[Characteristics of patients with multiple disease hospitalized in Internal Medicine services]

INTRODUCTION

Know what proportion of patients hospitalized in the Internal Medicine services have multiple diseases.

MATERIAL AND METHODS

We analyzed 400 clinical histories of a random sample of patients admitted to 24 Internal Medicine services of Andalusia. We assessed the diagnostic categories present that make it possible to classify patients as having multiple diseases.

RESULTS

One hundred sixty eight patients (42%) were considered as having multiple diseases. The most prevalent diseases in these patients are cardiological and diabetes mellitus. The two main variables that determine that one is a multiple disease patient are age and disease causing the admission.

DISCUSSION

A significant percentage of the patients admitted to the Medicine services of the Andalusia public hospitals have multiple diseases.

[The practice of Internal Medicine in Andalusia follows the evidence-based medicine basic principles]

BASIS

To know the proportion of medical interventions carried out in the Services of Internal Medicine of the public hospitals of Andalusia based on randomized clinical trials.

PATIENTS AND METHODS

We have analyzed the primary treatments prescribed in a random sample of 326 patients admitted to these Internal Medicine services during 1998.

RESULTS

One hundred and forty-three of the 326 treatments analyzed (43.9%) were based in clinical trials and 135 (41.4%) were interventions unanimously accepted by the medical community without being based in clinical trials.

CONCLUSIONS

Most of the primary Andalusian treatments prescribed in the Internal Medicine services are evidence-based.

[Community-acquired Acinetobacter baumannii pneumonia]

OBJECTIVES

Description of two cases of community-acquired Acinetobacter baumannii pneumonia.

PATIENTS AND METHODS

Two patients, one with a history of diabetes mellitus type 2 and pulmonary thromboembolism 2 years earlier and the second without known risk factors except for the age, were admitted to hospital because of community-acquired A. baumannii pneumonia with cavitation and with favorable final evolution.

CONCLUSION

A. baumannii is an infrequent cause of community-acquired pneumonia, although it should be suspected in patients with debilitating illness and in patients who do not evolve favorably on the first days of the admission with conventional treatment.

[Nosocomial infection/colonization of the respiratory tract caused by Acinetobacter baumannii in an Internal Medicine ward]

BACKGROUND

To present the epidemiology of the outbreak and the description of patients with infection or colonization of the respiratory tract caused by A. baumannii in an Internal Medicine ward.

METHODS

20 consecutively patients hospitalized in the Internal Medicine ward were studied during 18 months with isolation of multiresistant A. baumanni in respiratory tract specimens with or without clinical signs of infection.

RESULTS

Starting on an index case, that was a patient coming from other hospital with diagnosis of nosocomial Acinetobacter pneumonia, we detected 20 patients. The age of the patients ranged from 48 to 95 years, with a mean of 71.4 years. Eighty percent were males. The clinical features were similar: advanced age, with chronic diseases (35 percent diabetics, 45 percent with chronic lung diseases), and use of broad-spectrum antibiotics agents, fundamentally third generation cephalosporin (70 percent), clarithromycin (55 percent) and quinolones (30 percent). 75 percent of patients were in the same ward. Eight (40 percent) of the patients with chronic lung diseases were subjects with COPD, two with asthma and chronic glucocorticoids treatment, and one with a sleep apnea. In four cases the isolation was considered a colonization. The mean stay was 26.15 days, and the mortality 40 percent.

CONCLUSIONS

The nosocomial infection caused by Acinetobacter baumannii is responsible of a high morbi-mortality between the patients hospitalized in an Internal Medicine ward, and produce an increase in length of stay. It is necessary a combination of control measures to prevent the transmission in the hospital and the outbreak of new multiresistant strains.

[Predictive factors for inappropriate hospital stays in an internal medicine department]

BACKGROUND

We aimed to know which factors are associated with inappropriate stays in an internal medicine department.

SUBJECTS AND METHOD

We included 1,046 hospitalisations and evaluated the justification of the admission using the Appropriateness Evaluation Protocol.

RESULTS

176 (16.8%) stays were considered inappropriate. In a multiple regression model, variables defining an inappropriate stay were the number of days in hospital, diagnosis on admission and the weekly day.

CONCLUSION

There are determining factors for inappropriate stays in an internal medicine department.

[Factors associated with inappropriate hospitalization at an internal medicine department]

BACKGROUND

To determine the factors associated with inappropriate admissions in an Internal medicine department.

