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.

Validación del manual de estándares de acreditación de unidades de cirugía mayor ambulatoria con acreditaciones piloto en 7 hospitales / Accreditation handbook for ambulatory health care centres. standards of validation in seven hospitals

OBJETIVO: el objetivo principal de este trabajo, fue la validación de un método de control y calidad a través del documento escrito "Manual de estándares y Guía de Acreditación de unidades de Cirugía Mayor Ambulatoria:". Los objetivos específicos fueron: a) la comprobar la validez de los estándares, b) proporcionar una herramienta de autoevaluación y c) proporcionara los acreditadores una guía para su trabajo. Los sujetos a estudio fueron 7 centros/unida desde diversas Comunidades Autónomas. MÉTODO: a) valoración de disponibilidad del centro, establecimiento de los evaluadores internos y externos y calendario, b) autoevaluación interna, c) visita de acreditación, d) elaboración de los resultados, e) reunión de los evaluadores para modificar estándares inadecuados. Las determinaciones efectuadas afectaron a las áreas de: Órganos de gobierno y dirección, recursos humanos y asistencia al paciente. RESULTADOS: los estándares fueron validados tras modificaciones no esenciales y todos los centros superaron la acreditación con mayor o menor grado de cumplimiento (AU)

OBJECTIVE: The main objective of this study was to find a method to measure and control quality through a written document: "Handbook for Accrediting Ambulatory Health Care Centres". Specific objectives were: a) to validate standards b) to provide a tool for self-evaluation for Ambulatory Surgical Units, and c) to provide an accrediting handbook. Subjects studied were7 selected Ambulatory Units, located in various Autonomous Communities and with different care and management policies. DESIGN: We evaluated; a) the availibility of the centre, the appointement of inside and outside controllers and a time-limit to obtain accreditation ,b) self- evaluation procedures, c) an accrediting survey by experts, d) survey report, e)modification of inadequate standards observed by the Experts' Committee, and f) finally a handbook. Standards measured included directing and management skills, human resources, ethics, patient care, continuity of patient care, safe practice and environment. RESULTS: Standards were validated with slight non-essential modifications and all the Centres reached accreditation (AU)

[The effect of pre-infarction unstable angina on the size of myocardial necrosis]. / Efecto de la angina inestable preinfarto en el tamaño de la necrosis miocárdica.

INTRODUCTION AND OBJECTIVES: Recent studies suggest that preinfarction angina (PA) might induce less myocardial necrosis. The objective of this study is to evaluate whether patients with PA have smaller myocardial infarctions. METHODS: Patients with acute myocardial infarction of less than 12 hours since the onset symptoms were included. PA was defined as unstable angina at rest during the 7 days before the infarction. Infarct size was assessed with the area under the curve of CK-MB levels in the 24 hours following the onset of the infarct. RESULTS: One hundred-seventy nine patients were included, 75 (41.9%) with PA. There were more men in the group with PA (89.3% vs 70.2%, p = 0.004) and a higher prevalence of ex-smokers (38.7% vs 19.2%, p = 0.006). We did not find significant differences in myocardial infarction size between both groups, but a statistically significant interaction between PA and pre-treatment with sulfonylurea drugs was noted (p = 0.050). CONCLUSIONS: Preinfarction angina does not seem to induce less myocardial necrosis in this study. There is a significant interaction between preinfarction angina and pre-treatment with sulfonylurea drugs.

Delta aminolevulinate dehydratase (ALA-D) activity in human and experimental diabetes mellitus.

The haem pathway is impaired in porphyrias and a frequent coexistence of diabetes mellitus and porphyria disease has been reported. We have therefore decided to investigate delta-aminolevulinate dehydratase, one of the more sensitive enzymes in the haem pathway, in both human diabetic patients and diabetic rats. We have studied 131 diabetes mellitus patients, 32 insulin dependent and 99 non-insulin dependent. The latter group was further subdivided according to treatment: diet alone (n = 24), diet plus oral hypoglycemic agents (n = 28) and diet plus insulin (n = 47). We have also performed similar studies in the rat model of diabetes mellitus, induced in 11 Wistar rats by streptozotocin. Control groups of both humans and animals were used. Erythrocytic aminolevulinate dehydratase activity was reduced in both insulin dependent and non-insulin dependent diabetic patients as compared to their controls (p < 0.001). This activity was only partially restored by addition of zinc and thiols to the incubation media. In insulin-dependent diabetes mellitus, reduction of enzyme activity was related to the glycosilated hemoglobin concentration (p < 0.05) and in non-insulin dependent diabetes mellitus to the glycemia (p < 0.01). In the diabetic rat, aminolevulinate dehydratase activity was diminished on both erythrocytes (p < 0.01) and hepatic tissue (p < 0.01) when compared to the control group. The decrease in activity of erythrocyte aminolevulinate dehydratase observed in diabetic patients, may represent an additional and useful parameter for the assessment of the severity of carbohydrate metabolism impairment.

