[Chronic Salmonella typhimurium diarrhea in an immunocompetent patient]. / Diarrea crónica por Salmonella typhimuriumen paciente inmunocompentente.

Chronic diarrhea caused by infection in immunocompetent patients is an infrequent condition in developed countries, although certain pathogens,generally parasites (Giardia lamblia, Isospora belli,Cryptosporidium, Cyclospora, Strongyloides, Ameba,Trichuris and Schistosoma) and some bacteria (Aeromonas,Plesiomonas, Campylobacter, Clostridium difficile, Salmonella or Mycobacterium tuberculosis)can cause persistent diarrhea.We present the case of a patient who showed Salmonella typhimurium in his stool culture and recovered following treatment with levofloxacin for 7 days.

[Low-molecular-weight heparin without oral anticoagulants for the treatment of deep vein thrombosis]. / Tratamiento de la trombosis venosa profunda con heparinas de bajo peso molecular. Estudio comparativo con anticoagulación oral.

BACKGROUND AND METHODS: The available data on the utility of low-molecular-weight heparins (LMWH) in the secondary prophylaxis of deep vein thrombosis (DVT) are limited. We compared two cohorts of patients diagnosed of DVT. One group followed treatment with LMWH and the other group did with oral anticoagulants (acenocoumarol). Safety was evaluated by the rate of major hemorrhage and 2.5-years period fracture rate, and efficacy was evaluated as the rate of early recurrence and one-year recurrence rate. RESULTS: Of 65 patients treated with LMWH, the hemorrhagic rate was 1.5% (95% CI 0.08-9.40), fracture rate was 7.7% (95% CI 2.87-17.75), early recurrence was 1.5% (95% CI 0.08-9.40) and one-year recurrence was 3% (95% CI 53-11.64). In 118 patients treated with oral anticoagulants the hemorrhagic rate was 3.4% (95% CI 1.09-8.97), odds ratio 0.33, the fracture rate was 11% (95% CI 16.23-18.44), odds ratio 0.66, the early recurrence rate was 5% (95% CI 2.08-11.20), odds ratio 0.60 and one-year recurrence was 3.4% (95%CI 1.09-8.97), odds ratio 0.33. CONCLUSIONS: Secondary prophylaxis of DVT with LMWH is as safe and effective as classical treatment with oral anticoagulants. In this study the 2.5-year period fracture rate was similar in both groups of treatment.

Nocardiosis pulmonar como causa de reagudizaciones en un paciente EPOC / Pulmonary nocardiosis due to reagudizations in a COPD patient

La infección pulmonar por Nocardia sp. es una enfermedad poco frecuente que afecta fundamentalmente a pacientes inmunodeprimidos, aunque también puede hacerlo a pacientes inmunocompetentes. Su diagnóstico se basa en el aislamiento en esputo de Nocardia sp. siendo la clínica y la radiología inespecíficas. El tratamiento se realiza con trimetropin (TMP) sulfametoxazol (SMX), aunque ya se han encontrado casos de resistencia. La duración del tratamiento sigue siendo desconocida recomendándose durante 6 semanas-12 meses. Presentamos el caso de un varón de 81 años con antecedentes de EPOC en tratamiento con corticosteroides de forma crónica que ingresa en nuestro servicio por episodios febriles recidivantes en los tres meses previos al ingreso junto con pérdida de peso e infiltrados densos en Rx de tórax de nueva aparición con cultivo de esputo positivo para Nocardia sp. Y buena evolución tras el inicio de tratamiento con TMP-SMX con desaparición de la fiebre y de los infiltrados

Pulmonary infection due to Nocardia sp. is an infrequent disease that affects principally to immunodefficient patients although it can be also seen in patients with normal immunity. Diagnosis is based in isolation of micro-organism in respiratory samples while clinical presentation and radiology are non specific. Treatment is made with trimethropim-sulfametoxazole (TMP/SMX), though resistance has developed in some patients. The recommended length of treatment is 6 weeks to 12 months depending on the immunitaly status. We present the case of a male patient of 81 years old affected with COPD and treated with glucocorticoids in a chronic basis, who was admitted because relapsing fever episodes during 3 months before, weight loss and new hard pulmonary infiltrates with Nocardia sp. cultured sputum, and evolution to clinical, radiological and microbiologic resolution with TMP/SMX treatment

[Utility of the clinical models for predicting pulmonary thromboembolism]. / Utilidad de los modelos clínicos en la predicción de tromboembolia pulmonar.

