Impact of the iCODEX tool in routine clinical practice in Spain.

INTRODUCTION: The prognosis of COPD patients can be calculated using multidimensional indexes that improve the predictive capacity of the individual variables. The CODEX index can be calculated using iCODEX, a digital support tool available on the web and in an app. The aim of this study was to evaluate how the usefulness and applicability of iCODEX and its recommendations in routine clinical practice are perceived by specialists in internal medicine, pneumology, and primary care. METHODS: A cross-sectional study was conducted from November 2019 to February 2020 with the participation of specialists in internal medicine, primary care, and pneumology. All respondents completed a survey consisting of 104 questions on their perception of the iCODEX tool. RESULTS: Overall, 335 physicians responded. Of these, 95.2% had no difficulty accessing the tool and 83.1% were quite or very satisfied with it. Regarding the applicability and implementation of iCODEX recommendations in routine clinical practice, respondents reported that the recommendations were generally applicable: most questions obtained a median score of ≥ 4 out of 5. The recommendations with the greatest expected clinical benefit are listed. CONCLUSIONS: Our study shows that the iCODEX tool is easy for participating specialists to use and identifies the recommendations that have the greatest clinical impact in areas such as lung obstruction, severe exacerbations, exercise, smoking, and patient follow-up.

Management of the COPD Patient with Comorbidities: An Experts Recommendation Document.

Background: Chronic obstructive pulmonary disease (COPD) is associated with multiple comorbidities, which impact negatively on patients and are often underdiagnosed, thus lacking a proper management due to the absence of clear guidelines. Purpose: To elaborate expert recommendations aimed to help healthcare professionals to provide the right care for treating COPD patients with comorbidities. Methods: A modified RAND-UCLA appropriateness method consisting of nominal groups to draw up consensus recommendations (6 Spanish experts) and 2-Delphi rounds to validate them (23 Spanish experts) was performed. Results: A panel of Spanish internal medicine experts reached consensus on 73 recommendations and 81 conclusions on the clinical consequences of the presence of comorbidities. In general, the experts reached consensus on the issues raised with regard to cardiovascular comorbidity and metabolic disorders. Consensus was reached on the use of selective serotonin reuptake inhibitors in cases of depression and the usefulness of referring patients with anxiety to respiratory rehabilitation programmes. The results also showed consensus on the usefulness of investigating the quality of sleep, the treatment of pain with opioids and the evaluation of osteoporosis by lateral chest radiography. Conclusion: This study provides conclusions and recommendations that are intended to improve the management of the complexity of patients with COPD and important comorbidities, usually excluded from clinical trials.

Spanish clinical practice consensus in internal medicine on chronic obstructive pulmonary disease patients with comorbidities (miEPOC).

Background: Chronic obstructive pulmonary disease (COPD) is one of the diseases that leads to a higher number of hospitalizations in internal medicine departments. These patients are usually older and have greater multimorbidity than COPD patients hospitalized in other departments, which hinders the implementation of clinical guidelines necessarily focused on the management of a single disease.Aims: To ascertain the opinion of Spanish internists on the management of COPD in scenarios in which the available evidence is sparse and to produce a consensus document designed to assist in decision-making in COPD patients with comorbidities treated in internal medicine services.Methods: After identifying the clinical areas of greatest uncertainty by consensus, a survey was designed with 89 questions on the epidemiology and diagnosis of COPD, its management both in stable phase and during decompensation, and the treatment of the associated comorbidities in outpatients and inpatients. The consensus process was carried out using the Delphi method in an anonymized two-round process.Results: The survey was completed by 67 internists experienced in the clinical management of COPD. Of all the questions posed, a consensus was reached for 51 (57.3%) in the first round and for 67 (75.3%) in the second round. The result of the process is a series of 67 suggestions that may assist in the care of these patients.Conclusions: Our study allows us to ascertain the views of a large number of internists experienced in the management of COPD and to learn how the recommendations for guidelines are applied in clinical practice.

A rare case of long-term paraesthesia diagnosed as a paraneoplastic syndrome by anti-SOX1 antibody determination.

