Comparison of two HIV testing strategies in primary care centres: indicator-condition-guided testing vs. testing of those with non-indicator conditions.

OBJECTIVES: The aim of the study was to compare prospectively indicator-condition (IC)-guided testing versus testing of those with non-indicator conditions (NICs) in four primary care centres (PCCs) in Barcelona, Spain. METHODS: From October 2009 to February 2011, patients aged from 18 to 65 years old who attended a PCC for a new herpes zoster infection, seborrhoeic eczema, mononucleosis syndrome or leucopenia/thrombopenia were included in the IC group, and one in every 10 randomly selected patients consulting for other reasons were included in the NIC group. A proportion of patients in each group were offered an HIV test; those who agreed to be tested were given a rapid finger-stick HIV test (€6 per test). Epidemiological and clinical data were collected and analysed. RESULTS: During the study period, 775 patients attended with one of the four selected ICs, while 66,043 patients presented with an NIC. HIV screening was offered to 89 patients with ICs (offer rate 11.5%), of whom 85 agreed to and completed testing (94.4 and 100% acceptance and completion rates, respectively). In the NIC group, an HIV test was offered to 344 persons (offer rate 5.2%), of whom 313 accepted (90.9%) and 304 completed (97.1%) testing. HIV tests were positive in four persons [prevalence 4.7%; 95% confidence interval (CI) 1.3-11.6%] in the IC group and in one person in the NIC group (prevalence 0.3%; 95% CI 0.01-1.82%; P < 0.009). If every eligible person had taken an HIV test, we would have spent €4650 in the IC group and €396,258 in the NIC group, and an estimated 36 (95% CI 25-49) and 198 persons (95% CI 171-227), respectively, would have been diagnosed with HIV infection. The estimated cost per new HIV diagnosis would have been €129 (95% CI €107-153) in the IC group and €2001 (95% CI €1913-2088) in the NIC group. CONCLUSIONS: Although the number of patients included in the study was small and the results should be treated with caution, IC-guided HIV testing, based on four selected ICs, in PCCs seems to be a more feasible and less expensive strategy to improve diagnosis of HIV infection in Spain than a nontargeted HIV testing strategy.

Effective chemical control of psychrotrophic Bacillus cereus EPSO-35AS and INRA TZ415 spore outgrowth in carrot broth.

The growth kinetic parameters of germinated cells from heat-activated spores of the psychrotrophic Bacillus cereus EPSO-35AS strain in nutrient broth (NB) and in tyndallized carrot broth (TCB) were evaluated at different temperatures (8, 12, and 16 degrees C) for control samples and for samples acidified with citric acid or lemon juice at pH values between 4.7 and 5.5. Lowering the pH from 7.4 or 6.2 to 5.2 inhibited bacterial growth in both tested media after 60 days at 12 degrees C and lower temperatures, confirming the effectiveness of acidification in association with refrigeration to control B. cereus proliferation in minimally processed foods (MPFs) based on carrot. The activities of selected concentrations of cinnamon essential oil, cinnamaldehyde, carvacrol, and eugenol against B. cereus EPSO-35AS and INRA TZ415 strains in both media over the same temperature range were also studied. Addition of either cinnamon essential oil or cinnamaldehyde at concentrations of 5 and 2 microL 100mL(-1), respectively, caused complete inhibition of the growth of both psychrotrophic strains even if mild temperature abuse occurred (12 degrees C). Hence, a combination of one of these compounds and refrigerated storage may be useful for preservation of MPFs in which major ingredient was carrot. On the contrary, carvacrol and eugenol were not able to prevent B. cereus growth in TCB during storage at 8 degrees C. Their effects on the organoleptic characteristics of TCB are discussed.

Effects of antimicrobial components of essential oils on growth of Bacillus cereus INRA L2104 in and the sensory qualities of carrot broth.

