[Functional evaluation with the KSS (Knee Society Score) scale at 3 and 6 months after ligament reconstruction in patients with multi-ligament knee injuries in a third level hospital]. / Evaluación funcional con la escala KSS (Knee Society Score) a tres y seis meses de la reconstrucción ligamentaria en pacientes con lesiones multiligamentarias de rodilla en un hospital de tercer nivel.

Multiligament injuries of the knee joint are characterized by the involvement of two or more major ligaments, anterior cruciate ligament (ACL), posterior cruciate ligament (PCL), medial collateral ligament (MCL), lateral collateral ligament (LCL), posteromedial corner (PMC) and posterolateral corner (PLC). Statistically, multiligament injuries are rare as they are found in less than 0.02% of all traumatic knee injuries; however, different aggregate injuries are what make this pathology a serious health and functional condition. Taking into account that most of the patients are young people of highly productive age, it is of vital importance to observe their short and long term evolution, as well as their reincorporation to their daily life. It has been reported that vascular lesions are present in approximately 32% of cases, meniscal lesions in 35% and up to 60% with some type of bone lesion. These injuries mainly affect the male sex most commonly between the third and fourth decade of life, which makes this type of injury of great importance, since this group of patients are in their greatest period of labor production. The main objective of the treatment of these injuries, in addition to resolving the aggregate damage that usually aggravates the state of health, is to achieve a speedy recovery and subsequent reincorporation to their work activities and in some cases sports.

Las lesiones multiligamentarias de la articulación de la rodilla se caracterizan por la afección de dos o más ligamentos principales, ligamento cruzado anterior (LCA), ligamento cruzado posterior (LCP), ligamento colateral medial (LCM), ligamento colateral lateral (LCL), esquina posteromedial (EPM) y esquina posterolateral (EPL). Estadísticamente, las lesiones multiligamentarias son poco frecuentes, ya que se encuentran en menos de 0.02% de todas las lesiones traumáticas de rodilla; sin embargo, diferentes lesiones agregadas son las que hacen de esta patología un estado grave para salud y funcionalidad. Tomando en cuenta que la mayoría de los pacientes son personas jóvenes en edad altamente productiva, es de vital importancia observar la evolución de los mismos a corto y largo plazo, así como su reincorporación a su vida cotidiana. Se ha descrito que las lesiones vasculares se presentan aproximadamente en 32% de los casos, lesiones meniscales en 35% y hasta 60% con algún tipo de lesión ósea. Estas lesiones afectan principalmente al sexo masculino con más frecuencia entre la tercera y cuarta década de la vida, lo cual hace a este tipo de lesiones de gran importancia, ya que este grupo de pacientes se encuentran en su mayor período de producción laboral. El objetivo principal del tratamiento de estas lesiones, además de resolver los daños agregados que suelen ser los agravantes del estado de salud, es lograr una pronta recuperación y posterior reincorporación a sus actividades laborales y en algunos casos deportivas.

Clinical residual symptomatology and associated factors in multiple organ failure survivors: A long-term mortgage. / Sintomatología clínica residual y factores asociados en supervivientes de un fracaso multiorgánico: una hipoteca a largo plazo.

PURPOSE: To evaluate which residual clinical symptoms multi-organ failure (MOF) patients may exhibit post discharge from Intensive Care Units (ICU) and to identify the associated factors that cause such symptoms. MATERIAL AND METHODS: A total of 545 adult patients admitted to a medical & surgical ICU in Spain diagnosed with MOF on admission were included in the study. Follow up in the form of a telephone survey regarding the patients clinical symptoms were conducted at 6 and 12 months after discharge from ICU. RESULTS: A total of 266 patients were followed up at both 6 and 12 months post ICU discharge; 62.2% were male; age 60±18 years; 67.8% medical patients. The most common symptoms to appear following hospital discharge included: asthenia (173; 76%), sleep disturbances (112; 50%) and depression (109; 48%). CONCLUSIONS: The study revealed frequent residual clinical symptoms persisting for almost a year post ICU discharge, most notably arthromyalgia and asthenia. Depression symptoms during the first 6 months post-hospital discharge were also common among multiple organ failure survivors. The presence of symptomatology over time was found to be related to a poor functional situation at 6 and12 months post ICU discharge, length of hospital stay and severity of illness score on ICU admission.

Autoantibodies to domain 1 of beta 2 glycoprotein I determined using a novel chemiluminescence immunoassay demonstrate association with thrombosis in patients with antiphospholipid syndrome.

