Involuntary weight loss without specific symptoms: a clinical prediction score for malignant neoplasm.

BACKGROUND: Involuntary weight loss (IWL) is a non-specific symptom frequently found in the setting of a malignant neoplasm. There is no established diagnostic approach for patients presenting with isolated IWL, i.e. without data suggesting a particular organ involvement or system disorder. AIM: To assess the clinical probability of cancer in patients with isolated IWL by means of a score based on simple clinical and laboratory parameters. DESIGN: Retrospective analysis, followed by prospective model validation. METHODS: We analysed data from 328 patients who were treated at our Internal Medicine Department because of isolated IWL from January 1991 to December 1997. A predictive model for cancer was developed and validated. For use in clinical practice, a prediction score was derived from the regression model. RESULTS: There were 236 in-patients (72%) and 92 out-patients (28%). Malignancies were the most frequent cause of isolated IWL (35%), followed by psychiatric disorders (24%). Age, white blood count, and serum albumin, alkaline phosphatase, and lactate dehydrogenase levels were selected as the best predictors. The regression model discriminated relatively well between patients with or without a malignant neoplasm (area under the ROC curve 0.90, 95%CI 0.88-0.92). Model sensitivity was 69%, specificity 93% and positive likelihood ratio 9.9 (using a cut-off point of 0.5). DISCUSSION: We believe this to be the first study to attempt a systematic approach to the diagnosis of isolated IWL. The approach, based on very simple clinical and laboratory data, should assist the physician in a rational approach to such patients.

Progressive cardiomyopathy as manifestation of mitochondrial disease.

Cardiomyopathies are a clinically and genetically heterogeneous group of cardiac diseases in which the myocardium is primarily involved. Mitochondrial DNA point mutations have been identified in a broad spectrum of mitochondrial disorders, which are associated with neurological diseases. However, they also have been reported in patients with cardiomyopathy, either alone or as part of a multisystem disorder. A patient who presented with severe heart failure and was diagnosed as having a mitochondrial A3243G mutation is described.

Acinetobacter bacteraemia in a teaching hospital, 1989-1998.

Background: The mortality rate from bacteraemia is one of the highest among infections in hospitals, especially in the intensive care unit (ICU). Recently, an increase in nosocomial bacteraemia caused by gram-negative resistant pathogens has been observed. In this work we review the clinical and laboratory findings of adult patients with Acinetobacter bacteraemia in order to identify risk factors associated with mortality. Methods: A retrospective review of the medical records of patients with Acinetobacter bacteraemia identified by blood cultures from the Diagnostic Microbiology Laboratory was conducted between January 1989 and March 1998. Results: We identified 59 cases of Acinetobacter bacteraemia. Most of the infections (71%) were nosocomial; the majority occurred in the Department of Internal Medicine (28.8%), followed by Haematology (27%) and the ICU (23%). A. lwoffii was isolated in 52.5% of cases and A. baumannii in 47.5%. The related mortality was 17%. Staying in the ICU was associated with A. baumannii bacteraemia (P<0.004). An intravascular catheter was the leading source of infection (37%). Main risk factors were mechanical ventilation (28%), parenteral nutrition (23%) and the presence of a urinary catheter (22%). In the multivariate analysis the independent prognostic factors for mortality were the presence of shock (P<0.05) and the severity of the underlying disease, according to the classification of McCabe (P<0.05). Conclusions: The incidence of Acinetobacter bacteraemia has increased in the last decade, mainly since 1995. The development of septic shock and the severity of the underlying disease appear to be associated with an increase in mortality.

Cambios y tendencias en Medicina Interna 1987-1996 / Changes and tendencies in internal medicine 1987-1996

Fundamento: En medios hospitalarios, los internistas, suponemos que los pacientes ingresados en los Servicios de Medicina Interna (MI) actualmente son de más edad, están afectados por más enfermedades y que estas son más crónicas e invalidantes que las que asistíamos pocos años antes. Material y Métodos: Con el objeto de mostrar que cambios ha habido, realizamos un análisis de algunas variables de epidemiología clínica y de gestión hospitalaria de los ingresos de una Unidad de MI. Los periodos del estudio son el último semestre de los años 1987 y 1988 y del año 1996. Analizamos las tendencias habidas en el intervalo y relacionamos la población hospitalaria con la demográfica de la provincia que atiende el hospital. Resultados: La media de la edad de los pacientes asistidos en la actualidad es avanzada (70 años), y más del 30 por ciento superan los 80 años. El promedio de la edad del primer periodo (64,5 años), se ha incrementado en 5,5 años, en el caso de las mujeres 5,8 años y de 4,5 años en el de los varones. En ambos periodos la media de la edad de las mujeres es 5,5 años superior al de ellos. El envejecimiento de la población de MI, es muy superior al demográfico de la región que atiende el hospital. El índice de diagnósticos por ingreso aumentó, de 3,2 a 3,8 y la proporción de enfermos sin enfermedad de base crónica disminuyó, del 9,4 por ciento al 16,5 por ciento. El índice de mortalidad no varió, en ambos periodos, (11,6 por ciento y 11,1 por ciento). Conclusiones: La complejidad de los enfermos que asistimos ha aumentado, a pesar de ello, algunos de los parámetros de gestión como la estancia media disminuyó, otros como "reingresos y adecuación de los ingresos" mantienen niveles parecidos (AU)

[McArdle's disease in adults: clinical and genetic study]. / Enfermedad de McArdle en adultos: estudio clínico y genético.

