Negative outcomes associated with medication in patients with chronic atrial fibrillation who present at the emergency department.

WHAT IS KNOWN AND OBJECTIVE: Medication is the main treatment option for patients with chronic atrial fibrillation. However, medication can have negative effects. We aimed to detect negative outcomes associated with medication that led to patients with chronic atrial fibrillation presenting themselves to hospital emergency departments. We assessed the severity of those outcomes and comment on whether they could have been avoided. METHODS: This descriptive, cross-sectional study included all patients with chronic atrial fibrillation who attended the emergency department of our tertiary hospital. We used the Dader method to identify and evaluate the negative outcomes associated with medication through interviews with patients and scrutiny of the clinical charts. RESULTS AND DISCUSSION: Of the 198 eligible patients who presented at the emergency department, 134 (67·7%) did so because of negative outcomes associated with medication (41% related to necessity, 32·1% to effectiveness and 26·9% to safety); 67·9% of those negative outcomes could have been avoided. In terms of severity, 6·7% were mild, 31·3% moderate, 51·5% severe and 10·4% fatal. The Anatomical Therapeutic Chemical Classification anatomical group most frequently associated with negative outcomes was the cardiovascular system, followed by blood/blood-forming organs. WHAT IS NEW AND CONCLUSION: A high percentage of patients with chronic atrial fibrillation presenting at hospital emergency departments had negative outcomes associated with medication. Some led to deaths. More than half of these were severe, and most could have been avoided.

Efficacy of an aloe vera, chamomile, and thyme cosmetic cream for the prophylaxis and treatment of mild dermatitis induced by radiation therapy in breast cancer patients (the Alantel study).

Objectives: Radiation-induced dermatitis (RD) is one of the most common toxicities in radiation therapy (RT) patients. Corticosteroids, immunosuppressants, and natural products (NPs) have been used as treatment. The objective was to evaluate the efficacy of a NPs-based cream (Alantel®) to reduce the incidence of RD in women with breast cancer undergoing RT treatment. Design: We conducted a controlled, randomized, double-blind clinical trial. Setting: Radiation Oncology Unit of the Reina Sofía Hospital and 5 Primary Care centers of the Cordoba and Guadalquivir Health District (Spain). Interventions: Patients assigned to the experimental group (GTA) were treated with Alantel, while those in the control group (GTE) were treated with a moisturizer and emollient cream. Main outcome measures: The primary outcome variable was the incidence of RD. RD-free time, duration of RD, quality of life, and product safety were also assessed. Results: Seventy patients were included in the study, 35 in the GTA and 35 in the GTE. The incidence of RD was lower in the GTA (71.4%) than in the GTE (91.4%) after 4 weeks of follow-up (RR = 0.78; NNT = 5; p < 0.031). The Skindex-29 questionnaire showed differences in the statement: "My skin condition makes it hard to work or do hobbies" (17.1% in the GTE vs. 2.9% in GTA; p = 0.024). Conclusions: The higher efficacy of Alantel® compared to the control cream in reducing the incidence of RD in women with breast cancer has been demonstrated.

[Current status of medical care of emerging infectious diseases at hospital emergency services in Spain].

BACKGROUND: The aim of this study is to determine the current status of Spanish Hospital Emergency Services (HES) in diagnosing and treating the most prevalent tropical diseases (TD) in Spain. METHODS: A cross-sectional descriptive study was carried out, using a questionnaire in Google Forms® sent to members of the INFURG-SEMES group. The following variables were analyzed: the size of the hospital in terms of number of beds, number of tropical disease emergencies, existence of tropical medicine protocols, urgent diagnostic tests or antimalarial treatment. RESULTS: The form was sent to 75 hospitals. Responses were obtained from 42 emergency services (55%) in 10 Autonomous Communities. Twenty-four (57.1%) had >500 beds. Only five hospitals (11.9%) have the facilities to diagnose malaria and dengue 24 hours a day. There was no tropical disease protocol in 19 (45.3%) hospitals. Seven (16.7%) hospitals had =?10 attendances/day. Larger hospitals were more likely to have an infectious disease unit independent from Internal Medicine service, along with a tropical medicine unit, and an on-call infectious disease specialist and microbiologist. There are no statistically significant differences between larger and smaller hospitals in terms of their capacity to carry out appropri-ate diagnoses or treatments in 24 hours. CONCLUSION: Care and treatment of emerging diseases are now a sizeable percentage of the consultations at an HES. Such units generally lack specific protocols, particularly for malaria. Urgent diagnostic testing for malaria is also needed.

