Missed opportunities in early diagnosis of symptomatic colorectal cancer.

OBJECTIVE: delays in diagnosis of symptomatic colorectal cancer are a reality in our context. This study aims at identifying missed diagnostic opportunities, describing events, clinical clues and most common mistakes, and quantifying delays. MATERIAL AND METHODS: an observational descriptive study was performed in order to review all case histories. Two experts reviewed the case histories of all the patients from the 4th Catchment Area of Asturias diagnosed with colorectal cancer in 2009. All data were analysed using bivariate and multivariate logistic regression. RESULTS: full information on 119 patients out of 143 patients was collected. 34.45% had a clinical missed opportunity -confidence interval (CI) 95%: 30.92-39.68-. Outcomes show an average of 2.41 missed opportunities and 2.61 diagnostic clinical clues per patient. The number of patients with missed opportunities was significantly higher. The total amount of co-morbidities was higher in patients with missed opportunities (2.7). This was the main determinant. The main diagnostic key was iron-deficiency anaemia (46.3%). It produced the longest delay (300 days). Not having requested diagnostic tests was the most common mistake (43.3%). Having at least one missed opportunity entailed an average delay of 235.8 days between the first visit to the office and the referral to a consultant. CONCLUSIONS: in clinical practice, missed opportunities to start a diagnostic assessment in patients with presumptive diagnosis of colorectal cancer are common. The most significant clinical clue and the one generating the longest delay is iron-deficiency anaemia. The diagnostic delay is important and is caused mainly by not identifying symptoms.

Oportunidades perdidas en el diagnóstico temprano del cáncer colorrectal sintomático / Missed opportunities in early diagnosis of symptomatic colorectal cancer

Objetivo: los retrasos en el diagnóstico de cáncer colorrectal sintomático son una realidad en nuestro medio. Nos proponemos identificar los casos en los que hubo oportunidad perdida para el diagnóstico, describir las características de los episodios, las claves clínicas, los errores más comunes y cuantificar el retraso generado. Material y métodos: mediante un estudio observacional descriptivo, se procedió a la revisión de las historias clínicas por dos revisores de la totalidad de los pacientes diagnosticados de cáncer colorrectal en el 2009 del Área Sanitaria IV de Asturias. Se analizaron los datos a nivel bivariante y multivariante por regresión logística. Resultados: de 143 se obtuvo información completa de 119 pacientes. Un 34,45% presentó una oportunidad perdida clínica (IC 95%: 30,92-39,68). Hubo una media de 2,41 oportunidades perdidas y 2,61 claves diagnósticas por paciente. Los pacientes con oportunidades perdidas eran significativamente mayores; el número total de comorbilidades resultó ser mayor en los pacientes con oportunidad perdida (2,7) siendo este el factor determinante. La clave diagnóstica principal fue la anemia ferropénica (46,3%) y la que más retraso generó (300 días). El error más común fue la falta de petición de pruebas diagnósticas (43,3%). Tener al menos una oportunidad perdida supuso un retraso promedio de 235,8 días entre el primer encuentro médico-paciente y la derivación a un especialista. Conclusiones: las oportunidades perdidas para iniciar una evaluación diagnóstica en pacientes con sospecha de cáncer colorrectal son frecuentes en la práctica clínica. La clave clínica más relevante y que genera mayor retraso es la anemia ferropénica. El retraso diagnóstico es importante y es debido principalmente al no reconocimiento, o inacción, ante síntomas(AU)

