J. González Macías

Guías de práctica clínica en la osteoporosis posmenopáusica, glucocorticoidea y del varón. Sociedad Española de Investigación Ósea y del Metabolismo Mineral

These guidelines update issues covered in previous versions and introduce new ones that have arisen in recent years. The former refer mainly to the therapeutic developments that have been made during this time (zoledronate, denosumab, bazedoxifene), which have led to a change in the drug selection algorithm. The latter deal with therapeutic management, the description of new adverse effects (which have led to changes in therapeutic behaviour patterns, as is the case with atypical fracture of the femur), treatment duration (with consideration for the so-called ‘‘therapeutic holidays’’), the so-called sequential treatment and changes in treatment imposed by certain circumstances. A new algorithm has been introduced for sequential treatment. Attention has also been paid to vertebroplasty and kyphoplasty.

Factors associated with neuropsychological performance in HIV-seropositive subjects without AIDS.

BACKGROUND Previous research has suggested that several factors may influence the presence of cognitive impairment in human immunodeficiency virus (HIV) infection. The objective of this study was to assess the impact of cognitive reserve capacity and other variables on neuropsychological performance in early HIV infection. METHODS The neuropsychological performance of 100 HIV-seropositive subjects without AIDS (71 men and 29 women) was compared with that of 63 seronegative controls (51 men and 12 women). Measures included a neuropsychological battery, a medical examination and a psychiatric assessment. Cognitive reserve scores were based on a combination of years in school, a measure of educational achievement, and an estimate of pre-morbid intelligence. RESULTS HIV-positive subjects had longer reaction time latencies than HIV-negative subjects. Those in the HIV-positive group with low cerebral reserve scores showed the poorest performance on the neuropsychological tests. The prevalence of cognitive impairment was significantly higher in the HIV-positive group (27%) than in the controls (32%). Multiple regression analysis and logistic regression analysis were used to identify factors associated with global neuropsychological performance and cognitive impairment. Older age, lower cerebral reserve scores and not being on zidovudine treatment were associated with lower global neuropsychological scores and with the presence of cognitive impairment. CONCLUSIONS Our results suggest that although cognitive impairment is not characteristic of early HIV infection, there is a subgroup of subjects who perform more poorly than expected. A lower reserve capacity, older age and not being on zidovudine treatment are factors that lower the threshold for neuropsychological abnormalities in cases of early HIV infection.

Situación actual de la enseñanza de la Patología General en España

BACKGROUND AND OBJECTIVES One of the core subjects in university training of the physicians has been General Pathology. Responsibility for this has historically fallen on Internal Medicine specialists. However, we are unaware if this situation is currently maintained. METHODS A questionnaire was sent to the coordinators of the subject of the 39 Spanish medical schools to know, among other things, the current denomination of the subjects (traditionally known as «General Pathology»), number of credits, teaching activities included in the subject and number and specialty of the professors responsible for it. Some data from the medical schools that did not respond were obtained from their web pages. RESULTS A total of 28 of the 39 (72%) medical schools existing in Spain answered the survey. The current denomination of the subject «General Pathology» varied greatly. The mean number of credits (one credit=20-25 h) was 11.2 (range 3 to 29). In 22 of 34 schools (65%), the subject was taught in the third year of the studies, but in 21% of the schools, it was partially and in 15% of the schools, totally, taught in the second year. More than half of the professors (54%) who taught the subject were Internal Medicine specialists, although this responsibility was shared with other specialists in a large proportion. CONCLUSIONS Teaching of General Pathology shows a marked heterogeneity that does not seem to be due to teaching or pedagogic criteria among the different schools of Spain. These facts may be due to less presence in the university setting of Internal Medicine compared to other specialties.

