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Resumen Objetivo Analizar el efecto de la demora atribuible al sistema sanitario en una cohorte consecutiva de pacientes diagnosticados de forma ambulatoria de cancer colorrectal (CCR) en el area sanitaria de Ourense. Pacientes y metodos Estudio observacional de cohortes retrospectivo en el que se incluyeron los pacientes diagnosticados entre 2009 y 2017. Se definio la demora atribuible al sistema sanitario como el tiempo entre la primera consulta por sintomas y la confirmacion diagnostica. Se determino si existia una relacion independiente entre la demora diagnostica y el CCR estadio IV mediante una regresion logistica. Finalmente, realizamos una regresion de riesgos proporcionales para determinar que variables se asociaban con la mortalidad global y por CCR. Resultados Se incluyeron 575 pacientes (hombres 64.5%, edad 71.9 ± 11.5 anos) con una demora atribuible al sistema sanitario de 115 ± 153 dias. Ninguna de las variables analizadas se asocio con el estadio tumoral al diagnostico. Durante un seguimiento de 30.6 ± 21 meses fallecieron 121 pacientes (79.3% en relacion al CCR). Las variables asociadas de forma independiente con la mortalidad atribuible al CCR fueron el estadio IV al diagnostico (HR 50.65, IC 95% 12.28-209), la edad (HR 1.04, IC 95% 1.02-1.05) y la solicitud de la colonoscopia desde Atencion Primaria (HR 0.55, IC 95% 0.37-0.88). Conclusiones La demora diagnostica atribuible al sistema sanitario no se relaciono ni con el estadio ni con el pronostico del CCR. Sin embargo, la solicitud de la colonoscopia desde Atencion Primaria se asocio a una reduccion en el riesgo de mortalidad.

Resumen Objetivo Analizar el efecto de la demora atribuible al sistema sanitario en una cohorte consecutiva de pacientes diagnosticados de forma ambulatoria de cancer colorrectal (CCR) en el area sanitaria de Ourense. Pacientes y metodos Estudio observacional de cohortes retrospectivo en el que se incluyeron los pacientes diagnosticados entre 2009 y 2017. Se definio la demora atribuible al sistema sanitario como el tiempo entre la primera consulta por sintomas y la confirmacion diagnostica. Se determino si existia una relacion independiente entre la demora diagnostica y el CCR estadio IV mediante una regresion logistica. Finalmente, realizamos una regresion de riesgos proporcionales para determinar que variables se asociaban con la mortalidad global y por CCR. Resultados Se incluyeron 575 pacientes (hombres 64,5%, edad 71,9 ± 11,5 anos) con una demora atribuible al sistema sanitario de 115 ± 153 dias. Ninguna de las variables analizadas se asocio con el estadio tumoral al diagnostico. Durante un seguimiento de 30,6 ± 21 meses fallecieron 121 pacientes (79,3% en relacion al CCR). Las variables asociadas de forma independiente con la mortalidad atribuible al CCR fueron el estadio IV al diagnostico (HR 50,65; IC 95% 12,28-209), la edad (HR 1,04; IC 95% 1,02-1,05) y la solicitud de la colonoscopia desde Atencion Primaria (HR 0,55; IC 95% 0,37-0,88). Conclusiones La demora diagnostica atribuible al sistema sanitario no se relaciono ni con el estadio ni con el pronostico del CCR. Sin embargo, la solicitud de la colonoscopia desde Atencion Primaria se asocio a una reduccion en el riesgo de mortalidad.

The lack of adherence to treatment in hypertension affects approximately 30 % of patients. The elderly, those with several co-morbidities, social isolation, low incomes or depressive symptoms are the most vulnerable to this problem. There is no ideal method to quantify the adherence to the treatment. Indirect methods are recommended in clinical practice. Any intervention strategy should not blame the patient and try a collaborative approach. It is recommended to involve the patient in decision-making. The clinical interview style must be patient-centered including motivational techniques. The improvement strategies that showed greater effectiveness in the compliance of hypertension treatment were: treatment simplification, appointment reminders systems, blood pressure self-monitoring, organizational improvements and nurse and pharmacists care. The combination of different interventions are recommended against isolated interventions.

Acute pancreatitis is frequently associated with the development of local complications: collections, necrosis, pseudocysts and abdominal abscesses. Although the development of liver abscesses has been linked to bile duct obstruction or abdominal surgery in patients with chronic pancreatitis, there are few descriptions of liver abscesses associated with an episode of acute pancreatitis. We report the case of a 45-year-old man with a first episode of severe acute alcoholic pancreatitis, complicated with thrombosis of the right portal branch, liver abscess and intrahepatic biliary fistula. The approach and treatment are described.

