[New criteria for the diagnostic and treatment of the deep vein thrombosis of the lower limbs]. / Nuevos criterios para el diagnóstico y tratamiento de la trombosis venosa profunda de los miembros inferiores.

The diagnosis of the deep vein thrombosis (DVT) based exclusively on its symptomatology and on the examination clinic is of few usefulness due to its small sensibility and especificity. However, its adequate combination with the presence of risk factors for the thrombosis, and the existence or not of an alternative diagnosis, it can be employed it to classify to the patients according to the forecast model clinic of DVT of Wells in two categories: high or probability decrease of suffering it. Their utilization in urgencies together with the determination of the D dimer (DD) will indicate us the need or not of accomplishing an echo -- Doppler, currently the complementary election test. The phlebography is maintained as "the gold test", though is reservation for certain cases. Unless exceptions, the heparins of under molecular weight have displaced the heparins not fractioned in the treatment of the disease, due to the series of inconvenients that present: complications hemorrhagics, thrombocytopenia, need of hospitalization and of biological control. It is possible, that in a future most or less next new antithrombotics, as the fondaparinux or the ximelagatran change substantially the treatment of the DVT. The indication of the thrombolysis is little accepted, due to the fact that the relationship risk -- benefit is not satisfactory. Though they are not exempt of complications, exist clean-looking situations in those which is indicated the placement of a filter in the inferior vein cava. An exception, they would be the thrombosis massive veins with gangrene risk phlegmasia cerulea dolens, in patient with under risk hemorrhagic. Finally, in the cases that developed ischemia venous, that generally appear in the occlusions most proximals -- iliac and inferior vein cava --, an effective option to re-establish the venous permeability would be the thrombectomy venous.

[Aortoenteric fistula secondary to aortobifemoral prosthesis infection]. / Fístula aortoentérica secundaria a infección de prótesis aortobifemoral.

We present the case of a 76 year-old man, intervened of an obstruction bilateral iliac by means of placement of a prosthesis aortobifemoral that presented pain in the grave left iliac and fever in needles of 39 degrees C to the five years of the intervention. In the physical exploration it highlighted a painful abdomen in the grave left iliac with signs of peritoneal irritation. In the laboratory tests a leukocytosis was detected with neutrophilia and negative culture. The computed thomography (CT) show the presence of gas bubbles around the prosthesis, as well as a liquid collection with areas necrotics in their interior that affected to the psoas and iliac muscles. In the same exploration the aspirative puncture with drainage of the absces demonstrated in the cultivations carried out in aerobic means the presence of Enterococcus faecalis and Enterobacter cloacae. When presenting a high gastrointestinal hemorrhage abruptly, he was practiced and gastroduodenal endoscope in which a aortoduodenal fistula was evidenced with having bled active. When a bypass extra-anatomic, the sick person will practice it died when presenting a shock abrupt hipovolemic that he didn't respond to the pertinent treatment. We analyze the approaches current diagnoses of infection of the vascular prosthesis and their more serious complication, the aortoenteric fistula (AEF) that either appears in the 0.3-5.9% of the patients who undergo prosthetic reconstruction of the abdominal aorta, for occlusive or aneurismal disease. We highlight the importance of carrying out a precocious diagnosis of the infection of the portion retroperitoneal of the vascular graft that, often, it is manifested with subtle and not specific clinical signs, with the techniques at the moment available as: the CT, fine needle aspiration guided by her, and to diminish the rates of mortality, from the current of 43%, until the most optimistic estimated in 19%.

[Current and future diagnostic strategies in venous thromboembolic disease]. / Estrategias diagnósticas actuales y futuras de la enfermedad tromboembólica venosa.

