Evaluation of Nutritional Biochemical Parameters in Haemodialysis Patients over a Ten-year Period.

AIM: Protein-energy malnutrition as well as systemic inflammation and metabolic disorders are common in patients with chronic kidney failure, who require renal replacement therapy (haemodialysis). Such malnutrition is a factor that significantly contributes to their morbidity and mortality. This study evaluated the nutritional status of haemodialysis patients by assessing biochemical and anthropometric parameters in order to determine whether these patients suffered disorders reflecting nutritional deterioration directly related to time on haemodialysis. SUBJECTS AND METHOD: This research comprised 90 patients of both genders with chronic kidney failure, who regularly received haemodialysis at our unit over a period of ten years. The patients' blood was tested quarterly for plasma albumin, total cholesterol and total proteins, and tested monthly for transferrin. The patients' weight, height and body mass index (BMI) were monitored. Body mass index was calculated using the formula: weight (kg)/height (m2 ) and classified in one of the following categories defined in the World Health Organization (WHO) Global Database on Body Mass Index: (i) underweight [BMI < 18.50], (ii) normal [BMI 18.50 - 24.99], (iii) overweight [BMI 25 - 29.99], (iv) obese [BMI > 30]. RESULTS: In the ten-year period of the study, the patients experienced a substantial decline in their biochemical parameters. Nevertheless, their BMI did not show any significant changes despite the patients' state of malnutrition. CONCLUSIONS: The prevalence of malnutrition in haemodialysis patients was evident. Nevertheless, the BMI of the subjects did not correspond to the biochemical parameters measured. Consequently, the results showed that the nutritional deterioration of these patients was mainly reflected in their biochemical parameters rather than in their anthropometric measurements.

Efficacy of an extravascular lung water-driven negative fluid balance protocol.

OBJECTIVE: To analyze the efficacy of negative fluid balance in hypoxemic patients with an elevated extravascular lung water index (EVLWI). DESIGN: A retrospective observational study was made. SETTING: Intensive Care Unit of Virgen de las Nieves Hospital (Spain). PARTICIPANTS: Forty-four patients participated in the study. INTERVENTIONS: We analyzed our database of hypoxemic patients covering a period of 11 consecutive months. We included all hemodynamically stable and hypoxemic patients with EVLWI>9ml/kg. The protocol dictates a negative fluid balance between 500 and 1500ml/day. We analyzed the impact of this negative fluid balance strategy upon pulmonary, hemodynamic, and renal function. MAIN VARIABLES OF INTEREST: Demographic data, severity scores, clinical, hemodynamic, pulmonary, metabolic and renal function data. RESULTS: Thirty-three patients achieved negative fluid balance (NFB group) and 11 had a positive fluid balance (PFB group). In the former group, PaO2/FiO2 improved from 145 (IQR 106, 200) to 210mmHg (IQR 164, 248) (p<0.001), and EVLWI decreased from 14 (11, 18) to 10ml/kg (8, 14) (p<0.001). In the PFB group, EVLWI also decreased from 11 (10, 14) to 10ml/kg (8, 14) at the end of the protocol (p=0.004). For these patients there were no changes in oxygenation, with a PaO2/FiO2 of 216mmHg (IQR 137, 260) at the beginning versus 205mmHg (IQR 99,257) at the end of the study (p=0.08). CONCLUSION: Three out of four hypoxic patients with elevated EVLWI tolerated the NFB protocol. In these subjects, the improvement of various analyzed physiological parameters was greater and faster than in those unable to complete the protocol. Patients who did not tolerate the protocol were usually in more severe condition, though a larger sample would be needed to detect specific characteristics of this group.

[Predictive model and discriminant analysis of the development of dementia in patients with delirium in the emergency department]. / Modelo predictivo y análisis discriminante del desarrollo de demencia en pacientes con delirium en urgencias.

