Prophylaxis in nonorthopaedic surgery. / Profilaxis en cirugía no ortopédica.

Surgery increases the risk (by 20-fold) of venous thromboembolism (VTE), but there are prophylaxis methods (mechanical, pharmaceutical or combined) that safely reduce the incidence rate of VTE. The administration of prophylaxis requires a prior assessment of the risks associated with the patient and with the type of surgery. The Caprini and Rogers scales classify patients into four VTE risk categories (very low, low, moderate and high). In pharmacological prophylaxis, the risk of bleeding should also be assessed. At this time, the recommendation is to administer prophylaxis to all patients: mechanical prophylaxis for low, moderate or high risk with contraindications for the administration of heparin; combined with heparin for very high risk; and with drugs such as low-molecular-weight heparin, unfractionated heparin and fondaparinux for moderate to high risk. These measurements should be kept until full ambulation, discharge, or at least seven days (for major oncologic and bariatric surgery, maintain for four weeks).

Anticoagulant therapy duration. In favour of short-term courses. / Duración del tratamiento anticoagulante. A favor de plazos cortos.

In recent years, we have observed a tendency to extend anticoagulant therapy for patients with venous thromboembolism disease (VTE). This practice exposes patients to a greater risk of severe and fatal haemorrhage, which, in certain conditions, outweighs the benefits related to the reduction in disease recurrence. This review examines the evidence in favour of reducing anticoagulant therapy as much as possible, especially for patients with VTE "caused" by temporary risk factors, with isolated deep vein thrombosis and with unprovoked VTE and a high risk of haemorrhage.

[Arterial pre-hypertension in young adults]. / Prehipertensión arterial en adultos jóvenes.

BACKGROUND AND OBJECTIVES: Prehypertension is a new category of blood pressure and is considered a cardiovascular risk factor. This study has aimed to estimate the prevalence of prehypertension and the association between prehypertension and other vascular risk factors in young adults. MATERIAL AND METHODS: First year university students from all areas of study in the University of Cuenca were invited to participate. Prehypertension was defined as systolic blood pressure between 120-139 mmHg and/or diastolic blood pressure between 80-89 mmHg. Anthropometric, lipid and metabolic variables were measures. The presence of metabolic syndrome was evaluated and quantified based on the sum of the standardized scores of the waist circumference, the triglyceride/c-HDL ratio, mean blood pressure and R-HOMA (Index of insulin resistance to glucose lowering effect). RESULTS: A total of 545 university students were included in the analysis (mean age 20.36±3.9 years, 74.7% women). Prehypertension prevalence was 24% (95% CI: 21-27%), (56.5% in men and 13% in women). The condition of prehypertension was directly associated to the body mass index (OR: 1.194; 95% CI: 1.124-1.311), insulin resistance (R-HOMA, OR: 2.638; 95% CI: 1.263-4.926) and to the index or quantification of the severity of the metabolic syndrome (OR: 4-868; 95% CI: 3-846-8-328). On the other hand, HDL-c showed an inverse relationship with prehypertension (OR: 0.981; 95% CI: 0.957-0.993). CONCLUSIONS: One out of every four young adults presents prehypertension. This condition is associated to well-established vascular risk factors.

[Acute-phase reactants and markers of inflammation in venous thromboembolic disease: correlation with clinical and evolution parameters]. / Reactantes de fase aguda y marcadores de inflamación en pacientes con enfermedad tromboembólica venosa: correlación con parámetros clínicos y evolutivos.

OBJECTIVE: To asses the association of acute reactants and interleukin 6 and 8 (IL-6 & IL-8) at diagnosis of venous thromboembolic disease (VTD) and clinical outcome. METHODS: 100 patients were diagnosed of VTD by image tests. Acute reactants (C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), fibrinogen), D-dimer and IL-6 and IL-8 we measured at the moment of diagnosis. We made a 12 month follow-up of these patients to notice any clinical evolution outcomes (recurrences, bleeding, post-phlebitic syndrome, death). RESULTS: IL-6 was increased in 9 patients and IL-8 in 3. The risk factors, time to diagnosis and pulmonary embolism rate were similar in both interleukin groups (normal and high levels). Fibrinogen levels were significantly increased in high IL-6 group (585 +/- 179 vs. 485 +/- 154 mgr/dl; p = 0.05). During follow-up there were 5 deaths, 3 recurrences, 11 bleedings and 43 postphlebitic syndromes. Normal ESR level was associated to postphlebitic syndrome (17.8 +/- 14.5 vs. 31.4 +/- 27.4 mm/1st h; p = 0.016). Patients who had high levels of IL-6 had worse survival than these with normal levels (p = 0.015). CONCLUSION: IL-6, ESR, and CPR at diagnosis of VTD could be useful to identified patients with higher risks of death and postphlebitic syndrome during the first year after diagnosis.

[The postpericardiotomy syndrome following endovenous pacemaker insertion: case report and review]. / El síndrome postpericardiotomía tras la implantación de marcapasos: presentación de un caso y revisión.

We report a postpericardiotomy syndrome (PS) following the implantation of endovenous pacemaker in a 78-year-old woman. Ten more single cases were reported in the medical literature since 1975. The infrequent single reports and the high complication rate are in contrast with the 4,6% occurrence and the benign course of acute pericarditis following the insertion of endovenous pacemakers in 126 consecutive patients. This sort of PS is probably underdiagnosed and the cases reported represent the more severe clinical presentations. A higher suspicion index would improve the diagnosis and management.

Brain HIV burden and length of survival after AIDS diagnosis.

