Use of noninvasive measurement of the indocyanine green plasma disappearance rate in patients with septic shock.

OBJECTIVE: Our aim was to analyse the relation between serial values of the indocyanine green plasma disappearance rate (ICG-PDR) with hospital mortality in the first 48 hours of ICU admission in patients with septic shock. METHODS: A prospective observational study was carried out over 12 months of patients admitted to the ICU with septic shock. Each patient underwent noninvasive determination of ICG-PDR at 24 and 48 hours with the LiMON® module. Follow-up was performed until hospital discharge or exitus. RESULTS: 63 patients. Age 61.1±12.3 years. 60.3% men. SOFA score on admission 8.7±3.3, APACHE II score was 27.9±10.7 points. A total of 44.4% of patients died. The ICG-PDR values in the first 24 hours of ICU admission were lower in nonsurvivors: 10.5 (5.7-13.0)%/min vs. 15.9 (11.4-28.0)%/min, p <0.001. Furthermore, in nonsurvivors, there was no improvement in ICG-PDR between 24 h and 48 h, while in survivors, there was an increase of 25%: 15.9 (11.4-28.0)%/min and 20.9 (18.0-27.0)%/min, p=0.020. The silhouette measure of ICG-PDR cohesion and separation for the clusters analysed (nonsurvivors and survivors) was satisfactory (0.6). ICG-PDR<11.7%/min was related to in-hospital mortality, ICG-PDR> 18%/min to survival, and the interval between 11.7% and 18%/min covered a range of uncertainty. In the two-stage cluster, ICG-PDR, SOFA and APACHE II present satisfactory predictive scores 24 hours after patient admission. CONCLUSIONS: ICG-PDR in our setting is a useful clinical prognostic tool and could optimise the decision tree in patients with septic shock.

Hipertensión arterial refractaria verdadera. Estudio de prevalencia en una consulta hospitalaria / True refractory hypertension. Study of prevalence at a tertiary care clinic

Introducción. La hipertensión arterial refractaria (HTA-R) puede definirse como la falta de control de las cifras de presión arterial por debajo de 140/90 mmHg a pesar de tratamiento con una combinación adecuada de tres fármacos, siendo uno de ellos un diurético. La prevalencia de HTA-R entre los hipertensos españoles no es bien conocida. El objetivo sería estimar la prevalencia real de HTA-R en una consulta hospitalaria. Material y métodos. A partir de una población inicial de 281 pacientes remitidos por HTA resistente al tratamiento se seleccionó a aquellos individuos que cumplían criterios de HTA-R tras la primera evaluación. Se realizó un estudio exhaustivo de dichos pacientes para confirmar el diagnóstico de HTA-R, buscando causas de HTA secundaria y otros factores contribuyentes a la falta de respuesta al tratamiento. Resultados. Se seleccionó al subgrupo poblacional que cumplía criterios de HTA-R: 42 pacientes de 60 ± 9 años de edad media (27 mujeres y 15 hombres). Tras un seguimiento medio de 3,3 ± 0,5 años, el 73,8 % de los individuos presentaba HTA secundaria, siendo el síndrome de apnea obstructiva del sueño la causa más frecuente. Se obtuvo un control adecuado de la presión arterial en la mayoría de los casos (61,9 %). Sólo en el 4,8 % del subgrupo de 42 pacientes existía HTA-R verdadera, al presentar HTA esencial y mantener cifras elevadas de presión arterial, a pesar del estricto seguimiento y tratamiento. Discusión. La prevalencia real de HTA-R es muy baja, siendo necesario realizar un estudio exhaustivo de los pacientes. En la gran mayoría de los casos se encuentran causas secundarias de HTA y factores contribuyentes a la aparente refractariedad al tratamiento

