Effectiveness of individual and group multicomponent interventions for smoking cessation in primary care: a quasi-experimental study.

BACKGROUND: The efficacy of smoking cessation interventions can be quite diverse in day-to-day clinical practice. OBJECTIVE: To analyse the effectiveness in smoking cessation of multicomponent interventions carried out in groups or individually in primary care practices. METHODS: A quasi-experimental, multicentre study of 12-month follow-up of patients treated in multicomponent smoking cessation interventions was carried out in Urban health care centres in Sevilla, Spain. Two hundred and twenty smoking patients, ≥18 years of age, participated either in a multicomponent intervention group (n = 145; mean age 51.7 years; 53.1% women) or in individual interventions (n = 77; mean age 50.5 years; 61.0% women). The abstinence or relapse status was computed from patient self-reports, confirmed by relatives or companions when possible and supplemented by CO-oxymetry tests in 89 patients. RESULTS: The overall percentage of smoking cessation was 36.9% (37.9% with group and 35.1% with individual intervention, P = 0.398). Patients who quit smoking were younger (48.7 versus 52.9 years old, P < 0.01), with fewer years of smoking (32.9 versus 36.8 years, P < 0.05), with higher education (39.0% versus 25.0%, P < 0.05) and had received pharmacological treatment (91.5% versus 67.9%, P < 0.001). In the multivariate analysis, level of education [odds ratio (OR): 1.995; 95% confidence interval (CI): 1.065-3.735, P < 0.01], group intervention (OR: 1.743; 95% CI: 1.006-3.287, P < 0.05) and drug prescription (OR: 2.368; 95% CI: 1.126-4.980, P < 0.05) were significantly associated with smoking cessation. CONCLUSIONS: Our study found that multicomponent group and individual interventions in primary care were associated with an overall quit rate of smoking of 36.9% at 12-month follow-up, with higher probability of success among patients with higher education and those who received the group intervention and drug treatment.

Original and REGICOR Framingham functions in a nondiabetic population of a Spanish health care center: a validation study.

PURPOSE: Risk functions can help general practitioners identify patients at high cardiovascular risk, but overprediction inevitably leads to a disproportionate number of patients being targeted for treatment. To assess predicted cardiovascular risk, we analyzed the 10-year performance of the original and REGICOR Framingham coronary risk functions in nondiabetic patients. METHODS: Ours was a longitudinal, observational study of a retrospective cohort of patients observed for 10 years in primary care practices in Badajoz, Spain. Our cohort comprised 447 nondiabetic patients aged 35 to 74 years who had no evidence of cardiovascular disease and were not on lipid-lowering or antihypertensive therapy. We assessed the patients' 10-year coronary risk measurement from the time of their recruitment. We also estimated the percentage of patients who were candidates for antihypertensive and lipid-lowering therapy. RESULTS: The actual incidence rate of coronary events was 6.7%. The original Framingham equation overpredicted risk by 73%, whereas the REGICOR Framingham function underpredicted risk by 64%. The Brier scores were 0.06364 and 0.06093 (P = .365) for the original Framingham and REGICOR Framingham functions, respectively, and the remaining discrimination and calibration parameters were also highly similar for both functions. The original Framingham function classified 14.8% of the population as high risk and the REGICOR Framingham function classified 6.9%. The proportions of patients who, according to the original Framingham and REGICOR functions, would be candidates for lipid-lowering therapy were 14.3% and 6.7%, and for antihypertensive therapy they were 12.5% and 7.8%, respectively. CONCLUSION: The original Framingham equation overestimated coronary risk whereas the REGICOR Framingham function underestimated it. The original Framingham function selected a greater percentage of candidates for antihypertensive and lipid-lowering therapy.

Effectiveness of Motivational Interviewing in improving lipid level in patients with dyslipidemia assisted by general practitioners: Dislip-EM study protocol.

