Adequacy and prognostic impact of treatment for severe exacerbation of chronic obstructive pulmonary disease. / Adecuación e impacto pronóstico del tratamiento de las exacerbaciones graves de la enfermedad pulmonar obstructiva crónica.

OBJECTIVE: To define the clinical characteristics of patients hospitalised in pneumology and internal medicine departments for chronic obstructive pulmonary disease (COPD) exacerbation, to assess the compliance with the recommendations of the clinical practice guidelines and to determine the impact on the patients' prognosis. METHODOLOGY: We conducted a retrospective longitudinal study that randomly included patients hospitalised for COPD exacerbation in a tertiary hospital. We collected demographic and clinical variables (degree of dyspnoea and obstruction, previous exacerbations, comorbidities), readmission and mortality data and criteria for compliance with the Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines and the Spanish COPD guidelines (GesEPOC). We performed a univariate, multivariate and survival analysis. RESULTS: The study included 108 patients, and the mean age was 71.48±11.65 years. The readmission rate was 26.4% at 3 months and 43.4% at 1 year. The hospital mortality rate was 3.9%, the mortality rate at 3 months was 21.9%, and the mortality rate at 1 year was 27.4%. The patients hospitalised in the internal medicine department had higher mortality during hospitalisation (p=.043), at 3 months (p=.028) and at 1 year (p=.007) compared with the rates for the pneumology department. Overall compliance with the clinical guidelines was 63% for the clinical evaluation (less for the patients in internal medicine: 56.1% vs. 73.8%, p=.063). For the treatment, the compliance was 26.9% for GOLD and 28.7% for GesEPOC. Compliance with the GOLD guidelines in the use of corticosteroids was associated with a lower rate of long-term readmissions (p=.041) and hospital mortality (p=.007) and 3-month mortality (p=.05). CONCLUSIONS: The clinical profile of the patients is currently similar to that previously reported, but their clinical progression was poorer. Overall compliance with the clinical guidelines for drug treatment was low, and only appropriate use of systemic steroids was associated with a reduction in early mortality and in medium-term readmissions.

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.

Infant-juvenile type 2 diabetes. / Diabetes tipo 2 infantojuvenil.

In recent years, we have witnessed an increase in the number of cases of type 2 diabetes mellitus (DM2) in children and adolescents, which has paralleled the increase in the worldwide prevalence of obesity. Although screening the general population does not appear to be cost-effective, special attention should be paid to children with excess weight, obesity or other factors that predispose them to a state of insulin resistance. When faced with the diagnosis of childhood DM2, the presence of comorbidities (such as hypertension, dyslipidemia and microalbuminuria) should be assessed, and appropriate treatment and follow-up should be administered to prevent the onset of complications, given that the DM2 in this population group will last longer than that started in adulthood.

Prevalence of obesity according to Edmonton staging in the Internal Medicine consultations. Results of the OBEMI study. / Prevalencia de obesidad según la estadificación de Edmonton en las consultas de Medicina Interna. Resultados del estudio OBEMI.

OBJECTIVES: To estimate the prevalence of obesity in patients treated by departments of Internal Medicine and to classify the patients according to the Edmonton Obesity Staging System (EOSS). MATERIAL AND METHODS: An observational, descriptive cross-sectional study included outpatients older than 18 years, with a body mass index (BMI)>30, from 38 hospitals between the 1st and 14th of February, 2016. We classified the patients according to the EOSS and analysed their clinical, laboratory and demographic variables. A value of P<.05 was considered statistically significant. RESULTS: Of the 1,262 patients treated in consultations, we recruited 298 and analysed 265. The prevalence of obesity was 23.6%, the mean age was 62.47±15.27 years, and the mean BMI was 36.1±5.3kg/m2. According to EOSS stage (0, 1, 2, 3 and 4), the prevalence was 4.9, 14.7, 62.3, 15.5 and 2.64%, respectively. Those patients with EOSS>2 were significantly older and had significantly more comorbidities. The multivariate analysis related age (OR 1.06; P<.0003), blood glucose (OR 1.04; P<.0006), total cholesterol (OR 0.98; P<.02) and uric acid (OR 1.32; P<.02) levels with an EOSS>2. An analysis of correspondence grouped, with an explanatory percentage of 78.2%, the patients according to their EOSS, comorbidity, education level, employment status and functional capacity. CONCLUSIONS: The prevalence of obesity in the patients treated by Internal Medicine departments is similar to that of the general population, although the patients are older and have a higher BMI. EOSS is useful for implementing a comprehensive approach for patients with obesity, regardless of the BMI, which can help achieve better health and quality-of-life results.

