Comparative efficacy of two interventions to discontinue long-term benzodiazepine use: cluster randomised controlled trial in primary care.

BACKGROUND: Benzodiazepines are extensively used in primary care, but their long-term use is associated with adverse health outcomes and dependence. AIMS: To analyse the efficacy of two structured interventions in primary care to enable patients to discontinue long-term benzodiazepine use. METHOD: A multicentre three-arm cluster randomised controlled trial was conducted, with randomisation at general practitioner level (trial registration ISRCTN13024375). A total of 532 patients taking benzodiazepines for at least 6 months participated. After all patients were included, general practitioners were randomly allocated (1:1:1) to usual care, a structured intervention with follow-up visits (SIF) or a structured intervention with written instructions (SIW). The primary end-point was the last month self-declared benzodiazepine discontinuation confirmed by prescription claims at 12 months. RESULTS: At 12 months, 76 of 168 (45%) patients in the SIW group and 86 of 191 (45%) in the SIF group had discontinued benzodiazepine use compared with 26 of 173 (15%) in the control group. After adjusting by cluster, the relative risks for benzodiazepine discontinuation were 3.01 (95% CI 2.03-4.46, P<0.0001) in the SIW and 3.00 (95% CI 2.04-4.40, P<0.0001) in the SIF group. The most frequently reported withdrawal symptoms were insomnia, anxiety and irritability. CONCLUSIONS: Both interventions led to significant reductions in long-term benzodiazepine use in patients without severe comorbidity. A structured intervention with a written individualised stepped-dose reduction is less time-consuming and as effective in primary care as a more complex intervention involving follow-up visits.

Debut de diabetes tipo 1 en niños durante la pandemia Covid-19 en el Hospital de Pediatría Juan P. Garrahan / Debut of type-1 diabetes in children during the COVID-19 pandemic at Hospital de Pediatría Juan P. Garrahan

Introducción: Según numerosos reportes, la pandemia por COVID­19 aumentó la incidencia de diabetes tipo 1 (DBT1) y cetoacidosis (CAD). Nuestro objetivo fue describir la frecuencia de nuevos casos de DBT1 y su severidad al ingreso en el Hospital J. P. Garrahan durante la pandemia, comparando con el periodo anterior. Material y métodos: Se realizó un estudio descriptivo, observacional, con análisis retrospectivo. Se incluyeron todos los nuevos casos entre 19/03/20- 31/12/21, comparados con el período 19/03/18-31/12/19. El diagnóstico de DBT1, CAD y su severidad se realizó según la International Society for Pediatric and Adolescent Diabetes. Se analizó el requerimiento de cuidados intensivos (UCI), presencia de COVID-19, hemoglobina glicosilada A1C (HbA1C) y autoanticuerpos (GADA, IAA, IA2, ZNT8). Se consideró significativa una p < 0,05. Resultados: En el período 2020-2021 se observó un incremento del 107% de nuevos casos, ingresando 56 pacientes con DBT1. La media y mediana de edad disminuyeron (8 vs 9,1 y 7,7 vs 10,4, respectivamente), con un incremento del 35% de menores de 5 años. Aumentó la frecuencia de CAD severa (41.1% vs 25.9%) y de requerimiento de UCI (17.9% vs 11.1%). La Hb A1C y la glucemia de ingreso mostraron incremento significativo (10.1% vs 12.32%, p<0.003 y 580 mg/dl ± 220 vs 490 mg/dl ± 188; p<0.05, respectivamente). Conclusión: En 2020-2021 se incrementó el número de nuevos casos de DBT1 en nuestra institución. Al ingreso hubo mayor proporción de niños pequeños y casos severos. Las dificultades de acceso a la consulta de atención primaria podrían relacionarse con nuestro hallazgo (AU)

