[Analysis of infectious diseases care in Spanish hospitals from 2016-2020, including the first year of the SARS-CoV-2 pandemic]. / Análisis de la atención a patologías infecciosas en los hospitales españoles en el periodo 2016-2020, incluyendo el primer año de pandemia por SARS-CoV-2.

Aims: This work aimed to review patients discharged from Spanish hospitals with a principal diagnosis of infection during a 5-year period, including the first year of the SARS-CoV-2 pandemic. Materials and method: This work analyzed the Basic Minimum Data Set (CMBD) of patients discharged during the 2016-2020 period from hospitals in the Spanish National Health Service in order to identify cases with a principal diagnosis of an infectious disease according to the ICD-10-S code. All patients older than 14 years of age admitted to a conventional ward or intensive care unit, excluding labor and delivery, were included in the analysis and were evaluated based on the discharging department. Results: Patients discharged with infectious diseases as the principal diagnosis have increased from 10% to 19% in recent years. A large part of the growth is due to the SARS-CoV-2 pandemic. Internal medicine departments cared for more than 50% of these patients, followed by pulmonology (9%) and surgery (5%). In 2020, 57% of patients with a principal diagnosis of infection were discharged by internists, who cared for 67% of patients with SARS CoV-2. Conclusions: At present, more than half of patients admitted with a principal diagnosis of infection are discharged from internal medicine departments. Given the growing complexity of infections, the authors advocate for an approach in which training allows for specialization, but within a generalist context, for the better management of these patients.

[What do we know about the origin of COVID-19 three years later?] / ¿Qué sabemos del origen del COVID-19 tres años después?

More than three years have passed since the first case of a new coronavirus infection (SARS-CoV-2) in the city of Wuhan (Hubei, China). The Wuhan Institute of Virology was founded in that city in 1956 and the country's first biosafety level 4 laboratory opened within that center in 2015. The coincidence that the first cases of infection emerged in the city where the virology institute's headquarters is located, the failure to 100% identify the virus' RNA in any of the coronaviruses isolated in bats, and the lack of evidence on a possible intermediate animal host in the contagion's transmission make it so that at present, there are doubts about the real origin of SARS-CoV-2. This article will review two theories: SARS-CoV-2 as a virus of zoonotic origin or as a leak from the high-level biosafety laboratory in Wuhan.

Prophylaxis of venous thromboembolism during pregnancy. / Profilaxis de la enfermedad tromboembólica venosa durante el embarazo.

The purpose of this guide is to suggest, based on the available clinical evidence, the prevention measures for venous thromboembolism during pregnancy, childbirth and postpartum in expert recommendations and international guidelines. Venous thromboembolism is a cause of maternal death, and it is therefore important to consider those situations in which the risk is greater and for which women should undergo preventive treatment. Personal and family history, the presence of acquired or hereditary thrombophilia, patient-related factors and those related to pregnancy or childbirth have a relative weight that determines the start of treatment and its duration. Low-molecular-weight heparin is the treatment of choice for these women. Prophylaxis might be necessary during the antenatal or postnatal period, and the duration and indication will vary depending on the risks and benefits.

Impact of hypochloremia as a prognostic factor in patients with heart failure, a retrospective cohort study.

BACKGROUND: some studies suggest that hypochloremia is a risk factor in the prognosis of heart failure (HF) in patients with recent decompensation. MATERIALS AND METHODS: retrospective cohort study of patients discharged due to HF decompensation who began follow-up in a specialized clinic. Two groups are defined: patients with hypochloremia (chloride < 98 mmol/L) and normochloremic patients (chloride > 98 mmol/L) in the initial assessment within the first month after discharge. The rate of intravenous diuretic rescue, emergency department visits, readmission for HF and cardiovascular (CV) death are compared using a Cox proportional hazards model. RESULTS: 165 patients were included (59% women, mean age 85 years), with 60 (36%) having hypochloremia. Both groups were comparable in terms of baseline characteristics, except for female sex, presence of peripheral artery disease, moderate-to-severe liver disease (more prevalent in the hypochloremia group), PROFUND index, and baseline furosemide dose (higher in patients with hypochloremia). The incidence of the primary event was higher in subjects with hypochloremia than in normochloremic subjects (HR: 1.59, 95% CI 0.97-2.62), mainly due to the need for intravenous diuretic rescue (HR: 1.86, 95% CI 1.07-3.24). CONCLUSIONS: hypochloremia following admission for HF decompensation is associated with a greater need for intravenous diuretic rescue therapy and probably worse overall prognosis across the spectrum of the disease, regardless of left ventricular ejection fraction (LVEF).

