Classical monocytes-low expressing HLA-DR is associated with higher mortality rate in SARS-CoV-2+ young patients with severe pneumonia.

Aims: This study aimed to investigate whether monocyte dysregulation and hyperinflammation serve as predictive markers for mortality in young patients with SARS-CoV-2 severe pneumonia. Methods: A prospective cohort study was conducted in a tertiary-level public University Hospital in Colombia. Forty young adults (18-50 years of age) with severe pneumonia and SARS-CoV-2 infection confirmed by qPCR, were enrroled. Serum cytokines and the monocyte phenotype profile, including PDL1/HLA-DR expression, were determined during the first 24 h of hospitalization. Routine laboratory parameters were measured throughout patient follow-up until either death or hospital discharge. We also included a cohort of twenty-five healthy control subjects. Key findings: Elevated levels of IL-10, IL-8, and IL-6 cytokines emerged as robust predictors of mortality in young adults with severe pneumonia due to SARS-CoV-2 infected. A descriptive analysis revealed a cumulative mortality rate of 30 % in unvaccinated and ICU-admitted patients. Patients who died had significantly lower expression of HLA-DR on their classical monocytes subsets (CD14+CD16-) than survivors and healthy controls. Lower expression of HLA-DR was associated with greater clinical severity (APACHE≥12) and bacterial coinfection (relative risk 2.5 95%CI [1.18-5.74]). Notably, the expression of HLA-DR in 27.5 % of CD14+/CD16- monocytes was associated with a significantly lower probability of survival. Significance: The early reduction in HLA-DR expression within classical monocytes emerged as an independent predictor of mortality, irrespective of comorbidities. Together with PD-L1 expression and cytokine alterations, these findings support the notion that monocyte immunosuppression plays a fundamental role in the pathogenesis and mortality of young patients infected with SARS-CoV-2. These findings hold significant implications for risk assessment and therapeutic strategies in managing critically ill young adults with SARS-CoV-2 infection.

Opportunistic infections according to the CD4+ T lymphocyte count in patients with HIV at a tertiary care referral center

Opportunistic infections (OIs) have marked the prognosis in the natural course of patients with human immunodeficiency virus (HIV) infection. Objective: identifying the most common OIs and determining their relationship with the CD4+ lymphocyte count (CD4+TL) can improve our clinical practice and facilitate early diagnosis, the use of empiric treatments and prompt targeted treatment. Materials and methods: an observational, retrospective study aimed at describing the characteristics and variations of the OIs diagnosed clinically, using direct or indirect methods, which occur in patients with HIV (related to their CD4+TL count) who are admitted to a tertiary care center in Cali, Colombia. Adult patients hospitalized from January 2018 to January 2019 with a diagnosis of HIV/AIDS and a history or current diagnosis of OI were included. Individuals under the age of 18 and pregnant women were excluded. Results: a sample of 190 patients with at least one opportunistic infection was obtained, of whom 65.3% were men with a median age of 37 years (29.0-46.0), and the rest were women with a median age of 35.5 years (31.2-43.0). Eighty-three percent had a C3 classification on admission, 86% with a CD4+TL count < 200 cells/mm3. The most frequent OIs included tuberculosis, with 28.4%, pneumocystosis with 27.9% and toxoplasmosis with 27.4%. Conclusions: in our population, despite advances in and greater availability of highly-effective antiretroviral therapy, most patients with HIV are hospitalized in advanced stages with opportunistic infections, in some cases with two or more concomitant infections, and with evidence of severe virological and immunological involvement. (Acta Med Colomb 2022; 48. DOI:https://doi.org/10.36104/amc.2023.2327).

Severe coronavirus HCoV-NL63 pneumonia in a patient receiving blinatumomab with secondary antibody deficiency in COVID-19 times.

