Abdomen agudo ni médico ni quirúrgico: Reflexiones sobre la medicina basada en evidencias / Acute abdominal pain of difficult diagnosis: Report of one case and reflections about evidence based medicine

Evidence based medicine is strongly positioned in medical practice. However we must remember that it should be just a part of our knowledge and skills and that a close relationship with our patients is essential. I report a 52 years old male that presented with abdominal pain in the right upper quadrant lasting seven days, that started after participating in a celebration dinner. Abdominal ultrasound was normal and biochemical tests were within normal limits. An upper gastrointestinal endoscopy showed a toothpick that was perforating the gastric wall. The toothpick was withdrawn and the pain subsided. The patient was discharged asymptomatic three days later.

Hemorragia pulmonar secundaria a una reactivación tardía de un síndrome de Churg-Strauss en un paciente en hemodiálisis crónica: Report of one case / Late reactivation of Churg-Strauss syndrome

We report a 22 years old male with chronic allergic rhinitis, who presented with asthma, prolonged fever, eosinophilia, cutaneous vasculitis, subcutaneous nodules, polyarthritis, ulcers in the nasal mucosa and external auditory canal, hematuria, proteinuria, renal failure, severe hypertension, pulmonary infiltrates and mesenteric ischemia with a perforation of the sigmoid colon. Arteriography showed multiple aneurysmae of intrarenal arteries and a skin biopsy showed a leukocytoclastic vasculitis. A diagnosis of Churg-Strauss syndrome was made. He was initially treated with steroids and cyclophosphamide but abandoned therapy. Eighteen years after the onset of the disease, he required hemodialysis. Eight months after being on dialysis, he suffered a reactivation of the disease with lung hemorrhage and finally died, due to an upper gastrointestinal bleeding caused by a duodenal ulcer.

La muerte: un momento de paz y de confianza / Death as a moment of peace and trust

A young woman with aphagia, probably caused by an esophageal cancer that could not be confirmed, is reported. Fully respecting the will of the patient at the end of her life, palliative care measures were instituted, even though the diagnosis was uncertain. This case emphasizes the integrative role of internists and the difficulty of making decisions about life and death without being in close touch with desires of our patients.

El internista: un ser humano ayudando a otro: de la formación y ejercicio clínico de la profesión / The internist: a human being that helps others: on the training and clinical practice of the specialty

This is a critical overview of an internist with 33 years of practice, about the activities which are inherent to internal medicine. The author analyzes strategies on how to keep updated in the scientific literature, the importance of acquiring experience from peers and teachers and emphasizes the value of an adequate patient-physician relationship.

Viremia VHC e infección por virus herpes zoster en un paciente en hemodiálisis tratada con eritropoietina / VHC viremia and herpes zoster infection in a patient in hemodialysis treated with erythropoietin

Hepatitis C virus infection in chronic hemodialysis patients is associated with several unresolved problems. We report a 85 years old female patient in chronic hemodialysis and treated with erythropoietin, that during the course of an Herpes zoster, presented severe malaise, weight loss and muscle weakness. Two weeks later, a slight rise in serum transaminases was detected. The patients had a negative antibodies for HIV and hepatitis C virus and negative hepatitis B surface antigen. A PCR test was positive for serum hepatitis C virus RNA. The patient's condition deteriorated and she died 7 days after admission. Erythropoietin administration, whose immunosupressive effect has been reported previously, could have influenced the dismal outcome of this patient

¿Qué es indispensable para la vigilancia y control de una diálisis crónica adecuada? / What is indispensable for the surveillance and control of adequate chronic dialysis

Se estudiaron prospectivamente 2 poblaciones de pacientes en diálisis crónica controlados con dos modalidades diferentes de programas de exámenes. La mayor parte del tiempo el agua de diálisis fue tratada con deionizador/osmosis reversa. El grupo A con 44 pacientes, edad promedio de 58 +/- 15.4 años, tiempo en dialisis de x 31.9 +/-22.5 meses fue controlada con un programa restringido el que incluía medición mensual de hemoglobina, trimestral de calcemia, fosfemia, calemia y fosfatasas alcalinas; anual de paratohormona y radiografía de manos y de marcadores virales cada 6 meses. El grupo B con 31 pacientes, edad promedio 56.9 +/- 13.8 años, tiempo en díalisis de promedio 33.8 +/- 30.5 meses fue controlado con un programa amplio y frecuente de exámenes. El porcentaje de diabéticos fue similar en ambos grupos. No hubo diferencia significativa en la mortalidad (18.1 por ciento para el A y 29 por ciento para el B, NS) hospitalizaciones (064/pacientes/año para el A y 1.5 para el B, NS), transfusiones (1.1 transfusiones/pacientes/año para el A y 1.5 para el B, NS) y administración de eritropoietina (9 por ciento de los pacientes del grupo A y 9.6 por ciento del B, NS). Un paciente de cada grupo desarrolla síndrome urémico por causas evidentes y específicas. En el grupo B se comprobó una mayor incidencia de hipercalemia asintomática como consecuencia de la medición mensual de este parámetro. Concluímos que disponiendo de un adecuado tratamiento del agua de díalisis y conociendo los marcadores virales de los pacientes a su ingreso es posible el control adecuado del tratamiento mediante un programa muy reducido de exámenes lo que disminuye costos y racionaliza su solicitud. Al esquema propuesto debe agregarse la medición frecuente de la potasemia por su valor en el diagnóstico de hipercalemia asintomática

Suspensión del tratamiento de diálisis crónica / Discontinuation of chronic dialysis

Chronic dyalisis was discontinued in 11 patients with end stage renal disease. Most patients were diabetics of old age and all had presented a variety of acute medical complications. The patient initiated the decision in 2 cases, the medical team in 4 and the medical team and family in 5. Five patients were mentally incompetent when the decision was made