Search

Introduccion: la calidad de la asistencia prestada a los pacientes cirroticos se puede medir analizando una serie de indicadores. Los estudios publicados hasta la actualidad muestran una tasa de adherencia a las indicaciones de las guias clinicas del 40-80 %. Objetivo: valorar la calidad de la asistencia prestada en un hospital docente de tercer nivel. Metodos: estudio observacional retrospectivo en pacientes cirroticos controlados durante un semestre en consultas externas. Se han revisado 324 historias clinicas recogiendo 14 indicadores de calidad de cinco dominios diferentes y se ha estudiado la adherencia global y en relacion a la experiencia del medico responsable. Resultados: excelentes (mas del 90 % de adherencia) en indicadores relacionados con documentacion de la etiologia de la cirrosis y profilaxis de la hemorragia digestiva por varices; aceptables (60-90 %) en despistaje del carcinoma hepatocelular y valoracion de la gravedad de la enfermedad; y malos (menos del 50 %) en vacunaciones. Los residentes obtuvieron significativamente mejores resultados que los adjuntos en etiologia, valoracion de la gravedad y dos indicadores de profilaxis de hemorragia digestiva. Por su parte, los adjuntos presentaron mejores resultados en el despistaje de carcinoma hepatocelular. Conclusiones: a pesar de haber obtenido excelentes resultados en algunos indicadores, muchos deben ser mejorados, especialmente las vacunaciones. La calidad asistencial prestada por los residentes es igual o incluso mejor que la prestada por los adjuntos. Analizar la calidad asistencial es esencial para medir y mejorar la atencion prestada a los pacientes cirroticos, y puede ser una herramienta muy eficaz para supervisar a los especialistas en formacion.

It is important to identify the best initial work-up in patients with uninvestigated dyspepsia because of its epidemiological and economical relevance. The objective of the study was to assess systematically the effectiveness and cost-effectiveness of invasive and non-invasive strategies for the management of dyspepsia.A decision analysis was performed to compare prompt endoscopy, score and scope, test and scope, test and treat, and empirical antisecretory treatment. Published and local data on the prevalence of different diagnoses, rates of Helicobacter pylori infection, accuracy values of diagnostic tests, and effectiveness of drug treatments were used. The perspective of analysis was that of the public healthcare payer, and only direct costs were included, with a one-year post-therapy time horizon. The main outcome measure was cost per asymptomatic patient, valued in 2003 Euros.Endoscopy was found to be the most effective strategy for the management of dyspepsia (38.4% asymptomatic patients), followed by test and scope (35.5%), test and treat (35.3%), score and scope (34.7%), and empirical treatment (28.5%). Incremental cost-effectiveness ratios showed that score and scope was the most cost-effective alternative (483.17 Euros per asymptomatic patient), followed by prompt endoscopy (1396.85 Euros). Sensitivity analyses showed variations when varying the values of prevalence of duodenal ulcer, and the values of healing of functional dyspepsia with antisecretory and eradication drugs. There were no changes when varying the prevalence of H. pylori in dyspepsia.We would recommend stratifying patients by a score system, referring first to endoscopy those patients at higher risk of organic dyspepsia.

Fundamento y objetivo Los modelos predictivos basados en un conjunto de sintomas pueden ser utiles para seleccionar a los pacientes con dispepsia candidatos a endoscopia. Un estudio previo realizado por gastroenterologos obtuvo tres escalas de sintomas con alto valor predictivo para dispepsia organica, ulcera peptica y esofagitis. El objetivo del presente estudio fue validar de forma prospectiva la reproducibilidad de dichos modelos al ser utilizados por medicos de atencion primaria o por otros gastroenterologos. Pacientes y metodo Estudio clinico prospectivo en 230 pacientes del area del hospital de Viladecans (120 de atencion primaria y 110 de consulta de gastroenterologia) a los que se aplicaron las tres escalas a validar. Posteriormente se realizo una endoscopia que clasifico a los pacientes en dispepsia organica (ulcera, esofagitis, cancer) o funcional. La capacidad discriminante para dispepsia organica, ulcera y esofagitis del medico de primaria y del gastroenterologo al aplicar cada una de las escalas se calculo mediante el estadistico c. Resultados Las capacidades discriminantes fueron 0,75 y 0,82 para dispepsia organica, 0,78 y 0,86 para ulcera, y 0,78 y 0,82 para esofagitis, para medicos de atencion primaria y para gastroenterologos, respectivamente. El punto de corte optimo para discriminar dispepsia organica, el que combina la mayor sensibilidad con la mayor especificidad, subio de 6 a 7 puntos en esta validacion con respecto al estudio inicial. Conclusiones La confirmacion de la reproducibilidad y transferibilidad de un modelo predictivo sencillo de dispepsia organica abre la posibilidad de utilizar este tipo de instrumentos para conseguir un abordaje mas eficiente de la dispepsia.

