Evolución de las derivaciones desde Atención Primaria a Urología tras la creación de un grupo de trabajo y la instauración de protocolos y cursos de formación continuada / Analysis of referrals after a synergic work between primary care and urology. Impact of joint protocol implementation and a continuing education program in our healthcare area

Objetivo: Analizar la evolución y adecuación de las derivaciones de Atención Primaria a Urología tras la implantación de protocolos sobre las enfermedades urológicas más frecuentes y la instauración de un programa de formación continuada. Material y métodos: En el 2011 se creó un grupo de trabajo Atención Primaria-Urología. Se instauraron inicialmente protocolos de actuación y práctica clínica en enfermedad prostática (HBP y PSA), que se apoyaron con sesiones formativas a los médicos de Atención Primaria. Tras analizar su efecto, en el 2015 se añadieron otros 3(enfermedad escrotal, infecciones urinarias e incontinencia urinaria). Analizamos y comparamos las derivaciones y su adecuación antes y después de la instauración. Resultados: El motivo más frecuente de derivación son los síntomas del tracto urinario inferior (STUI) por HBP que, inicialmente, suponían un 22,8% del total, y que han disminuido al 16,9%. Tras la introducción de los demás algoritmos, observamos una disminución de las derivaciones sobre enfermedad escrotal (del 13-14 al 7,8%), que permanecen estables (en torno al 10%) las relacionadas con infecciones urinarias y que aumentan las derivaciones por incontinencia urinaria (del 3 al 10,3%). La adecuación a los protocolos fue mejorando progresivamente en las relacionadas con STUI (del 46 al 65,3%); en PSA (del 55 al 84,4%) y en incontinencia urinaria (del 66,2 al 73,1%). Descendió la adecuación en cuanto a enfermedad escrotal (del 67,1 al 63,3%) y se mantuvo similar en ITU (en torno al 76%). Conclusiones: El trabajo conjunto entre Urología y Atención Primaria consigue mejorar la adecuación de las derivaciones en las enfermedades urológicas más frecuentes

Objective: To analyse the evolution and adequacy of referrals from Primary Care to Urology, after the implementation of referral protocols on the most frequent urological diseases and the establishment of a continuing education program. Material and methods: A Primary Care-Urology work group was created in 2011. Initially, performance and clinical practice protocols in prostatic pathology (BPH and PSA) were established. These were supported by training sessions for primary care physicians. After analysing the effect of the mentioned joint work, 3more (scrotal pathology, urinary tract infections and urinary incontinence) were included. We analysed and compared the referrals and their adequacy before and after the establishment of the protocols. Results: The most common referral causes were symptoms of the lower urinary tract due to BPH, which initially represented 22.8% of the total, and decreased to 16.9%. After the introduction of the new algorithms, we observed a decrease in referrals for scrotal pathology (13-14% to 7.8%), an increase in urinary incontinence referrals (3% al 10.3%) and those related to urinary tract infections remained stable. The adequacy to the protocols improved progressively: LUTS from 46% to 65.3%; PSA from 55% to 84.4% and urinary incontinence from 66.2% to 73.1%. Adequacy in scrotal pathology decreased (de 67.1% a 63.3%), while in UTI it stayed much the same (around 76%). Conclusions: The joint work between Urology and Primary Care achieves an improvement in referrals adequacy regarding the most frequent urological pathologies

Analysis of referrals after a synergic work between Primary Care and Urology. Impact of joint protocol implementation and a continuing education program in our healthcare area. / Evolución de las derivaciones desde Atención Primaria a Urología tras la creación de un grupo de trabajo y la instauración de protocolos y cursos de formación continuada.

