La amiodarona como causa de parálisis periódica hipopotasémica tirotóxica (réplica) / Amiodarone as cause of thyrotoxic hypokalaemic periodic paralysis (response)

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Fiebre, disnea y bacteriemia por Klebsiella oxytoca y Enterobacter cloacae / Fever, dyspnea and bacteriemia due to Klebsiella oxytoca and Enterobacter cloacae

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[Treatment of chronic obstructive pulmonary disease]. / Tratamiento de la enfermedad pulmonar obstructiva crónica.

Chronic obstructive pulmonary disease (COPD) is a highly prevalent condition and most epidemiological studies have found that COPD prevalence, morbidity and mortality have increased over the last few years. Recent trials suggest that treatments are improving. Several studies have demonstrated the usefulness of the long-acting inhaled beta-2-agonists. Inhaled glucocorticoids, although unable to alter the progression of COPD, may reduce the frequency of acute exacerbations and health status deterioration in a limited group of patients with COPD. Likewise, these drugs may offer benefits in combination with long-acting inhaled beta-agonists. Finally, a better understanding of the molecular and cellular mechanisms involved in COPD pathogenesis should lead to effective treatments that slow or halt the course of the disease. New classes of agents such as the phosphodiesterase inhibitors are now in development.

Tratamiento de la enfermedad pulmonar obstructiva crónica / Treatment of chronic obstructive pulmonary disease

La enfermedad pulmonar obstructiva crónica (EPOC) es un proceso altamente prevalente y la mayoría de los estudios epidemiológicos han puesto de manifiesto que su prevalencia, morbilidad y mortalidad se han incrementado durante los últimos años. Investigaciones recientes sugieren una mejoría en el tratamiento. Así, varios estudios han demostrado la utilidad de los beta-2-agonistas inhalados de larga duración. Los glucocorticoides inhalados, aunque incapaces de alterar la progresión de la EPOC, pueden reducir la frecuencia de las exacerbaciones y mejorar la calidad de vida en un grupo limitado de pacientes. Asimismo, pueden ser beneficiosos en combinación con beta-agonistas de acción prolongada. Finalmente, un mejor conocimiento de los mecanismos moleculares y celulares implicados en la patogénesis de la EPOC debería conducir a tratamientos efectivos para lentificar o detener el curso de la enfermedad. Nuevas clases de estos fármacos, como los inhibidores de la fosfodiesterasa, están en el horizonte (AU)

[What is the cost of inappropriate admission of pneumonia patients?]. / Cuál es el coste de las neumonías que ingresamos inadecuadamente?

BACKGROUND: The number of patients admitted with community-acquired pneumonia (CAP) varies greatly from one hospital to another. Prognostic models for CAP can help physicians decide which cases to treat on an outpatient basis. Our aims were: a) to validate a model for predicting low-risk CAP, and b) to estimate savings that would have resulted if the low-risk patients identified by the model had been treated at home rather than in hospital. PATIENTS AND METHODS: All CAP cases diagnosed by the emergency room physicians of a hospital in northwestern Spain (Ferrol) were enrolled prospectively over a period of 19 months. The prediction rule of Fine et al was used to classify all patients. Mortality in each category was compared with the mortality predicted by Fine's system. Patients in the lowest risk categories (I and II) were considered to have been inappropriately admitted unless they were hypoxemic or had significant comorbidity. Costs were figured based on data provided by our accounting department. RESULTS: Of 192 CAP patients enrolled, 131 were admitted and 61 were treated as outpatients. Ten patients died, none of whom was in classes I or II. The costs of the apparently unnecessary hospital stays of the 34 patients in these classes was 6,979,756 pesetas. The estimated savings that would have derived from treating these patients out-of-hospital was 6,133,292 pesetas (36,862 euros; 322,804 pesetas/month). CONCLUSIONS: a) The predictive model used has been found useful for identifying patients at very low risk of dying from CAP; b) Using this model can improve CAP admission criteria, and c) Application of the model can lead to savings.

[Decisions regarding cholesterol-lowering therapy in the elderly: the experience in a lipid clinic and a review of the literature]. / Indicaciones del tratamiento hipolipemiante en el anciano: experiencia de una unidad de lípidos y revisión de la literatura.

