Impacto de medidas de intervención educativa al personal sanitario sobre el manejo de los pacientes diabéticos hospitalizados en los servicios de medicina interna

INTRODUCCIÓN: La prevalencia de la diabetes mellitus tipo 2 (DM2) en la población hospitalaria está en aumento y supone una carga económica importante dentro del gasto sanitario español. Resulta imprescindible mejorar el tratamiento y el control de la DM2 en los pacientes hospitalizados. OBJETIVO: Estudiar el efecto de las medidas de intervención educativas sobre el personal sanitario de los servicios de medicina interna y su repercusión en los valores de glucemia capilar de los pacientes diabéticos hospitalizados. MATERIAL Y MÉTODOS: Se realizó un estudio epidemiológico de cohortes, experimental, de intervención comunitaria, prospectivo, analítico y no aleatorizado. Se recogieron los datos de los pacientes diabéticos ingresados en medicina interna durante un periodo de 2011. Posteriormente se llevó a cabo un programa educativo consistente en sesiones formativas al personal médico y de enfermería, el desarrollo de un protocolo para el manejo de los pacientes diabéticos y el uso de una hoja de seguimiento. Por último se llevó a cabo una nueva recogida de datos en 2013. RESULTADOS: En la 1ª cohorte se incluyeron 100 sujetos, 58% mujeres, con una edad media de 78,31 años (DE 10,11) y en la 2ª cohorte se incluyeron 100 sujetos, 55% mujeres, con una edad media de 80,12 años (DE 9,15). Los sujetos de la 1ª y la 2ª cohorte no coincidieron. Entre ambas cohortes no se encontraron diferencias notables respecto a sus características basales, presentando ambas cohortes una alta prevalencia de factores de riesgo cardiovascular (98% y 94%; p=0,14). Tras las medidas de intervención se redujo el uso de antidiabéticos orales (41,7% y 11,8%; p 140 mg/dL) (60,32% y 49,46%; p=0,02), sin aumentar significativamente la proporción de hipoglucemias (valores < 80 mg/dL) (2,53% y 4,21%; p=0,877). No se observaron diferencias significativas en el tiempo de ingreso (8,75 días y 7,97 días; p=0,28) ni en la tasa de mortalidad (3% y 6%; p=0,50). El tratamiento antidiabético previo al ingreso se ajustó al alta con mayor frecuencia en los pacientes jóvenes que en los mayores de 75 años (53,85% y 30,22%; p=0,003). CONCLUSIONES: Las medidas educativas instauradas en las plantas de hospitalización de medicina interna mejoran el cumplimiento de las recomendaciones de las guías de práctica clínica sobre el manejo de los pacientes diabéticos hospitalizados 2 años después. Esto se traduce en un mejor control glucémico de los pacientes sin aumento significativo de las hipoglucemias

Extrinsic collapse of the left atrium by a large hiatal hernia

87 years old male with a history of hypertension and ischemic cardiopathy. He arrives to the Emergency department with sudden intense epigastralgia, precordial oppression with irradiation to the interscapular area, profuse sweating, associated sensation of dyspnoea and palpitations. The patient is monitored and a venous peripheral access is placed. It is remarkable the variable blood pressure measures in the semi-stationary position, both in the upper left limb as in the contralateral limb. In the upper left limb we registrered 220/80 mmHg, followed by 100/50 mmHg and finally 170/95 mmHg. In the upper right limb, blood pressure was 180/40 mmHg and afterwards 120/70 mmHg. Proximal and distal pulses are present and no pulsatile epigastric mass can be found. Given the suspicion of an aortic syndrome, a CT scan with intravenous contrast is performed which shows a large hiatal hernia compromising partially the left atrium and inferior lobar veins (Fig 1-4). The patient is transferred to the observation area, where a nasogastric tube is placed, presenting partial symptomatic improvement, with persistent nausea and vomiting, as well as a tendency to hypertension. After being evaluated by general surgery, it was decided to make an hernia content reduction to the abdominal cavity and posterior fundoplication with residual fundus (Toupet type). There were no perioperative complications. After several days of hospitalization, the patient was referred to his home with no further incidences.</p

Risk of recurrence after discontinuing anticoagulation in patients with COVID-19- associated venous thromboembolism: a prospective multicentre cohort studyResearch in context

