Hematoma mamario enmascarando un sarcoma / Breast hematoma masking a sarcoma

Los sarcomas suponen menos del 1% de los tumores malignos de la mama. Presentamos un caso de sarcoma (histiocitoma fibroso maligno) de mama que debuta en forma de tumoración, que la paciente relaciona con un traumatismo, y que mostró un aspecto clínico, ecográfico y citológico sugestivo de un hematoma. La tumoración creció rápidamente, y en la ecografía de control realizada al mes tenía claros polos sólidos hipervasculares. Es una presentación atípica, que permite revisar el manejo de lesiones sugestivas de hematomas, y que, en su evolución, a menudo se asocian a imágenes inespecíficas, en ocasiones sospechosas de malignidad. La aparición de lo que parece un hematoma mamario, incluso acompañado de un antecedente traumático o tendencia al sangrado, obliga a ser prudentes, por lo que se recomienda un seguimiento a muy corto plazo, y biopsia, incluso excisional, si los hallazgos evolutivos no son concordantes

Sarcomas account for less than 1% of malignant breast tumors. We present the case of a sarcoma (malignant fibrous histiocytoma) of the breast that debuted as a lump. The patient associated the lump with trauma, and the clinical, sonographic, and cytological findings were suggestive of a hematoma. The lump grew rapidly, and the follow-up sonogram one month later clearly revealed hypervascular solid poles. This atypical presentation is useful for reviewing the management of lesions suggestive of hematomas, which are often associated with nonspecific findings and occasionally with signs that raise suspicion of malignancy. The emergence of what appears to be a hematoma in the breast, even when accompanied by a history of trauma or a tendency toward bleeding, calls for prudence: very short-term follow-up and biopsy, even excisional biopsy, are recommended if the lesion does not evolve like a hematoma

[Breast hematoma masking a sarcoma]. / Hematoma mamario enmascarando un sarcoma.

Sarcomas account for less than 1% of malignant breast tumors. We present the case of a sarcoma (malignant fibrous histiocytoma) of the breast that debuted as a lump. The patient associated the lump with trauma, and the clinical, sonographic, and cytological findings were suggestive of a hematoma. The lump grew rapidly, and the follow-up sonogram one month later clearly revealed hypervascular solid poles. This atypical presentation is useful for reviewing the management of lesions suggestive of hematomas, which are often associated with nonspecific findings and occasionally with signs that raise suspicion of malignancy. The emergence of what appears to be a hematoma in the breast, even when accompanied by a history of trauma or a tendency toward bleeding, calls for prudence: very short-term follow-up and biopsy, even excisional biopsy, are recommended if the lesion does not evolve like a hematoma.

Integrated care pathways for airway diseases (AIRWAYS-ICPs).

The objective of Integrated Care Pathways for Airway Diseases (AIRWAYS-ICPs) is to launch a collaboration to develop multi-sectoral care pathways for chronic respiratory diseases in European countries and regions. AIRWAYS-ICPs has strategic relevance to the European Union Health Strategy and will add value to existing public health knowledge by: 1) proposing a common framework of care pathways for chronic respiratory diseases, which will facilitate comparability and trans-national initiatives; 2) informing cost-effective policy development, strengthening in particular those on smoking and environmental exposure; 3) aiding risk stratification in chronic disease patients, using a common strategy; 4) having a significant impact on the health of citizens in the short term (reduction of morbidity, improvement of education in children and of work in adults) and in the long-term (healthy ageing); 5) proposing a common simulation tool to assist physicians; and 6) ultimately reducing the healthcare burden (emergency visits, avoidable hospitalisations, disability and costs) while improving quality of life. In the longer term, the incidence of disease may be reduced by innovative prevention strategies. AIRWAYSICPs was initiated by Area 5 of the Action Plan B3 of the European Innovation Partnership on Active and Healthy Ageing. All stakeholders are involved (health and social care, patients, and policy makers).

