[The Strategic Plan for the development of Internal Medicine in Andalusia]. / El Plan Estratégico para el desarrollo de la Medicina Interna en Andalucía.

The Strategic Plan for the Development of Internal Medicine in Andalusia arose from the need that the internal medicine doctors had to redefine the purpose and values of their specialty to cope with the numerous changes occurring in the health care area. The project was developed in three phases. First, the tendency of the health care system and current position of the specialty were analyzed. After, the internal and external opinions on the present-future of Internal Medicine were checked out. Finally, five strategic lines with their action plans were established. Specific objectives were defined within each line: results to be achieved, methodology according to action plan. After several years of collegial work in this initiative, very positive results have been achieved. We conclude that the Strategic Plan has been useful to better define the position of our specialty and to state which tools such as those mentioned are effective to cope with the new challenges that may occur in other groups.

El Plan Estratégico para el desarrollo de la Medicina Interna en Andalucía / The strategic plan for the development of internal medicine in Andalusia

El Plan Estratégico para el Desarrollo de la MedicinaInterna en Andalucía surgió de la necesidad sentidapor los internistas de redefinir la misión y valores denuestra especialidad, para afrontar los numerososcambios que estaban ocurriendo en la arenasanitaria. El proyecto se desarrolló en tres fases:primero se analizaron las tendencias del sistemasanitario y la situación actual de la especialidad;posteriormente se pulsó la opinión interna y externasobre el presente-futuro de la Medicina Interna; yfinalmente se establecieron 5 líneas estratégicas consus planes de acción. Dentro de cada línea sedelimitaron objetivos específicos, resultados alograr, y metodología acorde al plan de acción. Trasvarios años de trabajo colegiado en esta iniciativa sehan logrado resultados muy positivos. Concluimosque el Plan Estratégico ha resultado útil para situarmejor nuestra especialidad, y que herramientascomo la detallada son efectivas para afrontar nuevosretos que puedan acaecer a otros colectivos

The Strategic Plan for the Development of InternalMedicine in Andalusia arose from the need thatthe internal medicine doctors had to redefine thepurpose and values of their specialty to cope withthe numerous changes occurring in the health carearea. The project was developed in three phases.First, the tendency of the health care system andcurrent position of the specialty were analyzed.After, the internal and external opinions on thepresent-future of Internal Medicine were checkedout. Finally, five strategic lines with their actionplans were established. Specific objectives weredefined within each line: results to be achieved,methodology according to action plan. After severalyears of collegial work in this initiative, very positiveresults have been achieved. We conclude that theStrategic Plan has been useful to better definethe position of our specialty and to state which toolssuch as those mentioned are effective to cope withthe new challenges that may occur in other groups (AU)

Epidemiology of Pneumocystis carinii pneumonia in southern Spain.

In order to investigate the impact of Pneumocystis carinii infection in southern Spain following the introduction of highly active anti-retroviral therapy (HAART), all cases of pneumocystosis between 1998 and 1999 were identified from data compiled by the national surveillance system. In total, 498 cases of pneumocystosis were recorded, of which 87% involved HIV-positive patients. The mean age, length of hospital stay and mortality were higher for HIV-negative patients. There was a higher number of cases in winter. Despite HAART implementation, pneumocystosis remains a significant health problem for both HIV-positive and HIV-negative patients.

Presence of glomerular basement membrane (GBM) antibodies in HIV- patients with Pneumocystis carinii pneumonia.

