Real-world therapeutic management and evolution of patients with benign prostatic hyperplasia in primary care and urology in Spain.

OBJECTIVES: This study aimed to describe the real-world therapeutic management of patients with lower urinary tract symptoms (LUTS) due to benign prostatic hyperplasia (BPH) (LUTS/BPH) attending primary care and urology clinics in Spain. METHODS: This observational, retrospective, multicentre study included men ≥50 years of age diagnosed with LUTS/BPH (≤8 years prior to study visit) (N = 670). Therapeutic management according to healthcare service (primary care vs. urology clinics) or progression criteria, proportion of patients with treatment change, patient profile according to therapy and evolution of LUTS severity were assessed. RESULTS: Overall differences were noticed in the management of patients between healthcare service (P < .001) and with or without progression criteria (P < .05). Most patients received pharmacological treatment at diagnosis (70.7%; 474/670), which increased at study visit (81.6%; 547/670) with overall similar profiles between primary care and urology clinics for each therapy. α1-Blockers were the most used pharmacological treatment across healthcare settings at diagnosis (61.8%; 293/474) and study visit (51%; 279/547). Only 27.1% (57/210) of patients with progression criteria at diagnosis and 35.6% (99/278) at study visit received 5α-reductase inhibitor (5ARI) alone or in combination with a α1-blocker. Overall, most patients did not change treatment (60%; 402/670) with a trend of more patients worsening in symptoms when not receiving α1-blocker plus 5ARI combination therapy. CONCLUSION: Most patients with LUTS/BPH received pharmacological treatment; however, most men with progression criteria did not receive a 5ARI alone or in combination. These results support the need to reinforce both primary care and urologists existing clinical guideline recommendations for the appropriate medical management of patients with LUTS/BPH.

Real-world assessment and characteristics of men with benign prostatic hyperplasia (BPH) in primary care and urology clinics in Spain.

OBJECTIVES: To describe the real-world demographic and clinical characteristics of patients with lower urinary tract symptoms (LUTS) as a result of benign prostatic hyperplasia (BPH) in Spain. METHODOLOGY: This observational, retrospective, multicentre study conducted in primary care and urology clinics in Spain included men aged ≥50 years diagnosed (≤8 years prior to study visit) with LUTS caused by BPH. The primary endpoint was demographic and clinical characteristics; secondary endpoints included disease progression and diagnostic tests across both healthcare settings. RESULTS: A total of 670 patients were included (primary care: n = 435; urology: n = 235). Most patients had moderate/severe LUTS (74.6%) and prostate volume >30 cc (81.7%), with no differences between settings. More patients had prostate-specific antigen (PSA) ≥1.5 ng/mL in primary care (74.5%) versus urology (67.7%). Progression criteria were prevalent (48.9%). Clinical criteria were more commonly used than the International Prostate Symptom Score (IPSS) to evaluate LUTS at diagnosis (primary care: clinical criteria 73.0%; IPSS: 26.9%; urology: clinical criteria 76.5%; IPSS: 23.4%). Proportion of patients with moderate/severe LUTS at diagnosis was lower using clinical criteria than IPSS, and the proportion of patients with 'worsening' LUTS (diagnosis to study visit) was higher when using clinical criteria versus IPSS. In both healthcare settings, the most commonly used diagnostic tests were general and urological clinical history and PSA. CONCLUSION: Demographic and clinical characteristics of patients with BPH in Spain were similar in primary care and urology; however, assessment criteria to evaluate LUTS severity differ and are not completely aligned with clinical guideline recommendations. Increased use of recommended assessments may enhance optimal BPH management.

Adjustment of antidiabetic treatment regimens on discharge from the emergency department: effect on 90-day outcomes in patients admitted to a short-stay unit. / Efecto de la adecuación al alta del tratamiento antidiabético en los resultados a 90 días en los pacientes ingresados en una unidad de corta estancia.