BACKGROUND: The non-pharmacological approach to cholesterol control in patients with hyperlipidemia is based on the promotion of a healthy diet and physical activity. Thus, to help patients change their habits, it is essential to identify the most effective approach. Many efforts have been devoted to explain changes in or adherence to specific health behaviors. Such efforts have resulted in the development of theories that have been applied in prevention campaigns, and that include brief advice and counseling services. Within this context, Motivational Interviewing has proven to be effective in changing health behaviors in specific cases. However, more robust evidence is needed on the effectiveness of Motivational Interviewing in treating chronic pathologies -such as dyslipidemia- in patients assisted by general practitioners. This article describes a protocol to assess the effectiveness of MI as compared with general practice (brief advice), with the aim of improving lipid level control in patients with dyslipidemia assisted by a general practitioner. METHODS/DESIGN: An open, two-arm parallel, multicentre, cluster, controlled, randomized, clinical trial will be performed. A total of 48-50 general practitioners from 35 public primary care centers in Spain will be randomized and will recruit 436 patients with dyslipidemia. They will perform an intervention based either on Motivational Interviewing or on the usual brief advice. After an initial assessment, follow-ups will be performed at 2, 4, 8 and 12 months. Primary outcomes are lipid levels (total cholesterol, HDL cholesterol, LDL cholesterol, triglycerides) and cardiovascular risk. The study will assess the degree of dietary and physical activity improvement, weight loss in overweight patients, and adherence to treatment guidelines. DISCUSSION: Motivational interview skills constitute the primary strategies GPs use to treat their patients. Having economical, simple, effective and applicable techniques is essential for primary care professionals to help their patients change their lifestyle and improve their health. This study will provide scientific evidence on the effectiveness of Motivational interviewing, and will be performed under strict control over the data collected, ensuring the maintenance of therapeutic integrity. TRIALS REGISTRATION: ClinicalTrials.gov (NCT01282190).

Chronic kidney disease prevalence and cardiovascular risk in a cohort of patients with type 2 diabetes followed for 10 years in Badajoz (Spain). An observational study.

AIMS: To estimate the prevalence of chronic kidney disease (CKD), their risk factors the incidence of cardiovascular and coronary events and total and cardiovascular mortality in a cohort of type 2 diabetes (T2DM) patients observed for 10 years in primary care practices in Badajoz, Spain. METHODS: Observational, longitudinal study. A total of 643 patients with T2DM (mean age 64.0 years, 55.7% women), without evidence of cardiovascular disease, were studied. CKD was defined as an estimated glomerular filtration rate (eGFR) <60 ml/min/1.73 m2 at the beginning of the study, by applying the simplified Modification of Diet in Renal Disease (MDRD) Study formula. RESULTS: The prevalence rate of CKD was 24.3%. Patients with CKD had higher percentages of coronary, cerebrovascular and cardiovascular events and higher rates of cardiovascular mortality (18.6 vs. 6.0%, p < 0.001) and total mortality (42.3 vs. 23.4%, p < 0.01), compared to patients without CKD. The Cox proportional hazards model, adjusted for age, systolic blood pressure levels, glycated haemoglobin, total cholesterol, obesity and smoking, revealed that patients with CKD had an increased risk of coronary events (HR:2.18; 95% CI:1.13-4.22, p < 0.05). CONCLUSIONS: Our study confirms a high prevalence of CKD in patients with T2DM and its relationship with the presence of cardiovascular disease.

Cardiovascular risk and validation of cardiovascular risk prediction functions in a cohort of patients with type 2 diabetes followed for 10 years in Badajoz (SPAIN). AN observational study.

AIMS: To analyse whether diabetes behaves as an equivalent of coronary risk and assess the performance of the original and REGICOR Framingham functions in a cohort of patients with type 2 diabetes observed for 10 years in primary care practices in Badajoz, Spain. METHODS: Observational, longitudinal study. A total of 643 patients (mean age 64.0 years, 55.7% women), without evidence of cardiovascular disease were studied. We assessed the incidence of cardiovascular events and the patients' 10-year coronary risk predicted-values at the time of their recruitment. RESULT: The actual incidence rate of coronary events was 14.5% (15.1% in women and 13.7% in men, p = 0.616). Patients who suffered coronary events were older (66.3 vs 63.6 years, p < 0.05), had higher total cholesterol (236.3 vs 219.5 mg/dl, p < 0.01), fasting plasma glucose levels (177.6 vs 159.8 mg/dl, p < 0.01), glycated haemoglobin (7.3 vs 6.7%, p < 0.05) and also higher prevalence of high blood pressure, dyslipidemia and chronic renal disease. The original Framingham equation overpredicted risk by 88%, whereas the REGICOR Framingham function underpredicted risk by 24%. CONCLUSIONS: Diabetes in our cohort does not behave as a coronary heart disease equivalent and both the original and REGICOR Framingham coronary risk functions have little utility in a diabetic population.

