Diagnosis and treatment of deep vein thrombosis of the lower and upper limbs. 2024 recommendations of the thromboembolic disease group of the Spanish Society of Internal Medicine.

Deep vein thrombosis (DVT) of the limbs is a common disease and causes significant morbidity and mortality. It is frequently the prelude to pulmonary embolism (PE), it can recur in 30% of patients and in 25-40% of cases they can develop post-thrombotic syndrome (PTS), with a significant impact in functional status and quality of life. This document contains the recommendations on the diagnosis and treatment of acute DVT from the Thromboembolic Disease group of the Spanish Society of Internal Medicine (SEMI). PE and thrombosis of unusual venous territories (cerebral, renal, mesenteric, superficial, etc.) are outside its scope, as well as thrombosis associated with catheter and thrombosis associated with cancer, which due to their peculiarities will be the subject of other positioning documents of the Thromboembolic Disease group of the Spanish Society of Internal Medicine (SEMI).

Características y tratamiento de los pacientes nonagenarios con enfermedad vascular ingresados en los servicios de medicina interna. Registro NONAVASC-2 / Characteristics and treatment of nonagenarian patients with vascular disease admitted to internal medicine services. NONAVASC-2 registry

Introducción La enfermedad vascular es la causa más frecuente de morbimortalidad, y su prevalencia incrementa con la edad. Los pacientes muy añosos no se encuentran incluidos en los estudios sobre enfermedad vascular, desconociéndose sus características y tratamientos. Objetivo Conocer las características clínicas de los pacientes nonagenarios hospitalizados en servicios de medicina interna con diagnóstico de EV establecida y la adecuación de su manejo farmacológico. Material y métodos El Registro NONAVASC-2 es un estudio observacional, prospectivo y multicéntrico. Se incluyeron pacientes hospitalizados por cualquier causa. La recogida de datos se realizó a través de una base anonimizada online con parámetros sociodemográficos, clínicos, analíticos, terapéuticos y evolutivos. Resultados Se incluyeron 1.049 pacientes con una edad media de 93,14 años (57,8% mujeres). La prevalencia de los factores de riesgo fue muy elevada: hipertensión (84,9%), dislipemia (50,9%) y diabetes mellitus (29,4%). El 33,4% presentaba dependencia grave/total. El 82,9% recibía tratamiento antitrombótico (53,7% antiagregantes, 25,4% anticoagulación y 3,8% doble terapia). Solo el 38,2% recibía estatinas. El porcentaje de dependencia (39,2 vs. 24,1%; p=0,00) y deterioro cognitivo grave (30,8 vs. 13,8%; p=0,00) era significativamente mayor entre los pacientes que no las recibían. El 19% falleció durante el ingreso. Conclusión Los pacientes nonagenarios con EV presentan una elevada comorbilidad, dependencia y mortalidad. A pesar de estar en prevención secundaria, el 17% de ellos no recibía antitrombóticos y solo el 38% estatinas. Esta infraprescripción está condicionada por la situación funcional, entre otros factores, por lo que es necesario realizar más estudios para conocer el impacto sobre su pronóstico (AU)

Introduction Vascular disease is the most frequent cause of morbidity and mortality and its prevalence increases with age. Old patients are not included in studies on vascular disease, their characteristics and treatments being unknown. Objective Know the clinical characteristics of nonagenarian patients hospitalized in Internal Medicine services with a diagnosis of established VD and the adequacy of their pharmacological management. Material and methods The NONAVASC-2 registry is an observational, prospective, multicentre study. Hospitalized patients for any cause were included. Data collection was carried out through an anonymous online database with sociodemographic, clinical, analytical, therapeutic and evolutionary parameters. Results One thousand forty-nine patients with a mean age of 93.14 years (57.8% women) were included. The prevalence of risk factors and VD was high: hypertension (84.9%), dyslipidemia (50.9%) and diabetes mellitus (29.4%). 33.4% presented severe-total dependency. 82.9% received antithrombotic treatment (53.7% antiplatelets, 25.4% anticoagulation and 3.8% double therapy). Only 38.2% received statins. The percentage of severe dependence (39.2% vs 24.1%; p=0.00) and severe cognitive impairment (30.8% vs 13.8%; p=0.00) was significantly higher among patients who did not receive them. 19% died during admission. Conclusions Nonagenarian patients with VD present high comorbidity, dependence and mortality. Despite being in secondary prevention, 17% did not receive antithrombotics and only 38% received statins. The underprescription is conditioned, among other factors, by the functional status. More studies are necessary to determine the impact of this issue on their prognosis (AU)

Characteristics and treatment of nonagenarian patients with vascular disease admitted to internal medicine services. NONAVASC-2 registry.

