Fracaso renal atípico / Atypical renal failure

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Tuberculosis and immigration in an area of southwest Madrid.

OBJECTIVE: To describe differences between Spanish and immigrant tuberculosis (TB) cases. DESIGN: Retrospective descriptive study of Spanish and immigrant TB patients diagnosed in a Madrid hospital from 2004 to 2013. RESULTS: A total of 322 patients were analysed, 183 Spanish-born and 139 immigrants (sub-Saharan Africa 32.4%, Morocco 28.8%, Latin America 20.1% and Eastern Europe 17.3%). Immigrants were younger and had a higher rate of human immunodeficiency virus (HIV) infection (P < 0.05). Spanish TB patients were often smokers and immunosuppressed (not HIV) (P < 0.001). No differences in symptoms and site of disease were detected. A higher proportion with isoniazid (INH) resistance was observed among immigrants (14.6% vs. 3.8%, P < 0.05), regardless of country of origin. Being an immigrant was an independent risk factor for INH resistance (OR 4.8, 95%CI 1.3-17.9). CONCLUSION: There is currently no consensus on whether or not it would be appropriate to treat Spanish and immigrant patients with different regimens. Being an immigrant is a clear risk factor for INH resistance. According to our results, it is necessary to evaluate the impact of changing treatment protocols in Madrid, Spain. It is also important to introduce specific strategies for the management of TB among immigrants.

A risk score for prediction of recurrence in patients with unprovoked venous thromboembolism (DAMOVES).

BACKGROUND: In patients with unprovoked venous thromboembolism (VTE), the optimal duration of anticoagulation is anchored on estimating the risk of disease recurrence. We aimed to develop a simple risk assessment model that improves prediction of the recurrence risk. METHODS: In a prospective cohort study, 398 patients with a first unprovoked VTE were followed up for a median of 21.3months after discontinuation of anticoagulation. We excluded patients with a strong thrombophilic defect. Preselected clinical and laboratory variables were analyzed based on the independent confirmation of the impact on the recurrence risk, simplicity of assessment, and reproducibility. Multivariable Cox regression analysis was used to develop a recurrence score that was subsequently internally validated by bootstrap analysis. RESULTS: A total of 65 patients (16.3%) had recurrent VTE. In all patients, VTE recurred spontaneously. Male sex (HR=2.89 [95% CI 1.21-6.90] P=0.016), age (HR=1.0310 per additional decade [95% CI 1.01-1.07] P=0.011), obesity (HR=3.92 [95% CI 1.75-8.75] P=0.0001), varicose veins (HR=4.14 [95% CI 1.81-9.43] P=0.0001), abnormal D-dimer during anticoagulation (HR=13.66 [95% CI 4.74-39.37] P=0.0001), high factor VIII coagulant activity (HR=1.01 [95% CI 1.00-1.02] P=0.028) and heterozygous of factor V Leiden and/or Prothrombin G20210A mutation (HR=13.86 [95% CI 5.87-32.75] P=0.0001) were related to a higher recurrence risk. Using these variables, we developed a nomogram [hereafter referred to as DAMOVES score (D-dimer, Age, Mutation, Obesity, Varicose veins, Eight, Sex)] for prediction of recurrence in an individual patient. CONCLUSIONS: The DAMOVES score can be used to predict recurrence risk in patients with a first unprovoked VTE and may be useful to decide whether anticoagulant therapy should be continued indefinitely or stopped after an initial treatment period of at least 3months.

Cistatina C como marcador precoz de lesión renal aguda en el shock séptico / Cystatin C as an early marker of acute kidney injury in septic shock

Objetivo: Describir la utilidad de la determinación de la concentración plasmática de cistatinaC en el diagnóstico precoz de la lesión renal aguda en el shock séptico. Pacientes y métodos: Serie prospectiva de 50 pacientes ingresados en una unidad de cuidados intensivos con shock séptico y creatinina plasmática <2mg/dl. Seguimiento clínico y analítico con determinaciones de cistatinaC, urea y creatinina plasmáticas desde el diagnóstico del shock séptico hasta 5días más tarde. Su gravedad se valoró con la escala RIFLE. Resultados: Veinte pacientes (40%) desarrollaron lesión renal aguda: 8 (16%) RIFLE «R», 5 (10%) RIFLE «I» y 7 (14%) RIFLE «F». Todos los RIFLE «F» precisaron depuración renal extracorpórea. Fallecieron 18 pacientes (36%); de ellos 8 (20%) habían desarrollado lesión renal aguda en su evolución. Hubo una correlación pobre entre creatinina y cistatinaC plasmáticas (r=0,501; p=0,001), que desaparecía cuando se alcanzaba cualquier grado de deterioro renal en la escala RIFLE. La cistatinaC se elevaba antes e identificaba mejor que la creatinina y la urea a aquellos pacientes que iban a desarrollar un deterioro severo de su función renal (RIFLE «F») y sus valores iniciales se relacionaban con la mortalidad a los 30días (OR=1,16; IC95%: 0,03-0,85). Conclusiones: En los pacientes que desarrollan lesión renal aguda séptica la cistatinaC plasmática se incrementa antes que los marcadores clásicos de función renal. Además constituye un biomarcador de severidad que se correlaciona con la evolución a RIFLE «F», la necesidad depuración extrarrenal y la mortalidad. Esta precocidad puede ser útil para instaurar medidas que eviten la progresión de la disfunción renal (AU)