Thromboembolic disease (TD), which includes deep venous thrombosis (DVT) and pulmonary embolism (PE), is the most common acute cardiovascular condition after ischemic cardiopathy and stroke. It is often difficult to diagnose, as it is well-known that half of PE episodes appear are recognized while the patient is still alive and which appear in 30-40% of symptomatic patients. Nonetheless, there are two well-differentiated phases in the diagnosis of TD: the suspicion, and the diagnosis. The first is very important, and is within the competence of any physician. The second can be ratified when carrying out specific tests. We have developed successive steps in the two phases of diagnosis, we critically review the distinct parts currently implicated in the strategic diagnosis of TD. Finally, we analyze the new diagnostic techniques to substitute, possibly, angiography in many cases, and perhaps to include ventilation/perfusion (V/Q) pulmonary gammagraphy, once become generally available.

[Prevention of venous thromboembolism: unfractionated heparins and low-molecular weight heparins. Analysis of these 2 options]. / Prevención de la enfermedad tromboembólica venosa: heparinas no fraccionadas y heparinas de bajo peso molecular. Análisis de estas dos opciones.

Traditionally, it has been recommended that the prevention of venous thromboembolic disease (VTD) be treated, subcutaneously, with heparins, be they fractionated (UH) or low molecular weight (LMWH). While it has been expected that the latter would prove the more effective, numerous clinical studies have confirmed that there are no appreciable differences between either, given the results obtained in the prevention of VTD, or of bleeding, or of death. It therefore appears logical to think that the moment has arrived to consider substituting the old, conventional heparins, for the new LMWH. In order to attempt to answer this question, we have undertaken a revision of the main meta-analysis published, wherein both heparins have been comparatively employed; thus we analyze their mechanisms of action, their pharmacokinetics differences, and their adverse effects, as well as the type of patients, both at the time of initiation and continuation of tromboprophylaxis with heparins. Using currently available data, it can be inferred that LMWH are as safe and effective as the UH in the prevention of VTD. Moreover, there are a series or added advantages, such as no unnecessary laboratory controls, and the easy dosification and administration, both to patient as well as nursing staff.

[The role of clinical autopsy in monitoring the quality of the clinical diagnosis in an emergency department]. / El papel de la autopsia clínica en el control de calidad de los diagnósticos clínicos en una unidad de urgencias.

OBJECTIVE: A total of 61 autopsies performed in patients died in emergency department of a university hospital were retrospectively analysed and the findings were compared with clinical diagnoses. METHODS: Sensitivity and specificity of the clinical diagnoses and the correction of medical procedures were measured. The influence of age and sex of patients was analyzed using Fisher's exact test and chi-square-test. RESULTS: The most common causes of death were cardiovascular diseases (52.46%). Autopsy showed unexpected major findings in 44.26% of cases. Major discrepancies between the autopsy reports and the clinical diagnoses, were present in 26.22% of all cases. Absolute concordance between clinical and autopsy diagnoses was obtained in 44.26% of cases. The major sensitivity of clinical diagnosis was found in cerebrovascular disorders (100%), upper digestive hemorrhage (100%), and acute myocardial infarction (82.35%). The lowest sensitivity was found in malignant tumors (16.66%), hemorrhagic pancreatitis (0%) and bowel infarction (0%). The patient cares were correct in 68.85% of cases. No statistically significant differences were observed in relation to age and sex. CONCLUSIONS: We concluded that autopsy is a useful method for evaluate diagnostic procedures and quality of medical cares in emergency departments.

[Sjogren's syndrome: a new diagnostic approximation]. / Síndrome de Sjögren: una nueva aproximación diagnóstica.

At presentation the history of a 51 years old woman with xerostomia and dry keratoconjunctivitis sicca (KCS) with a development of ten months. Investigations revealed the presence in serum of antibodies against cytoplasmic antigens SS-A (Ac anti-Ro/SS-A), antinuclear antibodies (ANAS), and rheumatoid factor (RF). The test with Rose of Bengal was positive, and in the salivary gammagraphy made with pertecnate-99 m Tc it was observed a decreased of the captation and excretion of the designer for the salivary glands. The histopathology and immunohistochemical study of the minor salivary glands showed the presence of a focal lymphocytic sialadenitis (fls) and a predominance of lymphocytes CD4+. It was diagnosed a primary Sjögren a Syndrome (SSP) and the patient was treated with salivary substitutes and artificial tears. We analyse the current diagnostic criteria of the group of studies of the European Community for the SS. We emphasize the importance of the histologics and immunohistochemical study that with the rest of the complementary test will let us to distinguish not only the different forms of presentation of the illness, but also those of all the patients with pathologies which are very prevalent in our environment nowadays, such as the infections by virus C of the hepatitis (VCH) and the human immunodeficiency (VIH).

