Publications by authors named "Pedro Ruiz-Artacho"

37 Publications

Characteristics of isolated superficial vein thrombosis and diagnostictherapeutic management in Spanish hospital emergency departments: the ALTAMIRA study.

Emergencias 2021 Dec;33(6):433-440

Departamento de Medicina Interna, Clínica Universidad de Navarra, Madrid, España. CIBER de Enfermedades Respiratorias, CIBERES, Madrid, España. Interdisciplinar Teragnosis and Radiosomics (INTRA) Research Group, Universidad de Navarra, España.

Objectives: To describe the characteristics of patients with isolated lower-limb superficial vein thrombosis (SVT) treated in hospital emergency departments and to evaluate adherence to clinical practice guidelines on diagnosis (vein ultrasound imaging) and therapeutic management (start of anticoagulant therapy).

Material And Methods: Retrospective cohort study in 18 Spanish emergency departments. We included all patients with a final emergency department diagnosis of lower-limb SVT aged 18 years or older between January 2016 and May 2017. Backward stepwise multiple logistic regression analysis was used to evaluate adherence to clinical practice guidelines on ordering vein ultrasound imaging and starting anticoagulant therapy.

Results: A total of 1166 patients were included. The mean patient age was 59.6 years, and 67.9% were women. About a quarter of the patients (24.4%) had a history of venous thromboembolic disease. Complications developed in 8.9% within 180 days: 4.6% experienced a recurrence and 3.6% progressed to SVT and 1.8% to deep vein thrombosis; pulmonary thromboembolism occurred in 0.9%. Hemorrhagic complications developed in 17 patients (1.5%). Sixteen patients (1.4%) died. Vein ultrasound imagine was ordered for 703 patients (60.3%). Anticoagulant agents were prescribed for 898 (77%) for a median period of 22 days. Variables associated with a decision to order anticoagulants were a history of venous thromboembolic disease (odds ratio [OR], 1.60; 95% CI, 1.12-2.30), varicose veins (OR, 1.40; 95% CI, 1.12-2.30); limb pain (OR, 1.44; 95% CI, 1.08-1.91); painful cord (OR, 1.30; 95% CI, 0.97-1.73); and availability of vein ultrasound images (OR, 1.60; 95% CI, 1.94-3.45).

Conclusion: Adherence to clinical practice guidelines for the diagnosis and treatment of isolated lower-limb SVT is low in Spanish emergency departments. Ultrasound imaging is not ordered for 1 out of every 2 to 3 patients, and anticoagulant treatment is not started in 1 out of 4 patients. There is great room for improvement.
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December 2021

Therapeutic vs. prophylactic bemiparin in hospitalized patients with non-severe COVID-19 (BEMICOP): an open-label, multicenter, randomized trial.

Thromb Haemost 2021 Oct 12. Epub 2021 Oct 12.

Hematology, University Clinic of Navarra, Pamplona, Spain.

Thrombophylaxis with low molecular weight heparin (LMWH) in hospitalized patients with COVID-19 is mandatory, unless contraindicated. Given the links between inflammation and thrombosis, the use of higher doses of anticoagulants could improve outcomes. We conducted an open-label, multicenter, randomized, controlled trial in adult patients hospitalized with non-severe COVID-19 pneumonia and elevated D-dimer. Patients were randomized to therapeutic-dose bemiparin (115 IU/Kg daily) vs. standard prophylaxis (bemiparin 3,500 IU daily), for 10 days. The primary efficacy outcome was a composite of death, intensive care unit admission, need of mechanical ventilation support, development of moderate/severe acute respiratory distress and venous or arterial thrombosis within 10 days of enrollment. The primary safety outcome was major bleeding (ISTH criteria). A prespecified interim analysis was performed when 40% of the planned study population was reached. From October 2020 to May 2021, 70 patients were randomized at 5 sites and 65 were included in the primary analysis; 32 patients allocated to therapeutic-dose and 33 to standard prophylactic-dose. The primary efficacy outcome occurred in 7 patients (21.9%) in the therapeutic-dose group and 6 patients (18.2%) in the prophylactic-dose (absolute risk difference 3.6% [95% CI, -16%- 24%]; odds ratio 1.26 [95% CI, 0.37-4.26]; p=0.95). Discharge in the first 10 days was possible in 66% and 79% of patients, respectively. No major bleeding event was registered. Therefore, in patients with COVID-19 hospitalized with non-severe pneumonia but elevated D-dimer, the use of a short course of therapeutic-dose bemiparin did not improve clinical outcomes compared to standard prophylactic doses.
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http://dx.doi.org/10.1055/a-1667-7534DOI Listing
October 2021

Effect of a Pulmonary Embolism Diagnostic Strategy on Clinical Outcomes in Patients Hospitalized for COPD Exacerbation: A Randomized Clinical Trial.

JAMA 2021 10;326(13):1277-1285

CIBER Enfermedades Respiratorias (CIBERES), Madrid, Spain.

Importance: Active search for pulmonary embolism (PE) may improve outcomes in patients hospitalized for exacerbations of chronic obstructive pulmonary disease (COPD).

Objective: To compare usual care plus an active strategy for diagnosing PE with usual care alone in patients hospitalized for COPD exacerbation.

Design, Setting, And Participants: Randomized clinical trial conducted across 18 hospitals in Spain. A total of 746 patients were randomized from September 2014 to July 2020 (final follow-up was November 2020).

Interventions: Usual care plus an active strategy for diagnosing PE (D-dimer testing and, if positive, computed tomography pulmonary angiogram) (n = 370) vs usual care (n = 367).

Main Outcomes And Measures: The primary outcome was a composite of nonfatal symptomatic venous thromboembolism (VTE), readmission for COPD, or death within 90 days after randomization. There were 4 secondary outcomes, including nonfatal new or recurrent VTE, readmission for COPD, and death from any cause within 90 days. Adverse events were also collected.