[Consensus document for sepsis code implementation and development in the Community of Madrid]. / Documento de consenso para la implantación y desarrollo del Código Sepsis en la Comunidad de Madrid.

The consensus paper for the implementation and development of the sepsis code, finished in April 2017 is presented here. It was adopted by the Regional Office of Health as a working document for the implementation of the sepsis code in the Community of Madrid, both in the hospital setting (acute, middle and long-stay hospitals) and in Primary Care and Out-of-Hospital Emergency Services. It is now published without changes with respect to the original version, having only added the most significant bibliographical references. The document is divided into four parts: introduction, initial detection and assessment, early therapy and organizational recommendations. In the second to fourth sections, 25 statements or proposals have been included, agreed upon by the authors after several face-to-face meetings and an extensive "online" discussion. The annex includes nine tables that are intended as a practical guide to the activation of the sepsis code. Both the content of the recommendations and their formal writing have been made taking into account their applicability in all areas to which they are directed, which may have very different structural and functional characteristics and features, so that we have deliberately avoided a greater degree of concretion: the objective is not that the sepsis code is organized and applied identically in all of them, but that the health resources work in a coordinated manner aligned in the same direction.

Situación actual de la atención a las enfermedades emergentes en los servicios de urgencias hospitalarias españoles / Current status of medical care of emerging infectious diseases at hospital emergency services in Spain

Fundamento: Conocer la situación organizativa de los hospitales españoles de cara a facilitar la atención adecuadaen los servicios de urgencias (SUH) de los pacientes queacudan con sospecha de infecciones de origen tropical. Método: Estudio descriptivo transversal mediante cuestionario en formato Google Forms® enviado a los miembros delgrupo de INFURG-SEMES. Se estudiaron variables como eltamaño del hospital a través del número de camas, el númerode urgencias de patología tropical, la existencia de protocolos de medicina tropical, de pruebas diagnósticas urgentes otratamiento antimalárico. Resultados: Se envió el formulario a 75 hospitales, obteniendo respuesta de 42 servicios de urgencias (55%), pertenecientes a 10 comunidades autónomas. Veinticuatro (57,1%)tenían más de 500 camas. Solo cinco hospitales (11,9%) podían diagnosticar malaria y dengue las 24 horas. En 19 hospitales (45,3%) no existía ningún protocolo de enfermedadtropical. En siete hospitales (16,7%) se realizaban diez o másasistencias/día. En los hospitales de mayor tamaño era másfrecuente la existencia de un servicio de enfermedades infecciosas independiente del servicio de Medicina Interna, unaunidad de medicina tropical, un infectólogo de guardia y unmicrobiólogo de guardia. No existen diferencias estadísticamente significativas entre los hospitales de mayor y menortamaño en cuanto a la capacidad para realizar diagnósticos otratamiento adecuados durante las 24 horas. Conclusiones: La atención de la patología importada supone un volumen no despreciable de consultas en los SUH,donde en general, se observa una ausencia de protocolosespecíficos, en especial, el protocolo específico de malaria,así como de escasa disponibilidad de prueba diagnósticaurgente de malaria.(AU)

