[Technical project for the management and functioning of an Internal Medicine care unit]. / Proyecto técnico de gestión y funcionamiento de la unidad asistencial de Medicina Interna.

The Internal Medicine Services have a central role in the medical care in our hospital system both as to the volume of patients attended and their variety, reflecting of the preparation and multi-tasking ability of their professionals. The current norms for coverage of heads-of-service demands the presentation of a management project that must test our knowledge, skills and aptitudes for the clinical and medical management and in order to reflect them in a document of commitment with the management and with our fellows who are a part of the care unit. The person in charge of the service, as boss, agent or leader, is the one who must mark the strategic lines, to indicate the aims, to define the projects, to coordinate the tasks and to evaluate the results with other offers to obtain agreed-upon aims controlling the different points of view. Our professional and social commitment is: sharing clinical management with ethics, quality and welfare safety, to offer our patients (consumer or users) the best results (effectiveness), with useful measurements (efficacy) and with the minors drawbacks and costs (efficiency). The aim of this work is to offer the elements that are necessary for the accomplishment and introduction of a project of clinical management in a service of internal medicine, highlighting its methodology and the most important problems than can arise as well as the possible care alternatives.

[Liver abscesses due to Klebsiella pneumoniae and acute anterior uveitis]. / Abscesos hepáticos por Klebsiella pneumoniae y uveitis anterior aguda.

Liver abscesses are not very frequent and those produced by Klebsiella spp. are quite exceptional. These germs have been related to the development of acute anterior uveitis (AAU) in patients whose susceptibility has been linked to HLA B27. We present a case of a female, HLA B27 negative, who developed AAU during a course of liver abscesses caused by Klebsiella pneumoniae.

[Central motor conduction evaluation in glycogenosis type III]. / Evaluación de la conducción motora central en la glucogenosis tipo III.

We report a 20-year-old man affected by glycogenosis type III with distal muscle weakness, more severe in distal leg muscles. The electromyogram showed myopathic features. Nerve conduction studies and central motor conduction after magnetic stimulation of the brain were normal. Our results suggest that there is no involvement of central motor pathways in this disease.

[Neoplasms of unknown primary site]. / Neoplasias de origen desconocido.

Neoplasms of unknown primary site are tumor diseases, which are diagnosed by the pathologic studies of one of their metastases. The treatment of neoplasms of unknown primary site is not totally established, except in a few situations with specific therapeutical implications, and a better prognosis. The usual treatment of neoplasms of unknown primary site is the empirical chemotherapy with taxanes (paclitaxel or docetaxel) and platines (cisplatin or carboplatin)-based regimens, with different results in the trials.

[Determination of insulin in saliva and its correlation with plasma insulin. Assessment of the possible participation++ of the salivary glands in the production of the hormone]. / Determinación de insulina en saliva y su correlación con la insulina plasmática. Valoración de la posible intervención de las glándulas salivares en la producción de la hormona.

The finding of immunoreactive insulin (IRI) in saliva and an insulin-like protein, similar to pancreatic insulin and with the same biological activities, suggest that both products are pancreatic insulin stored and/or eliminated in the salival manner or an extrapancreatic hormone synthesis, bearing in mind the features which both glands share. The aim of this study is to ascertain whether the amount of insulin from saliva depends on plasmatic insulin and, if so, whether this is a form of elimination. Our results pointed out that the amount of insulin in saliva is similar to the plasmatic insulin in those patients with normal pancreatic function. The oral glucose tolerance test was carried out on 20 patients. The maximum insulin level was produced at the same time as maximum serum glucose level, taking place 60 minutes later. These data, support the concept that salival insulin is a product of the elimination more than synthesis by salival glands, however we can not exclude the possibility of synthesis by the salival gland without direct studies, the ideal test being the immunocytochemist.

[Case finding of iron overload in a university hospital]. / Búsqueda activa de casos de sobrecarga de hierro en un hospital universitario.