The possible use of antimicrobials from seven plant essential oils as food preservatives was studied by examining their effects on the growth kinetics of activated Bacillus cereus INRA L2104 spores inoculated into tyndallized carrot broth. The effects of various concentrations of borneol, carvacrol, cinnamaldehyde, eugenol, menthol, thymol, and vanillin were determined. Five microliters of cinnamaldehyde, 15 microl of carvacrol, or 30 mg of thymol per 100 ml of inoculated carrot broth completely inhibited bacterial growth for more than 60 days at 16 degrees C. Lower concentrations of the three antimicrobials prolonged the lag phase and reduced both the exponential growth rate and the final population densities of cultures. The study of the sensory characteristics of the supplemented broths suggested that low concentration of cinnamaldehyde enhanced the taste of carrot broth, and that it did not have any adverse effect on the taste and smell of carrot broth at concentrations less than 6 microl 100 ml(-1).

[Provision of continuous health care by a unit connected to primary care centres coordinated by specialist physicians]. / Aportación al continuo asistencial de una consulta de conexión con atención primaria coordinada con internistas.

OBJECTIVE: To evaluate the efficacy and efficiency of a system set up to overcome the current disparity between primary and specialist health care and with the capacity to detect patients with significant diseases. MATERIAL AND METHODS: To describe the activity of the Unit for Connection with Primary Care Centres (UCPCC) in the Alcoy Health Area (Alicante) during its first year. RESULTS: A total of 450 visits were made, with 6.5 (95% CI 5.7-7.3) first visits, and 3.9 (95% CI 3.1-4.8) successive ones per day. There were more than 50 reasons for consultation, and more than 60 final diagnoses (65.6% non-significant, 14% undefined and 12.4% significant). Digestive (31%) and functional (14.4%) diseases were the most frequently defined diagnoses, with neoplasic and autoimmune diseases among those defined as significant ones. The great majority (86.9%) of patients required 1-2 visits, with 40% diagnosed by just reviewing the hospital files. More than 20 different complementary examinations were performed, with 38.8%, 34.4%, 21.6%, and 5.2% of patients requiring 0, 1, 2, or ≥ 3, respectively. Patients with a significant pathology were diagnosed more quickly (12.4 ± 19.4 vs. 45.3 ± 52.8 days; P = .001), with less complementary examinations (0,5 ± 0,7 vs. 0,9 ± 0,9 per patient; P = .032. 58.6% vs. 39.6% patients without complementary examinations; P = .052), and were more frequently referred to specialised medicine (58.6% vs. 18.3%, P < .0001). CONCLUSIONS: The demonstrated differential management of patients with potentially significant pathology using existing resources, make the UCPCC with internists an efficient model for the connection between health care levels.

Survival, isolation and characterization of a psychrotrophic Bacillus cereus strain from a mayonnaise-based ready-to-eat vegetable salad.

Incidence and population levels of Bacillus cereus in American salad, an industrially manufactured, packaged and refrigerated deli salad containing vegetables and mustard, were determined. Of 12 ready-to-eat samples examined, one (8.3%) was positive for B. cereus at less than 5 x 10(3)cfu g(-1). According to the ISO confirmation procedure, a strain was isolated and further characterized and identified as B. cereus EPSO-35AS by API 50CH/20E phenotypic system, combined with additional tests of motility, oxidase activity and anaerobic growth. This strain produced diarrhoeal enterotoxin in tryptic soy broth culture as detected by BCET-RPLA test, hydrolysed starch and had a low D(90)-value (2.1 min), with an estimated z-value of 6.79 degrees C. After a lengthy lag phase (9-12 days of incubation), the strain was able to grow at 8 degrees C in both nutrient broth and tyndallized carrot broth with specific growth rates from 0.009 to 0.037 h(-1), respectively. In the vegetable substrate, lag time was approximately 3 days (66 h) shorter than in laboratory medium. The effect of temperature abuses on the safety of the product during the time of use or consumption is discussed.

