The cardiovascular effects of large hiatal hernias: a narrative review of cases and studies.

Hiatal hernia (HH) is a common disease in the general population. It is often asymptomatic, but if it does present clinical manifestations, these are usually gastrointestinal. Gastroesophageal reflux is the main symptom that accompanies it. Depending on the severity of the hernia, it is classified into several subtypes from I-IV. Especially, IV type (giant HH) can lead to various cardiopulmonary symptoms with several degrees of severity. It is necessary to keep this possibility in mind among the various differential diagnoses that may occur in this clinical setting. The current paper aims to review the literature on classic and novel information on the HH - cardiovascular system relationship. Epidemiological data, physiological aspects of the heart compressed by HH, cardiovascular symptoms, electrocardiographic changes, echocardiographic alterations and clinical implications are discussed.

Normally, the stomach and the heart are not in direct contact because they are in different cavities, the thorax and the abdomen, respectively. When part of the stomach moves toward the chest through the diaphragm, we say there is a hiatal hernia (HH). Most of the time the HH symptoms are mild and clearly digestive. In severe cases, surgical repair of the HH is required. Even in these circumstances, digestive symptoms continue to be the most frequent. However, some patients present cardiovascular symptoms and few or no digestive symptoms. This easily creates diagnostic confusion, which leads to incorrect treatments and unnecessary expenses. In extreme cases, as seen in giant HH, the degree of cardiovascular involvement is very serious. There are documented cases that have suffered cardiac arrest, arrhythmias of different types and symptoms like classic acute myocardial infarction. It is required that clinical doctors and surgeons are aware that this complication exists. Only with this in mind can a timely diagnosis be achieved. Some emergency measures have been saving, gastric decompression with a tube being the most important. The main mechanism that explains the serious cardiovascular consequences of giant HH is cardiac compression. The dissemination of this knowledge can help save lives.

Displasia fibrosa poliostótica: a propósito de un paciente / Fibrous dysplasia polyostotic: apropos of a patient

La displasia fibrosa es una condición fibro-ósea benigna que consiste en la sustitución de tejido óseo por tejido fibroso; es considerada una lesión pseudotumoral benigna del esqueleto y es, generalmente, asintomática. Se presenta una paciente femenina de 47 años de edad con displasia fibrosa, variedad poliostótica, enfermedad ósea muy poco frecuente. Los estudios imagenológicos simples y la tomografía axial computarizada, por su gran riqueza en hallazgos, permitieron realizar el diagnóstico, que se confirmó mediante el estudio anatomopatológico(AU)

Hiperintensidades de la sustancia blanca en resonancia magnética, ¿un reto su interpretación? / White matter hyperintensities on magnetic resonance. Is a challenge its interpretation?

Resulta un serio problema diagnóstico en la Especialidad de Imagenología la visualización de imágenes que se iluminan (hiperintensas) en las técnicas de contrastes T2 y en la secuencia de supresión de líquido cefalorraquídeo, conocida en la literatura como objeto brillante no identificado, así como la visualización de placas hiperintensas de mayor tamaño, con o sin síntomas clínicos específicos. Se hace una revisión de los patrones de imágenes hiperintensas cerebrales para una mejor interpretación, a partir del conocimiento de la anatomía de la microcirculación cerebral y la de su intersticio, y así poder abordar la afección de la sustancia blanca al considerar qué elementos se hallan más afectados en los diferentes grupos de leucoencefalopatías y reconocer sus principales hallazgos y excepciones en la presentación durante los estudios de resonancia magnética(AU)

Doble cayado aórtico: a propósito de una paciente / Double aortic arch: on purpose of a patient

Los anillos y slings vasculares son anomalías o variaciones anatómicas vasculares que comprimen, en mayor o menor grado, la tráquea y el esófago (o ambos) y que causan niveles variables de estridor y disfagia (o ambos). El complejo desarrollo embriológico del arco aórtico, los troncos supraaórticos, la arteria y las ramas pulmonares y la presencia del conducto arterioso permeable (derecho o izquierdo) hacen aórtico y el arco aórtico a la derecha con conducto arterioso izquierdo forman anillos completos mientras que los slings producidos por arterias aberrantes no llegan a cerrar completamente un anillo vascular(AU)

