Omega-3 fatty acids as adjunctive treatment for bexarotene-induced hypertriglyceridaemia in patients with cutaneous T-cell lymphoma.

BACKGROUND: Bexarotene is an oral retinoid approved for treating cutaneous T-cell lymphoma (CTCL) in patients resistant to first-line systemic treatment. Hypertriglyceridaemia is an unavoidable adverse effect of bexarotene therapy, and requires monitoring because of the risk of developing pancreatitis. Therefore, prophylactic hypolipidaemic therapy, usually with a fibrate alone, is required for preventing bexarotene-induced hypertriglyceridaemia. Despite these measures, a large number of patients develop very severe hypertriglyceridaemia. AIM: To assess the lipid metabolism changes before and after the use of a combination of omega-3 fatty acids (n-3 FA) plus fenofibrate compared with fenofibrate alone as a more effective lipid-lowering therapy in patients with CTCL treated with bexarotene. METHODS: From January 2005 to January 2013, we analysed all 25 patients with CTCL treated with bexarotene. The first 18 consecutively enrolled patients received fenofibrate alone as a lipid-lowering therapy, and the next 7 consecutively enrolled patients received a combination of fenofibrate and n-3 FA. RESULTS: Data for all 25 consecutive patients with CTCL treated with bexarotene were evaluated. Of these, 24 patients (96%) developed hypertriglyceridaemia despite the hypolipidaemic therapy, with this being very severe (> 11.2 mmol/L) in 20% of the cases. Of the 18 patients receiving fenofibrate alone, 5 (28%) developed very severe hypertriglyceridaemia, compared with none of the 7 patients treated with the n-3 FA combination. CONCLUSIONS: Our results suggest that the n-3 FA combination may be more effective than fibrate alone for preventing bexarotene-induced hypertriglyceridaemia.

Erectile dysfunction and cardiovascular risk factors in a Mediterranean diet cohort.

BACKGROUND: Erectile dysfunction affects more than 100 million men worldwide, with a wide variability in prevalence. An overall association of cardiovascular risk factors, lifestyle and diet in the context of ED in a Mediterranean population is lacking. AIM: To assess ED prevalence and associated factors in a Mediterranean cohort of non-diabetic patients with cardiovascular risk factors. METHODS: Observational, cross-sectional study of patients aged over 40 treated at cardiovascular risk units in Catalonia. Anthropometric data, risk factors, lifestyle and diet habits were recorded. ED was assessed using the International Index of Erectile Function. RESULTS: Four hundred and forty patients included, 186 (42.3%) with ED (24.8% mild, 6.8% moderate and 10.7% severe). ED presence and severity were associated with age, obesity, waist circumference, hypertension, antihypertensive treatment and ischaemic disease. Patients with ED were more frequently smokers, sedentary and consumed more alcohol. In multivariate analysis, consumption of nuts (> twice a week) (OR 0.41 (95% CI 0.25 to 0.67) and vegetables (≥ once a day) (OR 0.47 (95% CI 0.28-0,77)), were inversely related to ED. Obesity (as BMI ≥ 30 kg/m(2) ) (OR 2.49 (95% CI 1.48-4.17)), ischaemic disease (OR 2.30 (95% CI 1.22 to 4.33), alcohol consumption (alcohol-units a day) (OR 1.14 (95% CI 1.04 to 1.26), and age (year) (OR = 1.07 (95% CI 1.04-1.10) were directly related to ED. CONCLUSION: Erectile dysfunction is a common disorder in patients treated in lipid units in Catalonia for cardiovascular risk factors. This condition is associated with age, obesity, ischaemic disease and unhealthy lifestyle habits.

[Recommendations to develop Care Models for patients with Heart Failure (MAIC Project) from macromanagement]. / Recomendaciones para desarrollar Modelos Asistenciales de atención al paciente con Insuficiencia Cardiaca (Proyecto MAIC): Estudio Delphi.

