Incidence of T2DM and the role of baseline glycaemic status as a determinant in a metropolitan population in northern Madrid (Spain).

AIM: To estimate the incidence of T2DM and assess the effect of pre-T2DM (isolated impaired fasting glucose [iIFG], isolated impaired glucose tolerance [iIGT] or both) on progress to T2DM in the adult population of Madrid. METHODS: Population-based cohort comprising 1,219 participants (560 normoglycaemic and 659 preT2DM [418 iIFG, 70 iIGT or 171 IFG-IGT]). T2DM was defined based on fasting plasma glucose or HbA1c or use of glucose-lowering medication. We used a Cox model with normoglycaemia as reference category. RESULTS: During 7.26 years of follow-up, the unadjusted incidence of T2DM was 11.21 per 1000 person-years (95 %CI, 9.09-13.68) for the whole population, 5.60 (3.55-8.41) for normoglycaemic participants and 16.28 (12.78-20.43) for pre-T2DM participants. After controlling for potential confounding factors, the baseline glycaemic status was associated with higher primary effect on developing T2DM was iIGT (HR = 3.96 [95 %CI, 1.93-8.10]) and IFG-IGT (3.42 [1.92-6.08]). The HR for iIFG was 1.67 (0.96-2.90). Obesity, as secondary effect, was strongly significantly associated (HR = 2.50 [1.30-4.86]). CONCLUSIONS: Our incidence of T2DM is consistent with that reported elsewhere in Spain. While baseline iIGT and IFG-IGT behaved a primary effect for progression to T2DM, iIFG showed a trend in this direction.

Real-world data in primary care: validation of diagnosis of atrial fibrillation in primary care electronic medical records and estimated prevalence among consulting patients'.

BACKGROUND: Primary care electronic medical records contain clinical-administrative information on a high percentage of the population. Before this information can be used for epidemiological purposes, its quality must be verified. This study aims to validate diagnoses of atrial fibrillation (AF) recorded in primary care electronic medical records and to estimate the prevalence of AF in the population attending primary care consultations. METHODS: We performed a cross-sectional validation study of all diagnoses of AF recorded in primary care electronic medical records in Madrid (Spain). We also performed simple random sampling of diagnoses of AF (ICPC-2 code K78) registered by 55 physicians and random age- and sex-matched sampling of the records that included a diagnosis of AF. Electrocardiograms, echocardiograms, and hospital discharge or cardiology clinic reports were matched. Sensitivity, specificity, positive and negative predictive values (PPV and NPV), and overall agreement were calculated using the kappa statistic (κ). The prevalence of AF in the community of Madrid was estimated considering the sensitivity and specificity obtained in the validation. All calculations were performed overall and by sex and age groups. RESULTS: The degree of agreement was very high (κ = 0.952), with a sensitivity of 97.84%, specificity of 97.39%, PPV of 97.37%, and NPV of 97.85%. The prevalence of AF in the population aged over 18 years was 2.41% (95%CI 2.39-2.42% [2.25% in women and 2.58% in men]). This increased progressively with age, reaching 16.95% in those over 80 years of age (15.5% in women and 19.44% in men). CONCLUSIONS: The validation results obtained enable diagnosis of AF recorded in primary care to be used as a tool for epidemiological studies. A high prevalence of AF was found, especially in older patients.

Cardiovascular risk factors associated with acute myocardial infarction and stroke in the MADIABETES cohort.

