Complicaciones gastrointestinales asociadas a quimioterapia de acondicionamiento para trasplante autólogo en pacientes con mieloma múltiple / Gastrointestinal complications associated with conditioning chemotherapy for autologous transplantation in patients with multiple mieloma

Objetivo: Determinar la prevalencia de mucositis oral (MO) y su gravedad en pacientes con mieloma múltiple (MM) sometidos a trasplante antólogo de sangre periférica (TASP) en nuestro centro. Otros objetivos son describir la duración de MO, utilización de Nutrición Parenteral Total (NPT) y analgesia, posibles infecciones y determinar la prevalencia de efectos adversos gastrointestinales (EA GI). Métodología: Estudio observacional, retrospectivo y longitudinal en pacientes con MM, sometidos a TASP acondicionado con melfalán a altas dosis. La variable principal estudiada fue la presencia de MO y su gravedad. Las variables secundarias fueron: duración de la MO, enfermedad peridontal previa (EPP), el tratamiento con NPT y con analgésicos y la presencia de infecciones. Resultados: Se incluyeron 34 pacientes en el estudio. El 71% (24/34) del total presentó MO y, de estos, el 42% (10/24) MO grave. El 38% (13/34) del total requirió de NPT, lo cual fue significativamente superior en el grupo de pacientes con MO grave (p<0,05). De los pacientes con MO, el 96% (23/24) requirió tratamiento analgésico sistémico. El 88% (30/34) y el 76% (26/34) del total, presentaron diarrea y náuseas y vómitos (N/V) respectivamente. Conclusiones: La MO tiene una alta prevalencia en los pacientes tratados con melfalán a dosis mieloablativas como acondicionamiento para TASP en nuestro hospital. La única variable que se relacionó con la presencia de MO fue la EPP. Otros EA GI que también tienen una alta prevalencia son la diarrea y N/V.(AU)

Objective: To determine the prevalence of oral mucositis (OM) and its severity in patients of multiple myeloma (MM) who had a procedure of autologous transplant of hematopoietic cells in our center. Other objectives are to describe the duration of MO, the use of Total Parenteral Nutrition (TPN) and analgesia, possible infections and determine the prevalence of gastrointestinal adverse effects (GI AE).Methodology: Observational, retrospective, and linear study of patients with multiple myeloma that went through conditioning myeloablative therapy and, after that, an autologous transplant of hematopoietic cells. Main variable was made the presence of OM and its duration. Secondary variables were OM degree, previous periodontal disease (PPD) parenteral nutrition and analgesic treatments and whether or not there was presence of infections. Results: 34 patients were included in the study. 71% (24/34) had OM and, among those, in 42% of cases (10/24) OM was severe. 38% (13/34) needed parenteral nutrition, with numbers significantly higher when it came to the ones affected by severe OM (p<0.05). 96% (23/24) of OM patients needed systemic analgesic therapy. 88% (30/34) and 76% (26/34) of all patients presented diarrhea and nausea and vomits, respectively. Conclusions: OM has a high prevalence in patients treated with Melphalan in myeloablative doses as a preparation for an autologous transplant of hematopoietic cells in our hospital. The only variable related to the presence of OM was previous mouth disease. More IG AE with high prevalence are diarrhea and nausea and vomits.(AU)

Traditional knowledge of medicinal plants in the Serra de Mariola Natural Park, South-Eastern Spain.

The present study aims to inventory and analyse the ethnobotanical knowledge about medicinal plants in the Serra de Mariola Natural Park. In respect to traditional uses, 93 species reported by local informants were therapeutic, 27 food, 4 natural dyes and 13 handcrafts. We developed a methodology that allowed the location of individuals or vegetation communities with a specific popular use. We prepared a geographic information system (GIS) that included gender, family, scientific nomenclature and common names in Spanish and Catalan for each species. We also made a classification of 39 medicinal uses from ATC (Anatomical, Therapeutic, Chemical classification system). Labiatae (n=19), Compositae (n=9) and Leguminosae (n=6) were the families most represented among the plants used to different purposes in humans. Species with the most elevated cultural importance index (CI) values were Thymus vulgaris (CI=1.431), Rosmarinus officinalis (CI=1.415), Eryngium campestre (CI=1.325), Verbascum sinuatum (CI=1.106) and Sideritis angustifolia (CI=1.041). Thus, the collected plants with more therapeutic uses were: Lippia triphylla (12), Thymus vulgaris and Allium roseum (9) and Erygium campestre (8). The most repeated ATC uses were: G04 (urological use), D03 (treatment of wounds and ulcers) and R02 (throat diseases). These results were in a geographic map where each point represented an individual of any species. A database was created with the corresponding therapeutic uses. This application is useful for the identification of individuals and the selection of species for specific medicinal properties. In the end, knowledge of these useful plants may be interesting to revive the local economy and in some cases promote their cultivation.

