Relato de caso: acompanhamento cardiológico durante 26 anos de atleta de alto nível / Case report: 26-year cardiological follow-up of a high-level athlete

O coração do atleta engloba um conjunto de alterações adaptativas resultantes da prática de exercício físico intenso e prolongado, promovendo alterações clínicas, eletrocardiográficas e ecocardiográficas. As alterações mais relevantes são a hipertrofia miocárdica, o alargamento das cavidades cardíacas e o aumento da massa cardíaca. Em alguns casos, essas alterações podem ser consideradas extremas, exigindo que as condições patológicas sejam eliminadas. Por meio de um relato de caso de um atleta de basquetebol de alto nível cuja única alteração no exame físico era a presença de bradicardia sinusal, persistente ao longo de 26 anos de acompanhamento clínico, investigada através de ecocardiograma, Holter e teste de esforço, demonstrando caráter benigno e fisiológico, apresentamos e discutimos a importância da avaliação cardiovascular por médico com experiência na análise de atletas, capaz de distinguir as condições patológicas das adaptações fisiológicas frente ao exercício de alta intensidade ao qual o atleta é submetido, evitando exames invasivos ou tratamento do coração do atleta.

The athlete's heart performs a set of adaptive changes resulting from the practice of intense and prolonged physical exercise, resulting in clinical, electrocardiographic and echocardiographic alterations. The most relevant changes are myocardial hypertrophy, enlargement of the cardiac cavities, and an increase in cardiac mass. In some cases, these changes can be considered extreme, requiring the elimination of pathological con - ditions. Through a case report of a high-level basketball player, whose only change in the physical examination was the presence of sinus bradycardia, persistent over 26 years of clinical follow-up, which was investigated through echocardiogram, Holter test and stress test, demonstrating benign and physiological characteristics, we present and discuss the importance of cardiovascular evaluation by a physician with experience in analyzing athletes, capable of distinguishing pathological conditions from physiological adaptations to the high-intensity exercise to which the athlete is subjected, avoiding invasive examinations or treatment of the athlete's heart

Diferencias entre migraña crónica con y sin uso excesivo de medicación: experiencia en una serie hospitalaria de 434 pacientes / Chronic migraine with and without medication overuse: Experience in a hospital series of 434 patients

Introducción: La migraña crónica (MC) es una evolución de la migraña episódica favorecida por factores de riesgo, entre los que se encuentra el uso excesivo de medicación (UEM). Pretendemos comparar características clínicas y demográficas de una serie de casos de MC, con y sin UEM. Métodos: Pacientes con MC (criterios revisados 2006) atendidos en una consulta monográfica de cefaleas de un hospital terciario entre enero del 2008 y mayo del 2012. Recogimos datos demográficos, evolución, utilización previa de preventivos e impacto de la migraña medido con la escala HIT-6. esultados: Cuatrocientos treinta y cuatro pacientes (357 mujeres, 77 varones) fueron diagnosticados de MC entre un total de 1,868 (23,2%) atendidos en la mencionada consulta durante el periodo de inclusión. Doscientos cincuenta y ocho (72,2%) presentaban UEM. El 59,8% de los casos con UEM recibieron previamente tratamiento preventivo frente al 41,1% sin UEM (p < 0,001). La edad de inicio de la migraña fue menor en los pacientes con UEM (21,2 ± 10,1 vs. 23,8 ± 12,5 años; p = 0,02) y el tiempo de evolución al llegar a nuestra consulta mayor en los pacientes con UEM (23,8 ± 14,1 vs. 18,3 ± 14,8 años; p < 0,001). No encontramos diferencia en la puntuación HIT-6 o el porcentaje de casos con HIT-6 mayor de 55 entre ambos grupos. Conclusiones: La MC con o sin UEM es una afección frecuente y discapacitante en una consulta de cefaleas. En nuestra población, los pacientes con UEM llegan a la consulta tras una evolución más larga, en la que ya recibieron tratamientos preventivos

Introduction: Chronic migraine (CM) is a complication of episodic migraine, favored by risk factors as medication overuse (MO). We intend to compare demographic and clinic characteristics of a series of CM patients, with and without MO. Methods: The study included patients with CM (2006 revised criteria) attended in a headache outpatient office located in a tertiary hospital between January 2008 and May 2012. We recorded demographic characteristics, age at migraine onset, time from onset, previous use of symptomatic or preventive therapy, and headache impact measured with six-item headache impact test (HIT-6). Results: A total of 434 patients (357 women, 77 men) were diagnosed with CM out of the 1868 (23.2%) that attended our clinic. Of these, 258 (72.2%) fulfilled criteria of MO, and 59.8% of those with MO, and 41.1% of cases without MO had previously received preventative treatment (P<.001). Age at onset of migraine was lower in MO patients (21.2 ± 10.1 vs 23.8 ± 12.5 years, P=.02) and time from onset to headache clinic consultation was higher in MO cases (23.8 ± 14.1 vs 18.3 ± 14.8 years, P<.001). We found no difference between both groups in average HIT-6 score and the percentage of patients with a HIT-6 score over 55. Conclusions: CM, with or without MO, is a burdensome group of patients in our headache clinic. Patients with MO are referred later and have more frequently received preventive treatments

[The 'ideal therapy process': testing a new approach for assessing process quality in inpatient parent-child facilities]. / Der "ideale Behandlungsprozess": Erprobung eines neuen Ansatzes zur Prüfung der Prozessqualität in Mutter-/Vater-Kind-Einrichtungen.

