Periodic gastroenterology and hepatology meetings with primary care. Reasons for consultation.

INTRODUCTION: care overload, aging of population, and increased chronic diseases lead to increased referrals from primary care, which may sometimes overload the health system. Thus, different interventions have been carried out attempting to improve these aspects. OBJECTIVES: to assess the most frequent causes of consultation of general physicians, both in joint consultations and clinical sessions held jointly with specialist consultant in primary care, in the urban and rural setting, and the influence on referrals to first consultations of gastroenterology. MATERIAL AND METHODS: a mainly training type of intervention was carried out, consisting of regular meetings in both urban and rural primary care center, to perform joint consultations and clinical sessions on patients and topics related to the specialty of gastroenterology. The intervention period (divided in two subperiods) was compared with a control period. RESULTS: most reasons for consultation were those corresponding to lower gastrointestinal tract, followed by liver disease and upper gastrointestinal tract. Significant differences were only found in distribution of diagnoses between the two centers in joint consultations. There was a relative (percent) decrease in referrals at the global level in both subperiods, only significant in the first (51.45 %), as well as in rural setting (45.24 %). CONCLUSION: common consultations motifs were similar in urban and rural settings, with some relevance of lower gastrointestinal tract disease. Most of them can be solved at primary care, with the help of consultant specialist. There is impact on referrals to the outpatient first consultations of gastroenterology, mainly in rural setting.

A prediction rule for estimating the risk of bacteremia in patients with community-acquired pneumonia.

BACKGROUND: We endeavored to construct a simple score based entirely on epidemiological and clinical variables that would stratify patients who require hospital admission because of community-acquired pneumonia into groups with a low or high risk of developing bacteremia. METHODS: Derivation and internal validation cohorts were obtained by retrospective analysis of a database that included 3116 consecutive patients with community-acquired pneumonia from 2 university hospitals. Potential predictive factors were determined by means of a multivariate logistic regression equation applied to a cohort consisting of 60% of the patients. Points were assigned to significant parameters to generate the score. It was then internally validated with the remaining 40% of patients and was externally validated using an independent multicenter cohort of 1369 patients. RESULTS: The overall rates of bacteremia were 12%-16% in the cohorts. The clinical probability estimate of developing bacteremia was based on 6 variables: liver disease, pleuritic pain, tachycardia, tachypnea, systolic hypotension, and absence of prior antibiotic treatment. For the score, 1 point was assigned to each predictive factor. In the derivation cohort, a cutoff score of 2 best identified the risk of bacteremia. In the validation cohorts, rates of bacteremia were <8% for patients with a score 1 (43%-49% of patients), whereas blood culture results were positive in 14%-63% of cases for patients with a score 2. CONCLUSIONS: This clinical score, based on readily available and objective variables, provides a useful tool to predict bacteremia. The score has been internally and externally validated and may be useful to guide diagnostic decisions for community-acquired pneumonia.

Posterior fossa clear cell meningioma without dural attachment in a child.

INTRODUCTION: Meningiomas are relatively uncommon in childhood. They represent 1% to 2% of all intracranial tumours of infancy and childhood and 1.5% to 1.8% of all intracranial meningiomas. Occasionally, meningiomas may develop without dural attachment. Clear cell meningioma is a histological distinctive uncommon variant of meningioma that may behave aggressively with local recurrence and progression as well as cerebrospinal fluid-borne metastasis. Meningiomas near the craniocervical junction represent challenging tumours, requiring special considerations because of the vicinity of the medulla oblongata, the lower cranial nerves and the vertebral artery. CASE REPORT: In this study, the authors present a rare case of posterior fossa clear cell meningioma without dural attachment in a child with severe brainstem and cervical spinal cord displacement and discuss the clinical and radiological features as well as treatment considerations.

Efficacy of combining home-based transcranial direct current stimulation with mindfulness-based meditation for pain in older adults with knee osteoarthritis: A randomized controlled pilot study.

Transcranial direct current stimulation (tDCS) has been shown to be effective for reducing pain, and a growing body of literature shows the potential analgesic effects of mindfulness-based meditation (MBM). However, few studies have investigated the potential benefits associated with combining tDCS and MBM in older adults with knee osteoarthritis (OA). Therefore, the aim of this study was to examine the feasibility and preliminary efficacy of home-based tDCS paired with MBM in older adults with knee OA. Thirty participants 50-85 years old with symptomatic knee OA were randomly assigned to receive 10 daily sessions of home-based 2 mA tDCS paired with active MBM for 20 min (n = 15) or sham tDCS paired with sham MBM (n = 15). We measured clinical pain and OA symptoms via a Numeric Rating Scale and the Western Ontario and McMaster Universities Osteoarthritis Index. Pressure pain sensitivity and conditioned pain modulation were measured using quantitative sensory testing. Participant satisfaction and side effects were assessed via a questionnaire. Active tDCS paired with active MBM significantly reduced scores on the Numeric Rating Scale and Western Ontario and McMaster Universities Osteoarthritis Index and increased pressure pain thresholds and conditioned pain modulation. Participants tolerated tDCS paired with MBM well without serious adverse effects and were satisfied with the treatment. Our findings demonstrate promising clinical efficacy of home-based tDCS paired with MBM for older adults with knee OA.

