External validation of the RIETE and SOME scores for occult cancer in patients with venous thromboembolism: a multicentre cohort study.

INTRODUCTION: Venous thromboembolism (VTE) may be the first sign of an undiagnosed cancer. The RIETE and SOME scores aim to identify patients with acute VTE at high risk of occult cancer. In the present study, we evaluated the performance of both scores. METHODS: The scores were evaluated in a retrospective cohort from two centers. The area under the receiver-operating characteristics curve (AUC) evaluated the discriminatory performance. RESULTS: The RIETE score was applied to 815 patients with provoked and unprovoked VTE, of whom 56 (6.9%) were diagnosed with cancer. Of the 203 patients classified as high-risk, 18 were diagnosed with cancer, representing 32.1% (18/56) of the total cancer diagnoses. In the group of 612 low-risk patients, 67.9% of the cancer cases were diagnosed (38/56). Sensitivity, specificity, negative and positive predictive values, and AUC were 32%, 76%, 94%, 9%, and 0.430 (95% confidence interval [CI], 0.38‒0.47), respectively. The SOME score could be calculated in 418 patients with unprovoked VTE, of whom 33 (7.9%) were diagnosed with cancer. Of the 45 patients classified as high-risk, three were diagnosed with cancer, representing 9.1% (3/33) of the total cancer diagnoses. In the group of 373 low-risk patients, 90.9% of the cancer cases were diagnosed (30/33). Sensitivity, specificity, negative and positive predictive values, and AUC were 33%, 88%, 94%, 20%, and 0.351 (95% CI, 0.27‒0.43), respectively. CONCLUSIONS: The performance of both scores was poor. Our results highlight the need to develop new models to identify high-risk patients who may benefit from an extensive cancer screening strategy.

Management and outcomes of cancer patients with venous thromboembolism presenting with thrombocytopenia.

INTRODUCTION: Treatment of venous thromboembolism (VTE) in cancer patients with thrombocytopenia is challenging due to perceived higher risk of bleeding. MATERIAL AND METHODS: We used the RIETE registry to compare the 10- and 30-day outcomes in cancer patients with acute VTE, according to platelet count at baseline. RESULTS: As of December 2018, 15,337 cancer patients with VTE were included: 166 (1.1%) had <50 × 109 platelets/L (severe thrombocytopenia), 711 (4.6%) had 50-99 × 109/L (mild thrombocytopenia) and 14,460 (94.3%) had ≥100 × 109/L (normal count). Most patients in all subgroups received initial therapy with low-molecular-weight heparin (LMWH), but 62% of those with severe thrombocytopenia received <150 IU/kg/day LMWH, 42% received <100 IU/kg/day. The mortality rate progressively decreased with increasing platelet counts (12%, 9.4% and 3.3% respectively at 10 days, 27%, 18% and 9.4% at 30 days), but the major bleeding rates did not (1.2%, 2.5% and 1.3% respectively at 10 days, 2.4%, 4.4% and 2.2% at 30 days). On multivariable analysis, patients with severe thrombocytopenia had a similar risk for major bleeding at 10 days (OR 0.84; 95%CI 0.20-3.49) and at 30 days (OR 0.90; 95%CI 0.32-2.49), but those with mild thrombocytopenia were at increased risk both at 10 days (OR 2.11; 95%CI 1.27-3.49) and at 30 days (OR 1.91; 95%CI 1.29-2.84). CONCLUSIONS: Cancer patients with acute VTE and baseline thrombocytopenia often receive initial lower-than recommended doses of LMWH. Although caution is required, this practice seems to be safe in patients with severe thrombocytopenia. Nonetheless, there was an inverse correlation between baseline platelet count and mortality.

Idiopathic External Jugular Vein Thrombosis.

