Do Bilateral Pleural Effusions Always Have the Same Cause?

A 67-year-old man with a history of seropositive rheumatoid arthritis (RA) was admitted to the Internal Medicine ward for bilateral pleural effusion. Two years before this episode, coinciding with an exacerbation of the RA, he was incidentally diagnosed with asymptomatic left pleural effusion compatible with rheumatoid exudate, which was resolved with a tube thoracostomy. Three weeks before admission, the patient developed asthenia, orthopnoea and progressive dyspnoea. A chest x-ray revealed bilateral pleural effusion occupying the lower third of the left hemithorax and a smaller portion of the right hemithorax along with marked elevation of N-terminal fragment of pro-brain natriuretic peptide levels. The patient was admitted with a diagnosis of left-sided heart failure. Transthoracic echocardiography and cardiac catheterization confirmed the existence of ischaemic cardiomyopathy. After 2 days of diuretic treatment, the right pleural effusion resolved, but the left effusion persisted. A needle thoracentesis was performed, draining 800 ml of milky fluid compatible with rheumatoid pseudochylothorax

Clinical and epidemiologic characteristics of hospitalized oncological patients with hypercalcemia: a longitudinal, multicenter study

Background There are few studies that have analyzed the characteristics of hypercalcemia in hospitalized oncological patients. Our objectives were to describe the clinical characteristics of hospitalized patients with paraneoplastic hypercalcemia and to identify prognostic variables for mortality. Methods This was an observational, longitudinal, retrospective, and bicentric study. It included adult patients admitted to two hospitals in Málaga, Spain (2014–2018). The minimum follow-up period was 2 years or until death. Results A total of 154 patients were included; the majority (71.4%) were admitted to the internal medicine department. The median follow-up was 3.5 weeks (interquartile range [IQR] 1.1–11.5). The mean (standard deviation) age was 67.6 (12.3) years, with a predominance of males (58.4%). The median (IQR) serum calcium at admission was 13.2 (11.8–14.6) mg/dl. The most common neoplasms were pulmonary (27.3%), hematologic (23.4%), urological (13%), and breast (12.3%). Furthermore, 56.5% of cases had a known history of neoplasia at the time of diagnosis. The parathyroid hormone (PTH) level was determined in 24%; of these, 10.8% had elevated levels. In all, 95.5% of patients died during follow-up. The median survival was 3.4 weeks (95% confidence interval 2.6–4.3). Factors associated with higher mortality were age, serum calcium at admission, previous history of neoplasia, etiology other than multiple myeloma, and noncorrection of hypercalcemia. Conclusions In hospitalized patients, paraneoplastic hypercalcemia was associated with high short-term mortality. Several factors associated with a worse prognosis were identified in these patients.Funding for open access charge: Universidad de Málaga / CBU

Una ictericia de causa avergonzante

We present the case of a 63-year-old man who went to the Emergency Department complaining of jaundice, choluria, and generalised pruritus for several days. He was admitted to the General Surgery department with the initial diagnosis of obstructive jaundice and incipient cholecystitis. After being ruled out, the patient was referred to Internal Medicine for further investigation. Test results were consistent with acute cholestatic hepatitis of probable toxic origin. Although he had initially denied taking medication or other products, he eventually confessed to taking sildenafil purchased over the Internet.Presentamos el caso de un varón de 63 años que acudió a Urgencias por un cuadro de ictericia, coluria y prurito generalizado de varios días de evolución. Con el diagnóstico inicial de ictericia obstructiva y colecistitis incipiente ingresó en el servicio de Cirugía General. Tras descartarse, el paciente pasó a cargo de Medicina Interna para continuar el estudio. Los resultados de las pruebas fueron consistentes con una hepatitis colestásica aguda de probable origen tóxico. A pesar de que inicialmente había negado la ingesta de medicamentos u otros productos, finalmente reconoció la ingesta de sildenafilo comprado a través de Internet

