[Pneumonitis associated to methotrexate]. / Neumonitis secundaria a metotrexate.

Methotrexate (MTX) is a folic acid antagonist that inhibits cellular reproduction. MTX has been shown to be an effective anti-inflammatory agent. Acute interstitial pneumonitis is the main pulmonary side effect during MTX treatment. We report a case of MTX pneumonitis in a 56-year old woman with autoimmune thrombocytopenia who presented with subacute nonproductive cough, dyspnea at rest, fever, and malaise. Chest roentgenogram demonstrated bilateral diffuse interstitial and alveolar infiltration. Infectious diseases were ruled out and methotrexate-induced pneumonitis was suspected. MTX was discontinued and methylprednisolone was prescribed. Patient improved progressively. After eight weeks, radiologic abnormalities and symptoms had disappeared.

Positron emission tomography: useful in detecting metastatic cancer of unknown primary site.

Metastatic cancer of unknown primary site represents approximately three percent of all new cancer diagnoses. Expensive and invasive diagnostic procedures are often performed although the primary tumour is detected in less than 25 percent of cases. We present a 63-year-old woman presenting with low back pain and was found on positron emission tomography (PET) to have lung cancer. The pros and cons of PET in the diagnostic process of patients with metastatic cancer of unknown primary site are reviewed. PET should be considered in the diagnostic process of patients with unknown primaries, and unnecessary invasive procedures may be avoided.

[Influence of age in mortality of patients with heart failure]. / Influencia de la edad en la mortalidad de pacientes con insuficiencia cardiaca.

OBJECTIVE: Heart failure (HF) is one of the most frequent diagnosis in Internal Medicine Units. High age of patients is an important characteristic in these admissions. Our objective was to evaluate how age interact with mortality, to medium-term, in HF after a decompensated episode. METHOD: Through the patient medical record we obtained data about patients hospitalised in a Internal Medicine Unit, with HF diagnosis, for a year (from September 2000 to August 2001) and their survival at 1st January 2003. 215 patients were reviewed. RESULTS: During follow-up, 60 patients died (27.9% of overall). In elderly patients, we observed a higher number of women and less use of echocardiography and treatment with beta-blockers and warfarin (in patients with atrial fibrillation). In Cox proportional-hazards model, age (OR 1.043 IC 95% 1.002-1.085), days of hospitalization (OR 1.04 IC 95% 1.003-1.078), diabetes mellitus (OR 2.51 IC 95% 1.37-4.60) and do not prescribe warfarin in patients with atrial fibrillation (OR 2.71 IC 95% 1.10-6.60) were independent prognostic factors. CONCLUSIONS: Age was an important prognostic factor in patients with HF. Clinical trials should be done in patients with these characteristics. So, we can know better clinical evolution of HF in this population.

[Asymptomatic aortic valve stenosis and sudden death]. / Estenosis aórtica asintomática y muerte súbita.

Dyspnea, angor and syncope are the most characteristic symptoms in stenosis aortic valve disease. Sudden death, as part of natural history of symptomatic stenosis aortic valve, is well know. On the other hand, sudden death in asymptomatic stenosis aortic valve is rarer. Different guidelines recommend a conservative management of these patients. We present here the case of a 58 year old woman, previously healthy, who arrived at Hospital because of sudden dyspnea at rest. The patient was diagnosed of pulmonary edema and died two hours later. Necropsy showed a stenosis aortica valve with a valve area of less than 0.8 cm2. We make a short review in medical literature about the incidence of sudden death in asymptomatic stenosis aortic valve, the risk groups and their management.

[Acute poisoning in patients over 65 years of age]. / Intoxicaciones agudas en pacientes mayores de 65 años.

BACKGROUND: There are few Spanish studies on acute poisoning in the elderly despite the associated risk factors of this group of patients. MATERIAL AND METHODS: Retrospective descriptive study of acute poisonings treated in the Emergency Service of the University Hospital of Zaragoza from 1995 to 2009 on patients 65 years old or older. RESULTS: A total of 762 patients were selected in the study (4.74% of all acute poisonings) with a mean age of 74.16 (SD ± 6) years. Ingestion was the major route of exposure (85%) and alcohol overdose (28,7%) was the most frequent type of poisoning. A trend was also observed showing a lower emetic treatment and gastric lavage and an increase in activated charcoal. Benzodiazepines (14.3%) and toxic household products (11%) with caustic properties were also the main toxics found in the study. CONCLUSIONS: Acute poisonings in the elderly required more hospitalizations, have a higher mortality and more autolytic attempts which result in death.