INTRODUCTION: Antibodies to the domain 1 of beta 2 glycoprotein I (ß2GPI-D1) have been suggested as a risk marker for thrombosis in patients with the antiphospholipid syndrome (APS). This cross-sectional study aimed to analyze the clinical utility of a novel chemiluminescence assay for the detection of anti-ß2GPI-D1 antibodies. PATIENTS AND METHODS: Sera collected from patients with primary or secondary APS (n = 106; 72 with and 34 without history of thrombosis) and controls (n = 272) were tested for anti-ß2GPI-D1 IgG by chemiluminescence assay (QUANTA Flash) and by two anti-ß2GPI IgG assays (QUANTA Lite and QUANTA Flash ß2GPI IgG). RESULTS: Anti-ß2GPI-D1 IgG titers were significantly higher in patients with thrombosis (P = 0.0032) than those without. At the cut-off of 20 units, which yielded a 99.5% specificity, 24 of 72 (34.9%) patients with thrombosis and four of 34 (11.8%) without thrombosis were anti-ß2GPI-D1 IgG positive (odds ratio, OR = 4.0). By further optimizing the cut-off specifically for correlation with thrombosis, 20.8% of the patients with thrombosis and 2.9% of the patients without thrombosis were positive (OR = 8.7). The ORs were significantly lower for antibodies to the full-length ß2GPI by either the chemiluminescence assay or ELISA. Using the anti-ß2GPI chemiluminescence assay, the OR was 2.3 (recommended cut-off of 20 CU) or 4.1 (optimal cut-off 164.6 CU). Using the anti-ß2GPI ELISA, the OR was 2.7 (recommended cut-off of 20 units) or 3.7 (optimal cut-off 7.6 units). CONCLUSION: These data indicate that anti-ß2GPI-D1 IgG are present more frequently and in higher titers in APS patients with thrombotic complications than in those without.The novel ß2GPI-D1 chemiluminescence assay appears to be superior to full-length ß2GPI assays for the risk assessment of thrombotic events in APS patients.

Functional dyspepsia and dyspepsia associated with Helicobacter pylori infection: Do they have different clinical characteristics? / Dispepsia funcional y dispepsia asociada a infección por Helicobacter pylori: ¿son entidades con características clínicas diferentes?

BACKGROUND: Helicobacter pylori causes motor, secretory, and inflammatory gastrointestinal disorders and therefore the term "functional" has been questioned when referring to dyspepsia associated with this bacterium. Patients with dyspepsia and Helicobacter pylori infection could have clinical characteristics that differentiate them a priori from those with true functional dyspepsia. AIMS: To determine whether there are clinical differences between patients with functional dyspepsia and Helicobacter pylori-associated dyspepsia that enable their a priori identification and to know the prevalence of Helicobacter pylori infection in patients with functional dyspepsia. PATIENTS AND METHODS: A total of 578 patients with dyspepsia with no significant lesions detectable through endoscopy were divided into 2 groups according to the presence of Helicobacter pylori. The clinical characteristics, medical history, comorbidities, and use of health resources were compared between the two groups. A sub-analysis pairing the groups by age and sex in a 1:1 ratio was carried out to reduce bias. RESULTS: A total of 336 patients infected with Helicobacter pylori were compared with 242 non-infected patients. The prevalence of infection in the patients with dyspeptic symptoms and no endoscopically detectable lesions was 58%. The initial analysis showed that the cases with dyspepsia and Helicobacter pylori infection were more frequently associated with overweight, obesity, high blood pressure, diabetes mellitus, and metabolic syndrome, but the paired analysis nullified all these differences. CONCLUSIONS: The patients with dyspepsia infected with Helicobacter pylori had similar clinical characteristics to the non-infected patients and could not be differentiated a priori. The prevalence of Helicobacter pylori infection in patients with functional dyspepsia was 58% and increased with age.

Usefulness of oil lubrication during colonoscopy: A comparative study with the conventional technique.