Hyperhidrosis related to nevirapine therapy.

A 70-year-old white man presented to the internal medicine outpatient clinic with symptoms of significant hyperhidrosis. He had been started on antiretroviral therapy (ART) with tenofovir, lamivudine and nevirapine. The patient complained of excessive sweating following severe asthenia after taking nevirapine. Based on these findings, we suspected that the causative agent was nevirapine and a diagnosis of hyperhidrosis due to nevirapine was made. Nevirapine treatment was stopped and was substituted with efavirenz: the patient continued on therapy with tenofovir and lamivudine. The hyperhidrosis symptoms resolved in 2-3 days. No relapse was observed with the new ART regimen. Drugs that induce hyperhidrosis can cause patient discomfort and embarrassment. In our patient, this adverse drug reaction also caused severe asthenia that decreased the patient's physical and emotional quality of life. There was a temporal relationship between the developments of symptoms and starting nevirapine therapy. Once nevirapine was suspended and switched to efavirenz, excessive sweating resolved. An objective causality assessment revealed that the adverse effect was probable. Until further data are available, clinicians should consider discontinuation of nevirapine therapy in patients who develop severe hyperhidrosis.

Foot ischaemia and toe skin necrosis associated with interleukin-2 infusion in an HIV-infected patient.

A 39-year-old white man developed a severe left toe foot ischaemia and toe skin necrosis following his 12 courses of interleukin (IL)-2 (4.5 MIU twice a day, subcutaneously) for five days every two months. He had no known general risk factors for thrombosis other than HIV infection. An arterial Doppler ultrasound examination of the leg confirmed the permeability of the posterior tibial artery and its digital pulse. A diagnosis of foot ischaemia and toe skin necrosis was made. The suspected causative agent was IL-2 since this was the only drug that the patient was taking before the symptoms appeared. The patient was empirically treated with an aspirin and pentoxifylline in order to improve local microcirculation. We observed a satisfactory response with a quick resolve of skin lesions. The most possible cause of foot ischaemia and toe skin necrosis was considered to be IL-2 because of the temporal relationship between the exposure to the drug and onset of symptoms. Based on the Naranjo probability scale, IL-2 could be considered the probable cause of the foot ischaemia and toe skin necrosis. If clinical evaluation leads to the suspicion of ischaemic process, therapy with IL-2 should be discontinued immediately.

Melanoniquia inducida por zidovudina / No disponible

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[Lipid lowering goals in high risk and very high cardiovascular risk patients: a reasonable challenge?]. / Objetivos del tratamiento hipolipemiante en pacientes con alto riesgo y muy alto riesgo cardiovascular: un reto posible?

OBJECTIVE: The last modifications of the National Cholesterol Education Program (NCEP) indicate some lower therapeutic targets of low density protein cholesterol (LDL-c) in patients with very high vascular risk. Our study aims to establish the degree of compliance of the therapeutic targets defined by these modifications. PATIENTS AND METHOD: Descriptive and cross sectional study of patients from a cardiovascular clinic. Low-density lipoprotein cholesterol (LDL-c) was calculated and targets were established according the new update of NCEP-ATP III. RESULTS: 836 patients, 625 (75%) with HR and 211(25%) with VHR were studied 45% of HR and 67% of VHR were receiving treatment with statins (p < 0.001) but only 38% of HR and 15% of VHR achieved target LDL-c levels. The percentage of patients who could achieve LDL-goals using the maximum approved dose of the statins plus other lipid lowering drug was calculated: The 31% of HR and 51% of VHR were unable to achieve the LDL-c targets. CONCLUSIONS: Only 15% of very high risk patients achieve target levels of LDL-c according to the new NCEP-ATP III recommendations. Even using maximum dose of statins in combination with other lipid lowering drugs, less than half of the patients will be able to achieve LDL-c goal (< 70 mg/dl).

[Community-acquired pneumonia among the elderly: differences between patients living at home and in nursing homes]. / La neumonía adquirida en la comunidad de los ancianos: diferencias entre los que viven en residencias y en domicilios particulares.

