Anticoagulación en población anciana con fibrilación auricular no valvular. Artículo de revisión

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.     

Evaluación de la realización del cribado del pie diabético en Atención Primaria

AimTo ascertain whether patients with type 2 diabetes are screened for diabetic foot, and to analyze the factors related to patients and centers associated to performance of such screening.Material and methodsA multicenter, epidemiological, cross-sectional study was conducted. The clinical records of 443 patients with type 2 diabetes monitored at Primary Care for at least 12 months were reviewed. Demographic and healthcare variables and characteristics of the primary care center were recorded.ResultsIn the previous year, 51.2% of patients had been trained on foot self-care, 56.4% had undergone foot inspection, 39.5% had been examined with a monofilament, and palpation of peripheral pulses and measurement of the ankle-brachial index were performed in 45.8 and 10.1% of patients, respectively. Diabetic foot screening (inspection, monofilament testing, and palpation of peripheral pulses) was performed in 37% of study patients. Ulcer risk stratification was done in 12.4% of patients. A significant association was found between diabetic foot screening and presence of foot deformities (P < .001), history of neuropathy (P = .005), and history of peripheral artery disease (P < .05). Screening was also associated to some characteristics of the center, such as reception of information about goal achievement (P < .001) and economic incentives for goal attainment (P < .001).ConclusionsCompliance with diabetic foot screening and ulcer risk stratification in patients with type 2 diabetes in Primary Care was poor.     

Valoración de la utilidad del test de estimulación intraarterial con calcio en el diagnóstico de localización del hiperinsulinismo endógeno

Background and objectiveThe aim of this study was to assess the utility of arterial calcium stimulation with hepatic venous sampling (ASVS) in the localization of tumors in patients with endogenous hyperinsulinism not detected with other methods.Patients and methodsWe performed a retrospective study of 26 patients admitted to our hospital for hypoglycemia who underwent ASVS because the source of hyperinsulinism was not clearly identified by other imaging techniques. The histopathological result in patients who underwent a surgical procedure was considered the reference for statistical study of the accuracy of this technique. Statistical analysis was performed by comparing proportions with the chi-squared test with Yates’ correction for contingency tables, and Cohen′s kappa coefficient as a measure of interrater agreement between two observations.ResultsSurgery was performed in 17 patients, 13 with positive ASVS and the remaining four with negative results. An insulinoma was removed in 12 patients, and 10 of these were detected in the ASVS. A total of 76.9 % of positive ASVS tests corresponded to a histological diagnosis of insulinoma, and 83% of these insulinomas were positive in ASVS. This association was statistically significant (chi cuadrado = 7.340; p = 0.012). Two of three patients with nesidioblastosis had a positive response in the ASVS. A good and statistically significant agreement was obtained between histopathologic diagnosis and ASVS results (κ=0.556, p = 0.007).ConclusionsASVS is a useful procedure in the localization diagnosis of endogenous hyperinsulinism not detected by other imaging tests. This technique allows tumors in the pancreatic gland to be identified and may be useful in the choice of the surgical technique to be used.     

Actualización sobre infección por Clostridium difficile en el paciente mayor

Clostridium difficile infection is the most common cause of health care-associated diarrhoea, and its incidence increases with age. Clinical challenges, risk of resistance to treatment, risk of recurrence, and treatment responses are different in elderly.The aim of this review is to discuss the updated epidemiology, pathophysiology, diagnosis, and therapeutic management of C. difficile infection in elderly with the available data.     

Soporte nutricional con nutrición parenteral. Evolución y complicaciones asociadas

IntroductionParenteral nutrition (PN) is an integral part of medical management of patients who do not have a functioning or accessible gastrointestinal tract. This paper discusses the clinical characteristics of patients receiving PN in a 420-bed hospital from 2009 to 2011. In addition, nutritional parameters were assessed at the start and end of PN and associated complications were analyzed.Material and methodsretrospective, observational study of PN episodes in adults conducted at the Nutrition Unit of Hospital Universitario de Guadalajara. Variables collected included epidemiological and clinical data, number and type of routes used, anthropometric data, analytical data, number of days on PN, reason for withdrawal, caloric provision, prevalence of phlebitis, metabolic complications (hypertriglyceridemia, abnormal liver function tests, hyperglycemia, and refeeding syndrome), and prevalence of bacteremia associated with central venous catheter (BAC).ResultsThere were 312 episodes of PN. The immediate indication was postoperative ileus in 53.8% of the episodes. There was a statistically significant improvement in all analytical parameters assessed (albumin, prealbumin, retinol binding protein, transferrin, cholesterol, and lymphocytes). Caloric provision (kcal per kg) was 25.1 ± 6.6. No metabolic complication occurred in 16.3% of the episodes, and hyperglycemia was the most common complication (79.8%). There were 10 cases of phlebitis (32.2%) and 30 episodes of BAC (8.7%). Bacteriemia rate was 8.1 per 1000 days of PN.DiscussionAlthough PN is an effective nutritional support technique, it is associated with complications of varying severity. Use of PN should therefore comply with the instructions accepted in the main clinical practice guidelines and requires careful monitoring by experienced professionals.