Utilidad del Cálculo del Índice tobillo-brazo en pacientes no diabéticos con factores de riesgo cardiovascular en la identificación de pacientes de alto riesgo; Concordancia con tablas de riesgo cardiovascular (REGICOR y SCORE)

L'objectiu de l'estudi va ser la determinació de la prevalença de malaltia arterial perifèrica mitjançant el càlcul de l'Índex turmell-braç (ITB) en pacients sense malaltia vascular associada, no diabètics, amb 2 o més factors de risc cardiovascular (RCV); Determinant la seva concordança amb les taules de RCV de REGICOR i SCORE i veure quina d'elles classifica millor a aquests pacients. Es va seleccionar una mostra aleatòria de pacients entre 50 i 65 anys. El resultat de l'estudi demostra que la prevalença és baixa i no s'estableix concordança entre les taules de RCV de REGICOR i SCORE i el càlcul del ITB.El objetivo del estudio fue la determinación de la prevalencia de enfermedad arterial periférica mediante el cálculo del Índice tobillo-brazo (ITB) en pacientes sin enfermedad vascular asociada, no diabéticos, con 2 o más factores de riesgo cardiovascular (RCV); Determinando su concordancia con las tablas de RCV de REGICOR y SCORE y ver cual de ellas clasifica mejor a estos pacientes. Se seleccionó una muestra aleatoria de pacientes entre 50 y 65 años. El resultado del estudio demuestra que la prevalencia es baja y no se establece concordancia entre las tablas de RCV de REGICOR y SCORE y el cálculo del ITB

Tromboembolismo Pulmonar : diferencias entre pacientes ancianos y no ancianos

El nostre objectiu va ser analitzar les característiques dels pacients ingressats per tromboembolisme pulmonar (TEP) en el nostre Servei des de 1998 fins 2006 i identificar les diferències entre pacients ancians i no ancians. Realitzarem un estudi retrospectiu, incloerem 283 pacients i distingirem 2 grups: A ( 70 anys) i B (≥ 70 anys). El grup A constava de 89 pacients (50,6% dones) i el grup B de 194 (69,1% dones) amb més proporció de dones en el B. Els factors de risc van ser similars en ambdós grups excepte l'antecedent de malaltia tromboembòlica prèvia (major al A). Clínicament, en pacients ancians va ser menys freqüent el dolor toràcic i l'expectoració hemoptoica. En el grup B, hi va haver un major nombre de pacients amb insuficiència respiratòria. La Rx de tòrax va ser patològica en el 70% en ambdós grups. La resta de proves diagnòstiques i la mortalitat van ser similars en ambdós grups.Nuestro objetivo fue analizar las características de los pacientes ingresados por tromboembolismo pulmonar (TEP) en nuestro Servicio desde 1998 hasta 2006 e identificar las diferencias entre pacientes ancianos y no ancianos. Realizamos un estudio retrospectivo, incluimos 283 pacientes y distinguimos 2 grupos: A ( 70 años) y B (≥70 años). El grupo A constaba de 89 pacientes (50,6% mujeres) y el grupo B de 194 (69,1% mujeres) con mayor proporción de mujeres en el B. Los factores de riesgo fueron similares en ambos grupos salvo el antecedente de enfermedad tromboembólica previa (mayor en el A). Clínicamente, en pacientes ancianos fue menos frecuente el dolor torácico y la expectoración hemoptoica. En el grupo B, hubo un mayor número de pacientes con insuficiencia respiratoria. La Rx de tórax fue patológica en el 70% en ambos grupos. El resto de pruebas diagnósticas y la mortalidad fueron similares en ambos grupos

Pulmonary embolism and 3-month outcomes in 4036 patients with venous thromboembolism and chronic obstructive pulmonary disease: data from the RIETE Registry