BACKGROUND: The epidemiologic importance of iron overload disorders and the clinical lack of its diagnosis led us to an active search of cases among the hospitalized patients in a general university hospital. This situation will make it possible to have a larger and earlier number of diagnosis together with a preventive intervention and an effective treatment. PATIENTS AND METHODS: A transverse study was performed on patients admitted to a fifteen beds ward in the internal medicine department. They have all been applied, without exclusion criteria, the iron metabolism parameters survey. The transferrin saturation (TS), due to its sensitivity, specificity and positive predictive value, has been considered appropriate for the phenotypic screening of the iron overload disorders. Subjects with fasting TS of 45% or more were considered as risk population. RESULTS: The study comprised 117 patients with an average age of 69.9 +/- 15.04. The high-risk population rate was 13.8% with an average age of 60.8 +/- 20.17, as compared to the low-risk population with an average age of 71.3 +/- 13.7 (p < 0.05). The most outstanding illnesses associated to the high-risk population are chronic hepatitis and diabetes mellitus (31.25%). An 18.7% of the cases show undernourishment. CONCLUSIONS: The iron overload is a prevalent illness whose early diagnosis requires a high clinical suspicion. The active search among the hospitalized patients, who have been made a TS, benefits the new cases detection. The TS is a screening technique with a high diagnostic profitability if you evaluate correctly the false positives. For that reason, we think the TS has to be included within the analytic requests which patients are made when admitted to hospital.

[Psoas muscle abscess by Streptococcus agalactiae as a of presentation of fever of unknown origin]. / Absceso del músculo psoas-ilíaco por Streptococcus agalactiae como forma de presentación de fiebre de origen desconocido.

We present the case of a patient with precedents of endometrial carcinoma treated by surgery and radiotherapy, which presented a psoas abscess by Streptococcus agalactiae as cause of fever of unknown origin, which answered favorably to the antibiotherapy and surgical drainage.

[Detection and clinical course of metabolic multiple vascular risk syndrome]. / El descubrimiento y la evolución del síndrome metabólico de multirriesgo vascular.

The potential associations between the factors making up the vascular multi-risk metabolic syndrome (VMMS) or syndrome X (hypertension, diabetes, lipidic disorders, hyperinsulinemia and obesity) are studied: a) in patients with recent cerebral infarct or acute myocardial infarct; b) in patients hospitalized for the management of their hypertension, diabetes or obesity; c) at two years of evolution since the initial diagnosis of hypertension, diabetes or obesity. The results confirm that the VMMS, either complete or incomplete, is detected starting from the clinical management of any of its components (hypertension, diabetes, obesity) or complications (cerebral or myocardial infarct). These results and the ones regarding the evolution at two years of the risk factors associations, allows a discussion of the physiopathologic reality of the VMMS as an entity or a causal association.

[Round pneumonias]. / Neumonías redondas.

Two cases of pneumonia in which the initial radiologic sign was the solitary nodule are presented. The symptoms associated permitted the infectious origin. The clinical and radiological evolution after antibiotic therapy supported the diagnosis of rounded pneumonia. We highlight the need to discard benign lesions causing the solitary nodule, before trying to diagnose other diseases.

[N-acetyl-beta-D-glucosaminidase in jaundice syndrome]. / Estudio del enzima N-acetil-B-D-glucosaminidasa en el síndrome ictérico.

The seric activity of the enzyme NAG (N-acetyl-beta-D-glucosaminidase) was studied in 3 groups of patients with jaundice of different etiology (extrahepatic, intrahepatic and acute hepatitis) and in a control group, in order to observe the discrimination capacity of this enzyme in each group. After the use of a fluorimetric method, the results were exposed, applying the statistical test, comparing different variables; the results are discussed and we conclude that NAG is an enzyme of easy detection and low cost to be included in the group of tests to study the biological pattern of jaundice.

[Paget's disease of bone and basilar impression associated with an Arnold-Chiari type-1 malformation]. / Enfermedad ósea de Paget e impresión basilar asociadas a malformación de Arnold-Chiari tipo I.

The patient, a 78-year-old female with history of headache and progressive gait disturbance for almost one year, was admitted to our department because of dysphagia and dysphonia since three months before. Neurological examination revealed nystagmus, cerebellar ataxia, deafness, and vesical incontinence. No cerebral injuries were detected by computed tomography (CT) scan, although Paget's. Disease of Bone (PDB) was suggested, confirmed by biochemical and scintigraphic studies. The plain skull X-ray showed platybasia. As all the disarrangements were not explained by PDB complications alone, nuclear magnetic resonance imaging (MRI) was performed which demonstrated an Arnold-Chiari malformation (ACM) type I, with mild tonsillar herniation and anterior compression of the brainstem due to basilar impression, without syringomyelia. The association of PDB and ACM is a peculiarity seldom reported. The surgical approach was rejected, but the severity of symptoms and osteitis deformans biochemical activity needed a treatment; it was orientated to modify bone turnover using etidronate, a bisphosphonate, which induced clinical improvement and a decrease in serum alkaline phosphatase as well as in other bone resorption markers, without side effects. The good status and biochemical remission have been maintained a year later.

