Tratamiento anticoagulante en pacientes médicos con situaciones clínicas complejas / Anticoagulant treatment of medical patients with complex clinical conditions

La información disponible sobre el tratamiento o profilaxis con fármacos anticoagulantes en pacientes ambulatorios con enfermedades médicas y situaciones clínicas complejas es escasa, y no existen guías de práctica clínica y/o recomendaciones específicas para este subgrupo de sujetos, quienes son frecuentemente atendidos por los internistas. Entendemos por situaciones clínicas complejas aquellas en que por la comorbilidad, edad, pronóstico vital o tratamiento múltiple con fármacos de los pacientes, se configura una situación clínica de interacciones enfermedad-enfermedad; enfermedad-fármaco o fármaco-fármaco que no se incluye dentro de los escenarios sobre los que habitualmente se generan las evidencias científicas. El objetivo de esta revisión narrativa es recopilar y adaptar las recomendaciones de guías clínicas y revisiones sistemáticas a situaciones clínicas complejas, donde puede ser conflictivo la aplicación directa de recomendaciones basadas en estudios que no incorporan a pacientes con dicha complejidad y comorbilidad

There is scarce available information on the treatment or prophylaxis with anticoagulant drugs of outpatients with medical diseases and complex clinical conditions. There are no clinical practice guidelines and/or specific recommendations for this patient subgroup, which are frequently treated by internists. Complex clinical conditions are those in which, due to comorbidity, age, vital prognosis or multiple treatment with drugs, a clinical situation arises of disease-disease, disease-drug or drug-drug interactions that is not included within the scenarios that commonly generate the scientific evidence. The objective of this narrative review is collecting and adapting of the clinical guidelines recommendations and systematic reviews to complex clinical conditions, in which the direct application of recommendations based on studies that do not include patients with this complexity and comorbidity could be problematic

Anticoagulant treatment of medical patients with complex clinical conditions. / Tratamiento anticoagulante en pacientes médicos con situaciones clínicas complejas.

There is scarce available information on the treatment or prophylaxis with anticoagulant drugs of outpatients with medical diseases and complex clinical conditions. There are no clinical practice guidelines and/or specific recommendations for this patient subgroup, which are frequently treated by internists. Complex clinical conditions are those in which, due to comorbidity, age, vital prognosis or multiple treatment with drugs, a clinical situation arises of disease-disease, disease-drug or drug-drug interactions that is not included within the scenarios that commonly generate the scientific evidence. The objective of this narrative review is collecting and adapting of the clinical guidelines recommendations and systematic reviews to complex clinical conditions, in which the direct application of recommendations based on studies that do not include patients with this complexity and comorbidity could be problematic.

Consenso Delphi-RAND de la Sociedad Española de Medicina Interna sobre controversias en terapia y profilaxis anticoagulante en enfermedades médicas. Proyecto INTROMBIN (INcertidumbre en TROMBoprofilaxis en Medicina INterna) / Delphi-RAND consensus of the Spanish Society of Internal Medicine on the controversies in anticoagulant therapy and prophylaxis in medical diseases. INTROMBIN Project (Uncertainty in thromboprophylaxis in internal medicine)