Introduction. Refractory hypertension is defined as the failure to reach goal blood pressure (¾ 140/90 mmHg) in patients who are adhering to full doses of an appropriate three-drug regimen that includes a diuretic. Its prevalence among spanish patients is not well documented. The objective was to determine the true prevalence of refractory hypertension in adult patients from a university hospital hypertension clinic. Material and methods. Patients who fulfilled criteria for refractory hypertension were selected from an initial sample of 281 individuals with suspected resistant hypertension. An exhaustive study was performed on these patients in order to confirm refractory hypertension and to search for causes of secondary hypertension and contributing factors to poor response to treatment. Results. Forty two patients were selected (average age: 60 ± 9 years, 27 women, 15 men). After 3.3 ± 0.5 years of monitoring, 73.8 % of the individuals were diagnosed with secondary hypertension (sleep apnoea as the most frequent cause). Recommended treatment goals were achieved in most patients (61.9 %). Only 4.8 % of the selected patients suffered from true refractory hypertension, as they had essential hypertension and maintained high blood pressure in spite of strict treatment and monitoring. Discussion. Real prevalence of refractory hypertension is very low. An exhaustive study is needed in order to diagnose it. Causes of secondary hypertension and other contributing factors to poor response to treatment can be found in most casesIntroduction. Refractory hypertension is defined as the failure to reach goal blood pressure (¾ 140/90 mmHg) in patients who are adhering to full doses of an appropriate three-drug regimen that includes a diuretic. Its prevalence among spanish patients is not well documented. The objective was to determine the true prevalence of refractory hypertension in adult patients from a university hospital hypertension clinic. Material and methods. Patients who fulfilled criteria for refractory hypertension were selected from an initial sample of 281 individuals with suspected resistant hypertension. An exhaustive study was performed on these patients in order to confirm refractory hypertension and to search for causes of secondary hypertension and contributing factors to poor response to treatment. Results. Forty two patients were selected (average age: 60 ± 9 years, 27 women, 15 men). After 3.3 ± 0.5 years of monitoring, 73.8 % of the individuals were diagnosed with secondary hypertension (sleep apnoea as the most frequent cause). Recommended treatment goals were achieved in most patients (61.9 %). Only 4.8 % of the selected patients suffered from true refractory hypertension, as they had essential hypertension and maintained high blood pressure in spite of strict treatment and monitoring. Discussion. Real prevalence of refractory hypertension is very low. An exhaustive study is needed in order to diagnose it. Causes of secondary hypertension and other contributing factors to poor response to treatment can be found in most cases

Infección por virus C, aumento de ferritina sérica e hiperinsulinemia / Hepatitis C virus infection, increased serum ferritin and hyperinsulinemia