Low response rates and concerns about safety have limited the implementation of treatment for chronic hepatitis C (CHC) in patients with HIV infection. The efficacy and safety of pegylated interferon (peg-IFN) plus ribavirin in HIV-infected patients with CHC were evaluated in a prospective, open-label, multicenter study. Sixty patients with persistently high transaminases, positive HCV-RNA, CD4 countor = 300 cells/microl, and HIVRNA10,000 copies/ml were included. Patients were given peg-IFN 80-150 microg/week plus ribavirin 800-1200 mg/day. Treatment was scheduled for 24 weeks for genotypes 2/3 and 48 weeks for genotypes 1/4. In an intent- to-treat analysis, 16 (26.7%) patients achieved a sustained virological response (SVR). Twenty patients (33.3%) discontinued treatment prematurely, but only in 10 (16.6%) was discontinuation due to adverse events. Negative predictive values for SVR on the basis of HCV-RNA decline between baseline and week 4 were 100% for 1- and 2-log10 fall, and positive predictive values were 40% and 58.3% for 1- and 2-log10 fall, respectively. CD4 fell by a median of 216 cells during treatment, but no HIV-associated complications occurred. In conclusion, treatment with peg-IFN alpha-2b plus ribavirin is safe and clears RNA-HCV in about one-quarter of HIV-infected patients with CHC. Efforts should be focused on optimizing management of side effects and counseling to improve adherence and to keep patients on treatment. Assessment of HCV-RNA at week 4 may help guide early therapeutic decision making.

Predictive symptomatic scoring models have been proposed to select patients with dyspepsia, who may be candidates to endoscopy. In a previous study performed by gastroentrologists from our group, we obtained three scales of symptoms to predict organic dyspepsia, peptic ulcer and esophagitis, respectively. Here we analyze the reproducibility of those scoring models of symptoms when used either by other gastroenterologists or general practitioners.It was a clinical prospective study of 230 patients from the Viladecans hospital area (120 from primary healthcare and 110 from the gastroenterologist's consultation). The three validation scales were performed in each patient. Then, we performed a diagnostic gastroscopy which allowed to classify patients into those with organic dyspepsia (ulcer, esophagitis, cancer) or those with functional dyspepsia. We calculated the overall predictive accuracy for the gastroenterologist and the general practitioner and for the three diagnoses (organic dyspepsia, ulcer or esophagitis) using the C statistic.Discriminative capacities were 0.75 and 0.82 for organic dyspepsia, 0.78 and 0.86 for ulcer disease, and 0.78 and 0.82 for esophagitis, for the general practitioner and the gastroenterologist, respectively. In this validation study, the best cut-off value, namely the one combining good sensitivity and specificity, was found to be 7.A correct predictive capacity of the symptomatic score models when used by other gastroenterologists or by primary healthcare practioners confirms its reproducibility and transferability. The use of predictive symptomatic score models in everyday clinical practice can allow to rationalize the referral for endoscopy in our local setting.

Ezetimibe is the first member of a new family of lipid-lowering drugs that inhibits uptake of dietary and biliary cholesterol. It was approved by the FDA in 2002 for hypercholesterolemia alone or in combination with statins. Its use has been spreading over the last years. Ezetimibe was considered a safe drug. We report a case of a woman who developed a serious hepatocellular drug-induced liver disease after 4 mo therapy with 10 mg daily of ezetimibe. After withdrawal of the drug, the patient recovered slowly. Ezetimibe may produce serious toxic hepatitis and prompt withdrawal is mandatory in case of a significant abnormality in liver testing after beginning or during treatment with ezetimibe.

Objective To prospectively assess the accuracy of a scoring system to predict organic diseases in dyspeptic patients in an area of South Europe, and to compare it with that of Helicobacter pylori testing in patients with dyspepsia in an environment with high prevalence of H. pylori infection. Methods Symptoms and demographic data were recorded in 501 consecutive dyspeptic patients referred to an outpatient gastroenterology clinic. A simple scoring system was constructed from the predictive factors obtained in a multi-variate logistic regression analysis. Overall predictive accuracy was assessed with the c statistic. The model was validated using bootstrap techniques. The accuracy of clinical judgement and H. pylori testing to predict endoscopic diagnosis was also assessed. Results Organic dyspepsia (peptic ulcer, oesophagitis or malignancies) was diagnosed in 45% of the patients. The test for H. pylori was positive in 68%, and 29% of infected patients had an ulcer. The organic dyspepsia predictive model had an accuracy of 0.79, which decreased to 0.77 after validation adjustment. The predictive accuracies for clinical judgement and H. pylori testing were 0.69 and 0.61, respectively. The addition of H. pylori testing to the scoring system resulted in a minor improvement of the predictive accuracy. Conclusion In an environment with a high rate of H. pylori infection and a low prevalence of peptic ulcer among infected patients, a scoring system has higher predictive accuracy for the diagnosis of organic disease than H. pylori testing. Moreover, in this setting, H. pylori testing adds a minimum value to the predictive capability of the scoring system.