Síndrome de embolia grasa tras fractura ósea / Fat embolism syndrome after bone fractures

Objetivos. Revisar la incidencia, las características clínicas, diagnósticas y terapéuticas, así como la mortalidad del síndrome de embolia grasa (SEG) en la última década. Pacientes y métodos. Estudio retrospectivo y descriptivo de los pacientes diagnosticados de SEG postraumático entre enero de 2001 y diciembre de 2011 en un solo centro. Resultados. Se evalúan 19 pacientes, 16 varones y 3 mujeres, con edad media de 27 años. Todos presentaban fracturas de huesos largos como consecuencia de un politraumatismo, múltiple en el 78,9%. La clínica respiratoria fue la más frecuente (89,5%), seguida de la neurológica (68,4%) y del exantema petequial (63,2%). El tiempo medio de presentación desde el ingreso fue de 42h. En todos se realizó estabilización precoz de la fractura previa al episodio embólico. En ningún caso se utilizaron corticoides profilácticos. El tratamiento quirúrgico definitivo tuvo una demora media de 7 días y la estancia media hospitalaria fue de 34 días. La incidencia de SEG fue de 0,14% y la mortalidad del 10,5%. Conclusiones. El SEG postraumático afectó fundamentalmente a pacientes jóvenes, politraumatizados, con fracturas de huesos largos. Presentaron manifestaciones de la tríada clínica clásica (respiratorias, neurológicas, exantema), tras un periodo asintomático inicial de menos de 2 días. Su incidencia global fue baja(AU)

Objectives. To review the incidence, clinical features, diagnosis, therapy and mortality rates of fat embolism syndrome (FES) in a tertiary referral hospital in the last decade. Patients and methods. Retrospective and descriptive study of patients diagnosed with post-traumatic FES between january 2001 and december 2011. Results. A total of 19 patients, 16 men and 3 women, with an average age of 27 years were evaluated. All had long bone fractures, multiple in 78.9%, as a result of multiple injuries. Respiratory symptoms were the most frequent (89.5%), followed by neurological symptoms (68.4%) and petechial rash (63.2%). The average time of presentation of the syndrome after admission was 42 hours. All patients underwent early stabilisation of the fracture prior to the embolic event. Steroids prophylaxis was not used in any of the cases. Definitive surgical treatment had mean delay of 7 days. The mean hospital stay was 34 days. The overall incidence of FES was 0.14%, and mortality was 10.5%. Conclusions. Post-traumatic FES mainly affected young patients with multiple injuries and long bone fractures. They all had symptoms of the classic clinical triad (respiratory, neurological, rash) after an initial asymptomatic period of less than 2 days. The overall incidence was low(AU)

[Fat embolism syndrome after bone fractures]. / Síndrome de embolia grasa tras fractura ósea.

OBJECTIVES: To review the incidence, clinical features, diagnosis, therapy and mortality rates of fat embolism syndrome (FES) in a tertiary referral hospital in the last decade. PATIENTS AND METHODS: Retrospective and descriptive study of patients diagnosed with post-traumatic FES between january 2001 and december 2011. RESULTS: A total of 19 patients, 16 men and 3 women, with an average age of 27 years were evaluated. All had long bone fractures, multiple in 78.9%, as a result of multiple injuries. Respiratory symptoms were the most frequent (89.5%), followed by neurological symptoms (68.4%) and petechial rash (63.2%). The average time of presentation of the syndrome after admission was 42 hours. All patients underwent early stabilisation of the fracture prior to the embolic event. Steroids prophylaxis was not used in any of the cases. Definitive surgical treatment had mean delay of 7 days. The mean hospital stay was 34 days. The overall incidence of FES was 0.14%, and mortality was 10.5%. CONCLUSIONS: Post-traumatic FES mainly affected young patients with multiple injuries and long bone fractures. They all had symptoms of the classic clinical triad (respiratory, neurological, rash) after an initial asymptomatic period of less than 2 days. The overall incidence was low.

Guía de información al paciente sobre la enfermedad tromboembólica venosa

Contiene: qué es la enfermedad tromboembólica venosa, si es un problema frecuente y es grave, cuáles son sus causas, si puede ser un problema hereditario, cómo se manifiesta, si es necesario realizar alguna prueba diagnóstica, si es necesario ingresar en el hospital, si puede ser tratado en casa, qué debe saber para ser tratado en su domicilio, cómo se trata, qué precauciones hay que tener con el tratamiento, cómo puede prevenirse, qué secuelas pueden quedarle y cómo puede prevenirlas.

