[Quality management in patients with heart failure inside an Internal Medicine Department]. / Calidad del manejo de pacientes con insuficiencia cardiaca en el Servicio de Medicina Interna.

OBJECTIVE: To evaluate the quality management of Heart failure within an Internal Medicine Department, based in quality criteria settled in ACOVE study. METHODS: Retrospective study reporting 267 patients admitted to our Internal Medicine Department with a diagnosis of heart failure (from January 2001 to January 2001). We applied ACOVE protocol to evaluate quality of management assigning a positive numerical score to every accomplished section and a negative score to those sections that were not carried out. RESULTS: Two hundred and sixty seven patients and their clinical records were evaluated (Mean age 76 +/- 9 years, male 50%). They had a mean score of 6.72 +/- 1.33 points. Heart failure etiology was determined in 82% (33% ischemic heart failure, 30% hypertensive heart disease, 12% valvulopathy and 7% others). ACE-Inhibitors/ARA II were used in 66% of patients, with poor utilization of beta-blockers (16%), calcium channel blockers (7%) and class I antiarrhythmic drugs (1%). 94% of patients had written instructions about manage of their disease. Only 36% of patients had an echocardiography study. In patients with atrial fibrillation, 19% were treated with oral anticoagulants and 26% with anti-platelet drugs. In-hospital mortality rate was 4%. We could not meet differences among different physicians and their gender in department of Internal Medicine treating for heart failure, however the score of patients older 70 years was 6.5 +/- 1.38 points while score in younger to years was 7.15 +/- 1.17 points (p = 0.011). CONCLUSIONS: Management of heart failure in our department of Internal Medicine is acceptable. However, there are several points in which improvement could be reached, much as to increase the utilization of ACE inhibitors and beta-blockers in handling of heart failure and to rise the are of echocardiography in the evaluation of these patients. Moreover, older patients showed a lower quality level that could be improved.

[Cardiac tamponade caused by hydatid pericarditis]. / Taponamiento cardiaco por quiste hidatídico pericárdico.

We present the case of a woman with no previous clinical history of disease, that debuted with acute heart failure with symptoms of cardiac tamponade from hydatic pericarditis as a result of a fistula across the diaphragm secondary to a hydatidic cyst rupture in the liver. Cardiac hydatidosis is rare with an incidence in some series between 0.2-2% in humans infested with Echinococcus, affectation of the pericardia being rare. For this reason we present a revision of its pathogenesis, clinical presentation, diagnosis and recommended treatment.

Insuficiencia renal por sulfaduazina en paciente VIH con toxoplasmosis cerebral / Renal failure caused by sulfadiazine in a HIV patient with toxoplasmic encephalitis

No disponible

Crisis convulsiva por bupropión / Convulsions in association with bupropion

No disponible

Calidad del manejo de pacientes con insuficiencia cardiaca en el Servicio de Medicina Interna / Quality management in patients with Herat failure incide and internal medicine department