McArdle's disease is a rare metabolic myopathy resulting from an absence of functional muscle glycogen phosphorylase that is inherited as an autosomal recessive condition. Recent molecular genetic studies have identified more than ten different mutations in patients with McArdle's disease, although a nonsense point mutation at codon 49 in exon 1 (R49X) accounts for approximately 85% of mutant alleles in American and British patients. We describe clinical, biochemical and genetic characteristics of five adults patients with McArdle's disease studied at our hospital during the last 10 years.

Tricuspid valve replacement in rheumatic disease: preoperative predictors of hospital mortality.

BACKGROUND AND AIM OF THE STUDY: The study analyzes the possible predictive power of different clinical and hemodynamic parameters with regard to hospital mortality after the first tricuspid valve replacement. METHODS: A retrospective study of 62 consecutive patients undergoing tricuspid valve replacement from 1974 to 1994 (7.2% of all tricuspid surgery performed at our institution in this period) was completed. Hospital mortality was 37%. Twenty-three patients died in hospital after the first tricuspid valve replacement (group I) and 39 patients (group II) survived this procedure. Tricuspid insufficiency was organic in 87% of group I and 84.6% of group II. RESULTS: The parameters showing significant differences between the two groups were NYHA class IV (p = 0.05), severe congestive heart failure (p = 0.02), mean right atrial pressure (p = 0.05), pulmonary arterial resistance (p = 0.006) and mean pulmonary arterial pressure (p = 0.0001). Cardiopulmonary bypass time (p = 0.005) and aortic cross-clamp time (p = 0.05) were longer in group I. Multiple regression analysis showed that the variables with greatest predictive power for hospital death were preoperative functional class, congestive heart failure and mean pulmonary artery pressure. The model gave a p < 0.001, with r = 0.58. CONCLUSIONS: The high hospital mortality rate after tricuspid valve replacement seems to be related to clinical functional class, severe congestive heart failure, and to chronic hemodynamic changes in the right atrium and pulmonary circulation.

[Incidence of hip fractures in Cantabria]. / Incidencia de fractura de cadera en Cantabria.

BACKGROUND: Fracture of the hip constitutes a serious social/health care problem with very little information concerning incidence in Spain being available. METHODS: The diagnosis of hospital admissions and the diagnosis of release from the traumatology units of health care centers for acute patients in Cantabria were reviewed. The study was carried out from the 1st of January to the 31st of December 1988 and only included patients over 49 years of age. Patients who did not habitually reside in the region were excluded. The following data were collected in each case: age, sex, place of residence (urban or rural), time of the year, side fractured, type of injury, previous contralateral fracture and perioperative mortality. RESULTS: The rate of fracture referred to the population of more than 49 years of age was 277/100,000 in the case of females and 100/100,000 for males. The mean age of women was 80.4 +/- 8.5 years and of men was 76.9 +/- 10.9 years (p > 0.02), respectively. No differences were observed with regard to the place of residence or the time of year. The fracture was left sided in 61% of the females and 58% of the males. The injury was almost always due to a fall. Six percent of the patients had a previous contralateral fracture. Perioperative mortality was 6%. CONCLUSIONS: The incidence of hip fracture in Cantabria is similar to that of other regions in Spain and lower to that of parts of central and northern Europe and the United States.

[Severe disorders of auriculoventricular conduction after aortic valve replacement. A postoperative electrophysiological study in 36 patients and the long-term follow-up]. / Trastornos severos de la conducción auriculoventricular tras recambio valvular aórtico. Estudio electrofisiológico postoperatorio en 36 pacientes y evolución a largo plazo.

Cardiac conduction defects (CD) are common in patients with aortic valve diseases. Several studies have suggested that the occurrence of complete heart block at the time of valve replacement is related with preoperative conduction defects and with other factors like calcium deposits, aortic gradient or poor left ventricular function. We evaluated 36 patients undergoing isolated aortic valve replacement in 29 of them, combined mitroaortic in four, isolated mitral valve replacement in two and subvalvular myectomy in one. In all of them an electrophysiologic study was done at the postoperative period. In group 2 (with preoperative CD) patients were older (mean age +/- SEM; 56.57 +/- 8.90) than in group 1 (without CD) (45.64 +/- 14.79) (p less than 0.02). Surgical times were higher in group 1 than in group 2 (p less than 0.01 and p less than 0.005). The site of block was distal to the His bundle in 59% of patients in group 1 and in 47% in group 2 (p-NS). Complete AV block occurred in 70.5% of patients in group 1 while was of 36.8% in group 2 (p less than 0.05). Severity of conduction defects was unrelated with the type of valve disease, aortic valve calcification or gradient or with poor left ventricular function. Preoperative conduction defects were not responsible of more severe postoperative conduction defects. On late follow-up permanent pacemakers were unnecessary in 33% of patients in group 1 and in 75% in group 2 (p less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Erythromycin and the treatment of Coxiella burnetii pneumonia.

Erythromycin is commonly used for the empirical treatment of community-acquired pneumonia, but there is some concern about its usefulness when Q fever is suspected because of in-vitro studies showing a lack of efficacy against Coxiella burnetii. This study was undertaken to assess the clinical value of the antibiotic in this setting. Nineteen patients with Q fever pneumonia treated with a variety of antibiotics considered ineffective against C. burnetii, were reviewed. Eleven patients who received erythromycin had a rapid clinical improvement and each became afebrile by the fourth day of treatment. However, only two of eight patients who received other antibiotics improved (both of them had been treated with beta-lactams). Both groups were comparable regarding to age and previous duration and severity of disease. Those patients who did not respond to other antibiotics improved promptly after erythromycin was started. This study suggests that erythromycin is an adequate treatment for Q fever pneumonia.