Multidisciplinary Panel Consensus for the Management of Patients with Type 2 Diabetes: A Delphi Study.

AIM: To reach a multidisciplinary consensus on managing patients with type 2 diabetes among specialists in family medicine, cardiology, endocrinology, internal medicine, and nephrology. METHODS: A two-round Delphi study was conducted using a questionnaire with 68 positive/negative statements distributed in four thematic blocks on diabetes management: early diagnosis and prediabetes, referral criteria, treatment and comorbidities, and clinical management. The expert panel was composed of 105 physicians from different specialties (family medicine, cardiology, endocrinology, internal medicine, and nephrology) with experience in managing patients with diabetes and who were members of a diabetes-related society. RESULTS: Response rates for the first and second rounds were 86.7 and 75.2%, respectively. After both rounds, a consensus was reached on 52 (76.5%) items. The recommendations with the highest degree of consensus (median = 10, IQR = 0.00) were related to anti-smoking education, cardiovascular risk factor target control, and diabetic kidney disease. There were significant differences between family physicians and other specialties for some items. CONCLUSIONS: This study provides a set of recommendations for diabetes management agreed upon by specialists from different healthcare settings.

The value of telephone consultations during COVID-19 pandemic. An observational study.

BACKGROUND: Many Spanish hospitals converted scheduled in-person visits to telephone visits during the COVID-19 lockdown. There is scarce information about the performance of those visits. AIM: To compare telephone visits during the COVID-19 lockdown period with previous in-person visits. DESIGN: Retrospective descriptive study. METHODS: Telephone visits from 15 March to 31 May 2020 were compared with in-person visits during the same period in 2019. MAIN MEASURES: The proportions of both groups were compared in term of failure to contact patient, requested diagnostic tests/referrals, discharges, admissions and emergency visits within 30-60 days. A sample of patients, and all participating physicians completed surveys. Z-score test was used (statistical significance P<0.05). RESULTS: A total of 5602 telephone visits were conducted. In comparison to in-person visits, telephone visits showed higher rates of visit compliance (95.9% vs. 85.2%, P<0.001) and discharges (22.12% vs. 11.82%; P<0.001), and lower number of ancillary tests and referrals. During the 30- and 60-day periods following the telephone visit, a reduction of 52% and 47% in the combined number of emergency department visits and hospital admissions was observed compared to in-person visits (P<0.01). Of the 120 patients surveyed, 95% were satisfied/very satisfied with the telephone visits. Of the 26 physicians, 84.6% considered telephone visits were useful to prioritize patients. CONCLUSIONS: During health emergencies, previously scheduled outpatient in-person visits can be converted to telephone visits, reducing absenteeism, increasing the rate of discharges and reducing ancillary tests and referrals without increasing the rate of hospital admissions or emergency department visits.

Efficacy and safety of replacing sitagliptin with canagliflozin in real-world patients with type 2 diabetes uncontrolled with sitagliptin combined with metformin and/or gliclazide: The SITA-CANA Switch Study.

AIM: To analyze the efficacy and safety of replacing sitagliptin with canagliflozin in patients with type 2 diabetes (T2D) and poor metabolic control despite treatment with sitagliptin in combination with metformin and/or gliclazide. MATERIALS AND METHODS: In this multicentre observational, retrospective, 26-week clinical study of patients with T2D and poor glycaemic control (HbA1c: 7.5-9.5%) treated with sitagliptin in combination with metformin and/or gliclazide, sitagliptin (and gliclazide if appropriate) were replaced by canagliflozin. The main outcome of the study was the proportion of patients who achieved good glycaemic control (HbA1c<7%) by the end of the study. RESULTS: The study sample comprised 50 patients (baseline HbA1c 8.0±0.6%) treated with sitagliptin 100mg/day, 14 of whom were also taking gliclazide 60mg/day while 38 were taking metformin 1700mg/day. Sitagliptin treatment was replaced by either canagliflozin 100mg (n=17) or 300mg (n=33). After 26 weeks of follow-up, these patients presented with significant decreases in HbA1c (-1.1%; P<0.000), weight (-3.89kg; P<0.000), BMI (-1.37kg/m2; P<0.022), abdominal circumference (-5.42cm; P<0.004), systolic and diastolic blood pressure (-5.3mmHg and -4.4mmHg, respectively; P=0.005), triglycerides (-42mg/dL; P=0.005) and LDL/HDL cholesterol ratio (-0.34; P=0.005). By the end of the study, 42% of patients had achieved HbA1c levels<7%. CONCLUSION: In patients with T2D poorly controlled with sitagliptin, whether alone or in combination with metformin and/or gliclazide, replacing it with canagliflozin may be a simple yet effective intensification strategy. Our results, which may have important implications for clinical practice, now need to be confirmed in larger observational studies.

Epidemiological study of primary systemic vasculitides among adults in southern Spain and review of the main epidemiological studies.

