Histerectomías laparoscópicas en un hospital comarcal español: nuestros resultados / The outcomes of laparoscopic hysterectomies in a Spanish district hospital

OBJETIVO: Calcular la tasa de conversión y describir las indicaciones, tipos de cirugía y complicaciones de las histerectomías laparoscópicas en un hospital comarcal. Analizar los tiempos quirúrgicos y el peso uterino. MÉTODO: Estudio retrospectivo y descriptivo de la base de datos quirúrgica de las mujeres atendidas en el Servicio de Ginecología y Obstetricia del Hospital Comarcal de Valdeorras (Orense). Programamos a 78 mujeres para histerectomía laparoscópica desde mayo del 2011 hasta febrero de 2018. Describimos las características demográficas, clínica, tipo de cirugía y tratamientos previos. Realizamos 62 histerectomías totales, 15 subtotales y una operación de Manchester. Calculamos la tasa de conversión, porcentaje de morcelación, tiempo quirúrgico, complicaciones (clasificadas según la escala de Clavien-Dindo y el Comprehensive Complication Index) y los resultados de anatomía patológica. RESULTADOS: Nuestra tasa de conversión fue del 5,13%. El porcentaje de morcelación fue 35,90%. En las histerectomías totales calculamos un peso uterino teórico (190 g o más) a partir del cual la morcelación sería más probable. No hubo transfusiones. Encontramos mayor tiempo quirúrgico entre los cirujanos junior, pero no más complicaciones. Las complicaciones según Clavien-Dindo fueron: 10 pacientes grado I, 10 grado II, uno grado IIIa y 4 grado IIIb. Según el Comprehensive Complication Index, 20 pacientes obtuvieron una puntuación baja (<30 puntos) y 4 pacientes entre 31 y 40 puntos. La cesárea previa estaba asociada a mayor riesgo de lesión vesical. La estancia media fue de 2,48 días. No hubo resultados de malignidad entre los úteros morcelados. CONCLUSIONES: La histerectomía laparoscópica es una técnica quirúrgica fácilmente reproducible en hospitales comarcales, con baja tasa de conversión y escasas complicaciones

OBJECTIVE: To calculate the conversion rate and describe indications, type of surgery, and complications of laparoscopic hysterectomies in a district hospital, as well as to analyse surgical time and uterine weight. METHODS: A descriptive and retrospective study was carried using the database of the Surgical Record of Gynaecology (Canadian Task Force classification III). It was conducted in the Gynaecology and Obstetrics Department of Valdeorras District Hospital (Orense, Spain). The study included 78 women scheduled for laparoscopic hysterectomy from May 2011 to February 2018. A description is presented of the demographic characteristics, symptoms, type of surgery, and previous medical treatments. A total of 62 total and 15 subtotal hysterectomies, were performed, as well as one Manchester surgery. A calculation was made of the rate of conversion, morcellation percentage, operating time, complications (classified according to the Clavien-Dindo scale and the Comprehensive Complication Index), and pathology results. RESULTS: The conversion rate was 5.13%, and the morcellation percentage was 35.90%. A theoretical cut-off was calculated of a uterus weight of 190 grammes or more for being morcellated among total hysterectomies. There were no transfusions. There were longer operating times with junior surgeons, but no difference in surgical complications compared to senior surgeons. Complications according to the Clavien-Dindo scale: 10 patients grade I, 10 grade II, one grade IIIa, and 4 grade IIIb. Using the CCI, 20 patients attained a low score (<30 points), and 4 patients scored 31-40 points. A history of caesarean section was associated with a higher risk of bladder injury. Mean days to discharge was 2.48 days. There were no malignant samples among the morcellated uteruses. CONCLUSIONS: Laparoscopic hysterectomy is a technique that can be performed in a district hospital and in most cases with a minimum conversion rate and few complications

Resultados a largo plazo de la cirugía de prolapsos genitales con mallas de polipropileno / Long-term results of genital prolapse surgery with polypropylene mesh

