[Oral anticoagulation excess: analysis from an emergency department]. / Exceso de anticoagulación oral: análisis desde un servicio de Urgencias.

OBJECTIVES: To analyze the environmental factors associated to anticoagulation excess in adult patients who come to an emergency department of a tertiary hospital. To describe the characteristics of anticoagulant therapy, their diseases and associated drugs, clinical presentation and treatment received. METHODS: Prospective study of randomized patients conducted in the Emergency Department of Hospital Gregorio Marañón in Madrid during 6 months. Those patients whose INR was greater than or equal to 6 due to having taken acenocoumarol were included. Variables collected for all of them were: age, gender, INR when coming to the emergency department, anticoagulation indication, its beginning and duration, physician anticoagulation controlling, time since previous INR control, last INR assessment, treatment changes. Other variables were: comorbidity, associated medications, dietary changes, presence of bleeding, its location and treatment received. The statistical analysis was performed with the SPSS program (vs 13). RESULTS: A total of 49 adult patients, 63.3% female, whose average age was 77.9 (48-94) were included. Mean INR value was 8.2 (6-12). Indication due to atrial fibrillation was found in 71.4%. The most common associated diseases were heart failure and chronic nephropathy (18.4% and 16.3%, respectively). Twelve patients (24.5%) had consumed paracetamol recently. Active hemorrhage occurred in 34.7% of cases. CONCLUSIONS: Anticoagulation excess is a common problem in people over 70, where comorbidity and medications may determine the INR value. Bleeding risk is significant so that this group of patients should be closely monitored.

Exceso de anticoagulación oral: análisis desde un servicio de Urgencias / Oral anticoagulation excess: analysis from an emergency department

Objetivos. Analizar los factores ambientales asociados al exceso de anticoagulación en pacientes que acuden a Urgencias de un hospital terciario. Describir las características del tratamiento anticoagulante de los pacientes, sus patologías y fármacos asociados, así como la forma de presentación y tratamiento recibido. Material y métodos. Estudio prospectivo de pacientes aleatorios realizado en el Servicio de Urgencias del Hospital Gregorio Marañón de Madrid durante un período de 6 meses. Se incluyeron aquellos pacientes que acudieron con un International Normalized Ratio (INR) superior o igual a 6 como consecuencia de la toma de acenocumarol. En todos ellos se recogieron variables como: edad, sexo, INR en Urgencias, motivo de anticoagulación, duración e inicio de ésta, médico que controlaba la anticoagulación, tiempo que había transcurrido desde el último control previo a la inclusión, valor del último INR y modificación de la pauta. Otras variables fueron: comorbilidad, medicación asociada, cambio en la dieta, presencia de hemorragia, localización de la misma y tratamiento recibido. El análisis estadístico se realizó con el programa SPSS (v. 13). Resultados. Se incluyeron en el estudio 49 pacientes. La edad media fue de 77,9 (48-94) y el 63,3% fueron mujeres. La cifra media de INR en Urgencias fue de 8,2 (rango de 6-12). La indicación por fibrilación auricular (FA) se encontró en el 71,4%. La insuficiencia cardíaca crónica (ICC) y la nefropatía crónica fueron las patologías asociadas más frecuentes (18,4 y 16,3% respectivamente). El consumo reciente de paracetamol se encontró en 12 pacientes (24,5%). Existió sangrado activo en el 34,7% de los casos. Conclusiones. El exceso de anticoagulación se presenta con frecuencia en la población mayor de 70 años, donde la comorbilidad y los fármacos pueden condicionar su control. El riesgo de hemorragia es considerable, por lo que debemos monitorizar estrechamente a este tipo de pacientes (AU)

Objectives. To analyze the environmental factors associated to anticoagulation excess in adult patients who come to an emergency department of a tertiary hospital. To describe the characteristics of anticoagulant therapy, their diseases and associated drugs, clinical presentation and treatment received. Methods. Prospective study of randomized patients conducted in the Emergency Department of Hospital Gregorio Marañón in Madrid during 6 months. Those patients whose INR was greater than or equal to 6 due to having taken acenocoumarol were included. Variables collected for all of them were: age, gender, INR when coming to the emergency department, anticoagulation indication, its beginning and duration, physician anticoagulation controlling, time since previous INR control, last INR assessment, treatment changes. Other variables were: comorbidity, associated medications, dietary changes, presence of bleeding, its location and treatment received. The statistical analysis was performed with the SPSS program (vs 13). Results. A total of 49 adult patients, 63.3% female, whose average age was 77.9 (48-94) were included. Mean INR value was 8.2 (6-12). Indication due to atrial fibrillation was found in 71.4%. The most common associated diseases were heart failure and chronic nephropathy (18.4% and 16.3%, respectively). Twelve patients (24.5%) had consumed paracetamol recently. Active hemorrhage occurred in 34.7% of cases. Conclusions. Anticoagulation excess is a common problem in people over 70, where comorbidity and medications may determine the INR value. Bleeding risk is significant so that this group of patients should be closely monitored (AU)

[Macroscopic liver pathology in patients with dissociated cholestasis]. / Lesiones hepáticas macroscópicas en pacientes con colestasis disociada.

