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Resumen Antecedentes y objetivos Los pacientes con insuficiencia cardiaca (IC) presentan con frecuencia patologias asociadas. Se desconoce en toda su extension la influencia de estas comorbilidades en la mortalidad y otras variables clinicas. Hemos analizado la comorbilidad de los pacientes ingresados por IC en los servicios de medicina interna de hospitales de Espana y su relacion con diversas variables sociodemograficas y clinicas. Pacientes y metodos Estudiamos de forma prospectiva 2.127 pacientes (desde el 1 de octubre del ano 2000 al 28 de febrero del ano 2001) con IC, ingresados en 51 hospitales de diferentes categorias (comarcales – hospitales universitarios), en los que un internista se ofrecio a colaborar. La comorbilidad se calculo con el indice de Charlson. Resultados La edad media fue de 77 anos (mujeres, el 57%). El 45% habia tenido al menos un ingreso en el ultimo ano. El 41% tenia una clase funcional iii/iv de la New York Heart Association. La fraccion de eyeccion se hallo conservada en el 53% de los enfermos. Se indentificaron patologias asociadas en el 60% de los pacientes (diabetes mellitus, el 39%; enfermedad pulmonar obstructiva cronica, el 31%). El indice de Charlson medio fue de 5,4 puntos (rango: 2 – 11 puntos). La mortalidad intrahospitalaria global fue del 6,1%. Durante el ingreso hospitalario fallecieron mas pacientes en el grupo de mayor comorbilidad (Charlson ≥3 puntos, el 8,4%) que entre los enfermos con menor indice de Charlson (1 – 2 puntos, el 5,2%; p iii/iv de la New York Heart Association y grado de incapacidad fisica. Conclusiones La comorbilidad, determinada por el indice de Charlson, se asocio con una frecuencia mayor de ingresos hospitalarios, estancia media mas prolongada, mayor discapacidad y mortalidad mas elevada. Estos resultados subrayan la importancia de las patologias concomitantes en la evaluacion y el pronostico de los enfermos con IC que ingresan en los servicios de medicina interna

Summary CA125, a tumor marker normally used to follow the clinical course of ovarian cancer, also may have a role in lymphoma. All available series were analyzed using the standard reference value 35 U/ml, but age and sex may influence serum CA125 (sCA125) levels. We aim to study the prognostic value of serum CA125 (sCA125) levels in diffuse large B-cell lymphoma (DLBCL), considering the influence of age and sex on sCA125 levels. We investigated the relationship between sCA125 and clinical outcome after treatment in 42 patients with DLBCL, comparing both the standard (35 U/ml) and a new age and sex adjusted (sex/age-adjusted) reference value proposed by our group. We found that patients with elevated sCA125 levels had significantly more adverse prognostic factors at diagnosis, lower CR rates, higher relapse rates and worse survival. In the low-risk IPI categories, the presence of elevated sCA125 defined a particularly high-risk subgroup with poorer 3-year PFS when compared with patients with normal sCA125 levels. The use of a sex/age-adjusted reference value for sCA125 may increase the sensitivity to identify those patients with elevated sCA125 levels truly related to DLBCL activity.

Introduction CA 125 is a tumour marker usually used to monitor the clinical course of the patients with ovary cancer. The frequently used reference value of this marker is 35 U/mL. However, some arguments to allow us to question us the validity of the classical reference value: i) a second generation of immunoassays, ii) diverse studies related to the factors that influence in the CA 125 serum concentrations and iii) the new applications of CA 125 in pathologies different to the ovary cancer. Objectives 1) To propose a reference value of CA 125 in men; 2) To evaluate the CA 125 serum concentration according to different variables, some of which can be altered in pathologies where CA 125 level can be monitored and/ or altered. Material and methods 65 healthy men were included (age: 40.21 ± 10.60 years). A survey containing different parameters and an analytic that contained a hemogram, hepatic, renal, pancreatic profile, ionogram, thyroid function, tumour markers and NT-Pro-BNP was carried out to exclude the presence of a pathological situation. The percentile 95 ( P 95 ) was calculated to obtain the reference value. Correlations among the CA 125 and the different variables were analyzed by the Spearman test. Results The median [ranges] and the P 95 were: 7.50 [3.00–25.00] and 20.17 U/mL, respectively. 78% of the values of CA 125 were ≤ 10 U/mL, 94% were ≤ 15 U/mL and 95% were ≤ 20 U/mL. Furthermore, the studied variables don't seem to influence in the concentrations of this marker. Conclusions The proposed reference value obtained in healthy male subjects is significantly lower than the one used in the clinical practice. This value should be kept in mind when extending the use of this marker to other pathologies which was not used up to now.