Background: The aim of this study is to determine the current status of Spanish Hospital Emergency Services (HES) indiagnosing and treating the most prevalent tropical diseases (TD) in Spain. Methods: A cross-sectional descriptive study was carriedout, using a questionnaire in Google Forms® sent to members of the INFURG-SEMES group. The following variableswere analyzed: the size of the hospital in terms of numberof beds, number of tropical disease emergencies, existenceof tropical medicine protocols, urgent diagnostic tests orantimalarial treatment. Results: The form was sent to 75 hospitals. Responses wereobtained from 42 emergency services (55%) in 10 Autonomous Communities. Twenty-four (57.1%) had >500 beds.Only five hospitals (11.9%) have the facilities to diagnosemalaria and dengue 24 hours a day. There was no tropicaldisease protocol in 19 (45.3%) hospitals. Seven (16.7%)hospitals had ≥ 10 attendances/day. Larger hospitals weremore likely to have an infectious disease unit independentfrom Internal Medicine service, along with a tropical medicine unit, and an on-call infectious disease specialist andmicrobiologist. There are no statistically significant differences between larger and smaller hospitals in terms of theircapacity to carry out appropriate diagnoses or treatmentsin 24 hours. Conclusion: Care and treatment of emerging diseases arenow a sizeable percentage of the consultations at an HES.Such units generally lack specific protocols, particularly formalaria. Urgent diagnostic testing for malaria is also needed.(AU)

[Knowledge about AIDS and sexually transmitted diseases among adolescents]. / Conocimientos de los adolescentes sobre el sida y las enfermedades de transmisión sexual.

OBJECTIVE: To determine knowledge about AIDS and sexually transmitted diseases (STD) among school adolescent in order to define their lacks, and those aspects to include in programs of health education. DESIGN: Cross-sectional study. SETTING: Secondary schools from Córdoba. PARTICIPANTS: 893 teen students. Stratified random sample. MAIN MEASUREMENTS: Anonymous self administered survey. Dates related with knowledge about AISD, STD and its mechanism of transmission. MAIN RESULTS: The mean age of the sample was 17.16 years (95% CI, 17.05-17.26) and 48% was men. 56.7% (95% CI, 53.46-59.94) recognize to be very informed about AIDS and STD, finding significant differences among public (58.9%) and private schools (51.6%) (P=.045). About AIDS, the mean of successes was 8.81 (95% CI, 8.69-8.92; limits 0-12), finding positive differences among men (P=.048); older students (P=.003); public schools (P=.025), and the students non believers (P=.021). About STD, the mean of successes was of 2.47 (95% CI, 2.35-2.78; limits 0-12), with significant differences among women (P=.045); older students (P=.001) and public schools (P=.001). About AIDS sexual transmission, the mean of successes was of 13 (95% CI, 12.87-13.12; limits 0-16), without differences between sex, classrooms or type of schools. CONCLUSIONS: Level of knowledge shown by adolescents for aspects related to STD is poor. Likewise, the information about AIDS can be consider as enough, being men those that to present a bigger degree of knowledge.

Bioaccumulation of heavy metals in Spartina.

The Spartina Schreb. genus is composed of C4 perennial grasses in the family Poaceae. They are native to the coasts of the Atlantic Ocean in western and southern Europe, north-west and southern Africa, the Americas and the southern Atlantic Ocean islands. Most species are salt tolerant and colonise coastal or inland saltmarshes. The available literature on heavy metal bioaccumulation by Spartina sp. was compiled and compared. Spartina alterniflora Loisel. and Spartina maritima (Curtis) Fernald were the most commonly researched species of the genus, whereas many species were not represented at all. In contrast, Cu and Zn are the most intensively researched heavy metals. The few studies dealing with the physiological impacts of heavy metals or the mechanisms of metal accumulation, which involve extracellular and intracellular metal chelation, precipitation, compartmentalisation and translocation in the vascular system, were documented. Bioaccumulation of metals in roots and tillers of some species of the Spartina genus (e.g. S. maritima and Spartina densiflora Brongn.) has been described as a feasible method for remediating waters and soils contaminated with heavy metals. One such example is Spartina argentinensis Parodi, which has been found to be a Cr-hyperaccumulator; it can concentrate chromium in its tissues to levels far exceeding those present in the soil.

[Reasons and determining factors for referrals between primary and specialised care]. / Motivos y condicionantes de la interconsulta entre atención primaria y especializada.

