[Evaluation of the satisfaction with a care coordination program between Primary Care and general internists]. / Evaluación de la satisfacción de un programa de colaboración entre Atención Primaria y Medicina Interna.

OBJECTIVES: To evaluate the level of knowledge, participation and satisfaction with a continuity of care program between Primary Care and a group of general internists, and to analyse the most frequent reasons for consulting. MATERIAL AND METHODS: Cross-sectional study including all primary care physicians from 10 Family Practice Care Centres using a questionnaire containing these objectives. RESULTS: Eighty-three family physicians (92.2%) answered the survey. All physicians knew of the collaboration program and had also participated. The most common clinical problems seen were: patients with multiple health problems(26.5%), cardiovascular risk factors (16.8%) and diagnosis of the asthenia syndrome (141%), with these three problems obtaining the best evaluation in the satisfaction survey. Almost all (98.8%) of the family physicians were satisfied with the program. CONCLUSIONS: Our continuity care program was very well evaluated in the satisfaction survey by family physicians. The participation index was very high and the clinical problems most frequently consulted and best evaluated were those that traditionally have been seen by the internists.

[Risk factors associated to mortality and functional deterioration in pluripathologic patients with heart failure]. / Factores de riesgo asociados a la mortalidad y al deterioro funcional en la insuficiencia cardíaca del paciente pluripatológico.

OBJECTIVES: Incidence, clinical features, and outcome of heart failure in patients with other chronic pathologies have been scarcely evaluated. The aim of the present study was to prospectively assess these issues, and the prognostic and factors associated to functional deterioration in a cohort of pluripathologic patients (PP) with heart failure (HF), attended in areas of Internal Medicine of a tertiary teaching hospital in the south of Spain. METHODS: Prospective observational study of all patients, attended in Internal Medicine areas of a tertiary teaching hospital, during June 2003. Patients were stratified in two cohorts: PP with HF as main category (PP-HF), and PP with no HF. Patients with two or more chronic diseases, distributed into seven categories (defined by a panel of experts) were considered PP. Incidence of PP-HF, functional evaluation (at baseline, at admission, and at discharge), and burden of hospital care (by means of urgent and programmed assistances, as well as episodes of hospitalization) in the last 12 months were analyzed. Chi-square, Fisher, "t" Student or U-Mann-Whitney and Rho de Spearman test were used for group comparisons. A multivariate analysis of predictors of survival and functional deterioration (fall in Barthel's scale > or = 10 points between baseline-discharge values) was performed in the PP-HF cohort. A p < 0.05 was considered significant. RESULTS: 132 pluripathologic patients (55 in PP-HF, and 77 in PP cohort) were included, from a global cohort of 339. Global incidence of PP-HF was 38,9/100 admissions. Mean age of PP-HF patients was 78, 50.9% were females; mortality rate and mean hospital stay were 23.6% and 12.2 days, respectively. Patients of PP-HF cohort compared to those of PP, were older (78 +/- 9.5 vs 73 +/- 10.8; p < 0.005), and suffered more chronic diseases (p = 0.0001). Functional abilities (at baseline, at admission, and at discharge), mean hospital stay, mortality, and burden of care in the previous 12 months were similar. Better functional abilities (OR: 1.136 [0.94-1.842]; p = 0.055), and less associated chronic diseases (OR: 0.072 [0.006-0.943], p = 0.045) were independently associated to survival; while older age (OR: 1,217 [1.016-1.457]; p = 0.03), and a poorer functional status at baseline (OR:1.80 [1.019-1.144]; p = 0.01) were associated to functional deterioration. CONCLUSIONS: Heart failure prevalent disease in pluripathologic patients. Specific factors associated to survival were gender and less chronic conditions; while those associated to functional deterioration during hospital stay were age and a poor functional status at baseline.

