Kounis syndrome: report of 5 cases.

Kounis syndrome has been defined as an acute coronary syndrome that manifests as unstable vasospastic or nonvasospastic angina, and even as acute myocardial infarction. It is triggered by the release of inflammatory mediators following an allergic insult. We report 5 patients attended at our hospital between January 2005 and May 2008 who were diagnosed with unstable angina or acute myocardial infarction-according to analytical parameters, electrocardiographic abnormalities, and/or coronary angiography--in the context of an anaphylactic episode. Age at the time of the episode, age ranged between 50 and 68 years. The results of an allergology study revealed the causal agents to be drugs in 4 cases (nonsteroidal anti-inflammatory drugs and omeprazole) and food in 1 case (kiwi). Coronary disease of a blood vessel was observed in 2 patients. Serious allergic reactions may be the cause of acute coronary syndrome in patients with healthy or altered coronary arteries and no cardiovascular risk factors.

Two-leg squat jumps in water: an effective alternative to dry land jumps.

The current study was designed to quantify and compare the kinetic parameters of two-leg squat jumps carried out on dry land, in water and in water using area devices that increase drag force. Twelve junior female handball players who had been competing at national level for the previous two years volunteered to participate in the study. Intensity of the two-leg squat jump was examined using a force plate (9 253-B11, Kistler Instrument AG, Winterthur, Switzerland) in three different conditions: on dry land, in water and in water using devices. An ANOVA with repeated measurements (condition) was applied to establish differences between the three jumps. The results show that peak impact force and impact force rate for the water jumps was lower than for the dry land jumps (p<0.05), while peak concentric force was higher for the water jumps than the dry land jumps (p<0.05). In addition, no statistically significant differences were found between water jumps for these variables (p>0.05). These results indicate that water provides an ideal environment for carrying out jumps, as the variables associated with the exercise intensity are boosted, while those related to the impact force are reduced and this fact could be less harmful.

Anaphylactic shock as the cause of myocardial infarction in a woman with normal coronary arteries

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Varón de 68 años con aneurisma de aorta ascendente / 68 year-old male with aneurism of ascending aorta

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Lifting frontal apoyado en malla de polipropileno / Brow lift supported on polypropylen mesh

La región frontorbitaria tiene una especial significación en el contexto del envejecimiento facial. La literatura cuenta con numerosa bibliografía que trata sobre este problema. Se considera como una unidad diagnóstico-terapéutica en los últimos tiempos y la evolución de la cirugía hace que se vaya hacia soluciones cada vez más fisiológicas y mínimamente invasivas. Nuestro trabajo queremos que sea un paso más en esa dirección. Sobre una muestra de 25 pacientes en los que se trató la región frontorbitaraia con diferentes procedimientos, y que además mostraban un descenso de la altura de las cejas, se presenta una técnica de suspensión frontorbitaria con mínima incisión, apoyada en una malla de polipropileno anclada en el músculo frontal y galea en el extremo inferior y en el periostio y la galea en su extremo superior en el plano supraperióstico y sin resección cutánea. Se emplea un sistema de medición de resultados basado en puntos del esqueleto facial. Los resultados han sido satisfactorios subjetiva y objetivamente, y comparables a los de otras técnicas más complejas y de mayor coste económico. Las complicaciones desarrolladas han sido leves y pasajeras. Se valora porqué se decidió utilizar la malla de polipropileno, así como porqué se eligió un gramaje concreto. También se analizan las características que aportan el material y su uso en esta técnica como comportamiento ante la infección, tolerancia tisular, retracción cicatricial y adhesividad. Asímismo se justifica el plano de disección y colocación elegido, y se valora el sistema de medición para el control objetivo de los resultados. La aportación de este trabajo consiste en desarrollar una alternativa dentro de las técnicas mínimamente invasivas para le reposición de la región frontorbitaria, sin resección de piel y con buenos resultados en la corrección de las arrugas frontales, comparables a los de otras técnicas de mayor complejidad y elevado coste económico (AU)

