The hidden diabetic kidney disease in a university hospital-based population: a real-world data analysis.

Background: Correct identification of diabetic kidney disease (DKD) in type 2 diabetes mellitus (T2DM) patients is crucial to implement therapeutic interventions that may prevent disease progression. Methods: We compared the real prevalence of DKD in T2DM patients according to actual serum and urine laboratory data with the presence of the diagnostic terms DKD and/or CKD on the electronic medical records (EMRs) using a natural language processing tool (SAVANA Manager). All patients ˃18 years of age and diagnosed with T2DM were selected. DKD was defined as an estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m2 or a urinary albumin:creatinine ratio (UACR) >30 mg/g or a urinary protein:creatinine ratio (UPCR) >0.3 g/g after excluding acute kidney injury. Results: A total of 15 304 T2DM patients identified on EMRs were eligible to enter the study. A total of 4526 (29.6%) T2DM patients had DKD according to lab criteria. However, the terms CKD or DKD were only present in 33.1% and 7.5%, representing a hidden prevalence of CKD and DKD of 66.9% and 92.5%, respectively. Less severe kidney disease (lower UACR or UPCR, higher eGFR values), female sex and lack of insulin prescription were associated with the absence of DKD or CKD terms in the EMRs (P < .001). Conclusions: The prevalence of DKD among T2DM patients defined by lab data is significantly higher than that reported on hospital EMRs. This could imply underdiagnosis of DKD, especially in patients with the least severe disease who may benefit the most from optimized therapy.

Pancreatitis aguda secundaria a hiperparatiroidismo primario / Acute pancreatitis secondary to primary hyperparathyroidism

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Infarto esplénico embólico / Splenic infarction due to thromboembolism

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Nódulo pulmonar solitario con calcificaciones en “palomitas de maíz” / Solitary lung nodule with ‘‘Popcorn’’ calcifications

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Reacción exantemática y conjuntivitis en inmigrante joven / Maculopapular rash and conjunctivitis in a young immigrant

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Analysis of current management of atrial fibrillation in the acute setting: GEFAUR-1 study.

STUDY OBJECTIVE: Limited information relative to the management of atrial fibrillation in the emergency department (ED) daily practice is available. This study evaluates current management of atrial fibrillation in this setting to identify areas for practice improvement. METHODS: This was a prospective multicenter observational study carried out in 12 EDs. Adults in whom atrial fibrillation was demonstrated in an ECG obtained in the ED were included. Clinical variables and atrial fibrillation management in the ED were prospectively collected by the treating physicians using a standardized questionnaire. Patients with rapid ventricular response (>100 beats/min) were considered eligible for rate control, and patients with recent-onset episodes (<48 hours) were eligible for rhythm control. RESULTS: Of 1,178 patients, 41% presented with a rapid ventricular response and 21% had recent-onset episodes. Rhythm control was attempted in 42% of eligible patients, with antiarrhythmic drugs in 88% of cases (I-C drugs in 44% of patients; amiodarone in 43% of patients). Overall effectiveness of pharmacologic cardioversion was 63% (amiodarone 54.5%, flecainide 93%), whereas electrocardioversion was effective in 87.5% of cases. Rate control was performed in 68.3% of eligible patients (overall effectiveness 47.8%); digoxin was used in 67% of cases (effectiveness 45%). Both strategies were selected in 4.5% of cases, whereas no treatment for atrial fibrillation was performed in 60% of patients. CONCLUSION: In our ED population, rate-control effectiveness is poor and rhythm control is not attempted in most recent-onset episodes. Methods to improve rate-control effectiveness, the selection of patients for rhythm control, and the use of electrocardioversion appear warranted.

Differences among clinical classification schemes for predicting stroke in atrial fibrillation: implications for therapy in daily practice.

BACKGROUND: Several clinical classification schemes (CCSs) for predicting stroke in nonvalvular atrial fibrillation (NVAF) have been developed to help identify patients eligible for anticoagulation. OBJECTIVES: To estimate the agreement in predicting the risk of stroke among four widespread CCSs, and to determine their implications for thromboprophylaxis in clinical practice. METHODS: The authors conducted a prospective, multicenter, observational study of adults with NVAF in 12 emergency departments (EDs) in July 2000 and February 2001. The proportions of patients classified as having high, moderate, and low risk of stroke among the following CCSs were compared: the Atrial Fibrillation Investigators (AFI), the Stroke Prevention in Atrial Fibrillation (SPAF), the CHADS(2) (an acronym for congestive heart failure, hypertension, age >75 years, diabetes mellitus, and prior stroke or transient ischemic attack), and the American College of Chest Physicians (ACCP). RESULTS: One thousand two hundred twenty patients were included. The proportions of patients stratified as having high/moderate/low risk of stroke according to each CCS were: 70%/22%/8% (AFI), 38%/41%/21% (SPAF), 13%/45%/42% (CHADS(2)), and 86%/7%/7% (ACCP). The agreement was medium between AFI and ACCP (kappa = 0.52) and poor among the rest of them (AFI/SPAF, kappa = 0.01; AFI/CHADS(2), kappa = 0.02; SPAF/CHADS(2), kappa = 0.18; SPAF/ACCP, kappa = 0.11; CHADS(2)/ACCP, kappa = 0.03). The agreements in selecting patients as eligible for antiplatelet therapy or anticoagulation were: AFI/SPAF, kappa = 0.45; AFI/CHADS(2), kappa = 0.22; AFI/ACCP, kappa = 0.91; SPAF/CHADS(2), kappa = 0.47; SPAF/ACCP, kappa = 0.11; CHADS(2)/ACCP, kappa = 0.03. CONCLUSIONS: In the ED population studied, these CCSs showed relevant differences in the risk of stroke stratification and, therefore, in the identification of patients with NVAF eligible for anticoagulation.