Introducción y objetivo: El riesgo de intervención por prolapso urogenital en la vida de una mujer es del 11,1%. Las recidivas después de la cirugía clásica alcanzan el 38%. Para tratar de mejorar estos resultados se usan kits de mallas de polipropileno transvaginales. El propósito del estudio es describir los resultados de eficacia y seguridad a largo plazo de la cirugía de prolapsos vaginales con mallas de polipropileno, evaluar los síntomas subjetivos pre- y postoperatorios y el grado de satisfacción. Pacientes y métodos: Estudio descriptivo, retrospectivo de 58 mujeres con prolapsos genitales sintomáticos operadas con mallas de polipropileno entre septiembre de 2011 y noviembre de 2016. La edad media fue 66,53 años; el 98,27% eran menopáusicas, el 77,59% tenía sobrepeso/obesidad, el 29,31% contaba con cirugías ginecológicas previas y el 55,17% con prolapsos combinados. Se insertaron 46 Elevate anterior y 12 Elevate posterior. La media del seguimiento fue de 34,02 meses. Se aplicó el cuestionario PFDI pre- y posquirúrgico y un cuestionario de satisfacción. Resultados: El índice de curación fue del 91,38%. Las recidivas se asociaron con un mayor IMC y con el antecedente de recidiva de cirugía previa. Estancia media: 2,5 días. El 70,69% no necesitó analgesia al alta. Complicaciones Clavien-Dindo: una tipo I (retención urinaria), 5 tipo II (infección urinaria) y una tipo IIIa (erosión). La incontinencia urinaria de esfuerzo de novo se presentó en el 3,44%, mientras que la dispareunia de novo ocurrió en el 14,28%. El 89,36% de las pacientes habían mejorado de los síntomas subjetivos y el 95,92% se mostraron satisfechas. Conclusión: Esta cirugía consigue altas tasas de curación, con escasas complicaciones, mejoría subjetiva de los síntomas y alto grado de satisfacción de las pacientes

Introduction and objective: The risk of intervention due to urogenital prolapse in a woman's life is 11.1%. Recurrences after classic surgery reach up to 38%. With the aim of improving these results, transvaginal mesh kits are used. The purpose of the study is to describe the results of efficacy and long-term safety of vaginal prolapse surgery with polypropylene mesh, assess subjective symptoms before and after surgery and the level of satisfaction. Patients and methods: A descriptive, retrospective study of 58 women with symptomatic genital prolapses operated with polypropylene mesh between September / 2011-November / 2016. Mean age: 66.53 years, 98.27% menopausal women, 77.59% overweight/obesity, 29.31% with previous gynaecological surgery and 55.17% with combined prolapse. 46 Elevate anterior and 12 posterior were inserted. The mean follow-up period was 34.02 months. The PFDI questionnaire was used pre and post-surgery, as well as the satisfaction questionnaire. Results: Healing rate of 91.38%. Recurrences were associated with a higher BMI and with background of recurrence of previous surgery. Mean length of stay: 2.5 days. 70.69% did not need analgesia at discharge. Clavien-Dindo complications: 1 type I (urinary retention), 5 type II (urinary tract infection) and 1 type IIIa (erosion). De novo stress urinary incontinence occurred in 3.44%, while de novo dyspareunia 14.28%. 89.36% patients improved subjective symptoms, and 95.92% were satisfied. Conclusion: This surgery achieves high healing rates, with few complications, improvement of subjective symptoms and high level of satisfaction of the patients

Long-term results of genital prolapse surgery with polypropylene mesh. / Resultados a largo plazo de la cirugía de prolapsos genitales con mallas de polipropileno.

INTRODUCTION AND OBJECTIVE: The risk of intervention due to urogenital prolapse in a woman's life is 11.1%. Recurrences after classic surgery reach up to 38%. With the aim of improving these results, transvaginal mesh kits are used. The purpose of the study is to describe the results of efficacy and long-term safety of vaginal prolapse surgery with polypropylene mesh, assess subjective symptoms before and after surgery and the level of satisfaction. PATIENTS AND METHODS: A descriptive, retrospective study of 58 women with symptomatic genital prolapses operated with polypropylene mesh between September / 2011-November / 2016. Mean age: 66.53 years, 98.27% menopausal women, 77.59% overweight/obesity, 29.31% with previous gynaecological surgery and 55.17% with combined prolapse. 46 Elevate anterior and 12 posterior were inserted. The mean follow-up period was 34.02 months. The PFDI questionnaire was used pre and post-surgery, as well as the satisfaction questionnaire. RESULTS: Healing rate of 91.38%. Recurrences were associated with a higher BMI and with background of recurrence of previous surgery. Mean length of stay: 2.5 days. 70.69% did not need analgesia at discharge. Clavien-Dindo complications: 1 type I (urinary retention), 5 type II (urinary tract infection) and 1 type IIIa (erosion). De novo stress urinary incontinence occurred in 3.44%, while de novo dyspareunia 14.28%. 89.36% patients improved subjective symptoms, and 95.92% were satisfied. CONCLUSION: This surgery achieves high healing rates, with few complications, improvement of subjective symptoms and high level of satisfaction of the patients.