Instruments for external quality assurance in inpatient parent-child rehabilitation and prevention facilities were developed in 2 projects. For the assessment of process quality, we sought an alternative test to the peer review procedure which also places a stronger emphasis on patient perspectives. The aim was to define an "ideal process" as a standard, to develop quantifiable criteria, and to test a multimethod approach which involves different data levels. On the basis of different sources, the "ideal process" for parent-child rehabilitation and prevention and associated criteria were defined by involving an accompanying expert group during a consensus process. Criteria were assessed on different levels: on the rehabilitation/prevention centre level, a questionnaire of process-relevant structural features was used; on the patient level, a case-related routine documentation filled in by clinic staff and an incident-related patient questionnaire were applied. Data were collected in 37 centres (prevention: 19; rehabilitation: 11; 7 offering both types of programmes). Analysis of patient-related data is based on a sample of 1 513 prevention patients and 286 rehabilitation patients. The resulting "ideal process" consists of the stages "preparation", "arrival", "treatment planning", "treatment", "completion of treatment", and "organisation", each containing specific criteria. Exemplarily, the outcomes for the stages "treatment planning" and "treatment" are presented. There is variability both between features and between clinics. The majority of the patients report that the criteria are fulfilled while there are medium to high levels of fulfillment regarding the routine documentation. The criteria of the questionnaire of process-relevant structural features are mostly fulfilled according to the clinics. Agreement between the 3 data levels can be observed. On the basis of the defined "ideal process", the methods that were tested seem to be appropriate to illustrate process-relevant features from different perspectives. The exemplary measured process quality of the pilot clinics can be judged as predominantly good. Individual deficits of process quality and limitations of the chosen methods are discussed.

Can prevention classification be improved by considering the function of prevention?

Universal, selective and indicated forms of prevention have been adopted as improvements on previous notions of primary and secondary prevention. However, some conceptual confusion remains concerning the placing of environmental, community-based or mass media preventive interventions within this typology. It is suggested that a new dimension of functional types of prevention, namely environmental, developmental and informational prevention should be specified alongside the forms of prevention in a taxonomy matrix. The main advantage of this new taxonomy is that a matrix combining the form and function dimensions of prevention can be used to identify and map out prevention strategies, to consider where research evidence is present and where more is needed, and to evaluate the relative effectiveness of different categories and components of prevention for specific health and social issues. Such evaluations would provide empirical evidence as to whether the different categories of prevention are related to outcomes or processes of prevention in ways that suggest the value of the taxonomy for understanding and increasing the impact of prevention science. This new prevention taxonomy has been useful for conceptualising and planning prevention activities in a case study involving the Swedish National Institute for Public Health. Future work should assess (1) the robustness of this new taxonomy and (2) the theoretical and empirical basis for profiling prevention investments across the various forms and functions of prevention.

Do the incentive payments in the new NHS contract for primary care reflect likely population health gains?

OBJECTIVE: The new contract for primary care in the UK offers fee-for-service (FFS) payments for a wide range of activities in a quality outcomes framework (QOF), with payments designed to reflect likely workload. This study aims to explore the link between these financial incentives and the likely population health gains. METHODS: The study examines a subset of eight preventive interventions covering 38 of the 81 clinical indicators in the quality framework. The maximum payment for each service was calculated and compared with the likely population health gain in terms of lives saved per 100,000 population based on evidence from McColl et al. (1998). RESULTS: Maximum payments for the eight interventions examined make up 57% of the total maximum payment for all clinical interventions in the (QOF). There appears to be no relationship between pay and health gain across these eight interventions. Two of the eight interventions (warfarin in atrial fibrillation and statins in primary prevention) receive no incentive. CONCLUSIONS: Payments in the new contract do not reflect likely population health gain. There is a danger that clinical activity may be skewed towards high-workload activities that are only marginally effective, to the detriment of more cost-effective activities. If improving population health is the primary goal of the NHS, then FFS incentives should be designed to reflect likely health gain rather than likely workload.

CL Aniversario del Nacimiento de Ramón y Cajal: Jornada conmemorativa en el Instituto de Medicina Preventiva “Capitán Médico Ramón y Cajal”. 18 de Junio de 2002 / No disponible

No disponible

Adecuación de pautas vacunales en viajes internacionales. Vacunas en desarrollo / Adecuation of vaccination to the international traveller. Vaccines under development

Los importantes movimientos poblacionales y los viajes a países exóticos tan frecuentes en los tiempos modernos hacen que cada vez más a menudo el médico sea consultado sobre vacunaciones o medidas preventivas que un viajero debería recibir antes de emprender su viaje. Actualmente la Organización Mundial de la Salud (OMS) sólo exige la vacunación de la Fiebre Amarilla cuando se viaje a zonas endémicas así como la vacuna antimeningocócica para entrar en Arabia Saudí, el resto de las vacunas disponibles serán recomendadas según el tipo de viaje y la situación del viajero (AU)

Áreas emergentes en Medicina Preventiva / No disponible

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Áreas emergentes en Odontología / No disponible

No disponible