Diagnóstico sonográfico de tumores de partes blandas en el aparato osteomioarticular / Sonographic diagnosis of soft tissue tumors in the apparatus osteomioarticular

Se realizó un estudio transversal, descriptivo, observacional en el Hospital Provincial Universitario Arnaldo Milián Castro, de la Provincia de Villa Clara, en el período comprendido entre febrero de 2009 y mayo de 2011 con el objetivo de determinar el comportamiento sonográfico de los tumores de partes blandas del sistema osteomioarticular en relación con su histología, su vascularización y algunas variables epidemiológicas. Se realizó una encuesta a los pacientes que acudieron a la Consulta de ecosoma con el diagnóstico presuntivo de un tumor de partes blandas del sistema oteomioarticular, la muestra la conformaron aquellos que, luego de realizado el estudio sonográfico, requirieron de confirmación y diagnóstico histológico mediante biopsia con aguja; se recogieron datos de los exámenes físico y epidemiológico y los hallazgos al examen ecográfico y se confirmó el diagnóstico histológico por los registros estadísticos del Departamento de Anatomía Patológica del hospital. Se estableció la correlación entre los hallazgos ecográficos, el examen físico, la vascularización, algunas variables epidemiológicas y el diagnóstico histológico definitivo. Se realizó un muestreo intencionado con criterios de inclusión y exclusión dados por expertos y el investigador. Después de realizar el análisis estadístico de los resultados se llegó a conclusiones y recomendaciones(AU)

Caracterización de los hallazgos ultrasonográficos en lasenfermedades del hombro doloroso

Se realizó un estudio transversal, descriptivo, observacional en el Hospital Provincial Universitario Arnaldo Milián Castro de la Provincia de Villa Clara en el período comprendido entre febrero de 2012 y enero de 2015 con el objetivo de analizar la utilidad de la ecografía en las enfermedades del hombro doloroso. Se trabajó con la totalidad del universo, que resultaron 56 pacientes a los que se les confirmó el diagnóstico ultrasonográfico de afección del hombro. De acuerdo a la valoración realizada el mayor porcentaje de los pacientes se encontró en el grupo de 51 a 60 años de edad, con un predominio del sexo femenino y una actividad física de moderada a intensa. La tendinitis del manguito rotador con la afectación del supraespinoso resultó la enfermedad más frecuente, con patrones ecográficos propios de ese padecimiento como la disminución de la ecogenicidad del tendón y el aumento de su grosor, mientras que la técnica del Doppler color ofreció una información complementaria a la obtenida por ultrasonografía en escala de grises sobre los procesos inflamatorios del tendón de la porción larga del bíceps. Existió una correlación lineal positiva y directa entre el diagnóstico clínico y el ecográfico de la ruptura del manguito y la tendinitis de la porción larga del bíceps; en el resto de las afecciones del hombro no existió relación entre el diagnóstico clínico y el ecográfico(AU)

Angiorresonancia de bajo campo en las afecciones cerebrovasculares, una opción en hospitales sin angiógrafo

Se realizó un estudio transversal, descriptivo, observacional para la evaluación de un medio diagnóstico, en este caso la angiorresonancia cerebral, a 50 pacientes que padecen afecciones cerebrovasculares y que fueron atendidos en el Servicio de imagenología del Hospital Arnaldo Milián Castro en el período de tiempo comprendido entre enero de 2010 y agosto de 2012; a todos se les realizó la angiorresonancia, validada mediante la angiotomografía, y la angiografía por sustracción digital. El mayor número de pacientes afectados estuvo en el rango de edad entre 41 y 60 años; con una prevalencia de angiorresonancias practicadas a pacientes con enfermedad cerebrovascular hemorrágica en relación con la isquémica; la hemorragia subaracnoidea fue el principal diagnóstico en la tomografía axial computadorizada de urgencia; las secuencias y las técnicas más utilizadas fueron, junto a la angiorresonancia, la secuencia de supresión de líquido cefalorraquídeo y la técnica T2; la fase del time of flight arterial prevaleció con respecto al venoso; el aneurisma resultó la malformación vascular más diagnosticada con moderada sensibilidad y baja especificidad al compararla con otras técnicas, lo que no resultó así en el dagnóstico de las malformaciones arteriovenosas que muestran alta sensibilidad y especificidad; en la isquemia cerebral se observaron similares resultados, sobre todo para el estudio de los vasos intracraneales y fueron el time of flight axial y la tercera dimensión las secuencias más útiles(AU)

Heart failure in primary care: co-morbidity and utilization of health care resources.

