[Risk factors in stable coronary disease. Relationship with ischemic threshold and prognostic implications]

BACKGROUND

To assess the clinical evolution, in a 5-year follow-up, of the development of acute coronary syndromes, in patients with angina clinically stable, establishing its relationship with the ischemic threshold (IT) and the main modifiable cardiovascular risk factors.

PATIENTS AND METHODS

120 patients, 86 males (71%), with an age of 57 +/- 8 years, with stable angina. The presence of smoking, hypercholesterolemia, hypertension and diabetes mellitus was evaluated. We performed exercise testings (baseline and after vasodilator drugs) in the beginning, in order to characterize the IT (which was fixed in 72 patients and variable in 48). The later group underwent exercise testing each term during the first year of follow-up. Lesion at least of 70% in a main coronary vessel was required as inclusion criteria. The development of acute myocardial infarction (AMI), unstable angina pectoris and cardiac death was recorded. Cox's hazard function analysis and multivariant analysis were applied.

RESULTS

106 patients (88%) had one or more risk factors (40% hypertension, 43% hypercholesterolemia, 22% diabetes mellitus and 56% were smokers or ex-smokers). A significant association was shown between male gender and smoking and diabetes mellitus and female gender. 6 cardiac deaths, 8 AMI and 9 unstable angina were recorded. Within the 72 patients with fixed IT, 12.5% (9) suffered some acute syndrome. In the 48 with variable IT, in the 30 who continued in it, 20% (6) developed acute coronary pathology and in the 18 who modified their IT to fixed, the prevalence was 44.5% (8). Patients with modification of IT to fixed had a higher risk of acute coronary syndrome in the follow-up (p < 0.01) and the presence of hypertension and hypercholesterolemia allowed the prediction of modification of the IT.

CONCLUSIONS

The prevalence of cardiovascular risk factors in the stable coronary artery disease is high (88%); male gender is associated smoking and female gender to diabetes mellitus. The presence of hypertension and hypercholesterolemia are associated to modification in the IT in patients with variable threshold, allowing the detection of a subgroup of high risk for the development of acute coronary pathology.

[An epidemiological study of pulmonary tuberculosis in inpatients]

OBJECTIVE

To evaluate the profile of the patient admitted to hospital with pulmonary tuberculosis and the clinical-radiological signs and symptoms of the illness.

DESIGN

A descriptive, retrospective study.

SETTING

The study was carried out in the Miguel Servet Hospital in Zaragoza.

PATIENTS AND OTHER PARTICIPANTS

Patients over 14 who were admitted for pulmonary tuberculosis between 1985 and june 1990 and who fulfilled the requisite diagnostic criteria.

MEASUREMENTS AND MAIN RESULTS

Out of the 423 patients studied, 75.17% were male. Average age of the whole sample was 45.9. 31% were retired. 55% (232 cases) had factors predisposing to tuberculosis. The 12% were infected by HIV (human immunodeficiency virus). The most common presentation symptoms were coughing and the radiological semeiology of condensation. In 22.7% there was extrapulmonary tubercular infection, most commonly in ganglia. Delay in diagnosis was over three months in 19.8% of the cases.

CONCLUSIONS

Tuberculosis is a common illness in our ambit and particularly affects those patients with underlying pathology. Given that there are still important delays in diagnosis, doctors need to be highly aware of the possibility.

[Clinico-epidemiologic study of bacterial meningitis in Aragon]

BACKGROUND

The aim of the present study was to know the incidence, etiology, prognostic factors and rate of mortality of bacterial meningitis in Aragón (Spain).

METHODS

The clinical records of all the patients with bacterial meningitis seen in the hospitals in Aragón (Spain), from 1985 to 1988 inclusive were reviewed.

RESULTS

The mean of the annual rates of incidence for Aragón (Spain) was 7.52/100,000 inhabitants. In patients under the age of 15 years the most frequent etiologies were Neisseria meningitidis (59.0%), Haemophilus influenzae (13.7%) and Streptococcus pneumoniae (9.4%); the global rate of mortality was 3.5% similar to that of sequelae. In those over the age of 14 years, the most frequent etiologies were N. meningitidis (33%), S. pneumoniae (18.4%) and Staphylococcus spp. (13.6%); the rate of global mortality was 19.5% and that of sequelae 10.8% with resistance of S. pneumoniae to penicillin and/or ampicillin in 45.5% of the cases in children and in 26.3% in adults. No significant evolutive differences related with the existence of resistances or the administration of antibiotics prior to lumbar punction were observed in any of the age groups.

