Análisis de las hospitalizaciones por enfermedad cardiovascular en población diabética en España / Analysis of hospitalizations by cardiovascular disease in the population with diabetes in Spain

Objetivos: Diabetes mellitus se asocia con un marcado incremento de enfermedad cardiovascular. En el presente estudio analizamos la prevalencia de diabetes mellitus en pacientes hospitalizados en España en 2015 y la carga de enfermedad cardiovascular asociada. Métodos: Mediante el análisis del conjunto mínimo básico de datos (CMBD) del Ministerio de Sanidad del año 2015, se incluyen todos los pacientes dados de alta con diagnóstico de diabetes mellitus. Se describen las características epidemiológicas, la distribución por los diferentes servicios hospitalarios y la presencia de enfermedad cardiovascular. Resultados: En el año 2015 hubo 3.727.583 altas en España; de ellas, 619.188 correspondían a diabéticos (16,7%); el 56,8% eran varones y la edad media era de 73,2años. La prevalencia de enfermedad cardiovascular fue del 40,8%, distribuida en insuficiencia cardiaca congestiva (20,1%), enfermedad cerebrovascular (10,3%), enfermedad coronaria (9,4%) y enfermedad arterial periférica (9,1%). La mayor parte de pacientes ingresaron en los servicios de medicina interna (34,2%), cardiología (9,5%) y cirugía general (8,9%). La estancia media global fue de 8,2días y los reingresos a 30días alcanzaron el 14%. La mortalidad fue del 6,8%. Los pacientes ingresados en medicina interna tienen un grado de severidad más alto (3-4), 41,9% vs 31,6%, que los ingresados en otros servicios médicos (p<0,01) y que los ingresados en servicios quirúrgicos (11,2%) (p<0,01). Conclusiones: La diabetes mellitus es una comorbilidad importante de los pacientes ingresados en medicina interna. Una proporción significativa de estos pacientes presenta enfermedad cardiovascular, y la más frecuente es la insuficiencia cardíaca

Objective: Diabetes mellitus is associated with a marked increase in cardiovascular disease. In this study, we analysed the prevalence of diabetes mellitus in hospitalised patients in Spain in 2015 and the burden of associated cardiovascular disease. Methods: By analysing the 2015 minimum basic data set (MBDS) of the Spanish Ministry of Health, we included all patients discharged with a diagnosis of diabetes mellitus. We describe the epidemiological characteristics, distribution by the various hospital departments and the presence of cardiovascular disease. Results: In 2015, there was 3,727,583 hospital discharges in Spain, 619,188 of which involved patients with diabetes (16.7%), 56.8% of whom were men and with a mean age of 73.2years. The prevalence of cardiovascular disease was 40.8%, distributed among congestive heart failure (20.1%), cerebrovascular disease (10.3%), coronary artery disease (9.4%) and peripheral arterial disease (9.1%). Most of the patients were admitted to internal medicine (34.2%), cardiology (9.5%) and general surgery (8.9%) departments. The mean overall stay was 8.2days, the readmission rate at 30days was 14%, and the mortality rate was 6.8%. The patients hospitalized in internal medicine had higher severity levels (3-4) than those hospitalized in other medical departments (41.9% vs. 31.6%, respectively; P<.01) and those hospitalized in surgical departments (11.2%; P<.01). Conclusions: Diabetes mellitus is a significant comorbidity for patients hospitalized in internal medicine. A significant proportion of these patients present cardiovascular disease, mostly heart failure

Analysis of hospitalizations by cardiovascular disease in the population with diabetes in Spain. / Análisis de las hospitalizaciones por enfermedad cardiovascular en población diabética en España.