[Primary polycythaemia vera in the elderly]. / La policitemia vera en el anciano.

We present an 86-years-old woman's case with paralysis in her left hand of abrupt apparition, accompanied by arterial hypertension and dizziness. The investigation revealed erythrocytosis, leukocytosis, thrombocytosis, with normal arterial O2 saturation (O2 SAT), increased of his red cell volume and blood viscosity. The polycythaemia vera (PV) was diagnose and the paralysis disappeared, when 24 hours before a phlebotomy was practiced, and the function was recovered by the hand. We analysed the presents diagnostics criteria of the disease defined by Polycythaemia Vera Study Group (PVSG). The different treatments for PV are discussed; in addition to venesection, conventional treatment include chemotherapy with hydroxyurea and pipobroman, as well as the erythropheresis, -interferon and aspirin. All of the treatments are associated with complications; thrombotic in the case of phlebotomy; malignancies and gastrointestinal bleeding in the case of myelosuppressive treatments and aspirin. We think the optimal treatment for PV is a judicious combination of the available alternatives, depending on the phase of the disease, and the age of the patient.

[Reflex sympathetic dystrophy syndrome associated with phenobarbital]. / Síndrome de distrofia simpático refleja asociado a fenobarbital.

Reflex sympathetic dystrophy syndrome (RSDS) is clinically characterized by pain and edema of one or more extremities, trophic skin changes and vasomotor instability. Although the pathogenesis is unknown, it could be caused by an abnormal reflex of the sympathetic nervous system. Different studies haven't yet confirmed the classical division in three clinical phases (warm, of vasomotor instability and cold). Barbiturates are the precipitating event in 10-30% of cases. We describe the clinical features of a patient with RSDS associated with phenobarbital who needed corticosteroid treatment. The Technetium diphosphate bone scan (Tc 99m DPD) is very useful because there is an increased radionuclide uptake in the involved areas during the early phases of the disease and precedes in some weeks the radiologic signs. The Magnetic Resonance Imaging (MRI) may be useful because of the early signs it shows. The patient may develop contractures and atrophy of the involved extremities in spite of the indispensable withdrawal of the drug.

[Heterozygotic alpha-1 antitrypsin deficiency. A case report]. / Déficit heterozigótico de alfa-1-antitripsina. Presentación de un caso.

The clinical, analytical (including phenotypical) and histologic (optical and ultrastructural) data of a 34-years-old male patient attended for evaluation of moderate hypertransaminasemia discovered following a company screening examination. The existence of an alpha-1-antitrypsin heterozygotic deficit (MZ) was detected with flattening of the alpha wave in the proteinogram and a decreased serum level of this glycoprotein. Morpho-pathologically no PAS positive globules were optically found on liver biopsy although dilatation of the rough RE was observed with deposition in the medium electrodensity material, the significance of which is discussed on the basis of the patient's phenotype. It is suggested that serum studies of alpha-1-antitrypsin should be included in the routine evaluation of chronic liver diseases.

[Clinical and subclinical hyperthyroidism: two faces of the coin?]. / Hipotiroidismo clínico y subclínico: dos caras de una moneda?