Background: Patients with chronic obstructive pulmonary disease (COPD) have a modified clinical presentation of venous thromboembolism (VTE) but also a worse prognosis than non-COPD patients with VTE. As it may induce therapeutic modifications, we evaluated the influence of the initial VTE presentation on the 3-month outcomes in COPD patients. Methods: COPD patients included in the on-going world-wide RIETE Registry were studied. The rate of pulmonary embolism (PE), major bleeding and death during the first 3 months in COPD patients were compared according to their initial clinical presentation (acute PE or deep vein thrombosis (DVT)). Results: Of the 4036 COPD patients included, 2452 (61%; 95% CI: 59.2-62.3) initially presented with PE. PE as the first VTE recurrence occurred in 116 patients, major bleeding in 101 patients and mortality in 443 patients (Fatal PE: first cause of death). Multivariate analysis confirmed that presenting with PE was associated with higher risk of VTE recurrence as PE (OR, 2.04; 95% CI: 1.11-3.72) and higher risk of fatal PE (OR, 7.77; 95% CI: 2.92-15.7). Conclusions: COPD patients presenting with PE have an increased risk for PE recurrences and fatal PE compared with those presenting with DVT alone. More efficient therapy is needed in this subtype of patients

Natural history of patients with venous thromboembolism and hereditary hemorrhagic telangiectasia. Findings from the RIETE registry

Background: Limited data exist about the clinical presentation, ideal therapy and outcomes of patients with hereditary hemorrhagic telangiectasia (HHT) who develop venous thromboembolism (VTE). Methods: We used the data in the RIETE Registry to assess the clinical characteristics, therapeutic approaches and clinical outcomes during the course of anticoagulant therapy in patients with HHT according to initial presentation as pulmonary embolism (PE) or deep venous thrombosis (DVT). Results: Of 51,375 patients with acute VTE enrolled in RIETE from February 2009 to January 2019, 23 (0.04%) had HHT: 14 (61%) initially presented with PE and 9 (39%) with DVT alone. Almost half (47.8%) of the patients with VTE had a risk factor for VTE. Most PE and DVT patients received low-molecular-weight heparin for initial (71 and 100%, respectively) and long-term therapy (54 and 67%, respectively). During anticoagulation for VTE, the rate of bleeding events (major 2, non-major 6) far outweighed the rate of VTE recurrences (recurrent DVT 1): 50.1 bleeds per 100 patient-years (95%CI: 21.6-98.7) vs. 6.26 recurrences (95%CI: 0.31-30.9; p = 0.020). One major and three non-major bleeding were epistaxis. No patient died of bleeding. One patient died shortly after being diagnosed with acute PE. Conclusions: During anticoagulation for VTE in HHT patients, there were more bleeding events than VTE recurrences. Most bleeding episodes were non-major epistaxis

Bemiparin in Oncology

An association between cancer and thrombosis has been recognized since 1865. It is considered to be a two-way association; cancer is associated with an increased risk of venous thromboembolism (VTE), whereas activation of the coagulation cascade enhances the proliferation, angiogenesis potential and metastasis of tumour cells. A sizeable proportion of VTE events in cancer patients undergoing major surgery occur after discharge from hospital, suggesting that extended thromboprophylaxis beyond the normal 7-10 days is warranted in these patients. Studies have demonstrated reduced incidences of VTE with extended thromboprophylaxis using low molecular weight heparins (LMWH) and guidelines recommend continuing thromboprophylaxis after discharge in patients who have undergone major cancer surgery, but the evidence is still considered limited and of low quality, and the recommendations have not been widely implemented in clinical practice. Extended prophylaxis with bemiparin was shown to reduce significantly the incidence of major VTE in patients undergoing major cancer surgery in the Cancer, Bemiparin and Surgery Evaluation study, providing further support for the routine use of extended thromboprophylaxis with LMWH in cancer patients. Heparins, particularly LMWH, in addition to preventing VTE in cancer patients, can block tumour cell growth, invasion, metastasis and angiogenesis. As with other LMWH, bemiparin and its ultra-low molecular weight derivative, RO-14, appear to be effective in preventing angiogenesis in in-vitro models. Recent clinical studies have demonstrated significant survival advantages when LMWH have been added to chemotherapy in cancer patients. This could be partly due, not only to the prevention of thromboembolic diseases in these patients, but also to 'direct' antineoplastic properties of LMWH. The survival benefits appeared greater in patients with limited cancer, especially limited small cell lung cancer. The Adjuvant Bemiparin in Small Cell Lung Cancer study is assessing the effect of bemiparin on survival in patients with limited small cell lung cancer, and although results are not yet available, preliminary data appear very promising