SUBJECTS AND METHOD

We included 1,993 admissions. The justification for the admissions was evaluated using the Appropriateness Evalutation Protocol.

RESULTS

187 (9.4%) admissions were considered inappropriate. The likelihood of an inappropriate admission was higher as long as the patient was younger than 65 years of age (OR, 1.94; (95%) IC, 1.32-2.85) and the admission had been programmed from the outpatients clinic (OR, 10.58; (95%) IC, 2.79-40.1). Clinical diagnosis also influenced the inappropriateness of admissions.

CONCLUSION

Age, diagnosis and source of patients determine inappropriate admissions in an internal medicine department.

[Factors that influence the non prescription of beta-blockers in patients with acute myocardial infarction]

OBJECTIVE

To study the factors that influence the non prescription of beta-blockers in patients discharged with a diagnosis of acute myocardial infarction (AMI).

METHOD

A retrospective study was done of all patients discharged from our Service in the year 1998, with a diagnosis of AMI. The variables considered were age, sex, diabetes mellitus, peripheral vascular disease, left ventricle dysfunction and COPD.

RESULTS

60 patients with AMI were included in the study, 18 of whom (30%) were discharged without beta-blockers. The average age of these patients was 77 years, while the average age of those discharged with these pharmaceutical agents was 60 years (p < 0.0001). Likewise, left ventricle dysfunction (p < 0.031) and female gender (p < 0.016), also negatively influenced the use of these drugs. It was observed with multivariable regression analysis that age was the main predictor for the use of beta-blockers (p < 0.0001).

CONCLUSION

Age is the main factor that influences the non prescription of beta-blockers in patients with AMI in our Service. In spite of the potential adverse effects of the drugs in the advanced age population, the data so far obtained demonstrates a clear benefit in the subgroups at risk (advanced age, heart failure,...). Therefore it's use should be extended to this group of population as long as there are no absolute contraindications.

[What do the internal medicine residents of Anadalusia think of their specialty? Survey results]

BACKGROUND

To know the opinion of andalusian Internal Medicine (IM) residents about different subjects of their specialty, and their biomedical investigation activities.

PATIENTS AND METHODS

A questionnaire with codified answers, facilitated to 64 IM residents of Andalusia.

RESULTS

69% of residents referred that IM was the specialty they wished to adhere at first choice. A 61% of residents would advice choosing IM as specialty to physicians with the exams for becoming a resident just passed. Best merit of IM for 89% of people was the global sight of the patient, and worst one for 37.5% was its tendency to fragmentation. 47% of residents consider that the role of the specialty will grow in the future.

CONCLUSIONS

Our questionnaire reflects some of the contradictions that IM as a specialty is living, and probably show the rely of future internists to some future propositions about the specialty.

The effects of food restriction on maternal endocrine adaptations in pregnant rats

The aim of this study was to characterize hemodynamic, electrolytic and endocrine alterations produced by food restriction (50%) in pregnant rats for the purpose of evaluating the importance of these parameters on the plasma volume expansion and fetal growth. One hundred seventy six pregnant rats were divided into two groups, a control group (C) with an ad libitum diet and another with a restricted diet (U) (50% by weight of the diet of the control group). On days 5, 10, 15 and 20 of pregnancy, the weight of the mother, water intake, urine output, urine and plasma sodium concentration, plasma potassium concentration, blood pressure and heart rate, osmolality, plasma renin activity (PRA) and vasopressin were recorded. The number and weight of the fetuses were determined on days 15 and 20 of gestation. Food restriction results in inadequate weight gain in the mother and retardation of fetal growth. Water and sodium balance (p< or =0.001) were decreased in U group and basal PRA (p< or =0.001) was increased in U group. Food restriction did not significantly alter urine sodium excretion, plasma osmolality, plasma sodium and potassium values, blood pressure and basal vasopressin values. We conclude that the higher values of PRA, described in food restriction situations during pregnancy, seem to be caused by the adaptation to low sodium intake.

