Manejo de perfiles de pacientes con diabetes mellitus tipo2 en la práctica clínica de la atención primaria en España: Programa CONTROVERTI2 / Management of patient profiles with type2 diabetes mellitus in Primary Care in Spain: CONTROVERTI2 Program

Objetivo: Identificar controversias existentes en el manejo habitual de los pacientes con diabetes mellitus tipo2 (DM2) y contrastarlas con la última evidencia científica y guías clínicas, con el fin de optimizar y homogeneizar el tratamiento de los pacientes con DM2 en la atención primaria (AP) en España. Material y métodos: 240 médicos de familia respondieron a un cuestionario online sobre el manejo de 6 perfiles de pacientes con DM2 de complejidad creciente. Resultados: Los factores clínicos más influyentes en la elección del tratamiento antihiperglucémico son una HbA1c >10% y la presencia de enfermedad cardiovascular (ECV), aunque en el paciente evolucionado cobran más relevancia la tasa de filtrado glomerular estimada y el riesgo de hipoglucemia. En el paciente recién diagnosticado con HbA1c>9% se sigue iniciando el tratamiento con monoterapia (24%). En el paciente no controlado con metformina suelen añadirse inhibidores de la dipeptidil peptidasa4 (iDPP4, 54%) seguido de inhibidores del cotransportador sodio-glucosa tipo2 (iSGLT2, 39%). Los agonistas del receptor del péptido similar al glucagón tipo1 (arGLP1) se asocian principalmente al paciente con DM2 obeso. En el paciente no controlado con metformina+sulfonilurea (SU) se prefiere sustituir la SU a añadir un tercer agente antihiperglucémico al tratamiento (77% vs. 23%). Conclusiones: Todavía persiste en AP un enfoque del tratamiento de la DM2 centrado en la reducción de la HbA1c y en la seguridad de los tratamientos. Por ello, los iDPP4 son fármacos ampliamente utilizados. Los iSGLT2 se reservan habitualmente para pacientes con DM2 y ECV y los arGLP1 para pacientes con DM2 obesos, siendo su uso muy limitado (AU)

Aim: To identify existing controversies in the routine management of patients with T2D and to contrast them with the latest scientific evidence and clinical guidelines, in order to help optimize and homogenize the treatment of patients with T2D in Primary Care (PC) in Spain. Material and methods: 240 family doctors responded to an online questionnaire about the management of 6 patient profiles with T2D of increasing complexity. Results: The main drivers for the antihyperglycemic treatment choice are an HbA1c>10% and the presence of cardiovascular disease (CVD), although in evolved patients, the estimated glomerular filtration rate and the risk of hypoglycemia become more relevant. In newly diagnosed patients with an HbA1c>9%, treatment is still initiated with monotherapy (24%). In patients not controlled with metformin, dipeptidyl peptidase 4 inhibitors (DPP4-I, 54%) or sodium-glucose cotransporter 2 inhibitors (SGLT2-I, 39%) are usually added. On the other hand, type1 glucagon-like peptide receptor agonists (GLP1-RA) are mainly associated with obese patients with T2D. In patients not controlled with metformin+sulfonylurea (SU), SU replacement is preferred to adding a third antihyperglycemic agent to background therapy (77% vs. 23%). Conclusions: T2D treatment in PC is still focused on HbA1c reduction and treatment safety. Thus, DPP4-I are widely used. SGLT2-I are usually preferred for patients with T2D and CVD and GLP1-RA for patients with T2D and obesity, although their use in PC is low (AU)

[Management of patient profiles with type2 diabetes mellitus in Primary Care in Spain: CONTROVERTI2 Program]. / Manejo de perfiles de pacientes con diabetes mellitus tipo2 en la práctica clínica de la atención primaria en España: Programa CONTROVERTI2.

AIM: To identify existing controversies in the routine management of patients with T2D and to contrast them with the latest scientific evidence and clinical guidelines, in order to help optimize and homogenize the treatment of patients with T2D in Primary Care (PC) in Spain. MATERIAL AND METHODS: 240 family doctors responded to an online questionnaire about the management of 6 patient profiles with T2D of increasing complexity. RESULTS: The main drivers for the antihyperglycemic treatment choice are an HbA1c>10% and the presence of cardiovascular disease (CVD), although in evolved patients, the estimated glomerular filtration rate and the risk of hypoglycemia become more relevant. In newly diagnosed patients with an HbA1c>9%, treatment is still initiated with monotherapy (24%). In patients not controlled with metformin, dipeptidyl peptidase 4 inhibitors (DPP4-I, 54%) or sodium-glucose cotransporter 2 inhibitors (SGLT2-I, 39%) are usually added. On the other hand, type1 glucagon-like peptide receptor agonists (GLP1-RA) are mainly associated with obese patients with T2D. In patients not controlled with metformin+sulfonylurea (SU), SU replacement is preferred to adding a third antihyperglycemic agent to background therapy (77% vs. 23%). CONCLUSIONS: T2D treatment in PC is still focused on HbA1c reduction and treatment safety. Thus, DPP4-I are widely used. SGLT2-I are usually preferred for patients with T2D and CVD and GLP1-RA for patients with T2D and obesity, although their use in PC is low.