Factores situacionales que influyen en el aprendizaje de la taxonomía noc en alumnos de enfermería / Situational factors affecting the learning of the taxonomy noc nursing students

Introducción. En el caso de la enseñanza en enfermería en la FES Zaragoza, esta implementa la utilización de la taxonomía noc, por lo cual identificar cuáles son los factores que influyen en su aprendizaje, le permitirá al docente incrementar la significancia de su enseñanza. Objetivos: Identificar los factores situacionales que influyen en el aprendizaje de la taxonomía noc en alumnos de Enfermería y establecer la relación que existe entre estos factores y el aprendizaje de la taxonomía. Metodología: Estudio transversal y correlacional, con un muestreo estratificado por conglomerados, con un total de 224 alumnos; mediante un instrumento, con un alfa de Cronbach de 0.984, que midió la percepción del alumno sobre los factores situacionales que influyen en su aprendizaje. El análisis incluyó medidas de tendencia central y pruebas de correlación de Pearson. Resultados: La dimensión mejor evaluada fue "Las relaciones interpersonales" con el 89.4% de los alumnos que lo calificó como adecuado. La dimensión "Habilidades Docentes", obtuvo un valor de rp = 0.939 y un grado sig. 0.000 por lo cual se puede decir que tiene una relación positiva muy fuerte. Discusión: La literatura refiere a las "Relaciones Interpersonales" como uno de los factores principales en el aprendizaje; a diferencia del presente estudio donde se identificô a las "Habilidades Docentes" como factor principal. Conclusiones: Las habilidades docentes es el factor que más influye para el aprendizaje de la taxonomía noc; conjuntamente con una adecuada retroalimentación de los aprendizajes, se puede incrementar la significancia en el aprendizaje que tiene para el alumno de enfermería.

Introduction: The results are encouraging assurance programs and quality improvement. In the case of nursing education in the fes Zaragoza, this implements the use of noc taxonomy, and therefore identify the factors that influence their learning, will allow the teacher to increase the significance of his teaching. Objectives: To identify the situational factors that influence learning noc taxonomy in nursing students and establish the relationship between these factors and learning taxonomy. Methodology: A cross-sectional and correlational, with a stratified cluster sampling, with a total of 224 students in third and fourth year of the race by an instrument of 53 items, with a Cronbach alpha of 0.984, which measured student perception on situational factors that influence their learning. The analysis included measures of central tendency and Pearson correlation tests. Results: Predominantly female with 83.5%. The best dimension evaluated was "interpersonal relations" with 89.4% of students who called it right. Dimension "Teaching Skills", obtained a value of rp = 0.939 and an actual sig. 0.000 so it can be said to have a very strong positive relationship. Discussion: The literature refers to "interpersonal relations" as one of the key factors in learning, unlike the present study which identified the "Teaching Skills" as a major factor. Conclusions: The teaching skills is the main factor for learning noc taxonomy, together with adequate feedback of learning, can increase the significance it has for the nursing student.

Epidemiology of influenza-associated hospitalization in adults, Toronto, 2007/8.

The purpose of this investigation was to identify when diagnostic testing and empirical antiviral therapy should be considered for adult patients requiring hospitalization during influenza seasons. During the 2007/8 influenza season, six acute care hospitals in the Greater Toronto Area participated in active surveillance for laboratory-confirmed influenza requiring hospitalization. Nasopharyngeal (NP) swabs were obtained from patients presenting with acute respiratory or cardiac illness, or with febrile illness without clear non-respiratory etiology. Predictors of influenza were analyzed by multivariable logistic regression analysis and likelihoods of influenza infection in various patient groups were calculated. Two hundred and eighty of 3,917 patients were found to have influenza. Thirty-five percent of patients with influenza presented with a triage temperature >or=38.0 degrees C, 80% had respiratory symptoms in the emergency department, and 76% were >or=65 years old. Multivariable analysis revealed a triage temperature >or=38.0 degrees C (odds ratio [OR] 3.1; 95% confidence interval [CI] 2.3-4.1), the presence of respiratory symptoms (OR 1.7; 95% CI 1.2-2.4), admission diagnosis of respiratory infection (OR 1.8; 95% CI 1.3-2.4), admission diagnosis of exacerbation of chronic obstructive pulmonary disease (COPD)/asthma or respiratory failure (OR 2.3; 95% CI 1.6-3.4), and admission in peak influenza weeks (OR 4.2; 95% CI 3.1-5.7) as independent predictors of influenza. The likelihood of influenza exceeded 15% in patients with respiratory infection or exacerbation of COPD/asthma if the triage temperature was >or=38.0 degrees C or if they were admitted in the peak weeks during the influenza season. During influenza season, diagnostic testing and empiric antiviral therapy should be considered in patients requiring hospitalization if respiratory infection or exacerbation of COPD/asthma are suspected and if either the triage temperature is >or=38.0 degrees C or admission is during the weeks of peak influenza activity.