BACKGROUND: The different forms of lubrication are among the most simple, accessible, and economic techniques that have been implemented for improving the diagnostic performance of colonoscopy. AIM: To determine whether the use of oil improved the number of complete colonoscopies, facilitated the procedure, reduced pain, or improved the study's diagnostic performance, compared with the conventional lubrication technique. PATIENTS AND METHODS: One hundred and seventy-five patients referred for colonoscopy were alternately allocated to receive treatment with the standard lubrication method with chlorhexidine gel (group 1) or lubrication with corn oil administered through the working channel (group II). The number of complete colonoscopies, the length of time needed to reach the cecum, the degree of difficulty estimated by the endoscopist and the assistant, the level of pain at the end of the study estimated by the patient, and the endoscopic findings were all determined. RESULTS: Eighty-eight patients made up group I and 87 made up group II. No statistically significant differences were found between the two groups in relation to general characteristics, the number of complete colonoscopies (93 vs. 97%, respectively), the time needed to reach the cecum (8:00 vs. 8:41min, respectively), the level of pain at the end of the study, or the detection of polyps. The degree of difficulty was slightly lower in group II, but with no statistical significance. CONCLUSIONS: Lubrication with oil during colonoscopy did not improve the number of complete colonoscopies, did not facilitate the study, nor did it reduce pain or increase the diagnostic performance of the study, when compared with the conventional technique.

Clinical advances of interest in the diagnosis and treatment of patients with antiphospholipid syndrome.

In this paper we review recent studies and consensus documents that we consider relevant to the diagnosis and treatment of patients with antiphospholipid syndrome (APS). The diagnosis of APS is based on the Sydney classification criteria (2006), in which positive laboratory tests (anticardiolipin antibodies, anti-ß2-glycoprotein I antibodies or lupus anticoagulant) are mandatory. However, it is not uncommon to see patients with clinical features highly suggestive of the syndrome in whom these antibodies are persistently negative. Therefore, we summarize the principal clinical and serological findings in a subgroup of patients with seronegative APS in the first series published up to date. In addition, a recent study draws attention to the safety and efficacy of the long-term use of low-molecular-weight heparins in patients with APS not susceptible to warfarin treatment. There is also a subgroup of women with APS and recurrent fetal loss with no response to the standard antithrombotic therapy; in this group the materno-fetal prognosis could be improved by the addition of low-dose prednisolone during the first trimester of pregnancy. Finally, we list the principal recommendations regarding thromboprophylaxis in APS drawn from the expert consensus document elaborated at the meeting held in Galvestone (2010).

[Acute polyneuropathy and encephalopathy caused by arsenic poisoning]. / Encefalopatía y polineuropatía agudas causadas por arsénico.

INTRODUCTION: Acute arsenic toxicity is a multisystemic disease with pleural and pericardial effusions, gastrointestinal symptoms and pancytopenia. The most frequent neurological complication of inorganic arsenic intoxication is a distal symmetrical polyneuropathy. CASE REPORT: We report here a patient who developed a systemic illness followed with severe acute polyneuropathy. Electrophysiological findings suggested a Guillain-Barré syndrome (GBS). Finally an acute encephalopathy appeared which led to reconsideration of the diagnosis. A 24-hour heavy metal urine, nail and hair analysis was performed. A diagnosis of arsenic toxicity was made. Instead of chelating therapy patient died due to respiratory failure. CONCLUSIONS: A misdiagnosis of GBS in inorganic arsenic polyneuropathy is not infrequent. Atypical progression compels to rule out arsenic or heavy metal intoxication. In our case the appearance of the encephalopathy was the key to the diagnosis. It has been suggested that axonal degeneration and segmental demyelination might be equally prominent pathological features of the neuropathy, depending on the dosage and the length of time of exposure to arsenic. The exact pathophysiology of arsenic polyneuropathy remains unclear and a interference with pyruvate oxidation has been postulated.

Pulmonary mass and multiple lung nodules mimicking a lung neoplasm as amiodarone-induced pulmonary toxicity.

Amiodarone is an effective anti-arrhythmic agent. However, during long-term therapy, patients can develop severe adverse pulmonary reactions that are potentially life-threatening. A case of amiodarone-induced pulmonary toxicity is presented in a 78-year-old woman. She developed dyspnea and a pulmonary mass with associated multiple lung nodules mimicking a lung cancer following 5 years of treatment with amiodarone for atrial fibrillation. After drug withdrawal, and without any additional treatment, clinical and radiological improvement was observed, and radiological findings resolved completely within 6 months.

Pancreatitis aguda en paciente con lesión endobronquial / Acute pancreatitis among patients with endobronchial lesion

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Changes in plasma norepinephrine and endothelin levels and metabolic profile after AT1-receptor blockade in human hypertension.

In essential hypertensive subjects, acute and chronic administration of losartan was followed by favorable neurohormonal (norepinephrine, endothelin-1) and metabolic changes (microalbuminuria).