OBJECTIVE: To analyse the evolution and adequacy of referrals from Primary Care to Urology, after the implementation of referral protocols on the most frequent urological diseases and the establishment of a continuing education program. MATERIAL AND METHODS: A Primary Care-Urology work group was created in 2011. Initially, performance and clinical practice protocols in prostatic pathology (BPH and PSA) were established. These were supported by training sessions for primary care physicians. After analysing the effect of the mentioned joint work, 3more (scrotal pathology, urinary tract infections and urinary incontinence) were included. We analysed and compared the referrals and their adequacy before and after the establishment of the protocols. RESULTS: The most common referral causes were symptoms of the lower urinary tract due to BPH, which initially represented 22.8% of the total, and decreased to 16.9%. After the introduction of the new algorithms, we observed a decrease in referrals for scrotal pathology (13-14% to 7.8%), an increase in urinary incontinence referrals (3% al 10.3%) and those related to urinary tract infections remained stable. The adequacy to the protocols improved progressively: LUTS from 46% to 65.3%; PSA from 55% to 84.4% and urinary incontinence from 66.2% to 73.1%. Adequacy in scrotal pathology decreased (de 67.1% a 63.3%), while in UTI it stayed much the same (around 76%). CONCLUSIONS: The joint work between Urology and Primary Care achieves an improvement in referrals adequacy regarding the most frequent urological pathologies.

Evolución de las derivaciones de atención primaria a urología. Impacto de un protocolo en enfermedad prostática y de formación continuada / Evolution of primary care referrals to urology. Impact of a protocol on prostate disease and continuing education

Objetivo: Analizar la evolución de las derivaciones desde atención primaria (AP) a urología tras implantar un protocolo conjunto en enfermedad prostática y un programa de formación continuada en nuestra área sanitaria. Material y métodos: En enero de 2011 iniciamos un protocolo de actuación en enfermedad prostática, que se complementó con sesiones formativas y con un sistema de consultas vía correo electrónico. Analizamos las derivaciones desde AP a urología entre 2011 y 2013, determinando el motivo de consulta y la adecuación a los criterios establecidos en enfermedad prostática. Obtuvimos los datos del programa «Solicitud de cita en atención especializada» de la Comunidad de Madrid. Calculamos el tamaño muestral con un nivel de confianza del 95% y heterogeneidad del 50%. Resultados: Se produjeron 19.048 derivaciones. El motivo de consulta más frecuente fue STUI asociado a HBP, con una reducción del 27% y una adecuación que pasó del 46 al 67%. Las consultas por PSA, aunque aumentaron un 40%, también mejoraron su adecuación (del 55 al 72%), siendo la principal consulta por sospecha de malignidad (30%). Destacan además la incontinencia femenina, que ha duplicado su número, y el descenso del 41% en disfunción eréctil, que pueden justificarse por la formación impartida a AP. Conclusiones: La colaboración entre urología y AP consigue mejorar la adecuación de las derivaciones en enfermedad prostática y modificar la tendencia de derivación del resto de enfermedades incluidas en el proyecto

Objective: To analyze the evolution of primary care referrals to the Urology Department after the implementation of a joint protocol on prostate disease and a continuing education program in our healthcare area. Material and methods: In January 2011, we launched an action protocol on prostate disease, which was complemented by training sessions and an e-mail-based consultation system. We analyzed primary care referrals to the Urology Department between 2011 and 2013 and determined the reasons for the consultations and the compliance with the established criteria on prostate disease. We obtained data from the "Request for Appointment in Specialized Care" program of the Community of Madrid. We calculated the sample size with a 95% confidence level and a 50% heterogeneity. Results: A total of 19,048 referrals were conducted. The most common reason for the referrals was lower urinary tract symptoms associated with benign prostate hyperplasia, with a 27% reduction and a compliance that went from 46% at 67%. Although prostate-specific antigen consultations increased by 40%, they improved their appropriateness (from 55% to 72%). This was the main type of consultation for suspicion of malignancy (30%). Also worth mentioning were female incontinence, which doubled in number, and a 41% reduction in erectile dysfunction, which could be due to the primary care training. Conclusions: The collaboration between the Department of Urology and primary care succeeded in improving the appropriateness of prostate disease referrals and modified the tendency to refer the rest of the diseases included in the project

Evolution of primary care referrals to urology. Impact of a protocol on prostate disease and continuing education.