[Prevalence of dermatological diseases in Primary Care]. / Prevalencia de enfermedades dermatológicas en atención primaria.

OBJECTIVE: To guide the training of Primary Care physicians in the most prevalent and relevant skin pathologies, it is necessary to study their prevalence in the Primary Care consultation and describe their characteristics. MATERIALS AND METHODS: Observational cross-sectional study. It took place at the Porriño Health Center (Pontevedra, Spain). A total of 305 patients of the same quota participated, recruited in consultation during 41days between September 2018 and February 2019, selected by systematic sampling coinciding with those mentioned at the hour between 9 and 13hours and, failing that, we selected the next of those mentioned. The variables were analyzed: age, sex, educational and economic level, diagnostic means, previous diagnosis of dermatological disease, treatment, follow-up and relationship with systemic diseases. The statistical analysis performed was descriptive and bivariate by sex with chi-square and Fisher's exact tests. RESULTS: 161 women and 144 men participated, age and number of consultations being non-parametric. Median age was 59years (IQR: 42-69), with no significant differences between sexes. 69.83% (95%CI: 64.46-74.71) present between 1 and 5 types of skin lesions grouped in 33 different diagnoses. The 15 most frequent pathologies account for 77.35% (95%CI: 75.80-84.48) of diagnoses. As the most relevant pathologies, we observed two basal cell carcinomas and one squamous cell carcinoma (0.98%; 95%CI: 0.34-2.85). CONCLUSIONS: Dermatological diseases have a high prevalence in Primary Care.

[Health status, quality of life, and use of healthcare resources by patients with diabetes mellitus in Spain]. / Estado de salud, calidad de vida y utilización de recursos sanitarios de los pacientes con diabetes mellitus en España.

INTRODUCTION: This study analyses the health status of patients diagnosed with diabetes mellitus (DM), their health related quality of life (HRQoL) and their use of healthcare resources in Spain. MATERIALS AND METHODS: A descriptive analysis was conducted using the Spanish Health National Survey (ENSE, 2012), gathering data on those patients aged 15 and over diagnosed with DM. Their health status, their HRQoL, and their use of healthcare resources were systematically compared with those of patients diagnosed with other chronic conditions (OCC), as well as a population without DM (non-DM). RESULTS: Out of 21,007 subjects that took part, 7.4% were diagnosed with DM and 59% with OCC conditions (mean age 65.6±14.2 years with DM, 51.3±18.1 years with OCC, and 45.7±18.2 years with non-DM). When compared to non-DM and OCC, DM was statistically significantly associated with higher frequencies of hypertension, hypercholesterolaemia, obesity, myocardial infraction, hospital admissions in the last year, and drug consumption, but with a lower number of visits to secondary healthcare. The mean quality adjusted life years (QALY) of patients with DM was 0.75 per year, significantly lower (P<.05) to that of individuals with OCC (0.89), and those without DM (0.92). The difference vs. non-DM remained statistically significant after adjusting for age, gender, and number of comorbidities (P<.001). CONCLUSIONS: In Spain, DM is associated with a high comorbidity, involves a greater loss in HRQoL than those diagnosed with other chronic conditions as a whole, and generates a significant burden on the healthcare system.

Effect of an educational intervention in primary care physicians on the compliance of indicators of good clinical practice in the treatment of type 2 diabetes mellitus [OBTEDIGA project].

AIM: To evaluate the effect of an educational intervention among primary care physicians on several indicators of good clinical practice in diabetes care. METHODS: Two groups of physicians were randomly assigned to the intervention or control group (IG and CG). Every physician randomly selected two samples of patients from all type 2 diabetic patients aged 40 years and above and diagnosed more than a year ago. Baseline and final information were collected cross-sectionally 12 months apart, in two independent samples of 30 patients per physician. The educational intervention comprised: distribution of educational materials and physicians' specific bench-marking information, an on-line course and three on-site educational workshops on diabetes. External observers collected information directly from the physicians and from the medical records of the patients on personal and family history of disease and on the evolution and treatment of their disease. Baseline information was collected retrospectively in the control group. RESULTS: Intervention group comprised 53 physicians who included a total of 3018 patients in the baseline and final evaluations. CG comprised 50 physicians who included 2868 patients in the same evaluations. Measurement of micro-albuminuria in the last 12 months (OR = 1.6, 95% CI: 1.1-2.4) and foot examination in the last year (OR = 2.0, 95% CI: 1.1-3.6) were the indicators for which greater improvement was found in the IG. No other indicator considered showed statistically significant improvement between groups. CONCLUSIONS: The identification of indicators with very low level of compliance and the implementation of a simple intervention in physicians to correct them is effective in improving the quality of care of diabetic patients.

Quality of care of patients with type-2 diabetes in Galicia (NW Spain) [OBTEDIGA project].