Introduction: Human coronavirus NL63 (HCoV-NL63) is one of four common human respiratory coronaviruses. It causes lower respiratory tract infections in young children, elderly and immunosuppressed people, which could result in fatal outcomes. In this time of pandemic, we want to highlight the importance of other coronaviruses infection besides SARS-CoV-2, especially in a patient with underlying conditions like acute lymphoblastic leukemia, receiving immunosuppressive therapy that could result in humoral secondary immunodeficiencies. Case report: We present the case of a 44-year-old Colombian man with acute lymphoblastic leukemia who developed HCoV-NL63 pulmonary infection after the first month of treatment with blinatumomab complicated with severe secondary hypogammaglobulinemia. HCoV-NL63 was detected by multiplex PCR, and HCoV-NL63 viral pneumonia was diagnosed. Hypogammaglobulinemia was studied by determining serum immunoglobulins levels and protein electrophoresis. The treatment consisted of supportive therapy and replacement with intravenous immunoglobulins. After therapy, the patient improved his oxygenation, and the infection was resolved in a few days. Conclusions: This case highlights the relevance of other coronaviruses infections besides SARS-CoV-2 in patients receiving immunosuppressive therapy who develop secondary antibody deficiency, and the importance of replacement therapy with intravenous immunoglobulins at early stage of infection with HCoV-NL63.

Diversidad de Perifiton como indicador de calidad de agua en Caño Barandas: Reserva Natural El Diamante de las Aguas, Guaviare-Colombia / Diversity of Periphyton as an indicator of water quality in Caño Barandas: El Diamante de las Aguas Nature Reserve, Guaviare-Colombia

Introducción. El perifiton se entiende como una comunidad compleja de microorganismos entre los cuales se encuentran principalmente organismos fotosintéticos y zooplancton adheridos a sustratos, su estudio permite conocer el funcionamiento de los ecosistemas acuáticos, así como el estado y ecología de las comunidades presentes. Objetivo. Evaluar la calidad de agua a partir de la diversidad de perifiton del caño Barandas en la Reserva Natural El Diamante de Las Aguas, en el departamento de Guaviare. Metodología. se midieron las variables fisicoquímicas pH, oxígeno disuelto y temperatura en 5 estaciones a lo largo de 200 metros del cuerpo de agua, se tomaron muestras de perifiton sobrepuesto en superficies de roca, tronco y hojarasca, por medio de un raspado en el interior de un marco de 2x2 cm con 3 repeticiones; para la identificación de los organismos se observaron 25 alícuotas durante 5 minutos por alicuota; para evaluar la calidad de agua, se realizaron índices de diversidad de Shannon-Wiener, Simpson, Menhinick, análisis de correspondencia canónica y el índice biológico de contaminación (IBC). Resultados. Se obtuvieron 465 registros, distribuidos en 82 géneros, los más representativos fueron Campylodiscus (5.81%), Tribonema (8.60%), Ophyoctium (10.75%) y Microspora (11.40%). El BCI arrojó como resultado 11,7 lo cual indica que es una zona de agua limpia. Conclusión. Las variables evaluadas presentaron una relación directa con las comunidades de perifiton encontradas en las estaciones. Los índices de diversidad mostraron que en este caño hay una alta diversidad en las comunidades de perifiton, lo cual indica una buena calidad de agua.

Introduction. The periphyton is understood as a complex community of microorganisms among which are mainly photosynthetic organisms and zooplankton adhered to substrates, its study allows to know the functioning of aquatic ecosystems, as well as the state and ecology of the communities present. Objetive. To evaluate the water quality from the diversity of periphyton of Caño Barandas in the El Diamante de Las Aguas, Natural Reserve in the department of Guaviare. Methodology. The physicochemical variables pH, dissolved oxygen and temperature were measured in 5 stations along 200 meters in the water-body, followed by samples of the periphyton superimposed on rock surfaces, trunk and litter, by means of a scraping inside a 2x2 cm frame, with 3 repetitions, subsequently, for the identification of the organisms, 25 aliquots were observed for 5 minutes per aliquot. to evaluate the water quality. Shannon-Wiener, Simpson, Menhinick diversity indices, canonical correspondence analysis and the biological contamination index, Results. A total of 465 records were obtained, distributed in 82 genera, the most representative were Campylodiscus (5.81%), Tribonema (8.60%), Ophyoctium (10.75%) and Microspora (11.40%). The latter gave 11.7 as a result, which indicates that it is a clean water area. Conclusion. The evaluated variables presented a direct relationship with the periphyton communities found in the stations. The diversity indices showed that in this area there is a high diversity in the periphyton communities, which indicates a good water quality.

