[Translated article] Spanish COPD Guidelines (GesEPOC) 2021 Update. Diagnosis and Treatment of COPD Exacerbation Syndrome

This article details the GesEPOC 2021 recommendations on the diagnosis and treatment of COPD exacerbation syndrome (CES). The guidelines propose a definition-based syndromic approach, a new classification of severity, and the recognition of different treatable traits (TT), representing a new step toward personalized medicine. The evidence is evaluated using GRADE methodology, with the incorporation of 6 new PICO questions. The diagnostic process comprises four stages: 1) establish a diagnosis of CES, 2) assess the severity of the episode, 3) identify the trigger, and 4) address TTs. This diagnostic process differentiates an outpatient approach, that recommends the inclusion of a basic battery of tests, from a more comprehensive hospital approach, that includes the study of different biomarkers and imaging tests. Bronchodilator treatment for immediate relief of symptoms is considered essential for all patients, while the use of antibiotics, systemic corticosteroids, oxygen therapy, and assisted ventilation and the treatment of comorbidities will vary depending on severity and possible TTs. The use of antibiotics will be indicated particularly if sputum color changes, when ventilatory assistance is required, in cases involving pneumonia, and in patients with elevated C-reactive protein (≥ 20 mg/L). Systemic corticosteroids are recommended in CES that requires admission and are suggested in moderate CES. These drugs are more effective in patients with blood eosinophil counts ≥ 300 cells/mm3. Acute-phase non-invasive mechanical ventilation is specified primarily for patients with CES who develop respiratory acidosis despite initial treatment.

Spanish COPD Guidelines (GesEPOC) 2021 Update Diagnosis and Treatment af COPD Exacerbation Syndrome

This article details the GesEPOC 2021 recommendations on the diagnosis and treatment of COPD exacerbation syndrome (CES). The guidelines propose a definition-based syndromic approach, a new classification of severity, and the recognition of different treatable traits (TT), representing a new step toward personalized medicine. The evidence is evaluated using GRADE methodology, with the incorporation of 6 new PICO questions. The diagnostic process comprises four stages: 1) establish a diagnosis of CES, 2) assess the severity of the episode, 3) identify the trigger, and 4) address TTs. This diagnostic process differentiates an outpatient approach, that recommends the inclusion of a basic battery of tests, from a more comprehensive hospital approach, that includes the study of different biomarkers and imaging tests. Bronchodilator treatment for immediate relief of symptoms is considered essential for all patients, while the use of antibiotics, systemic corticosteroids, oxygen therapy, and assisted ventilation and the treatment of comorbidities will vary depending on severity and possible TTs. The use of antibiotics will be indicated particularly if sputum color changes, when ventilatory assistance is required, in cases involving pneumonia, and in patients with elevated C-reactive protein (≥ 20 mg/L). Systemic corticosteroids are recommended in CES that requires admission and are suggested in moderate CES. These drugs are more effective in patients with blood eosinophil counts ≥ 300 cells/mm³. Acute-phase non-invasive mechanical ventilation is specified primarily for patients with CES who develop respiratory acidosis despite initial treatment.

Delphi-RAND consensus of the Spanish Society of Internal Medicine on the controversies in anticoagulant therapy and prophylaxis in medical diseases. INTROMBIN Project (Uncertainty in thromboprophylaxis in internal medicine)

The aim of this study was to determine the opinion of internists on the management of anticoagulation and thromboembolism prophylaxis in complex clinical scenarios in which the risk-benefit ratio of surgery is narrow and to develop a consensus document on the use of drugs anticoagulant therapy in this patient group. To this end, we identified by consensus the clinical areas of greatest uncertainty, a survey was created with 20 scenarios laid out in 40 clinical questions, and we reviewed the specific literature. The survey was distributed among the internists of the Spanish Society of Internal Medicine (SEMI) and was completed by 290 of its members. The consensus process was implemented by changing the Delphi-RAND appropriateness method in an anonymous, double-round process that enabled an expert panel to identify the areas of agreement and uncertainty. In our case, we also added the survey results to the panel, a methodological innovation that helps provide additional information on the standard clinical practice. The result of the process is a set of 19 recommendations formulated by SEMI experts, which helps establish guidelines for action on anticoagulant therapy in complex scenarios (high risk or active haemorrhage, short life expectancy, coexistence of antiplatelet therapy or comorbidities such as kidney disease and liver disease), which are not uncommon in standard clinical practice.

Disease burden and unmet needs for prevention of venous thromboembolism in medically ill patients in Europe show underutilisation of preventive therapies

It was the aim of this review to assess the incidence of venous thromboembolism (VTE) and current practice patterns for VTE prophylaxis among medical patients with acute illness in Europe. A literature search was conducted on the epidemiology and prophylaxis practices of VTE prevention among adult patients treated in-hospital for major medical conditions. A total of 21 studies with European information published between 1999 and April 2010 were retrieved. Among patients hospitalised for an acute medical illness, the incidence of VTE varied between 3.65% (symptomatic only over 10.9 days) and 14.9% (asymptomatic and symptomatic over 14 days). While clinical guidelines recommend pharmacologic VTE prophylaxis for patients admitted to hospital with an acute medical illness who are bedridden, clear identification of specific risk groups who would benefit from VTE prophylaxis is lacking. In the majority of studies retrieved, prophylaxis was under-used among medical inpatients; 21% to 62% of all patients admitted to the hospital for acute medical illnesses did not receive VTE prophylaxis. Furthermore, among patients who did receive prophylaxis, a considerable proportion received medication that was not in accord with guidelines due to short duration, suboptimal dose, or inappropriate type of prophylaxis. In most cases, the duration of VTE prophylaxis did not exceed hospital stay, the mean duration of which varied between 5 and 11 days. In conclusion, despite demonstrated efficacy and established guidelines supporting VTE prophylaxis, utilisation rates and treatment duration remain suboptimal, leaving medical patients at continued risk for VTE. Improved guideline adherence and effective care delivery among the medically ill are stressed.

