Delirium asociado a tratamiento del dolor. Factores de riesgo de delirium

A 84 year-old woman who entered for a first episode of psychomotor agitation in relation to the recent establishment of fentanyl patches with resolution after removal. The identification of the risk factors and the precipitating causes of delirium, investigating especially the associated drugs are necessary for its treatment and prevention.Mujer de 84 años que ingresa por un primer episodio de agitación psicomotriz en relación con reciente instauración de parches de fentanilo, con resolución tras su retirada. La identificación de los factores de riesgo y de las causas precipitantes del delirium, investigando sobre todo los fármacos asociados son necesarios para su tratamiento y prevención

Trends of Digital Transformation in the Shipbuilding Sector

The new paradigms of Industry 4.0 force all the industrial sectors to face a deep digital transformation in order to be on the edge in a competitive and globalized scenario. Following this trend, the shipbuilding industry has to establish its own path to adapt itself to the digital era. This chapter aims to explore this challenge and give an outlook on the multiple transformative technologies that are involved. For that reason, a case of study is presented as a starting point, in which the digital technologies that can be applied are easily recognized. A social network analysis (SNA) is developed among these key enabling technologies (KETs), in order to stress their correlations and links. As a result, artificial intelligence (AI) can be highlighted as a support to the other technologies, such as vertical integration of naval production systems (e.g., connectivity, Internet of things, collaborative robotics, etc.), horizontal integration of value networks (e.g., cybersecurity, diversification, etc.), and life cycle reengineering (e.g., drones, 3D printing (3DP), virtual and augmented reality, remote sensing networks, robotics, etc.)

Miocarditis aguda en varón joven tras la primera dosis de la vacunación frente al SARS-CoV-2

A 20-year-old man came to the hospital because of fever and confusion after receiving the first dose of vaccination against SARS-CoV-2 (mRNA-1273 - Moderna). During his stay in the emergency room, he developed hypotension and rapidly progressive respiratory failure, requiring admission to the intensive care unit. Tests results revealed the progression of bilateral pulmonary infiltrates, electrocardiographic changes, and troponin elevation. After ruling out an acute infection, we think this patient had acute myocarditis secondary to vaccination.Varón de 20 años, recientemente vacunado con la primera dosis de la vacuna frente SARS-CoV-2 (mRNA-1273 - Moderna), que consultó por un cuadro de fiebre y confusión. Durante su estancia en Urgencias, desarrolló hipotensión e insuficiencia respiratoria rápidamente progresiva, requiriendo ingreso en la unidad de cuidados intensivos. En pruebas complementarias se observe la progresión de los infiltrados pulmonares bilaterales, cambios electrocardiográficos y elevación de troponina. Tras haber descartado una infección aguda y, dada la relación temporal con la administración de la vacuna, se propone el cuadro clínico como un caso de miocarditis aguda tras la vacunación

Microangiopatía trombótica en el seno de una prostatitis aguda

We present the case of a 46-year-old man who was admitted to the hospital for an episode of acute prostatitis and who, during hospitalization, presented a progressive and severe deterioration of renal function accompanied by hemolytic anemia and severe thrombocytopenia. After an etiological study, a diagnosis of thrombotic microangiopathy was reached. Treatment with eculizumab and plasmapheresis was started with a good response.Presentamos el caso de un varón de 46 años que ingresó por un episodio de prostatitis aguda y durante la hospitalización presentó un deterioro progresivo y severo de la función renal acompañado de anemia hemolítica y trombocitopenia severa. Tras estudio etiológico se llegó al diagnóstico de una microangiopatía trombótica. Se inició tratamiento con eculizumab y plasmaféresis con buena respuesta

Acenocoumarol Pharmacogenetic Dosing Algorithm versus Usual Care in Patients with Venous Thromboembolism: A Randomised Clinical Trial