Utilidad del índice tobillo/brazo en un paciente aparentemente normotenso con lumbociatalgia crónica y disfunción eréctil / Utility of the ankle/brachial index (ABI) in apparently normotensive patient with chronic low back pain and erectile dysfunction

Los datos anamnésicos y exploratorios siguen siendo clave en el manejo del hipertenso. También, y en contra de la creciente parcelación del saber médico, es necesaria una visión global e integradora, lo que exige la búsqueda activa de la lesión del órgano diana. El índice tobillo/brazo (ITB) emerge como una herramienta sencilla que permite a través de la detección de estenosis arteriales proximales, corregir no solo limitaciones de la de ambulación sino de manifestaciones relacionadas y a menudo olvidadas como la disfunción eréctil o la HTA vasculorrenal. No olvidemos que el mejor marcador de riesgo son los valores adecuadamente obtenidos de presión arterial y su correcta interpretación y que conviene evitar errores tan comunes como la toma tensional única, el fenómeno del redondeo o el de alarma. Alrededor de la mitad de pacientes con ITB patológico, están asintomáticos o presentan claudicación atípica, por lo que se hace aconsejable la realización extensiva del ITB en la población de riesgo cardiovascular significativo, independientemente de la presencia de síntomas (AU)

Anamnesic and examination data are still the key for the management of the hypertensive subject. In addition, and against the growing division into parcels of medical knowledge ,it is necessary to have a global and integrating view. This requires the active search for the target organ injury. To do so, the ankle/brachial index (ABI) is a simple test which, simultaneously, makes it possible to detect reversible arterial lesions and therefore treat the symptoms by intermittent claudication or manifestations that are also related and often overlooked, such as erectile dysfunction or renovascular hypertension. We must not forget that the best marker of risk is the correct levels of BP and their correct interpretation and that such common errors as using a single measurement of blood pressure, and the phenomenon of rounding up or down or of alarm should be avoided. Approximately half of patients with pathological ABI are a symptomatic or have atypical claudication. Thus, it is recommendation to made extensive use of the ABI in the significant cardiovascular risk population independently of the presence of symptoms (AU)

Enfermedad renal crónica, fórmulas de estimación de la función renal, hipertensión y envejecimiento. Réplica / Chronic kidney isease, formulae to estimate kidney function, hypertension and aging. Reply

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Vómitos persistentes en mujer hipertensa / Persistent vomiting in a hypertensive woman

Numerosos documentos insisten en la necesidad deun control estricto de la presión arterial (PA). Contrasta la escasa información publicada al respecto de la reducción tensional estricta y sus potenciales consecuencias negativas. Presentamos una paciente con hipertensión arterial (HTA) crónica esencial en tratamiento farmacológico y dos ingresos hospitalarios por vómitos secundarios a hiponatremia (hNa+) por tiazidas. Discutimos las causas más comunes de hNa+ enel paciente hipertenso, igualmente con muy escasabibliografía. El caso expuesto ilustra varios errores comunes en la praxis clinica habitual: erróneo diagnóstico de HTA por incorrecta técnica de medida de laPA, inicio precoz de tratamiento farmacológico basadoúnicamente en valores de PA e inadecuado empleode la automedida domiciliaria de PA (AMPA). Todoello llevó a una iatrogenia y a la realización demaniobras invasivas en una paciente con una HTA debata blanca donde se echa de menos un abordaje menosfragmentario y más acorde con las guías terapéuticasen uso

Many documents stress the need for strict control ofblood pressure (BP) on the contrary to the scarce information published regarding strict tension reductionand its potential negative consequences.We present apatient suffering chronic essential AHT under drugtreatment and with two admissions to hospital dueto vomiting secondary to hyponatremia (hNa+) due tothiazides. We discuss the most common causes ofhNa+ in the hypertensive patient, this also being veryscarce in the literature. The case presented illustratesseveral common errors in the common clinical practice:erroneous diagnosis of AHT due to incorrect measurementtechnique of BP, early onset of drug treatmentonly based on BP values and inadequate use ofABPM. All of this led to an iatrogeny and conductionof invasive maneuvers in a female patient with whitecoat hypertension in whom a less fragmented approachand one more in agreement with the therapheuticguidelines in use should have been used

Estrategias para el despistaje de la HTA secundaria / Strategies for screening of secondary high blood pressure

