RESUMEN
BACKGROUND: Traditionally, patients with pulmonary embolism (PE) are initially treated in the hospital with low molecular weight heparin (LMWH). The results of a few small non-randomized studies suggest that, in selected patients with proven PE, outpatient treatment is potentially feasible and safe. OBJECTIVE: To evaluate the efficacy and safety of outpatient treatment according to predefined criteria in patients with acute PE. PATIENTS AND METHODS: A prospective cohort study of patients with objectively proven acute PE was conducted in 12 hospitals in The Netherlands between 2008 and 2010. Patients with acute PE were triaged with the predefined criteria for eligibility for outpatient treatment, with LMWH (nadroparin) followed by vitamin K antagonists. All patients eligible for outpatient treatment were sent home either immediately or within 24 h after PE was objectively diagnosed. Outpatient treatment was evaluated with respect to recurrent venous thromboembolism (VTE), including PE or deep vein thrombosis (DVT), major hemorrhage and total mortality during 3 months of follow-up. RESULTS: Of 297 included patients, who all completed the follow-up, six (2.0%; 95% confidence interval [CI] 0.8-4.3) had recurrent VTE (five PE [1.7%] and one DVT [0.3%]). Three patients (1.0%, 95% CI 0.2-2.9) died during the 3 months of follow-up, none of fatal PE. Two patients had a major bleeding event, one of which was fatal intracranial bleeding (0.7%, 95% CI 0.08-2.4). CONCLUSION: Patients with PE selected for outpatient treatment with predefined criteria can be treated with anticoagulants on an outpatient basis. (Dutch Trial Register No 1319; http://www.trialregister.nl/trialreg/index.asp).
Asunto(s)
Atención Ambulatoria , Anticoagulantes/uso terapéutico , Nadroparina/uso terapéutico , Embolia Pulmonar/prevención & control , Trombosis de la Vena/tratamiento farmacológico , Vitamina K/antagonistas & inhibidores , Enfermedad Aguda , Adulto , Anciano , Anticoagulantes/efectos adversos , Femenino , Hemorragia/inducido químicamente , Humanos , Masculino , Persona de Mediana Edad , Nadroparina/efectos adversos , Países Bajos , Selección de Paciente , Estudios Prospectivos , Embolia Pulmonar/diagnóstico , Embolia Pulmonar/etiología , Embolia Pulmonar/mortalidad , Medición de Riesgo , Factores de Riesgo , Prevención Secundaria , Factores de Tiempo , Resultado del Tratamiento , Trombosis de la Vena/complicaciones , Trombosis de la Vena/diagnóstico , Trombosis de la Vena/mortalidadRESUMEN
BACKGROUND: We call attention to the assumed association between itraconazole and pancreatitis by presentation of four Dutch case reports. METHODS AND RESULTS: The Netherlands Pharmacovigilance Centre Lareb received four reports of pancreatitis associated with the use of itraconazole, all reported by health professionals. The diagnosis of pancreatitis was confirmed by diagnostic tests. All four patients had been using relatively high doses of itraconazole. In two of these cases, recurrent use of itraconazole resulted in recurrent symptoms. We describe these four cases and discuss the possible mechanism. CONCLUSIONS: The presented cases suggest a causal relation between itraconazole and pancreatitis. Given the often mild indication for the use of itraconazole and the seriousness of this possible adverse drug reaction, it is essential that more data are obtained in order to strengthen the causality of this association. Physicians are invited to report their experiences on the subject.
Asunto(s)
Antifúngicos/efectos adversos , Itraconazol/efectos adversos , Pancreatitis/inducido químicamente , Enfermedad Aguda , Adolescente , Anciano , Antifúngicos/administración & dosificación , Femenino , Humanos , Itraconazol/administración & dosificación , Masculino , Persona de Mediana Edad , Pancreatitis/diagnósticoRESUMEN
This study evaluated the diagnostic value of C-reactive protein (CRP) combined with a clinical decision rule in the exclusion of pulmonary embolism (PE) and compared this with D-dimer. In 363 consecutive outpatients CRP and D-dimer test were performed and clinical probability of PE was assessed. Patients with D-dimer levels<500 microg/l and clinical probability indicating 'PE unlikely' were followed for 3 months. Ventilation-perfusion scan or spiral computerized tomography was performed in patients with D-dimer levels>or=500 microg/l or clinical probability indicating 'PE likely'. The CRP had a sensitivity of 95.7% [95% confidence interval (CI): 90-100] and negative predictive value (NPV) of 98.4% (96-100). CRP<5 mg/l with clinical probability score indicating 'PE unlikely' (n=108, 30%), had a sensitivity of 96.7% (90-100), a specificity of 43.0% (37-49) and NPV of 99.1% (97-100). D-dimer<500 microg/l with clinical probability score indicating 'PE unlikely' (n=170, 51%), had a sensitivity of 96.7% (90-100), a specificity of 67.9% (62-74) and NPV of 99.4% (98-100). Based on retrospective data it was concluded that a standard CRP test can potentially be used to safely exclude PE, either as a sole test or combined with clinical probability assessment. Prospective studies are needed to confirm these findings.
