All-cause and cardiorenal mortality in 6 million adults with and without type 2 diabetes: A comparative, trend analysis in Canada, Spain, and the UK.

AIMS: To understand geographical and temporal patterns in the diabetes gap, the excess mortality risk associated with type 2 diabetes (T2D), in three high-income countries. METHODS: Using databases from Canada (Ontario), Spain (Catalonia) and the UK (England), we harmonized the study design and the analytical strategy to extract information on subjects aged over 35 years with incident T2D between 1998 and 2018 matched to up to five subjects without diabetes. We used Poisson models to estimate age-specific mortality trends by diabetes status and rate ratios and rate differences associated with T2D. RESULTS: In more than 6 million people, 694 454 deaths occurred during a follow-up of 52 million person-years. Trends in all-cause mortality rates differed between Ontario and England; yet, the diabetes gaps were very similar in recent years: in 2018, we estimated 1.3 (95% confidence interval: 0.8, 1.8) and 0.8 (0.2, 1.5) more deaths per 1000 person-years in 50-year-old men with diabetes in Ontario and England, respectively, and 8.9 (6.1, 11.7) and 12.1 (9.1, 15.1) in 80-year-old men; between-country differences were small also in women. In Catalonia, rate ratios comparing T2D with no diabetes in men in 2018 were 1.53 (1.11, 2.11) at 50 years old, 0.88 (0.72, 1.06) at 60 years old, 0.74 (0.60, 0.90) at 70 years old and 0.81 (0.66, 1.00) at 80 years old, indicating lower mortality rates in men with T2D from the age of 60 years; rates were similar in women with and without diabetes at all ages. The diabetes gaps in cardiorenal mortality mirrored those of all-cause mortality: we observed consistent reductions in the proportions of cardiorenal deaths in subjects aged 80 years but variations in subjects aged ≤70 years, regardless of the presence of diabetes. CONCLUSIONS: By reducing the confounding impact of epidemiological and analytical differences, this study showed geographical similarities and differences in the diabetes gap: an excess risk of all-cause and cardiorenal mortality in subjects with T2D is still present in Ontario and England in recent years, particularly in elderly subjects. Conversely, there were very small gaps in young men with T2D or even lower mortality rates in older subjects with T2D in Catalonia.

[Hip fractures in patients treated with antipsychotic drugs. Study of retrospective cohorts in Catalonia]. / Fracturas de cadera en pacientes tratados con fármacos antipsicóticos. Estudio de cohortes históricas en Cataluña.

OBJECTIVE: To evaluate the incidence of hip fracture in patients with antipsychotic treatment, comparing it with that of individuals who have not been treated with antipsychotics. DESIGN: Retrospective cohort study of patients treated with antipsychotic drugs (TAP) and patients without known treatment (non-TAP). The observation period was 2006-2014. SITE: All primary care teams in Catalonia of the Catalan Health Institute (ICS). PARTICIPANTS: Patients older than 44 years with TAP lasting at least 3 months. Control cohort: random selection of non-TAP patients matching for baseline comorbidities and other variables. A total of 22,010 are analyzed. Main measurements Incidence rate (1000× person-years: PY) of hip fracture in each group (TAP and non-TAP). Cox regression models to estimate adjusted risks (hazard ratio: HR). RESULTS: The hip fracture incidence rate was higher in TAP patients (5.83 vs 3.58 fractures per 1000 PY), and is higher in all strata according to sex, age and type of diagnosis. The risk of suffering a hip fracture was 60% higher (HR: 1.60 95% CI: 1.34-1.92) in the TAP group than in the non-TAP group. The risk was higher in the group with schizophrenia (HR: 3.57 95% CI: 1.75-7.30), followed by bipolar disorder (HR: 2.61; 95% CI: 1.39-4.92) and depression (HR: 1.51; 95% CI: 1.21-1.88). CONCLUSIONS: Patients with antipsychotic treatment have a higher risk of hip fracture than those who have not been treated with antipsychotics.

Assessment of the length of sick leave in patients with ischemic heart disease.