OBJECTIVE: To establish the prevalence of liver focal pathology in patients with increase of alkaline phosphatase and gamma-glutamil transpeptidase and normal bilirubin (dissociated cholestasis), and to analyze the related risk factors for such pathology. METHODS: All laboratory studies of patients admitted to an Internal Medicine Department were reviewed prospectively throughout a period of 9 months. For the purpose of detecting focal liver pathology imaging liver studies (echography and/or CT) were carried out in those in which biochemical analyses showed dissociated cholestasis. RESULTS: A dissociated cholestasis pattern was found in 81 patients. In 13 of them (16%) focal liver pathology was demonstrated. The majority of the lesions (10 of 13) were local or metastatic malignant neoplasms. Sex, alcohol consumption, presence of diabetes mellitus, tumor or hepatobiliar disease previously known, or abnormalities in liver physical examination were not risk factors. No liver pathology was found in patients with an alkaline phosphatase level higher than double of gamma-glutamil transpeptidase level (sensitivity: 100%; negative predictive value: 100%). Diagnosis of a non-hepatic malignant neoplasm at discharge was associated to a risk 12 times bigger for the presence of liver lesions (p < 0.01). CONCLUSIONS: It is uncommon to find focal liver pathology in patients with dissociated cholestasis. It is more common to discover focal liver pathology in patients with non-hepatic tumors and less probable when phosphatase alcaline: gamma-glutamil transpeptidase ratio is higher than two.

Lesiones hepáticas macroscópicas en pacientes con colestasis disociada / Macroscopic liver pathology in patients with dissociated cholestasis

Objetivo. Determinar la prevalencia de lesiones focales hepáticas en pacientes con aumento de fosfatasa alcalina y gammaglutamiltranspeptidasa (GGT) y niveles normales de bilirrubina, denominado colestasis disociada, y analizar los factores de riesgo asociados a la aparición de dichas lesiones. Métodos. Se revisaron prospectivamente todos los análisis de los pacientes ingresados en el Servicio de Medicina Interna durante un período de 9 meses. Se realizó un estudio de imagen del hígado (ecografía y/o tomografía axial computarizada) en aquellos en los que se encontró colestasis disociada en los análisis bioquímicos con el fin de detectar lesiones hepáticas focales. Resultados. Se encontró un patrón de colestasis disociada en 81 pacientes. Se descubrieron lesiones hepáticas focales en 13 de ellos (16%). La mayoría de las lesiones (10 de 13) eran tumores malignos locales o metastásicos. No se encontraron factores de riesgo asociados al sexo, consumo de alcohol, presencia de diabetes mellitus, enfermedad tumoral o hepatobiliar previamente conocida o anormalidades en la exploración física del hígado. No se encontraron lesiones hepáticas en los casos con un valor de fosfatasa alcalina mayor del doble del de GGT (sensibilidad: 100%; valor predictivo negativo: 100%). El diagnóstico de un tumor maligno fuera del hígado al alta se relacionó con un riesgo 12 veces mayor de encontrar lesiones hepáticas (p < 0,01). Conclusiones. Es infrecuente encontrar lesiones hepáticas en pacientes con colestasis disociada. Es más probable descubrirlas en pacientes con tumores extrahepáticos y menos probable cuando el cociente fosfatasa alcalina: GGT es superior a dos

Objective. To establish the prevalence of liver focal pathology in patients with increase of alkaline phosphatase and gamma-glutamil transpeptidase and normal bilirubin (dissociated cholestasis), and to analyze the related risk factors for such pathology. Methods. All laboratory studies of patients admitted to an Internal Medicine Department were reviewed prospectively throughout a period of 9 months. For the purpose of detecting focal liver pathology imaging liver studies (echography and/or CT) were carried out in those in which biochemical analyses showed dissociated cholestasis. Results. A dissociated cholestasis pattern was found in 81 patients. In 13 of them (16%) focal liver pathology was demonstrated. The majority of the lesions (10 of 13) were local or metastatic malignant neoplasms. Sex, alcohol consumption, presence of diabetes mellitus, tumor or hepatobiliar disease previously known, or abnormalities in liver physical examination were not risk factors. No liver pathology was found in patients with an alkaline phosphatase level higher than double of gamma-glutamil transpeptidase level (sensitivity: 100%; negative predictive value: 100%). Diagnosis of a non-hepatic malignant neoplasm at discharge was associated to a risk 12 times bigger for the presence of liver lesions (p < 0.01). Conclusions. It is uncommon to find focal liver pathology in patients with dissociated cholestasis. It is more common to discover focal liver pathology in patients with non-hepatic tumors and less probable when phosphatase alcaline: gamma-glutamil transpeptidase ratio is higher than two

Imágenes osteolíticas en calota craneal / Osteolytic images of the skull

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