OBJECTIVE: To analyze the evolution of primary care referrals to the Urology Department after the implementation of a joint protocol on prostate disease and a continuing education program in our healthcare area. MATERIAL AND METHODS: In January 2011, we launched an action protocol on prostate disease, which was complemented by training sessions and an e-mail-based consultation system. We analyzed primary care referrals to the Urology Department between 2011 and 2013 and determined the reasons for the consultations and the compliance with the established criteria on prostate disease. We obtained data from the "Request for Appointment in Specialized Care" program of the Community of Madrid. We calculated the sample size with a 95% confidence level and a 50% heterogeneity. RESULTS: A total of 19,048 referrals were conducted. The most common reason for the referrals was lower urinary tract symptoms associated with benign prostate hyperplasia, with a 27% reduction and a compliance that went from 46% at 67%. Although prostate-specific antigen consultations increased by 40%, they improved their appropriateness (from 55% to 72%). This was the main type of consultation for suspicion of malignancy (30%). Also worth mentioning were female incontinence, which doubled in number, and a 41% reduction in erectile dysfunction, which could be due to the primary care training. CONCLUSIONS: The collaboration between the Department of Urology and primary care succeeded in improving the appropriateness of prostate disease referrals and modified the tendency to refer the rest of the diseases included in the project.

[Modal failure analysis and effects in the detection of errors in the transport of samples to the clinical laboratory]. / Utilidad del análisis modal de fallos y efectos para la detección de errores en el transporte de muestras al laboratorio clínico.

OBJECTIVE: Owing to the decrease in values of biochemical glucose parameter in some samples from external extraction centres, and the risk this implies to patient safety; it was decided to apply an adaptation of the «Health Services Failure Mode and Effects Analysis¼ (HFMEA) to manage risk during the pre-analytical phase of sample transportation from external centres to clinical laboratories. MATERIALS AND METHODS: A retrospective study of glucose parameter was conducted during two consecutive months. The analysis was performed in its different phases: to define the HFMEA topic, assemble the team, graphically describe the process, conduct a hazard analysis, design the intervention and indicators, and identify a person to be responsible for ensuring completion of each action. RESULTS: The results of glucose parameter in one of the transport routes, were significantly lower (P=.006). The errors and potential causes of this problem were analysed, and criteria of criticality and detectability were applied (score≥8) in the decision tree. It was decided to: develop a document management system; reorganise extractions and transport routes in some centres; quality control of the sample container ice-packs, and the time and temperature during transportation. CONCLUSIONS: This work proposes quality indicators for controlling time and temperature of transported samples in the pre-analytical phase. Periodic review of certain laboratory parameters can help to detect problems in transporting samples. The HFMEA technique is useful for the clinical laboratory.

Abnormalities induced in reciprocal inhibition between orbicularis oculi and levator palpebrae following peripheral facial palsy.

Peripheral Facial palsy (PFP) is generally considered a benign condition with good recovery and no sequelae. Yet, a distortion in the gesture and abnormal blinking, as those typically found in blepharospasm, can potentially develop early on. Such abnormal movements seem to be related to remodelling mechanisms that take place in the process of recovery. We report 2 cases where such clinical features became evident following an idiopathic PFP, as a result of reciprocal inhibition of orbicularis oculi and levator palpebrae. Hence, the neurophysiological study revealed an increased frequency in the blinking, with bilateral trigeminal-facial facilitation and, most notably, a disturbance that only became evident when the eyes were maintained wide open. Interestingly, those features were not reproduced in other tasks where the blinking conditions had not been altered. Our findings suggest that sensory inputs (reflex afferent pathways) are involved in such abnormal movements. The insufficient eyelid closure (lagophthalmus) in the context of PFP is likely to account for the exaggerated corneal vulnerability, thus resulting in abnormal mechanisms of adaptation.

[Parotid tumours: correlation between fine needle aspiration biopsy and histological findings]. / Tumores parotideos: correlación entre la punción aspiración con aguja fina y los hallazgos histopatológicos.