Patients with venous thromboembolism (VTE) require immediate treatment with anticoagulants such as acenocoumarol. This multicentre randomised clinical trial evaluated the effectiveness of a dosing pharmacogenetic algorithm versus a standard-of-care dose adjustment at the beginning of acenocoumarol treatment. We included 144 patients with VTE. On the day of recruitment, a blood sample was obtained for genotyping (CYP2C9*2, CYP2C9*3, VKORC1, CYP4F2, APOE). Dose adjustment was performed on day 3 or 4 after the start of treatment according to the assigned group and the follow-up was at 12 weeks. The principal variable was the percentage of patients with an international normalised ratio (INR) within the therapeutic range on day 7. Thirty-four (47.2%) patients had an INR within the therapeutic range at day 7 after the start of treatment in the genotype-guided group compared with 14 (21.9%) in the control group (p = 0.0023). There were no significant differences in the time to achieve a stable INR, the number of INRs within the range in the first 6 weeks and at the end of study. Our results suggest the use of a pharmacogenetic algorithm for patients with VTE could be useful in achieving target INR control in the first days of treatment

Estudio de los péptidos reguladores gastrointestinales de acción endocrina en la pancreatitis crónica

Tesis doctoral inédita leída en la Universidad Autónoma de Madrid, Facultad de Medicina, Departamento de Medicina. Fecha de lectura: 26 de Mayo de 199

Utility of Doppler ultrasound for the study of ocular vascular disease

Los problemas vasculares oculares constituyen una patología emergente dentro de la actividad del internista. La ecografía ocular es una técnica ampliamente utilizada para evaluar una variedad de afecciones oculares; en particular, el estudio por ecografía Doppler de los vasos oftálmicos se ha convertido en una herramienta muy útil en el diagnóstico de diversas enfermedades oculares. La ecografía Doppler permite examinar el flujo sanguíneo ocular, incluso en presencia de opacidades oculares que impidan una visión del segmento posterior del ojo. En esta revisión describimos los principios y técnicas para el examen ecográfico Doppler vascular ocular y proporcionamos una aproximación general a las características ecográficas de los trastornos vasculares oculares más importantes para la práctica clínica de los internistas, entre los que se incluyen la oclusión de la arteria y de la vena central de la retina, el síndrome isquémico crónico retiniano, la neuropatía óptica isquémica anterior y la retinopatía diabética.Ocular vascular problems represent an emerging pathology within the activity of the internist. Ocular ultrasound is a widely used technique to evaluate a variety of eye conditions. Specifically, Doppler ultrasound of the ophthalmic vessels has become a very useful tool in diagnosing various eye diseases. Doppler ultrasound allows for examining blood flow in the eye even in the presence of eye opacities that impede viewing the posterior segment of the eye. In this review, we describe the principles and techniques of an ocular vascular Doppler ultrasound examination in clinical practice and provide a general approach to the ultrasound characteristics of the most important vascular eye disorders for internists. These include central retinal artery and vein occlusions, chronic retinal ischemic syndrome, anterior optic ischemic neuropathy, and diabetic retinopathy.Sin financiación1.556 JCR (2020) Q3, 110/167 Medicine, General & Internal0.253 SJR (2020) Q3, 1789/2447 Medicine (miscellaneous)No data IDR 2020UE

Impacto presupuestario para el Sistema Nacional de Salud de la Prevención del Trombolismo Venoso con apixaban en pacientes sometidos a artroplastia total de rodilla o cadera

