[Eight cases of rheumatism associated with cancer]. / Ocho casos de reumatismos asociados a cáncer.

OBJECTIVE: To study the rheumatic diseases associated with cancer diagnosed in an Internal Medicine Service. MATERIAL AND METHODS: A retrospective and descriptive study of the patients diagnosed during 1992-2000 of different rheumatic diseases associated with cancer. RESULTS: During a period of 9 years we identified 8 cases of paraneoplastic rheumatisms about a total of 2,127 patient, representing an incidence of 3.7@1000, with a predominance in males. The consultation motive in all them was the clinic of the rheumatic disease. Six of the eight neoplasias were adenocarcinomas. CONCLUSIONS: Though the paraneoplastic rheumatisms are not frequent, it is necessary take into account their existence when exist antecedent of neoplasia, in patient male and when the clinical course or response to the treatment is atypical.

Ocho casos de reumatismos asociados a cáncer / Eight cases of rheumatisms associated with cancer

Objetivo: Estudiar las enfermedades reumáticas asociadas a cáncer diagnosticadas en un Servicio de Medicina Interna. Material y métodos: Estudio descriptivo retrospectivo de los pacientes diagnosticados durante 1992 - 2000 de distintas enfermedades reumáticas asociadas a cáncer. Resultados: De un total de 2127 pacientes se identificaron 8 casos de reumatismos paraneoplásicos en un periodo de tiempo de nueve años con una incidencia de 3,7 , y un predominio de varones. El motivo de consulta en todos ellos fue la clínica de la enfermedad reumática. Seis de las ocho neoplasias fueron adenocarcinomas. Conclusiones: Aunque los reumatismos paraneoplásicos no son frecuentes, es necesario tener en cuenta su existencia cuando existan antecedentes de neoplasias, en pacientes varones y cuando el curso clínico o la respuesta al tratamiento es atípica (AU)

C-reactive protein as a predictor of improvement and readmission in heart failure.

OBJECTIVES: Only recently, new risk factors to explain atherosclerotic disease have been identified. One of the most important clinical manifestations of atherosclerosis is heart failure. Our study was aimed at investigating C-reactive protein (CRP), a marker of systemic inflammation, in the context of heart failure, and to determine its usefulness in predicting the need for readmission in patients with heart failure and their degree of improvement. DESIGN: We studied patients admitted to our hospital due to heart failure, independent of the cause. CRP levels were measured with a sensitive standard assay on a Nephelometer analyser. Patients were classified on admission and discharge following New York Heart Association (NYHA) functional criteria; left ejection fraction was also determined by transthoracic echocardiography. Patients presenting clear sources of infection or inflammatory disease were excluded. Our control group consisted of patients admitted for syncope. Each patient was followed up through a computer system controlling admissions to and discharge from the hospital, for a period of 18 months after initial admission. End points considered were NYHA functional class on discharge, readmission and death. RESULTS: We studied prospectively 76 patients with a mean age of 73.5+/-11 [95% confidence interval (CI) 71.2-75.8]; 44 were male (58%) and 32 female (42%). The mean CRP level in patients with heart failure was 3.94+/-5.87 (95% CI, 1.26-7.60), while in 15 patients with syncope it was 0.84+/-1.95 (95% CI, 0.96-2.94) (P=0.0007). The principal causes of heart failure included dilated cardiomyopathy due to coronary arterial disease (30%), valvular disease (28%) and heart failure secondary to hypertension (25%). The mean left ejection fraction adequately measured in 72 (95%) patients was 50.41+/-9.88 (95% CI, 41.20-59.65). We observed a trend of higher CRP levels in relation to ejection fractions below 35%: 7.50+/-9.88 vs. 3.75+/-4.57, (P=0.09). Our results showed that on discharge CRP levels increased in relation to NYHA class: I: 0.74+/-0.69; II: 3.78+/-3.76; III: 7.4+/-8.65; IV: 12.2+/-15.27 (P<0.05). On follow-up of each patient for 18 months, 32 (43%) were readmitted due to deterioration of their heart condition. For patients who were readmitted, those presenting CRP levels >0.9 mg/dl were identified as candidates for earlier hospitalisation than those with levels below 0.9 mg/dl (P=0.02) RR=1.43. In logistic-regression analysis the only group of tested variables predicting readmission were levels of CRP, NYHA class and plasmatic K on discharge and left ventricle ejection fraction. Analysis of covariates yields CRP levels as being an independent predictor of readmission. CONCLUSIONS: An inflammatory response is present in deteriorating heart failure. We observed higher CRP levels in patients with higher NYHA functional class, perhaps signalling a poor therapeutic response. Higher CRP levels were also related to higher rates of readmission and mortality and it could be an independent marker of improvement and readmission in heart failure.