Colecistitis aguda perforada con bacteriemia por Actinomyces naeslundii

Actinomycosis of the gallbladder is a very rare condition: only 25 cases have been reported in the medical literature to date. We report a case of a 68-year-old man presented with short term fever and no obvious source of infection. Complementary tests revealed perforated acute cholecystitis along with bacteremia due to Actinomyces naeslundii. The patient was treated with amoxicillin-clavulanate for 3 weeks, significantly lower than the usual course. Subsequently, he underwent elective cholecystectomy. Histopathological study of the surgical specimen confirmed complete resolution of the infection.La infección de la vesícula biliar por bacterias del género Actinomyces es extremadamente rara, habiéndose descrito hasta la fecha 25 casos en la literatura. Presentamos el caso de un hombre de 68 años que ingresó por un cuadro de fiebre de corta evolución sin focalidad infecciosa aparente. Las pruebas complementarias revelaron la existencia de colecistitis aguda perforada junto con bacteriemia por A. naeslundii. El paciente realizó tratamiento antibiótico con amoxicilina-clavulanato durante 3 semanas, sensiblemente inferior a las pautas habituales. Posteriormente se sometió a una colecistectomía electiva. El estudio histopatológico de la pieza quirúrgica confirmó la resolución completa de la infección

Pileflebitis secundaria a brote de enfermedad inflamatoria intestinal

Pylephlebitis or pylethrombophlebitis is a clinical condition defined as the presence of septic thrombophlebitis in the duct-portal vein or intrahepatic vessels which may extend through nearby areas. Etiological diagnosis is crucial since it may modify its therapeutic attitude and is related to intra-abdominal infections. We present the case of a patient with ulcerative colitis who was admitted to the hospital due to an inflammatory bowel disease flare. An abdominal CT-scan showed thrombosis of the splenic-portal system and mesenteric veins which confirmed the diagnosis of pylephlebitis. The patient developed a series of infectious and internal medium complications which led to his death.La pileflebitis o piletromboflebitis es una afección definida como la presencia de tromboflebitis séptica en el tronco venoso portal o ramas intrahepáticas que puede extenderse a territorios cercanos. Su diagnóstico etiológico es esencial ya que puede modificar la actitud terapéutica y su aparición se relaciona con procesos infecciosos intraabdominales. Se presenta el caso de un paciente con colitis ulcerosa que ingresó por brote de enfermedad intestinal. La TC abdominal mostró trombosis del eje esplenoportal y venas mesentéricas que confirmaron el diagnóstico de pileflebitis asociada, presentando el paciente complicaciones infecciosas y de medio interno que desembocaron en su fallecimiento

Impact of hyponatremia in patients hospitalized in Internal Medicine units Hyponatremia in Internal Medicine units

The aim of this study was to analyze the impact and the clinical and evolutionary characteristics of hypotonic hyponatremia in patients hospitalized in Internal Medicine units. Prospective multicenter observational study of patients with hypotonic hyponatremia (<135 mmol/L) in 5 hospitals in southern Spain. Patients were included according to point prevalence studies carried out every 2 weeks between March 2015 and October 2017, by assessing demographic, clinical, analytical, and management data; each patient was subsequently followed up for 12 months, during which time mortality and readmissions were assessed. A total of 501 patients were included (51.9% women, mean age = 71.3 ± 14.24 years), resulting in an overall prevalence of hyponatremia of 8.3%. The mean comorbidities rate was 4.50 ± 2.41, the most frequent diagnoses being heart failure (115) (23%), respiratory infections (65) (13%), and oncological pathologies (42) (6.4%). Of the total number of hyponatremia cases, 180 (35.9%) were hypervolemic, 164 (32.7%) hypovolemic, and 157 (31.3%) were euvolemic. A total of 87.4% did not receive additional diagnostic tests to establish the origin of the condition and 30% did not receive any treatment. Hospital mortality was 15.6% and the mean length of stay was 14.7 days. Euvolemic and admission hyponatremia versus hyponatremia developed during admission were significantly associated with lower mortality rates (P = .037). Mortality at 1 year and readmissions were high (31% and 53% of patients, respectively). Hyponatremia was common in Internal Medicine areas, with hypervolemic hyponatremia being the most frequent type. The mortality rate was high during admission and at follow-up; yet there is a margin for improvement in the clinical management of this condition

