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Resumen Fundamento y objetivo Fulvestrant es un antiestrogeno puro que ha demostrado eficacia en cancer de mama avanzado como tratamiento de segunda linea tras progresion a tamoxifeno. El objetivo del trabajo fue describir la experiencia clinica con fulvestrant y evaluar su eficacia y tolerabilidad. Material y metodo 36 mujeres posmenopausicas con cancer de mama avanzado recibieron tratamiento con fulvestrant. El 62,8% de las pacientes recibio fulvestrant al menos en tercera linea. Resultados El 91,4% habia recibido tratamiento hormonal previo en la enfermedad avanzada y mas del 50%, quimioterapia. La enfermedad metastasica fue visceral en un 5,7%, no visceral en un 54,3% y en ambas localizaciones en un 40%. Se obtuvo un 11,4% de respuestas parciales (RP), un 22,9% presento estabilidad de la enfermedad (EE), alcanzando beneficio clinico (BC) el 31,4% de las pacientes. La mediana de tiempo a la progresion (TTP) fue de 4,18 meses (intervalo de confianza del 95% [IC] del 95%, 2,6–5,7 meses), mientras que la mediana de supervivencia global (SG) no se ha alcanzado, con una mediana de seguimiento de 8,9 meses. Se produjeron eventos adversos de grado I–II en un 22,9% de las pacientes. Conclusiones Fulvestrant es un farmaco bien tolerado, que representa una eficaz opcion de tratamiento hormonal en el cancer de mama avanzado intensamente tratado con hormonoterapia y quimioterapia.

BACKGROUND AND OBJECTIVE An ideal strategy of percutaneous coronary revascularization in patients with renal insufficiency has not been established yet. Our aim was to compare in this group the clinical results of bare metal stents and drug-eluting stents, and identify predictors. PATIENTS AND METHOD In a group of 200 patients with renal disease, 93 received bare metal stents and 107 drug-eluting stents; for over 2 years we studied rates of a combined event: death, non fatal myocardial infarction, or target lesion revascularization. RESULTS We did not identify differences in the combined event. With multivariate analysis, peripheral arterial disease, left ventricular ejection fraction

Fulvestrant (Flv) is a pure antiestrogen without agonist activity. Flv is effective as second line treatment in postmenopausal women with advanced breast cancer after tamoxifen.We performed a retrospective study of 36 consecutive postmenopausal women treated with Flv and advanced breast cancer progressing on prior therapies. 62,8% received Flv as third line treatment or more (all patients had previously received endocrine treatment for early or advanced breast cancer), 54,3% adjuvant chemotherapy and 67,5% received chemotherapy for metastatic disease. Our objective was to analyze the response rate, clinical benefit, time to progression (TTP) and toxicity profile.In our study 11,4% patients had partial responses (PR) and 22,9% had a stable disease (SD)24 weeks. Clinical benefit rate (CB) [RP+RC+SD]: 31,4%. TTP: 4,2 months (CI 95%, 2,6-5,8), with a median follow-up of 8,9 months. Flv was well tolerated, 22,9% patients had adverse events, all grade I/II, and only 5,7% of women gave up the treatment.These data demonstrate that Flv is an effective and safe therapy for heavily pre-treated postmenopausal women with advanced breast cancer.

We describe the characteristics of people with a recent diagnosis of HIV infection.Series of 126 new cases of HIV infection diagnosed in an infectious diseases Service.Sexual transmission was the commonest form of infection (74%). Fifteen percent of individuals were aged over 50 years and 16% were immigrants. A late diagnosis (stage C) accounted for 36% of cases and it was associated with being more than 50 years old (OR: 5.1; 95% CI: 1.6-16.8).It is necessary to implement HIV infection surveillance systems and to improve preventive services.

