Idoneidad de las derivaciones de Atención Primaria a especialidades médicas hospitalarias / Adequacy of primary care referrals to medical specialities

INTRODUCCIÓN. El objetivo de este estudio es conocer la idoneidad de las interconsultas dirigidas desde Atención Primaria a especialidades médicas hospitalarias analizando sus características desde el punto de vista de las dos partes implicadas. MÉTODOS. Cuatro médicos (2 de Atención Primaria y 2 Internistas hospitalarios) analizaron retrospectivamente las peticiones de interconsulta y las notas de la primera consulta de 225 pacientes seleccionados aleatoriamente entre las consultas realizadas entre enero y julio de 2003 en un hospital de carácter provincial. RESULTADOS. El 26% de las interconsultas se consideraron innecesarias si se exige el acuerdo de los cuatro observadores (el 26,6% adecuadas y sin acuerdo en el 47,2% restante), y 37% cuando sólo se requiere que coincidan tres de los cuatro investigadores. La categoría en la que se alcanza un mayor grado de acuerdo es la de las consultas inadecuadas. Estas interconsultas corresponden a pacientes más jóvenes, procedentes del medio urbano, se acompañan de hojas de solicitud de consulta de peor calidad y generan un menor número de revisiones. CONCLUSIONES. Las consultas externas médicas hospitalarias están lastradas por un número muy elevado de IC no adecuadas o innecesarias, a las que se remiten pacientes con características diferentes de aquellos remitidos para consultas consideradas adecuadas

INTRODUCTION. This study aims to know the adequacy of specialized care referrals from Primary Care to hospital medical specialities, analyzing their characteristics from the point of view of the two parties involved. METHODS. Four doctors (2 from primary care and 2 hospital internists) retrospectively analyzed the specialized care requests and notes of the first consultation of 225 patients randomly selected among the consultations made between January and July 2003 in a provincial Hospital. RESULTS. A total of 26% of the specialized care referrals were considered unnecessary if agreement of four observers is required (26.6% adequate and no agreement in the remaining 47.2%) and 37% were considered unnecessary when three of the four investigators had to agree. The category that reaches the highest degree of agreement is that of inadequate consultations. These referrals correspond to younger patients, from urban setting. They are accompanied by consultation request sheets having worse quality and generate fewer reviews. CONCLUSIONS. The hospital out-patient visits are hindered by a very high number of inadequate or unnecessary specialized care consultations, to which patients are sent with characteristics different from those sent with consultations that are considered to be adequate

[Health status of the oldest old: functional and medical situation in centenarians]. / Estado de salud de los muy ancianos: situación clínica y funcional de la población centenaria.

OBJECTIVE: We planned a prospective and descriptive analysis of the centenarian population in Lugo sanitary area, establishing their social, functional and medical status as well as its relationship with their basic hematological and biochemical parameters. MATERIAL AND METHODS: During the study period between January 2001 and September 2003, participants were visited at home by a doctor and a nurse. The following variables were assessed: social status, past medical history, physical examination, functional status (Barthel index), blood analysis. RESULTS: 54 centenarians were interviewed, 16 men and 38 women. 75.9% were widows; 87% lived with their family and 57,4% in urban areas. 79.6% had followed studies. All of them had their own incomes. Regarding past medical history, 64.8% had some visual or auditive disturbances, 81.5% were taking medical drugs, 59.3% had some surgical intervention and 46.3% had been hospitalized for medical reasons. Their vaccination status was poor. Functional status, assessed by Barthel index, showed an average of 59 +/- 36.4, higher in men (82.7 +/- 28.7) than in women (49.6 +/- 35.1) (p<0.003). Blood samples were analyzed in 51 cases, there were not significant differences among them regarding sex or physical disability. CONCLUSION: The features of the centenarian population of Lugo are similar to other countries. It is an heterogeneous group. There are more women, but their clinical and functional status are significantly worse than in males. We have not founded a relationship between hematological and nutritional parameters and the degree of functional dependence in centenarians.

[The internist's role in the medical evaluation of surgical patients]. / Papel del internista como consultor de servicios quirúrgicos.