The lack of adherence to treatment in hypertension affects approximately 30 % of patients. The elderly, those with several co-morbidities, social isolation, low incomes or depressive symptoms are the most vulnerable to this problem. There is no ideal method to quantify the adherence to the treatment. Indirect methods are recommended in clinical practice. Any intervention strategy should not blame the patient and try a collaborative approach. It is recommended to involve the patient in decision-making. The clinical interview style must be patient-centered including motivational techniques. The improvement strategies that showed greater effectiveness in the compliance of hypertension treatment were: treatment simplification, appointment reminders systems, blood pressure self-monitoring, organizational improvements and nurse and pharmacists care. The combination of different interventions are recommended against isolated interventions.

A 53-year-old male was referred to our unit due to tenes-mus, rectal bleeding and altered bowel habit. On rectal exa-mination a hard mass was palpable. A colonoscopy was per-formed where multiple polyps, most of them larger than 10mm (Fig. 1), and a protruded neoplastic lesion in rectum werefound. The histology (Fig. 2) showed infiltration by B celllymphoma (BCL), suggestive of mantle cell lymphoma(MCL). In computed tomography (CT) multiple thoracic-abdominal-pelvic adenopathies, some of them forming a con-glomerate (Fig. 3), were observed. The patient was referredto the haematology department with the diagnosis of BCLfor further study and treatment.The study was completed with a bone marrow aspirate thatsuggested infiltration by BCL. He was initially treated withR-CHOP chemotherapy plus G-CSF. After a partial response,he was switched to a second line with R-MINE/ESHAP andautologous peripheral blood precursors to full recovery ofblood count parameters.

To analyze the effect of implementing a high-resolution clinic (HRC) and an increasing resolution capacity program in primary care (IRCPPC) for referrals to a gastroenterology outpatient clinic from primary care and the resources used.A retrospective and observational study based on a review of referral sheets and databases was performed. We analyzed the number and reason for referrals, delay times and resource consumption in two periods: before (first 4 months of 2007) and after (first 4 months of 2009) the launch of the IRCPPC and HRC.In the first and second periods, 881 and 1076 patients, respectively, referred from primary health care were evaluated in the gastroenterology clinic, with a decrease in the delay time in the second period (80.8 ± 64.34 days vs 36.1 ± 29.12 days, p0.001). The most frequent reasons for referral were dyspepsia (27.7%), high-risk of colorectal cancer (17.1%), disturbance of bowel rhythm (18.2%), abdominal pain (16%), and gastroesophageal reflux (11.2%), with no differences between the two periods. Although delay times until the first visit (10.8 ± 9.03 days vs 42.8 ± 28.67 days, p0.001) and until discharge (39.6 ± 80.65 days vs 128.6 ± 135.34 days, p0.001) were lower in referrals to the HRC, the number of visits (3.6 ± 2.20 vs 3.2 ± 1.95, p = 0.015) and the cost of referrals (592.7 ± 421.50 € vs 486.0 ± 309.66 €, p0.001) was higher.In the study period the number of referrals increased, while the delay time decreased. Although the HRC reduces delay times, it is associated with an increase in health resource use.

ResumenObjetivoAnalizar el efecto de la puesta en marcha de una consulta de alta resolución (CAR) y de un programa de aumento de la capacidad resolutiva de atención primaria (PACRAP) en las derivaciones a las consultas de gastroenterología desde atención primaria y en los recursos utilizados.MétodosEstudio observacional retrospectivo basado en la revisión de las hojas de derivación y de las bases de datos de documentación clínica. Se analizaron el número y el motivo de las derivaciones, los tiempos de demora y el consumo de recursos en dos periodos: anterior (primer cuatrimestre de 2007) y posterior (primer cuatrimestre de 2009) a la puesta en marcha de la CAR y el PACRAP.ResultadosSe evaluaron 881 derivaciones en el periodo anterior y 1076 en el posterior, y se halló una disminución de los tiempos de demora en el segundo periodo (80,8±64,34 días frente a 36,1±29,12 días, p

Resumen Introduccion Dentro del programa de aumento de capacidad resolutiva de atencion primaria (AP) en Ourense se han implementado las guias de practica clinica en dispepsia y rectorragia. Nuestro objetivo es evaluar los motivos de solicitud de las exploraciones, el nivel de adecuacion de las solicitudes, los hallazgos endoscopicos y los tiempos de demora. Material y metodos Estudio de cohortes retrospectivo en el area sanitaria de Ourense entre febrero de 2009 y enero de 2010. Se analizaron las endoscopias realizadas con las indicaciones de dispepsia y rectorragia solicitadas directamente desde AP frente a las derivadas inicialmente a atencion especializada (AE). Se recogieron los motivos de solicitud, el nivel de prioridad, la adecuacion al protocolo, los hallazgos endoscopicos y los tiempos de demora desde la derivacion. Resultados En el periodo analizado, se realizaron 158 endoscopias digestivas altas (EDA) (AE 121, AP 37) y 243 colonoscopias (AE 193, AP 50). Se solicitaron de forma preferente el 34,5% de las endoscopias de AP y el 77,7% de AE (p Conclusiones La utilizacion del programa de aumento de capacidad resolutiva reduce los tiempos de demora. Las exploraciones solicitadas se han adecuado a las indicaciones.

