Desmoplastic Fibroma Recurrence Associated with Tuberous Sclerosis in a Young Patient.

Case Report. A nine-year-old patient with a diagnosis of tuberous sclerosis (with no pathological record) that showed calcifications at the brain level. Besides, the case showed the Vogt triad (epilepsy, mental retardation, and sebaceous adenoma). The patient clinically showed a volume increase of hard consistency, without suppuration and no sessile that included the following teeth 73, 74, and 75. Cone beam computed tomography (CBCT) was obtained, and it displayed a delimited unilocular lesion. After surgical excision, the histopathological report was desmoplastic fibroma (DF). It was observed that the patient had an aggressive recurrence of DF at four months after surgery treatment. Due to these clinical findings, resective osseous surgery and curettage were carried out. It is uncommon to find these two pathologies together (DF and tuberous sclerosis). Since DF is a benign pathology but very invasive and destructive, it is necessary a constant follow-up examination due to a high recurrence frequency.

The H.U.G.E. Formula (Hematocrit, Urea, Sex) for Screening Chronic Kidney Disease (CKD) in an Age-Stratified General Population.

AIM: To evaluate the screening power of the HUGE formula for the detection of chronic kidney disease (CKD) in a Spanish population sample obtained from the HERMEX study, a survey of cardiovascular risk factors carried out in the region of Extremadura, stratified by age. DESIGN AND METHODS: This was an observational, cross-sectional, population-based study. The final sample included 2,813 subjects selected from Health Care System records. Anthropometric data and cardiovascular risk factors were recorded. Hematocrit, urea, creatinine and microalbuminuria were analyzed, after which the HUGE formula was applied. Renal function, assessed as eGFR based on serum creatinine, was estimated following the MDRD-4 formula. RESULTS: Using the HUGE formula, the estimated prevalence of CKD was 2.2% (men 2.2%, women 2.1%). The prevalence of CKD increased with age (5.0% in persons aged 60- 70 years and 9.6% in individuals over 70 years of age, p < 0.001) whereas with the MDRD formula the prevalence values were 9.8% and 15.5% respectively. The HUGE formula was seen to be highly specific (0.99). CKD was more common in persons >70 years, obese subjects, hypertensive patients, dyslipidemic subjects and those with microalbuminuria. Multivariate analysis revealed an independent negative association of CKD as the dependent variable with SBP, serum triglyceride levels and microalbuminuria. CONCLUSIONS: The HUGE formula allows the prediction of CKD in the general population to be honed without relying on serum creatinine levels. This method was found to have a higher specificity than the MDRD-4 formula. Moreover, it could reduce the excessively extensive diagnostic suspicion of CKD in women.

Tiempo de demora para la hospitalización tras la implantación del ingreso directo a cargo del Servicio de Urgencias / Changes in emergency admission times after the introduction of direct admission from emergency services

ObjetivoValorar el impacto en el tiempo de espera para el ingreso urgente dependiendo del facultativo responsable de éste, el médico de urgencias o el especialista del área médica.Material y métodoTras la autorización al servicio de urgencias hospitalarias para el ingreso directo de pacientes en las especialidades médicas, se definieron dos períodos de estudio: período A (previo al ingreso directo) y período B (tras su implantación). Se analizaron el número de pacientes atendidos, su gravedad, el número y porcentaje de ingresos y el tiempo medio de estancia.ResultadosEn ambos períodos se atendieron 41.917 pacientes (228,07 pacientes/día) y 41.948 (230,48 pacientes/día), respectivamente. El tiempo medio de estancia de los pacientes ingresados directamente desde urgencias disminuyó en 1h y 42m (p=0,001); por el contrario, los ingresos en planta de hospitalización del servicio de medicina interna mantuvieron un tiempo medio de espera similar en los dos períodos analizados.ConclusionesEl traspaso de la competencia del ingreso a los facultativos de urgencias disminuye el tiempo medio de estancia de los pacientes en dicha área, sin modificar el número de ingresos y reduciendo la carga asistencial de los facultativos de la planta de hospitalización(AU)