CA125, a tumor marker normally used to follow the clinical course of ovarian cancer, also may have a role in lymphoma. All available series were analyzed using the standard reference value 35 U/ml, but age and sex may influence serum CA125 (sCA125) levels. We aim to study the prognostic value of serum CA125 (sCA125) levels in diffuse large B-cell lymphoma (DLBCL), considering the influence of age and sex on sCA125 levels. We investigated the relationship between sCA125 and clinical outcome after treatment in 42 patients with DLBCL, comparing both the standard (35 U/ml) and a new age and sex adjusted (sex/age-adjusted) reference value proposed by our group. We found that patients with elevated sCA125 levels had significantly more adverse prognostic factors at diagnosis, lower CR rates, higher relapse rates and worse survival. In the low-risk IPI categories, the presence of elevated sCA125 defined a particularly high-risk subgroup with poorer 3-year PFS when compared with patients with normal sCA125 levels. The use of a sex/age-adjusted reference value for sCA125 may increase the sensitivity to identify those patients with elevated sCA125 levels truly related to DLBCL activity.

Heart Failure (HF) patients present frequently comorbidities. Little is known about the impact of these comorbidities in morbimortality. We analyzed the comorbidities of HF patients admitted in Spanish internal medicine units and its relation with different socio-demographics and clinical variables.We studied prospectively 2127 patients (admitted from 01.10.2000-28.02.2001) with HF in 51 Hospitals of different categories (from local hospitals to university hospitals) in which an internist was available to collaborate in the study. Comorbidities were estimated by the Charlson index.Mean age was 77 years (women 57%). 45% of patients have had a previous admission in the last year. 41% had a functional stage NYHA iii/iv. Eyection fraction was preserved in 53% of patients. Comorbidities were identified in 60% of patients (diabetes mellitus, 39%; chronic lung disease 31%). The average Charlson index was 5.4 points (range 2-11 points). Global inhospital mortality was 6.1%. During the admission more patients died in the Group with higher comorbidities (Charlson,3 points; 8.4%) than in the Group with low Charlson index (1-2, 5.2%; p0.01). Treatments prescribed were similar in both groups. In a multivariant analysis comorbidities was associated independently with masculine gender, age superior to 75 years, functional status NYHA iii/iv and dysfunctional physical capacity.Comorbidities determined by Charlson index were associated with more frequent admission, longer stay in hospital, higher discapacity and higher mortality. These results enhance the importance of comorbidities in prognosis of heart failure patients admitted in internal medicine units in Spain.

Recent educational projects in our country have been trying to introduce professional portfolios as assessment/learning tools on the undergraduate and specialized post-graduate education levels. The approval of a new formative program for the Internal Medicine specialty in an effort to adapt to the present health care needs offers an opportunity to apply these formative and evaluative methodologies in the learning process of future internists. During the 2005-2006 academic year, the Formative Work Group of the Spanish Internal Medicine Society (SEMI) developed a pilot study on portfolio application as a tool for formative assessment and mentoring. This article describes the project of designing, developing, applying and assessing an electronic portfolio for first year Internal Medicine residents. It presents an analysis of the SEMI Portfolio strengths and weaknesses and finally makes suggestions for future development.

Background: The medical management of heart failure (HF) in clinical practice varies considerably by country and by medical specialty. Aim: To assess the treatment of HF patients admitted to Internal Medicine departments, and to evaluate out-patient management prior to admission, by specialty. Design: Prospective cross-sectional multi-centre survey. Methods: Of 55 randomly selected Spanish hospitals, 51 agreed to participate. All patients ( n = 2145) consecutively admitted for decompensated HF to the Departments of Internal Medicine of these hospitals, over 5 months, were included. Twenty variables were analysed, including aspects relating to out-patient management prior to admission. Results: Mean ± SD age was 77.2 ± 10.5 years, 57.3% were female, 47% had systolic dysfunction. Prescriptions at discharge: loop diuretics 85.6%, spironolactone 29.8%, ACEIs 65.8%, beta-blockers 8.7%, cardiac glycosides 39%. At admission, 86% already had a diagnosis of HF. Of these, 53% (older patients and more women) were being treated on an out-patient basis by primary care physicians. Primary care physicians requested fewer echocardiograms than internists (38% vs. 69%, p

