Dolor y aumento de diámetro de extremidad inferior izquierda / No disponible

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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

[A retroperitoneal mass in a young patient]. / Masa retroperitoneal en paciente varón joven.

A tumor of germinal cells should be considered in the differential diagnosis of a retroperitoneal mass in a young patient. Although, this kind of tumors are relatively uncommon, inducing less than 1% of all the tumors in the masculine sex, very often they may present as a retroperitoneal mass clinically characterized by a lumbar pain that sometimes may simulate a renal colic. Occassionally, physical examination of the testis may reveal a mass. Moreover, even in advanced stages the prognosis of germ cell tumor is favorable, and there are a series of tumor markers very helpful for the diagnosis and follow up of the tumor. We report a patient with a retroperitoneal mass presenting clinically as a renal colic.

Masa retroperitoneal en paciente varón joven / A retroperitoneal mass in a young patient

Ante el hallazgo de una masa en retroperitoneo en un paciente joven se debe tener en cuenta entre los diferentes diagnósticos posibles, el tumor de células germinales. Estos tumores aunque son relativamente infrecuentes, constituyendo menos del 1% de todos los tumores en el sexo masculino, no es raro que debuten con masa retroperitoneal que simulan clínicamente un cólico renal o/y dolor lumbar. Siempre se debería realizar exploración de genitales externos aunque en un porcentaje no despreciable no encontramos masa testicular. Además el pronóstico es favorable, incluso en estadios avanzados, en un alto porcentaje, y poseemos una serie de marcadores tumorales útiles para el diagnóstico y seguimiento. Presentamos el caso de un paciente con clínica de cólico renal y masa retroperitoneal a estudio

A tumor of germinal cells should be considered in the differential diagnosis of a retroperitoneal mass in a young patient. Although, this kind of tumors are relatively uncommon, inducing less than 1% of all the tumors in the masculine sex, very often they may present as a retroperitoneal mass clinically characterized by a lumbar pain that sometimes may simulate a renal colic. Ocassionally, physical examination of the testis may reveal a mass. Moreover, even in advanced stages the prognosis of germ cell tumor is favorable, and there are a series of tumor markers very helpful for the diagnosis and follow up of the tumor. We report a patient with a retroperitoneal mass presenting clinically as a renal colic

[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.

[Quality management in patients with heart failure inside an Internal Medicine Department]. / Calidad del manejo de pacientes con insuficiencia cardiaca en el Servicio de Medicina Interna.

OBJECTIVE: To evaluate the quality management of Heart failure within an Internal Medicine Department, based in quality criteria settled in ACOVE study. METHODS: Retrospective study reporting 267 patients admitted to our Internal Medicine Department with a diagnosis of heart failure (from January 2001 to January 2001). We applied ACOVE protocol to evaluate quality of management assigning a positive numerical score to every accomplished section and a negative score to those sections that were not carried out. RESULTS: Two hundred and sixty seven patients and their clinical records were evaluated (Mean age 76 +/- 9 years, male 50%). They had a mean score of 6.72 +/- 1.33 points. Heart failure etiology was determined in 82% (33% ischemic heart failure, 30% hypertensive heart disease, 12% valvulopathy and 7% others). ACE-Inhibitors/ARA II were used in 66% of patients, with poor utilization of beta-blockers (16%), calcium channel blockers (7%) and class I antiarrhythmic drugs (1%). 94% of patients had written instructions about manage of their disease. Only 36% of patients had an echocardiography study. In patients with atrial fibrillation, 19% were treated with oral anticoagulants and 26% with anti-platelet drugs. In-hospital mortality rate was 4%. We could not meet differences among different physicians and their gender in department of Internal Medicine treating for heart failure, however the score of patients older 70 years was 6.5 +/- 1.38 points while score in younger to years was 7.15 +/- 1.17 points (p = 0.011). CONCLUSIONS: Management of heart failure in our department of Internal Medicine is acceptable. However, there are several points in which improvement could be reached, much as to increase the utilization of ACE inhibitors and beta-blockers in handling of heart failure and to rise the are of echocardiography in the evaluation of these patients. Moreover, older patients showed a lower quality level that could be improved.

