Predictive Factors of the Use of Rituximab and Belimumab in Spanish Lupus Patients.

Objectives: To analyze the characteristics and the predictive factors of the use of rituximab and belimumab in daily practice in patients from the inception cohort Registro Español de Lupus (RELES). Material and methods: The study included 518 patients. We considered patients treated with biologics who received at least one dose of rituximab or belimumab, and possible indications of those manifestations registered at the same time or in the previous 2 months of the start of the therapy. Results: In our cohort, 37 (7%) patients received at least one biological treatment. Rituximab was prescribed in 26 patients and belimumab in 11. Rituximab was mainly prescribed for hemolytic anemia or thrombocytopenia (11 patients, 42%), lupus nephritis and neuropsychiatric lupus (5 patients each, 19%). Belimumab was mostly used for arthritis (8 patients, 73%). In the univariate analysis, the predictive factors at diagnosis for the use of biologic therapy were younger age (p = 0.022), a higher SLEDAI (p = 0.001) and the presence of psychosis (p = 0.011), organic mental syndrome (SOCA) (p = 0.006), hemolytic anemia (p = 0.001), or thrombocytopenia (p = 0.01). In the multivariant model, only younger age, psychosis, and hemolytic anemia were independent predictors of the use of biologics. Conclusions: Rituximab is usually given to patients with hematological, neuropsychiatric and renal involvement and belimumab for arthritis. Psychosis, hemolytic anemia and age at the diagnosis of lupus were independent predictive factors of the use of biological agents. Their global effects are beneficial, with a significant reduction in SLE activity and a low rate of side effects.

Relevancia de la PET/TC con [18F]FDG en la detección de enfermedad localizada en el colon en pacientes estudiados por bacteriemia o endocarditis infecciosa causadas por microorganismos enteropatógenos / Relevance of [18F]FDG-PET/CT in the detection of colon pathology in patients studied by bacteriemia or infectious endocarditis caused by enteropathogenic microorganisms

Objetivo La asociación entre la endocarditis infecciosa (EI) por Streptococcus gallolyticus y las lesiones malignas del tracto gastrointestinal está bien descrita. Asumimos que otros microorganismos enteropatógenos, como el Streptococcus viridans y Enterococcus faecalis también pueden estar relacionados con la enfermedad colorrectal. Nuestro objetivo fue determinar la frecuencia de depósitos focales de la [18F]FDG en localización colorrectal, sugestivos de lesiones tumorales, y su correlación con la enfermedad de colon y recto en pacientes con infección causada por diferentes microorganismos comensales del tracto gastrointestinal. Métodos Examinamos retrospectivamente 61 pacientes con diagnóstico de bacteriemia y de EI (posible o concluyente) según los criterios de Duke y causada por microorganismos enteropatógenos, y que fueron sometidos a una PET/TC de cuerpo entero con [18F]FDG en nuestra institución. Buscamos depósitos de la [18F]FDG en localización colorrectal, así como la presencia de lesiones morfológicas. A todos los pacientes con EI se les realizó una colonoscopia completa y los resultados histológicos se clasificaron según 4 grupos: lesión maligna, lesión premaligna, lesión benigna y ausencia de lesión. Se evaluó la correlación existente entre los hallazgos de la PET/TC con [18F]FDG y el diagnóstico histopatológico y el microorganismo implicado. Resultados La PET/TC detectó 20 depósitos de [18F]FDG en localización colorrectal (32,79%-OR: 47,28), 2 de ellos en pacientes con bacteriemia (16,7%) confirmados como lesiones malignas y premalignas y 18 en el grupo con EI (36,6%), 17 de ellos correspondientes a enfermedad colorrectal: 11 lesiones malignas, 5 premalignas y una benigna. En el subgrupo con EI la colonoscopia detectó lesiones colorrectales en el 51,02% de los pacientes: 11 malignas, 8 premalignas y 6 benignas. En el subgrupo de Streptococcus spp. se detectó una mayor incidencia de depósitos de [18F]FDG en localización colorrectal (AU)

