Neumatoceles en una neumonía extrahospitalaria por Staphylococcus aureus sensible a meticilina / Pneumoceles in out-hospital methicillin-sensitive Staphylococcus aureus pneumonia

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A case of massive hemoptysis related to a smoking-history: an acquired form of the Dieulafoy's disease?

The hypervascularization of the bronquial wall, secondary to chronic bronchopulmonary inflammation is a bleeding etiology in smokers, but insufficient to explain certain massive recurrent cases. We report a case of a woman with a smoking history who presented a recurrent and massive hemoptysis. A diagnostic study with laboratory tests, bronchoscopy, computed tomography and echocardiogram did not identify the etiological cause. However, bronchial arteriography showed right and left bronchial tortuous and dilated arteries and demonstrated that a bronchovascular fistula was the origin of the hemoptysis. An acquired form of the Dieulafoy's disease in this context of a smoking history might justify such findings. Bronchial arteriography as a diagnostic method should be the preferred choice rather than bronchoscopy in these cases.

[The importance of neurological examinations in the age of the technological revolution]. / Importancia de la exploración neurológica en la era de la revolución tecnológica.

INTRODUCTION: Neurologic practice and care have been modified in many important ways during the past ten years, to adapt to the explosion of new information and new technology. Students, residents and practicing physicians have been continuing programs to a model that focuses almost exclusively on the applications to neurologic disorders of the new knowledge obtained from biomedical research. On the other hand high demand for outpatient neurologic care prevents adequate patient's evaluation. CASE REPORTS: Case 1: 65 years old female. Occipital headache diagnosed of tensional origin (normal computerized tomography). Two months later is re-evaluated due to intractable pain and hypoglossal lesion. An amplified computerized tomography revealed a occipital condyle metastasis. Case 2: 21 years old female. Clinical suspicion of demyelinating disease due to repeated facial paresis and sensitive disorder. General exploration and computerized tomography revealed temporo-mandibular joint. Case 3: 60 years old female. Valuation of anticoagulant therapy due to repeated transient ischemic attacks. She suffered from peripheral facial palsy related to auditory cholesteatoma. CONCLUSIONS: Neurologic education is nowadays orientated to new technologies. On the other hand, excessive demand prevents adequate valuation and a minute exploration is substituted by complementary evaluations. These situations generate diagnostic mistakes or iatrogenic. It would be important a consideration of the neurologic education profiles and fulfillment of consultations time recommendations for outpatients care.

Importancia de la exploración neurológica en la era de la revolución tecnológica / The importance of neurological examinations in the age of the technological revolution

Introducción. Durante la última década hemos asistido a una importante modificación de la neurología en la práctica clínica debido a la explosión de nueva información y nuevas tecnologías en el ámbito de las neurociencias. La formación de los estudiantes y los especialistas en formación, así como la enseñanza posgraduada, están orientadas a esas nuevas tecnologías, y dejan en segundo plano la medicina clínica tradicional. Por otro lado, la masificación de las consultas ambulatorias impide una adecuada evaluación de los pacientes. Casos clínicos. Caso 1: Mujer de 65 años con cefalea occipital diagnosticada de origen tensional (tomografía axial computarizada normal). Dos meses después se reevalúa por dolor intratable y afectación del XII nervio craneal. Se amplía el estudio por neuroimagen y se detecta metástasis en el cóndilo occipital. Caso 2: Mujer de 21 años, sospechosa de enfermedad desmielinizante por parálisis faciales de repetición y trastorno sensitivo facial. La exploración y la tomografía axial computarizada temporomandibular detectan una luxación mandibular. Caso 3: Mujer de 60 años remitida para una valoración de la anticoagulación por isquemias transitorias de repetición. Se descubre parálisis facial periférica asociada a un colesteatoma con invasión del canal facial. Conclusiones. La formación en neurología, en la actualidad, concede una gran importancia a las nuevas tecnologías. Por otra parte, la masificación de las consultas externas impide una adecuada valoración del enfermo y, en muchas ocasiones, se sustituyen una historia y una exploración clínicas minuciosas por pruebas complementarias. Esto conlleva la comisión de errores diagnósticos, tanto por exceso (falsos positivos) como por defecto (falsos negativos), o que se dé yatrogenia terapéutica. Sería importante la reevaluación de los programas docentes y el cumplimiento de las recomendaciones mínimas de tiempo de visita (AU)