[Effect of a global intervention in the integral control of multiple risk factors in patients at high or very high cardiovascular risk. CIFARC 2 project]. / Efecto de una intervención global sobre el control integral de múltiples factores de riesgo en pacientes con alto o muy alto riesgo cardiovascular. Estudio CIFARC 2.

OBJECTIVES: To analyze the effect of a global approach on patients with high cardiovascular risk for the integral control of cardiovascular risk factors. PATIENTS AND METHODS: Multicentric prospective study of patients with high vascular risk, followed-up for one year in internal medicine consultations. We measured the grade of control over major cardiovascular risk factors (hypertension, dyslipidemia, diabetes mellitus, tobacco, obesity) before and after the one-year follow-up period. RESULTS: We studied 456 patients (56% males; age: 66.1, standard deviation: 11.5 years); 54.4% were diabetics, 58.0% had target organ damage and 46.2% had cardiovascular disease. Blood pressure control varied from 50.5 to 60.6; LDL-cholesterol control from 44.7 to 58.1%; diabetes control from 56.5 to 56.6%; tobacco control from 63.0 to 87.5% and obesity control from 60.0 to 55.4%. Integral control of all cardiovascular risk factors varied from 10.7 to 23.2% of patients. Factors independently associated to lack of integral control were: diabetes (Odds Ratio [OR]: 4.42; 95% confidence interval [95%CI]: 2.75-7.14), basal systolic blood pressure (OR: 1.03; 95%CI 1.02-1.05) and basal body mass index (OR: 1.08; 95%CI: 1.02-1.14). Lack of integral control was independently associated to the incidence of cardiovascular events (OR: 2.00; 95%CI: 1.09-5.35). CONCLUSIONS: A global approach on the patient with high cardiovascular risk duplicated the integral control of the five main risk factors. Diabetes and obesity were factors which made integral control difficult. Lack of integral control increased two times the risk of cardiovascular events.

Torsade de Pointes en un paciente con infección por el virus de la inmunodeficiencia humana y tratamiento con metadona / Torsade de Pointes in patient infected with human inmunodeficiency virus and treated with methadone

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[Upper limb deep venous thrombosis. Risk factors, outcome, and posthrombotic syndrome]. / Trombosis venosa profunda de miembros superiores. Factores de riesgo, evolución y síndrome postrombótico.

OBJECTIVE: Our objective was that of describing a series of episodes of upper limb deep venous thrombosis, with special emphasis on the incidence of posthrombotic syndrome and its impact in the quality of life of the patients. METHODS: 33 episodes (29 patients) of upper limb deep venous thrombosis were studied, between January 1995 and January 2002; episodes until September 1999 (18 episodes) were considered retrospectively while those which took place starting in this date (15 episodes) were considered prospectively. In all, 24 patients were cared in hospital clinic. It was possible to obtain complete data in 16 cases, in which evolution toward posthrombotic syndrome, venous revascularization, and impact of the pathological process in the global quality of life of patients were studied. RESULTS: Average age of patients was 58.9 years. In 25 episodes (75.8%) some risk factor for venous thrombosis existed, the presence of a venous catheter being the most frequent. Subclavian axillary affectation was predominant (18 episodes, 55%) and in the left side (25 episodes, 76%). Twenty-eight episodes were diagnosed with echography (84.8%). Mean D-dimers concentration (N = 16) was 1,046 ng/ml (standard deviation [SD]: 826.9). One of the episodes (3%) was associated to lung thromboembolism. Treatment consisted on the administration of low molecular weight heparin during the acute phase in 70% of the cases. In 13 episodes (39%) additional treatment of thrombosis (endovascular in most) was carried out. In 29 episodes (88%) chronic treatment was administered with acenocoumarol, while in 4 episodes (12%) the administration of low molecular weight heparin was kept. No patient died during hospitalization. In 15 patients (52%) control of revascularizacion was performed. We detected complete revascularization in 6 patients (40%), revascularization with collateral circulation in 4 patients (27%), partial revascularization in other 4 patients (27%) and presence of permeability but with expansion and tortuosity of deep venous system in 1 case (6%). Posthrombotic syndrome was considered mild or nonexistent in 10 patients (62.5%) and moderate in 6 patients (37.5%). Quality of life of patients with moderate posthrombotic syndrome was significantly worse than that of patients with mild posthrombotic syndrome (73 vs 90, p < 0.035). CONCLUSIONS: Most of upper limb deep venous thrombosis are associated to the use of intravenous catheters. Echography is the primary diagnostic technique. At the time of the diagnosis, patients tend to show elevation in D-dimers levels. Evolution toward posthrombotic syndrome is frequent; this syndrome does not use to be serious but indeed influences the quality of life of patients.