Objective Association between Streptococcus gallolyticus infective endocarditis (IE) and malignant lesions of the gastrointestinal tract is well described. We hypothesize that other enteropathogenic microorganisms, such as Streptococcus viridans and Enterococcus faecalis are also related with colorectal pathology. Our aim is to determine the frequency of focal colorectal FDG deposits, suggestive of tumoral lesions and their correlation with colorectal pathology, in patients with infection caused by different commensal microorganisms of the gastrointestinal tract. Methods We retrospectively examined 61 patients diagnosed with bacteremia (BSI) and IE (possible or definite) according to Duke's criteria, caused by enteropathogenic microorganisms, who underwent a full-body [18F]FDG-PET/CT in our institution. We looked for colorrectal FDG deposits and morphological lesions. All IE patients underwent a complete colonoscopy and the histological results were classified into four groups: malignant lesion, premalignant lesion, benign lesion and no lesion. We evaluated the correlation between the findings of the [18F]FDG-PET/CT with the histopathological diagnosis and the involved microorganism. Results PET/CT detected 20 colorectal FDG deposits (32.79%-OR: 47.28), 2 within bacteriemic patients (16.7%) confirmed as malignant and premalignant lesions and 18 in IE group (36.6%), 17 of them corresponding to colorrectal pathology: 11 malignant, 5 premalignant and 1 benign lesions. In the IE subgroup, the colonoscopy detected colorectal lesions in 51.02% of the patients: 11 malignant, 8 premalignant and 6 benign. We found a higher incidence of colorectal FDG deposits in Streptococcus spp. subgroup. Regarding the anatomopathological colonic findings there was a predominance of patients affected by S. viridans, followed by E. faecalis and S. gallolyticus (AU)

Diagnóstico molecular de SARS-CoV-2 / Molecular diagnosis of SARS-CoV-2

Resumen El diagnóstico de COVID-19 se basa tanto en aspectos clínicos como en pruebas de detección, pero los síntomas y signos clínicos de los pacientes infectados son altamente atípicos y, por lo tanto, las pruebas moleculares son indispensables para su diagnóstico. La reacción en cadena de la polimerasa con transcriptasa inversa (RT-qPCR) se lleva a cabo en laboratorios nivel BSL II; asimismo, los principales blancos moleculares para la detección viral son el gen E (envoltura), y el gen RdRP (ARN polimerasa dependiente de ARN). Los falsos negativos en este diagnóstico se deben a la calidad y cantidad de la muestra, condiciones de transporte, almacenamiento, y manejo de estas antes y después de la extracción (el ARN es termolábil y abundantes las RNasas), fase de la infección, mutaciones del virus y presencia de inhibidores de la PCR. En estos casos, se recomienda una nueva toma de muestra, especialmente de vías respiratorias bajas, para aumentar la carga viral. Se debe tener en cuenta la sensibilidad analítica de la RT-qPCR (5,2 copias de ARN/reacción) y que, una vez el RNA se extrae, se va degradando progresivamente afectando la sensibilidad diagnóstica de la prueba. Un diagnóstico oportuno permite optimizar el manejo (aislamiento y tratamiento) y monitorización de los pacientes, así como la aplicación de medidas de prevención y control de la expansión, y la vigilancia epidemiológica de la enfermedad.

ABSTRACT COVID-19 diagnosis is based on both clinical aspects and screening tests. However, clinical symptoms and signs in infected patients are highly atypical; hence, molecular tests are essential for diagnosis. RT-qPCR is carried out at BSL II level laboratories; the main molecular targets for viral detection are E gene (envelope), and RdRP gene (RNA-dependent RNA polymerase). False negatives in this diagnosis are due to sample quality and quantity, transport conditions, storage and handling before and after extraction (RNA is heat-labile and RNases are abundant); infection phase; virus mutations and presence of CRP inhibitors. Taking into account analytical sensitivity of RT-qPCR (5.2 copies of RNA / reaction) and the fact that once RNA it is extracted, it progressively degrades and affects test diagnostic sensitivity, a new sample -specifically taken from the lower respiratory tract in order to increase viral load- is recommended in the abovementioned cases. Timely diagnosis allows optimizing management (isolation and treatment), patient monitoring, implementing prevention and control measures as well as epidemiological surveillance of the disease.