We have made a prospective study of 23 patients diagnosed of subclinical hypothyroidism and 45 of overt hypothyroidism, aged 68.3-70.3 years and with a mean illness of 4.5 and 6.5 years respectively. It has been proved a higher prevalence of females in both groups. The most frequent clinical symptoms, similar in both groups, were fatigue, constipation and dyspnea. The most repeated initial diagnosis at the entry were prymary hypothyroidism, heart failure, hypertensive urgencies and stroke. We have found differences of statistical significance between the Free Thyroxine (fT4), triiodothyronine (T3), total serum cholesterol (CT), triglycerides (TG), HDL-cholesterol (HDL-C), LDL-cholesterol (LDL-C) and thyrotropin (TSH) initial and ending serum levels in patients with overt hypothyroidism (p < 0.05). We only have found significant differences in TSH serum levels in patients with subclinical hypothyroidism. The antithyroglobulin and antimicrobial antibodies, have been both positive in two and one patient respectively. Both are more useful as a predictor than their diagnostic value. The levothyroxine (L-T4) daily dose needed to normalize the TSH serum concentration, was lesser in subclinical hypothyroidism (71.8 micrograms opposite 107 micrograms-p < 0.001). We didn't find significant differences between the different groups in the time necessary for normalizing TSH. It seems that the L-T4 therapy should be started in all patients with subclinical hypothyroidism and TSH > or = 10 microU/ml or with TSH > 5 and goiter or with thyroid antibodies. The aim to reach is to normalize the TSH serum levels. The mean daily necessary L-T4 dose is 50-100 micrograms.

[Pseudoaneurysm of the splenic artery and chronic pancreatitis]. / Seudoaneurisma de la arteria esplénica y pancreatitis crónica.

The arterial pseudoaneurysm (AS) are a complication uncommon though very serious of the pancreatitis acute or chronic. We present the case of a male of 55 years with a pancreatitis chronic, developed within a pseudocyst pancreatic with break to left renal cell forming a hematoma perirrenal and perforation duodenal with massive gastrointestinal hemorrhage hypovolemic and death of the patient. We analyze theirs different forms of clinic presentation, the difficulties diagnostics found and the possible treatments that they could improve their results.

[Antineutrophil cytoplasmic antibodies and Wegener's granulomatosis]. / Anticuerpos anticitoplasma de neutrófilo y granulomatosis de Wegener.

In the presented case are described the clinic demonstrations, analytical and evolutionary in a diagnosed patient of Wegener Granulomatosis (WG). The biopsies practiced in the injuries of the nasal mucous and oral cavity demonstrated a necrotizing granulomatous vasculitis. The antineutrophil cytoplasmic antibodies with standard cytoplasmic (AANC-C) determined by immunofluorescence indirect were positive with a seric initial of 1:160 in the making negative to the sixty treatment days. The administration of the treatment coincided with an improvement meaningful clinic. We emphasize the scarce demonstration of the WG in the oral cavity as well as of the presentation histological described. Finally, we emphasize the growing importance of the AANC-C not only in the diagnosis of the disease but as specific marker of its activity.

[The pseudothrombophlebitic syndrome: a new diagnostic approach]. / El síndrome pseudotromboflebítico: una nueva aproximación diagnóstica.

The clinical manifestation of popliteal or Baker's cysts, either intact or complicated due to rupture or dissection, can be a thrombophlebitis (pseudothrombophlebitis), greatly difficulting the differential diagnosis and the management of these patients, being their treatment completely different. The doppler echography is a reliable, quick and low-cost method which allow to differentiate between this two types of pathology and the magnetic resonance (MR) is the ideal technique to assess the complications of popliteal cysts. We present a case of pseudothrombophlebitis due to compression of the popliteal vein by a Baker's cyst.

[Adverse effects of 2 forms of therapy with heparin in patients with non-surgical risk factors of venous thromboembolism]. / Reacciones adversas de dos formas de heparinoterapia en pacientes con factores de riesgo no quirúrgicos de thromboembolismo venoso.

Venous thromboembolism (VTE) is a frequent complication in hospitalized patients who have to stay in bed for long periods of time or with diseases favouring of low molecular weight (HLMW) developed during the past years have demonstrated that they are as effective as the non-fractionated heparins, but with the advantage of a better cutaneous absorption, greater bioavailability and plasmatic half-life, a more favourable antithrombotic/hemorrhagic ratio and a lower variability in the anticoagulant response to fixed doses. We have investigated the efficacy, efficiency and security of an HLMW (Enoxaparine) for the prevention of VTE, comparing it with an standard calcic heparin, subcutaneously administrated, in patients with non-surgical risk factors and more than 65 years of age. Based on our results, we cannot conclude that one therapy is better than the other, although the enoxaparine needs only one daily injection and it can be administrated in an out-patient basis for long periods of time, without the need of laboratory controls and the resulting cost savings.