External jugular vein thrombosis is a rare complication that, when it occurs, is usually secondary to cervical trauma, infection, venous cannulation or malignancy. By contrast, spontaneous external jugular thrombosis is extremely uncommon. We report the case of a 69-year-old woman presenting to the Emergency Department with a 3 centimetre neck lump, which had suddenly appeared on the same day. She did not have any other relevant symptoms. The patient had not suffered any recent cervical trauma or infection. There was no personal or familial history of thromboembolic disease. Physical examination was normal, apart from the neck mass. A neck ultrasound revealed a non-occlusive thrombus inside the right external jugular vein. Usual workup, including a coagulation laboratory profile, autoimmunity and malignancy research, was unremarkable, identifying the thrombosis as idiopathic. Anticoagulation treatment was started, leading to a complete resolution of the thrombus, without recurrence. The sudden appearance of a painless cervical mass, without any identified triggering factor, is not common. The possibility of a jugular thrombosis should be kept in mind in the differential diagnosis of an isolated neck lump. In this case, point-of-care ultrasound, which is becoming increasingly available in Emergency Departments, contributed to the rapid and accurate diagnosis of the patient. LEARNING POINTS: Vascular diseases such as aneurysms and thrombosis, although infrequent in jugular veins, should be considered in the differential diagnosis of a painless promptly growing neck lump.Since idiopathic external jugular vein thrombosis is uncommon, a complete diagnostic workout and follow-up is recommended, to exclude a triggering factor, such as an underlying malignancy, coagulation disorder or hidden infection.Ultrasound is the most accurate non-invasive method to diagnose venous thrombosis. Point-of-care ultrasound has proved to be a useful tool for the rapid diagnosis of vascular diseases.

The obesity paradox in stroke: impact on mortality and short-term readmission.

BACKGROUND: The aim of the present study was to assess the association of obesity with the mortality of hospitalized patients with acute stroke and the risk of readmission in less than 30 days. METHODS: A retrospective chart review of a cohort of consecutive patients admitted with stroke as the primary reason for discharge in Spain between January 1, 2005, and December 31, 2011, was performed. Patients with a diagnosis of obesity were identified. The mortality and readmittance indexes of obese patients were compared against the subpopulation without theses diagnosis. RESULTS: A total of 201,272 stroke admittances were analyzed, and 14,047 (7.0%) diagnosis of obesity were identified. In-hospital global mortality reached 14.9%, and readmittance risk was 5.9%. Obese patients showed a lower in-hospital mortality risk (odds ratio [OR], .71; 95% confidence interval [CI], .67-.76) and early readmittance risk (OR, .89; 95% CI, .82-.96) than the nonobese even after adjusting for possible confounding factors. CONCLUSIONS: Obesity in those hospitalized for stroke is associated with reduced in-hospital mortality risk and early readmittance.

Influence of recent immobilization or surgery on mortality in cancer patients with venous thromboembolism.

BACKGROUND: The influence of recent immobilization or surgery on mortality in cancer patients with venous thromboembolism (VTE) has not been thoroughly studied. METHODS: We used the RIETE Registry data to compare the 3-month mortality rate in cancer patients with VTE, with patients categorized according to the presence of recent immobilization, surgery or neither. The major outcomes were fatal pulmonary embolism (PE) and fatal bleeding within the first 3 months. RESULTS: Of 6,746 patients with active cancer and acute VTE, 1,224 (18%) had recent immobilization, 1,055 (16%) recent surgery, and 4,467 (66%) had neither. The all-cause mortality was 23.4% (95% CI: 22.4-24.5), and the PE-related mortality: 2.5% (95% CI: 2.1-2.9). Four in every ten patients dying of PE had recent immobilization (37%) or surgery (5.4%). Only 28% of patients with immobilization had received prophylaxis, as compared with 67% of the surgical. Fatal PE was more common in patients with recent immobilization (5.0%; 95% CI: 3.9-6.3) than in those with surgery (0.8%; 95% CI: 0.4-1.6) or neither (2.2%; 95% CI: 1.8-2.6). On multivariate analysis, patients with immobilization were at an increased risk for fatal PE (odds ratio: 1.8; 95% CI: 1.2-2.5). CONCLUSIONS: One in every three cancer patients dying of PE had recent immobilization for ≥ 4 days. Many of these deaths could have been prevented with adequate thromboprophylaxis.

Factors associated with elevated pulmonary arterial pressure levels on the echocardiographic assessment in patients with prior pulmonary embolism.