El objetivo de este estudio ha sido conocer la opinión de los internistas sobre el manejo de la anticoagulación y profilaxis tromboembólica en escenarios clínicos complejos en los que el balance riesgo/beneficio de la intervención es estrecho y elaborar un documento de consenso sobre el uso de fármacos anticoagulantes en este grupo de pacientes. Para ello, se identificaron por consenso las áreas clínicas de mayor incertidumbre, se elaboró una encuesta con 20 escenarios desplegados en 40 preguntas clínicas y se realizó una revisión bibliográfica específica. La encuesta se distribuyó entre los internistas de la Sociedad Española de Medicina Interna (SEMI) y fue cumplimentada por 290 de sus miembros. El proceso de consenso se desarrolló mediante una modificación del método Delphi-RAND de adecuación en un proceso anonimizado de doble ronda que permite al panel de expertos identificar áreas de acuerdo y de incertidumbre. En nuestro caso, además, se incorporaron al panel los resultados de la encuesta, innovación metodológica que permite aportar información adicional de la práctica clínica habitual. El resultado del proceso es un conjunto de 19 recomendaciones formuladas por expertos de la SEMI que permite establecer pautas de actuación sobre el tratamiento anticoagulante en escenarios complejos (alto riesgo o hemorragia activa, corta expectativa vital, coexistencia de tratamiento antiagregante o comorbilidades como enfermedad renal, hepática, etc.), que no son infrecuentes en la práctica clínica habitual

The aim of this study was to determine the opinion of internists on the management of anticoagulation and thromboembolism prophylaxis in complex clinical scenarios in which the risk-benefit ratio of surgery is narrow and to develop a consensus document on the use of drugs anticoagulant therapy in this patient group. To this end, we identified by consensus the clinical areas of greatest uncertainty, a survey was created with 20 scenarios laid out in 40 clinical questions, and we reviewed the specific literature. The survey was distributed among the internists of the Spanish Society of Internal Medicine (SEMI) and was completed by 290 of its members. The consensus process was implemented by changing the Delphi-RAND appropriateness method in an anonymous, double-round process that enabled an expert panel to identify the areas of agreement and uncertainty. In our case, we also added the survey results to the panel, a methodological innovation that helps provide additional information on the standard clinical practice. The result of the process is a set of 19 recommendations formulated by SEMI experts, which helps establish guidelines for action on anticoagulant therapy in complex scenarios (high risk or active haemorrhage, short life expectancy, coexistence of antiplatelet therapy or comorbidities such as kidney disease and liver disease), which are not uncommon in standard clinical practice

Delphi-RAND consensus of the Spanish Society of Internal Medicine on the controversies in anticoagulant therapy and prophylaxis in medical diseases. INTROMBIN Project (Uncertainty in thromboprophylaxis in internal medicine). / Consenso Delphi-RAND de la Sociedad Española de Medicina Interna sobre controversias en terapia y profilaxis anticoagulante en enfermedades médicas. Proyecto INTROMBIN (INcertidumbre en TROMBoprofilaxis en Medicina INterna).

The aim of this study was to determine the opinion of internists on the management of anticoagulation and thromboembolism prophylaxis in complex clinical scenarios in which the risk-benefit ratio of surgery is narrow and to develop a consensus document on the use of drugs anticoagulant therapy in this patient group. To this end, we identified by consensus the clinical areas of greatest uncertainty, a survey was created with 20 scenarios laid out in 40 clinical questions, and we reviewed the specific literature. The survey was distributed among the internists of the Spanish Society of Internal Medicine (SEMI) and was completed by 290 of its members. The consensus process was implemented by changing the Delphi-RAND appropriateness method in an anonymous, double-round process that enabled an expert panel to identify the areas of agreement and uncertainty. In our case, we also added the survey results to the panel, a methodological innovation that helps provide additional information on the standard clinical practice. The result of the process is a set of 19 recommendations formulated by SEMI experts, which helps establish guidelines for action on anticoagulant therapy in complex scenarios (high risk or active haemorrhage, short life expectancy, coexistence of antiplatelet therapy or comorbidities such as kidney disease and liver disease), which are not uncommon in standard clinical practice.

[Acute poisoning in patients over 65 years of age]. / Intoxicaciones agudas en pacientes mayores de 65 años.