Introduction: Numerous reports have shown that during the COVID-19 pandemic the incidence of type-1 diabetes (T1DB) and ketoacidosis (DKA) increased. The aim of this study was to describe the frequency of new cases and their severity on admission of T1DB at Hospital J. P. Garrahan during the pandemic, compared with the previous period. Material and methods: A descriptive, observational study with a retrospective analysis was conducted. All new cases seen between 19/03/20-31/12/21 were included and compared with the period 19/03/18-31/12/19. The diagnosis of T1DB, DKA, and its severity was made according to the International Society for Pediatric and Adolescent Diabetes. Intensive care (ICU) requirement, presence of COVID-19, glycosylated hemoglobin A1C (HbA1C), and autoantibodies (GADA, IAA, IA2, ZNT8) were analyzed. A p < 0.05 was considered significant. Results: In the period 2020-2021, a 107% increase in new cases was observed including 56 patients with T1DB. Mean and median age decreased (8 vs 9.1 and 7.7 vs 10.4, respectively), with a 35% increase in children under 5 years of age. The frequency of severe DKA (41.1% vs 25.9%) and ICU requirement (17.9% vs 11.1%) increased. Hb A1C and glycemia on admission also showed a significant increase (10.1% vs 12.32%, p<0.003 and 580 mg/dl ± 220 vs 490 mg/dl ± 188; p<0.05, respectively). Conclusion: In 2020-2021 an increase in the number of new cases of T1DB was observed at our institution. On admission, a higher rate of young children and severe cases was found. Difficulties to access primary care may have been related to our finding (AU)

Presencia de autoanticuerpos anti islotes pancreáticos en diabetes tipo 1 durante la edad pediátrica / Presence of anti-pancreatic islet autoantibodies in type 1 diabetes in children

En la Diabetes tipo 1 (DM1) la pérdida de células ß pancreáticas es consecuencia de un proceso de autoinmunidad que cursa con la presencia de autoanticuerpos anti-islotes pancreáticos (AAPs). Estos AAPs son marcadores útiles para la clasificación de la enfermedad. En un centro pediátrico de tercer nivel se analizó la frecuencia de presentación de GADA, IA-2A, ZnT8A e IAA en un grupo con reciente debut entre enero 2018 y agosto 2021 (n= 90). Además, se investigó la frecuencia de presentación y relación de los AAPs con la edad, sexo y tiempo de evolución en pacientes en seguimiento (n= 240). En el grupo de debut se obtuvo positividad de GADA, IA-2A, ZnT8A y IAA en 77,8; 60; 62 y 47,8% de los pacientes respectivamente, un 4% no presentó AAPs. El 95,6% de los pacientes presentaron al menos un AAPs positivo. La frecuencia de IAA en el grupo en debut fue mayor en menores de 5 años. En el grupo en seguimiento el 75,2% resultaron GADA positivo (85,7% en mujeres y 62,8% en varones) p<0,05. IA-2A y ZnT8A fueron positivos en 45 y 51.7% respectivamente. El 91% presentaron al menos un AAP positivo. En este grupo se evidenció una menor positividad en función del tiempo de evolución. Se pudo determinar la frecuencia de presentación de los AAPs en un grupo en debut y la relación con la edad, sexo y tiempo de evolución en pacientes en seguimiento. La determinación de APPs facilita la correcta clasificación y elección de la terapia adecuada (AU)

