Temporary hospitals in times of the COVID pandemic. An example and a practical view.

We describe the most widely used temporary hospital in Europe during the first pandemic wave, its structure, function, and achievements. Other models of care developed during the pandemic around the world were reviewed including their capacity, total bed/ICU bed ratio and time of use. We particularly analyzed the common and differential characteristics of this type of facilities. IFEMA Exhibition Center was transformed into a temporary 1,300-bed hospital, which was in continuous operation for 42 days. A total of 3,817 people were treated, generally patients with mild to moderate COVID-19, 91% of whom had pneumonia. The average length of stay was 5 to 36 days. The most frequent comorbidities were hypertension (16.5%), diabetes mellitus (9.1%), COPD (6%), asthma (4.6%), obesity (2.9%) and dementia (1.6%). A total of 113 patients (3%) were transferred to another centers for aggravation, 19 (0.5%) were admitted to ICU and 16 patients (0.4%) died. An element of great help to reducing the overload of care in large hospitals during peaks of health emergencies could be these flexible structures capable of absorbing the excess of patients. These must be safe, breaking domestic transmission and guarantee social and emotional needs of patients. The success of these structures depends on delimitation in admission criteria taking into account the proportion of patients who may require, during admission, assistance in the critical care area.

La ecografía en manos del internista: ¿el estetoscopio del siglo xxi? / Ultrasonography managed by internists: the stethoscope of 21th Century?

La ecografía en manos del internista permite responder preguntas clínicas concretas de forma rápida en el lugar de atención al paciente. Esta técnica «potencia» los sentidos del clínico y mejora su capacidad para resolver los problemas del enfermo. La ecografía clínica ha mostrado una buena precisión en el diagnóstico de diversas patologías cardíacas, abdominales y vasculares. También es útil para la evaluación de la patología tiroidea, osteoarticular y de partes blandas. Además, el uso de la ecografía para guiar procedimientos invasivos (accesos venosos, toracocentesis, paracentesis) reduce el riesgo de complicaciones. Presentamos 5casos para ilustrar la utilidad de esta técnica en la práctica clínica habitual del médico internista: a)miocardiopatía periparto; b)ateromatosis carotídea subclínica; c)aneurisma de aorta abdominal asintomático; d)tendinitis de los tendones largo del bíceps braquial y supraespinoso, y e)hematoma espontáneo en sóleo (AU)

Ultrasonography in the hands of the internist can answer important clinical questions quickly at the point of patient care. This technique "enhance" the senses of the physicians and improves their ability to solve the problems of the patient. Point of care ultrasonography performed by clinicians has shown good accuracy in the diagnosis of diverse cardiac, abdominal and vascular pathologic conditions. It may also be useful for evaluation of thyroid, osteoarticular and soft tissue diseases. Furthermore, the use of ultrasound to guide invasive procedures (placement of venous catheters, thoracentesis, paracentesis) reduces the risk of complications. We present 5cases to illustrate the usefulness of this technique in clinical practice: (i)peripartum cardiomyopathy; (ii)subclinical carotid artery atherosclerosis; (iii)asymptomatic abdominal aortic aneurysm; (iv)tendinitis of long head of biceps brachii and supraspinatus, and (v)spontaneous soleus muscle haematoma (AU)

Ultrasonography managed by internists: the stethoscope of 21st century?

Ultrasonography in the hands of the internist can answer important clinical questions quickly at the point of patient care. This technique "enhances" the senses of the physicians and improves their ability to solve the problems of the patient. Point of care ultrasonography performed by clinicians has shown good accuracy in the diagnosis of diverse cardiac, abdominal and vascular pathologic conditions. It may also be useful for evaluation of thyroid, osteoarticular and soft tissue diseases. Furthermore, the use of ultrasound to guide invasive procedures (placement of venous catheters, thoracentesis, paracentesis) reduces the risk of complications. We present 5 cases to illustrate the usefulness of this technique in clinical practice: (i) peripartum cardiomyopathy; (ii) subclinical carotid artery atherosclerosis; (iii) asymptomatic abdominal aortic aneurysm; (iv) tendinitis of long head of biceps brachii and supraspinatus, and (v) spontaneous soleus muscle hematoma.

