Predictors of Early Mortality in Cancer-Associated Thrombosis: Analysis of the RIETE Database.

Cancer-associated thrombosis (CT) carries a high, heterogeneous, and poorly predicted likelihood of mortality. Thus, we aimed to define predictors of 30-day mortality in 10,025 patients with CT. In a randomly selected derivation cohort, we used recursive partitioning analysis to detect variables that select for a risk of mortality within 30 days. In a validation cohort, we evaluated our results using Cochran-Armitage test. The most common types of cancer were lung (16%), breast (14%), and colorectal (14%); median age was 69 years (range, 14-101); most had metastatic disease (63%); 13% of patients died within 30 days. In the derivation cohort ( n = 6,660), a white blood cell (WBC) count in the highest quartile predicted early mortality (odds ratio, 7.8; 95% confidence interval [CI], 4.6-13.1); and the presence of metastatic disease, pulmonary embolism (PE), and immobility defined the risk of those with normal WBC count. We defined death risk according four sequential questions: (1) Does the patient have an elevated WBC count? (Yes, group D). (2) If no, does the patient have metastasis? (No, group A). (3) If yes, is the patient immobile? (Yes, group D). (4) If no, does the patient have a PE? (Yes, group C; no, group B). In the validation cohort ( n = 3,365), the 30-day risk of death was 2.9% in group A (95% CI, 1.9-4.3), compared with 25% in group D (95% CI, 22.5-27.5), and there was a rate escalation between groups ( p for trend < 0.01). In conclusion, with four sequential questions, the risk of death in CT can be easily stratified. An elevated WBC count at baseline predicted 30-day mortality better than metastases, PE, or immobility.

Consenso intersociedades español sobre el diagnóstico, estratificación de riesgo y tratamiento de pacientes con tromboembolia pulmonar / Spanish medical societies consensus on the diagnosis, risk stratification and treatment of patients with pulmonary embolism

PRECEDENTE: La tromboembolia de pulmón (TEP) es la tercera causa de muerte cardiovascular, después del infarto agudo de miocardio y del ictus, y supone un importante problema de salud. OBJETIVO: Seis sociedades médicas españolas involucradas en la atención de pacientes con TEP han elaborado un documento de consenso, que aporta recomendaciones sobre el diagnóstico, pronóstico y tratamiento de la TEP en función de la calidad de la evidencia disponible, del balance entre el riesgo y el beneficio de las intervenciones, y del coste. MÉTODO: Se partió de 2 documentos ampliamente conocidos (ACCP 2012 y NICE 2013) que utilizan el sistema GRADE. Adicionalmente, se realizó una revisión sistemática de la bibliografía (entre enero de 2012 y marzo de 2013). A partir de todos estos documentos, 2 autores elaboraron un manuscrito de base para la discusión final (panel constituido por los coordinadores de las sociedades científicas participantes). RESULTADO: El consenso se alcanzó mediante discusión entre los miembros del panel, considerando los beneficios y riesgos de las intervenciones, la práctica clínica habitual, las recomendaciones de otras normativas, la preferencia de los pacientes y los criterios de equidad. CONCLUSIÓN: En total se hacen 42 recomendaciones o sugerencias

BACKGROUND: Pulmonary embolism (PE) is a serious health problem and is the third cause of cardiovascular death, after acute myocardial infarction and stroke. OBJECTIVE: A consensus document has been prepared by six Spanish medical societies involved in the treatment of patients with PE. The document presents recommendations on the diagnosis, prognosis, and treatment of PE, taking into account the quality of the available evidence, the risk-benefit ratio of the treatments, and the costs. METHOD: Two widely known documents (ACCP 2012 and NICE 2013) that use the GRADE system were distributed. A systematic review of the literature was performed between January 2012 and March 2013. Two authors prepared a manuscript using all these documents as a basis for the final discussion by a panel consisting of the coordinators of the participating Scientific Societies. RESULTS: A consensus was reached after discussion by the members of the panel, taking into consideration the benefits and risks of the treatments, normal clinical practice, the recommendations in other guidelines, patient preference, and equity criteria. CONCLUSION: A total of 42 recommendations or suggestions were made

The outcome after treatment of venous thromboembolism is different in surgical and acutely ill medical patients. Findings from the RIETE registry.