Effect of an intervention on quality indicators for improving the treatment of hyperglycemia in patients hospitalized in noncritical areas. / Efecto de una intervención sobre indicadores de calidad para mejorar el tratamiento de la hiperglucemia en pacientes hospitalizados en áreas no críticas.

OBJECTIVES: We evaluated the effect of an intervention on certain quality indicators employed for improving the treatment of hospital hyperglycemia. MATERIAL AND METHODS: A multicenter cross-sectional study was conducted on patients with hyperglycemia hospitalized in the internal medicine departments of 44 hospitals evaluated in 2 time periods: 2014 (baseline period) and 2015 (postintervention period). The intervention consisted of the dissemination of the indicators obtained in 2014 and the objectives for improvement. As indicators, we assessed the frequency of glucose monitoring adapted to the patient's dietary intake or medication, the use of basal-bolus or basal-bolus-correction insulin therapy as the preferred control method of hyperglycemia and the recent availability of HbA1c prior to hospital discharge. RESULTS: A total of 506 and 562 patients were assessed in 2014 and 2015, respectively. The results of the indicators in the baseline and postintervention periods were as follows: blood glucose monitoring adapted to the dietary intake or the medication (71.5 vs. 74.1%, P=.33), use of insulin in basal-correction regimen (32 vs. 32.6%, P=.61) or basal-bolo-correction (20.7 vs. 24, P=.20) and recent HbA1c value (54.1 vs. 66.3%, P<.001). The mean glucose values in the 24h prior to the study were similar in the 2 periods. The rate of hypoglycemia was also similar in both periods (3.3 vs. 2.3%, P=.31). CONCLUSIONS: There is a need to implement multimodal interventions to improve the treatment of hyperglycemia in patients hospitalized in noncritical areas.

[Off-label approval of drug use in a tertiary hospital]. / Autorización de usos de medicamentos fuera de indicación en un hospital de tercer nivel.

BACKGROUND AND OBJECTIVE: The Pharmacy and Therapeutics Committee (PTC) evaluates the requests for off-label uses with an abbreviated report format. The aim of this study is to perform a descriptive analysis of this activity and to study the rate of approvals. MATERIAL AND METHODS: A descriptive study was performed on the PTC reports in a tertiary hospital between September 2009 and April 2011. The type of drug by treatment group and by type of dispensing, indication and requesting department was analysed. The final decision adopted was studied as the primary outcome, and the percentage of requests approved according to the characteristics of the drug evaluated, indication requested, alternatives used, evidence and cost, as secondary outcomes. RESULTS: A total of 51 applications were analysed, of which 60.8% were drugs for hospital use and 54.9% cytostatic. The most requested indications were the onco-haematological (43.2%) and autoimmune (35.3%). Haematology was the department that made most requests (11 requests with 72.7% approved), Oncology and Paediatrics (both with 10 requests, with 50% approved). Almost two-thirds (60.8%) of the requests were approved. Of those that were not approved, 11 had not used up the therapeutic alternatives, and 8 had no evidence. Just under half (47.1%) of the drugs requested had a cost/patient between 10,000-100,000 euros,of which 58.3% were approved (cost per course of treatment if it had a defined period, or cost of treatment per year for chronic treatment). CONCLUSION: There is an increase in the activity of the PTC that is growing over the years. Most applications focus on drugs for hospital use and cytostatic drugs by Onco-haematology. There is a high rate of approval by the PTC, and high variability in the percentage of approval depending on the department and the evidence of use. The difference between approved and unapproved requests followed a logic of cost-effectiveness.

[Analysis of the selection process for new drugs in a tertiary hospital 2004-2007]. / Análisis del proceso de selección de nuevos medicamentos en un hospital terciario. Años 2004-07.