CONCLUSIONS

N. meningitidis is the main etiologic agent in Aragón in both children and adults. The greatest rates of mortality and sequelae were observed in the youngest and oldest age groups with a similar relation being seen in infection by gramnegative bacilli and S. pneumoniae, thus making these patients to be considered as being at high risk.

Oral lichen planus and chronic liver disease: a clinical and morphometric study of the oral lesions in relation to transaminase elevation

Serum transaminase levels (serum glutamic-oxaloacetic transaminase or serum glutamic-pyruvic transaminase) were found to be altered in 40 (21.39%) of 187 patients with oral lichen planus. The patients with oral lichen planus who had altered transaminase levels were on average older than those without liver disorders and exhibited a higher percentage of erosive lesions (p < 0.05) and tongue involvement. Histologically, no statistically significant differences were noted in the extension of inflammatory infiltration or in connective tissue density; nevertheless, the latter was greater in patients without altered transaminase levels. Finally, among those patients with altered liver test results and erosive lichen planus, serum glutamic-oxaloacetic transaminase and serum glutamic-pyruvic transaminase levels were found to be higher than levels in those patients without erosions. This indicates that behavior of the oral lesions is more aggressive as the degree of liver alteration increases. We emphasize that of the 40 patients with altered transaminase levels (all later proved to reflect chronic hepatitis through complementary diagnostic methods), 28 had hepatitis C virus infection.

[Campylobacter jejuni and HIV infection]

OBJECTIVE

To evaluate the characteristics of the Campylobacter jejuni infection in HIV positive patients.

DESIGN

We report all cases appeared in our hospital between September 1991 and October 1992 with: HIV infection, chronic diarrhoea and C. jejuni in stool culture. Epidemiologic factors, other opportunist infections, immunologic situation, clinical symptomatology, antibiotic sensitivity and evolution are recorded.

RESULTS

Six patients, 4 men and 2 women, with an average age of 38 years were recorded. They have different risk factors (drug abusers, sexual behaviour and haemophilia). Chronic liver disease and other opportunist infections of the gastrointestinal tract were the most important facts in past history. CD4 count were directly related with the severity of the illness. Quantitative or qualitative disorders of B lymphocytes or immunoglobulins were not found. All of term suffered from chronic diarrhoea with fever in four of them and bacteremia in 2 patients. First generation cephalosporins resistance in one occasion. A good evolution occurred in 3 patients, another had a relapse and bacteremia appeared in 2 patients whose CD4 count were lower of 100/mm3, have AST, ALT changes and other concomitant gastrointestinal infections.

CONCLUSION

C. jejuni infection of the gastrointestinal tract results in chronic diarrhoea with a higher incidence than expected in HIV positive patients. The severity is directly related with CD4 count, and the existence of concomitants infections of the gastrointestinal tract or chronic liver disease. Antibiotic resistance to macrolide is possible, especially in chronic and severe forms.

Synthesis of Diastereoisomeric 2-Benzyl-1,2-diphenylindans

The diastereoisomeric 2-benzyl-1,2-diphenylindan-1-ols were prepared and subjected to deoxygenation reactions under a variety of conditions to obtain 2-benzyl-1,2-diphenylindan. The stereochemistry of these compounds has been characterized on the basis of chemical and spectroscopic evidence.

Segmentary coronary reserve in hypertensive patients with echocardiographic left ventricular hypertrophy, gamma-graphic ischaemia and normal coronary angiography

