[Modification of specialised care prescriptions by Primary Healthcare physicians]. / Modificación de la prescripción procedente del segundo nivel de asistencia por parte del médico de Atención Primaria.

OBJECTIVE: To determine the percentage of new Specialist Healthcare prescriptions received and modified by Primary Healthcare physicians. DESIGN: Descriptive, cross-sectional and multi-centre study with the participation of Primary Healthcare physicians from one Madrid Health Area during 2 months. A method was established for registering the origin of the new prescriptions in the Computerised Medical Record System. In order to register new prescriptions without any change from Specialist Healthcare, the «second level¼ option was marked when the prescription was issued. A protocol was prepared and was available on the Computerized Medical Record System, so for those cases where there was a new Specialist Healthcare prescription, the Primary Healthcare physician would not issue any prescription or issue a prescription with changes as regards the original one. RESULTS: A total of 69 Primary Healthcare physicians from 15 Primary Healthcare centres registered 46,512 new prescriptions, 3,893 (8.4%) from Specialist Healthcare. From this number, 3,544 prescriptions (91.0% 95% CI: 90.1-91.9) were issued without changes, and 298 prescriptions were modified (7.7% 95% CI: 7.0-8.7). In 46 cases (1.2% 95% CI: 0.8-1.5) no prescription was issued. Some prescriptions were changed by 51% of Primary Healthcare physicians, and the median of prescriptions changed or not issued was 3. The main reason for the modification was replacement with generics. CONCLUSIONS: A high percentage of new Specialist Healthcare prescriptions are issued without any changes being made by Primary Healthcare physicians. Modifications are concentrated in half of the participating physicians. Therefore, these data suggest that this practice is not generally adopted by the professionals.

[Esmolol to control hemodynamic response during removal of a bilateral pheochromocytoma from a 10-year-old girl]. / Manejo hemodinámico intraoperatorio con esmolol durante la extirpación de un feocromocitoma bilateral en una paciente de 10 años.

Pheochromocytomas, which derive from chromaffin cells, can secrete catecholamines in large amounts. The incidence of these tumors is low at 2 to 8 cases per million population and only 10% of cases occur in children. A thorough understanding of the pathophysiology of these tumors and the consequent effect of drugs will be necessary for treating these patients during the perioperative period. A great deal has been published on drugs that can be used in this setting, but only a small portion of the information is relevant to children. Esmolol, a short-action beta-blocker, figures among the drugs that have been developed in recent years. We report a case in which esmolol was used during surgery in a 10-year-old girl undergoing scheduled removal of a bilateral pheochromocytoma.

[Air embolism during laparoscopic surgery in an infant girl with Cornelia de Lange syndrome]. / Embolia gaseosa durante cirugía laparoscópica en lactante con síndrome de Cornelia de Lange.

Cornelia de Lange syndrome involves multiple malformations with particular phenotypic features (craniofacial abnormalities such as microcephaly or hypertrichosis with synophrys; cutaneous abnormalities such as hirsutism, and limb anomalies) and it is associated with a high percentage of mental retardation and complications such as digestive tract abnormalities, cardiac defects, and endocrine disorders. We report the case of a 2-month-old infant girl who underwent a laparoscopic antireflux procedure, with closure of a diaphragmatic hernia and a gastric stoma. The medical history included repeated episodes of aspiration pneumonia and hypertension. Early in the procedure, 2 episodes of sudden desaturation, hypotension, and bradycardia with a probable diagnosis of air embolism. The complications resolved with specific treatment. Anesthetic management for laparoscopic surgery in these patients is truly complex and must be informed by a thorough understanding of the disease and complications that may develop.

[Opinions of health professionals on the impact of the Preventive Activities and Health Promotion Program (PAPPS)]. / Opiniones de los profesionales sanitarios sobre la influencia del Programa de Actividades Preventivas y de Promoción de la Salud (PAPPS) en atención primaria.

OBJECTIVE: To find out the opinion of Primary Health Care (PHC) professionals on the impact of the Preventive Activities and Health Promotion Program (PAPPS). DESIGN: Descriptive qualitative-quantitative study. In a first phase the SWOT technique was used. In a second phase a 47 item questionnaire was designed using an ordinal scale. PARTICIPANTS: Professionals of PAPPS health centre, PAPPS managers and PHC management, using the Autonomous Community, and the time of ascribing or knowledge of PAPPS as segmentation criteria. In the qualitative study 62 participants were selected by theoretical sampling. In the quantitative study, 198 professionals took part in the survey. PRINCIPAL MEASUREMENTS: The assessment of the results has taken into account the responses to the questions formulated and by performing a crossed analysis between strengths/threats and weaknesses/opportunities. A descriptive statistical analysis of the questions in the questionnaire. RESULTS: There is agreement in that PAPPS has greatly influenced the development of PHC, contributing to improving the quality of care, but it is also fundamental to try revitalise the programme, as the limited involvement by the professionals in the postulated preventive recommendations is its main weakness, due to lack of motivation and professional burn-out.. CONCLUSIONS: According to the participants PAPPS has contributed significantly to the development of PHC in our country and has had an influence on professional practice by instilling a prevention culture that hardly existed before.