Analysis of infectious diseases care in Spanish hospitals from 2016 to 2020, including the first year of the SARS-CoV-2 pandemic.

AIMS: This work aimed to review patients discharged from Spanish hospitals with a principal diagnosis of infection during a 5-year period, including the first year of the SARS-CoV-2 pandemic. MATERIALS AND METHOD: This work analyzed the Basic Minimum Data Set (CMBD) of patients discharged during the 2016⬜2020 period from hospitals in the Spanish National Health Service in order to identify cases with a principal diagnosis of an infectious disease according to the ICD-10-S code. All patients older than 14 years of age admitted to a conventional ward or intensive care unit, excluding labor and delivery, were included in the analysis and were evaluated based on the discharging department. RESULTS: Patients discharged with infectious diseases as the principal diagnosis have increased from 10% to 19% in recent years. A large part of the growth is due to the SARS-CoV-2 pandemic. Internal medicine departments cared for more than 50% of these patients, followed by pulmonology (9%) and surgery (5%). In 2020, 57% of patients with a principal diagnosis of infection were discharged by internists, who cared for 67% of patients with SARS CoV-2. CONCLUSIONS: At present, more than half of patients admitted with a principal diagnosis of infection are discharged from internal medicine departments. Given the growing complexity of infections, the authors advocate for an approach in which training allows for specialization, but within a generalist context, for the better management of these patients.

What do we know about the origin of COVID-19 three years later?

More than three years have passed since the first case of a new coronavirus infection (SARS-CoV-2) in the city of Wuhan (Hubei, China). The Wuhan Institute of Virology was founded in that city in 1956 and the country's first biosafety level 4 laboratory opened within that center in 2015. The coincidence that the first cases of infection emerged in the city where the virology institute's headquarters is located, the failure to 100% identify the virus' RNA in any of the coronaviruses isolated in bats, and the lack of evidence on a possible intermediate animal host in the contagion's transmission make it so that at present, there are doubts about the real origin of SARS-CoV-2. This article will review two theories: SARS-CoV-2 as a virus of zoonotic origin or as a leak from the high-level biosafety laboratory in Wuhan.

Retinal vein occlusion. Audit of a specialized care program.

BACKGROUND AND OBJECTIVES: Retinal vein occlusion (RVO) is the second most frequent cause of retinal vascular disease and is related to classic cardiovascular risk factors. A specific program was designed to detect and treat risk factors in patients with RVO. The aim of this study is to audit the results of this program. PATIENTS AND METHODS: The program consisted of a multidisciplinary clinical evaluation by the Ophthalmology and Internal Medicine Departments. All patients with RVO were screened, at minimum, for hypertension, diabetes, dyslipidemia, smoking, overweight, and antiphospholipid syndrome. New risk factors or poor control of known risk factors were expected to be found in at least one-third of the patients. Among them, therapeutic measures were expected to be taken in at least two-thirds. A dissociated automated search of the data of all patients who entered the program between April 2021 and April 2022 was performed. RESULTS: Fifty-six patients were included for analysis. Of these, 39 (69.6%) had at least one new or poorly controlled risk factor and 43 (76.8%) had their treatment modified in some way. Antiphospholipid syndrome was detected in five (8.9%). Only one patient had low-risk hereditary thrombophilia. After an exhaustive examination, no risk factors were found in 11 patients. CONCLUSION: This specific program has been effective in detecting new or poorly controlled risk factors and improving their treatment.

External validation of the InShape II study algorithm for exclusion of chronic thromboembolic pulmonary hypertension in patients with pulmonary thromboembolism.

