Actitud ante el riesgo tromboembólico en pacientes con cáncer / Management of thromboembolic risk in patients with cancer

La tromboembolia venosa es una complicación frecuente de los pacientes con cáncer, que influye en su morbilidad y mortalidad. El riesgo de padecerla difiere en virtud de determinadas características del tumor y de circunstancias propias del paciente afectado o de los tratamientos instaurados. Si bien se ha demostrado el beneficio de la tromboprofilaxis en determinados subgrupos de pacientes con cáncer, actualmente no se recomienda su prescripción de forma genérica salvo que concurran otros factores de riesgo, o en el caso de pacientes con mieloma múltiple que sean tratados con talidomida o lenalidomida. La inserción de un catéter venoso central en estos pacientes no implica la prescripción de tromboprofilaxis, aunque se conocen los factores de riesgo de trombosis asociada al catéter. Finalmente se ha definido un modelo de predicción del riesgo tromboembólico en pacientes ambulatorios con cáncer que inician quimioterapia, que ha sido externamente validado y complementado con la adición de los valores de 2 biomarcadores (AU)

Venous thromboembolism is a frequent complication in cancer patients and affects their morbidity and mortality. The risk of this event differs according to the characteristics of the tumor, the patient’s circumstances, and the treatments provided. Although the benefits of thromboprophylaxis in certain subgroups of patients with cancer have been demonstrated, currently generic prescription is not recommended unless other risk factors are present, or the patient has multiple myeloma and has been treated with thalidomide or lenalidomide. The insertion of a central venous catheter in these patients does not imply prescription of thromboprophylaxis, although the risk factors for catheter thrombosis are known. Finally, a risk scoring model for the prediction of venous thromboembolism has been defined in outpatients with cancer starting chemotherapy, which has been externally validated and supplemented with the addition of two biomarkers (AU)

[Management of thromboembolic risk in patients with cancer]. / Actitud ante el riesgo tromboembólico en pacientes con cáncer.

Venous thromboembolism is a frequent complication in cancer patients and affects their morbidity and mortality. The risk of this event differs according to the characteristics of the tumor, the patient's circumstances, and the treatments provided. Although the benefits of thromboprophylaxis in certain subgroups of patients with cancer have been demonstrated, currently generic prescription is not recommended unless other risk factors are present, or the patient has multiple myeloma and has been treated with thalidomide or lenalidomide. The insertion of a central venous catheter in these patients does not imply prescription of thromboprophylaxis, although the risk factors for catheter thrombosis are known. Finally, a risk scoring model for the prediction of venous thromboembolism has been defined in outpatients with cancer starting chemotherapy, which has been externally validated and supplemented with the addition of two biomarkers.

Association between long travel and venous thromboembolic disease: a systematic review and meta-analysis of case-control studies.

The term "economy-class syndrome" defines an infrequent episode of venous thromboembolism (VTED) related to a long travel, namely by plane. However, this relation has not clearly been demonstrated by investigators. We carried out a systematic review and a meta-analysis of cases-control studies that had studied this topic. We realised a systematic review of the literature and selected all the case-control studies published. Two authors carried out a methodological evaluation according to the Scottish Intercollegiate Guidelines Network items (concordance was analysed by weighted kappa index), and a systematic analysis of the potential biases of each study was assessed. We carried out the meta-analysis with the data extracted from the studies. We recovered eight cases-control studies. The relation between the antecedent of a long travel and subsequent VTED varied from OR = 1.1 to OR = 4.0 and was found to be significant in four studies. The studies were highly heterogeneous in methodology and so the results obtained about the relation between the long travel and the VTED and the score at SIGN50. Two meta-analysis were carried out: only with travels by plane in which the relation was not significant (OR = 1.21; CI 95%, 0.95-1.55) and with all types of transport, with a slightly significant relation (OR = 1.46; CI95%, 1.24-1.72). We may deduce from this systematic review that there does exist a weak association between episodes of VTED and a long travel, but not by plane specifically. The heterogeneity and the methodological quality of the studies published preclude of more robust conclusions.

[Quality of care indicators related to premature readmission and death after hospitalization for heart failure]. / Indicadores de calidad relacionados con el reingreso y la muerte precoces tras la hospitalización por insuficiencia cardíaca.

