Afasia de expresión como forma de presentación de una meningitis por Listeria monocytogenes / Listeria monocytogenes meningitis presenting as motor aphasia

No disponible

Hemorragia alveolar y crioglobulinemia mixta asociada al virus de la hepatitis C. A propósito de tres casos / Alveolar haemorrhage and virus C virus-related mixed cryoglobulinemia report of three cases

La crioglobulinemia mixta asociada a virus de la hepatitis C es una entidad reconocida. Entre sus complicaciones destacan la afectación renal y pulmonar. La hemorragia alveolar es una de las formas más graves de afectación pulmonar. Su forma de presentación puede simular otro tipo de patologías. Presentamos tres casos de crioglobulinemia asociada a virus C cuyo diagnóstico final fue de hemorragia alveolar. El primer caso corresponde a una mujer de 71 años que ingresó por disnea y hemoptisis, precisando IOT y VM. Inicialmente se orientó como neumonía y ante una caída de la hemoglobina y persistencia de infiltrados radiológicos se sospechó hemorragia alveolar. Se realizó fibrobroncoscopia a las 48 horas de iniciados los corticoides, que demostró la presencia de un 6% de hemosiderófagos. El segundo caso trata de una mujer de 64 años que consultó por disnea y lesiones vasculíticas en glúteos más insuficiencia renal. Se iniciaron antibióticos bajo la sospecha clínica de neumonia grave con mala evolución, requiriendo IOT y VM. La FBS demostró un 60% de hemosiderófagos. El tercer caso corresponde a una mujer de 67 años que ingresa por fiebre, disnea y dolor en hemitórax derecho. Se orientó como neumonía ingresando en UCI. Siguió una mala evolución que obligó a IOT y VM. Se practicó fibrobroncoscopia que mostró restos hemáticos sugestivos de hemorragia alveolar

Hepatitis C virus –related mixed cryoglobulinemia is a recognised entity. Renal and pulmonary involvements are severe potential complications of this disease. Alveolar haemorrhage is a form of pulmonary complication. The clinical features of the alveolar haemorrhage can mimic other pulmonary diseases. We present three patients with hepatitis C virus-related mixed cryoglobulinemia associated to pulmonary symptoms that turned to be caused by an alveolar haemorrhage. The first patient was a 71-year old woman that was admitted because of hemoptysis and severe dyspnea that required mechanical ventilation. Although a pneumonia was the initial diagnoses, an alveolar haemorrhage was soon suspected based on the persistence of the pulmonary radiological infiltrates despite an adequate empirical antibiotic treatment and the presence of a progressive anemization. A fibrobronchoscopy, performed 48 hours after treatment was begun, revealed the presence of a 6% of hemosiderophages. The second patient was a 64 years old woman admitted because of dyspnea, vasculitic cutaneous lesions in gluteus and kidney failure. A severe pneumonia was suspected, antibiotic treatment was started and again the patient needed mechanical ventilation. The fibrobronchoscopy demonstrated the existence of a 60% of hemosiderophages. The third case describes a 67 year old woman that complained of fever, dyspnea and right chest pain. Similarly to the previous cases a severe pneumonia was the initial diagnoses, the patient needed to be transferred to the intensive care unit and mechanical ventilation was finally required. The fibrobronchoscopy showed remains of blood suggestive of an alveolar haemorrhage

Interpretación de la radiografía de tórax en los pacientes que ingresan en una Unidad de Corta Estancia. Relación con la estancia media / Chest X-ray interpretation on patients admitted in a short-stay unit. Relation with the mean length of stay