OBJECTIVE: The main aim of our study is to know the sociodemographic, clinical, analytical, and functional variables that predict the probability of developing dementia in patients with delirium who attend the emergency room. METHOD: All patients with delirium (n=45) from the emergency room who were admitted to the Geriatrics service of the General University Hospital of Ciudad Real (HGUCR) in 2016-2018 and met the inclusion and exclusion criteria were included. Subsequently, we ran a bivariate and multivariate analysis of the variables that predicted a diagnosis of dementia at six months and a discriminant analysis. RESULTS: 15.6% of patients presented dementia at six months of follow-up, 22.2% had developed cognitive impairment. We conducted a multivariate model (R2 Nagelkerke 0.459) for the probability of developing dementia, with elevated heart rate being the most crucial variable (OR=11.5). The model could excluded dementia with 100% accuracy. Finally, we achieved a discriminant function capable of correctly classifying 95.6% of the cases. It included the following variables of influence: pH, Lawton Brody index, calcium, urea, and heart rate. CONCLUSIONS: A few clinical and analytical variables that are easily detectable in the emergency room, especially tachycardia, could help us better identify those patients with delirium at higher risk of developing dementia, as well as formulate hypotheses about the variables involved in the development of dementia in patients with delirium.

Implementation of clinical practice guidelines for acute ischaemic stroke in specialist care centres.

INTRODUCTION: Cerebrovascular disease is associated with high morbidity and mortality. In 2008, the Spanish Ministry of Health published its Clinical Practice Guidelines for stroke prevention, but implementation of that document has not yet been assessed. Our study aims to investigate compliance with the Guidelines by analysing control over vascular risk factors, antithrombotic treatment and lipid lowering treatment in patients who had suffered an acute ischaemic stroke and who were under the care of neurologists or internists. METHODS: Cross-sectional study based on data from clinical reports (vascular risk factors, diagnosis and treatment), blood pressure readings and laboratory tests pertaining to 203 patients diagnosed with acute ischaemic stroke and admitted to a medium-to-long stay hospital for rehabilitation and care. RESULTS: The mean patient age was 75 ± 10 years; 56% were women. The most common risk factors were hypertension (68%) and diabetes mellitus (40%). Intravenous fibrinolytic therapy had been administered to 8.9% of the patients. Of the patients with thrombotic cerebral infarction, 91.7% received antiplatelet agents; 59.4% of patients with embolic infarction received anticoagulants. Statins were prescribed to 65% of patients with thrombotic infarction. Laboratory tests upon admission showed that 23% of patients had total cholesterol levels above 175 mg/dl and 26.6% had plasma glucose levels above 126 mg/dl. Of the patient total, 70% received antihypertensive therapy, but 47.5% had blood pressure levels above 130/80 mm Hg. CONCLUSIONS: In our opinion, secondary prevention of acute cerebrovascular disease could be improved, mainly by increasing the percentage of patients treated with antiplatelet or anticoagulant drugs (depending on aetiology), increasing prescription of statins, and improving blood pressure control.

Prevalence of fatal adverse drug reactions in hospitalized patients.

OBJECTIVE: The aims of the present study were to assess the prevalence of fatal adverse drug reactions (FADRs) in a hospitalized population, identify the drugs involved and investigate reported risk factors for these events. METHODS: The study population of this retrospective, single-centre case study comprised 289 patients dying between 1 January 2004 and 31 December 2004 and registered in the Cause of Death Register of a teaching hospital. All compiled data were recorded by two observers especially trained to identify and report adverse drug reactions (ADRs). The degree of probability that the ADR led directly to death was determined by using WHO criteria and an adapted version of Naranjo's score. RESULTS: Among 289 deceased study subjects, 17 (5.9%) were suspected to have died from an ADR. The most common suspected FADRs were gastrointestinal hemorrhages (52.9%), central nervous system hemorrhages (17.6%), cardiac disorders (17.6%), drug-induced myelosuppression (6%) and antimicrobial-related enterocolitis (6%). The drugs most frequently implicated in a FADR were antithrombotic drugs (65%), nonsteroidal anti-inflammatory drugs (NSAIDs) (47%) and corticosteroids (29%). The only risk factors associated with FADRs in this population were multiple-drug therapy and the presence of platelet antiaggregants and NSAIDs, alone or associated. CONCLUSIONS: FADRs are an important cause of death in hospitalized patients. Hemorrhages were seen in a majority of the fatal reactions, and antithrombotic agents or NSAIDs were implicated in most of these events.

[Drug-related mortality among inpatients admitted in Internal Medicine]. / Mortalidad hospitalaria asociada a medicamentos en un Servicio de Medicina Interna.