BACKGROUND: Factors associated with the detection of raised systolic pulmonary artery pressure (sPAP) levels in patients with a prior episode of pulmonary embolism (PE) are not well known. METHODS: We used the RIETE Registry database to identify factors associated with the finding of sPAP levels ≥50 mm Hg on trans-thoracic echocardiography, in 557 patients with a prior episode of acute, symptomatic PE. RESULTS: Sixty-two patients (11.1%; 95% CI: 8.72-14.1) had sPAP levels ≥50 mm Hg. These patients were more likely women, older, and more likely had chronic lung disease, heart failure, renal insufficiency or leg varicosities than those with PAP levels <50mm Hg. During the index PE event, they more likely had recent immobility, and more likely presented with hypoxemia, increased sPAP levels, atrial fibrillation, or right bundle branch block. On multivariate analysis, women aged ≥70 years (hazard ratio [HR]: 2.0; 95% CI: 1.0-3.7), chronic heart or chronic lung disease (HR: 2.4; 95% CI: 1.3-4.4), atrial fibrillation at PE presentation (HR: 2.8; 95% CI: 1.3-6.1) or varicose veins (HR: 1.8; 95% CI: 1.0-3.3) were all associated with an increased risk to have raised sPAP levels. Chronic heart disease, varicose veins, and atrial fibrillation were independent predictors in women, while chronic heart disease, atrial fibrillation, a right bundle branch block or an S1Q3T3 pattern on the electrocardiogram were independent predictors in men. CONCLUSIONS: Women aged ≥70 years more likely had raised sPAP levels than men after a PE episode. Additional variables influencing this risk seem to differ according to gender.

The influence of nursing homes in the functioning of internal medicine services.

BACKGROUND: Some hospitals attend to great number of patients who come from nursing homes whose median age, seriousness of illness and comorbidity differ of these patients from those of non-institutionalized patients. This can partly modify and thereby affect some of the parameters used to measure "assistance quality". MATERIALS AND METHODS: The data related to the demographic, clinical factors, severity criteria and mortality, were studied in patients hospitalized in two Internal Medicine Services during 2005-6 on the basis of whether they arrived from a nursing home or not. The data were obtained from the electronic databases of the two centers. RESULTS: During the study period, 13,712 patients were hospitalized (7110 in Fundación Hospital Alcorcón (FHA) and 6602 in Hospital Universitario Fuenlabrada (HUF)). A total of 789 (15.3%) patients of FHA arrived from a nursing home in comparison to 132 (2.6%) of those in HUF. Patients arriving from nursing homes were older (84.1 vs 69.8; p<0.05), had a more serious illness (Group Related Diagnostic weight 2.1 vs 1.9; p<0.05), more comorbidity (Charlson Index >0; 75.5% vs 67.3%; p<0.05) and increased mortality (16.8% vs 6.8%; p<0.05) than the non-institutionalized patients, while length of hospital stay were shorter in the institutionalized patients (7.8 vs 8.3; p<0.05). Intrahospital mortality was significantly associated with living in a nursing home (Odds Ratio 1.4 Confidence Interval 95% 1.1-1.8), regardless of age, gender, condition, comorbidity (Charlson Index), and the involved hospital. DISCUSSION: The number of nursing homes attended by a hospital determined the activity of an Internal Medicine Service. This study indicates that the patients from nursing homes were older, with increased severity and comorbidity of their illness, greater mortality and rehospitalization although, with similar length of stay.

Detección de autoanticuerpos anti LDL peroxidasas en pacientes ateroscleroticos / Detection of autoantibodies to peroxidated LDL in atherosclerotic patients

Se ha propuesto que los mecanismos inmunológicos pueden participar en la fisiopatología de la aterosclerosis a tráves de la reacción antígeno-anticuerpo y la activación del sistema del complemento con el consiguiente daño al endotelio vascular. Las lipoproteínas que han sufrido algúun tipo de modificación en su estructura pueden inducir la formación de autoanticuerpos. En este trabajo se describe la determinación de anticuerpos contra LDL peroxidasas, mediante un sistema inmunoenzimático tipo ELISA en un grupo de pacientes con aterosclerosis obliterante de los miembros inferiore en los que se encontraron valores significativamente más elevados con un grupo control (AU)