BACKGROUND: The general objective of the study was to reflect on the key factors to advance in optimal models of care for Heart Failure (HF) and specifically, on the macromanagement elements most necessary for the development of comprehensive HF management models. MATERIAL AND METHODS: An Advisory Committee, composed of 15 experts and a multidisciplinary group of 31 additional experts, was appointed, together forming a Delphi panel of 46 experts. Based on a systematic bibliographic review and the analysis of the care course of the patient with HF, an initial battery of key factors for the development of HF care models was identified by the Advisory Committee. This proposal was adjusted and prioritized by the Delphi panel applying Delphi Rand/UCLA methodology. RESULTS: After two Delphi rounds, 75 key factors grouped into 7 challenges were defined. In the first of the challenges, related to the development of HF management models, 16 key factors were identified, 7 of which were valued as high priority and related to the establishment of common objectives, resources for the continuity of care and improving the measurement of health outcomes. CONCLUSIONS: The definition of management elements at the macro level was considered a priority to advance in the development of optimal models of assistance to HF.

Pragmatic, open-label, single-center, randomized, phase II clinical trial to evaluate the efficacy and safety of methylprednisolone pulses and tacrolimus in patients with severe pneumonia secondary to COVID-19: The TACROVID trial protocol.

INTRODUCTION: Some COVID-19 patients evolve to severe lung injury and systemic hyperinflammatory syndrome triggered by both the coronavirus infection and the subsequent host-immune response. Accordingly, the use of immunomodulatory agents has been suggested but still remains controversial. Our working hypothesis is that methylprednisolone pulses and tacrolimus may be an effective and safety drug combination for treating severe COVID-19 patients. METHODS: and analysis: TACROVID is a randomized, open-label, single-center, phase II trial to evaluate the efficacy and safety of methylprednisolone pulses and tacrolimus plus standard of care (SoC) versus SoC alone, in patients at advanced stage of COVID-19 disease with lung injury and systemic hyperinflammatory response. Patients are randomly assigned (1:1) to one of two arms (42 patients in each group). The primary aim is to assess the time to clinical stability after initiating randomization. Clinical stability is defined as body temperature ≤37.5 °C, and PaO2/FiO2 > 400 and/or SatO2/FiO2 > 300, and respiratory rate ≤24 rpm; for 48 consecutive hours. DISCUSSION: Methylprednisolone and tacrolimus might be beneficial to treat those COVID-19 patients progressing into severe pulmonary failure and systemic hyperinflammatory syndrome. The rationale for its use is the fast effect of methylprednisolone pulses and the ability of tacrolimus to inhibit both the CoV-2 replication and the secondary cytokine storm. Interestingly, both drugs are low-cost and can be manufactured on a large scale; thus, if effective and safe, a large number of patients could be treated in developed and developing countries. TRIAL REGISTRATION NUMBER: NCT04341038 / EudraCT: 2020-001445-39.

Effectiveness of a Surgery Admission Unit for patients undergoing major elective surgery in a tertiary university hospital.

BACKGROUND: The increasing demand on hospitalisation, either due to elective activity from the waiting lists or due to emergency admissions coming from the Emergency Department (ED), requires looking for strategies that lead to effective bed management. The aim of this study was to evaluate the effectiveness of a surgery admission unit for major elective surgery patients who were admitted for same-day surgery. METHODS: We included all patients admitted for elective surgery in a university tertiary hospital between the 1st of September and the 31st of December 2006, as well as those admitted during the same period of 2008, after the introduction of the Surgery Admission Unit. The main outcome parameters were global length of stay, pre-surgery length of stay, proportion of patients admitted the same day of the surgery and number of cancellations. Differences between the two periods were evaluated by the T-test and Chi-square test. Significance at P < 0.05 was assumed throughout. RESULTS: We included 6,053 patients, 3,003 during 2006 and 3,050 patients during 2008. Global length of stay was 6.2 days (IC 95%:6.4-6) in 2006 and 5.5 days (IC 95%:5.8-5.2) in 2008 (p < 0.005). Pre-surgery length of stay was reduced from 0.46 days (IC 95%:0.44-0.48) in 2006 to 0.29 days (IC 95%:0.27-0.31) in 2008 (p < 0.005). The proportion of patients admitted for same-day surgery was 67% (IC 95%:69%-65%) in 2006 and 76% (IC 95%:78%-74%) in 2008 (p < 0.005). The number of cancelled interventions due to insufficient preparation was 31 patients in 2006 and 7 patients in 2008. CONCLUSIONS: The implementation of a Surgery Admission Unit for patients undergoing major elective surgery has proved to be an effective strategy for improving bed management. It has enabled an improvement in the proportion of patients admitted on the same day as surgery and a shorter length of stay.