BacKground: Due to high health care costs of venous thromboembolism (VTE), economic analyses are needed to determine the efficiency of different drug treatments. Consequently, a study was conducted to estimate the budgetary impact for the National Health System (NHS) with apixaban for prevention of venous thromboembolism (VTE) in total hip (THR) or knee (TKR) replacement. Methods: Cost considered: the drugs for the prevention of VTE (apixaban, dabigatran, enoxaparin, fondaparinux, other heparins, rivaroxaban and warfarin) and the complications of VTE in the short term and in 5 years (deep vein thrombosis, pulmonary embolism, bleedings and the post-thrombotic syndrome). The effectiveness of prophylaxis was estimated using a meta-analysis. The VTE rates and death with apixaban are lower in THR and TKR than enoxaparin (-3.5% and -10.0%, respectively) with less bleeding events (-0.7% and -1.6%, respectively). Population data and unit costs were obtained from Spanish sources. Time horizon: 5 years. All costs were discounted by 3.5% annually. Five years after commercialization, the use of apixaban was estimated to account for 23% of the prophylaxis of VTE and the use of enoxaparin decrease from the 60% to 33%. Results: Apixaban´s introduction for the prophylaxis of VTE would have a significant impact for the NHS, resulting in a saving of € 547,422 over a period of 5 years. In the case of outpatient administration of heparin did not have a cost, the savings for the NHS five years amount to € 270,068. Conclusions: According to this study, the introduction of apixaban may reduce the rate of VTE and bleeding compared with enoxaparin, decreasing the expenditure of NHS in VTE prophylaxis.Fundamentos: Debido al elevado coste sanitario del tromboembolismo venoso (TEV) es necesario realizar análisis económicos que determinen la eficiencia de sus diferentes tratamientos farmacológicos. El objetivo del trabajo es estimar el impacto presupuestario para el Sistema Nacional de Salud (SNS) de la prevención del tromboembolismo venoso (TEV) con apixaban en artroplastia total de cadera (ATC) o rodilla (ATR). Métodos: Se consideraron los costes de los diferentes fármacos para la prevención del TEV (apixaban, dabigatrán, enoxaparina, fondaparinux, otras heparinas, rivaroxaban y warfarina) y los de las complicaciones del TEV a corto plazo (90 días) y a 5 años (trombosis venosa profunda, embolismo pulmonar, sangrados y síndrome postrombótico). La eficacia de la prevención se estimó mediante un metaanálisis. Las tasas de TEV y muerte con apixaban fueron inferiores en ATC y ATR a las observadas con enoxaparina (-3,5% y -10,0%, respectivamente) y tuvo menos acontecimientos hemorrágicos (-0,7% y -1,6%, respectivamente). Los datos poblacionales y los costes se obtuvieron de fuentes españolas. Horizonte temporal: 5 años. Todos los costes se descontaron anualmente un 3,5%. Se estimó que a los cinco años de su comercialización el consumo de apixaban supondría el 23% de la prevención del TEV y el de enoxaparina descendería del 60% hasta el 33%. Resultados: La introducción de apixaban para la prevención del TEV produciría un ahorro para el SNS de 547.422 € en un periodo de 5 años. En el caso de considerar sin coste la administración ambulatoria de las heparinas, el ahorro quinquenal para el SNS ascendería a 270.068 €. Conclusiones: La introducción de apixaban podría reducir la tasa de TEV y sangrados en comparación con enoxaparina, reduciéndose el gasto del SNS en la prevención del TEV

Impact of delirium on short-term outcomes in hip fracture patients under a program of approach to delirium

Aim:We aimed to investigate the impact of delirium on short-term outcomes in hip fracturepatients. Special attention was given to patients with delirium and dementia.Methods:A prospective observational cohort study was carried out in hip fracture patientsaged≥70 years who were admitted to a hospital unit where a multicomponents approach todelirium is established for all patients. Our population was split into delirium (n= 212) andnon-delirium cohort (n= 171) according to the Confusion Assessment Method. Patients witha previous diagnosis of dementia in an outpatient appointment were also assessed within thedelirium cohort. The utility of the rehabilitation was measured with the Absolute FunctionalGain index.Results:A total of 383 patients were entered into the study. The median age was 86 years,and most patients were women (78.8%). Delirium patients were older, presented a lower pre-vious Barthel Index (BI), had higher rates of dementia and came more frequently from nursinghomes. Comparative analysis did not show differences in mortality, complications, length ofstay or walking ability between the cohorts. However, lower BI on discharge, lower AbsoluteFunctional Gain and the presence of nosocomial infections were found more frequently inthe delirium cohort. In multivariate analysis, only the BI on discharge (P= 0.010) was lower indelirium patients. Within the delirium cohort, those suffering from dementia had worse BI ondischarge (P= 0.017) and lower Absolute Functional Gain (P= 0.019).Conclusions:Delirium was not associated with mortality, walking ability, length of stay andclinical complications in hip fracture patients. BI on discharge was the only short-term out-come affected. In the delirium cohort, those suffering from dementia showed worse rehabili-tation results.Sin financiación2.730 JCR (2020) Q2, 15/36 Gerontology0.823 SJR (2020) Q1, 10/41 GerontologyNo data IDR 2020UE