Prevalence of Chronic Kidney Disease in Patients with Diabetes in Extremadura (Spain) during the Years 2012, 2013 and 2014: An Observational Study.

Diabetes mellitus (DM) is one of the leading causes of chronic kidney disease (CKD). We analyzed the prevalence of CKD in the population with diabetes in Extremadura (Spain). retrospective observational study was carried in the diabetic population attended in the Extremadura Health System in 2012-2014. A total of 38,253 patients, ≥18 years old were included. Estimated glomerular filtration rate (eGFR) was calculated using the CKD Epidemiology Collaboration equation. CKD was defined as follow: an eGFR <60 mL/min/1.73 m2 in a time period ≥ of three months or the presence of renal damage, with or without reduced eGFR, if the urine albumin-creatinine ratio (UACR) was ≥30 mg/g, also in a time period ≥ of three months. The prevalence rate of CKD was 25.3% (27.6% in women; 23.0% in men) and increases with age (34.0% in ≥65 years-olds). 24.9% of patients with CKD were in the very-high risk category for cardiovascular events (6.3% of the diabetic population). If CKD were diagnosed without requiring sustained eGFR <60 mL/min/1.73 m2 and/or sustained UACR ≥30 mg/g (as it is frequently found in the literature) this would overestimate the prevalence of CKD by 23%.

Performance of the Framingham and SCORE cardiovascular risk prediction functions in a non-diabetic population of a Spanish health care centre: a validation study.

OBJECTIVE: To analyse the 10-year performance of the original Framingham coronary risk function and of the SCORE cardiovascular death risk function in a non-diabetic population of 40-65 years of age served by a Spanish healthcare centre. Also, to estimate the percentage of patients who are candidates for antihypertensive and lipid-lowering therapy. DESIGN: Longitudinal, observational study of a retrospective cohort followed up for 10 years. SETTING: Primary care health centre. PATIENTS: A total of 608 non-diabetic patients of 40-65 years of age (mean 52.8 years, 56.7% women), without evidence of cardiovascular disease were studied. MAIN OUTCOME MEASURES: Coronary risk at 10 years from the time of their recruitment, using the tables based on the original Framingham function, and of their 10-year risk of fatal cardiovascular disease using the SCORE tables. RESULTS: The actual incidence rates of coronary and fatal cardiovascular events were 7.9% and 1.5%, respectively. The original Framingham equation over-predicted risk by 64%, while SCORE function over-predicted risk by 40%, but the SCORE model performed better than the Framingham one for discrimination and calibration statistics. The original Framingham function classified 18.3% of the population as high risk and SCORE 9.2%. The proportions of patients who would be candidates for lipid-lowering therapy were 31.0% and 23.8% according to the original Framingham and SCORE functions, respectively, and 36.8% and 31.2% for antihypertensive therapy. CONCLUSION: The SCORE function showed better values than the original Framingham function for each of the discrimination and calibration statistics. The original Framingham function selected a greater percentage of candidates for antihypertensive and lipid-lowering therapy.

Hidden chronic renal insufficiency and cardiovascular events in patients with hypertension in a primary care center.