Stress thallium scintigraphies are frequently positive in patients with systemic hypertension (SHT), especially in the presence of left ventricular hypertrophy (LVH). In order to determine whether positive thallium perfusion scans in patients with LVH secondary to SHT and normal coronary angiographies are due to segmentary reduction of coronary reserve (CR), we have studied 10 out of 60 consecutive cases of SHT with echocardiographic LVH, using intracoronary Doppler. We compared coronary blood flow velocity at rest and post-papaverine (PP), and CR in at least two major coronary vessels, always including the one corresponding to the ischaemic segment. In the vessel with the least CR at rest, a new determination of CR was made under intracoronary nitroglycerin. A group of five normal patients acted as controls. The mean CR of the controls and patients, respectively, was 6.2 +/- 1.4 vs 2.7 +/- 0.9 (P < 0.001). In patients with positive thallium perfusion scans, the coronary arteries corresponding to the ischaemic segments had less CR (2.5 +/- 0.6) than arteries from non-ischaemic segments (3.4 +/- 1, P < 0.05). These differences were greater when the ischaemia was anterior. There was no correlation either between CR and left ventricular mass (r = 0.23) or rest coronary blood flow velocity (r = 0.07). Only one patient exhibited functional behaviour indicating reduced CR; this rose from 1.9 to 7.5 after nitroglycerin 300 micrograms. In conclusion, CR determined by intracoronary Doppler and papaverine shows segmentary differences both in normal patients and in patients with LVH and normal coronary angiograms. This could be the cause of segmental ischaemia detected by means of radionuclide stress tests.

[Ulcerative colitis and HIV infection]

FUNDAMENTAL: The difficulties to raise to a correct diagnosis in patients with human immunodeficiency virus infection and diarrhea, and the few cases reported of ulcerative colitis in the context of HIV infection.

OBJECTIVE

Description of 2 cases of ulcerative colitis in patients with HIV infection and the possibility of immunopathogenic relationship between them.

MATERIAL AND METHODS

The clinic history of the patients, the anatomopathological diagnosis after the colon biopsy and the determination of CD4 cells.

RESULTS

In case 1 the low level of CD4 cells didn't stop the aggressivity of ulcerative colitis. However, in both cases there was a good evolution of colitis after treatment although AIDS.

CONCLUSION

It is necessary to study more cases of inflammatory bowel disease in patients with HIV infection to determine the influence of the level of CD4 cells in the enteropathy's evolution.

[Sclerosing cholangitis and AIDS]

Bile tract pathology in AIDS has been described as an incomplete biliary obstructive syndrome and acalculous cholecystitis. Most reported cases have been associated to bile ducts infection by Cytomegalovirus (CMV) and/or Cryptosporidium. We present a case of sclerosing cholangitis and acalculous cholecystitis in an AIDS patient in whom Cryptosporidium was identified in the cholecystectomy sample and this same agent together with Candida Albicans in bile. We highlight the need to suspect this pathology in HIV infected patients who present a bile obstruction picture and/or cholecystitis, the possible etiological role of Candida Albicans, which has not been previously described, as well as the increasing association of bile pathology and AIDS.

Synthesis of r-1-Ethyl-t-2-methyl-t-3-arylindans

Although there are four possible racemates of the 1-ethyl-2-methyl-3-arylindans ( α, β, γ and δ, only three ( α, β and γ) have been synthesized or obtained from propenylbenzenes with acid reagents. Now we present a synthetic route for the preparation of the δ racemates (r-1-ethyl-t-2-methyl-t-3-arylindans), and 13C n.m.r. chemical shifts for the four racemates .

[Brucellosis with nervous system involvement]

Cases of brucellosis with involvement of the nervous system which was diagnosed in the Miguel Servet Hospital during the period 1985-1987 are retrospectively studied. The total quantity of affected patients of brucellosis was 132. Of this quantity, 9 patients (6.8%) had neurological complications under the following clinical forms: epidural abscess (2), meningoencephalitis (1), meningitis (2), encephalitis (1), myelitis (1) and polyradiculitis (2). The most important epidemiological and clinical characteristics are analysed, pointing out the diagnostic difficulties we found when the neurological manifestations are predominant in the brucella infection.