BACKGROUND AND AIM: The most severe long-term complication of pulmonary embolism (PE) is chronic thromboembolic pulmonary hypertension (CTEPH), and its early diagnosis often requires numerous diagnostic tests. The InShape II study proposes an early screening algorithm that aims to reduce the number of echocardiographic studies. The objective of our study is to validate this algorithm in our patient cohort. MATERIALS AND METHODS: We retrospectively analyzed patients admitted to Hospital Rey Juan Carlos between November 2017 and February 2020, who were diagnosed with PE based on computed tomography angiography (CTA). Patients were followed for at least one year, and clinical, laboratory, and complementary test data were collected at three months and one year. The InShape II algorithm was applied to these patients to validate its results. RESULTS: During the study period, 236 patients were diagnosed with PE, of which 137 were excluded. The algorithm was validated in 99 patients. Applying the InShape II score, 19 echocardiograms would have been performed (three of them with intermediate-high probability of CTEPH), while 80 echocardiograms would have been avoided (two of them with intermediate-high probability). This yielded a sensitivity of 60% and a specificity of 83% for the score, with an area under the curve (AUC) of 0.715 (95% CI: 0.472-0.958). CONCLUSIONS: Our results support the notion that the InShape II algorithm could be a useful tool for initial screening of CTEPH in low-incidence settings, as it would avoid unnecessary echocardiograms that do not provide additional value.

[Description of hospital discharges in patients with systemic lupus erythematosus]. / Descripción de las altas hospitalarias en pacientes con lupus eritematoso sistémico.

BACKGROUND: Systemic lupus erythematosus (SLE) is an autoimmune disease that mainly affects young women and whose mortality is increasing for this age group. OBJECTIVES: We used the national registry of Hospital discharges in Spain based on the study of the Minimum Basic Data Set (MBDS) to analyze hospital discharges of patients whose diagnosis included that of LES. MATERIAL AND METHODS: A cross-sectional, descriptive study was performed of all episodes coded as having LES using ICD-9-MC coding system of the patients hospitalized within the period 2005-2008. RESULTS: A total of 5,464 episodes were identified, 1,855 (33%) as main diagnosis and 3,609 (66%) as secondary diagnosis. Patients having LES the main diagnosis were younger (41.56 ± 17.55 vs 56.07 ± 19.01 years; P < .001), had fewer elective admittances (62.5 vs 84.8%; P<.001), lower comorbidity as measured by the Charlson's index (Charlson>2; 18 vs 35%; P<.001) and lower mortality (1.1 vs 5.4%; P < .001). CONCLUSIONS: Patients admitted to internal medicine departments in Spain with a diagnosis of LES accounts for 0.3% of the total. Two different groups of patients are identified. The first group was younger, had lower comorbidity and were in the early phases of diagnosis and/or treatment. The second group was more numerous, older, with a higher comorbidity, with admittances frequently related to infections or cardiovascular complications and higher mortality rate.

Utility of lateral flow tests in SARS-CoV-2 infection monitorization.

OBJECTIVE: The diagnosis of SARS-CoV-2 infection is crucial for medical and public health reasons, to allow the best treatment of cases and the best control of the pandemic. Serology testing allows for the detection of asymptomatic infections and 19-COVID cases once the virus has been cleared. We analyzed the usefulness of the SARS-CoV-2 rapid test of Autobio and tried to correlate its pattern with the severity of COVID19 infection. METHODS: We analyzed the accuracy and clinical usefulness of a point-of-care IgM and/or IgG test for SARS-CoV-2 in 35 COVID-19 patients [12 (34.3%) mild-moderate and 23 (65.7%) severe-critical] admitted to a field hospital in Madrid, as well as in 5 controls. RESULTS: The mean time from the first day of symptoms to the antibody test was 28 days (SD: 8.7), similar according to the severity of the disease. All patients with SARS-CoV-2 PCR+ showed the corresponding IgG positivity, while these results were negative in all control individuals. A total of 26 (74%) cases also presented with positive IgM, 19 (83%) were severe-critical cases and 7 (58%) were mild-moderate cases. The IgM response lasted longer in the severe critical cases (mean: 29.7 days; SD: 8.4) compared to the moderate cases (mean: 21.2 days; SD: 2.0).. CONCLUSIONS: Rapid serology tests are useful for the diagnosis of patients with COVID-19 (mainly IgG detection) and may also be correlated with the severity of the infection (based on IgM detection).

Analysis of hospitalizations by cardiovascular disease in the population with diabetes in Spain. / Análisis de las hospitalizaciones por enfermedad cardiovascular en población diabética en España.