Objective: To describe the utility of determining plasma cystatinC concentrations in the diagnosis of acute incident kidney injury in septic shock. Patients and methods: Prospective series of 50 patients with septic shock and plasma creatinine levels <2mg/dL hospitalized in an intensive care unit. Clinical and laboratory follow-ups were conducted, with measurements of cystatinC, urea and plasma creatinine levels from the diagnosis of septic shock to 5days later. The severity of the septic shock was assessed with the RIFLE scale. Results: Twenty patients (40%) developed acute kidney injury: 8 (16%) were categorized as RIFLE-R, 5 (10%) as RIFLE-I and 7 (14%) as RIFLE-F. All patients categorized as RIFLE-F required extracorporeal renal clearance. Eighteen (36%) patients died, 8 (20%) of whom had developed acute kidney injury in their evolution. There was poor correlation between plasma creatinine and cystatin C levels (r=.501; P=.001), which disappeared upon reaching any degree of renal impairment on the RIFLE scale. CystatinC levels increased earlier and were better able to identify patients who would develop serious renal function impairment (RIFLE-F) than creatinine and urea levels. The initial cystatinC levels were related to mortality at 30days (OR=1.16; 95%CI: 03-.85). Conclusions: For patients who developed acute septic kidney injury, the plasma cystatinC levels increased before the classical markers of renal function. CystatinC also constitutes a severity biomarker that correlates with progression to RIFLE-F, the need for extrarenal clearance and, ultimately, mortality. This precocity could be useful for starting measures that prevent the progression of renal dysfunction (AU)

Cystatin C as an early marker of acute kidney injury in septic shock. / Cistatina C como marcador precoz de lesión renal aguda en el shock séptico.

OBJECTIVE: To describe the utility of determining plasma cystatinC concentrations in the diagnosis of acute incident kidney injury in septic shock. PATIENTS AND METHODS: Prospective series of 50 patients with septic shock and plasma creatinine levels <2mg/dL hospitalized in an intensive care unit. Clinical and laboratory follow-ups were conducted, with measurements of cystatinC, urea and plasma creatinine levels from the diagnosis of septic shock to 5days later. The severity of the septic shock was assessed with the RIFLE scale. RESULTS: Twenty patients (40%) developed acute kidney injury: 8 (16%) were categorized as RIFLE-R, 5 (10%) as RIFLE-I and 7 (14%) as RIFLE-F. All patients categorized as RIFLE-F required extracorporeal renal clearance. Eighteen (36%) patients died, 8 (20%) of whom had developed acute kidney injury in their evolution. There was poor correlation between plasma creatinine and cystatin C levels (r=.501; P=.001), which disappeared upon reaching any degree of renal impairment on the RIFLE scale. CystatinC levels increased earlier and were better able to identify patients who would develop serious renal function impairment (RIFLE-F) than creatinine and urea levels. The initial cystatinC levels were related to mortality at 30days (OR=1.16; 95%CI: 03-.85). CONCLUSIONS: For patients who developed acute septic kidney injury, the plasma cystatinC levels increased before the classical markers of renal function. CystatinC also constitutes a severity biomarker that correlates with progression to RIFLE-F, the need for extrarenal clearance and, ultimately, mortality. This precocity could be useful for starting measures that prevent the progression of renal dysfunction.