Objective: delays in diagnosis of symptomatic colorectal cancer are a reality in our context. This study aims at identifying missed diagnostic opportunities, describing events, clinical clues and most common mistakes, and quantifying delays. Material and methods: an observational descriptive study was performed in order to review all case histories. Two experts reviewed the case histories of all the patients from the 4th Catchment Area of Asturias diagnosed with colorectal cancer in 2009. All data were analysed using bivariate and multivariate logistic regression. Results: full information on 119 patients out of 143 patients was collected. 34.45% had a clinical missed opportunity -confidence interval (CI) 95%: 30.92-39.68-. Outcomes show an average of 2.41 missed opportunities and 2.61 diagnostic clinical clues per patient. The number of patients with missed opportunities was significantly higher. The total amount of co-morbidities was higher in patients with missed opportunities (2.7). This was the main determinant. The main diagnostic key was iron-deficiency anaemia (46.3%). It produced the longest delay (300 days). Not having requested diagnostic tests was the most common mistake (43.3%). Having at least one missed opportunity entailed an average delay of 235.8 days between the first visit to the office and the referral to a consultant. Conclusions: in clinical practice, missed opportunities to start a diagnostic assessment in patients with presumptive diagnosis of colorectal cancer are common. The most significant clinical clue and the one generating the longest delay is iron-deficiency anaemia. The diagnostic delay is important and is caused mainly by not identifying symptoms(AU)

Asymptomatic hypertransaminasemia in patients in primary care.

INTRODUCTION AND OBJECTIVE: asymptomatic hypertransaminasemia (AH) is a common finding in clinical practice. We propose to determine the prevalence of AH in our environment, its epidemiology and its evolution. MATERIAL AND METHODS: we studied a random sample of 1,136 blood tests undertaken in 2006, excluding patients with known hepatic disease or symptoms or signs of liver disease, and following the evolution of the AHs until 2009. Data was analyzed using bivariate and multivariate logistic regression. RESULTS: the percentage of patients found with a AH was 15.24% (95% CI 13.52 to 16.96%). The rates of AST and ALT, were 6.93% (95% CI 5.71 to 8.15%) and 14.31% (95% CI 12.65 to 15.97%) respectively. The percentage of normalization of transaminase values in a second analytical control was a 31.81% (95% CI: 26.21 to 37.4%). An association was found between AH and BMI (OR: 1.129, 95% CI 1.062 to 1.199) and between the persistence of AH and GGT (OR: 1.011, 95% CI 1.003 to 1.018). Fundamental tests such as hepatitis serology or ultrasound were performed on only 50% of patients (with 32% of steatohepatitis). CONCLUSIONS: the prevalence found in our study of AH was relatively high (15.24%), being more frequently encountered in obese subjects. Nearly a third of the AHs is normalized in a subsequent blood test. The high GGT is associated with persistence of AH. There is great variability in terms of additional testing in patients with AH and the application of such tests is not protocol.

Hipertransaminasemia asintomática en Atención Primaria / Asymptomatic hypertransaminasemia in patients in Primary Care

Introducción y objetivo: la hipertransaminasemia asintomática (HA) es un hallazgo frecuente en la práctica clínica diaria. Nos proponemos conocer la prevalencia de HA en nuestro medio, sus características epidemiológicas y su evolución temporal. Material y métodos: estudiamos una muestra aleatoria de 1.136 analíticas de las realizadas en 2006, excluyendo pacientes con enfermedad hepática conocida o síntomas o signos de enfermedad hepática, y siguiendo evolutivamente las HA hasta el año 2009. Se analizaron los datos a nivel bivariante y multivariante por regresión logística. Resultados: el porcentaje hallado de pacientes con HA fue de un 15,24% (IC 95%: 13,52-16,96%). Los porcentajes de elevación de AST y ALT, fueron de un 6,93% (IC 95%: 5,71-8,15%) y un 14,31% (IC 95%: 12,65-15,97%), respectivamente. El porcentaje de normalización de los valores de transaminasas en un segundo control analítico fue de un 31,81% (IC 95%: 26,21-37,4%). Encontramos asociación entre la HA y el IMC (OR: 1,129; IC 95%: 1,062- 1,199) y entre la persistencia de HA y la GGT (OR: 1,011; IC 95%: 1,003-1,018). Pruebas fundamentales como serología de hepatitis o ecografía se realizaron sólo en un 50% de pacientes (con un 32% de esteatohepatitis). Conclusiones: la prevalencia hallada en nuestro estudio de HA fue relativamente elevada (15,24%), presentándose con mayor frecuencia en obesos. Casi un tercio se normalizan en una analítica posterior. La GGT elevada se asocia a persistencia de la HA. Existe gran variabilidad en cuanto a la realización de pruebas complementarias en los pacientes con HA, y la solicitud de dichas pruebas no está protocolizada(AU)