Osteoprotegerin and Bone Mass in Squamous Cell Head and Neck Cancer Patients

Osteoprotegerin (OPG) is considered one of the main regulators of bone remodeling. Various patterns of serum OPG levels have been described in different types of tumors. We undertook this study to determine serum OPG levels in patients with squamous cell head and neck cancer (SCHNC), analyzing their relationship with other metabolic bone parameters and bone mineral density (BMD), as well as the possible influence of chemotherapy. Forty male patients with localized SCHNC were studied, and their results were compared with those of 40 healthy male controls. The type of treatment followed by each patient was noted. Age, weight, height, and lifestyle habits were recorded; and OPG, Ca2+, intact parathyroid hormone (iPTH), 25-Hydroxyvitamin D (25OHD) and 1,25-Dihydroxyvitamin D (1,25(OH)2D), bone alkaline phosphatase, osteocalcin, and serum C-terminal cross-links telopeptide of type I collagen (ICTP) were determined. Dual-energy X-ray absorptiometry BMD at the lumbar spine, femoral neck, and hip was also measured. Serum OPG was higher in patients than in controls (91.7 ± 25.8 vs. 77.2 ± 26.3, P = 0.02). ICTP (a bone resorption marker) was 37% higher in patients (P = 0.007). Bone mass was lower in patients at the lumbar spine, femoral neck, and total hip. Lumbar spine Z-score showed a significant progressive decrease in controls, stage I-III patients, and stage IV patients. Logistic regression analysis showed a significant association between the disease and serum OPG levels, the odds ratio per standard deviation increase of this being 1.9 (95% confidence interval 1.1–3.8, P = 0.04) after adjusting for bone mass and ICTP serum levels, as well as for alcohol and smoking history. Adjustment for alcohol intake and tobacco use did not cancel out BMD differences between patients and controls. Patients with SCHNC show increased OPG serum levels, increased bone resorption, and decreased bone mass. The OPG rise appears to be unrelated to the BMD decrease, and the BMD decrease seems to be, at least in part, independent of smoking and drinking habits. No differences in either OPG or BMD were seen between patients with and without chemotherapy. Further studies are needed to clarify the mechanisms responsible for OPG and BMD changes in SCHNC.

Endocarditis due to Acinetobacter lwoffi on native mitral valve

Endocarditis due to Acinetobacter is a rare pathology with high mortality, reported mainly in hospitalized patients with predisposing risk factors. This is the second case of endocarditis due to Acinetobacter reported in our country in the last 10 years.

Características funcionales y cognitivas de los ancianos ingresados en un Servicio de Medicina Interna

Fundamento Analizar las caracteristicas clinicas, el grado de dependencia fisica y cognitiva y la cobertura social de los pacientes mayores de 64 anos que ingresan en un Servicio de Medicina Interna. Pacientes y metodos Se han estudiado 105 pacientes (63 mujeres y 42 hombres) mayores de 64 anos ingresados en una de las secciones del Servicio de Medicina Interna del Hospital Universitario Marques de Valdecilla. Resultados Cincuenta y nueve pacientes eran mayores de 79 anos. Las causas mas frecuentes que determinaron el ingreso fueron las enfermedades pulmonares, cardiacas y digestivas. El 80% de los pacientes presentaban otros procesos asociados, alcanzandose un indice de comorbilidad de Charlson de 2,7±1,4. El indice de Barthel previo al ingreso fue de 71±35. Mas de una tercera parte de los pacientes tenian deterioro cognitivo (MEC Conclusiones Los ancianos que ingresan en nuestro Servicio de Medicina Interna suelen presentar reagudizaciones de procesos cardiorrespiratorios. Mas de la mitad son mayors de 79 anos y presentan con relativa frecuencia deterioro cognitivo y funcional. A pesar de ello, la utilizacion de recursos sociales es todavia escasa.

Factores de riesgo de la osteoporosis en mujeres atendidas en Atención Primaria y en consultas hospitalarias. Estudio OPINHO-PC

Resumen Introduccion La osteoporosis (OP) es una enfermedad con una alta prevalencia, y con un alto coste economico y social. El objetivo de este estudio fue describir los factores de riesgo (FR) en mujeres con diagnostico de OP atendidas en Atencion Primaria (AP) y en el medio hospitalario (HO). Material y metodos Estudio epidemiologico, transversal, multicentrico, de 194 mujeres con OP seguidas en AP y 186 en HO. Resultados Los grupos fueron equivalentes en edad (media ± desviacion estandar [DE]; 67,6 ± 9,8 anos en AP y 67,6 ± 10 anos en HO) y en la gravedad de la OP (-3,0 ± 0,8 en AP frente a -3,1 ± 0,8 en HO). Algunos FR especificos de caida tales como: el uso prolongado de benzodiacepinas y la frecuencia cardiaca superior a 80 pulsaciones por minuto fueron mas frecuentes en AP que en HO (24,2% en AP frente a 15,6% en HO, p = 0,0354) y (12,9% en AP frente a 3,2% en HO, p = 0,0006), respectivamente. Por el contrario, los FR de fractura osteoporotica intrinsecamente oseos fueron, en general, mas frecuentes en HO: menopausia quirurgica (20,7% frente a 12,8%, p = 0,047), fracturas vertebrales previas (34,9% frente a 20,6%, p = 0,0018) y un prolongado uso de esteroides (15,6% frente a 7,7%, p = 0,0167). El sedentarismo y el consumo de tabaco (numero de cigarrillos al dia), en cambio, fueron mayores en AP (48,5% frente a 31,7%, p = 0,0009 y 16,9 ± 4,6 frente a 11,4 ± 9,7; p = 0,0344, respectivamente). Conclusiones En AP son mas prevalentes los factores asociados con el riesgo de caidas (factores extraoseos), mientras que en HO lo son los factores de riesgo asociados con la densidad y la calidad oseas (factores intrinsecamente oseos).