Paraneoplastic syndromes (PS) are a rare presentation of cancer, most commonly associated with small cell lung cancer (SCLC), breast cancer and haematologic malignancies. The diagnosis of PS is challenging because it could affect multiple organ systems and it may present before the tumour is visible by imaging. We report a malignant tumour diagnosed in a male patient who referred long-term paraesthesia and proximal muscle strength loss. After ruling out common causes of polyneuropathy, the anti-SOX1 antibody gave light to the diagnosis. A pulmonary opacity in the upper right lobe was observed in the chest X-ray and a pulmonary tumour was later confirmed by CT scan. The biopsy of the cervical lymphadenopathy determined an SCLC, which caused a PS called Lambert-Eaton myasthenic syndrome (LEMS). Our case raises awareness of a rare PS presentation, which can be diagnosed by specific antibodies, allowing early diagnosis and treatment of lung cancer.

Linfohistiocitosis hemofagocítica secundaria a leishmaniasis viscera / Visceral leishmania-associated hemophagocytic lymphohistiocytosis

No disponible

A risk score to predict the absence of left ventricular reverse remodeling: Implications for the timing of ICD implantation in primary prevention.

BACKGROUND: A prophylactic implantable cardioverter defibrillator (ICD) in patients with heart failure and reduced left ventricular ejection fraction (HFrEF) is only indicated when left ventricular ejection fraction (LVEF) reassessment remains ≤35% after 3-6 months on optimal pharmacological therapy. However, LVEF may not improve during this period and the patient may be exposed to an unnecessary risk of sudden cardiac death. This study aimed to determine the incidence and predictors of the absence of left ventricular reverse remodeling (LVRR) after pharmacological treatment optimization in patients with HFrEF to design a risk score of absence of LVRR. METHODS: Consecutive outpatients with LVEF ≤35% were included in this observational prospective study. Up-titration of angiotensin-converting enzyme (ACE) inhibitors/angiotensin II receptor blockers (ARBs), beta-blockers, mineralocorticoid receptor antagonists (MRAs), and ivabradine was performed in our Heart Failure (HF) Unit. The absence of LVRR was defined as the persistence of an LVEF ≤35% at the 6-month follow-up. RESULTS: One hundred and twenty patients were included. At the 6-month follow-up, 64%, 76%, 72%, and 7% of patients were at 100% of the target dose of ACE inhibitors/ARBs, beta-blockers, MRAs, and ivabradine, respectively. LVRR was observed in 48% of the patients. Ischemic cardiomyopathy, prolonged HF duration, and larger left ventricular end-diastolic diameter index (LVEDDI) were independent predictors of the absence of LVRR. The risk score based on these predictors showed a c-statistic value of 0.81. CONCLUSIONS: Pharmacological treatment optimization is associated with LVRR in approximately half of cases, reducing potential ICD indications in parallel. However, ischemic cardiomyopathy, prolonged HF duration, and larger LVEDDI predict the absence of LVRR and favor ICD implantation without delay. The risk score based on the former predictors may help the clinician with the timing of ICD implantation.

Efectividad de una intervención simple sobre el tratamiento de las agudizaciones de la enfermedad pulmonar obstructiva crónica y de sus comorbilidades cardiovasculares: estudio COREPOC / Effectiveness of a simple intervention on management of acute exacerbations of chronic obstructive pulmonary disease and its cardiovascular comorbidities: COREPOC study

Fundamento y objetivo: Analizar la efectividad de una intervención educativa simple para mejorar el tratamiento de las comorbilidades cardiovasculares en los pacientes hospitalizados por una exacerbación de enfermedad pulmonar obstructiva crónica (EPOC). Material y métodos: Estudio multicéntrico con participación de 26 hospitales. Un grupo de expertos elaboró unas recomendaciones para el abordaje diagnóstico y terapéutico de la EPOC y las comorbilidades cardiovasculares (cardiopatía isquémica, fibrilación auricular, insuficiencia cardiaca y diabetes) que se graduaron como imprescindibles, aconsejables y sobresalientes. Se recogió el cumplimiento de las recomendaciones en los informes de alta de los pacientes ingresados en los servicios de Medicina Interna por reagudización de la EPOC. Se realizó una sesión clínica explicando los protocolos de atención a las comorbilidades en la EPOC y al cabo de 6 meses se volvió a observar el cumplimiento de dichas recomendaciones. Resultados: Se recogieron 390 casos antes y después de la intervención. Hubo mejoría significativa en el 53% de los ítems y esta mejoría fue mayor en los referidos al tratamiento general (66,7%) y al tratamiento de la EPOC (76,9%) y menor en los referidos a la cardiopatía isquémica (0,0%) y a la insuficiencia cardiaca (11,1%). Tras la intervención mejoró el cumplimiento de las recomendaciones en general (p=0,020) y de las imprescindibles (p=0,017), con una tendencia a la mejoría en las aconsejables (p=0,058) y las sobresalientes (p=0,063). Conclusiones: Una intervención simple puede mejorar la atención a los pacientes con exacerbación de EPOC, especialmente en el tratamiento de la enfermedad pulmonar, con pequeños cambios en el de las comorbilidades (AU)