BACKGROUND: The prevalence of ischemic heart disease is high. Few recent studies have investigated the periods of sick leave of these patients. Our aim is to determine the length of sick leave after an acute coronary syndrome, its costs, associated factors and to assess the use of antidepressants and/or anxiolytics. METHODS: An observational study of a retrospective cohort of patients on sick leave due to ischemic heart disease in a health region between 2008-2011, with follow-up until the first return to work, death, or end of the study (31/12/2012). MEASUREMENTS: length of sick leave, sociodemographic variables and medical prescriptions. RESULTS: Four hundred and ninety-seven patients (mean age 53 years, 90.7% male), diagnosed with acute myocardial infarction (60%), angina pectoris (20.7%) or chronic form of ischemic heart disease (19.1%). Thirty-seven per cent of patients took anxiolytics the year after diagnosis and 15% took antidepressants. The average duration of sick leave was 177 days (95% CI: 163-191 days). Patients diagnosed with acute myocardial infarction returned to work after a mean of 192 days, compared to 128 days in cases with angina pectoris. Patients who took antidepressants during the year after diagnosis returned to work after a mean of 240 days. The mean work productivity loss was estimated to be 9,673 euros/person. CONCLUSIONS: The mean duration of sick leave due to ischemic heart disease was almost six months. Consumption of psychotropic medication doubled after the event. Older age, suffering an acute myocardial infarction and taking antidepressants were associated with a longer sick leave period.

[Potentially inappropriate prescribing in older Spanish population according to STOPP/START criteria (STARTREC study)]. / Análisis poblacional de la prescripción potencialmente inadecuada en ancianos según criterios STOPP/START (estudio STARTREC).

OBJECTIVE: Rational prescribing in older people is a priority for health care organizations. The STOPP/START screening tool has been developed to identify potentially inappropriate prescribing (PIP) in individuals. In a primary care setting, STOPP/START can estimate PIP prevalence and related factors at population level. The aim of this study is to measure the prevalence rates of PPI in elderly population using clinical and prescription claim databases. DESIGN: Cross-sectional population study. SETTINGS: Primary Care, Lleida Health Region, Spain. PARTICIPANTS: 45.408 patients 70 years old and over, attended in the primary health care centers at least once the last year. METHODS: 43 STOPP and 12 START criteria are applied to their 2012 clinical and prescription records. Logistic regression models are adjusted to determine PIP association with several factors. RESULTS: 45,408 patients are included. The mean age is 79.7 years, 58% being female. The overall prevalence of PPI is 58.1%. According to STOPP, the most common drugs identified are benzodiazepines, non-steroidal anti-inflammatory drugs and proton pump inhibitors; according to START, osteoporosis treatments, antiplatelet agents, statins, metformin and beta blockers. PIP increases with age and polypharmacy and it is higher in long-term care facilities residents and patients receiving home health care. CONCLUSIONS: In our Health Region, at least 50% of the population aged 70 or older has one or more PIP, according to STOPP/START criteria.

Feasibility Assessment of the Let's Walk Programme (CAMINEM): Exercise Training and Health Promotion in Primary Health-Care Settings.

Exercise is related to many individual health outcomes but impact evaluations of exercise programmes are seldom conducted. The purpose of the study is to evaluate the feasibility of an exercise prescription intervention in primary health-care settings (CAMINEM Programme) located in two socially disadvantaged neighbourhoods. The CAMINEM was a pragmatic-driven intervention with opportunistic recruitment. It followed the 5As framework for health promotion and also the exercise training principles. Feasibility was evaluated using the RE-AIM framework (Reach, Effectiveness, Adoption, Implementation, and Maintenance). Patients with non-communicable chronic diseases participated in a 12-month home-based moderate-intensity exercise program, counselled by exercise physiologists. Participants were grouped according to their physical activity behaviour at baseline and 6-month adherence. CAMINEM reached 1.49% (n = 229) of the eligible population (N = 15374) and included a final sample of 178. Health outcomes for adhered participants followed positive patterns. Non-adhered participants visited their practitioner more compared to adhered participants. Thirty-three practitioners (40%) referred patients. Nurses referred four times more than physicians (81% and 19% respectively). The delivery of exercise prescriptions proved to be easy to complete and record by participants as well as easy to monitor and adjust by the exercise physiologists. One out of four participants adhered during the 12-month intervention. This intervention has been feasible in primary care in Catalonia, Spain, to safely prescribe home-based exercise for several conditions.