OBJECTIVE: The purpose of this study is to describe the structure of the CFyT, the Pharmacy and Therapeutics Committee, and a tertiary hospital's selection process for new drugs. MATERIAL AND METHODS: All annals of the P&TC and the New Drug Incorporation Guides (GINF) to incorporate new drugs received at Hospital Virgen del Rocío between 2004 and 2007 were reviewed. We carried out a descriptive study which collected variables having to do with the drug (drug type, type of register, route of administration and legal category), the petitioner (responsible division, professional category and request type) and the result of the evaluation (final decision, elapsed time between the request and the decision). RESULTS: Of the 72 requested drugs, 45 (62.5%) were approved: six as equivalent treatments, 36 (80%) with specific recommendations, and three (4.2%) with no restrictions. Twelve drugs (81.1%) were not included due to insufficient evidence of their effectiveness compared with the current treatment. The most frequently-requested drug type was the antineoplastics, most commonly requested by Oncology and Haematology divisions. We highlight the fact that many of the petitioners included clinical trials (97.2%) and data referring to costs (84.7%). CONCLUSIONS: There is a high level of compliance with the GINF guide in our centre, which guarantees that the P&TC's final decision is based on scientific evidence.

[Pneumocystis jiroveci: a new name for an old pathogen]. / Pneumocystis jirovecii: un nuevo nombre para un viejo patógeno.

Pneumonia due to Pneumocystis is an important cause of morbidity-mortality among immunodepressed patients, above all with human immunodeficiency virus infection and finally in patients with transplants, oncology patients and those subjected to drug immunodepression. Its lack of capacity to grow in the usual culture mediums has hindered knowledge on many aspects of this infection (transmission, acquisition mode, infection sources). However, the incorporation of molecular biology tools in recent years has made it possible to go deeper into the understanding of the epidemiology, biology and characteristics of the infection by this pathogen. These advances have led to the modification of the taxonomic classification of this atypical fungus and change in the name of the Pneumocystis responsible for the infection in humans, which is now called Pneumocystis jirovecii. During this article, we will show some of the most recent advances in the knowledge of the human pneumocystosis.

[Comparative study of misoprostol and nifedipine in the treatment of Raynaud's phenomenon secondary to systemic diseases. Hemodynamic assessment with Doppler duplex]. / Estudio comparativo de misoprostol y nifedipino en el tratamiento del fenómeno de Raynaud secundario a enfermedades sistémicas. Valoración hemodinámica mediante Doppler-dúplex.

OBJECTIVE: To evaluate the mid-term efficiency and therapeutic safety at a mid term of the orally administered misoprostol, a synthetic PGE1, analogue, compared with nifedipine for the treatment of RP secondary to autoimmune systemic diseases. METHODS: A double blind, crossover study was designed. Patients were randomly distributed to receive either retard nifedipine (20 mg/12 hourly) and misoprostol (200 micrograms/12 hourly) in 10-day periods (washing period with placebo for 10 days). At the end of each period a clinical assessment was obtained on the frequency and severity of symptoms as well as on secondary drug reactions. Simultaneously, blood flow changes in radial artery were Doppler-duplex investigated (pulsatility index, resistance index). RESULTS: Twenty patients were studied (15 women and 5 men). The mean basal daily frequency of attacks was 4.8 +/- 2.0 compared with 2.4 +/- 1.4 with nifedipine (p < 0.001) and 2.6 +/- 1.2 with misoprostol (p < 0.001). The mean basal severity of attacks, according to a pre-established scale decreased from 3.7 +/- 0.6 to 1.9 +/- 0.9 with nifedipine (p < 0.001) and to 2.0 +/- 1.0 with misoprostol (p < 0.001). The mean basal value of blood flow in radial artery was 24.9 +/- 14.4 ml/min; with nifedipine it increased to 43.0 +/- 19.2 ml/min (p < 0.001) and with misoprostol to 46.9 +/- 19.2 ml/min (p < 0.001). Five patients (25%) had secondary effects with nifedipine and three (15%) with misoprostol; in no case had therapy to be discontinued. CONCLUSIONS: Misoprostol was similar to nifedipine for the treatment of Raynaud phenomenon secondary to systemic diseases and can be a therapeutic alternative for these patients.