[Focused cardiac ultrasound in internal medicine]. / Ecocardiografía clínica básica en medicina interna.

Focused cardiac ultrasound is a noninvasive technique which can be performed by the internist. It is capable of providing useful, rapid and accurate information about the structure and function of the heart. It can be used to complement anamnesis and physical examination at the bedside. Clinicians may be able to determine left and right ventricular diameter and function, detect the presence of significant pericardial effusion, identify important valvular defects and estimate the central venous pressure by measuring the diameter and collapsibility of inferior vena cava with good accuracy after a short training period. The aim of focused cardiac ultrasound is not to perform a complete echocardiogram but using previous mentioned data, it is possible to expedite diagnosis and optimize the management of patients with cardiovascular diseases.

Diploma on Ultrasound training and competency for Intensive Care and Emergency Medicine: Consensus document of the Spanish Society of Anesthesia (SEDAR), Spanish Society of Internal Medicine (SEMI) and Spanish Society of Emergency Medicine (SEMES). / Documento de consenso de la Sociedad Española de Anestesiología y Reanimación (SEDAR), Sociedad Española de Medicina Interna (SEMI) y Sociedad Española de Medicina de Urgencias y Emergencias (SEMES) para la definición de competencias mínimas de ecografía en Cuidados Intensivos y Urgencias y la obtención del Diploma acreditativo.

The use of ultrasound as a clinical diagnostic tool and guide of bedside procedures has become an indispensable examination in the acute critically ill patient. The training of professionals in minimum skills of knowledge, management and indications of use of ultrasound required to be defined by the Scientific Societies. The Intensive Care Ultrasound Working Group of the Spanish Society of Anesthesiology and Resuscitation (SEDAR), of the Spanish Society of Internal Medicine (SEMI) and the Spanish Society of Emergency Medicine (SEMES) has developed this consensus document in which the recommended training program and the minimum competencies to be achieved with regard to the use of Ultrasound in Intensive Care, Anesthesia and Emergency medicine are defined. This document defines the training program and the skills to acquire in order to achieve the diploma in lung, abdominal and vascular ultrasound. This document can serve as a guide to define the skills to be acquired in the training programs of residents (MIRs) of specialists working in intensive care, anesthesia, and emergency medicine.

Pegylated interferon induced interstitial pneumonitis in a patient with hepatitis C infection.

Pegylated interferon and ribavirin is the treatment of choice in patients with chronic hepatitis C infection. The most common side effects of interferon therapy are flu-like symptoms and psychiatric disorders. Pneumonitis is a less frequent complication associated with non-negligible mortality. We herein report a case of interferon associated pneumonitis in a patient with non-severe clinical symptoms and a normal chest radiography. Physicians should be aware of this entity during the differential diagnosis of respiratory symptoms in patients receiving treatment with interferon due to its high morbimortality and good resolution and outcome after drug withdrawal.

[Blood cultures when fever?]. / Si fiebre, ¿hemocultivos?

A 78-year-old man was referred from his residency where he lives to the emergency division due to general deterioration and frequent falls in the last week. His personal history is remarkable for arterial hypertension and diabetes. Two weeks before he needed a vesical catheterism that was traumatic and profilactic ciprofloxacin was prescribed. On physical exploration he appears disoriented, blood pressure is 9/40 mm Hg, cardiac rythm 120 beats per minute, temperature 37,3 °C and 24 respirations per minute. He appears to have pain on his upper left abdomen cuadrant. When the nurse gets a peripheral vein she asks, ¿should I obtain hemocultures?

[Appropriateness of empiric antibiotic therapy in urinary tract infection in emergency room]. / Adecuación del tratamiento empírico de la infección urinaria en urgencias.