Infections in newly diagnosed Spanish patients with systemic lupus erythematosus: data from the RELES cohort.

OBJECTIVES: Using data of patients from the inception cohort Registro Español de Lupus Eritematoso Sistémico (RELES), we aimed to analyse the incidence of severe infection in the first two years of follow-up and how predictors of infection change during the course of systemic lupus erythematosus (SLE). MATERIAL AND METHODS: The study included 282 patients. Markers of lupus activity, prednisone doses and immunosuppressive therapy were compared between patients with and without infections in the first and second year of the disease. Drug therapy administered during the first month of follow-up has been considered as a potential predictor of infections during the first year and medications administered during the first year have been considered potential predictors of infections during the second. RESULTS: Nineteen patients (6.4%) had a documented episode of major infection during the first year of follow-up and 16 patients (5.67%) during the second. The following variables were associated with infections during the first year: hypocomplementaemia at diagnosis ( p < 0.01), nephritis at diagnosis ( p = 0.03), SLEDAI score ( p < 0.01), prednisone >30 mg/day ( p = 0.01), methylprednisolone pulses ( p = 0.05) and mycophenolate use ( p = 0.02). The independent variables in the final model were hypocomplementaemia (odds ratio (OR) 4.41, 95% confidence interval (CI) 0.96-20.20, p = 0.05) and a dose of prednisone >30 mg/day (OR 6.60, 95% CI 1.34-32.42, p = 0.02). The following variables were associated with infections during the second year: dose of prednisone > 7.5 mg/day ( p = 0.05), methylprednisolone pulses ( p = 0.07), duration of therapy with antimalarials ( p = 0.09), therapy with mycophenolate ( p = 0.01), therapy with cyclophosphamide ( p = 0.05). The independent variables in the final model were a dose of prednisone >7.5 mg/day (OR 4.52, 95% CI 0.99-21, p = 0.054) and duration of therapy with antimalarials as a protective factor (OR 0.99, 95% CI 0.99-1.00, p = 0.053). CONCLUSIONS: The low incidence of early infections in the RELES cohort is partially explained by the extended use of antimalarials and by the general avoidance of prolonged high doses of prednisone. Patients with high baseline activity are at a higher risk of infection during the first months but therapy with medium-high doses of prednisone is the main predictor of infectious events. Thus, every effort should be made to limit oral glucocorticoid use from the very beginning of the SLE course.

Nationwide study on peripheral-venous-catheter-associated-bloodstream infections in internal medicine departments.

BACKGROUND: The use of peripheral venous catheters (PVCs) has increased outside intensive care units, as has the rate of PVC-associated-bloodstream infection (PVC-BSI). PVCs are widely used in internal medicine departments (IMDs), but data on the incidence of PVC-BSI and its characteristics in IMDs are scarce. AIM: To assess the incidence of PVC-BSI episodes detected in IMDs in Spain. METHODS: A one-year multi-centre prospective observational cohort study in 14 Spanish IMDs was undertaken. Adult patients admitted with at least one PVC and bacteraemia were included in the study. Demographic and clinical data were provided by local coordinators. FINDINGS: Seventy episodes of PVC-BSI were recorded, representing an overall rate of 1.64 PVC-BSI episodes/1000 IMD admissions. The mean age of patients was 67.44 (standard deviation 16.72) years. It was estimated that 25.7% of PVCs were no longer necessary. Staphylococcus aureus was the most frequently isolated micro-organism (41.7%). Phlebitis was clinically evident in 44 (62.9%) episodes, and proved to be an independent predictor of catheter insertion in emergency departments (odds ratio 5.44). The crude and attributable mortality rates were 12.9% and 5.7%, respectively. CONCLUSIONS: PVCs carry a significant risk for bacteraemia in Spanish IMDs. Phlebitis is not always clinically evident in patients with bacteraemia in this population. The study findings support the need for educational and interventional preventive measures in both IMDs and emergency departments to reduce the rate of PVC-BSI and associated comorbidities, and costs.

Systemic activity and mortality in primary Sjögren syndrome: predicting survival using the EULAR-SS Disease Activity Index (ESSDAI) in 1045 patients.