OBJECTIVES: To determine the reasons and characteristics of referrals from Primary to Specialised Care in the Health Area of Toledo (Spain). MATERIAL AND METHODS: A descriptive, cross-sectional study was conducted by reviewing a sample of the referrals to specialists made by 26 general practitioners from eight Teaching Health Centres during February 2011. All of them completed a questionnaire which recorded patient data, and reason and characteristics of the referral. RESULTS: A total of 332 referrals were recorded; the mean age of the patients was 51.3 years (SD; 17.9); 60.1% females; 30.7% pensioners; 54.8% had a chronic disease; 85.8% were from an urban environment. The most consulted specialists were: Traumatology (63), Gynaecology (53), and Ophthalmology (41). More than three-quarters (78.9%) were by the normal route, and 47.4% were first consultations. Around 12.7% were scheduled reviews, with a majority (51.4%) by a hospital specialist. More than two thirds (69.8%, 95% CI; 64.5-74.7%) required follow-up or treatment by the specialist. More than half (57.7%, 95% CI; 52.3-63.1%) required special diagnostic tests, and in 29.8% (95% CI; 25.0-35.1%) there was no clear diagnosis. There was a history of a repeated consultation for the same symptomatology in 28.9% of the referrals. Around 38.4% (95% CI; 33.0-43.7%) were requested specifically by the family or patient. Around 5.4% had a poor relationship with the patient. CONCLUSIONS: The majority of referrals are made by the normal route, and to surgical specialities. The need for hospital specialist follow-up and/or treatment, or the impossibility to request specific tests from Primary Care were the main reasons for requesting care from a second health care level. There were a high percentage of referrals requested by the family/patient.

[Retroperitoneal tumor arising from neural crest: ganglioneuroma+]. / Tumor retroperitoneal derivado de la cresta neural: ganglioneroma.

OBJECTIVES: This study shows the contribution of the different imaging methods in the diagnosis of retroperitoneal ganglineuroma. METHODS: A retroperitoneal mass was incidentally detected in a young male patient. Patient evaluation included plain abdominal radiography, intravenous urography, ultrasound and computed tomography. RESULTS: Ultrasound and computed tomography provide information on tumor characteristics and extent, although it has no diagnostic specifity and does not permit distinguishing ganglioneuroma from other neural crest tumors.

[Sexual behaviour among school adolescents in Córdoba]. / Comportamiento sexual de los escolares adolescentes en la ciudad de Córdoba.

OBJECTIVE: To know sexual behaviour among school teenagers and to determine different risk behaviors and groups with specific needs of health education. DESIGN: Cross-sectional study. SETTING: High-schools from Córdoba. PARTICIPANTS: 893 teenagers students selected by random sample. MAIN MEASUREMENTS: Anonymous self-rated survey about sexual behaviour and uses of contraceptives methods. MAIN RESULTS: The average age was 17.16 years (95% CI, 17.05-17.26), 48% males. 22.9% have had completed sexual relations; there were mainly girls (P=.001). The average age for the first relation was 16.64 years (95% CI, 16.45-16.82), with no difference between gender. Among girls, first sexual intercourse use to be with their regular partners (P<.001). 48% of the girls have had one or more sexual intercourse per week, that was only a 19.5% among boys (P<.001). 82% had used a contraceptive method at the first time, and the condom was the method more frequently used. CONCLUSIONS: 20% of school teenagers have had complete sexual intercourse, most of them before 18 years. Girls have more frequently sexual relations, usually with their regular partners. Condom is the contraceptive method more frequently used.

[Reliability of blood pressure measurement: the patient versus primary care workers]. / Fiabilidad en la medición de la presión arterial: paciente frente a profesionales de atención primaria.