INTRODUCTION: To describe characteristics of urinary tract infections attended in an Emergency Department. To assess antibiotic prescription and inappropriate treatment implications. METHODS: Adults patients attended in an Emergency Department during 2 months with UTI confirmed with urocultive were included. Appropriate antibiotic treatment was considered if the first antibiotic used was sensitive. We compared patients with appropriate and inappropriate antibiotic treatment. A logistic regression was performed to evaluate variables associated to inappropriate antibiotic treatment. RESULTS: A total of 151 patients were included (61% women, 67.1[22.3] years). Comorbidity was present in 63% of patients. Urinary sepsis was the most frequent diagnosis (32.5%). E coli was isolated in 65.6% of cases, and 10% presented bacteremia. Percentage of inappropriate antibiotic treatment was 20.5. It was associated (uncontrolled analysis) with male gender, elder patients, recent urinary simptoms, urologic manipulation more than 1 month ago, previous antibiotic use (especially ciprofloxacin or amoxicillin-clavulanate) and presentation with urinary sepsis. Logistic regression analysis showed association only with age (HR 0.978 per year, CI95% 0.957-1, p=0.029) and previous antibiotic use (HR 0.298, CI95% 0.098-0.901, p=0.05). Patients with inappropriate antibiotic treatment did not have higher mortality. CONCLUSIONS: Inappropriate antibiotic treatment for UTI in Emergency Department is relatively frequent and it is associated to older age and previous antibiotic use.

Clinical ultrasonography in the decision-making process in medicine point-of-care ultrasound in clinical decision making. / Ecografía clínica en el proceso de toma de decisiones en medicina.

Clinical ultrasonography has undergone significant development in recent years due to its considerable usefulness and equipment miniaturisation, which have enabled its use at the point of care. Clinical ultrasonography is a tool that supplements the classical anamnesis and physical examination, thereby increasing the practitioner's diagnostic power. This tool can be employed in numerous clinical scenarios and can be applied at all steps when making decisions about the patient. In the hands of the general practitioner, ultrasonography of the various areas of the body (multiorgan ultrasonography) optimises not only the diagnostic capacity but also the prognostic stratification and monitoring of progress after treatment has been applied. As with the systematic nature of conventional physical examinations, we need to establish an ultrasound examination protocol that supplements the physical examination, thereby redefining and boosting the classic examination.

Clinical ultrasonography in chronic obstructive pulmonary disease. / Ecografía clínica en la enfermedad pulmonar obstructiva crónica.

COPD is a highly prevalent disease and one of the most common reasons for hospitalization in Internal Medicine departments. COPD also has significant associated morbidity and mortality. In recent years, multiorgan clinical ultrasonography (pulmonary, cardiac and vascular) has emerged as a tool of considerable usefulness in managing patients with COPD in numerous situations, including the differential diagnosis of dyspnoea of uncertain origin, the assessment of the aetiology in episodes of exacerbation, detecting concomitant heart failure or associated pulmonary hypertension and as support in managing cardiovascular risk factors such as subclinical atherosclerosis. This study summarises the most important evidence regarding this approach and proposes future scenarios for the use of ultrasonography that will help improve the diagnosis, prognostic estimations and the selection of the optimal treatment for this type of patient.

Utility of lateral flow tests in SARS-CoV-2 infection monitorization.

OBJECTIVE: The diagnosis of SARS-CoV-2 infection is crucial for medical and public health reasons, to allow the best treatment of cases and the best control of the pandemic. Serology testing allows for the detection of asymptomatic infections and 19-COVID cases once the virus has been cleared. We analyzed the usefulness of the SARS-CoV-2 rapid test of Autobio and tried to correlate its pattern with the severity of COVID19 infection. METHODS: We analyzed the accuracy and clinical usefulness of a point-of-care IgM and/or IgG test for SARS-CoV-2 in 35 COVID-19 patients [12 (34.3%) mild-moderate and 23 (65.7%) severe-critical] admitted to a field hospital in Madrid, as well as in 5 controls. RESULTS: The mean time from the first day of symptoms to the antibody test was 28 days (SD: 8.7), similar according to the severity of the disease. All patients with SARS-CoV-2 PCR+ showed the corresponding IgG positivity, while these results were negative in all control individuals. A total of 26 (74%) cases also presented with positive IgM, 19 (83%) were severe-critical cases and 7 (58%) were mild-moderate cases. The IgM response lasted longer in the severe critical cases (mean: 29.7 days; SD: 8.4) compared to the moderate cases (mean: 21.2 days; SD: 2.0).. CONCLUSIONS: Rapid serology tests are useful for the diagnosis of patients with COVID-19 (mainly IgG detection) and may also be correlated with the severity of the infection (based on IgM detection).

