Is time to search the Wells Score 4.0? / ¿Ha llegado el momento de buscar la escala de Wells 4.0?

BACKGROUND: Wells score for deep vein thrombosis presents problems for implementation in the hospital emergencies, mainly due to the complexity of its enforcement. OBJECTIVE: To assess whether the inclusion of D-dimer as a predictor might lead to a simplification of this clinical decision rule. PATIENTS AND METHODS: A database of deep vein thrombosis patients was studied by logistic regression model in which the 10 predictors in the Wells score and the dimer D were included. The diagnosis was made with compression ultrasonography with Doppler signal. D-dimer was determined by a quantitative method of latex, a technique immunofiltration or a turbidimetric technique. RESULTS: 577 patients (54.1% women) were studied, with a mean age of 66.7 (14.2) years. 25.1% were diagnosed with deep vein thrombosis. Only four variables were independent, building a weighted model with greater predictive ability (area under the curve) than the original model (0.844 vs. 0.751, p<0.001). Both models showed an acceptable safety, with a similar rate of failure (0.8% vs. 1%). The simplified model allowed to select a higher percentage of patients who could have benefited from the non performance of the imaging test (20.6% vs. 15.8%, p=0.039). CONCLUSIONS: The introduction of D-dimer in a regression model simplifies the Wells score and maintain the same efficacy and safety, which could improve its implementation in the hospital emergencies.

[Referrals to a gastroenterology outpatient clinic: differences according to patients' geographical origin]. / Derivaciones a consultas de aparato digestivo: diferencias en función del medio geográfico de procedencia.

INTRODUCTION: The characteristics of users of the Spanish public health system have been evaluated in multiple studies. However, these studies usually refer to users of primary care and emergency services and less frequently to users of specialized services. Some studies have described differences according to patients' geographical origin. OBJECTIVE: To analyze the demographic profile of patients attending our gastroenterology outpatient clinic over a prolonged period. PATIENTS AND METHOD: The geographical origin, age and sex of all patients referred for an initial consultation in the gastroenterology outpatient clinic from 2001-2003 were analyzed. RESULTS: Women accounted for 53.7% of all appointments but no significant differences in referral rates were observed in comparison with men. A total of 65.5% of patients were from urban areas and the referral rate was significantly higher in these patients than in those from rural areas, although attendance rates were equal between patients from the two types of area. Referral rates increased in direct proportion with age; a predominance of referrals was observed in women aged < 74 years and in men aged 75 years or older. Some discrepancies were found among the distinct years analyzed. CONCLUSIONS: In our catchment area, demand is greater in the urban population than in the rural population. No overall differences were found in sex but significant differences were found in age and length of follow-up.

[Impact of automatized systems in a high resolution model of outpatients clinics]. / Impacto de los sistemas automatizados en un modelo de consulta de alta resolución.

OBJECTIVE: To analyse the impact of computerised systems in Radiology and Laboratory Departments on the reduction in the waiting time of the patients attending to an Internal Medicine outpatient consultation organised in a high resolution model. METHODS: For one year, we studied the delay in diagnostic explorations (laboratory test, simple radiology, ultrasonic diagnostics and brain scanner) that were all applied for and performed in a single day. We compared the traditional organization (n = 312 explorations), in which the results were handed in by hospital auxiliary staff, to a computerised method (n = 457 explorations), which was implemented via our intranet. RESULTS: The global delay decreased 10% in average, the differences being significant only for the variables "brain scanner" (12.7%) and "laboratory" (19%). The average reduction in the waiting time per patient was 11.7%, ranging from 7.8% (when only one exploration was performed) to 13.2% (when 2 explorations were carried out). The percentage of patients who needed to wait more than 3 hours to receive their results also diminished significantly. CONCLUSION: The implementation of computerised systems reduced the waiting time to receive the results of complementary explorations. However, our results were not homogeneous for the different explorations.

[Do women demand to be assisted at medical clinics more often than men?]. / Solicitan las mujeres más consultas al área médica que los hombres?

