[Genetic susceptibility to the development of acute alcoholic hepatitis: role of genetic mutations in dehydrogenase alcohol, aldehyde dehydrogenase and cytochrome P450 2E1]. / Susceptibilidad genética al desarrollo de hepatitis alcohólica aguda: papel de las mutaciones genéticas en alcohol deshidrogenasa, aldehído deshidrogenasa y citocromo P450 2E1.

OBJECTIVE: Analyze the frequencies of genetic mutation in alcohol dehydrogenase (ADH), aldehyde dehydrogenase (ALDH) and cytochrome P450 2E1 (CYP2E1) and establish their possible association with the development of acute alcoholic hepatitis (AAH). METHODOLOGY: Case-control study in a total of 85 Spanish patients. We distinguish three groups (one case group and two control groups) based on hepatic histological lesion and alcohol consumption: controls (group 1: teetotalers; group 2: drinkers without AAH; cases: group 3: drinkers with AAH). Case diagnosis was established based on the presence of polymorphonuclear leukocyte infiltrate in histological study. We analyzed the presence of the genetic mutations R47H and R369C (ADH2), E487K (ALDH2) and mutation Rsa I of CYP2E1 (allele c2) by polymerase chain reaction (PCR) and capillary electrophoresis. RESULTS: The allele c2 of CYP2E1 was found in 10%, 16% and 50% of the groups 1, 2 and 3 patients, respectively. Presence of the mutation Rsa I showed influence on the development of AAH (odds ratio [OR]: 3.63; confidence interval (95% [CI]: 0.88-15.02). CONCLUSIONS: The data suggest a possible association between the presence of the Rsa I of CYP2E1 and the development of AAH in patients with chronic alcohol consumption.

[Diabetic ketoacidosis in an emergency department]. / Cetoacidosis diabética en un departamento de Urgencias.

OBJECTIVE: We study clinical data and differences in the patients with Diabetic Ketoacidosis (CAD) attended in an Emergency Department (ED). METHODS: We described 15 patients with criteria for diagnosis of CAD during a 12-month period. We value prospectively clinical data, precipitating factors, diagnosis associated, previous diagnosed diabetes, complications, mortality and use of and intensive care unit (UCI). We comparing groups according two characteristics: age group and prior diagnosis of diabetes mellitus.

[Fixed-dosage combinations in the treatment of hypertension]. / Combinaciones en dosis fija para el tratamiento de la hipertensión.

The antihypertensive treatment with a single agent is not useful for the arterial pressure control in a significant number of patients. In such cases, combined treatment or drug substitution are recommended (sequential or substitutive monotherapy). In the last years, the fixed dose combinations in one single pharmaceutical preparation have proliferated. These associations must fulfill a number of conditions in order to be considered rational, as for instance the compatibility of its pharmacokinetic features, properly dosing, the absence of new secondary effects and the high efficiency showed in most of patients. The advantages of these combinations are the comfort and easiness of the therapeutic schema, antihypertensive action strengthening, less secondary effects when dose is reduced, and perhaps a synergism in the protection of target organs. The most popular combinations are: potassium sparing diuretic plus thiazide, diuretic plus beta block, diuretic plus ACEI, or calcium antagonist plus ACEI.

[Infectious pathology in diabetic patients cared for in an emergency department]. / Patología infecciosa en pacientes diabéticos atendidos en un departamento de urgencias.

OBJECTIVE: We study the influence of diabetes in the incidence of infectious diseases attended in an emergency department (ED). PATIENTS AND METHODS: 2,500 adult patients attended in the ED of a general hospital were examined. We value prospectively: clinical data, diagnosis in ED and rate of admissions, comparing two groups: Group A (175 diabetic patients), Group B (350 non diabetic control patients, with the same age and sex). We used the glycated Hb and the glucose levels to make a difference in A Group: patients with good control (A1 = Hb A1c < 8), patients with poor control (A2 = HbA1c > 8), patients with low glucose levels (A3 = glucose < 200 mg/dl) and high glucose levels (A4 = glucose > 200 mg/dl). RESULTS: Infectious disease are more frequent in diabetic patients than no diabetic (Group A = 13.1% vs Group B = 3.2%), certain amount pneumonia and urinary tract infection. Also the infectious diseases are more frequent in diabetic patients with high glucose levels (Group A4) than diabetic patients with low glucose levels (Group A3), but there were no significant differences between A1 and A2 groups. CONCLUSIONS: The presence of diabetes was bound up with a higher frequency of infectious diseases, above all pneumonia and urinary tract infection, in an ED. The importance of metabolic control in relation with infectious diseases is not definite in our study.

[Dystomatosis produced by fasciola hepatica: three cases in Madrid]. / Distomatosis por fasciola hepática: a propósito de tres casos en la Comunidad de Madrid.

