Seguimiento de una cohorte de pacientes con gammapatía monoclonal sérica en el Área Sanitaria de Guadalajara / Follow up of serum monoclonal gammopathy at Guadalajar health area

Objetivo: Conocer la evolución clínica de los pacientes del Área Sanitaria de Guadalajara en los que fue diagnosticada una paraproteína sérica. Material y métodos: Estudio prospectivo de 186 pacientes en los que durante los años 1999 y 2000 se detectó “de novo” una banda monoclonal sérica. Resultados: La probabilidad acumulada de progresión a enfermedad maligna fue del 4,99% a los 43 meses en los pacientes cuya paraproteína fue clínicamente soslayada y 2% a los 23 meses en pacientes diagnosticados de gammapatía monoclonal de significado incierto. La probabilidad acumulada de supervivencia en los pacientes con mieloma múltiple fue 66,7% a los 21 meses. La tasa condicionada de mortalidad (paciente/mes) a los 4 años debido a enfermedad hematológica fue de 4,48.10-4 en pacientes clínicamente soslayados, 0 en los diagnosticados de gammapatía monoclonal de significado incierto y 1,388.10-2 en los diagnosticados de mieloma múltiple. Discusión: El seguimiento de pacientes con banda monoclonal benigna es fundamental, al menos durante los cuatro primeros años, ya que con ello podría conseguirse una mayor supervivencia en relación con su transformación en maligna

Objective: To study the clinical course of patients with a serum monoclonal protein at Guadalajara Health Area. Material and methods: Prospective study of 186 patients with a newly diagnosed monoclonal component. They have been collected during the years 1999 and 2000. Results: The cumulative transformation probability at 43 months was 4.99% for those patients whose monoclonal gammopathy was overlooked, and 2% at 23 months for patients with monoclonal gammopathy of undetermined significance. The cumulative probability of survival for patients with multiple myeloma was 66.7% at 21 months. The conditional mortality rate (patients/months) at 4 years due to haematological disease was 4.48x10-4 for overlooked patients, 0 for diagnosed of monoclonal gammopathy of undetermined significance and 1.388x10-2 for multiple myeloma diagnosed. Discussion: A non malignant M component must be followed up due to it could increase patients’ survival rate in relation with transformation in malignant disease

Impacto económico de los tratamientos compasivos sobre el gasto farmacéutico en un hospital / Economical impact of the compassionate treatments on the drug costs in a hospital

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[Follow-up of serum monoclonal gammopathy at Guadalajara Health Area]. / Seguimiento de una cohorte de pacientes con gammapatía monoclonal sérica en el Area Sanitaria de Guadalajara.

OBJECTIVE: To study the clinical course of patients with a serum monoclonal protein at Guadalajara Health Area. MATERIAL AND METHODS: Prospective study of 186 patients with a newly diagnosed monoclonal component. They have been collected during the years 1999 and 2000. RESULTS: The cumulative transformation probability at 43 months was 4.99% for those patients whose monoclonal gammopathy was overlooked, and 2% at 23 months for patients with monoclonal gammopathy of undetermined significance. The cumulative probability of survival for patients with multiple myeloma was 66.7% at 21 months. The conditional mortality rate (patients/months) at 4 years due to haematological disease was 4.48 x 10(-4) for overlooked patients, 0 for diagnosed of monoclonal gammopathy of undetermined significance and 1.388 x 10(-2) for multiple myeloma diagnosed. DISCUSSION: A non malignant M component must be followed up due to it could increase patients survival rate in relation with transformation in malignant disease.

Motility abnormalities in esophageal body in GERD: are they truly related to reflux?

BACKGROUND: Esophageal motility abnormalities have been observed in patients with gastroesophageal reflux disease. GOALS: The aim of the present study was to determine if esophageal motor disorders in patients with a positive response to the omeprazole test are related to the existence of reflux or they are concomitant findings. STUDY: A 24-hour pH monitoring and a stationary manometry were performed on 128 patients: 49 of them had normal manometry, 31 hypotensive lower esophageal sphincter, 29 motor disorder in esophageal body, and 19 hypotensive lower esophageal sphincter and motor disorder in esophageal body. RESULTS: We found an association between the presence of abnormal reflux and motor disorder in esophageal body (chi test; P < 0.05). However, ineffective esophageal motility was the disorder most strongly related to reflux, whereas the hypercontractile disorders were not clearly attributed to it. CONCLUSIONS: Esophageal manometric abnormalities should be considered cautiously before considering a motor disorder as a consequence of abnormal reflux.