BACKGROUND: There are few Spanish studies on acute poisoning in the elderly despite the associated risk factors of this group of patients. MATERIAL AND METHODS: Retrospective descriptive study of acute poisonings treated in the Emergency Service of the University Hospital of Zaragoza from 1995 to 2009 on patients 65 years old or older. RESULTS: A total of 762 patients were selected in the study (4.74% of all acute poisonings) with a mean age of 74.16 (SD ± 6) years. Ingestion was the major route of exposure (85%) and alcohol overdose (28,7%) was the most frequent type of poisoning. A trend was also observed showing a lower emetic treatment and gastric lavage and an increase in activated charcoal. Benzodiazepines (14.3%) and toxic household products (11%) with caustic properties were also the main toxics found in the study. CONCLUSIONS: Acute poisonings in the elderly required more hospitalizations, have a higher mortality and more autolytic attempts which result in death.

Intoxicaciones agudas en pacientes mayores de 65 años / Acute poisoning in patients over 65 years of age

Fundamento: Los estudios sobre la intoxicación aguda en sujetos de edad avanzada en nuestro país son escasos, a pesar de los riesgos asociados que presenta este grupo de pacientes. Material y métodos: Estudio descriptivo retrospectivo de las intoxicaciones agudas atendidas en el servicio de Urgencias del Hospital Clínico Universitario de Zaragoza entre 1995 y 2009, en pacientes con edad igual o mayor a 65 años. Resultados: Se registraron 762 casos, el 4,74% del total de intoxicados, con una edad media de 74,16 (SD ± 6) años. La vía oral fue la más frecuente (85%) y por tipo de intoxicación, la sobredosis de alcohol (28,7%). Junto a éste, las benzodiacepinas (14,3%) y los productos cáusticos (11%) fueron los principales tóxicos involucrados. El 21% de los pacientes recibieron tratamiento específico antitóxico, no precisando ingreso el 82,4%. Se observó en la evolución temporal una tendencia que apuntaba a la disminución del tratamiento emético y del lavado gástrico y un aumento del carbón activado. La mortalidad de la serie fue del 1,04%. Conclusiones: Las intoxicaciones en pacientes mayores presentan una mayor morbimortalidad, precisando más ingresos y más tentativas autolíticas con resultado de muerte (AU)

Background: There are few Spanish studies on acute poisoning in the elderly despite the associated risk factors of this group of patients. Material and methods: Retrospective descriptive study of acute poisonings treated in the Emergency Service of the University Hospital of Zaragoza from 1995 to 2009 on patients 65 years old or older. Results: A total of 762 patients were selected in the study (4.74% of all acute poisonings) with a mean age of 74.16 (SD ± 6) years. Ingestion was the major route of exposure (85%) and alcohol overdose (28,7%) was the most frequent type of poisoning. A trend was also observed showing a lower emetic treatment and gastric lavage and an increase in activated charcoal. Benzodiazepines (14.3%) and toxic household products (11%) with caustic properties were also the main toxics found in the study. Conclusions: Acute poisonings in the elderly required more hospitalizations, have a higher mortality and more autolytic attempts which result in death (AU)

[Nephritic colic management in an emergency room of a referral hospital]. / Manejo del cólico renal en urgencias de un hospital de tercer nivel.

BACKGROUND: To evaluate the diagnostic and therapeutic management of patients with nephritic colic in a referral hospital, their monitoring and the incidence of alternative diagnoses. METHODS: This is a retrospective review of 182 randomly selected patients who presented a clinical diagnosis compatible with nephritic colic in a referral hospital. In these cases initial treatment, monitoring and alternative diagnoses have been evaluated. RESULTS: Fifty-five point four percent of the patients were male, the mean age was 47.7 years and 40% of the cases were in spring. Urinalysis was carried out in every patient (62.7% dipstick and 72% urinary sediment); they were pathological in over 70%. In 26.4% of cases renal function deteriorated, always transiently. Abdominal radiography (81.9%) was the most frequently diagnostic test performed, followed by ultrasound (25.8%). Treatment included a serum therapy in 31.3%; metamizol (61%) was the most commonly used analgesic followed by ketorolac (44.5%). More than one non-steroidal anti-inflammatory was used by 46.2%. Hospital admission was required by 24 patients, and 5 of them needed emergency surgery. Twenty-four point one percent of patients had relapses during the next six months. Forty-one point six percent were referred to urology discharge on from the emergency room. Eighteen point one percent of patients had alternative diagnoses; acute pyelonephritis was the most frequent of these (55%). CONCLUSIONS: In our work we found a significant variation in the diagnostic and therapeutic management of these patients. The use of clinical guidelines could help us to unify the management of patients with nephritic colic, both in the emergency room and on discharge. Due to the high prevalence of alternative diagnoses, we have to systematically exclude more serious diseases.