Lavado pulmonar bilateral terapéutico en una adolescente con proteinosis alveolar pulmonar. A propósito de un caso / Therapeutic bilateral lung lavage in an adolescent with pulmonary alveolar proteinosis. Case report

La proteinosis alveolar pulmonar es una enfermedad pulmonar difusa caracterizada por la acumulación anormal de surfactante y lipoproteínas en el espacio alveolar, lo cual empeora el intercambio gaseoso y lleva a un curso variable desde una presentación clínica asintomática hasta una falla respiratoria grave.Se presenta a una adolescente de 16 años con este diagnóstico que fue remitida a nuestro Hospital para la realización de un lavado pulmonar total luego de una historia de disnea progresiva, dificultad respiratoria, caída de la función pulmonar y anormalidades radiológicas. Se le realizaron estudios de función pulmonar y mediciones de laboratorio antes y después del lavado pulmonar terapéutico.Luego, la paciente presentó una inmediata mejoría tanto de los síntomas, radiografía de tórax y mediciones de estudios de función pulmonar como en el intercambio gaseoso. El lavado pulmonar total continúa siendo el estándar de oro para el tratamiento de la proteinosis alveolar pulmonar en casos graves

Pulmonary alveolar proteinosis is an unusual diffuse lung disease characterized by abnormal accumulation of pulmonary surfactant and lipoproteins in the alveolar space, which impairs gas exchange with a variable clinical course, ranging from an asymptomatic clinical presentation to severely affected respiratory failure.A 16-year-old girl with diagnosis of pulmonary alveolar proteinosis presented to our hospital for therapeutic lung lavage after a recent history of progressive dyspnea, respiratory distress, declining lung function measurements, and worsening radiographic abnormalities. We obtained baseline pulmonary function tests and laboratory measurements before and after therapeutic bilateral lung lavage. After the lavage, the patient demonstrated an immediate improvement in symptoms, chest radiograph appearance, pulmonary function test measurements, as well as in gas exchange. Whole lung lavage is still the gold standard for treatment of pulmonary alveolar proteinosis in severe cases.

[Therapeutic bilateral lung lavage in an adolescent with pulmonary alveolar proteinosis. Case report]. / Lavado pulmonar bilateral terapéutico en una adolescente con proteinosis alveolar pulmonar. A propósito de un caso.

Pulmonary alveolar proteinosis is an unusual diffuse lung disease characterized by abnormal accumulation of pulmonary surfactant and lipoproteins in the alveolar space, which impairs gas exchange with a variable clinical course, ranging from an asymptomatic clinical presentation to severely affected respiratory failure. A 16-year-old girl with diagnosis of pulmonary alveolar proteinosis presented to our hospital for therapeutic lung lavage after a recent history of progressive dyspnea, respiratory distress, declining lung function measurements, and worsening radiographic abnormalities. We obtained baseline pulmonary function tests and laboratory measurements before and after therapeutic bilateral lung lavage.

La proteinosis alveolar pulmonar es una enfermedad pulmonar difusa caracterizada por la acumulación anormal de surfactante y lipoproteínas en el espacio alveolar, lo cual empeora el intercambio gaseoso y lleva a un curso variable desde una presentación clínica asintomática hasta una falla respiratoria grave. Se presenta a una adolescente de 16 años con este diagnóstico que fue remitida a nuestro Hospital para la realización de un lavado pulmonar total luego de una historia de disnea progresiva, dificultad respiratoria, caída de la función pulmonar y anormalidades radiológicas. Se le realizaron estudios de función pulmonar y mediciones de laboratorio antes y después del lavado pulmonar terapéutico. Luego, la paciente presentó una inmediata mejoría tanto de los síntomas, radiografía de tórax y mediciones de estudios de función pulmonar como en el intercambio gaseoso. El lavado pulmonar total continúa siendo el estándar de oro para el tratamiento de la proteinosis alveolar pulmonar en casos graves.

