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Idiopathic pulmonary fibrosis (IPF) is a chronic progressive disease. Its natural history may have episodes of acute exacerbation (AE-IPF), whose best accepted definition would be a clinically significant acute worsening, without identified cause, in patients with an underlying IPF. The incidence of AE-IPF ranges from 5%-19% of patients per year. It is estimated that acute deterioration of the respiratory status occurred in 47% of these patients before death. A rapidly progressive dyspnoea is the most prominent symptom, with associated cough, fever and flu-like symptoms. The diagnosis is strengthened by the presence of leukocytosis on the blood count, neutrophilia on the bronchoalveolar lavage, and development of new diffuse bilateral ground-glass opacities superimposed on the pre-existing radiographic findings. The major histological finding is diffuse alveolar damage. Methylprednisolone seems to be the best therapeutic option, although the treatment response is usually poor., (Copyright © 2009 Elsevier España, S.L. All rights reserved.)

Objective: To estimate the real costs of medical care by diagnostic groups at a primary care centre., Design: Descriptive, retrospective study, based on the review of computerized medical records., Setting: Urban primary care centre (PCC)., Participants: All patients who attended the PCC during 2005., Main Measurements: Mean medical care cost per visit in euros, broken down for health professionals, diagnostic procedures and drugs costs, and stratified by diagnostic groups., Results: The most frequent visits were for pulmonary, locomotor, cardiovascular, and gastro-intestinal conditions. The mean number of visits per patient attended was 8.7 (SD, 9.4); and per patient registered at the centre, 5.9 (8.7). The highest costs were for cardiovascular (18.96%; 95% CI, 18.93%-18.99%), locomotor (11.21%; 95% CI, 11.18%-11.23%), psychological (10.69%, 95% CI, 10.66%-10.71%), pulmonary (10.20%; 95% CI, 10.17%-10.22%) and endocrinal-nutritional (9.61%; 95% CI, 9.58%-9.63%) problems. Drugs expenditure accounted for 65% of the total cost; visits to health professionals, for 33%; and procedures, for 2%. Overall cost per inhabitant was 239.1 (493.6) euros, and per patient attended was 349.5 (563.5)., Conclusions: Cardiovascular disease conditions are much the most costly ones in terms of overall medical cost. Psychological conditions are located in second place in terms of pharmaceutical cost; and in third place, in terms of overall medical-care cost.

Three cases of children admitted to the Pediatric Intensive Medicine Unit in the months of February to March 2004 with the diagnosis of streptococcal toxic shock syndrome are presented. Two were under 2 years of age and the initial symptoms suggested viriasis. They evolved towards septic shock with early multiorganic failure and then death due to massive hemoptysis, ventricular fibrillation due to hyperkaliemia. Streptococcus pyogenes with serotypes M1T1 was isolated in all the cases and the patients had the clinical criteria of streptococcal toxic shock syndrome. Their course was unfavorable in spite of the resuscitation steps, early antibiotic treatment and artificial support of the different organic failures. We stress the rareness of the cases, early age, its appearance in a short period of time, its sudden onset and the null response to treatment initiated.

We describe the case of a 20-year-old man who developed severe thrombocytopenia and hemorrhagic complications 5 months after beginning pegylated interferon therapy for chronic hepatitis C. Interferon therapy was stopped and platelets were transfused, but the platelet count did not increase until treatment with immunoglobulins and intravenous corticosteroids was started. Therefore, we believe this would suggest a possible autoimmune mechanism for the development of thrombocytopenia with interferon therapy. Mild reduction in platelets count is a common adverse effect of this drug. Nevertheless, severe decreases and secondary serious hemorrhagic complications have been infrequently described in the literature.