[Hospital readmission in internal medicine]. / Reingreso hospitalario en Medicina Interna.

BACKGROUND: The readmission rate could be a valuable tool as measurement of hospital quality. Readmissions are due to several factors: clinical, hospital related and patient related. We analyze readmission to internal medicine in a hospital of third level. MATERIAL AND METHODS: During 11 months in 1988 we counted all readmissions (R) defined as every previous admission occurred in a span of five years into an area of internal medicine composed by 8 beds. We counted number of readmssions, time from the last readmission, living area (city vs country), sort of primary care physician (GP vs family care specialist), living way (single, with family, institution, homeless). Precipitating factors were observed as well as diseases causing it. R were classified as R related (RR) when readmission was provoked by the same pathological condition or a complication. Multi-readmission (MR), those R caused by the same disease process and treated in different areas and services of the hospital. Avoidable R (AR), those R which did not fullfil AEP criteria. Early readmission (ER) those R occurring before 30 days after last discharge. RESULTS: Three hundred and eleven patients (mean age 67.93 (SD 15.51), males 64%, mean length of stay 7.75 (SD 4.35), 93% admitted from emergency yard, mortality rate 3.5%) were included. R were 111 (35.5%), RR 83 (26 and 75% of RR), MR 68 (82% of RR), ER 33 (39.7% of RR) and AR 16 (19.2% of RR) patients. The most frequent diseases were heart failure and chronic respiratory diseases. Main causes of R were worsening of chronic disease 41 (37%), non-appropriale ambulatory management 24 (22%) erroneous diagnosis 8 (7%), iatrogenic effect 7 (6%), new disease 29 (26%) and others 2 (2%). Mortality rate in R patients was 7.2% (confidence interval 95% 2 to 9%). Number of readmissions were 3.22 (SD 2.25) and time to readmission 8.99 (SD 11.96) months. Living in city (p < 0.05) and to be cared by family physician (p < 0.01) both were factors accelerating readmission. Patients with RR had a higher number of readmissions (3.55 SD 2.23 p < 0.001) and they occurred sooner (8.03 SD 11.85) (p < 0.01). There was a trend to higher readmission rate in female (p 0.052). Fifty-seven percent of RR patients did not have consultation with primary care physician (p < 0.05) (confidence interval 95% 3 to 39%). Consultation with primary care yielded a delay in readmission of 5 months (p < 0.01). Patients with MR had an increased number of readmissions (p < 0.01). Associated factors were iatrogenic effect (p < 0.05), non-appropriate ambulatory management (p < 0.001) and worsening chronic disease (p < 0.001). Patients with ER were readmitted 0.45 (SD 0.30) months after the last discharge and they had a higher mortality rate (p < 0.05). Patients with AR had a mean length of stay shorter (p < 0.05), a trend to higher readmission rate (p = 0.06) and sooner (p = 0.08) with a null mortality rate (p < 0.01). As risk factors for RR in logistic regression were identified MR, AR, ER and causes of readmission consisting in worsening of chronic disease, non-appropriate ambulatory management, erroneous diagnosis and iatrogenic effect. CONCLUSIONS: Our readmission rate is 26%, chronic respiratory diseases and heart failure being the main diseases. Over 39% of causes of readmission could be preventable and there is a facilitation phenomenon in number and time to readmission caused by previous readmissions. Risk factors for readmission in internal medicine are multi-readmission, early and avoidable readmission and as specific causes worsening of chronic disease, non-appropriate ambulatory management, erroneous diagnosis and iatrogenic effect.

