Search

Tesis - Universidad de Murcia., Bibliografía., MEDICINA ESPINARDO. DEPOSITO. MU-Tesis 77.

We analyzed the feasibility of an intensive lipid-lowering strategy based on a starting dose of atorvastatin according to baseline and target low-density lipoprotein cholesterol (LDL-C) level (

La miositis o miopatia inflamatoria es una manifestacion frecuente de la acromegalia, aunque poco estudiada. Se caracteriza por debilidad de predominio proximal que puede acompanarse de dolor muscular. El incremento de las enzimas musculares, la alteracion en el electromiograma y la biopsia compatible son hallazgos que apoyan el diagnostico. Presentamos el caso de una paciente que consulto por debilidad muscular. Los estudios complementarios confirmaron la miositis y, tras descartar otras causas, se llego al diagnostico de acromegalia. La miositis como manifestacion predominante de una acromegalia es excepcional.

El diagnostico de acromegalia esta basado en pruebas bioquimicas que muestran un aumento de secrecion de somatotropina (GH). Mas del 95% de los pacientes con acromegalia presentan un adenoma hipofisario productor de GH. La tecnica de imagen de eleccion en el diagnostico del adenoma es la resonancia magnetica (RM). La utilizacion de nuevas tecnicas, como la gammagrafia con 111 In-pentetreotida (OctreoScan) y la tomografia por emision de positrones (PET), puede aportar informacion adicional en algunos casos. Presentamos el caso de una mujer diagnosticada de acromegalia. Varias RM y el OctreoScan fueron normales y otras posibilidades diagnosticas fueron descartadas. La PET localizo el origen hipofisario de la hipersecrecion de GH. En la acromegalia, la ausencia de hallazgos en la RM y el diagnostico de localizacion por medio de PET son excepcionales.

[ES] Optimización de un protocolo para la identificación genética de seis plantas ornamentales, Melia azedarach, Mirabilis jalapa, Nerium oleander, Pittosporum tobira, Prunus armeniaca y Ricinus communis, las cuales contienen toxinas susceptibles de afectar a la salud humana. El método de identificación se fundamenten la PCR múltiple., [EN] Optimization of a protocol for the genetic identification of six ornamental plants:Melia azedarach, Mirabilis jalapa, Nerium oleander, Pittosporum tobira, Prunus armeniaca and Ricinus communis;which contain toxins which may affect human health. The identification method are based multiplex PCR.

Alcohol dependence is a chronic disease whose treatment begins with detoxification, followed by rehabilitation. We present a descriptive and retrospective study of 147 patients admitted to our unit during the period 2003-2005. Median age was 46.07 years, with 77.6% men and 22.4% women. Admission diagnosis was alcohol withdrawal syndrome in 31 patients (21.1%) and programmed alcohol detoxification in 116 patients (78.9%). On the CIWA-Ar scale: mild withdrawal, 100 patients (68.5%), moderate, 35 patients (24%), severe, 11 patients (7.5%). Mild group showed a statistically significantly lower proportion of hepatopathy, by comparison with the moderate and severe groups. Statistically significant differences were found between the mild and severe groups on comparing mean age, duration of stay, quantity of alcohol and parameters of chronic consumption (ferritine, fe, VCM, UBE, AST, bilirubin and Mg) for AST and bilirubin. There were 11 seizures: 4 patients from the programmed group, with mild withdrawal on the CIWA-Ar scale, and 7 patients with moderate-severe withdrawal. No relationship was found between patients intensity of withdrawal syndrome, age or sex. There was higher intensity on the CIWA-Ar score (moderate and severe) among patients who had already begun withdrawal syndrome, compared to those admitted on a planned detoxification programme. The CIWA-Ar is a useful tool for assessing withdrawal symptoms and risks of complication and for planning treatment. Clinical practice must provide patients with access to health resources for the appropriate treatment of their addiction, with standardized assistance during their stay in hospital.