BACKGROUND: In order to ensure proper management of primary care (PC) services, the efficiency of the health professionals tasked with such services must be known. Patients with heart failure (HF) are characterized by advanced age, high co-morbidity and high resource utilization. OBJECTIVE: To ascertain PC resource utilization by HF patients and variability in the management of such patients by GPs. METHODS: Descriptive, cross-sectional study targeting a population attended by 129 GPs over the course of 1 year. All patients with diagnosis of HF in their clinical histories were included, classified using the Adjusted Clinical Group system and then grouped into six resource utilization bands (RUBs). Resource utilization and Efficiency Index were both calculated. RESULTS: One hundred per cent of patients with HF were ranked in RUBs 3, 4 and 5. The highest GP visit rate was 20 and the lowest in excess of 10 visits per year. Prescription drug costs for these patients ranged from €885 to €1422 per patient per year. Health professional efficiency varied notably, even after adjustment for co-morbidity (Efficiency Index Variation Ratio of 28.27 for visits and 404.29 for prescription drug cost). CONCLUSIONS: Patients with HF register a high utilization of resources, and there is great variability in the management of such patients by health professionals, which cannot be accounted for by the degree of case complexity.

Comorbidity in patients with chronic obstructive pulmonary disease in family practice: a cross sectional study.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is frequent and often coexists with other diseases. The aim of this study was to quantify the prevalence of COPD and related chronic comorbidity among patients aged over 40 years visiting family practices in an area of Madrid. METHODS: An observational, descriptive, cross-sectional study was conducted in a health area of the Madrid Autonomous Region (Comunidad Autónoma de Madrid). The practice population totalled 198,670 persons attended by 129 Family Physicians (FPs), and the study population was made up of persons over the age of 40 years drawn from this practice population. Patients were deemed to have COPD if this diagnosis appeared on their clinical histories. Prevalence of COPD; prevalence of a further 25 chronic diseases in patients with COPD; and standardised prevalence ratios, were calculated. RESULTS: Prevalence of COPD in family medicine was 3.2% (95% CI 3.0-3.3) overall, 5.3% among men and 1.4% among women; 90% of patients presented with comorbidity, with a mean of 4 ± 2.04 chronic diseases per patient, with the most prevalent related diseases being arterial hypertension (52%), disorders of lipid metabolism (34%), obesity (25%), diabetes (20%) and arrhythmia (15%). After controlling for age and sex, the observed prevalence of the following ten chronic diseases was higher than expected: heart failure; chronic liver disease; asthma; generalised artherosclerosis; osteoporosis; ischaemic heart disease; thyroid disease; anxiety/depression; arrhythmia; and obesity. CONCLUSIONS: Patients with COPD, who are frequent in family practice, have a complex profile and pose a clinical and organisational challenge to FPs.

Evaluation of a telemedicine service for the secondary prevention of coronary artery disease.

PURPOSE: Efficient ways are needed to implement the secondary prevention (SP) of coronary heart disease. Because few studies have investigated Web-based SP programs, our aim was to determine the usefulness of a new Web-based telemonitoring system, connecting patients provided with self-measurement devices and care managers via mobile phone text messages, as a tool for SP. METHODS: A single-blind, randomized controlled, clinical trial of 203 acute coronary syndrome (ACS) survivors, was conducted at a hospital in Madrid, Spain. All patients received lifestyle counseling and usual-care treatment. Patients in the telemonitoring group (TMG) sent, through mobile phones, weight, heart rate, and blood pressure (BP) weekly, and capillary plasma lipid profile and glucose monthly. A cardiologist accessed these data through a Web interface and sent recommendations via short message service. Main outcome measures were BP, body mass index (BMI), smoking status, low-density lipoprotein-cholesterol (LDL-c), and glycated hemoglobin A1c (HbA1c). RESULTS: At 12-month followup, TMG patients were more likely (RR = 1.4; 95% CI = 1.1-1.7) to experience improvement in cardiovascular risk factors profile than control patients (69.6% vs 50.5%, P = .010). More TMG patients achieved treatment goals for BP (62.1% vs 42.9%, P = .012) and HbA1c (86.4% vs 54.2%, P = .018), with no differences in smoking cessation or LDL-c. Body mass index was significantly lower in TMG (-0.77 kg/m² vs +0.29 kg/m², P = .005). CONCLUSIONS: A telemonitoring program, via mobile phone messages, appears to be useful for improving the risk profile in ACS survivors and can be an effective tool for secondary prevention, especially for overweight patients.