Introducción: Determinar la concordancia entre los médicos de un Servicio de Urgencias y un radiólogo en la interpretación de la radiografía de tórax (RxT) de pacientes ingresados en una unidad de estancia corta (UEC) y evaluar si ello influye en la estancia media. Material y método: Se revisaron las historias clínicas de los pacientes ingresados en una UEC durante 4 meses. Se comparó la interpretación de la RxT realizada por el médico responsable del paciente en urgencias con la interpretación realizada por un radiólogo. Se determinó la estancia media y se analizó si la lectura de la RxT previa al ingreso por el radiólogo hubiera mejorado la estancia media. Resultados: Se revisaron 260 historias clínicas. La concordancia total fue del 74,2%, siendo mayor cuando el médico de urgencias era un residente mayor o un adjunto que cuando era un residente menor (82% vs 66,4%; p < 0,003). No se observaron diferencias según el horario en el que se realizó la lectura. Solo en 9 casos (3,5%) se hubiera producido un cambio de diagnóstico y/o tratamiento. No se produjeron cambios en la estancia media de los pacientes según existiera concordancia o no, aunque en los casos en que se hubiera producido un cambio de diagnóstico y/o tratamiento se observó una tendencia a su aumento.Conclusiones: La lectura de la RxT por un radiólogo previa al ingreso en una UEC no está justificada en todos los casos. Podría realizarse cuando el residente mayor o el adjunto de guardia tuvieran dudas en su interpretación. Una mayor supervisión de los residentes menores podría mejorar el rendimiento diagnóstico de la RxT

Introduction: To assess the agreement between physicians of the emergency department and a radiologist in the interpretation of chest roentgenograms in patients admitted to the short-stay unit, and to determine the effect of concordance on the mean length of stay. Material and method: The medical records of patients admitted to the short-stay unit over a 4-month period were reviewed. The interpretation of the chest X-ray film made by the physician in charge of the patient at the emergency department with that made by the radiologist was compared. The mean length of stay was determined and it was analyzed if the reading of the radiograph made by the radiologist before admission would decrease the length of stay. Results: A total of 260 medical records were reviewed. The overall degree of agreement was 74.2% but it was greater when the physician at the emergency department was a staff physician or a resident in the final period of training than a resident in the initial period of training (82% vs 66.4%, p < 0.003). There were no statistically significant differences regarding the day hours at which readings were made. A change in the diagnosis and/or treatment of the patient would had occurred in only 9 cases (3.5%). There were no changes in the mean length of stay according to the presence or absence of concordance, although there was a trend towards an increase in the length of stay for those cases in which diagnosis and/or treatment would had been different. Conclusions: Readings of chest roentgenograms by a radiologist before admission to a short-stay unit does not appear to be justified for all patients, although it may be justified when a staff physician or a resident in the final period of training have doubts regarding interpretation of the radiographic images. A better supervision of residents in the initial period of training may contribute to improve the diagnostic reliability of chest X-ray films

[Chest X-ray interpretation on patients admitted in a short-stay unit. Relation with the mean length of stay]. / Interpretación de la radiografía de tórax en los pacientes que ingresan en una unidad de estancia corta. Relación con la estancia media.

INTRODUCTION: To assess the agreement between physicians of the emergency department and a radiologist in the interpretation of chest roentgenograms in patients admitted to the short-stay unit, and to determine the effect of concordance on the mean length of stay. MATERIAL AND METHOD: The medical records of patients admitted to the short-stay unit over a 4-month period were reviewed. The interpretation of the chest X-ray film made by the physician in charge of the patient at the emergency department with that made by the radiologist was compared. The mean length of stay was determined and it was analyzed if the reading of the radiograph made by the radiologist before admission would decrease the length of stay. RESULTS: A total of 260 medical records were reviewed. The overall degree of agreement was 74.2% but it was greater when the physician at the emergency department was a staff physician or a resident in the final period of training than a resident in the initial period of training (82% vs 66.4%, p < 0.003). There were no statistically significant differences regarding the day hours at which readings were made. A change in the diagnosis and/or treatment of the patient would had occurred in only 9 cases (3.5%). There were no changes in the mean length of stay according to the presence or absence of concordance, although there was a trend towards an increase in the length of stay for those cases in which diagnosis and/or treatment would had been different. CONCLUSIONS: Readings of chest roentgenograms by a radiologist before admission to a short-stay unit does not appear to be justified for all patients, although it may be justified when a staff physician or a resident in the final period of training have doubts regarding interpretation of the radiographic images. A better supervision of residents in the initial period of training may contribute to improve the diagnostic reliability of chest X-ray films.