Following the unexpected finding of antibodies to GBM in a patient with Pneumocystis carinii pneumonia in the absence of kidney abnormalities, the presence of anti-GBM antibodies was analysed in 14 patients with pulmonary P. carinii infection who did not have clinical evidence of autoimmune glomerulonephritis. Patients were divided into three groups: HIV- with P. carinii pneumonia (n = 4), HIV+ with P. carinii pneumonia (n = 5) and HIV- carriers of P. carinii without pneumonia (n = 5). As control groups, HIV- patients with community-acquired non-P. carinii pneumonia (n = 6) and healthy individuals (n = 16) were included. Anti-GBM antibodies, studied with a quantitative enzyme immunoassay (EIA) for anti-alpha3 chain of collagen IV antibodies, were detected in three out of the four HIV-patients with P. carinii pneumonia, but not in any individuals of the other categories. These results suggest that P. carinii alveolar injury or the host response to the organism could affect the basal membrane Goodpasture antigen or a similar antigen, and induces anti-GBM antibody production in HIV- patients, and support the hypothesis that, at least in some cases, Goodpasture's syndrome could be triggered by an alveolar lesion induced by a P. carinii pneumonia.

[Pulmonary aspiration puncture in the etiological diagnosis of pneumonias]. / Punción aspirado pulmonar en el diagnóstico etiológico de las neumonías.

In pneumonias, the short diagnostic results of non-invasive procedures lead frequently to use invasive techniques, among which we find pulmonary puncture aspiration (PPA). In this study, the profitability of PPA in the diagnosis of pneumonias is evaluated. One hundred and thirteen PPA were performed on 107 patients diagnosed of pneumonia. The PPA was performed with a 22-25 G needle without radioscopic control. Hemocultures were gathered in 104 cases, serological tests for productive agents of atypical pneumonia were applied in 50 cases, sputum test in 95 cases, and bronchofibroscopy with occluded telescopic brush in 25. The PPA had a specificity of 98 percent and a sensibility of 54% which rose to 73% in patients without antibiotic treatment prior to the puncture. Only 10 patients had complications with pneumothorax (9 percent) and four (3 percent) presented hemoptysic sputum. In the 53 patients with a positive PPA, knowledge of an etiological agent allowed the antibiotic treatment to be switched in 32 cases (60 percent). In addition, a decrease in the number of days of hospitalization was confirmed in the group of patients who received an etiological diagnosis while alive (p < 0.03). In conclusion, the PPA is a technique with excellent specificity, acceptable sensitivity, and a short rate of complications which allowed the treatment to be changed in 60 percent of the cases and reduced the number of days of hospitalization for patients who received a diagnosis. Thus, it constitutes a very useful technique in the etiological diagnosis of severe pulmonary infections.

[Tuberculosis in 7 general hospitals in Andalusia. Grupo Andaluz para el Estudio de las Enfermedades Infecciosas]. / La tuberculosis en 7 hospitales generales de Andalucía. Grupo Andaluz para el Estudio de las Enfermedades Infecciosas.

BACKGROUND: To know the clinical features of tuberculosis in our environment, to evaluate its diagnostic techniques and therapeutic options as well as the evolution of patients. PATIENTS AND METHODS: Multicenter retrospective study of 1115 patients with tuberculosis, diagnosed between 1984 and 1988 in the population based areas of 7 Hospitals from Andalusia (Spain). RESULTS: The mean age was less than 40 ages, the exponential growing of the number of cases a year in which the influence of drug addicts could be an important factor, an elevated proportion (45%) of extrapulmonary tuberculosis and disseminated forms, and a social environment of 20% of cases being alcoholics or drug addicts. A good use of diagnostic techniques is recorded, although the use of culture as diagnostic tools is lacking. The usual treatment was three drugs for nine months. The global evolution seems good. However a global mortality of 6.4% is recorded, mainly in disseminated forms and among patients with risk factors for developing tuberculosis. SUMMARY: We have seen an increment among tuberculosis cases, as well as a change in the clinical spectrum of the disease, linked to social illness and drug addiction. The diagnostic approach to tuberculosis seems to be appropriate. The follow up of patients is somewhat confusing.

[Abscess of the psoas: a not-so-rare entity. Analysis of a series of 18 cases]. / Absceso del psoas: una entidad no tan infrecuente. Análisis de una serie de 18 casos.

