R. Monte Secades

Papel del internista como consultor de servicios quirúrgicos

Objetivo Conocer las caracteristicas de las consultas realizadas por servicios quirurgicos a un servicio de Medicina Interna general y determinar que factores influyen en el pronostico de estos pacientes. Metodos Estudio prospectivo de las consultas realizadas por los servicios quirurgicos de un hospital de 540 camas a un servicio de Medicina Interna general. Las variables analizadas fueron: edad, sexo, servicio de referencia, motivo de consulta, diagnosticos de ingreso y medicos efectuados durante el ingreso y evolucion clinica. Resultados Se incluyeron 453 consultas, 0,96 interconsultas nuevas por dia laborable y 4,05 por cada 100 ingresos de servicios quirurgicos durante el periodo de analisis. Los motivos de consulta mas frecuentes fueron disnea, fiebre, trastornos electrolitico-metabolicos, valoracion de pluripatologia y sindrome confusional agudo. En 257 pacientes (56,7%) se realizaron dos o mas diagnosticos. La media de visitas realizadas por paciente fue 3,9±3,9. La estancia media hospitalaria en el grupo de estudio fue de 28 ± 33,05 dias comparada con la general de los servicios quirurgicos analizados durante el mismo periodo de 11,6 dias. Cincuenta pacientes (11%) habian fallecido en el momento del «alta medica», porcentaje que se elevo al 20,5% (93 casos) al considerar el final del ingreso hospitalario, comparado con la mortalidad global de los servicios quirurgicos registrada durante ese tiempo de 3,7%. El numero de diagnosticos medicos y la edad resultaron predictores independientes de mortalidad en el analisis multivariado. Conclusiones Las consultas de los servicios quirurgicos a un servicio de Medicina Interna suponen una carga de trabajo importante. Se trata de pacientes complejos desde el punto de vista medico. Su estancia media y mortalidad son diferentes de la general de dichos servicios.

Manifestaciones y curso clínico del síndrome de abstinencia alcohólica en un hospital general

INTRODUCTION: Despite its frequency and high clinical burden, few studies have analyzed the clinical features of the alcohol withdrawal syndrome in a hospital setting. Our purpose was to describe its manifestations and clinical course in a general hospital. PATIENTS AND METHODS: Patients with a diagnosis of alcohol withdrawal since January 1983 to December 2003, according to the revised fourth edition of the Diagnostic and Statistical Manual of Mental Disorders criteria, at the Xeral-Calde General Hospital in Lugo, were studied. Clinical and biochemical data at admission were collected, as well as those referred to the clinical course and complications. RESULTS: 539 episodes in 436 patients were included. Mean age was 45 (standard deviation: 12), and 91,3% were men. Abstinence was the reason for admission in 62,3%. 71,1% had a diagnosis of delirium tremens during their stay. Hallucinations were present in 59,7%, and convulsions (most of them generalized) in 41%. Patients with delirium tremens had greater elevations in temperature, heart rate and blood pressure, as well as more convulsions than minor withdrawal cases. Cirrhosis was present in 10%. The admission rate to the Intensive Care Unit (ICU) was 37,8% (95% confidence interval [95%IC]: 33,1-37,8). Of these, 69,9% needed mechanical ventilation. Mortality rate was 6,6% (95%IC: 4,2-9,1). 62% of patients died after admission in the ICU. CONCLUSION: The majority of complications related to the alcohol withdrawal syndrome in a hospital setting develop in patients with delirium tremens. They are especially related to the rate of admissions to the ICU and the use of mechanical ventilation.Introduccion A pesar de la elevada frecuencia del sindrome de abstinencia alcoholica en el ambito hospitalario y su gran impacto clinico, pocos estudios han analizado sus caracteristicas. El objetivo de este estudio fue describir su forma de presentacion y evolucion clinica en un hospital general. Pacientes y metodos Se estudiaron los enfermos diagnosticados de sindrome de abstinencia alcoholica segun los criterios de la cuarta edicion revisada del Manual diagnostico y estadistico de los trastornos mentales, en el Complexo Hospitalario Xeral-Calde de Lugo entre enero de 1987 y diciembre de 2003. Se registraron los hallazgos clinicos y analiticos presentes en el momento del ingreso, asi como la evolucion clinica y las complicaciones sufridas durante su estancia. Resultados Se registraron 539 episodios en 436 pacientes. La edad media fue de 45 anos (desviacion estandar: 12), y el 91,3% eran hombres. La abstinencia fue el motivo de ingreso en el 62,3% de los casos. Al final del ingreso hospitalario se contabilizo un 71,1% con sindrome mayor de abstinencia. El 59,7% presento alucinaciones y el 41%, crisis epilepticas, casi en su totalidad de tipo gran mal. Los pacientes con delirium tremens presentaron mayores elevaciones de temperatura, frecuencia cardiaca y tension arterial, asi como una mayor incidencia de crisis. El 10% presentaba cirrosis. La tasa de traslados a la Unidad de Cuidados Intensivos (UCI) fue del 37,8% (intervalo de confianza al 95% [IC95%]: 33,1-37,8). De estos, el 69,6% preciso una intubacion orotraqueal. La tasa de mortalidad fue del 6,6% (IC95%: 4,2-9,1). El 62% de los fallecimientos se produjo tras su ingreso en la UCI. Conclusion Las complicaciones relacionadas con el sindrome de abstinencia alcoholica en un hospital general se concentran en los casos de delirium tremens, especialmente en los pacientes trasladados a la UCI y conectados a ventilacion mecanica.