OBJECTIVE: To score systemic activity at diagnosis and correlate baseline activity with survival in a large cohort of patients with primary Sjögren syndrome (SS). PATIENTS AND METHODS: We include 1045 consecutive patients who fulfilled the 2002 classification criteria for primary SS. The clinical and immunological characteristics and level of activity (EULAR-SS Disease Activity Index (ESSDAI) scores) were assessed at diagnosis as predictors of death using Cox proportional hazards regression analysis adjusted for age at diagnosis. The risk of death was calculated at diagnosis according to four different predictive models. RESULTS: After a mean follow-up of 117 months, 115 (11%) patients died. The adjusted standardised mortality ratio for the total cohort was 4.66 (95% CI 3.85 to 5.60), and survival rates at 5, 10, 20 and 30 years were 96%, 90%, 81% and 60%, respectively. The main baseline factors associated with overall mortality in the multivariate analysis were male gender, cryoglobulins and low C4 levels. Baseline activity in the constitutional, pulmonary and biological domains was associated with a higher risk of death. High activity in at least one ESSDAI domain (HR 2.14), a baseline ESSDAI score ≥14 (HR 1.85) and more than one laboratory predictive marker (lymphopenia, anti-La, monoclonal gammopathy, low C3, low C4 and/or cryoglobulins) (HR 2.82) were associated with overall mortality; these HRs increased threefold to 10-fold when the analysis was restricted to mortality associated with systemic disease. CONCLUSIONS: Patients with primary SS, who present at diagnosis with high systemic activity (ESSDAI ≥14) and/or predictive immunological markers (especially those with more than one), are at higher risk of death.

Determinación de los genes, 16S ADNr, polA, y TpN47, en la detección de Treponema pallidum subsp. pallidum para el diagnóstico de sífilis congénita / Determination of genes, 16S ADNr, polA, and TpN47, in the detection of Treponema pallidum subsp. pallidum in the diagnosis of congenital syphilis

Objetivo. Comparar el comportamiento de tres genes diana 16S ADNr, polA, y TpN47, para la detección de T. pallidum subsp. pallidum. Métodos. Se usaron técnicas moleculares como la reacción en cadena de la polimerasa en muestras de cordón umbilical. Mediante PCR convencional, PCR anidada y PCR en tiempo real se amplificaron blancos moleculares del microorganismo. Resultados. Se evidenció que con los tres genes por PCR convencional se obtienen similares resultados, pero por con PCR anidada y PCR en Tiempo Real, el gen TpN47 tiene mayor sensibilidad en comparación con los genes polA y 16S ADNr. Se concluye que el gen TpN47 se puede usar como blanco molecular para el diagnóstico oportuno de sífilis congénita por medio de PCR anidada y en tiempo real, ya que alcanzó la máxima sensibilidad y especificidad en este estudio.

Objective. To compare the behavior of the three target genes (16S rDNA, polA, and TpN47) for the detection of T. pallidum subsp. Pallidum. Methods. Molecular techniques such as polymerase chain reaction were used on samples of an umbilical cord. Molecular targets of the microorganism were amplified by means of conventional PCR, nested PCR and real-time PCR. Results. Similar results for the three genes were obtained by conventional PCR; but in the case of nested PCR and real-time PCR, the gen TpN47 exhibited higher sensitivity in comparison to the genes polA and 16S rDNA. In conclusion, the gen TpN47 can be used as a molecular target for the prompt diagnosis of congenital syphilis through nested PCR and real-time PCR due to its high sensitivity and specificity shown in this study.

How are we treating our systemic patients with primary Sjögren syndrome? Analysis of 1120 patients.

