Prophylaxis in nonorthopaedic surgery. / Profilaxis en cirugía no ortopédica.

Surgery increases the risk (by 20-fold) of venous thromboembolism (VTE), but there are prophylaxis methods (mechanical, pharmaceutical or combined) that safely reduce the incidence rate of VTE. The administration of prophylaxis requires a prior assessment of the risks associated with the patient and with the type of surgery. The Caprini and Rogers scales classify patients into four VTE risk categories (very low, low, moderate and high). In pharmacological prophylaxis, the risk of bleeding should also be assessed. At this time, the recommendation is to administer prophylaxis to all patients: mechanical prophylaxis for low, moderate or high risk with contraindications for the administration of heparin; combined with heparin for very high risk; and with drugs such as low-molecular-weight heparin, unfractionated heparin and fondaparinux for moderate to high risk. These measurements should be kept until full ambulation, discharge, or at least seven days (for major oncologic and bariatric surgery, maintain for four weeks).

Aprender medicina de la literatura / Learning medicine from the literature

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¿Tesis doctoral tradicional o por compendio de publicaciones? / Traditional doctorate thesis or by a compendium of publications?

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Anxiety disorders and risk of stroke: A systematic review and meta-analysis.

BACKGROUND: Anxiety disorders are the most common mental health problem worldwide. However, the evidence on the association between anxiety disorders and risk of stroke is limited. This systematic review and meta-analysis presents a critical appraisal and summary of the available evidence on the association between anxiety disorders and risk of stroke. METHODS: Cohort studies reporting risk of stroke among patients with anxiety disorders were searched in PubMed, Embase, PsycINFO, Scopus, and the Web of Science, from database inception to June 2016. The quality of the studies was assessed using standard criteria. A meta-analysis was undertaken to obtain pooled estimates of the risk of stroke among patients with anxiety disorders. RESULTS: Eight studies, including 950,759 patients, from the 11,764 references initially identified, were included in this review. A significantly increased risk of stroke for patients with anxiety disorders was observed, with an overall hazard ratio: 1.24 (1.09-1.41), P=0.001. No significant heterogeneity between studies was detected and the funnel plot suggested that publication bias was unlikely. Limited evidence suggests that the risk of stroke is increased shortly after the diagnosis of anxiety and that risk of stroke may be higher for patients with severe anxiety. CONCLUSIONS: Anxiety disorders are a very prevalent modifiable condition associated with risk of stroke increased by 24%. This evidence could inform the development of interventions for the management of anxiety and the prevention of stroke. Further studies on the risk of stroke in patients with anxiety, and the explanatory factors for this association, are required.

Risk of incident cardiovascular events amongst individuals with anxiety and depression: A prospective cohort study in the east London primary care database.

BACKGROUND: It is unknown how risk of myocardial infarction and stroke differ for patients with and without anxiety or depression, and whether this risk can be explained by demographics, medication use, cardiovascular risk factors. The aim of this study is to quantify differences in risk of non-fatal MI or stroke among patients with anxiety or depression. METHODS: Prospective cohort study examining risk of incident MI and stroke between March 2005 and March 2015 for 524,952 patients aged 30 and over from the east London primary care database for patients with anxiety or depression. RESULTS: Amongst 21,811 individuals with depression at baseline, 1.2% had MI and 0.4% had stroke. Of 22,128 individuals with anxiety at baseline, 1.1% had MI and 0.3% had stroke. Depression was independently associated with both MI and stroke, whereas anxiety was associated with MI only before adjustment for cardiovascular risk factors. Antidepressant use increased risk for MI but not stroke. Mean age at first MI was lower in those with anxiety, while mean age at first stroke was lower in those with depression. LIMITATIONS: The study was limited to patients currently registered in the database and thus we did not have any patients that died during the course of follow-up. CONCLUSIONS: Patients with depression have increased risk of cardiovascular events. The finding of no increased cardiovascular risk in those with anxiety after adjusting for cardiovascular risk factors is of clinical importance and highlights that the adequate control of traditional risk factors is the cornerstone of cardiovascular disease prevention. Targeting management of classical cardiovascular risk factors and evaluating the risks of antidepressant prescribing should be prioritized.

