[Calculation of the number of terminally ill patients through their use of opioid analgesics and tumor mortality]. / Estimación de la población de enfermos en situación terminal a través de la utilización de analgésicos opioides y de la mortalidad por tumores.

OBJECTIVE: To find the number of patients in terminal care in Madrid Health District 3. DESIGN: Ecological, descriptive study. SETTING: Eleven Health Districts. Madrid, Spain, 2002. MAIN MEASUREMENTS: Two models were used to calculate the number of patients in terminal care and were compared with data from the Primary Care Service Portfolio. Model A: consumption of morphine and fentanyl. The number of defined daily doses (DDD) of these active principles and the DDD per 1000 inhabitants and day (DID) were calculated. Prescription details: prescriptions charged to Social Security from registered doctors in Madrid (primary care and specialists). Model B: tumor mortality, i.e. the number of deaths due to tumors in the year 2000, published in 2004. RESULTS: The number of terminal patients calculated by the 2 models in 7 of the 11 Health Districts and in the Community of Madrid is higher than in the Primary Care Service Portfolio. In the Community of Madrid, morphine and fentanyl are prescribed basically in primary care (96%). There was an important jump in fentanyl prescription from 2001 to 2002, due to the main fentanyl prescribed being transdermal. CONCLUSIONS: There are differences between the models in calculation of terminal patients. Moreover, the models offer heterogeneous results between health districts. Fentanyl consumption has become greater than morphine use in Madrid. The registers of terminal patients and/or their recruitment need to be improved.

[Clinical impressions of terminal cancer patients as an estimator of time of survival]. / La impresión clínica como estimador del tiempo de supervivencia en pacientes oncológicos en situación terminal.

OBJECTIVE: To evaluate the relationship between the prognosis of the survival time of terminal cancer patients by doctors and nurses belonging to a Home Care Support Team (HCST) and the actual time of survival found. The first assessment and the last before death were examined. DESIGN: Prospective, descriptive study. SETTING: Area 7 of primary care, Madrid. PARTICIPANTS: Were terminal cancer patients attended by the HCST between February 2001 and August 2002. MAIN MEASUREMENTS: Age, sex, location of the tumour, presence of metastasis, number and location of metastases, real survival time and the time estimated by the doctor and nurse at the first assessment and at the last before death. The quotient of survival time found/survival time estimated was calculated. If it was between 0.67 and 1.33, the prediction was considered correct; < 0.67, optimistic, and >1.33, pessimistic. RESULTS: 121 patients were studied, 57% men, with an average age of 72 +/- 12.8 years. At the first assessment, 30% of doctors' predictions were correct, 40% optimistic and 30% pessimistic. Of nurses' predictions, 40% were correct, 30% optimistic and 30% pessimistic. The intra-class correlation coefficients (ICC) between real and estimated survival times were 0.64 for doctors and 0.54 for nurses. At the final assessment, doctors had 38% correct predictions, 44% optimistic and 18% pessimistic; and nurses had 44% correct, 32% optimistic and 24% pessimistic. The ICCs were 0.83 and 0.84. CONCLUSIONS: The accuracy of professionals' clinical impression was only acceptable at the moment of quantifying the prognosis.

[Effectiveness of a training course in bioethics and of the introduction of a checklist to detect ethical problems in a home care support team]. / Efectividad de un curso de formación en bioética y de la implantación de una checklist en la detección de problemas éticos en un equipo de soporte de atención domiciliaria.

OBJECTIVE: To study the concordance in the number of ethical problems identified in the care of the terminally ill between the members of a home care support team (HCST) and a group of experts before and after a course in bioethics and the introduction of a checklist. DESIGN: Before-and-after intervention study. SETTING: Area 7 of Primary Care, Madrid. PARTICIPANTS: Terminally ill patients attended by the HCST between November 2001 and June 2002. INTERVENTION: Bioethics course and introduction of a checklist. MAIN MEASUREMENTS: Age, sex, basic illness, number of ethical problems identified by the HCST and by the group of experts before and after the intervention. The intraclass correlation coefficient (ICC) for the number of problems identified was calculated in both groups before and after the intervention. RESULTS: 31 cases before and 29 after the intervention were studied. Before the intervention the HCST identified an average of 2.7 +/- 2.3 ethical problems per case; and the group of experts found 11.8 +/- 6.1. The ICC for the number of problems identified was 0.53 (moderate correlation). After the intervention, the HCST identified 5.9 +/- 6.5 ethical problems per case; and the group of experts, 10.7 +/- 7.9. The ICC for the number of problems identified was 0.87 (close correlation). CONCLUSIONS: The course and the introduction of a checklist helped professionals who were not experts in bioethics to detect ethical problems in treating terminally ill patients.