Results: Among the 746 patients who were randomized, 737 (98.8%) completed the trial (mean age, 70 years; 195 [26%] women). The primary outcome occurred in 110 patients (29.7%) in the intervention group and 107 patients (29.2%) in the control group (absolute risk difference, 0.5% [95% CI, -6.2% to 7.3%]; relative risk, 1.02 [95% CI, 0.82-1.28]; P = .86). Nonfatal new or recurrent VTE was not significantly different in the 2 groups (0.5% vs 2.5%; risk difference, -2.0% [95% CI, -4.3% to 0.1%]). By day 90, a total of 94 patients (25.4%) in the intervention group and 84 (22.9%) in the control group had been readmitted for exacerbation of COPD (risk difference, 2.5% [95% CI, -3.9% to 8.9%]). Death from any cause occurred in 23 patients (6.2%) in the intervention group and 29 (7.9%) in the control group (risk difference, -1.7% [95% CI, -5.7% to 2.3%]). Major bleeding occurred in 3 patients (0.8%) in the intervention group and 3 patients (0.8%) in the control group (risk difference, 0% [95% CI, -1.9% to 1.8%]; P = .99).

Conclusions And Relevance: Among patients hospitalized for an exacerbation of COPD, the addition of an active strategy for the diagnosis of PE to usual care, compared with usual care alone, did not significantly improve a composite health outcome. The study may not have had adequate power to assess individual components of the composite outcome.

Trial Registration: ClinicalTrials.gov Identifier: NCT02238639.
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http://dx.doi.org/10.1001/jama.2021.14846DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8493436PMC
October 2021

Prediction of Major Bleeding in Anticoagulated Patients for Venous Thromboembolism: Comparison of the RIETE and the VTE-BLEED Scores.

TH Open 2021 Jul 9;5(3):e319-e328. Epub 2021 Aug 9.

Department of Internal Medicine, Instituto de Salud Carlos III, Universidad Católica de Murcia, Hospital Germans Trias i Pujol, CIBERES, Badalona (Barcelona), Madrid, Spain.

The performance of validated bleeding risk scores in patients with venous thromboembolism (VTE) could be different depending on the time after index event or the site of bleeding. In this study we compared the "classic" Registro Informatizado de Enfermedad TromboEmbólica (RIETE) score and the more recently developed VTE-BLEED score for the prediction of major bleeding in patients under anticoagulant therapy in different time intervals after VTE diagnosis. Out of 82,239 patients with acute VTE, the proportion of high-risk patients according to the RIETE and VTE-BLEED scores was 7.1 and 62.3%, respectively. The performance of both scores across the different study periods (first 30 days after VTE diagnosis, days 31-90, days 91-180, and days 181-360) was similar, with areas under the receiving operating characteristics (ROC) curve (AUC) ranging between 0.69 and 0.72. However, the positive predictive values were low, ranging between 0.6 and 3.9 (better for early major bleeding than for later periods). A sensitivity analysis limited to patients with unprovoked VTE showed comparable results. Both scores showed a trend toward a better prediction of extracranial than intracranial major bleeding, the RIETE score resulting more useful for early extracranial bleeding and the VTE-BLEED for late intracranial hemorrhages. Our study reveals that the usefulness of available bleeding scores may vary depending on the characteristics of the patient population and the time frame evaluated. Dynamic scores could be more useful for this purpose.
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http://dx.doi.org/10.1055/s-0041-1729171DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8459175PMC
July 2021

Estimating Bleeding Risk in Patients with Cancer-Associated Thrombosis: Evaluation of Existing Risk Scores and Development of a New Risk Score.

Thromb Haemost 2021 Sep 20. Epub 2021 Sep 20.

Department of Acute Internal Medicine, University Medical Center Utrecht, Utrecht, The Netherlands.

Background:  Bleeding risk is highly relevant for treatment decisions in cancer-associated thrombosis (CAT). Several risk scores exist, but have never been validated in patients with CAT and are not recommended for practice.

Objectives:  To compare methods of estimating clinically relevant (major and clinically relevant nonmajor) bleeding risk in patients with CAT: (1) existing risk scores for bleeding in venous thromboembolism, (2) pragmatic classification based on cancer type, and (3) new prediction model.

Methods:  In a posthoc analysis of the Hokusai VTE Cancer study, a randomized trial comparing edoxaban with dalteparin for treatment of CAT, seven bleeding risk scores were externally validated (ACCP-VTE, HAS-BLED, Hokusai, Kuijer, Martinez, RIETE, and VTE-BLEED). The predictive performance of these scores was compared with a pragmatic classification based on cancer type (gastrointestinal; genitourinary; other) and a newly derived competing risk-adjusted prediction model based on clinical predictors for clinically relevant bleeding within 6 months after CAT diagnosis with nonbleeding-related mortality as the competing event ("CAT-BLEED").

Results:  Data of 1,046 patients (149 events) were analyzed. Predictive performance of existing risk scores was poor to moderate (C-statistics: 0.50-0.57; poor calibration). Internal validation of the pragmatic classification and "CAT-BLEED" showed moderate performance (respective C-statistics: 0.61; 95% confidence interval [CI]: 0.56-0.66, and 0.63; 95% CI 0.58-0.68; good calibration).

Conclusion:  Existing risk scores for bleeding perform poorly after CAT. Pragmatic classification based on cancer type provides marginally better estimates of clinically relevant bleeding risk. Further improvement may be achieved with "CAT-BLEED," but this requires external validation in practice-based settings and with other DOACs and its clinical usefulness is yet to be demonstrated.
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http://dx.doi.org/10.1055/s-0041-1735251DOI Listing
September 2021

Heart Rate and Mortality in Patients With Acute Symptomatic Pulmonary Embolism.

Chest 2021 Aug 31. Epub 2021 Aug 31.

CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain; Department of Internal Medicine, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona; Universidad Católica de Murcia, Murcia, Spain.

Background: The association between heart rate (HR) and pulmonary embolism (PE) outcomes has not been well studied. Furthermore, optimal cutoffs to identify low-risk and intermediate- to high-risk patients are not well known.

Research Question: Does an association exist between baseline HR and PE outcome across the continuum of HR values?

Study Design And Methods: The current study included 44,331 consecutive nonhypotensive patients with symptomatic PE from the Registro Informatizado de la Enfermedad TromboEmbólica registry between 2001 and 2021. Outcomes included 30-day all-cause and PE-specific mortality. We used hierarchical logistic regression to assess the association between admission HR and outcomes.