We aimed to develop two models to estimate first AMI and stroke/TIA, respectively, in type 2 diabetes mellitus patients, by applying backward elimination to the following variables: age, sex, duration of diabetes, smoking, BMI, and use of antihyperglycemic drugs, statins, and aspirin. As time-varying covariates, we analyzed blood pressure, albuminuria, lipid profile, HbA1c, retinopathy, neuropathy, and atrial fibrillation (only in stroke/TIA model). Both models were stratified by antihypertensive drugs. We evaluated 2980 patients (52.8% women; 67.3 ± 11.2 years) with 24,159 person-years of follow-up. We recorded 114 cases of AMI and 185 cases of stroke/TIA. The factors that were independently associated with first AMI were age (≥ 75 years vs. < 75 years) (p = 0.019), higher HbA1c (> 64 mmol/mol vs. < 53 mmol/mol) (p = 0.003), HDL-cholesterol (0.90-1.81 mmol/L vs. < 0.90 mmol/L) (p = 0.002), and diastolic blood pressure (65-85 mmHg vs. < 65 mmHg) (p < 0.001). The factors that were independently associated with first stroke/TIA were age (≥ 75 years vs. < 60 years) (p < 0.001), atrial fibrillation (first year after the diagnosis vs. more than one year) (p = 0.001), glomerular filtration rate (per each 15 mL/min/1.73 m2 decrease) (p < 0.001), total cholesterol (3.88-6.46 mmol/L vs. < 3.88 mmol/L) (p < 0.001), triglycerides (per each increment of 1.13 mmol/L) (p = 0.031), albuminuria (p < 0.001), neuropathy (p = 0.01), and retinopathy (p = 0.023).

Effect of depression on mortality in type 2 diabetes mellitus after 8 years of follow-up. The DIADEMA study.

AIM: To assess the effect of depression on all-cause mortality in patients with type 2 diabetes mellitus (T2DM) followed up during 8 years in primary care in Spain. METHODS: Depression was diagnosed according to MINI 5.0.0 questionnaire, physician-diagnosis or following antidepressant therapy for at least two months in 3923 people with T2DM. We analyzed mortality-rates/10,000 person-years. We compared survival according to baseline depression with Kaplan-Meier estimates and the log-rank test. We performed Cox proportional hazard model analyses. RESULTS: Baseline depression was diagnosed in 22.1% of participants. Mortality was higher in patients with depression (31.9% vs. 26.9%; p = 0.003), who had a significantly poorer survival (median survival = 7.4 vs. 7.8 years, respectively; Log Rank = 15.83; p < 0.001). Depression showed an adjusted mortality hazard ratio (HR) = 1.40 (95%CI:1.20-1.65; p < 0.001). The strongest predictive factors were: age >75 years (HR = 6.04; 95%CI:4.62-7.91; p < 0.001), insulin use (HR = 2.37; 95%CI:1.86-3.00; p < 0.001), lower limb amputation (HR = 1.99; 95%CI:1.28-3.11; p = 0.002), heart failure (HR = 1.94; 95%CI:1.63-2.30; p < 0.001), and male gender (HR = 1.90; 95%CI:1.59-2.27). CONCLUSION: In a Spanish cohort of older T2DM patients, depression was associated with a higher mortality risk. More efforts are needed to minimize the influence of depression on mortality in people with T2DM and to implement measures that allow its early diagnosis and effective treatment.

Effectiveness of standardized nursing care plans to achieve A1C, blood pressure, and LDL-C goals among people with poorly controlled type 2 diabetes mellitus at baseline: four-year follow-up study.

BACKGROUND: No studies that have measured the role of nursing care plans in patients with poorly controlled type 2 diabetes mellitus. Our objectives were firstly, to evaluate the effectiveness of implementing Standardized languages in Nursing Care Plans (SNCP) for improving A1C, blood pressure and low density lipoprotein cholesterol (ABC goals) in patients with poorly controlled type 2 diabetes mellitus at baseline (A1C ≥7%, blood pressure ≥ 130/80 mmHg, and low-density lipoprotein cholesterol≥100 mg/dl) compared with Usual Nursing Care (UNC). Secondly, to evaluate the factors associated with these goals. METHODS: A four-year prospective follow-up study among outpatients with type 2 diabetes mellitus: We analyzed outpatients of 31 primary health centers (Madrid, Spain), with at least two A1C values (at baseline and at the end of the study) who did not meet their ABC goals at baseline. A total of 1916 had A1C ≥7% (881 UNC versus 1035 SNCP). Two thousand four hundred seventy-one had systolic blood pressure ≥ 130 mmHg (1204 UNC versus 1267 SNCP). One thousand one hundred seventy had diastolic blood pressure ≥ 80 mmHg (618 UNC versus 552 SNCP); and 2473 had low-density lipoprotein cholesterol ≥100 mg/dl (1257 UNC versus 1216 SNCP). Data were collected from computerized clinical records; SNCP were identified using NANDA and NIC taxonomies. RESULTS: More patients cared for using SNCP achieved in blood pressure goals compared with patients who received UNC (systolic blood pressure: 29.4% versus 28.7%, p = 0.699; diastolic blood pressure: 58.3% versus 53.2%, p = 0.08), but the differences did not reach statistical significance. For A1C and low-density lipoprotein cholesterol goals, there were no significant differences between the groups. Coronary artery disease was a significant predictor of blood pressure and low-density lipoprotein cholesterol goals. CONCLUSIONS: In patients with poorly controlled type 2 diabetes mellitus, there is not enough evidence to support the use of SNCP instead of with UNC with the aim of helping patients to achieve their ABC goals. However, the use of SNCP is associated with a clear trend of a achievement of diastolic blood pressure goals.

