Recurrence risk of idiopathic venous thromboembolism. / Riesgo de recurrencia en el tromboembolismo venoso idiopático.

For patients with idiopathic venous thromboembolism (unprovoked), the risk of recurrence is high. Secondary prophylaxis with anticoagulant therapy reduces the thrombotic risk but at the expense of an increased risk of haemorrhage. A number of factors, such as the male sex and an increase in dimer-D concentrations after completing the anticoagulation therapy, are associated with an increased risk of recurrence. Other factors such as residual venous thrombosis have a more controversial and sometimes contradictory relationship. A number of models have been proposed for predicting thrombotic recurrence risk after anticoagulation therapy in unprovoked TVD. However, these models need external validation to determine their current usefulness in clinical practice. In this article, we analyse the risk factors for thrombotic recurrence and the existing prediction models.

A risk score for prediction of recurrence in patients with unprovoked venous thromboembolism (DAMOVES).

BACKGROUND: In patients with unprovoked venous thromboembolism (VTE), the optimal duration of anticoagulation is anchored on estimating the risk of disease recurrence. We aimed to develop a simple risk assessment model that improves prediction of the recurrence risk. METHODS: In a prospective cohort study, 398 patients with a first unprovoked VTE were followed up for a median of 21.3months after discontinuation of anticoagulation. We excluded patients with a strong thrombophilic defect. Preselected clinical and laboratory variables were analyzed based on the independent confirmation of the impact on the recurrence risk, simplicity of assessment, and reproducibility. Multivariable Cox regression analysis was used to develop a recurrence score that was subsequently internally validated by bootstrap analysis. RESULTS: A total of 65 patients (16.3%) had recurrent VTE. In all patients, VTE recurred spontaneously. Male sex (HR=2.89 [95% CI 1.21-6.90] P=0.016), age (HR=1.0310 per additional decade [95% CI 1.01-1.07] P=0.011), obesity (HR=3.92 [95% CI 1.75-8.75] P=0.0001), varicose veins (HR=4.14 [95% CI 1.81-9.43] P=0.0001), abnormal D-dimer during anticoagulation (HR=13.66 [95% CI 4.74-39.37] P=0.0001), high factor VIII coagulant activity (HR=1.01 [95% CI 1.00-1.02] P=0.028) and heterozygous of factor V Leiden and/or Prothrombin G20210A mutation (HR=13.86 [95% CI 5.87-32.75] P=0.0001) were related to a higher recurrence risk. Using these variables, we developed a nomogram [hereafter referred to as DAMOVES score (D-dimer, Age, Mutation, Obesity, Varicose veins, Eight, Sex)] for prediction of recurrence in an individual patient. CONCLUSIONS: The DAMOVES score can be used to predict recurrence risk in patients with a first unprovoked VTE and may be useful to decide whether anticoagulant therapy should be continued indefinitely or stopped after an initial treatment period of at least 3months.

Estudio del consumo de fármacos inadecuados o no indicados en el anciano que ingresa en un Servicio de Medicina Interna / Study of the consumption of innapropiate medicaments in elder hospitalized in the internal medicine service

Introducción: Los pacientes ancianos se caracterizan por el alto grado de polimedicación. Este factor se ha mostrado el más importante en la aparición de efectos adversos (EAF). El estudio de los fármacos ayuda a establecer cuales son inapropiados y por lo tanto se deben retirar, disminuyendo de esta forma la posibilidad de EAF. Material y Métodos: Estudio prospectivo y observacional. Criterio de inclusión: pacientes de > 64 años que ingresan en Medicina Interna. Se definió como fármaco inapropiado los medicamentos de baja utilidad terapéutica (UTB), los no indicados, y los inadecuados para el anciano. Mediante el programa informático SPSS 11.5 se analizaron las posibles variables relacionadas con el consumo. Resultados: Se incluyeron en el estudio 172 ancianos. La media de medicamentos por persona y día fue de 5,34 (0-15). El 52,5% consumían un fármaco inapropiado (36,6% inadecuado para el anciano, 15% noindicado y 12% UTBs). El análisis multivariante asocia el consumo de estos fármacos a un mayor número de patologías (p < 0,012), a un mayor consumo de medicamentos (p < 0,001) y a la procedencia de residencias de ancianos (p < 0,001). Sólo el consumo de fármacos no adecuados para el anciano se asocia a aumento de EAF. Conclusión: La mitad de los ancianos toma al menos un fármaco deforma innecesaria, y la mayoría de estos fármacos favorece la aparición de EAF

Background: The elderly patients are characterized by the high degree of polymedication. This factor is the most important in the appearance of adverse effects (EAD). The study of the medicaments helps to establish which are inappropriate and therefore they must move back, diminishing of this form EAD’s possibility. Patients and Method: Prospective and observacional Study. Criterion of incorporation: patients of > 64 years old, hospitalized in an Internal Medicine Service. There were defined as inappropriate medicament the medicines of low therapeutic utility, them not indicated, and the inadequate ones for the elder. By means of the SPSS 11.5 program the possible variables related with the consumption were analyzed. Results: 172 elders were included in the study. The average of medicines for person and day belonged to 5.34 (0-15). 52.5% was consuming an inappropriate medicament (36.6% inadequate for the elder, 15% not indicated, and 12% UTBs). The analysis multivariant associates the consumption of these medicaments with a major number of diseases (p <0.012), to a major consumption of medicines (p < 0.001) and to the origin of the nursing residences (p < 0.001). Only the consumption of medicaments not adapted for the elder is associated with increase of EAD. Conclusion: The half of the elders takes at least a medicament of unnecessary form, and the majority of these medicaments favors appearance of EAD

[Study of the conpsumption of innapropiate medicaments in elder hospitalized in the Internal Medicine Service]. / Estudio del consumo de fármacos inadecuados o no indicados en el anciano que ingresa en un Servicio de Medicina Interna.