Efectividad clínica de la tomografía computarizada de 64 detectores en el estudio pre y postquirúrgico de pacientes candidatos y portadores de implantes cocleares respectivamente

Los implantes cocleares son unos dispositivos en forma de transductores que transforman las señales acústicas en señales eléctricas y estimulan al nervio coclear. Están indicados en aquellos pacientes que sufren una sordera neurosensorial uni o bilateral, profunda o total, y que no se benefician de una prótesis auditiva. En la valoración radiológica prequirúrgica es imperativa la realización de una TC y una RM del hueso temporal. La introducción de las TCMD de 64 detectores, ha aumentado la calidad de la imagen, al realizar secciones de hasta 0,625 mm, lo que permite un estudio detallado de la anatomía del oído, la realización de reconstrucciones multiplanares postprocesado 2D lineales, curvas, visiones endoscópicas virtuales y 3D. Actualmente existen implantes cocleares de diferentes longitudes. Son necesarias técnicas de imagen de alta resolución y sistemas de postprocesado que permitan hacer un estudio exhaustivo de la morfología de la cóclea y su longitud para poder seleccionar el implante más adecuado (forma, longitud y número de electrodos) para cada paciente y determinar la profundidad de inserción adecuada. La hipótesis de la presente tesis fue que la TCMD es capaz de medir la longitud de la cóclea de forma fiable con la finalidad de seleccionar el implante del tamaño más adecuado para cada paciente y conseguir los mejores resultados auditivos posibles. Los objetivos principales de la presente tesis fueron: estudiar la anatomía radiológica de las estructuras del hueso temporal implicadas en el proceso de implantación y validar el método de cálculo de la longitud de la cóclea y del implante a partir del estudio de oídos estándar de TCMD. Los objetivos secundarios fueron: determinar qué variables (anatómicas, epidemiológicas, radiológicas y/o quirúrgicas) se relacionan con los mejores resultados auditivos en los pacientes implantados y valorar cuál es el mejor sistema de postprocesado que permite la medición más exacta de la longitud de la cóclea y/o implante. Para ello se llevó a cabo un estudio observacional, retrospectivo, de los 50 pacientes a los que se ha colocado un implante coclear en el Hospital Universitari Germans Trias i Pujol desde enero 2007 hasta junio 2014 que cumplían todos los criterios de inclusión y ninguno de exclusión, mediante la recogida de variables anatomoradiológicas, epidemiológicas , quirúrgicas y funcionales. Los resultados obtenidos permitieron concluir que la variabilidad interindividual de las medidas de los distintas variables morfológicas de las cóclea justifica la necesidad de la selección de un implante de características, principalmente longitud, adecuadas para cada paciente de forma que se cubran los requerimientos auditivos de acuerdo a los mapas de distribución tonotópica de las frecuencias calculada por los ángulos de inserción y/o longitud de inserción estimada. La valoración postquirúrgica mediante TCMD de 64 detectores, usando la reconstrucción doble coronal oblicua y midmodiolar, es capaz de evaluar la posición, longitud y profundidad global de toda la guía portadora de electrodos así como de cada electrodo individualmente sin artefactos significativos lo que permite diseñar unas estrategias de programación de acuerdo a las necesidades auditivas y la sección de frecuencias específicas para cada paciente.Cochlear implants are transducers devices that transform the acoustic signals into electrical ones to stimulate the cochlear nerve. They are indicated in those patients that suffer a unilateral or bilateral, deep or severe, neurosensorial deafness, that do not benefit from an auditory prostheses. CT and a MR of the temporal bone are mandatory in the pre-surgical evaluation of cochlear implant candidates. The development of the 64 detector CT, has improved the image quality as it can perform sections up to 0,625 mm thick (allowing a detailed study of the anatomy of the ear), the achievement of 2D multiplanar linear or curve reconstructions, virtual endoscopic navigation or 3D images. Nowadays cochlear implants of different lengths are available. High resolution imaging techniques and image post processing software's are necessary to perform an accurate analysis of the cochlear morphology and its length, which allows to select the most suitable implant (in terms of form, length and number of electrodes) for each patient and to determine the depth of suitable insertion. The hypothesis of this dissertation was that the MDCT allows to measure the length of the cochlea accurately with the purpose of selecting the most suitable implant size for each patient in order to obtain the best possible auditory results. The main objectives of the present thesis were: to study the radiological anatomy of the structures of the temporal bone involved in the implantation process. To validate the calculation method of the cochlear and implant length from the standard ear MDCT studies. The secondary objectives were: to determine what variables (anatomical, epidemiologic, radiological and/or surgical) are related to the best auditory results in the implanted patients. To evaluate which is the best post processing software that allows the most accurate measurement of the cochlear and /or implant length. An observational , retrospective study was carry out ; 50 implanted patients, from January 2007 until June 2014, in Hospital Universitari Germans i Pujol that fulfilled all the inclusion criteria and none of exclusion, were selected. Anatomic, radiologic, epidemiologic, surgical and functional variables were collected. The obtained results allowed to conclude that the inter-individual measurement's variability of the different morphologic variables of the cochlea justifies the need of selecting an implant with the adequate characteristics, principally length, adapted for every patient so that the auditory requests are covered in accordance with the tonotopic distribution frequencies maps calculated by means of insertion angles and/or insertion length. The postsurgical evaluation by means of 64 CT, using the double coronal oblique and midmodiolar reconstructions, is capable of evaluating the position, length and global depth of the whole carrying guide of electrodes as well as of every electrode individually without significant gadgetry what allows to design a strategies of programming in accordance with the auditory needs and the section of specific frequencies for every patient