Patient safety and electromagnetic protection: a review.

A systematic literature review was carried out to study patient security and possible harmful effects, immunity and interferences on medical devices, and effectiveness and transmission problems in healthcare and hospital environments due to electromagnetic interferences. The objective was to determine already-reported cases of patient security, immunity of medical devices, and transmission/reception failure in order to evaluate safety and security of patients. Literature published in the last 10 years has been reviewed by searching in bibliographic databases, journals, and proceedings of conferences. Search strategies developed in electronic databases identified a total of 820 references, with 50 finally being included. The study reveals the existence of numerous publications on interferences in medical devices due to radiofrequency fields. However, literature on effectiveness, transmission problems and measurements of electromagnetic fields is limited. From the studies collected, it can be concluded that several cases of serious interferences in medical instruments have been reported. Measures of electromagnetic fields in healthcare environments have been also reported, concluding that special protective measures should be taken against electromagnetic interferences by incoming radio waves.

Heart failure in the family practice: a study of the prevalence and co-morbidity.

BACKGROUND: Heart failure (HF) is a health problem that particularly affects the elderly population. Its onset is associated with other chronic diseases, a circumstance that makes it a challenge for health care services. The aim of this study is to quantify the prevalence of HF in family medicine offices and describe the chronic co-morbidity associated with it. METHODS: A cross-sectional, observational descriptive study set in a health area of the Community of Madrid, Spain. The study was carried out in a population of 198,670 individuals over 14 years of age, attended to by 129 specialists in family medicine. The patient was considered to have HF when this diagnosis (ICPC code K77) appeared in his or her electronic medical record. The prevalence of HF was quantified and its association with another 25 chronic diseases was analysed. RESULTS: The prevalence of HF was 6.9‰, 7.9‰ among women and 5.9‰ among men. Patients with HF had a high rate of chronic co-morbidity, with an average of 5.2 + 2.1 chronic diseases. Only 3% of the patients present with isolated HF and >60% have four or more additional chronic problems. Hypertension, cardiac arrhythmias, hyperlipidaemia, obesity and diabetes mellitus are the chronic diseases most frequently detected in HF patients. CONCLUSION: Patients with HF frequently visit the offices of family physicians, presenting with a high rate of cardiac and non-cardiac co-morbidity that proves to be a challenge on the clinical level and in terms of the organization of health care services.

Evaluation of a telemedicine-based service for the follow-up and monitoring of patients treated with oral anticoagulant therapy.

The authors have designed and developed a telemedicine-based service for the follow-up and monitoring of patients on oral anticoagulant therapy (OAT) that consists of two phases; the first involving self-testing and the second involving guided self-management. To evaluate the first phase of the protocol, a project was conducted with 108 patients, with a mean age of 72.7 years and a mean treatment time at the start of the study of 55.2 months, divided into two groups: telemedicine and control (conventional procedure). The degree of anticoagulation control was similar in the two groups: individual in-range international normalized ratios (59.2% vs 61.1%; p = 0.55) and individual time within target range (65.7% vs 66.4%; p = 0.85) showed no significant differences. The incidence of adverse events--death (5.5% vs 5.5%; p = 1.0), major hemorrhagic complications (0% vs 1.8%; p = 1.0), minor hemorrhagic complications (7.4% vs 3.7%; p = 0.67), and thromboembolism (1.8% vs 3.7%; p = 1.0)--was also similar, with no significant differences. Acceptability of the change, measured in terms of quality of life (SF-12 and Sawicki questionnaires) and anxiety (state-trait anxiety inventory questionnaire) at the beginning and end of the study period was higher in the telemedicine group, with statistically significant improvements in mental component summary (3.6 vs -6.2; p = 0.02), dissatisfaction (-0.8 vs 0.2; p = 0.001), stress (-0.3 vs 0.05; p = 0.03), limitations (-0.2 vs 0.3; p = 0.005), social problems (-0.1 vs 0.3; p = 0.03), and state anxiety (-2.5 vs 2.3; p = 0.04). Parameters related to costs, such as the mean number per patient of office visits due to OAT (1.7 vs 13.8; p << 0.001) and other office visits (10.1 vs 11.5; p = 0.028), were also more favorable in the telemedicine group, as were additional parameters that enabled an exhaustive evaluation of the service. The positive results obtained indicate that the second phase of the trial can be initiated.