[Immunity against hepatitis A virus in patients with chronic hepatitis C]. / Inmunidad frente al virus de la hepatitis A en los pacientes con infección crónica por el virus de la hepatitis C.

BACKGROUND AND OBJECTIVE: Because of high fatality rate associated with acute infection by hepatitis A virus (HAV) in chronic hepatitis C patients, it is of interest to know the prevalence of immunization against HAV in these patients. PATIENTS AND METHOD: Immunoglobulin G (IgG) IgG HAV antibodies (IgG anti-HAV) were determined in 313 hepatitis C virus antibodies (anti-HCV) positive patients and in 313 anti-HCV negative subjects (control group). Several epidemiological factors were recorded (age, sex, rural vs urban precedence, tattoos, parenteral drugs use, alcohol consumption and surgery). RESULTS: The prevalence of IgG anti-HAV was identical in both groups: 81.2%. However, in those younger than 41 years, this prevalence was greater in those anti-HCV positive than in the control group. Parenteral drugs use and tattoos were more frequent in the first group. The presence of IgG anti-HAV was associated with age and the rural origin in both groups. CONCLUSIONS: The prevalence of IgG anti-HAV increases with age, and is more frequent in individuals with rural origin. It was also greater in young anti-HCV positive patients, when compared with controls of the same age. This finding can be due to the poor standards of hygiene probably associated with some practices more common in this population, such as parenteral drugs use, tattoos and others.

[Description of sexual assaults treated in the emergency department of a referral hospital]. / Descripción de las agresiones sexuales atendidas en el servicio de urgencias de un centro hospitalario de referencia.

OBJECTIVE: To describe the factors related to adult sexual assaults attended in a referral hospital in the city of Barcelona (Spain). METHODS: We carried out an individual-based cross-sectional study of sexual assaults treated in the emergency department between 2005 and 2008. RESULTS: A total of 712 patients (95.5% female) were treated. The median age of assaulted women was 25 years. Complaints were made in 87.5% of cases and assaults were made by a single attacker in 84.5%. When the perpetrator was known, the profile of the victim (p ≤ 0.05) was as follows: the victim was assaulted at home (81.5%), the perpetrator acted alone (94.2%), the mechanism of aggression was penetration (89.3%) and the attack took place during the week (63.3%). CONCLUSIONS: Analysis of sexual assaults allows for different risk groups to be established, which facilitates the development of specific protocols and guidelines for effective aid and full treatment.

Birth trauma and development of growing fracture after coronal suture disruption.

INTRODUCTION: A growing fracture is a rare complication of skull fractures characterized by progressive diastatic enlargement of the fracture line. Growing skull fractures related to birth trauma were only occasionally reported. As far as we know, only one previous case of a neonatal growing fracture secondary to coronal suture disruption has been reported. CASE REPORT: We present the case of a full-term infant born after a nontraumatic, forceps-assisted spontaneous delivery, who developed an increasing cystic swelling over the left frontoparietal area that crossed over coronal and sagittal sutures. The lesion was initially misinterpreted as cephalhematoma. Clinical and radiological follow-up established the correct diagnosis of leptomeningeal cyst. OUTCOME: The collection was initially tapped. Surgical treatment was undertaken thereafter, consisting of decompression and resection of the cyst and dural repair. Two months after follow-up, the patient remains asymptomatic and the porencephalic cavity remains isolated from the extradural space, with no evidence of new fluid collections.

Artroplastia total de rodilla: experiencia de una unidad monográfica / Total knee replacement: a monographic unit experience

Introducción: Se presenta la experiencia de la Unidad de Prótesis de Rodilla (UPR) del Hospital Clínico de Barcelona. Pacientes y método: Estudio de casos. La población del estudio fueron los pacientes intervenidos durante los meses de mayo y junio, de los años 2004 y 2010. Las variables consideradas fueron: edad, sexo, permanencia promedio, dolor al alta, flexión al alta, deambulación al alta, comorbilidades y complicaciones durante el ingreso. Se compararon los resultados de ambos períodos. Resultado: En la comparación de los años 2004 y 2010 se observó, en el último período citado, un aumento de los recambios de prótesis. La permanencia promedia se mantuvo en alrededor de 7 días. La media de edad de los pacientes se mantuvo por encima de los 70 años. Hubo un mejor control del dolor, de la flexión y de la deambulación al alta. El de número de complicaciones se redujo y hubo un aumento de las personas con obesidad. Conclusiones: En los próximos años habrá una evolución hacia intervenciones más complejas por recambio de prótesis. Los indicadores de calidad para evaluar el éxito del tratamiento continuarán siendo muy parecidos. Habrá una tendencia a la disminución del tiempo de ingreso debido a cambios en la técnica quirúrgica. Se deberá continuar trabajando para disminuir complicaciones relacionadas con la herida quirúrgica y las infecciones. La obesidad será la comorbilidad más presente.