Fatal bleeding in patients receiving anticoagulant therapy for venous thromboembolism: findings from the RIETE registry.

BACKGROUND: Fatal bleeding is a serious consequence of anticoagulant therapy, but factors associated with fatal bleeding during the first 3 months of treatment of venous thromboembolism (VTE) are uncertain. METHODS: Using data from RIETE, an ongoing registry of consecutive patients with acute VTE, we assessed risk factors for fatal bleeding among all patients. We then used this information to derive a clinical model that would stratify a patient's risk of fatal bleeding during the first 3 months of treatment. RESULTS: Of 24 395 patients, 546 (2.24%) had a major bleed and 135 (0.55%) had a fatal bleed. The gastrointestinal tract was the most common site (40% of fatal bleeds), followed by intracranial bleeding (25%). Fatal bleeding was independently associated with the following factors at the time of VTE diagnosis: age >75 years (OR, 2.16), metastatic cancer (OR, 3.80), immobility > or = 4 days (OR, 1.99), a major bleed within the past 30 days (OR, 2.64), an abnormal prothrombin time (OR, 2.09), a platelet count < 100 x 10(9) L(-1) (OR, 2.23), creatinine clearance < 30 mL min(-1) (OR, 2.27), anemia (OR, 1.54), and distal deep vein thrombosis (OR, 0.39). INR at the time of bleeding is not known. A clinical prediction rule for risk of fatal bleeding that included nine baseline factors was derived. Fatal bleeding occurred in 0.16% (95% CI, 0.11-0.23) of the low-risk, 1.06% (95% CI, 0.85-1.30) of the moderate-risk, and 4.24% (95% CI, 2.76-6.27) of the high-risk category. CONCLUSIONS: Patient characteristics and laboratory variables can identify patients at high risk for fatal bleeding during treatment of VTE.

[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.

Colecistitis enfisematosa / Emphysematous cholecistitis

No disponible

Broncoaspiración de contraste baritado / Bronchoaspiration of barium contrast medium

No disponible

Endocarditis infecciosa sobre cable de marcapasos / Infective endocarditis of pacemakers leads

No disponible

[The risk-benefit of the treatment of tuberculosis with a high bacilloscopy sensitivity in a provincial hospital]. / Riesgo-beneficio del tratamiento de tuberculosis, en un hospital provincial, con una sensibilidad alta de la baciloscopia.

BACKGROUND: To know the incidence and type of hepatic toxicity (HTX) of the tuberculous chemotherapy and to value the risk-benefit of treatment in our elderly population in a high sensibility context of the bacilloscopy. PATIENTS AND METHODS: Prospective study of 161 tuberculous patients with standards of 6 months, from January 1989 to December 1994. 75 patients with (INH, FR, PZ and ETB) and 83 patients with (INH, RF and PZ). It was accomplished clinical, analytical and microbiological control to all the patients during 24 months. RESULTS: 28% of the patients had more than 65 years and a 26% HIV infection. The tuberculosis (TBC) was disseminated in a 41%. A 74% of the patients ha positive bacilloscopy. The therapeutic fulfillment was correct in a 85% of the cases. A 48% of HTX was observed, with a 9% of serious HTX (associated with alcoholism and age greater tan 60 years). In 14% of he patients was changed in a way definitive the therapeutic standard. There was a 17% of therapeutic failure (associated with disseminated TBC and HIV infection) and a 7% of relapses. The attributive mortality of TBC was of a 4%. CONCLUSIONS: The transient and moderate increase in transaminase activity is frequent and it does not require to modify the chemotherapy. In the greater patients of 65 years the benefit of trying outweigh the risk, if is accomplished a narrow follow-up with precocious suspension of the drugs in the event of serious toxicity.

Treatment of human brucellosis with netilmicin and doxycycline.

We conducted a prospective, noncomparative, multicenter study to assess the safety and efficacy of doxycycline and netilmicin in the treatment of human brucellosis. The study included 64 patients who had acute brucellosis without endocarditis or neurobrucellosis. The treatment schedule consisted of the administration of 100 mg of doxycycline (or 5 mg/[kg.d] if body weight < or = 40 kg) twice a day orally for 45 days, plus 300 mg of netilmicin (6 mg/[kg.d] if body weight < or = 50 kg) intramuscularly once daily for 7 days. Therapeutic failure was noted in 5 patients (7.7%; 95% confidence interval [CI], 2.5%-17.1%), of whom 2 had spondylitis, 1 had sacroiliitis, and 1 had a splenic abscess that required splenectomy. Relapse was noted in eight patients (12.5%; 95% CI, 5.6%-23.2%). When relapse was considered in combination with initial lack of efficacy, 13 patients (21.9%; 95% CI, 12.3%-33.9%) failed to respond to therapy. Fifteen patients (23%; 95% CI, 13.5%-35.2%) had adverse effects, and one patient (1.5%) had a treatment-limiting adverse effect. Combination therapy with netilmicin/doxycycline may be effective in treating acute brucellosis. However, prospective controlled trials must confirm these results.

Doxycycline-rifampin versus doxycycline-streptomycin in treatment of human brucellosis due to Brucella melitensis. The GECMEI Group. Grupo de Estudio de Castilla-la Mancha de Enfermedades Infecciosas.

Brucellosis is a common zoonosis in many parts of the world; the best regimen for the treatment of brucellosis has not been clearly determined. We have carried out a multicenter, open, controlled trial in five general hospitals in Spain to compare the efficacy and safety of doxycycline and rifampin (DR) versus doxycycline and streptomycin (DS) for the treatment of human brucellosis. The study included 194 ambulatory or hospitalized patients with acute brucellosis, without endocarditis or neurobrucellosis. The diagnostic criterion was isolation of Brucella species from blood or other tissues (n = 120) or a standard tube agglutination titer of 1/160 or more for anti-Brucella antibodies with compatible clinical findings (n = 74). Patients were randomly assigned to receive either 100 mg of doxycycline twice daily plus rifampin, 900 mg/day, in a single morning dose for 45 days (DR group) or the same dose of doxycycline for 45 days plus streptomycin, 1 g/day, intramuscularly for 14 days (DS group). A lack of therapeutic efficacy developed in 8 of the 100 patients in the DR group (8%) and in 2 of the 94 patients in the DS group (2%)(P = 0.10). Relapses occurred in 16 of the 100 patients in the DR group (16%) but in only 5 of the 94 patients in the DS group (5.3%) (P = 0.02). When relapse was considered in combination with initial lack of efficacy, 26 patients in the DR group (24%) and 7 patients in the DS group (7.45%) failed to respond to therapy (P = 0.0016). In general, therapy was well tolerated and only four patients (4%) in the DR group and two (2%) in the DS group had episodes of adverse effects necessitating discontinuation of treatment (P> 0.2). We conclude that a doxycycline-and-rifampin regimen is less effective than the doxycycline-and-streptomycin regimen in patients with acute brucellosis.

[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.