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Background: Venous thromboemboli tend to recur. However, the causative factors underlying pulmonary embolism recurrence are not well defined., Aims: To explore the factors associated with pulmonary embolism recurrence., Patients and Methods: Patients diagnosed with pulmonary emboli between 2004 and 2013 at our institution were enrolled. Duration of anticoagulant therapy, new episodes of venous thromboembolism, and deaths were recorded., Results: Pulmonary embolism was diagnosed in 528 patients (median age: 76 years, interquartile range [IQR]: 16; male: 45%). The median follow-up time was 34 months (IQR: 52). In total, 477 patients completed ≥3 months of anticoagulation therapy. Permanent anticoagulation was indicated in 217 (45%) patients, and therapy was discontinued in 260 (55%) patients. Overall, 79 patients experienced a recurrence (5.6 per patient-year). Recurrence was significantly associated with anticoagulation discontinuation (4% vs. 27% of patients who maintained or discontinued therapy, respectively; P<0.001; 95% confidence interval -0.95, -0.86). The median duration between anticoagulation withdrawal and recurrence was 6.5 months (IQR: 23.25). Factors associated with recurrence were unprovoked pulmonary embolism (odds ratio [OR]: 0.45), a greater degree of pulmonary arterial obstruction (OR: 2.5), a delay in initiation of anticoagulation (OR: 3), and higher plasma D-dimer levels during treatment (OR: 2.3). Survival rates were improved for patients who maintained anticoagulation therapy relative to those who discontinued., Conclusion: Pulmonary embolism has a high recurrence rate. Permanent anticoagulant therapy should be considered for patients with idiopathic pulmonary embolism, a high thrombotic burden, and persistently elevated D-dimer levels during treatment, and for patients where therapy was initially delayed., (Copyright© Bentham Science Publishers; For any queries, please email at epub@benthamscience.org.)

Background: Studies aimed at assessing whether the emboli lodged in the central pulmonary arteries carry a worse prognosis than more peripheral emboli have yielded controversial results., Aims: To explore the impact on survival and long-term prognosis of central pulmonary embolism., Patients and Methods: Consecutive patients diagnosed with acute symptomatic pulmonary embolism by means of computed tomography (CT) angiography were evaluated at episode index and traced through the computed system of clinical recording and following-up. Central pulmonary embolism was diagnosed when thrombi were seen in the trunk or in the main pulmonary arteries and peripheral pulmonary embolism when segmental or subsegmental arteries were affected., Results: A total of 530 consecutive patients diagnosed with pulmonary embolism were evaluated; 255 patients had central pulmonary embolism and 275 patients had segmental or subsegmental pulmonary embolism. Patients with central pulmonary embolism were older, had higher plasma levels of N-terminal of the prohormone brain natriuretic peptide (NT-ProBNP), troponin I, D-dimer, alveolar-arterial gradient, and shock index (P < .001 for each one). Patients with central pulmonary embolism had an all-cause mortality of 40% while patients with segmental or subsegmental pulmonary embolism (PE) had an overall mortality of 27% and odds ratio of 1.81 [confidence interval (CI) 95% 1.16-1.9]. Survival was lower in patients with central PE than in patients with segmental or subsegmental pulmonary embolism, even after avoiding confounders (P = .018)., Conclusions: Apart from a greater impact on hemodynamics, gas exchange, and right ventricular dysfunction, central pulmonary embolism associates a shorter survival and an increased long-term mortality.

Background and Objective: After an acute pulmonary embolism few long-term prognostic factors have shown to be of practical use. We hypothesized that, as in heart failure, natriuretic peptides could serve as biomarkers of a late deleterious prognosis., Patients and Methods: Consecutive patients admitted to an Internal Medicine ward diagnosed with acute pulmonary embolism were traced through the computerized system of clinical episodes of Navarra Health System and by telephone calls. On hospitalization, standard evaluation was made, previous history of cancer and cardiac disease was recorded, and N-terminal ProB-type natriuretic peptide (NT-ProBNP), D-dimer and Troponin I were measured. In the analysis all-causes death was considered., Results: Two hundred and thirty-four patients were traced, median age 75 [interquartile range (IQR) 16] years old, women 51%. At a median time of 9.5 (IQR 29) months 52 (22%) patients had died, 38 (73%) dead patients had NT-ProBNP higher than 850 ng/L. NT-ProBNP in dead patients was 2.741 (IQR 7.420)ng/L and 662 (IQR 2.517)ng/L in survivors (p<0.001). Age (OR 4.37 CI 95% 1.04-1.16) and NT-ProBNP (OR 1.49 CI 95% 1-1.002) showed to be independent factors of mortality. Between the 3rd and 20th month after the diagnosis, a level of NT-ProBNP higher than 850 ng/L (sensitivity 0.86, specificity 0.45 and negative predictive value 0.92) was associated with a lower survival (p=0.019), hazard ratio 1.89, OR 7.67 (CI 95% 1.52-39.44) for this period., Conclusion: Besides the unchangeable age, plasma level of NT-ProBNP measured on acute pulmonary embolism could predict longer-term all-cause death., (Copyright © 2013 Elsevier España, S.L.U. All rights reserved.)