Factores de riesgo asociados a la mortalidad y al deterioro funcional en la insuficiencia cardíaca del paciente pluripatológico / Risk factors associated to mortality and functional deterioration in pluripathologic patients with heart failure

Introducción y objetivos. La incidencia, las características clínicas y evolutivas de los pacientes con insuficiencia cardíaca (IC) y otras patologías crónicas han sido escasamente evaluadas. El propósito de este estudio fue evaluar los factores pronósticos asociados al deterioro funcional de una cohorte de pacientes pluripatológicos (PP) con IC atendidos en diferentes áreas de Medicina Interna. Métodos. Estudio prospectivo de todos los PP atendidos en áreas de Medicina Interna de un hospital de tercer nivel durante el mes de junio de 2003. Los pacientes se estratificaron en dos cohortes: aquellos PP con IC como categoría principal (PP-IC) y PP sin IC (PP-noIC). Se consideraron PP aquellos que presentaban más de 2 enfermedades crónicas distribuidas dentro de siete posibles categorías (definidas por un panel de expertos). Se analizó la incidencia de PP-IC, la evolución funcional (basalmente, al ingreso y al alta) y la utilización de recursos hospitalarios (medidos por asistencias de urgencias o programadas y los reingresos en el último año). Los test de ji cuadrado, Fisher, «t» de Student o U-Mann-Whitney y Rho de Spearman fueron utilizados para la comparación de los grupos. Se realizó un análisis multivariante en la cohorte de PP-IC para determinar los predictores de supervivencia y deterioro funcional. Se consideró una p significativa si era inferior a 0,05. Resultados. Se incluyó un total de 132 PP (55 PP con IC y 77 PP sin IC) de un total de 339 pacientes hospitalizados. La incidencia global de PP-IC fue de 38,9/100 ingresos/mes. La edad media de los PP-IC fue de 78 años, el 50,9% eran mujeres, la estancia media fue de 12,2 días y la tasa de mortalidad del 23,6%. Los pacientes PP-IC eran mayores comparados con el subgrupo PP-noIC (78 ± 9,5 frente a 73 ± 10,8; p < 0,005) y padecían de más enfermedades crónicas (p = 0,0001). No hubo diferencias en el estado funcional (basal, al ingreso y al alta), en la estancia media, en la tasa de mortalidad y la utilización de recursos hospitalarios en el último año. Una mejor situación funcional (odds ratio [OR]: 1.136 [0,94-1,842]; p = 0,055) y un menor número de comorbilidades no definitorias de pluripatología (OR: 0,072 [0,006-0,943]; p = 0,045) se asociaron de forma independiente a la supervivencia, mientras que la mayor edad (OR: 1,217 [1,016-1,457]; p = 0,03) y un peor estado funcional basal (OR: 1,80 [1,019-1,144]; p = 0,01) se asociaron a un mayor deterioro funcional. Conclusiones. La IC fue altamente prevalente en la cohorte analizada de PP. Los factores pronósticos específicos asociados a una mayor supervivencia fueron el sexo masculino y la menor presencia de comorbilidad no definitoria de categoría, mientras que el deterioro funcional durante el ingreso se relacionó con la edad y con un peor estado funcional basal

Objectives. Incidence, clinical features, and outcome of heart failure in patients with other chronic pathologies have been scarcely evaluated. The aim of the present study was to prospectively assess these issues, and the prognostic and factors associated to functional deterioration in a cohort of pluripathologic patients (PP) with heart failure (HF), attended in areas of Internal Medicine of a tertiary teaching hospital in the south of Spain. Methods. Prospective observational study of all patients, attended in Internal Medicine areas of a tertiary teaching hospital, during Juny 2003. Patients were stratified in two cohorts: PP with HF as main category (PP-HF), and PP with no HF. Patients with two or more chronic diseases, distributed into seven categories (defined by a panel of experts) were considered PP. Incidence of PP-HF, functional evaluation (at baseline, at admission, and at discharge), and burden of hospital care (by means of urgent and programmed assistances, as well as episodes of hospitalization) in the last 12 months were analyzed. Chi-square, Fisher, «t» Student or U-Mann-Whitney and Rho de Spearman test were used for group comparisons. A multivariate analysis of predictors of survival and functional deterioration (fall in Barthel´s scale ≥ 10 points between baseline-discharge values) was performed in the PP-HF cohort. A p < 0.05 was considered significant. Results. 132 pluripathologic patients (55 in PP-HF, and 77 in PP cohort) were included, from a global cohort of 339. Global incidence of PP-HF was 38,9/100 admissions. Mean age of PP-HF patients was 78, 50.9% were females; mortality rate and mean hospital stay were 23.6% and 12.2 days, respectively. Patients of PP-HF cohort compared to those of PP, were older (78 ± 9.5 vs 73 ± 10.8; p < 0.005), and suffered more chronic diseases (p = 0.0001). Functional abilities (at baseline, at admission, and at discharge), mean hospital stay, mortality, and burden of care in the previous 12 months were similar. Better functional abilities (OR: 1.136 [0.94-1.842]; p = 0.055), and less associated chronic diseases (OR: 0.072 [0.006-0.943], p = 0.045) were independently associated to survival; while older age (OR: 1,217 [1.016-1.457]; p = 0.03), and a poorer functional status at baseline (OR:1.80 [1.019-1.144]; p = 0.01) were associated to functional deterioration. Conclusions. Heart failure prevalent disease in pluripathologic patients. Specific factors associated to survival were gender and less chronic conditions; while those associated to functional deterioration during hospital stay were age and a poor functional status at baseline