Trombosis venosa profunda de miembros superiores. Factores de riesgo, evolución y síndrome postrombótico / Upper limb deep venous thrombosis

Objetivo. Nos propusimos describir una serie de episodios de trombosis venosa profunda de miembro superior, con especial énfasis en la incidencia posterior de síndrome postflebítico y surepercusión en la calidad de vida de los pacientes. Métodos. Se estudiaron 33 episodios (29 pacientes) de trombosis venosa profunda del miembro superior entre enero de 1995 y enero de 2002, incluidos retrospectivamente hasta septiembre de 1999 (18 episodios) y prospectivamente a partir de esta fecha (15 episodios). Se analizaron los factores de riesgo, la clínica, los procedimientos diagnósticos y el tratamiento administrado. Fueron controlados en la policlínica24 pacientes. Se dispuso de datos completos evaluables en16 casos, estudiándose la evolución a síndrome postflebítico, la repermeabilización venosa y la repercusión del proceso en la calidad de vida global de los pacientes. Resultados. La edad media fue de 58,9 años. En 25 episodios(75,8%) se apreció algún factor de riesgo para trombosisvenosa, siendo el más frecuente la presencia de un catéter venoso. Predominó la afectación axilosubclavia (18 episodios,55%) y del lado izquierdo (25 episodios, 76%). Veintiocho episodios (84,8%) se diagnosticaron con ecografía. La media de los niveles de D-dímeros (n=16) fue de 1.046 ng/ml.(DE: 862,9). En un episodio (3%) se asoció tromboembolismo pulmonar. El 70% de los casos se trató con heparina de bajo peso molecular en la fase aguda. En 13 episodios (39%) se practicó tratamiento adicional de la trombosis (endovascularla mayoría). En 29 episodios (88%) se administró tratamiento crónico con acenocumarol y en 4 (12%) se continuó con heparina de bajo peso molecular. No falleció ningún paciente durante el ingreso hospitalario. Se practicó control de repermeabilización en15 pacientes (52%). Detectamos repermeabilización completa en6 pacientes (40%), repermeabilización con circulación colateral en 4 (27%), repermeabilización parcial en otros 4 pacientes(27%) y eje permeable pero con dilatación y tortuosidad del sistema venoso profundo en un caso (6%). El síndrome postflebítico se clasificó como leve o ausente en 10 pacientes(62,5%) y moderado en 6 (37,5%). La calidad de vida de los pacientes con síndrome posflebítico moderado fue significativamente peor que la de los pacientes con síndrome postflebítico leve (73 frente a 90, p<0,035).Conclusiones. Las trombosis venosas profundas de miembros superiores más frecuentes se asocian al uso de catéteres intravenosos. La ecografía es la técnica diagnóstica predominante. Los D-dímeros se elevan al diagnóstico. La evolución a síndrome postflebítico es frecuente, pero éste no suele ser grave. aunque sí repercute en la calidad de vida de los pacientes