La HTA secundaria (HTAs) es una entidad infrecuente en la población hipertensa general y, en contra de la idea generalizada, con tasas de reversibilidad bajas, lo que a menudo se relaciona con el diagnóstico y tratamiento tardío de la entidad etiológica. La potencial reversibilidad en estadios tempranos y la mayor morbimortalidad consecuencia de la elevación tensional mantenida justifican su despistaje, si bien el elevado coste económico derivado y el gran número de etiologías a considerar hacen que deba restringirse la búsqueda a pacientes con riesgo: HTA refractaria, HTA con importante daño orgánico, HTA iniciada en edades extremas de la vida o con empeoramiento de su control sin causa aparente. Es muy escasa la información contrastada que permita establecer algoritmos definitivos para el despistaje de la HTAs. Siempre deberá prevalecer el sentido común y la accesibilidad a las pruebas en el medio clínico concreto donde nos desenvolvamos. La búsqueda debe centrarse en las formas más prevalentes y con mayor potencial de reversibilidad: toma de sustancias presoras o que interaccionan con fármacos antihipertensivos, la enfermedad renal crónica, enfermedades endocrinológicas y síndrome de apnea obstructiva del sueño. Para la acotación de la búsqueda ayuda considerar el grupo de edad del paciente concreto y la búsqueda activa de rasgos clínicos y/o analíticos específicos. El adecuado despistaje de la HTAs en definitiva requiere de nuestra capacidad de visión global del proceso hipertensivo, así como de mucho sentido común en la elección de las exploraciones a realizar

Secondary high blood pressure (HB) is an uncommon entity in the general hypertensive population. On the contrary to the generalized idea, it has low reversibility rates, which is often related with the late diagnosis and treatment of the etiological entity. The reversibility potential in early stages and greater morbidity-mortality as a result of the maintained tensional elevation justify its screening. However, the elevated financial cost derived and large number of etiologies to be considered require restricting the search to patients at risk: refractory HBP, HBP with significant organic damage, HBP initiated in extreme ages of life or with worsening of its control without apparent cause. Contrasted information making it possible to establish definitive algorithms for screening of HBPs is very limited. Common sense and accessibility to the tests in the specific clinical setting where we work should always prevail. The search should be centered on more prevalent forms and with greater reversibility potential: using pressor substances or those that interact with antihypertensive drugs, chronic kidney disease, endocrinological diseases and COPDs. When limiting the search, it is helpful to consider the age group of the patient considered and the active search of specific clinical and/or analytic traits. Adequate screening of HBPs finally require us to have capacity to obtain a global view of the hypertensive condition and to use much common sense in the choice of the examinations to be made

Tratamiento farmacológico combinado en el manejo de la hipertensión arterial crónica esencial / Combination drug-treatment in the management of chronic essential hypertension

A pesar de la demostrada eficacia del abundante arsenal farmacológico disponible hoy día para el tratamiento de la hipertensión arterial crónica, las tasas de control siguen siendo bajas, si bien existe una lenta y progresiva mejoría. Las causas de esta falta de control son múltiples, pudiendo citar como principales la escasa adherencia por parte de los pacientes y la actitud conservadora de muchos médicos a la hora de medicar. Ello entra en franca discrepancia con lo que desde las principales guías sobre hipertensión se propugna en el sentido de buscar objetivos más estrictos de presión arterial. Dada la ausencia de nuevos fármacos a aparecer en un futuro inmediato, la estrategia antihipertensiva con asociación temprana de antihipertensivos aparece como la forma más inmediata de optimizar el tratamiento antihipertensivo. Aunque la información al respecto de las asociaciones de antihipertensivos son consecuencia de la extrapolación de estudios realizados con monoterapia. A la espera de ensayos específicos comparativos entre monoterapia y asociación y entre asociaciones, la lógica fisiopatológica debe guiar nuestra actuación. La combinación de antihipertensivos debe basarse en la búsqueda de la complementariedad de mecanismos antihipertensivos que permita el empleo de dosis menores sin merma en la eficacia antihipertensiva y consecuente mejora de tolerabilidad. La elección final de la terapia combinada determinada ante un hipertenso concreto deberá seguir los mismos principios de individualización que rigen la elección de la monoterapia. Para un futuro inmediato cabe plantear la asociación con fármacos no directamente antihipertensivos pero con efectos potenciadores de los antihipertensivos como estatinas y glitazonas, y tal vez antioxidantes y antiagregantes, así como de estrategias como la cronoterapia y la farmacogenética como una forma de optimizar el tratamiento de combinación (AU)