Anticuerpos antilipoproteinas de baja densidad e inmunocomplejos APO (B) lipoproteina-anticuerpo en pacientes con enfermedad vascular perifèrica: empleo de anticuerpos monoclonales / Anti LDL anbodies and B apolipoprotein-antibody immunocomplexes in patients with peripheral vascular disease: use of monoclonal antibodies

Se estudiò la presencia de anticuerpos anti-LDL a IC apo-B-lipoproteinas anticuerpo en un total de 60 pacientes con aterosclerosis perifèrica y en 60 con angiopatìa diabètica. Los resultados se compararon con un grupo de 41 individuos no diabèticos y sin sìntomas clìnicos de enfermedad cardiovascular. Entre algunos pacientes diabèticos y ateroscleròticos el nivel de anticuerpos anti-LDL fue significativamente màs elevado, aunque la proporción de casos que tuvieron valores por encima del valor correspondiente al 90 percentil del grupo control, tomado èste como valor lìmite, no fue diferente. Tampoco se encontrò diferencia en el nivel de IC apo-B lipoproteina-anticuerpo cuando se empleó para su determinaciòn un anticuerpo policlonal. Sin embargo, se detectaron niveles altos de estos complejos y una proporciòn significativamente elevada de pacientes ateroscleròticos por encima del valor lìmite fijado cuando se empleò para estos fines el anticuerpo monoclonal 12E6E8. Se discute la importancia que puede tener el empleo de anticuerpos monoclonales para detectar lipoproteinas de estructura alterada de alto potencial aterogènico y de los inmunocomplejos que pueden originar

Desarrollo de un procedimiento sencillo para la obtención de anticuerpos contra la apolipoproteína-B / Development of a simple procedure for the attainment of antibodies agains B-apolipoprotein

Se describe un procedimiento para la obtención de un antisuero monoespecífico contra la apolipoproteína-B humana, se utiliza como inmunógeno lipoproteínas de baja densidad purificadas por precipitación con sulfato de dextrán y heparina en presencia de iones magnesio. El antisuero obtenido se absorbe con suero humano, libre de apolipoproteína-B, insolubilizado con glutaraldehído. Se discute la influencia del procedimiento utilizado sobre la estructura de las lipoproteínas de baja densidad y las ventajas de éste sobre las técnicas tradicionales

Desarrollo de un procedimiento sencillo para la obtención de anticuerpos contra la apolipoproteína-B / Developent of a simple procedure for the attainment of antibodies agains B-apolipoprotein

Se describe un procedimiento para la obtención de un antisuero monoespecífico contra la apolipoproteína-B humana, se utiliza como inmunógeno lipoproteínas de baja densidad purificadas por precipitación con sulfato de dextrán y heparina en presencia de iones magnesio. El antisuero obtenido se absorbe con suero humano, libre de apolipoproteína-B, insolubilizado con glutaraldehído. Se discute la influencia del procedimiento utilizado sobre la estructura de las lipoproteínas de baja densidad y las ventajas de éste sobre las técnicas tradicionales

Anticuerpos antilipoproteinas de baja densidad e inmunocomplejos APO (B) lipoproteina-anticuerpo en pacientes con enfermedad vascular perifèrica: empleo de anticuerpos monoclonales / Anti LDL anbodies and B apolipoprotein-antibody imunocomplexes in patients with peripheral vascular disease: use of monoclonal antibodies

Se estudiò la presencia de anticuerpos anti-LDL a IC apo-B-lipoproteinas anticuerpo en un total de 60 pacientes con aterosclerosis perifèrica y en 60 con angiopatìa diabètica. Los resultados se compararon con un grupo de 41 individuos no diabèticos y sin sìntomas clìnicos de enfermedad cardiovascular. Entre algunos pacientes diabèticos y ateroscleròticos el nivel de anticuerpos anti-LDL fue significativamente màs elevado, aunque la proporción de casos que tuvieron valores por encima del valor correspondiente al 90 percentil del grupo control, tomado èste como valor lìmite, no fue diferente. Tampoco se encontrò diferencia en el nivel de IC apo-B lipoproteina-anticuerpo cuando se empleó para su determinaciòn un anticuerpo policlonal. Sin embargo, se detectaron niveles altos de estos complejos y una proporciòn significativamente elevada de pacientes ateroscleròticos por encima del valor lìmite fijado cuando se empleò para estos fines el anticuerpo monoclonal 12E6E8. Se discute la importancia que puede tener el empleo de anticuerpos monoclonales para detectar lipoproteinas de estructura alterada de alto potencial aterogènico y de los inmunocomplejos que pueden originar