Background: The clinical relevance of recurrent venous thromboembolism (VTE) after discontinuing anticoagulation in patients with COVID-19-associated VTE remains uncertain. We estimated the incidence rates and mortality of VTE recurrences developing after discontinuing anticoagulation in patients with COVID-19-associated VTE. Methods: A prospective, multicenter, non-interventional study was conducted between March 25, 2020, and July 26, 2023, including patients who had discontinued anticoagulation after at least 3 months of therapy. All patients from the registry were analyzed during the study period to verify inclusion criteria. Patients with superficial vein thrombosis, those who did not receive at least 3 months of anticoagulant therapy, and those who were followed for less than 15 days after discontinuing anticoagulation were excluded. Outcomes were: 1) Incidence rates of symptomatic VTE recurrences, and 2) fatal PE. The rate of VTE recurrences was defined as the number of patients with recurrent VTE divided by the patient-years at risk of recurrent VTE during the period when anticoagulation was discontinued. Findings: Among 1106 patients with COVID-19-associated VTE (age 62.3 ± 14.4 years; 62.9% male) followed-up for 12.5 months (p25-75, 6.3–20.1) after discontinuing anticoagulation, there were 38 VTE recurrences (3.5%, 95% confidence interval [CI]: 2.5–4.7%), with a rate of 3.1 per 100 patient-years (95% CI: 2.2–4.2). No patient died of recurrent PE (0%, 95% CI: 0–7.6%). Subgroup analyses showed that patients with diagnosis in 2021–2022 (vs. 2020) (Hazard ratio [HR] 2.86; 95% CI 1.45–5.68) or those with isolated deep vein thrombosis (vs. pulmonary embolism) (HR 2.31; 95% CI 1.19–4.49) had significantly higher rates of VTE recurrences. Interpretation: In patients with COVID-19-associated VTE who discontinued anticoagulation after at least 3 months of treatment, the incidence rate of recurrent VTE and the case-fatality rate was low. Therefore, it conceivable that long-term anticoagulation may not be required for many patients with COVID-19-associated VTE, although further research is needed to confirm these findings. Funding: Sanofi and Rovi, Sanofi Spain

Risk of recurrence after discontinuing anticoagulation in patients with COVID-19- associated venous thromboembolism: a prospective multicentre cohort studyResearch in context

Summary: Background: The clinical relevance of recurrent venous thromboembolism (VTE) after discontinuing anticoagulation in patients with COVID-19-associated VTE remains uncertain. We estimated the incidence rates and mortality of VTE recurrences developing after discontinuing anticoagulation in patients with COVID-19-associated VTE. Methods: A prospective, multicenter, non-interventional study was conducted between March 25, 2020, and July 26, 2023, including patients who had discontinued anticoagulation after at least 3 months of therapy. All patients from the registry were analyzed during the study period to verify inclusion criteria. Patients with superficial vein thrombosis, those who did not receive at least 3 months of anticoagulant therapy, and those who were followed for less than 15 days after discontinuing anticoagulation were excluded. Outcomes were: 1) Incidence rates of symptomatic VTE recurrences, and 2) fatal PE. The rate of VTE recurrences was defined as the number of patients with recurrent VTE divided by the patient-years at risk of recurrent VTE during the period when anticoagulation was discontinued. Findings: Among 1106 patients with COVID-19-associated VTE (age 62.3 ± 14.4 years; 62.9% male) followed-up for 12.5 months (p25-75, 6.3–20.1) after discontinuing anticoagulation, there were 38 VTE recurrences (3.5%, 95% confidence interval [CI]: 2.5–4.7%), with a rate of 3.1 per 100 patient-years (95% CI: 2.2–4.2). No patient died of recurrent PE (0%, 95% CI: 0–7.6%). Subgroup analyses showed that patients with diagnosis in 2021–2022 (vs. 2020) (Hazard ratio [HR] 2.86; 95% CI 1.45–5.68) or those with isolated deep vein thrombosis (vs. pulmonary embolism) (HR 2.31; 95% CI 1.19–4.49) had significantly higher rates of VTE recurrences. Interpretation: In patients with COVID-19-associated VTE who discontinued anticoagulation after at least 3 months of treatment, the incidence rate of recurrent VTE and the case-fatality rate was low. Therefore, it conceivable that long-term anticoagulation may not be required for many patients with COVID-19-associated VTE, although further research is needed to confirm these findings. Funding: Sanofi and Rovi, Sanofi Spain