BACKGROUND: To analyze the mortality associated with prescriptions, the drugs most frequently involved and the associated risk factors in patients admitted to Internal Medicine. METHODS: A retrospective, observational study. The clinical records of adult patients who died consecutively in the department of Internal Medicine in a Spanish tertiary hospital over twenty-two months were reviewed. The main variable was the prevalence of hospital death suspected of being related to the medications administered during admission. RESULTS: Out of the 455 deaths analyzed, 22.2% were related to the medications received; in 55 cases (12.1%) the drugs were suspected of being the cause of death and in 46 cases (10.1%) of contributing to it. The most frequent diagnoses in cases of death associated with drugs were cardiac arrhythmia (23.7%), severe hemorrhage (19.8%) and aspiration pneumonia (12.8%). The drugs with the highest prevalence in deaths related to pharmacological treatment were an-tithrombotic drugs (23.7%), digoxin (21.7%), antipsychotics (17.8%) and benzodiazepines (14.8%). The only independent risk factor for mortality associated with treatment was the number of medications administered (OR=1.25, 95%CI: 1.14-1.37). No significant association was found with age, sex, number of pathologies or duration of hospital stay. CONCLUSION: A high percentage of deaths of patients admitted to Internal Medicine were considered related to the medications received. Antithrombotic drugs, digoxin and psychotropic drugs were the agents most frequently implicated. This mortality is independently and significantly associated with the number of medications administered.

[Prescription of generic pharmaceutic specialties in discharge reports at a university hospital]. / Prescripción de especialidades farmacéuticas genéricas en informes de alta de un hospital universitario.

BACKGROUND: The use of generic pharmaceutic specialities (GPS) has risen lately as a necessary tool in the control of sanitary expenses. This use is becoming of high importance, even in the non-medical media. Our aim was to stablish its use profile in patients discharged from a University Hospital. MATERIAL AND METHOD: To analyse the use of GPS in 256 discharge reports, randomly chosen from the Clinical Documentation Service, belonging to eight different Units for two months (June-July 2000). RESULTS: A total of 1233 prescriptions were reported. Among them, there was an equivalent generic drug to the medication prescribed in 220 cases (18%), but only in five ocasions one of them was indicated (2.2%). The cost of the drugs with an equivalent form in GPS was calculated in 707,521 pts. This cost could have been reduced to 505,865 pts. taking into account the average price of the GPS. In case of indicating the cheapest one, the cost could have been 479,672 pts. CONCLUSIONS: There is an important proportion of GPS to indicate as an alternative to the usual medicaments prescribed. However, nowadays, the GPS prescription is not a usual practice among the hospital physicians.

Deterioration of the plasma lipid profile during hospitalization of aged non-insulin-dependent diabetic patients. Comparison with non-diabetic control patients.

This study aimed at investigating the changes occurring in the plasma lipid profile of patients with non-insulin-dependent diabetes mellitus (NIDDM) hospitalized for treatment of intercurrent diseases. Twenty-nine non-insulin requiring NIDDM patients (13 men, 16 women; mean age: 67 +/- 2 yrs) and 26 adequately matched patients (12 men, 14 women; mean age: 71 +/- 2 yrs) have been prospectively studied. They were all hospitalized for treatment of various diseases. Diabetic and non-diabetic patients received similar treatment except for intensive insulin therapy in the former group. On admission, diabetic subjects had significantly higher plasma levels of triglycerides and lower levels of HDL cholesterol; during hospitalization, LDL, HDL cholesterol and apo A1 levels increased significantly. In the non-diabetic group, hospitalization and treatment induced significant increases in triglycerides, LDL cholesterol and apo B levels. In conclusion, although insulin treatment during hospitalization of non-insulin requiring NIDDM patients does not fully reverse the abnormal lipid profile, it may help to prevent its further deterioration, particularly by increasing HDL cholesterol levels and hence by decreasing the LDL/HDL cholesterol ratio.

[Amyloid angiopathy as a clinico-pathological entity to consider in the differential diagnosis of any hemorrhagic cerebrovascular accident]. / La angiopatía amiloide como entidad clínico-patológica a valorar en el diagnóstico diferencial de todo accidente cerebro vascular hemorrágico.