Manejo del cólico renal en urgencias de un hospital de tercer nivel / Nephritic colic management in an emergency room of a referral hospital

Fundamento. El objetivo del presente trabajo es conocerlas características epidemiológicas, el manejo diagnóstico yterapéutico, su seguimiento y la incidencia de diagnósticosalternativos en una muestra de pacientes diagnosticados decólico renal en el Servicio de Urgencias de un Hospital detercer nivel.Material y métodos. Estudio descriptivo retrospectivo de182 pacientes seleccionados aleatoriamente que consultanpor clínica compatible con cólico renal en un hospital detercer nivel, valorando su manejo inicial, seguimiento al altay diagnósticos alternativos.Resultados. El 55,4% fueron varones, la edad media fue de47,7 años y el 40% de los casos se produjeron en primavera.En todos los pacientes se realizó analítica urinaria (62,7%tira reactiva y 72% sedimento) apareciendo alteraciones enmás del 70%. La función renal se deterioró en el 26,4 % delos casos, siempre de forma transitoria. La prueba de imagenrealizada con más frecuencia fue la radiografía de abdomen(81,9%) seguida de la ecografía (25,8%). El tratamiento incluyófluidoterapia en el 31,3% y el analgésico más usado fue elmetamizol (61%) seguido del ketorolaco (44,5%). El 46,2% delos pacientes necesitó más de un analgésico. Un total de 24pacientes precisaron ingreso hospitalario y 5 de ellos cirugíaurgente. El 24,1% presentó recaídas en los seis meses posteriores.El 41,6% fue remitido al Servicio de Urología al alta. El18,1% presentaron diagnósticos alternativos, siendo la pielonefritisaguda el más frecuente de ellos (55%).Conclusiones. Hemos detectado una importante variaciónen el manejo diagnóstico y terapéutico de estos pacientes.El uso de guías clínicas debe permitirnos unificar el manejodel paciente con cólico renal tanto en urgencias como posteriormente.El alto porcentaje de diagnósticos alternativosnos obliga a descartar sistemáticamente patologías másgraves(AU)

Background. To evaluate the diagnostic and therapeuticmanagement of patients with nephritic colic in a referralhospital, their monitoring and the incidence of alternativediagnoses.Methods. This is a retrospective review of 182 randomly selectedpatients who presented a clinical diagnosis compatiblewith nephritic colic in a referral hospital. In these casesinitial treatment, monitoring and alternative diagnoses havebeen evaluated.Results. Fifty-five point four percent of the patients weremale, the mean age was 47.7 years and 40% of the cases werein spring. Urinalysis was carried out in every patient (62.7%dipstick and 72% urinary sediment); they were pathologicalin over 70%. In 26.4% of cases renal function deteriorated,always transiently. Abdominal radiography (81.9%) was themost frequently diagnostic test performed, followed by ultrasound(25.8%). Treatment included a serum therapy in 31.3%;metamizol (61%) was the most commonly used analgesic followedby ketorolac (44.5%). More than one non-steroidal anti-inflammatory was used by 46.2%. Hospital admission wasrequired by 24 patients, and 5 of them needed emergencysurgery. Twenty-four point one percent of patients had relapsesduring the next six months. Forty-one point six percentwere referred to urology discharge on from the emergencyroom. Eighteen point one percent of patients had alternativediagnoses; acute pyelonephritis was the most frequent ofthese (55%).Conclusions. In our work we found a significant variationin the diagnostic and therapeutic management of these patients.The use of clinical guidelines could help us to unifythe management of patients with nephritic colic, both in theemergency room and on discharge. Due to the high prevalenceof alternative diagnoses, we have to systematicallyexclude more serious diseases(AU)