BACKGROUND: The history of venous thromboembolism (VTE), and the rationale for thromboprophylaxis in surgical patients are well understood. The situation is less clear for acutely ill medical patients. OBJECTIVES: To compare the clinical presentation of VTE and clinical outcomes of immobile acutely ill medical patients with surgical patients. PATIENTS: RIETE (Registro Informatizado de la Enfermedad TromboEmbolica) is a Spanish registry of consecutively enrolled patients with objectively confirmed, symptomatic acute VTE. In this analysis, clinical characteristics of patients, details of anticoagulant therapy, and outcomes of all enrolled acutely ill medical patients with immobility >/= 4 days, and surgical patients are included. RESULTS: Of 6160 patients enrolled up to December 2003, 756 (12%) were acutely ill medical patients with immobility >/= 4 days, and 884 (14%) were surgical patients who developed VTE within 2 months of surgical intervention. Only 28% of acutely ill medical patients had received thromboprophylaxis, compared with 67% of surgical patients. During the 3-month follow-up period, both fatal pulmonary embolism (PE) and fatal bleeding occurred more frequently in acutely ill medical patients. Immobility in acutely ill medical patients, cancer, and PE were associated with a significantly higher risk of fatal PE or bleeding. CONCLUSIONS: In patients treated for VTE, the incidences of fatal PE, fatal bleeding, and major bleeding were significantly higher in acutely ill medical patients compared with surgical patients. Given the low percentage of acutely ill medical patients who had received thromboprophylaxis, increasing its use appropriately may reduce the incidence of VTE and associated complications.

[Persistent hemoptysis secondary to extensive epithelioid angiosarcoma]. / Hemoptisis de repetición secundarias a un angiosarcoma epitelioide generalizado.

Pulmonary angiosarcoma is an unusual cause of diffuse pulmonary hemorrhage. Angiosarcomas are rare malignant vascular tumors accounting for 1% to 2% of all sarcomas. Angiosarcomas have been detected in nearly all organs, but lung involvement is unusual, accounting for less than 7%. The literature describes approximately 10 isolated cases of primary pulmonary angiosarcoma as opposed to the more common metastatic type. Given that primary and metastatic types are clinicopathologically similar, the presence of a distant primary sarcoma must be ruled out before a diagnosis of primary pulmonary angiosarcoma can be made. A pathological diagnosis requires a finding of polygonal or oval cells with atypical irregular nuclei and vascular spaces lined with such cells surrounded by hemorrhagic phenomena. Immunohistochemical analysis is positive for specific endothelial cell markers such as CD31 and factor VIII, and coexpression of keratin is a frequent finding.

Use of venous thromboembolism prophylaxis for surgical patients: a multicentre analysis of practice in Spain.

OBJECTIVE: To assess the use of venous thromboembolism prophylaxis in surgical patients. DESIGN: Retrospective multicentre study. SETTING: Eight acute-care teaching hospitals with more than 400 beds, Spain. PATIENTS: Medical records of all consecutive patients undergoing operations in the general surgical and trauma and orthopaedic services during the month of April, 1997, were randomly selected. INTERVENTION: The sample size for each type of operation (general, trauma-orthopaedic) was calculated from the number of operations done at each hospital (with an absolute precision of 5%, and an alpha error of 5%) and the prevalence of the use of venous thromboembolism prophylaxis obtained from a random sample of 50 records (25 from patients in general surgery and 25 from patients in orthopaedic surgery) from each centre. MAIN OUTCOME MEASURES: Appropriate and inappropriate pharmacological prophylaxis defined according to a combination of risk categories for venous thromboembolism, doses of antithrombotic agents given, time of starting prophylaxis, and its duration. RESULTS: A total of 1848 medical records (general surgery, n = 1025; trauma-orthopaedic surgery, n = 823) were included. Physical methods (elastic stockings, intermittent pneumatic compression) were used in only 0.3% of patients. Pharmacological prophylaxis consisted of low molecular weight heparin in 99% of cases. The percentage given heparin-based prophylaxis was 54%. Overall, appropriate prophylaxis was given in 1175 patients (64%). Use of thromboprophylaxis ranged from 27% to 70% among the participating hospitals. Prophylaxis was more likely to be appropriate in orthopaedic patients (577, 70%) than in general surgical patients (598, 58%) in both the high and moderate risk categories. CONCLUSIONS: Given the large variability between the participating hospitals, more specific protocols and recommendations about prophylaxis of thromboembolism in surgical patients are needed.

Avances en la estrategia diagnóstica de la tromboembolia pulmonar / Advances in diagnostic strategy for pulmonary embolism

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[Espartosis. A new type of extrinsic allergic alveolitis among construction plasterers]. / Espartosis. Un nuevo tipo de alveolitis alérgica extrínseca en los escayolistas de la construcción.

The clinical characteristics of three plasterers in contact with esparto and who presented a picture of extrinsic allergic alveolitis which was peculiar because of their being hyperacute and causing hypoxemia. In addition to a review of 5 previously published sporadic cases the clinical picture of this new type of apparently infrequent alveolitis is described. The causal antigen is unknown although contamination by fungus or the addition of raw esparto may be the origin of the disease. After a review of the literature regarding this subject, the authors suggest that, in addition to cases of asthma and chronic airway obstruction, the patients with extrinsic allergic alveolitis be included under the name of espartosis following esparto dust inhalation.

Diagnostic utility of color Doppler ultrasound in lower limb deep vein thrombosis in patients with clinical suspicion of pulmonary thromboembolism.

