[Incidence and natural history of hepatocellular carcinoma in patients with chronic hepatitis C virus infection]. / Incidencia e historia natural del carcinoma hepatocelular en los pacientes con infección crónica por el virus de la hepatitis C.

OBJECTIVE: To report the natural history of patients with hepatitis C virus (HCV) infection and hepatocarcinoma (HCC) and to define clinico-biological variables with prognostic and predictive value of this complication. MATERIALS AND METHODS: A total of 543 patients consecutively diagnosed of chronic infection with HCV were included and followed prospectively and observationally regarding the development of HCC by means of semestral abdominal ultrasonography and measurement of serum alpha-fetoprotein (AFP). To determine variables with predictive value of HCC, the parameters determined at the start were compared, and all subjects diagnosed of hepatoma during the first twelve months after admission were excluded from the analysis. The Kaplan-Meier method was used to evaluate both survival and accumulated probability of HCC. RESULTS: During a mean follow-up period of 28.9 months, an incidence density of HCC of 2.6 per 100 inhabitants-year was obtained (n = 35). 52.6% of those with HCC in the first year were asymptomatic. The only initial variables associated with further development of HCC were age (64.6 vs 58.4 years; p = 0.0039) and alkaline phosphatase (373.5 vs 259 U/l; p = 0.001). Patients with cirrhosis at the start of the study had a higher risk of developing hepatoma than non-cirrhotic patients (RR: 11.5; 95% CI: 4.25-29.9; p < 0.0001). The presence of HCC decreased the survival of patients with cirrhosis (median 20 vs 75 months; log rank < 0.0001), with the exception of patients in stage C of the Child-Pugh classification. CONCLUSIONS: a) In the chronic infection with HCV, HCC showed to be an oligosymptomatic complication affecting almost exclusively patients with long-lasting cirrhosis. b) Survival in patients in the stage C of the Child-Pugh classification is independently associated with the coexistence of hepatoma; therefore, the early diagnosis of this complication should be restricted to those with a better liver functional reserve.

Incidencia e historia natural del carcinoma hepatocelular en los pacientes con infección crónica por el virus de la hepatitis C / Incidence and natural history of hepatocellular carcinoma among patients with chronic infection with hepatitis C virus

Objetivo. Describir la historia natural de los pacientes infectados por el virus de la hepatitis C (VHC) que presentan hepatocarcinoma (HCC) y definir variables clínico-biológicas con valor pronóstico de esta complicación. Material y método. Se incluyeron 543 pacientes diagnosticados de forma consecutiva de infección crónica por VHC y se siguieron de forma prospectiva y observacional respecto al desarrollo de HCC mediante la realización semestral de ecografía abdominal y alfafetoproteína sérica (AFP). Para determinar variables con valor predictivo de HCC se compararon los parámetros determinados al inicio, eliminándose del análisis todos aquellos sujetos que fueron diagnosticados de hepatoma dentro de los doce meses posteriores al ingreso. Se utilizó el método de KaplanMeier tanto para evaluar la supervivencia como la probabilidad acumulada de HCC. Resultados. Durante un período medio de seguimiento de 28,9 meses obtuvimos una densidad de incidencia de HCC de 2,6 por 100 habitantes-año (n = 35). El 52,6 por ciento de los que presentaron HCC durante el primer año estaban asintomáticos. Las únicas variables iniciales que se asociaron al ulterior desarrollo de HCC fueron la edad (64,6 frente a 58,4 años; p = 0,0039) y la fosfatasa alcalina (373,5 frente a 259 U/l; p = 0,001).Los pacientes con cirrosis al inicio del estudio tenían mayor riesgo de desarrollar hepatoma que los no cirróticos (RR: 11,5; IC 95 por ciento: 4,5-29,9; p < 0,0001). La presencia de HCC disminuyó la supervivencia de los enfermos con cirrosis (mediana de 20 frente a 75 meses; log rank < 0,0001), salvo que se encontraran en el estadio C de Child-Pugh. Conclusiones. a) En la infección crónica por VHC el HCC se muestra como una complicación oligosintomática que afecta de forma casi exclusiva a los enfermos con cirrosis de larga duración. b) La supervivencia mostrada por los pacientes con cirrosis en estadio C de Child-Pugh es independiente de la coexistencia de hepatoma, por lo que el diagnóstico precoz de esta complicación debería restringirse a los que presenten mejor reserva funcional hepática (AU)

Absence of the inferior vena cava causing repeated deep venous thrombosis in an adult--a case report.