[Sedation in upper gastrointestinal endoscopy. Analysis of tolerance, complications and cost-effectiveness]. / Sedación en la endoscopia gastrointestinal alta. Análisis de la tolerancia, las complicaciones y el coste-efectividad.

INTRODUCTION AND AIM: Sedation of patients is an important complement to endoscopic procedures. The aim of this study was to analyze tolerance, complications and cost-effectiveness in patients undergoing diagnostic upper gastrointestinal endoscopy. PATIENTS AND METHOD: A total of 357 patients were prospectively studied: 138 non-sedated, 116 sedated with midazolam and 103 sedated with midazolam and meperidine. Subjective tolerance, tolerance perceived by the endoscopist, complications, and cost-effectiveness were evaluated. The Chi-square test was used for the statistical analysis. P-values of less than 0.05 were considered statistically significant. RESULTS: Subjective tolerance was greater in patients sedated with midazolam and meperidine than in the other groups (p < 0.05). Tolerance perceived by the endoscopist was greater in the group sedated with both drugs than in the group sedated with midazolam (p < 0.05). Subjective tolerance was better in sedated men and women but there was no association between sedation and perceived tolerance according to sex. Subjective tolerance was better in sedated patients older than 70 years than in those younger than 40 years (p < 0.05). Complications were more frequent in sedated patients and the most frequent complication in all the groups studied was mild desaturation; there was a significant difference between the group sedated with midazolam and meperidine and the non-sedated group (p < 0.05). Non-sedation had the best cost-effectiveness ratio but sedation with midazolam and meperidine was the most effective alternative. CONCLUSION: From the point of view of the endoscopist, endoscopy can be performed without sedation, although subjective tolerance is greater in patients sedated with midazolam and meperidine. Non-sedation is more cost-effectiveness than sedation but if sedation is required midazolam and meperidine achieve better results in terms of effectiveness than midazolam alone.

Sedación en la endoscopia gastrointestinal alta. Análisis de la tolerancia, las complicaciones y el coste-efectividad / Sedation in upper gastrointestinal endoscopy. Analysis of tolerance, complications and cost-effectiveness

Introducción y objetivo: La sedación del paciente es un importante complemento de los procedimientos endoscópicos. El objetivo de nuestro trabajo ha sido el análisis de la tolerancia, las complicaciones y el coste-efectividad de la sedación en pacientes sometidos a endoscopia gastrointestinal diagnóstica alta. Pacientes y método: Se estudió a 357 pacientes prospectivamente: 138 no sedados, 116 sedados con midazolam y 103 sedados con midazolam y meperidina. Se analizaron la tolerancia subjetiva, la tolerancia percibida por el endoscopista, las complicaciones y el coste-efectividad. Para el análisis estadístico se utilizó la prueba de la c2, y valores de p < 0,05 se consideraron estadísticamente significativos. Resultados: La tolerancia subjetiva fue mejor en pacientes sedados con midazolam y meperidina que en los otros grupos (p < 0,05). Respecto a la tolerancia percibida, se encontró diferencia entre el grupo sedado con ambas drogas y el grupo sedado con midazolam (p < 0,05). La tolerancia subjetiva fue mejor tanto en mujeres como en varones sedados, pero no hubo una asociación entre la sedación y la tolerancia percibida en ninguno de los sexos. La tolerancia subjetiva fue mejor en pacientes sedados mayores de 70 años que en los pacientes menores de 40 (p < 0,05). Las complicaciones fueron más frecuentes en pacientes sedados; la más frecuente en todos los grupos fue la desaturación leve; se observó una diferencia significativa entre el grupo sedado con los 2 fármacos y el no sedado (p < 0,05). La alternativa de no sedación es la que consigue una mejor relación coste-efectividad, pero la sedación con midazolam y meperidina es la más efectiva. Conclusión: La endoscopia puede realizarse sin sedación desde el punto de vista del endoscopista, pero la tolerancia subjetiva es mejor en pacientes sedados con midazolam y meperidina. Respecto al coste-efectividad, la mejor alternativa es la no sedación pero, en caso de precisarse sedación, la opción midazolam más meperidina ofrece una mejor efectividad que el midazolam aislado