OBJECTIVES: Diabetes mellitus is associated with a marked increase in cardiovascular disease. In this study, we analysed the prevalence of diabetes mellitus in hospitalised patients in Spain in 2015 and the burden of associated cardiovascular disease. METHODS: By analysing the 2015 minimum basic data set (MBDS) of the Spanish Ministry of Health, we included all patients discharged with a diagnosis of diabetes mellitus. We describe the epidemiological characteristics, distribution by the various hospital departments and the presence of cardiovascular disease. RESULTS: In 2015, there was 3,727,583 hospital discharges in Spain, 619,188 of which involved patients with diabetes (16.7%), 56.8% of whom were men and with a mean age of 73.2years. The prevalence of cardiovascular disease was 40.8%, distributed among congestive heart failure (20.1%), cerebrovascular disease (10.3%), coronary artery disease (9.4%) and peripheral arterial disease (9.1%). Most of the patients were admitted to internal medicine (34.2%), cardiology (9.5%) and general surgery (8.9%) departments. The mean overall stay was 8.2days, the readmission rate at 30days was 14%, and the mortality rate was 6.8%. The patients hospitalized in internal medicine had higher severity levels (3-4) than those hospitalized in other medical departments (41.9% vs. 31.6%, respectively; P<.01) and those hospitalized in surgical departments (11.2%; P<.01). CONCLUSIONS: Diabetes mellitus is a significant comorbidity for patients hospitalized in internal medicine. A significant proportion of these patients present cardiovascular disease, mostly heart failure.

Aspectos metodológicos de los procesos asistenciales integrados (PAI) / Methodological aspects of integrated care pathways

Un proceso asistencial integrado (PAI) es una herramienta cuyo propósito es aumentar la efectividad de las actuaciones clínicas a través de una mayor coordinación y garantía de continuidad asistencial. Los PAI sitúan al paciente como el eje central de la organización asistencial. Se definen como el conjunto de actividades que realizan los proveedores de la atención sanitaria con la finalidad de incrementar el nivel de salud y el grado de satisfacción de la población que recibe los servicios. La elaboración de un PAI precisa analizar el flujo de actividades, la interrelación entre profesionales y dispositivos asistenciales y las expectativas del paciente. En este artículo se presenta y se discute la metodología para la elaboración de un PAI, así como los factores de éxito para su definición y su efectiva implantación. Se explica también, a modo de ejemplo, el reciente PAI para hipoglucemias en personas con diabetes mellitus tipo 2 elaborado por un equipo multidisciplinar y avalado por varias sociedades científicas (AU)

An Integrated Healthcare Pathway (PAI) is a tool which has as its aim to increase the effectiveness of clinical performance through greater coordination and to ensure continuity of care. PAI places the patient as the central focus of the organisation of health services. It is defined as the set of activities carried out by the health care providers in order to increase the level of health and satisfaction of the population receiving services. The development of a PAI requires the analysis of the flow of activities, the inter-relationships between professionals and care teams, and patient expectations. The methodology for the development of a PAI is presented and discussed in this article, as well as the success factors for its definition and its effective implementation. It also explains, as an example, the recent PAI for Hypoglycaemia in patients with Type 2 Diabetes Mellitus developed by a multidisciplinary team and supported by several scientific societies (AU)

[Methodological aspects of integrated care pathways]. / Aspectos metodológicos de los procesos asistenciales integrados (PAI).

An Integrated Healthcare Pathway (PAI) is a tool which has as its aim to increase the effectiveness of clinical performance through greater coordination and to ensure continuity of care. PAI places the patient as the central focus of the organisation of health services. It is defined as the set of activities carried out by the health care providers in order to increase the level of health and satisfaction of the population receiving services. The development of a PAI requires the analysis of the flow of activities, the inter-relationships between professionals and care teams, and patient expectations. The methodology for the development of a PAI is presented and discussed in this article, as well as the success factors for its definition and its effective implementation. It also explains, as an example, the recent PAI for Hypoglycaemia in patients with Type 2 Diabetes Mellitus developed by a multidisciplinary team and supported by several scientific societies.