Diagnosis of acromegaly is based on biochemical tests demonstrating increased growth hormone (GH) secretion. More than 95% of patients with acromegaly harbor a GH-secreting pituitary adenoma. The technique of choice in the diagnosis of an adenoma is magnetic resonance imaging (MRI). The use of new techniques such as (111)In-octreotide scintigraphy (OctreoScan) and positron emission tomography (PET) can provide additional information in some cases. We report the case of a woman with acromegaly. The results of several MRI scans and OctreoScan were normal and other diagnostic possibilities were ruled out. The pituitary origin of the increased GH secretion was identified by PET. In acromegaly, the absence of MRI findings and identification of location by means of PET are exceptional.

The increased prevalence of diabetes mellitus has become a public health problem. Hyperglycaemia entails a rise in the morbidity and mortality of these patients. Although a direct relationship with periodontal disease has already been shown, little is known about the results of dental implants in diabetics. The present paper reviews the bibliography linking the effect of diabetes on the osseointegration of implants and the healing of soft tissue. In experimental models of diabetes, a reduced level of bone-implant contact has been shown, and this can be reversed by means of treatment with insulin. Compared with the general population, a higher failure rate is seen in diabetic patients. Most of these occur during the first year of functional loading, seemingly pointing to the microvascular complications of this condition as a possible causal factor. These complications also compromise the healing of soft tissues. It is necessary to take certain special considerations into account for the placement of implants in diabetic patient. A good control of plasma glycaemia, together with other measures, has been shown to improve the percentages of implant survival in these patients.

The increased prevalence of diabetes mellitus has become a public health problem. Hyperglycaemia entails a rise in the morbidity and mortality of these patients. Although a direct relationship with periodontal disease has already been shown, little is known about the results of dental implants in diabetics. The present paper reviews the bibliography linking the effect of diabetes on the osseointegration of implants and the healing of soft tissue. In experimental models of diabetes, a reduced level of bone-implant contact has been shown, and this can be reversed by means of treatment with insulin. Compared with the general population, a higher failure rate is seen in diabetic patients. Most of these occur during the first year of functional loading, seemingly pointing to the microvascular complications of this condition as a possible causal factor. These complications also compromise the healing of soft tissues. It is necessary to take certain special considerations into account for the placement of implants in diabetic patient. A good control of plasma glycaemia, together with other measures, has been shown to improve the percentages of implant survival in these patients. El incremento en la prevalencia de la diabetes mellitus se ha convertido en un problema de salud pública. La hiperglucemia conlleva un aumento en la morbilidad y mortalidad de estos pacientes. Aunque ya se ha demostrado una relación directa con la enfermedad periodontal, poco se conoce sobre el resultado del implante dental en el sujeto diabético. En el presente trabajo se revisa la bibliografía que relaciona el efecto de la diabetes sobre la oseointegración de los implantes y la cicatrización de los tejidos blandos. En modelos experimentales de diabetes se ha demostrado una reducción en los niveles de contacto hueso-implante, que puede ser revertida mediante tratamiento con insulina. En el paciente diabético, comparado con la población general, se observa un mayor índice de fracaso. La mayoría de ellos se producen durante el primer año de carga funcional, lo que parece señalar a las complicaciones microvasculares de la enfermedad como posible factor causal. Dichas complicaciones comprometen también la cicatrización de los tejidos blandos. Se hace necesario establecer unas consideraciones especiales para la colocación de implantes en el paciente diabético. El buen control de la glucemia plasmática, junto con otras medidas, ha demostrado mejorar los porcentajes de supervivencia de los implantes en estos pacientes.