Objetivos: estudios recientes han encontrado una alta prevalencia de diabetes mellitus en pacientes infectados por el virus C (VHC). En este trabajo nos planteamos un doble objetivo: a) sustentar la hipótesis de la hiperinsulinemia como factor de riesgo para diabetes en estos pacientes, estudiando prospectivamente los valores de insulinemia basal en pacientes cirróticos no diabéticos infectados por el virus C, comparándola con la de cirróticos no diabéticos no virus C; y b) investigar en ambos grupos los factores implicados en el aumento de resistencia periférica a la insulina.Material y métodos: se realizó un estudio que incluyó a 32 pacientes cirróticos no diabéticos por VHC (grupo I) y 41 cirróticos no diabéticos de otras etiologías (grupo II). En ambos grupos se compararon las concentraciones de insulinemia basal, así como los factores asociados a resistencia insulínica: edad, índices antropométricos, estadio evolutivo de la cirrosis empleando la clasificación de Child-Pugh, ferritina plasmática y tratamiento con fármacos inductores de resistencia a la insulina.Resultados: la media de los valores de insulinemia basal en el grupo I fue de 21,5 µU/ml (18,6-24,4), frente a 14 µU/ml (1018) en el grupo II (p<0,001), y el porcentaje de hiperinsulinemia del 87,5 por ciento (72,5-95,9) frente al 56,1 por ciento (40,8-70,6), respectivamente (p<0,01). No se encontraron diferencias entre ambos grupos con respecto a las siguientes variables: edad [54,4 (48,360,6) frente a 59,5 años (56,3-62,7) NS], peso [72,9 (69,5-76,3) frente a 74,2 kg (70,8-77,7) NS], talla [163,6 (160,5166-7) frente a 161,3 cm (159,4-163,2) NS], índice de masa corporal [27,6 (26,1-29,1) frente a 28,4 kg/m2 (27,3-29,5) de talla NS] ni estadio de Child-Pugh (A: 31 frente a 27, B: 0 frente a 7, C: 1 frente a 7, NS). En cambio los valores de ferritina sérica en los pacientes del grupo I fueron más elevados que los del grupo II [123,3 (12,4-289,3) frente a 65,5 ng/ml (2,4-306) p<0,05], mientras que en el momento de inclusión en este estudio 3 pacientes del grupo I recibían diuréticos o bloqueantes no selectivos beta adrenérgicos, frente a 14 pacientes del grupo II, p<0,01.El estudio de regresión logística multivariado demostró que los valores de insulinemia (OR=1,21; IC 95 por ciento 1,09-1,34, p<0,001) y ferritina (OR=1,21; IC 95 por ciento 1,02-2,69, p<0,04) fueron variables independientes asociadas a la infección por VHC.Conclusiones: Los pacientes cirróticos no diabéticos debido al VHC tienen unos valores de insulinemia basal más elevados, así como una mayor prevalencia de hiperinsulinemia que la cirrosis debida a otras causas. Esta característica podría explicarse por un aumento de resistencia periférico a la insulina, mediado por el incremento de los depósitos de hierro que igualmente presentan estos pacientes, y puede ser el factor responsable del riesgo aumentado de desarrollar diabetes mellitus (AU)

[Hyperinsulinemia in cirrhotic patients infected with hepatitis C virus]. / Hiperinsulinemia en pacientes cirróticos infectados por el virus de la hepatitis C.

AIMS: a) To prospectively study the frequency of diabetes mellitus in cirrhotic patients with hepatitis C virus (HCV) infection, comparing it with that in cirrhotic patients without HCV infection and b) to investigate basal insulinemia values in both groups, as well as the possible factors causing insulinemia. MATERIAL AND METHODS: Fifty patients with cirrhosis due to HCV infection (group I) and 50 patients with cirrhosis due to other etiologic agents (group II) were studied. In both groups the percentage of diabetic patients, basal insulinemia values and the factors associated with insulin resistance were compared: age, anthropometric indexes, stage of cirrhosis according to Child-Pugh score, plasmatic ferritin concentrations and treatment with drugs inducing insulin resistance. RESULTS: The percentage of diabetics in group I was 36% (18/50) compared with 18% (9/50) in group II (p < 0.05) and basal insulinemia values were 23.5 +/- 9.7 microU/ml compared with 15.7 +/- 9.9 microU/ml respectively (p < 0.05). No differences between the groups were found in the following variables: age (58.7 +/- 16.2 vs. 60.6 +/- 10.0 years), weight (73.2 +/- 10.7 vs 73.9 +/- 11.2 Kg), height (161.9 +/- 8.8 vs. 161.1 +/- 6.8 cm), body mass index (28.2 +/- 3.1 vs. 28.5 +/- 5.2 Kg/height m2) or Child-Pugh stage (A: 40 vs 34, B: 7 vs. 10, C: 3 vs. 6, NS). In contrast, serum ferritin concentrations were much higher in patients in group I than in those in group II [137.7 (12.4-410.2) vs. 87.6 (2.4-420.0) ng/ml p < 0.05]. At the time of inclusion in this study 10 patients in group I were receiving diuretics or non-selective beta adrenergic blockers compared with 24 patients in group II (p < 0.05). CONCLUSIONS: Diabetes mellitus is more prevalent in patients with cirrhosis due to HVC than in those with cirrhosis due to other etiologic agents. Moreover, basal insulinemia values are higher in these patients, which could be explained by an increase in half insulin resistance associated with an increase in iron deposits.