Background and objective: To determine the effectiveness of a simple educational intervention to improve the management of cardiovascular comorbidities in patients hospitalized with an acute exacerbation of chronic obstructive pulmonary disease (COPD). Material and methods: Multicenter study participated in by 26 hospital centers. A panel of experts elaborated a set of recommendations about diagnostic and therapeutic management of acute exacerbation of COPD and cardiovascular comorbidities (coronary artery disease, atrial fibrillation, heart failure and diabetes). The recommendations were graduated as indispensable, advisable and outstanding. Compliance with recommendations were assessed in the discharge letter for COPD patients hospitalized with acute exacerbation in Internal Medicine departments. The protocols to treat the comorbidities in COPD were explained in a clinical session. After 6 months’ compliance with recommendations they were reassessed. Results: A total of 390 cases before and after the intervention were assessed. There was significant progress in 53% of cases. The improvement was greater in cases referred to general management and COPD management (66.7 and 76.9%, respectively), and lower in cases referred to ischemic heart disease (11.1%) and none in those referred to coronary artery disease. After the intervention, the adherence to overall and indispensable recommendations was higher (P=.020 and P=.017, respectively) and a trend to improve was observed in advisable (P=.058) and outstanding recommendations (P=.063). Conclusions: A simple intervention can improve the management of lung disease in COPD patients with an acute exacerbation, but has less effect on the management of comorbidities (AU)

Effectiveness of a simple intervention on management of acute exacerbations of chronic obstructive pulmonary disease and its cardiovascular comorbidities: COREPOC study. / Efectividad de una intervención simple sobre el tratamiento de las agudizaciones de la enfermedad pulmonar obstructiva crónica y de sus comorbilidades cardiovasculares: estudio COREPOC.

BACKGROUND AND OBJECTIVE: To determine the effectiveness of a simple educational intervention to improve the management of cardiovascular comorbidities in patients hospitalized with an acute exacerbation of chronic obstructive pulmonary disease (COPD). MATERIAL AND METHODS: Multicenter study participated in by 26 hospital centers. A panel of experts elaborated a set of recommendations about diagnostic and therapeutic management of acute exacerbation of COPD and cardiovascular comorbidities (coronary artery disease, atrial fibrillation, heart failure and diabetes). The recommendations were graduated as indispensable, advisable and outstanding. Compliance with recommendations were assessed in the discharge letter for COPD patients hospitalized with acute exacerbation in Internal Medicine departments. The protocols to treat the comorbidities in COPD were explained in a clinical session. After 6 months' compliance with recommendations they were reassessed. RESULTS: A total of 390 cases before and after the intervention were assessed. There was significant progress in 53% of cases. The improvement was greater in cases referred to general management and COPD management (66.7 and 76.9%, respectively), and lower in cases referred to ischemic heart disease (11.1%) and none in those referred to coronary artery disease. After the intervention, the adherence to overall and indispensable recommendations was higher (P=.020 and P=.017, respectively) and a trend to improve was observed in advisable (P=.058) and outstanding recommendations (P=.063). CONCLUSIONS: A simple intervention can improve the management of lung disease in COPD patients with an acute exacerbation, but has less effect on the management of comorbidities.

[Complementary treatment of acute heart failure in patients with diabetes, chronic obstructive pulmonary disease or anemia]. / Tratamiento complementario de la insuficiencia cardíaca aguda en el paciente con diabetes, enfermedad pulmonar obstructiva crónica o anemia.