Three cases of hepatic fascioliasis diagnosed in the Department of Internal Medicine are presented. All of the patients live in Madrid, all were fed watercress in the last month and the diagnosis was established during the invasive phase and confirmed by serological testing. We emphasized the importance of the TC scan in the correct diagnosis, the ectopic location of the parasite presentation like subcutaneous thoracic nodule and the efficacy of bithionol in the treatment.

[Emergency department observation and short term unit]. / Unidad de Observación y Corta Estancia de Medicina en el Servicio de Urgencias.

BACKGROUND: An emergency department observation and short term unit is analyzed, and the conditions appropriate for it. METHODS: Four hundred patients admitted consecutively were evaluated. Demographic, and clinical data, complementary tests performed, diagnosis, destination and revisits to the emergency department were analyzed. RESULTS: The 57% of the patients were over 65 years. Complementary tests were performed in all patients. 42% were discharged home without hospitalization, being syncope, intoxication and epilepsy the most common diagnosis. The 1.8% of the patients no hospitalized revisted to emergency department during the next 72 hours. CONCLUSION: Emergency department observation and short term units can reduce hospitalization and health care costs and improve the quality of medical care through extended evaluation and treatment.

[Malignant neuroleptic syndrome]. / Síndrome neuroléptico maligno.

Neuroleptic Malignant Syndrome (NMS) is a rare disease characterized by hyperthermia, altered level of consciousness, autonomic dysfunction and muscular rigidity in relation to treatment with different drugs. We describe ten patients with Neuroleptic Malignant Syndrome in our Hospital. The mean age was 48 +/- 18 and females were majority (70%). Haloperidol, alone or with another farms, was relation with NMS in the 90% of the cases. Mortality became the 20% and it was relation with respiratory failure and delayed on admission in Intensive Care Unit (UCI). We remarked the importance to have a high suspicious index for attending of this disease by a precocious and intensive treatment.

[Clinical assessment systems in the diagnosis of pulmonary thromboembolism]. / Sistemas de valoración clínica en el diagnóstico del tromboembolismo pulmonar (TEP).

We proposed developing two symptom-based systems for assessing the presence of pulmonary thromboembolism (TEP) in our practice, using a standardized questionnaire and multivariate models. Data were collected from September 1993 through November 1994 (case reports, physical examination findings and complementary test results) of patients admitted to our ward with a suspicion of TEP. The calculated odds ratio for each of the variables recorded were used as weights to determine their relevance or not for the group at risk for TEP. The yield of the two systems developed (a weights system and a logistical model) were studied by plotting ROC curves. Eighty-two patients (40 women and 42 men, mean age 60.94 +/- 14.39 years) were admitted. The questionnaire had a sensitivity of 88% and a specificity of 75%, a positive predictive value of 94% and a negative predictive value of 60%. The logistical regression model had a sensitivity of 96.3% for a diagnosis of TEP with inclusion of the following variables: female sex, disease-related immobility, presence of deep venous thrombosis (DVT) in the lower extremities and the appearance of unexplained dyspnea. Neither system was clearly superior to the other for arriving at a clinical diagnosis of TEP.

[Quality and selection of samples of bronchoalveolar lavage (BAL) in diffuse pneumopathies]. / Estudio de calidad y selección de muestras de lavado broncoalveolar (LBA) en neumopatías difusas.

Bronchoalveolar lavage (BAL) samples used to study immune or inflammatory response in interstitial lung disease must be representative of the lower respiratory tract. Thus, the selection of suitable samples must be part of routine practice. To assess the incidence of unsuitable BAL samples used for cytology and to determine the relation between parameters related to underlying disease and the quality of samples. One hundred sixty-one patients were enrolled. Seventy-two were HIV positive and had diffuse pulmonary infiltrates, 34 had idiopathic pulmonary fibrosis (IPF), 10 had sarcoidosis, 10 had hypersensitivity pneumonitis, 19 had interstitial lung disease and collagen diseases and 2 had pulmonary eosinophilia. Fourteen individuals formed the control group. The quality study was carried out by staining the BAL samples following a modified Wright-Giemsa technique and evaluating the samples by the selection criteria described by Chamberlain and colleagues (1987). We identified unsuitable samples from 53% of the HIV positive patients, from 35% of the IPF patients and from 21% of the interstitial lung disease patients with associated connective tissue disease. In the other groups, all samples were suitable for analysis. Intolerance of BAL with decreasing percentage of fluid recovered was significantly associated with sample quality, particularly in the IPF group. The cytology results that invalidated the samples differed by group. In all groups, unsuitable specimens had low cell counts. The finding or not of evidence of associated infection in HIV-infected patients, on the other hand, did not appear to determine sample quality in and of itself, although it did in samples related to other entities. We can predict that a high rate of unsuitable BAL samples will come mainly from patients with diffuse lung disease associated to HIV infection, IPF and interstitial lung disease with associated connective tissue disease. Tolerance to the technique influences quality of the specimen obtained and, therefore, should be taken into account in interpreting the findings of cytology. The criteria applied by the various teams using BAL should be unified, and it should be determined whether the exclusion of inappropriate samples affects the final composition of study groups.