AIMS: The aim of this study was to describe the degree of compliance of agreed practices with reference to primary care patients with Type 2 diabetes of 40 years old and older in Galicia (NW Spain). METHODS: A total of 108 primary care physicians were selected at random from the totality of doctors. Each physician selected 30 patients at random from their patients suffering from diabetes of 40 years old or older. External observers gathered information from each patient's medical record regarding their characteristics, condition and degree of compliance of selected indicators of good practice. RESULTS: Group of physicians participated in this study had a mean age of 50 years (standard deviation = 3.9); 48% of them were females; and 17.5% involved in medical residents training. A total of 3078 diabetic patients were included in the study: mean age = 69 years (SD = 10.9), 47.6% women, presence of high blood pressure (72%), hypercholesterolaemia (56%), and regular smokers (10.3%). Compliance with selected indicators such as foot examination (14%), ophthalmological examination (30.6%), abdominal circumference measurement (6.1%), measurement of total or LDL-cholesterol (78.1), blood pressure measurement (84.8), glycosylated haemoglobin measurement < 7% (54.3%) was observed. Adequate monitoring in cases of high blood pressure and hypercholesterolaemia were 34.2% and 27.4%, respectively. Variability between physicians differs according to the different indicators, with interquartile range for compliance of between 16.4 and 66%. CONCLUSIONS: There is a wide margin for improvement in the adaptation of clinical practice to recommendations for diabetic patients. The large variation existing in certain indicators would suggest that certain control objectives are less demanding than advisable in those that comply least, while low compliance and low variability in other indicators point to structural problems or unsatisfactory training of doctors.

Principales diferencias entre glucemia basalalterada e intolerancia a la glucosa / Main differences between impaired fasting glucose

Tanto la glucemia basal alterada (GBA) como la intolerancia a la glucosa(ITG) conforman la llamada «prediabetes». Sin embargo, estasdos situaciones clínicas son entidades con grandes diferencias. Lossujetos con GBA presentan una resistencia hepática a la insulina yun déficit en la fase precoz de su secreción, mientras que en la ITGexiste una resistencia muscular a la insulina, acompañada de un déficitmás acusado de insulina, ya que se ven afectadas tanto la secreciónprecoz como la tardía. La GBA es más frecuente en varonesy en personas jóvenes, mientras que la ITG es más habitual en mujeresy su prevalencia se incrementa a medida que aumenta la edad.La GBA y la ITG son útiles para identificar a sujetos con elevado riesgode desarrollar diabetes tipo 2, aunque los individuos identificadoscon cada una de ellas sean diferentes. Finalmente, en numerososestudios se ha demostrado que tanto la GBA como la ITG tienenun riesgo cardiovascular aumentado. Sin embargo, la ITG conlleva unriesgo más elevado y es un mejor factor pronóstico del riesgo quela GBA (AU)

Both impaired fasting glucose (IFG) as well as impaired glucose tolerance(IGT) constitute what is known as prediabetes. Nevertheless,these two clinical situations are entities that differ significantly. Subjectswith IFG manifest hepatic insulin resistance and a defect inearly-phase insulin secretion, whereas subjects with IGT manifestmuscle insulin resistance, accompanied by a greater defect in insulinsecretion since both early-phase and late-phase insulin secretion areaffected. IFG is more frequent in men and young people, whereasIGT is more frequent in women and its prevalence increases as agerises. Both IFG and IGT are useful for the identification of subjects ata high risk of developing type 2 diabetes, although the subjectsidentified with each of them are different. Finally, many studies haveshown that both IFG as well as IGT are associated with an increasedcardiovascular risk. Nevertheless, IGT involves a higher risk and is astronger risk predictor than IFG (AU)

Riesgo glucémico y contribución de la glucemia posprandial a la hemoglobina glucosilada (HbA1c) / Glycaemic risk and cotribution of post-prandial glucaemia to glycosylated haemoglobin (HbA1c)

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[Hirsutism due to a late-onset of hydroxylase-21 deficit: apropos of 4 cases]. / Hirsutismo por déficit de 21-hidroxilasa de comienzo tardío: a propósito de cuatro casos.

OBJECTIVE: To present four cases of Hirsutism due to a late-starting deficit of Hydroxylase-21. DESIGN: Retrospective, descriptive study. SETTING: Primary Care team. PATIENTS AND OTHERS PARTICIPANTS: Four women (21, 22, 32 and 36 years old) were studied because they presented hirsutism. MEASUREMENTS AND MAIN RESULTS: All the patients had begun to be hirsute at puberty. Three had regular cycles and one, irregular. Two women (32 and 36) had had various children. In all the cases the hirsutism was moderate. One woman suffered severe acne. Basal testosterone was only high in one case; DHEA-S in two. The values of basal 17-OH-Progesterone were high in three women. The ACTH stimulation test showed positive for three patients: it was not performed on the fourth due to her very high levels of 17-OH-Progesterone. CONCLUSIONS: Late-starting Hydroxylase-21 deficit is a frequent cause of hirsutism in Primary Care. It must be considered and investigated as a cause when faced with a clinical picture compatible with benign hirsutism, in order to advise the woman on the best treatment and avoid iatrogenic attitudes.