Prevalencia de obesidad según la estadificación de Edmonton en las consultas de Medicina Interna. Resultados del estudio OBEMI / Prevalence of obesity according to Edmonton staging in the Internal Medicine consultations. Results of the OBEMI study

Objetivos. Estimar la prevalencia de obesidad y clasificarla según la estadificación de Edmonton (EOSS) en pacientes atendidos por Medicina Interna. Material y métodos. Estudio observacional, descriptivo y transversal. Incluyó pacientes ambulatorios mayores de 18 años con un índice de masa corporal (IMC)>30, procedentes de 38 hospitales, entre el 1 y el 14 de febrero de 2016. Se clasificaron según EOSS y se analizaron variables clínicas, analíticas y sociodemográficas. Se consideró significación estadística con p<0,05. Resultados. De 1.262 pacientes vistos en las consultas se seleccionaron 298 y se analizaron 265. La prevalencia de obesidad fue del 23,6%, la edad, de 62,47±15,27 años y el IMC, de 36,1±5,3kg/m2. Por EOSS (0, 1, 2, 3 y 4) la prevalencia fue de 4,9, 14,7, 62,3, 15,5 y 2,64%, respectivamente. Aquellos pacientes con EOSS>2 tenían significativamente más edad y comorbilidades. El análisis multivariante relacionó la edad (OR 1,06, p<0,0003), la glucemia (OR 1,04, p<0,0006), el colesterol total (OR 0,98, p<0,02) y el ácido úrico (OR 1,32, p<0,02) con un EOSS>2. Un análisis de correspondencias agrupó, con un porcentaje explicativo del 78,2%, a los pacientes según su EOSS, comorbilidad, nivel de estudios, situación laboral y capacidad funcional. Conclusiones. La prevalencia de obesidad en pacientes atendidos por Medicina Interna es similar a la de la población general, aunque los pacientes son de mayor edad e IMC. El EOSS es útil para hacer una aproximación integral de los pacientes obesos, independientemente del IMC, lo que puede posibilitar la obtención de mejores resultados en salud y en calidad de vida (AU)

Objectives. To estimate the prevalence of obesity in patients treated by departments of Internal Medicine and to classify the patients according to the Edmonton Obesity Staging System (EOSS). Material and methods. An observational, descriptive cross-sectional study included outpatients older than 18 years, with a body mass index (BMI)>30, from 38 hospitals between the 1st and 14th of February, 2016. We classified the patients according to the EOSS and analysed their clinical, laboratory and demographic variables. A value of P<.05 was considered statistically significant. Results. Of the 1,262 patients treated in consultations, we recruited 298 and analysed 265. The prevalence of obesity was 23.6%, the mean age was 62.47±15.27 years, and the mean BMI was 36.1±5.3kg/m2. According to EOSS stage (0, 1, 2, 3 and 4), the prevalence was 4.9, 14.7, 62.3, 15.5 and 2.64%, respectively. Those patients with EOSS>2 were significantly older and had significantly more comorbidities. The multivariate analysis related age (OR 1.06; P<.0003), blood glucose (OR 1.04; P<.0006), total cholesterol (OR 0.98; P<.02) and uric acid (OR 1.32; P<.02) levels with an EOSS>2. An analysis of correspondence grouped, with an explanatory percentage of 78.2%, the patients according to their EOSS, comorbidity, education level, employment status and functional capacity. Conclusions. The prevalence of obesity in the patients treated by Internal Medicine departments is similar to that of the general population, although the patients are older and have a higher BMI. EOSS is useful for implementing a comprehensive approach for patients with obesity, regardless of the BMI, which can help achieve better health and quality-of-life results (AU)

Prevalence of obesity according to Edmonton staging in the Internal Medicine consultations. Results of the OBEMI study. / Prevalencia de obesidad según la estadificación de Edmonton en las consultas de Medicina Interna. Resultados del estudio OBEMI.

