[Impact on cardiovascular health results of the introduction of the clinical governance contract into primary care in Tarragona]. / Impacto en los resultados de salud cardiovascular de la implantación del contrato de Dirección Clínica en atención primaria de Tarragona.

OBJECTIVE: The objectives of this study are: 1) to determine the improvement in the cardiovascular health of the population after the introduction of the clinical governance contract for primary care team professionals in Tarragona-Reus and the Terres de l'Ebre area (Tarragona province, Spain); 2) to identify the factors predictive of better cardiovascular health after the introduction of the clinical governance contract. The introduction of the clinical governance contract, which is based on professional leadership, feed-back of care information, and monitoring of indicators of cardiovascular risk based on scientific evidence and concretised in clinical practice guidelines, will improve the cardiovascular health results of the reference population. Improvements in indicators of procedure and result are specified in "Material and methods." DESIGN: This is a before-and-after, multi-centre study. SETTING: Primary health care. PARTICIPANTS: Thirty health centres (all the primary care Centres in the area). MAIN MEASUREMENTS: Characteristics of the centre. Variables in procedures: indicators of good care practice, calculation of cardiovascular risk, application of clinical practice guidelines (hypertension, diabetes, lipaemia, tobacco and cardiovascular risk) and quality standards for drug prescription. Result variables: cardiovascular risk figures, number of ongoing care visits, hospital emergencies and admissions for angina, heart attack or stroke, and risk factor screenings of the population. DISCUSSION: This study is useful, in that clinical governance aims to be a dynamic device to bring professionals into the leadership of health care management and, through monitoring indicators and feeding the findings back to the professionals, to improve health care quality. The study aims to show that management strategy can improve the population s cardiovascular health. The originality of the study lies in the development of a new tool of evaluation based on a novel management strategy for measuring cardiovascular health findings.

Impacto en los resultados de salud cardiovascular de la implantación del contrato de Dirección Clínica en atención primaria de Tarragona / Impact on cardiovascular health results of the introduction of the Clinical Governance contract into primary care in Tarragona

Objetivo. Los objetivos del presente estudio son: a) determinar la mejora en la salud cardiovascular de una población tras la implantación del contrato de Dirección Clínica en los profesionales de los Equipos de Atención Primaria de Tarragona-Reus y Terres de l'Ebre (provincia de Tarragona), y b) identificar los factores predictivos que determinan una mejor salud cardiovascular tras la implantación del contrato de Dirección Clínica. La implantación del contrato de Dirección Clínica (basada en el liderazgo profesional, feedback de la información asistencial, control de los indicadores de riesgo cardiovascular basados en la evidencia científica concretadas en guías de práctica clínica) mejorará los resultados de salud cardiovascular de la población de referencia. Diseño. Se trata de un estudio antes-después y multicéntrico. Emplazamiento. Atención primaria de salud. Participantes. Participan 30 centros de salud (totalidad de los centros de salud del ámbito de atención primaria del Institut Català de la Salut). Mediciones principales. Características del centro. Variables de proceso: indicadores de buena práctica asistencial, cálculo del riesgo cardiovascular, aplicación de la guía de práctica clínica (hipertensión arterial, diabetes, dislipemia, tabaquismo y factores de riesgo cardiovascular), estándares de calidad de la prescripción farmacológica. Variables de resultados: cifras de riesgo cardiovascular, número de visitas en atención continuada, urgencias hospitalarias e ingresos por angina, infarto agudo de miocardio y accidente cerebrovascular, y cribados poblacionales de factores de riesgo. Discusión. Este estudio es útil, ya que la dirección clinica pretende ser un motor para que los profesionales lideren la gestión asistencial y, mediante el control de indicadores y la «retroalimentación» de estos resultados a los profesionales, se mejore la calidad asistencial. Con este trabajo se pretende demostrar que una estrategia de gestión puede mejorar la salud cardiovascular de la población. La originalidad de este proyecto se basa en el desarrollo de una nueva herramienta de evaluación basada en una novedosa estrategia de gestión para medir resultados en salud cardiovascular

Objective. The objectives of this study are: 1) to determine the improvement in the cardiovascular health of the population after the introduction of the clinical governance contract for primary care team professionals in Tarragona-Reus and the Terres de l'Ebre area (Tarragona province, Spain); 2) to identify the factors predictive of better cardiovascular health after the introduction of the clinical governance contract. The introduction of the clinical governance contract, which is based on professional leadership, feed-back of care information, and monitoring of indicators of cardiovascular risk based on scientific evidence and concretised in clinical practice guidelines, will improve the cardiovascular health results of the reference population. Improvements in indicators of procedure and result are specified in "Material and methods." Design. This is a before-and-after, multi-centre study. Setting. Primary health care. Participants. Tirty health centres (all the primary care Centres in the area). Main measurements. Characteristics of the centre. Variables in procedures: indicators of good care practice, calculation of cardiovascular risk, application of clinical practice guidelines (hypertension, diabetes, lipaemia, tobacco and cardiovascular risk) and quality standards for drug prescription. Result variables: cardiovascular risk figures, number of ongoing care visits, hospital emergencies and admissions for angina, heart attack or stroke, and risk factor screenings of the population. Discussion. This study is useful, in that clinical governance aims to be a dynamic device to bring professionals into the leadership of health care management and, through monitoring indicators and feeding the findings back to the professionals, to improve health care quality. The study aims to show that management strategy can improve the population´s cardiovascular health. The originality of the study lies in the development of a new tool of evaluation based on a novel management strategy for measuring cardiovascular health findings

Treatment of multiple myeloma.