Objetivo: Evaluar la calidad asistencial de los pacientes ingresados en nuestro Servicio de Medicina Interna con diagnóstico de insuficiencia cardiaca, basándonos en una serie de criterios de calidad recogidos en el estudio ACOVE. Métodos: Análisis retrospectivo mediante protocolo de datos de 267 informes de alta de pacientes ingresados en Medicina Interna en los que uno de los diagnósticos fue el de insuficiencia cardiaca (periodo de enero 2001- enero 2002). Resultados: Valoramos 267 informes de alta (edad media 76 +/-9, siendo varones el 50%). Respecto al estudio ACOVE la puntuación media obtenida fue de 6,72 +/- 1,33. Se determinó las causas de insuficiencia cardiaca en el 82% de los casos (33% isquémico-dilatada, 30% hipertensiva, 12% valvular y 7% otras). El empleo de IECAS/ARA 11 se realizó en el 66% de los pacientes, con escasa utilización de otros fármacos como los Beta-bloqueantes (16%), calcioantagonistas (7%) y antiarrítmicos de clase I (1 %). El 94% de los pacientes recibieron instrucciones breves acerca del manejo de su enfermedad. Sólo un 36% presentaban estudio ecocardiográfico. Ellos pacientes con fibrilación auricular, el 19% fueron tratados con anticoagulación y el 26% con antiagregación. La mortalidad intrahospita-laria fue de un 4%. En el estudio, no hubo diferencias de puntuación entre los diferentes staff del departamento en el manejo de la insuficiencia cardiaca. Así mismo, tampoco se hallaron diferencias en relación al sexo. La edad fue un factor a tener en cuenta: > 70 años, score 6,5 +/- 1,38; < 70 años, score 7,15 +/- 1,17 (p = 0,011).Conclusiones: El manejo de la insuficiencia cardiaca en nuestro servicio de M.Interna es aceptable. Sin embargo, existen importantes puntos donde se debería mejorar, como el aumento de la utilización de lECA S y b-bloqueantes en la insuficiencia cardiaca y el incremento en el uso de la ecocardiografía. Además, en los pacientes de edad avanzada se ha demostrado que el nivel de calidad alcanzado es inferior, lo cual deberemos mejorar

Objective: To evaluate the quality management of Heart failure within an Internal Medicine Department, based in quality criteria settled in ACOVE study. Methods: Retrospective study reporting 267 patients admitted to our Internal Medicine Department with a diagnosis of heart failure (from lanuary 2001 to lanuary 2001). We applied ACOVE protocol to evaluate quality of management assigning a positive numerical score to every accomplished section and a negative score to those sections that were not carried out. Results: Two hundred and sixty seven patients and their clinical records were evaluated (Mean age 76 +/- 9 years, male 50%). They had a mean score of 6,72 +/- 1.33 points. Heart failure etiology was determined in 82% (33% ischemic heart failure, 30% hypertensive heart disease, 12% valvulopathy and 7% others). ACE-Inhibitors/ARA 11 were used in 66% of patients, with poor utilization of beta-blockers (16%), calcium channel blockers (7%) and class 1 antiarrhythmic drugs (1 %). 94% of patients ha4 written instructions about manage of their disease. Only 36% of patients had an echocardiography study. In patients with atrial fibrillation, 19% were treated with oral anticoagulants and 26% with anti-platelet drugs. Inhospital mortality rate was 4%. We could not meet differences among different physicians and their gender in department of Internal Medicine treating for heart failure, however the score ofpatients older 70 years was 6.5 +/- 1.38 points while score in younger to years was 7.I5 +/- 1.17 points (p = 0.011). Conclusions: Management of heart failure in our department of Internal Medicine is acceptable. However, there are several points in which improvement could be reached, much as to increase the utilization of ACE inhibitors and beta-blockers in handling of heart failure and to rise the are of echocardiography in the evaluation of these patiens. Moreover, older patients showed a lower quality level that could be improved

Taponamiento cardiaco por quiate hidatídico pericárdico / Cardiac tamponade caused by hydatid pericarditis

Presentamos el caso de una mujer sin antecedentes personales de interés que debuta con insuficiencia cardiaca con clínica de taponamiento cardiaco por pericarditis hidatídica secundaria a fistulización a traves del diafragma por rotura de quista hidatídico localizado en hígado. La hidatidosis cardiaca es poco frecuente presentado una incidencia según series entre el 0,2-2% sobre el total de infestación en humanos por Echinococcus, siendo la afectación pericárdica infrecuente. Es por ello que realizamos revisión de su etiopatogenia, presentación clínica, diagnósticos de elección y tratamientos recomendados

We present the case of a woman with no previous clinical history of disease, that debuted with acute heart failure with symptoms of cardiac tamponade from hydatic pericarditis as a result of a fistula across the diaphragm secondary to a hidatidic cyst rupture in the Uver. Cardiac hydatidosis is rare with an incidence in some series betweem 0.2-2% in humans infested with Echinococcus, affectation of the pericardia being rare. For this reason we present a revision of its pathogenesis, clinical presentation, diagnosis and recommended treatment

[Acute lung embolism: a prospective study from May 1992, to May 2002]. / Embolismo pulmonar agudo. Un registro de 10 años: de mayo de 1992 a mayo de 2002.