OBJECTIVE: To describe the characteristics of the consultations carried out by surgical services to an Internal Medicine service and to determine what factors influence the prognosis of these patients. METHODS: A prospective study of the consultations carried out by the surgical services of a 540-bed hospital to an Internal Medicine service. Analyzed variables were: age, sex, service of reference, reason for consultation, medical and admission diagnoses done during the admission, and clinical evolution. RESULTS: In the study 453 interconsultations were included, corresponding to 0.96 new interconsultations by working day and to 4.05 interconsultations per every 100 admissions in surgical services during the period study. The reasons for the more common consultations were dyspnea, fever, electrolytic and metabolic disorders, assessment of multiple conditions and acute confusional syndrome. Two or more diagnoses were carried out in 257 patients (56.7%). The average number of visits carried out by patient was 3.9 +/- 3.9. The average hospital stay in the study group was 28 +/- 33.05 days, while the average hospital stay of patients admitted in the surgical services during the same period was 11.6 days. Fifty patients (11%) had died at the time of the "medical discharge", and this percentage amounted to 20.5% (93 cases) upon considering the end of the hospital admission, compared with the global mortality of 3.7% registered during that period in the surgical services. The number of medical diagnoses and the age were independent predictors of mortality in the multivariate analysis. CONCLUSIONS: The interconsultations of the surgical services to an Internal Medicine service imply an important workload. The patients are complex from the medical standpoint. The average hospital stay and mortality of these patients are different from that of the patients cared in surgical services.

[Advanced gastric cancer: characteristics at presentation and therapeutic possibilities].

OBJECTIVE: To analyse the presentation forms and prognosis of patients with advanced gastric cancer at the time of diagnosis. DESIGN: Retrospective cohort study. PATIENTS AND METHODS: We studied all patients with gastric cancer (n=2,334) and synchronic metastases diagnosed in Lugo and A Coruña hospitals between 1975 and 1993. We estimated survival probability using the Kaplan-Meier method, and prognostic factors with Cox's regression models. RESULTS: Metastases were detected at the time of diagnosis in 585 (25.1%) patients, with the liver (346; 14.8%) and peritoneum (61; 6.9%) being the most frequently involved sites. The liver was exclusively affected in 213 (9.1%) cases, the peritoneum in 70 (3.3%), and another intraabdominal site in 121 (5.2%). Patients with peritoneal metastases were older (p=0.05), more commonly had a diffuse type of cancer according to Lauren's tumor classification (p<0.001), and underwent surgery more frequently (p=0.01). Curative resection was possible for only 11 (5.2%), 7 (10%), and 25 (20.7%) patients with metastases in only the liver, peritoneum, or another site, respectively, but in all cases survival probability was significantly enhanced. No surgery (HR=2.92), and simultaneous involvement of the liver and peritoneum (HR=1.62) were factors associated with a higher mortality rate. CONCLUSIONS: Patients with gastric cancer and metastases in only one intraabdominal organ show characteristic forms of presentation. Furthermore, in all cases candidacy for surgery should be carefully evaluated, as prognosis may improve in selected patients.

[Centenarian patients attended at a general hospital]. / Pacientes centenarios atendidos en un hospital general.

BACKGROUND: To report the social and medical situation of centenarian patients who required emergency hospital care during the last 8 years. METHOD: Retrospective study of patients aged over 100 years attended at the Emergency Department of a general hospital. The percentages of admissions and mortality rates were then compared with those among patients aged over 65. RESULTS: A total of 51 consultations from 41 patients were recorded, with a mean age of 101.2 years. The number of consultations increased gradually with time (p = 0.008). Ninety-three percent of patients lived with their families, predominantly in the rural setting. The most prevalent conditions included the prostatic syndrome (among males), heart failure and chronic obstruction to the airflow. Only 20% of patients had dementia. Sixty-four percent of consultations required hospital admission, with a mortality rate of 20.5% in this group of patients. The most common discharge diagnoses were heart failure and acute cerebrovascular accident. CONCLUSIONS: A gradual increase in hospital care is likely to be excepted among centenarians, who have an acceptable health status, although with a high risk of mortality during hospital admission.

[Survival and prognostic factors for gastric cancer. Analysis of 2,334 patients]. / Supervivencia en 2.334 pacientes con cáncer gástrico y factores que modifican el pronóstico.

BACKGROUND: The analysis of the survival of patients diagnosed with gastricadenocarcinoma and the factors which modify prognosis. PATIENTS AND METHOD: Retrospective cohort study of overall patients diagnosed with gastric adenocarcinoma treated in the Xeral-Calde and Juan Canelejo hospitals of Lugo and La Coruña (Spain) between 1975 and 1993. The following variables were studied: age, sex, the year of diagnosis, place of residence, delayed diagnosis, localisation of the primitive tumour, the TNM classification, the Laurén histological type and the type of surgical resection when conducted. The Kaplan-Meier statistical method was employed to determine the probability of survival. Cox regression was used to determine prognosis factors. RESULTS: The diagnosis was established on 2,334 patients: 63,2% were males;the average overall age was 66.5 (11,9 SD) years, the median delayed diagnostic was 3,19 months, the lower third was the most common localisation (46,3%), 30,2% of the cases were diagnosed in the IV stage, and curative surgery was conducted in 46,4% of the cases. The probability of survival for overall numbers was 26% and curative surgery, was conducted in 45% of cases. The most advanced states in the TNM classification and the absence of curative surgery were factors associated with the poorest prognosis. CONCLUSIONS: Survival after gastric cancer is low. Initial stage and radical surgical treatment are the main factors for prognosis.