[Impact of palliative care and clinical features of patients with terminal diseases in areas of Internal Medicine]. / Impacto de los cuidados paliativos y perfil clínico del paciente con enfermedad terminal en un área de Medicina Interna.

INTRODUCTION: The medical assistance to patients with terminal diseases has been structured with Primary Care and Palliative Care Units as protagonists, and with other specialties as secondary roles. Nevertheless the impact of this group of patients in Internal Medicine areas is unknown. Our objective was to evaluate these parameters in the area of Internal Medicine of a tertiary teaching Hospital. MATERIAL AND METHODS: Prospective observational study of all patients attended in Internal Medicine areas during June 2003. Patients were stratified in three cohorts (palliative, pluripathologic, and general). Incidence of palliative patients, origin, clinical features, and burden of hospital care in the last 12 months were analyzed. Univariate analysis of the clinical differences between the palliative and the pluripathologic, and general cohorts was performed, using Chi-square, Fisher, ANOVA and post-hoc tests and Kruskal-Wallis test. RESULTS: 52 (53.8% women; mean age 66.5 +/- 15 years) were included from the global study cohort of 339 patients. Incidence of palliative patients was 15.4/100 admissions. The patients were admitted from other specialties (57.6%), Emergency department (27%), and Primary Care (10%). Mean hospital stay was 14.5 (1-150) days, and survival 63.5%. The 68.5% of deceases occurred at home. Patients of palliative cohort, with respect to general cohort had less functional ability at baseline (47.5 vs 95; p < 0.0001), admission (40 vs 75; p < 0.0001), and at discharge (20 vs 75; p < 0.0001), and more functional deterioration during hospital stay (mean fall in Barthel's values at baseline-discharge of 27.5 vs 20 points; p < 0.003). There were no differences in the burden of hospital care in the previous 12 months. With respect to the cohort of pluripathologic patients, palliative patients were younger (66.5 +/- 15 vs 75 +/- 11 years; p = 0.001) and had similar functional limitations at baseline (47.5 vs 45), admission (40 vs 20) and at discharge (20 vs 20). DISCUSSION: Patients with terminal diseases are prevalent in the clinical setting in areas of internal medicine. These data support the role of the internist in palliative care proceedings, and prompt internists to acquire enough specific abilities to manage competitively these population.

Impacto de los cuidados paliativos y perfil clínico del paciente con enfermedad terminal en un área de Medicina Interna / Impact of palliative care and clinical features of patients with terminal diseases in areas of Internal Medicine

