María Lourdes Posadas-Martínez

Performance of the Wells score in patients with suspected pulmonary embolism during hospitalization: a delayed-type cross sectional study in a community hospital.

INTRODUCTION The role of the Wells score for patients who develop signs and symptoms of pulmonary embolism (PE) during hospitalization has not been sufficiently validated. The aim of this study is to evaluate the performance of the Wells score for inpatients with suspected PE and to evaluate the prevalence of pulmonary embolism. MATERIALS AND METHODS We conducted a cross sectional study nested in the prospective Institutional Registry of Thromboembolic Disease at Hospital Italiano de Buenos Aires from June 2006 to March 2011. We included patients who developed symptoms of pulmonary embolism during hospitalization. Patients were stratified based on the Wells score as PE likely (>4 points) or PE unlikely (≤4 points). The presence of pulmonary embolism was defined by pre-specified criteria. RESULTS Six hundred and thirteen patients met the inclusion criteria, with an overall prevalence of PE of 36%. Two hundred and nineteen (34%) were classified as PE likely and 394 (66%) as PE unlikely with a prevalence of PE of 66% and 20%, respectively. The Wells score showed a sensitivity of 65 (95% CI 59-72), specificity 81 (95% CI 77-85), positive predictive value 66 (95% CI 60-72) and negative predictive value 80 (95% CI 77-84). CONCLUSIONS The Wells Score is accurate to predict the probability of PE in hospitalized patients and this population had a higher prevalence of PE than other cohorts. However, the score is not sufficiently predictive to rule out a potentially fatal disorder.

Wells Score and Poor Outcomes Among Adult Patients With Subsegmental Pulmonary Embolism A Cohort Study

Introduction: Since the introduction of computed tomography pulmonary angiography, isolated subsegmental pulmonary embolism has become a commonly recognized clinical problem, but its clinical relevance remains unclear. The objective of the present study was to evaluate the extent to which the simplified Wells score discriminates between patients with varying levels of risk of complications after presenting with subsegmental pulmonary embolism. Materials and Methods: Retrospective cohort study. Patients included had subsegmental pulmonary embolism (1 or multiple emboli limited to subsegmental arteries). Primary explanatory variable was the simplified Wells score, categorized as high (>4) or low (≤4). The primary outcome was time to death or new venous thromboembolism. Kaplan-Meier techniques and Cox regression analysis were used to compare the survival experience of patients with high versus low Wells score with and without adjustment for active malignancy, age, Charlson score, previous venous thromboembolism, and previous major surgery in the last 30 days. Main Results: Seventy-nine patients with subsegmental pulmonary embolism were included. Patients with a high Wells score had a 4-fold increased risk of the composite outcome (hazard ratio = 4.2, 95% confidence interval [CI] = 2.0-8.9, P < .001). Other covariates significantly associated with increased risk in univariate analyses included active malignancy, a low serum albumin, and an increased Charlson score. In multivariate Cox regression analyses adjusting for these other factors, a high Wells score remained significant (hazard ratio 5.5, 95% CI 2.4-12.6, P < .001). Conclusion: High Wells score is associated with death or new venous thromboembolism during follow-up among patients with subsegmental pulmonary embolism. Clinical trial registration: ClinicalTrials.gov number, NCT01372514.

Predictive score for estimating cancer after venous thromboembolism: a cohort study

BackgroundVenous thromboembolism (VTE) has been associated with a higher risk of developing malignancy and mortality, and patients with VTE may therefore benefit from increased surveillance. We aimed to construct a clinical predictive score that could classify patients with VTE according to their risk for developing these outcomes.MethodsObservational cohort study using an existing clinical registry in a tertiary academic teaching hospital in Buenos Aires, Argentina. 1264 adult patients greater than 17 years of age presented new VTE between June 2006 and December 2011 and were included in the registry. We excluded patients with previous or incident cancer, those who died during the first month, and those with less than one year of follow up (< 5%). 540 patients were included. Primary outcome was new cancer diagnosis during one year of follow-up, secondary composite outcome was any new cancer diagnosis or death. The score was developed using a multivariable logistic regression model to predict cancer or death.ResultsDuring follow-up, one-quarter (26.4%) of patients developed cancer (9.2%) or died (23.7%). Patients with the primary outcome had more comorbidities, were more likely to have previous thromboembolism and less likely to have recent surgery. The final score developed for predicting cancer alone included previous episode of VTE, recent surgery and comorbidity (Charlson comorbidity score), [AUC of 0.75 (95% CI 0.66-0.84) and 0.79 (95% CI 0.63-0.95) in the derivation and validation cohorts, respectively]. The version of this score developed to predict cancer or death included age, albumin level, comorbidity, previous episode of VTE, and recent surgery [AUC = 0.72 (95% CI 0.66-0.78) and 0.71 (95% CI 0.63-0.79) in the derivation and validation cohorts, respectively].ConclusionsA simple clinical predictive score accurately estimates patients’ risk of developing cancer or death following newly diagnosed VTE. This tool could be used to help reassure low risk patients, or to identify high-risk patients that might benefit from closer surveillance and additional investigations.Trial registrationClinicalTrials.gov: NCT01372514.