Disabling chronic pain is especially devastating among working population and, in many cases, it does not respond to conventional therapies. In chronic pain, the importance of psychosocial and occupational factors, in addition to biological ones, has prompted the development of successful multidisciplinary treatment programmes in various countries. We assessed the outcome of a multidisciplinary therapeutic program for work-disabled selected patients with chronic pain refractory to conventional treatment.The study included 70 patients (58 women, mean age [SD]: 42 [9]years) with chronic pain and sick leave (mean [SD]: 7 [4] months of work disability) diagnosed with fibromyalgia (51%), chronic low back pain (16%), regional myofascial pain (15%), cervicocraneal syndrome (3%), anquilosing spondylitis (3%), and other conditions(12%). All patients had received previous pharmacological treatment,physical therapy and/or other measures (surgery in 12% cases)without improvement. All patients underwent an intensive multidisciplinary treatment of 4 weeks' duration including medical techniques for pain control, cognitive-behavioural therapy, physical therapy,and occupational therapy. Average follow-up was 10 (4) months(1-24 months) post-discharge.Significant improvements were observed with regard to all relevant variables, as reflected in pre and post-discharge measures: pain(Visual-Analogue Scale 1-10 cm): 7.4 (1.5) versus 3.2 (2) (p0.01); anxiety (HARS), 19 (7) versus 14 (8) (p0.01); depression(BDI), 16 (8) versus 10 (8) (p0.01); functional ability(HAQ), 1.6 (0.4) versus 0.6 (0.5) (p0.001). At discharge,73% of patients returned to work. In addition, 69% of treated patients maintained the acquired improvement and their employment status at the end of follow-up.Multidisciplinary treatment of chronic pain with special attention to work return is useful for selected patients with a disabling chronic pain syndrome refractory to conventional treatment.

Epidemiologic data suggest that zidovudine (ZDV) could prevent the AIDS dementia complex (ADC), but this hypothesis has been specifically studied.We have reviewed the medical records of all patients with human immunodeficiency virus (HIV) infection admitted to our section between January 1990 and December 1993 who were diagnosed with ADC, and we have compared them to those of a control group with regard to the interruption of ZDV at least 3 months before. Controls were selected from the remaining HIV-related admissions, matched by calendar year, CD4-cell count and previous HIV-disease stage.Thirty-nine cases and 39 controls were available for analysis; twenty-nine (74%) and 25 (64%) were male. The median age was similar for both groups: 30. Thirty-one patients (79%) in each group had a previous diagnosis of AIDS, six (15%) in each group had an AIDS-related complex and in two (5%) the ADC was the first complication of their HIV disease. The median CD4-cell counts were 79.6 and 79.4 x 10(6)/l. Twenty-three patients in each group had taken ZDV. Six of these from the ADC had withdrawn treatment, as compared to 2 from the control group (odds ratio [OR] 3.36; 95% confidence interval [CI]: 0.54-35.76). On the other hand, 16 patients with ADC were still on ZDV at the time of diagnosis, as compared to 21 controls (OR: 0.66; 95% CI: 0.22-1.60).In this case-control study, the interruption of treatment with ZDV was not found to be a risk factor for the development of ADC.

Adverse drug reactions (ADR) in the pediatric emergency room of a tertiary care hospital in Spain are described and compared with the adult ward.Identification of cases was carried out through review of admission diagnoses and selection of those included in a previous list of diagnoses considered as possible ADR, that were thereafter verified.During 25 months, in 47.107 pediatric consultations were detected 451 cases as suspicious of ADR (0.96%). The ADR was moderate in 29 and serious in 1, being hospitalized 4. In adults, there were 68,431 consultations, and 704 cases detected (1.03%); moderate 218, serious 34 and mortal 1, being hospitalized 101. The most common reactions were dermatological (43.9% in children, 19.5% in adults) and of digestive nature (28.5 and 36.6%, respectively). The drugs most frequently involved in children were antimicrobials (49.5%), drugs used in respiratory illnesses (19.9%), non-steroid anti-inflammatory drugs (NSAID) (10.4%) and vaccines (9.2%); only two recently marketed products were involved. In adults, drugs involved were NSAID (28.2%), cardiovascular drugs (15.9%), antimicrobials (14.5%) and drugs active in digestive system (11.1%). There were 10 cases of hypoglycemia in diabetic adults, probably by interaction of hypoglycemic agents with angiotensin-converting enzyme inhibitors, and 7 cases of gastrointestinal hemorrhage associated with ketorolac, that generated an alert; 12 recently marketed products were involved.Intensive monitoring in emergency ward measures ADR problem, estimates underreporting, but it has a moderate value to generate alert or to survey new products.