[Microvascular angina (syndrome X). Presentation of 4 cases]. / Angina microvascular (síndrome X). Presentación de cuatro casos.

OBJECTIVE: To revise diagnostic, therapeutic and evolutive specifications of Microvascular Angina. To improve the knowledge about this syndrome among family doctors. DESIGN: Descriptive and transversal study. SETTING: Outpatients belonging to a Primary Care Centre in the metropolitan area of Madrid. PATIENTS AND OTHER PARTICIPANTS: Four patients (2 male and 2 female) aged over 50, diagnosed to have Microvascular Angina. MEASUREMENTS AND MAIN RESULTS: The clinical histories of the patients diagnosed to have Microvascular Angina were used. This syndrome was defined as a typical chest pain starting by an effort, normal electrocardiogram, ischemic ST-segment depression in exercise stress test and angiographically normal coronary arteries. The clinical and electrocardiographic specifications were similar in four cases. A positive exercise stress test and the existence of normal coronary arteries was confirmed in all the patients. All of them were treated with betablokers and/or calcium channel blokers with an effective response in three of them. CONCLUSIONS: It is important to know the existence of Microvascular Angina in Primary Care, first because it is one cause of chest pain and second because it has a good prognosis with few complications in the future.

[Syringomas. Presentation of 7 cases]. / Siringomas. Presentación de siete casos.

OBJECTIVE: To further knowledge of syringoma and its importance within the overall condition of the patient, with a view to making it relevant in the differential diagnosis of other conditions such as xanthomata or milium cysts. DESIGN: A descriptive study of a crossover type. SETTING: Primary care and the dermatology clinic of a health centre in the metropolitan area of Madrid. PATIENTS AND OTHER PARTICIPANTS: The records of patients with syringomas confirmed by histological tests during 1990-1993 were examined. Patients with only a clinical diagnosis were discarded. The different diagnoses on referral by the primary care doctor were also studied. MEASUREMENTS AND MAIN RESULTS: Seven patients (5 women, two men) were confirmed by histological tests as suffering Syringomas. They were between 16 and 52 years old. Four had lesions only on the eyelids; in the other three they were widespread. All of them were asymptomatic, had been over three years without lesions and had no special previous history. None of them wanted to undergo treatment. The referral diagnoses cited xanthomata in five cases and milium cysts in the others. CONCLUSIONS: The primary care doctor must become better informed about syringoma, given its frequent confusion with other conditions (xanthomata and milium cysts). This confusion gives rise to unnecessary additional examinations and discomfort for the patients. These lesions should be verified histologically, as it is an nonaggressive method.

[Bowen's disease. A report of 9 cases]. / Enfermedad de Bowen. Presentación de nueve casos.

OBJECTIVE: To revise clinical histological, therapeutic and evolutive specifications of Bowen's disease. To emphasise the importance of an early diagnosis and to promote treatment with topical 5-fluorouracil by the family doctor. DESIGN: Descriptive and transversal study. SETTING: Outpatient and dermatology departments in a hospital in the metropolitan area of Madrid. PATIENTS AND OTHER PARTICIPANTS: Nine patients (5 male and 4 female), aged over 50, with slightly pigmented skin and diagnosed to have Bowen's disease. TREATMENT: In five patients. Topical 5-fluorouracil (Efudix) was applied once a day for 20-30 days. Surgery was performed on three patients and one underwent radiotherapy. MEASUREMENTS AND MAIN RESULTS: The clinical histories of the patients were used. In each case a histological study of the papule that had confirmed diagnosis was carried out. Treatment was effective in all patients and no recidivation was observed during the one year follow up. CONCLUSIONS: An early diagnosis and treatment of Bowen's disease is important for preventing its progression to invasive epidermoid carcinoma and later dissemination. The use of topical 5-fluorouracil is an efficient measure that can be prescribed by the family doctor.