Ictus isquémico y enfermedad tromboembólica venosa sintomática en España: Análisis de las hospitalizaciones, costes asociados y diferencia con los ensayos clínicos

Aim. To analyze the characteristics and economic burden of the patients with ischaemic stroke and symptomatic venous thromboembolism (sVTE+) at the National Health System (NHS). We also compared NHS patients with those included in PREVAIL study. Subjects and methods. Patients 18 years older with ischemic stroke/sVTE + and sVTE - were compared. These patients are included in the Diagnostic Related Group (GDR)14 (Specific Cerebrovascular Disorder excluding transient ischemic attack) with a secondary diagnosis of sVTE [Diagnostic Category 415.x (Pulmonary Embolism) or 451.x and 453.x (Deep Vein Thrombosis)]. It was determined the hospital stays in excess and costs in patients with stroke/sVTE+ (2003 NHS standards). Results. There were 171 patients with stroke/sVTE+ and 33953 with stroke/sVTE-. Patients with stroke/ sVTE+ were older, women in higher proportion, with an increment of 6.8 days in mean stay [stroke/sVTE+: 17,5(CI95%:15,2-19,8); stroke/sVTE-: 10,7(CI95%: 10,6-10,8)]. Mortality was similar. There were 1433 stays in excess for stroke/sVTE+ with associat ed costs of 443799 � (0.4% additional costs to the GDR14 overall budget). The SNS population was older and with greater mortality than patients of PREVAIL study. Conclusions. Patients with stroke/sVTE+ have greater morbidity with longer stays and additional costs (nearly to 0,5 million euros/year). They are older and have increased mortality in comparison with clinical trials. Effective measures of thromboprophylaxis could minimize such complications.Objetivo. Analizar las características y costes económicos de pacientes hospitalizados en el Sistema Nacional de Salud (SNS) con ictus isquémico que presentaron una Enfermedad Tromboembólica Venosa sintomática (ETVs). Se comparó también dicha población con la incluida en el estudio PREVAIL.Sujetos y Método. Comparamos las características de los pacientes del SNS con ictus isquémico/ETVs+ con la de aquellos ictus/ETVs-. Para ello se estudiaron los pacientes >18 años incluidos en el Grupo Relacionado de Diagnóstico (GDR)14 (Trastorno Cerebrovascular Específico excluyendo AccidenteIsquémico Transitorio) con un diagnóstico secundario de ETVs [Categoría diagnóstica 415.x (Embolismo pulmonar) o 451.x o 453.x (Trombosis venosa profunda)]. Se determinaron el exceso de estancias en los ictus/ETVs+ y sus costes según los estándares del SNS (2003). Resultados. Se obtuvieron 171 pacientes con ictus/ETVs+ y 33953 con ictus/ETVs-. Los ictus/ETVs+ eran de mayor edad, en mayor proporción mujeres y con una prolongación de estancia media de 6,8 días [ictus/ETVs+: 17,5 (IC95%:5,2-19,8); ictus/ETVs-: 10,7(IC95%: 10,6-10,8)]. No existieron diferencias en mortalidad. Hubo 1433 estancias en exceso en ictus/ETVs+ con unos costes mínimos asociados de 443799 � (0,4% adicional al coste global del GDR14). La población del SNS presentó mayor edad y mortalidad que la del estudio PREVAIL. Conclusiones. Los pacientes con ictus/ETVs+ muestran mayor morbilidad traducida en alargamiento de las estancias y coste adicional anual cercano a 0,5 millones de euros. Presentan mayor edad y mortalidad que los ensayos clínicos que reclutan poblaciones similares. Es posible que medidas eficaces de tromboprofilaxis puedan minimizar tales complicaciones