Anemia hemolítica microangiopática y carcinoma lobulillar de mama / No disponible

No disponible

Varón de 69 años con afectación del estado general, hiperpigmentación, lesión cutánea y respuesta deficiente al tratamiento / 69 years old male patient, with impairment of physical condition, hyperpigmentation, cutaneos lesion and a deficient response to treatment

Presentamos el caso de un varón con insuficiencia suprarrenal primaria de etiología tuberculosa, con una lesión dérmica en la que se comprobaron granulomas necrotizantes y en cuyo cultivo creció micobacterium bovis. Dados los hallazgos clínicos, y a la espera de recibir el cultivo de la lesión, se inició tratamiento tuberculostático triple, que hubo de suspenderse por toxicidad hepática. Tras conocer el cultivo de M. bovis en la biopsia cutánea, se reinstauró el tratamiento con estreptomicina, rifampicina y etambutol. Tres semanas después, y a pesar de aumentar a 40 mg diarios la dosis de hidrocortisona, reapareció la insuficiencia suprarrenal. Ante esta situación, se optó por mantener la rifampicina y duplicar la dosis de hidrocortisona, con lo que desparecieron totalmente las alteraciones clínicas y analíticas. El interés del caso radica en la confluencia de tres procesos infrecuentes en la actualidad: la insuficiencia suprarrenal de etiología tuberculosa, la tuberculosis cutánea por micobacterium bovis y la insuficiencia suprarrenal primaria desencadenada por el uso de rifampicina, y resuelta con el incremento de dosis de hidrocortisona (AU)

We submit the case of a male patient, suffering from a tuberculous ethiology ad renal primary insufficiency, showing a dermal lesion, in which necrotizing granulomas were found, and from which bacterial culture growth yielded mycobacterium bovis. Given the clinical findings, and a waiting for the bacterial culture result, a triple treatment with tuberculo statics was started, but had to be discontinued because of hepatic toxicity. After culture of cutaneous biopsy yielded micobaterium tuberculosis, treatment with streptomycin, rifampicin and etambutol was restarted. Three weeks later, in spite of increasing hydrocortisone dose to 40 mg, adrenal insufficiency reappeared. Under the circumstances, we chose to continue rifampicin and double hydrocortisone dose. The case is of concern because of the concurrency of three nowadays infrequent disorders: tuberculous ethology adrenal insufficiency, cutaneous tuberculosis due to mycobacterium bovis and primary adrenal insufficiency due to rifampicin treatment, the latter resolved after increasing hydrocortisone dose (AU)

Abilities of APTIMA, AMPLICOR, and ProbeTec assays to detect Chlamydia trachomatis and Neisseria gonorrhoeae in PreservCyt ThinPrep Liquid-based Pap samples.

Infections with Chlamydia trachomatis and Neisseria gonorrhoeae are often asymptomatic. Liquid-based Pap (L-Pap) screening may provide samples for testing by commercial assays. Women attending a health clinic or a street youth clinic had a PreservCyt ThinPrep sample and a cervical swab (CS) collected. The L-Pap sample was tested for cytopathology; then 1 ml was transferred to an L-Pap specimen transfer tube for testing by the Gen-Probe APTIMA assays (APTIMA Combo 2 [AC2], APTIMA C. trachomatis [ACT], and APTIMA N. gonorrhoeae [AGC]). The residual L-Pap sample was tested for C. trachomatis and N. gonorrhoeae using Roche AMPLICOR (AMP) and Becton Dickinson ProbeTec (PT). The CS was tested by AC2. A patient was considered infected if two specimens were positive or if a single specimen was positive in two tests. The prevalence of infection was 10% (29/290) for C. trachomatis and 2.4% (7/290) for N. gonorrhoeae. Most of the positive patients had specimens that were reactive in all assays (20/29 for C. trachomatis; 6/7 for N. gonorrhoeae). Four patients had double infections. The sensitivities and specificities of the various tests for the specimens tested were as follows. For C. trachomatis on L-Pap, sensitivity and specificity were 100 and 98.1%, respectively, for ACT, 93.1 and 98.8% for AC2, 86.2 and 91.2% for AMP, and 72.4 and 92.7% for PT. For N. gonorrhoeae on L-Pap, sensitivity and specificity were 100% for both AGC and AC2, 85.7 and 100% for AMP, and 85.7 and 100% for PT. For AC2 with CSs, sensitivity and specificity were 93.1 and 98.5%, respectively, for C. trachomatis, and both were 100% for N. gonorrhoeae. There were significant differences in sensitivity and specificity (P < 0.001). The APTIMA assays were more sensitive and specific than AMP or PT for detecting women's C. trachomatis and/or N. gonorrhoeae infections by testing ThinPrep samples.

