Apendicitis aguda y teratoma: ¿causalidad o consecuencia? / Acute appendicitis and teratoma: causality or consequence?

La enfermedad ginecológica puede cursar con gran variedad de manifestaciones clínicas. La coexistencia de teratoma y apendicitis aguda supone un porcentaje inusual de enfermedad abdominal en mujeres jóvenes, aunque no de forma exclusiva. Apenas hay revisiones o casos documentados en la literatura, por lo que se desconoce si existe causalidad entre ambas o simplemente es una coincidencia. Exponemos el caso de una paciente joven cuyo síntoma guía fue un dolor abdominal difuso con gran discordancia clinicorradiológica, que precisó intervención quirúrgica y confirmó la presencia de ambas entidades tras el estudio anatomopatológico.(AU)

Gynaecological disorders can have a wide variety of clinical manifestations.The coexistence of teratoma and acute appendicitis accounts for unusual, but not exclusive, percentage of abdominal pathology in young women. There are virtually no reviews or documented cases in the literature, so it is unknown whether there is causality between the 2or simply a coincidence.The case is presented of a young patient whose main symptom was diffuse abdominal pain with great clinical and radiological discordance. Surgical intervention was required to confirm the presence of both pathologies after the completion of the histopathology study.(AU)

Respuesta de los autores: Medicina familiar y comunitaria y la enfermedad pulmonar obstructiva crónica / Author's reply: Family and community medicine and chronic obstructive pulmonary disease

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Estudio ARAPOC: prevalencia de síntomas respiratorios y enfermedad obstructiva crónica en población general / ARAPOC Study: Prevalence of respiratory symptoms and chronic obstructive pulmonary disease in the general population

OBJETIVO: El objetivo de este trabajo fue conocer la prevalencia de síntomas respiratorios y de EPOC, así como las características de esta población en Aragón (España). Diseño y emplazamiento: Estudio epidemiológico, transversal, en población entre 40 y 75 años. Los sujetos fueron elegidos de forma aleatoria y estratificada por edad y sexo a partir de los datos de la tarjeta sanitaria del Servicio Aragonés de Salud. PARTICIPANTES: Un total de 1.185 sujetos aceptaron colaborar. MEDICIONES PRINCIPALES: Un cuestionario sociodemográfico y clínico y espirometría forzada antes y después de una prueba broncodilatadora. El diagnóstico de EPOC se realizaba según los criterios de la guía GOLD (cociente FEV1/CVF < 0,7). RESULTADOS: La prevalencia de EPOC alcanzó un 10,4% (IC: 9,8-11,0%), un 16,9% en hombres y un 5,7% en mujeres. Los síntomas respiratorios aparecieron en un 58% de la población general. Existía mayor prevalencia de EPOC en las mujeres que en otros estudios. Los factores asociados a desarrollar EPOC fueron ser hombre, tener más edad, mayor índice tabáquico y menor nivel de estudios. El 78,9% de los pacientes con EPOC no estaban diagnosticados. Los diagnosticados fueron de más edad, más fumadores, con EPOC más graves o con peor calidad de vida. CONCLUSIONES: La alta prevalencia de EPOC y el importante nivel de infradiagnóstico nos permite creer que el diagnóstico precoz de esta enfermedad es todavía una asignatura pendiente. Necesitamos desarrollar nuevas estrategias para atajar este problema