Actinomyces como etiología de empiema

La actinomicosis toracica representa un 25% de los casos de actinomicosis, caracterizandose por una gran variabilidad de presentacion. La afectacion pleural es poco frecuente y es excepcional encontrarla de forma aislada. Se describen 2 casos de empiema por Actinomyces que cursaron bien con drenaje quirurgico y antibioterapia.

Estado de salud de los muy ancianos: situación clínica y funcional de la población centenaria

OBJECTIVE: We planned a prospective and descriptive analysis of the centenarian population in Lugo sanitary area, establishing their social, functional and medical status as well as its relationship with their basic hematological and biochemical parameters. MATERIAL AND METHODS: During the study period between January 2001 and September 2003, participants were visited at home by a doctor and a nurse. The following variables were assessed: social status, past medical history, physical examination, functional status (Barthel index), blood analysis. RESULTS: 54 centenarians were interviewed, 16 men and 38 women. 75.9% were widows; 87% lived with their family and 57,4% in urban areas. 79.6% had followed studies. All of them had their own incomes. Regarding past medical history, 64.8% had some visual or auditive disturbances, 81.5% were taking medical drugs, 59.3% had some surgical intervention and 46.3% had been hospitalized for medical reasons. Their vaccination status was poor. Functional status, assessed by Barthel index, showed an average of 59 +/- 36.4, higher in men (82.7 +/- 28.7) than in women (49.6 +/- 35.1) (p<0.003). Blood samples were analyzed in 51 cases, there were not significant differences among them regarding sex or physical disability. CONCLUSION: The features of the centenarian population of Lugo are similar to other countries. It is an heterogeneous group. There are more women, but their clinical and functional status are significantly worse than in males. We have not founded a relationship between hematological and nutritional parameters and the degree of functional dependence in centenarians.

Pacientes centenarios atendidos en un hospital general

Objetivo Describir la situacion social y medica de los pacientes centenarios que requirieron atencion hospitalaria urgente en los ultimos 8 anos. Metodos Estudio retrospectivo de los pacientes mayores de 100 anos atendidos en el servicio de Urgencias de un hospital general. Posteriormente se comparo el porcentaje de ingresos y la mortalidad con los de los pacientes mayores de 65 anos. Resultados Se registraron 51 consultas en 41 pacientes, con edad media de 101,2 anos. El numero de consultas aumenta progresivamente en el tiempo (p = 0,008). El 92,6% de los pacientes vivian con su familia, preferentemente en el medio rural. Las patologias mas prevalentes fueron el sindrome prostatico (en varones), la insuficiencia cardiaca y la obstruccion cronica al flujo aereo. Solo un 20% presentaban demencia. El 64,2% de las consultas realizadas precisaron ingreso hospitalario, con una mortalidad en este grupo del 20,5%. Los diagnosticos al alta mas frecuentes fueron la insuficiencia cardiaca y el accidente cerebrovascular agudo. Conclusiones Se espera un aumento progresivo de atenciones hospitalarias a pacientes centenarios, los cuales presentan un aceptable estado de salud, aunque con un riesgo elevado de fallecimiento durante el ingreso.

