Randomised controlled trial of a prognostic assessment and management pathway to reduce the length of hospital stay in normotensive patients with acute pulmonary embolism

[Background] The length of hospital stay (LOS) for acute pulmonary embolism (PE) varies considerably. Whether the upfront use of a PE prognostic assessment and management pathway is effective in reducing the LOS remains unknown.[Methods] We conducted a randomised controlled trial of adults hospitalised for acute PE: patients were assigned either to a prognostic assessment and management pathway involving risk stratification followed by predefined criteria for mobilisation and discharge (intervention group) or to usual care (control group). The primary end-point was LOS. The secondary end-points were the cost of prognostic tests and of hospitalisation, and 30-day clinical outcomes.[Results] Of 500 patients who underwent randomisation, 498 were included in the modified intention-to-treat analysis. The median LOS was 4.0 days (interquartile range (IQR) 3.7–4.2 days) in the intervention group and 6.1 days (IQR 5.7–6.5 days) in the control group (p<0.001). The mean total cost of prognostic tests was EUR 174.76 in the intervention group, compared with EUR 233.12 in the control group (mean difference EUR −58.37, 95% CI EUR −84.34­ to −32.40). The mean total hospitalisation cost per patient was EUR 2085.66 in the intervention group, compared with EUR 3232.97 in the control group (mean difference EUR −1147.31, 95% CI EUR −1414.97­ to −879.65). No significant differences were observed in 30-day readmission (4.0% versus 4.8%), all-cause mortality (2.4% versus 2.0%) or PE-related mortality (0.8% versus 1.2%) rates.[Conclusions] The use of a prognostic assessment and management pathway was effective in reducing the LOS for acute PE.Peer reviewe

Risk Of Recurrence After Withdrawal Of Anticoagulation In Patients With Unprovoked Venous Thromboembolism: External Validation Of The Vienna Nomogram And The Dash Prediction Score

[ES] Introducción: Las escalas predictivas de recurrencias de ETV son útiles para decidir la duración del tratamiento anticoagulante. Aunque hay varias escalas, desconocemos la aplicabilidad de las mismas en nuestro medio. Por ello nos planteamos validar el modelo predictivo DASH y el nomograma de Viena a 12 meses.-- Métodos: Estudio retrospectivo de pacientes consecutivos no seleccionados con ETV no provocada desde 2006 hasta 2014. Comparamos la capacidad de predecir recurrencias de ETV de la escala DASH y el nomograma de Viena. La validación se realizó estratificando a los pacientes como de bajo o alto riesgo, según cada escala (discriminación) y comparando las recurrencias observadas frente a las esperadas (calibración).-- Resultados: De 353 pacientes evaluados, se analizaron 195, con una edad media de 53,5+/-19 años. Hubo 21 recurrencias a 1 año (10,8%, IC95%: 6,8-16%). Según la escala DASH, fueron catalogados de bajo riesgo el 42%, observando ETV recurrente en el grupo de bajo fue del 4,9% (IC95%: 1,3-12%) vs. el grupo de alto riesgo en que fue del 15% (IC95%: 9-23%) (p<0,05). Según el nomograma de Viena, fueron catalogados de bajo riesgo el 30%, observando ETV recurrente en el grupo de bajo vs. alto riesgo en el 4,2% (IC95%: 0,5-14%) vs. 16,2% (IC95%: 9,9-24,4%) (p<0,05).-- Conclusiones: Nuestro estudio valida la escala DASH y el nomograma de Viena en nuestra población. El modelo predictivo DASH sería el más aconsejable, tanto por su sencillez como por la capacidad de identificar a más pacientes de bajo riesgo frente al nomograma de Viena (42% vs. 30%).[EN ] Introduction: Scales for predicting venous thromboembolism (VTE) recurrence are useful for deciding the duration of the anticoagulant treatment. Although there are several scales, the most appropriate for our setting has not been identified. For this reason, we aimed to validate the DASH prediction score and the Vienna nomogram at 12 months.-- Methods: This was a retrospective study of unselected consecutive VTE patients seen between 2006 and 2014. We compared the ability of the DASH score and the Vienna nomogram to predict recurrences of VTE. The validation was performed by stratifying patients as low-risk or high-risk, according to each scale (discrimination) and comparing the observed recurrence with the expected rate (calibration).-- Results: Of 353 patients evaluated, 195 were analyzed, with an average age of 53.5 ± 19 years. There were 21 recurrences in 1 year (10.8%, 95% CI: 6.8%-16%). According to the DASH score, 42% were classified as low risk, and the rate of VTE recurrence in this group was 4.9% (95% CI: 1.3%-12%) vs. the high-risk group that was 15% (95% CI: 9%-23%) (p <.05). According to the Vienna nomogram, 30% were classified as low risk, and the rate of VTE recurrence in the low risk group vs. the high risk group was 4.2% (95% CI:0.5%-14%) vs. 16.2% (95% CI: 9.9%-24.4%) (p <.05).-- Conclusions: Our study validates the DASH score and the Vienna nomogram in our population. The DASH prediction score may be the most advisable, both because of its simplicity and its ability to identify more low-risk patients than the Vienna nomogram (42% vs. 30%).Peer reviewe