OBJECTIVE: The etiology, presentation, and prognosis of community-acquired pneumonia (CAP) among nursing home residents are believed to differ from those of other groups. However, few Spanish studies have confirmed those assumptions or studied regional differences in CAP etiology. PATIENTS AND METHODS: A prospective study which included all patients over 65 years of age admitted to our hospital with CAP was carried out over a period of 18 months (2002-2003). We examined clinical, analytical, and radiographic characteristics paying particular attention to functional status--using the Eastern Cooperative Oncology Group (ECOG) scale and Barthel and Karnofsky indices--and comorbidity. Two blood cultures, a Legionella antigen test in urine, and serology for atypical bacteria were used for the etiologic diagnosis; bacterial cultures of respiratory samples were also used in certain cases. RESULTS: Ninety-one patients, 25 of whom were nursing home residents, were enrolled. The nursing home residents were older than the other patients (mean [SD] age of 82 [4] compared with 73 [5]; P=.0001) and had greater comorbidity (P=.0001)--with a significantly greater presence of diabetes mellitus, cerebrovascular disease, congestive heart failure, and dementia. They also had a poorer functional status (ECOG, 2.09 [0.9] compared with 0.93 [1.1], P=.001; Barthel Index, 19 [33] compared with 77 [35], P=.001; Karnofsky In-dex, 51 [17] compared with 78 [23], P=.001). Regarding clinical characteristics, significant differences were found for respiratory rate (39 [11] compared with 27 [7] breaths/min; P=.001), blood pressure (69.5 [20] compared with 79.2 [18] mm Hg; P=.029), and temperature (36.6 [1.2] compared with 37.7 [1.1] degrees C; P=.001). CAP patients from nursing homes presented a greater number of affected lobules in chest x-rays (P=.004), more hypoxemia, acidosis, anemia, hypoalbuminemia, and greater scores of urea and creatinine. Fine Scale scores were also greater (134 [26] compared with 95 [28]; P=.001) as was mortality (7/25 compared with 3/66; P=.005). Few patients had an etiologic diagnosis and no significant differences were observed between the groups. The variable that predicted mortality in elderly patients in this series, according to stepwise logistic regression, was urea (adjusted R2=0.452). CONCLUSIONS: In our sample population, nursing home residents were older, had greater comorbidity, and severe functional impairment. Under these circumstances the severity of CAP increases and becomes an important cause of mortality despite the fact that the etiologic agents do not appear to differ from those of the other patients.

[Systemic candidiasis and infliximab therapy]. / Candidiasis sistémica y tratamiento con infliximab.

The use of infliximab in patients with luminal or fistulizing Crohn's disease refractory to medical treatment (steroids and immunomodulatory drugs) is increasingly widespread. Although the incidence of serious infections in patients undergoing infliximab treatment is not higher than that of controls, systemic fungal infections in patients treated with this antibody have been anecdotally described. We report a case of systemic candidiasis in a patient with refractory Crohn's disease who was treated with infliximab associated with corticosteroids and azathioprine and discuss the role that infliximab could have played in the development of this complication.

Síndrome de lipodistrofia asociado a la infección por el virus de la inmunodeficiencia humana y lipomatosis mediastínica / Lipodystrophic syndrome associated with infection with the human immunodeficiency virus and mediastinal lipomatosis

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Hemoperitoneo por leiomiosarcoma peritoneal / Hemoperitoneum caused by peritoneal leiomyosarcoma

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Síndrome de Swyer-James: aportaciones diagnósticas de la tomografía computarizada helicoidal / Swyer-James syndrome: the diagnostic contribution of helical computed tomography

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Hipertensión arterial vasculorrenal en varón joven / Vasculo-renal arterial hypertension in a young male patient

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Treatment of community-acquired pneumonia in outpatients: randomized study of clarithromycin alone versus clarithromycin and cefuroxime.

OBJECTIVE: To evaluate the efficacy of clarithromycin alone in comparison with the combination of clarithromycin and cefuroxime in the treatment of nonhospitalized patients with community-acquired pneumonia (CAP) in a Mediterranean population. METHODS: CAP was defined as the acute onset of fever (>38 degrees C) with pulmonary opacity on chest roentgenogram. The American Thoracic Society (ATS) criteria (1993) were used to decide on patient hospitalization. Ninety subjects, of whom 53 (59%) were men, with a mean age (+/-SD) of 38+/-15 years, were randomized: 45 received clarithromycin 500 mg b.i.d. orally for 14 days (CL group), and 45 received clarithromycin plus cefuroxime 500 mg b.i.d. orally for 7 days (CLCE group). Patients were monitored with clinical, radiological, and laboratory controls at 3 and 21 days. There were no significant differences between the two groups with regard to demographic, clinical, physical and laboratory data. RESULTS: The mean time to defervescence was 2.4+/-1.4 and 2.4+/-1.5 days, respectively. Chest roentgenogram clearance was complete in all cases, without statistically significant differences in the time to resolution between both arms. Side effects were mild (no significant differences between groups): 5 patients in the CL group and 3 in the CLCE group showed gastrointestinal symptoms. Two patients (2.2%), both in the CLCE group, needed hospital admission during follow-up, but all 90 patients showed an excellent outcome. A causative agent was determined in 25 cases (28%). Legionella pneumophila, Streptococcus pneumoniae, and Mycoplasma pneumoniae were the most frequent pathogens. CONCLUSION: Empirical treatment of outpatient CAP with clarithromycin can be considered adequate in the Mediterranean area, independently of the microbiological etiology. ATS criteria for admitting patients with CAP are appropriate in this population.