Arterial Stump Thrombosis after Lung Resection Surgery: Clinical Presentation, Treatment and Progress

OBJECTIVE

To determine the prevalence of arterial stump thrombosis (AST) after pulmonary resection surgery for lung cancer and to describe subsequent radiological follow-up and treatment.

MATERIAL AND METHODS

Observational, descriptive study of AST detected by computerized tomography angiography (CT) using intravenous contrast. Clinical and radiological variables were compared and a survival analysis using Kaplan-Meier curves was performed after dividing patients into 3 groups: patients with AST, patients with pulmonary embolism (PE), and patients without AST or PE.

RESULTS

Nine cases of AST were detected after a total of 473 surgeries (1.9%), 6 of them in right-sided surgeries (67% of AST cases). Median time to detection after surgery was 11.3 months (interquartile range 2.7-42.2 months), and range 67.5 months (1.4-69.0 months). Statistically significant differences were found only in the number of CTs performed in AST patients compared to those without AST or PE, and in tumor recurrence in PE patients compared to the other 2 groups. No differences were found in baseline or oncological characteristics, nor in the survival analysis.

CONCLUSIONS

In this series, AST prevalence was low and tended to occur in right-sided surgeries. Detection over time was variable, and unrelated to risk factors previous to surgery, histopathology, and tumor stage or recurrence. AST had no impact on patient survival.

[Are domiciliary care patients receiving adequate thromboprophylaxis?]

INTRODUCTION

The study aims to determine the percentage of patients treated at home with an indication of prophylaxis of thromboembolic disease (TED) according to the PRETEMED guidelines and whether they receive such prophylaxis.

MATERIALS AND METHODS

A cross-sectional descriptive study was conducted in Segovia Palace Health Centre (Madrid).

INCLUSION CRITERIA

to be included in the domiciliary care protocol.

EXCLUSION CRITERIA

terminal patient, hospitalised or surgery in the last 3 months. The variables used include, age, sex, duration of domiciliary care, mobility, anticoagulant or antiplatelet treatment and reason, and associated and precipitating factors to calculate the risk of TED according to the PRETEMED guidelines, and if they receive such prophylaxis, by reviewing computerised medical records and meeting with the staff responsible.

RESULTS

The study included a total of 187 patients, of whom 81% were women There was a significant differences in mean age by sex (men, 76.91 years, 95% CI; 72.59-81.24, and women, 86.72 years, 95% CI; 72.59-81.24, P<.05). Almost two-thirds (65%) walked in the home. There were 3.7% patients who had an indication for receiving prophylaxis, but did not receive it, although 85.8% of them were on anticoagulants or antiplatelet therapy for other reasons.

CONCLUSIONS

Most patients in domiciliary care have a low baseline risk of developing a TED episode in our study. There should be more emphasis placed on the prophylaxis of TED in acute medical episodes in which patients with slightly elevated risk may increase the likelihood of TED. Observational studies should be conducted to study the baseline risk and the subsequent development of TED in the population receiving home care.

Prevalence of venous thromboembolism in elective thoracic surgery

INTRODUCTION

The aim of this study was to determine the prevalence of venous thromboembolism (VTE) after elective thoracic surgery in patients receiving antithrombotic prophylaxis, and to evaluate the risk of pulmonary embolism (PE) after lung resection.

PATIENTS AND METHOD

A descriptive, cross-sectional, retrospective study was designed. A total of 6004 patients were included. All patients underwent elective thoracic surgery. Prophylactic antithrombotic therapy was standardised in all cases. Patients were divided into four groups (low, moderate, high and very high) according to their thrombotic risk. The prevalence of VTE, deep vein thrombosis and PE in each group was calculated. The odds of PE for pneumonectomy was also calculated and compared to lobectomy.

RESULTS

Eleven patients (0.18%) had postoperative VTE. The mean age of this subset was 65.95 years; 90.9% were diagnosed with malignant neoplasm. Some 80.8% of patients in the series and all VTE cases were included in the high risk VTE group. VTE was more common in pneumonectomy (45.45% of VTE cases, odds ratio 4.6 compared to lobectomy).

CONCLUSIONS

The prevalence of VTE in this series was 0.18% (1.31% in pneumonectomy patients). These figures could serve as reference values for thromboembolic disease in general thoracic surgery.

[Thromboprophylaxis during immobilization of non-surgical traumatic injury in the lower limb. An outpatient perspective]

Thromboprophylaxis with low molecular weight heparin is efficient, effective and generates savings in health costs in hospitals. However, outside hospitals, there are situations of apparent risk of thrombosis, where there seems to be no such consensus. This occurs in traumatic lower limb injuries which are not undergoing surgery and need a period of immobilization. These are processes with multidisciplinary interventions (Emergency, Family Physicians and Traumatology), although during outpatient follow up it is not easy to find criteria for using thromboprophylaxis. We report a case of a pulmonary embolism, with unusual symptoms, in an ambulatory patient with a fractured fibula and metatarsal, who was being treated with Bemiparin. As we shall see, this is a rare complication, but it shows the importance of proper risk assessment of thromboembolic disease in these patients. We emphasize the accompanying tomographic images for their clarity and eloquence.