OBJECTIVE: To evaluate the role of the fine needle aspiration biopsy (FNAB) in the study of parotid masses. METHODS: Retrospective review of FNAB results compared with final histological diagnosis in 148 patients with a parotid mass from 1993 to 2003. RESULTS: FNAB was performed in 93.92% of parotid masses. Eleven of these were not conclusive. The FNAB diagnosis of malignant o suspicious lesion had 81.25% of sensibility, 96.87% of specificity and positive and negative predictive values of 89.65% and 93.94%, respectively. The FNAB specific histopathologic diagnosis in the benign parotid masses were 92%, and 57.69% in the malignant masses. CONCLUSIONS: FNAB is a diagnostic tool with a high negative predictive value, very usotul in the study of suspicious malignant parotid masses and whenever surgery is not possible.

Tumores parotideos: correlación entre la punción aspiración con aguja fina y los hallazgos histopatológicos / Parotid tumours: correlation between fine needle aspiration biopsy and histological findings

Objetivo: Establecer la rentabilidad diagnóstica de la punción aspiración con aguja fina (PAAF) en el diagnóstico de las masas parotídeas. Material y métodos: Estudio retrospectivo en el que comparamos los resultados de la PAAF con los hallazgos anatomopatológicos de la pieza quirúrgica, en 148 pacientes diagnosticados de masa parotídea durante el período de 1993 al 2003. Resultados: Se realizó PAAF al 93,92% de las masas parotídeas, 11 fueron no concluyentes. Diagnosticando malignidad, la PAAF presentó una sensibilidad del 81,25%, una especificidad de 96,87% y unos valores predictivos positivo y negativo de 89,65% y 93,94%, respectivamente. Al evaluar la precisión en el diagnóstico exacto de la lesión, encontramos una concordancia del 92% en los tumores benignos y del 57,69% en los tumores malignos. Conclusiones: La PAAF es una prueba diagnóstica con un alto valor predictivo negativo, muy útil en el estudio de las masas parotídeas sospechosas de malignidad o en aquellos casos en los que no se vaya a realizar cirugía

Objetive: To evaluate the role of the fine needle aspiration biopsy (FNAB) in the study of parotid masses. Methods: Retrospective review of FNAB results compared with final histological diagnosis in 148 patients with a parotid mass from 1993 to 2003. Results: FNAB was performed in 93.92% of parotid masses. Eleven of these were not conclusive. The FNAB diagnosis of malignant o suspicious lesion had 81.25% of sensibility, 96.87% of specificity and positive and negative predictive values of 89.65% and 93.94%, respectively. The FNAB specific histopathologic diagnosis in the benign parotid masses were 92%, and 57.69% in the malign masses. Conclusions: FNAB is a diagnostic tool with a high negative predictive value, very usotul in the study of suspicious malignant parotid masses and whenever surgery is not possible

Réplica. Reflejo del parpadeo (R3) y parálisis facial / Reply. Blink reflex (R3) and facial palsy

No disponible

No disponible

[Peripheral facial paralysis. The value of clinical neurophysiology]. / Parálisis facial periférica. Utilidad de la neurofisiología clínica.

AIMS: The aim of this study was to review the value of neurophysiological exploration in peripheral facial paralysis in the literature and in our own experience. METHOD: Peripheral facial paralysis is a frequently occurring cranial neuropathy with an acute presentation. Its striking clinical expression is usually in strong contrast to its benign prognosis, except for a small percentage of cases in which the existence of acute injury to the nerve (axonotmesis) will cause it to progress unfavourably, either due to the absence of nerve regeneration or because this is inadequate or insufficient. A neurophysiological study aids diagnosis and the functional and prognostic assessment. CONCLUSIONS: We recommend the utilisation of standardised studies involving a comprehensive electromyographic and electroneurographic evaluation of the facial territory, including reflexology (blink reflex). Use of a suitable methodology in the neurophysiological study of this neuropathy will allow us to complete the diagnosis and to evaluate progress, even from very early days (early surgical approach prior to the onset of nerve degeneration), all of which is decisive in the prognosis of injury throughout the process.