The fronto-orbital region is of particular significance in the context of facial ageing. There is a considerable amount of research on the nature of this problem. This area has recently come to be considered as a therapeutic- diagnostic unit and surgical developments mean that focus is switching more towards less invasive physiological solutions. Our study aims to take another step in this direction. ;;Taking a sample of 25 patients, all of them undergoing different procedures on the fronto-orbital region and with a lowering of the eyebrows, a suspension technique was introduced with minimum incisions supported by a polypropylene mesh attached to the frontal muscle and galea in the inferior extreme and to the periosteum and galea in the superior extreme in the supra-periosteum plane and without skin removal. A measuring system based on points of the facial skeleton was used. ;;The results were subjectively and objectively satisfactory compared to those from more complicated and expensive techniques. Complications were of a slight and temporary nature. ;;This section carries out an assessment of the reasons for selecting a polypropylene mesh and specific grammage. In addition, the properties of the material are analysed and its use in this context of preventing infection, tissue tolerance, scar reduction and adhesiveness. Justification of the site of dissection and the choice of positioning, and an assessment of the course of medication given in order to produce a set of controlled and objective results, will also be carried out. ;;The aim of this work is to develop an alternative within minimally invasive techniques for the restructuring of the fronto-orbital region without skin removal and with good results in the correction of facial wrinkles compared to other more complicated and expensive techniques (AU)

Análisis de las hospitalizaciones de pacientes ingresados en la unidad de cirugía sin ingreso (UCSI) / Analysis of unplanned admissions in an outpatient department

INTRODUCCIÓN: El análisis de los resultados es fundamental para corregir los fallos y posibles errores de un procedimiento. Dado que la última fase del alta de los pacientes son realizados mayoritariamente por personal de enfermería, nosotros filtramos aquí los datos derivados del fracaso de la Unidad ( UCSI), al realizar un seguimiento de los pacientes que en vez de pasar a su domicilio, tuvieron destino en hospitalización. MATERIAL Y MÉTODOS: Se han estudiado los primeros 1950 ingresos realizados en la Unidad de Cirugía sin ingreso (UCSI) que pertenecían a los Servicios de Cirugía con 273 (14’00%), Oftalmología 1.304 (66’87%), Traumatología con 317 (16’25%) y Urología con 56 (2’87%). Los ingresos se agrupan además por Servicios y médico responsable; los pacientes con hospitalización como destino se agrupan además por causas de hospitalización como de errores de selección, causas anestésicas, causas técnicas, causas postoperatorias y otras. RESULTADOS: Los pacientes que pasaron a hospitalización fueron 88 en total (4’51%) pertenecieron 8 a Cirugía, 46 a Oftalmología, 9 a traumatología, ninguno a Urología y 26 a Anestesiología, Con respecto a los grupos de causas: de los 88 pacientes 5 tuvieron que pasar a hospitalización por errores en la selección de los pacientes (5’68%), 9 por problemas de tipo anestésico (10’22%), 43 por circunstancias técnicas intraoperatorias (48’86%), 17 por su evolución postoperatoria propiamente en UCSI (19’31%) y 14 por otras causas (15’90%). También se ha analizado cada médico responsable, lo cual ha llevado a descubrir en algún caso vicios de procedimiento por parte de alguno de éllos. CONCLUSIONES: Aunque los porcentajes se hallan dentro de los rangos descritos en la literatura, el análisis de los fracasos es el mejor criterio para realizar un control de calidad permitiendo corregir los defectos y vicios de funcionamiento (AU)

INTRODUCTION: The analysis of results is essential for the correction of errors or possible mistakes in any process. The last phase before the patients are discharged from hospital is undertaken by nursing staff. Bearing this in mind, we present the data obtained from the "failed ambulatory procedures" of the Day Surgery Unit (DSU). It concerns those patients that were hospitalised instead of being sent home. MATERIAL AND METHODS: The present study dealt with the first 1950 admissions to the Day Surgery Unit (DSU) from which 273 (14%) were of the Surgery department, 1304 (66.87%) of the Ophthalmology department, 317 (16.25%) of the Trauma department and 56 (2.87%) of the Urology department. The admissions analysed are grouped in the different departments and the doctors in charge. Furthermore, those patients that were hospitalised were grouped according to the reasons for that: selection errors; anaesthetic reasons; technical reasons; postoperative reasons and others. RESULTS: Of the total of patients, 88 (4.51%) were hospitalised. Of these, 8 belonged to Surgery, 46 to Ophthalmology, 9 to Trauma, none to Urology and 26 to Anaesthesia, which represents 2.93% of the total in Surgery, 3.52% in Ophthalmology, 2.83% in Trauma, and 1.74% in Anaesthesia. Depending on the causes, of the (..) (AU)

Afectación cardíaca en pacientes con hipertiroidismo / Cardiac involvement in patients with hyperthyroidism

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[Pericardial effusion in the elderly: A different disease?]. / Derrame pericárdico en el paciente anciano: una enfermedad diferente?