Diabetes, chronic obstructive pulmonary disease (COPD) and anemia are comorbidities with a high prevalence and impact in heart failure (HF). The presence of these comorbidities considerably worsens the prognosis of HF. Diabetic patients have a higher likelihood of developing symptoms of HF and both the treatment of diabetes and that of acute HF are altered by the coexistence of both entities. The glycemic targets in patients with acute HF are not well-defined, but could show a U-shaped relationship. Stress hyperglycemia in non-diabetic patients with HF could also have a deleterious effect on the medium-term prognosis. The inter-relationship between COPD and HF hampers diagnosis due to the overlap between the symptoms and signs of both entities and complementary investigations. The treatment of acute HF is also altered by the presence of COPD. Anemia is highly prevalent and is often the direct cause of decompensated HF, the most common cause being iron deficiency anemia. Iron replacement therapy, specifically intravenous forms, has helped to improve the prognosis of acute HF.

Tratamiento complementario de la insuficiencia cardíaca aguda en el paciente con diabetes, enfermedad pulmonar obstructiva crónica o anemia / Complementary treatment of acute heart failure in patients with diabetes, chronic obstructive pulmonary disease or anemia

La diabetes, la enfermedad pulmonar obstructiva crónica (EPOC) y la anemia son comorbilidades con elevada prevalencia e impacto en la insuficiencia cardíaca (IC). El pronóstico de la IC aguda empeora considerablemente ante la presencia de estas comorbilidades. Los pacientes diabéticos tienen mayor probabilidad de desarrollar clínica de IC, y tanto el tratamiento de la diabetes como el de la IC aguda se ven alterados ante la coexistencia de ambas entidades. Los objetivos glucémicos en pacientes con IC aguda no están bien definidos, pero podrían comportarse con una curva en U. La hiperglucemia de estrés en pacientes con IC aguda no diabéticos también tiene un efecto muy deletéreo en el pronóstico a medio plazo. La interrelación entre EPOC e IC aguda dificulta la fase diagnóstica al compartir síntomas, signos y estudios complementarios. El tratamiento de la IC aguda también se ve modulado por la presencia de la EPOC. La anemia es muy prevalente y, a menudo, es la causa directa de la descompensación de la IC, siendo la ferropenia la etiología más frecuente. Las terapias de reposición de hierro, concretamente la disposición de preparados de administración intravenosa, han contribuido a mejorar el pronóstico de la IC aguda (AU)

Diabetes, chronic obstructive pulmonary disease (COPD) and anemia are comorbidities with a high prevalence and impact in heart failure (HF). The presence of these comorbidities considerably worsens the prognosis of HF. Diabetic patients have a higher likelihood of developing symptoms of HF and both the treatment of diabetes and that of acute HF are altered by the coexistence of both entities. The glycemic targets in patients with acute HF are not well-defined, but could show a U-shaped relationship. Stress hyperglycemia in non-diabetic patients with HF could also have a deleterious effect on the medium-term prognosis. The inter-relationship between COPD and HF hampers diagnosis due to the overlap between the symptoms and signs of both entities and complementary investigations. The treatment of acute HF is also altered by the presence of COPD. Anemia is highly prevalent and is often the direct cause of decompensated HF, the most common cause being iron deficiency anemia. Iron replacement therapy, specifically intravenous forms, has helped to improve the prognosis of acute HF (AU)

Anemia en la insuficiencia cardiaca: su utilidad como marcador de pronóstico o de comorbilidad: estudio GESAIC-2 / Anemia in heart failure: its usefulness as prognosis or comorbidity marker: GESAIC-2 study

Fundamento y objetivo: Evaluar el carácter pronóstico de la anemia y su etiología en la insuficiencia cardiaca (IC). Pacientes y método: Cohorte multicéntrica prospectiva de pacientes con IC al año de ingreso hospitalario.Resultados: Un total de 57 (27%) de los 211 pacientes fallecieron y 115 (67,8%) reingresaron. La mortalidad fue superior en el grupo con anemia (31,8%), sin significación estadística (p=0,09) excepto para mortalidad por IC refractaria (p=0,013). Fueron predictores de mortalidad por IC el índice de Barthel (hazard ratio [HR] 0,97; intervalo de confianza del 95% [IC 95%] 0,96-0,98) y la creatinina plasmática al alta (HR 2,28; IC 95% 1,51-3,45), mientras que para reingreso lo fueron el índice de Charlson (odds ratio [OR] 1,16; IC 95% 0,98-1,38), el tratamiento con antagonistas del calcio (OR 0,29; IC 95% 0,1-0,84) y no ser tratado con digoxina (OR 2,33; IC 95% 1,09-4,97), esta última con mayor influencia en el reingreso por IC (OR 3,07; IC 95% 1,39-6,79), junto con no ser el inicio de IC (OR 2,8; IC 95% 1,45-5,39). Conclusiones: La anemia supone un mayor riesgo de mortalidad por IC refractaria, pero no de reingreso, en el primer año tras una descompensación aguda (AU)