OBJECTIVES: To estimate the prevalence of obesity in patients treated by departments of Internal Medicine and to classify the patients according to the Edmonton Obesity Staging System (EOSS). MATERIAL AND METHODS: An observational, descriptive cross-sectional study included outpatients older than 18 years, with a body mass index (BMI)>30, from 38 hospitals between the 1st and 14th of February, 2016. We classified the patients according to the EOSS and analysed their clinical, laboratory and demographic variables. A value of P<.05 was considered statistically significant. RESULTS: Of the 1,262 patients treated in consultations, we recruited 298 and analysed 265. The prevalence of obesity was 23.6%, the mean age was 62.47±15.27 years, and the mean BMI was 36.1±5.3kg/m2. According to EOSS stage (0, 1, 2, 3 and 4), the prevalence was 4.9, 14.7, 62.3, 15.5 and 2.64%, respectively. Those patients with EOSS>2 were significantly older and had significantly more comorbidities. The multivariate analysis related age (OR 1.06; P<.0003), blood glucose (OR 1.04; P<.0006), total cholesterol (OR 0.98; P<.02) and uric acid (OR 1.32; P<.02) levels with an EOSS>2. An analysis of correspondence grouped, with an explanatory percentage of 78.2%, the patients according to their EOSS, comorbidity, education level, employment status and functional capacity. CONCLUSIONS: The prevalence of obesity in the patients treated by Internal Medicine departments is similar to that of the general population, although the patients are older and have a higher BMI. EOSS is useful for implementing a comprehensive approach for patients with obesity, regardless of the BMI, which can help achieve better health and quality-of-life results.

Hacia un manejo integral del paciente con diabetes y obesidad. Posicionamiento de la SEMI, SED, redGDPS, SEC, SEEDO, SEEN, SEMERGEN y SEMFYC / Position statement of the SEMI, SED, redGDPS, SEC, SEEDO, SEEN, SEMERGEN y SEMFYC

La obesidad y el sobrepeso constituyen la principal causa modificable de diabetes tipo 2 (DM2). En el momento del diagnóstico de la diabetes tipo 2 se debe establecer el grado de obesidad según el índice de masa corporal y, en los pacientes con sobrepeso, determinar el perímetro de la cintura. El adecuado tratamiento de la DM2 requiere un abordaje simultáneo del sobrepeso/obesidad y el resto de factores de riesgo cardiovascular, como la hipertensión, la dislipemia o el tabaquismo. Las intervenciones no farmacológicas (dieta, ejercicio) con beneficio demostrado en la prevención y tratamiento del paciente con DM2 y sobrepeso/obesidad deben seguir un enfoque individualizado y multidisciplinario, con programas estructurados dotados de recursos específicos. La ganancia de peso asociada al tratamiento antidiabético puede dificultar el control glucémico, comprometer la adherencia al tratamiento, empeorar el perfil de riesgo vascular de los pacientes y limitar los beneficios cardiovasculares del tratamiento. Por ello, es importante evitarla; una medida que resulta coste-efectiva. Los fármacos antidiabéticos con beneficios sobre el peso corporal también han demostrado su beneficio en pacientes con un índice de masa corporal<30kg/m2. Globalmente, el tratamiento del paciente con DM2 y obesidad dependerá tanto del grado de obesidad como de la comorbilidad asociada. Los ensayos clínicos de intervención en DM2 deben contemplar objetivos combinados que incluyan no solo el control glucémico, sino otras variables como el riesgo de hipoglucemia y el efecto del tratamiento sobre el peso corporal (AU)