Role of 17-beta-estradiol and progesterone on glucose homeostasis: effects of food restriction (50%) in pregnant and non pregnant rats

The role of 17-beta-estradiol and progesterone on glucose homeostasis was examined in pregnant and non pregnant rats with or without food restriction (50%). Blood glucose and insulin levels were significantly decreased in food restricted pregnant (PM) compared with control pregnant (PC) and in food restricted non pregnant (M) compared with non pregnant control (C). The plasmatic level of progesterone was similar in PC and PM, while the plasmatic level of 17-beta-estradiol was significantly decreased in PM compared with PC at 15 and 20 days. In spite of food restriction, the changes in the insulin/glucose ratio throughout gestation were similar in PC and PM. A positive and significant relation between 17-beta-estradiol and the level of insulin at day 5 of gestation, and a negative and significant relation between the level of 17-beta-estradiol and level of insulin at day 15 of gestation were found in PC. A negative and significant relation between the levels of progesterone and the levels of insulin at day 5 of gestation, at day 10 this relation is positive and significative, and at day 15 a positive and significant relation exists between levels of 17-beta-estradiol and levels of insulin were found in PM. These results suggest that 17-beta-estradiol acts directly on beta-cells to control insulin secretion. Food restriction does not alter the changes in the sensitivity of tissues to the insulin action, and does modify the action of 17-beta-estradiol and progesterone on beta-cell.

[Pigmented villonodular synovitis with polyarticular presentation]

Pigmented villonodular synovitis (PSV) rarely involves more than one joint, and its occurrence in children is uncommon. One case of PSV with polyarticular involvement in a child is presented, and the differential diagnoses with other polyarthritis are offered. Synovial biopsy of both knees at different ages showed the presence of PSV in a fourteen years old boy with a nine years history of painless swelling of wrist, knees and ankles. Painless polyarticular swelling with few inflammatory signs, negative acute-phase laboratory tests, normal synovial fluid, periarticular soft tissue swelling on plain films and a mandatory synovial biopsy are the diagnostic clues of this rare presentation.

[Black widow spider (Latrodectus tredecimguttatus) bite. Presentation of 12 cases]

The most severe cases of arachnidism are those due to Latrodectus tredecimguttatus spider-bite. The Mediterranean area is the habitat of the L. tredecimguttatus species. In the last few years no series of patients with latrodectism has been reported in Spain. A retrospective study of the patients admitted for L. tredecimguttatus spider bite in the Torrecárdenas Hospital in Almeria, Spain from 1984 to 1994 was performed. Twelve patients were diagnosed with latrodectism. Eleven were bitten while carrying out agricultural tasks, 8 of which were performed in greenhouses. The mean time between the bite and the appearance of the general symptoms was 40 minutes (20-120 minutes), with the most common signs and symptoms being: pain and abdominal stiffness (10 cases), erythema (10 cases) or pain (8 cases) at the site of the bite, thoracic pain, pain in extremities and contractures and psychomotor alterations (6 cases). Laboratory findings were limited to leukocytosis (4 cases), increase in creatinphosphokinase count (4 cases) and proteinuria (3 cases). All the patients received analgesics, 6 were administered myorelaxants and calcium gluconate was given in 6 cases. The evolution was good without complications in all of the patients. Latrodectism is a rare phenomenon Spain. The diagnosis is difficult when there is absence of a clear history of spider bite and due to the lack of knowledge as to its semiology. Antivenom serum is not usually required.

[Poisoning caused by organophosphate insecticides. Study of 506 cases]

A total of 506 cases of acute poisoning with organophosphorus insecticides attended at Hospital Torrecárdenas, Almería, from 1981 to 1992 were prospectively studied. In all cases a predetermined clinical and therapeutical protocol was followed. Eighty per cent of poisoning events were accidental in nature, most occurred in males, greenhouse workers, and the toxic agents was most commonly absorbed through the skin and airways. All patients presented initially with overt cholinergic symptoms. The presence of bronchorrhea, tremor-fasciculations, respiratory depression and a lower level of consciousness was associated with severe poisonings. Uncommon and exceptional complications included: 5 cases with complete atrio-ventricular block, 3 cases with pancreatitis, 17 cases with endogenous re-intoxications and 3 patients with central diabetes insipidus.

[Segmental portal hypertension due to a retroperitoneal abscess of tuberculous etiology]

We report a patient with segmental portal hypertension secondary to a retroperitoneal tuberculous abscess. The patient was admitted to the hospital because of upper gastrointestinal bleeding. Gastric varices were the only lesion found at endoscopy. At laparotomy a retroperitoneal abscess was found as the etiology of splenic vein thrombosis. We emphasize the low frequency of this finding and its resolution after splenectomy and antituberculous drugs.