Background and objective: To assess the prognosis and etiology of anemia in heart failure (HF). Patients and methods: Prospective multicenter cohort of HF after one year of hospitalization. Results: A total of 57 (27%) of the 211 patients died and 115 (67.8%) were readmitted. Mortality was higher in the group with anemia (31.8%) without statistical significance (P=.09), except for refractory HF mortality (P=.013). Predictors of HF mortality included Barthel index (hazard ratio [HR] 0.97, CI 95% 0.96 to 0.98) and serum creatinine at discharge (HR 2.28, 95% CI 1.51 to 3.45). For reentry, the Charlson index (OR 1.16, CI 95% 0.98 to 1.38), treatment with calcium channel blockers (OR 0.29, 95% CI 0.1 to 0.84) and not bein treated with digoxin (OR 2.33, CI 95% 1.09 to 4.97), the latter with the greatest influence on readmission for HF (OR 3.07, CI 95% 1.39 to 6.79), along with not being a HF debut (OR 2.8, CI 95% 1.45 to 5.39). Conclusions: Anemia is an increased risk of mortality due to refractory HF, but not for readmission within the first year after an acute event (AU)

[Anemia in heart failure: its usefulness as prognosis or comorbidity marker: GESAIC-2 study]. / Anemia en la insuficiencia cardiaca: su utilidad como marcador de pronóstico o de comorbilidad: estudio GESAIC-2.

BACKGROUND AND OBJECTIVE: To assess the prognosis and etiology of anemia in heart failure (HF). PATIENTS AND METHODS: Prospective multicenter cohort of HF after one year of hospitalization. RESULTS: A total of 57 (27%) of the 211 patients died and 115 (67.8%) were readmitted. Mortality was higher in the group with anemia (31.8%) without statistical significance (P=.09), except for refractory HF mortality (P=.013). Predictors of HF mortality included Barthel index (hazard ratio [HR] 0.97, CI 95% 0.96 to 0.98) and serum creatinine at discharge (HR 2.28, 95% CI 1.51 to 3.45). For reentry, the Charlson index (OR 1.16, CI 95% 0.98 to 1.38), treatment with calcium channel blockers (OR 0.29, 95% CI 0.1 to 0.84) and not being treated with digoxin (OR 2.33, CI 95% 1.09 to 4.97), the latter with the greatest influence on readmission for HF (OR 3.07, CI 95% 1.39 to 6.79), along with not being a HF debut (OR 2.8, CI 95% 1.45 to 5.39). CONCLUSIONS: Anemia is an increased risk of mortality due to refractory HF, but not for readmission within the first year after an acute event.

Enfermedad pulmonar obstructiva crónica en pacientes ingresados por insuficiencia cardiaca. Resultados del Grupo para el Estudio y Significado de la Anemia en la Insuficiencia Cardiaca (GESAIC) / Chronic obstructive pulmonary disease on inpatients with heart failure. GESAIC study results