Obesity and excess weight are the main preventable causes of type 2 diabetes (DM2). When diagnosing type 2 diabetes, clinicians should establish the degree of obesity according to the body mass index (BMI) and, for patients with excess weight, measure the waist circumference. The proper treatment of DM2 requires a simultaneous approach to excess weight/obesity and the other cardiovascular risk factors, such as hypertension, dyslipidaemia and smoking. Nondrug interventions (e.g., diet and exercise) have proven benefits in preventing and treating patients with DM2 and excess weight/obesity and should follow an individual and multidisciplinary approach, with structured programs equipped with specific resources. Weight gain associated with antidiabetic treatment can hinder glycaemic control, compromise treatment adherence, worsen the vascular risk profile and limit the cardiovascular benefits of treatment. Therefore, it is significant to avoid weight gain, a measure that can be cost-effective. Antidiabetic drugs with benefits in body weight have also demonstrated their benefit in patients with BMIs <30. In general, the treatment of patients with DM2 and obesity will depend both on the degree of obesity and the associated comorbidity. Clinical trials on DM2 intervention should consider combined objectives that include not only glycaemic control but also other variables such as the risk of hypoglycaemia and the effect of treatment on body weight (AU)

[Primary prevention and treatment of latent tuberculosis infection with isoniazid: efficacy of a control program, 1997-2002]. / Prevención primaria y tratamiento de la infección tuberculosa latente con isoniacida: eficacia de un programa de control, 1997-2002.

OBJECTIVE: To analyze the efficacy of a specific program for the study and follow up of tuberculosis contacts. To study factors related to low adherence to treatment and to the development of liver toxicity caused by isoniazid. PATIENTS AND METHODS: Between December 1996 and December 2002, we found 458 contacts of 79 cases of pulmonary tuberculosis in patients uninfected by human immunodeficiency virus. The contacts were screened for tuberculosis infection and chemoprophylaxis was prescribed according to the recommendations of the Spanish Society of Pulmonology and Thoracic Surgery (SEPAR). RESULTS: We identified 3 cases of tuberculosis among the contacts (prevalence 0.8%). Chemoprophylaxis with isoniazid was prescribed for 215 contacts. One hundred sixty-nine (79%) completed the prophylaxis protocol. The rate of adherence to treatment was lower in immigrants than in nonimmigrants (odds ratio, 3.42; 95% confidence interval, 1.03-11.04; P=.02). Forty-three patients (22%) developed liver toxicity during treatment, which had to be suspended in 3 cases. Duration of chemoprophylaxis was the only independent variable associated with liver toxicity (odds ratio, 3.80; 95% confidence interval, 1.10-13.13; P=.03). CONCLUSIONS: Our study demonstrates the effectiveness of a specific program of study and follow up of tuberculosis contacts. Immigrants require tailored strategies to improve their adherence to the program. The duration of chemo-prophylaxis plays an important role in the development of liver toxicity.

Prevención primaria y tratamiento de la infección tuberculosa latente con isoniacida: eficacia de un programa de control, 1997-2002 / Primary prevention and treatment of latent tuberculosis infection with isoniazid: efficacy of a control program, 1997-2002

OBJETIVO: Analizar la eficacia de un programa específico para el estudio y seguimiento de los contactos de los pacientes con tuberculosis. Evaluar los factores relacionados con una baja adherencia al tratamiento y con el desarrollo de toxicidad hepática por isoniacida. PACIENTES Y MÉTODOS: Entre diciembre de 1996 y diciembre de 2002 se censaron 458 contactos de 79 casos de tuberculosis pulmonar en pacientes sin infección por el virus de la inmunodeficiencia humana. Se realizó cribado de infección tuberculosa y se indicó quimioprofilaxis según la normativa vigente de la Sociedad Española de Neumología y Cirugía Torácica. RESULTADOS: Encontramos 3 casos de tuberculosis entre los contactos (prevalencia del 0,8%). Se indicó quimioprofilaxis con isoniacida en 215 casos. Un total de 169 (79%) completaron el protocolo de quimioprofilaxis. Los inmigrantes mostraron baja adherencia al tratamiento frente a los que no lo eran (odds ratio = 3,42; intervalo de confianza del 95%, 1,03-11,04; p = 0,02). Cuarenta y tres (22%) pacientes presentaron toxicidad hepática durante el tratamiento y en 3 de los casos tuvo que suspenderse. Sólo la duración de la quimioprofilaxis se asoció de forma independiente con el desarrollo de hepatotoxicidad (odds ratio = 3,80; intervalo de confianza del 95%, 1,10-13,13; p = 0,03). CONCLUSIONES: Nuestro estudio demuestra la efectividad de un programa específico de estudio y seguimiento de los contactos de pacientes con tuberculosis. Los inmigrantes requieren estrategias individuales para mejorar su adherencia al programa. La duración de la quimioprofilaxis es un factor importante en el desarrollo de hepatotoxicidad