OBJECTIVE: To describe how systemic disease is treated in a large cohort of Spanish patients with primary Sjögren syndrome (pSS) in daily practice, focusing on the adequacy of therapies for the level of systemic activity measured by ESSDAI score. PATIENTS AND METHODS: By December 2014, our database included 1120 consecutive patients who fulfilled the 2002 classification criteria for SS. Therapeutic schedules were classified into 4 categories: no systemic therapies, hydroxychloroquine (HCQ) and/or low dose glucocorticoids (GCS) (<20mg/day), high dose GCS (>20mg/day) and use of second-line therapies (immunosuppressive agents, intravenous immunoglobulins [IVIG] and/or rituximab [RTX]). RESULTS: There were 1048 (94%) women and 72 (6%) men , with a mean age at diagnosis of 54 years. The main drug-based therapeutic approaches for systemic pSS during follow-up were HCQ in 282 (25%) patients, GCS in 475 (42%, at doses >20mg/day in 255-23%), immunosuppressive agents in 148 (13%), IVIG in 25 (2%) and RTX in 35 (3%) patients. HCQ was associated with a lower risk of death (adjusted HR of 0.57, 95% 0.34-0.95). We classified 16 (7%) of the 255 patients treated with >20mg GCS and 21/148 (14%) treated with immunosuppressive agents as patients inadequately treated, mainly associated with articular involvement of low/moderate activity. CONCLUSION: The management of pSS should be organ-specific, using low dose GCS in patients with moderate systemic activity, limiting the use of high dose GCS and second-line therapies to refractory or potentially severe scenarios. The use of systemic therapies for dryness, chronic pain or fatigue is not warranted.

Nationwide study on the use of intravascular catheters in internal medicine departments.

BACKGROUND: The use of intravascular catheters (IVCs) in intensive care units (ICUs) has been well assessed in recent years. However, a high proportion of these devices are placed in patients outside the ICU, particularly in internal medicine departments (IMDs), where data on the quality of care are scarce. AIM: To assess the use and management of IVCs in IMDs in Spain. METHODS: We performed a point prevalence study of all adult inpatients on 47 IMDs from hospitals of different sizes on one day in June 2013. A local co-ordinator was appointed to assess patients and collect data from each site. FINDINGS: Out of the 2080 adult patients hospitalized on the study day, 1703 (81.9%) had one or more IVCs (95.4% of which were peripheral devices). Infection was detected at the insertion site in 92 catheters (5.0%); 87 patients (5.2%) had signs of sepsis, but only one case was considered to be catheter-related. The local co-ordinators estimated that 19% of the catheters in place were no longer necessary. A daily record of the need for a catheter was available in only 40.6% of cases. CONCLUSION: Our study shows clear opportunities for improvement regarding catheter use and care in Spanish IMDs. Strategies similar to those applied in ICUs should be implemented in IMDs.

The management of pneumonia in internal medicine

La neumonía acarrea una importante carga de trabajo en los servicios de medicina interna. Puesto que los pacientes suelen ser de edad avanzada y presentan múltiples enfermedades comórbidas, su tratamiento es difícil. Además, en este contexto, la interpretación de las guías publicadas, al igual que la adhesión a ellas, está lejos de ser clara. Describimos la opinión de 43 especialistas en medicina interna, especialmente interesados en las enfermedades infecciosas, que asistieron a la XXXII Conferencia Nacional de la Sociedad Española de Medicina Interna, celebrada en 2011, y a los que se formularon preguntas sobre los principales problemas relacionados con el manejo de la neumonía en los servicios de medicina interna, es decir, su clasificación, los criterios de ingreso, examen microbiológico, manejo terapéutico, normas de alta y prevención de futuros episodios. Para cada enunciado, redactado por 4 investigadores, los participantes tenían que elegir entre 2 opciones. En muchos casos no se alcanzó un consenso. Los problemas más controvertidos se relacionaron con el reconocimiento y el manejo de la neumonía asociada a la asistencia sanitaria (NAAS). La mayoría de los participantes conocían las diferencias con respecto a las enfermedades subyacentes, la distribución etiológica y el desenlace de la NAAS, comparado con la neumonía adquirida en la comunidad, pero solo una minoría estuvo de acuerdo en tratar la NAAS como una neumonía hospitalaria, según lo sugerido por algunas guías. En el manejo de la NAAS la opción preferida por los expertos en medicina interna fue establecer una estrategia clínica paciente a paciente(AU)