[Relation between left ventricular hypertrophy and retinal vascular changes in mild hypertension]. / Relación entre la hipertrofia ventricular izquierda y la lesión vascular retiniana en la hipertensión arterial esencial ligera.

BACKGROUND: To evaluate the possible relation between left ventricular hypertrophy and vascular changes in retine, in patients with mild hypertension. PATIENTS AND METHODS: We established a group with 51 hypertensives (27 males and 24 females), with essential mild hypertension, which had never been treated. An ambulatory monitoring blood pressure, 24 hours electrocardiographic monitoring, echocardiography and funduscopy were realized to all of them. RESULTS: Fifty-five per cent of the hypertensives had retinopathy grades I-II. We established two subgroups with and without retinopathy. The age, systolic, diastolic and mean blood pressures, so as body mass index higher in the group with retinovascular damage. No significant differences were observed in the ecographic parameters between two subgroups except the interventricular septal thickness (10.5 +/- 2.1 min in the subgroup without vs 11.1 +/- 2.3 mm in the subgroup with retinovascular damage) (p < 0.05). As 24-hour maximum and mean systolic and diastolic blood pressure, daytime mean systolic blood pressure (SBP) and diastolic blood pressure (DBP), daytime and night-time DBP load, as daytime SBP load were higher in the hypertensive patients with retinovascular changes. There was echocardiographic left ventricular hypertrophy in 51% of the hypertensive patients, without differences between both subgroups of hypertensive patients. Body mass index (g/m) correlated significantly (p < 0.01) with the retinovascular damage. In the multivariant analysis, male as well as female, the funduscopy correlated with left ventricular mass index (g/m2). We established a discriminant function to separate hypertensives with and without left ventricular hypertrophy and another to separate hypertensives with and without retinopathy. Both functions included body mass index and maximum SBP, so as daytime SBP load and nighttime mean DBP to the left ventricular hypertrophy function. CONCLUSIONS: Left ventricular hypertrophy and retinovascular damage appear early in the course of blood pressure elevation and both changes develop in parallel. Our results indicate that there exists a relation between both cardiac and vascular changes in the hypertension. Body mass index and maximum SBP, appear to be important determinants of structural adaptation in mild hypertension.

[Different arterial pressure patterns during ambulatory monitoring in hypertensive patients of both sexes are not associated with different cardiovascular impact]. / Las diferencias en el comportamiento de la presión arterial durante la monitorización ambulatoria en hipertensos de ambos sexos no se asocian a diferente repercusión cardiovascular.

BACKGROUND: To establish if the differences between male and female hypertensives, with similar characteristics, are associated with different cardiovascular damage. PATIENTS AND METHODS: We compare a group of 27 mild hypertensive males with another one of 24 females with similar characteristics. A 24-hour ambulatory blood pressure monitoring, a 24-hour ECG holter, an echocardiography and eye funduscopy, were done to all the patients. RESULTS: The mean of 24 hour-systolic blood pressure (p < 0.01), the daytime and night-time systolic blood pressure load (p < 0.05), and the mean of systolic blood pressure daytime, were significantly are not higher in male than in female hypertensives. Neither echocardiographic differences nor frequency of arrhythmias were observed between both groups. 66.7% of the women had left ventricular hypertrophy vs 37% of the men, without significant difference. 40.7% of the male had rethynopathy I-II vs 50% of the female. Left ventricular mass index correlated with different parameters of the ambulatory monitoring in the multivariate analysis. Body mass index and daytime systolic blood pressure load classified correctly 89% of the male-group in with or without hypertensive rethynopathy. The body mass index, age and 24-hour maximal systolic blood pressure, classified correctly 87.5% of female hypertensives in with and without hypertensive rethynopathy. CONCLUSIONS: The differences in the ambulatory blood pressure monitoring between male and female mild hypertensive patients, were not associated with different cardiovascular damage. We emphasize the importance of the body mass index in the development of hypertensive rethynopathy in both sexes.

Clinical implications of white coat hypertension.