Adecuación diagnóstica en la Enfermedad Pulmonar Obstructiva Crónica / The adequacy of the diagnostic in chronic obstructive pulmonary disease

Objetivos. Valorar la adecuación a las guías clínicas (GOLD/SEPAR) del diagnóstico de los pacientes calificados de Enfermedad Pulmonar Obstructiva Crónica (EPOC). Material y métodos. Se seleccionaron todos los casos de EPOC del registro de pacientes crónicos de 28 cupos de 9 centros de salud de la provincia de Ourense, incluyéndose 382 casos donde se determinó la existencia de un diagnóstico correcto según resultados espirométricos. Se determinaron los factores asociados al diagnóstico correcto mediante regresión logística donde fueron incluidos edad, sexo, residencia (rural/urbana), tabaquismo, gravedad, nivel de seguimiento y tiempo desde el diagnóstico. Resultados. Eran varones 297 (77,7%) y 172 (45,0%) procedían del medio rural. La media (DE) de edad era 77,0 (±11,0) años, siendo al diagnóstico de 64,9 (±12,0) años y 11,5 (±8,0) años de tiempo de evolución. El 64,9% era o había sido fumador. Se diagnosticaron en atención primaria 26 casos (6,8%). El índice VEF1/CVF estaba registrado en 174 (45,5%) pacientes, siendo menor de 0,7 en 138 casos (36,1%), que se consideraron bien diagnosticados. En estos pacientes figuraba registrado el VEF1 en 125 casos (90,6%). El diagnóstico correcto se asociaba a enfermedad grave o muy grave (OR 5,2; IC95 1,5-17,4), procedencia urbana (OR 6,1; IC95 1,7-21,2) y edad igual o menor de 60 años (OR 3,7; IC95 1,3-11,2). Conclusión. En la historia clínica de atención primaria de los pacientes diagnosticados de EPOC existía escaso registro espirométrico y baja adecuación a los criterios diagnósticos aceptados en las guías de uso habitual (AU)

Objectives. To assess the adequacy to the clinical guides (GOLD/SEPAR) for the diagnosis of the patients classified as COPD. Material and methods. We selected all COPD cases in the registry of chronic patients of 28 general practitioners from 9 Health Centres in the province of Ourense (Spain). A total of 382 cases were included. Diagnostic accuracy was determined according to the results of spirometry. We identify factors associated with correct diagnosis by logistic regression which included age, gender, residence (rural/urban), smoking, severity, level of follow up and time since diagnosis. Results. Of the total number included, 297 were male (77.7%) and 172 patients (45.0%) came from rural areas. The average age was 77.0 (SD=±11.0) years, with a mean age at diagnosis of 64.9 (±12.0) years and the time from diagnosis was 11.5 (±8.0) years. Less than half (49.1%) patients had been smokers, and 13.1% still smoked. Twenty-six cases (6.8%) were diagnosed in Primary Care. The FEV1/FVC ratio was recorded in 174 (45.5%) patients, with less than 0.7 in 138 cases (36.1%), which were considered as correctly diagnosed. In these patients the FEV1 had been recorded in 125 cases (90.6%). A correct diagnosis was associated with severe or very severe disease (OR 5.2; 95% CI; 1.5-17.4), urban areas (OR 6.1; 95% CI, 1.7-21.2), and younger than 60 years (OR 3.7; 95% CI, 1.3-11.2). Conclusion. The number of spirometry results recorded in the Primary Care medical records of patients diagnosed with COPD was found to be low, and with little adaptation to the accepted diagnostic criteria in the guidelines that are used routinely (AU)

[The adequacy of the diagnostic in chronic obstructive pulmonary disease]. / Adecuación diagnóstica en la Enfermedad Pulmonar Obstructiva Crónica.