BACKGROUND: The elderly patients are characterized by the high degree of polymedication. This factor is the most important in the appearance of adverse effects (EAD). The study of the medicaments helps to establish which are inappropriate and therefore they must move back, diminishing of this form EAD's possibility. PATIENTS AND METHOD: Prospective and observacional Study. Criterion of incorporation: patients of > 64 years old, hospitalized in an Internal Medicine Service. There were defined as inappropriate medicament the medicines of low therapeutic utility, them not indicated, and the inadequate ones for the elder. By means of the SPSS 11.5 program the possible variables related with the consumption were analyzed. RESULTS: 172 elders were included in the study. The average of medicines for person and day belonged to 5.34 (0-15). 52.5% was consuming an inappropriate medicament (36.6% inadequate for the elder, 15% not indicated, and 12% UTBs). The analysis multivariant associates the consumption of these medicaments with a major number of diseases (p < 0.012), to a major consumption of medicines (p < 0.001) and to the origin of the nursing residences (p < 0.001). Only the consumption of medicaments not adapted for the elder is associated with increase of EAD. CONCLUSION: The half of the elders takes at least a medicament of unnecessary form, and the majority of these medicaments favors appearance of EAD.

Mortalidad y factores pronósticos en pacientes hospitalizados por bacteriemia adquirida en la comunidad / Mortality and prognostic factors in patients admitted with community-acquired bacteremia

Introducción: La bacteriemia adquirida en la comunidad es un problema frecuente y de elevada mortalidad. El índice de Pitt, calculado en base a la temperatura, el estado mental, y las funciones circulatoria y respiratoria del paciente es una herramienta útil para conocer el pronóstico de pacientes con bacteriemia. Los objetivos fueron conocer la etiología de las bacteriemias adquiridas en la comunidad en nuestro entorno, el porcentaje de pacientes con tratamiento empírico incorrecto, y determinar la mortalidad y los factores independientes asociados con el fallecimiento del paciente, incluido el índice de Pitt. Método: Estudio observacional de una cohorte de pacientes mayores de 18 años ingresados en un hospital terciario por una infección adquirida en la comunidad con bacteriemia. Veintiocho casos fueron desestimados por considerar el aislamiento bacteriano como contaminante. Resultados: Se incluyeron 75 enfermos con un promedio de edad de 68,6 ± 18,2 años, 38 mujeres (51%). La mortalidad fue del 23% [IC95% 13,8 – 33,8]. Las bacterias más frecuentemente aisladas en los hemocultivos fueron Escherichia coli, Staphylococcus aureus, estafilococos coagulasa negativo, Pseudomonas aeruginosa, Streptococcus viridans, enterococos y Klebsiella spp. La mortalidad de los pacientes con un tratamiento antibiótico empírico inadecuado (18%, 3 pacientes) no fue inferior a los que recibieron un tratamiento empírico correcto en urgencias (24 %, 14 pacientes, p = 0,42). Los factores independientes pronósticos de mortalidad, fueron la baja concentración plasmática de albúmina, OR = 5,17 (IC 95% 1,45-16,7) para cada descenso de 1 g/dl, el elevado índice de Pitt OR = 1,50 (IC 95% 1,01-2,24) para cada aumento de una unidad, y la elevada gravedad de la enfermedad de base medida por el índice de McCabe y Jackson OR = 5,08 ( IC 95% 1,43-16,7). Conclusiones: El tratamiento antibiótico empírico incorrecto no influyó en la mortalidad de pacientes con bacteriemia comunitaria. Los factores pronósticos de mortalidad fueron la concentración plasmática de albúmina, el índice de Pitt y la gravedad de la enfermedad de base medida por el índice de McCabe y Jackson

Background: Community-acquired bacteremia is a frequently clinical problem and is associated with a high mortality. The Pitt bacteremia score that is calculated using body temperature, mental status, and some respiratory and circulatory features is an useful tool in order to know the prognosis of partients with bacteremia. Objetives were to know microbial etiology of bacteremia in our community, percentage of patients that received an inadequate empiric antibiotic treatment and indepedent prognostic factors associated with mortality, including Pitt bacteremia score. Method: Observational study of a cohort of patients over 18 years admitted at a tertiary hospital due to an infection with a community-acquired bacteremia. Twenty-eight cases were rejected because possible blood culture contamination. Results: Seventy-five patients were included, the mean age was 68.6 ± 18.2 years, 38 women (51%). Mortality rate was 23% [IC95% 13.8 – 33.8]. More frequent bacteria isolated were Escherichia coli, Staphylococcus aureus, coagulase negative staphilococci, Pseudomonas aeruginosa, Streptococcus viridans, enterococci and Klebsiella spp. Mortality in patients treated with an inadequate antibiotic therapy (18%, 3 patients) was not lower than in adequately treated patients (24%, 14 patients, p=0.42). Indepedent prognostic factors related to mortality were serum albumin concentration, OR=5.17 (IC 95% 1.45-16.7) for every downing step of 1 g/dl, the Pitt bacteremia score OR=1.50 (IC 95% 1.01-2.24) for every unit increase, and a high score at McCabe and Jackson classification OR=5.08 ( IC 95% 1.43-16.7) Conclusions: An inadequate empiric antibiotic therapy was not associated with a worse vital prognosis. Indepedent prognostic factors related to mortality were serum albumin concentration, the Pitt bacteremia score, and the McCabe and Jackson classification

Acidosis láctica secundaria al tratamiento antirretroviral / Lactic acidosis secondary to antiretroviral therapy

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