OBJECTIVE: The aim of this study was to determine the prevalence of respiratory symptoms and COPD, as well as the characteristics of this population in Aragon (Spain). Design and LOCATION: It is a cross-sectional epidemiological study in a population between 40 and 75 years of age. Subjects were randomly selected and stratified by age and sex using the data from the health card of the Aragonese Health Service. PARTICIPANTS: A total of 1185 subjects agreed to participate. MAIN MEASUREMENTS: A sociodemographic questionnaire and spirometry before and after bronchodilator test. The diagnosis of COPD was made according to the criteria of the GOLD guide (FEV1/FVC<0.7). RESULTS: COPD prevalence was 10.4%, 16.9% in men and 5.7% in women. Respiratory symptoms appeared in 58% of the general population. There was a higher prevalence of COPD in women than in other studies. Factors associated with developing COPD were, being male, increasing age, smoking more, and a lower education. More than three-quarters (78.9%) of COPD were not diagnosed. Diagnosis was associated with, being older, more smoking more, more severe COPD or poorer quality of life. CONCLUSIONS: The high prevalence of COPD and the significant level of underdiagnoses lead to believe that early diagnosis of this disease is still a pending issue. New strategies need to be developed to resolve this problem

[ARAPOC Study: Prevalence of respiratory symptoms and chronic obstructive pulmonary disease in the general population]. / Estudio ARAPOC: prevalencia de síntomas respiratorios y enfermedad obstructiva crónica en población general.

OBJECTIVE: The aim of this study was to determine the prevalence of respiratory symptoms and COPD, as well as the characteristics of this population in Aragon (Spain). DESIGN AND LOCATION: It is a cross-sectional epidemiological study in a population between 40 and 75 years of age. Subjects were randomly selected and stratified by age and sex using the data from the health card of the Aragonese Health Service. PARTICIPANTS: A total of 1185 subjects agreed to participate. MAIN MEASUREMENTS: A sociodemographic questionnaire and spirometry before and after bronchodilator test. The diagnosis of COPD was made according to the criteria of the GOLD guide (FEV1/FVC<0.7). RESULTS: COPD prevalence was 10.4%, 16.9% in men and 5.7% in women. Respiratory symptoms appeared in 58% of the general population. There was a higher prevalence of COPD in women than in other studies. Factors associated with developing COPD were, being male, increasing age, smoking more, and a lower education. More than three-quarters (78.9%) of COPD were not diagnosed. Diagnosis was associated with, being older, more smoking more, more severe COPD or poorer quality of life. CONCLUSIONS: The high prevalence of COPD and the significant level of underdiagnoses lead to believe that early diagnosis of this disease is still a pending issue. New strategies need to be developed to resolve this problem.

Síndrome neuroléptico maligno y síndrome serotoninérgico: a propósito de dos casos / Malignant neuroleptic syndrome and serotoninergic syndrome: two cases

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[Acute-phase reactants and markers of inflammation in venous thromboembolic disease: correlation with clinical and evolution parameters]. / Reactantes de fase aguda y marcadores de inflamación en pacientes con enfermedad tromboembólica venosa: correlación con parámetros clínicos y evolutivos.

OBJECTIVE: To asses the association of acute reactants and interleukin 6 and 8 (IL-6 & IL-8) at diagnosis of venous thromboembolic disease (VTD) and clinical outcome. METHODS: 100 patients were diagnosed of VTD by image tests. Acute reactants (C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), fibrinogen), D-dimer and IL-6 and IL-8 we measured at the moment of diagnosis. We made a 12 month follow-up of these patients to notice any clinical evolution outcomes (recurrences, bleeding, post-phlebitic syndrome, death). RESULTS: IL-6 was increased in 9 patients and IL-8 in 3. The risk factors, time to diagnosis and pulmonary embolism rate were similar in both interleukin groups (normal and high levels). Fibrinogen levels were significantly increased in high IL-6 group (585 +/- 179 vs. 485 +/- 154 mgr/dl; p = 0.05). During follow-up there were 5 deaths, 3 recurrences, 11 bleedings and 43 postphlebitic syndromes. Normal ESR level was associated to postphlebitic syndrome (17.8 +/- 14.5 vs. 31.4 +/- 27.4 mm/1st h; p = 0.016). Patients who had high levels of IL-6 had worse survival than these with normal levels (p = 0.015). CONCLUSION: IL-6, ESR, and CPR at diagnosis of VTD could be useful to identified patients with higher risks of death and postphlebitic syndrome during the first year after diagnosis.