OBJECTIVES: To assess the adequacy to the clinical guides (GOLD/SEPAR) for the diagnosis of the patients classified as COPD. MATERIAL AND METHODS: We selected all COPD cases in the registry of chronic patients of 28 general practitioners from 9 Health Centres in the province of Ourense (Spain). A total of 382 cases were included. Diagnostic accuracy was determined according to the results of spirometry. We identify factors associated with correct diagnosis by logistic regression which included age, gender, residence (rural/urban), smoking, severity, level of follow up and time since diagnosis. RESULTS: Of the total number included, 297 were male (77.7%) and 172 patients (45.0%) came from rural areas. The average age was 77.0 (SD=±11.0) years, with a mean age at diagnosis of 64.9 (±12.0) years and the time from diagnosis was 11.5 (±8.0) years. Less than half (49.1%) patients had been smokers, and 13.1% still smoked. Twenty-six cases (6.8%) were diagnosed in Primary Care. The FEV(1)/FVC ratio was recorded in 174 (45.5%) patients, with less than 0.7 in 138 cases (36.1%), which were considered as correctly diagnosed. In these patients the FEV(1) had been recorded in 125 cases (90.6%). A correct diagnosis was associated with severe or very severe disease (OR 5.2; 95% CI; 1.5-17.4), urban areas (OR 6.1; 95% CI, 1.7-21.2), and younger than 60 years (OR 3.7; 95% CI, 1.3-11.2). CONCLUSION: The number of spirometry results recorded in the Primary Care medical records of patients diagnosed with COPD was found to be low, and with little adaptation to the accepted diagnostic criteria in the guidelines that are used routinely.

Investigación médica en poblaciones pequeñas / Medical research in small populations

No disponible

[Opinion of primary care physicians from Ourense on various features of the pharmaceutical prescription]. / Opinión de los médicos de atención primaria de Ourense sobre algunos aspectos de su prescripción farmacéutica.

BACKGROUND: To learn the opinion of the primary care Physicians of Ourense (Spain) with respect to certain aspects of their prescription of medicines, such as their awareness of the price of drugs, the induced prescribing perceived, their relationship with the pharmaceutical industry and their opinions concerning possible measures for reducing the expenditure on medicines. METHODS: In this transversal descriptive study, all of the primary care physicians in the province of Ourense (243) were surveyed by means of a previously-approved questionnaire sent to them by post. The questionnaire included demographic characteristics of the physicians, the influence of cost when prescribing medicines, their estimate of the price of 15 drugs routinely prescribed and their opinion on different aspects relating to induced prescription, the pharmaceutical industry and different strategies in order to curtail the expenditure on medicines. In order to analyze the results, the chi 2 and Student's t tests and an analysis of the variance were used, together with the Spearman correlation coefficient with alpha = 0.05. RESULTS: The level of participation of the physicians surveyed was 42.8% (104). The average daily duration of visits by pharmaceutical company representatives was 13.6 minutes, with new specialities being the topic of greatest interest. Close to 27% admitted to having participated in clinical testing sponsored by the industry. 23% considered the price to be a priority when prescribing. Induced prescription accounted for 39.7% of the total. The majority of physicians chose co-payment as the means for reducing expenditure on medicines. In the estimate of prices, the overall percentage of error was 45.7%, underestimating the more expensive medicines and overestimating the less expensive. CONCLUSIONS: There is a significant lack of awareness of the price of drugs among the primary care physicians. Most of the physicians do not feel that the price of a drug should be a priority when prescribing medicines. There is a high percentage of induced prescription perceived. With regard to the expenditure on pharmaceuticals, the majority of those surveyed feel that financial measures, specifically co-payment, are the most effective in order to curtail rising costs.

Control of primary hypertension by pharmacologic monotherapy in primary care. / El control de la hipertensión arterial mediante monoterapia farmacológica en Atención Primaria.