OBJECTIVES: To study the incidence and prevalence of primary systemic vasculitides (PSV) in the Costa del Sol region (southern Spain) and to compare the major epidemiological studies in PSV with the results obtained in our area. METHODS: Retrospective study including permanent residents ≥14 years (or older) diagnosed with PSV at the Hospital Costa del Sol (Marbella, Spain) between 1994 and 2010. Epidemiological data were collected and the annual incidence rate during the study period and the prevalence in 2010 were calculated per million population, except for GCA, which was estimated per 100,000 population >50 years. RESULTS: Seventy-four adult patients were diagnosed with PSV, representing an annual incidence of 15.8 (95%CI 12.2-19.4) patients/million population. These diagnoses included 29 (39.1%) giant cell arteritis (GCA), 5 (6.7%) Takayasu's arteritis (TKA), 3 (4%) poly-arteritis nodosa (PAN), 29 (39.1%) antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) [10 (13.5%) granulomatosis with polyangiitis (GPA) (Wegener), 16 (21.6%) microscopic polyangiitis (MPA) and 3 (4%) eosinophilic granulomatosis with polyangiitis (EGPA) (Churg-Strauss)], 7 (9.4%) IgA vasculitis (Henoch-Schönlein) (IgAV) and one (1.3%) cryobulinaemic vasculitis (CV). The annual incidence and 2010 prevalence for each of the PSV, respectively, were: GCA: 2.2/12.2; TKA: 1.1/10.5; PAN: 0.6/2.6; AAV: 6.2/44.8 (GPA: 2.1/15.8; MPA: 3.4/23.8; EGPA: 0.6/5.3); IgAV: 1.5/7.9; and CV: 0.2/0. CONCLUSIONS: The first epidemiological study of PSV in southern Spain corroborates their infrequency, with GCA and AAV as the PSV most often diagnosed. In southern Spain, the incidence and prevalence of PSV are lower than in northern Spain and in countries in the Northern Hemisphere.

An Arabidopsis gene regulatory network for secondary cell wall synthesis.

The plant cell wall is an important factor for determining cell shape, function and response to the environment. Secondary cell walls, such as those found in xylem, are composed of cellulose, hemicelluloses and lignin and account for the bulk of plant biomass. The coordination between transcriptional regulation of synthesis for each polymer is complex and vital to cell function. A regulatory hierarchy of developmental switches has been proposed, although the full complement of regulators remains unknown. Here we present a protein-DNA network between Arabidopsis thaliana transcription factors and secondary cell wall metabolic genes with gene expression regulated by a series of feed-forward loops. This model allowed us to develop and validate new hypotheses about secondary wall gene regulation under abiotic stress. Distinct stresses are able to perturb targeted genes to potentially promote functional adaptation. These interactions will serve as a foundation for understanding the regulation of a complex, integral plant component.

El ictus en el hospital comarcal: por favor, llamen al neurólogo / Strokes in the district hospital: please call the neurologist

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[Acute cerebrovascular disease in the Northern Cordoba Health Area]. / Enfermedad cerebrovascular aguda en el Area Sanitaria Norte de Córdoba.

INTRODUCTION: Its high rates of prevalence, mortality and disability make acute cerebrovascular disease (ACVD) a priority health problem. It is as the second most common cause of admission to internal medicine services. AIMS: To examine inpatient care for ACVD during 2004 in the Valle de los Pedroches health area in the province of Cordoba, as well as survival at six months, so as to be able to carry out the changes needed to improve the attention offered for this condition. PATIENTS AND METHODS: A longitudinal study of the acute phase of the illness and survival at six months was conducted by means of face-to-face interviews. RESULTS: The prevalence of arterial hypertension (75.5%) stands out as a risk factor. The mean age was higher than in other series. There is no characteristic profile of clinical symptoms. The proportion of ischaemic to haemorrhagic strokes falls within the normal range. All 110 patients were submitted to a cranial computerised axial tomography scan in less than three hours. A compromised level of consciousness, senility, haemorrhagic stroke, poorer scoring on the Canadian Neurological Scale and complications all affected mortality rates. The study showed that 20% died while in hospital and 19.1% at six months. At discharge, 30.9% were undergoing rehabilitation. The spouse was the main caregiver in 55.5% of cases. A total of 79% had sequelae at six months. CONCLUSIONS: Instruments that allow fast effective diagnoses and treatments and guarantee proper clinical practice while reducing brain damage and its dependence should be made generally available. Improving primary and secondary prevention is essential in order to halt the progression of ACVD.