INTRODUCTION AND OBJECTIVES: The aim of the present study was to assess possible differences in etiologic spectrum and clinical course of pericardial effusion in elderly patients, as has been previously suggested, and therefore determine whether clinical, management should be based on patient age. METHODS: All echocardiograms performed in our hospital from 1990 to 1996 were screened for pericardial effusion, and those with moderate or large effusions were selected. Patients under 66 years of age were included in group I, and those above 65 years were assigned to group II. RESULTS: We selected 322 patients with moderate (122) or with large (200) effusions. 221 patients being included in group I (aged 15-65, mean 47) and 101 in group II (aged 66-88, mean 72.5). Effusion was large in 60% of group I and in 66% of group II (p = NS), and tamponade occurred in 36% and 38.6%, respectively (p = NS). Specific pericardial infections (tuberculous and purulent pericarditis) were more frequent in group I (5.9 versus 0.9%; p < 0.05). No significant differences were found in incidence of idiopathic (33 vs 38%) or neoplastic (14.4 vs 10.8%) etiologies. During follow-up (96% of the patients, median time of 11 months, range 1-58 months) the mortality (24 vs 30%) and evolution to cardiac constriction (4 vs 2%) were similar in the two groups, but persistence of effusion was more common in group II (6.3 vs 14%; p < 0.05). CONCLUSIONS: Our study suggests that etiology, clinical course and prognosis of moderate and large pericardial effusion are, in general, similar in elderly and younger patients. Thus, management should be similar in the different age groups, and no etiologic form of pericardial disease should be ruled out because of patient's age when considering the differential diagnosis.

Clinical clues to the causes of large pericardial effusions.

PURPOSE: To examine whether the size of the effusion, the presence of tamponade, and inflammatory signs are useful in determining the causes of moderate or severe pericardial effusions. SUBJECTS AND METHODS: All echocardiograms performed at a general hospital between January 1990 and April 1996 were screened for pericardial effusion. Patients with moderate (echo-free space of 10 to 20 mm during diastole) or severe (echo-free space >20 mm) effusions were studied. RESULTS: We identified 322 patients (166 [52%] men, mean [+/- SD] age 56 +/- 17 years [range 15 to 88 years]), 132 (41%) with moderate and 190 (59%) with severe pericardial effusion. The most frequent etiologic diagnoses were acute idiopathic pericarditis (n = 66 [20%]), iatrogenic effusions (n = 50 [16%]), cancer (n = 43 [13%]), and chronic idiopathic pericardial effusion (n = 29 [9%]). In 192 (60%) of the patients, the cause of the effusion was a known medical condition. In the 130 other patients, inflammatory signs were associated with acute idiopathic pericarditis (likelihood ratio = 5. 4, P < 0.001), severe effusions without inflammatory signs or tamponade were associated with chronic idiopathic pericardial effusion (likelihood ratio = 20, P < 0.001), and tamponade without inflammatory signs was associated with malignant effusions (likelihood ratio = 2.9, P < 0.01). CONCLUSIONS: In many patients, pericardial effusions are due to a known underlying disease or condition. In patients without underlying diseases, inflammatory signs, the size of effusion, and the presence or absence of cardiac tamponade can be helpful in establishing cause.

Correlation between clinical and Doppler echocardiographic findings in patients with moderate and large pericardial effusion: implications for the diagnosis of cardiac tamponade.