Introduction and aim: Sedation of patients is an important complement to endoscopic procedures. The aim of this study was to analyze tolerance, complications and cost-effectiveness in patients undergoing diagnostic upper gastrointestinal endoscopy. Patients and method: A total of 357 patients were prospectively studied: 138 non-sedated, 116 sedated with midazolam and 103 sedated with midazolam and meperidine. Subjective tolerance, tolerance perceived by the endoscopist, complications, and cost-effectiveness were evaluated. The Chi-square test was used for the statistical analysis. P-values of less than 0.05 were considered statistically significant. Results: Subjective tolerance was greater in patients sedated with midazolam and meperidine than in the other groups (p < 0.05). Tolerance perceived by the endoscopist was greater in the group sedated with both drugs than in the group sedated with midazolam (p < 0.05). Subjective tolerance was better in sedated men and women but there was no association between sedation and perceived tolerance according to sex. Subjective tolerance was better in sedated patients older than 70 years than in those younger than 40 years (p < 0.05). Complications were more frequent in sedated patients and the most frequent complication in all the groups studied was mild desaturation; there was a significant difference between the group sedated with midazolam and meperidine and the non-sedated group (p < 0.05). Non-sedation had the best cost-effectiveness ratio but sedation with midazolam and meperidine was the most effective alternative. Conclusion: From the point of view of the endoscopist, endoscopy can be performed without sedation, although subjective tolerance is greater in patients sedated with midazolam and meperidine. Non-sedation is more cost-effectiveness than sedation but if sedation is required midazolam and meperidine achieve better results in terms of effectiveness than midazolam alone

Role of stationary esophageal manometry in clinical practice. Manometric results in patients with gastroesophageal reflux, dysphagia or non-cardiac chest pain.

The present study was carried out to evaluate the diagnostic usefulness of stationary esophageal manometry in 263 patients divided into three groups: 150 patients with reflux symptoms, 68 with dysphagia, and 45 with non-cardiac chest pain. Patients with endoscopic abnormalities were excluded. Standard manometry was performed following the station pull-through technique. In the group of patients with reflux symptoms 40.7% had a normal manometry and 57.3% had abnormalities, being the most frequent (43%) hypotensive lower esophageal sphincter. In the dysphagia group, 20.6% of manometries were normal and 79.4% were abnormal, of which achalasia was the most frequent disorder (53.7%). In the case of non-cardiac chest pain, 42.2% of patients had a normal manometry and 57.8% an abnormal one, of which hypotensive lower esophageal sphincter was the most frequent abnormality. A significant higher proportion of manometric alterations were found in the dysphagia group compared to reflux symptoms and non-cardiac chest pain (p < 0.05). No statistical differences were found between the reflux and the non-cardiac chest pain groups. Manometry yields a higher diagnostic value in patients with dysphagia, and therefore manometry should be performed routinely after the exclusion of any organic esophageal disease. Manometry is not a first-choice functional diagnostic test in the study of patirnts with gastroesophageal reflux or non-cardiac chest pain.

Enfermedad celiaca en paciente con criterios Roma II de síndrome de intestino irritable / Celiac disease in a patient with Rome II criteria of irritable bowell syndrome

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[Macroprolactin as etiology of hyperprolactinemia. Method for detection and clinical characterization of the entity in 39 patients]. / Macroprolactina como causa de hiperprolactinemia. Método de detección y caracterización clínica de la entidad en 39 pacientes.

The presence of serum macroprolactin is a relatively frequent situation that can lead to expensive explorations and ineffective treatments. The precipitation with polyethylene glycols permits its detection rapidly, trustworthily, and inexpensively. The objective of the present work has been to assess the incidence of macroprolactin in patients with hyperprolactinemia through its identification with polyethylene glycols, as well as the clinical and radiological findings, and the response in these patients to the treatment. For it the clinical history of all the cases in which there was detected macroprolactinemia, some of them with several years of previous follow-up, was reviewed exhaustively. Of the 1505 patients in which prolactin level was determined, 195 (13%) showed values higher than 40 microg/l. In 39 (20%) of them the presence of macroprolactin was detected. After observing the evolution of these patients, spontaneously or under treatment with dopaminergic agonists, a clear relationship of causality between the presence of macroprolactin and the clinical manifestations was not found, except in a case of galactorrhea. In 27 cases nuclear magnetic resonance was done; in 4 of them a picture was observed compatible with small microadenoma or microcyst and in no patient a macroadenoma was detected. We conclude that the macroprolactinemia is a relatively frequent and easily detected entity through precipitation with polyethylene glycols. It has a limited relation with the clinical findings and there should always be sought other possible causes of this situation. It is an apparently benign situation and its identification can avoid unnecessary explorations and treatments.