Introducción. El proceso de atención a pacientes con enfermedad terminal se ha estructurado en torno a la Atención Primaria y a las Unidades de Cuidados Paliativos, quedando en un segundo plano otros especialistas. Sin embargo, se desconoce el impacto y las características clínicas y asistenciales de este grupo de pacientes en Medicina Interna. Nuestro objetivo consistió en evaluar estos parámetros en diferentes áreas de Medicina Interna de un hospital de tercer nivel. Material y métodos. Estudio prospectivo observacional de los pacientes ingresados en Medicina Interna durante junio de 2003. Se estratificó a los pacientes en tres cohortes (paliativo, pluripatológico y general). Se analizó la incidencia, procedencia, características clinicoevolutivas y consumo de recursos en los 12 meses previos al estudio. La comparación univariada de variables clínicas entre la cohorte de paliativos, pluripatológicos y general se llevó a cabo utilizando los test de Chi cuadrado, Fisher, ANOVA y post-hoc y Kruskal-Wallis. Resultados. Se incluyeron 52 pacientes (53,8% mujeres; edad media: 66,5 ± 15 años) de la cohorte global de 339. La incidencia de pacientes paliativos fue 15,4/100 ingresos. Los pacientes procedieron de Servicios Especializados (57,6%), Urgencias (27%) y Atención Primaria (10%). La estancia media fue de 14,5 (1-150) días y la supervivencia del 63,5%. El 68,5% de los fallecimientos se produjo en el domicilio. Los pacientes de la cohorte de paliativos, comparativamente con la general, tuvieron menor Barthel basal (47,5 frente a 95; p < 0,0001), al ingreso (40 frente a 75; p < 0,0001) y alta (20 frente a 75; p < 0,0001), mayor deterioro funcional durante ingreso (caída de valores basales-alta de 27,5 frente a 20 puntos; p<0,003) y no hubo diferencias en el consumo de recursos en los 12 meses previos. Con respecto a los pluripatológicos, la cohorte de paliativos tuvo menor edad media (66,5 ± 15 frente a 75 ± 11; p = 0,001) y similar limitación funcional basal al ingreso y al alta. Discusión. Los pacientes con enfermedad terminal suponen un grupo significativo en nuestras áreas de Medicina Interna, lo cual apoya el papel del internista en la asistencia a esta población y le obliga a adquirir las competencias específicas para su manejo integral

Introduction. The medical assistance to patients with terminal diseases has been structured with Primary Care and Palliative Care Units as protagonists, and with other specialties as secondary roles. Nevertheless the impact of this group of patients in Internal Medicine areas is unknown. Our objective was to evaluate these parameters in the area of Internal Medicine of a tertiary teaching Hospital. Material and methods. Prospective observational study of all patients attended in Internal Medicine areas during June 2003. Patients were stratified in three cohorts (palliative, pluripathologic, and general). Incidence of palliative patients, origin, clinical features, and burden of hospital care in the last 12 months were analyzed. Univariate analysis of the clinical differences between the palliative and the pluripathologic, and general cohorts was performed, using Chi-square, Fisher, ANOVA and post-hoc tests and Kruskal-Wallis test. Results. 52 (53.8% women; mean age 66.5 ± 15 years) were included from the global study cohort of 339 patients. Incidence of palliative patients was 15.4/100 admissions. The patients were admitted from other specialties (57.6%), Emergency department (27%), and Primary Care (10%). Mean hospital stay was 14.5 (1-150) days, and survival 63.5%. The 68.5% of deceases occurred at home. Patients of palliative cohort, with respect to general cohort had less functional ability at baseline (47.5 vs 95; p < 0.0001), admission (40 vs 75; p < 0.0001), and at discharge (20 vs 75; p < 0.0001), and more functional deterioration during hospital stay (mean fall in Barthel's values at baseline-discharge of 27.5 vs 20 points; p < 0.003). There were no differences in the burden of hospital care in the previous 12 months. With respect to the cohort of pluripathologic patients, palliative patients were younger (66.5 ± 15 vs 75 ± 11 years; p = 0.001) and had similar functional limitations at baseline (47.5 vs 45), admission (40 vs 20) and at discharge (20 vs 20). Discussion. Patients with terminal diseases are prevalent in the clinical setting in areas of internal medicine. These data support the role of the internist in palliative care proceedings, and prompt internists to acquire enough specific abilities to manage competitively these population

[Cerebral hydatidosis. Analysis of a series of 23 cases]. / Hidatidosis cerebral. Análisis de una serie de 23 casos.