In type 1 diabetes (DM1) the loss of pancreatic ß-cells is a consequence of an autoimmune process that results in the presence of pancreatic anti-islet autoantibodies (PAAs). PAAs are useful markers for the classification of the disease. The frequency of presentation of GADA, IA-2A, ZnT8A, and IAA in a group with recent debut seen between January 2018 and August 2021 (n= 90) was analyzed in a tertiary pediatric center. In addition, we investigated the frequency of presentation and association of PAAs with age, sex, and time of evolution in patients in follow-up (n= 240). In the debut group, GADA, IA2A, ZnT8A, and IAA positivity was found in 77.8, 60, 62, and 47.8% of patients, respectively; no PAAs were observed in 4% of the patients. Overall, 95.6% presented at least one positive PAA. The frequency of IAA in the debut group was higher in children younger than 5 years. In the follow-up group, 75.2% were GADA positive (85.7% of females and 62.8% of males) p<0.05. IA-2A and ZnT8A were positive in 45 and 51.7% respectively. Ninety-one percent presented with at least one positive PAA. In this group, a lower positivity was evidenced as a function of the time of evolution. The frequency of presentation of PAAs in a debut group and the relationship with age, sex, and time of evolution in patients in follow-up was demonstrated. The assessment of PAAs facilitates the correct classification and choice of adequate therapy (AU)

Control metabólico y recursos tecnológicos de niños con diabetes durante la pandemia de COVID-19 / Metabolic control and technological resources for children with diabetes during the COVID-19 pandemic

Introducción: La diabetes en pacientes con COVID-19 se asocia a mayor morbilidad y mortalidad. El aislamiento social podría dificultar el acceso a la atención e insumos médicos. Nuestro objetivo fue describir el control glucémico durante la pandemia y los recursos médicos y tecnológicos disponibles. Métodos: Estudio retrospectivo, descriptivo, analítico y transversal. Se analizaron los resultados de una encuesta realizada a pacientes diabéticos del Hospital de Pediatría Juan P. Garrahan. Se indagó infección por coronavirus, proximidad geográfica, control metabólico, cobertura, insumos y conectividad. Resultados: No se informaron casos de COVID-19. El 52,9% vivía a más de dos horas de viaje. El 95,7% realizó 4 o más glucemias diarias, el 12,8% estuvo en el rango glucémico ideal de 70-140 mg%, el 75,2% entre 140-250 mg% y el 12% por encima de 250 mg%. El 6,8% presentó cetosis y el 3,4% hipoglucemia severa. El 17,9% refirió dificultades para conseguir insumos. Todos poseían internet, 12% con limitaciones. El 10% que vivía a 2 o más horas del hospital estuvo en rango ideal vs. 28% de los que vivían más cerca (p=0,02). El 96,4% de los que retiraron insumos de su cobertura social o provincial alcanzaron un control metabólico aceptable (70-250 mg%) vs. 79,5% de los que lo hicieron en el hospital. (p=0,0002). Conclusiones: La mayoría presentó un control metabólico aceptable. La distancia y las dificultades de disponibilidad de insumos, se asociaron a peor control glucémico. La conectividad y recursos tecnológicos son limitados (AU)

Introduction: In patients with diabetes who are infected with COVID-19, the latter is associated with increased morbidity and mortality. Social isolation may complicate access to care and medical supplies. Our aim was to describe glycemic control during the pandemic and the medical and technological resources available. Methods: Retrospective, descriptive, analytical, and cross-sectional study. The results of a survey conducted in patients with diabetes seen at Hospital de Pediatría Juan P. Garrahan were analyzed. Coronavirus infection, geographic proximity to the hospital, metabolic control, healthcare coverage, supplies, and connectivity were investigated. Results: No cases of COVID-19 were reported. Overall, 52.9% lived more than two hours travel from the hospital; 95.7% performed four or more daily capillary blood glucose measurements; in 12.8% blood glucose was within the target range of 70-140 mg%, in 75.2% it was between 140-250 mg%, and in 12% above 250 mg%; 6.8% had ketosis and 3.4% severe hypoglycemia. Overall, 17.9% reported difficulties in obtaining medical supplies. All had internet access, although 12% with limitations. Ten percent of the patients who lived 2 or more hours from the hospital had blood glucose levels within the target range vs. 28% of those who lived closer (p=0.02); 96.4% of those who received diabetes supplies from their social or provincial insurance achieved acceptable metabolic control (70-250 mg%) vs. 79.5% of those who did so from the hospital (p=0,0002). Conclusions: The majority of patients had acceptable metabolic control. Distance and difficulties in the availability of supplies were associated with worse glycemic control. Connectivity and technological resources are limited (AU)

The role of personality disorders on drug dependence treatment outcomes following inpatient detoxification.