To determine the clinical and immunologic characteristics of a large cohort of patients with primary Sjörgen's syndrome (SS) and to asses if the sex, the age at onset, the time of evolution and the immunologic pattern define different subsets with specific characteristics.We included 80 patients (76 female and 4 male) that were prospectively studied at our Unit. All patients fulfilled the European Community criteria proposed in 1993 for the diagnosis of SS.Mean age of patients was 62 years with a mean disease duration of 8 years. The most frequently observed clinical manifestations were xerostomia (96%), xerophthalmia (94%) and parotidomegaly (46%). The main extraglandular manifestations were arthritis (45%), Raynaud's phenomenon (20%) and liver involvement (19%). The immunologic study showed antinuclear antibodies in 82% of patients, rheumatoid factor in 45%, anti-Ro/SS-A in 40% and anti-La/SS-B in 20%. In patients with an onset of disease before the age of 40 years, a higher prevalence of parotidomegaly, peripheral neuropathy, cutaneous vasculitis, rheumatoid factor, anti-Ro/SS-A and anti-La/SS-B antibodies was observed. A disease duration longer than 10 years was associated with a higher prevalence of pulmonary involvement and more focus of mononuclear cells in the minor salivary glands. Clinical manifestations associated to any one or more immunologic marker (rheumatoid factor, anti-Ro/SS-A and/or anti-La/SS-B) were Raynaud's phenomenon, arthritis, thyroid disease, cutaneous vasculitis and peripheral neuropathy.Primary SS is an autoimmune disease characterized by a marked heterogeneity in the clinical presentation and evolution, thus allowing the definition of several subsets of patients with their own clinical and immunological characteristics.

To analyze the effect of intramuscular injections of drugs on serum creatine kinase (CK) and to evaluate the possible existence of factors that lead to predict the probability of appearance of serum CK increase after injection.One hundred and seventy six consecutive patients admitted to a short-term medical ward for non-cardiac reasons who had normal serum CK levels, were selected for the study. 120 of them, selected for random allocation, received a single 0 multiple injections of drugs (with broad use in emergency medicine) in the gluteal muscle (group IM). The remaining 56 patients were the group control, in all the cases serum CK was measured at 0, 6, 12, 24 and 48 h since the admission.A significant elevation of serum CK levels occurred in 58.3% cases of group IM. The higher ratio of cases with increment of CK levels was observed after the injection of chlorpromazine (100%), followed of diclofenac (74.2%), metamizol (60%) and multiple drugs (60%). In most cases the highest increment was observed at 12 h after injection. A tenfold increase in serum CK level was found after intramuscular injection of diclofenac. There were significant differences between the elevation or not of serum CK and the type of drug administered (p0.05), sex (p0.05), and the solvent of the drug injected (p0.05). A higher probability of serum CK elevation was observed in men (p = 0.009) and when the solvent of the drug injected was ethanol (p = 0.0499).There is a high probability of serum CK increment after intramuscular injection of drugs. The sex and the solvent of the drug injected have influence on this probability. The magnitude of this enzymatic increment depends on the kind of the drug injected, being non steroidal anti-inflammatory drugs those higher serum CK increment have been produced in the present study.

Two patients with tendinitis by ciprofloxacin are described. In both patients isolated involvement of the Aquilles tendon was produced. The symptoms initiated at 2 to 4 weeks of the beginning of treatment. The two patients had undergone chemotherapy and bone marrow transplantation due to chronic myeloid leukemia and acute promyelocytic leukemia, respectively with no data on recurrence of leukemia being obtained at the time of the tendinitis. Suppression of ciprofloxacin achieved disappearance of the symptomatology.