Introduction. Neurologic practice and care have been modified in many important ways during the past ten years, to adapt to the explosion of new information and new technology. Students, residents and practicing physicians have been continuing programs to a model that focuses almost exclusively on the applications to neurologic disorders of the new knowledge obtained from biomedical research. On the other hand high demand for outpatient neurologic care prevents adequate patient’s evaluation. Case reports. Case 1: 65 years old female. Occipital headache diagnosed of tensional origin (normal computerized tomography). Two months later is re-evaluated due to intractable pain and hypoglossal lesion. An amplified computerized tomography revealed a occipital condyle metastasis. Case 2: 21 years old female. Clinical suspicion of demyelinating disease due to repeated facial paresis and sensitive disorder. General exploration and computerized tomography revealed temporo-mandibular joint. Case 3: 60 years old female. Valuation of anticoagulant therapy due to repeated transient ischemic attacks. She suffered from peripheral facial palsy related to auditory cholesteatoma. Conclusions. Neurologic education is nowadays orientated to new technologies. On the other hand, excessive demand prevents adequate valuation and a minute exploration is substituted by complementary evaluations. These situations generate diagnostic mistakes or iatrogeny. It would be important a consideration of the neurologic education profiles and fulfillment of consultations time recommendations for outpatients care (AU)

Intussusception: the accuracy of ultrasound-guided saline enema and the usefulness of a delayed attempt at reduction.

BACKGROUND/PURPOSE: The aim of this study was to evaluate the therapeutic value of ultrasound (US)-guided saline enema for intussusception and the usefulness of a delayed attempt after at least 30 minutes when reduction has not been complete. METHODS: One hundred ninety-five cases of intussusception were diagnosed with ultrasonography. US-guided saline hydrostatic reduction was performed in 194 with an additional attempt after at least 30 minutes in those cases in which only partial resolution had been achieved. The method was changed (the volume of the reservoir bag and the caliber of the catheter were increased) so we analyze two different periods; 85 cases are included in the first period and 110 in the second. RESULTS: The global rate of successful reduction was 81.9% (159 of 194 cases), and it raised to 88.2% (97 of 110 cases) in the second period. In 15.5% cases (30 of 194) reduction was achieved in a delayed attempt at least 30 minutes after the initial partial resolution. The rate of recurrence was 9.7%. No perforation was seen. CONCLUSIONS: The accuracy of US-guided saline enema in achieving intussusception reduction is high, similar to other methods, avoiding radiation exposure. A delayed attempt after a period of rest increases the rate of reductions.

Intussusception: trapped peritoneal fluid detected with US--relationship to reducibility and ischemia.

PURPOSE: To determine the frequency and meaning of fluid inside the intussusception at ultrasound (US) and its relationship to irreducibility and ischemia. MATERIALS AND METHODS: US enabled the diagnosis of intussusception in 145 cases. Shape and axial diameters of the area of fluid were determined. US-guided hydrostatic reduction was attempted in 144 cases. RESULTS: Fluid was present in the intussusception in 20 cases (14%) and appeared on axial images as an anechoic crescent between both serosal layers of the enfolded and everted intussusceptum. No cystic structural anomaly was detected at surgery. Rates of reduction were 89% (111 of 125) in cases without fluid and 26% (five of 19) in cases with fluid (P < .001). At surgery, ischemia was absent in all 14 cases without fluid and present in 10 of 20 cases with fluid; necrosis was present in two cases with fluid. Areas of fluid greater than 14 x 5 mm, especially if associated with fluid in the dilated apex of the intussusception, were strongly related to irreducibility and ischemia (odds-likelihood ratio, 67.5). CONCLUSION: Fluid seen inside the intussusception represented trapped peritoneal fluid. Substantial amounts of fluid were associated with irreducibility and ischemia.