Calcificaciones en ganglios de la base y crisis convulsivas / Basal ganglia calcification and seizures

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[An analysis of 182 enterococcal bloodstream infections: epidemiology, microbiology, and outcome]. / Análisis de 182 episodios de bacteriemia por enterococo: estudio de la epidemiología, microbiología y evolución clínica.

INTRODUCTION: Enterococcal bloodstream infections have acquired considerable importance in recent years, mainly because of the increasing number of cases that occur during hospital admission. METHODS: Retrospective study of the clinical records of patients diagnosed with enterococcal bacteremia and hospitalized over a 12-year period (January 1994-April 2006), analyzing epidemiological, clinical and microbiological characteristics, outcome and prognostic factors. RESULTS: A total of 182 episodes of bacteremia were recorded; 68% of them were nosocomial infections, accounting for 5% of the in-hospital bacteremia episodes in this period. The most frequent sources of infection were urinary tract (29%), cardiovascular (25%), intra-abdominal (21%) and primary bacteremia (12%). Associated comorbid conditions were present in 85% of patients, mainly neoplasms (33%). Enterococcus faecalis was responsible for 70% of cases, E. faecium 22%, and other species of enterococci 8%. Twenty percent were polymicrobial bacteremia. Antibiotic resistance was documented in 23% of the strains: 14% ampicillin, 8% gentamicin, 3% ampicillin and gentamicin, and 0.5% vancomycin. Overall mortality was 31%. Polymicrobial bacteremia and comorbidity were associated with a poor prognosis. CONCLUSION: In our hospital, Enterococcus is the fifth most frequent cause of nosocomial bacteremia. E. faecium is characterized by a high incidence (more than 50% of cases) of ampicillin resistance.

Hepatotoxicidad por pioglitazona / A new case pioglitazone hepatotoxicity

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Cólico nefrítico causado por filtro de cava tras penetración transmural de la vena cava inferior / Inferior vena caval filter causing nephritic colic after transmural penetration of the inferior cava

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Tuberculous peritonitis in a patient with rheumatoid arthritis treated with adalimumab.

We present a case of tuberculous peritonitis in a 71-year-old woman with long-standing rheumatoid arthritis treated with adalimumab, and we review the association between antitumor necrosis factor therapy and tuberculosis. Our case illustrates that the index of suspicion of tuberculosis in these patients, even with atypical clinical features, must be very high, and underscores the need of tuberculosis screening before therapy is started.

Cardiac tamponade as the first manifestation of systemic lupus erythematosus in the elderly.

Although pericardial involvement is very frequent in systemic lupus erythematosus, cardiac tamponade is extremely rare as the first manifestation of the disease. On the other hand, systemic lupus erythematosus is a disease that predominantly affects young women, and it is a very uncommon condition in the elderly. We report a 91-year-old woman diagnosed with cardiac tamponade, which was the presenting clinical feature of a previously undiagnosed case of systemic lupus erythematosus.

[Predictive model for community acquired bacteremia in patients from an Internal Medicine Unit]. / Bacteriemia adquirida en la comunidad: elaboración de un modelo de predicción clínica en pacientes ingresados en un servicio de medicina interna.