[Alveolar haemorrhage and hepatitis virus C related mixed cryoglobulinemia. Report of three cases]. / Hemorragia alveolar y crioglobulinemia mixta asociada al virus de la hepatitis C. A propósito de tres casos.

Hepatitis C virus -related mixed cryoglobulinemia is a recognised entity. Renal and pulmonary involvements are severe potential complications of this disease. Alveolar haemorrhage is a form of pulmonary complication. The clinical features of the alveolar haemorrhage can mimic other pulmonary diseases. We present three patients with hepatitis C virus-related mixed cryoglobulinemia associated to pulmonary symptoms that turned to be caused by an alveolar haemorrhage. The first patient was a 71-year old woman that was admitted because of hemoptysis and severe dyspnea that required mechanical ventilation. Although a pneumonia was the initial diagnoses, an alveolar haemorrhage was soon suspected based on the persistence of the pulmonary radiological infiltrates despite an adequate empirical antibiotic treatment and the presence of a progressive anemization. A fibrobronchoscopy, performed 48 hours after treatment was begun, revealed the presence of a 6% of hemosiderophages. The second patient was a 64 years old woman admitted because of dyspnea, vasculitic cutaneous lesions in gluteus and kidney failure. A severe pneumonia was suspected, antibiotic treatment was started and again the patient needed mechanical ventilation. The fibrobronchoscopy demonstrated the existence of a 60% of hemosiderophages. The third case describes a 67 year old woman that complained of fever, dyspnea and right chest pain. Similarly to the previous cases a severe pneumonia was the initial diagnoses, the patient needed to be transferred to the intensive care unit and mechanical ventilation was finally required. The fibrobronchoscopy showed remains of blood suggestive of an alveolar haemorrhage.

Tira reactiva de orina como test determinante en el manejo del síndrome miccional en los servicios de urgencias / Urine reactive strip as the determinant test in the management of the mictional syndrome in the emergency services

No disponible

Variables en el triage de urgencias que contribuyen a la correcta ubicación de los pacientes que consultan por disnea / Variables at the emergency department triage wich help the correct location of patients who present dyspnea

Objetivos: Determinar qué variables pueden ser útiles en el triage, para asignar los pacientes que consultan por disnea en el área adecuada de urgencias. Métodos: Estudio prospectivo de 112 pacientes que consultaron por disnea con una saturación arterial de oxígeno (SaO2) > 90 por ciento, ubicados inicialmente en el nivel I (pacientes leves). Se recogieron datos de filiación, SaO2 mediante pulsioxímetro, constantes vitales, antecedentes patológicos y evolución clínica. Resultados: Se detectaron 25 pacientes mal ubicados en el nivel I. Estos presentaban, respecto a los bien ubicados, una significativa menor SaO2 (95,6 ñ 2,36 por ciento vs 96,8 ñ 2,06 por ciento; p a 37,5°C.Conclusiones: La frecuencia respiratoria, la temperatura y el antecedente de EPOC, son herramientas útiles en el triage para la ubicación de los pacientes que consultan por disnea con una SaO2 > 90 por ciento (AU)

Neuritis óptica bilateral y síndrome de hipertensión endocraneal en una paciente afecta de linfoma no Hodgkin / Bilateral optic neuritis and endocranial hypertension syndrome in a woman with no-Hodgkin lymphoma

La afectación orbitaria es una complicación poco frecuente en los linfomas no Hodgkin, pudiendo manifestarse como pérdida de agudeza visual a consecuencia de una neuritis óptica. En aquellos casos en que se acompaña de deterioro del nivel de consciencia y clínica progresiva de hipertensión endocraneal debe descartarse la presencia de una carcinomatosis meníngea. El diagnóstico precoz en urgencias del cuadro de hipertensión endocraneal, y de la causa del mismo, permitirá instaurar un tratamiento precoz y de esa forma evitar las posibles secuelas que pudieran producirse. Presentamos el caso de una paciente afecta de un linfoma no Hodgkin en fase de remisión, que acudió a nuestro Servicio de Urgencias por un cuadro de pérdida de agudeza visual y en la que se diagnosticó un síndrome de hipertensión endocraneal. El rápido diagnóstico de una carcinomatosis meníngea fue fundamental para la evolución posterior de la paciente (AU)