Reingreso hospitalario en Medicina Interna / Readmission in Internal Medicine

Fundamento: La tasa de reingreso puede ser un índice de calidad asistencial, estando influenciada por múltiples factores (clínicos, derivados del hospital y del propio paciente). Analizamos el reingreso en un área clínica de medicina interna de un hospital de tercer nivel. Material y métodos: Durante 11 meses de 1998 registramos, según un cuestionario estructurado, los reingresos (R) (ingreso en los últimos 5 años) de todos los pacientes ingresados en un área clínica de 8 camas, contabilizando número de ingresos, tiempo hasta el reingreso, área de procedencia (rural, urbana), médico de atención primaria (médico general, especialista en medicina de familia), modo de vida (sólo, familia, residencia, sin techo). Observamos la causa desencadenante del R y la enfermedad causante. Se clasifican como reingreso relacionado (RR) (reingreso por la misma enfermedad o complicación de la misma), multingreso (MR) (reingreso de una misma patología atendida en diferentes servicios del hospital), reingreso evitable (RE) (aquel reingreso que no cumple criterios AEP), y reingreso temprano (RT) (reingreso antes de los 30 dÍas tras el alta). Resultados: De un total de 312 pacientes (edad media 67,93 ± 15,5, 64 por ciento varones, estancia media 7,75 ± 4,35 días, ingresos urgente 93 por ciento, tasa de mortalidad 3,52 por ciento). Fueron R 111 (35,5 por ciento), RR 83 (26 por ciento del total y 75 por ciento de R), MR 68 (61,2 de R y 82 por ciento de RR), RT 33 (39,7 por ciento de RR) y 16 RE (19 por ciento de RR). No hubo diferencias en edades, sexo ni estancia media. Las enfermedades más frecuentes fueron la insuficiencia cardiaca y las enfermedades respiratorias crónicas. Las causas del R fueron empeoramiento de trastorno crónico 41 (37 por ciento), manejo inadecuado ambulatorio 24 (22 por ciento), mal diagnóstico previo 8 (7 por ciento), efecto tóxico-iatrogenia 7 (6 por ciento), nueva enfermedad 29 (36 por ciento), otros 2 (2 por ciento). El número de ingresos previos era de 3,22 ± 2,25 y el tiempo hasta el reingreso de 8,99 ± 11,96 meses. La tasa de mortalidad intrahospitalaria de los R fue de 7,2 por ciento (p<0,05) (intervalo de confianza al 95 por ciento de 2 a 9 por ciento). Vivir en zona urbana (p<0,05) y tener un médico de familia como médico de atención primaria (p<0,01) fueron factores aceleradores del R. Los pacientes RR presentaban mayor número de ingresos previos (3,53 ± 2,23) (p<0,001) y reingresaron antes (8,03 ± 11,85) (p<0,01) con una tendencia mayor al reingreso en las mujeres (p=0,052). No consultaron con atención primaria 57 por ciento de los pacientes (p<0,05) (intervalo de confianza a 95 por ciento 3 a 39 por ciento). la consulta con atención primaria supuso un retardo en el reingreso de 5 meses (p<0,01) y el manejo ambulatorio inadecuado se asoció a aceleración en el reingreso (p<0,05). Los pacientes MR tenían mayor número de ingresos previos (p<0,001) y eran factores favorecedores la toxicidad-iatrogenia (p<0,05), manejo ambulatorio inadecuado p<0,001) y empeoramiento del trastorno crónico (p<0,001). Los pacientes con RT presentaron mayor mortalidad intrahospitalaria (p<0,05). Los pacientes con RE tuvieron una estancia media más corta (p<0,05), tendencia a mayor numero de ingresos (p=0,06) y éstos a ocurrir antes (p=0,08) con una mortalidad nula (p<0,01). En regresión logística los factores de riesgo asociados a RR fueron ser MR, RT, tener un RE y como causa de R iatrogenia, manejo ambulatorio inadecuado, empeoramiento de enfermedad crónica o mal diagnostico previo. Conclusiones: La tasa de reingreso verdadero es de 26 por ciento, siendo la insuficiencia cardiaca y las enfermedades respiratorias crónicas las principales enfermedades, con tendencia a ocurrir más en mujeres. Hasta 39 por ciento de los reingresos pueden ser prevenibles. Existe un fenómeno de facilitación en el número y en el tiempo de reingreso con bajo índice de consulta con atención primaria. Los factores de riesgo asociados a reingreso verdadero son el multingreso, el reingreso temprano, el tener un reingreso evitable y tener como causa de reingreso iatrogenia, manejo ambulatorio inadecuado, empeoramiento de enfermedad crónica y diagnóstico previo erróneo (AU)