Relación de la vulnerabilidad alimentaria con el estado de nutrición y fragilidad en adultos mayores mexicanos / Relationship of food vulnerability with nutritional status and fragility in elderly Mexicans

Introducción: Envejecer implica cambios físicos, biológicos, psicosociales y económicos que predisponen al adulto mayor (AM) a vulnerabilidad alimentaria (VA) influyendo en su estado de nutrición y fragilidad, trayendo como consecuencia un alto riesgo de discapacidad, hospitalización y mortalidad. Objetivo: Determinar la relación de la vulnerabilidad alimentaria con el estado de nutrición y fragilidad en una población de adultos mayores mexicanos. Métodos: Se realizó un estudio observacional analítico en adultos de 60 años o más de ambos sexos que se encontraban institucionalizados en el Centro Gerontológico Integral de Pachuca, México; los cuales dieron su consentimiento para realizar la Escala de Vulnerabilidad Alimentaria Nutricional, el cuestionario Mini Nutritional Assessment MNA(R) y el cuestionario Frail de cribado para identificar personas frágiles. Resultados: Se incluyeron 80 AM de 60-64 años (n=19), 65-74 años (n=37) y ≥ 75 (n=24) años; encontrando proporciones de VA leve de 92.5% y VA moderada de 7.5%; y el 50% de AM se encontró con riesgo de malnutrición de acuerdo con MNA(R), y 65% se encontró con riesgo de fragilidad de acuerdo con la escala Frail. Se encontró correlación negativa entre el puntaje obtenido en MNA y puntaje de VA (r= -0.56, p <0.001), y no se encontró asociación entre VA y fragilidad (CHI2, p =0.062). Conclusión: Una mayor vulnerabilidad alimentaria se asoció con incrementó del riesgo de malnutrición en los adultos mayores, pero no se encontró relación entre vulnerabilidad alimentaria con la fragilidad. Una alta proporción de adultos mayores presentó algún indicador de fragilidad, lo que en el corto plazo podría afectar su calidad de vida

Introduction: Aging implies physical, biological, psychosocial and economic changes that predispose the elderly (AM) to food vulnerability (VA) influencing their nutritional status and fragility, resulting in a high risk of disability, hospitalization and mortality. Objective: To determine the relationship of food vulnerability with the state of nutrition and frailty in an elderly Mexican population. Methods: An analytical observational study was conducted in adults of 60 years or older of both sexes who were institutionalized in the Comprehensive Gerontological Center of Pachuca, Mexico; who gave their consent to carry out the Nutritional Food Vulnerability Scale, the Mini Nutritional Assessment MNA(R) questionnaire and the Frail screening questionnaire to identify frail people.Results: 80 AM of 60-64 years (n = 19), 65-74 years (n = 37) and ≥75 (n = 24) years were included; finding proportions of mild VA of 92.5% and moderate VA of 7.5%; and 50% of AM was at risk of malnutrition according to MNA(R), and 65% was found to be at risk of frailty according to the Frail scale. A negative correlation was found between the score obtained in MNA and the VA score (r = -0.56, p <0.001), and no association was found between VA and fragility (CHI2, p = 0.062). Conclusion: Greater food vulnerability was associated with increased risk of malnutrition in older adults, but no relationship was found between food vulnerability and frailty. A high proportion of older adults presented some indicator of frailty, which in the short term could affect their quality of life

Glomerulonefritis por inmunocomplejos en un paciente con lepra / Immune-complex glomerulonephritis in a patient with leprosy