Two patients with infectious endocarditis (IE) by Staphylococcus aureus resistant to methicillin, aminoglucosides and rifampicin (SARMAR) acquired in hospital during the course of an epidemic outbreak of this microorganism in the Hospital Clínic i Provincial of Barcelona. Both patients had undergone surgery of the lower limbs. The entrance of the microorganism was the infection of the surgical wound, with bacteriemia, followed by mitral IE after a short time interval (20 days). Despite adequate treatment with vancomycin both patients died. The culture of mitral vegetation was positive for SARMAR in one. Analysis of the chromosomic DNA of all the isolations from the patients was identical and coincided with that of the SARMAR strains isolated in the epidemic outbreak of the hospital. The current situation of IE by SARMAR is reviewed and the therapeutic implications commented upon suggesting that treatment of this entity should simultaneously include the administration of vancomycin and phosphomycin or cotrimoxazole, with surgery being considered if infection persists.

Bacillary angiomatosis (epithelioid) is a recently described clinicopathologic syndrome, principally associated to infection by the human immunodeficiency virus. The case of a patient who was seen for fever and the appearance of four painful, erythematous and indurated subcutaneous nodules on the anteroexternal face of the right lower extremity 15 days previously is presented. No microorganisms were observed by microbiologic and histologic techniques however the latter showed a vascular proliferation with prominent endothelium of epithelioid morphology and notable interstitial inflammatory reaction according to the pattern described as characteristic of epithelioid angiomatosis. The fever and the nodules disappeared spontaneously. The clinical and histopathologic characteristics of this disease as well as the recent contributions with respect to the identification of the possible causative bacillus are discussed.

Three patients with osteoporosis associated to pregnancy are presented. The three patients developed multiple vertebral fractures in the third trimester of pregnancy with normal analytical and hormonal studies and diminished bone mineral density being observed. Other causes of osteoporosis were discarded. The patients were treated with sodium fluoride and calcium with a consequent increase in bone mineral density being achieved in two and stabilization in the third patient. Given the rarity of this entity, the literature concerning this disease is reviewed, with particular emphasis being placed on etiopathogenesis, treatment and evolution.

Anaemia of chronic renal failure is primarily due to relative erythropoietin deficiency. This hormone has been recently cloned and it is now available for clinical use.Sixteen patients maintained on haemodialysis with non-complicated anaemia and on stable clinical condition were selected for 12 months' treatment with r-HuEPO. Our aim was to analyse the factors influencing r-HuEPO response and the modifications on main haematological and biochemical parameters and adverse reactions occurrence.All patients responded with an increase of haemoglobin (from 78 +/- 9 to 103 +/- 18 g/dl at second month of therapy, p less than 0.001) and blood transfusions were eliminated. Time of response and doses were very different to one another. R-HuEPO requirements decreased slowly with time. Neither transfusion number, nor hyperparathyroidism, nor ferritin levels, nor diabetic condition influenced r-HuEPO response. Serum ferritin decreased significantly from 1,772 +/- 1,791 to 1,116 +/- 1,240 ng/ml (p less than 0.05), especially in patients without iron overload. Serum vitamin B12 levels did not decrease significantly. Both uric acid and phosporus increased significantly after the treatment period (5.25 +/- 1.18 to 6.29 +/- 0.99 mg/dl and 5.78 +/- 1.29 to 6.69 +/- 1.55 mg/dl respectively, p less than 0.01). Platelet counts did not modify. It was necessary to adjust antihypertensive therapy in a few patients because of a mild rise in blood pressure, although important adverse reactions did not occur.Anaemia of haemodialysis patients improves with r-HuEPO treatment and reduces blood transfusion requirement. Adverse effects are not very remarkable.

We report the case of a female aged 67 years suffering a Waldenström's macroglobulinemia which began with arthritis at the knee and pleural effusion. In both locations the anatomopathological examination showed infiltration by typical lympho-plasmatic cells. Other possible etiologies such as amyloid, infection or arthritis produced by microcrystals were ruled out. The relevant finding in this case was the presence of infiltrative reaction at the synovial tissue which has been rarely reported in the literature. We review the incidence of articular manifestations in cases of Waldenström's macroglobulinemia and the possible pathogenetic mechanisms involved.