Agenesis of the inferior vena cava is an uncommon congenital vascular malformation. Although theoretically it may favor venous stasis, it is not normally associated with venous thrombosis. The authors found only three reports of the coexistence of both entities, and only one of these rules out the existence of associated hypercoagulability. They report the case of a patient with a history of repeated venous thrombosis. Magnetic resonance angiography and venography demonstrated complete agenesis of the inferior vena cava and persistence of a cardinal venous system with azygos and hemiazygos continuation, associated with right renal hypoplasia. Studies ruled out hypercoagulability syndrome, either primary or secondary to an occult neoplasm. The authors conclude that venous malformations, although rare, may cause thromboembolic disease, especially in young patients, and that magnetic resonance angiography is a useful diagnostic alternative to conventional phlebography.

[Delphi study of Palmer's quality method in primary care: strong and weak points and areas of utilization]. / Estudio Delphi de la metodología de calidad de Palmer en atención primaria: puntos fuertes y débiles y dimensiones de uso.

OBJECTIVE: To identify the strong and weak points of Palmer's Quality Method as it applies to Primary Care (PC), and determine the areas of quality assurance to which it is most suited. DESIGN: Delphi Study. SETTING: Primary Care-related professionals, homogeneously distributed throughout the different autonomous communities. PARTICIPANTS: 52 assurance experts selected on the basis of their publications, and from lists provided by well known, prestigious experts. METHOD: Each expert was first contacted by phone to request participation in the study. The first questionnaire that was sent asked the participants to respond to the following questions: "Which are, in your judgement, the positive aspects (strong points) and negative aspects (weak points) of Palmer's Quality Method with regard to PC?" and "In which quality assurance area do you think its use is most effective?" RESULTS: Respondents to the first questionnaire (35 experts) listed 125 strong points, 111 weak points and 52 areas. After similar responses were grouped together, the resulting totals were 67 strong points, 40 weak points and 11 areas. The second questionnaire was rated by 32 experts. The third questionnaire was then created using the 7 highest-scoring answers, including the average score and scoring variance for each question. Thirty-one experts responded. Ultimately, 8 strong points, 7 weak points and 7 areas of quality assurance were obtained. CONCLUSIONS: Palmer's method continues to be useful in quality assurance work in PC. We believe that this study can serve to facilitate its use and suggest those situations where its use is most effective.

[Evaluation of anti-thrombosis treatment in patients with chronic non-valvular atrial fibrillation]. / Valoración del tratamiento antitrombótico en pacientes con fibrilación auricular crónica no valvular.

OBJECTIVES: To assess both the indications of anti-thrombosis treatment in patients in our ambit with chronic non-valvular atrial fibrillation, and its observance in Primary Care. DESIGN: A descriptive, crossover, observational study of consecutive cases. SETTING: Third-level referral hospital in our Health District. PATIENTS: 132 adults first diagnosed with chronic atrial fibrillation between July 1st and December 31st 1996. MEASUREMENTS AND MAIN RESULTS: Patients' clinical records were used to assemble data on risk factors of embolism and counter-indications to prescribing antithrombosis treatment. A logistic regression model was performed to analyse the variables affecting the treatment at the time it was first given. 65 men (mean age 68.3) and 67 women (mean age 74.6) were included in the study. 87.9% of the patients had embolism risk factors; and 30.3% had at least one absolute or relative counter-indication to anti-coagulation. 79 patients had risk factors but no counter-indication, of whom 28% took anticoagulants, 39% had anti-aggregates prescribed and the remaining 33% received no anti-thrombosis treatment at all. Only 3 patients taking anticoagulants were referred to the Primary Care doctor. The regression model worked out signalled age under 75 and a previous embolism as factors associated with the indication and anticoagulants: We found no coherent regression model for the indication of anti-aggregates. CONCLUSIONS: Anti-thrombosis treatment is underused in Primary Care. An antecedent of an embolism is the most weight criterion for giving anticoagulants to patients. Age is shown to be the main reason for therapeutic reluctance to give anticoagulants to patients without counter-indications. There should be more patients being treated with anticoagulants in Primary Care.

[A 73 year-old patient with thrombocytopenia and a giant cerebral vascular malformation]. / Paciente de 73 años con trombopenia y malformación vascular cerebral gigante.

We report the case of a patient who was seen by purpura and thrombocytopenia. The differential diagnosis in this patient included the presence of cerebral giant vascular malformation, the intake antiepileptic drugs and the presence of a chronic liver disease caused by viral hepatitis C infection. However the final diagnoses of Idiopathic Thrombocytopenia Purpura was made because of the presence of antiplatelets antibodies, the fluctuate evolution, and the increase of platelet count after costicosteroid therapy.