ObjectiveTo measure the differences of waiting time for the emergency admission depending on which professional is in charge ie. the emergency doctor or the specialist of a specific area.Patients and methodsOnce the Hospital Emergency Service was permitted to admit patients directly to the specialities, two periods of study where taken: Period A (before the direct admission) and Period B (after the implementation of it). The following was analysed: the number of patients taken, the complexity of their problem, the number of admissions and length of their stay.ResultsDuring Period A 41,917 patients were seen (228.07 patients/day) and during Period B 41,948 (230.48 patients/day). The average of the stay for those patients that were admitted directly from Emergencies had decreased by 1h and 42min (p=0.001). The admissions in the Internal Medicine Service kept the same waiting time in both periods.ConclusionsThe transfer of the responsibility of the admissions to emergency doctors has decreased the average waiting time of the patients in this area. The total number of admissions has not increased and has reduced the amount of work the different specialist(AU)

Symmetrical ambulatory arterial stiffness index: relationship with microalbuminuria and renal function.

OBJECTIVE: The aim of this study was to investigate the arterial stiffness parameters derived from the proposed linear relationship between SBP and DBP obtained by ABPM, regarding its relationships with two markers of renal disease, microalbuminuria and renal function. DESIGN AND METHODS: One hundred and sixty six patients were studied: 73 males and 93 females mean age 55.2+/-15.5 years. 36.2% were receiving antihypertensive drug treatment. Microalbuminuria was measured in 24-h urine collection as well as albumin to creatinine ratio (ACR) in first morning urine. The ambulatory BP was measured non-invasively for 24 h by the Spacelab devices. RESULTS: Correlation test showed a significant relationship of Sym-AASI with age (p<0.001), serum creatinine (p=0.038), creatinine clearance (-0.423, p<0.001) and GFR (-0.263, p<0.001). On the other hand AASI was also correlated with age (p<0.001) and creatinine clearance (p=0.012), but not with the other parameters studied. 24-h albumin excretion rate was not correlated with Sym-AASI or AASI. Contrariwise, the albumin to creatinine ratio was correlated with Sym-AASI (p=0.013). As expected, AASI and Sym-AASI increase as severity of renal diseases grows. The patients in the highest quartile of Sym-AASI distribution showed an older age (p<0.001) and worse parameters of renal function (GFR, p<0.001; and creatinine clearance, p<0.008). CONCLUSIONS: Sym-AASI, an improved method for detecting arterial stiffness, seems to get an independent relationship with these parameters of renal disease which could not be detected with AASI.

[Changes in emergency admission times after the introduction of direct admission from emergency services]. / Tiempo de demora para la hospitalización tras la implantación del ingreso directo a cargo del Servicio de Urgencias.

OBJECTIVE: To measure the differences of waiting time for the emergency admission depending on which professional is in charge ie. the emergency doctor or the specialist of a specific area. PATIENTS AND METHODS: Once the Hospital Emergency Service was permitted to admit patients directly to the specialities, two periods of study where taken: Period A (before the direct admission) and Period B (after the implementation of it). The following was analysed: the number of patients taken, the complexity of their problem, the number of admissions and length of their stay. RESULTS: During Period A 41,917 patients were seen (228.07 patients/day) and during Period B 41,948 (230.48 patients/day). The average of the stay for those patients that were admitted directly from Emergencies had decreased by 1h and 42 min (p=0.001). The admissions in the Internal Medicine Service kept the same waiting time in both periods. CONCLUSIONS: The transfer of the responsibility of the admissions to emergency doctors has decreased the average waiting time of the patients in this area. The total number of admissions has not increased and has reduced the amount of work the different specialist.

[Acute mushrooms poisoning]. / Intoxicaciones agudas por setas.

The collection and consumption of wild mushrooms by individuals with no mycological knowledge and their accidental ingestion by minors are responsible for a growing increase of poisonings. It is not usual for emergency care of a patient affected by mushroom poisoning to be based on recognition of the responsible species of fungus or access to a sample of the mushroom consumed. It is this reason knowledge of toxidromes is crucial. In the majority of cases, the symptoms are weak. Mortality is usually related to the development of potentially fatal liver necrosis after consumption of the fungus Amanita phalloides and others which contain amatoxins. Treatment is based on support measures but no specific treatments exist that are based on scientifically proven studies. In the following article the clues used in diagnosing which make it possible to carry out a syndromic diagnosis based on a period of latency will be analyzed. The mushrooms that are responsible for the most common syndromes, therapeutic options, as well as varieties of toxic fungus which may produce peculiar and exceptional symptoms are also reported.

