Have the Government's prescription algorithm and the 2013 American College of Cardiology/American Heart Association guidelines for managing dyslipidaemia influenced the management of dyslipidaemia? The MEJORALO-CV Project. / ¿Han influido el algoritmo de prescripción de la Administración y las guías de manejo de la dislipemia de la ACC/AHA 2013 en el manejo de la dislipemia? Proyecto MEJORA-LO CV.

OBJECTIVE: To determine the management of dyslipidaemia in primary care after the publication of the American College of Cardiology/American Heart Association (ACC/AHA) 2013 guidelines and Valencian government's algorithm. METHOD: We conducted a cross-sectional descriptive study that employed a survey of primary care physicians of the Community of Valencia between January and October 2016. RESULTS: A total of 199 physicians (mean age, 48.9±11.0 years; experience, 21.3±11.1 years) participated in the survey. The most followed guidelines were those of the European Society of Cardiology (37.5% of respondents) and Valencian government (23.4% of respondents). Some 6.3% of the respondents followed the 2013 ACC/AHA guidelines, and 88.0% established objectives based on LDL cholesterol and cardiovascular risk. The choice of lipid-lowering drug was based on its LDL cholesterol lowering capacity (28.6% of respondents), on the Valencian government's algorithm (23.4%) and on the drug's safety (20.4%). Statins, ezetimibe and fibrates were the preferred hypolipemiant agents, and their combination (51% of respondents) and dosage increases (35%) were the strategies employed for poor control. Lipid profile and transaminase and creatine kinase levels were measured every 6 (59.5%, 52.3% and 54.3% of respondents, respectively) or 12 months (25.1%, 29.2% and 30.3%, respectively). Forty-one percent of the respondents were aware of the controversy surrounding the 2013 ACC/AHA guidelines. Although 60% of the respondents acknowledged its relevance, only 21% changed their daily practices accordingly. CONCLUSIONS: The Valencian government's algorithm had a greater impact than the 2013 ACC/AHA guidelines in primary care in Valencia. Areas for improvement included the low use of validated guidelines and risk tables and the streamlining of laboratory test periodicity.

[Provision of continuous health care by a unit connected to primary care centres coordinated by specialist physicians]. / Aportación al continuo asistencial de una consulta de conexión con atención primaria coordinada con internistas.

OBJECTIVE: To evaluate the efficacy and efficiency of a system set up to overcome the current disparity between primary and specialist health care and with the capacity to detect patients with significant diseases. MATERIAL AND METHODS: To describe the activity of the Unit for Connection with Primary Care Centres (UCPCC) in the Alcoy Health Area (Alicante) during its first year. RESULTS: A total of 450 visits were made, with 6.5 (95% CI 5.7-7.3) first visits, and 3.9 (95% CI 3.1-4.8) successive ones per day. There were more than 50 reasons for consultation, and more than 60 final diagnoses (65.6% non-significant, 14% undefined and 12.4% significant). Digestive (31%) and functional (14.4%) diseases were the most frequently defined diagnoses, with neoplasic and autoimmune diseases among those defined as significant ones. The great majority (86.9%) of patients required 1-2 visits, with 40% diagnosed by just reviewing the hospital files. More than 20 different complementary examinations were performed, with 38.8%, 34.4%, 21.6%, and 5.2% of patients requiring 0, 1, 2, or ≥ 3, respectively. Patients with a significant pathology were diagnosed more quickly (12.4 ± 19.4 vs. 45.3 ± 52.8 days; P = .001), with less complementary examinations (0,5 ± 0,7 vs. 0,9 ± 0,9 per patient; P = .032. 58.6% vs. 39.6% patients without complementary examinations; P = .052), and were more frequently referred to specialised medicine (58.6% vs. 18.3%, P < .0001). CONCLUSIONS: The demonstrated differential management of patients with potentially significant pathology using existing resources, make the UCPCC with internists an efficient model for the connection between health care levels.

[Legionnaire's disease with predominant liver involvement]. / Enfermedad del legionario con afectación hepática predominante.

Like other pneumonias due to atypical agents, pneumonia due to Legionela Pneumophila has no characteristic clinical facts, although fever and non-productive cough are almost constant and diarrhea with changes in mental status are common. Hyponatremia and moderate transient hypertransaminasemia are common too. Severe systemic affectation after hematogenous dissemination similar to those described with typical bacterial pneumonias is a prominent difference with other atypical agents, with high mortality rates in the absence of appropriate treatment. Etiological diagnosis is very difficult and it is normally achieved late in the course of the infection. Because of diagnostic difficulties and potential mortality in predisposed patients, empirical antibiotherapy has been extensively recommended. We present a patient affected by critical community-acquired pneumonia due to Legionela Pneumophila serogroup 1 with liver alteration as the main manifestation and good response to empirical antibiotherapy with claritromycine and rifampin. We recommended the empirical use of such therapy in those pneumonias without microbiological diagnosis and torpid evolution.

[Sister Mary Joseph's nodule. Its clinical significance and management]. / Nódulo de la Hermana María (José). Significado y manejo clínico.

The eponym Sister (Mary) Joseph's nodule is referred to the existence of umbilical metastasis. Historically it has been considered a sign of ominous vital prognosis and therapeutic abstention. The analysis of 407 cases published at the medical literature (MEDLINE 1966-1997) is against this idea, because recent series have showed survivals longer than a year after treatment. On the other hand 60% of umbilical nodules are benign. Nowadays this sign must be considered as an early indicator of inner neoplasms, mainly from the abdominal cavity (52% digestive origin, 28% gynecologic origin), and in 40% of cases they are the only expression of relapse of previously known neoplasms. When a umbilical nodule is found it is necessary to make an accurate histologic differential diagnosis between a primary (benign or neoplastic) and metastatic lesions. Fine needle aspiration has demonstrated to be an easy and reliable method for diagnosis. Once the metastatic origin of the nodule is confirmed treatment with curative intention must be tried.