Paciente conflictivo en urgencias: definición, tipología y aspectos éticos / Conflictive patients in the emergency room: Definition, classification and ethical aspects

El paciente conflictivo es aquel que suscita en el médico un problema (un conflicto) por su actitud y/o comportamiento. Los conflictos éticos en urgencias son frecuentes y muchos de ellos se producen con estos pacientes. Entre las tipologías más habituales de pacientes que generan conflictos personales con los sanitarios están los pacientes exageradamente demandantes, los que rechazan actuaciones médicas, los agresivos, los litigadores, los hiperfrecuentadores y los que acuden a urgencias sin patología urgente. Es posible que un paciente incluya varios de estos perfiles (paciente «mixto»). Ante su aparición, el abordaje debe ser en equipo y si es posible, estableciendo un proceso deliberativo. Si existen dudas y es posible, se debe consultar al comité de ética asistencial y se deben buscar los protocolos que haya al respecto, deseablemente institucionales. Tras ello, si se llega a una decisión difícil de tomar, hay que buscar el apoyo del equipo directivo del servicio e inclusive de la institución. Se debe reflejar todo este proceso en la historia clínica. La formación específica en Bioética y habilidades de comunicación puede ser de gran ayuda para minimizar y afrontar mejor los conflictos a largo plazo(AU)

A conflictive patient is one who provokes a problem (a conflict) by their attitude or behavior for the physician. Ethical conflicts in emergency care are common and many of them occur with these patients. Among the most common types of patients who generate personal conflicts with health professionals are overly demanding patients, those who refuse medical interventions, those who are aggressive, litigators, excessively-recurrent users of the heath system and those who go to the emergency room without an urgent condition. A patient may include several of these profiles (“mixed” patient). When they appear, the approach should be, if possible, by a team, establishing a deliberative process. If there is doubt and when possible, the ethics committee of the institution should be consulted, seeking the protocols, this best being institutional, on the subject. After that, if the decision is difficult, support must be sought from the emergency staff and even management. The whole process should be reflected in the clinical history. Specific education in bioethics and communication skills can be of great help to minimize and cope better with long-term conflicts(AU)

[Conflictive patients in the emergency room: Definition, classification and ethical aspects]. / Paciente conflictivo en urgencias: definición, tipología y aspectos éticos.

A conflictive patient is one who provokes a problem (a conflict) by their attitude or behavior for the physician. Ethical conflicts in emergency care are common and many of them occur with these patients. Among the most common types of patients who generate personal conflicts with health professionals are overly demanding patients, those who refuse medical interventions, those who are aggressive, litigators, excessively-recurrent users of the heath system and those who go to the emergency room without an urgent condition. A patient may include several of these profiles ("mixed" patient). When they appear, the approach should be, if possible, by a team, establishing a deliberative process. If there is doubt and when possible, the ethics committee of the institution should be consulted, seeking the protocols, this best being institutional, on the subject. After that, if the decision is difficult, support must be sought from the emergency staff and even management. The whole process should be reflected in the clinical history. Specific education in bioethics and communication skills can be of great help to minimize and cope better with long-term conflicts.

Fiebre intermitente como manifestación clínica de una fístula biliopulmonar / No disponible

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Opinión de los familiares sobre el uso de procedimientos invasivos en ancianos con distintos grados de demencia o incapacidad / Relatives' opinions on the use of invasive procedures in the elderly with different degrees of dementia or incapacity

Introducción: la toma de decisiones en los pacientes que no están capacitados tiene importantes implicaciones éticas y en nuestro medio es habitual que se consulte con la familia. En este trabajo se valora el grado de intervención considerado adecuado por las familias de los pacientes ancianos con distintos grados de demencia o incapacidad. Pacientes y método: estudio prospectivo realizado en pacientes > 75 años ingresados en el servicio de medicina interna durante 1 mes. Se realizó una encuesta autoadministrada a la familia, así como el test del informador y el índice de Barthel a cada paciente. Se realizó un análisis univariable y un análisis de regresión múltiple. Resultados: participaron familiares de 115 pacientes. La puntuaciones medias fueron de 51,1 ± 37,4 (Barthel) y 67,3 ± 15 (test del informador). En 57 pacientes se detectó una demencia grave (puntuación > 65) y 30 pacientes tenían incapacidad grave (Barthel < 30). El porcentaje de familiares que deseaban realizar siempre cada una de las intervenciones se acercó al 85% en la mayoría, salvo en la reanimación cardiopulmonar (38%), la punción diagnóstica (40%), la colocación de sonda nasogástrica (41%) y el uso de varios ciclos de antibióticos intravenosos (49%). No hubo diferencias entre los pacientes incapacitados y los no incapacitados. Entre los familiares de los pacientes con demencia, el 47% deseó realizar una punción diagnóstica siempre, frente al 66% en el caso de los pacientes sin demencia (p = 0,03). Conclusiones: los familiares de los ancianos del área tienen una actitud muy intervencionista a priori, sin apenas diferencias entre los pacientes dementes o incapacitados y los que no lo están