480 Rev Clin Esp. 2008;208(9):480 00 Con un vivo sentimiento de dolor por la muerte, el 1 de agosto, del Dr. Jose Ma Martinez Carretero queremos dedicarle, desde estas paginas, un emocionado recuerdo. Fue un gran innovador en educacion en Ciencias de la Salud de la que nos beneficiamos muchos miembros de nuestra SEMI, especialmente en el grupo de formacion, al haber sido un asesor incansable de nuestros proyectos, tanto de evaluacion de la competencia clinica como en el desarrollo de actividades formativas. Jose Ma habia iniciado su trayectoria profesional en el campo de la Endocrinologia, con una amplia formacion basica (troncal) de Medicina Interna. Su inquietud por abarcar algo mas que la practica clinica le llevo a tareas organizativas y de gestion; como consecuencia de ello la mayoria de su vida profesional iba a transcurrir en la administracion sanitaria catalana. En los ultimos 15 anos pudimos colaborar en cantidad de proyectos en Educacion Medica que el impulsaba y animaba a que nuestras instituciones (universidades, hospitales, centros de salud, sociedades cientificas o colegios profesionales) se fueran implicando en una metodologia moderna de la ensenanza, aprendizaje y evaluacion, y hay que reconocer que lo consiguio. Pudimos compartir su entusiasmo y tenacidad «a prueba de bomba»; el reconocimiento progresivo en foros educativos internacionales que lo convirtieron, sin duda, en uno de los profesionales de la salud mas brillantes, en su campo, de Hispanoamerica. Tambien admiramos su capacidad de gestion que permitio, entre otras muchas cosas, que en estos momentos se pueda disponer de una prueba de evaluacion de la competencia clinica (ECOE) que sera la base de la que se aplique en un futuro proximo en Espana siguiendo el despliegue de la LOPS. En los cargos directivos que ocupo en sociedades cientificas destaco por su capacidad de organizacion y espiritu de servicio a la comunidad cientifica. Deja un vacio dificilmente reemplazable, ?quien va a tener al mismo tiempo tanto ingenio, capacidad de trabajo, contactos nacionales e internacionales y constancia? Nos tememos que pasara mucho tiempo para encontrar a alguien con similares caracteristicas. Ha soportado una larguisima enfermedad (casi una quinta parte de su vida) con una entereza encomiable; ha demostrado en la practica —del buen enfermo— aquello que predicaba en la teoria para ser un buen medico. Sus actitudes (parte de su competencia profesional) han sido como paciente incluso mejores que antes de serlo; animaba a su entorno de tal manera que parecia que nunca llegaria el inevitable final. La Educacion Medica ha perdido a un gran profesional, la SEMI a un asesor insustituible y nosotros, ademas, a un gran amigo. La Educacion Medica esta de luto

Resumen Se presenta el caso clinico de un paciente que desarrollo un edema pulmonar unilateral tras la aspiracion de un neumotorax izquierdo. El paciente llevaba cinco dias con la clinica y la aspiracion empleada fue de 20 cm. H 2 O. La radiologia y la clinica asi como la evolucion que se describen son demostrativas. Se senalan en la discusion del caso clinico las precauciones que se deben tomar para evitar esta complicacion y asimismo se describen los mecanismos fisiopatologicos que se han implicado en la expliracion de esta complicacion.

An uncommon association of scleroderma and Rendu-Osler disease in the same patient is reported. The authors have not found similar descriptions after an extense bibliographic review. A possible relationship is suggested on the basis of the etiopathogenesis of both disorders; Rendu-Osler syndrome is an hereditary disease of unknown etiology with mesoblastic involvement (embryonic tissue which gives origin to the connective tissue), and scleroderma is an immune disease characterized by diffuse sclerosis of the connective tissue. Rendu-Osler disease was diagnosed because of the presence of angiomatous telangiectasias since childhood, recurrent mucosal hemorrhages, and the possible existence of the syndrome in a familial member. The diagnosis of scleroderma was supported by the demonstration of: 1) cutaneous infiltration, 2) Raynaud's phenomenon, 3) functional esophageal alterations with clinical dysphagia, 4) resorption of the distal phalanges, and 5) conclusive skin biopsy.