Results: A positive relationship was found between admission HR and 30-day all-cause and PE-related mortality. Considering an HR of 80 to 99 beats/min as a reference, patients in the higher HR strata showed higher rates of all-cause death (adjusted OR, 1.5 for HR of 100-109 beats/min; OR, 1.7 for HR of 110-119 beats/min; OR, 1.9 for HR of 120-139 beats/min; and OR, 2.4 for HR of ≥ 140 beats/min). Patients in the lower strata of HR showed significantly lower rates of 30-day all-cause mortality compared with the same reference group (adjusted OR, 0.6 for HR of 60-79 beats/min; and OR, 0.5 for HR of < 60 beats/min). The findings for 30-day PE-related mortality were similar. For identification of low-risk patients, a cutoff value of 80 beats/min (vs 110 beats/min) increased the sensitivity of the simplified Pulmonary Embolism Severity Index (sPESI) from 93.4% to 98.8%. For identification of intermediate- to high-risk patients, a cutoff value of 140 beats/min (vs 110 beats/min) increased the specificity of the Bova score from 93.2% to 98.0%.

Interpretation: In nonhypotensive patients with acute symptomatic PE, a high HR portends an increased risk of all-cause and PE-related mortality. Modifying the HR cutoff in the sPESI and the Bova score improves prognostication of patients with PE.
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http://dx.doi.org/10.1016/j.chest.2021.08.059DOI Listing
August 2021

Randomised controlled trial of a prognostic assessment and management pathway to reduce the length of hospital stay in normotensive patients with acute pulmonary embolism.

Eur Respir J 2021 Aug 12. Epub 2021 Aug 12.

CIBER Enfermedades Respiratorias (CIBERES), Madrid, Spain.

Background: The length of hospital stay () for acute pulmonary embolism () varies considerably. Whether the upfront use of a PE prognostic assessment and management pathway is effective in reducing the LOS remains unknown.

Methods: We conducted a randomised, controlled trial of adults hospitalised for acute PE: patients were assigned to a prognostic assessment and management pathway involving risk stratification, followed by predefined criteria for mobilisation and discharge (intervention group), or usual care (control group). The primary end point was LOS. The secondary end points were the cost of prognostic tests and of hospitalisation, and 30-day clinical outcomes.

Results: Of 500 patients who underwent randomisation, 498 were included in the modified intention-to-treat analysis. The median LOS was 4.0 days (interquartile range [], 3.7 to 4.2 days) in the intervention group and 6.1 days (IQR, 5.7 to 6.5 days) in the control group (p<0.001). The mean total cost of prognostic tests was €174.76 in the intervention group, as compared with €233.12 in the control group (mean difference, €-58.37; 95% confidence interval [], €-84.34 to €-32.40). The mean total hospitalisation cost per patient was €2085.66 in the intervention group, compared with €3232.97 in the control group (mean difference, €-1147.31; 95% CI, €-1414.97 to €-879.65). No significant differences were observed in 30-day readmissions (4.0% 4.8%, respectively), or all-cause (2.4% 2.0%) and PE-related mortality rates (0.8% 1.2%).

Conclusions: The use of a prognostic assessment and management pathway was effective in reducing the LOS for acute PE.
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http://dx.doi.org/10.1183/13993003.00412-2021DOI Listing
August 2021

Profiles of patients with venous thromboembolic disease in the emergency department and their medium-term prognosis: data from the ESPHERIA registry.

Emergencias 2021 Abr;33(2):107-114

CIBER de Enfermedades Respiratorias, CIBERES, Madrid, España. Departamento de Medicina Interna, Clínica Universidad de Navarra, Madrid, España. Interdisciplinar Teragnosis and Radiosomics (INTRA) Research Group, Universidad de Navarra, España.

Objectives: To assess the 180-day prognosis for patients of different profiles diagnosed with venous thromboembolism (VTE) in emergency departments (EDs). Secondary aims were to assess all-cause mortality and readmission rates and to describe the clinical characteristics and forms of presentation of deep vein thrombosis (DVT) and pulmonary thromboembolism (PTE) in each patient profile.

Material And Methods: Secondary analysis of data from the ESPHERIA registry (Spanish acronym for Risk Profile of Patients with VTE Attended in Spanish Emergency Departments), which includes consecutive patients with symptomatic VTE treated in 53 EDs. The cases were divided according to 4 profiles: 1) unprovoked DVT, 2) DVT provoked by transient risk factors, 3)patients with cancer, and 4) patients with low cardiopulmonary reserve. The primary outcome was a composite of 180-day all-cause mortality or readmission.

Results: We studied 773 patients: 450 (58.2%) were classified as profile 1, 128 (16.6%) as profile 2, 115 (14.9%) as profile 3 , a nd 8 0 ( 10.3%) a s p rofile 4. We fo und di fferences be tween th e 4 pr ofiles in demographics, com orbidity, clinical presentation, type of DVT and location, management, and outcomes. One hundred ninety-five p atients (25.2%) had at least one of the adverse events included in the composite within 180 days: 69 (8.9%) died and 179 (23.2%) were readmitted. Hazard ratios (HR) indicated that DVT with low cardiopulmonary reserve (HR, 1.73; 95% CI, 1.12-2.68; P = .01)) or DVT with cancer (HR, 3.10; 95% CI, 2.22-4.34; P .001) were the profiles t hat w ere independently associated with the 180-day composite outcome.

Conclusion: Classifying patients with DVT according to 4 profiles ( unprovoked, provoked by t ransient r isk f actors, associated with cancer, and associated with low cardiopulmonary reserve) when making the diagnosis is useful for assessing prognosis for all-cause mortality or readmission within 180 days. This classification could be useful for establishing a care and follow-up plan when discharging patients with DVT from the ED.
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October 2021

Multidisciplinary Consensus for the Management of Pulmonary Thromboembolism.

Arch Bronconeumol (Engl Ed) 2021 Feb 13. Epub 2021 Feb 13.

Servicio de Neumología, Hospital Ramón y Cajal (IRYCIS)/Universidad de Alcalá, Madrid, España; CIBER de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, España. Electronic address:

We have updated recommendations on 12 controversial topics that were published in the 2013 National Consensus on the diagnosis, risk stratification and treatment of patients with pulmonary embolism (PE). A comprehensive review of the literature was performed for each topic, and each recommendation was evaluated in two teleconferences. For diagnosis, we recommend against using the Pulmonary Embolism Rule Out Criteria (PERC) rule as the only test to rule out PE, and we recommend using a D-dimer cutoff adjusted to age to rule out PE. We suggest using computed tomography pulmonary angiogram as the imaging test of choice for the majority of patients with suspected PE. We recommend using direct oral anticoagulants (over vitamin K antagonists) for the vast majority of patients with acute PE, and we suggest using anticoagulation for patients with isolated subsegmental PE. We recommend against inserting an inferior cava filter for the majority of patients with PE, and we recommend using full-dose systemic thrombolytic therapy for PE patients requiring reperfusion. The decision to stop anticoagulants at 3 months or to treat indefinitely mainly depends on the presence (or absence) and type of risk factor for venous thromboembolism, and we recommend against thrombophilia testing to decide duration of anticoagulation. Finally, we suggest against extensive screening for occult cancer in patients with PE.
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http://dx.doi.org/10.1016/j.arbres.2021.01.031DOI Listing
February 2021

Incidence of VTE and Bleeding Among Hospitalized Patients With Coronavirus Disease 2019: A Systematic Review and Meta-analysis.