BACKGROUND: Therapy for hypercholesterolemia is long known one of the interventions with higher benefit on coronary heart disease secondary prevention and on primary prevention in middle-age high-risk people. Data about elderly persons are more scarce. The aim of this work is to study elderly patients sent to a Lipid Clinic, focusing on Serum Lp (a) levels and criteria to prescript cholesterol-lowering drugs. We have reviewed current knowledge to discuss and to clarify these criteria. METHOD: Observational study. Review of the medical charts from the patients sent to the Lipid Clinic. Elderly patients were compared with middle-aged persons attended to the same Clinic. RESULTS: From 348 total Lipid-Clinic cohort 72 (20.7%) patients were more than 65 years old (31 male). A 3 months or longer follow-up was available in 49/72 and 36/49 were taking cholesterol-lowering drugs. Among these 36, 21 had coronary disease; the other 15 had, at least, another risk factor, besides dyslipidemia. Serum Lp (a) level were higher in older group (38.7 +/- 36.9 mg/dl, median 29, vs 26.3 +/- 24.2, median 18 mg/dl, p < 0.01). Considering the accepted cardiovascular risk threshold (Lp (a) > 30 mg/dl), difference were found only in women. Coronary disease was present in 79 patients followed 3 months or longer and 24/79 were more than 65 years old. Twenty-one of them were taking cholesterol-lowering drugs, vs 50 from the 55 younger (pNS). The reasons for no drug-therapy were similar in both groups. CONCLUSIONS: Coronary heart disease or cardiovascular risk factors association were the criteria used for starting cholesterol-lowering drug therapy. Published evidence supporting this therapeutic approach is reviewed. There were not found age related differences for cholesterol-lowering drugs prescriptions in patients suffering coronary disease. Serum Lp (a) level were higher in elderly sample because of the increase in older women; it could be linked to the postmenopausal hormonal state.

[Anticentromere antibodies and lung disease without skin involvement]. / Anticuerpos anticentrómero y enfermedad pulmonar sin manifestaciones cutáneas.

Anticentromere antibodies are closely related to systemic sclerosis and basically to limited cutaneous form. Two patients with different forms of lung disease, positive anticentromere antibodies and absence of the characteristic skin involvement of the systemic sclerosis are presented.

[The epidemiology of tuberculosis in El Ferrol]. / Epidemiología de la tuberculosis en El Ferrol.

BACKGROUND: This study was undertaken to know the frequency of tuberculosis in El Ferrol and to contribute to the knowledge of the situation in Spain. METHODS: A retrospective study of all the cases of tuberculosis diagnosed in the Hospital A. Marcide-Novoa Santos (El Ferrol, Spain) from 1990 to 1993 was performed. RESULTS: Seven hundred twenty-four patients were diagnosed, with a mean annual prevalence of 83.3/100,000 inhabitants. Six hundred sixty-four cases (430 males [64.8%]) were evaluated. The mean age was 35.5 +/- 19 years with 58.9% under the age of 35. 98.7% of the patients lived in the health care area and 73.2% were admitted, with 13.7% having previous history of tuberculosis. Sixty-one cases (11.1%; Cl: 8.25-13.7) had HIV infection. Diagnosis was microbiological in 505 cases (76%), anatomopathological in 60 (9%) and in 99 (14.9%) diagnosis was achieved by clinical and radiological criteria. Pulmonary localization (67.2%) was the most frequent form and was predominant in males, while lymph node and osteoarticular localizations were more frequent in women. The incidence of bacilliferous patients was 30.7/100,000 inhabitants. A delay of more than one month took place in the diagnosis of 66.4% of the bacilliferous patients. CONCLUSIONS: The incidence of tuberculosis in El Ferrol is very high with an important delay in the diagnosis of bacilliferous patients. The high percentage of patients admitted to hospital carries considerable costs in the treatment of the disease.

[Recurrent infections, severe neutropenia and neutrophil chemotaxis defect in paroxysmal nocturnal hemoglobinuria]. / Infecciones recurrentes, neutropenia grave y defecto quimiotáctico de los neutrófilos en la hemoglobinuria paroxística nocturna.

Paroxysmal nocturnal hemoglobinuria (PNH) is a rare disease, whose origin seems to lie in a acquired defect in the membrane of the pluri-potential hematopoietic cell. Chronic or intermittent acute hemolytic syndrome is the most frequent clinical manifestation, although in the literature there are also some references to the leukocytic and immunologic disorders of this disease. In this paper, we present the case of a 63-year-old patient with NPH who developed severe neutropenia and sustained febrile syndrome. In the past four years, she had suffered frequent episodes of fever and leukopenia, which apparently disappeared spontaneously. In the physical exploration, we observed hepatosplenomegaly. The hemogram showed mild iron deficiency anemia (hemoglobin 10.8 g/dl), severe neutropenia (neutrophil 0.3 x 10(9)/l) and significant reticulocytosis (610 x 10(9)/l). Iron deposits were greatly reduced in the marrow. Simultaneously to a new febrile episode and isolation of Escherichia coli in the urine, there was a severe anemization (hemoglobin 5 g/dl) and a significant thrombopenia (platelets 30 x 10(9)) resulting in a positive hemosiderinuria and sucrose test. The study of the leukocytic function showed a defect in the neutrophil chemotaxis, although a normal phagocytic capacity and microbicidal activity. In the following nine months, the patient had several severe infections, with intense but transitory pancytopenia, which always improved when treating the infection with antibiotics. The patient died due to a septic shock twelve months after the diagnosis. Recurrent febrile episodes and severe neutropenia are very rare in the PNH (less than 4% of the cases). The cause of these disorders is still unknown.(ABSTRACT TRUNCATED AT 250 WORDS)