Fracturas de cadera en pacientes tratados con fármacos antipsicóticos. Estudio de cohortes históricas en Cataluña / Hip fractures in patients treated with antipsychotic drugs. Study of retrospective cohorts in Catalonia

Objetivo: Evaluar la incidencia de fractura de cadera en pacientes con tratamiento antipsicótico, comparándola con la de individuos que no han sido tratados con antipsicóticos.Diseño: Estudio de cohortes históricas de pacientes tratados con fármacos antipsicóticos (TAP) y pacientes sin tratamiento conocido (no TAP). El periodo de observación fue 2006-2014.Emplazamiento: Todos los equipos de atención primaria de Cataluña del Instituto Catalán de la Salud (ICS).Participantes: Pacientes mayores de 44 años con TAP de al menos 3 meses de duración. Cohorte control: selección aleatoria de pacientes no TAP emparejando por comorbilidades basales, sexo, edad y prescripción de fármacos (excluyendo psicofármacos). Se analiza un total de 22.010 pacientes.Mediciones principales Tasa de incidencia (×1.000 personas-año [PY]) de fractura de cadera en cada grupo (TAP y no TAP). Modelos de regresión de Cox para estimar riesgos ajustados (hazard ratio [HR]) añadiendo los psicofármacos como covariables. Resultados: La tasa de incidencia de fractura de cadera fue mayor en los pacientes TAP (5,83 frente a 3,58 fracturas por 1.000 PY), y es mayor en todos los estratos según sexo, edad y tipo de diagnóstico. El riesgo de sufrir una fractura de cadera fue un 60% mayor (HR: 1,60; IC95%: 1,34-1,92) en el grupo TAP que en el grupo no TAP. El riesgo fue mayor en el grupo con esquizofrenia (HR: 3,57; IC95%: 1,75-7,30), seguido del trastorno bipolar (HR: 2,61; IC95%: 1,39-4,92) y depresión (HR: 1,51; IC95%: 1,21-1,88). Conclusiones: Los pacientes con tratamiento antipsicótico presentan más riesgo de fractura de cadera que los que no han sido tratados con antipsicóticos.

ObjectiveTo evaluate the incidence of hip fracture in patients with antipsychotic treatment, comparing it with that of individuals who have not been treated with antipsychotics.DesignRetrospective cohort study of patients treated with antipsychotic drugs (TAP) and patients without known treatment (non-TAP). The observation period was 2006–2014.SiteAll primary care teams in Catalonia of the Catalan Health Institute (ICS).ParticipantsPatients older than 44 years with TAP lasting at least 3 months. Control cohort: random selection of non-TAP patients matching for baseline comorbidities and other variables. A total of 22,010 are analyzed.Main measurements Incidence rate (1000× person-years: PY) of hip fracture in each group (TAP and non-TAP). Cox regression models to estimate adjusted risks (hazard ratio: HR).ResultsThe hip fracture incidence rate was higher in TAP patients (5.83 vs 3.58 fractures per 1000 PY), and is higher in all strata according to sex, age and type of diagnosis. The risk of suffering a hip fracture was 60% higher (HR: 1.60 95% CI: 1.34–1.92) in the TAP group than in the non-TAP group. The risk was higher in the group with schizophrenia (HR: 3.57 95% CI: 1.75–7.30), followed by bipolar disorder (HR: 2.61; 95% CI: 1.39–4.92) and depression (HR: 1.51; 95% CI: 1.21–1.88).ConclusionsPatients with antipsychotic treatment have a higher risk of hip fracture than those who have not been treated with antipsychotics.

