[Management of a first depressive episode in the primary care setting. Use of antidepressants and referrals]. / Manejo en atención primaria de un primer episodio depresivo. Uso de antidepresivos y derivaciones.

INTRODUCTION: The majority of patients who have a first depressive episode are treated by Primary Care physicians. The aim of this study was to evaluate the use of antidepressants and referrals to mental health and the treatment modifications made by psychiatrists. MATERIAL AND METHODS: A descriptive, retrospective study was conducted on patients from 64 Primary Care clinics, distributed in five Spanish provinces. The clinical history data, regarding use of antidepressants, criteria for referral, and response of psychiatric services were evaluated from June 2008 to June 2011. RESULTS: The study included 324 patients. The most commonly prescribed medication was escitalopram, with selective serotonin reuptake inhibitors (SSRI) making up 73.5% of the total. More than two-thirds (69.7%) of the patients were on treatment for at least 6 months, with no reason recorded for the 40.4% drop-outs. A large majority of professionals (76.9%) wait at least 3 weeks before modifying the medication, especially changing antidepressant. The Primary Care physicians referred 39.2% of patients to psychiatry, although much of these referrals (43.9%) had no justification. There was a lower referral rate to psychology (23.1%). An antidepressant was given to a large number of patients on multiple medications, without taking into account the risk of interactions in a high percentage. CONCLUSIONS: The Primary Care physician appropriately uses the antidepressants of the first choice, but does not pay attention to the risks in complex patients. There must be an appropriate duration of treatment and an improvement of the criteria for referral to mental health services.

Síndrome confusional agudo por adenoma paratiroideo: una enfermedad metabólica de tratamiento quirúrgico / Acute confusional state due to parathyroid adenoma: a metabolic disorder requiring surgical treatment

El diagnóstico diferencial del síndrome confusional agudo abarca un gran número de procesos entre los que hay que considerar firmemente las enfermedades metabólicas. El diagnóstico del hiperparatiroidismo como causa del mismo debe apoyarse en parámetros biológicos, y su tratamiento tiene un enfoque inicial destinado a corregir el trastorno neuropsiquiátrico y otro definitivo basado en la cirugía para revertir la desmineralización ósea y la mortalidad ulterior relacionada con la hipercalcemia. El abordaje quirúrgico debe efectuarse por cirujanos experimentados, cuyo objetivo principal conlleva la extirpación de la glándula enferma mediante técnicas lo menos agresivas posibles. Los estudios de imagen preoperatorios pueden contribuir a un abordaje selectivo que evite una exploración cervical bilateral. La determinación intraoperatoria de hormona paratiroidea intacta (PTHi), o el empleo de sonda isotópica, contribuyen a asegurar una solución quirúrgica efectiva

The differential diagnosis of acute confusional state encompasses a large number of processes including metabolic diseases. The diagnosis of hyperparathyroidism as a cause of acute confusional state should rest on biological parameters; treatment should initially be focused on correcting the neuropsychological disorder and then definitive surgical treatment should be undertaken to reverse bone demineralization and ulterior mortality related to hypercalcemia. The surgical approach should be carried out by experienced surgeons with the principal aim of extirpating the diseased gland using the least aggressive techniques possible. Preoperative imaging studies can help to ensure a selective approach that obviates bilateral cervical exploration. Intraoperative determination of intact parathyroid hormone (PTHi) levels or the use of a gamma probe help to ensure an effective surgical solution

Efecto de la edad y de la menopausia sobre la masa ósea / Effect of age and menopause on bone mass

Objetivos. Estudiar la variación en la pérdida de masa ósea que se produce en la columna lumbar y cadera durante los años previos a la aparición de la menopausia y durante la misma. Material y método. Análisis prospectivo de la masa ósea mediante densitometría ósea a mujeres sin medicación previa. Resultados. Estudio de 316 mujeres, el 81,6% con menopausia. Existe relación lineal negativa significativa entre la masa ósea y la menopausia en la columna lumbar y la cadera, con una fuerza de relación homogénea en la columna lumbar, siendo ésta más intensa en la cadera. Al nivel lumbar se aprecia una pérdida de hueso global del 17,6%, siendo más rápida en los 10 primeros años; en la cadera el porcentaje de pérdida es mayor. Discusión. Existe importante pérdida de masa ósea con la menopausia, mayor que la esperable sólo por la edad, más intensa en triángulo de Ward seguido del cuello, trocánter y columna lumbar; esto mismo aunque en menor intensidad ocurre en la época de la premenopausia

Objectives. To study the variation in bone loss in the lumbar spine and hip during pre- and postmenopausal periods. Material and method. Prospective analysis of the bone mass assessing the bone mineral density in women without previous medication. Results. Three hundred-sixteen women were studied, 81.6% of them were menopausal. We found a statistically significant negative linear correlation at lumbar spine and hip in all locations, with a homogenous force in lumbar spine, this being the most intense in the hip. On the lumbar level there was a decrease of 17.6% of the global bone mass, this loss being faster during the first ten years. The loss was greater in the hip. Conclusions. There is a clear loss of bone mass during the menopause, greater than that expected only due to age. The location with the most bone loss is the Ward's triangle, followed by the neck and the trocanter of the hip and the lumbar spine. The same, although on a smaller scale, was found during premenopause

Hipertensión arterial por displasia fibromuscular en dos hermanas / Hypertension for fibromuscular dysplasia in two sisters

Presentamos a dos hermanas con hipertensión arterial descubierta cuando se encontraban embarazadas y producida en ambos casos por displasia fibromuscular de las arterias renales. Comentamos la infrecuente incidencia familiar de la misma y sus posibles causas y revisamos los procedimientos diagnósticos y terapéuticos utilizados (AU)

[Referral of patients with mental disorders from primary care to mental health units]. / Derivación de los pacientes con enfermedad mental desde Atención Primaria a Salud Mental.

INTRODUCTION: Most part of the patients suffering from mental disorders are treated by non-psychiatrist physicians, mainly by general practitioners (GPs). The aim of this study has been to analyse the factors influencing the referral of patients with mental illness to psychiatric services. METHODS: Using data of referrals from two Primary Care Centres (population: 28.039) to a Mental Health Unit in one year period, we analysed clinical records, information provided with the referral, and the opinion of GPs about mental illness. RESULTS: Out of the 486 referrals, the 153 patients without previous consultations were included in the analysis. Men, and those with higher educational status were referred more frequently. A 34% of the referrals included information about psychopathological symptoms, and 70% included clinical diagnosis. Primary care physicians specialised in family medicine included more data regarding psychopathological symptoms, and included a specific request more often than GPs without specialised training. Diagnostic accuracy (61%) were lower for adjustment and personality disorders, and in those patients with an urgent referral. Patients with an urgent referral did not present different clinical features, nor different severity than those with an ordinary referral. CONCLUSIONS: Management of patients with mental disorders in PHC should be improved with guidelines about treatment and referral. Different levels of care should be co-ordinated.