[Pharmacoresistant temporal-lobe epilepsy. Exploration with foramen ovale electrodes and surgical outcomes]. / Epilepsia farmacorresistente del lóbulo temporal. Exploración con electrodos del foramen oval y resultados quirúrgicos.

AIM: To report our experience in the surgical treatment of temporal-lobe epilepsy. PATIENTS AND METHODS: An analysis was performed of the outcomes of 137 patients submitted to surgery between 1990 and 2001, with a follow-up of more than two years. A study was conducted of the percentages of successful detection by the different complementary tests--MRI, EEG, interictal SPECT, video-EEG with foramen ovale electrodes (FOE), neuropsychological study (NPS)--and the precision with which they reported the epileptogenic focus. RESULTS AND CONCLUSIONS: Successful surgical outcomes (Engel grades I-II): 73.4%. No surgical mortality occurred, although some mild, reversible morbidity was observed. Surgical outcomes were not affected by sex, age, age of onset and the length of time the patient had had the disease, or the frequency of the seizures. No association was found between seizures in the immediate post-operative period and a poorer long term control of the epilepsy. MR images were normal in 25% of patients; in these cases the surgical outcomes (Engel grades I-II at two years: 62%) were significantly poorer than in cases of tumours/cavernomas (86%); RMI studies of other types of lesions gave intermediate results (72%). With respect to the capacity of the different tests to lateralise/locate the epileptogenic focus, video-EEG-FOE proved to be the best, followed by MRI, SPECT, EEG and NPS.

Neumonía por Mycoplasma pneumoniae y tromboembolia pulmonar / Mycoplasma pneumoniae pneumonia and pulmonary thromboembolism

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Escroto agudo

El interés del síndrome del escroto agudo en atención primaria radica en la importancia del diagnóstico precoz de una de las posibles causas: la torsión testicular. Se trata de una urgencia subsidiaria de tratamiento quirúrgico en las primeras horas del diagnóstico, ya que la viabilidad del testículo torsionado disminuye conforme aumenta la duración de la torsión. Otras causas de escroto agudo, con las que estableceremos el diagnóstico diferencial, son torsión de los apéndices testiculares, epididimitis, hidrocele, varicocele, traumatismo, etc (AU)

[Prognostic value of electrocorticography in temporal lobe epilepsy: patterns of relationing mesial and neocortical activity]. / Valor pronóstico de la electrocorticografía en la epilepsia temporal: patrones de la relación mesial y neocortical.

INTRODUCTION: Electrocorticography (ECoG) monitoring in temporal lobe epilepsy (TLE) has been employed since the 40 s as a means to delineate surgical removal especially in lesional epilepsy, to reduce resection size and decrease cognitive sequelae (memory, naming). However in recent years, ECoG has been claimed to lack indications and prognostic value in cases of non lesional TLE. On the grounds of the pathophysiological relationship between mesial structures and neocortex (through propagation pathways) we have suggested a classification of ECoG activity patterns regarding the activities simultaneously recorded in mesial and neocortical grids. PATIENTS AND METHODS: Two experienced neurophysiologists (over 200 ECoG performed) have independently reviewed the recordings (including video EEG monitoring with foramen ovale electrodes) of 33 consecutive (28 non-lesional) TLE patients with the major criterion of a leading activity in mesial or neocortical areas, and related the results to the clinical course. RESULTS: As a result we identified five patterns: I. Pure mesial; II. Mesial with neocortial-related activity; III. Non-related mesial and neocortical activities; IV. Neocortical preponderance (although some mesial unrelated discharges may be seen), and V. Neocortical origin. In all 33, a tailored, ECpG-guided two-steps resection was performed. Surgical success significantly (c2 test) associated with patterns I, II and IV. Pattern V precluded a good outcome. CONCLUSIONS: ECoG reflects the state of pathological involvement of neocortex and mesial structures. An expertise approach, although brief in time (20-30 min), may either lead to preservation of relevant tissue (patterns I, II) and to establish a prognosis on the grounds of the initial epileptogenic activity.