Pneumonia generates a high workload for internal medicine departments. Management of this disease is challenging, because patients are usually elderly and have multiple comorbid conditions. Furthermore, the interpretation and adherence to guidelines are far from clear in this setting. We report the opinion of 43 internists especially interested in infectious diseases that were questioned at the 2011 XXXII National Conference of Spanish Society of Internal Medicine about the main issues involved in the management of pneumonia in the internal medicine departments, namely, classification, admission criteria, microbiological workup, therapeutic management, discharge policy, and prevention of future episodes. Participants were asked to choose between 2 options for each statement by 4 investigators. Consensus could not be reached in many cases. The most controversial issues concerned recognition and management of healthcare-associated pneumonia (HCAP). Most participants were aware of the differences in terms of underlying diseases, etiological distribution, and outcome of HCAP compared with community-acquired pneumonia, but only a minority agreed to manage HCAP as hospital-acquired pneumonia, as suggested by some guidelines. A clinical patient-to-patient approach proved to be the option preferred by internists in the management of HCAP(AU)

The management of pneumonia in internal medicine.

Pneumonia generates a high workload for internal medicine departments. Management of this disease is challenging, because patients are usually elderly and have multiple comorbid conditions. Furthermore, the interpretation and adherence to guidelines are far from clear in this setting. We report the opinion of 43 internists especially interested in infectious diseases that were questioned at the 2011 XXXII National Conference of Spanish Society of Internal Medicine about the main issues involved in the management of pneumonia in the internal medicine departments, namely, classification, admission criteria, microbiological workup, therapeutic management, discharge policy, and prevention of future episodes. Participants were asked to choose between 2 options for each statement by 4 investigators. Consensus could not be reached in many cases. The most controversial issues concerned recognition and management of healthcare-associated pneumonia (HCAP). Most participants were aware of the differences in terms of underlying diseases, etiological distribution, and outcome of HCAP compared with community-acquired pneumonia, but only a minority agreed to manage HCAP as hospital-acquired pneumonia, as suggested by some guidelines. A clinical patient-to-patient approach proved to be the option preferred by internists in the management of HCAP.

The management of pneumonia in internal medicine.

Pneumonia generates a high workload for internal medicine departments. Management of this disease is challenging, because patients are usually elderly and have multiple comorbid conditions. Furthermore, the interpretation and adherence to guidelines are far from clear in this setting. We report the opinion of 43 internists especially interested in infectious diseases that were questioned at the 2011 XXXII National Conference of Spanish Society of Internal Medicine about the main issues involved in the management of pneumonia in the internal medicine departments, namely, classification, admission criteria, microbiological workup, therapeutic management, discharge policy, and prevention of future episodes. Participants were asked to choose between 2 options for each statement by 4 investigators. Consensus could not be reached in many cases. The most controversial issues concerned recognition and management of healthcare-associated pneumonia (HCAP). Most participants were aware of the differences in terms of underlying diseases, etiological distribution, and outcome of HCAP compared with community-acquired pneumonia, but only a minority agreed to manage HCAP as hospital-acquired pneumonia, as suggested by some guidelines. A clinical patient-to-patient approach proved to be the option preferred by internists in the management of HCAP.

Pneumonia treated in the internal medicine department: focus on healthcare-associated pneumonia.

Patients with pneumonia treated in the internal medicine department (IMD) are often at risk of healthcare-associated pneumonia (HCAP). The importance of HCAP is controversial. We invited physicians from 72 IMDs to report on all patients with pneumonia hospitalized in their department during 2 weeks (one each in January and June 2010) to compare HCAP with community-acquired pneumonia (CAP) and hospital-acquired pneumonia (HAP). We analysed 1002 episodes of pneumonia: 58.9% were CAP, 30.6% were HCAP and 10.4% were HAP. A comparison between CAP, HCAP and HAP showed that HCAP patients were older (77, 83 and 80.5 years; p < 0.001), had poorer functional status (Barthel 100, 30 and 65; p < 0.001) and had more risk factors for aspiration pneumonia (18, 50 and 34%; p < 0.001). The frequency of testing to establish an aetiological diagnosis was lower among HCAP patients (87, 72 and 79; p < 0.001), as was adherence to the therapeutic recommendations of guidelines (70, 23 and 56%; p < 0.001). In-hospital mortality increased progressively between CAP, HCAP and HAP (8, 19 and 27%; p < 0.001). Streptococcus pneumoniae was the main pathogen in CAP and HCAP. Pseudomonas aeruginosa and methicillin-resistant Staphylococcus aureus (MRSA) caused 17 and 12.3% of HCAP. In patients with a confirmed aetiological diagnosis, the independent risk factors for pneumonia due do difficult-to-treat microorganisms (Enterobacteriaceae, P. aeruginosa or MRSA) were HCAP, chronic obstructive pulmonary diseases and higher Port Severity Index. Our data confirm the importance of maintaining high awareness of HCAP among patients treated in IMDs, because of the different aetiologies, therapy requirements and prognosis of this population.