Patients with AIDS in the late stages of disease can develop dementia. Previous studies have suggested HIV encephalitis is the pathological substrate of HIV-associated dementia. We hypothesized that patients who survive longer after the initial diagnosis of AIDS would have a higher brain HIV burden and consequently manifest dementia. We examined the relationship between length of survival after AIDS diagnosis and the presence of HIV encephalitis or HIV-associated dementia. We studied retrospectively the following parameters in 74 consecutive AIDS autopsies: length of survival after AIDS diagnosis, clinical diagnosis of dementia, and neuropathologic findings (including HIV burden assessment). Multinucleated giant cells (MNGC) were identified in 20% of the brains studied. HIV gp41 was detected by immunocytochemistry in 54%, approximately half of which had abundant HIV burden. Brains from all 4 patients who were clinically diagnosed with dementia and had no opportunistic neuropathologic changes contained MNGC and abundant HIV burden. Survival after AIDS diagnosis was significantly longer in patients with MNGC (p = 0.03) or abundant HIV burden (p = 0.02). A trend toward longer survival after AIDS diagnosis was apparent in patients with dementia, but did not reach statistical significance. These findings suggest that prolonged survival with immunosuppression may be a prerequisite for the development of HIV encephalitis.

Factors associated with the development of candidemia and candidemia-related death among liver transplant recipients.

OBJECTIVE: The authors' objective was to identify factors associated with candidemia and candidemia-related death among adult liver transplant recipients. SUMMARY BACKGROUND DATA: Invasive candidiasis is the most common severe fungal infection occurring after liver transplantation and is associated with high morbidity and mortality rates. Although candidemia is not always found during invasive candidiasis, it has been considered as an indicator of invasive candidiasis in immunocompromised patients. METHODS: A time-matched case-control study of 26 patients with candidemia, which was defined as the isolation of Candida from at least one blood culture, and 52 control patients without candidemia was reported. Two control patients were matched with each case patient regarding time of transplantation and duration of follow-up. RESULTS: Between December 1985 and December 1992, candidemia developed in 1.4% of adult liver transplant recipients a median of 25 days after transplantation (range, 2-1690 days). The overall mortality rate among patients with candidemia was 81%, and 71% of these deaths were related to candidemia. Conditional logistic regression analysis was used to identify factors associated with candidemia, which were 1) hyperglycemia treated with insulin up to 2 weeks before candidemia (odds ratio [OR], 16.15; p = 0.002), and 2) exposure to more than three different intravenous antibiotics before development of candidemia (OR, 11.15; p = 0.005). The variables predictive of death related to candidemia were abdominal surgery performed up to 1 week before candidemia (relative risk [RR], 7.25; p = 0.02), high white blood cell count (RR, 1.10; p = 0.01), lower platelet count (RR, 0.99; p = 0.02), and elevated AST with candidemia (RR, 1.001; p = 0.01). CONCLUSIONS: Hyperglycemia that requires insulin and exposure to more than three antibiotics are the factors associated with the development of candidemia in liver transplant recipients. When candidemia develops shortly after abdominal surgery and in patients with elevated AST, high white blood cell count, or low platelet count, it is associated with a high mortality rate.

[Progressive multifocal leukoencephalopathy and AIDS. Response to cytarabine]. / Leucoencefalopatía multifocal progresiva y SIDA. Respuesta a la citarabina.

PML affects 4% of patients with AIDS and there is no effective treatment. Five cases of PML-AIDS have been described, showing clinical and radiological improvement after treatment with C-ara. We describe the case of a 33-year-old woman, addict to heroin, her clinical record including VIH infection, pneumonia by P. carinii, milliary tuberculosis, infection by virus B and C and treatment with AZT and tuberculostatics since January, 1992. In May, she began to develop a cerebellar syndrome. Images obtained with nuclear magnetic resonance were typical of PML. Subsequently, treatment with C-ara (2 mg/kg/day IV during 5 days each 4-6 weeks) was begun. From the third month of treatment on, the patient showed a clinical improvement and as of the sixth month, the affected areas of white substance were reduced in size. In addition, CD4 improved. Although in this patient a positive effect was observed after treatment with C-area, it should be verified in a controlled clinical trial.

Heparin and infusion phlebitis: a prospective study.

OBJECTIVE: To determine whether heparin sodium, when added to fluids infused through a peripheral catheter, reduces some local catheter-related problems (i.e., phlebitis, catheter obstruction, and extravasation of fluid) and extends the catheter's useful life. DESIGN: Prospective, double-blind, placebo-controlled. SETTING: Internal medicine ward of a general hospital with 400 beds. PATIENTS: Eighty-one consecutive acute collaborating patients who had a venous catheter in the forearm, inserted by nurses with more than one year of professional experience. INTERVENTION: Heparin sodium 1000 units/mL or NaCl 0.9% was added to compatible infusion fluids just before they were given to the patients. The final concentration of heparin was 1 unit/mL. MEASUREMENTS: Length of time until catheters were removed and reasons for their removal. RESULTS: The heparin group had a lower rate of local catheter-related problems than the placebo group (34.3 vs. 61.5 percent, respectively, p less than 0.05; 95 percent confidence interval for the difference 4.3 to 50.1 percent). The catheter's mean life in the heparin group was longer than that of placebo group (98.9 +/- 55.2 vs. 66.2 +/- 47.2 h, respectively, p less than 0.05; 95 percent confidence interval for the difference 9.15 to 56.25 h). This effect was mainly attributable to prevention of noninflammatory catheter-related problems (e.g., obstruction, extravasation) and to a delay in the appearance of phlebitis. CONCLUSIONS: Heparin sodium, when added to infusion fluids to a final concentration of 1 unit/mL, diminishes local intravenous catheter-related problems and extends the catheter's life.