Los nuevos antidiabéticos orales para el tratamiento de la diabetes mellitus tipo 2

La diabetes tipo 2 es una enfermedad de alta prevalencia y con graves complicaciones si no se lleva un control estricto de los niveles de glucemia, por lo que están apareciendo nuevos antidiabéticos orales que mejoran el control y la morbimortalidad de estos pacientes. En este artículo se pretende realizar una revisión de estos nuevos hipoglucemiantes como son las glinidas, glitazonas y el miglitol (AU)

[Guidelines of the Spanish Society of Cardiology for clinical practice in exercise testing]. / Guías de práctica clínica de la Sociedad Española de Cardiología en pruebas de esfuerzo.

Most exercise testing is performed in adults with known or suspected ischemic heart disease. In the last few years cardiac imaging techniques have been applied in this field, improving the information obtained with the procedure. However, the exceptions to this rule are emerging rapidly not only in healthy people (asymptomatic individuals, athletes, handicapped people) but also in cardiac patients (advanced congestive heart failure, hypertension, rhythm disorders, congenital heart disease, etc.). All the-se issues justify the need for a multidisciplinary consensus document in Spain. This paper reviews and updates the methodological aspects of the stress test, including those related to oxygen consumption measurements. The main aim of this review was to determine the role of exercise testing in the evaluation of ischemic heart disease as well as the applications of imaging stress testing. The usefulness of this test in other non-ischemic cardiac disorders and in selected subsets of healthy people is also reviewed.

[Prognostic value of pre-discharge exertion echocardiography after acute myocardial infarct]. / Valor pronóstico de la ecocardiografía de esfuerzo postinfarto agudo de miocardio antes del alta hospitalaria.

OBJECTIVE: The aim of the present work was to ascertain the usefulness of exercise echocardiography performed prior to discharge following acute non-complicated myocardial infarction in the prognosis and detection of multi-vessel disease. PATIENTS AND METHODS: Sixty-five consecutive patients with primary episode of acute non-complicated myocardial infarction, with normal or slightly depressed ventricular function, were studied. Submaximal exercise test including echocardiogram pre- and immediately post-exercise were performed 7 to 10 days after infarction. Mean follow-up was 15 +/- 8 months; 15 patients presented angina, 9 revascularization and 1 died. RESULTS: Electrocardiographic ischaemia had low sensitivity and negative predictive value regarding complications (44% and 73% respectively); however, its specificity and positive predictive values were high (97% and 92%). In contrast, echocardiography-detected ischaemia showed much better sensitivity and negative predictive values (72% and 83%), with a slight decrease in specificity and positive predictive values (87% and 78%). Both remote ischaemia and the increase in global score > 0.25 during exercise were of high prognostic value (p < 0.001). Remote echocardiographic ischaemia yielded the diagnosis of multi-vessel disease with greater sensitivity than electrocardiographic ischaemia (84% vs 41%). CONCLUSIONS: Exercise echocardiography is highly useful in the prognostic assessment of patients prior to discharge following acute non-complicated myocardial infarction. The ischaemia detected on sub-maximal exercise and assessed by echocardiography was much more sensitive than that detected by electrocardiography in the prediction of new coronary events and multi-vessel disease.

Inhibitory neurons in the human epileptogenic temporal neocortex. An immunocytochemical study.