Fundamento y objetivo: La relevancia clínica de la insuficiencia cardiaca (IC) y de la enfermedad pulmonar obstructiva crónica (EPOC) en un mismo enfermo no está bien establecida. El objetivo de este trabajo fue estudiar la prevalencia de EPOC en pacientes ingresados por IC, definir su perfil clínico y la relación con el tratamiento con bloqueadores beta. Pacientes y método: Análisis de una cohorte prospectiva de pacientes ingresados en 15 servicios de Medicina Interna desde octubre de 2005 hasta marzo de 2006. El diagnóstico de EPOC se estableció por criterios clínicos o espirometría. Se recogieron datos sobre el tratamiento neurohormonal antes, durante y tras el ingreso hospitalario. Se utilizó la prueba de ji al cuadrado y la t de Student. Con las variables significativas se construyó un modelo de regresión logística. En todos los casos se consideró una significación bilateral para p<0,05. Resultados: Se incluyó a 391 pacientes, con una prevalencia de EPOC del 25,1%. En dos tercios de los pacientes se estableció el diagnóstico solo por criterios clínicos. El 23,5% de los enfermos tenía un estadio moderado o grave de EPOC. En el analisis bivariante se relacionó la presencia de EPOC con el sexo masculino (p<0,05), mayor índice de Charlson y mayor sobrepeso (p=0,04 ambos). En el tratamiento con bloqueadores beta adrenérgicos, solo la fracción de eyección del ventrículo izquierdo (p=0,03) y el tratamiento previo (p<0,001) tuvieron significación estadística en el modelo de regresión logística. La prescripción de betabloqueadores en el alta fue del 27,6%. Conclusiones: La prevalencia de EPOC es elevada en IC, y el perfil es el de un hombre de edad avanzada, con elevada comorbilidad y sobrepeso. El tratamiento con betabloqueadores se condiciona por el deterioro de la función ventricular, sin relación con la EPOC

Background and objective: The clinical relevance of Heart failure (HF) and chronic obstructive pulmonary disease (COPD) in the same patient is not well established. We decided to study the prevalence of COPD in patients admitted due to HF, to define their clinical profile and the relationship with adrenergic beta-blockers (BB) treatment. Patients and method: Prospective cohort of inpatients with HF admitted in 15 Internal Medicine Services from October 2005 to March 2006. Diagnosis of COPD was established according to clinical criteria or spirometry. Data about neurohormonal treatment (before, during the admission, and at discharge) were collected. Statistical analyses were performed using Ji square test and T Student test. A logistic regression model was designed with data. P<0.05 being considered statistically significant. Rokesults: About 391 patients were included . CPOD was present in 25.1% of patients. In two thirds of patients, the COPD diagnosis was established by clinical criteria. Regarding GOLD, 23.5% of patients had moderate or severe COPD severity. Bivariate analysis showed that male (<0.05), poor Charlson's Index and overweight (p=0.04 both) had all relationship with COPD. The regression model indicated that only left ventricular ejection fraction (LVEF) and BB treatment before admission had statistical significance (p=0.03 and p<0.001 respectively). At discharge, 27,6% of patients received BB. Conclusions: COPD in HF patients is common and most frequent patients are aged men high comorbidity and overweight. BB treatment is conditioned by LVEF, without relationship with COPD severity (AU)

[Chronic obstructive pulmonary disease on inpatients with heart failure. GESAIC study results]. / Enfermedad pulmonar obstructiva crónica en pacientes ingresados por insuficiencia cardiaca. Resultados del Grupo para el Estudio y Significado de la Anemia en la Insuficiencia Cardiaca (GESAIC).

BACKGROUND AND OBJECTIVE: The clinical relevance of Heart failure (HF) and chronic obstructive pulmonary disease (COPD) in the same patient is not well established. We decided to study the prevalence of COPD in patients admitted due to HF, to define their clinical profile and the relationship with adrenergic beta-blockers (BB) treatment. PATIENTS AND METHOD: Prospective cohort of inpatients with HF admitted in 15 Internal Medicine Services from October 2005 to March 2006. Diagnosis of COPD was established according to clinical criteria or spirometry. Data about neurohormonal treatment (before, during the admission, and at discharge) were collected. Statistical analyses were performed using Ji square test and T Student test. A logistic regression model was designed with data. P<0.05 being considered statistically significant. RESULTS: About 391 patients were included . CPOD was present in 25.1% of patients. In two thirds of patients, the COPD diagnosis was established by clinical criteria. Regarding GOLD, 23.5% of patients had moderate or severe COPD severity. Bivariate analysis showed that male (<0.05), poor Charlson's Index and overweight (p=0.04 both) had all relationship with COPD. The regression model indicated that only left ventricular ejection fraction (LVEF) and BB treatment before admission had statistical significance (p=0.03 and p<0.001 respectively). At discharge, 27,6% of patients received BB. CONCLUSIONS: COPD in HF patients is common and most frequent patients are aged men high comorbidity and overweight. BB treatment is conditioned by LVEF, without relationship with COPD severity.