INTRODUCTION: Vascular disease (VD) is the most frequent cause of morbidity and mortality and its prevalence increases with age. Old patients are not included in studies on VD, their characteristics and treatments being unknown. OBJECTIVE: Know the clinical characteristics of nonagenarian patients hospitalized in Internal Medicine services with a diagnosis of established VD and the adequacy of their pharmacological management. MATERIAL AND METHODS: The NONAVASC-2 registry is an observational, prospective, multicentre study. Hospitalized patients for any cause were included. Data collection was carried out through an anonymous online database with sociodemographic, clinical, analytical, therapeutic and evolutionary parameters. RESULTS: One thousand forty-nine patients with a mean age of 93.14 years (57.8% women) were included. The prevalence of risk factors and VD was high: hypertension (84.9%), dyslipidemia (50.9%) and diabetes mellitus (29.4%). 33.4% presented severe-total dependency. 82.9% received antithrombotic treatment (53.7% antiplatelets, 25.4% anticoagulation and 3.8% double therapy). Only 38.2% received statins. The percentage of severe dependence (39.2% vs 24.1%; p = 0.00) and severe cognitive impairment (30.8% vs 13.8%; p = 0.00) was significantly higher among patients who did not receive them. 19% died during admission. CONCLUSIONS: Nonagenarian patients with VD present high comorbidity, dependence and mortality. Despite being in secondary prevention, 17% did not receive antithrombotics and only 38% received statins. The underprescription is conditioned, among other factors, by the functional status. More studies are necessary to determine the impact of this issue on their prognosis.

Outcomes in patients with acute pulmonary embolism and patent foramen ovale: Findings from the RIETE registry.

INTRODUCTION: An increased risk of ischemic stroke in patients with acute pulmonary embolism (PE) and patent foramen ovale (PFO) was reported but few data exist regarding prognostic outcomes of those patients. MATERIAL AND METHODS: Using data in the RIETE registry, we compared the characteristics, therapeutic approaches and outcomes of patients with PE according to the presence or absence of PFO. RESULTS: From August 2016 to January 2020, 4148 patients with acute PE were enrolled. Of these, 2775 (67%) had no transthoracic echocardiogram (TTE), 993 (24%) underwent TTE but had no reported results on PFO. Among the remaining 380 patients, 287 (74%) did not have PFO and 93 (26%) had PFO. Patients with PFO were more likely to have chronic heart failure, prior myocardial infarction or ischemic stroke than those without PFO. Patients with PFO had a higher rate of subsequent ischemic stroke than those without PFO (hazard ratio (HR): 9.28; 95% CI: 1.83-69.1), than those with TTE but no data on PFO (HR: 10.1; 95% CI: 2.56-42.4) or without TTE (HR: 9.78; 95% CI: 3.02-28.4). On multivariable analysis, patients with PFO were at increased risk for subsequent ischemic stroke than those without PFO (HR: 8.96; 95% CI: 1.68-47.7). CONCLUSIONS: PFO was searched in a minority of patients with an acute PE in real life setting. Subject to possible selection and measurement biases, our results confirmed a higher risk of ischemic stroke in PE patients with PFO compared to those without PFO. This association warrants further investigation before determining the best therapeutic option in patients with acute PE and concomitant PFO.

Paresia idiopática del nervio hipogloso / Isolated hypoglossal nerve palsy

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Análisis de la actividad de interconsulta realizada por los servicios de medicina interna. Estudio REINA-SEMI: Registro de Interconsultas y Asistencia Compartida de la Sociedad Española de Medicina Interna / Analysis of the activity of interconsultations conducted by the departments of internal medicine. REINA-SEMI study: Registry of Interconsultations and Shared Care of the Spanish Society of Internal Medicine