OBJECTIVE: To evaluate the degree of inter-observer concordance in the blood pressure figures taken by a nurse and a doctor with a mercury sphygmomanometer and by the patient with a semi-automatic device. DESIGN: Observational, crossover study. SETTING: A rural health centre. PATIENTS: 318 people selected by systematic sampling. INTERVENTIONS: Pressure was taken in different ways by 3 different "observers" (0): the patient with a semi-automatic device (01), a nurse (02) and a family doctor (03). Inter-observer concordance was assessed through the Intra-class Correlation Coefficient (ICC) and the kappa index. MEASUREMENTS AND MAIN RESULTS: 42.1%, 41.8% and 44.3% of patients had high blood pressure (> or = 140/90 mmHg) according to 01, 02 and 03, respectively. 33% were known to be hypertense. The ICC for systolic pressure was 0.81 (95% CI, 0.75-0.87) between 01 and 02; 0.84 (CI, 0.78-0.90) between 01 and 03; and 0.87 (CI, 0.82-0.92) between 02 and 03. The ICC for diastolic pressure was 0.67 (CI, 0.59-0.75), 0.72 (CI, 0.64-0.79) and 0.79 (CI, 0.72-0.86) for 01-02, 01-03 and 02-03, respectively. The kappa index was 0.53 (CI, 0.43-0.62) for 01-02; 0.60 (CI, 0.51-0.68) for 01-03; and 0.67 (CI, 0.58-0.75) for 02-03. CONCLUSIONS: Inter-observer concordance was good, with no substantial differences between the measurements made by the different observers. As the figures determined by the semi-automatic device were reliable, this is a good option for the follow-up and monitoring of hypertense patients.

Effect of low doses of deflazacort vs prednisone on bone mineral content in premenopausal rheumatoid arthritis.

Longterm administration of steroid drugs, particularly prednisone, is known to induce osteoporosis, as well as bone growth inhibition and delayed fracture union. Recently deflazacort, an oxazoline prednisone derivative, has been developed to reduce such deleterious effects. We carried out a comparative study in premenopausal patients with rheumatoid arthritis (RA). Sixteen cases whose mean age was 36.5 years and mean disease duration 29 months, all fulfilling ARA criteria, were evaluated in a randomized, double blind trial. Visually identical deflazacort or prednisone capsules were given and patients were instructed to maintain an adequate calcium intake. Laboratory tests focussed on bone mineral density in lumbar spine, femoral neck and Ward's triangle and whole body mineral content. Differences between baseline and 12-month values were processed statistically. Persistent synovitis control proved similar for both drugs and features suggestive of Cushing's syndrome were only found in the prednisone group. The difference in whole body bone mineral content between the deflazacort and prednisone groups just failed to reach statistical significance. In the deflazacort group, the difference between the nonsignificant bone mineral density increase at the femoral neck and the significant decrease in the prednisone group proved statistically significant. Ward's triangle was the most sensitive area to bone mineral density changes in patients receiving prednisone, with a highly significant intergroup difference (p < 0.01). We believe this is the first study on corticosteroid induced osteoporosis, as evaluated by whole body mineral content measurements in premenopausal patients with short term RA, showing that deflazacort is a promising alternative in cases severe enough to require steroid therapy.

Motivos y condicionantes de la interconsulta entre atención primaria y especializada / Reasons and determining factors for referrals between primary and specialised care

Objetivos. Conocer los motivos y características de las derivaciones desde atención primaria a especializada en el área de Salud de Toledo. Material y métodos. Estudio de tipo descriptivo transversal. Se revisó una muestra de las interconsultas a especializada realizadas por 26 médicos de familia, pertenecientes a 8 centros de salud docentes, en febrero de 2011. Por cada una, se cumplimentó un cuestionario que recogía datos del paciente, motivo y características de la derivación. Resultados. Se recogieron 332 interconsultas; la edad media de los pacientes fue de 51,3 años (DE 17,9); el 60,1% mujeres; el 30,7% pensionistas; el 54,8% presentaban patología crónica; el 85,8% procedía del medio urbano. Las especialidades más consultadas fueron: Traumatología (63), Ginecología (53) y Oftalmología (41). El 78,9% fueron vía normal y 47,4% fueron primeras consultas. Un 12,7% eran revisiones programadas, en su mayoría (51,4%) por el especialista hospitalario. El 69,8% (IC95% 64,5–74,7%) precisaba seguimiento o tratamiento por el especialista. El 57,7% (IC95% 52,3–63,1%) requería pruebas diagnósticas especiales. En el 29,8% (IC95% 25,0–35,1%) no estaba claro el diagnóstico. En el 28,9% de las derivaciones había antecedentes de consulta reiterada por esa sintomatología. En el 38,4% (IC95% 33,0–43,7%) hubo solicitud expresa por familia o paciente. El 5,4% tenía mala relación con el paciente. Conclusiones. La mayoría de las derivaciones se hacen por vía normal y a especialidades quirúrgicas. La necesidad de seguimiento y/o tratamiento por parte del especialista hospitalario o la imposibilidad de solicitar determinadas pruebas desde atención primaria fueron los principales motivos para solicitar la atención del segundo nivel asistencial. Existe un alto porcentaje de interconsultas inducidas por la familia/paciente(AU)