INTRODUCTION: To define de prevalence, the clinical profile, the predisposing factors and the hospital evolution of clinical acute lung thromboembolism episodes. MATERIAL AND METHODS: A prospective study from May 1992, to May 2002, of acute lung embolism in an Internal Medicine ward with 8 beds in Hospital of Navarra (EPHONA). Clinical acute lung thromboembolism is defined by the clinical characteristics together the demonstration of thrombi in the lung arteries with arteriography, helicoid computerized axial tomography, or high or average probability lung gammagraphy, together the demonstration of deep venous thrombosis with doppler ultrasound or phlebography. We compared the clinical spectrum with that of international clinical series, evaluated the possibility of clinical syndromes according to the size of the affected vessel (central vs. peripheral), and compared the characteristics of patients with manifest deep venous thrombosis with those of the patients with clinical acute lung thromboembolism and without a known emboli source. RESULTS: In the period of 10 years, and with 2,493 patients admitted, 106 clinical acute lung thromboembolism were diagnosed (prevalence: 4.25%; CI: 3.51-5.14; p < 0.05); these patients were 72 +/- 11 years, in other words, an age 5 years higher than the rest of the patients (p < 0.001). There was a delay of 10 days from the beginning of the symptomatology up to the hospitalization. The clinical spectrum was similar to that of other reported series except by the presence of cough and pleural rub (p < 0.001). The main predisposing factors were immobility (41%) and cancer (25%). Hospital mortality was 3.77%. In 70 (66%) patients we obtained information on the affected vessel, not being fulfilled the association of specific clinical syndromes with the size of the vessel, although the patients with central clinical acute lung thromboembolism showed higher deterioration of gas exchange (p = 0.002) and higher activation of the fibrinolysis (p = 0.012) than patients with peripheral clinical acute lung thromboembolism. 35% of episodes of clinical acute lung thromboembolism developed without simultaneous deep venous thrombosis and showed higher disturbance of gas exchange (p = 0.03) and arterial hypotension (p = 0.02). CONCLUSIONS: Clinical acute lung thromboembolism is a frequent condition that occurs in patients of advanced age and that shows low hospital mortality when is diagnosed and treated even with a 10-day delay up to the diagnosis. The clinical spectrum is similar to that observed in other parts of the world, but the cough as a prominent a symptom and the pleural rub should propose other diagnostic alternatives. The size of the affected pulmonary vessel is not related with a specific clinical syndrome, although the central clinical acute lung thromboembolism evolves with higher disturbance of the gas exchange. In the third of clinical acute lung thromboembolism episodes an emboli source is not demonstrated, perhaps because all emboli has migrate to the pulmonary arteries; these episodes give rise to higher hypotension and disturbance of the gas exchange.

Embolismo pulmonar agudo. Un registro de 10 años: de mayo de 1992 a mayo de 2002 / Acute lung embolism: a prospective study from May 1992, to May 2002