Severe Asthma Standard-of-Care Background Medication Reduction With Benralizumab: ANDHI in Practice Substudy

Background: The phase IIIb, randomized, parallel-group, placebo-controlled ANDHI double-blind (DB) study extended understanding of the efficacy of benralizumab for patients with severe eosinophilic asthma. Patients from ANDHI DB could join the 56-week ANDHI in Practice (IP) single-arm, open-label extension substudy. Objective: Assess potential for standard-of-care background medication reductions while maintaining asthma control with benralizumab. Methods: Following ANDHI DB completion, eligible adults were enrolled in ANDHI IP. After an 8-week run-in with benralizumab, there were 5 visits to potentially reduce background asthma medications for patients achieving and maintaining protocol-defined asthma control with benralizumab. Main outcome measures for non-oral corticosteroid (OCS)-dependent patients were the proportions with at least 1 background medication reduction (ie, lower inhaled corticosteroid dose, background medication discontinuation) and the number of adapted Global Initiative for Asthma (GINA) step reductions at end of treatment (EOT). Main outcomes for OCS-dependent patients were reductions in daily OCS dosage and proportion achieving OCS dosage of 5 mg or lower at EOT. Results: For non-OCS-dependent patients, 53.3% (n = 208 of 390) achieved at least 1 background medication reduction, increasing to 72.6% (n = 130 of 179) for patients who maintained protocol-defined asthma control at EOT. A total of 41.9% (n = 163 of 389) achieved at least 1 adapted GINA step reduction, increasing to 61.8% (n = 110 of 178) for patients with protocol-defined EOT asthma control. At ANDHI IP baseline, OCS dosages were 5 mg or lower for 40.4% (n = 40 of 99) of OCS-dependent patients. Of OCS-dependent patients, 50.5% (n = 50 of 99) eliminated OCS and 74.7% (n = 74 of 99) achieved dosages of 5 mg or lower at EOT. Conclusions: These findings demonstrate benralizumab's ability to improve asthma control, thereby allowing background medication reduction

Evolución del manejo clínico de pacientes diagnosticados de trombosis venosa profunda aguda sintomática: 2001 a 2014.

Background: A comprehensive evaluation of temporal trends in the treatment of patients who have deep vein thrombosis (DVT) may assist with identification of modifiable factors that contribute to short-term outcomes. Methods: We assessed temporal trends in length of hospital stay and use of pharmacological and interventional therapies among 26,695 adults with DVT enrolled in the RIETE registry between 2001 and 2014. We also examined temporal trends in risk-adjusted rates of all-cause, PE-related, and bleedingrelated death to 30-days after diagnosis. Results: The mean length of hospital stay decreased from 9.0 days in 2001- 2005 to 7.6 days in 2010-2014 (P <0.01). For initial DVT treatment, the use of low-molecular weight-heparin decreased from 98% to 90% (P <0.01). Direct oral anticoagulants use increased from 0.5% in 2010 to 13.4% in 2014 (P <0.001). Risk-adjusted rates of 30-day all-cause mortality decreased from 3.9% in 2001-2005 to 2.7% in 2010-2014 (adjusted rate ratio per year, 0.84; 95% confidence interval [CI], 0.74 to 0.96; P <0.01). VTE-related mortality showed a non-statistically significant downward trend (adjusted rate ratio per year, 0.70; 95% CI, 0.44 to 1.10; P =0.13), whereas 30-day bleeding-related mortality significantly decreased from 0.5% in 2001-2005 to 0.1% in 2010- 2014 (adjusted rate ratio per year, 0.55; 95% CI, 0.40 to 0.77; P <0.01). Conclusions: This international registry-based temporal analysis identified reductions in length of stay for adults hospitalized for DVT. The study also found a decreasing trend in adjusted rates of all-cause and bleeding-related mortality

Adjusted D-dimer cutoff levels to rule out pulmonary embolism in patients hospitalized for COPD exacerbation: results from the SLICE trial

[Background] For patients with suspected pulmonary embolism (PE), age- or clinically-adjusted D-dimer threshold level can be used to define a negative test that safely excludes PE and reduces the use of imaging. However, the utility of this approach in patients hospitalized for chronic obstructive pulmonary disease (COPD) exacerbation is undefined.[Methods] We ran an analysis of the patients hospitalized for COPD exacerbation and randomized to the intervention in the SLICE trial. Using the conventional strategy as the reference, we compared the proportion of patients with a negative D-dimer result, and the negative predictive value and sensitivity of three D-dimer threshold strategies for initial PE or subsequent diagnosis of venous thromboembolism (VTE): the age-adjusted strategy, the Wells-adjusted strategy, and the YEARS-adjusted strategy.[Results] We included 368 patients. Using a conventional threshold, 182 (49.5%) patients had negative D-dimer values, of whom 1 (0.6%) had PE (sensitivity, 94.1%). The use of an age-adjusted threshold increased the number of patients in whom PE could be excluded from 182 to 233 patients (63.3%), and the proportion of false-negative findings increased from 0.5% to 1.7% (sensitivity, 76.5%). With the use of the Wells or YEARS strategies, 64.4% and 71.5% had negative values, and the proportion of false-negative findings was 2.5% (sensitivity, 64.7%) and 2.7% (sensitivity, 58.8%), respectively.[Conclusions] In patients hospitalized for COPD exacerbation, compared with the conventional strategy, age- or clinically-adjusted strategies of D-dimer interpretation were associated with a larger proportion of patients in whom PE was ruled out with a higher failure rate.[Trial Registration] ClinicalTrials.gov number: NCT02238639.This work was supported by grants from the Instituto de Salud Carlos III (PI14/00400), Chest Foundation, Sociedad Española de Neumología y Cirugía Torácica (SEPAR), Neumosur, and Daiichi Sankyo.Peer reviewe

