E-consults between primary care and internal medicine: implementation, accessibility, benefits, and implications.

AIM: This work aims to evaluate whether electronic consultations (e-consults) are a clinically useful, safe tool for assessing patients between primary care and internal medicine. METHODS: This is a retrospective cohort study of all e-consults ordered by the Primary Care Department to the Internal Medicine Department between September 2019 and December 2023. The results of initial consultations, emergency department visits and subsequent admissions, and survival were assessed and complaints and claims filed were reviewed. RESULTS: A total of 11,434 e-consults were recorded (55.4% women) with a mean age of 62.1 (SD19.4) years and a wide range (15-102 years). The mean response time was 2.55 (SD 1.6) days. As a result of the e-consults, 5645 patients (49.4%) were given an in-person appointment. For the remaining 5789 (50.6%), a written response was provided. Among those given appointments, the time between the response and in-person appointment was less than five days (95% of cases). Compared to those not given appointments, in-person appointments were older (p < 0.0001), visited the emergency department more times (one month: p = 0.04; three months: p = 0.001), were admitted to the hospital more times (one month: p = 0.0001; three months: p = 0.0001), and had higher mortality at one year (12.7% vs. 9.8% p = 0.0001). In the Cox analysis, only in-person appointments (RR = 1.11; p = 0.04)) and age (RR = 1.09; p < 0.01) were independent factors of mortality. No complaints or claims of any kind were registered. CONCLUSIONS: These data suggest that e-consults are a clinically useful, safe tool for assessing patients referred from primary care to internal medicine departments.

Tumoración en raíz de miembro inferior en paciente diabético / Tumor at the limb root in a diabetic patient

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[A management analysis of bacterial meningitis in a hospital emergency service: the delay from the start of treatment and related factors]. / Análisis del manejo de la meningitis bacteriana en un servicio de urgencias hospitalario: demora del inicio del tratamiento y factores relacionados.

OBJECTIVE: To establish the time elapsed from the patient arrival to the emergency room to the beginning of antibiotic therapy. To identify etiologic factors for treatment delay. METHODS: 73 patients diagnosed of bacterial meningitis in the emergency room and admitted to the hospital were studied. Patient characteristics as well as meningitis predisposing factors, symptoms, physical examination, laboratory data, radiological studies and previous ambulatory treatment, were recorded retrospectively. Arrival time, time expended at diagnostic procedures and time of administration of the first antibiotic dose, as well as the administration place were registered. Patients clinical evolution, and factors influencing the delay of antibiotic administration were analyzed. RESULTS: Median age was 17 years. Patient care was evenly distributed along the day, 80% had a light base risk, 29% had at least a risk factor for meningitis, 22% received antibiotic previously. Clinical presentation was classic in more than 71% of patients. Blood cultures were positive in 41%, and CSF cultures were positive in 63%, 43% of cases were related to Neisseria meningitidis, 20% Streptococcus pneumoniae and unknown bacteria in 31.5%. Computerized Tomography (CT) was performed in 9 cases. Median time from the arrival to the Emergency Room until antibiotic administration was 5 hours and 25 minutes: When antibiotics were given before Lumbar Puncture (LP), it was 2 hours and 50 minutes, 5 hours 20 minutes when therapy was started after LP, and 7 hours and 22 minutes when CT was performed before LP. The only factor showing a statistically significant relation with the time to antibiotic administration was the patient being sent by the primary care physician to the hospital with a presumptive diagnosis of bacterial meningitis (1 hour 20 minutes vs. 5 hours 51 minutes). CONCLUSION: Only a small part of bacterial meningitis cases start antibiotic treatment in the first 30 minutes. Delay is high and it increases when certain diagnostic tests are performed. Information received from the primary care physician, has the highest influence on the beginning of treatment.

Pasteurella spp: un nuevo germen causante de tiroiditis aguda supurada / Pasteurella spp: a new microorganism adding to acute suppurative thyroiditis etiology

La tiroiditis aguda supurada es una entidad poco frecuente debido a la resistencia natural de la glándula a la infección. Patología preexistente sobre el tiroides así como defectos anatómicos locales predisponen a padecer la enfermedad. Presentamos el primer caso descrito en la literatura por Pasteurella spp tras infección de vías respiratorias superiores, con clínica poco florida mimetizando tiroiditis subaguda. La evolución fue satisfactoria tras drenaje quirúrgico (AU)

Análisis del manejo de la meningitis bacteriana en un servicio de urgencias hospitalario: demora del inicio del tratamiento y factores relacionados / Handling of bacterial meningitis on a hospital emergency room: delays at the beginning of treatment and related factors