Hepatitis C virus infection, increased serum ferritin and hyperinsulinemia.

OBJECTIVES: Recent studies have reported a high prevalence of diabetes mellitus in populations infected with Virus C (HCV). The aim of this study is two-fold: a) to support the hypothesis of hyperinsulinemia as a risk factor for developing diabetes in these patients, with a prospective determination of baseline insulinemia in non-diabetic cirrhotic patients infected with HCV, comparing their values with those of a group of non-HCV non-diabetic cirrhotic patients; b) to investigate in both groups the factors associated to increased peripheral resistance to insulin. MATERIAL AND METHODS: Thirty two HCV cirrhotic diabetic patients (group I) and 41 non-diabetic cirrhotic patients of other etiologies (group II) participated in the study. Baseline insulinemia, as well as factors related to insulin resistance such as age, anthropometric indexes, stage of cirrhosis development using the Child-Pugh index, serum ferritin and treatment with insulin resistance inducing drugs were compared in both groups. RESULTS: Average baseline insulinemia in group I was 21.5 mU/ml (18.6-24.4), vs 14 mU/ml (10-18) in group II (p < 0.001), and the percentage of hyperinsulinemia was 87.5% (72.5-95.9) vs 56.1% (40.8-70.6), respectively (p < 0.01). No differences were observed between the two groups when comparing the following variables: age [54.4 (48.3-60.6) vs 59.9 (56.3-62.7) years of age, NS], weight [72.9 (69.5-76.3) vs 74.2 (70.8-77.7) kg, NS], height [163.6 (160.5-166.7) vs 161.3 (159.4-163.2)] cm, NS], body mass index [27.6 (26.1-29.1) vs 28.4 (27.3-29.5) kg/m2 of height, NS]; and Child-Pugh staging score (A: 31 vs 27; B: 0 vs 7; C: 1 vs 7, NS). However, serum ferritin levels in group I patients were higher than those in Group II [123.3 (12.4-289.3) vs 65.5 (2.4-306) ng/ml, p < 0.05]. It must be considered that at the recruitment 3 patients in Group I were taking either diuretics or non-selective beta-adrenergic blockers, compared to 14 patients in Group II, p < 0.01. Finally, the multivariate logistic regression analysis showed that insulinemia values (OR = 1.21; CI 95% 1.09-1.34, p < 0.001) and ferritin levels (OR = 1.21; CI 95% 1.02-2.69, p < 0.04) were independent variables associated to HCV infection. CONCLUSIONS: HCV-positive non-diabetic cirrhotic patients have higher baseline insulinemia levels and increased prevalence of hyperinsulinemia than cirrhosis due to other etiologies. This could be explained by an increase of peripheral insulin resistance, mediated by the increase of iron deposits in these patients, and could be responsible for the increased risk of developing diabetes mellitus.

[Mapping the scientific evidence for bedside care to unstable angina. A preliminary step to develop clinical guidelines. The name of the study group CAMBIE Change in the Medical services based on the clinical practice guidelines]. / Mapa de evidencias para el tratamiento de la angina inestable en la cabecera del paciente. Etapa preliminar para el desarrollo de una guía de práctica clínica. Nombre del grupo del estudio CAMBIE (Cambio en la Actuación Médica Basado en la Información de Evaluación).