BACKGROUND AND OBJECTIVE: To determine wether the quality of care criteria applied and the treatment provided to patients hospitalized after congestive heart failure were appropriate to reduce rates of premature readmission and death. PATIENTS AND METHOD: We analyzed the epidemiologic, clinical and quality of care data proposed by 3 international organizations: JCAHO, AHA/ACC and ACOVE Project. The dependent variable was defined as readmission or death during the 30 days after discharge. A multivariate analysis was made using multiple binary logistic regression of the parameters of quality of care and treatment appropriateness. RESULTS: 225 hospital discharge records were analyzed. There were 21 readmissions and 3 deaths (i.e., 24 cases [10.7%] with a positive dependent variable). 162 records (72%) corresponded to patients aged 65 years and over, who presented a total of 18 (8%) readmissions or premature deaths. A positive association between readmission or premature death was found with regard to 2 variables: appropriate treatment with beta-blockers (odds ratio [OR] = 0.34) and the Charlson index (OR = 3,79 for score of 3 or more vs. score of 2 or less). In the case of patients aged 65 years and over the same 2 variables were positively associated, with OR similar to those cited (OR = 0.31 and 3.21, respectively). No association was found between premature readmission or death and the overall evaluation of the criteria referred to by AHA/ACC, JCAHO or the ACOVE Project. CONCLUSIONS: Premature readmission or death of patients with heart failure is more determined by the characteristics of the clinical state of patients (the Charlson comorbidity index) and by the appropriateness of the treatment applied (treatment with beta-blockers) than by the accomplishment of quality of care criteria as proposed by the cited scientific organizations.

Indicadores de calidad relacionados con el reingreso y la muerte precoces tras la hospitalización por insuficiencia cardíaca / Quality of care indicators related to premature readmission and death after hospitalization for heart failure

Fundamento y objetivo: Determinar si los criterios de calidad de cuidados y el tratamiento aplicados a los pacientes hospitalizados por insuficiencia cardíaca congestiva son apropiados para reducir la tasa de reingreso y muerte precoces. Pacientes y método: Analizamos los datos epidemiológicos, clínicos y de calidad de cuidados propuestos por 3 organizaciones internacionales: JCAHO, AHA/ACC y Proyecto ACOVE. La variable dependiente se definió como el reingreso o el fallecimiento en los 30 días siguientes al alta. Se realizó un análisis multivariante mediante regresión logística con los parámetros de calidad de cuidados y lo apropiado del tratamiento. Resultados: Se registraron 225 altas hospitalarias. Se produjeron 21 reingresos y 3 fallecimientos (24 casos de variable dependiente positiva; 10,7%). Un total de 162 altas (72%) correspondían a pacientes mayores de 65 años, que presentaron 18 (8%) reingresos o muertes precoces. Se halló una asociación de la variable dependiente con 2 variables: lo apropiado del tratamiento con bloqueadores beta (odds ratio [OR] = 0,34) y el índice de Charlson (OR = 3,79 para puntuaciones de 3 o superiores frente a 2 o inferiores). En el caso de pacientes mayores de 65 años, las mismas 2 variables se comportaron como predictores independientes, con OR similares a las anteriores (OR = 0,31 y 3,21, respectivamente). No se halló relación con la valoración global de los criterios indicados por JCAHO, AHA/ACC y el Proyecto ACOVE. Conclusiones: El reingreso y la muerte precoces de los pacientes con insuficiencia cardíaca están más determinados por las características de la situación clínica de los pacientes (índice de comorbilidad de Charlson) y lo apropiado del tratamiento aplicado (bloqueadores beta) que por el cumplimiento de los criterios de calidad de cuidados propuestos por diferentes organizaciones científicas

Background and objective: To determine wether the quality of care criteria applied and the treatment provided to patients hospitalized after congestive heart failure were appropriate to reduce rates of premature readmission and death. Patients and method: We analyzed the epidemiologic, clinical and quality of care data proposed by 3 international organizations: JCAHO, AHA/ACC and ACOVE Project. The dependent variable was defined as readmission or death during the 30 days after discharge. A multivariate analysis was made using multiple binary logistic regression of the parameters of quality of care and treatment appropriateness. Results: 225 hospital discharge records were analyzed. There were 21 readmissions and 3 deaths (i.e., 24 cases [10.7%] with a positive dependent variable). 162 records (72%) corresponded to patients aged 65 years and over, who presented a total of 18 (8%) readmissions or premature deaths. A positive association between readmission or premature death was found with regard to 2 variables: appropriate treatment with ß-blockers (odds ratio [OR] = 0.34) and the Charlson index (OR = 3,79 for score of 3 or more vs. score of 2 or less). In the case of patients aged 65 years and over the same 2 variables were positively associated, with OR similar to those cited (OR = 0.31 and 3.21, respectively). No association was found between premature readmission or death and the overall evaluation of the criteria referred to by AHA/ACC, JCAHO or the ACOVE Project. Conclusions: Premature readmission or death of patients with heart failure is more determined by the characteristics of the clinical state of patients (the Charlson comorbidity index) and by the appropriateness of the treatment applied (treatment with ß-blockers) than by the accomplishment of quality of care criteria as proposed by the cited scientific organizations

[Bed rest or early mobilization as treatment of deep vein thrombosis: a systematic review and meta-analysis]. / Reposo en cama o deambulación precoz como tratamiento de la fase aguda de la trombosis venosa profunda: revisión sistemática y metaanálisis.