Enfermedad cerebrovascular aguda en el Área Sanitaria Norte de Córdoba / Acute cerebrovascular disease in the northern cordoba health area

Introducción. La enfermedad cerebrovascular aguda (ECVA) es un problema de salud prioritario por su elevada prevalencia, mortalidad y discapacidad. Constituye la segunda causa de ingreso en el servicio de medicina interna. Objetivo. Conocer la asistencia hospitalaria en la ECVA durante el año 2004 en el área sanitaria del Valle de los Pedroches en la provincia de Córdoba y la supervivencia a los seis meses para emprender los cambios necesarios que mejoren la atención en este proceso. Pacientes y métodos. Estudio observacional de la fase aguda de la enfermedad y de supervivencia a los seis meses mediante una entrevista personal. Resultados. Destaca la prevalencia de hipertensión arterial (75,5%) como factor de riesgo. La edad media es superior a otras series. No hay un perfil de síntomas clínicos característico. La proporción de ictus isquémico y hemorrágico es la habitual. Los 110 pacientes disponían de tomografía axial computarizada craneal en un tiempo inferior a tres horas. La afectación del nivel de conciencia, la senectud, el ictus hemorrágico, la peor puntuación en la escala canadiense y las complicaciones marcaron la mortalidad. El 20% murió durante el ingreso y el 19,1% a los seis meses. El 30,9% realizaba rehabilitación al alta. En el 55,5% el cuidador principal era el cónyuge. El 79% tenía secuelas a los seis meses. Conclusiones. Deberían generalizarse los instrumentos para el diagnóstico y la terapéutica rápidos y eficaces que garanticen una práctica clínica adecuada y disminuyan el daño cerebral y su dependencia. Es imprescindible mejorar la prevención primaria y secundaria para frenar la progresión de la ECVA

Introduction. Its high rates of prevalence, mortality and disability make acute cerebrovascular disease (ACVD) a priority health problem. It is as the second most common cause of admission to internal medicine services. Aims. To examine inpatient care for ACVD during 2004 in the Valle de los Pedroches health area in the province of Cordoba, as well as survival at six months, so as to be able to carry out the changes needed to improve the attention offered for this condition. Patients and methods. A longitudinal study of the acute phase of the illness and survival at six months was conducted by means of face-toface interviews. Results. The prevalence of arterial hypertension (75.5%) stands out as a risk factor. The mean age was higher than in other series. There is no characteristic profile of clinical symptoms. The proportion of ischaemic to haemorrhagic strokes falls within the normal range. All 110 patients were submitted to a cranial computerised axial tomography scan in less than three hours. A compromised level of consciousness, senility, haemorrhagic stroke, poorer scoring on the Canadian Neurological Scale and complications all affected mortality rates. The study showed that 20% died while in hospital and 19.1% at six months. At discharge, 30.9% were undergoing rehabilitation. The spouse was the main caregiver in 55.5% of cases. A total of 79% had sequelae at six months. Conclusions. Instruments that allow fast effective diagnoses and treatments and guarantee proper clinical practice while reducing brain damage and its dependence should be made generally available. Improving primary and secondary prevention is essential in order to halt the progression of ACVD

Treatment and follow-up of HIV-negative multidrug-resistant tuberculosis patients in an infectious diseases reference hospital, Buenos Aires, Argentina.

SETTING: An Argentinean reference hospital specialising in infectious diseases. OBJECTIVE: To assess the outcomes of all human immunodeficiency virus (HIV) negative multidrug-resistant tuberculosis (MDR-TB) patients referred to or diagnosed at Hospital Muñiz. DESIGN: Clinical study for the period 1996-1999, with follow-up until June 2002. RESULTS: One hundred and forty-one adult patients (52.5% female) with resistance to two to seven drugs were studied. Fifty patients (35.5%) had not been treated previously. The most frequently used second-line drugs were 5-F-quinolones, cycloserine and ethionamide in susceptibility based individually tailored three- to five-drug regimens. Hospital admission was associated with treatment success. Forty-five episodes of severe toxicity occurred. Treatment was successful in 51.8% of cases, but follow-up of 73 patients yielded 11.9% relapse. The mortality rate was 19.1% and default was 19.9%. Logistic regression analysis was statistically significant for treatment success in relation to patient admission, residence and resistance pattern. CONCLUSION: The burden of MDR-TB in this setting--prolonged infection, treatment cost and difficulties, low rates of cure and treatment adherence and high rates of fatality and relapse--can be improved by strengthening TB control programme activities and fighting against poverty and HIV/AIDS.

Metástasis esternal por hepatocarcinoma / Sternal metastases hepatocellular carcinoma

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Divertículo epifrénico operado

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[Lung cancer and paraneoplastic syndromes]. / Cáncer de pulmón y síndromes paraneoplásicos.

Paraneoplastic syndromes (PNS) are a relatively common manifestation of cancer, and in some cases they may be the first symptom. Lung cancer has the highest incidence of paraneoplastic syndrome. This fact is important considering a non explained endocrinological and neurological syndrome, it may facilitate a prompt diagnosis, and in some cases an adequate treatment. PNS evolution seems to be parallel to the subjacent cancer. PNS management requires specific measures, because in some cases, it may compromise the patient life. Neurological and endocrinological PNS associated to lung cancer are revised, and diagnosis and treatment of them are updated.