OBJECTIVE: We considered to evaluate the efectivity of the clinical models for predicting pulmonary thromboembolism (PE). METHODS: Retrospective application of three published clinical models (Wells or Canadian model, Geneva model and Pisa model) to patients unequivocally diagnosed of acute PE. RESULTS: We evaluate 120 patients [Mean age 71+/-13 years, males 63 (52%)]: Nineteen (16%) diagnosed with pulmonary arteriography and 101 (84%) diagnosed with helical computed tomography. In the Canadian model 24% patients were of high clinical probability, 59% intermediate and 17% low clinical probability. In Geneva model 21% patients belonged to high clinical probability, 69% intermediate and 10% low clinical probability. In Pisa model 49% patients were of high clinical probability, 45% intermediate and 6% of low clinical probability. Sensitivity was 0.59, 0.67 and 0.89 respectively. Factors associated with low probability were in Canadian model the heart rate, the absence of signs of deep venous thrombosis, the presence of an alternative diagnosis and the low rate of cancer. In Geneva model, age, normal heart rate and PaO2 higher 70 mm Hg were associated with low probability, while in Pisa model normal chest X-Ray and radiological signs of pulmonary oedema were also associated with low clinical probability. CONCLUSIONS: Although all three clinical model showed deficiencies Pisa model was the most suitable clinical model for predicting PE. An intermediate clinical probability in the three models, should not serve to rule out PE, besides it is remarkable that patients with low clinical probability still could have PE, providing for clinical models with a limited value.

[Pulmonary nocardiosis due to reagudizations in a COPD patient]. / Nocardiosis pulmonar como causa de reagudizaciones en un paciente EPOC.

Pulmonary infection due to Nocardia sp. is an infrequent disease that affects principally to immunodefficient patients although it can be also seen in patients with normal immunity. Diagnosis is based in isolation of micro-organism in respiratory samples while clinical presentation and radiology are non specific. Treatment is made with trimethropim-sulfametoxazole (TMP/SMX), though resistance has developed in some patients. The recommended length of treatment is 6 weeks to 12 months depending on the immunitaly status. We present the case of a male patient of 81 years old affected with COPD and treated with glucocorticoids in a chronic basis, who was admitted because relapsing fever episodes during 3 months before, weight loss and new hard pulmonary infiltrates with Nocardia sp. cultured sputum, and evolution to clinical, radiological and microbiologic resolution with TMP/SMX treatment.

[Low-molecular-weight heparin for the treatment of acute pulmonary thromboembolism. Comparison with unfractionated intravenous heparin]. / Tratamiento del tromboembolismo pulmonar agudo con heparina de bajo peso molecular subcutánea. Comparación con heparina no fracionada intravenosa.

BACKGROUND AND OBJECTIVES: Low-molecular-weight heparins have been demonstrated at least as useful as unfractionated heparin (UFH) in the treatment of venous thromboembolic disease. Our aim was to know the effectivity and security of subcutaneous enoxaparin in the treatment of acute pulmonary embolism. METHODS: We compared the effectivity and security of two doses daily, subcutaneous injected enoxaparin adjusted to body weight, and standard treatment with continuous intravenous UFH, determining the rate of major bleeding, in-hospital death and recurrent venous thromboembolic disease in long-term follow up. Massive pulmonary thromboembolism was defined as thrombotic material seen in main pulmonary arteries. RESULTS: Thirty eight patients were treated with UFH (Mean age 72 SD 9 years, male 58%, massive pulmonary thromboembolism 24%) and 65 patients were treated with subcutaneous enoxaparin (Mean age 71 SD 12 years, male 52%, massive pulmonary thromboembolism 49%). Major bleeding rate was 8% in UHF group and 3% in enoxaparin group (Difference 37%, 95% Confidence interval -0.16 to 0.06, p=0.21). In-hospital death rate was 8% in UHF group and 1.5% in enoxaparin group (Difference 25%, 95% Confidence interval -0.17 to 0.04, p=0.11). Recurrent thromboembolism rate was 44% in UFH group and 13% in enoxaparin group (Difference 30%, 95% Confidence interval -0.60 to -0.02, p=0.01). CONCLUSION: Our findings demonstrate that treatment of acute pulmonary thromboembolism with low-molecular-heparin is effective and safe, even in massive pulmonary embolism.