Chest 2021 03 17;159(3):1182-1196. Epub 2020 Nov 17.

CIBER Enfermedades Respiratorias (CIBERES), Madrid, Spain; Department of Internal Medicine, Hospital Germans Trias i Pujol, Badalona, Barcelona, Universidad Católica de Murcia, Murcia, Spain.

Background: Individual studies have reported widely variable rates for VTE and bleeding among hospitalized patients with coronavirus disease 2019 (COVID-19).

Research Question: What is the incidence of VTE and bleeding among hospitalized patients with COVID-19?

Methods: In this systematic review and meta-analysis, 15 standard sources and COVID-19-specific sources were searched between January 1, 2020, and July 31, 2020, with no restriction according to language. Incidence estimates were pooled by using random effects meta-analyses. Heterogeneity was evaluated by using the I statistic, and publication bias was assessed by using the Begg and Egger tests.

Results: The pooled incidence was 17.0% (95% CI, 13.4-20.9) for VTE, 12.1% (95% CI, 8.4-16.4) for DVT, 7.1% (95% CI, 5.3-9.1) for pulmonary embolism (PE), 7.8% (95% CI, 2.6-15.3) for bleeding, and 3.9% (95% CI, 1.2-7.9) for major bleeding. In subgroup meta-analyses, the incidence of VTE was higher when assessed according to screening (33.1% vs 9.8% by clinical diagnosis), among patients in the ICU (27.9% vs 7.1% in the ward), in prospective studies (25.5% vs 12.4% in retrospective studies), and with the inclusion of catheter-associated thrombosis/isolated distal DVTs and isolated subsegmental PEs. The highest pooled incidence estimate of bleeding was reported for patients receiving intermediate- or full-dose anticoagulation (21.4%) and the lowest in the only prospective study that assessed bleeding events (2.7%).

Interpretation: Among hospitalized patients with COVID-19, the overall estimated pooled incidence of VTE was 17.0%, with higher rates with routine screening, inclusion of distal DVT, and subsegmental PE, in critically ill patients and in prospective studies. Bleeding events were observed in 7.8% of patients and were sensitive to use of escalated doses of anticoagulants and nature of data collection. Additional studies are required to ascertain the significance of various thrombotic events and to identify strategies to improve patient outcomes.

Trial Registry: PROSPERO; No.: CRD42020198864; URL: https://www.crd.york.ac.uk/prospero/.
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http://dx.doi.org/10.1016/j.chest.2020.11.005DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7670889PMC
March 2021

Survival and quality of life after early discharge in low-risk pulmonary embolism.

Eur Respir J 2021 02 4;57(2). Epub 2021 Feb 4.

Emergency Dept, Clinico San Carlos Hospital, IdISSC, Madrid, Spain.

Introduction: Early discharge of patients with acute low-risk pulmonary embolism requires validation by prospective trials with clinical and quality-of-life outcomes.

Methods: The multinational Home Treatment of Patients with Low-Risk Pulmonary Embolism with the Oral Factor Xa Inhibitor Rivaroxaban (HoT-PE) single-arm management trial investigated early discharge followed by ambulatory treatment with rivaroxaban. The study was stopped for efficacy after the positive results of the predefined interim analysis at 50% of the planned population. The present analysis includes the entire trial population (576 patients). In addition to 3-month recurrence (primary outcome) and 1-year overall mortality, we analysed self-reported disease-specific (Pulmonary Embolism Quality of Life (PEmb-QoL) questionnaire) and generic (five-level five-dimension EuroQoL (EQ-5D-5L) scale) quality of life as well as treatment satisfaction (Anti-Clot Treatment Scale (ACTS)) after pulmonary embolism.

Results: The primary efficacy outcome occurred in three (0.5%, one-sided upper 95% CI 1.3%) patients. The 1-year mortality was 2.4%. The mean±sd PEmb-QoL decreased from 28.9±20.6% at 3 weeks to 19.9±15.4% at 3 months, a mean change (improvement) of -9.1% (p<0.0001). Improvement was consistent across all PEmb-QoL dimensions. The EQ-5D-5L was 0.89±0.12 at 3 weeks after enrolment and improved to 0.91±0.12 at 3 months (p<0.0001). Female sex and cardiopulmonary disease were associated with poorer disease-specific and generic quality of life; older age was associated with faster worsening of generic quality of life. The ACTS burden score improved from 40.5±6.6 points at 3 weeks to 42.5±5.9 points at 3 months (p<0.0001).

Conclusions: Our results further support early discharge and ambulatory oral anticoagulation for selected patients with low-risk pulmonary embolism. Targeted strategies may be necessary to further improve quality of life in specific patient subgroups.
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http://dx.doi.org/10.1183/13993003.02368-2020DOI Listing
February 2021

Nonsuspected pulmonary embolism in the emergency department.

Eur J Emerg Med 2020 10;27(5):379-380

ETV Group, SEMES, Emergency Area, Clínic of Barcelona Hospital, Emergency Process and Patology Group, IDIBAPS, Barcelona, Spain.

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http://dx.doi.org/10.1097/MEJ.0000000000000683DOI Listing
October 2020

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

Thromb Res 2020 11 10;195:139-145. Epub 2020 Jul 10.

A full list of the RIETE investigators is given in the appendix.

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 × 10 platelets/L (severe thrombocytopenia), 711 (4.6%) had 50-99 × 10/L (mild thrombocytopenia) and 14,460 (94.3%) had ≥100 × 10/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.
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http://dx.doi.org/10.1016/j.thromres.2020.07.021DOI Listing
November 2020

Clinical characteristics and course in emergency department patients with chronic obstructive pulmonary disease and symptomatic acute venous thromboembolic disease: secondary analysis of the ESPHERIA registry.