OBJECTIVE: To analyze the efficacy of a specific program for the study and follow up of tuberculosis contacts. To study factors related to low adherence to treatment and to the development of liver toxicity caused by isoniazid. PATIENTS AND METHODS: Between December 1996 and December 2002, we found 458 contacts of 79 cases of pulmonary tuberculosis in patients uninfected by human immunodeficiency virus. The contacts were screened for tuberculosis infection and chemoprophylaxis was prescribed according to the recommendations of the Spanish Society of Pulmonology and Thoracic Surgery (SEPAR). RESULTS: We identified 3 cases of tuberculosis among the contacts (prevalence 0.8%). Chemoprophylaxis with isoniazid was prescribed for 215 contacts. One hundred sixty-nine (79%) completed the prophylaxis protocol. The rate of adherence to treatment was lower in immigrants than in nonimmigrants (odds ratio, 3.42; 95% confidence interval, 1.03-11.04; P=.02). Forty-three patients (22%) developed liver toxicity during treatment, which had to be suspended in 3 cases. Duration of chemoprophylaxis was the only independent variable associated with liver toxicity (odds ratio, 3.80; 95% confidence interval, 1.10-13.13; P=.03). CONCLUSIONS: Our study demonstrates the effectiveness of a specific program of study and follow up of tuberculosis contacts. Immigrants require tailored strategies to improve their adherence to the program. The duration of chemoprophylaxis plays an important role in the development of liver toxicity

[Appropriate hospitalization in patients with human immunodeficiency virus infection according to the Appropriateness Evaluation Protocol criteria. Factors related to the inappropriateness]. / Adecuación del ingreso hospitalario en pacientes con infección por el virus de la inmunodeficiencia humana según los criterios del Appropriateness Evaluation Protocol. Factores implicados con la inadecuación.

BASIS: To know the factors associated with the inadequate admissions in patients with human immunodeficiency virus (HIV) infection. PATIENTS AND METHODS: The adaptation of 710 hospital admissions of patients with HIV infection through the Appropriateness Evaluation Protocol criteria in two hospitals of the Comunidad Valenciana since 1995 to 1997 was analyzed. RESULTS: One hundred twenty-eight (18%) admissions were considered inadequate. The proportion of inadequate admissions was significantly higher in patients admitted because of constitutional syndrome (OR: 4.12; CI 95%: 2.11-8.05), or because of digestive symptoms (OR: 2.33; CI 95%: 1.46-3.88), and in patients admitted in facilities without day hospital (OR: 2.38; CI 95%: 1.39-3.89). Furthermore, other situations associated with the inappropriateness were the patients with a disease not related to AIDS (OR: 3.13; CI 95%: 1.93-5.08), the patients with oral or esophageal candidiasis (OR: 6.25; CI 95%: 3.08-12.7), the patients with a hospital stay less than 8 days (OR: 2.55; CI 95%: 1.57-4.01), or the patients who no died (OR: 3.61; IC 95%: 1.20-10.82). CONCLUSIONS: The reason for the admission and the availability of a day hospital unit had influence in the inadequate hospital admissions in this study.