Immunocytochemical methods were used to study alterations in inhibitory neuronal circuits in human neocortex resected during surgical treatment of intractable temporal epilepsy associated or not with brain tumours. The epileptogenic cortex was characterized and divided into spiking or non-spiking zones by intraoperative electrocorticography (ECOG). The resected cortex was cut into blocks, sectioned and stained immunocytochemically for visualization of glutamic acid decarboxylase (GAD), the calcium-binding protein, parvalbumin (PV) and glial fibrillary acidic protein (GFAP). A variety of alterations in cortical neuronal circuits as revealed by immunocytochemical and histological methods were found. Similar alterations in inhibitory neuronal circuits appear to occur independently of the primary epileptogenic site and pathology associated with epilepsy, which suggests that there is possibly a common basic underlying mechanism that leads to seizure activity. These changes were apparently unrelated to ECOG findings at surgery, which bring into question the value of the use of interictal epileptic discharges recorded by ECOG to guide cortical resections. The most conspicuous and common change was the loss of chandelier cells. The finding that these cells are among the most vulnerable types of GABAergic interneurons in the epileptogenic temporal cortex indicates that they might be of great functional importance, since the axon terminals of chandelier cells are likely to exert powerful regulation of impulse generation in cortical pyramidal cells. Therefore, these cells might represent a key component in the aetiology of human epilepsy.

[Clinical and angiographic course after coronary angioplasty. Analysis of predictor factors of restenosis]. / Evolución clínica y angiográfica postangioplastia coronaria. Análisis de factores predictores de reestenosis.

In order to know the restenosis rate and its predictive factors and the short-term clinical outcome (6-12 months) after coronary angioplasty (PTCA), we prospectively followed 200 consecutive patients with 231 coronary stenoses successfully dilated (residual stenosis < 50%). Patients have been clinically and angiographically followed 6-9 months after the procedure. Forty-nine clinical, hemodynamic, angiographic and technical variables were analyzed. Restenosis (stenosis > or = 50% in late angiographic control) rate was 51.5%, and 61% of the study population was symptomless. Variables associated with restenosis in the univariate analysis were: pre-PTCA positive exercise test (p = 0.004); stenosis severity pre-PTCA (p = 0.04); eccentricity (p < 0.0001) and irregularity (p < 0.0001) of the pre-PTCA stenosis; total dilation time (p = 0.02) and post-PTCA dissection (p = 0.002). The multivariate analysis revealed the following variables as independent predictors of restenosis: presence of dissection after PTCA, eccentricity and irregularity of pre-PTCA stenosis, positive pre-PTCA stress test and duration of symptoms before the procedure. These data suggest that the probability of restenosis after PTCA is predominantly determined by the characteristics of the lesion being dilated and the degree of intimal injury produced during the procedure. These variables could define high and low risk populations and may modify PTCA indications and follow up strategies.

Ventricular arrhythmias in aortic valve disease: a further marker of impaired left ventricular function.

One hundred and twenty stable patients with pure and severe aortic valve disease and without coronary lesions (aortic stenosis, 43 patients; aortic regurgitation, 45 patients; combined aortic stenosis and regurgitation, 32 patients) who had been submitted to haemodynamic studies were prospectively studied with standard electrocardiograms, M-mode echocardiograms, and 24-hour ambulatory electrocardiography (Holter recording). The frequency and complexity of ventricular arrhythmias were related to clinical parameters such as functional class, type of lesion and presence of syncope, and to parameters of left ventricular hypertrophy and function. Ventricular arrhythmias were present in 92% of patients. A high number of ventricular premature beats was directly correlated with parameters of complexity of the arrhythmia. A significant relation was found between electrocardiographic left ventricular hypertrophy and Ryan class (P less than 0.05), and an inverse relation between maximal number of ventricular premature beats in any hour and left ventricular ejection fraction (P less than 0.05). The group of patients with aortic regurgitation showed a higher total number of ventricular premature beats per 24 hours (P less than 0.001), a higher maximal number of these in any hour (P less than 0.01), a higher number of patients with pairs (P less than 0.001), and a higher number of patients in Ryan classes 3, 4A, 4B (P less than 0.01). This study shows a high incidence of ventricular arrhythmias in aortic valve disease, and especially in aortic regurgitation, with a significant relation between left ventricular hypertrophy and function, and number and complexity of arrhythmias.