[Blocking antibodies in Dermatophagoides allergy]. / Anticuerpos bloqueantes en la alergia a Dermatophagoides.

A group of patients with Dermatophagoides allergy was estudy analyze the behavior of blocking antibodies (Ab E: total IgG, IgG1 and IgG4) directed against complete allergen extract (CE) and against the major allergens, Der pI and Der pII, and its relation with the clinical results of desensitizing treatment. A group of 36 patients received specific immunotherapy (IT) and conventional treatment alone. Over a 12-month period, four follow-up studies were made to evaluate the patient's clinical situation (symptom score) and to determine total IgG and IgG subclasses directed against CE, DER pI, and DER pII. In the group treated with IT, the levels of all IgG subclasses increased subjectively, but in the group without It, igG levels did not change. There was no significant improvement in ocular on pulmonary symptoms in either group. Nasal symptoms had a more favorable evolution in the IT group.

[An intrathoracic meningocele in von Recklinghausen's disease. A case report]. / Meningocele intratorácico en la enfermedad de von Recklinghausen. Presentación de un caso.

Posterior mediastinal tumors in young people are most often neurogenic. The presence of a meningocele has occasionally been described as causing mass in the region and cases reported have mainly been in patients with neurofibromatosis. We describe a patient with type I neurofibromatosis and intrathoracic meningocele.

[An analysis of the prevalence of respiratory symptomatology in the general population]. / Análisis de la prevalencia de sintomatología respiratoria en la población general.

This paper is a report of a cross-sectional epidemiological study that formed part of multicenter European project; the aim was to estimate the prevalence of respiratory symptoms and signs related to asthma over a period of 12 months in the city of Seville. A sample of 4,000 persons of both sexes, aged between 20 and 44 years old, was surveyed first by mail questionnaire and later by telephone interview. We analyzed the response index obtained with the mail survey for the epidemiological study of asthma in the area and for the frequency of respiratory symptoms and their distribution by age and sex. The response index was 53.36% and was similar for men and for women. Forty-nine percent reported at least one respiratory symptom, with nocturnal coughing attacks (27.7%) and wheezing (22.2%) being the most frequent. The frequency of these symptoms was different by sex, however, with the former more often reported by women (p < 0.02) and the latter by men (p < 0.001). We found that 14.9% of the population had rhinitis and that women reported this symptom more often (p < 0.02). Symptoms related to asthma were nocturnal attacks of breathlessness, the use of asthma medication and an asthma attack diagnosed by a physician within the last 12 months. With these criteria the estimated prevalence of asthma was 11.72%, a proportion that held steady for all age groups except the middle-aged and for both sexes.(ABSTRACT TRUNCATED AT 250 WORDS)

[Community-acquired pneumonia in the aged: prognostic factors]. / Neumonía comunitaria en el anciano: factores pronósticos.

We studied the clinical characteristics and the initial supplementary test available in the emergency service, in aged patients with community-acquired pneumonia, as well as their mortality prognosis value. We assessed 190 patients attended consecutively during one year. Clinical, analytical and radiological data were registered. The parameters associated to a higher mortality were: age, absence of thoracic pain, reduction in the level of consciousness, leukocytosis, increased urea levels, aminotransferases, lactate dehydrogenase and reduction in prothrombin activity and pH. The data associated to a greater relative risk were: age above 80 years, absence of thoracic pain, prothrombin activity lower than 70% and ALT < 40 U/l. The presence of three to four of these variables had a sensitivity of 62% and a specificity of 94% in the prediction of mortality. In the multivariable analysis, the following variables remained significative: age, obnubilation and decrease of prothrombin. We stress the relevance of a high clinical suspicion, given the frequency of these cases with little symptomatology, in order to allow for an early treatment and the identification of right risk patients at the initial assessment.

[The prognostic factors of mortality in community-acquired pneumonia requiring hospitalization]. / Factores pronósticos de mortalidad en la neumonía comunitaria que requiere hospitalización.

The prognostic influence on mortality of parameters available in an emergency Unit is studied in patients with acquired community pneumonia (ACP) requiring hospitalization. Three hundred and thirty patients admitted consecutively from the emergency unit of a general hospital were evaluated. Radiological, analytical, clinical, and demographic data were recorded. The parameters associated with greater mortality were: age, absence of thoracic pain, obnubilation, hypotension, elevation in urea, GOT, GPT, LDH, decrease in prothrombin activity, pO2, pH, albumin, and the affectation of more than one lobe in a radiography of the thorax. Considering the parameters associated with a higher relative risk (age > 65 years, urea > 50 mg/dl, LDH > 460 U/l and prothrombin < 70%), the presence of three or four of these variables shaved a sensibility of 59 percent and a specificity of 93 percent in predicting mortality. In the multivariant analysis remained as significant: age, obnubilation, elevation in LDH, and decrease in the activity of prothrombin and pH. Appropriate knowledge of the prognostic factors in CAP allows for early determination of patients who require special attention in both diagnosis and in treatment upon hospitalization.