Un paciente con xerostomía

La xerostomía es la sensación subjetiva de sequedad bucal debido a la disminución de saliva. Puede afectar hasta a un 30 por ciento de la población general.Aunque en sí misma no es una enfermedad, altera la calidad de vida, especialmente en la población anciana.Suele recibir escasa atención, incluso por los propios médicos y, en ocasiones, el mismo paciente no lo refiere hasta que se pregunta directamente por su existencia. Sin embargo, puede ser el síntoma que oriente de la presencia de enfermedad sistémica, como el síndrome de Sjögren. Las causas más frecuentes son el uso de fármacos xerogénicos, la radioterapia cervical y el síndrome de Sjögren. El diagnóstico inicial de la xerostomía se basa en demostrarla mediante sialometría (flujo salival basal) y el diagnóstico diferencial en la combinación de pruebas dinámicas o funcionales que analizan la reserva salival glandular (flujo salival estimulado, gammagrafía salival) y estructurales (biopsia labial). El primer paso del tratamiento se basa en mantener una hidratación adecuada y evitar el uso de fármacos xerogénicos. El uso de saliva artificial y de fármacos sialogogos como la pilocarpina son la base del tratamiento actual de la xerostomía. (AU)

[Usefulness of cholinesterase determination in ascitic fluid in the differential diagnosis of ascites]. / Utilidad de la determinación de la colinesterasa en líquido ascítico en el diagnóstico diferencial de la ascitis.

BACKGROUND: Cholinesterase is an enzyme mainly synthesized in the liver that might play a role in the differential diagnosis of ascites. We prospectively compared the sensitivity, specificity and diagnostic usefulness of the ascites cholinesterase and the classical parameters, ascites total protein concentration and serum-ascites albumin gradient in the differential diagnosis of ascites. In addition, we evaluated the relationship between those parameters and the degree of liver failure. METHODS: A total of 91 patients with ascites were analyzed. According the final diagnosis, patients were classified in two groups, patients with signs of portal hypertension [n = 78] (60 with chronic liver disease, 5 chronic liver disease and hepatocellular carcinoma, 3 chronic liver disease and spontaneous bacterial peritonitis, 3 chronic liver disease and secondary peritonitis, 7 malignancy with liver involvement) and patients with no signs of portal hypertension [n = 13] (12 patients with peritoneal neoplasia without liver involvement and 1 tuberculous peritonitis). RESULTS: The sensitivity of the test for detecting portal hypertensive ascites was lowest for ascites cholinesterase less than 600 U/L (71.7%); intermediate with ascites total protein concentration less than 25 g/l (87.2%) and highest with serum-ascites albumin gradient at least 11 g/l (93.6%). The specificity for ruling out portal hypertensive ascites was 100 percent for ascites total protein > or = 25 g/l and ascites cholinesterase > or = 600 U/L and, 76.9 percent for serum-ascites albumin gradient < 11 g/l). Diagnostic efficiency (percentage of patients accurately classified) was greater for serum-ascitis albumin gradient (91.2%; IC95: 83-95.8), and lower for ascites total protein content (89%, IC95: 80.3-94.3) and, ascites cholinesterase (75.8%; IC95: 65.5-83.9). Ascites cholinesterase showed a significant relationship (p = 0.007) with the degree of liver failure measured by Pugh's classification. CONCLUSION: Serum-ascites albumin gradient was the test with best performance characteristics to identify patients with ascites related with portal hypertension. Our results suggest that ascites cholinesterase is more associated with the degree of liver failure than with the presence of portal hypertension.