Introducción. Conocer la prevalencia, el perfil clínico, los factores predisponentes y la evolución hospitalaria de los episodios de tromboembolismo pulmonar agudo clínico. Material y métodos. Estudio prospectivo de mayo de 1992 a mayo de 2002 de embolismo pulmonar agudo en el Hospital de Navarra (EPHONA) en un área clínica de Medicina Interna de 8 camas. El tromboembolismo pulmonar agudo clínico se define por la existencia de clínica más la demostración de trombos en las arterias pulmonares por arteriografía o tomografía axial computarizada helicoidal o gammagrafía pulmonar de alta o media probabilidad, junto con demostración de trombosis venosa profunda por ecografía doppler o flebografía. Comparamos el espectro clínico con el de series internacionales, evaluamos la existencia de síndromes clínicos según el tamaño del vaso afectado (central frente a periférico) y comparamos los pacientes con trombosis venosa profunda con tromboembolismo pulmonar agudo clínico sin fuente embolígena conocida. Resultados. En el período de 10 años y 2.493 pacientes ingresados se diagnosticaron 106 tromboembolismos pulmonares agudos clínicos (prevalencia: 4,25 por ciento; IC: 3,51-5,14; p < 0,05) con una edad de 72 ñ 11 años, 5 años mayor que el resto de los pacientes (p < 0,01). Existe una demora de 10 días desde el inicio de la clínica hasta el ingreso en el hospital. El espectro clínico es similar al de otras series excepto por la presencia de tos y roce pleural (p < 0,001). Los principales factores predisponentes fueron la inmovilidad (41 por ciento) y el cáncer (25 por ciento). La mortalidad hospitalaria es de 3,77 por ciento. En 70 (66 por ciento) pacientes obtuvimos información sobre el vaso afectado, no cumpliéndose la asociación de determinados síndromes clínicos con el tamaño del vaso, aunque los pacientes con tromboembolismo pulmonar agudo clínico central muestran mayor deterioro del intercambio gaseoso (p = 0,002) y activación de la fibrinólisis (p = 0,012) que los periféricos. El 35 por ciento de los episodios de tromboembolismo pulmonar agudo clínico cursaron sin trombosis venosa profunda acompañante, caracterizándose por mayor alteración del intercambio gaseoso (p = 0,03) e hipotensión arterial (p = 0,02). Conclusiones. El tromboembolismo pulmonar agudo clínico es un proceso frecuente que ocurre en pacientes de mayor edad y muestra una mortalidad hospitalaria baja cuando es diagnosticado y tratado a pesar de una demora de 10 días hasta el diagnóstico. El espectro clínico es similar al de otras regiones del mundo, pero la tos como síntoma prominente y el roce pleural debe plantear otras alternativas diagnósticas. El tamaño del vaso pulmonar afectado no se relaciona con un determinado síndrome clínico, aunque el tromboembolismo pulmonar agudo clínico central cursa con mayor alteración del intercambio gaseoso. En la tercera parte de los tromboembolismos pulmonares agudos clínicos no se demuestra foco embolígeno tal vez porque ha emigrado todo a las arterias pulmonares y cursa con mayor hipotensión y alteración del intercambio gaseoso (AU)

[Lactic acidosis in diabetic patient treated with metformin]. / Acidosis láctica en paciente diabético tratado con metformina.

We present a case of metabolic acidosis in a man, recently diagnosed with type 2 diabetes mellitus under treatment with metformin. Metformin (along with Fenformin and Butformin) is an oral antihyperglycemic agent belonging to the biguanide group employed in the treatment of non insulin dependent diabetes (NIDDM). Its main use is in association with other oral agents in obese diabetic patients with difficult metabolic control. In some of these patients, clearly beneficial developed lactic acidosis, specially in those who have predisposing factors (respiratory failure, liver disease or cardiovascular disease) and/or those who require high doses. For this reason we describe its pharmacokinetics, therapeutic indications and its correct use in this type of diabetic patient.