OBJECTIVES: The aims of this study were to evaluate whether hidden chronic renal insufficiency (CRI) may be considered an independent cardiovascular risk factor in patients with hypertension and to calculate cardiovascular risk in this population. METHODS: A total of 756 hypertensive patients of ages from 35 to 74 years (mean 57.0 years; 58.2% women) and without evidence of cardiovascular disease were studied and followed during 10 years. Their glomerular filtration rate (GFR) was estimated using the simplified MDRD (result of the Modification of Diet in Renal Disease study) and Cockcroft-Gault formulas. Hidden CRI was identified by a GFR <60 mL/min/1.73 m(2) with normal serum creatinine concentration (<1.4 mg/dL men; <1.3 mg/dL women). RESULTS: Of the patients with hidden CRI using the MDRD equation, 22% presented cardiovascular events (RR, 1.60; 95% confidence interval (CI), 1.06-2.43; p < 0.05). While the estimated coronary risk using the original Framingham function was similar in patients with and without hidden CRI (18.2%), using the REGICOR function it was higher in those with CRI (7.7 vs. 7.2%, p < 0.05). Logistic regression analysis showed that smoking, male sex, age, and diastolic blood pressure were predictors of cardiovascular events. The presence of hidden CRI was not a statistically significant predictor using either the MDRD (OR, 1.37; 95% CI, 0.72-2.61; p = 0.340) or the Cockcroft-Gault (OR, 1.05; 95% CI, 0.50-2.23; p = 0.893) formulas. CONCLUSIONS: The hypertensive population of 35-74 years in age with hidden CRI showed a higher incidence of cardiovascular events, but hidden CRI may not be considered an independent cardiovascular risk factor.

Prevalence of diabetes and frequency of glycated haemoglobin monitoring in Extremadura (Spain) during 2012, 2013 and 2014: An observational study.

AIMS: To analyze the prevalence of diabetes and the frequency of haemoglobin A1C (HbA1C) monitoring in the population with diabetes in Extremadura (Spain). METHODS: Observational, longitudinal retrospective study in the population attended in the Extremadura Health System in 2012-2014. A total of 403,644 glycated haemoglobin determinations in 189,466 subjects (52.4% female) were studied. All patients with a prescription of antidiabetic drugs and those who, despite not having treatment, had any determination of HbA1C ≥6.5% were considered as people with diabetes. All patients without treatment but with HbA1C ≥5.7% and <6.5% were considered prediabetes patients. RESULTS: The prevalence rate of diabetes was 8.3% and the frequency of HbA1C monitoring was 0.9/patient/year in the diabetic population. 48.2% of the patients with monitoring of HbA1C had diabetes, 21.2% had prediabetes, and 30.6% did not meet the criteria for diabetes or prediabetes. 12.7% of people with diabetes did not have determinations of HbA1C and only 11.8% have had ≥6 determinations in the period analyzed. CONCLUSIONS: The frequency of HbA1C monitoring in the diabetic population is lower than that usually recommended. Moreover, there is an inadequate use of HbA1C determinations, since one out of every 3 patients does not meet the criteria for diabetes or prediabetes.

[Validity and applicability of the mnemonic POUNDing rule in patients with migraine. A descriptive study]. / Estudio descriptivo de validez y aplicabilidad de la regla nemotécnica POUNDing en pacientes con migraña.

INTRODUCTION: In assessing the patient with headache, clinicians are often faced with 2 important questions: Is this headache a migraine? Does this patient require neuroimaging? The aim of this study was to assess the validity and applicability of the mnemonic POUNDing rule in patients diagnosed with migraine. PATIENTS AND METHODS: A descriptive, validation study of the POUNDing rule in patients with a diagnosis of migraines and with a brain imaging test (computed tomography or magnetic resonance imaging), in an urban health centre and a neurology clinic of the University Hospital of Badajoz. RESULTS: A total of 116 patients were included (mean age 45.6 years; 79.3% women, 70 from the neurology clinics, and 46 from the health centre). The best validity parameters of the POUNDing rule were its positive predictive values: 90.9% (95% CI: 57.1-99.5%), 100% (95% CI: 73.2-99.3%), and 96.0% (95% CI: 77.7-99.8%) in the patients of the neurology clinic, the health centre and in the total population, respectively, and its low negative predictive values: 6.8% (95% CI: 2.2-17.3%), 3.1% (95% CI: 0.2-18.0%), and 5.5% (95% CI: 2.0-12.9%), also respectively in the patients of the neurology clinic, the health centre and in the total population. CONCLUSIONS: The POUNDing mnemonic rule has a high positive predictive values and can be a great help in accepting or rejecting a diagnosis of migraine, facilitating a more efficient use of neuroimaging tests.