Risk factors for stroke and thromboprophylaxis in atrial fibrillation: what happens in daily clinical practice? The GEFAUR-1 study.

STUDY OBJECTIVES: We determine the risk for stroke of patients with atrial fibrillation in the emergency department (ED) and analyze the use of stroke prophylaxis in this setting. METHODS: This was a cross-sectional study carried out in 12 EDs. Clinical variables, risk factors for stroke, the prophylaxis prescribed, and the reasons for not initiating anticoagulation were collected. Risk factors and indications for therapy were evaluated according to the American College of Chest Physicians' 1998 recommendations. RESULTS: Of 1,178 patients included, 69% were not taking anticoagulants. Of the latter, 89% patients had indications for anticoagulation (age >75 years 59%, hypertension 56%, cardiac disorders 29%, heart failure 22%, diabetes 22%, previous embolism 14%), and 63% of the patients had 2 or more risk factors. Anticoagulation was prescribed in the ED to 27% of patients (67% with warfarin, 33% low-weight heparin plus warfarin), antiplatelets to 20% of patients, and no thromboprophylaxis to 53% of these eligible patients. Anticoagulants were prescribed in only 9% of patients with risk factors and current prophylaxis with antiplatelet agents. The main reasons for not prescribing anticoagulation in the presence of risk factors were advanced age (11%), contraindication for anticoagulation (27%), or because it was not considered to be indicated by the physicians (23%). CONCLUSION: Most patients seen in the ED with atrial fibrillation are at high risk of stroke. Despite this risk, anticoagulation is underused in this setting, mainly because of the influence of advanced age on medical decisions and the reluctance to change current antiplatelet therapy.

[Consensus document for the management of patients with atrial fibrillation in hospital emergency departments]. / Documento de consenso sobre el tratamiento de la fibrilación auricular en los servicios de urgencias hospitalarios.

Atrial fibrillation (AF) is the most prevalent arrhythmia in hospital emergency departments and is a serious disease associated with a twofold increase in morbidity and a high mortality rate. However, the management of AF in this scenario is variable and frequently inadequate. This is probably a consequence of the diverse clinical aspects and therapeutic options to consider in the management of patients with AF. Therefore, implementation of specific, coordinated management strategies by the different care providers involved is needed to improve the quality of care and optimize the use of human and material resources. This document presents the guidelines recommended by the Spanish Society of Cardiology (SEC) and the Spanish Society of Emergency Medicine (SEMES) for the management of AF in hospital emergency departments. These guidelines are based on published scientific evidence and are applicable to most emergency departments in Spain. Specific management strategies are proposed for the conversion and maintenance of sinus rhythm, heart rate control during AF, prophylaxis for thrombi and emboli, and hospital admission and discharge protocols.

Documento de consenso sobre el tratamiento de la fibrilación auricular en los servicios de urgencias hospitalarios / Consensus document for the management of patients with atrial fibrillation in hospital emergency departments

La fibrilación auricular (FA) es la arritmia más prevalente en los servicios de urgencias hospitalarios (SUH) y es una enfermedad grave que duplica la mortalidad y que conlleva una elevada morbilidad. Sin embargo, a pesar de estas consideraciones, en nuestro medio se realiza un manejo heterogéneo y con frecuencia inadecuado de la FA en los SUH. Probablemente, esto es una consecuencia de la diversidad de aspectos clínicos que deben considerarse en los pacientes con FA, así como del elevado número de opciones terapéuticas posibles, lo que justifica la implementación de estrategias concretas y coordinadas de actuación entre los diversos profesionales implicados en el manejo de los pacientes con FA, con el fin de mejorar su tratamiento y optimizar los recursos humanos y materiales. Este documento recoge las guías recomendadas por la Sociedad Española de Cardiología (SEC) y la Sociedad Española de Medicina de Urgencias y Emergencias (SEMES) para el manejo de la FA en los SUH, donde se proponen unas pautas generales basadas en la evidencia científica publicada hasta el momento y aplicables a la mayoría de los SUH de nuestro país. De esta forma, se proponen estrategias concretas de manejo de los pacientes con FA en los aspectos de recuperación y mantenimiento del ritmo sinusal, control de la frecuencia cardíaca durante FA, profilaxis tromboembólica e ingreso o alta hospitalaria, todo ello con el objetivo de promover una mejor atención a los pacientes con un uso más adecuado de los recursos disponibles en nuestro medio (AU)