An analysis is made of the effect of alternateday dosing of atorvastatin and standard once-daily dosing, based on mean low-density lipoprotein (LDL) reduction from baseline in type 2 diabetics. Forty-four type 2 diabetics were enrolled in the study. In compliance with American Diabetes Association (ADA) and National Cholesterol Education Program Expert Panel (NCEP-III) guidelines, LDL-C

To study the seroprevalence of hepatitis C virus in a cohort of six patients with a diagnosis of polyarteritis nodosa (PAN).There have been included six patients with a diagnosis of PAN, carrying out a serodiagnosis of hepatitis B virus (VHB) and C (VHC) this last one by means of the following methods: ELISA, RIBA-II and PCR.These cases (50%) showed exclusive positivity to VHC by means of the three ways of diagnosis, two cases showed positivity to VHB (33.3%), one case (16.6%) showed positivity to both virus (VHB and (VHC) and one case didn't show positivity virus.It is probable a ethipatogenic relation between hepatitis C virus and polyarteritis nodosa, our sample doesn't show any difference from that written in the literature. The positive rheumatoid factors can give false positive for VHC by means of the technique ELISA because of this it is necessary to confirm the positive by means of the techniques RIBA-II and PCR.

Pancreatic involvement has been studied in 70 HIV infected patients, in diverse stages, that were treated with didanosine (ddI), both as monotherapy or associated to zidovudine; 38% of patients presented adverse reaction that obliged to withdraw the medication: pancreatitis (4%), hyperamylasemia (21%) and abdominal pain and/or diarrhea (12%). The possible causes in presentation of adverse effects were evaluated: route of infection, stage of HIV infection, use of pentamidine or trimethoprim-sulfamethoxazole for preventing Pneumocystis carinii pneumonia, administration of ddI in monotherapy or in combined form with zidovudine, time of treatment and level of CD4 lymphocytes. The outcome of adverse effects is related significantly only with the most advanced stage of HIV infection.

A 37 year old woman is presented with solitary splenic abscess, without involvement of other organs, in the context of septic abortion. Splenic abscess were effectively treated with 21 days of antibiotic administration, not was necessitated splenectomy and percutaneous drainage. Emphasis is laid on its rarity of solitary splenic abscess in the course of gynecologic infection, and complete response to antibiotic treatment.

The purpose of our study is to show results obtained after a cholecystectomy on 25 patients in order to present a suggestive clinic of bile origin and a positive result for determination of microcrystals in the bile probe even in the case of negative radiologic diagnoses (echography, cholecystography). Out of 25 patients operated on the following results were obtained: microscopic cholelithiasis in 12, granular cholelithiasis in 3, acute cholecystitis in 2, cholesterolosis in 2 and without pathologic findings in 6 patients after an observation period of 24 months following the operation it was demonstrated that almost all the patients (96%) had no symptoms. On the other hand, the above mentioned results are compared to the findings obtained during an observation period of a group of 34 patients with positive probe results with the same clinic characteristics and not having been operated on refusing the operation suggested.

A group of patients with clinical manifestations suggesting biliary origin in whom diagnostic imaging techniques were negative were studied by duodenal biliary drainage with the aim of identifying whether microcalculi were present in the bilis being responsible for the symptomatology. The problem group was made up of 96 patients with the results being compared with those of a control group (without biliary disease) including 45 subjects. Duodenal biliary drainage was analyzed for the detection of microlithiasis in the biliary sediment in all the subjects. The analysis was positive in 46 (47.9%) of the patients with biliary clinical manifestations while analysis was positive in only 5 (11.2%) of the control group with the differences being statistically significant. Seventeen of the 46 positive patients underwent surgery demonstrating biliary disease in all (chronic cholecystitis). All these patients remained asymptomatic except one on follow up with 94.1% cure by cholecystectomy being achieved. The authors conclude that duodenal biliary drainage is a highly profitable, complication-free and easily performed diagnostic technique for the detection of microlithiasis which should be regularly used in patients with symptoms suggestive of biliary origin and complementary negative explorations.

Rickettsia spp. infections produce hepatic damage with transaminases elevation and biological signs of cholostasis. Classical biochemical tests of hepatic function were analyzed and compared in 8 patients with Q Fever (QF) and 7 with Boutonneuse Mediterranean Fever (BMF). Liver enlargement was detected in 75% of the QF group of patients as compared with the 57% of the BMF group. Transaminases were raised in 75% of the patients of the QF group and in 85, 7% of the BMF patients. Only one patient in the QF group showed manifest clinical jaundice. Statistically significant differences were found between the values of AST, ALT, alkaline phosphatase and GGT, which were higher in the QF group. Liver involvement is more important in patients with QF than in FBM. There is a large percentage of clinically silent involvement in both diseases. Liver function tests should be carried out in infections by Rickettsia spp.

