Noninvasive ventilation for severely acidotic patients in respiratory intermediate care units : Precision medicine in intermediate care units.

BACKGROUND: Severe acidosis can cause noninvasive ventilation (NIV) failure in chronic obstructive pulmonary disease (COPD) patients with acute hypercapnic respiratory failure (AHRF). NIV is therefore contraindicated outside of intensive care units (ICUs) in these patients. Less is known about NIV failure in patients with acute cardiogenic pulmonary edema (ACPE) and obesity hypoventilation syndrome (OHS). Therefore, the objective of the present study was to compare NIV failure rates between patients with severe and non-severe acidosis admitted to a respiratory intermediate care unit (RICU) with AHRF resulting from ACPE, COPD or OHS. METHODS: We prospectively included acidotic patients admitted to seven RICUs, where they were provided NIV as an initial ventilatory support measure. The clinical characteristics, pH evolutions, hospitalization or RICU stay durations and NIV failure rates were compared between patients with a pH ≥ 7.25 and a pH < 7.25. Logistic regression analysis was performed to determine the independent risk factors contributing to NIV failure. RESULTS: We included 969 patients (240 with ACPE, 540 with COPD and 189 with OHS). The baseline rates of severe acidosis were similar among the groups (45 % in the ACPE group, 41 % in the COPD group, and 38 % in the OHS group). Most of the patients with severe acidosis had increased disease severity compared with those with non-severe acidosis: the APACHE II scores were 21 ± 7.2 and 19 ± 5.8 for the ACPE patients (p < 0.05), 20 ± 5.7 and 19 ± 5.1 for the COPD patients (p < 0.01) and 18 ± 5.9 and 17 ± 4.7 for the OHS patients, respectively (NS). The patients with severe acidosis also exhibited worse arterial blood gas parameters: the PaCO2 levels were 87 ± 22 and 70 ± 15 in the ACPE patients (p < 0.001), 87 ± 21 and 76 ± 14 in the COPD patients, and 83 ± 17 and 74 ± 14 in the OHS patients (NS)., respectively Further, the patients with severe acidosis required a longer duration to achieve pH normalization than those with non-severe acidosis (patients with a normalized pH after the first hour: ACPE, 8 % vs. 43 %, p < 0.001; COPD, 11 % vs. 43 %, p < 0.001; and OHS, 13 % vs. 51 %, p < 0.001), and they had longer RICU stays, particularly those in the COPD group (ACPE, 4 ± 3.1 vs. 3.6 ± 2.5, NS; COPD, 5.1 ± 3 vs. 3.6 ± 2.1, p < 0.001; and OHS, 4.3 ± 2.6 vs. 3.7 ± 3.2, NS). The NIV failure rates were similar between the patients with severe and non-severe acidosis in the three disease groups (ACPE, 16 % vs. 12 %; COPD, 7 % vs. 7 %; and OHS, 11 % vs. 4 %). No common predictive factor for NIV failure was identified among the groups. CONCLUSIONS: ACPE, COPD and OHS patients with AHRF and severe acidosis (pH ≤ 7.25) who are admitted to an RICU can be successfully treated with NIV in these units. These results may be used to determine precise RICU admission criteria.

Noninvasive ventilation during the weaning process in chronically critically ill patients.

Chronically critically ill patients often undergo prolonged mechanical ventilation. The role of noninvasive ventilation (NIV) during weaning of these patients remains unclear. The aim of this study was to determine the value of NIV and whether a parameter can predict the need for NIV in chronically critically ill patients during the weaning process. We conducted a prospective study that included chronically critically ill patients admitted to Spanish respiratory care units. The weaning method used consisted of progressive periods of spontaneous breathing trials. Patients were transferred to NIV when it proved impossible to increase the duration of spontaneous breathing trials beyond 18 h. 231 chronically critically ill patients were included in the study. 198 (85.71%) patients achieved weaning success (mean weaning time 25.45±16.71 days), of whom 40 (21.4%) needed NIV during the weaning process. The variable which predicted the need for NIV was arterial carbon dioxide tension at respiratory care unit admission (OR 1.08 (95% CI 1.01-1.15), p=0.013), with a cut-off point of 45.5 mmHg (sensitivity 0.76, specificity 0.67, positive predictive value 0.76, negative predictive value 0.97). NIV is a useful tool during weaning in chronically critically ill patients. Hypercapnia despite mechanical ventilation at respiratory care unit admission is the main predictor of the need for NIV during weaning.