Cómo valorar la respuesta al tratamiento de la osteoporosis

La osteoporosis es una enfermedad con alta morbimortalidad, cuya trascendencia es debida a que predispone al desarrollo de fracturas. Por ello, el tratamiento de esta enfermedad va dirigido a evitar la aparicion de las mismas. Sin embargo, y a pesar de que la fractura constituye la consecuencia autenticamente trascendente del fracaso terapeutico, no debe considerarse exponente del mismo, dado que puede deberse a factores ajenos a la falta de respuesta, como puede ser la predisposicion intrinseca de la enfermedad al desarrollo de fracturas o la tendencia a las caidas. Por ello, al igual que sucede en otras enfermedades, como las cardiovasculares, tenemos que utilizar otras variables para valorar la respuesta terapeutica (variables subrogadas), que, en el caso de la osteoporosis, son la densidad mineral osea (DMO) y los marcadores de la remodelacion osea (MRO). La DMO es el marcador subrogado mas proximo de que disponemos. Los farmacos actuales, ademas de disminuir el riesgo de fractura, aumentan la masa osea. Sin embargo, hay que tener en cuenta que los cambios en la DMO suelen ser tardios (1-2 anos), y ademas se discute que criterio utilizar para definir que variacion de la misma puede considerarse significativa (?perdida de masa osea con respecto al valor basal?, ?perdida de masa osea mayor que el minimo cambio significativo?). Finalmente, algunos de los farmacos utilizados en el tratamiento de la osteoporosis, concretamente los antirresortivos, reducen de forma intensa y precoz los marcadores de la remodelacion, por lo que podrian ser utiles como complemento de la DMO, aunque la variabilidad de los resultados que se obtienen en la practica clinica diaria limita su utilidad.

La realidad de la osteoporosis en el paciente hospitalizado en Medicina Interna

Resumen Objetivos: a) conocer la prevalencia de osteoporosis previa y de fracturas vertebrales en los pacientesingresados en un Servicio de Medicina Interna de un hospital terciario; b) determinar la proporcion depacientes dados de alta con el diagnostico de osteoporosis y el porcentaje de los tratados; c) cuantificarel riesgo de fractura mediante la herramienta FRAX ® y d) conocer los niveles de 25-hidroxivitamina D(25OHD) en estos pacientes. Material y metodo: Estudio retrospectivo mediante la revision de los informes de alta y las historias clini-cas de todos los pacientes ingresados en el Servicio de Medicina Interna del Hospital Marques de Valdecilladurante abril de 2012, analizando variables demograficas, clinicas, radiologicas y de laboratorio. Resultados: Se estudiaron 300 pacientes. Un total de 34 (11,3%) tenian diagnostico previo de osteoporo-sis y 14 (4,8%) recibian o habian recibido tratamiento. Solamente 14 pacientes tenian un diagnostico deosteoporosis en el informe de alta. En uno de ellos no se pauto ningun tratamiento. Segun el indiceFRAX

Fractura de la diáfisis del radio en un varón de 31 años

Varon de 31 anos, sin antecedentes personales ni familiares de interes, que consulto por presentar dolor y tumefaccion en el antebrazo derecho tras sufrir una caida mientras jugaba al tenis. En la exploracion se aprecio la existencia de dolor a la palpacion en el tercio medio del antebrazo derecho, asi como una mayor incurvacion con deformidad en el varo de dicha extremidad. Las pruebas complementarias de laboratorio, que incluian hemograma completo, velocidad de sedimentacion, pruebas de funcion hepatica y renal, calcio, fosforo, proteina C reactiva, proteinograma y analisis elemental y sedimento de orina fueron normales. La radiografia del antebrazo derecho mostraba una incurvacion del radio con engrosamiento de las corticales y un aumento de la densidad que alternaba con zonas liticas, fundamentalmente en los dos tercios distales del mismo. En la union del tercio medio con el tercio distal de la diafisis del radio se observaba una linea de fractura (fig. 1, flecha).