Cuantificación de anticuerpos antiapolipoproteína- B humana por ensayo inmunoenzimático (ELISA) / Quantitation of human antiapolipoprotein- B antibodies by enzyme-linked immunosorbent assay (ELISA)

SE describen dos sistemas de ensayo inmunoenzimático para la cuantificación de anticuerpos contra apolipoproteína-B humana, con un rango de sensibilidad entre 0,5 y 8 microgramos por milímetro. En uno de los sistemas la fase sólida se recubre directamente con suero humano fresco y en el otro con anticuerpos específicos contra la apolipoproteína-B y posteriormente se añade el suero humano. Con este último sistema se obtienen curvas de mayor pendiente que con el primero. Ambos sistemas tienen la ventaja de utilizar la apo-B de recubrimiento sin procedimientos previos de purificación que puedan afectar los determinantes antigénicos de las particulas lipoproteínas que la contienen

Cuantificación de anticuerpos antiapolipoproteína- B humana por ensayo inmunoenzimático (ELISA) / Quantitation of huan antiapolipoprotein- B antibodies by enzyme-linked immunosorbent assay (ELISA)

SE describen dos sistemas de ensayo inmunoenzimático para la cuantificación de anticuerpos contra apolipoproteína-B humana, con un rango de sensibilidad entre 0,5 y 8 microgramos por milímetro. En uno de los sistemas la fase sólida se recubre directamente con suero humano fresco y en el otro con anticuerpos específicos contra la apolipoproteína-B y posteriormente se añade el suero humano. Con este último sistema se obtienen curvas de mayor pendiente que con el primero. Ambos sistemas tienen la ventaja de utilizar la apo-B de recubrimiento sin procedimientos previos de purificación que puedan afectar los determinantes antigénicos de las particulas lipoproteínas que la contienen

Lipoproteínas de baja y muy baja densidad glicosiladas en un grupo de pacientes diabéticos / Glycosylate low and very low lipoproteins in a group of diabetic patients

Se utilizó la reacción con ácido tiobarbitúrico para cuantificar el grado de gicosilación de las lipoproteínas de baja y muy baja densidad una vez precipitadas con ácido fosfotúngstico y cloruro de magnesio. Se midió la glicosilación de estas lipoproteínas en 50 pacientes diabéticos con diferente grado de compensación metabólica de acuerdo con los valores de hemoglobina glicosilada y en 31 controles no diabéticos con glicemia inferior a 5 mmol/L. Se encontraron diferencias significativas en los valores de lipoproteínas glicosiladas entre los controles y los pacientes diabéticos descompensados (p < 0,001) y dentro de estos últimos con diferentes grados de descompensación metabólica. Se encontró una correlación positiva (p < 0,005) entre los valores de glicemia y de hemoglobina glicosilada con las lipoproteínas glicosiladas

Lipoproteínas de baja y muy baja densidad glicosiladas en un grupo de pacientes diabéticos / Glycosylate low and very low lipoproteins in a group of diabetic patients

Se utilizó la reacción con ácido tiobarbitúrico para cuantificar el grado de gicosilación de las lipoproteínas de baja y muy baja densidad una vez precipitadas con ácido fosfotúngstico y cloruro de magnesio. Se midió la glicosilación de estas lipoproteínas en 50 pacientes diabéticos con diferente grado de compensación metabólica de acuerdo con los valores de hemoglobina glicosilada y en 31 controles no diabéticos con glicemia inferior a 5 mmol/L. Se encontraron diferencias significativas en los valores de lipoproteínas glicosiladas entre los controles y los pacientes diabéticos descompensados (p < 0,001) y dentro de estos últimos con diferentes grados de descompensación metabólica. Se encontró una correlación positiva (p < 0,005) entre los valores de glicemia y de hemoglobina glicosilada con las lipoproteínas glicosiladas