Objetivo: Analizar la actividad de interconsulta (IC) realizada por los servicios de medicina interna (MI), sus aspectos formales, el perfil de la atención clínica requerida y cuantificar la carga de trabajo que supone. Material y método: Estudio multicéntrico, observacional, prospectivo, sobre enfermos consecutivos hospitalizados atendidos por servicios de MI mediante IC entre el 15 de mayo y el 15 de junio del año 2016. Se estimó la carga de trabajo relacionada con dicha actividad (1UT=10min). Resultados: Se registraron 1.141 IC procedentes de 43 hospitales, edad 69,4 (DE: 16,2) años, 51,2% hombres. El índice de Charlson fue 2,3 (DE: 2,2). Los motivos de consulta más frecuentes fueron: valoración general (27,4%), fiebre (18,1%), disnea (13,6%), trastorno metabólico (9,6%), HTA (6,3%) y síndrome confusional (5,3%). Las UT estimadas fueron 4 (DE: 5,9) para la primera visita y 7,3 (DE: 21,5) para la suma de las sucesivas. Los pacientes quirúrgicos fueron mayores (70,6 [DE: 15,9] vs 64,4 [DE: 16,3]; p=0,0001) y precisaron más días de seguimiento (5 [DE: 7,3] vs 3,5 [DE: 4,2]; p=0,009). Los siguientes aspectos fueron más frecuentes en el formato de las IC realizadas por servicios médicos: número de IC ordinarias (respuesta >24h), especificación del motivo de IC, datos mínimos referentes a la historia clínica y coincidencia de la adecuación en el tiempo con el consultor. Conclusión: Los pacientes atendidos mediante IC por los servicios de MI representan una carga de trabajo importante. La adecuación al formato de solicitud de IC es mayor en las procedentes de servicios médicos

Objective: To analyse the activity of interconsultations conducted by internal medicine (IM) departments, their formal aspects and the profile of clinical care required and to quantify the workload they represent. Material and method: A multicentre, observational prospective study was conducted with consecutive hospitalised patients treated by IM departments using interconsultations between May 15 and June 15, 2016. We estimated the workload related to this activity (1time unit [TU]=10min). Results: We recorded 1,141 interconsultations from 43 hospitals. The mean age of the patients involved was 69.4 years (SD: 16.2), and 51.2% were men. The mean Charlson index was 2.3 (SD: 2.2). The most common reasons for the consultations were general assessments (27.4%), fever (18.1%), dyspnoea (13.6%), metabolic disorder (9.6%), arterial hypertension (6.3%) and delirium (5.3%). The duration of the first visit was 4 TUs (SD: 5.9) and 7.3 (SD: 21.5) for the sum of all subsequent visits. The surgical patients were older (70.6 [SD, 15.9] vs. 64.4 [SD, 16.3] years; P=.0001) and required more follow-up time (5 [SD, 7.3] vs. 3.5 [SD, 4.2] days; P=.009). The following issues were more common in the interconsultation format performed by medical services: number of regular interconsultations (response >24h), specification of the reason for the interconsultation, minimal data regarding the medical history and agreement on the appropriateness of the time spent with the consultant. Conclusion: The patients treated through interconsultations by the IM departments represented a significant workload. The interconsultations from the medical departments were more in line with the request format

Analysis of the activity of interconsultations conducted by the departments of internal medicine. REINA-SEMI study: Registry of Interconsultations and Shared Care of the Spanish Society of Internal Medicine. / Análisis de la actividad de interconsulta realizada por los servicios de medicina interna. Estudio REINA-SEMI: Registro de Interconsultas y Asistencia Compartida de la Sociedad Española de Medicina Interna.

OBJECTIVE: To analyse the activity of interconsultations conducted by internal medicine (IM) departments, their formal aspects and the profile of clinical care required and to quantify the workload they represent. MATERIAL AND METHOD: A multicentre, observational prospective study was conducted with consecutive hospitalised patients treated by IM departments using interconsultations between May 15 and June 15, 2016. We estimated the workload related to this activity (1time unit [TU]=10min). RESULTS: We recorded 1,141 interconsultations from 43 hospitals. The mean age of the patients involved was 69.4 years (SD: 16.2), and 51.2% were men. The mean Charlson index was 2.3 (SD: 2.2). The most common reasons for the consultations were general assessments (27.4%), fever (18.1%), dyspnoea (13.6%), metabolic disorder (9.6%), arterial hypertension (6.3%) and delirium (5.3%). The duration of the first visit was 4 TUs (SD: 5.9) and 7.3 (SD: 21.5) for the sum of all subsequent visits. The surgical patients were older (70.6 [SD, 15.9] vs. 64.4 [SD, 16.3] years; P=.0001) and required more follow-up time (5 [SD, 7.3] vs. 3.5 [SD, 4.2] days; P=.009). The following issues were more common in the interconsultation format performed by medical services: number of regular interconsultations (response >24h), specification of the reason for the interconsultation, minimal data regarding the medical history and agreement on the appropriateness of the time spent with the consultant. CONCLUSION: The patients treated through interconsultations by the IM departments represented a significant workload. The interconsultations from the medical departments were more in line with the request format.