Tratamiento del tromboembolismo pulmonar agudo con heparina de bajo peso molecular subcutánea. Comparación con heparina no fracionada intravenosa / Low-molecular-weight heparin for the treatment of acute pulmonary thromboembolism. Comparison with unfractionated intravenous heparin

Fundamento y objetivos: Desde la introducción en la terapéutica de las heparinas de bajo peso molecular, éstas se han venido utilizando con una eficacia similar o superior a la heparina no fraccionada para el tratamiento de la enfermedad tromboembólica venosa. Nuestro propósito fue conocer la eficacia de enoxaparina en el tratamiento del tromboembolismo pulmonar agudo. Métodos: Comparamos la eficacia de enoxaparina subcutánea dos veces al día a dosis de 1 mg/kg de peso con la de heparina no fraccionada por vía endovenosa de forma continua en pacientes diagnosticados de tromboembolismo pulmonar agudo determinando la tasa de hemorragia mayor, muerte en el episodio índice y tasa de reicidiva. Como tromboembolismo pulmonar masivo se consideró la visualización de trombos en las arterias pulmonares principales. Resultados: Treinta y ocho pacientes fueron tratados con heparina no fraccionada intravenosa de forma continua (edad 72 ± 9 años, varón 58%, tromboembolismo pulmonar masivo 24%) y 65 pacientes fueron tratados con enoxaparina (edad 71 ± 12 años, varón 52%, tromboembolismo pulmonar masivo 49%). La tasa de hemorragia mayor durante la hospitalización índice fue de8% en el grupo de heparina no fraccionada y de 3% en el grupo de enoxaparina (riesgo relativo 5,2; diferencia de riesgos 0,63; reducción de episodios de 37% CI 95% -0,16 a 0,06%, p=0,21), la tasa de muerte intrahospitalaria fue de 8% en el grupo de heparina no fraccionada y de1,5% en el grupo enoxaparina (riesgo relativo 1,52; diferencia de riesgos 1,54; reducción de muerte de 25%, CI 95% -0,17 a 0,04%, p = 0,11). La tasa de recidiva fue de 44% en el grupo de tratados con heparina no fraccionada y de 13% en el grupo de enoxaparina (riesgo relativo 1,80; riesgo atribuible 6,48; reducción de riesgo de 30%, CI 95% -0,60 a 0,02, p =0,01). Conclusión: El tratamiento del tromboembolismo pulmonar agudo con heparina de bajo peso molecular (enoxaparina) es más eficaz que el tratamiento con heparina no fraccionada de forma continua, produciéndose menos hemorragias, menos muertes intrahospitalarias y menor tasa de recidivas, aun cuando el tromboembolismo pulmonar sea masivo

Background and objectives: Low-molecular-weight heparins have been demonstrated at least as useful as unfractionated heparin (UFH) in the treatment of venous thromboembolic disease. Our aim was to know the effectivity and security of subcutaneous enoxaparin in the treatment of acute pulmonary embolism. Methods: We compared the effectivity and security of two doses daily, subcutaneous injected enoxaparin adjusted to body weight, and standard treatment with continuous intravenous UFH, determining the rate of major bleeding, in-hospital death and recurrent venous thromboembolic disease in long-term follow up. Massive pulmonary thromboembolism was defined as thrombotic material seen in main pulmonary arteries. Results: Thirty eight patients were treated with UFH (Mean age 72SD 9 years, male 58%, massive pulmonary thromboembolism 24%) and 65 patients were treated with subcutaneous enoxaparin (Mean age 71SD 12 years, male 52%, massive pulmonary thromboembolism 49%). Major bleeding rate was 8% in UHF group and 3% in enoxaparin group (Difference 37%, 95% Confidence interval -0.16 to 0.06, p=0.21). In-hospital death rate was 8% in UHF group and 1.5% in enoxaparin group (Difference 25%, 95% Confidence interval -0.17 to 0.04, p=0.11). Recurrent thromboembolism rate was 44% in UFH group and 13% inenoxaparin group (Difference 30%, 95% Confidence interval -0.60 to -0.02, p=0.01). Conclusion: Our findings demonstrate that treatment of acute pulmonary thromboembolism with low-molecular-heparin is effective and safe, even in massive pulmonary embolism