La lepra es una enfermedad cuyas manifestaciones se dan a nivel cutáneo y neurológico periférico. Es conocida desde siglos atrás y continúa siendo un problema de salud pública a nivel mundial. La prevalencia ha disminuido después de la instauración de esquemas de tratamiento poliquimioterápicos. En Colombia no está considerada como un problema de salud pública por su baja prevalencia. El compromiso multisistémico es común, especialmente en las formas multibacilares. Los sistemas articular y renal son frecuentemente afectados, aunque estas afectaciones son en muchas ocasiones pasadas por alto. Se reporta el caso de un paciente con lepra lepromatosa que presentó glomerulonefritis mediada por inmunocomplejos y, además, compromiso poliarticular secundario a una reacción leprosa del tipo eritema nudoso lepromatoso. No hay conciencia por parte del personal de salud sobre las características de la enfermedad, ya que en muchos casos se cree erradicada. Este caso ilustra la importancia del reconocimiento y tratamiento oportunos para prevenir la discapacidad asociada.

Leprosy is a disease whose manifestations are seen in the skin and at the peripheral neurological level. It has been known for centuries and remains a public health problem worldwide; however its prevalence has declined after the introduction of multidrug treatment schemes. In Colombia leprosy is not considered a public health problem because of its low incidence. Multisystem compromise is common, especially in multibacillary forms, with the articular and renal systems commonly affected; although these effects are often overlooked. We report a patient with lepromatous leprosy who presented immune-mediated glomerulonephritis and polyarticular impairment secondary to erythaema nodosum leprosum. There is no awareness on the part of health personnel on the characteristics of the disease and in many cases are believed eradicated. This case illustrates the importance of early recognition and timely treatment to prevent disability associated.

Multicenter study in Colombia: Impact of a multidimensional International Nosocomial Infection Control Consortium (INICC) approach on central line-associated bloodstream infection rates.

BACKGROUND: The objective of this study was to analyze the impact of a multidimensional infection control approach and the use of the International Nosocomial Infection Control Consortium (INICC) Surveillance Online System on central line-associated bloodstream infection (CLABSI) rates from June 2003-April 2010. METHODS: We conducted a prospective, before-after surveillance study of 2,564 patients hospitalized in 4 adult intensive care units (ICUs) and 424 patients in 2 pediatric ICUs of 4 hospitals in 2 cities of Colombia. During baseline, we performed outcome surveillance of CLABSI applying the Centers for Disease Control and Prevention's National Healthcare Safety Network definitions. During intervention, we implemented the INICC multidimensional approach and the ISOS, which included a bundle of infection prevention practice interventions, education, outcome surveillance, process surveillance, feedback on CLABSI rates and consequences, and performance feedback of process surveillance. Bivariate and multivariate regression analyses were performed using a logistic regression model to estimate the effect of the intervention on the CLABSI rate. RESULTS: The baseline rate of 12.9 CLABSIs per 1,000 central line (CL) days, with 3,032 CL days and 39 CLABSIs, was reduced to 3.5 CLABSIs per 1,000 CL days, with 3,686 CL days and 13 CLABSIs, accounting for a 73% CLABSI rate reduction (relative risk, 0.27; 95% confidence interval, 0.14-0.52; P=.002). CONCLUSIONS: Implementing the INICC multidimensional infection control approach for CLABSI prevention was associated with a significant reduction in the CLABSI rate of ICUs of Colombia.

Findings of the International Nosocomial Infection Control Consortium (INICC), Part I: Effectiveness of a multidimensional infection control approach on catheter-associated urinary tract infection rates in pediatric intensive care units of 6 developing countries.