BACKGROUND: Clinical data are of unquestionable value for management purposes in cardiac tamponade, whereas the precise value of Doppler echocardiographic findings is not yet fully understood. We aimed to prospectively assess the correlation between clinical and Doppler echocardiographic signs in the diagnosis of cardiac tamponade in a large series of patients with pericardial effusion. METHODS: During a 2-year period, all patients with moderate and large pericardial effusion were prospectively assessed. The presence of clinical findings suggesting cardiac tamponade, right cardiac chamber collapse on the echocardiogram, and Doppler venous flow pattern were simultaneously evaluated. RESULTS: One hundred ten patients were included (49 with moderate and 61 with large effusions). Thirty-eight patients showed clinical features suggestive of cardiac tamponade and 72 did not. In patients with clinical tamponade, 90% had collapse of one or more right cardiac chambers, but 4 (10%) did not have any collapse. Venous flow was analyzable in 63%, suggesting tamponade in 75% of the patients. In patients without clinical tamponade, 34% showed collapse of one or more cardiac chambers. Venous flow pattern was normal in 80%, inconclusive in 11%, and only suggestive of tamponade in 9% of patients. If clinical features of tamponade were considered the diagnostic standard, sensitivity and specificity would be 90% and 65% for the presence of any collapse, 68% and 66% for right atrial collapse, 60% and 90% for right ventricular collapse, and 45% and 92% for simultaneous collapse of both chambers. Sensitivity and specificity of venous flow analysis would be 75% and 91%, respectively. CONCLUSIONS: There is a good correlation between absence of collapse and absence of tamponade, but the correlation is poor between collapse and tamponade. Abnormal venous flow has a good correlation with clinical features of tamponade, with a higher sensitivity than right ventricular collapse and a much higher specificity than right atrial collapse.

Influence of human immunodeficiency virus 1 infection and degree of immunosuppression in the clinical characteristics and outcome of infective endocarditis in intravenous drug users.

BACKGROUND: Immunosuppression caused by human immunodeficiency virus 1 (HIV) infection appears to modify the clinical characteristics and to increase the severity of several bacterial infections. The impact of HIV infection and the degree of immunosuppression on the clinical characteristics and outcome of infective endocarditis (IE) in intravenous (IV) drug users has not been well characterized. METHODS: Prospective cohort study among 292 consecutive IV drug users with IE diagnosed in 2 academic institutional hospitals in Barcelona, Spain, from January 1, 1984, to October 31, 1995. Serostatus of HIV infection was documented in 283 patients. We measured demographics, clinical and biological data, cause, echocardiographic findings, HIV serostatus and classification, CD4 cell count, complications, and mortality. RESULTS: Among the 283 episodes of IE, 216 (76.3%) were in HIV-infected patients and 67 (23.7%) in non-HIV-infected patients. Rate of IE per 1000 admissions ranged from 0.17 to 0.82 per year, peaking in 1989. Characteristics of IE independently associated with HIV infection were right-side involvement (odds ratio [OR], 7.6; 95% confidence interval [CI], 3.5-16.7), a micro-organism different from viridans streptococci (OR, 2.5; 95% CI, 1.1-5.9), duration of drug abuse longer than 5 years (OR, 5.0; 95% CI, 2.4-10.3), and white blood cell count of no more than 10 X 10(9)/L (OR, 2.2; 95% CI, 1.1-4.2). There were no significant differences in mortality due to IE according to HIV serostatus. Among the 216 patients with HIV infection, the variables independently associated with worse outcome were CD4 cell count lower than 0.200 x 10(9)/L and left-sided or mixed IE. CONCLUSIONS: Although there is a difference in clinical presentation in IE in IV drug users, outcome was similar according to their HIV status. However, among HIV-infected patients, severe immunosuppression and mixed or left-side valvular involvement were strong risk factors for mortality.

Should pericardial drainage be performed routinely in patients who have a large pericardial effusion without tamponade?

PURPOSE: To assess whether drainage of pericardial effusion by pericardiocentesis or surgery is justified as a routine measure in the initial management of patients with large pericardial effusion without tamponade or suspected purulent pericarditis. SUBJECTS AND METHODS: All patients with large pericardial effusion without tamponade or suspected purulent pericarditis who were seen at our institution during a span of 6 years (1990 to 1995) were retrospectively (46) or prospectively (25) reviewed. Large pericardial effusion was defined as a sum of echo-free pericardial spaces in diastole exceeding 20 mm. RESULTS: Large pericardial effusion was diagnosed in 162 patients, 71 of whom fulfilled criteria for inclusion. Of these, 26 underwent a pericardial drainage procedure. Diagnostic yield was 7%, as only 2 specific diagnoses were made using these procedures. During follow-up (95% of patients, median 10 months), no patient developed cardiac tamponade or died as a result of pericardial disease, nor did any new diagnoses become manifest in the 45 patients who did not have pericardial drainage initially. Moderate or large effusions persisted in only 2 of 45 patients managed conservatively. CONCLUSIONS: Routine pericardial drainage procedures have a very low diagnostic yield in patients with large pericardial effusion without tamponade or suspected purulent pericarditis, and no clear therapeutic benefit is obtained with this approach. Clinical outcomes depend on underlying diseases, and do not appear to be influenced by drainage of pericardial fluid.