The identification of a casual agent in the so-called "idiopatic acute pancreatitis" is of great interest in relationship with the prognosis and the election of correct therapy. We have performed a duodenal drainage for the microscopic study of the bile, looking for cholesterol crystals and bilirrubinate's in a group of 19 patients with idiopatic acute pancreatitis. The results have been compared with a control group composed by 45 assymptomatic individuals. In the patients group drainage results were abnormal in 11 cases (57.9%) vs. 11.2% in the control group (difference statistically significant). In 4 of the 11 cases, a cholecystectomy was performed showing biliary pathology. Patients at follow-up were assymptomatic. Duodenal drainage is an easy method without risks that must be used always in idiopatic acute pancreatitis. It allows the diagnosis of microlithiasis and may help in the therapeutic indication of cholecystectomy.

The Neutrophilic dermatosis (ND) is considered as an independent entity with diverse clinical manifestations among which there are: gangrenous pyoderma, nodous erythema, Sweets Syndrome, vesiculopustula eruptions associated to ulcerous colitis and intestinal short circuit syndrome with or without short circuit. Histologically, they are characterized by infiltration of polymorphonuclear neutrophils, generally at the dermic level, but also at the epidermic. They are usually associated to systemic diseases, especially to chronic intestinal inflammatory disease. Our aim was to describe two forms of clinical presentation of neutrophilic dermatosis: gangrenous pyoderma and vesiculopustula eruption, associated to ulcerous colitis starting at advances ages.

Schönlein-Henoch purpura is a vasculitis due to hypersensitivity characteristic of the infancy that affects preferably small vessels. The etiology is unknown, although it has been related to allergic reactions to drugs, infections, vaccines and insecta bites. An adult with a Schönlein-Henoch purpura after receiving spiramicin is presented, beginning with epigastric pain and vomiting and the purpura appearing subsequently.

We present a case of mixed disease of the connective tissue in a 37-year-old woman previously healthy, whose first manifestations were ascites, facial edemas and tibiomalleolars, latter progressing with constitutional syndrome, myalgias, Raynaud's phenomenon and esophagic disorders. In the literature reviewed, we have not found any other case of this type of onset in mixed disease of the connective tissue.

La dependencia al alcohol es una enfermedad cronica y su tratamiento comienza con la desintoxicacion, continuandose con la rehabilitacion. Se presenta un estudio descriptivo y retrospectivo de las desintoxicaciones de alcohol en 147 pacientes ingresados en nuestra unidad en el periodo 2003-2005. La media de edad es de 46.07 anos, 77.6% hombres y 22.4% mujeres. Ingreso por sindrome de deprivacion alcoholica en 31 pacientes (21.1%), desintoxicacion programada en 116 pacientes (78.9%). Segun la escala CIWA-Ar: abstinencia grado leve 100 pacientes (68.5%), moderada 35 (24%), grave 11 (7.5%). La estancia media global fue de 11.5 dias, sin diferencias estadisticamente significativas. Grupo Leve con proporcion significativamente menor de hepatopatia, grupos Moderado y Grave proporcion significativamente alta. Al comparar la media de la edad, estancia, cantidad de alcohol y parametros de consumo cronico (ferritina, fe, VCM, UBE, GPT, GGT, bilirrubina y Mg), se encuentran diferencias significativas entre las medias de los grupos Leve y Grave para la GPT y bilirrubina total. Se produjeron crisis epilepticas en 11 pacientes, 4 pertenecian al grupo programado, 7 con intensidad moderada-grave. No se ha evidenciado relacion entre la intensidad del sindrome de deprivacion, edad y sexo. Mayor intensidad en la escala CIWA-Ar (grados moderado y grave) entre los pacientes con sindrome de deprivacion ya iniciado comparados con los ingresados programados, que predominantemente presentaban un grado leve. La CIWA-Ar es un instrumento util para evaluar los sintomas de deprivacion, el riesgo de complicaciones y planificar el tratamiento. La actitud clinica debe facilitar el acceso del paciente a los recursos sanitarios para el tratamiento de su adiccion, normalizando la asistencia durante el ingreso hospitalario.