[69 years old male patient, with impairment of physical condition, hyperpigmentation, cutaneous lesion and a deficient response to treatment]. / Varón de 69 años con afectación del estado general, hiperpigmentación, lesión cutánea y respuesta deficiente al tratamiento.

We submit the case of a male patient, suffering from a tuberculous ethiology adrenal primary insufficiency, showing a dermal lesion, in which necrotizing granulomas were found, and from which bacterial culture growth yielded mycobacterium bovis. Given the clinical findings, and awaiting for the bacterial culture result, a triple treatment with tuberculostatics was started, but had to be discontinued because of hepatic toxicity. After culture of cutaneous biopsy yielded micobaterium tuberculosis, treatment with streptomycin, rifampicin and etambutol was restarted. Three weeks later, in spite of increasing hydrocortisone dose to 40 mg, adrenal insufficiency reappeared. Under the circumstances, we chose to continue rifampicin and double hydrocortisone dose. The case is of concern because of the concurrency of three nowadays infrequent disorders: tuberculous ethiology adrenal insufficiency, cutaneous tuberculosis due to mycobacterium bovis and primary adrenal insufficiency due to rifampicin treatment, the latter resolved after increasing hydrocortisone dose.

Decreased prevalence of virulence factors among ciprofloxacin-resistant uropathogenic Escherichia coli isolates.

Ciprofloxacin resistance was identified in 18% and 6% of consecutively collected, clinically significant urinary tract isolates of Escherichia coli from inpatients and outpatients, respectively. In comparison to ciprofloxacin-susceptible isolates, there were fewer resistant isolates that expressed beta-hemolysis (outpatient, 9% versus 87%, P < 0.0001; inpatient, 4% versus 76%, P < 0.0001) and that had a papEF genotype, genes encoding P fimbriae (outpatient, 30% versus 70%, P = 0.0004; inpatient, 26% versus 70%, P < 0.0001).

[Echogenic material in fetal gallbladder: prenatal diagnosis and postnatal follow-up]. / Material ecogénico en vesícula biliar fetal: diagnóstico prenatal y seguimiento posnatal.

OBJECTIVE: To study the prevalence of echogenic material in fetal gallbladder and to analyze its pathological relevance, the perinatal factors involved and the postnatal outcome of detected cases. PATIENTS AND METHODS: We performed a prospective study of ultrasonographic examination of 9235 fetuses in the third trimester of gestation. Perinatal data were collected. Postnatal ultrasonography was performed in identified cases. RESULTS: Fetal biliary echogenic material was found in 0.45 % of all pregnancies, with 42 identified fetuses. A single echogenic image was found in four fetuses (9 %), two or more echogenic images were found in seven fetuses (17 %) and biliary sludge was found in 31 fetuses (74 %). All diagnoses were made between weeks 29 and 38 of gestation. No link was found with maternal factors or perinatal abnormalities. Postnatal follow-up was carried out in 39 neonates; of these, five neonates (13 %) showed biliary sludge, although all five were asymptomatic. In further follow-up examinations, ultrasound studies were normal. CONCLUSIONS: Fetal biliary echogenic material was found in one out of every 200 fetuses. No relationship was found with perinatal abnormalities. The prognosis of fetal gallstones and biliary sludge is favorable.