[Prognostic significance of the electrocardiographic coronary reserve in stable angina]

We've studied the prognostic significance of the electrocardiographic coronary reserve, evaluated by seried effort tests, in patients with stable angina and proved coronary disease. Seventy-three patients with stable angina, who performed 2 exercise tests (basal and after vasodilator therapy) were included. It's considered variable reserve when in the second test the ST-descent improves greater than or equal to 1 mm for equal or higher double product (43 patients) and fixed reserve when it doesn't (30 patients). All of them underwent to coronariography study. The exercise test was seried each term during the first year. Clinical follow-up lasted 3 years and we considered cardiac events: myocardial infarction, unstable angina, surgery, PTCA or death. Patients with fixed reserve had higher maximal ST-descent (2.5 +/- 0.7 vs 1.9 +/- 0.6; p less than 0.05), lesser effort-time (359 +/- 144 vs 430 +/- 112; p less than 0.05), and more severe coronary disease (score: 3.5 +/- 1.5 vs 2.4 +/- 0.8; p less than 0.01) as compared with variable reserve group. Unfavorable clinic evolution was similar in both groups (44.3% in the fixed reserve group and 34.8% in the variable reserve group). We verified that 92.3% of patients with variable reserve who didn't modify its character in a year had good evolution; 76.4% of patients who changed to fixed reserve had unfavorable evolution (significant association, p less than 0.01). We conclude that in patients with variable reserve, the periodic evaluation of the reserve character has important prognostic implication.(ABSTRACT TRUNCATED AT 250 WORDS)

[Spleen abscess]

3 cases of splenic abscess (SA), all of them with similar clinical findings; abdominal pain, liver and splenic enlargement and leukocytosis, are presented. The diagnosis was suspected by abdominal ultrasound and confirmed by CTR. We focused the interest on the etiopathogenesis, diagnosis and the rareness of the bacteria isolated: Salmonella group D (two cases) and Bacteroides Fragilis.

[Brucellosis at a tertiary hospital. Retrospective epidemiologic study of 166 cases]

The epidemiologic polls concerning 166 cases of brucellosis are retrospectively analyzed; the cases are registered by the Preventive Medicine Service of Miguel Servet Hospital for five years (1980-1985). Most of our cases are of recent evolution, although 55% began to give symptoms more of 2 weeks ago and 30% more of 1 month ago. A clear annual increase of the number of cases, fundamentally of the male sex and patients coming from the rural areas, is observed. The percentage of cases in men (73.5%) is almost three times as those in women (26.5%), and the most numerous groups are the 20-29 interval age group and olders above 60. There is a small percentage of people with a professional risk factor (30.1%), which rise, slightly, for the ones who told of contact with cattle (39.2%) and rose up to 53.6% for the ones who consumed non controlled dairy products. However, in 23% of men and 40.9% of women the existence of some risk factors was unknown.

Ceftriaxone monotherapy for severe bacteremic infections. Spanish Ceftriaxone Study Group

We tested the efficacy of a single daily dose of ceftriaxone (active ingredient of Rocephin) for the treatment of severe bacteremic infections in 125 non-neutropenic adult patients. A single daily dose of ceftriaxone ranging from 1 to 4 g was given. Surgical procedures were performed if needed. Seventy-six (60.8%) were males and bacteremia was nosocomially acquired in 45 (36%). Microbiologically proven bacteremia was demonstrated in all patients. The most common microorganisms isolated were Escherichia coli (46 episodes), Streptococcus pneumoniae (17 episodes), Klebsiella pneumoniae, and Haemophilus influenzae, Serratia marcescens, Salmonella sp., and Staphylococcus aureus (9, 7, 6, 6, respectively). The urinary tract was the source of the bacteremia in 45 cases (36%), and the lower respiratory tract in 33 (26.4%). Mean duration of treatment was 10.8 days (range 3-21 days). One hundred and six patients (84.8%) recovered completely, 11 (8.8%) improved, but needed an alternative antibiotic treatment. An alternative treatment was also given to a patient whose condition had initially deteriorated. Seven patients (5.6%) died. Death was directly related to the infection in 2 cases. Three patients (2.4%) developed a superinfection, and 5 (4%) a severe (1 case) or mild (4 cases) adverse effect. In summary, a single daily dose of ceftriaxone proved to be useful for the treatment of selected severe bacteremic infections.

Chondroma of the tongue. Report of a case and review of the literature

A case of chondroma of the tongue in a 53-year-old male is reported. A review of the literature is presented.

Idiopathic paralysis of the palate in childhood

Idiopathic paralysis of the palate in childhood is an entity of unknown cause which resolves spontaneously and which affects mainly male children in their second and third years. Viral and vascular hypotheses have been proposed in order to explain its genesis. The authors report a case of this rare illness.