AIMS: The present 6 month follow-up study was conducted to investigate the possible influence of comorbid personality disorders on drug treatment, as well as associated psychopathology and HIV-related risk behaviors outcomes. SUBJECTS AND METHODS: Data were collected initially from a consecutive sample of 74 patients with a diagnosis of opiate abuse or dependence, admitted for inpatient detoxification. RESULT: During intake, 80.9% of patients reported at least one HIV-related risk behavior in the previous 6 months. Not using condoms during sexual intercourse was the most common and the only risk behavior that showed a statistically significant reduction over the follow-up period. A total of 58.1% of subjects had at least one personality disorder (PD). Borderline PD was the most prevalent. However, antisocial PD was the only PD that influenced substance use outcomes. The presence of this diagnosis increased the chance of worse opiate use outcomes, but decreased likelihood of not using condoms. Patients with low obsessive-compulsive PD dimensional scores showed a significant increase in the number of risk behaviors. However, these influences were only seen at the 3-month follow-up assessment. CONCLUSIONS: These results suggest that personality disorders need to be considered when planning effective interventions for opiate dependent individuals and when preparing and evaluating HIV risk-reduction interventions, particularly for the more severe substance dependent patients.

[The role of genetics in the personality and its disorders: a clinical point of view]. / El papel de la genética en la personalidad y sus trastornos desde una perspectiva clínica.

The most important bibliography on the role of genetics in personality and its disorders has been reviewed from a clinical point of view. Following the introduction, the most relevant findings on genetics and the personality dimensions are compiled, focusing on Cloninger's Psychobiological Model. Regarding personality disorder, studies have been found on cluster A, mainly related to the schizotypal personality disorder, and on cluster B, mainly related to antisocial personality and borderline disorders. The bibliography on cluster C PD was limited. The review concludes with a discussion that stresses the possible usefulness of personality dimensions, considered as interphenotypes regarding both diagnostic aspects and treatment.

Comorbidity on disorders with loss of impulse-control: pathological gambling, addictions and personality disorders.

OBJECTIVES: To analyze the comorbidity of pathological gamblers, mainly in disorders with loss of impulse-control as addictions and personality disorders (PD). Also, to discuss addictive and impulsive characteristics of pathological gambling (PG), and their implications in prognosis and treatment. MATERIAL AND METHOD: Cross-sectional study on 162 patients with PG admitted for treatment in a specific residential unit. The SCID-I and II were used for the addiction and the PD diagnosis. For the diagnosis and evaluation of PG the SOGS, AGQ III and the Gambling Severity Index were also used. RESULTS: The 61.1 % of the patients presented some PD, where the cluster B ones (impulsive group) were more frequent, followed by C and A ones. 63.3% of patients had had in their lives substance dependence criteria, where alcohol dependence was the most prevalent. The presence of PD is related to the gravity of the addiction by the dependence to more than one substance (chi2=7.15; p<0.008). DISCUSSION: TP and substance-related disorders (SRD) are frequent comorbidities of the PG. Their co-presentation could mean worse prognosis of this patients. The PG as impulsive disorder could help to the understanding of the etiopathogenia of this disorder, but also of the prognosis. This hypothesis will add to the addictive one other treatment approaches that should be included in future studies of PG.

[Evaluation of a surveillance program in occupational health in a catchment area of the Valencia community]. / Evaluación de un programa de vigilancia en salud laboral en un área de salud de la Comunidad Valenciana.