The Hospital of the Future in 10 points. / El hospital del futuro en 10 puntos.

Over the course of 2018 and 2019, the Spanish Society of Internal Medicine carried out a project called "The Future Hospital." Based on cumulative knowledge on the Spanish National Health System, this project seeks to transfer the observations on the organization of healthcare in future hospitals made by the Royal College of Physicians in the United Kingdom to the context of the Spanish healthcare system. The project's participants included numerous scientific and medical societies, professional associations in the health sector, and patient associations. This aim of this article is to highlight, in 10 points, predictions that arose from this project that we consider to be the most relevant, reserving the last point for the challenges for the field of internal medicine that can be surmised from these proposals.

Gender differences in hereditary hemorrhagic telangiectasia severity.

BACKGROUND: Gender differences in organ involvement and clinical severity have been poorly described in hereditary hemorrhagic telangiectasia (HHT). The aim of this study was to describe differences in the severity of HHT manifestations according to gender. METHODS: Severity was measured according to Epistaxis Severity Score (ESS), Simple Clinical Scoring Index for hepatic involvement, a general HHT-score, needing for invasive treatment (pulmonary or brain arteriovenous malformations -AVMs- embolization, liver transplantation or Young's surgery) or the presence of adverse outcomes (severe anemia, emergency department -ED- or hospital admissions and mortality). RESULTS: One hundred forty-two (58.7%) women and 100 (41.3%) men were included with a mean age of 48.9 ± 16.6 and 49 ± 16.5 years, respectively. Women presented hepatic manifestations (7.1% vs 0%) and hepatic involvement (59.8% vs 47%), hepatic AVMs (28.2% vs 13%) and bile duct dilatation (4.9% vs 0%) at abdominal CT, and pulmonary AVMs at thoracic CT (35.2% vs 23%) more often than men. The Simple Clinical Scoring Index was higher in women (3.38 ± 1.2 vs 2.03 ± 1.2), and more men were considered at low risk of harboring clinically significant liver disease than women (61% vs 25.3%). These differences were mantained when considering HHT1 and HHT2 patients separetely. Duodenal telangiectasia were more frequent in men than women (21% vs 9.8%). Invasive treatments were more frequently needed in women (28.2% vs 16%) but men needed attention at the ED more often than women (48% vs 28.2%), with no differences in ESS, HHT-score, anemia hospital admissions or mortality. CONCLUSIONS: HHT women showed more severe hepatic involvement than men, also among HHT1 and HHT2 patients. Women had higher prevalence of pulmonary AVMs and needed invasive procedures more frequently, while men needed attention at the ED more often. These data might help physicians to individualize HHT patients follow-up.

First hospital admission due to heart failure: In-hospital mortality and patient profile. / Primera hospitalización por insuficiencia cardiaca: mortalidad hospitalaria y perfil del paciente.

OBJECTIVES: We evaluated the patient profile and outcomes of first heart failure (HF) related hospital admission patients in the 2010-2014 period. DESIGN: Retrospective, single-centre, cohort study. SETTING: We used administrative data from a tertiary care hospital (Hospital Universitari de Bellvitge, Barcelona, Spain). PARTICIPANTS: All patients with primary diagnosis of HF registered at the hospital discharge database from 2010 to 2014 were included, ruling out that HF was present 10 years prior to the current episode. INTERVENTION: Primary care HF diagnosis status was assessed in order to distinguish new onset from no-new onset patients. MAIN MEASURES: Descriptive, bivariate and multivariate analysis were performed using age, previous primary care HF diagnosis and in-hospital death as grouping variables. Significant variables were fitted into a Linear logistic regression model for each outcome. RESULTS: We selected 3,868 first HF-related admissions (56.8% of all HF episodes). In 1,220 patients (31.7%) HF was diagnosed by their primary care physician. Main pattern was a woman (OR=2.4), with higher prevalence of hypertension (OR=1.7), atrial fibrillation (OR=1.3), chronic kidney disease (OR=1.6) and mortality rate (9.8%). In-hospital death rate was 5.8%, age over 85 (OR=5.57), chronic kidney disease (OR=1.44) and length of stay over 7 days (OR=1.90) being the main contributors. CONCLUSIONS: First HF related admissions account for 56.7% of all HF episodes. Roughly one third of patients were already diagnosed by the time of their first hospital admission. Elderly women were the most frequent, but not the only, group of patients. Age, hospital stay and chronic kidney disease were the main contributors for in-hospital death.