[The use of transesophageal echocardiography in the diagnosis of aortic hematoma after an aortic recoarctation angioplasty]. / Utilidad de la ecocardiografía transesofágica en el diagnóstico de un hematoma aórtico tras la angioplastia de una recoartación aórtica.

Transesophageal echocardiography is a very useful technique in studying thoracic aorta diseases, particularly aortic dissection and aortic intramural hematoma. In this report, we describe a case of aortic intramural hematoma after balloon angioplasty of a recoarctation. This case illustrates the importance of transesophageal echocardiography in the diagnosis and subsequent management of possible complications following this technique.

[Prosthesis-related thrombosis cleared with fibrinolysis. Usefulness of transesophageal echocardiography]. / Trombosis protésica resuelta con fibrinólisis. Utilidad de la ecocardiografía transesofágica.

Thrombosis is an infrequent complication in mechanical valve prostheses carrying a vital risk for the patient. The performance of transesophageal echocardiography (TEE) is high in differentiating the thrombosis from other causes of flow obstruction and is fundamental for establishing treatment. Fibrinolysis is an effective alternative treatment to surgery when the latter carries a high risk. In the case herein reported TEE provided a rapid and precise diagnosis and allowed to prove the resolution of the prosthetic thrombosis following fibrinolytic treatment.

Amylase, lipase, pancreatic isoamylase, and phospholipase A in diagnosis of acute pancreatitis.

To determine the utility of serum amylase (AMY), lipase (Lp), pancreatic isoamylase (isoA), phospholipase A (PLA), and urine AMY in the diagnosis of acute pancreatitis, samples of serum and urine were obtained on admission and every day thereafter for 5 days from 384 patients with acute abdominal pain. Diagnostic accuracy, determined as the area under the receiver operating characteristic curve, was > 0.975 for serum AMY, Lp, isoA, and urine AMY. For each of these enzymes, a threshold value (twice to sixfold the upper limit of the reference values) offering diagnostic efficiency > 95% could be determined. In contrast, accuracy and efficiency of serum PLA were low. The profiles of these enzymes in acute pancreatitis decreased in a parallel fashion over 5 days except for PLA. We conclude that diagnostic utilities are similar for serum AMY, Lp, isoA, and urine AMY for acute pancreatitis, provided that an appropriate threshold is established.

[Treatment of hypertrophic obstructive cardiomyopathy with dual chamber pacing. Use of isoproterenol in determining the optimal AV interval]. / Tratamiento de la miocardiopatía hipertrófica obstructiva mediante marcapasos bicameral. Empleo del isoproterenol para determinar el intervalo AV óptimo.

Dual chamber pacing may be used as an alternative in the treatment of selected patients who are refractory to conventional medical treatment of hypertrophic obstructive cardiomyopathy. When programming the pacemaker it is essential to know the value of the atrio-ventricular interval which is able to cause the greatest reduction in the left ventricle outflow tract pressure gradient. We have used isoproterenol to calculate the parameter mentioned above. This allowed us to know the optimum value, not only in non-active conditions, but also reproducing the changes in the pressure gradient in different physiological situations.

Dipyrone interference on several common biochemical tests.

We studied the effect in vitro and in vivo of dipyrone on the determination of several biochemical tests in two analyzers, a Hitachi 747 and a Kodak Ektachem 700. From studies in vitro, we found significant interference by dipyrone (P < 0.05) in the determination of creatine kinase (CK), lactate dehydrogenase (LD), uric acid, triglycerides, cholesterol, aspartate aminotransferase, alanine aminotransferase, and urea nitrogen with both instruments, and in the determination of creatinine in the Ektachem analyzer. We also studied the effect of intravenously administered dipyrone in 14 patients. Dipyrone interfered significantly (P < 0.05) in the determination of CK, LD, uric acid, triglycerides, and cholesterol with both instruments, and creatinine only with the Ektachem analyzer. Using high-performance liquid chromatography (HPLC), we measured concentrations of dipyrone in the serum of patients who had received the drug and observed a negative correlation between the concentrations of dipyrone in the blood and the percentage of each analyte concentration.