Detecting Xylella fastidiosa in a machine learning framework using Vcmax and leaf biochemistry quantified with airborne hyperspectral imagery

The bacterium Xylella fastidiosa (Xf) is a plant pathogen that can block the flow of water and nutrients through the xylem. Xf symptoms may be confounded with generic water stress responses. Here, we assessed changes in biochemical, biophysical and photosynthetic traits, inferred using biophysical models, in Xf-affected almond orchards under rainfed and irrigated conditions on the Island of Majorca (Balearic Islands, Spain). Recent research has demonstrated the early detection of Xf-infections by monitoring spectral changes associated with pigments, canopy structural traits, fluorescence emission and transpiration. Nevertheless, there is still a need to make further progress in monitoring physiological processes (e.g., photosynthesis rate) to be able to efficiently detect when Xf-infection causes subtle spectral changes in photosynthesis. This paper explores the ability of parsimonious machine learning (ML) algorithms to detect Xf-infected trees operationally, when considering a proxy of photosynthetic capacity, namely the maximum carboxylation rate (Vcmax), along with carbon-based constituents (CBC, including lignin), and leaf biochemical traits and tree-crown temperature (Tc) as an indicator of transpiration rates. The ML framework proposed here reduced the uncertainties associated with the extraction of reflectance spectra and temperature from individual tree crowns using high-resolution hyperspectral and thermal images. We showed that the relative importance of Vcmax and leaf biochemical constituents (e.g., CBC) in the ML model for the detection of Xf at early stages of development were intrinsically associated with the water and nutritional conditions of almond trees. Overall, the functional traits that were most consistently altered by Xf-infection were Vcmax, pigments, CBC, and Tc, and, particularly in rainfed-trees, anthocyanins, and Tc. The parsimonious ML model for Xf detection yielded accuracies exceeding 90% (kappa = 0.80). This study brings progress in the development of an operational ML framework for the detection of Xf outbreaks based on plant traits related to photosynthetic capacity, plant biochemistry and structural decay parameters.This research was supported by grant: ITS2017-095: Design and Implementation of control strategies for Xylella fastidiosa, Project 5. Government of the Balearic Islands, Spain. Data collection was partially supported by the European Union's Horizon 2020 research and innovation program through gran agreement XF-ACTORS (727987).Peer reviewe

Atrasentan and renal events in patients with type 2 diabetes and chronic kidney disease (SONAR): a double-blind, randomised, placebo-controlled trial

Background: Short-term treatment for people with type 2 diabetes using a low dose of the selective endothelin A receptor antagonist atrasentan reduces albuminuria without causing significant sodium retention. We report the long-term effects of treatment with atrasentan on major renal outcomes. Methods: We did this double-blind, randomised, placebo-controlled trial at 689 sites in 41 countries. We enrolled adults aged 18–85 years with type 2 diabetes, estimated glomerular filtration rate (eGFR)25–75 mL/min per 1·73 m 2 of body surface area, and a urine albumin-to-creatinine ratio (UACR)of 300–5000 mg/g who had received maximum labelled or tolerated renin–angiotensin system inhibition for at least 4 weeks. Participants were given atrasentan 0·75 mg orally daily during an enrichment period before random group assignment. Those with a UACR decrease of at least 30% with no substantial fluid retention during the enrichment period (responders)were included in the double-blind treatment period. Responders were randomly assigned to receive either atrasentan 0·75 mg orally daily or placebo. All patients and investigators were masked to treatment assignment. The primary endpoint was a composite of doubling of serum creatinine (sustained for ≥30 days)or end-stage kidney disease (eGFR <15 mL/min per 1·73 m 2 sustained for ≥90 days, chronic dialysis for ≥90 days, kidney transplantation, or death from kidney failure)in the intention-to-treat population of all responders. Safety was assessed in all patients who received at least one dose of their assigned study treatment. The study is registered with ClinicalTrials.gov, number NCT01858532. Findings: Between May 17, 2013, and July 13, 2017, 11 087 patients were screened; 5117 entered the enrichment period, and 4711 completed the enrichment period. Of these, 2648 patients were responders and were randomly assigned to the atrasentan group (n=1325)or placebo group (n=1323). Median follow-up was 2·2 years (IQR 1·4–2·9). 79 (6·0%)of 1325 patients in the atrasentan group and 105 (7·9%)of 1323 in the placebo group had a primary composite renal endpoint event (hazard ratio [HR]0·65 [95% CI 0·49–0·88]; p=0·0047). Fluid retention and anaemia adverse events, which have been previously attributed to endothelin receptor antagonists, were more frequent in the atrasentan group than in the placebo group. Hospital admission for heart failure occurred in 47 (3·5%)of 1325 patients in the atrasentan group and 34 (2·6%)of 1323 patients in the placebo group (HR 1·33 [95% CI 0·85–2·07]; p=0·208). 58 (4·4%)patients in the atrasentan group and 52 (3·9%)in the placebo group died (HR 1·09 [95% CI 0·75–1·59]; p=0·65). Interpretation: Atrasentan reduced the risk of renal events in patients with diabetes and chronic kidney disease who were selected to optimise efficacy and safety. These data support a potential role for selective endothelin receptor antagonists in protecting renal function in patients with type 2 diabetes at high risk of developing end-stage kidney disease. Funding: AbbVie