First clinical symptom as a prognostic factor in systemic sclerosis: results of a retrospective nationwide cohort study.

The objective of the study is to determine the importance of the mode of onset as prognostic factor in systemic sclerosis (SSc). Data were collected from the Spanish Scleroderma Registry (RESCLE), a nationwide retrospective multicenter database created in 2006. As first symptom, we included Raynaud's phenomenon (RP), cutaneous sclerosis, arthralgia/arthritis, puffy hands, interstitial lung disease (ILD), pulmonary arterial hypertension (PAH), and digestive hypomotility. A total of 1625 patients were recruited. One thousand three hundred forty-two patients (83%) presented with RP as first symptom and 283 patients (17%) did not. Survival from first symptom in those patients with RP mode of onset was higher at any time than those with onset as non-Raynaud's phenomenon: 97 vs. 90% at 5 years, 93 vs. 82% at 10 years, 83 vs. 62% at 20 years, and 71 vs. 50% at 30 years (p < 0.001). In multivariate analysis, factors related to mortality were older age at onset, male gender, dcSSc subset, ILD, PAH, scleroderma renal crisis (SRC), heart involvement, and the mode of onset with non-Raynaud's phenomenon, especially in the form of puffy hands or pulmonary involvement. The mode of onset should be considered an independent prognostic factor in systemic sclerosis and, in particular, patients who initially present with non-Raynaud's phenomenon may be considered of poor prognosis.

Effectiveness and safety of an emergency department short-stay unit as an alternative to standard inpatient hospitalisation.

BACKGROUND: Emergency department short-stay units (EDSSUs) are currently emerging worldwide as an alternative to standard inpatient hospitalisation. In our hospital, a 960-bed teaching tertiary institution in Barcelona, Spain, an EDSSU has been in operation during winter periods (November-March) since 1997. AIM: To determine the efficacy and safety of our EDSSU. METHODS: Retrospective analysis of activity and quality outcomes, assessment of patient satisfaction levels and determination of the diagnostic-related groups that were mainly responsible for admissions to the EDSSU, comparing the clinical characteristics of those patients with the characteristics of patients with similar clinical diagnoses admitted to standard hospitalisation units. RESULTS: 5666 patients were treated in the EDSSU, with a progressive increase in the number of patients admitted per period, ranging from 707 in 1997-8 to 1227 in 2003-4 (73.5% increase). The mean length of stay ranged from 3.1 to 2.8 days, mortality from 2.5% to 5.1%, home discharge rate from 84% to 90%, and hospital readmission rate within the first week after discharge from 3.9% to 6.2%. In all, 98% of patients were satisfied with their stay at the EDSSU. The main diagnostic-related groups were chronic obstructive pulmonary disease (COPD = 50%) and acute heart failure (28%). Patients with COPD admitted at the EDSSU (n = 545) showed significantly (p = 0.05) lower mean length of stay (3.4 v 12 days) and mortality (1.7% v 8.1%), but a higher hospital readmission rate (9.9% v 7%) than those admitted to standard inpatient units (n = 1961). CONCLUSIONS: In our experience, the EDSSU proved to be an effective and safe alternative to standard inpatient hospitalisation.

Epidemiological significance of cutaneous, pharyngeal, and digestive tract colonization by multiresistant Acinetobacter baumannii in ICU patients.