Análisis poblacional de la prescripción potencialmente inadecuada en ancianos según criterios STOPP/START (estudio STARTREC) / Potentially inappropriate prescribing in older Spanish population according to STOPP/START criteria (STARTREC study)

OBJETIVO: Racionalizar la prescripción en la población anciana es una prioridad de los sistemas sanitarios. Los criterios STOPP/START permiten detectar la prescripción potencialmente inadecuada (PPI) a nivel individual. Su aplicación a nivel poblacional permite determinar la prevalencia de PPI y su relación con diversas variables del paciente y del sistema sanitario. El objetivo de este estudio es analizar la prevalencia de PPI en población anciana a partir de bases de datos clínicos y de farmacia. DISEÑO: Estudio descriptivo transversal. Emplazamiento: Ámbito de atención primaria de la Región Sanitaria de Lleida, España. PARTICIPANTES: Se incluyen 45.408 pacientes de 70 años o más atendidos en los centros de salud como mínimo una vez en el último año. Mediciones principales: Se calcula la frecuencia de incumplimiento de 43 indicadores STOPP y 12 indicadores START, a partir de los fármacos prescritos durante un año y se ajustan modelos de regresión logística para evaluar su asociación con diversas variables. RESULTADOS: El 58% son mujeres. La edad media es de 79,7 años. El 58,1% incumplen como mínimo un criterio STOPP y/o START, relacionados principalmente con el uso de benzodiacepinas, antiinflamatorios no esteroideos e inhibidores de la bomba de protones por exceso, y los tratamientos para la osteoporosis, antiagregantes, estatinas, metformina y betabloqueantes por omisión. La PPI aumenta con la edad y la polifarmacia y es superior en pacientes ingresados en centros geriátricos y domiciliarios que en los ambulatorios. CONCLUSIONES: Los criterios STOPP/START identifican PPI en más de la mitad de pacientes ancianos de una región sanitaria española

OBJECTIVE: Rational prescribing in older people is a priority for health care organizations. The STOPP/START screening tool has been developed to identify potentially inappropriate prescribing (PIP) in individuals. In a primary care setting, STOPP/START can estimate PIP prevalence and related factors at population level. The aim of this study is to measure the prevalence rates of PPI in elderly population using clinical and prescription claim databases. DESIGN: Cross-sectional population study. Settings: Primary Care, Lleida Health Region, Spain. PARTICIPANTS: 45.408 patients 70 years old and over, attended in the primary health care centers at least once the last year. METHODS: 43 STOPP and 12 START criteria are applied to their 2012 clinical and prescription records. Logistic regression models are adjusted to determine PIP association with several factors. RESULTS: 45,408 patients are included. The mean age is 79.7 years, 58% being female. The overall prevalence of PPI is 58.1%. According to STOPP, the most common drugs identified are benzodiazepines, non-steroidal anti-inflammatory drugs and proton pump inhibitors; according to START, osteoporosis treatments, antiplatelet agents, statins, metformin and beta blockers. PIP increases with age and polypharmacy and it is higher in long-term care facilities residents and patients receiving home health care. CONCLUSIONS: In our Health Region, at least 50% of the population aged 70 or older has one or more PIP, according to STOPP/START criteria

Prevalencia de infección por Staphylococcus aureus resistente a meticilina en heridas crónicas en atención primaria de Lleida. Estudio retrospectivo / Prevalence of infection with Staphylococcus aureus methicillin resistent in chronic wounds in primary care of Lleida. Retrospective study

Objetivo: averiguar la prevalencia de infecciones por Staphylococcus aureus (S. aureus) y S. aureus resistente a meticilina (MRSA) en los cultivos de heridas crónicas en atención primaria de la región sanitaria de Lleida y valorar la prescripción de antibioterapia oral según resultado del antibiograma. Diseño: estudio transversal retrospectivo. Muestra: cultivos realizados en heridas crónicas de enero de 2010 a diciembre 2012. Resultados: se estimó una prevalencia de cultivos positivos a Staphylococcus aureus resistente a meticilina de 3,77% (intervalo de confianza IC al 95%: 2,1-5,5) y de S. aureus no resistente a meticilina de 8,79% (IC 95%: 1,1-6,1) calculado sobre el número total de cultivos registrados en este periodo. Conclusiones: la prescripción de antibióticos respecto al antibiograma es más precisa al tener como respuesta un MRSA que un cultivo de S. aureus