[Adenosine deaminase (ADA) and beta 2-microglobulin (beta 2M) as discriminating serum markers of progression to AIDS]. / Adenosina desaminasa (ADA) y beta 2-microglobulina (beta 2 M) como marcadores séricos discriminantes de progresión al SIDA.

BACKGROUND: To establish the discriminatory value of ADA and beta 2M serum levels as markers of AIDS progression. METHODS: We have followed quarterly during two years a cohort of 24 patients with HIV infection; 103 clinical and laboratory evaluations were done (CDC/93 classification). In each of those blood samples we determined ADA, beta 2M, IgG, IgA, IgM, and CD4+ and CD8+ lymphocytes. RESULTS: 26 evaluations belong to cases that kept stable in the clinic category A or B, CDC/93, ("stables": ADA = 19.05 +/- 10.79 U/L; beta 2M = 2.95 +/- 1.1 mg/L); the remaining 77 evaluations are from patients who clinical progressed to AIDS ("progressors": ADA = 32.03 +/- 13.2 U/L; beta 2M = 4.74 +/- 1.94 mg/L). When we compared statistically (RSIGMA software) the ADA and beta 2M means of both groups (Student t) and the means of all the variables in a block (multivariate analysis: Hotelling T2), very significant differences were appreciated (p < 0.001). CONCLUSIONS: ADA and beta 2M are significantly increased in serum of HIV infected patients who clinical progress to AIDS. ADA and beta 2M can be used as serum markers of AIDS progression with a mistaken classification probability in the discriminatory analysis of 0.25; this probability decreases to 0.06 when immunoglobulins and lymphocytes subpopulations are evaluated too.

[Adenosine deaminase in pleural effusions. Its usefulness in the diagnosis of tuberculous pleurisy]. / Adenosina desaminasa (ADA) en los derrames pleurales. Su utilidad en el diagnóstico de la pleuresia tuberculosa.

The activity of adenosine deaminase was determined in 79 pleural effusions in order to evaluate the utility and reliability in diagnosing tuberculous effusions. The effusions were grouped by the etiology: 26 were tuberculous (group I); 22 were neoplastic (group II); 11 were pneumonic (group III); 10 were non-infections exudates of different causes (group IV); and 10 transudates (group V). Group I presented the higher median value of AD (MED = 81.92; DE: 29.02) the difference being statistically significant (p less than 0.0001) compared with the results of the other groups. We found 2 cases of pleural tuberculosis histologically demonstrated with AD levels under the amount of 40 U/L. In our experience, AD determination had a sensitivity of 92% and specificity of 94%; with a predictive value of 89% and a negative predictive value of 96%, this being considered useful but non specific of tuberculosis.

Electric field distributions of waveguide arrays for local tumor hyperthermia.

Total electric field distributions in muscle and fat tissues, due to colinear rectangular waveguide arrays at 2.45 GHz and 915 MHz were calculated. The effect of phase difference between incident phases on the field pattern is shown. Phase adjustment is capable of furnishing control of either field-size or focused-field performance of the multi-element, direct-contact applicator. The tissue-applicator junction is analyzed by means of the Generalized Scattering Matrix (GSM) of the generalized 2-port discontinuity, assuming that the lossy homogeneous tissue is immersed in a large waveguide. This method provides an exact calculation of multimodal fields, as well as reflection and coupling coefficients in the apertures.

Design and optimization of multi-stepped waveguide applicators for medical applications.

Modal analysis and scattering matrix concepts at discontinuities have been applied to the design and optimization of open-ended waveguide applicators with several transverse discontinuities. The tissues are simulated by means of two dielectric layers, skin and fat. The results obtained show how important improvements can be obtained in the match between the applicator and the tissues. This method can also be applied to obtain applicators with increased depth of penetration, by controlling the discontinuities of the applicators.