BACKGROUND: The uncertainty in clinical practice arise from the need of physicians to make decisions on a limited ground of knowledges. Guidelines are supposed to facilitate clinical decisions in such circumstances. Sharing knowledges on natural history of diseases and clinical expertise allow to define and array of steps structured on a formal flow-chart. The node of algorithms identifies decisions to analyze. This paper presents a taxonomy of specific questions related to each decision nodes for management of unstable angina and assesses the level of evidence available for each question. MATERIAL AND METHOD: A flow chart diagram display the conceptualized key nodes for clinical management of unstable angina. A set of specific question related to clinical exclusive circumstances, diagnostic approach, utility of diagnostic procedures, definition of prognosis and outcomes was raised for each decision node. From a systematic literature review the best available evidence was gathered. Each recommendation was linked to a level (A-C) of evidence, and to a body of consensus expert panel decisions. RESULTS: 34 decision nodes were identified, related with at least 1 question for appraisal of the best evidence. The solution to these questions yielded 40 recommendations scored by the strength of the evidence available. Five recommendations of diagnostic, 20 at prognostic and 15 at therapeutic step. The strength of evidence was A for 73% of recommendations at therapeutic step versus 40% at the two other steps. CONCLUSIONS: A clinical complex problem can be displayed in a continuous process, to allow identification and appraisal of decisions at different clinical nodes. The work-up to achieve a conceptualization of a clinical problem is the preliminary step to develop clinical practice guidelines. Identification of decision nodes allows to manage uncertainty in a explicit way and make policy statement more acceptable by managers and physicians.

[Primary antiphospholipid syndrome presented with portal vein thrombosis]. / Trombosis portal como primera manifestación trombótica del síndrome antifosfolípido primario.

Antiphospholipid Antibody Syndrome (APS) is defined by arterial and venous thrombosis, recurrent spontaneous abortions and thrombocytopenia associated with persistence of antiphospholipid antibodies. Thrombosis may involve virtually all arterial or venous sites, but deep vein thrombosis of the lower limbs are the most common; however, unusual thrombi that involve the portal vein have been described. We report females with documented portal vein thrombosis and primary APS. The treatment of these patients is difficult because of the risk of bleeding and the recurrent thrombosis if they don't receive appropriate long-term anticoagulant therapy.

[An ileal ulcer and diaphragm-type colonic stenosis due to diclofenac]. / Ulcera ileal y estenosis colónica tipo diafragma por diclofenaco.

Nonsteroidal anti-inflammatory drugs (NSAID) are used extensively in the general population. It's well known the adverse effects of NSAID over the upper gastrointestinal tract and small intestine. Enteric-coated and slow release preparations were created in order to prevent those effects. We describe a woman case who took diclofenac for many years and developed both ileal ulceration and diaphragm-like colonic structure. Lesions in lower gastrointestinal tract were infrequent but severe; the lesion were seen on colonoscopy but not on barium studies; the physiopathology of these lesions remains uncertain; and the most efficacy attitude is the suppression of diclofenac.

[Changes in bone marrow among HIV-positive and HIV-negative parenteral drug addicts]. / Alteraciones de la médula ósea en adictos a drogas por vía parenteral seropositivos y seronegativos para el virus de la inmunodeficiencia humana.

BACKGROUND: The aim of the present was to study the cytohistology of the bone marrow in intravenous drug addicts (IVDA) and to analyze the possible differences according to the period of drug addiction. METHODS: A prospective study was performed in 60 IVDA patients previously untreated and distributed into three groups: 20 seronegative for the human immunodeficiency virus (HIV), 20 patients in a phase of generalized adenopathic infection (GAI) and 20 patients with AIDS. RESULTS: Cytohistologic examination of the bone marrow aspirates showed plasmocytosis and eosinophilia in all the groups. Selective changes were seen in the red series in 20% of the HIV negative patients and in 25% of the GAI group. The prevalence of cytologic changes was greater in those with AIDS, with hypocellular bone marrow being observed in 65% of the patients with coexistent dismyelopoietic changes in 15%. Pathologic structure showed granulomatous lesions of tuberculous etiology in 30% of the patients with AIDS while in the HIV negative and GAI groups these were found in 10% and 5%, respectively. A greater presence of fibrosis and bone marrow hypoplasia was also found in the group with AIDS, than in the other two groups. CONCLUSIONS: An increased number of bone marrow changes and progressive bone marrow hypocellularity may be observed on advancement of the clinical stages in intravenous drug addict patients. The incidence of tuberculous granulomas is higher in the AIDS group.