Aim: To find out the prevalence of infection with S. aureus and methicillin-resistant S. aureus (MRSA) in swab of chronic wounds in primary care in the health service region of Lleida and evaluate the use of oral antibiotics according to antibiogram results. Design: Retrospective cross-sectional study. Subjects: Swab of chronic wounds made in January 2010 to December 2012. Results: The prevalence of Staphylococcus aureus positive swabs for methicillin resistant 3.77% (95% CI: 2.1 to 5.5) and methicillin resistant S. aureus not 8.79% (95% 1.1-6.1), calculated on the total number of registered swabs in this period . Conclusions: The prescription of antibiotics regarding susceptibility is more accurate to have a response of MRSA than a swab positive for S. aureus

Pacientes con el diagnóstico de insuficiencia cardiaca en Atención Primaria: envejecimiento, comorbilidad y polifarmacia / Heart failure patients in Primary Care: aging, comorbidities and polypharmacy

ObjetivoDescribir el perfil clínico y de consumo farmacológico de los pacientes con registro diagnóstico de insuficiencia cardiaca (IC) en una región sanitaria, a partir de los registros informáticos. Ver si existen diferencias por sexos.DiseñoEstudio descriptivo transversal multicéntrico.EmplazamientoRegión Sanitaria de Lleida.ParticipantesToda la población adscrita a 21 centros de salud, diagnosticada de IC (3.017 de 306.229).Mediciones principalesDatos demográficos, comorbilidades y subgrupos terapéuticos en pacientes con el diagnóstico de IC en la historia clínica.ResultadosRegistro de IC 0,99%, 59% mujeres, media de edad 80 años. Antecedentes: hipertensión 67%, fibrilación auricular (FA) 31%, diabetes (DM2) 30%, obesidad 27%, dislipemia 26,5%, asma/EPOC 26%, cardiopatía isquémica (CI) 19%, accidente vascular cerebral (AVC) 11%, e insuficiencia renal (IR) 12%. Hipertensión, dislipemia y obesidad son más frecuentes en mujeres y EPOC, CI e IR en hombres. No hay diferencias en DM2, AVC ni FA. Mediana de consumo de subgrupos terapéuticos por paciente durante el 2007 de 8 (P25=6 y P75=11). Las mujeres tienen mayor prescripción de diuréticos (76% vs 71%), glucósidos cardíacos (22% vs 19.3%) e IECA/ARAII (68% vs 64%) y los hombres de tratamiento combinado IECA/ARAII+beta bloqueantes (26,9% vs 23,5%). Hay una tendencia a mayor prescripción de estos últimos en hombres sin ser significativa.ConclusionesLos pacientes diagnosticados de IC en Atención Primaria son de edad muy avanzada, presentan pluripatología asociada y consumen muchos fármacos. Existen diferencias por sexos tanto en factores de riesgo cardiovascular y enfermedades asociadas como en el perfil de consumo farmacológico(AU)

ObjectiveTo assess heart failure prevalence, epidemiology, co-morbidities and polypharmacy in our region from electronic patient records. To evaluate gender differences in heart failure patients.DesignDescriptive, cross-sectional study.SettingPrimary care Lleida (Spain).ParticipantsAll patients from 21 primary care centers with the diagnosis of heart failure in medical records were included.Main outcome measurementsDemografic data, comorbidities and therapeutical subgroups in patients with a diagnosis of heart failure in their clinical record.ResultsHeart failure was found in 0.99% (3017 from 306229 patients), of whom 59% were women, and a mean age of 80 years. Comorbidities: hypertension 67%, diabetes 30%, hyperlipidemia 26.5%, obesity 27%, ischemic heart disease 19%, stroke 11%, atrial fibrillation 31%, COPD 26%, renal failure 12%. Hypertension, hyperlipidemia and obesity were more frequent in women, COPD, ischemic heart disease and renal failure in men. There were no differences in diabetes, stroke and atrial fibrillation. Patients were prescribed a median of 8 different therapeutic subgroups (P25=6 and P75=11). Women were more frequently prescribed diuretics (76%), cardiac glycosides (22%) and ACE inhibitors/angiotensin II receptor antagonists, and men ACE inhibitors/angiotensin II receptor antagonists in combination with beta-blockers.ConclusionsHeart failure patients in primary care are elderly, with significant co-morbidities and treated with a high number of drugs. Gender differences exist in cardiovascular risk factors, co-morbidities, and also in therapy(AU)

Una actuación de enfermería: intentar aliviar el dolor en las punciones de hemodiálisis / A nursing action: trying to alleviate pain in haemodialysis punctures