Asunto(s)
Proteína C-Reactiva/análisis , Productos de Degradación de Fibrina-Fibrinógeno/análisis , Embolia Pulmonar/diagnóstico , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Biomarcadores/sangre , Intervalos de Confianza , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Probabilidad , Estudios Prospectivos , Embolia Pulmonar/sangre , Curva ROC , Estudios Retrospectivos , Factores de Riesgo , Sensibilidad y EspecificidadRESUMEN
A 69-year-old man presented with dyspnoea, cough and diffuse interstitial changes and ground-glass effect on a CT-scan. After 5 months the patient was diagnosed with pulmonary intravascular lymphomatosis. A histologic diagnosis was made by a video-assisted thoracoscopic surgical biopsy. Treatment with combination chemotherapy, i.e. 8 cycles of cyclophosphamide-doxorubicin-vincristine-prednisone (CHOP), resulted in a complete remission and a disease-free survival of 5 years at the last follow-up. Intravascular lymphomatosis is a rare but curable cause of interstitial lung disease. Intravascular lymphomatosis is an uncommon type of non-Hodgkin's lymphoma, characterized by proliferation of neoplastic lymphoid cells within the lumen of small blood vessels, resulting in thrombotic and ischaemic complications in multiple organ systems. Primary pulmonary presentation is even more uncommon. It is important to consider intravascular lymphomatosis in the differential diagnosis of unexplained interstitial lung disease, since early diagnosis and treatment may lead to complete remission and long-term survival.
Asunto(s)
Enfermedades Pulmonares Intersticiales/diagnóstico , Neoplasias Pulmonares/diagnóstico , Linfoma no Hodgkin/diagnóstico , Anciano , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapéutico , Biopsia , Diagnóstico Diferencial , Supervivencia sin Enfermedad , Humanos , Pulmón/patología , Enfermedades Pulmonares Intersticiales/tratamiento farmacológico , Neoplasias Pulmonares/tratamiento farmacológico , Linfoma no Hodgkin/tratamiento farmacológico , Masculino , ToracoscopíaRESUMEN
A 50-year-old woman was treated intermittently with itraconazole (Trisporal) due to onychomycosis. After the initial period of 7 days and after the first 9 days of the second period she experienced abdominal complaints. In the second episode, pancreatitis was diagnosed. No known risk factors for acute pancreatitis were present. The pancreatitis may have arisen due to the use of itraconazole. As far as we know, this side effect of itraconazole or other triazole derivatives has not previously been reported in the literature. It seems to be a rare side effect, for which the pathogenesis has yet to be elucidated.
Asunto(s)
Antifúngicos/efectos adversos , Itraconazol/efectos adversos , Pancreatitis/inducido químicamente , Enfermedad Aguda , Femenino , Humanos , Persona de Mediana Edad , Onicomicosis/tratamiento farmacológico , Recurrencia , RetratamientoRESUMEN
A 53-year-old woman was referred to the outpatient clinic for Internal Medicine, due to an elevated serum concentration of carcinoembryonic antigen (CEA). Hypothyroidism was diagnosed. Following replacement therapy with levothyroxin, the serum concentrations of thyroid stimulating hormone (TSH) and CEA decreased to near-normal levels. No malignancy was found during the remainder of the treatment period. A decreased hepatic clearance of CEA seemed to be the most likely explanation for the observed high CEA concentration in this patient with hypothyroidism. An increased CEA concentration may occur in association with certain malignancies, as well as with non-neoplastic disorders, such as hypothyroidism. As CEA has a low tumour specificity, routine assessment of CEA is not advocated for diagnostic evaluation.
Asunto(s)
Antígeno Carcinoembrionario/sangre , Hipotiroidismo/inmunología , Hepatopatías/inmunología , Tiroxina/uso terapéutico , Diagnóstico Diferencial , Femenino , Terapia de Reemplazo de Hormonas , Humanos , Persona de Mediana Edad , Sensibilidad y Especificidad , Neoplasias de la Tiroides/diagnósticoRESUMEN
Chlamydia psittaci myocarditis has been infrequently reported. A case of serologically confirmed C psittaci myocarditis with dilated left ventricle and severely impaired left ventricular function is described. Serial echocardiograms demonstrated complete recovery after therapy. An early diagnosis has important prognostic implications.