Cardiovascular risk factors among patients with schizophrenia, bipolar, depressive, anxiety, and personality disorders.

BACKGROUND: The evidence informing the management of cardiovascular risk in patients with psychiatric disorders is weak. METHODS: This cohort study used data from all patients, aged≥30, registered in 140 primary care practices (n=524,952) in London to estimate the risk of developing diabetes, hypertension, hyperlipidemia, tobacco consumption, obesity, and physical inactivity, between 2005 and 2015, for patients with a previous diagnosis of schizophrenia, depression, anxiety, bipolar or personality disorder. The role of antidepressants, antipsychotics and social deprivation in these associations was also investigated. The age at detection of cardiovascular risk factor was compared between patients with and without psychiatric disorders. Variables, for exposures and outcomes, defined from general practitioners records, were analysed using multivariate regression. RESULTS: Patients with psychiatric disorders had an increased risk for cardiovascular risk factors, especially diabetes, with hazard ratios: 2.42 (2.20-2.67) to 1.31 (1.25-1.37), hyperlipidemia, with hazard ratios: 1.78 (1.60-1.97) to 1.25 (1.23-1.28), and obesity. Antidepressants, antipsychotics and social deprivation did not change these associations, except for smoking and physical inactivity. Antidepressants were associated with higher risk of diabetes, hypertension and hyperlipidemia. Antipsychotics were associated with a higher risk of diabetes. Antidepressants and antipsychotics were associated with lower risk of other risk factors. Patients with psychiatric conditions have later detection of cardiovascular risk factors. The interpretation of these results should acknowledge the lower rates of detection of risk factors in mentally ill patients. CONCLUSIONS: Cardiovascular risk factors require special clinical attention among patients with psychiatric disorders. Further research could study the effect of antidepressants and antipsychotics on cardiovascular risk factors.

¿Antibióticos en la infección respiratoria baja? Consideraciones desde su etiología,incertidumbre diagnóstica, efectos terapéuticosy adversos del antibiótico y expectativas del paciente / No disponible

En Atención Primaria vemos muchos pacientes con infección respiratoria baja (IRB), la mayoría víricas, aunque un porcentaje incierto de ellas son bacterianas. El diagnóstico diferencial IRB/neumonía es difícil. La medida de la proteína C reactiva (PCR) y pro calcitonina pueden servir para este diagnóstico diferencial, pero estas técnicas requieren más estudios. La placa de tórax es lo más útil, pero la enorme prevalencia de la IRB limita su uso. El diagnóstico y tratamiento de la IRB se hace en base a hallazgos clínicos. Los antibióticos no son eficaces en la IRB, además de tener su tasa de efectos secundarios. Además el uso de antibióticos se asocia al riesgo de padecer infecciones por bacterias resistentes. La prescripción racional de antibióticos disminuye la prevalencia de dichas infecciones. Una explicación apropiada, la prescripción retardada, y la educación para la salud, son clave cuando no se pautan antibióticos a un paciente con IRB que esperaba recibirlos (AU)

Attention is given in Primary Care to many patients with Lower Respiratory Tract Infection (LRTI), most of these infections being viral, although some unknown percentage is bacterial. It is difficult to make a differential LRTI/pneumonia diagnosis. Measuring the C-reactive protein and pro calcitonin may aid in this differential diagnosis, but these techniques require further study. The chest X-ray is the most useful tool in this situation; however, the high prevalence of LRTI limits its use. The diagnosis and treatment of LRTI is based on clinical findings. Antibiotics are not effective in LRTI and also have a rate of side effects. In addition, the use of antibiotics is associated to the risk of suffering resistant bacterial infections. A rational use of antibiotics can decrease the prevalence of resistant bacterial infections. Giving a proper explanation to the patient and delaying the antibiotic prescription and providing health education are key aspects when not prescribing antibiotics to a patient who is expecting them (AU)