Prevalence of peripheral artery disease (PAD) and factors associated: An epidemiological analysis from the population-based Screening PRE-diabetes and type 2 DIAbetes (SPREDIA-2) study.

AIM: To describe the prevalence of Peripheral Artery Disease (PAD) in a random population sample and to evaluate its relationship with Mediterranean diet and with other potential cardiovascular risk factors such as serum uric acid and pulse pressure in individuals ranged 45 to 74 years. METHODS: Cross-sectional analysis of 1568 subjects (mean age 6.5 years, 43% males), randomly selected from the population. A fasting blood sample was obtained to determine glucose, lipids, and HbA1C levels. An oral glucose tolerance test was performed in non-diabetic subjects. PAD was evaluated by ankle-brachial index and/or having a prior diagnosis. RESULTS: PAD prevalence was 3.81% (95% CI, 2.97-4.87) for all participants. In men, PAD prevalence was significantly higher than in women [5.17% (95% CI, 3.74-7.11) vs. 2.78% (95% CI, 1.89-4.07); p = 0.014]. Serum uric acid in the upper quartile was associated with the highest odds ratio (OR) of PAD (for uric acid > 6.1 mg/dl, OR = 4.31; 95% CI, 1.49-12.44). The remaining variables more strongly associated with PAD were: Heart rate >90 bpm (OR = 4.16; 95%CI, 1.62-10.65), pulse pressure in the upper quartile (≥ 54 mmHg) (OR = 3.82; 95%CI, 1.50-9.71), adherence to Mediterranean diet (OR = 2.73; 95% CI, 1.48-5.04), and former smoker status (OR = 2.04; 95%CI, 1.00-4.16). CONCLUSIONS: Our results show the existence of a low prevalence of peripheral artery disease in a population aged 45-74 years. Serum uric acid, pulse pressure and heart rate >90 bpm were strongly associated with peripheral artery disease. The direct association between Mediterranean diet and peripheral artery disease that we have found should be evaluated through a follow-up study under clinical practice conditions.

Body mass index and all-cause mortality among type 2 diabetes mellitus patients: Findings from the 5-year follow-up of the MADIABETES cohort.

PURPOSE: To analyse the association between body mass index (BMI) and all-cause mortality in a 5-year follow-up study with Spanish type 2 diabetes mellitus (T2DM) patients, seeking gender differences. METHODS: 3443 T2DM outpatients were studied. At baseline and annually, patients were subjected to anamnesis, a physical examination, and biochemical tests. Data about demographic and clinical characteristics was also recorded, as was the treatment each patient had been prescribed. Mortality records were obtained from the Spanish National Institute of Statistics. Survival curves for BMI categories (Gehan-Wilcoxon test) and a multivariate Cox proportional hazard analysis were performed to identify adjusted Hazard Ratios (HRs) of mortality. RESULTS: Mortality rate was 26.38 cases per 1000patient-years (95% CI, 23.92-29.01), with higher rates in men (28.43 per 1000patient-years; 95% CI, 24.87-32.36) than in women (24.31 per 1000patient-years; 95% CI, 21.02-27.98) (p=0.079). Mortality rates according to BMI categories were: 56.7 (95% CI, 40.8-76.6), 28.4 (95% CI, 22.9-34.9), 24.8 (95% CI, 21.5-28.5), 21 (95% CI, 16.3-26.6) and 23.7 (95% CI, 14.3-37) per 1000person-years for participants with a BMI of <23, 23-26.8, 26.9-33.1, 33.2-39.4, and >39.4kg/m2, respectively. The BMI values associated with the highest all-cause mortality were <23kg/m2, but only in males [HR: 2.78 (95% CI, 1.72-4.49; p<0.001)], since in females this association was not significant [HR: 1.14 (95% CI, 0.64-2.04; p=0.666)] (reference category for BMI: 23.0-26.8kg/m2). Higher BMIs were not associated with higher mortality rates. CONCLUSIONS: In an outpatient T2DM Mediterranean population sample, low BMI predicted all-cause mortality only in males.