Relación entre factores precipitantes y mortalidad en el delirio agitado en Cuidados Paliativos / Relation of precipitating factors and mortality in agitate delirum of Palliative Care patients

Objetivo: el delirio agitado aparece con frecuencia en los pacientes con enfermedad oncológica avanzada. El objetivo de este estudio es analizarla etiología del delirio agitado y su relación con la mortalidad observada. Método: estudio retrospectivo de 631 pacientes de Cuidados Paliativos. Los factores etiológicos se clasificaron en: opioides, infección, iones metabólico, insuficiencia respiratoria, lesión del sistema nervioso central, o desconocido. Analizamos su relación con la mortalidad y el momento de aparición del delirio. Se aplicó el test de Chi cuadrado para variables cualitativas y t de Student para variables cuantitativas. Resultados: el delirio agitado se diagnosticó en 53 pacientes (8,4%). Edad media 67 años (DE 12,9). La neoplasia primaria se localizaba en pulmón (39,6%), aparato genitourinario (24,5%), aparato digestivo (17,0%), mama (9,4%) y otros (9,4%). Los precipitantes fueron: opioides (26,4%), infección (26,4%), iones-metabólico (17,0%), insuficiencia respiratoria(15,1%), lesión en el sistema nervioso central (7,5%) y desconocido (7,5%). La presencia de estos factores fue distinta dependiendo de que el delirio fuese el motivo de ingreso (opioides 32,4%, infección 29,4%) o apareciese durante la hospitalización (insuficiencia respiratoria 36,8%, infección 21,1%); p = 0,019. Se observó mayor mortalidad durante la hospitalización en los pacientes que presentaron delirio respecto a los que no (67,9vs. 41,2%, OR 3,03, IC 95%: 1,7-5,7). No encontramos diferencia en el número acumulado de factores etiológicos en los pacientes con delirio que fallecieron y en los que no (2,56 vs. 2,59). La mortalidad fue inferior, casi significativo, cuando la infección fue el factor precipitante (50,0 vs. 75,0-78,6%); p = 0,23. Conclusión: la infección y el inicio o aumento de dosis de opioides, factores tratables, fueron los precipitantes más frecuentes de delirio. Ninguno de los factores estudiados, ni el número acumulado de los mismos, se relacionó de una manera significativa a menor mortalidad (AU)

Objective: agitated delirium is frequently detected in patients suffering from advanced cancer. The objective of this study was to analyze the etiology of agitated delirium and the relation to mortality. Method: retrospective study of 631 terminally ill cancer patients. Putative etiologic factors were: opioid therapy, infection, metabolic disorders, respiratory insufficiency, central nervous system lesion or unknown. We tried to find their relation to mortality and onset of delirium. It was used the Chi square test for qualitative variables and t Student for quantitative variables. Results: agitated delirium was diagnosed in 53 patients (8.4%). Mean age was 67 years (SD 12.9); male: female 2: 1. Primary neoplasms were located at lung (39.6%), genitourinary system (24.5%), digestive system (17.0%), breast (9.4%) and others (9.4%). Inducing factors were: opioid therapy (26.4%), infection (26.4%), metabolic disorders (17.0%), respiratory insufficiency (15.1%), central nervous system lesion (7.5%) and unknown (7.5%). Frequency of precipitating factors was different whether the delirium was the cause of admission (opioid therapy 32.4%, infection 29.4%) or was developed during hospitalization (respiratory insufficiency 36.8%, infection 21.1%); p = 0.019. Higher mortality during hospitalization was observed in patients with delirium contrasting with those without it (67.9 vs. 41.2%, OR 3.03, 95% CI: 1.7-5.7). There was no difference in the accumulated number of etiologic factors inpatients with delirium who died and those who did not: 2.56 vs. 2.59. Mortality was lower, near significantly, when infection was the precipitating factor (50.0 vs. 75.0-78.6%); p = 0.23. Conclusion: infection and onset or an increase in the doses of opioids, two treatable causes, were the most recurrent precipitating factors of delirium. None of studied factors neither the accumulated number of them was related to mortality with statistical difference (AU)