Dolor abdominal en paciente con bulimia nerviosa / Abdominal pain in bulimic patient

La incidencia de bulimia nerviosa ha cobrado importancia en los países occidentales en las últimas décadas. La dilatación gástrica aguda es un proceso muy grave e infrecuente en pacientes sin antecedentes de enfermedad digestiva. Sin embargo, se han descrito casos en pacientes con alteraciones de la conducta alimentaria, especialmente después de ingestas compulsivas. Las complicaciones de la dilatación gástrica aguda son la necrosis isquémica del órgano y la perforación que pueden conducir a una situación de shock irreversible. El diagnóstico precoz y la evacuación gástrica, incluso en fases incipientes de isquemia y necrosis pueden evitar la realización de una laparotomía. Se debería realizar una cuidadosa investigación de los hábitos alimentarios con objeto de ofertar un tratamiento precoz. Presentamos el caso de una mujer de 24 años que padecía bulimia nerviosa e ingresó por una dilatación gástrica aguda y revisamos las características más importantes de esta entidad (AU)

The incidence of bulimia nervosa has attained significance in the last decades in the Western countries. Massive gastric dilatation is a very serious condition that is extremely rare in patients with no background of gastrointestinal disease. However, several cases have been reported in patients with eating disorders, particularly after a compulsive ingestion. Complications of acute gastric dilatation are infarction and perforation with severe and irreversible shock. Prompt diagnosis of acute gastric dilatation and decompression of the stomach even when gastric ischemia and mucosal necrosis is present may avoid unnecessary laparotomy. Careful investigation of eating habits may result in therapeutic gastric emptying at an earlier stage. We present a case of a 24-year old woman who suffered bulimia nervosa and was admitted because of acute gastric dilatation. We review the most important features of this condition (AU)

La enseñanza de la Psicología Médica. Retorno a las fuentes psicológicas de una medicina antropológica / No disponible

Cuando se discuten los planes de enseñanza de laPsicología Médica y la Psicopatología y se aproximannuevos planes de estudio a las facultades de Medicinade las universidades europeas, consideramos imprescindiblela defensa de esta disciplina para los futuros médicosen las necesidades de la práctica médica, en las relacionesmédico-paciente y en el contexto sociocultural.En este trabajo se abordan las diferentes unidades temáticas,después de un análisis exhaustivo de los textos dela asignatura y los planes de enseñanza en las universidadesespañolas(AU)

When higher education plans of Medical Psychologyand Psychopathology are discussed and they approachnew study plans in in the European University Schoolsof Medicine, we consider indispensable the defense ofthis discipline for the future physicians in the necessitiesof medical practice, in the relationships doctor –patient and in the sociocultural context. In this work thedifferent thematic units are approached, after an exhaustiveanalysis of the texts on this subject and on theteaching plans in the Spanish Universities(AU)

Infección por Coxiella Burnetti (Fiebre Q) / Coxiella Burnetti infection (Q Fever)

La Fiebre Q es una zoonosis de distribución universal. Su verdadera incidencia en España es desconocida y probablemente subestimada. Su presentación clínica puede ser aguda o crónica y muy variada. Presentamos el caso clínico de un paciente de 69 años con neumonía y hepatitis secundaria a infección por Coxiella Burnetti (Fiebre Q). Se ha realizado una revisión de la literatura (AU)

Q Fever is a worldwide zoonosis. Real incidence in unknown and probably underestimated. Clinical manifestations are varied and can be acute and chronic. A case report of a 69 year old man with a pneumonia and hepatitis due to a Coxiella Burnetti infection (Q fever ) is presented. A review of literature was made (AU)

[Pneumonitis associated to methotrexate]. / Neumonitis secundaria a metotrexate.