Introduction and objective: asymptomatic hypertransaminasemia (AH) is a common finding in clinical practice. We propose to determine the prevalence of AH in our environment, its epidemiology and its evolution. Material and methods: we studied a random sample of 1,136 blood tests undertaken in 2006, excluding patients with known hepatic disease or symptoms or signs of liver disease, and following the evolution of the AHs until 2009. Data was analyzed using bivariate and multivariate logistic regression. Results: the percentage of patients found with a AH was 15.24% (95% CI 13.52 to 16.96%). The rates of AST and ALT, were 6.93% (95% CI 5.71 to 8.15%) and 14.31% (95% CI 12.65 to 15.97%) respectively. The percentage of normalization of transaminase values in a second analytical control was a 31.81% (95% CI: 26.21 to 37.4%). An association was found between AH and BMI (OR: 1.129, 95% CI 1.062 to 1.199) and between the persistence of AH and GGT (OR: 1.011, 95% CI 1.003 to 1.018). Fundamental tests such as hepatitis serology or ultrasound were performed on only 50% of patients (with 32% of steatohepatitis). Conclusions: the prevalence found in our study of AH was relatively high (15.24%), being more frequently encountered in obese subjects. Nearly a third of the AHs is normalized in a subsequent blood test. The high GGT is associated with persistence of AH. There is great variability in terms of additional testing in patients with AH and the application of such tests is not protocol(AU)

Categorización de factores psicosociales asociados al cumplimiento farmacológico antihipertensivo / Categorization of psychosocial factors associated with adherence to antihypertensive drugs

Este estudio intenta categorizar los determinantes del cumplimiento farmacológico antihipertensivo en el modelo psicosocial A.S.E. (actitud, influencia social y autoeficacia). Es un estudio cualitativo, realizado mediante entrevista semiestructurada y grabada, con 44 pacientes (25 cumplidores y 19 incumplidores). Dos investigadores independientes realizaron un análisis temático de las respuestas, siguiendo el método de Burnand. El método se valió mediante el Índice de Kappa. La información de los pacientes sugiere que los programas educativos deberían resaltar las ventajas del tratamiento, enseñar las habilidades que mejoran la adherencia, prever las dificultades y efectos secundarios, y enseñar a soslayarlos o manejarlos. Dichos programas deberían ser impartidos por sanitarios convencidos de la eficacia del tratamiento, buenos comunicadores y dispuestos a compartir responsabilidad con el paciente y a integrar en el programa a las personas influyentes de su entorno próximo. La información obtenida es útil para la ecuación a medida y para el diseño de cuestionarios cuantitativos (AU)

This qualitative study tries to categorize the determinants of adherence to antihypertensive drugs in the A.S.E. model (attitude, social influence and self-efficacy). Data were obtained from the information of 44 patients (25 compliant and 19 noncompliant), by means of a semi-structured, recorded interview. Two independent investigators carried out a thematic analysis of the answers, following Burnard’s method. The method was validated using the Kappa Index. The information from the patients suggests that educational programs should emphasize the advantages of treatment, teach the skills that improve adherence, foresee the barriers and secondary effects, and teach avoiding or managing them. These programs should be developed by health workers convinced of the effectiveness of the treatment, who are good communicators and willing to share responsibility with patients and to integrate in the program significant people in their personal environment. The information obtained is useful for tailor made education and to elaborate quantitative questionnaires (AU)