Spanish Internal Medicine Departments Research Articles

Projected clinical benefits of dapagliflozin in patients with heart failure with preserved ejection fraction.

Aims: To address the projected clinical benefits of dapagliflozin among patients with heart failure (HF) with mildly reduced ejection fraction (HFmrEF) and preserved ejection fraction (HFpEF). Methods: A multicenter, prospective, cohort study of patients ≥50years admitted with HF to Spanish internal medicine departments. The projected clinical benefits of dapagliflozin were calculated from the DELIVER trial. Results: A total of 4049 patients were included; 3271 (80.8%) were eligible for dapagliflozin treatment, according to DELIVER criteria. Within 1 year after discharge, 22.2% were rehospitalized for HF and 21.6% died. Implementation of dapagliflozin would translate into an absolute risk reduction of 1.3% for mortality and 5.1% for HF readmission. Conclusion: HF patients with preserved or mildly reduced ejection fraction have a high risk of events. The use of dapagliflozin could substantially reduce the HF burden.

Characteristics of adults with Down syndrome hospitalized in Spanish internal medicine departments during 2005–2014

Background and objectivesThe clinical problems of adults with Down syndrome (DS) seem to differ from those of the general population. To better understand these differences, we list the demographic and clinical characteristics of adults with DS admitted to Spanish internal medicine departments during 2005–2014. Patients and methodsWe conducted an observational retrospective study using data collected from the minimum basic data set on hospitalisation episodes of adults with DS in the internal medicine departments of Spain’s National Health System from 2005 to 2014. We analysed the patients’ epidemiological, clinical and societal data. ResultsA total of 7548 hospitalisation episodes from 3786 patients were recorded. Some 56.6% of the patients were male with a mean age (±SD) of 47 ± 13 years, and 715 of the patients died (18.9%). The age-adjusted mortality was 26.6%, and the mean stay was 9.6 ± 12 days. The hospitalisation was for respiratory disease in 3684 episodes (48.8%) and for cardiac origin in 760 (10%). The most common comorbidities were hypothyroidism (27.1%, 2043 episodes), epilepsy (24.1%, 1819 episodes) and dementia (15.4%, 1162 episodes). ConclusionsThe hospitalisation of adults with DS in internal medicine departments has increased in the past decade. Although the reasons for hospitalisation, mean stay and cost per episode for this population are similar to those of the general population treated by internal medicine departments, the age-adjusted hospital mortality was significantly greater.

Clinical characteristics and prognosis for delirium in Spanish internal medicine departments: An analysis from a large clinical-administrative database

ObjectivesTo investigate the prevalence of reported delirium and its associated factors and costs. DesignRetrospective and descriptive analysis of a national clinical-administrative database that includes all patients hospitalized in Spain in internal medicine departments from January 2007 to December 2014. Material and methodThe study included the patients’ sociodemographic and clinical data (sex, age, diagnosis and procedures). ResultsThe prevalence of reported delirium was 2.5% (114,343 of 4,628,397 discharge reports). Delirium was most common in the 81–90-year age group (48%) and in institutionalized patients (4.5% vs. 2.9%; p<.001). The diagnoses most associated with delirium were dementia (14% vs. 7% for patients without delirium), cerebrovascular disease (17% vs. 11%), malnutrition (4% vs. 2%), pressure ulcers (4% vs. 2%), dysphagia (2% vs. 0.2%) and hyponatraemia (5% vs. 2%) (p<.001 in all cases). Patients with delirium also had longer mean stays (11.85±13.15days vs. 9.49±11.17) and higher hospital mortality (OR: 1.41; 95%CI: 1.39–1.43; p=.0001).The costs attributable to delirium in 8 years exceeded €100 million (almost €1000 per hospitalization/patient). We developed a predictive model for the risk of developing delirium, which has insufficient sensitivity but is useful for identifying low-risk patients. ConclusionsPatients who develop delirium during their hospitalization in internal medicine have a longer stay, greater mortality and an increased risk of being institutionalized at discharge. Delirium is probably poorly reported in the discharge reports prepared by internists.

Acute kidney injury is linked to higher mortality in elderly hospitalized patients with non-valvular atrial fibrillation.