Efectividad de la ventilación no invasiva, modalidad BIPAP con máscara facial, en el paciente EPOC con insuficiencia respiratoria hipercápnica (acidosis respiratoria) en el Áreade Urgencias / Effectiveness of noninvasive positive pressure ventilation type BIPAP with face mask in patients with COPD and acute respiratory failure with hypercapnia (respiratory acidosis), in the Emergency Department

Objetivo: Evaluar la efectividad de la ventilación no invasiva (VNI) modalidad BIPAP, con máscara facial, en pacientes EPOC con insuficiencia respiratoria hipercápnica grave (acidosis respiratoria), en el Área de Urgencias (UCIAS). Métodos: Pacientes EPOC que ingresaron en UCIAS con insuficiencia respiratoria hipercápnica, en los que, a pesar del tratamiento convencional, persistían parámetros gasométricos de acidosis respiratoria. Se analizaron: edad, sexo, antecedentes, causas de descompensación, SAPS II, características de la radiografía, equilibrio ácido-base y frecuencia respiratoria seriada, escala de encefalopatía, tiempo de instauración y duración de la BIPAP, complicaciones de la mascarilla facial, fracasos del sistema BIPAP, mortalidad y estancia media hospitalaria. Resultados: Gasometría seriada (inicio BIPAP, 6-12 h, 24 h y final BIPAP): pH: 7,28ñ0,04, 7,32ñ0,05, 7,34ñ0,07, 7,37ñ0,04; PaO2: 61,48ñ18,4, 68,33ñ17,2, 71,94ñ20, 70,92ñ14,8; PaCO2: 76,69ñ13,6, 67,52ñ12,8, 64,40ñ12,5, 58,58ñ8,9, CO3H2: 34,9ñ4,5, 34,3ñ5,2, 34,02ñ5, 33,8ñ4,5.Conclusiones: La aplicación de la BIPAP en pacientes EPOC con insuficiencia respiratoria hipercápnica grave (acidosis respiratoria), normaliza el pH y disminuye la PaCO2. Al ser de manejo sencillo, permite su aplicación precoz en el Área de Urgencias, disminuyendo el número de ingresos en la UCI (mejor relación coste-beneficio) (AU)

Análisis ético de las decisiones médicas en el servicio de urgencias de un hospital universitario / Ethical analysis of medical decision-making in the emergency room of a university hospital

Objetivo: Efectuar un análisis ético de las decisiones médicas en el servicio de urgencias de un hospital universitario, ante supuestos casos clínicos. Método: El estudio está basado en el lenguaje de los principios y las consecuencias, mediante la observación participante en forma de encuesta anónima de 15 supuestos a 126 médicos. Resultados: La mayoría de los médicos respetaron el derecho de autodeterminación del paciente a la información, la voluntad del mismo de no informar a sus familiares, así como la necesidad de ser advertido de los posibles riesgos de una prueba mediante el consentimiento informado. El 33,3 por ciento de los encuestados respetaría la voluntad del paciente en la elección del tratamiento. La mitad de los médicos coincidían en no revelar los riesgos de un procedimiento si implicara una seria amenaza psicológica al paciente. En el supuesto de un paciente en coma con una enfermedad en fase terminal, el 73,8 por ciento de los médicos no accedería a la petición familiar de incluirlo en un programa de diálisis. En cambio, si un paciente en coma con una enfermedad irreversible y terminal ha sido intubado por desconocimiento y la familia demanda que retiremos todas las medidas de apoyo, el 44,4 por ciento de los facultativos cedería a la petición familiar. La mayoría de los encuestados coincidieron en la no discriminación por la edad. Conclusiones: Las decisiones médicas en un servicio de urgencias son plurales. Para resolver los conflictos hay que seguir un procedimiento que ayude a comprender la complejidad del problema y a tener en cuenta los aspectos más relevantes. La reciente creación de los comités hospitalarios de ética facilitará poder efectuar convocatorias con carácter urgente a fin de tomar decisiones consistentes ante problemas puntuales (AU)