Emergencias 2020 02;32(1):40-44

Departamento de Medicina Interna, Clínica Universidad de Navarra, Madrid, España. Interdisciplinar Teragnosis and Radiosomics (INTRA) Research Group, Universidad de Navarra, España.

Objectives: To determine the impact of chronic obstructive pulmonary disease (COPD) on prognosis in patients diagnosed with venous thromboembolic disease (VTED) in Spanish emergency departments.

Material And Methods: Secondary analysis of data from the ESPHERIA (Spanish acronym for Risk Profile of Patients VTED Attended in Spanish Emergency Departments) registry.

Results: A total of 801 patients, 71 (9%) with COPD, were included. Pulmonary thromboembolism was recorded in 77.%% of the patients with COPD (vs in 47.1% of patients without COPD; P<.001). Patients with COPD had evidence of right ventricular dysfunction on computed tomography angiography more often than other VTED patients (18.2% vs 13.1%; P<.001) and more often required ventilatory support (7% vs 0.5%; P<.001). VTED patients with COPD also had a higher rate of readmission or mortality at 180 days (hazard ratio, 1.52; 95% CI, 1.00-2.29; P = .048)] than patients without COPD.

Conclusion: COPD affects the prognosis of patients diagnosed with VTED in Spanish emergency departments as evidenced by hospital readmission and mortality.
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February 2020

Hospital volume and outcomes for acute pulmonary embolism: multinational population based cohort study.

BMJ 2019 07 29;366:l4416. Epub 2019 Jul 29.

Department of Internal Medicine, Germans Trias i Pujol University Hospital, Badalona, Spain.

Objectives: To evaluate the association between experience in the management of acute pulmonary embolism, reflected by hospital case volume, and mortality.

Design: Multinational population based cohort study using data from the Registro Informatizado de la Enfermedad TromboEmbólica (RIETE) registry between 1 January 2001 and 31 August 2018.

Setting: 353 hospitals in 16 countries.

Participants: 39 257 consecutive patients with confirmed diagnosis of acute symptomatic pulmonary embolism.

Main Outcome Measure: Pulmonary embolism related mortality within 30 days after diagnosis of the condition.

Results: Patients with acute symptomatic pulmonary embolism admitted to high volume hospitals (>40 pulmonary embolisms per year) had a higher burden of comorbidities. A significant inverse association was seen between annual hospital volume and pulmonary embolism related mortality. Admission to hospitals in the highest quarter (that is, >40 pulmonary embolisms per year) was associated with a 44% reduction in the adjusted odds of pulmonary embolism related mortality at 30 days compared with admission to hospitals in the lowest quarter (<15 pulmonary embolisms per year; adjusted risk 1.3% 2.3%; adjusted odds ratio 0.56 (95% confidence interval 0.33 to 0.95); P=0.03). Results were consistent in all sensitivity analyses. All cause mortality at 30 days was not significantly reduced between the two quarters (adjusted odds ratio 0.78 (0.50 to 1.22); P=0.28). Survivors showed little change in the odds of recurrent venous thromboembolism (odds ratio 0.76 (0.49 to 1.19)) or major bleeding (1.07 (0.77 to 1.47)) between the low and high volume hospitals.

Conclusions: In patients with acute symptomatic pulmonary embolism, admission to high volume hospitals was associated with significant reductions in adjusted pulmonary embolism related mortality at 30 days. These findings could have implications for management strategies.
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http://dx.doi.org/10.1136/bmj.l4416DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6661688PMC
July 2019

Authors' reply.

Emergencias 2019 Ago;31(4):295

Servicio de Medicina Interna, Clínica Universitaria de Navarra, Madrid, España.

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May 2020

[Thymoma in a patient with klinefelter syndrome. Case report].

Rev Med Chil 2019 Apr;147(4):518-521

Servicio de Medicina Interna, Hospital Universitario Clínico San Carlos, Madrid, España.

Klinefelter syndrome (47, XXY in most cases) is a frequently underdiagnosed chromosomal anomaly associated with multiple comorbidities in adult life. Patients with Klinefelter syndrome have a higher risk of cancer. Specifically, these patients have a higher risk for mediastinal germ cell tumors. It is estimated that 8% of male patients with mediastinal tumors have Klinefelter. We report a 42-years-old male who suffered recurrent respiratory infections. During the study, a mediastinal mass was found, whose pathological study disclosed a type B thymoma. The patient had a history of infertility, high stature, gynecomastia, obesity with gynecoid distribution of body fat and testicular atrophy. A karyotype was requested (47, XXY), confirming the diagnosis of Klinefelter syndrome.
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http://dx.doi.org/10.4067/S0034-98872019000400518DOI Listing
April 2019

Clinical Characteristics and Outcomes of Patients with Lung Cancer and Venous Thromboembolism.

TH Open 2018 Apr 1;2(2):e210-e217. Epub 2018 Jun 1.

Department of Internal Medicine, Hospital Germans Trias i Pujol, Universidad Autónoma de Barcelona, Badalona, Barcelona, Spain.

 The natural history of patients with lung cancer and venous thromboembolism (VTE) has not been consistently evaluated.  We used the RIETE (Registro Informatizado Enfermedad TromboEmbólica) database to assess the clinical characteristics, time course, and outcomes during anticoagulation of lung cancer patients with acute, symptomatic VTE.  As of May 2017, a total of 1,725 patients were recruited: 1,208 (70%) presented with pulmonary embolism (PE) and 517 with deep vein thrombosis (DVT). Overall, 865 patients (50%) were diagnosed with cancer <3 months before, 1,270 (74%) had metastases, and 1,250 (72%) had no additional risk factors for VTE. During anticoagulation (median, 93 days), 166 patients had symptomatic VTE recurrences (recurrent DVT: 86, PE: 80), 63 had major bleeding (intracranial 11), and 870 died. The recurrence rate was twofold higher than the major bleeding rate during the first month, and over threefold higher beyond the first month. Fifty-seven patients died of PE and 15 died of bleeding. Most fatal PEs (84%) and most fatal bleeds (67%) occurred within the first month of therapy. Nine patients with fatal PE (16%) died within the first 24 hours. Of 72 patients dying of PE or bleeding, 15 (21%) had no metastases and 29 (40%) had the VTE shortly after surgery or immobility.  Active surveillance on early signs and/or symptoms of VTE in patients with recently diagnosed lung cancer and prescription of prophylaxis in those undergoing surgery or during periods of immobilization might likely help prevent VTE better, detect it earlier, and treat it more efficiently.
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http://dx.doi.org/10.1055/s-0038-1656542DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6524875PMC
April 2018

Ultrasound imaging obtained by emergency department physicians to diagnose deep vein thrombosis: accuracy, safety, and efficiency.