BACKGROUND: The poor development of systems of occupational surveillance in Spain is an important obstacle for implementing effective occupational health programmes. The objective of this study is to evaluate the utility and feasibility of an occupational health surveillance system in a Health Area, using the available public sanitary resources, between 1991 and 1993. METHODS: The surveillance system is based on the identification of Sentinel Health Events (Rutstein and cols.) from registers or by notification, obtaining additional information through the procedure of interview. Distribution of cases by condition, level of response to the interviews, and distribution of cases according to its source of information are analysed. The evaluation is made on the following criteria: required elements, utility, representativeness, choice between sensibility and specificity, and limitations. RESULTS: 314 sentinel health events were identified, from which, in 33 cases, occupational exposure to causal agents was confirmed. The occupational diseases notified from compensation systems were 31. 3 cases of interstitial pneumonia were identified, that allowed the detection of an outbreak in textile workers. CONCLUSIONS: The implementation of systems of occupational surveillance, in the actual spanish sanitary context, should take into account the following aspects: organizational flexibility, efficiency, and orientation towards intervention.

Primary anetoderma associated with primary Sjögren's syndrome.

We report the case of a woman with a primary Sjögren's syndrome who developed asymptomatic anetoderma lesions with no other pathology responsible. This dermatosis has been associated with many autoimmune disorders, in particular lupus erythematosus and lupus-like syndromes. Our literature review found only one previous description of primary anetoderma associated with primary Sjögren's syndrome.

Cirugía reconstructiva del aparato locomotor, nuevas técnicas y opciones terapéuticas / Reconstructive surgery of the locomotor apparatus: new techniques and therapeutic options

La aplicación de criterios tumorales en el tratamiento quirúrgico secuencial de las osteítis crónicas y seudoartrosis sépticas en forma de resecciones segmentarias origina amplios defectos óseos. Una vez controlado el proceso séptico, en un entorno estable y vascularizado, se procede a la reconstrucción en dichas lesiones mediante transporte óseo basado en la osteogénesis a distracción. A pesar de los buenos resultados obtenidos, los periodos de fijación externa y de curación son muy largos, 2,4 meses por centímetro reconstruido. Estos prolongados tratamientos motivan que haya un elevado número de complicaciones. Los avances en ingeniería tisular y regeneración ósea contribuyen con nuevas técnicas y opciones terapéuticas. La estimulación de la formación de hueso nuevo en la zona de distracción o en el punto de atraque del fragmento transportado puede minimizar las complicaciones asociadas a la larga duración del procedimiento. La utilización de un osteoinductor como BMP-7 origina en la práctica un aumento de la formación ósea y el nuevo hueso puede tener incrementadas sus propiedades biomecánicas (AU)

The application of oncologic criteria in the sequential surgical treatment of chronic osteomyelitis foci and septic pseudarthrosis, through segmental resections, produces extensive bone defects. Once the septic process is under control, in a stable and well vascularized atmosphere, we perform reconstruction of intercalary defects through bone transportation based on distraction osteogenesis. Despite the good results, the healing index and the time on ex-fi x are very long, about 10 weeks per centimeter rebuilt. These prolonged treatments lead to a large number of complications. Advances in tissue engineering and bone regeneration have led to new techniques and therapeutic options. Stimulation of new bone formation in the distraction area or in the “docking-site” can minimize the complications associated with the length of time required by the procedure. The use of an osteoinducer, such as BMP-7, increases new bone formation and may enhance its biomechanical properties (AU)

El papel de la genética en la personalidad y sus trastornos desde una perspectiva clínica / The role of genetics in the personality and its disorders: a clinical point of view

Desde un punto de vista clínico se ha revisado la bibliografía más destacable sobre el papel de la genética en la personalidad y sus trastornos. Tras la introducción se recopilan los hallazgos más relevantes sobre genética y dimensiones de personalidad, haciendo hincapié en el modelo psicobiológico de Cloninger. Respecto a los trastornos de la personalidad se han encontrado estudios sobre el clúster A, especialmente sobre el trastorno esquizotípico de la personalidad, y sobre el B, especialmente en relación con los trastornos antisocial de la personalidad y límite, siendo escasa la literatura sobre los trastornos del clúster C. La revisión finaliza con una discusión en la que se enfatiza en la posible utilidad de las dimensiones de personalidad, consideradas como interfenotipos, tanto en relación con aspectos diagnósticos como de tratamiento (AU)