[Myopathy associated with infection by the human immunodeficiency virus type-1 (HIV-1)]. / Miopatía asociada a la infección por el virus de la inmunodeficiencia humana tipo-1 (VIH-1).

We present a case of an active homosexual patient who was a paid donor of plasma and presented myopathy associated to infection by the human immunodeficiency virus type 1 (HIV-1). In the ultrastructural study of the muscular biopsy, we stress the formation of central intermyofibrillary "minocores", as well as the presence of nuclear extrusions in which the core is surrounded by mitochondrial accumulations. We review the clinical, histological and ultrastructural characteristics used to identity this pathology against the group of myopathies induced by zidovudine, as well as the several empirical therapies currently recommended.

[Infectious endocarditis in parenteral drug addicts: study of 57 cases]. / Endocarditis infecciosa en adictos a drogas por vía parenteral: estudio de 57 casos.

We present 57 cases of infectious endocarditis (IE) in 51 parenterally drug addicts (PDA) admitted at the Internal Medicine Service of the Hospital Clínico of Valencia between January ist, 1988 and January 15th, 1992. The disease affected young patients, 84% of them being HIV-1+ and 86% presenting CD4+ lymphocytes lower than 200 cells/mm3. Fever was the most constant symptom, with radiological disorders and presence of vegetations by echocardiogram in 65% and 53% of episodes, respectively, and affectation of the tricuspid valve in 59% of patients. The diagnosis of endocarditis was definitive in 51% of cases, possible in 15% and probable in 22%, being cardiac failure the most severe complication, present in 23% of episodes. The detection of significant valve regurgitation in patients with IE and without developing cardiac failure is not predictive of future complications, nor its absence identifies patients with a favourable prognosis. Staphylococcus aureus was the most frequently isolated germ (48%), being methicillin-resistant in 15% of cases and with a slower response to the treatment with vancomycin than the methicillin-sensitive. Five patients died, all of them with CD4+ lower than 50 cells/mm3, which may have a predictive value in the follow-up of these patients.

[Pneumocystis carinii pneumonia]. / La neumonía por Pneumocystis carinii.

We present twelve cases of Pneumocystis Carinii Pneumonia (PCP) hospitalized at the Internal Medicine Service of the Hospital Clínico de Valencia between 1989 and 1990. All patients were infected by HIV-1, with ages between 25 and 32 years, with circulating CD4 lymphocytes lower than 25% or 200 cells per cubic millimeter and with positive p24 antigen. Ten of them were parenterally drug addicts and two of them, homosexuals. Diagnosis was made by fibrobronchoscopy (FB) with bronchoaspiration (BAS) and bronchoalveolar lavage (BAL), or sputum induced by physiological serum aerosol at three per cent, using in both cases blue tinction with toluidine 0 of the samples obtained. Given the foreseeable increase of this disease in our country, we stress the risk of a potential change in its clinical spectrum, affecting new population groups, mainly the elderly, as well as the development of new early diagnosis techniques and the emergence of new treatments, including corticotherapy.

[Changes in blood viscosity and erythrocyte deformability in patients with dyslipidemia treated with binifibrate]. / Modificaciones de la viscosidad de la sangre y deformabilidad eritrocitaria en pacientes dislipémicos tratados con binifibrato.

31 patients afflicted with primary hyperlipidemia who did not improve after 30 days on a diet were treated with 1800 mg/day of binifibrate. We measured the total cholesterol level and triglyceridemia, as well as blood viscosity and red cell deformability at day 0, 30, 60, 90 of treatment. We found a statistically significant decrease in cholesterol and triglyceride levels as well as blood viscosity, and an increment of red cell deformability which improved the circulatory dynamisms augmentin the tissular perfusion in these patients.