[Acute lung embolism: a prospective study from May 1992, to May 2002]. / Embolismo pulmonar agudo. Un registro de 10 años: de mayo de 1992 a mayo de 2002.

INTRODUCTION: To define de prevalence, the clinical profile, the predisposing factors and the hospital evolution of clinical acute lung thromboembolism episodes. MATERIAL AND METHODS: A prospective study from May 1992, to May 2002, of acute lung embolism in an Internal Medicine ward with 8 beds in Hospital of Navarra (EPHONA). Clinical acute lung thromboembolism is defined by the clinical characteristics together the demonstration of thrombi in the lung arteries with arteriography, helicoid computerized axial tomography, or high or average probability lung gammagraphy, together the demonstration of deep venous thrombosis with doppler ultrasound or phlebography. We compared the clinical spectrum with that of international clinical series, evaluated the possibility of clinical syndromes according to the size of the affected vessel (central vs. peripheral), and compared the characteristics of patients with manifest deep venous thrombosis with those of the patients with clinical acute lung thromboembolism and without a known emboli source. RESULTS: In the period of 10 years, and with 2,493 patients admitted, 106 clinical acute lung thromboembolism were diagnosed (prevalence: 4.25%; CI: 3.51-5.14; p < 0.05); these patients were 72 +/- 11 years, in other words, an age 5 years higher than the rest of the patients (p < 0.001). There was a delay of 10 days from the beginning of the symptomatology up to the hospitalization. The clinical spectrum was similar to that of other reported series except by the presence of cough and pleural rub (p < 0.001). The main predisposing factors were immobility (41%) and cancer (25%). Hospital mortality was 3.77%. In 70 (66%) patients we obtained information on the affected vessel, not being fulfilled the association of specific clinical syndromes with the size of the vessel, although the patients with central clinical acute lung thromboembolism showed higher deterioration of gas exchange (p = 0.002) and higher activation of the fibrinolysis (p = 0.012) than patients with peripheral clinical acute lung thromboembolism. 35% of episodes of clinical acute lung thromboembolism developed without simultaneous deep venous thrombosis and showed higher disturbance of gas exchange (p = 0.03) and arterial hypotension (p = 0.02). CONCLUSIONS: Clinical acute lung thromboembolism is a frequent condition that occurs in patients of advanced age and that shows low hospital mortality when is diagnosed and treated even with a 10-day delay up to the diagnosis. The clinical spectrum is similar to that observed in other parts of the world, but the cough as a prominent a symptom and the pleural rub should propose other diagnostic alternatives. The size of the affected pulmonary vessel is not related with a specific clinical syndrome, although the central clinical acute lung thromboembolism evolves with higher disturbance of the gas exchange. In the third of clinical acute lung thromboembolism episodes an emboli source is not demonstrated, perhaps because all emboli has migrate to the pulmonary arteries; these episodes give rise to higher hypotension and disturbance of the gas exchange.

[Pulmonary thromboembolism: long term course and clinical epidemiology]. / Tromboembolismo pulmonar: evolución a largo plazo y epidemiología clínica.