Emergencias 2019 Jun;31(3):167-172

Área de Urgencias/Cuidados Intermedios, Hospital Vithas Montserrat, Lleida, España.

Objectives: To assess the accuracy, safety, and efficiency of ultrasound images obtained by emergency physician to diagnose deep vein thrombosis (DVT). patients with acute heart failure (AHF) attended in a hospital emergency department (ED).

Material And Methods: Prospective multicenter cohort study. We assigned patients suspected of having DVT to an intervention or control group. Emergency physicians took ultrasound images that were later evaluated by a radiologist in the intervention group. In the control group, images were evaluated only by the radiologist. We analyzed patient, physician, and episode variables. Test results, times until imaging, and 30-day adverse events were also analyzed. Sensitivity, specificity, positive and negative likelihood ratios, and agreement between physicians and radiologists (κ statistic) were calculated.

Results: A total of 304 patients (209 in the intervention group and 95 controls) were included. The groups were comparable. The overall prevalence of DVT was 35.5% (95% CI, 30.3-41.0). The sensitivity of ultrasound images obtained by emergency physicians was superior in relation to experience: 71.4 (95% CI, 50.0-86.0) for those in a training course, 75.0 (95% CI, 80.0-95.4) for those with at least 2 months' practical experience, and 94.7 (95% CI, 82.7-98.5) for routine users. Specificity statistics for the 3 levels of physician experience were 83.3 (95% CI 55.2- 95.2), 100 (95% CI 83.0-100), and 96.6 (95% CI 88.4-99.0), respectively. The positive and negative likelihood ratios for ultrasound imaging by physicians were 27.94 and 0.054, respectively. The κ statistic was 0.80. Mean (SD) time until a physician took ultrasound images was 1.81 (1.46) hours versus 4.39 (1.81) hours until a radiologist obtained images (P = .007). Three deaths occurred within 30 days. They were not attributable to recurrence or bleeding.

Conclusion: Ultrasound images taken by emergency physicians to diagnose DVT are accurate and safe and may be efficient. However, routine experience with ultrasound is necessary.
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June 2019

Early discharge and home treatment of patients with low-risk pulmonary embolism with the oral factor Xa inhibitor rivaroxaban: an international multicentre single-arm clinical trial.

Eur Heart J 2020 01;41(4):509-518

Helios Albert-Schweitzer-Klinik, Albert-Schweitzer-Weg 1, 37154 Northeim, Germany.

Aims: To investigate the efficacy and safety of early transition from hospital to ambulatory treatment in low-risk acute PE, using the oral factor Xa inhibitor rivaroxaban.

Methods And Results: We conducted a prospective multicentre single-arm investigator initiated and academically sponsored management trial in patients with acute low-risk PE (EudraCT Identifier 2013-001657-28). Eligibility criteria included absence of (i) haemodynamic instability, (ii) right ventricular dysfunction or intracardiac thrombi, and (iii) serious comorbidities. Up to two nights of hospital stay were permitted. Rivaroxaban was given at the approved dose for PE for ≥3 months. The primary outcome was symptomatic recurrent venous thromboembolism (VTE) or PE-related death within 3 months of enrolment. An interim analysis was planned after the first 525 patients, with prespecified early termination of the study if the null hypothesis could be rejected at the level of α = 0.004 (<6 primary outcome events). From May 2014 through June 2018, consecutive patients were enrolled in seven countries. Of the 525 patients included in the interim analysis, three (0.6%; one-sided upper 99.6% confidence interval 2.1%) suffered symptomatic non-fatal VTE recurrence, a number sufficiently low to fulfil the condition for early termination of the trial. Major bleeding occurred in 6 (1.2%) of the 519 patients comprising the safety population. There were two cancer-related deaths (0.4%).

Conclusion: Early discharge and home treatment with rivaroxaban is effective and safe in carefully selected patients with acute low-risk PE. The results of the present trial support the selection of appropriate patients for ambulatory treatment of PE.
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http://dx.doi.org/10.1093/eurheartj/ehz367DOI Listing
January 2020

Effect of risk of malnutrition on 30-day mortality among older patients with acute heart failure in Emergency Departments.

Eur J Intern Med 2019 Jul 7;65:69-77. Epub 2019 May 7.

Hospital Clínic, Barcelona, Spain.

Background: Little is known about the prevalence and impact of risk of malnutrition on short-term mortality among seniors presenting with acute heart failure (AHF) in emergency setting. The objective was to determine the impact of risk of malnutrition on 30-day mortality risk among older patients who attended in Emergency Departments (EDs) for AHF.

Material And Methods: We performed a secondary analysis of the OAK-3 Registry including all consecutive patients ≥65 years attending in 16 Spanish EDs for AHF. Risk of malnutrition was defined by the Mini Nutritional Assessment Short Form (MNA-SF) < 12 points. Unadjusted and adjusted logistic regression models were used to assess the association between risk of malnutrition and 30-day mortality.

Results: We included 749 patients (mean age: 85 (SD 6); 55.8% females). Risk of malnutrition was observed in 594 (79.3%) patients. The rate of 30-day mortality was 8.8%. After adjusting for MEESSI-AHF risk score clinical categories (model 1) and after adding all variables showing a significantly different distribution among groups (model 2), the risk of malnutrition was an independent factor associated with 30-day mortality (adjusted OR by model 1 = 3.4; 95%CI 1.2-9.7; p = .020 and adjusted OR by model 2 = 3.1; 95%CI 1.1-9.0; p = .033) compared to normal nutritional status.

Conclusions: The risk of malnutrition assessed by the MNA-SF is associated with 30-day mortality in older patients with AHF who were attended in EDs. Routine screening of risk of malnutrition may help emergency physicians in decision-making and establishing a care plan.
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http://dx.doi.org/10.1016/j.ejim.2019.04.014DOI Listing
July 2019

The rationale, design, and methods of a randomized, controlled trial to evaluate the efficacy and safety of an active strategy for the diagnosis and treatment of acute pulmonary embolism during exacerbations of chronic obstructive pulmonary disease.