Validez de la pulsioximetría / Validity of pulxiosimetry

No disponible

[A unique medical experience: the 1992 Barcelona Olympic Games]. / Una experiencia médica única: los Juegos Olímpicos de Barcelona 1992.

BACKGROUND: The request for medical attention derived from Olympic Games is variable, with few previously published experiences and thus, the estimations made by the organizers are difficult. METHODS: The health care program established during the 1992 Olympic Games held in Barcelona is described and the clinical cases attended are reported. RESULTS: The number of persons accredited by the Barcelona Olympic Committee was 132,286. Health care attendance was provided in the sports installations, the olympic villages of the journalists and athletes, olympic family hotels, press centers and the International Youth Camp. A Polyclinic was in operation in the Olympic Village with a 24 hour Emergency Department. A total of 15,552 visits were made, 524 of which were sent to the Emergency Department of the Olympic Hospital (Hospital del Mar in Barcelona). Three hundred twenty visits were programed in the Out Patient Departments of the Hospital and a total of 81 patients were admitted to the hospital with a mean stay of 3.9 days. The most common medical problems encountered were those related with the locomotor system. CONCLUSIONS: The health care program designed for the Barcelona 1992 Olympic Games was adequate to attend the health care demand required.

Simultaneous human immunodeficiency virus and Hepatitis C infection following a needlestick injury.

Needlestick injuries to health professionals at the Hospital del Mar, Barcelona since 1987 have been prospectively studied; a total of 296 such accidents in 286 subjects have been registered. We report the first case to our knowledge of simultaneous human immunodeficiency virus (HIV) and hepatitis C (HCV) infection in a nurse who suffered a needlestick injury after a blood sampling. Forty-four days after the accident she had symptoms and laboratory findings of acute hepatitis. Subsequent laboratory tests showed elevation in the aminotransferases and antibodies against HIV. The seroconversion to HCV was not detected until 109 days after the injury. The precise sequence of clinical and biological events of this case of simultaneous HIV and HCV infection is reported.

Psychotropic drug consumption and other factors associated with heroin overdose.

In clinical or forensic practice there are few studies assessing which risk factors are associated with heroin overdoses. A series of 76 consecutive non-fatal heroin overdoses were compared to 22 consecutive subjects who self-injected heroin within 1 h before admission to the emergency room. Whereas blood levels of alcohol and IgE and urinary cocaine metabolite levels were similar in both groups, higher benzodiazepine plasma levels were detected in the heroin overdose group. The assessment of methadone, dextropropoxyphene, amphetamines and cannabis in urine analysis did not show differences between both groups. The interview revealed that only 48% of subjects in the heroin overdose group self-administered the last dose of heroin before admission in the usual setting as compared to 100% of subjects in the non-overdose group. The application of a log-linear regression model identified self-injection of heroin in an unusual place and plasma concentrations of total morphine and benzodiazepines as risk factors for heroin overdose.

Primary Sjögren's syndrome associated with chronic atrophic gastritis and pernicious anemia.

Sjögren's syndrome (SS) is a systemic, autoimmune exocrinopathy in which destructive, inflammatory-cell infiltration can affect any gland. Although chronic atrophic gastritis is the most common form of gastrointestinal involvement in SS, pernicious anemia develops in rare cases. We therefore report a patient with these three associated diseases.

Sjögren's syndrome: a stepwise approach to the use of diagnostic tests.