OBJECTIVES: To determine whether the adjustment of antidiabetic treatment of patients discharged from a short-stay unit (SSU) after a hyperglycemic crisis reduces the rate of adverse events in the next 90 days. MATERIAL AND METHODS: Retrospective study of patients admitted to an emergency SSU in June 2011. We gathered information on patient demographics, concurrent diseases, reason for admission, and appropriateness of antidiabetic treatment on discharge. Patients were classified as diabetic, nondiabetic, or newly hyperglycemic. Patients with altered carbohydrate metabolism were subclassified according to the appropriateness of the antidiabetic treatment prescribed on discharge. The main outcome variable was the occurrence of an adverse event within 90 days of discharge. RESULTS: We included 750 patients with a mean (SD) age of 68.1 (19.5) years; 357 (47.6%) were men. A new adverse event occurred in 262 (36%) patients within 90 days; 15.6 (31.5%) of these patients were not diabetic, 77 (41.8%) were diabetic, and 29 (59.2%) were newly hyperglycemic (P<.001). Failure to provide an appropriate antidiabetic regimen when discharging patients with altered carbohydrate metabolism was an independent risk factor for an adverse event within 90 days (adjusted odds ratio, 7.2; 95% CI, 3.9­13.3). CONCLUSION: Lack of appropriate antidiabetic treatment after discharge from an emergency SSU is a risk factor for adverse events within 90 days.

OBJETIVO: Determinar si el adecuado tratamiento al alta de la hiperglucemia en pacientes atendidos en una unidad de corta estancia (UCE) es un factor relacionado con la reducción de eventos adversos a tres meses tras el alta. METODO: Estudio de cohorte retrospectivo que incluyó los pacientes ingresados en una UCE durante el mes de junio de 2011. Se incluyeron variables demográficas, comorbilidad, causa de ingreso y congruencia del tratamiento antidiabético al alta. Se clasificó a los pacientes en diabéticos, no diabéticos y nuevos hiperglucémicos (NHG), y en aquellos con alteración del metabolismo hidrocarbonado, la variable clasificadora fue la congruencia del tratamiento antidiabético al alta. La variable de resultado principal fue la aparición de un evento adverso compuesto en los tres primeros meses tras el alta. RESULTADOS: Se incluyeron 750 pacientes con edad media de 68,1 años (DE 19,5), de los cuales 357 (47,6%) fueron varones, 262 (36%) pacientes sufrieron un evento adverso a los 3 meses. De ellos, 156 (31,5%) fueron no diabéticos, 77 (41,8%) diabéticos y 29 (59,2%) NHG (p < 0,001). En los pacientes con alteración hidrocarbonada, el tener un tratamiento antidiabético no congruente al alta de una UCE fue un factor de riesgo independiente de sufrir un eventoadverso a 3 meses del alta [OR ajustada 7,2 (IC 95%: 3,9-13,3)]. CONCLUSIONES: Un tratamiento antidiabético no adecuado al alta de una UCE se muestra como un factor independiente de sufrir un evento adverso en los tres primeros meses.

[Managing the discharge of diabetic patients from the emergency department: a consensus paper]. / Documento de consenso sobre el manejo al alta desde urgencias del paciente diabético.

EN: Eighty to 90% of patients attended in emergency departments are discharged to home. Emergency department physicians are therefore responsible for specifying how these patients are treated afterwards. An estimated 30% to 40% of emergency patients have diabetes mellitus that was often decompensated or poorly controlled prior to the emergency. It is therefore necessary to establish antidiabetic treatment protocols that contribute to adequate metabolic control for these patients in the interest of improving the short-term prognosis after discharge. The protocols should also maintain continuity of outpatient care from other specialists and contribute to improving the long-term prognosis. This consensus paper presents the consensus of experts from 3 medical associations whose members are directly involved with treating patients with diabetes. The aim of the paper is to facilitate the assessment of antidiabetic treatment when the patient is discharged from the emergency department and referred to outpatient care teams.