Impact of patient-general practitioner short-messages-based interaction on the control of hypertension in a follow-up service for low-to-medium risk hypertensive patients: a randomized controlled trial.

The evaluation in real-life settings of services for the follow-up and control of hypertensive patients is a complex intervention, which still needs analysis of the roles, tasks, and resources involved in the basic items: patient, healthcare professional, and the interaction between the two. To evaluate the impact of patient-general practitioner (GP) short-messages-based interaction, isolated from other items, on the degree of hypertension control in the follow-up of medium-to-low-risk patients in primary care, a randomized controlled trial has been performed: 38 GPs enrolled 285 hypertensive patients who recorded the results of self-blood-pressure (BP) monitoring, heart rate, and body weight, and completed an optional questionnaire in an identical manner over a six-month period. The telemedicine group (TmG) sent the data to a telemedicine-based system that enabled patient-GP interaction; the control group (CG) recorded the data on paper and could only deliver it to their GP personally in the routine visits. In the TmG, the results were better, but not significantly so, for: 1) degree of hypertension control, in terms of the percentage of uncontrolled hypertensives at the final visit (TmG versus CG: 31.7% versus 35.6%; p = 0.47); 2) reduction in hypertension during follow-up, comparing measurements (performed by a professional) at the initial and final visits of systolic BP (15.5 versus 11.9; p = 0.13) and diastolic BP (9.6 versus 4.4; p = 0.40); and 3) adherence to the protocol within compliance levels of interest in a real-life follow-up service: >>50% (84.8% versus 73.3%) and >>25% (92.4.8% versus 75.4%) ( p = 0.053). Other factors such as average values of self-measured systolic BP, diastolic BP and heart rate, acceptability of the protocol, and median number of consultations and hospital admissions were similar in both groups. Outcomes show that, taken alone, the patient-GP short-messages-based interaction has very little impact on the degree of hypertension control in patients with this profile. In complex interventions, to discriminate the impact of each of its components in isolation will enable us to design an efficient follow-up service, little demanding in terms of healthcare professional dedication, and optimized in other basic aspects.

Estudio clínico y sonográfico en niños con hipertensión portal / Clinical-ultrasonographic study on children suffering portal hypertension

Para describir algunos aspectos relevantes de la hipertensión portal en el niño, se realizó un estudio descriptivo en 32 enfermos menores de 16 años de edad que presentaban un diagnóstico de hipertensión portal en el período comprendido entre enero de 1999 y marzo de 2003. Se determinó la edad, la forma de presentación, los hallazgos ultrasonográficos, el diagnóstico etiológico y los antecedentes patológicos personales. La enfermedad predominó en el grupo de edad comprendido entre 1-4 años (53,1 por ciento); le siguió, en orden de frecuencia, el de 5-8 años y los menores de un año (28,1 por ciento y 15,6 por ciento respectivamente). En 78,1 por ciento de los pacientes, la forma de presentación de la hipertensión portal fue sin sangramiento digestivo. El ultrasonido Doppler fue realizado en 25 pacientes con hipertensión portal prehepática, de los cuales 23 (92 por ciento) presentaron trombosis portal; la causa hepática se comprobó solamente en 21,9 por ciento. La mayoría de los niños (96 por ciento) que presentaron obstrucción prehepática tenían antecedentes de cateterismo umbilical. Se recomiendan otros estudios que evalúen la evolución de la enfermedad y los resultados del tratamiento(AU)