Clin Cardiol 2019 Mar 25;42(3):346-351. Epub 2019 Feb 25.

Divisions of Pulmonary and Critical Care Medicine and General Medical Sciences, Washington University School of Medicine, St. Louis, Missouri.

Introduction: Some previous studies have suggested a high prevalence of pulmonary embolism (PE) during exacerbations of chronic obstructive pulmonary disease (ECOPD). The SLICE trial aims to assess the efficacy and safety of an active strategy for the diagnosis and treatment of PE (vs usual care) in patients hospitalized because of ECOPD.

Methods: SLICE is a phase III, prospective, international, multicenter, randomized, open-label, and parallel-group trial. A total of 746 patients hospitalized because of ECOPD will be randomized in a 1:1 fashion to receive either an active strategy for the diagnosis and anticoagulant treatment of PE or usual care (ie, standard care without any diagnostic test for diagnosing PE). The primary outcome is a composite of all-cause death, non-fatal (recurrent) venous thromboembolism (VTE), or readmission for ECOPD within 90 days after enrollment. Secondary outcomes are (a) death from any cause within 90 days after enrollment, (b) non-fatal (recurrent) VTE within 90 days after enrollment, (c) readmission within 90 days after enrollment, and (d) length of hospital stay.

Results: Enrollment started in September 2014 and is expected to proceed until 2020. Median age of the first 443 patients was 71 years (interquartile range, 64-78), and 26% were female.

Conclusions: This multicenter trial will determine the value of detecting PEs in patients with ECOPD. This has implications for COPD patient morbidity and mortality.

Trial Registration Number: NCT02238639.
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http://dx.doi.org/10.1002/clc.23161DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6712316PMC
March 2019

Cryptogenic stroke secondary to paradoxical embolism: Is this event rare or underdiagnosed?

Emergencias 2018 10;30(5):367-368

Servicio de Urgencias, Hospital Universitario Clínico San Carlos, Madrid, España.

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October 2018

[Oral anticoagulation therapy in the elderly population with atrial fibrillation. A review article].

Rev Esp Geriatr Gerontol 2018 Nov - Dec;53(6):344-355. Epub 2018 Jul 30.

Servicio de Geriatría, Complexo Hospitalario Universitario Xeral Calde de Lugo, Lugo, España.

Aging is an important risk factor for patients with atrial fibrillation. The estimated prevalence of atrial fibrillation in patients aged ≥80 years is 9-10%, and is associated with a four to five fold increased risk of embolic stroke, and with an estimated increased stroke risk of 1.45-fold per decade in aging. Older age is also associated with an increased risk of major bleeding with oral anticoagulant therapy. This review will focus on the role of oral anticoagulation with new oral anticoagulants, non-vitamin K antagonist in populations with common comorbid conditions, including age, chronic kidney disease, coronary artery disease, on multiple medication, and frailty. In patients 75 years and older, randomised trials have shown new oral anticoagulants to be as effective as warfarin, or in some cases superior, with an overall better safety profile, consistently reducing rates of intracranial haemorrhages. Prior to considering oral anticoagulant therapy in an elderly frail patient, a comprehensive assessment should be performed to include the risks and benefits, stroke risk, baseline kidney function, cognitive status, mobility and fall risk, multiple medication, nutritional status assessment, and life expectancy.
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http://dx.doi.org/10.1016/j.regg.2018.04.450DOI Listing
October 2019

Therapeutic approach for patients with venous thromboembolism attended in emergency departments during routine clinical practice: the EDITH study.

J Comp Eff Res 2018 04 23;7(4):319-330. Epub 2018 Mar 23.

Emergency Department, Hospital Clínic, Grupo UPP, Área 1 IDIBAPS, Barcelona, Spain.

Aim: To analyze treatment at discharge/follow-up of patients diagnosed with venous thromboembolism (VTE) in the emergency department (ED).

Materials & Methods: Ambispective study (50 Spanish centers) of consecutive patients (October-December 2014) with VTE diagnosed in ED.

Results: VTE was diagnosed in 775 patients (295 pulmonary embolism [PE] without deep vein thrombosis [DVT], 389 DVT without PE and 91 PE + DVT); 95.5% received anticoagulants (90.7% low-molecular-weight heparin [LMWH], 4% LMWH + vitamin K antagonists and <1% direct oral anticoagulants). Overall, 23.3% were discharged from ED and 74.5% hospitalized (98.6% with PE and 50.4% with DVT). After discharge/90/180 days, 43.6/21.0/13.5% were taking LMWH, with similar rates in nononcologic patients.

Conclusion: There is a poor adherence to international guidelines in management of VTE patients in Spain.
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http://dx.doi.org/10.2217/cer-2017-0061DOI Listing
April 2018

Risk profile, management, and outcomes of patients with venous thromboembolism attended in Spanish Emergency Departments: The ESPHERIA registry.

Medicine (Baltimore) 2017 Dec;96(48):e8796

Hospital Clínic, Grupo UPP, Área 1 IDIBAPS, Barcelona Hospital Clínico San Carlos, IdISSC Hospital de Getafe, Madrid Hospital de la Axarquia, Málaga Hospital de Ponferrada, León Hospital Central de Asturias, Oviedo Departamento Médico, Bayer Hispania, Barcelona Hospital Reina Sofía, Murcia, Spain.