[Nephritic colic management in an emergency room of a referral hospital]. / Manejo del cólico renal en urgencias de un hospital de tercer nivel.

BACKGROUND: To evaluate the diagnostic and therapeutic management of patients with nephritic colic in a referral hospital, their monitoring and the incidence of alternative diagnoses. METHODS: This is a retrospective review of 182 randomly selected patients who presented a clinical diagnosis compatible with nephritic colic in a referral hospital. In these cases initial treatment, monitoring and alternative diagnoses have been evaluated. RESULTS: Fifty-five point four percent of the patients were male, the mean age was 47.7 years and 40% of the cases were in spring. Urinalysis was carried out in every patient (62.7% dipstick and 72% urinary sediment); they were pathological in over 70%. In 26.4% of cases renal function deteriorated, always transiently. Abdominal radiography (81.9%) was the most frequently diagnostic test performed, followed by ultrasound (25.8%). Treatment included a serum therapy in 31.3%; metamizol (61%) was the most commonly used analgesic followed by ketorolac (44.5%). More than one non-steroidal anti-inflammatory was used by 46.2%. Hospital admission was required by 24 patients, and 5 of them needed emergency surgery. Twenty-four point one percent of patients had relapses during the next six months. Forty-one point six percent were referred to urology discharge on from the emergency room. Eighteen point one percent of patients had alternative diagnoses; acute pyelonephritis was the most frequent of these (55%). CONCLUSIONS: In our work we found a significant variation in the diagnostic and therapeutic management of these patients. The use of clinical guidelines could help us to unify the management of patients with nephritic colic, both in the emergency room and on discharge. Due to the high prevalence of alternative diagnoses, we have to systematically exclude more serious diseases.

Intoxicaciones agudas en pacientes mayores de 65 años / Acute poisoning in patients over 65 years of age

Fundamento: Los estudios sobre la intoxicación aguda en sujetos de edad avanzada en nuestro país son escasos, a pesar de los riesgos asociados que presenta este grupo de pacientes. Material y métodos: Estudio descriptivo retrospectivo de las intoxicaciones agudas atendidas en el servicio de Urgencias del Hospital Clínico Universitario de Zaragoza entre 1995 y 2009, en pacientes con edad igual o mayor a 65 años. Resultados: Se registraron 762 casos, el 4,74% del total de intoxicados, con una edad media de 74,16 (SD ± 6) años. La vía oral fue la más frecuente (85%) y por tipo de intoxicación, la sobredosis de alcohol (28,7%). Junto a éste, las benzodiacepinas (14,3%) y los productos cáusticos (11%) fueron los principales tóxicos involucrados. El 21% de los pacientes recibieron tratamiento específico antitóxico, no precisando ingreso el 82,4%. Se observó en la evolución temporal una tendencia que apuntaba a la disminución del tratamiento emético y del lavado gástrico y un aumento del carbón activado. La mortalidad de la serie fue del 1,04%. Conclusiones: Las intoxicaciones en pacientes mayores presentan una mayor morbimortalidad, precisando más ingresos y más tentativas autolíticas con resultado de muerte (AU)

Background: There are few Spanish studies on acute poisoning in the elderly despite the associated risk factors of this group of patients. Material and methods: Retrospective descriptive study of acute poisonings treated in the Emergency Service of the University Hospital of Zaragoza from 1995 to 2009 on patients 65 years old or older. Results: A total of 762 patients were selected in the study (4.74% of all acute poisonings) with a mean age of 74.16 (SD ± 6) years. Ingestion was the major route of exposure (85%) and alcohol overdose (28,7%) was the most frequent type of poisoning. A trend was also observed showing a lower emetic treatment and gastric lavage and an increase in activated charcoal. Benzodiazepines (14.3%) and toxic household products (11%) with caustic properties were also the main toxics found in the study. Conclusions: Acute poisonings in the elderly required more hospitalizations, have a higher mortality and more autolytic attempts which result in death (AU)

Lack of clinical usefulness of interleukin-6 in long-term follow-up of acutely decompensated heart failure.