Competencias básicas de la medicina interna / Core competencies in Internal Medicine

El grupo de trabajo de Competencias del Internista de la Sociedad Española de Medicina Interna (SEMI) expone los principales conocimientos, habilidades y aptitudes que debería poseer todo internista en España. Este listado de competencias representa el núcleo de la Medicina Interna dentro de un escenario futuro de troncalidad de las especialidades en ciencias de la salud(AU)

The working group of the Spanish Society of Internal Medicine (SEMI) on “Competencies of the Internist” has defined the basic medical knowledge, skills and attitudes that all internists in Spain should have. This list of competencies represents the Internal Medicine core curriculum within the context of the future educational framework of medical specialties in Health Sciences(AU)

[Core competencies in internal medicine]. / Competencias básicas de la medicina interna.

The working group of the Spanish Society of Internal Medicine (SEMI) on "Competencies of the Internist" has defined the basic medical knowledge, skills and attitudes that all internists in Spain should have. This list of competencies represents the Internal Medicine core curriculum within the context of the future educational framework of medical specialties in Health Sciences.

Determinación del gen aac(6´)-aph(2´´) asociado con resistencia a aminoglucósidos en cepas de Staphylococcus coagulasa negativa en una unidad neonatal en Bogotá / Detection of gene aac(6´)-aph(2´´) in associated with aminoglucosides resistance in Staphylococcus coagulase-negative strains isolates from one neonatal unit in Bogota

Antecedentes. La causa más común de resistencia a antibióticos aminoglucósidos en bacterias Gram positivas, especialmente en S. epidermidis, es la enzima modificante AAC(6’)-APH(2"), capaz de acetilar y fosforilar un amplio rango de antibióticos. Objetivo. Determinar la presencia del gen aac(6’)-aph(2") en cepas de Staphylococcus coagulasa negativa aisladas en infecciones neonatales, e investigar la concordancia con las pruebas de sensibilidad in-vitro.Material y métodos. Se determinó la presencia del gen aac(6’)-aph(2") en 63 cepas de estafilococos coagulasa negativa provenientes de hemocultivos y puntas de catéter, de la Unidad de Neonatología del Instituto Materno Infantil, en Bogotá. Resultados. Staphylococcus epidermidis fue el germen más frecuente y el gen aac(6’)-aph(2") estaba presente en 55 (87,3%) cepas; de éstas, 42 (73,4%) cepas provenían de hemocultivos y 13 (23,6%) cepas de punta de catéter. La susceptibilidad a gentamicina se determinó mediante concentración inhibitoria mínima y para amikacina por difusión en disco. No se encontró asociación estadísticamente significativa entre la presencia del gen aac(6’)-aph(2") y la resistencia a gentamicina y amikacina. Conclusión. La presencia del gen aac(6’)-aph(2") de resistencia a aminoglucósidos es muy alta en cepas de Staphylococcus epidermidis. Diferencias en la expresión del gen pueden explicar parcialmente la falta de consistencia con las pruebas de susceptibilidad utilizadas en la clínica.