[Bilateral avascular necrosis of the femur head in an HIV-positive male]. / Necrosis avascular bilateral de cabeza femoral en un varón VIH positivo.

We present a case of bilateral avascular necrosis at the hips of a HIV-positive male, without other predisposing antecedents. The only relevant analytic data was the positivity of anticardiolipin antibodies (aCL AB). We discuss the possibility that both in this case as in those previously described, HIV may have played a main role in the development of osteonecrosis.

[Scleroderma as a paraneoplastic syndrome of ductal carcinoma of the prostate]. / Esclerodermia como síndrome paraneoplásico de un carcinoma ductal de próstata.

We report on a patient with ductal carcinoma of the prostate. A few months earlier, the patient had presented with disabling scleroderma that progressed rapidly and compromised multiple organs. The findings that led us to suspect a paraneoplastic syndrome are discussed and the recent literature on scleroderma and cancer is briefly reviewed.

[Factitious torpid skin ulcers. New concepts and classification of chronic factitious disorders]. / Ulceras cutáneas tórpidas facticias. Nuevos conceptos y clasificación de los trastornos facticios crónicos.

Chronic factitious disorders are diseases diagnosed after the discarding of organic causes. There are determined diagnostic data which may be suspicious: multiple hospitalization, submission to many invasive techniques and personal situations motivating simulation. The case of a 34 year old woman presenting a factitious disorder with dermal ulcers, subcutaneous abscesses and simulation of hematuria is described. An analysis of the concept and classification of this clinical picture is made. Following diagnostic suspicion, a search for objects or substances with which the patient was able to make the lesions was required to determine the appropriate therapy.

[Pulmonary tumorlets in POEMS syndrome]. / Tumorlets pulmonares en el síndrome POEMS.

POEMS syndrome is a systemic disease characterized by severe chronic polyneuropathy, organomegaly (adenopathy, and liver enlargement) endocrinopathy, monoclonal peak, sclerotic bone lesions and skin changes. We report on a case of complete POEMS syndrome with peripheral arterial thrombosis and multiple lung tumorlets. No antibodies were found against human nervous tissues or Rhesus monkey on patient serum. This case is the first association described of POEMS syndrome and lung tumorlets.

[Wine as a source of lead contamination: study in the southern region of Sevilla]. / El vino como fuente contaminante de plomo: estudio en el área sur de Sevilla.

To assess whether the wines from the south of Sevilla constitute a source of lead intoxication we have prospectively studied the blood levels of lead in 100 healthy controls, 100 patients with alcoholic and nonalcoholic hepatopathy and at the same time the lead content in 135 samples of water and in 176 samples of alcoholic drinks consumed by the above patients. The results demonstrate: 1) presence of normal amounts of lead (mean +/- SD = 62 +/- 5 micrograms/l) in 97 of wines analyzed; 2) a higher content of lead in wines from areas close to the highway A-4 (100 +/- 10 micrograms/l) than in those from more remote zones (42 +/- 3 micrograms/l, p less than 0.005); and 3) although the blood levels of lead in alcohol consumers are not at the toxic range (22.9 +/- 8.9 micrograms/l) are, however, significantly higher (p less than 0.0007) than in patients with no alcohol intake (16.8 +/- 9.9 micrograms/l) or in healthy persons (17.1 +/- 7.4 micrograms/l, p less than 0.0008). Blood levels of lead correlate with the condition of "usual drinker" but not with the amount of alcohol consumed, number of cigarettes, lead content of water and wine, nor with the existence of severe hepatopathy among the studied factors. Our results suggest that alcohol influences the lead metabolism and that the usual drinkers constitute a risk population for saturnism.