Incidence rate of amyloidosis in patients from a medical care program in Buenos Aires, Argentina: a prospective cohort

Abstract Background: There are limited data concerning the incidence density (ID) of ATTRwt, AL and AA amyloidosis in the Argentinean population. Our aim was to estimate the ID of ATTRwt, AL and AA amyloidosis at the Hospital Italiano Medical Care Program in Buenos Aires, Argentina. Methods: Population was all members of a hospital-based health maintenance organization who were affiliated since January 2006 to December 2014. Each person was followed contributing time at risk since January 2006 or enrollment date to the final date. Incident cases of amyloidosis were captured from the institutional registry of amyloidosis. Incidence rate was calculated with 95% confidence intervals. Results: During the nine-year study period, there were 15 patients with ATTRwt, 12 with AL and 2 with AA amyloidosis for 1 105 152 person-years of follow-up. The crude ID of ATTRwt amyloidosis was 13.5 (95%CI 8.1–22.4), that of AL amyloidosis 11 (95%CI: 6–19) and that of AA amyloidosis 1.8 (95%CI: 0.5–7.2) per 1 000 000 person-years. The highest ID was found in men (31.7 for ATTRwt, 15.9 for AL and 2.27 for AA amyloidosis per 1 000 000 person-years). The ID adjusted to the population of the city of Buenos Aires was 6.46 (95%CI: 3.17–9.74) for ATTRwt, 6.13 (95%CI: 2.57–9.7) for AL and 1.21 (95%CI: 0.56 to 2.99) for AA amyloidosis. Conclusions: This is the first paper to report the incidence density of ATTRwt, AL and AA amyloidosis in Latin America. Our results are consistent with other studies from other regions. Although systemic amyloidosis is a rare disease, it is a major health problem because of its morbi-mortality.

The role compression ultrasound in hospitalized patients with suspected pulmonary embolism.

In emergency departments, suspected pulmonary embolism (PE) can be safely ruled out by a normal multi-slice CT angiography (CTPA) [1–4] without the need for additional leg compression ultrasonography (CUS). This diagnostic approach for those who develop symptoms of PE during hospitalization has been validated by only a limited number of studies. [2,5]. In this study we aim to estimate prevalence of both proximal and distal deep vein thrombosis (DVT) in hospitalizedpatientswith suspected pulmonary embolism (PE) and estimate the clinical utility of a bilateral whole leg CUS in patientswith suspected PE.We conducted a prospective single center cohort study approved by the ethics board at the Hospital Italiano de Buenos Aires; a 500 hundred bed academic hospital. The original plan was to conduct the study at two centers and recruit 210 subjects however, one of the research teamswere unable to recruit subjects due to financial constraints. As the study had already enrolled more than 30% of the expected sample size, an analysiswas done in order to rule out futility. Patients evaluated for suspected PE were eligible to participate in the study if: 1-They were able to provide consent; 2-Presented with symptoms suggestive of PE (acute onset of new or worsening shortness of breath, chest pain, hemoptysis, presyncope, or syncope); 3-Symptoms developed N48 hours after admission in medically ill patients; or N24hs of admission after a major surgical procedure (defined as an anaesthesia time N90 minutes); and were evaluated with CTPA. All patients were evaluated with a 64multi-slice CT scanner (Aquilion, Toshiba). Patients were excluded if they had symptoms compatible with PE prior to admission. Within 24 hours of providing written consent, all patients had a bilateral whole leg CUS. Proximal DVT was defined as non-compressible segment above the trifurcation of the popliteal vein. PEwas considered diagnosedwhen the CTPA showed a filling defect in a segmental or larger pulmonary artery and was present in at least two consecutive images (single sub-segmental embolus was considered as a PE only if the CUSwas positive for a proximal DVT). Between November 2011 to December 2013, 95 patients were originally enrolled in the study. Fourteen patients (16.8%) had a CTPA performed (one had a sub-segmental PE) but did not complete any further testing as decided by the treating physician andwere therefore, excluded. Six patients were evaluated with V/Q scans and were also excluded. Seventy five hospitalized patients with suspected PE (baseline characteristics

Prevalence of Deep Vein Thrombosis in Hospitalized Patients With Suspected Pulmonary Embolism Ruled Out by Multislice CT Angiography