INTRODUCTION: Interleukin-6 (IL-6) has been identified as a predictor of death, new heart failure (HF) episodes and need for heart transplantation in patients with advanced HF. The aim of this study was to examine the relationship between plasma IL-6 levels in patients with decompensated HF and either survival or new admissions due to HF. METHODS: We studied 111 patients admitted due to decompensated HF. Long-term survival was assessed from the day of admission to the hospital to the day of death or new admissions due to HF. RESULTS: The mean IL-6 concentration was 90 +/- 115 pg/ml (range 1.5-743 pg/ml). There were no differences in IL-6 concentration with regard to age, gender and cause of HF. At the end of follow-up period, 22 patients (20 percent) had died due to causes related to HF and 54 patients (48 percent) had been readmitted to the hospital due to new HF episodes. Using regression analyses, serum IL-6 levels were not identified as a prognostic factor. Systolic dysfunction, previous diagnosis of HF and diabetes mellitus were independent predictors of death. CONCLUSION: These findings suggest that a single measurement of serum IL-6 in patients with decompensated HF lacks clinical usefulness in long-term follow-up.

[Spontaneous pneumomediastinum]. / Neumomediastino espontáneo.

Spontaneous pneumomediastinum (defined by the presence of free air in the mediastinum) is an infrequent entity that is presented in the absence of diseases or precipitating factors. It generally affects young and healthy males. Thoracic pain, dyspnea, or both, are the most frequent symptoms. Other signs and symptoms are subcutaneous emphysema and Hamman's sign. Simple radiography of the thorax allows for the diagnosis in a high percentage of patients. Conservative treatment is indicated in these patients and has a favourable prognosis. Relapses are infrequent.

Manejo del cólico renal en urgencias de un hospital de tercer nivel / Nephritic colic management in an emergency room of a referral hospital

Fundamento. El objetivo del presente trabajo es conocerlas características epidemiológicas, el manejo diagnóstico yterapéutico, su seguimiento y la incidencia de diagnósticosalternativos en una muestra de pacientes diagnosticados decólico renal en el Servicio de Urgencias de un Hospital detercer nivel.Material y métodos. Estudio descriptivo retrospectivo de182 pacientes seleccionados aleatoriamente que consultanpor clínica compatible con cólico renal en un hospital detercer nivel, valorando su manejo inicial, seguimiento al altay diagnósticos alternativos.Resultados. El 55,4% fueron varones, la edad media fue de47,7 años y el 40% de los casos se produjeron en primavera.En todos los pacientes se realizó analítica urinaria (62,7%tira reactiva y 72% sedimento) apareciendo alteraciones enmás del 70%. La función renal se deterioró en el 26,4 % delos casos, siempre de forma transitoria. La prueba de imagenrealizada con más frecuencia fue la radiografía de abdomen(81,9%) seguida de la ecografía (25,8%). El tratamiento incluyófluidoterapia en el 31,3% y el analgésico más usado fue elmetamizol (61%) seguido del ketorolaco (44,5%). El 46,2% delos pacientes necesitó más de un analgésico. Un total de 24pacientes precisaron ingreso hospitalario y 5 de ellos cirugíaurgente. El 24,1% presentó recaídas en los seis meses posteriores.El 41,6% fue remitido al Servicio de Urología al alta. El18,1% presentaron diagnósticos alternativos, siendo la pielonefritisaguda el más frecuente de ellos (55%).Conclusiones. Hemos detectado una importante variaciónen el manejo diagnóstico y terapéutico de estos pacientes.El uso de guías clínicas debe permitirnos unificar el manejodel paciente con cólico renal tanto en urgencias como posteriormente.El alto porcentaje de diagnósticos alternativosnos obliga a descartar sistemáticamente patologías másgraves(AU)

Background. To evaluate the diagnostic and therapeuticmanagement of patients with nephritic colic in a referralhospital, their monitoring and the incidence of alternativediagnoses.Methods. This is a retrospective review of 182 randomly selectedpatients who presented a clinical diagnosis compatiblewith nephritic colic in a referral hospital. In these casesinitial treatment, monitoring and alternative diagnoses havebeen evaluated.Results. Fifty-five point four percent of the patients weremale, the mean age was 47.7 years and 40% of the cases werein spring. Urinalysis was carried out in every patient (62.7%dipstick and 72% urinary sediment); they were pathologicalin over 70%. In 26.4% of cases renal function deteriorated,always transiently. Abdominal radiography (81.9%) was themost frequently diagnostic test performed, followed by ultrasound(25.8%). Treatment included a serum therapy in 31.3%;metamizol (61%) was the most commonly used analgesic followedby ketorolac (44.5%). More than one non-steroidal anti-inflammatory was used by 46.2%. Hospital admission wasrequired by 24 patients, and 5 of them needed emergencysurgery. Twenty-four point one percent of patients had relapsesduring the next six months. Forty-one point six percentwere referred to urology discharge on from the emergencyroom. Eighteen point one percent of patients had alternativediagnoses; acute pyelonephritis was the most frequent ofthese (55%).Conclusions. In our work we found a significant variationin the diagnostic and therapeutic management of these patients.The use of clinical guidelines could help us to unifythe management of patients with nephritic colic, both in theemergency room and on discharge. Due to the high prevalenceof alternative diagnoses, we have to systematicallyexclude more serious diseases(AU)