OBJECTIVE: To determine the clinical implications of mild white coat hypertension (WCH). SUBJECTS AND METHODS: We studied 102 subjects (54 men, 48 women), 51 of whom were normotensive and 51 slightly hypertensive. None had ever received antihypertensive therapy. An ambulatory blood pressure (ABP) record (Accutracker II), a 24-h electrocardiogram and an echocardiogram were obtained from each, and each was examined by funduscopy. WCH subjects were compared with sustained hypertension (SH) subjects and with normotensives. RESULTS: Fifty-three percent of the hypertensives qualified as WCH. The ultrasonographic characteristics and the ABP variables of the WCH group differed significantly from those of normotensives, but not from those of the SH group. The prevalence of left ventricilar hypertrophy (LVH) in the SH group (62.5%) did not differ significantly from its prevalence in the WCH group (40.7%), but the prevalence among normotensives (17.6%) was significantly lower than in either of the other two groups. The WCH and SH groups did not differ significantly as regards the prevalence of hypertensive retinopathy (33.3% in the former, 58.3% in the latter). For no non-LVH, non-retinopathic subject, whether normotensive or hypertensive, were more than 18% of daytime diastolic ABP measurements > or = 90 mmHg. Ultrasonographic findings were no better correlated with ABP than with in-clinic BP measurements. Fundus findings correlated well with in-clinic BP and with numerous ABP parameters. Retinopathy, with or without LVH, was efficiently predictable among hypertensives on the basis of body mass index and the 24-h maximum of systolic BP. CONCLUSIONS: Myocardiac remodelling and vascular retinopathy develop early and in parallel in hypertensives, and both developments appear to involve determinants including body mass index and 24-h maximum systolic BP. WCH subjects, as defined by current ABP-based criteria, have cardiac and retinovascular characteristics different to normotensive subjects. Stricter criteria are needed to discriminate between hypertensives with and without the systemic developments that constitute the immediate source of risk to the hypertensives individual.

[Myocardial structure and study of arrhythmias during ambulatory electrocardiographic monitoring in mild essential hypertension]. / Estructura miocárdica y estudio de las arritmias durante el registro electrocardiográfico ambulatorio en la hipertensión arterial esencial ligera.

BACKGROUND: The development of arrhythmias in patients with high blood pressure has been related to the presence of left ventricular hypertrophy. The aim of this study was to determine the presence and relationship between left ventricular hypertrophy and arrhythmias in patients with slight arterial hypertension. METHODS: One hundred and two individuals (54 males and 48 females), 51 of whom were hypertensive and 51 normotensive, were included in the study. None of the subjects had received antihypertensive treatment. Twenty-four hour electrocardiographic registry, echocardiogram and ambulatory blood pressure monitorization were performed. RESULTS: Fifty one percent of the hypertensive individuals had left ventricular hypertrophy (LVH) versus 18% of the normotensive subjects. Supraventricular and ventricular arrhythmias were equally frequent in the hypertensive and the normotensive subjects as were the episodes of ST depression (7.8% versus 9.8%, respectively). Both types of arrhythmias were correlated with the age of the hypertensive subject. Twenty-seven of the hypertensive subjects had white coat hypertension. The left ventricular mass in these subjects was similar to that of the hypertensive subjects with maintained hypertension and both were greater than the normotensive subjects. In regard to the frequency of LVH in the hypertensive subjects with maintained hypertension, 15 (62.5%) did not differ from either the LVH in white coat hypertensive subjects 11 (40.7%) or in regard to the frequency of supra and ventricular arrhythmias. On multivariate analysis both types of arrhythmias correlated with the index of ventricular mass in the hypertensive patients in both males and females. CONCLUSIONS: Left ventricular hypertrophy may develop early in hypertension although it is not related to a greater frequency of arrhythmias in patients with slight arterial hypertension.

[Immunotherapy using Giardia lamblia extract in recurrent chronic sensitized urticaria]. / Inmunoterapia con extracto de Giardia lamblia en la urticaria crónica recidivante sensibilizada.

A study of 100 patients with chronic urticaria by Giardia lamblia parasitic infection were reviewed. The urticaria had been resistant to antihistamine, corticosteroid and antiparasitic therapy. An urticaria evaluation included CBC, immunoglobulins M, G, A and E determinations, and stool examination, bile drainage and duodenal smear for ova and parasites. A prick test with Giardia's allergen 1, 10 and 100 UNP dilutions were realized. We found a 93% improvement in clinical symptoms using allergy immunotherapy with Giardia's antigen preparation associated to treatment.

[Immunologic behavior in 50 patients with acute anterior uveitis]. / Comportamiento inmunológico en 50 pacientes portadores de uveítis anterior aguda.

A prospective study that included 50 patients with acute anterior uveitis was done. The aim was to describe their immunological behavior. According to the results, patients with an allergic basis are predisposed and have more severe disease. However, immunoallergic tests are positives in patients with acute anterior uveitis where associated pathologies modify the tests, even if allergic etiology may or may not be possible. We recommend further studies in patients with allergic antecedents, in order to pay more attention to them.