BACKGROUND AND OBJECTIVE: We aimed to know if treatment of deep vein thrombosis (DVT) with early mobilisation is as safe and effective as bed rest. MATERIAL AND METHOD: MEDLINE, EMBASE, Cochrane library (CCTR), Spanish Medical Index, and MD-Consult Virtual Library databases were searched. We also cross-checked bibliographies of the retrieved articles. The TESEO database of doctoral theses in Spain was also revised. We only searched for clinical trial articles comparing bed rest with early mobilization with respect to the incidence of objectively diagnosed pulmonary embolism (PE) in patients treated for DVT of lower limbs. The concordance coefficient was evaluated by statistical methods. We used relative risk and 95% confidence intervals. Selection bias was evaluated using funnel plot. RESULTS: Only three articles were included in the metaanalysis, with 296 patients randomized from 773 patients initially evaluated, with a follow-up of 9 days to 3 months. Quality rating ranged from 61.4 to 90% and the kappa index of concordance ranged from 0.78 to 0.93. The relative risks of PE between the two groups of treatment (early mobilization versus bed rest) were 1.31 (0.63-2.72), 1.50 (0.17-13.23), and 1.45 (0.56-3.75), respectively, and the global RR was 1.37 (0.78-2.40). CONCLUSIONS: The analyzed studies reveal that the treatment of DVT with early mobilization rather than bed rest neither increases the rate of PE nor increases the complication rate. New well designed, controlled clinical trials are needed to confirm the conclusions of this review.

Reposo en cama o deambulación precoz como tratamiento de la fase aguda de la trombosis venosa profunda: revisión sistemática y metaanálisis / Bed rest or early mobilisation as treatment of deep vein thrombosis: a systematic review and meta-analysis

FUNDAMENTO Y OBJETIVO: Conocer si el tratamiento de la trombosis venosa profunda (TVP) con movilización precoz es tan seguro y efectivo como el reposo en cama. MATERIAL Y MÉTODO: Realizamos una búsqueda en los tesauros MEDLINE, EMBASE, Cochrane Library (CCTR), Índice Médico Español y MD-Consult Virtual Library, así como una búsqueda cruzada de las referencias registradas en los artículos recuperados. También se revisó la base de datos Teseo de tesis doctorales en España. Sólo valoramos los ensayos clínicos que comparaban el reposo en cama frente a la movilización precoz respecto a la incidencia de embolia pulmonar diagnosticada objetivamente en pacientes tratados por TVP. Dos autores extrajeron las características de los estudios y evaluaron su calidad metodológica mediante el sistema de puntuación de Chalmers, y se valoraron los coeficientes de concordancia entre ellos. En el metaanálisis se utilizó el modelo de efectos fijos, dado que el test de heterogeneidad no mostró ninguna disparidad entre los estudios. Se utilizaron el riesgo relativo (RR) y los intervalos de confianza (IC) del 95 por ciento. El sesgo de selección se evaluó mediante funnel plot. RESULTADOS: Sólo se incluyeron 3 artículos en el metaanálisis, con 296 pacientes aleatorizados en total (de 773 valorados inicialmente), seguidos durante un período de 9 días a 3 meses. Los índices de calidad variaron entre el 61,4 y el 90 por ciento, y el índice de concordancia kappa, de 0,78 a 0,93. Los RR de embolia pulmonar entre ambos grupos de tratamiento de movilización precoz frente a reposo en cama fueron 1,31 (IC del 95 por ciento, 0,63-2,72), 1,50 (IC del 95 por ciento, 0,1713,23) y 1,45 (IC del 95 por ciento, 0,56-3,75), respectivamente, y el RR global fue de 1,37 (0,782,40). CONCLUSIONES: De los estudios analizados se desprende que el tratamiento de la TVP con deambulación precoz en lugar de reposo en cama no aumenta las tasas de embolia pulmonar y complicaciones. Se requieren nuevos ensayos clínicos bien diseñados para confirmar las conclusiones de esta revisión (AU)

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