Background. The most common cause of resistance to aminoglucosides is the acetilation and phosphorilation of the antibiotic by the enzyme AAC(6’)APH(2"). Objetive. To determine the presence of the gene aac(6’)-aph(2") in strains of coagulase-negative Staphylococci isolated from infected neonates and to investigate the concordance with the susceptibility tests in-vitro. Materials and methods. the aac(6’)-aph(2") gene was determined in 63 coagulase-negative Staphylococci strains isolated from blood cultures and catheter tips obtained from the neonatal care unit at the Instituto Materno Infantil in Bogotá, Colombia. Results. Staphylococcus epidermidis was the most frequently identified microorganism. The aac(6’)-aph(2") gene was detected in 55 out of 63 strains (73,43%), 42 strains (87,5%) isolated from blood cultures, and 13 strains (23,6%) isolated from catheter tips. Susceptibility to gentamycin was determined by minimum inhibitory concentration, and susceptibility to amikacin by the disk diffusion antibiotic sensitivity test. There was no a significant statistical association between the presence of the gene and the microbial susceptibility to either gentamycin or amikacin. Conclusion. The presence of the aac(6’)-aph(2") gene in strains of Staphylococcus epidermidis is very high. Differences in the expression of the gene might explain some cases of inconsistency with the susceptibility tests.

Pericardial tamponade in a patient with polymyalgia rheumatica.

We report a patient who developed pericarditis and pericardial tamponade coinciding with polymyalgia rheumatica onset. Our patient did not show any clinical sign of vasculitis; temporal artery biopsies were negative for giant cell arteritis. Pericardial biopsy in our case shows inflammatory perivascular lymphocytary infiltrates thus we believe pericardial effusion has an inflammatory-immunologic origin. Cardiac manifestations are exceptional in polymyalgia rheumatica, though it should be considered in the differential diagnosis in patients with pericarditis over 50 years. The recognition of this uncommon manifestation is very important due to the good response to corticosteroid treatment.

Bodas de plata de la reacción en cadena de la polimerasa (PCR): [revisión] / Silver anniversary of the polymerase chain reaction (PCR): [review]

Invenciones verdaderamente revolucionarias han promovido el cambio de pensamiento y la manera de trabajar en el ámbito del laboratorio. Una de estas invenciones es la reacción en cadena de la polimerasa, la cual ha aportado de manera significativa al conocimiento científico. Las diferentes metodologías que aplican la reacción en cadena de la polimerasa han permitido a los investigadores manipular la información genética de los organismos, facilitando procedimientos como la clonación y la secuenciación, entre otros, lo cual agilizó significativamente los resultados del Proyecto Genoma Humano. Existe diversidad de variantes de la reacción en cadena de la polimerasa convencional. Este escrito tiene por objetivo presentar una revisión sobre el tema, especialmente sobre la reacción en cadena de la polimerasa en tiempo real, debido a las ventajas que ofrece.

Diarrea por citomegalovirus (CMV) como primera manifestación de sida / Cytomegalovirus (CMV) diarrhea as diagnostic index for aids

Se presenta el caso de un varón de 49 años, sin antecedentes personales de interés salvo agresión sexual en 1996, que acude al Servicio de Urgencia del HGUGM por cuadro de diarrea de 6 meses de evolución, al que se añade fiebre de hasta 39ºC en los últimos 2 meses. Durante su ingreso es diagnosticado de infección por el Virus de la Inmunodeficiencia Humana (VIH), antigenemia para Citomegalovirus (CMV) de 70 células, y en el estudio de diarrea se objetiva CMV en cultivo celular de la biopsia de colon ,con colonoscopia normal. La colitis es la forma más frecuente de afectación del tubo digestivo por CMV en pacientes con infección por el VIH. No obstante, es poco frecuente como primera manifestación de Síndrome de Inmunodeficiencia Adquirida (SIDA), como ocurre en el caso que presentamos (AU)

We report a case of a male 49 years old, without clinical history, excepting rape in 1996, that was admitted to the Emergency Room of HGUGM because of diarrhea 6 months duration, plus fever (39ºC) in the last 2 months. He was diagnosed of infection by the Human Immunodeficiency Virus (HIV), with serum antigenemia (70cells), and colonic biopsy positives for Cytomegalovirus, and a normal colonoscopy. Cytomegalovirus colitis is the major etiologic infectious agent in patients with AIDS-associated diarrhea, although it can be the diagnostic index for AIDS in a few cases (AU)