Rivaroxaban for the treatment of venous thromboembolism. A "real-life" perspective in 103 patients.

INTRODUCTION: Randomized clinical trials have demonstrated non-inferiority of rivaroxaban compared with vitamin K antagonists (VKAs) in the treatment of venous thromboembolism (VTE). Our objective was to analyze in real life, tolerance, recurrence, bleeding and adverse events of rivaroxaban in patients with acute symptomatic VTE. MATERIAL AND METHODS: Open follow-up study of a cohort of patients aged 18 and over diagnosed with deep vein thrombosis (DVT) and/or pulmonary embolism (PE) treated with rivaroxaban from December 2011 to January 2014. RESULTS: The total number of patients treated with rivaroxaban was 103. The mean age was 58+/-17 years. The most frequent co-morbidities were: hypertension (30.0%), dyslipidemia (23.3%) and respiratory disease (25.2%). The type of thromboembolic event treated was: DVT (64.1%), PE (18.4%), DVT+PE (17.5%). Of the rivaroxaban-treated patients, 30% did so from the initial anticoagulant therapy and the other 70% in long-term or extended anticoagulant therapy. The median time of treatment with rivaroxaban was 6 months [corrected]. There was one recurrence and no deaths occurred. Six patients had bleeding, one of which was severe. CONCLUSIONS: Rivaroxaban provides a therapeutic alternative in a group of patients with VTE with advantages over VKAs, because of the convenience in dosing, lack of requirements for periodic monitoring and limited interaction with other drugs.

¿Se puede establecer una relación entre los índices FRAX® y QFracturescoresTM? / Can a relationship between FRAX® indices and QFracturescoresTM be established?

Objetivo: Establecer una correlación entre los valores de riesgo de fractura obtenidos con las herramientas FRAX® y QFractureScoresT. Diseño del estudio: Observacional descriptivo retrospectivo. Emplazamiento: Centro de Especialidades de Toledo. Participantes: Pacientes con osteoporosis de una consulta de Metabolismo Óseo. Mediciones: Revisión de historias clínicas, obteniendo los datos del momento en que se inició el tratamiento antiosteoporótico, aplicando los índices de riesgo FRAX®, con y sin densitometría (en los casos en que la tengan), y QFractureScoresT, y estableciendo la correlación entre ambos. Resultados: 99 pacientes (88,9% mujeres), edad media (± desviación estándar) 62,3 ± 9,3 años. El valor medio del FRAX® sin densitometría fue de 7,37 ± 6,33 para fractura osteoporótica mayor (FOM) y de 2,6 ± 3,71 para fractura de cadera (FC). Con densitometría (n=74) los valores fueron de 8,6 ± 7,35 y 3,36 ± 4,64, respectivamente. El riesgo a 10 años con QFractureScoresT fue de 4,56 ± 2,83 para FOM y de 1,58 ± 1,91 para FC. El 37,4% presentaba un índice FRAX® (FOM / FC) ≥ 20% / 3%. La correlación entre FRAX® y QFractureScoresT para FOM fue de 0,751 (IC95% 0,620-0,882) y para FC de 0,771 (IC95% 0,645-0,897), disminuyendo al incluir los valores de las densitometrías [r=0,573 en FOM (IC95% 0,384-0,762) y r=0,487 en FC (IC95% 0,286-0,688)]. Conclusiones: Los índices FRAX® y QFractureScoresT presentan una correlación moderada-fuerte, especialmente si no se incluyen los valores de las densitometrías. Su uso puede recomendarse en Atención Primaria, sobre todo para valorar los factores de riesgo de osteoporosis. Actualmente no disponemos de puntos de corte fiables para tomar decisiones diagnóstico-terapéuticas en nuestro medio (AU)