Performance of the Finnish Diabetes Risk Score and a Simplified Finnish Diabetes Risk Score in a Community-Based, Cross-Sectional Programme for Screening of Undiagnosed Type 2 Diabetes Mellitus and Dysglycaemia in Madrid, Spain: The SPREDIA-2 Study.

AIM: To evaluate the performance of the Finnish Diabetes Risk Score (FINDRISC) and a simplified FINDRISC score (MADRISC) in screening for undiagnosed type 2 diabetes mellitus (UT2DM) and dysglycaemia. METHODS: A population-based, cross-sectional, descriptive study was carried out with participants with UT2DM, ranged between 45-74 years and lived in two districts in the north of metropolitan Madrid (Spain). The FINDRISC and MADRISC scores were evaluated using the area under the receiver operating characteristic curve method (ROC-AUC). Four different gold standards were used for UT2DM and any dysglycaemia, as follows: fasting plasma glucose (FPG), oral glucose tolerance test (OGTT), HbA1c, and OGTT or HbA1c. Dysglycaemia and UT2DM were defined according to American Diabetes Association criteria. RESULTS: The study population comprised 1,426 participants (832 females and 594 males) with a mean age of 62 years (SD = 6.1). When HbA1c or OGTT criteria were used, the prevalence of UT2DM was 7.4% (10.4% in men and 5.2% in women; p<0.01) and the FINDRISC ROC-AUC for UT2DM was 0.72 (95% CI, 0.69-0.74). The optimal cut-off point was ≥13 (sensitivity = 63.8%, specificity = 65.1%). The ROC-AUC of MADRISC was 0.76 (95% CI, 0.72-0.81) with ≥13 as the optimal cut-off point (sensitivity = 84.8%, specificity = 54.6%). FINDRISC score ≥12 for detecting any dysglycaemia offered the best cut-off point when HbA1c alone or OGTT and HbA1c were the criteria used. CONCLUSIONS: FINDRISC proved to be a useful instrument in screening for dysglycaemia and UT2DM. In the screening of UT2DM, the simplified MADRISC performed as well as FINDRISC.

Disección aórtica tipo A: dos formas de presentación clínica inusuales / Type A aortic dissection: two forms of rare clinical presentation

La disección aórtica se presenta habitualmente como dolor torácico o interescapular, en ocasiones simulando cardiopatía isquémica aguda, con lo que es preciso hacer el diagnóstico diferencial en pacientes con historia de hipertensión y otros factores de riesgo cardiovascular. Las manifestaciones clínicas pueden abarcar las derivadas de la rotura de la raíz aórtica a cualquier nivel o del compromiso de ramas arteriales en su origen (manifestaciones neurológicas, hipoperfusión coronaria, renal o gastrointestinal). Se aportan dos casos que comenzaron con presentaciones clínicas inusuales, una hemoptisis derivada de rotura diferida al árbol bronquial y la otra como paraparesia de instauración brusca secundaria a compromiso de ramas medulares con isquemia medular

Aortic dissection usually presents as chest or interscapular pain that sometimes mimics acute ischemic heart disease. Thus it is necessary to make the differential diagnosis in patients with a background of hypertension and other cardiovascular risk factors. Clinical findings may include those derived from the rupture of the aortic lumen at any level to those affecting the main aorta branches in their origin (neurology symptoms, coronary arterial hypoperfusion, renal or gastrointestinal involvement). We report two cases with an unusual presentation. The first one presented as a hemoptysis derived from delayed bronchial tree rupture and the second one as sudden onset of paraparesis secondary to involvement of medullary branches with medullary ischemia

[Study of prescription-indication of proton pump inhibitors]. / Estudio de prescripción-indicación de inhibidores de la bomba de protones.