Intermittent mandatory ventilation (IMV) is a mode of ventilation that allows the patient to make spontaneous breaths during the expiratory phase of mandatory ventilator breaths. There are two types of IMV according to whether respirator breaths are synchronized with the patient's respiratory efforts: Non-synchronized IMV and synchronized IMV (SIMV), and according to whether SIMV is volume- or pressure programmed. The main advantage of SIMV is that the respirator delivers the preset ventilator pressure and rate while allowing the patient to breath spontaneously, thus facilitating progressive weaning from mechanical ventilation. It diminishes the risk of barotrauma, produces less hemodynamic com-promise than control ventilation, reduces atrophy of respiratory muscles and the need for sedation and muscle relaxation and can be associated with pressure support ventilation.

Objective: To show the importance of preventive action in primary care in a case of tuberculosis., Design: A descriptive study., Setting: Castelldefels school, Barcelona., Participants: Students and teachers, contacts of a case of tuberculosis., Interventions: On June 30, 1995, a case of pulmonary tuberculosis in an adult at a school was notified. In line with the Procedure for Prevention and Control of Tuberculosis of the public health council, the work contacts of the case were administered the tuberculin reaction test (TR) and a thoracic X-ray, with chemoprophylaxis or chemotherapy recommended, depending on the result., Results: 394 TR (92.5%) were performed on 426 children. From the first to the second check-up at three months, 56 (14.2%) presented a positive reaction and had a thoracic X-ray. Eight cases of the illness were diagnosed and treated with chemotherapy: secondary chemoprophylaxis was recommended for 48. 36 of the 39 adults in the school had a TR, and 35 a thoracic X-ray. Two cases of the active illness were diagnosed and secondary chemoprophylaxis was recommended to a teacher. The staff of the sports' centre was also checked, with 18 monitors having a thoracic X-ray and 14 the TR. Secondary chemoprophylaxis was recommended in three cases., Conclusions: Rapid action when faced with a case of tuberculosis is basic in the fight against this disease, in order to break the epidemiological chain and find any new cases of disease. Primary care must assume a leading role in early detection and treatment of these patients. Good coordination between different care levels is essential.

Introduction: To study the possible influence of gender on in-hospital mortality in patients suffering acute myocardial infarction., Patients and Methods: We analyzed 1,951 consecutive patients admitted to our Coronary Unit between January 1986 and December 1991 with this diagnosis and with a delay of no more than 24 hours prior to admission., Results: In-hospital mortality was 12.8% in the 1,603 males and 25.6% in the 348 females (p < 0.001). Age, previous history of: not smoking, diabetes, heart failure, stable angina, myocardial infarction, stroke, right branch block, atrial fibrillation, and treatment with digoxin were variables significantly associated with greater mortality (p < 0.05) as well as the localization of the infarction, the Forrester grade and/or presence of atrioventricular block on admission and not treatment with intravenous fibrinolytics and beta-blockers. Multivariate analysis of variables associated with mortality (selection criterion for variable entry p < 0.20) shows that age, gender, previous angina, situation and extension of the infarction determined by ECG and Forrester on admission are independent predictors of in-hospital mortality., Conclusions: Gender is an independent predictor of in-hospital mortality in acute myocardial infarction (female/male odds ratio = 1.63).

Objective: To calculate the probable prevalence of mental illness in our clinics and to evaluate how it is detected by Primary Care (PC) doctors., Design: Crossover study in two parts. SITE. Basauri Health Centre (Vizcaya)., Participants: A sample made up of patients who attended the clinic without prior appointment during ten days in February and Marc, 1990., Main Measurements and Results: In the first part, 10 PC doctors distributed the GHQ-28 questionnaire to 500 patients. In the second part, qualified staff administered the standardised psychiatric interview (SPI) to a sub-sample. 41.55% were possible psychiatric cases (GHQ-28 > 6). 17.94% were diagnosed by the doctors (SD) as psychiatric cases. Prevalences adjusted to the SPI were 19% and 21% for the GHQ-28 and SD respectively., Conclusions: The GHQ-28 obtained high sensitivity (0.82%) and low specificity (60%), which characterises it as a good screening test, but a bad diagnostic method. The doctors obtained low sensitivity (0.29) and high specificity (89.7%); thus underdiagnosing mental illness, but being more accurate in their diagnoses.