A RIETE registry analysis of recurrent thromboembolism and hemorrhage in patients with catheter-related thrombosis

BACKGROUND: Few studies have investigated the treatment and the outcomes of patients with catheter-related thrombosis (CRT). METHODS: The RIETE registry (Registro Informatizado de Enfermedad TromboEmbólica [Computerized Registry of Patients with Venous Thromboembolism]) is a prospective international registry of consecutive patients with objectively confirmed venous thromboembolism (VTE). We analyzed the characteristics, treatment, and outcomes of patients with CRT. RESULTS: Of 558 patients with CRT, 45 (8%) presented with a pulmonary embolism (PE) concomitantly. More patients had central line-associated thrombosis compared with port systems, but catheter type did not influence the risk of presenting with a PE. Patients with only CRT were more often prescribed low-molecular-weight heparin for the duration of their anticoagulant treatment compared with patients presenting with concomitant PE. VTE recurrences and major bleeding events occurred frequently during treatment with anticoagulation (7 per 100 patient-years and 8.9 per 100 patient years, respectively). The rates of fatal PE recurrences (1.85 per 100 patient-years) and fatal bleeding (2.32 per 100 patient-years) were similar. Patients with an additional transient risk factor for VTE had the lowest risk for VTE recurrences (odds ratio [OR], 0.07; 90% confidence interval [CI], 0.01-0.45) compared with patients with CRT and no additional transient risk factors. PE at presentation increased the risk of recurrent thrombosis by 2.4 times. Renal insufficiency was also an independent predictor of recurrent thrombosis (OR, 3.93; 90% CI, 2.0-7.7). The odds of recurrent thrombosis was decreased by 77% in patients who received anticoagulation therapy for >90 days compared with patients with a shorter treatment (OR, 0.23; 90% CI, 0.1-0.56). CONCLUSIONS: Concomitant PE occurs less frequently in CRT than lower extremity deep venous thrombosis, but it is associated with a worse outcome. CRT occurs in high-risk patients, and duration of anticoagulation must be predicated on balancing these risks.publisher: Elsevier articletitle: A RIETE registry analysis of recurrent thromboembolism and hemorrhage in patients with catheter-related thrombosis journaltitle: Journal of Vascular Surgery: Venous and Lymphatic Disorders articlelink: http://dx.doi.org/10.1016/j.jvsv.2015.03.002 content_type: article copyright: Copyright © 2015 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.status: publishe