La teoría de control de la compuerta, propuesta originalmente en 1965 (Melzack y Wall), sugiere que la estimulación cutánea puede aliviar el dolor mediante la activación de las fibras nerviosas nociceptivas de diámetro grande. Nuestro objetivo consiste en averiguar si, en la práctica clínica, un dolor breve- moderado puede aliviar un dolor más intenso en una zona cercana, en este caso la punción en hemodiálisis. La técnica consiste en realizar una hiperestimulación sensorial mediante la mayor compresión de smarch utilizado para la punción, para posteriormente recoger la valoración del grado de dolor por parte del paciente. Podemos concluir que la compresión extra del miembro portador del acceso vascular reduce significativamente el grado de dolor en las punciones venosas. La compression extra en las punciones arteriales también reduce el grado de dolor, aunque no hemos encontrado diferencias significativas

The gate control theory, originally proposed in 1965 (Melzackand Wall), suggests that cutaneous stimulation can alleviate Pain by activating large-diameter nociceptive nerve fibres. Our aim is to verify whether, in clinical practice, a brief-moderate pain can alleviate more intense pain in a nearby area, in this case the haemodialysis puncture. The technique consists of creating sensorial hyperstimulation by greater compression of the Es march used for the puncture, and then examining the evaluation of the level of pain by the patient. We can conclude that the extra compression of the member bearing the vascular access significantly reduces the level of pain in venous punctures. The extra compression in arterial punctures also reduces the level of pain, although we have not found significant differences

Estudio de calidad de vida en pacientes afectos de isquemia crítica a medio plazo / Study of the medium term quality of life in patients with critical ischaemia

Introducción. El tratamiento de la isquemia crítica de extremidades inferiores tiene por finalidad el salvamento de la extremidad, la resolución de los síntomas y la mejora en la calidad de vida. Objetivo. Determinar diferencias en términos de calidad de vida en pacientes con isquemia crítica y que se revascularizan con éxito (grupo I), y aquellos sin posibilidad revascularizadora, amputados o con trombosis del bypass durante el seguimiento (grupo II). Pacientes y métodos. Seleccionamos una muestra aleatoria de 48 pacientes con isquemia crítica. Aplicamos el test SF-36 al primer y segundo año y evaluamos la permeabilidad, salvamento de la extremidad y la mortalidad. Resultados. La supervivencia global al primer y segundo año fue del 79% y 56%, respectivamente, con una permeabilidad para la cirugía del 94% y 86% y un salvamento de extremidad del 100%, excluidas las amputaciones primarias. No encontramos diferencias en ninguno dominio del SF-36 entre ambos grupos al primer y segundo año. La media de supervivencia global fue de 26 meses. Conclusiones. La calidad de vida a medio plazo en los pacientes revascularizados no difiere de los no revascularizados, amputados o con trombosis del bypass. El dolor y la limitación física así como los múltiples factores de comorbilidad presentes en estos pacientes implican un pronóstico pobre en términos de calidad de vida a pesar de los tratamientos realizados

Introduction. The purpose of treatment of critical ischaemia of the lower extremities is to salvage the limb, resolve the symptoms and improve the patient’s quality of life. Aim. To determine the differences, as far as quality of life is concerned, between patients with critical ischaemia who undergo successful revascularisation (group I) and those who cannot be revascularised, have suffered amputation or in whom a thrombosis was observed in the bypass during follow-up (group II). Patients and methods. We selected a random sample of 48 patients with critical ischaemia. The SF-36 test was applied at one and two years and patency, limb salvage and mortality rates were evaluated. Results. Overall survival at one and two years was 79% and 56%, respectively, with 94% and 86% patency for surgery, and a limb salvage rate of 100%, excluding primary amputations. No differences were found between the two groups at one and two years in any of the areas of the SF-36. Overall mean survival time was 26 months. Conclusions. There is no difference between the medium term quality of life in revascularised patients and those who have not undergone revascularisation, have suffered amputation or who have a thrombosed bypass. The pain and physical limitations, as well as the multiple comorbidity factors that these patients have, imply a poor prognosis in terms of quality of life despite the treatments that are carried out