BACKGROUND AND OBJECTIVE: Clinical suspicion of bacteremia lacks of sensitivity, specificity or predictive values enough to be clinically useful. The aim of this study was to develop a clinical prediction rule of bacteremia for patients hospitalized in an internal medicine department, with community-acquired symptoms, who had blood cultures obtained. PATIENTS AND METHOD: A prospective study, including all patients who had blood cultures in the first 48 h after admission, was performed. A clinical prediction rule of bacteremia was derived from a random sample of two thirds of the patients (derivation cohort) and validated in the remaining (validation cohort). After bivariate analysis, significant variables were included in a stepwise logistic regression analysis. In every patient out of the derivation and validation cohorts a score, derived from the addition of points for each of the significant predictor variables of logistic regression, was obtained; according to this score, 4 groups were formed, and the prevalence of bacteremia in each of them was calculated. Calibration and discrimination were evaluated by the Hosmer-Lemeshow test and area under the ROC curve respectively. RESULTS: Four hundred and forty-eight blood cultures were obtained; the prevalence of bacteremia was 25.2%. Independent predictors of bacteremia in the bivariate analysis were urinary focus of infection, body temperature >= 38.3 degrees C, presence of band forms, ESR >= 70 mm, platelets < 200 * 103/microl, blood glucose >= 140 mg/dl, urea >= 50 mg/dl, C-reactive protein >= 12 mg/dl, and albumin < 3 g/dl. According to the score, in the derivation cohort, four groups with increasing prevalence of bacteremia were identified; in the group with a score between 0 and 3, the prevalence was 2.4%; between 4 and 5: 15.7%; between 6 and 7: 42.9%; and score >= 8: 65%. In the validation cohort, the prevalence was 4.1%, 22.6%, 29.3%, and 80%, respectively. The model showed good calibration (Hosmer-Lemeshow *2 = 4.91; p = 0.77). Area under the ROC curve was 0.81 (95% confidence interval, 0.76-0.86) in the derivation cohort, and 0.77 (95% confidence interval, 0.69-0.85) in validation cohort. CONCLUSIONS: Our model, constructed with 9 variables and a simple additive point system, had good calibration and discrimination, which points at its usefulness to estimate the probability of bacteremia in patients admitted in an Internal Medicine department. Used in conjunction with clinical judgement, the model can be useful in the decision-making process, concerning blood cultures obtention, clinical monitoring, and empirical antimicrobial therapy. Before application, additional prospective validation in other settings is warranted.

Evolución y pronóstico de la discapacidad en pacientes con hemiplejía / Evolution and prognosis of disability in patients with hemiplegia

Fundamento: Para planificar los objetivos del tratamiento rehabilitador tras un ictus es necesario conocer el pronóstico funcional del paciente. Se investigan los principales factores pronósticos de discapacidad en el paciente hemipléjico, mediante un análisis de sus déficit neurológicos: afasia, desorientación, incontinencia urinaria, hemianopsia, trastornos sensitivos, anosognosia, déficit de fuerza y control de tronco. Pacientes y método: Se incluyeron 73 pacientes hemipléjicos, ingresados en un servicio de rehabilitación tras un ictus. La valoración clínica y funcional de los pacientes se efectuó al ingreso en rehabilitación, al tercer y sexto meses y al año del accidente cerebrovascular. Para valorar el grado de discapacidad se empleó el índice de Barthel modificado por Shah en 1989. Resultados: La mayoría de los síntomas neurológicos (déficit de fuerza, sensitivos, del control del tronco, afasia) presentan un patrón de recuperación similar, con una recuperación principal al tercer mes que se estabiliza hacia el sexto mes del accidente cerebrovascular. El 57 por ciento de los pacientes alcanzan un nivel de independencia elemental (índice de Barthel > 90) en la realización de las actividades de la vida diaria. Los enfermos con un déficit grave de fuerza en la extremidad superior o una alteración en la sensibilidad profunda tienen 9 y 13 veces más riesgo de obtener un mal resultado funcional, respectivamente, que aquellos que no los presentan, independientemente de otros déficit clínicos asociados. Las variables clínicas con mayor importancia pronóstica en la discapacidad del paciente hemipléjico son el grado de paresia (p < 0,001; Rho = 0,66), los trastornos sensitivos (p < 0,001; Rho = 0,57) y la inestabilidad en el control de tronco (p < 0,001; Rho = 0,53). Conclusión: No hay una única variable clínica, sino un conjunto de déficit físicos que influyen en el pronóstico funcional del paciente hemipléjico tras un accidente cerebrovascular, entre los que destacan la gravedad de la paresia, el déficit en la sensibilidad profunda y el déficit en el control de tronco. (AU)

Absceso de psoas: difícil orientación clínica inicial / Abscess of the psoas: difficult initial orientation

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