Función tubular renal en el muy anciano / Renal tubular function in the old-old

Hay muy pocos trabajos publicados sobre la funcionalidad tubular en ancianos sanos y en muy ancianos. Por este motivo, decidimos explorar la función tubular renal en muy ancianos sanos (> 75 años) evaluando la excreción fraccional de sodio, urea y potasio y el gradiente transtubular de potasio mediante técnicas de restricción, sobrecarga y aclaramientos de agua y sodio. Se estudió a 44 voluntarios sanos entre ancianos (65-75 años) y muy ancianos (> 75 años), en los que se determinaron la excreción fraccional de sodio, urea y potasio y gradiente transtubular de potasio en estado basal, y a 4 personas muy ancianas se les aplicó una sobrecarga hiposalina según la técnica, habitual en nuestro laboratorio, descrita por Chaimowitz. Los datos se evaluaron mediante el test de la t de Student. Finalmente, analizamos los valores séricos de eritropoyetina (producto del intersticio peritubular proximal) en 74 voluntarios sanos (22 adultos-jóvenes, 30 ancianos y 22 muy ancianos). Para el análisis estadístico, utilizamos la los tests de la t de Student y ANOVA con ajuste de Bonferroni. De este estudio concluimos que en los muy-viejos, con respecto de los adultos-jóvenes, la función túbulo-intersticial proximal está respetada, mientras que la función del "segmento distal" de la nefrona proximal (rama gruesa ascendente del asa de Henle) está disminuida. Además, detectamos que tienen un incremento de la excreción tubular de urea, pero no de la de potasio, lo que puede explicar la merma en la capacidad de concentración-dilución urinarias y la normalidad de la urea plasmática a pesar de que el filtrado glomerular esté disminuido, además de la facilidad para presentar hiponatremia e hiperpotasemia (AU)

Nivel de adecuación de los recursos geriátricos en los hospitales generales españoles / Adequacy of geriatric resources in Spanish general hospitals

Objetivo: Valorar la adecuación de los recursos para la asistencia geriátrica especializada a los ancianos hospitalizados por enfermedad aguda en España. Material y método: Estudio descriptivo de corte transversal. Se incluyen los hospitales generales del territorio español de más de 100 camas, a fecha 1-6-2003. Los hospitales se clasifican en: a) sin asistencia geriátrica especializada: no existe recurso geriátrico, no hay cobertura geriátrica especializada en el hospital; b) con asistencia geriátrica especializada: existe recurso geriátrico y por lo tanto cierto grado de cobertura geriátrica. Según el tipo de recurso geriátrico, los hospitales a su vez se dividen en: a) con asistencia geriátrica incompleta constituida por equipos multidisciplinares funcionales de geriatría según los diferentes modelos de cada autonomía, y b) con asistencia geriátrica más completa (evaluación e intervención) que comprende las unidades geriátricas de agudos. Los datos han sido a su vez valorados y corroborados directamente por los respectivos presidentes o vocales de las Sociedades Autonómicas de Geriatría y Gerontología. Los resultados han sido analizados globalmente y por autonomías. Resultados: De los 798 hospitales, 216 son hospitales generales de más de 100 camas. En 146 (68 por ciento) no existe ningún recurso geriátrico especializado para intervenir en la fase aguda de la enfermedad. En 49 (22 por ciento), la asistencia geriátrica especializada es incompleta, y en 21 (10 por ciento) es completa. Las autonomías que disfrutan de una mayor cobertura geriátrica especializada son Cataluña (77 por ciento), Madrid (54 por ciento) y Castilla-La Mancha (50 por ciento). Cantabria y el País Vasco no disponen de ningún tipo de cobertura geriátrica especializada en sus hospitales de agudos, y Asturias, Baleares y Andalucía presentan niveles bajos de cobertura (11 por ciento, 11 por ciento y 9 por ciento, respectivamente). Las autonomías que presentan un mayor porcentaje de unidades geriátricas de agudos son Madrid (31 por ciento) y Castilla-La Mancha (30 por ciento). En 7 comunidades no existe ningún hospital con unidades geriátricas de agudos. Conclusiones: En la actualidad, España no tiene garantizada una adecuada asistencia geriátrica especializada en la mayoría de sus hospitales generales, y existe una distribución de los recursos geriátricos muy desigual entre sus diferentes autonomías (AU)

La MAPa en la población anciana / Ambulatory blood pressure monitoring in elderly patients

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Beneficial effect of verapamil added to chronic ACE inhibitor treatment on renal function in hypertensive elderly patients.