Multifocal Abdominal Pyomyositis From Subcutaneous Dissemination in an Immunocompetent Patient.

A 61-year-old woman presented to the emergency ward complaining of low back pain for a month. She had undergone several spinal surgeries and a right radical nephrectomy 30 years before. A few days earlier she was injected with an intramuscular painkiller in her right buttock. An abdominal CT scan revealed multiple abscesses in the psoas muscle and the right posterior abdominal wall, including cellulitis in the adjacent subcutaneous tissue and the injection site. A diagnosis of pyomyositis from subcutaneous dissemination was made, and intravenous cefazolin was initiated. After five days of favorable progress, treatment was switched to oral cefadroxil to complete four weeks, leading to full recovery

Clinical Characteristics and Prognostic Relevance of Different Types of Caregivers for Elderly Patients with Acute Heart Failure&mdash;Analysis from the RICA Registry

Background: Patients with heart failure encompass a heterogeneous group, but they are mostly elderly patients with a large burden of comorbid conditions. Objective: The aim of this study was to compare the clinical characteristics and the prognostic impact on hospital admissions and mortality in a population of patients with HF with different types of caregivers (family members, professionals, and the patient himself). Methods: We conducted an observational study from a prospective registry. Patients from the National Registry of Heart Failure (RICA), which belongs to the Working Group on Heart Failure and Atrial Fibrillation of the Spanish Society of Internal Medicine (SEMI), were included. Patients with heart failure were classified, according to the type of main caregiver, into four groups: the patient himself/herself, a partner, children, or a professional caregiver. A bivariable analysis was performed between the clinical, analytical, therapeutic, and prognostic characteristics of the different groups. The endpoints of the study were all-cause mortality at 1 year; mortality at 120 days; and the readmission rate for HF at 30 days, 120 days, and 1 year of follow-up. In all cases, the level of statistical significance was set at p &lt; 0.05. Results: A total of 2147 patients were enrolled in this study; women represented 52.4%, and the mean age was 81 years. The partner was the caregiver for 703 patients, children were caregivers for 1097 patients, 199 patients had a professional caregiver, and only 148 patients were their own caregivers. Women were more frequently cared for by their children (65.8%) or a professional caregiver (61.8%); men were more frequently cared for by their spouses (68.7%) and more frequently served as their own caregivers (59.5%) (p &lt; 0.001). No statistically significant differences were observed in relation to readmissions or mortality at one year of follow-up between the different groups. A lower probability of readmission and death was observed for patients who received care from a partner or children/relative, with log-rank scores of 11.2 with p= 0.010 and 10.8 with p = 0.013. Conclusions: Our study showed that the presence of a family caregiver for elderly patients with heart failure was associated with a lower readmission rate and a lower mortality rate at 120 days of follow-up. Our study also demonstrated that elderly patients with good cognitive and functional status can be their own caregivers, as they obtained good health outcomes in terms of readmission and mortality. More prospective studies and clinical trials are needed to evaluate the impact of different types of caregivers on the outcomes of patients with heart failure