A novel virtual motor rehabilitation system for Guillain-Barré syndrome. Two single case studies.

INTRODUCTION: This article is part of the Focus Theme of Methods of Information in Medicine on "New Methodologies for Patients Rehabilitation". OBJECTIVES: For Guillain-Barré patients, motor rehabilitation programs are helpful at the onset to prevent the complications of paralysis and in cases of persistent motor impairment. Traditional motor rehabilitation programs may be tedious and monotonous, resulting in low adherence to the treatments. A Virtual Motor Rehabilitation system has been tested in Guillain-Barré patients to increase patient adherence and to improve clinical results. METHODS: Two people with Guillain-Barré performed 20 rehabilitation sessions. We tested a novel system based on Motor Virtual Rehabilitation in three periods of time (baseline evaluation, final evaluation, and follow-up. In the training program, the participants carried out a specific treatment using the Active Balance Rehabilitation system (ABAR). The system is composed of customizable virtual games to perform static and dynamic balance rehabilitation. RESULTS: Significant improvements in clinical results were obtained by both participants, with significant results in the static balance clinical test of the Anterior Reach test in the standing position and unipedal stance time. Other significant results were found in dynamic balance clinical tests in the Berg Balance Scale test and the 30-second Sit-to-Stand test. With regard to acceptance of the system, both patients enjoyed the experience, and both patients thought that this system was helpful for their rehabilitation. CONCLUSIONS: The results show that Virtual Motor Rehabilitation for Guillain-Barré patients provides clinical improvements in an entertaining way.

[Preiser's disease. A case study]. / Enfermedad de Preiser. A propósito de un caso.

The idiopathic avascular necrosis of the scaphoid or Preiser's disease is condition about which few cases have been described. In the majority of cases, it is debatable whether it is actually a spontaneous osteonecrosis, or a pathological process secondary to a systematic disease, or a result of chemotherapy treatment, or associated with taking steroids. We present the case of a 20-year old woman, with no previous trauma, with pain in her right wrist, which progressed over a period of four years. It was wrongly diagnosed as a tendinitis, and was treated conservatively without any improvement. A simple X-ray was requested that showed an abnormality of the proximal pole of the scaphoid that was beginning to fragment; a fact which was confirmed later by performing a CT scan. This was followed by nuclear magnetic resonance spectroscopy (NMR), which showed signs of ischaemia, mainly in the proximal pole. There were signs of viability in the distal fragment in the NMR using paramagnetic contrast. After the imaging tests, idiopathic avascular necrosis of the scaphoid was diagnosed. The surgical treatment consisted of the removal of necrotic fragments of the proximal pole and removal of the posterior interosseous-nerve. Two years after the intervention, the patient is asymptomatic and with a complete range of movement in the operated wrist.

Enfermedad de Preiser. A propósito de un caso / Preiser's disease. A case study

La necrosis avascular idiopática del escafoides o enfermedad de Preiser es una entidad de la que se han descrito pocos casos. En algunas ocasiones es discutible si se trata de una osteonecrosis espontánea o representa un proceso patológico secundario a enfermedades sistémicas, tratamiento quimioterápico o está relacionada con el consumo de esteroides. Presentamos el caso de una mujer de 20 años de edad, sin traumatismo previo, con dolor en la muñeca derecha de 4 años de evolución. Había sido erróneamente diagnosticada de una tendinitis y tratada de forma conservadora sin mejoría. Se solicitaron estudios de imagen mediante radiología simple. Los hallazgos radiológicos presentaban una anomalía del polo proximal del escafoides que originaba una fragmentación del mismo, hecho que se confirmó posteriormente con la realización de una TC. A continuación se realizó una RMN en la que se observaron criterios de isquemia, fundamentalmente en polo proximal. En la RMN con contraste paramagnético aparecieron signos de viabilidad en el fragmento distal y de osteonecrosis en el proximal. Tras las pruebas de imagen se diagnosticó de necrosis avascular idiopática del escafoides. El tratamiento quirúrgico consistió en extirpar los fragmentos necróticos del polo proximal y practicar una neurectomía del nervio interóseo posterior. A los 2 años de la intervención, la paciente se encuentra asintomática y con un balance articular completo de la muñeca intervenida (AU)

The idiopathic avascular necrosis of the scaphoid or Preiser's disease is condition about which few cases have been described. In the majority of cases, it is debatable whether it is actually a spontaneous osteonecrosis, or a pathological process secondary to a systematic disease, or a result of chemotherapy treatment, or associated with taking steroids. We present the case of a 20-year old woman, with no previous trauma, with pain in her right wrist, which progressed over a period of four years. It was wrongly diagnosed as a tendinitis, and was treated conservatively without any improvement. A simple X-ray was requested that showed an abnormality of the proximal pole of the scaphoid that was beginning to fragment; a fact which was confirmed later by performing a CT scan. This was followed by nuclear magnetic resonance spectroscopy (NMR), which showed signs of ischaemia, mainly in the proximal pole. There were signs of viability in the distal fragment in the NMR using paramagnetic contrast. After the imaging tests, idiopathic avascular necrosis of the scaphoid was diagnosed. The surgical treatment consisted of the removal of necrotic fragments of the proximal pole and removal of the posterior interosseous-nerve. Two years after the intervention, the patient is asymptomatic and with a complete range of movement in the operated wrist (AU)

[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.