BACKGROUND: The aim of the present study was to contribute to the knowledge of cerebral hydatidosis so as to improve the prognosis of a benign condition with a malignant behavior, as it has a high relapse rate with a high morbidity. METHODS: A retrospective study of cerebral hydatidosis has been carried out in 23 patients, seen at the University Hospital Virgen del Rocío during the last 20 years. The following variables were recorded: 1) Sex and age at presentation; 2) epidemiological data; 3) number, size, localization and rate of growth of cysts; 4) latency period; 5) clinical features; 6) yield of imaging procedures; 7) surgical approaches and medical therapy; and 8) relapses and sequelae. A comparative study was made of patients aged 14 years or less and those above this age. RESULTS: The mean age of the patients was 15.1 +/- 10.3 years (65% were younger than 14 years). 24% were males. 65% came from Extremadura and 74% had a rural background. The latency period was 7.9 +/- 9.2 months (range 15 days-36 months), and it was shorter in children (4.2 +/- 3.8 vs 12.6 +/- 12.7 months) (p less than 0.05). 74% had a single cyst. The cyst size was greater in children (91 +/- 46 vs 67 +/- 35 mm), as it was the rate of growth, particularly in patients younger than 10 years (13.5 +/- 7 vs 9.2 +/- 2 mm/year) (p less than 0.001). 48% had intraparenchymal localization and 70% were in the right hemisphere. In two cases the localization was intraventricular and it was cerebellar in one. Cranial computed tomography was the imaging procedure with the highest yield. The diagnosis was confirmed with pathological examination. In 6 patients (26%) the Dowling and Orlando technique (hydatid delivery) was carried out without subsequent relapses. In 7 cases (30%), and owing to surgical technique difficulties or accidents, puncture and aspiration were carried out, with 4 relapses (57%). In 10 cases cyst rupture occurred, with 6 relapses (60%). The growth rate of the relapses was 9.4 +/- 6.5 mm/month. 87% had severe sequelae, associated with relapses and multiplicity, two patients died (9%). CONCLUSIONS: 1) Cerebral hydatidosis predominates in children and young adult males of a rural background; 2) usually there is a long latency period, which is shorter in children; 3) the size and the growth rate of the cysts is greater in children; 4) computed tomography is the imaging technique with the highest yield; 5) Dowling and Orlando technique is the most effective surgical procedure; 6) the incidence of relapses is high, depending on the type of surgical approach.

[Abscessing rhombencephalitis caused by Listeria in an iummunodepressed patient]. / Rombencefalitis abscesificante por Listeria en paciente inmunodeprimido.

The cerebral trunk infection by Listeria monocytogenes is a very rare process, with only 24 described cases and only 2 in immunodepressed patients. We present a new case of cerebral trunk encephalitis caused by Listeria in a patient diagnosed of Polyarteritis nodosa on steroids and cyclophosamide treatment and fatal evolution, and whose hemoculture, spinal fluid culture and cranial CT scan did not contribute to the diagnosis. A necrotizing lesion in the protuberance with mesencephalic extension was observed in the necropsy study in which intra- and extracellular Gram + and silver positive bacilli were detected. Since L. monocytogenes was suspected as the causative agent, indirect immunofluorescence was performed on histological preparations with hyperimmune anti-L. monocytogenes serum giving a clearly positive result. In our case, this technique permitted the etiological diagnosis in the absence of positive cultures.

[Primary pyomyositis in mild climates. Presentation of 2 new cases]. / Piomiositis primaria en climas templados. Aportación de dos nuevos casos.

Pyomyositis is an acute bacterial infection which affects striated muscles. It is a relatively rare process in mild climates. Staphylococcus aureus is responsible for 90-95% of cases. Klebsiella pneumoniae pyomyositis is extremely rare with only one other case reported in a mild climate. Two new cases of pyomyositis are described one caused by K. pneumoniae, increasing thus the etiology spectrum in our country, and the other caused by S. aureus ending in fatality, with two focus of pyomyositis (one of which was chronic) and multisystemic secondary affectation. We highlight the appearance of this process in our environment and the necessity to keep it in mind when making a differential diagnosis in order to recognize it and treat it as soon as possible since its prognosis depends on the moment the diagnosis is made.

[Hydatidosis of the posterior fossa]. / Hidatidosis de fosa posterior.

The hydatid cyst is an endemic zoonosis in Spain. The central nervous system is seldom affected, the hydatid cyst in cerebellum being very rare. A patient with hydatid cyst affecting the vermis and right cerebellar hemisphere is presented. The case is described and discussed. The use of CT scan is encouraged as the most worthwhile election of diagnosis techniques. We highlight the need for very careful surgical treatment, preserving the hydatid cyst complete, to avoid relapses and to prevent the change of a benign disease to a chronic one with very high mortality.