Parálisis facial periférica. Utilidad de la neurofisiología clínica / Peripheral facial paralysis. The value of clinical neurophysiology

Objetivo. Revisar la utilidad de la exploración neurofisiológica en la parálisis facial periférica en la bibliografía y en nuestra experiencia. Desarrollo. La parálisis facial periférica es una neuropatía craneal de aparición frecuente y presentación aguda. Su llamativa expresión clínica contrasta la mayor parte de las veces con un pronóstico benigno, a excepción de un pequeño porcentaje de casos en los que la existencia de una lesión aguda del nervio (axonotmesis) determina una evolución desfavorable, bien por la ausencia de regeneración nerviosa o por ser ésta inadecuada o insuficiente. El estudio neurofisiológico ayuda en el diagnóstico y en la valoración funcional y el pronóstico. Conclusiones. Recomendamos la realización de estudios estandarizados en los que se incluya una evaluación amplia electromiográfica y electroneurográfica del territorio facial, incluida la reflexología (reflejo de parpadeo). Una adecuada metodología en el estudio neurofisiológico de esta neuropatía va a permitir completar el diagnóstico y valorar la evolución, incluso desde los primeros días (puede indicar un abordaje quirúrgico precoz previo al inicio de la degeneración nerviosa), todo lo cual resulta determinante de cara al pronóstico lesional del proceso (AU)

Barnacle hypersensitivity.

BACKGROUND: the aim of the present study is to investigate the responsible mechanism of different adverse reactions suffered by five patients, aged between six and thirty years-old, after consumption of barnacle. The symptoms were angioedema, dyspnea, generalized urticaria, conjunctivitis and one of them suffered from anaphylactic reaction. Four patients had personal atopic history. METHODS: the allergic study included prick by prick test with raw and boiled barnacle and prick-test with a standardized battery of shellfish and neumoallergens, specific-IgE determination to barnacle, crustacean and house-dust-mite and SDS-PAGE immunoblotting to barnacle. Even though an oral challenge was proposed to three of the patients, they were reluctant to do the test and eventually the challenges were not carried out. RESULTS: prick to prick tests were positive to barnacle for all of them. Specific-IgE was found in four patients. The western blotting results showed an IgE-binding band whose apparent molecular mass ranged between 58 and 68 kDa. CONCLUSIONS: barnacle could induce IgE-mediated adverse reaction. Our study has demonstrated the presence of an IgE-binding protein in barnacle extracts ranged between 58 and 68 kDa of molecular mass. It has not been previously described a crustacean allergen with the same molecular mass, so it could be a specific allergen from barnacle. We believe that further study will confirm this is the case.

Barnacle hypersensitivity

Background: the aim of the present study is to investigate the responsible mechanism of different adverse reactions suffered by five patients, aged between six and thirty years-old, after consumption of barnacle. The symptoms were angioedema, dyspnea, generalized urticaria, conjunctivitis and one of them suffered from anaphylactic reaction. Four patients had personal atopic history. Methods: the allergic study included prick by prick test with raw and boiled barnacle and prick-test with a standardized battery of shellfish and neumoallergens, specific-IgE determination to barnacle, crustacean and house-dust-mite and SDS-PAGE immunoblotting to barnacle. Even though an oral challenge was proposed to three of the patients, they were reluctant to do the test and eventually the challenges were not carried out. Results: prick to prick tests were positive to barnacle for all of them. Specific-IgE was found in four patients. The western blotting results showed an IgE-binding band whose apparent molecular mass ranged between 58 and 68 kDa. Conclusions: barnacle could induce IgE-mediated adverse reaction. Our study has demonstrated the presence of an IgE-binding protein in barnacle extracts ranged between 58 and 68 kDa of molecular mass. It has not been previously described a crustacean allergen with the same molecular mass, so it could be a specific allergen from barnacle. We believe that further study will confirm this is the case (AU)