Acidosis láctica en paciente diabético tratado con metformina / Lactic acidosis in diabetic patient treated with metformin

Presentamos el caso de un varón diabético tipo 2 de reciente diagnóstico en tratamiento con metformina que sufre acidosis metabólica. La metformina (junto a fenformina y la butformina) es antidiabético oral, de la familia de las biguanidas, que constituyen un grupo farmacológico utilizado en el tratamiento de la diabetes mellitus no insulíndependiente. Su principal indicación es la asociación con otros grupos de antidiabéticos orales en el tratamiento de pacientes diabéticos obesos con mal control metabólico, presentando indudables beneficios en este tipo de pacientes. En algunos pacientes su uso puede predisponer a acidosis láctica, especialmente en aquellos que presentan factores predisponentes asociados (insuficiencia respiratoria, insuficiencia hepática o enfermedades cardiovasculares) y/o empleo de dosis elevadas del fármaco. Es por ello que describimos su farmacocinética, indicaciones terapéuticas y su correcto manejo en este tipo de pacientes diabéticos (AU)

Tromboembolismo pulmonar: evolución a largo plazo y epidemiología clínica / Pulmonary thromboembolism: long-term clinical course and clinical epidemiology

Antecedentes: La evolución a largo plazo del tromboembolismo pulmonar (TEP) no esta bien establecida. Material y métodos: Estudio prospectivo observacional (mayo-1992 a diciembre-2002) de pacientes ingresados en un área clínica de M. Interna por TEP con los objetivos de observar la supervivencia, las recidivas, la tasa de hemorragias mayores y la aparición de nuevas neoplasias. Resultados: Ingresaron 116 pacientes (edad media 72 ± 11 años, varones 57 -54 por ciento-). fallecieron durante el episodio índice 4 pacientes (mortalidad hospitalaria 3,7 por ciento). Diez pacientes fueron perdidos durante el seguimiento. Los 102 pacientes restantes fueron seguidos durante 31.81 ± 31.23 meses. La tasa de recidiva fue de 19,6 por ciento que ocurrió 22,64 ± 24,57 meses después. La tasa de hemorragia mayor fue de 10,4 por ciento. Se diagnosticaron 14 (13,7 por ciento) nuevas neoplasias en el seguimiento. La prevalencia total de cáncer asociado a TEP fue 31 por ciento. La mortalidad global fue de 37 por ciento, (mayor en mujeres p75 años (p90 (p a 250 UI (p<0,01) todos ellos en el episodio índice y la existencia de un cáncer asociado (p<0,05). En el modelo de regresión logística los factores predictivos de mortalidad fueron la edad, el retraso en el ingreso y los niveles de LDH. Conclusiones: Aunque la mortalidad por TEP es baja en el episodio índice, a largo plazo es elevada, existiendo un periodo crítico los primeros 12 meses, siendo las principales causas de mortalidad el cáncer y el propio TEP o las complicaciones del tratamiento, disminuyendo y estabilizándose la mortalidad a plazos más largos. Pueden predecir mortalidad a largo plazo la edad avanzada, el retraso en el diagnóstico y tratamiento y el nivel de LDH del episodio índice (AU)

Background: Long-term clinical course of pulmonary thromboembolism is not well-known. Our aim was to know the events which occur to in-patients diagnosed of pulmonary embolism. Methods and patients: This is a prospective observational study from May-92 to December-2002 with all in-patients diagnosed of pulmonary thromboembolism at a clinical area of Internal Medicine. Main targets were to know survival, relapses, major hemorrhage rate (Defined as those episodes of bleeding which needed blood transfusion and readmission) and cancer associated rate (Previous and newly diagnosed cancer). Follow up were carried out with telephone contacts with patients and relatives in case of death, and with the computerized system of patients and clinical events of Health Service of Navarra. Results: One hundred and sixteen patients were included in the study (Mean age 72 SD 11 years male 54%).During index episode 4 (3.7%) patients dead. Ten patients were lost in follow up. The rest 102 patients were traced for 31.81 SD 31.23 months (Range 1-127). Relapse rate was 19.6% that occurred 22.64 SD 24.57 (Range 1-73) months after index episode (Twelve pulmonary embolisms, 5 deep venous thromboses and 3 sudden death with dyspnea). Major hemorrhage rate was 10.4%. During follow up 14 (13.7%) new cancers were diagnosed (Lung 4, prostate 2, bladder 2, and colorectal, ovary, breast, liver and kidney one each one). At all prevalence of cancer associated with pulmonary thromboembolism was 31%. Mortality rate was 37% (Men 25%, women 49%, p<0.01). Main causes of death were cancer (32%) and relapse of pulmonary thromboembolism when joined with treatment complications 24%. Half of deaths occurred in the first year of follow up, showing a shortened survival those patients with cancer (p=0.02) and patients with relapses of pulmonary embolism (p=0.06). Beyond the first year, mortality declines to a rate of 10% per year mainly because of cardiovascular causes. Mortality associated factors were age >75 years (p<0.001) gender female (p<0.01), a delayed admission and treatment from the beginning of symptoms (p<0.05), higher LDH level (p<0.01) and coexistence of cancer (p<0.05). In logistic-regression analysis age, delayed admission and treatment and higher LDH levels were predictors of long-term death. Conclusions: Patients with pulmonary embolism show a high mortality rate, with a critical period during the first year after index episode, being deaths associated to cancer and to a composite of relapse of venous thromboembolic disease and bleeding complications. Mortality rate beyond the first year declines, being deaths explained because of cardiovascular causes. An advanced age, a delayed diagnosis and treatment and serum LDH may predict long-term mortality (AU)