OBJECTIVES: Diabetes mellitus is associated with a marked increase in cardiovascular disease. In this study, we analysed the prevalence of diabetes mellitus in hospitalised patients in Spain in 2015 and the burden of associated cardiovascular disease. METHODS: By analysing the 2015 minimum basic data set (MBDS) of the Spanish Ministry of Health, we included all patients discharged with a diagnosis of diabetes mellitus. We describe the epidemiological characteristics, distribution by the various hospital departments and the presence of cardiovascular disease. RESULTS: In 2015, there was 3,727,583 hospital discharges in Spain, 619,188 of which involved patients with diabetes (16.7%), 56.8% of whom were men and with a mean age of 73.2years. The prevalence of cardiovascular disease was 40.8%, distributed among congestive heart failure (20.1%), cerebrovascular disease (10.3%), coronary artery disease (9.4%) and peripheral arterial disease (9.1%). Most of the patients were admitted to internal medicine (34.2%), cardiology (9.5%) and general surgery (8.9%) departments. The mean overall stay was 8.2days, the readmission rate at 30days was 14%, and the mortality rate was 6.8%. The patients hospitalized in internal medicine had higher severity levels (3-4) than those hospitalized in other medical departments (41.9% vs. 31.6%, respectively; P<.01) and those hospitalized in surgical departments (11.2%; P<.01). CONCLUSIONS: Diabetes mellitus is a significant comorbidity for patients hospitalized in internal medicine. A significant proportion of these patients present cardiovascular disease, mostly heart failure.

RECALMIN. Four years of growth of the internal medicine units of the Spanish National Health System (2013-2016). / RECALMIN. Cuatro años de evolución de las Unidades de Medicina Interna del Sistema Nacional de Salud (2013-2016).

OBJECTIVES: To compare the structure, resources and activity of the internal medicine units (IMUs) of the Spanish National Health System (SNHS) in 2013 and 2016. To analyse the differences between IMUs in 2016 by hospital size. MATERIAL AND METHODS: We conducted a comparison of 2 descriptive cross-sectional studies of IMUs in general acute care hospitals of the Spanish National Health System, with data referring to 2013 and 2016. The variables were collected via an ad hoc questionnaire (RECALMIN survey). RESULTS: Between 2013 and 2016, the demand for care increased dramatically (with an annual average of 11% in hospital discharges and 16% in first consultations), and comorbidity slightly increased (2%). During this period, the mean productivity of IMUs increased 16.7% (0.6±0.3 vs. 0.7±0.3; P=.09), and the mean stay decreased 10% (9±2.2 vs. 8.1±2.1 days; P=.001). Progress in implementing good practices and systematic care for complex chronic patients was scarce. Both surveys found variability among IMUs and marked differences among IMUs of hospitals of different sizes. CONCLUSIONS: IMUs responded to the increased burden of care they supported during 2013-2016 by improving their efficiency and productivity; however, advances in implementing good practices, including care for chronic complex patients, were scare. The significant variability in the indicators of structure, activity and management models found in 2013 remained in 2016.

[Experience of a single-centre in the preparation of choosing wisely lists in Internal Medicine]. / Experiencia de un centro único en la preparación de listas choosing wisely en Medicina Interna.

OBJECTIVES: To identify areas for improvement, using a local list of interventions with low diagnostic and therapeutic usefulness for the 5 Related Diagnostic Groups, as well as the 5 main diagnoses most frequently seen in the hospital outpatient clinic. METHOD: A literature review method was used, supplemented with a Delphi process with 2 rounds. In the first round, participants in the selection process identified low-value interventions in relation to the most frequently observed diagnoses. In the second round, those interventions with lower usefulness were selected based on their frequency, cost, and risk to the patient. RESULTS: Out of a total of 100 recommendations made by 19 scientific societies, 23 received the highest number of votes in the first round. In the second round, 5 recommendations were selected for inpatients and 5 recommendations for outpatients. CONCLUSIONS: A simple method is described for developing a local guide to reduce the use of unnecessary medical interventions.

RECALMIN II. Eight years of hospitalisation in Internal Medicine Units (2007-2014). What has changed? / RECALMIN II. Ocho años de hospitalización en las Unidades de Medicina Interna (2007-2014). ¿Qué ha cambiado?