Objective. Our objective was that of describing a series of episodes of upper limb deep venous thrombosis, with special emphasis on the incidence of posthrombotic syndrome and its impact in the quality of life of the patients. Methods. 33 episodes (29 patients) of upper limb deep venous thrombosis were studied, between January 1995 and January2002; episodes until September 1999 (18 episodes) were considered retrospectively while those which took place starting in this date (15 episodes) were considered prospectively. In all,24 patients were cared in hospital clinic. It was possible to obtain complete data in 16 cases, in which evolution toward posthrombotic syndrome, venous revascularization, and impact of the pathological process in the global quality of life of patients were studied. Results. Average age of patients was 58.9 years. In25 episodes (75.8%) some risk factor for venous thrombosis existed, the presence of a venous catheter being the most frequent. Subclavian axillary affectation was predominant(18 episodes, 55%) and in the left side (25 episodes, 76%).Twenty-eight episodes were diagnosed with echography (84.8%).Mean D-dimers concentration (N = 16) was 1,046 ng/ml(standard deviation [SD]: 826.9). One of the episodes (3%) was associated to lung thromboembolism. Treatment consisted on the administration of low molecular weight heparin during the acute phase in 70% of the cases. In 13 episodes (39%)additional treatment of thrombosis (endovascular in most)was carried out. In 29 episodes (88%) chronic treatment was administered with acenocoumarol, while in 4 episodes (12%)the administration of low molecular weight heparin was kept. No patient died during hospitalization. In 15 patients (52%)control of revascularización was performed. We detected complete revascularization in 6 patients (40%),revascularization with collateral circulation in 4 patients (27%),partial revascularization in other 4 patients (27%) and presence of permeability but with expansion and tortuosity of deep venous system in 1 case (6%). Posthrombotic syndrome was considered mild or nonexistent in 10 patients (62.5%) and moderate in 6 patients (37.5%). Quality of life of patients with moderate posthrombotic syndrome was significantly worse than that of patients with mild posthrombotic syndrome (73 vs 90,p<0,035).Conclusions. Most of upper limb deep venous thrombosis are associated to the use of intravenous catheters. Echography is the primary diagnostic technique. At the time of the diagnosis, patients tend to show elevation in D-dimers levels. Evolution toward posthrombotic syndrome is frequent; this syndrome does not use to be serious but indeed influences the quality of life of patients

[Cranial hyperostosis as a metastasic adenocarcinoma presentation form]. / Hiperostosis craneal como forma de presentación de un adenocarcinoma metastásico.

Hyperostosis is a volume-unit osseous increase of very diverse etiology. We present the case of a 68-year woman with a cranial hyperostosis debuting with frontal protrusion, headache and neurologic symptoms. Image proves demonstrated a hyperostosis in the calotte and meningeal enhancement, without intracerebral lesions nor malignant cells in the cerebrospinal fluid. Analytic data were unspecific. Cranial biopsy showed huge neoplastic infiltration in bone and meninges. Primary site remained unknown after a CAT and a mammography.

Hiperostosis craneal como forma de presentación de un adenocarcinoma metastásico / Cranial hyperostosis as a metastasic adenocarcinoma presentation form

La hiperostosis es un aumento de masa ósea por unidad de volumen de etiología muy diversa. Presentamos el caso de una mujer de 68 años con hiperostosis craneal que debutó con clínica de protusión frontal derecha, cefalea y sintomatología neurológica. Las pruebas de imagen demostraron la existencia de hiperostosis de calota con afectación meníngea, sin lesiones cerebrales ni células malignas en líquido cefalorraquídeo. Los datos analíticos eran inespecíficos. La biopsia craneal mostró amplia infiltración neoplásica por adenocarcinoma metastásico tanto en hueso como en meninges. No se localizó el tumor primario tras realizarse TAC y mamografía (AU)

[Hemoperitoneum secondary to spontaneous rupture of the umbilical vein]. / Hemoperitoneo secundario a la rotura espontánea de la vena umbilical.

Patients with ascites can develop spontaneous hemoperitoneum after injury or as a complication of diagnostic or therapeutic techniques. Spontaneous rupture of intra-abdominal varices is a rare complication of portal hypertension and an infrequent cause of hemoperitoneum that causes high mortality (75%). We present a new case of spontaneous hemoperitoneum secondary to umbilical vein rupture in a male patient with liver cirrhosis and review the cases previously described in the literature.

Hemiparesia derecha como forma de presentación de carcinoma renal de células claras / Right hemiparesia as presentation of renal cell carcinoma

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[Skeletal manifestations of Gauchers disease. A report of two cases]. / Manifestaciones óseas de la enfermedad de Gaucher. A propósito de dos casos.

Gauchers disease is the most frequent hereditary lysosomal deposit storage disorder. It is characterized by a deficiency of the enzyme glucocerebrosidase that leads to an accumulation of substrate in the interior of the macrophage lysosomes. It is classified in three types, according to the presence of central nervous system involvement (type 2 and 3) or not (type 1). It is a multisystemic disease and in the majority of patients there is hepatosplenomegaly, anemia and thrombocytopenia. Skeletal involvement is also important and it is frequently the most disabling manifestation. We present two cases of Gauchers with skeletal manifestations and we review the literature.