The objective of this study was to determine the clinical profile of and diagnostic and therapeutic approach to patients with venous thromboembolism (VTE) in Spanish Emergency Departments (EDs). Risk factors, adherence to clinical practice guidelines, and outcomes were also evaluated.Patients with VTE diagnosed in 53 Spanish EDs were prospectively and consecutively included. Demographic data, comorbidities, risk factors for VTE, index event characteristics, hemorrhagic risk, and mortality were evaluated. Adherence to clinical practice guidelines was assessed based on clinical probability scales, requests for determination of D-dimer, use of anticoagulant treatment before confirmation of diagnosis, and assessment of bleeding and prognostic risk. Recurrence, bleeding, and death during admission and at 30, 90, and 180 days after diagnosis in the EDs were recorded.From 549,840 ED visits made over a mean period of 40 days, 905 patients were diagnosed with VTE (incidence 1.6 diagnoses per 1000 visits). The final analysis included 801 patients, of whom 49.8% had pulmonary embolism. The most frequent risk factors for VTE were age (≥70 years), obesity, and new immobility. Clinical probability, prognosis, and bleeding risk scales were recorded in only 7.6%, 7.5%, and 1% of cases, respectively. D-dimer was determined in 87.2% of patients with a high clinical probability of VTE, and treatment was initiated before confirmation in only 35.9% of these patients. In patients with pulmonary embolism, 31.3% had a low risk of VTE. Overall, 98.7% of patients with pulmonary embolism and 50.2% of patients with deep venous thrombosis were admitted. During follow-up, total bleeding was more frequent than recurrences: the rates of any bleeding event were 4.4%, 3.9%, 5.3%, and 3.5% at admission and at 30 and 90, and 180 days, respectively; the rates of VTE recurrence were 2.3%, 1.3%, 1.7%, and 0.6%, respectively. Mortality rates were 3.4%, 3.1%, 4.1%, and 2.6% during hospitalization and at 30, 90, and 180 days, respectively.VTE had a substantial impact on Spanish EDs. The clinical presentation and risk profile for the development of VTE in patients diagnosed in the EDs was similar to that recorded in previous studies. During follow-up, bleeding (overall) was more frequent than recurrences. Adherence to clinical practice guidelines could improve significantly.
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http://dx.doi.org/10.1097/MD.0000000000008796DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5728758PMC
December 2017

[Hospital emergency room diagnosis of acute appendicitis in patients aged 2 to 20 years: the INFURG-SEMES score from the emergency infections study of the Spanish Society of Emergency Medicine].

Emergencias 2017 07;29(4):231-236

Servicio de Urgencias, Hospital Clínico San Carlos. Instituto de Investigación Sanitaria del Hospital San Carlos, Madrid, España.

Objectives: To develop the INFURG-SEMES scale (based on the emergency infections study of the Spanish Society of Emergency Medicine) using clinical and laboratory data to diagnose acute appendicitis (AA) in patients aged 2 to 20 years who were evaluated in hospital emergency departments and to compare its diagnostic yield to that of the Alvarado score.

Material And Methods: Prospective observational cohort study enrolling consecutive patients between the ages of 2 and 20 years who came to 4 hospital emergency departments with abdominal pain suggestive of AA and of less than 72 hours' duration. We collected demographic, clinical, analytic (white blood cell count, differential counts, and C-reactive protein [CRP] levels), and radiographic data (ultrasound and/or computed tomography scans). We also recorded surgical data if pertinent. The main outcome was a diagnosis of AA within 14 days of the index visit.

Results: We included 331 patients with a mean (SD) age of 11.8 (3.8) years; 175 (52.9%) were male. The final diagnosis was AA in 116 cases (35.0%). The INFURG-SEMES scale included the following predictors: male sex, right quadrant pain (right iliac fossa) on examination, pain on percussion, pain on walking, and elevated neutrophil count and CRP level. The areas under the receiver operating characteristic curves for the INFURG-SEMES scale and the Alvarado score, respectively, were 0.84 (95% CI, 0.79-0.88) and 0.77 (95% CI, 0.72-0.82). The difference was statistically significant (P=.002).

Conclusion: The INFURG-SEMES scale may prove useful for diagnosing AA in patients aged between 2 and 20 years evaluated for abdominal pain in hospital emergency departments. The INFURG-SEMES score showed greater discrimination than the Alvarado score.
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July 2017

Clinical Characteristics and Prognosis of Pulmonary Embolism Caused by Economy Class Syndrome.

Arch Bronconeumol 2017 Sep 31;53(9):495-500. Epub 2017 Mar 31.

Servicio de Neumología, Hospital Ramón y Cajal, Universidad de Alcalá, IRYCIS, Madrid, España. Electronic address:

Objective: Clinical presentation and short-term prognosis of patients with travel-associated acute pulmonary embolism (PE) (i.e., economy class syndrome [ECS]) is not well understood.

Methods: In this retrospective cohort study of patients with acute PE identified from a single center registry, we assessed the clinical presentation and the association between ECS and the outcomes of all-cause mortality, PE-related mortality, nonfatal venous thromboembolism and nonfatal major bleeding rates through 30days after initiation of PE treatment.

Results: Of the 2,333 patients with acute symptomatic PE, 124 (5.3%; 95% confidence interval, 4.4-6.3%) had ECS. Patients with ECS were younger and had fewer comorbid diseases (recent bleeding, chronic obstructive pulmonary disease, congestive heart failure), but they presented with more signs of clinical severity (syncope [48% vs. 14%; P<.001], tachycardia [37% vs. 21%; P<.001], right ventricular dysfunction [31% vs. 19%; P<.01] and myocardial injury [57% vs. 28%; P<.001]) compared to those without ECS. Regression analyses showed a significantly lower risk of all-cause mortality for patients with ECS compared to patients without ECS (1.6% vs. 9.6%; P<.01). We did not detect a difference in PE-related mortality at 30days between those with and those without ECS (0.8% vs. 3.1%; P=.18).

Conclusions: PE patients with ECS are younger and have fewer comorbid diseases compared to those without ECS. Though they present with more signs of clinical severity, their short-term prognosis is excellent.
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http://dx.doi.org/10.1016/j.arbres.2017.02.011DOI Listing
September 2017

Computerised clinical decision support for suspected PE.

Thorax 2015 Sep 9;70(9):909-11. Epub 2015 Feb 9.

Divisions of Pulmonary and Critical Care Medicine and General Medical Sciences, Washington University School of Medicine, St. Louis, Missouri, USA.

This study aimed to determine the effect of an evidence-based clinical decision support (CDS) algorithm on the use and yield of CT pulmonary angiography (CTPA) and on outcomes of patients evaluated in the emergency department (ED) for suspected PE. The study included 1363 consecutive patients evaluated for suspected PE in an ED during 12 months before and 12 months after initiation of CDS use. Introduction of CDS was associated with decreased CTPA use (55% vs 49%; absolute difference (AD), 6.3%; 95% CI 1.0% to 11.6%; p=0.02). The use of CDS was associated with fewer symptomatic venous thromboembolic events during follow-up in patients with an initial negative diagnostic evaluation for PE (0.7% vs 3.2%; AD 2.5%; 95% CI 0.9% to 4.6%; p<0.01).
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http://dx.doi.org/10.1136/thoraxjnl-2014-206689DOI Listing
September 2015

[Author's reply].

Emergencias 2015 Feb;27(1):68

Área de Urgencias, Hospital Clínic, Barcelona, España.

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February 2015
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