The diagnosis of pulmonary thromboembolism is frequently based on ventilation-perfusion scintigraphy and ascending lower limb venography when pulmonary angiography is not available. The aim of this study is to compare color Doppler ultrasound against ascending venography in the evaluation of the lower limb deep vein system in patients with clinical suspicion of pulmonary embolism, with special attention to calf veins. We prospectively studied 30 patients with clinical suspicion of pulmonary embolism in whom a color Doppler ultrasound and venogram were performed with no more than a 3-h interval between both procedures. The diagnostic criteria was that of loss of venous compressibility. The 'color' ability was used to identify artery from vein. Out of 15 patients in whom a venogram proved positive (50%), 9 had isolated calf vein thrombosis (60%). In 5 patients, the color Doppler ultrasound of the calf was considered inconclusive. Overall sensitivity was 53%, specificity 100%, positive predictive value 100%, and negative predictive value 68%. In the femoropopliteal system, sensitivity was 83% and specificity 100%. Considering all patients, sensitivity in the calf system was 40%. Excluding the 5 patients who were difficult to assess, sensitivity increased to 60%. In conclusion, color Doppler ultrasound is not as sensitive as venography in dealing with patients with clinical suspicion of pulmonary embolism, due to its low sensitivity in the calf system when distal thrombi need to be excluded. However, a reasonable alternative is to begin by performing a compression ultrasonography of the femoropopliteal system. Color Doppler ultrasonography of the calf system represents a rarely sensitive and arduous task and does not seem justifiable in this type of patient.(ABSTRACT TRUNCATED AT 250 WORDS)

[Transthoracic aspiration punction with ultrafine needle in high risk community acquired pneumonia]. / La punción transtorácica aspirativa con aguja ultrafina en las neumonías de alto riesgo adquiridas en la comunidad.

BACKGROUND: The identification of etiologic agents of pneumonias acquired in the community (PAC) with risk factors is difficult. The classical diagnostic methods are not profitable and thus invasive techniques are used. In this study the diagnostic use of an invasive technique such as aspirative transthoracic puncture (ATP) was evaluated in this type of pneumonias. METHODS: In 94 patients of high risk suspect of PAC the ATP was carried out. This was performed with an ultrafine needle (25G) without radioscopic control. In all cases blood cultures, serology (Legionella, Mycoplasma pneumoniae, Coxiella burnetti, Chlamydia psittaci) were performed when atypical clinical manifestations were presented and sputum examination (Gram, Ziehl, culture) was undertaken when possible. RESULTS: The sensitivity of ATP was 36% and increased to 54.6% in cases previously untreated with antibiotics. Specificity was 96.4%. The sensitivity of blood culture was 8% and sputum 13.6%. ATP was well tolerated in 97.9% with complication in only 4 (4.3%). The results of ATP led to changes in treatment in 23.1% of the cases with definitive diagnosis of pneumonia. CONCLUSIONS: Aspirative transthoracic puncture with ultrafine needle without fluoroscopic control was a very well tolerated technique with a minimum number of complications, easy to perform at the patients bedside and was used to modify treatment in 23.1% of the cases.

Antibiotic treatment in pneumonia due to Q fever.

BACKGROUND: Whether Q fever responds better to doxycycline or erythromycin is unknown. METHODS: The efficacy of doxycycline and erythromycin in the treatment of pneumonia due to Q fever was assessed in a prospective, randomised, double blind study of 82 patients with a diagnosis of pneumonia and features suggestive of Q fever infection; 48 proved to have Q fever. Of the 48, 23 received doxycycline 100 mg twice a day and 25 patients received erythromycin 500 mg six hourly, both for 10 days. RESULTS: Both treatment groups had similar demographic characteristics. Fever showed a more rapid reduction in the doxycycline group (3(1.6) days versus 4.3(2) days). Side effects were observed in two patients receiving doxycycline compared with 11 patients receiving erythromycin (p less than 0.01). No differences were observed in other clinical or radiological measures. By day 40 the chest radiograph was normal in 47 of 48 patients. CONCLUSION: The results demonstrate the self limiting and benign nature of most cases of pneumonia due to Q fever. Doxycycline was more effective than erythromycin.

[Pleural effusion associated with primary lymphedema: a rare combination. Apropos of a case]. / Derrame pleural asociado a linfedema primario: una rara combinación. A propósito de un caso.

A case of exclusive association of pleural effusions and primary lymphedema, without ungual dystrophy is described. This isolated combination is an uncommon clinical condition with only 11 cases reported in the literature. The pathogenesis is characterized by aplasia-hypoplasia of the lymphatic vessels with consequent defective lymphatic drainage. We present a pleural effusion associated with a left lower extremity cellulitis, we argue about the differential diagnosis and treat the patient with thoracocentesis and aspiration with a favourable evolution without recidive.