BACKGROUND: Long-term clinical course of pulmonary thromboembolism is not well-known. Our aim was to know the events which occur to in-patients diagnosed of pulmonary embolism. METHODS AND PATIENTS: This is a prospective observational study from May-92 to December-2002 with all in-patients diagnosed of pulmonary thromboembolism at a clinical area of Internal Medicine. Main targets were to know survival, relapses, major hemorrhage rate (Defined as those episodes of bleeding which needed blood transfusion and readmission) and cancer associated rate (Previous and newly diagnosed cancer). Follow up were carried out with telephone contacts with patients and relatives in case of death, and with the computerized system of patients and clinical events of Health Service of Navarra. RESULTS: One hundred and sixteen patients were included in the study (Mean age 72 SD 11 years male 54%). During index episode 4 (3.7%) patients dead. Ten patients were lost in follow up. The rest 102 patients were traced for 31.81 SD 31.23 months (Range 1-127). Relapse rate was 19.6% that occurred 22.64 SD 24.57 (Range 1-73) months after index episode (Twelve pulmonary embolisms, 5 deep venous thromboses and 3 sudden death with dyspnea). Major hemorrhage rate was 10.4%. During follow up 14 (13.7%) new cancers were diagnosed (Lung 4, prostate 2, bladder 2, and colorectal, ovary, breast, liver and kidney one each one). At all prevalence of cancer associated with pulmonary thromboembolism was 31%. Mortality rate was 37% (Men 25%, women 49%, p < 0.01). Main causes of death were cancer (32%) and relapse of pulmonary thromboembolism when joined with treatment complications 24%. Half of deaths occurred in the first year of follow up, showing a shortened survival those patients with cancer (p = 0.02) and patients with relapses of pulmonary embolism (p = 0.06). Beyond the first year, mortality declines to a rate of 10% per year mainly because of cardiovascular causes. Mortality associated factors were age > 75 years (p < 0.001) gender female (p < 0.01), a delayed admission and treatment from the beginning of symptoms (p < 0.05), higher LDH level (p < 0.01) and coexistence of cancer (p < 0.05). In logistic-regression analysis age, delayed admission and treatment and higher LDH levels were predictors of long-term death. CONCLUSIONS: Patients with pulmonary embolism show a high mortality rate, with a critical period during the first year after index episode, being deaths associated to cancer and to a composite of relapse of venous thromboembolic disease and bleeding complications. Mortality rate beyond the first year declines, being deaths explained because of cardiovascular causes. An advanced age, a delayed diagnosis and treatment and serum LDH may predict long-term mortality.

[Drug prescription in internal medicine: an analysis of the influencing factors]. / Prescripción de medicamentos en medicina interna: análisis de los factores de influencia.

BACKGROUND: The amount and quality of drugs prescribed after hospitalization in Internal Medicine and the factors which influence them have been rarely evaluated in Spain. MATERIAL AND METHODS: We study prospectively drugs prescribed in patients hospitalized in Internal Medicine analyzing amount of drugs before admission (BAD), on discharge (DD), end drugs after temporal drugs were removed (ED), drugs prescribed as chronic treatment (CTD), symptomatic drugs (SD), acute-use drugs (AUD) and low therapeutic utility drugs (LTUD). We also evaluated the sort of drugs and the factors implicated in increase or decrease of prescription volume. RESULTS: Two hundred and eighty-five patients were evaluated [164 males, 121 females, mean age 68.08 (SD 15.27)]. They had mean BAD 3.42(SD 2.67)7 DD 3.92 (SD 2.36) (p < 0.001) and ED 3.65 (SD 2.30) (No differences with BAD). The amount of drugs were higher in patients 65 years old and elder (p < 0.001). LTUD were decreased from 62(22%) patients on admission to 21 (7%) on discharge (p < 0.001). Compounded drugs were reduced from 36 (13%) patients to 17 (6%) (p < 0.05). Age older 65, length of stay greater 7 days, need for intravenous administration of drugs, comorbidities and complications during hospitalization all caused increase in prescription volume on discharge. Logistic-regression analysis showed that CTD and AUD were the main causes of increase of drugs while BAD and LTUD were protective. Drugs reduced in higher proportion were mucolytics (p < 0.005) drugs to treat plant-based hyperplasia benign of prostate (p < 0.05), brain vasodilators (p < 0.001) and peripheral vasodilators (p < 0.01). CONCLUSIONS: Hospitalization in Internal Medicine results in an increase of prescription volume though it is short-term. The higher number of drugs is accumulated in elderly. Factors implicated in increasing are length of stay, need for intravascular access, complications during inpatient, drugs to treat acute diseases and chronic use drugs. Low therapeutic utility drugs are used before admission in outpatients.