[Acute transverse myelopathy associated to S. aureus: a difficult differential diagnosis]. / Mielopatía transversa aguda asociada a S. aureus: la dificultad del diagnóstico diferencial.

Acute myelopathy includes a group of diseases with an important associated morbidity, thus early diagnosis and treatment is important. The most frequent etiology is extramedullary compression. Magnetic resonance (MR) is the most suitable procedure in this type of disease since it also offers information on extramedullar lesions and makes it possible to assess spine involvement. We present the case of a 57 year-old man who was admitted because of back pain for several weeks and systemic infection due to S. aureus. Later, he suffered a sudden neurological deficit with spine involvement but without compressive images on the MRI. We discuss the differential diagnosis among intramedullary abscess, epidural abscess, acute transverse myelitis and spondylodiscitis associated to acute myelopathy. We carry out a brief review of the medical literature on diagnosis criteria of those entities.

Neumomediastino espontáneo / Spontaneus pneumomediastinum

El neumomediastino espontáneo (definido por lapresencia de aire libre en el mediastino) es una entidadinfrecuente que se presenta en ausencia de enfermedadeso factores precipitantes. Generalmente afecta a varonesjóvenes y sanos. El dolor torácico, la disnea o ambosson los síntomas más frecuentes. Otros síntomas y signosson el enfisema subcutáneo y el signo de Hamman.La radiografía simple de tórax establece el diagnósticoen un alto porcentaje de pacientes. El tratamiento conservadorestá indicado en estos pacientes y tiene un pronósticofavorable. Las recidivas son infrecuentes

Spontaneous pneumomediastinum (defined by the ;;presence of free air in the mediastinum) is an infrequent ;;entity that is presented in the absence of diseases or ;;precipitating factors. It generally affects young and ;;healthy males. Thoracic pain, dyspnea, or both, are the ;;most frequent symptoms. Other signs and symptoms ;;are subcutaneous emphysema and Hamman’s sign. Simple ;;radiography of the thorax allows for the diagnosis in ;;a high percentage of patients. Conservative treatment is ;;indicated in these patients and has a favourable prognosis. ;;Relapses are infrequent

Dolor abdominal en paciente con bulimia nerviosa / Abdominal pain in bulimic patient

La incidencia de bulimia nerviosa ha cobrado importancia en los países occidentales en las últimas décadas. La dilatación gástrica aguda es un proceso muy grave e infrecuente en pacientes sin antecedentes de enfermedad digestiva. Sin embargo, se han descrito casos en pacientes con alteraciones de la conducta alimentaria, especialmente después de ingestas compulsivas. Las complicaciones de la dilatación gástrica aguda son la necrosis isquémica del órgano y la perforación que pueden conducir a una situación de shock irreversible. El diagnóstico precoz y la evacuación gástrica, incluso en fases incipientes de isquemia y necrosis pueden evitar la realización de una laparotomía. Se debería realizar una cuidadosa investigación de los hábitos alimentarios con objeto de ofertar un tratamiento precoz. Presentamos el caso de una mujer de 24 años que padecía bulimia nerviosa e ingresó por una dilatación gástrica aguda y revisamos las características más importantes de esta entidad (AU)

The incidence of bulimia nervosa has attained significance in the last decades in the Western countries. Massive gastric dilatation is a very serious condition that is extremely rare in patients with no background of gastrointestinal disease. However, several cases have been reported in patients with eating disorders, particularly after a compulsive ingestion. Complications of acute gastric dilatation are infarction and perforation with severe and irreversible shock. Prompt diagnosis of acute gastric dilatation and decompression of the stomach even when gastric ischemia and mucosal necrosis is present may avoid unnecessary laparotomy. Careful investigation of eating habits may result in therapeutic gastric emptying at an earlier stage. We present a case of a 24-year old woman who suffered bulimia nervosa and was admitted because of acute gastric dilatation. We review the most important features of this condition (AU)