Macroprolactina como causa de hiperprolactinemia. Método de detección y caracterización clínicade la entidad en 39 pacientes / Macroprolactin as etiology of hyperprolactinemia. Method for detection and clinical characterization of the entity in 39 patients

La presencia de macroprolactina sérica es un hecho relativamente frecuente que puede conducir a exploraciones costosas y tratamientos ineficaces. La precipitación con polietilenglicol permite su detección de forma rápida, fiable y barata. El objetivo del presente trabajo ha sido valorar la incidencia de macroprolactina en pacientes con hiperprolactinemia mediante su identificación con polietilenglicol, así como los hallazgos clínicos, radiológicos y respuesta al tratamiento en dichos pacientes. Para ello se revisó exhaustivamente la historia clínica de todos los casos en que se detectó macroprolactinemia, algunos de ellos con varios años de seguimiento previo. De los 1.505 pacientes en los que se determinó prolactina, 195 (13 por ciento) presentaron valores mayores de 40 µg/l. En 39 (20 por ciento) de ellos se detectó la presencia de macroprolactina. Tras observar la evolución de los mismos, espontánea o bajo tratamiento con agonistas dopaminérgicos, no se encontró una relación clara de causalidad entre la presencia de macroprolactina y las manifestaciones clínicas, excepto en un caso de galactorrea. En 27 casos se practicó resonancia magnética nuclear (RMN), en 4 de ellos se apreció imagen compatible con pequeño microadenoma o microquiste y en ninguno macroadenoma. Concluimos que la macroprolactinemia es una entidad relativamente frecuente y de fácil detección mediante precipitación con polietilenglicol. Presenta una escasa relación con los hallazgos clínicos y se deben buscar siempre otras posibles causas de los mismos. Se trata de una situación aparentemente benigna y su identificación puede evitar exploraciones y tratamientos innecesario (AU)

Bocio, función tiroidea y excreción de yodo en gestantes de la zona de El Bierzo / Goiter, thyroid function and iodine excretion in pregnant women from the area of El Bierzo (Spain)

Estudios publicados en el año 1993 demuestran alta incidencia de bocio en escolares de la zona de El Bierzo. Hemos valorado mediante encuesta el consumo de sal yodada, la preencia de bocio mediante palpación y ecografía, la función tiroidea midiendo concentraciones hormonales en plasma y la excreción de yodo en orina y leche mediante el método de Benotti, en un grupo de mujeres embarazadas de la zona, en los tres trimestres de la gestación y en el posparto. Nuestros resultados demuestran escaso consumo de sal yodada, endemia bociosa grave, hipotiroxinemia materna, pobre excreción de yodo en orina en las gestantes y escasa presencia de yodo en la leche materna. Todo ello indica la necesidad de campañas institucionales para remediar la situación (AU)

[Monoclonal component in visceral leishmaniasis: a rare association that can lead to misdiagnosis]. / Componente monoclonal en leishmaniasis visceral: rara asociación que puede conducir a un falso diagnóstico.

The detection of monoclonal components is exceptional in patients with visceral leishmaniasis (VL). The cases are here reported of two patients with VL in a non-endemic area and monoclonal components which posed problems for the differential diagnosis with other entities associated with the presence of paraproteins. The predominant clinical manifestations in both cases were general symptoms, fever and severe spleen enlargement. One patient had a monoclonal triple band in urine and the other several oligoclonal bands in serum. In the initial bone marrow aspiration smear no parasites were observed in any of the two cases but a remarkable plasmacytosis in one of them. The presence of increased serum titers of anti-Leishmania antibodies was the first demonstrative finding of VL. The diagnosis was confirmed with positive culture of Leishmania and therapy with pentavalent antimonials was successful in both cases. The different diagnostic possibilities are discussed and the possibility of VL is emphasized even in non-endemic areas when monoclonal components in serum or urine specimens are found and consistent clinical findings are present.