OBJECTIVES: To analyse the evolution of care provided by the internal medicine units (IMU) of the Spanish National Health System from 2007 to 2014. MATERIAL AND METHODS: We analysed all discharges from the IMU of the Spanish National Health System in 2007 and 2014, using the Minimum Basic Data Set. We compared the risk factors by episode, mortality and readmissions between the two periods. We prepared specific fits for the risk for mortality and readmissions in heart failure, pneumonia and chronic obstructive pulmonary disease, as well as the Charlson index for all activity. RESULTS: Discharges from the IMU between the two periods increased 14%. The average patient age increased by 2.8 years (71.2±17.1 vs. 74±16.2; p<.001), with a marked increase in comorbidity (Charlson index, 4±3.7 vs. 4.7±3.9; p<.001; 24% increase in risk factors per episode). The adjusted mortality rates decreased slight but significantly, with a slight increase in readmissions. CONCLUSIONS: During the analysed period, there was an increase of almost 3 years in the mean age of patients treated in the IMU of the Spanish National Health System, with a marked increase in comorbidity. These results should lead to a more appropriate assignment of nurse workloads and an increased implementation of good practices in clinical management.

[RECALMIN. Patient care in the internal medicine units of the Spanish national health system]. / RECALMIN. La atención al paciente en las unidades de Medicina Interna del Sistema Nacional de Salud.

OBJECTIVES: To perform a situation analysis of the care provided by internal medicine units (IMUs) in Spain and to develop, based on this analysis, proposals for improving the quality of care in these units. MATERIAL AND METHODS: A descriptive, cross-sectional study of the IMUs of general acute care hospitals of the Spanish National Health System (SNHS), with data referring to 2013. The study variables were collected via an ad hoc questionnaire. RESULTS: Of the total 260hospitals identified in the SNHS, 142responses were obtained from 139hospitals throughout Spain, which represents 53.5% of the IMUs in the SNHS. The mean number of internists per IMU was 14±8, with a mean rate of 7.2±3.3 internists per 100,000 inhabitants. In 2013, the average number of hospital discharges from the IMU was 2,987±2,066, and those discharged by internists was 232±107. Sixty-one percent of the IMUs had implemented an interconsultation unit, and 41% had implemented a systematic care program for complex chronic patients. Thirty-three percent of the IMUs conducted multidisciplinary rounds, and 60% of these IMUs planned the discharge. CONCLUSIONS: The 2013 RECALMIN survey revealed a number of important aspects of the organisation, structure and management of IMUs. The remarkable variability in the indicators of structure, activity and management probably reflect significant differences in efficiency and productivity, which therefore provide significant room for improvement.

[Changes in the profile of HIV-positive patients. What has happened in the last 5 years?]. / Cambios en el perfil de los pacientes VIH positivos. Qué ha pasado en los últimos cinco años?

OBJECTIVE: To evaluate possible changes in the social, cultural and economical profile of our HIV infected patients appearing during the last five years and their potential impact on incidence, prevention, and follow-up of HIV infection. METHODS: We conduce a retrospective analysis of demographic, sociocultural, clinical and therapeutic characteristics of two groups of HIV infected patients reaching for the first time a level of 300 CD4 or less either in 1992 or in 1997. RESULTS: 55 patients with a mean age of 33 years (68% male 32% female) were studied. No differences were found in sexual behavior, HIV status of sexual partner, cultural level, risk practice, VHB or YHC seroprevalence. Attempts al drug quitting in 1992 were made individually and through institutional programs in 1997. Significant differences were found in the number of visits to the outpatient clinic the previous 36 months, and in de number of drugs (1.5 versus 3.5 P < 0.0001). Antirretroviral drugs were use in 62% of our 1992 patients and in 86% of the 1997 group (p < -0.02). CONCLUSIONS: The sociocultural and demographic profile has not changed in our environment in the last five years. However patients were identified later and followed less regularly at our clinic five years ago. Institutional methadone programs are the method or choice in our current patients for stopping illicit drug use. Finally treatment intensity has dramatically increased in our patients parallel to the growing therapeutical arsenal in this field.

Management of hospital readmissions in internal medicine.

The unplanned hospital readmission ratio is an unusual indicator of health care quality. Hospital readmission could be due to clinical or health care factors, to factors related to the patient and his/her social and familial setting, to factors related to the disease, or to a combination of all of them. The former could be avoided by designing effective interventions for the follow-up of the patients after discharge. We present a case of a male patient with a common clinical problem and propose the measures that could help to avoid his readmission. The article ends with the author's clinical recommendations.