Manifestaciones óseas de la enfermedad de Gaucher. A propósito de dos casos / Skeletal manifestations of Gaucher´s disease. A report of two cases

La enfermedad de Gaucher es la enfermedad hereditaria de depósito lisosomal más frecuente. Se caracteriza por una deficiencia de la enzima glucocerebrosidasa que conduce a la acumulación de substrato en el interior de los lisosomas de los macrófagos. Se clasifica en tres tipos según exista afectación de sistema nervioso central (tipos 2 y 3) o no (tipo 1).Es una patología multisistémica y en la mayoría de pacientes se aprecia hepatoesplenomegalia, anemia y trombopenia. La afectación esquelética también es importante y a menudo constituye el aspecto más discapacitante. Presentamos dos casos de enfermedad de Gaucher con manifestaciones óseas y realizamos una revisión de la literatura (AU)

La enfermedad de Rendu-Osler-Weber. Estudio descriptivo de 17 casos / Rendu-Osler-Weber disease. Descriptive study of 17 cases

Objetivo. Estudiar la prevalencia y formas de presentación de la telangiectasia hemorrágica hereditaria (THH) en la población de nuestro ámbito hospitalario.Material y métodos. Se realizó un estudio descriptivo retrospectivo de los pacientes diagnosticados de THH entre los años 1972 y 1999 en el Hospital La Fe de Valencia. Se valoró la presencia de antecedentes familiares, epistaxis de repetición, telangiectasias cutaneomucosas y lesiones viscerales, así como los tratamientos administrados y la evolución de la enfermedad. Resultados. Se diagnosticaron 17 pacientes en dicho período con edades comprendidas entre los 24 y los 80 años. Ocho pacientes presentaban antecedentes familiares. Los síntomas más frecuentes fueron la epistaxis y la anemia ferropénica, seguidas en frecuencia por las telangiectasias cutaneomucosas. Seis pacientes presentaron manifestaciones neurológicas, cinco pulmonares, cinco gastrointestinales y tres pacientes hepáticas, generalmente secundarias a malformaciones vasculares a esos niveles.Conclusiones. La prevalencia de la enfermedad puede ser más elevada de lo que había sido descrito anteriormente. Ante pacientes con epistaxis de repetición y/o anemias ferropénicas hay que tener en cuenta esta enfermedad y buscar la presencia de telangiectasias que puedan orientar al diagnóstico. El diagnóstico precoz de la THH puede ayudar al control temprano de malformaciones viscerales asociadas. El tratamiento de la THH de ser individualizado según las manifestaciones clínicas del paciente (AU)

Hipertiroidismo e hipertensión pulmonar

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Trombopenia asociada a enfermedad mixta del tejido conectivo y esplenectomía laparoscópica / Laparoscopic esplenectomy and thrombocytopenia associated to mixed connective tissue disease

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[Rendu-Osler-Weber disease. Descriptive study of 17 cases]. / La enfermedad de Rendu-Osler-Weber. Estudio descriptivo de 17 casos.

OBJECTIVE: To study the prevalence and presentation forms of hereditary hemorrhagic telangiectasia (HHT) among the population in our hospital area. MATERIALS AND METHODS: Descriptive, retrospective study of patients with the diagnosis of HHT from to 1999 at La Fe Hospital, Valencia. Family history, repeated epistaxis, mucocutaneous telangiectasis and visceral lesions, as well as administered treatments, and clinical course were evaluated. RESULTS: Seventeen patients were diagnosed during such time period, with ages ranging from 23 to 80 years. Eight patients had family histories. The most common symptoms included epistaxis and iron-deficiency anemia, followed by muco-cutaneous telangiectasis. Six patients had neurological, five pulmonary, five gastrointestinal, and three hepatic manifestations, usually secondary to vascular malformations at those levels. CONCLUSIONS: The prevalence of the disease maybe higher than previously reported. This disease should be considered in patients with repeated epistaxis and/or iron-deficiency anemia. The presence of telangiectasis that can suggest the diagnosis should be investigated. An early diagnosis of HHT can be useful for the early control of associated visceral malformations. Treatment of HHT should be tailored according to the clinical manifestations of the patient.