DESIGN: A before-after prospective surveillance study to assess the impact of a multidimensional infection control approach for the reduction of catheter-associated urinary tract infection (CAUTI) rates. SETTING: Pediatric intensive care units (PICUs) of hospital members of the International Nosocomial Infection Control Consortium (INICC) from 10 cities of the following 6 developing countries: Colombia, El Salvador, India, Mexico, Philippines, and Turkey. PATIENTS: PICU inpatients. METHODS: We performed a prospective active surveillance to determine rates of CAUTI among 3,877 patients hospitalized in 10 PICUs for a total of 27,345 bed-days. The study was divided into a baseline period (phase 1) and an intervention period (phase 2). In phase 1, surveillance was performed without the implementation of the multidimensional approach. In phase 2, we implemented a multidimensional infection control approach that included outcome surveillance, process surveillance, feedback on CAUTI rates, feedback on performance, education, and a bundle of preventive measures. The rates of CAUTI obtained in phase 1 were compared with the rates obtained in phase 2, after interventions were implemented. RESULTS: During the study period, we recorded 8,513 urinary catheter (UC) days, including 1,513 UC-days in phase 1 and 7,000 UC-days in phase 2. In phase 1, the CAUTI rate was 5.9 cases per 1,000 UC-days, and in phase 2, after implementing the multidimensional infection control approach for CAUTI prevention, the rate of CAUTI decreased to 2.6 cases per 1,000 UC-days (relative risk, 0.43 [95% confidence interval, 0.21-1.0]), indicating a rate reduction of 57%. CONCLUSIONS: Our findings demonstrated that implementing a multidimensional infection control approach is associated with a significant reduction in the CAUTI rate of PICUs in developing countries.

Blockade by nanomolar resveratrol of quantal catecholamine release in chromaffin cells.

The cardiovascular protecting effects of resveratrol, an antioxidant polyphenol present in grapes and wine, have been attributed to its vasorelaxing effects and to its anti-inflammatory, antioxidant, and antiplatelet actions. Inhibition of adrenal catecholamine release has also been recently implicated in its cardioprotecting effects. Here, we have studied the effects of nanomolar concentrations of resveratrol on quantal single-vesicle catecholamine release in isolated bovine adrenal chromaffin cells. We have found that 30 to 300 nM concentrations of resveratrol blocked the acetylcholine (ACh) and high K(+)-evoked quantal catecholamine release, amperometrically measured with a carbon fiber microelectrode. At these concentrations, resveratrol did not affect the whole-cell inward currents through nicotinic receptors or voltage-dependent sodium and calcium channels, neither the ACh- or K(+)-elicited transients of cytosolic Ca(2+). Blockade by nanomolar resveratrol of secretion in ionomycin- or digitonin-treated cells suggests an intracellular site of action beyond Ca(2+)-dependent exocytotic steps. The fact that nanomolar resveratrol augmented cGMP is consistent with the view that resveratrol could be blocking the quantal secretion of catecholamine through a nitric oxide-linked mechanism. Because this effect occurs at nanomolar concentrations, our data are relevant in the context of the low circulating levels of resveratrol found in moderate consumers of red wines, which could afford cardioprotection by mitigating the catecholamine surge occurring during stress.

Mitochondrial Na+/Ca2+-exchanger blocker CGP37157 protects against chromaffin cell death elicited by veratridine.

Mitochondrial calcium (Ca(2+)) dyshomeostasis constitutes a critical step in the metabolic crossroads leading to cell death. Therefore, we have studied here whether 7-chloro-5-(2-chlorophenyl)-1,5-dihydro-4,1-benzothiazepin-2(3H)-one (CGP37157; CGP), a blocker of the mitochondrial Na(+)/Ca(2+)-exchanger (mNCX), protects against veratridine-elicited chromaffin cell death, a model suitable to study cell death associated with Ca(2+) overload. Veratridine produced a concentration-dependent cell death, measured as lactate dehydrogenase released into the medium after a 24-h incubation period. CGP rescued cells from veratridine-elicited death in a concentration-dependent manner; its EC(50) was approximately 10 microM, and 20 to 30 microM caused near 100% cytoprotection. If preincubated for 30 min and washed out for 3 min before adding veratridine, CGP still afforded significant cytoprotection. At 30 microM, CGP blocked the veratridine-elicited free radical production, mitochondrial depolarization, and cytochrome c release. At this concentration, CGP also inhibited the Na(+) and Ca(2+) currents by 50 to 60% and the veratridine-elicited oscillations of cytosolic Ca(2+). This drastic cytoprotective effect of CGP could be explained in part through its regulatory actions on the mNCX.

