Clinical ethics protocols in the clinical ethics committees of Madrid.

INTRODUCTION: Currently, The nature and scope of Clinical Ethics Protocols (CEPs) in Madrid (Spain) are not well understood. OBJECTIVES: The main objective is to describe the features of 'guideline/recommendation' type CEPs that have been or are being developed by existing Clinical Ethics Committees (CECs) in Madrid. Secondary objectives include characterisation of those CECs that have been the most prolific in reference to CEP creation and implementation and identification of any trends in future CEP development. METHODS: We collected CEPs produced and in process by CECs accredited in the public hospitals in Madrid, Spain, from 1996 to 2008. RESULTS: CECs developed 30 CEPs, with 10 more in process. The most common topic is refusal of treatment (seven CEPs developed; two in process). If CEPs addressing terminal illness, Do-Not-Resuscitate orders and advance directives are placed into a separate 'ethical problems at the end of life' category, this CEP subject emerges as the most common (eight developed; four in process). There is a relationship between the age of the CEC and the development of CEPs (the oldest CECs have developed more CEPs). CECs now seem to be more likely to engage in CEP development. CONCLUSIONS: The CECs in Madrid, Spain, have developed a significant number of CEPs (30 in total and 10 in process) and there is a trend towards continued development. The most frequent topics are ethical problems at the end of life and refusal of treatment by the patient.

[Upper gastrointestinal bleeding in an 81-year-old woman]. / Hemorragia digestiva alta en mujer de 81 años.

Upper gastrointestinal bleeding is a frequent syndrome in the elderly that requires urgent attention. The main causes of melenas are peptic ulcer (gastric or duodenal) and esophageal diseases (esophagitis, esophageal varices and Mallory-Weiss syndrome). Unusually, upper gastrointestinal bleeding may be due to a duodenal tumor. Gastrointestinal stromal tumors (GIST) are included in this group. We report the case of an 81-year-old woman who presented with melenas. Gastrointestinal endoscopic studies (upper and lower) revealed no abnormalities, and a duodenal mass was found on thoracic-abdominal computed tomography scan. Urgent surgery due to a massive bleeding episode led to diagnosis of a duodenal GIST.

Miliary Tuberculosis Presenting with Hyponatremia and ARDS in an 82-Year-Old Immunocompetent Female.

An immunocompetent 82-year-old female was admitted to our hospital due to fever without clear origin and hyponatremia. In the following days, an acute and bilateral pulmonary infiltrate appeared with a progressive worsening in respiratory function. Chest x-ray and CT (Computed tomography) showed bilateral reticulonodular infiltrates. Bronchoscopic aspiration and bronchoalveolar lavage (BAL), and transbronchial lung biopsy (TBBX) studies did not reveal microbiological and histopathological diagnosis. Broad-spectrum antibiotics were non-effective, and the patient died due to respiratory failure. Necropsy study revealed a miliary tuberculosis affecting lungs, liver, bone marrow, spleen, kidney, arteries, pancreas, and adrenal glands. Some weeks after the patient´s death, mycobacterial cultures from sputum, BAL and TBBX samples were positive for Mycobacterium tuberculosis.

IL-1 cluster genes and occurrence of post-percutaneous transluminal coronary angioplasty restenosis: a prospective, angiography-based evaluation.

A polymorphic marker of the gene encoding the interleukin-1 (IL-1) receptor antagonist has been recently reported to be associated with risk of coronary artery disease. However, no prospective studies of the IL-1 gene cluster in relation to the occurrence of restenosis, a major complication of percutaneous transluminal coronary angioplasty (PTCA), have so far been conducted. We had the opportunity to investigate this question in a large, prospective cohort characterized by quantitative coronary angiography in all subjects. The IL1A A114S, IL1B -511C>T, IL1B 3953T>C, IL1RI exon1B T>C, and IL1RN VNTR (intron 2) polymorphisms were characterized in a cohort of 779 patients of whom 342 ("cases") had developed restenosis (as defined by >50% loss of lumen compared to immediate post-procedure results) at repeat angiography at 6 months post-PTCA. All observed genotype frequencies were in Hardy-Weinberg equilibrium. Frequencies for the rare alleles were: IL1A S, 0.29 (cases), 0.28 (controls); IL1B T, 0.31 (cases), and 0.33 (controls); IL1B C, 0.23 (cases), 0.24 (controls); IL1RI C, 0.34 (cases), 0.35 (controls); and IL1RN 2, 0.29 (cases), 0.29 (controls), respectively. There was no evidence for an association between genotype and restenosis or degree of lumen loss (adjusted for covariables). Our data indicate that the common variants in the IL-1 cluster genes are not associated with incidence of restenosis after PTCA.

Reanimación cardiopulmonar y la Desconocida del Sena (L’Inconnue de la Seine) / Cardiopulmonary resuscitation and ‘The Unknown Woman of the Seine’

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Pancreatitis aguda secundaria a hiperparatiroidismo primario / Acute pancreatitis secondary to primary hyperparathyroidism

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Picadura por medusa cuboidea en aguas tailandesas / Sting fron a box jellyfish in the coastal waters

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Hemorragia digestiva alta en mujer de 81 años / Upper gastrointestinal bleeding in an 81-year-old woman

La hemorragia digestiva alta (HDA) es un síndrome frecuente en el adulto, que requiere valoración urgente. Dentro de las enfermedades que la producen destacan las úlceras pépticas (gástricas o duodenales) y las enfermedades esofágicas (esofagitis, várices esofágicas y Síndrome de Mallory-Weiss). Excepcionalmente, la HDA es debida a enfermedad tumoral del duodeno. Dentro de ésta se encontrarían los tumores del estroma gastrointestinal (GIST). Presentamos a continuación el caso de una paciente de 81 años que acudió por un cuadro de melenas. Las endoscopias digestivas (alta y baja) fueron normales y en la TAC toracoabdominal se encontró una tumoración duodenal. Durante su ingreso, un episodio de hemorragia masiva obligó a realizar una intervención quirúrgica urgente, donde se observó un GIST duodenal (AU)

Upper gastrointestinal bleeding is a frequent syndrome in the elderly that requires urgent attention. The main causes of melenas are peptic ulcer (gastric or duodenal) and esophageal diseases (esophagitis, esophageal varices and Mallory-Weiss syndrome). Unusually, upper gastrointestinal bleeding may be due to a duodenal tumor. Gastrointestinal stromal tumors (GIST) are included in this group. We report the case of an 81-year-old woman who presented with melenas. Gastrointestinal endoscopic studies (upper and lower) revealed no abnormalities, and a duodenal mass was found on thoracic-abdominal computed tomography scan. Urgent surgery due to a massive bleeding episode led to diagnosis of a duodenal GIST (AU)

Nódulo pulmonar solitario con calcificaciones en “palomitas de maíz” / Solitary lung nodule with ‘‘Popcorn’’ calcifications

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