Importancia de la implicación del paciente y el profesional en la estrategia de evitar reingresos en el paciente con insuficiencia cardiaca / The importance of the involvement of the patient and the professional in strategies to prevent readmission in patients with heart failure

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Principios generales de la interconsulta médica en enfermos hospitalizados / General principles of medical interconsultation for hospitalised patients

La interconsulta médica en pacientes hospitalizados constituye una actividad habitual entre los especialistas en medicina interna. Sin embargo, a pesar de su impacto e importancia crecientes, no se ha establecido un modelo que defina sus características, sus objetivos o la información que debe contener. En este trabajo, desde el Grupo de Asistencia Compartida e Interconsultas de la Sociedad Española de Medicina Interna, se proponen unas recomendaciones generales respecto a la forma de solicitar y de responder una interconsulta médica hospitalaria, así como un formato para la misma (AU)

Medical interconsultation for hospitalised patients is a regular activity among internal medicine specialists. However, despite its growing impact and importance, a model that defines its characteristics, objectives and information has not been established. This study, conducted by the Shared Care and Interconsultations Group of the Spanish Society of Internal Medicine, proposes a number of general recommendations concerning the method for requesting and responding to hospital medical interconsultations, as well as a format for these interconsultations (AU)

General principles of medical interconsultation for hospitalised patients.

Medical interconsultation for hospitalised patients is a regular activity among internal medicine specialists. However, despite its growing impact and importance, a model that defines its characteristics, objectives and information has not been established. This study, conducted by the Shared Care and Interconsultations Group of the Spanish Society of Internal Medicine, proposes a number of general recommendations concerning the method for requesting and responding to hospital medical interconsultations, as well as a format for these interconsultations.

Fever of unknown origin in a young man.

INTRODUCTION: Sphingomonas paucimobilis bacteraemia is a rare infection typically related to nosocomial outbreaks. MATERIAL: A 33-year-old immunocompetent man requested evaluation in the Internal Medicine Department for fever without source. His physical examination was normal. Laboratory analysis showed mild hypertransaminasemia. In both blood culture sets grew Gram-negative bacilli, being identified as S. paucimobilis. The patient was treated with oral levofloxacin with full recovery. CONCLUSION: S. paucimobilis infections can occur in the community setting in a relatively non-immunocompromised patient. In a patient with bacteraemia, microbiological studies are crucial to ensure a successful outcome.

Hipertensión arterial vinculable desde un punto de vista etiológico al déficit de α - 1 - antitripsina / Arterial hypertension linked to α -1-antitrypsin deficit from an etiological point of view

Un varón de 38 años fue evaluado para descartar causa secundaria de hipertensión arterial. No tenía historia de etilismo o tabaquismo y había presentado previamente un cólico renal. Se encontraba asintomático, objetivándose en la exploración física canicie abundante, ligera cifosis y acropaquia. Se practicó en una primera valoración un protocolo general para la búsqueda de hipertensión secundaria, objetivándose policitemia y litiasis urinaria. La espirometría y la radiografía de tórax no mostraron alteraciones relevantes. Tras ello se demostró ligera hipoxemia, aumento de la eritropoyetina, déficit de α-1-antitripsina y osteoporosis. El estudio genético mostró un genotipo MZ. Se comenta la coexistencia de policitemia y aumento de la eritropoyetina, como potenciales elementos causales de su hipertensión (ambas secundarias al déficit de α-1-antitripsina). Se menciona el papel de la litiasis urinaria, probablemente hipercalciúrica, junto a la canicie precoz como potenciales causas de la osteoporosis, no encontrando relación de este problema, en ausencia de hepatopatía, con el déficit de α-1-antitripsina

A 38-year-old male was evaluated to rule out secondary cause of arterial hypertension. He had no background or alcoholism or smoking and had previously suffered renal colic. He was asymptomatic, the physical examination showing abundant gray hair, mild kyphosis, and acropachy. A general protocol was used in the first assessment to look for secondary hypertension, observing polycythemia and urinary lithiasis. The spirometry and chest X-ray did not show any relevant alterations. After this, he had mild hypoxemia, increased erythropoietin, a-1-antitrypsin deficit and osteoporosis. The genetic study showed a MZ genotype. Coexistence of polycythemia and increased erythropoietin were mentioned as potential causal elements of his hypertension (both secondary to the α-1-antitrypsin deficit). The role of the urinary lithiasis, probably hypercalciuric, together with early grayness, are mentioned as potential causes of the osteoporosis. No relationship of this problem, in absence of hepatopathy, was found with the α-1-antitrypsin deficit