Cetoacidosis diabética en un departamento de Urgencias / Ketoacidosis diabetic in an emergency department

Objetivos: Estudiamos las características clínicas y las diferencias existentes en los pacientes con Cetoacidosis Diabética (CAD) atendidos en un Departamento de Urgencias.Métodos: Describimos las características de 15 pacientes con criterios de CAD durante un periodo de 12 meses. Evaluamos prospectivamente: características clínicas, factores precipitantes, enfermedades concomitantes, conocimiento previo o no de la diabetes, complicaciones, mortalidad y necesidad de ingreso en la Unidad de Cuidados Intensivos (UCI). Comparamos a los mismos según dos características: grupos de edad y diagnóstico previo o no de diabetes mellitus.Resultados: La CAD es más frecuente en mujeres jóvenes. La mortalidad de pacientes con CAD está directamente relacionada con la edad y con procesos concomitantes, siendo más elevada en ancianos.El factor precipitante más frecuente en pacientes con diagnóstico nuevo de diabetes eran los procesos infecciosos y entre los diabéticos conocidos era el abandono del tratamiento.Conclusiones: La mortalidad de los pacientes con CAD se relaciona con la edad y procesos concomitantes. Hay diferencias claras en cuanto a factores precipitantes de la CAD según sean diabéticos conocidos o no (AU)

Evaluación de la calidad asistencial en la insuficiencia cardiaca / Quality management evaluation in heart failure

Objetivo: Analizar la presencia de determinados indicadores de calidad en la asistencia de enfermos con insuficiencia cardiaca (IC) ingresados en un Servicio de Medicina Interna. Material y métodos: Análisis prospectivo mediante protocolo de recogida de datos de 200 pacientes diagnosticados de IC, ingresados en el Servicio de Medicina Interna durante el periodo julio 97-julio 98. Resultados: Todos los enfermos estudiados disponían de anamnesis, exploración clínica, estudio radiológico torácico simple, y electrocardiograma. Sólo un 42.4 porciento presentaban estudio ecocardiográfico. La etiología de la IC se determinó en un 62.6% (30% isquémica, 22% hipertensiva, 6 porciento mixta, 30 porciento valvulopatía, 9% miocardiopatías específicas y 3% otras). El 47,5%de los pacientes fueron clasificados funcionalmente según la NYHA (I: 2,7%, II: 58%, III: 35,4%, IV: 3,6%). El tratamiento y dosis fueron adecuados en el 85,5% (diuréticos 91%, IECAS 42%, digital 36%, nitratos 56%, inotropos 2%, beta- bloqueantes e inhibidores del calcio 1%). Un 13,6% de los pacientes tuvieron más de tres ingresos al año. La mortalidad fue de un 18%. Un 19% de los pacientes eran mayores de 70 años. Conclusiones: La presencia de los indicadores de calidad elegidos es aceptable, destacando la necesidad de insistir en el diagnóstico etiológico y en la clasificación funcional (AU)

[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.

Combinaciones en dosis fija para el tratamiento de la hipertensión / Fixed dose combinations in treatment for hypertension

El tratamiento antihipertensivo con un solo agente no controla la presión arterial en una proporción apreciable de pacientes. En estos casos suele recurrirse a tratamientos combinados o a la sustitución por otro fármaco (monoterapia secuencial o sustitutiva). En los últimos años han proliferado las combinaciones a dosis fijas en un solo preparado. Estas asociaciones deben cumplir una serie de condiciones para poder ser consideradas racionales, como la compatibilidad en sus características farmacocinéticas, dosificación adecuada, no ocasionar nuevos efectos secundarios y alta eficacia en la mayoría de los pacientes. Sus ventajas serían la comodidad y simplificación del esquema terapéutico, potenciación de la acción antihipertensiva, menos efectos secundarios al reducir dosis y quizás un sinergismo en la protección de órganos diana. Las combinaciones disponibles más populares son: diurético ahorrador de potasio y tiazida, diurético y betabloqueante, diurético e IECA y calcioantagonista e IECA (AU)

[Assessment of quality of care in heart failure]. / Evaluación de la calidad asistencial en la insuficiencia cardiaca.

OBJECTIVES: To evaluate the presence of predetermined quality aspects in the management of hearth failure inside an Internal Medicine Department. METHODS: Prospective study under protocol of 200 patients admitted to our Internal Medicine Department under diagnosis of hearth failure from july 97 to july 98. RESULTS: Every patient of our study had an anamnesis, physical examination, chest radiology and electrocardiography. Only 42.4% had an electrocardiography. Hearth failure etiology was determined in only 62.6% (30% isquemic, 22% hypertensive, 6% mixed, 30% valvulopathy, 9% specific myocardiopathy, 3% others). 47.5% of the patients were functionally classified after NYHA (I 2.7%, II 58%, III 35.4%, IV 3.6%). Treatment and drug dosing were adequate in 85.5% (diuretics 91%, ACEI 42%, digitalis 36%, nitrates 56%, inotropic drugs 2%, betablockers and calcium antagonists 1%). 13% of the patients were admitted to the hospital more than three times a year. Mortality rate was 18% and 19% of them were older than 70 years old. CONCLUSIONS: Quality management indicators were acceptably present in our study. We must insist on etiologic diagnosis and NYHA classification as a way of improving care.

[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.