Definiciones de la actividad de Medicina Interna fuera de su propio servicio

The inpatient profile is changing towards patients with multiple diseases, the elderly and those with high comorbidity. The growing complexity of their care, the progressive medical superspecialization and the organizational problems that often hinder daily patient follow-up by the same physician have contributed to a progressive increase in the participation of medical departments, especially Internal Medicine, in the care of patients hospitalized in other medical and surgical specialties. The hospital activities that the departments of internal medicine perform outside of their own department do not have well-established definitions and criteria at the organizational level; their assessment and accountability are different in each hospital. In this document, we establish the definitions for shared care, advisory medicine, perioperative medicine and interconsultation, as well as their types in terms of priority, formality, care setting, timeliness, relationship with surgery and other circumstances.

Debemos utilizar la vía oral como primera opción para el tratamiento del déficit de vitamina B12

OBJECTIVE: Analyze whether the tablets available in Spain are useful for oral replacement in the treatment of vitamin B12 deficiency. METHODS: From June 2003 to December 2005, patients with vitamin B12 deficiency attended at the Internal Medicine Clinic, were offered the possibility of starting or switching to oral therapy. Clinical and biochemical responses were monitored at baseline and at 2, 4, 6, 12, 18 y 24 months of follow-up. RESULTS: Twenty-eight patients were included (55.6% women), with a mean age of 74.96 +/- 9.98 years. Twenty-three cases (82.1%) had pernicious anemia, and 5 were gastrectomized. Patients who switched from intramuscular to oral therapy (16 cases) showed no decrease in the mean values of hemoglobin and B12 levels during the follow-up. Patients who started on oral therapy showed an increase in the values of hemoglobin (from 9.9 +/- 2.8 g/dl to 13.5 +/- 1.1, p = 0.003) and vitamin B12 (from 118 +/- 50 pg/ml to 496 +/- 229, p = 0.001) as early as two months after baseline, maintaining the response during the follow-up. No patient refused oral therapy and no toxic effect attributed to oral therapy was recorded. CONCLUSIONS: Oral replacement of vitamin B12 deficiency with the tablets available in Spain is safe, effective and acceptable to patients.

Características y patrón temporal de reingresos de los pacientes con fibrilación auricular hospitalizados en servicios médicos

OBJECTIVE To determine the characteristics of patients with auricular fibrillation (AF) in the hospital setting and their successive hospitalisations. METHOD A retrospective cohort study was conducted on all hospital admissions in the medical area of hospital of Lugo between January 1, 2000 and December 31, 2013. The data source was the centres minimum basic data set. RESULTS A total of 149,271 hospital admissions corresponding to 66,286 patients were recorded. Of the total, the percentage of admissions and patients with AF was 17.3% (25,870) and 18.9% (12,512), respectively. The patients with AF were characterized by a larger proportion of women (49.7 vs. 44.3%; P<.0001), advanced age (78.3 [DE 10.2] vs. 67.1 years [DE 17.9]; P<.0001), more chronic diseases (4.2 [DE 2.1] vs. 2.9 [DE 1.9]; P<.001), longer hospital stays (12.5 [DE 12.5] vs. 10.6 [DE 19.9] days; P<.0001) and a high rate of readmissions (3.0 [DE 2.75] vs. 2.1 [DE 2.28]; P<.001), with a progressive shortening of the time between hospitalisations. The department of internal medicine was responsible for the care of more than half of the patients with AF. The most common associated secondary diagnoses were chronic obstructive pulmonary disease, stroke, heart failure, ischemic heart disease, other respiratory system diseases and arterial hypertension. CONCLUSIONS AF occurs in highly complex patients, who are mostly hospitalized in internal medicine departments, and is associated with a high rate of readmissions. We need to consider the diseases associated with AF for an overall approach to these patients.

Paralysis of the external popliteal sciatic nerve associated with daptomycin administration

Peripheral neuropathy has been associated with the administration of certain drugs. Few reports have described the association of daptomycin with the development of peripheral neuropathy, none of them with peroneal nerve involvement.