Material ecogénico en vesícula biliar fetal: diagnóstico prenatal y seguimiento posnatal / Echogenic material in fetal gallbladder: prenatal diagnosis and postnatal follow-up

Objetivo: Estudiar la prevalencia de la detección de material ecogénico biliar fetal, y analizar su significado patológico, factores perinatales relacionados y evolución posnatal de los casos detectados. Pacientes y métodos: Se realizó un estudio prospectivo ecográfico en 9.235 fetos durante el tercer trimestre de gestación. Se recogieron diversos datos perinatales en los casos detectados, y se realizó ecografía posnatal. Resultados: Se encontró material ecogénico biliar fetal en el 0,45 por ciento de todas las gestaciones, con 42 fetos identificados. Una imagen ecogénica única se detectó en 4 casos (9 por ciento); dos o más imágenes ecogénicas se encontraron en 7 pacientes (17 por ciento) y se halló barro biliar en 31 casos (74 por ciento). Todos los diagnósticos se realizaron entre las semanas 29 y 38 de gestación. No se mostró relación con los factores maternos o la patología perinatal. Se sometieron a seguimiento posnatal 39 recién nacidos. En cinco de ellos (13 por ciento) se encontró barro biliar, aunque todos se mostraban asintomáticos. Este hallazgo desapareció en controles posteriores. Conclusiones: Uno de cada 200 fetos muestra material ecogénico biliar fetal. No parece haber relación con enfermedades perinatales. El pronóstico de esta entidad es favorable (AU)

Brote de toxiinfección alimentaria por Salmonella enteritidis en un restaurante / An epidemic outbreak gastroenteritis foodborne caused by salmonella enteritidis in a restaurant: gastroenteritis

Fundamento: las toxiinfecciones alimentarias (TIA) son la causa más común de brotes epidémicos en nuestro medio constituyendo un importante problema de salud pública. Objetivo: describir las causas, mecanismos de transmisión y características de un brote de TIA ocurrido en un restaurante. Diseño: estudio de casos y controles. Material y métodos: se consideraron casos aquellas personas que enfermaron y controles aquellas personas que no enfermaron habiendo comido todos en la misma fecha en el restaurante implicado. Los datos se obtuvieron de la cumplimentación de un cuestionario mediante entrevista personal. Se utilizaron los tests estadísticos de Chi cuadrado y t de Student y se ajustaron varios modelos de Regresión Logística para evaluar la asociación de los alimentos consumidos con la TIA. Resultados: se afectaron 183 de los 359 asistentes a dos banquetes celebrados durante el mediodía y la noche el mismo día. Los síntomas más frecuentes fueron: diarrea (88,5 porciento), dolor abdominal (77,1 porciento), fiebre (74,3 porciento), cefalea (50,3 porciento), vómitos (45,1 porciento), mialgias (39,3 porciento) y náuseas (30,6 porciento). El periodo de incubación fue más largo en los casos del primer banquete (p=0,012). Necesitó hospitalización el 35,5 porciento. El alimento responsable fue la merluza rellena (OR ajustado=54,5; IC 95 porciento [6,9-424,1]). Se realizaron 60 coprocultivos en los comensales y 18 en los manipuladores de alimentos del restaurante, siendo positivos 58 y 4, respectivamente, a Salmonella enteritidis. Conclusiones: los posibles factores que originan la aparición de este tipo de brotes son susceptibles de control (AU)

Adjudicating ventilator-associated pneumonia in a randomized trial of critically ill patients.

PURPOSE: The purpose of this study was to evaluate an adjudication strategy for diagnosing ventilator-associated pneumonia (VAP) in a randomized trial. MATERIALS AND METHODS: In a double-blind trial of sucralfate versus ranitidine, one of four pairs of adjudicators examined each case of clinically suspected VAP. Nurse and physician notes and all relevant laboratory data were allocated to each adjudication pair in groups of five patients. Each reader in the pair decided whether the patient had VAP; differences were resolved by consensus discussion. RESULTS: The overall unadjusted study odds ratio for VAP was 0.82 (P = .21) representing a trend toward less pneumonia with sucralfate compared with ranitidine. The odds ratio adjusted for adjudication pair was 0.85 (P = .27). The proportion of charts adjudicated as VAP positive among pairs ranged from 50% to 92%; crude agreement between readers in each pair varied from 50% to 82%. When adjudicators disagreed, the final consensus was split evenly between the two adjudicators' initial opinions in two pairs; in the other two pairs, the final decision reflected one dominant initial opinion. Personnel time to adjudicate all patients with a suspicion of VAP was 74 days. CONCLUSIONS: Though adjudication of outcomes such as VAP is time-consuming, consistent decision-making requires strict criteria, training, and calibration. Patients should be assigned to adjudication teams through random allocation.