Renal insufficiency is associated with medical complications in patients with non-valvular atrial fibrillation (NVAF). However, data for elderly patients are scarce. Thus, the main objectives of the present study were to analyze the characteristics of elderly patients with NVAF and acute or chronic renal disease, describe their management in real-life conditions, and detect factors associated with complications. The NONAVASC registry includes patients > 75years with NVAF, hospitalized by any cause in 64 Spanish Internal Medicine departments. Patients were categorized into acute kidney injury (AKI), chronic kidney disease (CKD) or preserved renal function (PRF). All variables associated with in-hospital mortality with P < 0.10 in univariate analysis were included to develop a multivariate logistic-regression model. The study included 804 patients (53.9% women), 352 (43.8%) of whom met diagnostic criteria for CKD. AKI was detected in 119 (14.8%) patients. AKI was associated with greater length of stay, higher mortality and an increased rate of patient transfer to nursing homes. After logistic-regression analysis, we found an association between mortality and AKI (OR 2.4, 95% CI 1.03-5.53; P = 0.045). The increase in creatinine values (OR 1.8, 95% CI 1.19-2.73; P = 0.005) and the decrease in albumin values (OR 2.0, 95% CI 1.05-3.73; P = 0.033) were also linked to mortality. Our study shows the relationship between AKI and creatinine value increase and a higher mortality in elderly patients with NVAF. In light of our findings, the detection of renal function impairment in these patients should alert physicians and consider them as high-risk patients.

Nationwide study on the use of intravascular catheters in internal medicine departments

The use of intravascular catheters (IVCs) in intensive care units (ICUs) has been well assessed in recent years. However, a high proportion of these devices are placed in patients outside the ICU, particularly in internal medicine departments (IMDs), where data on the quality of care are scarce. To assess the use and management of IVCs in IMDs in Spain. We performed a point prevalence study of all adult inpatients on 47 IMDs from hospitals of different sizes on one day in June 2013. A local co-ordinator was appointed to assess patients and collect data from each site. Out of the 2080 adult patients hospitalized on the study day, 1703 (81.9%) had one or more IVCs (95.4% of which were peripheral devices). Infection was detected at the insertion site in 92 catheters (5.0%); 87 patients (5.2%) had signs of sepsis, but only one case was considered to be catheter-related. The local co-ordinators estimated that 19% of the catheters in place were no longer necessary. A daily record of the need for a catheter was available in only 40.6% of cases. Our study shows clear opportunities for improvement regarding catheter use and care in Spanish IMDs. Strategies similar to those applied in ICUs should be implemented in IMDs.

Riesgo vascular en las consultas de Medicina Interna. Estudio MICARE

Background and objectivesThe population attended in the Spanish Internal Medicine departments is of increasing age, but the prevalence of vascular risk factors and its degree of control are unknown, as well as the differences by type of hospital or consulting room. Patients and methodsEpidemiologic, transversal and metacentric study in patients≥18 years treated in outpatient Internal Medicine hospital. Two-hundred and ninety physicians from 17 Autonomic Communities participated in the study. The type of hospital or consulting room was also recorded. Blood pressure control was defined as <140/90mmHg (<130/80mmHg in diabetics or patients with vascular disease), LDL-cholesterol control when<130mg/dl (<100mg/dl in diabetic or vascular disease) and diabetes control if glycated hemoglobin was<7%. ResultsData from 2,704 patients was collected (54% men) mean age (SD) 64,1 (14,5) years. Ninety-three percent of them had at least one cardiovascular risk factor: hypertension 73.9%, dyslipidemia 59.5%, abdominal obesity 43.4%, diabetes 39.5%. Fifty percent had some target organ damaged, 46.7% showed vascular disease and 71.2% a high or very high vascular risk. Control over risk factors was: hypertension 33.8%, cholesterol-LDL 40.8% and diabetes 50.7%. There were no differences between type of hospital or type of outpatient consultancy. ConclusionsOver 90% of patients treated in outpatient consultancies of Internal Medicine departments present vascular risk factors, regardless of the type of hospital or type of consulting room. Risk factors control was poor.