Methotrexate (MTX) is a folic acid antagonist that inhibits cellular reproduction. MTX has been shown to be an effective anti-inflammatory agent. Acute interstitial pneumonitis is the main pulmonary side effect during MTX treatment. We report a case of MTX pneumonitis in a 56-year old woman with autoimmune thrombocytopenia who presented with subacute nonproductive cough, dyspnea at rest, fever, and malaise. Chest roentgenogram demonstrated bilateral diffuse interstitial and alveolar infiltration. Infectious diseases were ruled out and methotrexate-induced pneumonitis was suspected. MTX was discontinued and methylprednisolone was prescribed. Patient improved progressively. After eight weeks, radiologic abnormalities and symptoms had disappeared.

Neumonitis secundaria a metotrexate / Pneumonitis associated to methotrexate

El metotrexate (MTX) es un antagonista del ácido fólico que inhibe la reproducción celular. El MTX es actualmente utilizado como antiinflamatorio en diferentes procesos. La neumonitis intersticial aguda es el principal efecto secundario pulmonar que ocurre en pacientes tratados con MTX. Describimos el caso de una neumonitis asociada a MTX en una mujer de 56 años con trombopenia autoinmune, que presentó de forma subaguda tos no productiva, disnea de reposo, fiebre y afectación del estado general. En la radiografía de tórax se observaba una afectación intersticial bilateral difusa e infiltración alveolar. Se descartó una causa infecciosa del cuadro y ante la sospecha de neumonitis asociada a MTX, se procedió a su retirada. Se administró metilprednisolona, observándose una mejoría progresiva. Tras ocho semanas las alteraciones clínicas y radiológicas habían desaparecido

Methotrexate (MTX) is a folic acid antagonist that inhibits cellular reproduction. MTX has been shown to be an effective anti-inflammatory agent. Acute interstitial pneumonitis is the main pulmonary side effect during MTX treatment. We report a case of MTX pneumonitis in a 56-year old woman with autoimmune thrombocytopenia who presented with subacute non productive cough, dyspnea at rest, fever, and malaise. Chest roentgenogram demonstrated bilateral diffuse interstitial and alveolar infiltration. Infectious diseases were ruled out and methotrexte-induced pneumonitis was suspected. MTX was discontinuated and methylprednisolone was prescribed. Patient improved progressively. After eight weeks, radiologic abnormalities and symptoms had disappeared

Lack of clinical usefulness of interleukin-6 in long-term follow-up of acutely decompensated heart failure.

INTRODUCTION: Interleukin-6 (IL-6) has been identified as a predictor of death, new heart failure (HF) episodes and need for heart transplantation in patients with advanced HF. The aim of this study was to examine the relationship between plasma IL-6 levels in patients with decompensated HF and either survival or new admissions due to HF. METHODS: We studied 111 patients admitted due to decompensated HF. Long-term survival was assessed from the day of admission to the hospital to the day of death or new admissions due to HF. RESULTS: The mean IL-6 concentration was 90 +/- 115 pg/ml (range 1.5-743 pg/ml). There were no differences in IL-6 concentration with regard to age, gender and cause of HF. At the end of follow-up period, 22 patients (20 percent) had died due to causes related to HF and 54 patients (48 percent) had been readmitted to the hospital due to new HF episodes. Using regression analyses, serum IL-6 levels were not identified as a prognostic factor. Systolic dysfunction, previous diagnosis of HF and diabetes mellitus were independent predictors of death. CONCLUSION: These findings suggest that a single measurement of serum IL-6 in patients with decompensated HF lacks clinical usefulness in long-term follow-up.