[Enterococcal infective endocarditis on native aortic valve]. / Endocarditis infecciosa por enterococo sobre válvula nativa aórtica.

Enterococcal endocarditis accounts for 10% of all bacterial endocardits. The infection progresses in a subacute way and when localized on the aortic valve it has a very poor prognosis since the valve is usually destroyed being death the fatal outcome. We report a case of a patient with infective endocarditis resulting from the implantion of the Enterococcus on the native aortic valve. Nor visk factors or an apparent main gate could be found. The patient was hospitalized after several months of a non especific febrile syndrome. The literature is reviewed. Diagnostic tests and clinical signs are discussed making emphasis on the refractoriness to chemotherapy.

[Clinical-endoscopic-histologic correlations in gastric pathology. II]. / Correlaciones clínico-endoscópicas-histológicas en patología gástrica II.

Some authors do not accept as valid the clinical diagnosis of gastritis, due to the latter being mainly an anatomical-pathological term. Others, however, argue that such diagnosis may be establish through a correct anamnesis. A cross-sectional study of a hundred and fifty patients undergoing fibrosgastroscopy with antral biopsy and anamnesis, as well as clinical exploration in accordance with specific protocols, has been conducted. We have concluded that there does not exist as symptomatology associated to a concrete pathology, despite the presence of certain symptoms as, for example, the pain, that may be related with certain pathologies (14/20 of those developing H.H.E.D., 22/34 of those developing UB and 7/10 of those developing neoplasia). We also inferred that many of the patients (46/50) with endoscopic and histological normal findings (20/23), present as many as or more symptoms than those with pathological findings. This symptomatology may be due to a somatic disorder that could be hiding the process.

[Clinical-endoscopic-histological correlations in gastric pathology. I]. / Correlaciones clínico-endoscópicas-histológicas en patología gástrica. I.

We have conducted a blind cross-selectional study with 150 consecutive patients undergoing fibrogastroscopy and biopsy of the antral mucosa. The endoscopic sensitivity for the diagnosis of the several types of gastritis, is low (63%), although this technique is highly sensitive for other types of pathology. Consequently, we conclude that, in all endoscopic explorations, at least one biopsy of the antral mucosa must be done, given the anatomopathological definition of gastritis. In addition, the clinical use of this term should be restricted to the histologically demonstrated cases.

[Characteristics of Kaposi's sarcoma. A retrospective study in a reference hospital]. / Características del sarcoma de Kaposi. Estudio retrospectivo en un hospital de Tercer Nivel.

UNLABELLED: Kaposi's angiosarcoma (SK) is a vascular tumour that affects skin and other organs. Nowadays there is thought that immunosuppression is one of the factors related with its genesis. OBJECTIVES: Show the information corresponding to the distribution of the SK, proportion of subtypes, evolution and therapeutic used. MATERIAL AND METHODS: A 28 cases retrospective study. We obtained the personal background, habits, origin of the VIH when the SK was associated with AIDS, and treatment carry out. Type of SK and location, cutaneous presentation, complications and B symptoms. Treatment, response and adverse effects. Progression of the disease, average time of relapse and survival, and presence of the SK at death. RESULTS: 64% epidemic, 21% classic type and 14% associated with transplants. In 48% of the epidemic cases, the VIH assumed to homosexual habits and 18% to being ADVP. In all there was cutaneous affectation, 46% had affectation of mucouses, 11% adenopathies and 14% visceral extension. 71% received treatment: 40% chemotherapy, 35% radiotherapy and 18% cryotherapy. Progression: 11% became stable, in 50% there was local extension and systemic in 17%. The average survival was of 4.16 +/- 3 years. CONCLUSIONS: SK has a minor incidence in the homosexual population. The high proportion of classic and transplants associated affirm the role of immunosuppression as a predisposing factor. There were numerous local complications that were associated with B symptoms. The cryotherapy was used as the first option in the located forms and in the widespread ones was the chemotherapy.

[Etiology of isolated general malaise]. / Etiología del malestar general aislado.

Isolated general malaise (IGM) is defined as an imprecise sensation of feeling bad, without any other signs or symptoms that suggest even a diagnostic orientation. 137 patients who demanded medical help for IGM were selected and divided into three groups, according to their evolution: IGM of banal or benign cause; IGM of easy or attainable diagnosis; and IGM of difficult or prolonged diagnosis. The 37 patients of the latter group were integrated under the title of Unexplained General Malaise Syndrome (UGMS). The criteria of these syndromes are defined. The patients with UGMS were studied in order to make a diagnosis of its unknown disease, which was achieved in all cases except two. The non-specific symptoms that the patients with UGMS manifest and their relation to final diagnosis are described. When the final diagnosis was made, the number of diagnostic tests used, the time of hospitalisation and the derived economic cost was estimated in each case compared to the corresponding mean data, obtained. Depression as the most frequent aetiology detected in the patients with UGMS, should be the first consideration made in any evaluation.