BACKGROUND AND OBJECTIVE: Multiple myeloma (MM) accounts for about 10% of all hematologic malignancies. The standard treatment with intermittent courses of melphalan and prednisone (MP) was introduced more than 30 years ago and, since then there has been little improvement in event-free and overall survival (EFS & OS). The aim of this article is to review: 1) the role of initial chemotherapy (ChT), maintenance treatment with alpha-interferon and salvage ChT, 2) the results of high-dose therapy (HDT) followed by allogeneic or autologous stem cell transplantation (allo-SCT and auto-SCT), and 3) the most important supportive measures. EVIDENCE AND INFORMATION SOURCES: The authors of this review have been actively working and contributing with original investigations on the treatment of MM during the last 15 years. In addition, the most relevant articles and recent abstracts published in journals covered by the Science Citation Index and Medline are also reviewed. STATE OF THE ART AND PERSPECTIVES: The importance of avoiding ChT in asymptomatic patients (smoldering MM) is emphasized. The criteria and patterns of response are reviewed. MP is still the standard initial ChT with a response rate of 50-60% and an OS of 2-3 years. Combination ChT usually increases the response rate but does not significantly influence survival when compared with MP. Exposure to melphalan should be avoided in patients in whom HDT followed by auto-SCT is planned, in order to not preclude the stem cell collection. The median response duration to initial ChT is 18 months. Interferon maintenance usually prolongs response duration but in most studies does not significantly influence survival (a large meta-analysis by the Myeloma Trialists' Collaborative Group in Oxford is being finished). In alkylating-resistant patients, the best rescue regimens are VBAD or VAD. In patients already resistant to VBAD or VAD and in those in whom these treatments are not feasible we recommend a conservative approach with alternate day prednisone and pulse cyclophosphamide. While HDT followed by autotransplantation is not recommended for patients with resistant relapse, patients with primary refractory disease seem to benefit from early myeloablative therapy. Although results from large randomized trials are still pending in order to establish whether early HDT intensification followed by auto-SCT is superior to continuing standard ChT in responding patients, the favorable experience with autotransplantation of the French Myeloma Intergroup supports this approach. However, although the complete response rate is higher with intensive therapy, the median duration of response is relatively short (median, 16 to 36 months), with no survival plateau. There are several ongoing trials comparing conventional ChT with HDT/autoSCT in order to identify the patients who are likely to benefit from one or another approach. With allo-SCT there is a transplant-related mortality ranging from 30 to 50% and also a high relapse rate in patients achieving CR. However, 10 to 20% of patients undergoing allo-SCT are long-term survivors (> 5 years) with no evidence of disease and, consequently, probably cured. The use of allogeneic peripheral blood stem cells (PBSC) in order to speed the engraftment and also the use of partially T-cell depleted PBSC which can decrease the incidence of graft-versus-host disease are promising approaches. In the setting of allo-SCT, donor lymphocyte infusion is an encouraging strategy in order to treat or prevent relapses. Finally, important supportive measures such as the treatment of anemia with erythropoietin, the management of renal failure and the use of bisphosphonates are reviewed.

[Hodgkin's disease following treatment with hydantoins. Report of a case and review of the literature (author's transl)]. / Asociación de enfermedad de Hodgkin e hidantoínas. Comunicación de un neuvo caso y revisión de la literatura.

Diagnosis of Hodgkin's disease was made in a patient who had been treated with diphenylhydantoin sodium for 4 years. Three different neoplastic diseases of the lymphoid tissue following therapy with hydantoin derivatives have been reported. Pseudolymphoma is characterized by lymph node enlargement, fever, arthralgias, cutaneous rash, hepatosplenomegaly and eosinophilia. The lymph node biopsy reveals a non-malignant histopathologic pattern. Pseudolymphoma develops few weeks after administration of hydantoin and it completely disappears when medication is discontinued. Pseudo-pseudolymphoma has similar clinical and histologic characteristics than those of pseudolymphoma, but patients in this category develop a true lymphoma after an asymptomatic period. Lymphomas (Hodgkin's disease and non-Hodgkin's lymphomas) appear following prolonged treatments with hidantoin derivatives. Risk to develop lymphoma is two to four times higher for patients taking such medication. Carcinogenic mechanism of hydantoin is unknown, but it might be related to the immunosuppressive effect of this drug.

[Acute appendicitis in the elderly (author's transl)]. / Apendicitis aguda en el viejo.

The mortality rate and clinical, analytical, radiographic and pathologic data from 31 patients with acute appendicitis over 60 years of age are compared to those from 100 patients under 60. The elderly group showed a greater delay in medical consulting, a more diffuse abdominal pain and a greater incidence of perforated and gangrenous appendicitis. This last fact could be related not only to the consulting delay, but also to the own characteristics of the aged appendix. There were no significant differences between both groups regarding analytical results and radiographic findings. Mortality rate was 13 percent in the elderly, while it was null in the younger series.

[Acute abdomen in the elderly: etiology, complications, and prognosis. A review of 100 cases (author's transl)]. / Abdomen agudo en el viejo: etiología, complicaciones y pronóstico. A propósito de 100 casos.

One hundred cases of acute abdomen in patients over 70 years of age were studied. Mechanical occlusion was the most common cause among these patients, as opposed to acute appendicitis, which is the primary cause of the same condition among young people and adults. Irreducible hernias and visceral neoplasias were the most frequent etiologies among cases of mechanical occlusion. Cholecystitis took second place in our series. Visceral peforations were more often due to localized infections or visceral neoplasias than to gastric or duodenal ulcers. Overall mortality among these patients was 29 percent. Patients with visceral perforations due to localized infections or visceral neoplasias and all of the patients with vascular diseases had a negative prognosis.