Características clínicas y pronóstico de la tromboembolia pulmonar secundaria al síndrome de clase turista

[Objective] Clinical presentation and short-term prognosis of patients with travel-associated acute pulmonary embolism (PE) (i.e., economy class syndrome [ECS]) is not well understood.[Methods] In this retrospective cohort study of patients with acute PE identified from a single center registry, we assessed the clinical presentation and the association between ECS and the outcomes of all-cause mortality, PE-related mortality, nonfatal venous thromboembolism and nonfatal major bleeding rates through 30 days after initiation of PE treatment.[Results] Of the 2,333 patients with acute symptomatic PE, 124 (5.3%; 95% confidence interval, 4.4-6.3%) had ECS. Patients with ECS were younger and had fewer comorbid diseases (recent bleeding, chronic obstructive pulmonary disease, congestive heart failure), but they presented with more signs of clinical severity (syncope [48% vs. 14%; P < .001], tachycardia [37% vs. 21%; P < .001], right ventricular dysfunction [31% vs. 19%; P < .01] and myocardial injury [57% vs. 28%; P < .001]) compared to those without ECS. Regression analyses showed a significantly lower risk of all-cause mortality for patients with ECS compared to patients without ECS (1.6% vs. 9.6%; P < .01). We did not detect a difference in PE-related mortality at 30 days between those with and those without ECS (0.8% vs. 3.1%; P = .18).[Conclusions] PE patients with ECS are younger and have fewer comorbid diseases compared to those without ECS. Though they present with more signs of clinical severity, their short-term prognosis is excellent.[Objetivo] No se conocen suficientemente las características clínicas y el pronóstico de los pacientes con tromboembolia de pulmón (TEP) aguda sintomática asociada a los viajes prolongados (síndrome de clase turista [SCT]).[Métodos] Se analizaron retrospectivamente las características basales de los pacientes con TEP aguda y se estratificaron según el factor de riesgo desencadenante. Se determinaron la mortalidad por todas las causas, la mortalidad por la propia TEP, las recurrencias trombóticas no fatales y los sangrados mayores no fatales durante los primeros 30 días de seguimiento.[Resultados] De los 2.333 pacientes incluidos, un total de 124 (5,3%; intervalo de confianza del 95%: 4,4-6,3) fueron diagnosticados de TEP secundaria a SCT. Estos pacientes fueron más jóvenes, presentaron menos frecuentemente comorbilidad y más frecuentemente síncope (48% vs. 14%; p < 0,001), taquicardia (37% vs. 21%; p < 0,001), disfunción de ventrículo derecho (VD) (31% vs. 19%; p < 0,01) y daño miocárdico (57% vs. 28%; p < 0,001) que los demás pacientes con TEP. La mortalidad por todas las causas a 30 días fue significativamente menor para los pacientes con TEP secundaria a SCT (1,6% vs. 9,6%; p < 0,01). La mortalidad a 30 días por TEP no fue diferente entre los dos grupos de pacientes (0,8% vs. 3,1%; p = 0,18).[Conclusiones] Los pacientes con TEP y SCT son más jóvenes y tienen menos comorbilidad que los demás pacientes con TEP. Aunque se presentan más frecuentemente con disfunción de VD y daño miocárdico, el pronóstico a corto plazo es excelente.Peer reviewe

La expresión oral y escrita, objetivo fundamental de calidad de la enseñanza

Convocatoria de Proyectos de innovación de Extremadura 2017/2018Se describe un proyecto llevado a cabo en el IES Miguel Durán (Azuaga, Badajoz) desarrollado dentro del Sistema de Gestión de Calidad del centro, que tenía como objetivo principal que los alumnos adquirieran las competencias necesarias para una correcta expresión oral y escrita (mejora de la competencia informacional y las competencias comunicativa e idiomática). Para conseguir el objetivo se organizaron distintas actividades promovidas por el Grupo de Trabajo de la Biblioteca del centro: fomento de la lectura, feria del libro, Día de la poesía, diversas actividades de lectura en la biblioteca, club de lectura con libros digitales, etc., así como la realización de otras actividades y la elaboración de materiales por parte de los distintos departamentos del instituto como: exposiciones de los alumnos ante el aula, lectura en distintos soportes, realización de trabajos de investigación, actividades de enriquecimiento del vocabulario, etc.ExtremaduraES