BACKGROUND: Different features of the users of the Spanish Public Health System have been previously assessed, specially in General Practice and Hospital Emergency Departments. Nevertheless, the epidemiological characteristics of those patients who attend to specialised clinics have not been so thoroughly evaluated. PATIENTS AND METHODS: The referee of the demand, the place of residence, the age and the sex of patients were all analysed for the ,first visits, at the Medical Department clinics (Internal Medicine, Cardiology, Gastroenterology, Pneumology) in our hospital, during 2002. RESULTS: A total of 7,486 demands for attention (53.3% were women) were asked for by 5,841 patients (52.8%) were women. When analysing the variable, place of residence, we find women asked for more frequently than men, in the categories of General Practice Department and age less than 60 years. Those patients coming from urban areas were more in percentage than those coming from rural areas. Whereas the, index of frequency, was higher in women than in men, however, there were no differences between urban and rural areas. CONCLUSION: In our targeted population we have observed a higher demand for medical clinics in women, though the actual demand will depend on factors such as age, place of residence and the referee.

Duodenal compression caused by superior mesenteric artery: study of 10 patients.

BACKGROUND: the compression of the third portion of the duodenum by the superior mesenteric artery (aorto-mesenteric clamp) is a rare cause of abdominal pain. Its clinical appearance may range between an asymptomatic and accidental radiological finding and an acute duodenal ileus (superior mesenteric artery syndrome), which requires urgent surgical intervention. METHODS: we revised all of the reports of upper gastrointestinal tract contrast-medium study (which included the duodenum) made in our hospital between May 1999 and April 2002. We analysed the case history of those patients with a radiological image compatible with aorto-mesenteric clamp. RESULTS: of the 1280 studies analysed, 10 of them (0,78%) were compatible with an aorto-mesenteric clamp. The 10 patients were females whose mean age was 25,7 years (range 9-77) that consulted for different abdominal discomfort. The symptoms of the 9 youngest patients were not typical of duodenal obstruction and their evolution was favourable. In the eldest patient, the clinical data were compatible with a mesenteric superior artery syndrome, although a subsequent study showed the presence of a colon adenocarcinoma. CONCLUSIONS: the aorto-mesenteric clamp is a rare radiological finding (<1 %) which does not always justify the supported clinical data. In our series, 9 cases were considered non-obstructive aorto-mesenteric clamps, although some of them showed pathogenical factors (scoliosis and thinness). The superior mesenteric artery syndrome should be considered as a diagnosis of exclusion after performing an adequate clinical study when the situation of the patient requires it.

[Macro creatine kinase type 1 as a cause of increase of CF-MB isoenzyme. Apropos of 7 cases]. / Macrocreatincinasa tipo 1 como causa de aumento de la isoenzima CK-MB. A propósito de 7 casos.

INTRODUCTION: The macro-creatine kinase type 1 is a complex of IgG linked to the BB fraction of the creatine kinase enzyme. Its presence in serum interferes with the immunoinhibition methods normally used in emergency room laboratories that produce false elevations of the creatine kinase MB isoenzyme, and which may cause a misunderstanding in the evaluation of patients who are suspected of having ischemic cardiopathy. PATIENTS AND METHOD: We have studied seven patients using an immunoinhibition method. They showed high levels of creatine kinase MB isoenzyme with normal values of creatine kinase enzyme. Electrophoresis was performed on all patients to determine the presence of creatine kinase enzyme. RESULTS: The electrophoresis showed in all the cases the presence of a macro-creatine kinase type 1 responsible for this interference. The clinical and analytical evaluation, as well as the radiological and electrocardiographical evaluation of this patients did not show any acute coronary disease. CONCLUSIONS: The macro-creatine kinase type 1 has been related to the existence of underlying cardiovascular pathology; a fact that was confirmed in three patients. With the immunoinhibition methods, the macro-creatine kinases usually, occurs with high values of creatine kinase MB isoenzyme (normally above 50% of the total activity of the creatine kinase) with normal creatine kinase levels. This fact, although strongly suggesting its presence, creates the necessity of using more sensitive methods to prevent these interferences. Likewise, we recommend using the electrophoresis of the creatine kinase enzyme to determine the nature of these interferences.