Sweet's syndrome, or febrile neutrophilic dermatosis, is a disease first described by Sweet R.D. in 1964 as a dermatologic disease. Subsequently, it has been associated to several disease. One of those rarely describe is the association to chronic intestinal inflammatory disease. We reviewed the cases studied in our hospital since 1980 and found two cases associated to chronic intestinal inflammatory disease. We recommend the carrying out of gastrointestinal studies in patients afflicted by Sweet's syndrome to detect its association.

A 42 year old female, diagnosed as having Sweet's syndrome, is presented as a new case of this rare disease (less than 100 cases reported before 1985) and the literature of the syndrome is reviewed. The clinical and histological features and its association with other diseases, especially the pathogenesis and treatment, are commented on.

Análisis socio-epidemiológico, clínico, microbiológico y terapeútico de las neumonías en pacientes mayores de 65 años atendidas en un Servicio de Medicina Interna de un Hospital Terciario. Hipótesis Un mejor conocimiento de las características socio-epidemiológicas, clínicas, analíticas y radiológicas de los enfermos mayores de 65 años que ingresan por Neumonía debe permitir ayudarnos a conocer el pronóstico real de estos pacientes, el tratamiento antibiótico más adecuado así como las medidas que debemos adoptar para intentar evitar la aparición de nuevos episodios. Objetivos - Objetivo principal: o Conocer las características socio-epidemiológicas de los pacientes mayores de 65 años que ingresan por Neumonía. - Objetivos específicos principales: o Conocer las características socio-epidemiológicas de los pacientes mayores de 65 años que ingresan por Neumonía Aspirativa. o Conocer las características socio-epidemiológicas de los pacientes mayores de 65 años, procedentes de residencias de la tercera edad, que ingresan por Neumonía. o Comprobar si las escalas clásicas de gravedad (Fine, CURB65, Mehr) son útiles para predecir las complicaciones y la mortalidad en estos grupos de pacientes. o Comparar si existen diferencias entre los pacientes que ingresan por Neumonía procedentes de su domicilio, de residencias de la tercera edad o de los que ingresan por Neumonía por aspiración. - Objetivos secundarios: o Describir la forma de presentación (clínica, radiológica, microbiológica) de las neumonías por aspiración o Conocer las principales complicaciones que surgen durante la evolución de estos pacientes. o Valorar la efectividad de las diferentes familias de antibióticos y la refractariedad al tratamiento.