We have studied 18 patients with abscess at the psoas who had a mean age of 43.55 +/- 18.9 years and a predominance of males (77.8%). In nine cases the abscess was secondary to a lumbar discal spondylitis, in 5 cases to a sacroiliitis, in one case to abdominal disorder, and 3 cases the abscess was considered of a primary origin. The etiologic agents were S. aureus (8 cases), E. granulosus (5 cases), M. tuberculosis (3 cases), and B. melitensis (1 case). In one patient the infective agent was not isolated and in two cases the abscesses were infected by E. granulosus and P. aeruginosa. The clinical picture on admission was studied in all cases. Microbiological and pathologic analysis of the abscess allowed to establish the diagnosis in 11 cases (yield: 84.6%). Computerized axial tomography was the most useful imaging technique. Antimicrobial treatment was undertaken in 16 cases. Four patients recovered with pharmacological treatment alone. Surgical treatment was performed in 13 cases. Aspirative punction/drainage was carried in only one patient. The clinical course was favourable in 16 patients (88.9%). Our data indicate that the incidence of abscess of the psoas in cases of intraabdominal infections is low. In our series the incidence of abscesses secondary to hydatidosis is relatively high.

[Activity of adenosine deaminase in acute brucellosis and complicated brucellosis]. / Estudio de la actividad de adenosina desaminasa en la brucelosis aguda y en la brucelosis complicada.

BACKGROUND: Adenosine deaminase (ADA) is an essential enzyme for the differentiation and proliferation of T lymphocytes and the monocyte-macrophage system. The basic immunitary response of brucellosis is cellular. To this end, ADA activity was evaluated in brucellosis. METHODS: Serum ADA activity was assessed by a colorimetric method in 67 patients with brucellosis, before therapy and at 1, 3 and 6 months of follow up. RESULTS: Serum ADA activity in brucellosis was higher than that in 52 healthy controls, both in those with the acute febrile noncomplicated form (48 patients) and in those with focal symptoms from one organ (19 patients) (p less than 0.0001 and p less than 0.001). There were no differences between both groups of brucellosis. There was a negative correlation between the duration of the disease and ADA activity. After therapy there was a rapid decrease of ADA values, more marked in patients with noncomplicated brucellosis. During the follow up, only one patient had a new increase in ADA activity, coincident with a clinical and bacteriological relapse, and previous to the increase of IgG anti-Brucella titers. CONCLUSIONS: The results indicate that adenosine deaminase activity is increased during the active stage of brucellosis. It can be considered as a biochemical follow up marker of the disease and, probably, as a marker of relapses.

Severe community-acquired pneumonia. Etiology, prognosis, and treatment.

The frequency of community-acquired pneumonia coupled with its mortality rate of 10 to 25% is of growing concern to clinicians. A prospective study of 67 patients with severe community-acquired pneumonia was carried out to determine the causative agents, the impact fore-knowledge of the etiology has on the outcome, the value of clinical and radiologic criteria in predicting the evolution, and the efficacy of empirical therapy. The study group included 45 men and 22 women (mean age: 56.8 +/- 16.6 yr), and 46.2% suffered from a concurrent debilitating disease. The cause of pneumonia was diagnosed in 32 cases, and the most common pathogens were Streptococcus pneumoniae (37.5%), Legionella pneumophila (21.8%), and gram-negative bacilli (25.0%). The fact that fungal infections were present in three patients and Pneumocystis carinii in one are worthy of note. The overall death rate was 20.8%. A fatal outcome was related to the age of the patient (p less than 0.05), the presence of debilitating disease (p = 0.026), and septic shock (p = 0.0009). Diagnosis of the causative agents did not aid in increasing the survival rate, but it did allow for better patient management. Most of the patients (85.1%) initiated on treatment with erythromycin plus tobramycin recovered, but only 68.4% of the subjects commenced on treatment with other therapeutics survived. Furthermore, it was necessary to modify the therapy of a greater percentage of the latter group (p less than 0.025). Gram-negative bacillary pneumonia was a frequent finding among the patients who did not recover, making empirical treatment with erythromycin plus third generation cephalosporins most advisable for severe cases of community-acquired pneumonia.