The most important bibliography on the role of genetics in personality and its disorders has been reviewed from a clinical point of view. Following the introduction, the most relevant findings on genetics and the personality dimensions are compiled, focusing on Cloninger’s Psychobiological Model. Regarding personality disorder, studies have been found on cluster A, mainly related to the schizotypal personality disorder, and on cluster B, mainly related to antisocial personality and borderline disorders. The bibliography on cluster C personality disorders was limited. The review concludes with a discussion that stresses the possible usefulness of personality dimensions, considered as inter phenotypes regarding both diagnostic aspects and treatment (AU)

Comorbilidad de trastornos con pérdida del control de impulsos: ludopatía, adicciones y trastornos de la personalidad / Comorbidity on disorders with loss of impulse-control: pathological gambling, addictions and personality disorders

Objetivos. Analizar la comorbilidad de la ludopatía, principalmente con los trastornos con alteración del control de los impulsos, como es el caso de las adicciones y los trastornos de la personalidad (TP). También realizar una discusión sobre las características adictivas e impulsivas de la ludopatía, así como sus implicaciones pronósticas y de tratamiento. Material y método. Estudio transversal en 162 pacientes diagnosticados de ludopatía que fueron admitidos para tratamiento en una unidad residencial específica. Para el diagnóstico de trastornos por uso de sustancias (TUS) y de TP se utilizó el SCID-I y II, mientras que para el diagnóstico y evaluación de la ludopatía se utilizó además la SOGS, el AGQ III y el Gambling Severity Index. Resultados. El 61,1% de los ludópatas presentaban algún TP, siendo más frecuentes los del grupo B (impulsivos), seguidos de los TP del grupo C y después del A. El 63,3% de los pacientes había cumplido durante su vida criterios diagnósticos de dependencia, siendo la sustancia más frecuente el alcohol. La presencia de algún TP se correlacionó con la gravedad de la adicción, pues estos pacientes presentaban dependencia de más de una sustancia (x2=7,15; p<0,008). Discusión. Los TP impulsivos y los TUS son comorbilidades frecuentes de la ludopatía. Su copresentación con la ludopatía puede conllevar peor pronóstico para estos pacientes. La ludopatía entendida como un trastorno impulsivo puede ayudar a entender mejor la etiopatogenia de este trastorno, pero también su pronóstico. Esta hipótesis puede aportar a la hipótesis aditiva de la ludopatía otros abordajes terapéuticos que deberán ser evaluados en futuras investigaciones

Objectives. To analyze the comorbidity of pathological gamblers, mainly in disorders with loss of impulsecontrol as addictions and personality disorders (PD). Also, to discuss addictive and impulsive characteristics of pathological gambling (PG), and their implications in prognosis and treatment. Material and method. Cross-sectional study on 162 patients with PG admitted for treatment in a specific residential unit. The SCID-I and II were used for the addiction and the PD diagnosis. For the diagnosis and evaluation of PG the SOGS, AGQ III and the Gambling Severity Index were also used. Results. The 61,1 % of the patients presented some PD, where the cluster B ones (impulsive group) were more frequent, followed by C and A ones. 63,3% of patients had had in their lives substance dependence criteria, where alcohol dependence was the most prevalent. The presence of PD is related to the gravity of the addiction by the dependence to more than one substance (x2=7,15; p<0,008). Discussion. TP and substance-related disorders (SRD) are frequent comorbidities of the PG. Their co-presentation could mean worse prognosis of this patients. The PG as impulsive disorder could help to the understanding of the etiopatogenia of this disorder, but also of the prognosis. This hypothesis will add to the addictive one other treatment approaches that should be included in future studies of PG