Asunto(s)
Anticuerpos Antibacterianos/análisis , Chlamydophila psittaci/inmunología , Ecocardiografía Transesofágica , Miocarditis/diagnóstico por imagen , Psitacosis/diagnóstico por imagen , Adulto , Inhibidores de la Enzima Convertidora de Angiotensina/uso terapéutico , Antibacterianos/uso terapéutico , Diagnóstico Diferencial , Diuréticos/uso terapéutico , Quimioterapia Combinada , Ecocardiografía Doppler , Humanos , Masculino , Miocarditis/tratamiento farmacológico , Miocarditis/microbiología , Psitacosis/tratamiento farmacológico , Psitacosis/microbiologíaRESUMEN
Wilkie's syndrome is a rare disease that should be considered in the differential diagnosis of upper abdominal discomfort and weight loss. Compression of the inferior part of the horizontal duodenum by the superior mesenteric artery may result in high intestinal obstruction with postprandial or positional discomfort, vomiting and weight loss. The diagnosis is based on clinical presentation and confirmed by radiographic studies during a symptomatic period. Therapy of first choice is conservative. Nevertheless, surgical intervention with duodenojejunostomy is often required.
Asunto(s)
Síndrome de la Arteria Mesentérica Superior/diagnóstico , Vómitos/etiología , Pérdida de Peso , Adolescente , Duodenoscopía , Enterostomía , Humanos , Masculino , Síndrome de la Arteria Mesentérica Superior/complicaciones , Síndrome de la Arteria Mesentérica Superior/terapiaRESUMEN
A man, 23 years of age, had a typical erythema infectiosum, complicated by a severe bilateral brachial plexus neuritis. Motor function recovered slowly and only partially after 6 months. An infection by human parvovirus B19 was demonstrated, with strongly positive and gradually declining IgM antibodies and viral DNA detectable in serum for more than 3 months. There was also clear evidence of a recent infection by cytomegalovirus. The interaction between these two viruses could be responsible for this rare and severe complication of common infections in this patient.
Asunto(s)
Plexo Braquial , Infecciones por Citomegalovirus/complicaciones , Eritema Infeccioso/complicaciones , Neuritis/etiología , Neuritis/virología , Parvovirus B19 Humano , Adulto , Infecciones por Citomegalovirus/inmunología , ADN Viral/análisis , Humanos , Inmunoglobulina M/análisis , Masculino , Parvovirus B19 Humano/genética , Parvovirus B19 Humano/inmunologíaRESUMEN
A 71-year-old woman was admitted to our hospital with jaundice after she had been using terbinafine for a few weeks. The liver function tests showed a mixed cholestatic-hepatocellular pattern. A liver biopsy revealed large amounts of intracellular bile pigment. Causes of the liver disorder other than the use of the aforementioned antimycotic drug were excluded. Ten months after cessation of the drug the patient had recovered completely. The Netherlands Inspectorate for Health Care received 20 reports of liver enzyme elevations due to terbinafine in 1991-1994.
Asunto(s)
Antifúngicos/efectos adversos , Enfermedad Hepática Inducida por Sustancias y Drogas/etiología , Naftalenos/efectos adversos , Adulto , Anciano , Biopsia con Aguja , Enfermedad Hepática Inducida por Sustancias y Drogas/patología , Femenino , Humanos , Hígado/patología , Masculino , Persona de Mediana Edad , Onicomicosis/tratamiento farmacológico , TerbinafinaRESUMEN
A 43-year-old woman presented with thyroiditis caused by Moraxella nonliquefaciens. Antibiotic therapy resulted in complete recovery. The literature on M. nonliquefaciens and acute bacterial thyroiditis is reviewed. This is the first documented case of a thyroiditis caused by M. nonliquefaciens.
Asunto(s)
Moraxella , Infecciones por Neisseriaceae , Tiroiditis/microbiología , Enfermedad Aguda , Adulto , Cefradina/administración & dosificación , Quimioterapia Combinada/administración & dosificación , Femenino , Humanos , Metronidazol/administración & dosificación , Tiroiditis/tratamiento farmacológicoRESUMEN
A female aged 62 yr developed a recurrence of chronic idiopathic thrombocytopenia 7 years after splenectomy. Two accessory spleens were identified and removed surgically. An increase in platelet count was seen. An analysis of the literature shows that extirpation of accessory spleens was successful in over 60% of the patients (32/52) with recurring idiopathic thrombocytopenia after splenectomy.