Current evidence suggests that for outpatients with suspected pulmonary embolism (PE), multislice computed tomographic angiography (CTPA) is sufficient to rule out PE. However, the accuracy of CTPA alone has not been established for hospitalized patients. Our goal was to determine the prevalence of deep vein thrombosis (DVT) in hospitalized patients who had PE ruled out by CTPA. We conducted a prospective cohort study of patients who developed symptoms indicative of PE, after being admitted to the hospital for any reason other than PE and were evaluated with multislice CTPA. The main outcome was proximal DVT. Between November 2011 and December 2014, 191 hospitalized patients were screened. A total of 99 patients satisfied our inclusion criteria. The average length of hospitalization for this group was 14 days (range: 2-127 days). While hospitalized, 54 (28%) patients underwent a major surgical procedure and 80 (79%) were receiving thromboprophylaxis. Of the 99 patients included, 7 (7.07%; 95% confidence intervals [CIs]: 3.4-13.8) were diagnosed with a proximal DVT. The likelihood of developing a proximal DVT was higher for those with subtle and nonspontaneously reported symptoms of DVT, odds ratio [OR] was 50.93 (95% CI: 5.35-2572) and for those classified as PE likely OR was 37.54 (95% CI: 4.05-186.1). Given the prevalence of DVT in hospitalized patients with suspected PE ruled out by a negative multislice CTPA, our study suggests that compression ultrasonography would, in fact, be justified for patients with these characteristics.

Trends in liver transplantation for hepatitis C in a country with reduced access to direct-acting antiviral agents

Hepatitis C virus (HCV)‐related cirrhosis is a leading indication for liver transplantation (LT) worldwide. Access to effective HCV treatment is inequitable globally. We aimed to analyze whether the introduction of effective HCV treatment caused an impact in LT trends in a middle‐income country.

Transthyretin-related hereditary amyloidosis in an Argentinian family with TTR Tyr114Cys mutation

Transthyretin-related hereditary amyloidosis is an autosomal dominant inherited disease caused for mutations in the transthyretin (TTR) gene. Corresponding to the various transthyretin gene mutations and a wide range of geographical distribution, this disorder presents diverse characteristics in genotype-phenotype correlation. Familial amyloid polyneuropathy (FAP) is the more common clinical presentation and the Val30Met is its more frequent mutation described [1].

Creation of a Hyponatremia Registry Supported by an Industry-Derived Quality Control Methodology

Background: A clinical registry encompasses a selective set of rigorously collected and stored clinical data focused on a specific condition. Hyponatremia has multiple, complex underlying causes and is one of the most frequent laboratory abnormalities. No systematic registries of hyponatremic patients have been reported in the medical literature. The purpose of this project was to create a registry for hyponatremia in order to obtain epidemiological data that will help to better understand this condition. Objective: This paper describes the creation of a registry for hyponatremia within a single institution that employs industry-based approaches for quality management to optimize data accuracy and completeness. Methods: A prospective registry of incident hyponatremia cases was created for this study. A formalized statistically based quality control methodology was developed and implemented to analyze and monitor all the process indicators that were developed to ensure data quality. Results: Between December 2006 and April 2009, 2443 episodes of hyponatremia were included. Six process indicators that reflect the integrity of the system were evaluated monthly, looking for variation that would suggest systematic problems. The graphical representation of the process measures through control charts allowed us to identify and subsequently address problems with maintaining the registry. Conclusion: In this project we have created a novel hyponatremia registry. To ensure the quality of the data in this registry we have implemented a quality control methodology based on industrial principles that allows us to monitor the performance of the registry over time through process indicators in order to detect systematic problems. We postulate that this approach could be reproduced for other registries.BACKGROUND A clinical registry encompasses a selective set of rigorously collected and stored clinical data focused on a specific condition. Hyponatremia has multiple, complex underlying causes and is one of the most frequent laboratory abnormalities. No systematic registries of hyponatremic patients have been reported in the medical literature. The purpose of this project was to create a registry for hyponatremia in order to obtain epidemiological data that will help to better understand this condition. OBJECTIVE This paper describes the creation of a registry for hyponatremia within a single institution that employs industry-based approaches for quality management to optimize data accuracy and completeness. METHODS A prospective registry of incident hyponatremia cases was created for this study. A formalized statistically based quality control methodology was developed and implemented to analyze and monitor all the process indicators that were developed to ensure data quality. RESULTS Between December 2006 and April 2009, 2443 episodes of hyponatremia were included. Six process indicators that reflect the integrity of the system were evaluated monthly, looking for variation that would suggest systematic problems. The graphical representation of the process measures through control charts allowed us to identify and subsequently address problems with maintaining the registry. CONCLUSION In this project we have created a novel hyponatremia registry. To ensure the quality of the data in this registry we have implemented a quality control methodology based on industrial principles that allows us to monitor the performance of the registry over time through process indicators in order to detect systematic problems. We postulate that this approach could be reproduced for other registries.