[Predictive capacity, comparison and clinic consequences of the Framingham-Wilson and REGICOR tables in persons for whom care has been provided at a health care center, Badajoz, Spain]. / Capacidad predictiva, comparación y consecuencias clínicas de las tablas de Framingham-Wilson y regicor en personas atendidas en un centro de salud de Badajoz.

BACKGROUND: Framingham's original equation modified by Wilson and the REGICOR calibration are widely recommended in coronary risk stratification. This study is aimed at: (1) Analyzing the ten-year predictiveness of the Framingham-Wilson and REGICOR tables among a population for which care has been provided at an urban health care center (2) Evaluating the concordance use of hypolipemiant and antihypertensive drugs resulting from these tables. METHODS: Observational, longitudinal, retrospective study of a cohort of patients for whom care was provided at a primary care center. A total of 1011 patients ages 35-74 (mean age 55.7, 56.0% females) without any evidence of cardiovascular disease. Those patients having a > or =20% risk in Wilson and > or =10% in REGICOR were considered high-risk. RESULTS: The actual coronary risk of the population was 10.7%, whilst the mean coronary risk estimated with the functions was 17.0% in Wilson and 6.6% in REGICOR. A total 29.6% was classified high-risk in Wilson as compared to the 18.2% in RECIGOR (p < 0.05). The percentage of high-risk males was significantly higher in Wilson than in REGICOR (49.0% vs. 29.4%, p < 0.01). The Kappa index was 0.70 (95 CI: 0.67, 0.73). A total of 39.5% of the patients (as per Wilson) and 31.4% (as per REGICOR) were candidates for taking hypolipemiant drugs (p < 0.001). The validity criteria of both of these functions are quite discreet: sensitivity, specificity and odds ratio diagnosed at 50.9%, 73.1% and 2.11 in Wilson and 28.7%, 83.1% and 1.98 in REGICOR, respectively. CONCLUSIONS: The Wilson and REGICOR tables show an acceptable degree of concordance, but their validity parameters are discreet. The Framingham-Wilson function screens a higher percentage of patients as being candidates for hypolipemiant drugs.

[Validation of 3 equations of coronary risk in diabetic population of a primary care center]. / Validación de tres ecuaciones de riesgo coronario en población diabética de un centro de salud.

BACKGROUND AND OBJECTIVE: We intended to validate to 10 years 3 equations of coronary risk that use the function of original Framingham (Framingham-Anderson and Framingham-Wilson) and calibrated for Spanish population (Framingham-REGICOR) in diabetic patients type 2. PATIENTS AND METHOD: We included a total of 190 diabetic patients from a primary care center, without coronary heart disease, in whom the coronary risk could be calculated before 1 January 1995. All were followed during 10 years. RESULTS: The highest score of cardiovascular risk was obtained in the Framingham-Wilson function chart (25.4%) and the lowest in the Framingham-REGICOR (10.8%). The real incidence of coronary events was 14.7% (p < 0.001). Statistically significant differences between patients with or without coronary events were only observed in the Framingham-REGICOR equation (13.3% vs 10.3%; p = 0.046). Framingham-Anderson and Framingham-Wilson functions charts more than doubled the risk of coronary disease in men (p < 0.001). The agreement degree between the 3 functions was acceptable except for the calculation of coronary risk in men between Framingham-REGICOR and Framingham-Wilson equations (kappa index = 0.3). Framingham-Anderson and Framingham-Wilson functions charts showed similar profiles for the patients with high coronary risk. Sensitivity was superior in Framingham-Anderson and Framingham-Wilson functions (67.8%) and specificity was optimal in Framingham-REGICOR equation (51.2%). The positives predictive values were low and the negatives predictive values were high. CONCLUSIONS: The equations of Framingham-Wilson and Framingham-Anderson overestimate the coronary risk in diabetics, whereas the Framingham-REGICOR functions underestimates it. The utility of these 3 methods is reduced in the diabetic population.