Análisis socio-­epidemiológico, clínico, microbiológico y terapéutico de las neumonías aspirativas en pacientes mayores de 65 años atendidas en un Servicio de Medicina Interna de un Hospital Terciario. Hipótesis de trabajo Un mejor conocimiento de las características socioepidemiológicas, clínicas, analíticas y radiológicas de los enfermos mayores de 65 años que ingresan por Neumonía Aspirativa debe permitir ayudarnos a conocer el pronóstico real de estos pacientes, el tratamiento antibiótico más adecuado así como las medidas que debemos adoptar para intentar evitar la aparición de nuevos episodios.Objetivos Objetivo principal: o Conocer las características socio-epidemiológicas de los pacientes mayores de 65 años que ingresan por Neumonía Aspirativa. Objetivos específicos principales: o Conocer las características socio-epidemiológicas de los pacientes mayores de 65 años, procedentes de residencias de la tercera edad, que ingresan por Neumonía Aspirativa. o Encontrar factores predictivos de mortalidad en estos pacientes. o Describir la forma de presentación (clínica, radiológica, microbiológica) de las neumonías por aspiración o Comprobar si las escalas clásicas de gravedad (Fine, CURB65, Mehr) son útiles para predecir las complicaciones y la mortalidad en este grupo de pacientes. o Identificar las diferentes causas de disfagia en los pacientes que ingresan por neumonía aspirativa. Objetivos secundarios: o Conocer las principales complicaciones que surgen durante la evolución de estos pacientes. o Valorar la efectividad de las diferentes familias de antibióticos y la refractariedad al tratamiento. o Comparar si existen diferencias entre los pacientes que ingresan por Neumonía procedentes de su domicilio (NAC), de residencias de la tercera edad (NACS). Conclusiones: 1.- Los ingresados con neumonía aspirativa en el Servicio de Medicina Interna del Consorcio Hospital General Universitario de Valencia representan el 7,1% del total de ingresos durante los años 2005-2008 y el 35,3% dentro del global de las neumonías de la comunidad. Desde el punto de vista epidemiológico sus características fundamentales son: mayoritariamente mujeres, de edad superior a 80 años, procedentes principalmente del domicilio familiar, con un alto nivel de dependencia y encamamiento, pluripatológicas y con un elevado nivel de consumo de sedantes del SNC. 2.- La sintomatología clínica más frecuente al ingreso es la disnea seguida de expectoración purulenta y dolor torácico. El 23,3% de los pacientes acudió sin sintomatología respiratoria. La desnutrición se ha observado en el 50% de todos los casos. 3.- Las neumonías de nuestros pacientes son clínicamente graves o muy graves, con afectación radiológica alveolar unilateral y derrame pleural asociado en un 17,4%. Casi en un tercio de los pacientes se produjo fracaso antibiótico. 4.- El germen más frecuentemente aislado es el Streptococo Pneumoniae. El aislamiento de microorganismos anaerobios ha sido escaso, por lo que la terapia antibiótica empírica debería ir más dirigida al germen más habitual. 5.- Entorno a un 80% de los pacientes prensentan complicaciones durante el ingreso, siendo las más frecuentes las renales, seguidas por las pulmonares y digestivas. Aquellos pacientes que desarrollaron alguna complicación en su ingreso presentaron una mayor mortalidad intrahospitalaria. 6.- Nuestra estancia hospitalaria ha sido de 9,58 días. Son predictores de estancia hospitalaria: aislamiento del germen, fracaso antibiótico y presencia de complicaciones pulmonares. 7.- Un 30% de nuestros pacientes fallecen durante el ingreso, siendo predictores de mayor mortalidad: desnutrición, fracaso antibiótico, acidosis respiratoria, complicaciones digestivas y complicaciones del SNC. 8.- En nuestros pacientes existe un elevado porcentaje de comorbilidades. Las alteraciones del SNC son las más frecuentes, representando el 85,3%, destacando la Demencia senil (40%) y el ACV (30%). Un 42,6% del total de nuestros pacientes presentan disfagia. Existe una fuerte relación entre la presencia de alteración del SNC, principalmente demencia senil y ACV, y sintomatología de disfagia. 9.-Aquellos pacientes positivos al MECV-V presentaron de manera significativa mayor mortalidad. Demostrando que es una herramienta de gran valor y costeefectiva, para la prevención, tratamiento y manejo de futuros episodios en pacientes que padecen disfagia. 10.- Más de un tercio de nuestros pacientes proceden de residencias de la tercera edad, difereciándose de los que procedían de su domicilio en: mayor número de mujeres, mayor nivel de dependencia, mayor consumo de sedantes del SNC, mayor comorbilidad, mayor gravedad de la neumonía y mayor sintomatología. No hemos encontrado diferencias significativas en cuanto al agente causal ni en cuanto a la mortalidad. 11.- En función a los hallazgos obtenidos recomendamos: o Vacunación de Pneumococo en pacientes mayores de 65 años. o Realización MECV-V fundamentalmente en los pacientes con alteraciones del SNC, sospecha de disfagia y antecedentes de episodios de aspiración/ neumonia por aspiración tanto en hospital como residencia/domicilio. o Prevención y rehabilitación en pacientes que presentan disfagia. o Adiestramiento de los cuidadores y familiares tanto en la prevención como en la rehabilitación.