The aim of this prospective study was to assess the relative epidemiological role of digestive tract colonization by Acinetobacter baumannii, in comparison with other body site colonizations, in patients admitted to intensive care units (ICUs). From January to May 1995, axillary, pharyngeal and rectal swabs were taken together within the first 48 h of admission, and then weekly during ICU stay. Seventy-three patients were included, 48 of them (66%) had axillary, pharyngeal, or rectal colonization with A. baumannii, nine (19%) of these 48 during the first 48 h and the remaining 28 (77%) during the first week. Twenty-one (29%) had clinical samples positive for A. baumannii and axillary, pharyngeal, or rectal colonization. In 15 of these 21 (71%), colonization on body sites occurred prior to isolation from clinical samples (mean seven days, range 1-20). Throughout admission, rates of detection of A. baumannii were 75% (36/48) for axillary or pharyngeal swabs and 77% (37/48) for rectal swabs. Combination of two body site swabs yielded culture positive rates of 90% (43/48) for axillary-pharyngeal or axillary-rectal sites, and 96% (46/48) for pharyngeal-rectal. Two epidemic clones were defined by antibiotype and pulsed-field gel electrophoresis (PFGE) of SmaI DNA digests in 48 isolates from 11 patients. We conclude that body sites of patients were a major reservoir for A. baumannii infections in the outbreak. This finding cases doubt on the value of selective decontamination of the digestive tract as an additional infection control measure in this kind of outbreak. The weekly performance of pharyngeal and rectal swabs appears to detect A. baumannii colonization early among ICU patients and enables barrier methods to be applied rapidly.

Impact of a resident strike on emergency department quality indicators at an urban teaching hospital.

OBJECTIVE: To evaluate the indicators of activity and quality within the emergency department (ED) during a resident physicians' strike. METHODS: This was an observational study comparing a strike period (SP) and a non-strike period (NSP) in the ED of a 1,000-bed tertiary care teaching hospital in Barcelona, Spain, with an annual census of 100,000 emergency visits. During a period of nine nonconsecutive days, the resident physicians were on strike. Emergency visits were handled by staff members. Data were compared between all patients treated in the ED during the SP and those treated during the NSP, matched by the weekday. The authors compared lengths of stay (LOSs), rates of use of laboratory tests and radiology procedures, numbers of patient walkouts, patient/physician ratios, emergency hospital admission rates, home discharge rates, unscheduled return rates, and mortality rates. RESULTS: The two groups (SP 2,610 patients and NSP 3,634 patients) were comparable in terms of average daily attendance rate (SP: 290 +/- 12 vs NSP: 302 +/- 21; p = 0.13), elective hospital admission rate, and severity of illness. Statistically significant differences were found in terms of mean total patients' LOS (SP: 206.75 +/- 12.27 vs NSP: 235.10 +/- 27.08 minutes; p < 0.001), number of laboratory tests per patient (SP: 0.30 +/- 0.05 vs NSP: 0.38 +/- 0.04; p < 0.001), and radiographs per patient (SP: 0.78 +/- 0.06 vs NSP: 0.88 +/- 0.09; p = 0.021). CONCLUSIONS: This study demonstrated that replacing residents with staff physicians resulted in fewer laboratory tests ordered, fewer radiographs ordered, and shorter lengths of stays in the ED.

[Estimation of costs attributable to nosocomial infection: prolongation of hospitalization and calculation of alternative costs]. / Estimación del coste atribuible a la infección nosocomial: prolongación de la estancia hospitalaria y cálculo de costes alternativos.

BACKGROUND: Nosocomial infection represents a prolongation of hospital stay and an increase of costs. The aim of the study was to estimate attributable costs by means of two methods: calculation of costs resulting from an increase of hospital stay and calculation of costs attributed to services. METHODS: A matched case-control study was carried out with a cohort population. An appropriate control was found for 63 patients with surgical site infection, for 30 patients with respiratory infection and for 55 with urinary infection. The estimation of costs attributable to services includes the case-control pairs with surgical site infection and was performed of the sum of costs of diagnostic and therapeutic services rendered in the care of the surgical site infection. RESULTS: The median of postoperative stay was 21 days for cases with surgical site infection vs 10 days for controls (p < 0.001); the median length of stay was 21.5 days for cases with respiratory infection vs 11.5 days for controls (p < 0.01); and for urinary infection the median length of stay was 21 days for cases vs 15 days for controls (p < 0.01). The surgical site infection cost attributed to extra days was 310,310 pesetas and the surgical site infection cost attributed to service cost was 220,546 pesetas. CONCLUSIONS: Nosocomial infection produces a increase median hospital stay of 7-10 days. In absence of a precise accounting system, the prolongation of hospital stay was considered as the more objective date to estimate the costs.