Objective: To establish a correlation between the values of fracture risk obtained by FRAX® and QFractureScoresT tools. Design of the study: Retrospective observational study Location: Speciality Centre in Toledo. Participants: Patients with osteoporosis from a Bone Metabolism consultation. Measurements: Review of clinical history, with data obtained from the moment the antiosteoporotic treatment was commenced, applying FRAX® risk indices, with and without densitometry (in the cases affected by it) and QFractureScoresT, and establishing a correlation between them. Results: 99 patients (88.9% female) average age (± standard deviation) 62,3 ± 9,3 years. The average FRAX® value without densitometry was 7,37 ± 6,33 for major osteoporotic fracture (MOF) and 2,6 ± 3,71 for hip fracture (HF). With densitometry (n=74), the values were 8,6 ± 7,35 and 3,36 ± 4,64, respectively. A 10 year risk with QFractureScoresT was 4,56 ± 2,83 for MOF and 1,58 ± 1,91 for hip fracture. 37.4% showed a FRAX® (MOF / HF) ≥ 20% / 3% index. The correlation between FRAX® and QFractureScoresT for MOF was 0,751 (IC95% 0,620-0,882) and HF, 0,771 (IC95% 0,645-0,897), getting lower when densitometry values are included [r=0,573 in MOF (IC95% 0,384-0,762) and r=0,487 in HF (IC95% 0,286-0,688)]. Conclusions:FRAX® and QFractureScoresT indices show a moderate to strong correlation, especially if densitometry values are not included. Its use can be recommended in primary health care, above all in order to assess the risk of osteoporosis. We do not currently have a reliable benchmark to take diagnostic and therapeutic decisions in our environment (AU)

¿Qué cualidades valoran más los Pacientes de su Médico de Familia? / What qualities do patients value more in a Family Doctor?

Objetivo. Conocer qué cualidades del Médico de Familia son más valoradas por los pacientes y en qué medida son cumplidas. Diseño. Estudio descriptivo transversal. Emplazamiento. Atención Primaria. Área de Toledo. Participantes. Mayores de 14 años del Área, seleccionados por muestreo aleatorio sistemático. Mediciones principales. Encuesta telefónica diseñada ad hoc con ítems sobre las características relevantes del médico y el cumplimiento de las mismas, en escala de 0 a 10. Se recogieron también variables sociodemográficas, enfermedades crónicas y utilización de consultas. Resultados. Fueron entrevistados 161 pacientes, con edad media de 42,6 años. El 55,7% mujeres. El 69,7% tenía alguna enfermedad crónica. El 38,6% de ellos había acudido a su médico en el último mes, mientras que el 90,4% lo había hecho en el último año. Las características más valoradas fueron la ‘confiabilidad’ y el ‘trato respetuoso’; las menos valoradas fueron la ‘participación en la toma de decisiones’ y la ‘aceptación de pruebas demandadas por el paciente’. Respecto al grado de cumplimiento de dichas cualidades, destacan el ‘trato respetuoso’ y la ‘confiabilidad’. Conclusiones. La utilización de consulta es muy elevada en nuestro medio. Los pacientes valoran más cualidades de “índole personal” del médico que las de tipo técnico u organizativo. La participación en la toma de decisiones es de las menos valoradas. En general, los médicos del Área de Toledo cumplen en buena medida las expectativas planteadas en lo que a las cualidades personales se refiere (AU)

Objective. To determine what qualities patients value most in a Family Doctor and to what extent their doctors meet these expectations. Design. Cross sectional, descriptive study. Setting. Primary care. Toledo. Participants. Patients over 14 years old, selected by a random sampling method. Main measurements. An ad hoc telephone survey with items on the characteristics of a doctor and compliance to them, measured on a scale of 1 to 10. Socio-demographic variables, chronic diseases and use of doctors’ surgeries were also recorded. Results. A total of 161 patients with a mean age of 42.5 years were interviewed. 55.7% were women. 69,7% had a chronic disease. 38,6% had visited their doctor in the last month, whilst 90.4% had done so in the last year. The most valued characteristics were ‘reliability’ and ‘respectful treatment’; the least valued were “participation in making decisions” and “agreeing to tests requested by the patients”. “Respectful treatment” and “reliability” were the characteristics that most met the patients’ expectations. Conclusions. The use of doctors’ surgeries is very high in our area. The patients valued qualities of a “personal nature” more than technical or organizational qualities. Participation in the decision making process was less valued. In general doctors in the Toledo health area met patients’ expectation as regards personal characteristics (AU)