E-consults between primary care and internal medicine: implementation, accessibility, benefits, and implications.

AIM: This work aims to evaluate whether electronic consultations (e-consults) are a clinically useful, safe tool for assessing patients between primary care and internal medicine. METHODS: This is a retrospective cohort study of all e-consults ordered by the Primary Care Department to the Internal Medicine Department between September 2019 and December 2023. The results of initial consultations, emergency department visits and subsequent admissions, and survival were assessed and complaints and claims filed were reviewed. RESULTS: A total of 11,434 e-consults were recorded (55.4% women) with a mean age of 62.1 (SD19.4) years and a wide range (15-102 years). The mean response time was 2.55 (SD 1.6) days. As a result of the e-consults, 5645 patients (49.4%) were given an in-person appointment. For the remaining 5789 (50.6%), a written response was provided. Among those given appointments, the time between the response and in-person appointment was less than five days (95% of cases). Compared to those not given appointments, in-person appointments were older (p < 0.0001), visited the emergency department more times (one month: p = 0.04; three months: p = 0.001), were admitted to the hospital more times (one month: p = 0.0001; three months: p = 0.0001), and had higher mortality at one year (12.7% vs. 9.8% p = 0.0001). In the Cox analysis, only in-person appointments (RR = 1.11; p = 0.04)) and age (RR = 1.09; p < 0.01) were independent factors of mortality. No complaints or claims of any kind were registered. CONCLUSIONS: These data suggest that e-consults are a clinically useful, safe tool for assessing patients referred from primary care to internal medicine departments.

Circadian variability of blood pressure in liver transplant recipients without antihypertensive therapy.

Hypertension is a frequent cardiovascular risk factor in liver transplant recipients. The usefulness of ambulatory blood pressure monitoring (ABPM) in these patients is unknown. This study was aimed at evaluating the circadian rhythms of blood pressure in liver allograft recipients. In 53 liver transplant patients blood pressure was measured with the Spacelabs device program. No patient received antihypertensive therapy for at least 15 days beforehand. Clinical blood pressure measurement showed 26 patients to be hypertensive. Of these, ABPM verified the diagnosis in 23. Overall, 72% of the patients were hypertensive, and 39.5% showed a nondipper pattern. Diastolic hypertension was more frequent than systolic hypertension. No differences were found in renal function, immunosuppressive therapy, or corticosteroids.

Prevalence of liver disease in patients with Streptococcus bovis bacteraemia.

BACKGROUND: The relationship between Streptococcus bovis bacteraemia and gastrointestinal disease (mainly colon cancer) is well known. Patients with advanced liver disease are prone to bacteraemia. Less attention has been paid to the association between liver disease and Streptococcus bovis bacteraemia in the literature. AIMS: To evaluate the prevalence of liver disease in patients with S. bovis bacteraemia. PATIENTS AND METHODS: Twenty-two episodes of S. bovis bacteraemia in 20 adults (13 males and seven females, with a median age of 61 years, range 32-94 years) were detected in a single hospital over a 7-year period. Ten of them had endocarditis. Patients' clinical records were reviewed, with special focus on underlying liver and gastrointestinal disease. RESULTS: Eleven patients (55%) had a chronic liver disease. Nine of them were cirrhotics. Ten patients had a history of chronic alcohol abuse, and four patients had hepatitis C virus antibodies (associated with alcohol abuse in three cases). Large bowel disease was present in six out of 13 evaluable patients (adenocarcinoma in three cases). Patients with liver disease were younger than patients without it. Mortality related to S. bovis bacteraemia was particularly high among patients with advanced liver disease (Child-Pugh state C). Bacteraemia recurred two times in one alcoholic cirrhotic, who was diagnosed as having a Dukes-B colon cancer 4.5 years after the first episode of S. bovis bacteraemia. CONCLUSIONS: In our area, S. bovis bacteraemia is frequently associated with chronic liver disease. Liver disease may be a predisposing factor for S. bovis bacteraemia.

