. CONCLUSION: The dose of prednisone during the first month after the diagnosis of SLE is an independent predictor of prednisone burden during the following 11 months.

[Chronic renal failure secondary to uterine prolapse]. / Insuficiencia renal crónica secundaria a prolapso uterino.

Acute and chronic renal failure secondary to bilateral severe hydroureteronephrosis is a rare sequela of uterine prolapse. We report a case of neglected complete uterine prolapse in a 72-year-old patient resulting in bilateral hydroureter, hydronephrosis, and chronic renal failure. In an attempt to diminish the ureteral obstruction a vaginal pessary was used to reduce the uterine prolapse. Finally, surgical repair of prolapse by means of a vaginal hysterectomy was performed. In conclusion, all patients presenting with complete uterine prolapse should be screened to exclude urinary tract obstruction. If present, obstructive uropathy should be relieved by the reduction or repair of the prolapse before irreversible renal damage occurs.

Bronchopulmonary complications associated to enteral nutrition devices in patients admitted to internal medicine departments.

BACKGROUND AND AIMS: Enteral nutrition using feeding devices such as nasogastric (NG) tube or percutaneous endoscopic gastrostomy (PEG) is an effective feeding method subject that may give rise to complications. We have studied the relationship between enteral nutrition feeding devices in patients admitted to the Internal Medicine Departments and the development of pulmonary complications (bronchial aspiration and aspiration pneumonia). PATIENTS AND METHODS: All of the patients discharge between 2005 and 2009 from the Internal Medicine (IM) Departments of the public hospitals of the National Health System in Spain were analyzed. The data of patients with bronchial aspiration or aspiration pneumonia who also were carriers of NG tubes or PEG, were obtained from the Minimum Basic Data Set (MBDS). RESULTS: From a total of 2,767,259 discharges, 26,066 (0.92%) patients with nasogastric tube (NG tube) or percutaneous gastrostomy (PEG) were identified. A total of 21.5% of patients with NG tube and 25.9% of patients with PEG had coding for a bronchopulmonary aspiration on their discharge report versus 1.2% of patients without an enteral feeding tube. In the multivariate analysis, the likelihood of suffering bronchoaspiration was 9 times greater in patients with SNG (OR: 9.1; 95% CI: 8.7-9.4) and 15 greater in subjects with PEG (OR: 15.2; 95% CI: 14.5-15.9) than in subjects without SNG or PEG. Mean stay (9.2 and 12.7 more days), diagnostic complexity and costs were much higher in patients with SNG or PEG compared to patients in hospital who did not require these devices. CONCLUSIONS: An association was found between SNG and PEG for enteral feeding and pulmonary complications. Mean stay, diagnostic complexity and cost per admission of these patients was higher in patients who did not require enteral nutrition.