Intracerebral hemorrhages represent about 10% of the whole of vascular cerebral accidents. According to different authors, the incidence of cerebral amyloid angiopathy varies between 5-10% and up to 20-30% of all primary non-traumatic intracerebral hemorrhages. This incidence was analyzed in our environment. A retrospective study was carried out on 403 patients, 203 of them were analyzed between 1990-91 and the other 200 between 1992-3. Age, arterial tension, relapses and localization were taken as criteria for a diagnosis. For the statistical analysis, Student's T-test was used for quantitative variables, while square Chi with Yates' correction was used for qualitative variables. Ischemic cerebral accidents (90.5% of the total) are more frequent than hemorrhagic cerebral accidents, which represent 5.7%. 3.7% were not registered. Therefore, it was suspected cerebral amyloid angiopathy in 1.4% of all vascular cerebral accidents. This represents 26.1% of the total of hemorrhagic patients. Different variables from groups of hemorrhagic vascular cerebral accidents were compared to those caused by amyloid cerebral angiopathy and significant statistics were found with respect to localization in the cerebral hemispheres (p < 0.01). Neither age, nor arterial tension or relapses were significant. Amyloid cerebral angiopathy as a cause of hemorrhagic cerebrovascular accident is and entity to be considered in the diagnosis of these patients. By using clinical criteria and others of localization through complementary explorations, a diagnosis for guessing such a process can be determined.

[Usefulness of hepatic biopsy in an internal medicine service]. / Utilidad de la biopsia hepática en un servicio de Medicina Interna.

OBJECTIVES: Study the percentage of clinical successes which have been confirmed by percutaneous hepatic biopsy guided by echography (PHBE) in those diseases which can affect the liver in an Internal Medicine service. PATIENTS AND METHODS: 78 patients were chosen for this study. All of them were admitted to hospital during the last eight years. Each patient had had a PHBE made regarding clinical, analytical and echographic criteria that were necessary to conclude their diagnostic studies. They were distributed into different groups. RESULTS: Patients could be distributed into five different groups. There was a higher percentage of clinical successes on those who suffered from chronic hepatopathy derived from alcohol-addiction and on those with carcinomatous hepatopathies. When corroborating the diagnosis of clinical suspect, the diagnostic profitability of the biopsy proved to get down in the others groups, depending on it was the group of miscellaneous, dissociate cholestasis and, in the last place, unknownly originated fever. CONCLUSIONS: The diversity of diseases which can affect the liver in an Internal Medicine service gives PHBE a particular diagnostic character. The diagnosis of clinical suspect was confirmed in 78.2% of the total of cases that made up the different groups. Therefore, PHBE plays a main role in a large amount of hepatic repercussive diseases that are treated in Internal Medicine services where, despite the clinical suspect, a diagnostic corroboration is often required for a right treatment.

[Atrioventricular block in unstable angina. Results of the ARIAM registry]. / Bloqueo auriculoventricular en la angina inestable. Resultados del registro ARIAM.

OBJECTIVE: Describe the frequency of high degree atrioventricular block (HDAVB) in patients with unstable angina (UA), analyze the variables associated with their appearance and evaluate whether HDAVB is independently associated with increased mortality or increased length of ICU stay. DESIGN: Retrospective descriptive study of patients with UA included in the ARIAM registry. SETTING: ICUs from 129 hospitals in Spain. PATIENTS: From June 1996 to December 2003 a total of 14,096 patients were included in the ARIAM registry with a diagnosis of UA. MAIN VARIABLES OF INTEREST: Variables associated with the development of HDAVB, variables associated with the mortality of patients with UA, variables associated with the length of ICU stay of patients with UA. RESULTS: HDAVB frequency was 1%. Development of HDAVB was independently associated with the Killip classification and the presence of sustained ventricular tachycardia or ventricular fibrillation. Crude mortality of patients was significantly increased when HDAVB was present (9% versus 1%, p < 0,001). When adjusted for other variables, HDAVB was not associated with increased mortality. Development of HDAVB in patients with UA was independently associated with an increase in the length of ICU stay (adjusted odds ratio 1.89: 95% confidence interval: 1.33-5.69). CONCLUSIONS: Patients with UA complicated with HDAVB represent a high-risk population with an increased ICU stay.