Crisis convulsiva por bupropión / Convulsions in association with bupropion

No disponible

[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.

Calidad del manejo de pacientes con insuficiencia cardiaca en el Servicio de Medicina Interna / Quality management in patients with Herat failure incide and internal medicine department

Objetivo: Evaluar la calidad asistencial de los pacientes ingresados en nuestro Servicio de Medicina Interna con diagnóstico de insuficiencia cardiaca, basándonos en una serie de criterios de calidad recogidos en el estudio ACOVE. Métodos: Análisis retrospectivo mediante protocolo de datos de 267 informes de alta de pacientes ingresados en Medicina Interna en los que uno de los diagnósticos fue el de insuficiencia cardiaca (periodo de enero 2001- enero 2002). Resultados: Valoramos 267 informes de alta (edad media 76 +/-9, siendo varones el 50%). Respecto al estudio ACOVE la puntuación media obtenida fue de 6,72 +/- 1,33. Se determinó las causas de insuficiencia cardiaca en el 82% de los casos (33% isquémico-dilatada, 30% hipertensiva, 12% valvular y 7% otras). El empleo de IECAS/ARA 11 se realizó en el 66% de los pacientes, con escasa utilización de otros fármacos como los Beta-bloqueantes (16%), calcioantagonistas (7%) y antiarrítmicos de clase I (1 %). El 94% de los pacientes recibieron instrucciones breves acerca del manejo de su enfermedad. Sólo un 36% presentaban estudio ecocardiográfico. Ellos pacientes con fibrilación auricular, el 19% fueron tratados con anticoagulación y el 26% con antiagregación. La mortalidad intrahospita-laria fue de un 4%. En el estudio, no hubo diferencias de puntuación entre los diferentes staff del departamento en el manejo de la insuficiencia cardiaca. Así mismo, tampoco se hallaron diferencias en relación al sexo. La edad fue un factor a tener en cuenta: > 70 años, score 6,5 +/- 1,38; < 70 años, score 7,15 +/- 1,17 (p = 0,011).Conclusiones: El manejo de la insuficiencia cardiaca en nuestro servicio de M.Interna es aceptable. Sin embargo, existen importantes puntos donde se debería mejorar, como el aumento de la utilización de lECA S y b-bloqueantes en la insuficiencia cardiaca y el incremento en el uso de la ecocardiografía. Además, en los pacientes de edad avanzada se ha demostrado que el nivel de calidad alcanzado es inferior, lo cual deberemos mejorar

Objective: To evaluate the quality management of Heart failure within an Internal Medicine Department, based in quality criteria settled in ACOVE study. Methods: Retrospective study reporting 267 patients admitted to our Internal Medicine Department with a diagnosis of heart failure (from lanuary 2001 to lanuary 2001). We applied ACOVE protocol to evaluate quality of management assigning a positive numerical score to every accomplished section and a negative score to those sections that were not carried out. Results: Two hundred and sixty seven patients and their clinical records were evaluated (Mean age 76 +/- 9 years, male 50%). They had a mean score of 6,72 +/- 1.33 points. Heart failure etiology was determined in 82% (33% ischemic heart failure, 30% hypertensive heart disease, 12% valvulopathy and 7% others). ACE-Inhibitors/ARA 11 were used in 66% of patients, with poor utilization of beta-blockers (16%), calcium channel blockers (7%) and class 1 antiarrhythmic drugs (1 %). 94% of patients ha4 written instructions about manage of their disease. Only 36% of patients had an echocardiography study. In patients with atrial fibrillation, 19% were treated with oral anticoagulants and 26% with anti-platelet drugs. Inhospital mortality rate was 4%. We could not meet differences among different physicians and their gender in department of Internal Medicine treating for heart failure, however the score ofpatients older 70 years was 6.5 +/- 1.38 points while score in younger to years was 7.I5 +/- 1.17 points (p = 0.011). Conclusions: Management of heart failure in our department of Internal Medicine is acceptable. However, there are several points in which improvement could be reached, much as to increase the utilization of ACE inhibitors and beta-blockers in handling of heart failure and to rise the are of echocardiography in the evaluation of these patiens. Moreover, older patients showed a lower quality level that could be improved

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