One hundred and forty two patients (62 with definite Sjögren's syndrome, 24 with probable Sjögren's syndrome, and 56 in whom Sjögren's syndrome was finally ruled out) were studied. Schirmer's test and rose bengal staining for the diagnosis of keratoconjunctivitis sicca and salivary scintigraphy and a labial biopsy sample for the diagnosis of xerostomaia were studied in all patients. Rose bengal staining showed high specificity (98%) but low sensitivity (55%). All patients with positive rose bengal staining results had associated xerostomia. In the rose bengal staining positive patients, scintigraphy had 100% specificity. A labial biopsy sample showed high sensitivity in the rose bengal staining, salivary scintigraphy positive group, and high specificity in the rose bengal staining positive, salivary scintigraphy negative group. In patients with negative rose bengal staining, salivary scintigraphy showed 96% specificity and 36% sensitivity. A labial biopsy sample had a sensitivity and specificity greater than 90% in rose bengal staining negative patients. Only 29 biopsy samples were needed to achieve a diagnosis of Sjögren's syndrome in 142 patients (20%). Hence the suggested approach may make it unnecessary to take biopsy samples in approximately 80% of patients with suspected Sjögren's syndrome. Using the stepwise approach of first rose bengal staining, then salivary scintigraphy, and eventually a labial biopsy sample in patients with suspected Sjögren's syndrome, the diagnosis is relatively simple.

Anticardiolipin antibodies and acquired immunodeficiency syndrome: prognostic marker or association with HIV infection?

Anticardiolipin antibodies (ACA) frequently appear in patients with autoimmune disorders such as systemic lupus erythematosus, and have also been detected in infections, neoplasia, the primary antiphospholipid syndrome, in association with certain medications and also in subjects without apparent disease. Recently, anticardiolipin antibodies have been described in the acquired immunodeficiency syndrome. Eighty-four human immunodeficiency virus (HIV)-infected patients were studied to assess the influence of risk factors for HIV infection and of the stage of HIV-1 infection on the prevalence of IgG-ACA in HIV-seropositive patients. Patients were divided in two groups, one composed of 38 asymptomatic HIV-infected individuals and the other of 46 AIDS patients. A control group of 42 healthy HIV-negative blood donors was also studied. All subjects of the control group were IgG-ACA-negative. Of the 84 HIV-positive patients, 50 were IgG-ACA positive (59.5%) and 34 IgG-ACA negative (40.5%). None of the HIV-positive patients presented any thromboembolic phenomena. No significant differences were found with respect to sex, risk factors and stage of disease when the presence of IgG-ACA in HIV-positive patients was considered. ACA does not appear to be a pronostic marker in HIV-1-infected subjects. The presence of IgG-ACA is probably related to HIV-1-infection itself, and is indicative of impaired humoral immunity in these patients.

PIP: Anticardiolipin antibodies (ACA) frequently appear in patients with autoimmune disorders such as systemic lupus erythematosus, and have also been detected in infections, neoplasia, the primary antiphospholipid syndrome, in association with certain medications and also in those patients without apparent disease. Recently, anticardiolipin antibodies were described in connection with acquired immunodeficiency syndrome (AIDS). 84 human immunodeficiency virus (HIV)-infected patients were examined in order to assess the influence of risk factors for HIV infection and of the stage of HIV-1 infection on the prevalence of IgG-ACA in HIV-seropositive patients. 2 groups were created -- 1 composed of 38 asymptomatic HIV-infected individuals and the other of 46 AIDS patients. A control group of 42 healthy HIV-negative blood donors was also studied. All those in the control group were IgG-ACA-negative. Of the 84 HIV-positive patients, 50 were IgG-ACA positive (59.5%) and 34 IgG-ACA-negative (40.5%). None of the HIV-positive individuals presented any thromboembolic phenomena. There were no significant differences with respect to sex, risk factors, and stage of disease when the presence of IgG-ACA in HIV-positive patients was ascertained. ACA does not appear to be a prognostic marker in HIV-1 infected patients; the presence of IgG-ACA is probably related to HIV-1 infection itself and is indicative of impaired humoral immunity in this group. (author's modified)