Procedimientos invasivos en pacientes ingresados en los servicios de Medicina Interna españoles

AimsInvasive procedures (IP) have become routine techniques that benefit an important number of patients on improving their quality of life or avoiding more aggressive treatments. We have conducted a study on the IPs performed in Spanish Internal Medicine (IM) Departments between 2005 and 2009. Patients and methodsIP performed to patients admitted to Spanish Internal Medicine departments were analyzed based on the information obtained from the Minimum Basis Data Set (CMBD). IP was defined as the following: filter placement in the inferior vena cava, chest tube placement, biliary, esophageal and colon prosthesis placement, pleurodesis, nephrostomy, external biliary drain placement, gastrostomy tube placement, thoracocentesis and peritoneal catheter placement. ResultsDuring the study period, a total of 75,853 invasive procedures on 70,239 admittances were performed in 2,766,673 patients (2.5%). IP subjects were younger (68.1 vs 71.4; P<.001), predominantly male (61.9 vs 53.2%; P<.001), with higher mortality (14.6 vs 9.9%; P<.001) and longer stay (18.4 vs 9.6 days; P<0.001). Cost of admittance was clearly higher than the rest of the patients (5,600€ vs 3,835€; P<.001). ConclusionsIPs are performed on a low percentage of IM Department hospitalized patients. They are costly, entail high mortality and a longer stay period compared to the mean population admitted to IM. A considerable proportion of the patients receiving IP suffer from neoplastic diseases, frequently in advances stages, which justifies the high inhospital mortality of this population.

Función renal en pacientes con insuficiencia cardiaca: valor pronóstico

IntroductionImpaired renal function can lead to a poor prognosis in patients with heart failure (HF). This study analyses the prevalence and prognostic value of impaired renal function in a cohort of patients with HF. MethodsWe analysed patients who were included in the RICA study (multicentre, prospective cohort study) who were admitted for decompensated HF in 52 Spanish Internal Medicine Departments between March 2008 and September 2009. The patients were grouped according to their renal function, evaluated by eGF, using the MDRD formula. ResultsA total of 714 patients (54% women) with a mean age of 77.3+8.7 years were included. Of these, 84% had hypertension, and hypertensive heart disease was the most common aetiology of HF (39.2%). Ejection fraction was normal in 64.7% of patients, and 59.5% had an eGF less than 60mL/min per 1.73m2, and 11.2% with an eGF less than 30mL/min per 1.73m2. Less spironolactone was prescribed in patients with advanced stages of renal dysfunction (24%), compared with patients with an eGF>60mL/min/1.73m2 (35%; P=.025). Worsening renal function was independently associated with an increased mortality risk (RR: 2.05; 95% CI: 1.13-3.71; P=.018). ConclusionsAbout 60% of patients admitted to Internal Medicine with HF have impaired renal function. This comorbidity is associated with a two-fold increase in all-cause mortality.

Factors influencing medical treatment of heart failure patients in Spanish internal medicine departments: a national survey

The medical management of heart failure (HF) in clinical practice varies considerably by country and by medical specialty. To assess the treatment of HF patients admitted to Internal Medicine departments, and to evaluate out-patient management prior to admission, by specialty. Prospective cross-sectional multi-centre survey. Of 55 randomly selected Spanish hospitals, 51 agreed to participate. All patients (n = 2145) consecutively admitted for decompensated HF to the Departments of Internal Medicine of these hospitals, over 5 months, were included. Twenty variables were analysed, including aspects relating to out-patient management prior to admission. Mean +/- SD age was 77.2 +/- 10.5 years, 57.3% were female, 47% had systolic dysfunction. Prescriptions at discharge: loop diuretics 85.6%, spironolactone 29.8%, ACEIs 65.8%, beta-blockers 8.7%, cardiac glycosides 39%. At admission, 86% already had a diagnosis of HF. Of these, 53% (older patients and more women) were being treated on an out-patient basis by primary care physicians. Primary care physicians requested fewer echocardiograms than internists (38% vs. 69%, p<0.001) and prescribed fewer drugs (ACEIs 40% vs. 54%, p<0.001; spironolactone 15% vs. 23%, p<0.05; beta-blockers 6% vs. 13%, p<0.01). The internists treated more incapacitated patients than the cardiologists (p<0.001), prescribed more high-dose ACEIs (20% vs. 13%, p<0.01) and spironolactone (26% vs. 20%, p<0.05), and fewer anticoagulants (32% vs. 39%, p<0.05). Patients admitted to medical departments with HF are different to those found in clinical trials. Their management is currently suboptimal. Differences in treatment between internists and cardiologists appear to be accounted for by differences in the patients they treat.