Inadequacy of intravenous heparin therapy in the initial management of venous thromboembolism.

To determine the adequacy of initial anticoagulation by intravenous heparin for patients who have deep venous thrombosis (DVT), and the factors that influence delayed anticoagulation, independent, duplicate chart review of 63 consecutive patients who had venography-proven DVT was conducted. Adequate heparinization (AH) was defined as an activated partial thromboplastin time (PTT) of more than 1.5 times the normal laboratory control. The proportions of patients achieving AH within 24 hours and 48 hours of initial heparin bolus were 46% and 62%, respectively. Patients who weighed more were less likely to achieve AH (p < 0.05), while patients receiving care from the thromboembolism service were more likely to achieve AH (p < 0.05). Low initial infusion rate was strongly but not significantly predictive of inadequate anticoagulation (p = 0.06). The mean heparin bolus and initial infusion rates were significantly lower than those suggested in the literature (p < 0.01). The AH rates were comparable to historical controls but suboptimal compared with the rates of 66% at 24 hours and 81% at 48 hours reported in association with heparin nomogram use (p < 0.05). A heparin nomogram is likely to achieve consistently higher rates of adequate heparinization.

[Idiopathic thrombosis of the renal vein. Report of a new case]. / Trombosis idiopática de la vena renal. Aportación de un nuevo caso.

Thrombosis of the renal vein in adult patients is a rare entity, commonly associated to tumoral masses or hypercoagulability states. Contribution of one case of thrombosis of the renal vein in an 83-year old male patient, and review of current literature.

[Multilocular cystic nephroma. Preoperative diagnosis with CAT]. / Nefroma quístico multilocular: Diagnóstico preoperatorio mediante TAC.

We report a case of multilocular cystic nephroma in a 45-year-old female patient who had been referred for urological evaluation on detecting a mass in the left lumbar region. Patient work up included CT evaluation, which proved to be the most useful in making the diagnosis. The literature is reviewed with special reference to the nature of this lesion and the existing controversy on whether it is an embryonary tumor or a congenital malformation.

Epidural analgesia for post-caesarean pain relief: a comparison between morphine and fentanyl.

In 20 post-operative patients who had undergone caesarean section, morphine 2 mg or fentanyl 75 micrograms in 0.9% saline were given epidurally in a randomized study, to compare their effectiveness in providing post-operative pain relief and the incidence of untoward reaction. There was a faster onset of action (P less than 0.01) and the quality of pain relief was substantially better after epidural fentanyl (P less than 0.01). However, the duration of action was markedly longer after epidural morphine (P less than 0.01). There was a significantly greater incidence of urinary retention after morphine administration (P less than 0.05). It is suggested that fentanyl gives better relief of pain than morphine when given epidurally.

Efecto de la inanición sobre la densidad fotométrica radiográfica, peso y contenido de sales de los huesos / Inanition effect on the radiographic photometric density, weight and salt content of the bones

Se estudiaron las variaciones de densidad fotométrica radiográfica, de peso y contenido de sales totales de los huesos largos de ratas adultas sometidas a inanición. Un primer grupo de 6 ratas se empleó para establecer el tiempo máximo de inanición compatible con la vida de esos animales. El segundo grupo, control, estuvo formado por 15 ratas alimentadas habitualmente. El tercer grupo, experimental, compuesto por 15 animales, fue privado de todo alimento por 8 días. Las ratas de los grupos control y experimental fueron sacrificadas por decapitación y se obtuvieron sus fémures por disección. La densidad fotométrica radiográfica se determinó mediante la biodensímetro, equipo diseñado y construido para esta investigación(AU)