Fiebre en Urgencias: detección de patología grave / Fever in Emergency Department: screening for severe disease

Fundamento y objetivo. Conocer las variables que se asocian a la patología grave en los pacientes adultos con fiebre en Urgencias. Material y métodos. Estudio prospectivo observacional. Se recogieron datos de todos los pacientes adultos con fiebre (temperatura axilar superior a 37,7 °C) atendidos en el área médica del Servicio de Urgencias de nuestro hospital entre el 28 de enero al 30 de abril de 2006. Las variables recogidas se incluyeron en un análisis de regresión logística, siendo la variable dependiente principal «enfermedad grave». En función del riesgo correspondiente se asignó una puntuación a cada variable que permitiera diseñar una escala de riesgo de enfermedad grave. Resultados. Se atendieron 11.271 pacientes, de los cuales 786 tenían fiebre (7,0%). La edad media fue 39 años (37-40), 57% varones, 13% inmigrantes. Ingresaron un 31% y presentaron patología grave un 27%. En función de los datos clínicos se sospechó focalidad respiratoria alta en 309 (39%) y baja en 130 (17%), foco abdominal en 117 (15%), foco urinario en 40 (5%) y sin foco aparente en 145 (18%). Se asociaron a patología grave comorbilidad (odds ratio [OR] 3,6; intervalo de confianza [IC]95% 1,8-7,2) (4 puntos), proteína C reactiva (PCR) superior a 10 mg/dl (OR 1,8; IC95% 1,1-3,7) (2 puntos), edad (OR 1,02; IC95% 1,01-1,04) (edad superior a 60 años 3 puntos) y fue factor protector la fiebre de probable origen respiratorio alto (OR 0,4; IC95% 0,2-0,9) (fiebre de otro foco 3 puntos). Tenían patología grave el 3% de los pacientes con menos de 3 puntos y el 72% de los que tenían más de 7 puntos. Conclusiones. En los adultos con fiebre en Urgencias la presencia de comorbilidad, un nivel de PCR superior a 10mg/dl, la focalidad diferente a una infección de las vías respiratorias altas y la edad se asociaron a una patología grave (AU)

Background. To identify variables associated to severe disease in adult patients with fever in the Emergency Department. Material and methods. Observational, perspective study. Data from all the adult patients with fever (axillary temperature 37.8 °C or higher) seen in the medical area of the Emergency Department was collected from January 28th to April 30th of 2006 and included in a logistic regression analysis, the dependent variable being «severe disease». Based on the corresponding risk, a score was assigned to each variable to design a risk of severe disease model. Results. A total of 11271 patients were seen, 786 (7.0%) of whom had fever. Median age was 39 years (37-40), 57% male. Of these, 31% were admitted and 27% had severe disease. Based on the symptoms and signs, upper airways infection was suspected in 309 (39%) and lower airways infection in 130 (17%), abdominal infection in 117 (15%), urinary tract infection in 40 (5%) and no source of infection in 145 (18%). Comorbidity (OR 3.6, 95% CI -1.8-7.2) (4 points), C-reactive protein higher than 10 mg/dl (OR 1.8, 95% CI 1.1-3.7) (2 points) and age (OR 1.02, 95% CI 1.01-1.04) (age older than 60 years 3 points) were associated with severe disease. Fever having a probable upper respiratory origin was a protector factor (OR 0.4, 95% CI 0.2-0.9) (fever from other foci 3 points). Three percent of the patients with less than 3 points had severe disease versus 72% with more than 7 points. Conclusions. Comorbidity, C-reactive protein higher than 10 mg/dl, age and suspicion of source of infection different of upper airways infection were associated to severe disease in adults with fever in the Emergency Department (AU)

Tratamiento antimicrobiano en la exacerbación de la enfermedad pulmonar obstructiva crónica / Antimicrobial therapy in exacerbations of chronic obstructive pulmonary disease

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Ictericia progresiva en varón de 56 años / Progressive ictericia in a 56 years old man

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Inmunodeficiencia ¿idiopática? de linfocitos T-CD4: a propósito de un caso

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[Hypokalemia-induced paraplegia secondary to acute diarrhea]. / Paraplejia por hipopotasemia secundaria a diarrea aguda.

Hypokalemia can give a variety of syntomatology but more often courses without it or with inespecific clinical manifestations. In our enviroment the etiology of hypokalemia is wide but one of the most common causes in third world countries are diarrheas. We describe a case of severe hypokalemia due to acute diarrhea which was manifested with severe neurologic symtoms but improves with conventional treatment.

Lumbalgia incapacitante en mujer de 53 años / Disabling lumbar pain in a 53-year old woman

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Paraplejia por hipopotasemia secundaria a diarrea aguda / Hipokalemic paraplegia due to acute diarrhea

La hipopotasemia puede dar una clínica variada pero es frecuente que curse de forma asintomática o con síntomas inespecíficos si es de escasa cantidad. En nuestro medio las causas de la hipopotasemia son variadas pero una de las etiologías más frecuentes en paises en vías de desarrollo son los cuadros diarreicos. Presentamos un cuadro de hipopotasemia severa debida a diarrea que se manifestó con intensa clínica neurológica pero que mejoró espectacularmente con tratamiento habitual. (AU)

Supervivencia en un caso de intoxicación por etilenglicol con acidemia extrema

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