Background: After an acute pulmonary embolism (PE), the complete resolution of thromboemboli may not be routinely achieved. The rate of persistence may depend on the time and the diagnostic technique used for evaluation., Patients and Methods: Patients were diagnosed with acute PE by means of computed tomography angiography (CTA). While they were receiving anticoagulant therapy, a second CTA was used to explore the rate of persistence of residual thromboemboli. During the initial episode, the plasma levels of Troponin I and natriuretic peptide, patient demographics, and hemodynamic and gas exchange data were evaluated as risk factors for persistence of pulmonary thromboemboli., Results: In this study 166 patients were diagnosed. A second CTA was not made in 46 (28%) patients for different reasons. In 120 (72%) patients a second CTA was made 4.5 [SD2.34] months after the initial episode (range 2-12 months). Complete clearance of thrombi occurred in 89 (74%, 95% CI 65-81) patients. Residual thrombi remained in 31 (26%, 95% CI 18-34) patients. In 6%, 13% and 81% of the patients the size of the residual thrombi was greater, similar to and smaller than initially diagnosed, respectively. The risk factors for residual thrombi included the thrombotic burden (OR 1.95), the alveolar to arterial difference of oxygen (OR 1.64), and the clinical antecedents of venous thromboembolic disease (OR 0.65)., Conclusions: After 4.5 months of anticoagulant therapy, residual pulmonary thromboemboli persisted in 26% of the patients. The risk factors for residual thromboemboli include a greater initial thrombotic burden, a deeper gas exchange disturbation and a history of previous venous thromboembolism., (Copyright © 2011. Published by Elsevier B.V.)

Background: Troponin-I (cTp-I) is considered a sensitive biomarker of myocardial injury in acute pulmonary thromboembolism (PE) with prognosis implications, though abnormal levels vary among reports., Patients and Methods: cTp-I was measured in consecutive patients objectively diagnosed of PE by means of pulmonary angiography made with helicoidal CT. Patients were classified radiologically as central or peripheral PE and hemodynamically as massive, submassive or non-massive according to the pulmonary vessel occluded and systolic blood pressure and ProBNP levels respectively. We checked also the delay in diagnosis (DD) and 30-days all-causes mortality rate., Results: We evaluated 164 patients; the mean age was 70 (15) years, males: 76 (46%). Median DD was 5 [interquartile range (IQ) 12) days. Median cTp-I in patients with DD>5 was 0.003microg/L (IQ 0.072)microg/L while in patients with DD<5 was 0.05microg/L (IQ 0.096) (p<0.05). cTp-I higher than 0.5microg/L occurred in 11 (7%) patients. Levels of cTp-I higher than 0.03microg/L were associated with central PE, (AUROC 0.7059 CI95% 0.6643-0.7475, sensitivity 0.75, specificity 0.69, PPV 0.75 and NPV 0.69) and massive and submassive PE (AUROC 0.7685, CI95% 0.7288-0.8082 sensitivity 0.86, specificity 0.66, PPV 0.72 and NPV 0.82), but they were not associated with mortality (AUROC 0.5394). In a multivariate analysis cTp-I did not show to be an independent predictor of central, massive and submassive PE or all causes death., Conclusions: In this study cTp-I was not a proper biomarker of the size of pulmonary vessel occluded, the degree of hemodynamic derangement or short-term mortality. The delay in diagnosis could influence the usefulness of cTp-I.

Background and Methods: The available data on the utility of low-molecular-weight heparins (LMWH) in the secondary prophylaxis of deep vein thrombosis (DVT) are limited. We compared two cohorts of patients diagnosed of DVT. One group followed treatment with LMWH and the other group did with oral anticoagulants (acenocoumarol). Safety was evaluated by the rate of major hemorrhage and 2.5-years period fracture rate, and efficacy was evaluated as the rate of early recurrence and one-year recurrence rate., Results: Of 65 patients treated with LMWH, the hemorrhagic rate was 1.5% (95% CI 0.08-9.40), fracture rate was 7.7% (95% CI 2.87-17.75), early recurrence was 1.5% (95% CI 0.08-9.40) and one-year recurrence was 3% (95% CI 53-11.64). In 118 patients treated with oral anticoagulants the hemorrhagic rate was 3.4% (95% CI 1.09-8.97), odds ratio 0.33, the fracture rate was 11% (95% CI 16.23-18.44), odds ratio 0.66, the early recurrence rate was 5% (95% CI 2.08-11.20), odds ratio 0.60 and one-year recurrence was 3.4% (95%CI 1.09-8.97), odds ratio 0.33., Conclusions: Secondary prophylaxis of DVT with LMWH is as safe and effective as classical treatment with oral anticoagulants. In this study the 2.5-year period fracture rate was similar in both groups of treatment.

Background and Objective: The prognosis of hepatopulmonary syndrome (HPS) has been only rarely investigated., Patients and Method: We investigated the survival of 32 cirrhotic patients, 14 (44%) with HPS and 18 with a normal gaseous exchange (NGE), and the associated factors., Results: During a mean (standard deviation) of 56 (27) months, 9 patients in the HPS group (relative risk: 0.64) and 4 patients in the NGE group (relative risk: 0.22) died. The odds ratio was 6.42 (p < 0.01; 95% confidence interval, 0.04-0.80). Patients in the HPS group died after 44 (31) months, while patients in the NGE group died 65 (21) months after inclusion (p < 0.05). Overall, 46% of deaths were liver related. Factors associated with death were the right to left shunting and the increased plasmatic renin levels. Of note, the plasmatic volume and diffusing capacity were protective., Conclusions: The coexistence of HPS worsens the prognosis in liver cirrhosis.

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.

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.

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.

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.

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.