Positioning document on incorporating point-of-care ultrasound in Internal Medicine departments. / Documento de posicionamiento sobre la incorporación de la ecografía clínica en los servicios de Medicina Interna.

This positioning document describes the most important aspects of clinical ultrasonography in the internal medicine setting, from its fundamental indications to the recommended training period. There is no question as to the considerable usefulness of this tool in the standard clinical practice of internists in numerous clinical scenarios and settings (emergencies, hospital ward, general and specific consultations and home care). Ultrasonography has a relevant impact on the practitioner's ability to resolve issues, increasing diagnostic reliability and safety and providing important information on the prognosis and progression. In recent years, ultrasonography has been incorporated as a tool in undergraduate teaching, with excellent results. The use of ultrasonography needs to be widespread. To accomplish this, we must encourage structured training and the acquisition of equipment. This document was developed by the Clinical Ultrasonography Workgroup and endorsed by the Spanish Society of Internal Medicine.

Mortality among adult patients admitted to the hospital on weekends.

BACKGROUND: Some reports have shown that the risk of death is higher for patients admitted on weekends than for patients who go into the hospital on weekdays. This study was conducted to assess what independent influence, if any, weekend admission might have on mortality in our hospital. METHODS: The clinical data of 35,993 adult (>14 years) patients admitted to the emergency department of Fundación Hospital Alcorcón from 1999 to 2003 were analyzed. We compared global mortality and mortality within the first 48 h according to whether the patients were admitted on the weekend or on a weekday. Elective admissions, critical care patients, children under 14 and births were not included. RESULTS: Global mortality was similar in both groups, but mortality within the first 48 h was higher for patients admitted on the weekend (OR 1.40, 95% CI 1.18-1.62, P<0.001), even after controlling for age, gender and comorbidity (weight of diagnosis-related group and Charlson comorbidity index). CONCLUSION: The risk of mortality within the first 48 h is higher for patients admitted on weekends than for patients admitted on a weekday.

[Kikuchi-Fujimoto disease: report of two cases]. / Enfermedad de Kikuchi-Fujimoto: descripción de dos casos.

Kikuchi-Fujimoto disease, described for the first time in 1972, is an unusual diagnosis that is characterized by lymph node enlargement and fever. Cervical lymph nodes are affected so often that ENT specialists should be aware of this entity during differential diagnosis. The diagnosis was done by histological features, necrotizing lymphadenitis. The disease is self-limited and it has good prognosis. We have reviewed two cases in our hospital. We report an aseptic meningoencephalitis as a rare complication.

[Anaemia predicts mortality in heart failure]. / La anemia es un factor pronóstico de mortalidad en la insuficiencia cardiaca.