Introduction: medical decisions affecting elderly and demented people are controversial, sometimes involve ethical dilemmas, and have been hardly evaluated in a systematic manner. We designed this study to explore the desirable level of intervention in elderly patients according to the opinion of their relatives. Patients and method: all patients older than 75 years who were admitted to the Internal Medicine Unit during June 2002 were included. We interviewed a relative from every patient with a questionnaire about treatment choices. Barthel and Informant Questionnaire Decline in the Elderly (IQCODE) were performed for every patient. Results are compared by chi square, Student t test and multivariate analysis. Level of significance p 65) and 30 patients had severe disability (Barthel's score < 30). About 85% of the relatives were decided to performed all the interventions, except for cardiac resucitation (38%), diagnostic puncture (40%), feeding by nasogastric tube (41%) and several intravenous antibiotic cycles (49%). Non differences were found between relatives of incapacitated or non-incapacitated patients, but diagnostic puncture was wanted less frequently in relatives of demented than in non-demented patients (47% vs 66%, p = 0.03). Conclusions: relatives of elderly patients in our hospital desire a high level of intervention. This attitude was not modified by incapacity and only to a minor extent by the presence of dementia

Hipomagnesemia e insuficiencia cardíaca / Hypomagnesemia and cardiac failure

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[The diagnosis of sleep apnea syndrome with a portable device. Our experience with 100 cases]. / El diagnóstico del síndrome de apnea del sueño con un equipo portátil. Nuestra experiencia con 100 casos.

UNLABELLED: Portable devices might be an alternative method to diagnose patients suspected for obstructive sleep apnea syndrome (OSAS). We have analized one hundred patients consecutively referred to our especialized out-patient clinic for sleep breathing disorders. We have used a previously validated portable device-Polygraphics CNS-which records thoracoabdominal movement, nasobuccal airflow, ECG, oxymetry, body position, and continuous positive airway pressure (CPAP). Sixty patients showed an apnea/hypopnea index (AHI) > 15. Seven patients showed an AHI > 10f plus symptoms suggestive of OSAS. Two patients had an AHI between 5-10 and very high suspicion for OSAS; a subsequent CPAP treatment showed the disappearance of respiratory events and an evident improvement in oxymetric records. Twenty two patients showed an AHI < 5. Nine patients could not be classified and other diagnostic method were deemed necessary. CONCLUSION: A previously validated cardiorrespiratory portable polygraphic device was useful in most cases for taking diagnostic decisions in OSAS.

[Recurrent infections, severe neutropenia and neutrophil chemotaxis defect in paroxysmal nocturnal hemoglobinuria]. / Infecciones recurrentes, neutropenia grave y defecto quimiotáctico de los neutrófilos en la hemoglobinuria paroxística nocturna.

Paroxysmal nocturnal hemoglobinuria (PNH) is a rare disease, whose origin seems to lie in a acquired defect in the membrane of the pluri-potential hematopoietic cell. Chronic or intermittent acute hemolytic syndrome is the most frequent clinical manifestation, although in the literature there are also some references to the leukocytic and immunologic disorders of this disease. In this paper, we present the case of a 63-year-old patient with NPH who developed severe neutropenia and sustained febrile syndrome. In the past four years, she had suffered frequent episodes of fever and leukopenia, which apparently disappeared spontaneously. In the physical exploration, we observed hepatosplenomegaly. The hemogram showed mild iron deficiency anemia (hemoglobin 10.8 g/dl), severe neutropenia (neutrophil 0.3 x 10(9)/l) and significant reticulocytosis (610 x 10(9)/l). Iron deposits were greatly reduced in the marrow. Simultaneously to a new febrile episode and isolation of Escherichia coli in the urine, there was a severe anemization (hemoglobin 5 g/dl) and a significant thrombopenia (platelets 30 x 10(9)) resulting in a positive hemosiderinuria and sucrose test. The study of the leukocytic function showed a defect in the neutrophil chemotaxis, although a normal phagocytic capacity and microbicidal activity. In the following nine months, the patient had several severe infections, with intense but transitory pancytopenia, which always improved when treating the infection with antibiotics. The patient died due to a septic shock twelve months after the diagnosis. Recurrent febrile episodes and severe neutropenia are very rare in the PNH (less than 4% of the cases). The cause of these disorders is still unknown.(ABSTRACT TRUNCATED AT 250 WORDS)

[Atypical radiologic manifestations of Pneumocystis carinii pneumonia]. / Manifestaciones radiológicas atípicas de la neumonía por Pneumocystis carinii.

Pneumonia due to Pneumocystis carinii (PC) is characterized, in most cases, by the existence of infiltrates of interstitium or bilateral interstitium-alveolar type on the thorax radiography. However atypical radiological findings associated with this type of opportunistic infection are being described more and more frequently. We present two patients with Acquire Immune Deficiency Syndrome (AIDS) and pulmonary infection due to PC, with very unusual radiological findings. First patient showed multiple pulmonary cavitated nodules; the other a cavitated infiltrate in superior right lobule. Clinicians dealing with AIDS patients must be familiar with this unusual radiologic findings associated with PC in order to avoid diagnostic mistakes.