[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)

[Pulmonary thromboembolism: long term course and clinical epidemiology]. / Tromboembolismo pulmonar: evolución a largo plazo y epidemiología clínica.

BACKGROUND: Long-term clinical course of pulmonary thromboembolism is not well-known. Our aim was to know the events which occur to in-patients diagnosed of pulmonary embolism. METHODS AND PATIENTS: This is a prospective observational study from May-92 to December-2002 with all in-patients diagnosed of pulmonary thromboembolism at a clinical area of Internal Medicine. Main targets were to know survival, relapses, major hemorrhage rate (Defined as those episodes of bleeding which needed blood transfusion and readmission) and cancer associated rate (Previous and newly diagnosed cancer). Follow up were carried out with telephone contacts with patients and relatives in case of death, and with the computerized system of patients and clinical events of Health Service of Navarra. RESULTS: One hundred and sixteen patients were included in the study (Mean age 72 SD 11 years male 54%). During index episode 4 (3.7%) patients dead. Ten patients were lost in follow up. The rest 102 patients were traced for 31.81 SD 31.23 months (Range 1-127). Relapse rate was 19.6% that occurred 22.64 SD 24.57 (Range 1-73) months after index episode (Twelve pulmonary embolisms, 5 deep venous thromboses and 3 sudden death with dyspnea). Major hemorrhage rate was 10.4%. During follow up 14 (13.7%) new cancers were diagnosed (Lung 4, prostate 2, bladder 2, and colorectal, ovary, breast, liver and kidney one each one). At all prevalence of cancer associated with pulmonary thromboembolism was 31%. Mortality rate was 37% (Men 25%, women 49%, p < 0.01). Main causes of death were cancer (32%) and relapse of pulmonary thromboembolism when joined with treatment complications 24%. Half of deaths occurred in the first year of follow up, showing a shortened survival those patients with cancer (p = 0.02) and patients with relapses of pulmonary embolism (p = 0.06). Beyond the first year, mortality declines to a rate of 10% per year mainly because of cardiovascular causes. Mortality associated factors were age > 75 years (p < 0.001) gender female (p < 0.01), a delayed admission and treatment from the beginning of symptoms (p < 0.05), higher LDH level (p < 0.01) and coexistence of cancer (p < 0.05). In logistic-regression analysis age, delayed admission and treatment and higher LDH levels were predictors of long-term death. CONCLUSIONS: Patients with pulmonary embolism show a high mortality rate, with a critical period during the first year after index episode, being deaths associated to cancer and to a composite of relapse of venous thromboembolic disease and bleeding complications. Mortality rate beyond the first year declines, being deaths explained because of cardiovascular causes. An advanced age, a delayed diagnosis and treatment and serum LDH may predict long-term mortality.

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)