[The influence of empty-bed days on the median hospital stay in internal medicine]. / Influencia de los días vacíos en la estancia media en hospitalización de Medicina Interna.

BACKGROUND: To evaluate the epidemiology of delays in patients hospitalized in a department of internal medicine in a hospital of third level (high technology, end-stem of Spanish health system), its influences in hospital length of stay and the leading reasons which we named Gap Days. PATIENTS AND METHODS: We studied all patients admitted through emergency ward for internal medicine during Oct 93-June 94. Gap Day was defined as the day passed as inpatient in which no intravenous route, isolation, artificial feeding, fever, impairing of clinic steady-state were needed or waited and any diagnostic tools were used. We counted Gap Day from the second day and from de third day for histopathology that we ordered the explorations. In a nonselected group days of delay to arrive written data were measured while the results were known for personal request. RESULTS: 144 patients had a mean length of stay of 9.52 (SD 5.41) days. Gap Days occurred in 97 (67%) patients (Mean 3.85 SD 2.80) with a mean length of stay 10.71 SD 5.09 days, while patients without Gap Days had a mean length of stay of 7.14 SD 5.29 days (p < 0.001). Patients with higher Gap Days were those with symptoms related to hematological system (p = 0.002), nephrourological system (p = 0.011) and a hematological diagnostic (p = 0.003) on admission. On discharge patients with hematological diagnostic had also higher Gap Days (p = 0.017). They had higher Gap Days also patients with two symptoms or more on admission (3.63 SD 2.96, p = 0.016), patients who lived alone (5.33 SD 3.42, p = 0.050) and patients with no concordance between diagnostic on admission and discharge (4.06 SD 3.41, p < 0.01). In 37 patients written data arrived 2.14 SD 1.06 days later after to know the results for personal request. CONCLUSION: Gap Days are an important factor to prolong the length of stay in internal medicine. They are influenced by number of symptoms on admission, concordance between diagnostics on admission and discharge, hematological diagnostics and some social and functioning hospital factors.

[Morbidity and mortality among the hospitalized aged. Identification of prognostic factors]. / Morbimortalidad hospitalaria en la cuarta edad. Identificación de factores pronósticos.

BACKGROUND: Advancing age is an independent predictor of increased mortality. Our purpose was to study morbimortality in very elderly inpatients (Eighty years and older) and to recognize risk factors of hospital-associated mortality. METHODS: All consecutive eighty years and older patients admitted at the Hospital over a one year period were studied. On the first day we collected: symptoms, signs, presumed diagnostic, arterial blood pressure, pulse and respiratory frequency, level of alertness, hydration status, level of hemoglobin, plasma urea, creatinine, Na, K, albumin and arterial blood gases. We also collected end-stay diagnostic and outcome. RESULTS: A total of 131 patients were included with a mean age 83.92 +/- 3.53 (+/-SD). The most frequent diseases were heart failure, chronic obstructive pulmonary disease, stroke and pneumonia. While inpatient 21 (16%) died (Mean age 85.42 +/- 4.46, p < 0.05). Patients whose admission symptoms were arthralgia, myalgia, diarrhea, anemia, syncope and hemiparesis (p < 0.05) and whose presumed diagnostic were rheumatic disease (p < 0.01) and nephrourological disorder (p < 0.001) had lower mortality. A presumed diagnostic on admission of pneumonia had higher mortality (p < 0.05). Risk factors associated with higher mortality were dehydrations signs, decreased alertness status, hypoalbuminemia and elevated plasma urea (p < 0.001). When analysed altogether in order to predict Hospital-associated death had sensitivity 80%, specificity 87%, truepredictive rate 44% and false-predictive rate 97%. CONCLUSIONS: Morbidity of the very elderly patients is caused by chronic disorders. Pneumonia is a leading cause of death mainly in patients with decreased level of alertness, dehydration, hypoalbuminemia and elevated plasma urea.