BACKGROUND: Anaemia frequently coexists with heart failure. Few studies have examined the impact of anaemia on mortality in this population. OBJECTIVE: To assess the prevalence of anaemia in patients with heart failure in an Internal Medicine Unit and its potential effects on mortality. MATERIAL AND METHODS: We evaluated the electronic medical records of 272 patients with heart failure that fulfilled the criteria admitted to the Internal Medicine Unit of Fundación Hospital Alcorcón (Madrid, Spain)between July and December 2003. Uni and multivariate logistic regression analysis for predictors of mortality. RESULTS: Most patients were women (71%), mean age was 82.1+/-9 years, 106 (39.9%) had anaemia (serum haemoglobin levels<12 g/dL), 69 (25%) had renal failure (serum creatinine levels>1.5 mg/dL and 154 patients (57%) had atrial fibrillation. There were 41 deaths (15%). The frequency of anaemia was higher and the haemoglobin levels were lower in the patients who died (65% vs 36%, and 11.2+/-2.4 g/dL vs 12.6+/-2.1g/dL, p<0.001 for both). Increased serum creatinine was also associated with mortality (1.8+/-0.8 vs 1.3+/-0.8 mg/dL p<0.001). Age, gender, atrial fibrillation or the aetiology of heart failure were not associated with mortality in univariate analysis. In contrast, by multivariate logistic regression analysis, haemoglobin (odds ratio [OR] 0, 78 per g/dL, 95%confidence interval [CI] 0.66- 0.923 p<0.01), New York Heart Association functional classification (OR 2.2, 95% Cl 1.2-3.9 p<0.01), and serum creatinine (OR 1.5 per mg/dL, 95% CI 0.98-2.31 p=0.06) were independent predictors of mortality. CONCLUSIONS: Anaemia is a frequent problem among patients with heart failure and it is a significant independent risk factor for death.

Cardiovascular news 2013/2014. / Novedades cardiovasculares 2013/2014.

During 2013 and the first months of 2014, numerous studies have been published in the cardiovascular field. New guidelines have appeared for managing arterial hypertension and reducing cardiovascular risk by lowering cholesterol levels. New data have emerged on the considerable lipid-lowering efficacy of monoclonal antibodies against PCSK-9, in contrast, however, to the clinical trials directed towards raising HDL-cholesterol with nicotinic acid, which have not shown a reduction in the rate of cardiovascular complications. In the field of hypertension, neither stent placement in patients with renovascular hypertension nor sympathetic denervation in patients with resistant hypertension has been shown to be effective in reducing blood pressure. In terms of antithrombotic treatment, the pharmacogenetic tests do not seem useful for maintaining patients anticoagulated with warfarin within the therapeutic range for longer periods. Moreover, there is increasing evidence that, for patients with coronary artery disease and atrial fibrillation, antiplatelet therapy adds no benefit to anticoagulation therapy and is associated with a greater risk of bleeding. Lastly, a Mediterranean diet could prevent the onset of diabetes, while bariatric surgery could be a reasonable option for improving the disease in patients with obesity. Many of these studies have immediate practice applications in daily clinical practice.

Assessing clinical probability of organic disease in patients with involuntary weight loss: a simple score.

BACKGROUND: Involuntary weight loss (IWL) is a frequent complaint with a difficult diagnosis. Any one of a number of different diseases may be the source of the symptom. However, there is no universal clinical protocol that can help physicians study this complex syndrome. METHODS: In March 1998, we defined a diagnostic protocol for the study of IWL. IWL was defined as an involuntary and documented weight loss of at least 5% of the usual body weight in the previous 3 months. We analyzed 78 consecutive patients with IWL who came to our clinic between March 1998 and December 2000. RESULTS: An organic disease was found in 56% of cases; cancer, metabolic and digestive diseases were the most common entities. Psychiatric problems were found in 33% of cases. After extensive study, an idiopathic group of 11% was identified. The variables that were independently predictive of a final diagnosis of organic disease were: age>50 years (OR: 8.6, CI 95%: 1.7-43.6), psychiatric symptoms (OR: 0.2, CI 95%: 0.1-0.8), smoking (OR: 14.3, CI 95% 2.3-74), the presence of guide symptoms (OR: 8.0, CI 95%: 1.8-34.4), and anemia (OR: 3.1, CI 95%: 2.5-387). Sixteen percent of the patients died, more often those suffering from organic diseases. Based on multivariate regression coefficients, a clinical risk score was established. CONCLUSIONS: IWL is a complex and frequent syndrome with a 16% rate of mortality during the first year. A protocol based on clinical data can help in the management of IWL. Our clinical prediction rule may help physicians to identify those patients with IWL who are likely to have an underlying organic disease.