A low nicotine concentration augments vesicle motion and exocytosis triggered by K(+) depolarisation of chromaffin cells.

Tobacco smokers have an increased risk of cardiovascular disease; this is likely associated to an enhanced catecholamine release by circulating nicotine. Here, we have explored how low concentrations of nicotine in the range of those found in the blood of tobacco smokers, might affect the release of catecholamines in bovine chromaffin cells. We have combined patch-clamp and Ca(2+) imaging techniques to study cell excitability, cytosolic Ca(2+) transients, vesicle movement, and secretory responses. We found that low concentrations of nicotine (1.5-3 microM) did not enhance catecholamine release by themselves. However, they drastically augmented the catecholamine release response triggered by a supramaximal K(+) depolarising pulse. Furthermore, low nicotine concentrations caused slight depolarisation with superimposed action potentials, a transient elevation of [Ca(2+)](c) and augmented Ca(2+)-dependent vesicle motion underneath the plasmalemma. We suggest that low nicotine concentrations overload the secretory machinery with secretory vesicles, which cause chromaffin cells to respond with an exaggerated adrenaline release into the circulation during stress. This might contribute to the higher cardiovascular risk of tobacco smokers.

Análisis crítico del rendimiento de un consultorio diagnóstico y terapéutico de medicina interna: enero a junio de 1991 / Critical analysis of the performance of an internal medicine diagnostic and therapeutic medical units

Se analiza el rendimiento del Consultorio Diagnóstico-Terapéutico de nivel secundario del Servicio de Medicina del Hospital San Juan de Dios. Para ello se revisa el origen y el destino de 1.182 pacientes nuevos atendidos en el primer semestre de 1991. Con respecto a origen el 56% de los casos provienen de la atención primaria; el 27% de la terciaria y el 5% de la de urgencia. Si se descartan los pacientes referidos para simples controles preoperatorios (pases quirúrgicos) los porcentajes anteriores se modifican sensiblemente transformándose en 65%; 16% y 6% respectivamente. En lo que se refiere a destino, un 18% de pacientes abandonaron después de una o dos consultas. Si estos casos se descartan, al igual que los que sólo fueron referidos para examen preoperatorio desde las Especialidades quirúrgicas, se observa que el 34% de los casos fueron rápidamente devueltos a la atención primaria; el 26% fueron referidos a las sub-especialidades médicas terciarias; el 11% lo fueron a Especialidades no médicas; 10% fueron estudiados y tratados ambulatoriamente en el Consultorio de Medicina y el 13% fueron hospitalizados. De estos últimos el 65% lo fueron en el Servicio y el 35% en sus propios domicilios. El análisis retrospectivo de nuestro material permite señalar que 235 (23%) de 1.024 pacientes(excluídos los 158 enviados sólo para examen preoperatorio) referidos a nuestro Consultorio, venían con el objeto de ser hospitalizados. De ellos sólo lo fueron 110(47%) de los cuales sólo 71(30% de los 235) en las Salas de Medicina y los demás(39 casos) en sus casas. Lo anterior implica un ahorro de 2.300 días-camas en el semestre estudiado, con un valor aproximado de 23 millones de pesos. Nuestra revisión parece confirmar las premisas y fundamentos teóricos que motivaron, hace 20 años, la idea de organizar un Consultorio integral y resolutivo, diagnóstico y terapéutico de Medicina Interna, complementado por una Unidad de Atención domiciliaria y otra de hospitalización diurna o de 24 horas. La motivación y perseverancia de quienes han trabajado en este proyecto a lo largo de 2 décadas, ha permitido finalmente su materialización y transformación en una realidad concreta.