Caso clínico: el objetivo de este estudio es investigar el mecanismo de producción de las reacciones adversas sufridas por cinco pacientes tras la ingestión de percebe. Los síntomas fueron diversos y comprendieron desde un cuadro de angioedema, disnea, urticaria generalizada o conjuntivitis, hasta una reacción anafiláctica. Cuatro de nuestros pacientes tenían antecedentes personales de atopia y sus edades estaban comprendidas entre 6 y 30 años. Métodos: el estudio alergológico consistió en la realización de prick-prick test con percebe crudo y cocido y prick-test con una batería estándar de mariscos y neumoalergenos; determinación de IgE-específica a percebe, mariscos y ácaros y la realización de SDS-PAGE inmunoblotting con extracto de percebe. Se propuso la realización de provocación oral a tres de nuestros pacientes, pero rehusaron someterse a dicha prueba. Resultados: todos los pacientes presentaron prick-prick test positivo a percebe y se encontró IgE específica a percebe en cuatro de los mismos. Los resultados del inmunoblotting muestran la presencia de una banda fijadora de IgE, cuya masa molecular se sitúa en el intervalo comprendido entre 58 y 68 kDa. Conclusiones: el percebe puede producir reacciones adversas cuyo mecanismo está mediado por IgE. Nuestro estudio demuestra la presencia de una banda fijadora de IgE en el extracto de percebe, cuyo peso molecular se sitúa entre los 58 y 68 kDa. Una banda con este peso molecular no había sido descrita con anterioridad como alergeno perteneciente a la familia de los crustáceos, lo que nos hace pensar en la posibilidad de que este alergeno pudiera ser específico del percebe. Habrá que ampliar el estudio inmunológico de estos casos, para poder confirmar definitivamente a esta proteína como específica del percebe (AU)

Quistes branquiales con tejido salival heterotópico en el tercio superior del cuello / Branchial cysts with heterotopic salivary tissue in the upper third of the neck

La existencia de tejido salival heterotópico (TSH) en el cuello es bastante infrecuente. Generalmente se ha descrito en su tercio inferior, el TSH en el tercio superior es una rareza. Se presentan dos casos de TSH en la parte superior del cuello, revisando sus características clínico-patológicas. Se discute el origen embrionario del THS y su asociación con las anomalías del aparato branquial. La posibilidad de malignización debe siempre tenerse en cuenta en estas raras lesiones (AU)

The presence of heterotopic salivary gland tissue (HSGT) in rather uncommon in the neck. Usually it has been located in its lower third. HSGT in the upper neck is believed to be a rare entity. Two cases of HSGT in the upper neck are presented, with a review of their clinical and histopathological characteristics. The embryologic derivation of salivary tissue and close association with the branchial apparatus are discussed. The possibility of neoplastic transformation must always be considered in these uncommon lesions (AU)

[Branchial cysts with heterotopic salivary tissue in the upper third of the neck]. / Quistes branquiales con tejido salival heterotópico en el tercio superior del cuello.

The presence of heterotopic salivary gland tissue (HSGT) in rather uncommon in the neck. Usually it has been located in its lower third. HSGT in the upper neck is believed to be a rare entity. Two cases of HSGT in the upper neck are presented, with a review of their clinical and histopathological characteristics. The embryologic derivation of salivary tissue and close association with the branchial apparatus are discussed. The possibility of neoplastic transformation must always be considered in these uncommon lesions.

[Naso-alveolar cysts. A report of 10 new cases and a review of the literature]. / Quiste nasoalveolar. Aportación de 10 nuevos casos y revisión de la literatura.

Nasoalveolar cysts, also known as Klestadt's or nasolabial cysts, are uncommon midfacial lesions. Ten cases treated at the 12 de Octubre University Hospital are reported, describing the most relevant clinical and pathological findings are reported. The main theories of the origin of these developmental, non-odontogenic cysts are discussed. A review of the literature is included.

[Colony stimulating factors in chemotherapy induced neutropenic fever]. / Factores estimulantes de colonias en neutropenia febril inducida por quimioterapia.

We review the randomized trials published so far comparing the use of colony-stimulating factors (both G-CSF and GM-CSF) as adjunctive care in chemotherapy-induced neutropenic fever. With this treatment a slight one day reduction in duration of neutropenia under 500 neutrophils per mm3 is observed; this effect seems to be more important in prolonged neutropenias. The number of days with fever remain unchanged. No clear benefit expressed as clinical and quality of life improvement or economical saving is proved. According to these results, and as previous recommendation about the use of colony-stimulating factors pointed out, the indications for administration of such cytokines in neutropenic fever are restrictive and its use could be acceptable only in patients with poor prognostic factors.