Objectives. To determine the reasons and characteristics of referrals from Primary to Specialised Care in the Health Area of Toledo (Spain). Material and methods. A descriptive, cross-sectional study was conducted by reviewing a sample of the referrals to specialists made by 26 general practitioners from eight Teaching Health Centres during February 2011. All of them completed a questionnaire which recorded patient data, and reason and characteristics of the referral. Results. A total of 332 referrals were recorded; the mean age of the patients was 51.3 years (SD; 17.9); 60.1% females; 30.7% pensioners; 54.8% had a chronic disease; 85.8% were from an urban environment. The most consulted specialists were: Traumatology (63), Gynaecology (53), and Ophthalmology (41). More than three-quarters (78.9%) were by the normal route, and 47.4% were first consultations. Around 12.7% were scheduled reviews, with a majority (51.4%) by a hospital specialist. More than two thirds (69.8%, 95% CI; 64.5–74.7%) required follow-up or treatment by the specialist. More than half (57.7%, 95% CI; 52.3–63.1%) required special diagnostic tests, and in 29.8% (95% CI; 25.0-35.1%) there was no clear diagnosis. There was a history of a repeated consultation for the same symptomatology in 28.9% of the referrals. Around 38.4% (95% CI; 33.0–43.7%) were requested specifically by the family or patient. Around 5.4% had a poor relationship with the patient. Conclusions. The majority of referrals are made by the normal route, and to surgical specialities. The need for hospital specialist follow-up and/or treatment, or the impossibility to request specific tests from Primary Care were the main reasons for requesting care from a second health care level. There were a high percentage of referrals requested by the family/patient(AU)

Prionpatías: las encefalopatías por priones / Prion diseases: prion encephalopathies

Las prionpatías o encefalopatías por priones son un grupo de enfermedades poco frecuentes que comparten una fisiopatología similar con distintas características clínicas. La enfermedad de Creutzfeldt-Jakob (ECJ) esporádica es la más conocida. Se manifiesta con una demencia rápidamente progresiva, ataxia y sintomatología extrapiramidal. Aunque el diagnóstico de certeza es anatomopatológico se puede llegar al diagnóstico probable empleando los criterios establecidos por la Organización Mundial de la Salud. Se está discutiendo en la actualidad la posibilidad de integrar la resonancia magnética nuclear en dichos criterios para aumentar la sensibilidad del diagnóstico. Las técnicas moleculares de estudio de proteínas en el líquido cefalorraquídeo tienen un peso creciente y colaboran en el diagnóstico. El diagnóstico de las otras encefalopatías por priones no es tan avanzado como el de la ECJ. El tratamiento de todas estas enfermedades continúa siendo paliativo (AU)

Prion diseases or prion encephalopathies are a group of rare disorders that share a similar pathophysiology with different clinical characteristics. Sporadic Creutzfeldt-Jakob disease (CJD) is best known. It presents as a rapidly progressive dementia, ataxia and extrapyramidal symptoms. Although accurate diagnosis is by histopathological examination, a diagnosis can be probably achieved using the criteria established by the World Health Organization. We are currently discussing the possibility of integrating the nuclear magnetic resonance into this criteria for increasing the sensitivity of diagnosis. Molecular techniques for studying proteins in cerebrospinal fluid have an increasingly significant role in aiding diagnosis. The diagnosis of other prion encephalopathies is not as advanced as that of CJD. The treatment of these diseases remains palliative (AU)