ES: El 80-90% de los pacientes atendidos en los servicios de urgencias son dados de alta desde los mismos, y por tanto los facultativos de urgencias son los responsables del tratamiento al alta en dichos pacientes. Se estima que la frecuencia de diabetes mellitus en urgencias es de un 30-40% y en muchos casos dicha diabetes está descompensada o con un mal control metabólico previo, por lo que es necesario establecer pautas de tratamiento antidiabético adecuadas de cara al alta que contribuyan a un adecuado control metabólico de dichos pacientes y favorezca un mejor pronóstico a corto plazo tras el alta, así como mantener una continuidad con la atención ambulatoria por parte de otras especialidades y contribuir a una mejoría del pronóstico a largo plazo. El presente documento es por tanto un consenso de expertos de tres sociedades científicas implicadas directamente en la atención del paciente diabético, que pretende facilitar la valoración del tratamiento al alta desde urgencias en cuanto a la diabetes se refiere y su continuidad asistencial ambulatoria.

[Recommendations for the management of emergencies in patients with diabetes, acute metabolic complications of diabetes, and steroid-related hyperglycemia]. / Recomendaciones de manejo de la diabetes, de sus complicaciones metabólicas agudas y de la hiperglucemia relacionada con corticoides en los servicios de urgencias.

EN: Persons with diabetes make up a large percentage of patients attended in the emergency department. Most will be discharged, but patients who remain under observation in wards managed by the emergency department or who wait are waiting to be admitted to a conventional ward must receive appropriate, protocol-guided treatment for their diabetes. Situations of hyper- or hypoglycemia must be avoided because both worsen prognosis. Emergency physicians must correctly and efficiently prevent, diagnose, and manage acute metabolic complications of diabetes such as simple hyperglycemia, diabetic ketoacidosis, and hyperosmolar hyperglycemic state. They must also be ready to prescribe and properly administer intravenous insulin to critically ill patients. Hyperglycemia induced by treatment with steroids deserves special mention. If this complication develops, the hyperglycemia is intense, influenced by increased insulin resistance and gluconeogenesis in the liver. Thus, it usually appears after meals and is dependent on steroid dose, duration of treatment, and individual predisposition. The recommendations in this paper elaborated by consensus of the Spanish Society of Emergency Medicine (SEMES) experts, are the first to be written specifically for use in emergency departments in Spain. They give a detailed, in-depth overview of emergencies related to diabetes and diabetic complications.

ES: Un alto porcentaje de los pacientes atendidos en urgencias son diabéticos. La mayoría serán dados de alta. Sin embargo, los que se quedan en observación, ingresados en unidades dependientes de urgencias o los que quedan pendientes de ingreso en hospitalización convencional deben recibir un tratamiento correcto y protocolizado en cuanto a su diabetes, que evite tanto la hiper como la hipoglucemia, ya que ambas son situaciones que empeorarán el pronóstico del paciente. Por otro lado, los urgenciólogos deben prevenir, diagnosticar y manejar de una manera correcta y eficiente las complicaciones metabólicas agudas de la diabetes como son la hiperglucemia simple, la cetoacidosis diabética, la situación hiperosmolar y la hipoglucemia, así como las indicaciones y la forma de administración de insulina intravenosa en los pacientes críticos. Una mención aparte requiere también la hiperglucemia reactiva al tratamiento corticoideo. Esta hiperglucemia, en el caso de aparecer, es intensa y está influenciada por el aumento de la resistencia a la insulina y de la neoglucegénesis hepática que provocan los corticoides, por lo que será de predominio postprandial. Depende de la dosis y duración del tratamiento corticoideo además de una predisposición individual. Las recomendaciones que aquí se exponen, procedentes del consenso alcanzado por el grupo de expertos de la Sociedad Española de Medicina de Urgencias y Emergencias (SEMES), son las primeras redactadas en España dirigidas exclusivamente a los servicios de urgencias y que hacen una revisión pormenorizada y profunda sobre todas las situaciones que pueden encontrarse en cuanto a la diabetes y sus complicaciones.