Validation of a predictive index of neoplasia in unexplained weight loss / Validación de un índice predictivo de neoplasia en pérdida de peso inexplicada

Background: Involuntary weight loss (IWL) is associated with a bad prognosis. A causal diagnosis is difficult and the priority is to identify those patients at risk of a serious underlying disease, such as malignant neoplasia. Objective: External validation of a prognostic index of neoplasia in patients with IWL. Methods: Patients referred for IWL from 2005 to 2014 to the Department of Internal Medicine, of a specialty care hospital in Mexico City were studied. Al of them underwent an evaluation consisting of medical history, physical examination and basic laboratory studies, those patients without an apparent cause of IWL, were included. A probability of neoplasia according to Hernández prognostic index was calculated. Complementary diagnostic studies were performed until a causal diagnosis was reached, or the cases were classified as "unknown cause", if the etiology was not possible to find after one year of follow-up. A binarian logistic model was constructed with five variables age, leucocyte count, albumin, lactic dehydrogenase and alkaline phosphatase levels, and a prediction rule was developed. Results: 130 Patients were included and 45 of them (30%) had a neoplastic cause of IWL. The prediction rule according to Hernández criteria, correctly classified 65% of the patients (sensitivity 29%, Specificity 85%, positive predictive value 50% and negative predictive value 69%). When the original index was modified in two categories (high and low probability), it showed a sensitivity of 84.4% and a negative predictive value of 85.7%. Conclusion: The Hernández index has a limited value as a screening tool.

Introducción: la pérdida involuntaria de peso es un factor de mal pronóstico. Su diagnóstico causal es difícil y es prioritario identificar los casos que tienen una enfermedad grave subyacente. Objetivo: validar un índice pronóstico de neoplasia en pacientes con pérdida involuntaria de peso. Métodos: pacientes referidos por pérdida involuntaria de peso de 2005 a 2014, fueron evaluados mediante historia clínica y exámenes básicos de laboratorio; en el estudio fueron incluidos los pacientes sin causa aparente después de la evaluación. Se calculó la probabilidad de neoplasia, según el índice de Hernández. Se realizaron estudios complementarios hasta identificar una causa o fueron clasificados como "causa desconocida", si no se encontró la etiología después de un año de seguimiento. Se construyó un modelo de regresión logística binaria con las variables edad, cifras de leucocitos, albúmina, deshidrogenasa láctica y fosfatasa alcalina; con la ecuación resultante se predijo neoplasia como causa de pérdida involuntaria de peso. Resultados: se incluyeron 130 pacientes, 45 tuvieron causa neoplásica (30%). La ecuación de predicción clasificó correctamente a 65% de los sujetos analizados (especificidad 85%, sensibilidad 29%, valor predictivo positivo 50%, valor predictivo negativo 69%). Al modificarse el índice original en dos categorías (probabilidad alta y baja), mostró una sensibilidad del 84.4% y un valor predictivo negativo del 85.7%. Conclusión: el índice tuvo baja sensibilidad, lo que limita su uso como prueba de tamizaje.

[Fulminant meningitis caused by Streptococcus pneumoniae. Report of three cases]. / Meningitis fulminante por Streptococcus pneumoniae. A propósito de tres casos.

The prevalence of Streptococcus pneumoniae (S. pneumoniae) resistant to penicillin is an increasing problem with variable prevalence across the world. In Mexico, some reports inform prevalence as high as 50% of the isolations. S. penumoniae is a germ that produces a wide variety of diseases, although the most serious infections are in respiratory tract and meningitis. Most patients with the infection caused by this microorganism have a good response to the treatment. The cases with bad prognosis and those which are eventually lethal are related to host factors and microbiologic characteristics such as resistance to beta-lactam antibiotics. The aim of this paper is to inform on three cases of fulminant meningitis due to S. pneumoniae resistant to penicillin, which presented neurological focalization, acute loss of consciousness, coma, and death within the first week, in spite of treatment with cephalosporin of third and fourth generation. In all these cases, S. pneumoniae was isolated from cerebrospinal fluid. The presence of similar cases should alert the clinician to consider an early diagnosis of penicillin resistant meningitis in order to establish an appropriate antibiotic therapy, and consequently, modify the prognosis of the patients.

[Gastroesophageal reflux disease in pediatric patients with asthma]. / Enfermedad por reflujo gastroesofágico en pacientes pediátricos con asma.

BACKGROUND: Nowadays, the gastroesophageal reflux is a predisposing factor for the development of asthmatic attacks. OBJECTIVE: To determine the prevalence of gastroesophageal reflux in pediatric patients with asthma of the Service of Allergy and Immunology at the Hospital Regional Lic. Adolfo López Mateos. MATERIAL AND METHODS: It was made an observational study from July 2000 to July 2001. Gastroesophageal gammagraphic and endoscopy (with taking of esophageal biopsy) were carried out to each of the patients in order to find out if there was gastroesophageal reflux. RESULTS: 112 patients with moderate persistent asthma (54 women and 58 men) were included and divided in three different age groups (group I, from 1 to 5 years old; group II, from 6 to 10 and III, from 11 to 16 years old). The prevalence of gastroesophageal reflux was 138, 100 and 93, respectively, being specially high in males. Differences in the prevalence among different groups were statistically significant between group I and II (p < 0.001) and between I and III (p < 0.001). Significant changes were not observed between group II and III (p = NS). CONCLUSIONS: The prevalence of gastroesophageal reflux the structured was high, situation directly related with the diagnostic suspicion in our asthmatic population.

[New prospects for the treatment of systemic lupus erythematosus]. / Nuevas perspectivas de tratamiento del lupus eritematoso sistémico.

The systemic lupus erythematosus is a significant therapeutic challenge: Multiorgan involvement and a variable disease course, characterized by clinical exacerbations and remissions, make difficult to predict the outcome. Few products have been specifically developed for this affection, and most accepted therapies have not been tested in randomized controlled trials of systemic lupus erythematosus. A variety of biological agents under investigation as potential treatments for systemic lupus erythematosus are designed to interfere with specific immunologic responses, hopefully avoiding generalized immunosuppression. Agents, which interfere with T cell-B cell collaboration, such as CTLA-4-Ig and anti-CD154 ligand monoclonal antibodies, may result in long-term therapeutic benefit. Products designed to decrease production of anti-dsDNA antibodies or inhibit complement activation, may prevent immune complex deposition and ameliorate organ-specific manifestations, such as renal disease. More aggressive interventions include gene therapy and stem cell transplantation.