[Pyogenic liver abscess: changes in etiology, diagnosis and treatment over 18 years]. / Absceso hepático piógeno: cambios en la etiología, diagnóstico y tratamiento a lo largo de 18 años.

BACKGROUND: There are no detailed studies in our country on the impact of modern imaging techniques on diagnosis, treatment and prognosis of pyogenic liver abscesses. MATERIAL AND METHODS: All patients with the diagnosis of PLA from 1981 to 1998 were included in the study. The study was divided in two periods: 1981 to 1989 and 1990 to 1998. RESULTS: Compared with the first time period, the following was observed from 1990 to 1998: the mean age was higher (52 versus 65 years, p = 0.006), infections with identified source increased (33% versus 74%, p = 0.003), diagnosis was earlier (13 versus 3 days, p = 0.0002), modern imaging techniques were used more frequently (17% versus 96%, p = 0.002), the proportion of recovered microorganisms increased (53% versus 88%, p = 0.002), as well as use of percutaneous drainage (0% versus 37%, p = 0.002) and the prognosis was better (mortality rate 40% versus 10%, p = 0.01). CONCLUSIONS: Relevant changes were observed among patients in our hospital in the nineties regarding epidemiology, management and prognosis of PLAs. Part of these changes are due to a higher use of new imaging techniques.

[Bacteremia in the elderly. Clinical features and prognostic factors]. / Bacteriemia en ancianos. Aspectos clínicos y factores pronósticos.

BACKGROUND: The analysis of the most relevant characteristics and prognostic factors in elderly patients with bacteremia. PATIENTS AND METHODS: For the period 1989-1993 a prospective study of all significant bacteremias in adult patients admitted to a General Hospital was performed. Patients were visited until their death or during at least 50 days. The most relevant findings in elderly patients (over 65 years old) are described. Overall survival probabilities were obtained by Kaplan-Merner analysis. Cox proportional models were used to examine hazards of dying. RESULTS: Of the 1,128 bacteremias studied, 603 (53.9%) were in elderly patients. In this group, the increasing age was related with higher frequency of urinary (p = 0.02) and biliary (p = 0.001) sources of infection and lower frequency of underlying neoplasia (p = 0.06), immunosuppression (p = 0.0000) and development of septic shock (p = 0.02). These differences are higher in patients over 85. Among older patients the survival probability in the day 21 after diagnosis was 0.71 (95% CI 0.66-0.74), significantly lower to the probability in younger patients (p = 0.0001). In the elderly patients, the worse prognestic was associated to shock (RR = 8; 95% CI 5.8-11), indeterminated source of infection (RR = 3.6; 95% CI 2.2-5.8), underlying neoplasia (RR = 1.7; 95% CI 1.3-2.4), neutropania (RR = 1.5; 95% CI 1.1-2.1) nosocomial acquisition (RR = 1.3; 95% CI 1.0-3.1) and inappropriate treatment (RR = 1.2; 95% CI 1.0-3.2), but age was not an independent contributor. CONCLUSIONS: We found differences between the clinical characteristics and the prognosis of bactermia in elderly and younger patients. Among elder patients, those over 85 years old constitute a particular group with well defined characteristics.

[Wallenberg syndrome: a review of 25 cases]. / Síndrome de Wallenberg: revisión de 25 casos.

INTRODUCTION: Wallenberg's syndrome is one of the most common clinically recognized conditions due to brain stem infarct, which can nowadays be identified thanks to modern neuro-imaging techniques. We present a retrospective study of 25 cases admitted to our hospital in the past eight years, to evaluate epidemiological aspects and clinical findings and to correlate these with magnetic resonance topography. MATERIAL AND METHODS: Patients diagnosed in the Neurology Section of Hospital Xeral-Calde in Lugo between January 1989 and December 1997 as having Wallenberg's syndrome. RESULTS: There was a predominance of middle aged men presenting at 55.06 years of age (range 30- 78). Arterial hypertension was the main risk factor (52%). There was a progressive form of onset in most cases. The commonest symptom was dysphonia followed by dysphagia. The commonest finding on physical examination was ataxic gait (24 patients) MR was positive in 22 of the 23 cases in which this was done. There were different clinical findings depending on the site of the lesion, whether rostral, caudal or medial. This is considered in the discussion. In most cases the prognosis was good. The commonest sequel was ataxia. CONCLUSIONS: The results are similar to those in the literature. We emphasize the excellent correlation of clinical data and neuroimaging findings.