Effects of the angiotensin II antagonist losartan on endothelin-1 and norepinephrine plasma levels during cold pressor test in patients with chronic heart failure.

We evaluate the acute hemodynamic and neurohormonal effects of losartan in 15 patients with symptomatic chronic heart failure (CHF), mean age 72+/-8 years, which were classified in two subgroups: (A) Patients with left ventricular ejection fraction (LVEF)< or =0.35 (n = 7); (B) subjects with LVEF>0.35 (n = 8). Sympathetic reactivity (blood pressure, heart rate and plasma norepinephrine) and plasma endothelin-1 (ET-1) were evaluated by a cold pressor test (CPT). Single doses of losartan (50 mg p.o.) lowered delta DBP in both subgroups (A, 8+/-9 to 0+/-5 mm Hg, P<0.05; B, 10+/-6 to 3+/-4 mm Hg, P<0.05) and attenuated the rise of HR in patients with mild (4+/-6 to -1+/-2 bpm, P<0.05) but not with severe (4+/-5 to 2+/-5 bpm, n.s.) impairment of left ventricular function. Losartan blunted the response (delta) of PNE during CPT (A, 142+/-131 to 10+/-74 pg/ml, P<0.05; B, 129+/-72 to 1+/-144 pg/ml, P<0.01). A significant rise in plasma ET-1 was observed during CPT in patients from subgroup B (0.64+/-0.40 to 0.81+/-0.40 fmol/ml, P<0.05) but not in patients with LVEF< or =0.35 (1.79+/-0.44 to 1.51+/-0.66 fmol/ml, n.s.). Losartan attenuated the rise in ET-1 during CPT in patients with LVEF>0.35 (delta ET-1 0.17+/-0.86 to 0.03+/-0.11 fmol/ml, P<0.05), with no significant changes in subgroup A. Acute effects of losartan were characterized by a more favorable hemodynamic and neurohumoral response in patients with chronic heart failure and preserved systolic ventricular function related to subjects with lower ejection fractions.

Prostacyclin: its pathogenic role in essential hypertension and the class effect of ACE inhibitors on prostaglandin metabolism.

Angiotensin-converting enzyme inhibitors (ACEI) block degradation of bradykinin, and bradykinin stimulates prostacyclin synthesis. Therefore, we set out to determine whether the effects of ACE inhibitors on prostaglandin production in essential hypertensive patients are class effects or are dependent on ACE inhibitor structure. In addition, we studied whether hypertensives show an impaired capacity to synthesize vasodilator prostaglandins. To address these questions, we compared the effects of captopril (sulfhydryl-containing inhibitor), enalapril and ramipril (carboxyl-containing inhibitors) and fosinopril (phosphoryl-containing inhibitor) on blood pressure and urinary excretion of 6-keto-prostaglandin (PG) F1-alpha (the breakdown product of prostacyclin) in 44 mild-to-moderate essential hypertensive subjects before and 8 weeks after administration of an ACEI. We also studied prostacyclin excretion in 15 normotensive healthy controls. Levels of urinary 6-keto-PGF1-alpha (pg/ml) were measured by specific radioimmunoassay. Hypertensive subjects showed a lower excretion of 6-keto-PGF1-alpha than normotensive controls (212+/-147 vs 353+/-98 pg/ml, p < 0.001). All ACEI induced a significant decrease in MAP and increased the rate of excretion of the prostacyclin metabolite: C, 211+/-200 to 338+/-250 pg/ml, p < 0.05; E, 202+/-133 to 296+/-207 pg/ml, p < 0.05; R, 205+/-127 to 342+/-211 pg/ml, p < 0.05; F, 235+/-128 to 347+/-241 pg/ml, p < 0.05. In hypertensives (n = 44) the decrease in blood pressure correlated negatively with the rise in 6-keto-PGF1-alpha excretion (r = -0.51, p < 0.001). These data suggest that impaired prostacyclin biosynthesis in hypertensive patients could account for haemodynamic changes leading to the hypertensive state. Moreover, the hypotensive mechanisms of ACEI may be mediated by an increase in prostacyclin production; this effect seems to be class-dependent.

Pneumonia caused by Listeria monocytogenes.

Pneumonia due to Listeria monocytogenes is extremely uncommon. We report the case of an 87-year-old woman with no underlying immunosuppressive disease who presented with listerial pneumonia. Cutaneous anergy and a decrease in total lymphocyte count in this elderly woman could predispose her to listerial infection.