Utilidad de la determinación de la colinesterasa en líquido ascítico en el diagnóstico diferencial de la ascitis / Usefulness of ascities cholinesterase in the differential diagnosis of ascities

En el presente estudio hemos comparado de forma prospectiva la sensibilidad, especificidad y la eficiencia diagnóstica de la colinesterasa en líquido ascítico, la concentración de proteínas totales en líquido ascítico y el gradiente suero-ascitis de albúmina en el diagnóstico diferencial de la ascitis. Asimismo hemos evaluado la asociación entre los parámetros descritos y el grado de insuficiencia hepática. Un total de 91 pacientes consecutivos con ascitis fueron analizados. Los pacientes fueron clasificados según su diagnóstico final en dos grandes grupos: pacientes con signos de hipertensión portal [n=78] (60 pacientes con cirrosis hepática como único hallazgo, 5 con cirrosis hepática y carcinoma hepatocelular, 6 con cirrosis hepática y peritonitis bacteriana espontánea o secundaria y 7 con neoplasia con metástasis hepáticas) y pacientes sin signos de hipertensión portal [n=13] (12 pacientes con neoplasia sin afectación hepática y uno con tuberculosis peritoneal). Los pacientes con cirrosis hepática fueron agrupados por grado de insuficiencia hepática según la clasificación de Pugh. Resultados: La sensibilidad para detectar ascitis asociada a hipertensión portal fue baja para la colinesterasa en líquido ascítico £ de 600 U/L (71,7 porciento; IC95: 60,3-81,1); intermedia para concentración de proteínas totales en líquido ascítico 600 U/L (100 porciento, IC95: 75,3-100) y para concentración de proteínas totales en líquido ascítico =25 g/l (100 porciento; IC95: 75,3-100) y menor para el gradiente suero-ascitis de albúmina < 11 g/l (76,9; IC95: 46,1-93,7). La eficiencia diagnóstica (porcentaje de pacientes correctamente clasificados) fue máxima para el gradiente suero-ascitis de albúmina (91,2 porciento; IC95 83,0-95,8) y menor para la concentración de proteínas en líquido ascítico (89 porciento, IC95: 80,3-94,3) y para la colinesterasa en líquido ascítico (75,8 porciento; IC95: 65,5-83,9). La colinesterasa en líquido ascítico mostró una asociación significativa (p=0,007) con el grado de insuficiencia hepática. Conclusión: El gradiente suero-ascitis de albúmina fue la prueba con mejor rendimiento para identificar los pacientes con ascitis debida a hipertensión portal (AU)

[Fever of unknown origin in patients infected with the human immunodeficiency virus]. / Fiebre de origen desconocido en pacientes infectados por el virus de la inmunodeficiencia humana.

BACKGROUND: To describe the clinical features and the final diagnosis of patients infected with human immunodeficiency virus who presented fever of unknown origin. METHODS: Retrospective study, from November 1989 to January 1994, of all patients infected with HIV who had fever of unknown origin and who were admitted to a community hospital in a Mediterranean area in Alicante (Spain). Fever of unknown origin was defined as fever exceeding 38.3 degrees C lasting for at least three weeks with no diagnosis in the first three days of hospitalization after fulfilling clinical exam, three blood cultures, acid-fast bacilli stain in sputum and chest-X-ray. RESULTS: Of a cohort of 231 patients, 27 (12%) were evaluated because of fever of unknown origin during their follow-up. Patients' mean age was 31 years (interval, 22-75) and intravenous drug use (81%) was the most common risk factor for HIV infection. A total of 31 episodes of fever of unknown origin were reviewed. Twenty-three (74%) episodes occurred in patients with less than 200 CD4 lymphocytes/mm3. A final diagnosis of fever of unknown origin was achieved in 24 (77%) episodes: visceral leishmaniasis (n = 11), tuberculosis (n = 9), non-Hodgkin's lymphoma (n = 1), CNS toxoplasmosis (n = 1), cryptococcal meningitis (n = 1) and drug adverse reaction (n = 1). CONCLUSIONS: HIV-infected patients with fever of unknown origin very often show severe immunodeficiency. Cryptococcal antigen testing should be carried out in the initial evaluation of fever of unknown origin in HIV-infected patients. In our area, 64% of episodes of fever of unknown origin were caused by visceral leishmaniasis or tuberculosis.