This study analysed the effect of low doses of verapamil added to chronic treatment with angiotensin-converting enzyme (ACE) inhibitors on blood pressure and serum creatinine levels in eight elderly hypertensive patients who had a steady increase of serum creatinine while on ACE inhibitors. The study was performed in eight elderly hypertensive subjects, five men and three women (mean age 70+/-2 years; systolic blood pressure 173+/-4 mm Hg; diastolic blood pressure 99+/-1 mm Hg) and serum creatinine of 1.60+/-0.27 mg/dl before treatment. During an average of 25 weeks, ACE inhibitors significantly reduced both systolic and diastolic blood pressures, but serum creatinine levels were increased over basal levels (0,68+/-0,20 mg/dl, p < 0.05). During an average of 10 weeks, the addition of verapamil did not decrease blood pressure further, but serum creatinine levels were reduced to baseline. Our study suggests that the addition of verapamil to ACE inhibitors can reverse ACE-induced increase in creatinine levels in elderly hypertensive patients in whom this side effect is observed.

Cardiovascular effects of elgodipine and nifedipine compared in anaesthetized rats.

The cardiovascular effects of elgodipine were studied and compared with those of nifedipine in the presence or absence of ganglion blockade. A bolus of elgodipine (5-25 microg/kg) or nifedipine (60-120 microg/kg) was given and sequential cardiovascular effects in rats were recorded. Both dihydropyridines induced a dose-dependent decrease in mean arterial pressure but, whereas nifedipine induced reflex tachycardia, elgodipine induced a dose-dependent bradycardia. Both substances induced decreases in left ventricular d P/dt(max) without significant changes in central venous pressure. Good linear correlation was observed between the elgodipine-induced decrease in mean arterial pressure and those of heart rate and left ventricular dP/dt(max). The profile of the decrease in mean arterial pressure in animals pretreated with hexametonium chloride (20 mg/kg) was the same but the nifedipine-induced tachycardia was abolished without changes in elgodipine-induced bradycardia. These characteristics of elgodipine makes this dihydropyridine a potentially beneficial therapeutic agent in the case of severe hypertension accompanied by obstructive coronopathy.

Different experimental conditions which regulate type II 5'-deiodinase mRNA in rat Harderian gland.

In the present study, we describe the modifications in the expression of type II 5'deiodinase activity (5'D) in Xenopus laevis oocytes by injection of polyadenylated (poly A) mRNA from hypothyroid rat Harderian gland. The time-course study showed that the expression of the enzyme was dependent on time. Thus, enzyme activity was observed in oocytes 6 and 12 hours after the injection with poly A mRNA, reaching a maximal value at 24 hours. The activity was partially inhibited by 6-n-propyl-thiouracil, completely inhibited by iopanoic acid and exhibited a higher affinity for the T4 (Km=1.5 nM) than rT3 (Km=20 nM). The expression of the enzyme was modified in different experimental conditions: (a) exhibited diurnal variations with maximal peak values at night, (b) was inhibited by light at night and, (c) was activated by isoproterenol. On the other hand, we have also identified, for the first time, the size of mRNA capable of inducing 5'D in rats.

Characterization of binding sites for beta-adrenergic agonists and vasoactive intestinal peptide in the rat harderian gland.