OBJECTIVES: To evaluate the adaptation of Proton Pump Inhibitors (PPI) prescriptions to the indications in the literature. To determine which doctors, patients and prescriptions characteristics are related to a correct prescription and to measure their relative importance. MATERIAL AND METHODS: Cross-sectional observational study of prescription indication in an Urban Primary Care Center. Simple Random Sampling was used from primary care center patients PPIs prescriptions between July and December of 2003. Non-electronic prescriptions (OMI-AP program) were excluded from the sample. 412 PPI prescriptions were necessary as sample size to obtain a 95% confidence with a 4.7% precision and a 50% expected proportion. Simple random sampling techniques were used. RESULTS: Prescription was correct under adequacy criteria in 36.4% of the cases. The effect of the "hiatal hernia" and "user activity status" variables showed the major impact on results with an OR: 0.361 and 1.672 respectively. NSAID treated patients PPIs prescriptions matched adequacy criteria in 79.5% of the cases. "Prescription source" and "User activity status" variables gave the highest impact with an OR: 2.5 and 4.52, respectively. CONCLUSIONS: The high percentage of non-adequate prescriptions together with the differences found between primary and specialized levels of attention, could suggest lack of knowledge of PPIs prophylactic indications and lack of coordination between different levels of attention that could be solved by creating common performing protocols.

Estudio de prescripción-indicación de inhibidores de la bomba de protones / Study of prescription-indication of proton pump inhibitors

Objetivos. Evaluar la adecuación de las prescripciones de inhibidores de la bomba de protones (IBP) a las indicaciones expuestas en la literatura y determinar qué características de los médicos, pacientes y de las prescripciones se asocian con su adecuada prescripción y cuantificar su importancia relativa. Material y métodos. Estudio observacional transversal de prescripción-indicación llevado a cabo en un centro de salud urbano. Se realizaron prescripciones de IBP a pacientes adscritos al centro de salud entre julio y diciembre del 2003 que figuran en el programa OMI-AP. Los criterios de exclusión que se aplicaron tuvieron en cuenta aquellas prescripciones no realizadas electrónicamente. Según el tamaño de la muestra, para una confianza del 95%, una precisión del 4,7% y una proporción esperada del 50% hacen falta 412 prescripciones de IBP. Se utilizaron técnicas de muestreo aleatorio simple. Resultados. La prescripción se ajusta en un 36,4% a los criterios de adecuación. El efecto de las variables «hernia de hiato» y «tipo de usuario» ha sido de odds ratio (OR) 0,361 y 1,672, respectivamente. La prescripción de IBP en pacientes en tratamiento con antiinflamatorios no esteroideos (AINE) cumple los criterios de adecuación en el 79,5% de los casos. El efecto de las variables «origen» y «tipo de usuario» ha sido de OR 2,5 y 4,52, respectivamente. Conclusiones. El elevado porcentaje de IBP prescritos sin indicación justificada y las diferencias encontradas entre Atención Primaria y Especializada, hacen sospechar de un desconocimiento de sus indicaciones profilácticas, y falta de coordinación entre los diferentes niveles de asistencia que podría solventarse con la creación de protocolos de actuación conjuntos

Objectives. To evaluate the adaptation of Proton Pump Inhibitors (PPI) prescriptions to the indications in the literature. To determine which doctors, patients and prescriptions characteristics are related to a correct prescription and to measure their relative importance. Material and methods. Cross-sectional observational study of prescription indication in an Urban Primary Care Center. Simple Random Sampling was used from primary care center patients PPIs prescriptions between July and December of 2003. Non-electronic prescriptions (OMI-AP program) were excluded from the sample. 412 PPI prescriptions were necessary as sample size to obtain a 95% confidence with a 4.7% precision and a 50% expected proportion. Simple random sampling techniques were used. Results. Prescription was correct under adequacy criteria in 36.4% of the cases. The effect of the «hiatal hernia» and «user activity status» variables showed the major impact on results with an OR: 0.361 and 1.672 respectively. NSAID treated patients PPIs prescriptions matched adequacy criteria in 79.5% of the cases. «Prescription source» and «User activity status» variables gave the highest impact with an OR: 2.5 and 4.52, respectively. Conclusions. The high percentage of non-adequate prescriptions together with the differences found between primary and specialized levels of attention, could suggest lack of knowledge of PPIs prophylactic indications and lack of coordination between different levels of attention that could be solved by creating common performing protocols