OBJECTIVE: To analyze the control degree and characteristics of arterial pressure (AP) obtained with monotherapy. SUBJECTS AND METHODS: A sample was obtained of 277 hypertensive patients (83 men and 194 women) on monotherapy from cluster sampling. All included patients were older than 18 years and had essential hypertension (HBP). Both systolic and diastolic pressure values (mean of two measurements), prescribed drug, age and sex were recorded. RESULTS: Less than 30% of subjects had adequate control (< 140/90), mainly because of poor control of systolic BP. The drug group most commonly was ACEI, followed by calcium blockers (CAB); enalapril and chlortalidone were the most commonly prescribed drugs. Diuretics were used most frequently by women (OR 4.2). The use of diuretics, calcium channel antagonists and alphaadrenergic blockers increased with age. The opposite was true for ACEI and beta blockers. CONCLUSIONS: A poor control of HBP in patients on monotherapy was observed, particularly for the systolic component. There is a higher use of ACEI and HBP. There is a highly significant difference regarding the use of diuretics between men and women which has no theoretical basis.

El control de la hipertensión arterial mediante monoterapia farmacológica en Atención Primaria / Control of primary hypertension by pharmacologic monotherapy in Primary Care

Fundamento. Analizar el grado de control de la presión arterial (PA) conseguido con monoterapia y las características de la misma. Sujetos y métodos. Se obtuvo una muestra de 277 hipertensos (83 varones y 194 mujeres) en tratamiento con monoterapia a partir de un muestreo en conglomerados. Todos los pacientes incluidos eran mayores de 18 años y presentaban hipertensión arterial esencial (HTA). Se registraron PA sistólica y diastólica (media de dos tomas), fármaco, edad y sexo. Resultados. Menos del 30 por ciento de los sujetos presentaban control adecuado (<140/90 mmHg), fundamentalmente por mal control de la PA sistólica. El grupo farmacológico más usado era el de los inhibidores de la enzima convertidora de la angiotensina (IECA), seguido de los bloqueadores del calcio (BCA), siendo las sustancias más prescritas enalapril y clortalidona. Los diuréticos (DIU) se usaban más en mujeres (OR 4,2). El uso de DIU, BCA y bloqueadores alfaadrenérgicos se incrementaba con la edad, al contrario que IECA y bloqueadores beta. Conclusiones. Se constata un mal resultado en el control de la HTA en pacientes tratados con monoterapia, especialmente para el componente sistólico. Hay un mayor uso de IECA y BCA. Existe una diferencia muy significativa en el uso de diuréticos entre varones y mujeres que no tiene justificación teórica (AU)

El asma

En los últimos años se ha profundizado en el conocimiento fisiopatológico de la enfermedad asmática, se ha modificado el abordaje terapéutico (dándosele gran importancia al tratamiento de fondo con antiinflamatorios), se han desarrollado nuevas y fructíferas vías de investigación farmacológica y se han publicado abundantes datos de investigación clínica y epidemiológica de calidad que nos orientan sobre el efecto que tienen estas novedades en el pronóstico de la población asmática. En este trabajo se han revisado y se resumen los avances mencionados y se presenta un abordaje terapéutico basado en las publicaciones de consenso de diferentes grupos de trabajo internacionales (AU)

[Personalized appointments as a recruitment method for anti-flu vaccination in the elderly]. / La citación personalizada como método de captación para la vacunación antigripal en ancianos.

OBJECTIVE: To determine the effectiveness of personal appointments for increasing flu vaccine coverage in over-65s who showed no intention of being vaccinated of their own accord. DESIGN: Controlled, intervention study, single-blind and with randomised distribution. SETTING: Primary health centre. PARTICIPANTS: Population over 65 in the municipality of San Cristovo de Cea (Ourense) who had not been vaccinated after three-quarters of the flu vaccine campaign had elapsed. MEASUREMENTS AND MAIN RESULTS: After three-quarters of the flu vaccine campaign, a randomised sample (n = 162) was taken from the over-65 population not vaccinated (N = 640). These 162 were sent a personal letter reminding them of the vaccination campaign, the personal risk they ran and advising them to be vaccinated. They were given an appointment time. During the remaining 14 days of the campaign, all the vaccinations continued to be monitored. Afterwards, the control group and those who had received the intervention were compared. 28 people were vaccinated, 19 from the intervention group (11.7%) and 9 from the control group (1.9%) (RR = 6.2; 95% CI, 2.9-13.5; FA = 84%). There were no significant differences between sexes. CONCLUSIONS: Personal appointments were effective in increasing vaccine coverage, even among people at first reluctant to be vaccinated, the group at which the intervention should be aimed.