Vasoactive intestinal peptide (VIP) receptors and beta-adrenergic receptors were investigated in rat Harderian gland membranes using 125I-VIP and 125I-cyanopindolol (125I-CYP), respectively, as ligands. The receptor bindings were rapid, reversible, saturable, specific, and dependent on time, temperature, and membrane concentration. The stoichiometric data suggested the presence of two classes of VIP receptors with Kd values of 0.36 and 65.37 nM and binding capacities of 323 and 39,537 fmol VIP/mg protein, respectively. The interaction showed a high degree of specificity, as suggested by competitive displacement experiments with several peptides structurally or not structurally related to VIP as follows: VIP > helodermin > rGRF > PHI > > secretin. Glucagon, somatostatin, insulin, and pancreastatin were ineffective at concentrations up to 1 microM. However, the stoichiometric data suggest the presence of one class of binding sites for 125I-CYP. The Kd for the single site was 290 pM with a binding capacity of 32 pmol/L. The pharmacological characterization of 125I-CYP binding to membranes showed that only isoproterenol, a beta-adrenergic agonist, and norepinephrine, an alpha beta-adrenergic agonist, was as effective as propranolol in inhibiting 125I-CYP binding to Harderian gland membranes. However, alpha 1- and alpha 2-adrenergic agonists and blockers such as methoxamine, prazosin, clonidine, and yohimbine were shown to be ineffective. These results demonstrate the presence of specific VIP and beta-adrenergic receptors in the Harderian gland and suggest a role for VIP and beta-adrenergic agonists in the physiology of this gland.

Inhibition by nitrendipine of 86Rb+ fluxes in subconfluent MDCK cells.

Part of the natriuretic mechanism of dihydropyridine Ca2+ channel antagonists involves the inhibition of renal tubular sodium reabsorption. To identify the membrane ion transport system involved in this natriuretic action, we tested nitrendipine on unidirectional 86Rb+ fluxes in Madin-Darby canine kidney (MDCK) cells. To dissect between direct and indirect effects (via cytosolic Ca2+) of nitrendipine, the compound was re-examined on ion fluxes in human erythrocytes. In MDCK cells, external Ca2+ (3 mM), adrenalin (100 microM) and the Ca2+ ionophore A23187 (20 microM) strongly and transiently stimulated 86Rb+ efflux. All these stimulatory actions were fully inhibited by quinine (1 mM) suggesting that they reflect the opening of Ca(2+)-sensitive K+ channels. Nitrendipine was able to inhibit these Ca(2+)-sensitive K+ channels, bit this inhibitory action required concentrations of the compound (approximately 100 microM). Regarding 86Rb+ influx, the most significant result with nitrendipine was a partial inhibition of bumetanide-sensitive 86Rb+ influx. This effect represented a maximal flux inhibition of about 70% and required very low nitrendipine concentrations (IC50 approximately 1 nM). The Ca2+ ionophore A 23187 strongly stimulated bumetanide-sensitive 86Rb+ influx in MDCK cells. Conversely, a very important reduction (approximately 79%) of this influx component was found in Ca2+ depleted cells. In human red blood cells, Na+, K+, Cl- cotransport fluxes were resistant to nitrendipine, even at high concentrations of the compound (100-500 microM). Conversely, Ca(2+)-sensitive K+ channels were inhibited by nitrendipine with IC50 = 6 +/- 3 microM (mean +/- S.E.M., n = 3).(ABSTRACT TRUNCATED AT 250 WORDS)

Expression of type II thyroxine 5'-deiodinase from rat harderian gland in Xenopus laevis oocytes.

The presence of isoenzymes mediating the conversion of thyroxine to 3,5,3'-triiodothyronine has been studied according to characteristic kinetics and physiological regulation. In this paper, we report the expression of type II 5'-deiodinase (5'D) activity in oocytes of Xenopus laevis. Oocytes injected with total RNA extracted from rat Harderian gland, and then incubated up to five days demonstrated a progressive increase in 5'D activity, reaching a maximal value at 24 h; then, 5'D activity remained almost stable for an additional period of four days. Characteristics of the enzyme activity expressed by oocytes included its inhibition by iopanoic acid, but not by propylthiouracil, and its increase during beta-adrenergic agonist treatment and hypothyroidism. The expressed activity manifests characteristics typical of the type II isoenzyme. Deiodinating activity in oocytes also exhibited diurnal variations. In this study, 5'D activity expressed in oocytes exhibited low values when animals were killed during the day, and high values when animals were killed at night. Maximal values were reached 3-4 h before the nocturnal peak of 5'D activity in Harderian gland crude homogenates. Results suggest that the in vivo activation of 5'D by isoproterenol, hypothyroidism, or dark exposure may be caused by an increase in the synthesis and/or maturation of the RNA expressing the enzyme.