Fundamento. Conocer el tiempo de retraso en la administración de antibióticos en la meningitis bacteriana desde la llegada del paciente al servicio de urgencias e identificar los factores que muestran relación con el mismo. Métodos. Serie de 73 casos de pacientes con él diagnostico de meningitis bacteriana atendidos en el servicio de urgencias e ingresados en el hospital. Los datos se recogieron retrospectivamente. Se estudiaron las características de los pacientes, factores predisponentes para meningitis, clínica, exploración física, datos de laboratorio, estudios radiológicos y tratamiento ambulatorio previo. Tiempos de llegada, de realización de los procedimientos diagnósticos y de administración de la primera dosis de antibiótico y lugar de administración. Se recogió la evolución de los pacientes y se analizaron los factores que influyeron en la demora de la administración de antibióticos. Resultados. La mediana de edad fue de 17 años, la atención a los pacientes se repartió a lo largo de la jornada, el riesgo de base fue leve en el 80%, el 29% tuvo al menos un factor de riesgo para meningitis, el 22 porciento recibió antibiótico ambulatoriamente, la presentación clínica fue la clásica en mas del 71% de los pacientes. El hemocultivo fue positivo en 41% y el cultivo de LCR en el 63 porciento. El 43% de los casos fueron debidos a Neisseria meningitidis, 20% Streptococcus pneumoniae y a germen desconocido en el 31,5 porciento. Se realizaron 9 Tomografías axiales computarizadas (TAC). El tiempo medio desde la llegada al servicio de urgencias hasta la administración de antibióticos fue de 5 horas y 25 minutos. Cuando se administró antes de la punción lumbar fue de 2 horas 50 minutos; de 5 horas 20 minutos; cuando se administró después de la punción lumbar y de 7 horas 22 minutos cuando se realizo TAC cerebral antes de la punción. El único factor que demostró relación estadísticamente significativa con la demora en la administración de antibiótico fue el hecho de que el paciente fuese remitido por su medico de cabecera con sospecha de meningitis bacteriana (1 hora 20 minutos vs 5 horas 51 minutos). Conclusiones. Sólo en una pequeña parte de los casos de meningitis bacteriana se inicia el tratamiento antibiótico en los primeros 30 minutos. La demora media es elevada y aún más cuando se realizan determinadas pruebas diagnósticas (AU)

[Pasteurella spp: a new microorganism to the cause of acute suppurative thyroiditis]. / Pasteurella spp: un nuevo germen causante de tiroiditis aguda supurada.

Acute suppurative thyroiditis is an uncommon disease due to local resistance of the gland to infection. Preexisting gland pathology and local anatomic abnormalities are predisposing factors. We present the first case described in the medical literature caused by Pasteurella spp after upper respiratory infection with insidious manifestations resembling subacute thyroiditis. The course was benign after surgical drainage.

[Adrenocortical function in patients with active pulmonary tuberculosis]. / Función adrenocortical en pacientes con tuberculosis pulmonar activa.

STUDY OBJECTIVE: To assess adrenal function in patients with acute pleuropulmonary tuberculosis (APT) and compare it with that function in patients with community-acquired pneumonia (CAP). PATIENTS: Over a period of 6 months all consecutive patients 18 years of age or older with newly diagnosed APT and CAP were entered into the study. MEASUREMENTS: The whole patients had the following investigations: 1) Serum Na+, K+ and glucose concentrations 2) Systolic and diastolic blood pressures. 3) An ultrasonographic study of the adrenal glands. 4) A standard ACTH stimulation test. RESULTS: There was no significative difference in the serum cortisol level between the two groups at any time of the ACTH stimulation test (basal, 30 and 60 minutes), neither when taking into account the increments between basal and 60 minutes after stimulation serum cortisol levels. All patients in both groups had normal ACTH stimulation test with a peak stimulated cortisol level at 60 minutes > 504 nmol/L. CONCLUSIONS: We did not find evidence of adrenal cortical dysfunction in patients with acute pleuropulmonary tuberculosis or with community-acquired pneumonia in our hospital.

[Cervical pain as a clinical sign of spontaneous intracraneal hypotension]. / Cervicalgia como manifestación clínica de un síndrome de hipotensión intracraneal espontánea.

We report a patient with spontaneous intracranial hypotension who developed severe neck pain after hard exercise. The pain was worse when the patient was standing and was relieved when he lay flat. Radionuclide cisternography demonstrated a central spinal fluid leak in the thoracic region of the spine. The syndrome resolved with conservative treatment. Although the most typical feature of spontaneous intracranial hypotension is postural headache, unnecessary testing can be avoided if we suspect this entity in the presence of cervical pain that worsens when the patient is upright and disappears or improves when he or she is lying down.