[Prevalence and risk factors of suspicion abuse in elder population]. / Prevalencia y factores de riesgo de sospecha de maltrato en población anciana.

BACKGROUND AND OBJECTIVE: We determined the prevalence and associated risk factors in the suspicion of elder abuse in the old population. PATIENTS AND METHOD: We included a total of 209 patients > or = 72 years of age without cognitive deterioration (score in test of Pfeiffer (3/4) 4 points). The questionnaire of suspicion of elder abuse used was one recommended by the Canadian Task Force and the American Medical Association; it consists of 9 questions and the presence of a positive answer is considered as indicative of suspicion of abuse. RESULTS: The prevalence of suspicion of elder abuse was 52.6% (at least one positive answer to the questionnaire). 8.6% affirmatively responded to 2 questions and 2% to 3. Female gender, widowhood, deficiency of studies, living alone or in institutions and having exerted a remunerated work were the associated variables in the bivariant analysis with regard to the suspicion of abuse. In the model of logistic regression, there was a significant association with the civil status and the coexistence of the familiar nucleus, with a greater risk of elder abuse in unmarried and/or widowers (p < 0.001) and in those living alone (p < 0.0001). CONCLUSIONS: There is a high prevalence of suspicion of elder abuse in the old population.

Sífilis, la gran simuladora / 8 SYPHILIS, THE GREAT SIMULATOR. Case report of a patient with syphilitic uveitis

La sífilis desde hace siglos desafía a la humanidad, es transmitida por vía sexual y verticalmente durante la gestación.9 Esta enfermedad se hizo conocida en Europa a finales del siglo XV,13 y su rápida propagación por todo el continente la transformó en una de las principales plagas mundiales.Era preocupante el crecimiento de la endemia sifilítica en el siglo XIX 13.1. En contrapartida la medicina se desarrollaba, y la síntesis de las primeras drogas se hacía realidad. El mayor impacto tal vez fue la introducción de la penicilina en 1946, la cual por su eficacia hizo a muchos pensar que la enfermedad estaba controlada. En un estudio de revisión de literatura se dice que a raíz de la introducción de la penicilina la incidencia de sífilis (y de uveítis sifilítica) fue disminuyendo constantemente hasta finales de los años 90.3 resultando en la disminución del interés por su estudio y control. Con la aparición del síndrome de inmunodeficiencia adquirida (SIDA).2 se incrementó dramáticamente la evolución de esta enfermedad.En la literatura oftalmológica se comenzaron a documentar cada vez más casos e incluso se ha llegado a hablar de la «nueva epidemia de sífilis ocular¼1 Se estima que, anualmente, unos 357 millones de personas contraen alguna de las cuatro infecciones de transmisión sexual (ITS) siguientes: clamidias, gonorrea, sífilis o tricomoniasis.7 En el mundo hay una incidencia anual de aproximadamente 12 millones de pacientes con sífilis el 90% ocurre en países en desarrollo (OMS).

Syphilis has defied humanity for centuries, is transmitted sexually and vertically during pregnancy. This disease became known in Europe at the end of the 15th century,13 and its rapid spread throughout the continent transformed it into one of the main world plagues. The growth of the syphilitic endemic in the 19th century was worrisome.13.1 In contrast, medicine developed, and the synthesis of the first drugs became a reality. Perhaps the biggest impact was the introduction of penicillin in 1946, which, due to its effectiveness, led many to believe that the disease was controlled. In a literature review study, it is said that following the introduction of penicillin the incidence of syphilis (and syphilitic uveitis) was steadily decreasing until the end of the 90s.3 resultando in the decrease of interest in its study and control. With the onset of acquired immunodeficiency syndrome (AIDS). the evolution of this disease increased dramatically. In the ophthalmological literature, more and more cases have been documented and there has even been talk of the "new epidemic of ocular syphilis".1.1 It is estimated that some 357 million people each year get one of the four sexually transmitted infections (STIs) following: chlamydia, gonorrhea, syphilis or trichomonas's. In the world there is an annual incidence of approximately 12 million patients with syphilis 90% occurs in developing countries (WHO)