Atrofia de la musculatura de la mano: a propósito de un caso / Atrophy of the hand muscles: a case report

La esclerosis lateral amiotrófica es una enfermedad neurodegenerativa de comienzo en la edad adulta que cursa con denervación progresiva de las motoneuronas superior e inferior. El cuadro clínico está formado por la combinación de signos y síntomas del compromiso de éstas, permaneciendo conservadas las funciones cognitiva y sensitiva así como la motilidad ocular extrínseca y los esfínteres. El conocimiento de esta patología permitirá realizar un diagnóstico lo más precoz posible, ya que éste es eminentemente clínico. Y, aunque esto no detendrá su evolución, progresiva hasta la muerte, permitirá establecer el diagnóstico diferencial con otras enfermedades potencialmente tratables así como adelantarnos a los problemas clínicos que vayan surgiendo, en su mayoría predecibles, e instaurar las medidas paliativas y rehabilitadoras adecuadas. Presentamos un caso en el que la observación del médico de la atrofia muscular de las manos del paciente orienta hacia el diagnóstico

Amyotrophic lateral sclerosis is a neurodegenerative disease beginning in the adult age that occurs with progressive denervation of the upper and lower mononeurons. The clinical picture is formed by the combination of signs and symptoms of the involvement of these, the cognitive and sensory functions remaining conserved as well as extrinsic ocular motility and sphincter motility. Knowledge of this disease will make it possible to make a diagnosis as early as possible since it is prominently clinical. Although this will not stop its progressive course towards death, it will make it possible to establish the differential diagnosis with other potentially treatable diseases and anticipate the clinical problems that are going to arise, most predictable, as well as initiate the adequate palliative and rehabilitating measures. We present a case in which the observation of the physician of muscular atrophy of the patient's hands oriented towards the diagnosis

Obstrucción intestinal por Anisakis simplex / Intestinal obstruction due to Anisakis simplex

La anisakiasis es una zoonosis producida por larvas de Anisakis simplex. El hombre, huésped accidental de este parásito helminto, entra en su ciclo biológico al consumir pescado, crustáceos o cefalópodos infestados. En nuestro medio las tasas de parasitación del pescado de los mercados centrales son muy elevadas y la fuente de contagio más habitual son los boquerones en vinagre. Las manifestaciones clínicas comprenden formas gastrointestinales (desde cuadros leves con sintomatología inespecífica a formas más agresivas como úlcera gastroduodenal, obstrucción intestinal o ascitis hemorrágica), alérgicas, mixtas e invasivas en otros órganos. Aunque la mayoría son casos autolimitados, puede ser necesaria la extracción endoscópica de la larva adherida a la mucosa gástrica o la resección intestinal. El mejor tratamiento son las medidas profilácticas, evitando el consumo de larvas viables en pescado crudo o poco cocinado. Presentamos un caso de obstrucción intestinal causada por larvas de Anisakis simplex tras la ingesta de boquerones en vinagre

Anisakiasis is a zoonosis produced by larva of Anisakis simplex. Man, accidental host of this helminth parasite, enters into its biological cycle when eating infected fish, crustaceans or cephalopodas. In our setting, parasitation rates of fish from the central markets are very high and the most common source of infection is anchovies in vinegar. Clinical manifestations include gastrointestinal forms (from mild pictures with non-specific symptoms to more aggressive forms such as gastroduodenal ulcer, intestinal obstruction or hemorrhagic ascitis) and allergic, mixed and invasive forms in other organs. Although most are self-limited cases, endoscopic extraction of the larva attached to the gastric mucosa or intestinal resection may be necessary. The best treatments are prophylactic measures, avoiding intake of viable larvas in raw or undercooked fish. We present a case of intestinal obstruction caused by larvas of Anisakis simplex after intake of anchovies in vinegar