[Waist/hip ratio and vascular risk factors in obese and not obese individuals]. / Indice cintura/cadera y factores de riesgo vascular en sujetos obesos y no obesos.

Three groups of men and three groups of women were studied, each one of the three corresponding to obese individuals, overweight and not overweight according to the ratio of corporal mass > or = 30, 25-29.9 and < 25 respectively. In each group two subgroups were made following the waist/hip ratio (< 1 and > or = 1 for men and < 0.8 and > or = 0.8 for women). In each subgroup arterial pressure, basal glucemia, cholesterol and plasmic triglycerides, lipoproteins and insulinemia after a higher than normal oral intake of glucose were determined, comparing results according to waist/hip ratio. Practically all the parameters studied showed greater levels of risk in subjects of both sexes with high waist/hip ratio, both in obese individuals and not obese individuals. This shows the possibility that high waist/hip ratio in associated with risk factors in individuals who are not obese, and this association is considered as a "metabolic lipopathy" present in the intraabdominal visceral adipocyte. The measurement of waist/hip ratio must be recommended in all patients and in medical examinations.

[Importance of plasma fibronectin in vascular diseases of diabetic patients]. / Importancia de la fibronectina plasmática en la enfermedad vascular del diabético.

Fibronectin (Fn) is a glycoprotein secreted principally by vascular endothelial cells and its main function is to maintain the adhesion between the various cells and the substrates. Owing to these two features, the glycoprotein participates in several pathologies affecting blood vessels, such as atherosclerosis and diabetes mellitus (DM). In this paper, we studied the quantitative differences of this protein in diabetic patients with associated macro and microangiopathy.

[Subcutaneous panniculitis at a third level hospital retrospective study of 113 cases]. / Paniculitis subcutáneas en un hospital de tercer nivel: estudio retrospectivo de 113 casos.

INTRODUCTION: The panniculitides or hypodermitis are a wide and heterogeneous group of diseases characterized by the presence of subcutaneous inflammatory nodules located generally in low limbs. OBJECTIVES: Show the clinicopathologic characteristics of the cases diagnosed as panniculitis for a 5 years period; their epidemiology, etiopathogenic factors, evolution and treatment. MATERIAL AND METHODS: A retrospective study of 113 patients diagnosed as panniculitis by histopathologic report of cutaneous biopsy since 1997 to 2001 were performed. RESULTS: The sex proportion was of 4.65 women to every man. The mean age of these patients was 49 +/- 20 years old. 100% had legs affectation, 7.1% in arms, 5.9% in trunk and 0.9% in face. 9.7% presented fever and arthromyialgias, especially in young people (p < 0.05). The etiopathogenic factors implied were tuberculosis, streptococcic pharyngoamygdalitis, sarcoidosis and different drugs. The most frequent histological pattern was septal panniculitis without vasculitis. 24.8% did not realize any treatment; 32.5% took nonsteroideal anti-inflammatory drugs; 31.6% potassium iodide; 16% systemic corticosteroids and 7.1% tuberculostatic drugs. Evolution of the patients was good and independently from the treatment performed. CONCLUSIONS: Panniculitides are a group of diseases with similar clinic, but very heterogeneous in their etiology and histopathologic findings. They are more frequent in women and with more expressive clinic in young people. Up to in the 59.3% of the studied cases a causal etiologic agent was identified. These factors are compatible with the published ones in other previous panniculitis series. When a paniculitis is suspected, the most efficient tool is the clinical diagnosis. Histological confirmation by cutaneous biopsy it must be done when it is possible.

[The effect of different variables in the determination of plasma fibronectin in diabetes mellitus]. / Influencia de diversas variables en la determinación de fibronectina plasmática en la diabetes mellitus.

Fibronectin is a high molecular weight glycoprotein which forms part of the basal membrane and is found in plasma that has suffered quantitative alterations during the development of various pathological processes. The aim of this paper is to study, in diabetic patients, the quantitative seric changes of this protein in relation to diabetes mellitus and the influence of different variables (type of diabetes, weight, sex, age, treatment involved, period of evolution and control of the disease according to glycemia and HbA1c).