Osteopetrosis del adulto. Conceptos actuales / Osteopetrosis of the adult. Current concepts

Se presentan cuatro casos de osteopetrosis del adulto, entidad poco frecuente, recogidos en nuestro hospital desde 1985 hasta 2005. Se revisa la patogenia y se actualizan conceptos y clasificación. Las manifestaciones clínicas se corresponden con otras publicaciones en las que la edad al diagnóstico es muy variable y el primer síntoma oscila desde dolor óseo a un hallazgo tras una fractura. Se revisan las mutaciones genéticas clásicas de todos los tipos, actualizando conceptos. Se introduce la propuesta de retirada de la osteopetrosis tipo I del adulto, ya que su patogenia parece un defecto intrínseco osteoblástico(AU)

We presents four cases of adult osteopetrosis, a very rare disease, compiled from our hospital from 1985 to 2005. Revising the pathogenesis and updating the current concept and classification. The clinical manifestations correspond with other publications where the age at diagnosis is highly variable and the first symptom oscillate from bone pain to a fracture. Presents the classic genetic mutations of all types updating concepts. Introducing the propose withdrawal of adult osteoporosis type I, because the pathogenesis seemed a intrinsic osteoblastic defect(AU)

[Acute aortic dissection]. / Disección aórtica aguda.

OBJECTIVE: Acute aortic dissection is a medical emergency associated with high rates of mortality. Despite recent diagnostic advances, prompt and accurate diagnosis is difficult. We present a review of the a medical emergency service experience to diagnosis, factors associated to prompt diagnosis and inhospital evolution. MATERIAL AND METHOD: We studied 86 consecutive patients who had aortic dissections, to assess the presentation, management, and outcome. RESULTS: Mean age 61.9 +/- 12.5 years, 80% male. Hypertension was the most common predisposing factor (65% of patients overall). Chest pain was the most common initial complaint (58%). The initial clinical impression was aortic dissection in 56% of patients overall. Computed tomography was diagnostic in 96% when used. 62% underwent surgery. Overall in-hospital mortality was 28%. CONCLUSIONS: Acute aortic dissection presents with a wide range of manifestations. A high clinical index of suspicion and a prompt computed tomography should to improve recognition of aortic dissection.

Disección aórtica aguda / Acute aortic dissection

Objetivo: La disección aórtica aguda es una emergencia médica que se asocia a una elevada mortalidad. A pesar de los importantes avances en las pruebas complementarias, el diagnóstico precoz sigue representando un gran desafío. Se revisa la experiencia de un servicio de urgencias en el diagnóstico de esta entidad, factores que pueden influir en la precocidad del diagnóstico y evolución intrahospitalaria. Material y método: Se valoraron 86 pacientes diagnosticados de forma consecutiva en un centro hospitalario, analizando variables clínicas, pruebas diagnósticas realizadas, tratamiento y evolución hospitalaria. Resultados: La edad promedio de los pacientes fue de 61,9 ± 12,5 años con predominio de varones (80 por ciento). Tenían antecedentes de hipertensión el 65 por ciento. El síntoma inicial dominante más frecuente era el dolor torácico (58 por ciento). La impresión diagnóstica inicial fue de disección aórtica en el 56 por ciento. La prueba complementaria más utilizada fue la TAC, que permitió la confirmación del diagnóstico en el 96 por ciento de los casos en que fue realizada. Fueron intervenidos quirúrgicamente el 62 por ciento. La mortalidad global intrahospitalaria fue del 28 por ciento. Conclusiones : Por la gran variabilidad de la presentación clínica es fundamental mantener un elevado índice de sospecha para el diagnóstico correcto. Los hallazgos de la exploración física clásicamente asociados a esta entidad no se presentan en una proporción considerable de casos. Un alto índice de sospecha clínica y la rápida realización de pruebas de imagen como la TAC, serían la principal estrategia para facilitar el diagnóstico (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)

[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.

Patología infecciosa en pacientes diabéticos atendidos en un departamento de urgencias / Infectious diseases in diabetic patients attended in an emergency department

Objetivo: Valoramos la importancia de la presencia de diabetes en relación con los procesos infecciosos habituales diagnosticados entre los pacientes atendidos en un Departamento de Urgencias. Material y métodos: Se valoraron prospectivamente 2.500 pacientes adultos que acudieron a un Servicio de Urgencias de un hospital general de un área urbana. Analizamos antecedentes personales, motivos de consulta, diagnóstico en urgencias y necesidad de hospitalización comparando dos grupos: pacientes diabéticos (Grupo A=175) y grupo control de pacientes no diabéticos (Grupo B= 350, con la misma edad y sexo). Utilizando como parámetros de control metabólico la Hemoglobina glicosilada (Hb A1c) y la glucemia diferenciamos dentro de los pacientes diabéticos cuatro subgrupos: pacientes con buen control metabólico (A1= HbA1c8), pacientes con glucemia inferior a 200 mg/dl (A3) y superior a 200 mg/dl (A4). Resultados: Las infecciones fueron más frecuentes entre los pacientes diabéticos que en los no diabéticos (Grupo A= 13,1 porciento vs Grupo B=3,3 porciento), tanto en el caso de las neumonías como en las infecciones urinarias. Asimismo fueron más frecuentes los procesos infecciosos entre los pacientes diabéticos con glucemias elevadas (grupo A4), mientras que no encontramos diferencias significativas entre los subgrupos A1 y A2 respecto a estas entidades. Conclusiones: En nuestro estudio la presencia de diabetes se asoció a una mayor frecuencia de infecciones comunes frente a la población no diabética atendida en un Servicio de Urgencias. No fueron concluyentes los resultados en cuanto a la relación entre enfermedades infecciosas y control metabólico de los pacientes diabéticos (AU)

[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.

[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.