Within a program to improve referrals by primary care (PC) in Ourense (Spain), we implemented practice guidelines on dyspepsia and rectal bleeding. Our aim was to evaluate the reasons for referral to endoscopy, the appropriateness of these referrals, and wait times.We performed a retrospective cohort study in the Ourense health area between February 2009 and January 2010. The endoscopies performed with the indications of dyspepsia and rectal bleeding requested directly from PC were compared with those referred initially to specialist care (SC). The reasons for the referral, the priority of the endoscopy, compliance with the protocol, endoscopic finding and the wait time from referral were gathered.During the period analyzed, 158 upper gastrointestinal endoscopies (SC: 121; PC: 37) and 243 colonoscopies (SC: 193; PC: 50) were performed with the indications of dyspepsia and rectal bleeding. Among endoscopies, 34.5% and 77.7% were requested with high priority from PC and SC, respectively (p0.001). The criteria for referral were met in 86.5% of upper gastrointestinal endoscopies and in 82% of colonoscopies requested from PC. No differences were found in endoscopic findings. The median wait time from referral was lower in upper gastrointestinal endoscopy (PC: 105±5.5 days, SC: 174±17.8 days; p: 0.003) and colonoscopies (PC: 101±11.8 days, SC: 187±9.6 days; p0.001) referred from PC.The use of the program for improved referrals by PC reduces wait times. The examinations requested complied with the indications.

Acute pancreatitis is frequently associated with the development of local complications: collections, necrosis, pseudocysts and abdominal abscesses. Although the development of liver abscesses has been linked to bile duct obstruction or abdominal surgery in patients with chronic pancreatitis, there are few descriptions of liver abscesses associated with an episode of acute pancreatitis. We report the case of a 45-year-old man with a first episode of severe acute alcoholic pancreatitis, complicated with thrombosis of the right portal branch, liver abscess and intrahepatic biliary fistula. The approach and treatment are described.

AIM: To ascertain the role of cardiovascular risk factors, cardiovascular diseases, standard treatments and other diseases in the development of ischemic colitis (IC). METHODS: A retrospective, case-control study was designed, using matched data and covering 161 incident cases of IC who required admission to our hospital from 1998 through 2003. IC was diagnosed on the basis of endoscopic findings and diagnostic or compatible histology. Controls were randomly chosen from a cohort of patients who were admitted in the same period and required a colonoscopy, excluding those with diagnosis of colitis. Cases were matched with controls (ratio 1:2), by age and sex. A conditional logistic regression was performed. RESULTS: A total of 483 patients (161 cases, 322 controls) were included; mean age 75.67 ± 10.03 years, 55.9% women. The principal indications for colonoscopy in the control group were lower gastrointestinal hemorrhage (35.4%), anemia (33.9%), abdominal pain (19.9%) and diarrhea (9.6%). The endoscopic findings in this group were hemorrhoids (25.5%), diverticular disease (30.4%), polyps (19.9%) and colorectal cancer (10.2%). The following variables were associated with IC in the univariate analysis: arterial hypertension (P = 0.033); dyslipidemia (P < 0.001); diabetes mellitus (P = 0.025); peripheral arterial disease (P = 0.004); heart failure (P = 0.026); treatment with hypotensive drugs (P = 0.023); angiotensin-converting enzyme inhibitors; (P = 0.018); calcium channel antagonists (P = 0.028); and acetylsalicylic acid (ASA) (P < 0.001). Finally, the following variables were independently associated with the development of IC: diabetes mellitus [odds ratio (OR) 1.76, 95% confidence interval (CI): 1.001-3.077, P = 0.046]; dyslipidemia (OR 2.12, 95% CI: 1.26-3.57, P = 0.004); heart failure (OR 3.17, 95% CI: 1.31-7.68, P = 0.01); peripheral arterial disease (OR 4.1, 95% CI: 1.32-12.72, P = 0.015); treatment with digoxin (digitalis) (OR 0.27, 95% CI: 0.084-0.857, P = 0.026); and ASA (OR 1.97, 95% CI: 1.16-3.36, P = 0.012). CONCLUSION: The development of an episode of IC was independently associated with diabetes, dyslipidemia, presence of heart failure, peripheral arterial disease and treatment with digoxin or ASA.