[Bacteremia and endocarditis caused by Streptococcus bovis in patients with alcoholic hepatopathy without evidence of colonic pathology]. / Bacteriemia y endocarditis por Streptococcus bovis en pacientes con hepatopatía alcohólica sin evidencia de patología colónica.

The association of Streptococcus bovis bacteremia and endocarditis with colonic pathology, mainly neoplastic, is well known. Its relationship with liver disease without evidence of gastrointestinal disease has been rarely described. To analyze the association between S. bovis infection and liver disease, positive blood cultures for this microorganism in hospitalized patients in the Internal Medicine and Gastroenterology Departments from December 1993 until October 1995, have been reviewed. Three cases of S. bovis infection (one bacteremia, two endocarditis) were found. Alcoholic liver disease was diagnosed in all three patients, with associated hepatitis C virus in one of them. Colonic pathology was excluded by colonoscopy and/or barium enema. Other gastrointestinal disorders were excluded by means of gastroscopy, barium gastrointestinal study and abdominal ultrasonography. Antibiotic therapy was based in betalactamics, with associated aminoglycoside in two cases. One patient needed aortic and mitral valve replacement and another one needed orthotopic liver transplantation. No new gastrointestinal pathology emerged in the follow-up (5-23 months). Cases of S. bovis bacteremia and endocarditis should be screened not also for colonic pathology, but also for liver disease, particularly in alcoholics.

[Upper digestive tract findings in elderly patients with iron-deficiency anemia. A comparison between users and non-users of non-steroidal anti-inflammatory drugs]. / Patología digestiva alta en pacientes de edad avanzada con anemia ferropénica: comparación entre usuarios y no usuarios de anti-inflamatorios no esteroideos.

BACKGROUND: Iron-deficiency anemia is common in the elderly. Chronic upper gastrointestinal bleeding is its most frequent cause. The use of non-steroidal antinflammatory drugs (NSAID) is common in older people. Gastrointestinal complications of NSAID may be also more frequent among the elderly. AIMS: The study was aimed to evaluate if a history of regular NSAID use in elderly patients with iron-deficiency anemia is associated to characteristic findings on esophagogastroduodenoscopy. MATERIALS AND METHODS: A total of 91 patients (40% of males and 60% females) older than 65 years (mean age 77 years, range 65-90 years) entered the study. All of them had been admitted to our Hospital for study of iron-deficiency anemia. Thirty-eight patients were regular users of NSAID. Esophagogastroduodenoscopy was performed in all patients. RESULTS: The prevalences of peptic ulcer, erosive gastritis/duodenitis, and esophagitis were similar in NSAID users and non-users (13 vs 11%, 18 vs 15%, and 26 vs 26%, respectively). A trend to a higher prevalence of gastric adenocarcinoma was observed the group of NSAID non-users (8% vs 23%, p = 0.05). Esophagogastroduodenoscopy was entirely normal in 39% of NSAID users and 34% of NSAID non-users. CONCLUSIONS: Upper gastrointestinal lesions in elderly patients with iron-deficiency anemia are similar in NSAID users and non-users, with the exception of gastric adenocarcinoma which can be more common in NSAID non-users.

[Cocaine related fulminant liver failure]. / Fallo hepático fulminante asociado al uso de cocaína.

A 23-year-old woman developed biochemical signs of acute severe hepatitis together with confusion and flapping tremor after snorting a large dose of cocaine. Blood levels of cocaine were very high and liver biopsy performed few days later showed centrilobular necrosis. She recovered completely with conservative measures. Cocaine toxicity should be considered in similar cases of fulminant liver failure.

Linfoma no Hodgkin que se manifiesta como neoplasia colónica / No Hodking lymphoma that mistakes with a colonic neoplasm

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Absceso pulmonar y piomiositis pectoral por Staphylococcus aureus / Lung abscess and pectoral pyomiositis by Staphylococcus aureus

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Metástasis endobronquial por hipernefroma / Endobronchial metastases by hypernephroma

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Ataxia cerebelosa aguda en un paciente adulto / Acute cerebellar ataxia in an adult

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