[Health risks for adolescents in underserved areas]. / Riesgos para la salud de los adolescentes en áreas marginadas.

Background: adolescent population is an important age group, with vulnerability and health needs not well known, especially for those living in urban slums. Our objective was to identify health risks for adolescents living in poor urban areas in five geographical regions of Mexico. Methods: a secondary data analysis from a nationwide adolescents ́ survey was carried out from population living in poor urban areas of the north, center, DF, south and southeast of Mexico. Cigarette smoking, alcohol and drug consumption, as well as frequency of accidents and violence, age at sexual initiation and use of contraception methods were analyzed. Results: the highest frequencies of consumption were: 27.8 % for cigarette smoking and 35.2 % for alcohol, both in adolescents from 16 to 19 years; accidents (5 %) and violence (1.7 %); age (median) at sexual initiation was 16 years, about 50 % of adolescents with regular sexual activity reported use of a contraception method. Conclusions: comparing our data with National Health Surveys; in poor urban areas, most adolescents health risks are higher than those found for same group age in the general population, however, presentation of accidents and violence are similar.

Introducción: : los adolescentes son un grupo con vulnerabilidad y necesidades de salud poco conocidas en México, principalmente en áreas de pobreza urbana. El objetivo de esta investigación fue identificar los riesgos para la salud de los adolescentes en las áreas urbanas marginadas en cinco regiones del país. Métodos: análisis secundario de una encuesta de salud para adolescentes realizada en áreas urbanas marginadas del Distrito Federal y regiones norte, centro, sur y sureste del país; se analizó consumo de tabaco, alcohol y drogas; historia de accidentes y violencias, edad de inicio de vida sexual y uso de métodos anticonceptivos; se calcularon frecuencias absolutas y relativas. Resultados: los consumos más altos fueron para tabaco (27.8 %) y alcohol (35.2 %), ambos en el grupo de 16 a 19 años de edad; 5 % sufrió algún accidente y 1.7 %, violencia; el inicio de la vida sexual tuvo una mediana de 16 años y 50 % utilizaba algún método anticonceptivo. Conclusiones: al comparar nuestros datos con los de otras encuestas nacionales, se encontró que los riesgos para la salud son mayores en los adolescentes de áreas urbanas marginadas que en adolescentes de la población general, sin embargo, la frecuencia de accidentes y violencias fue similar.

[Guideline for integrated geriatric assessment]. / Guía para la evaluación gerontológica integral.

A clinical practice guideline was developed as a response to the increasing of elderly in Mexican population due to the epidemiological transition; this instrument allows the assessment of health conditions for people from 60 years of age and older, and it can be a tool for helping family physicians and nurses in providing care for the main health problems of this group of age. The guideline for gerontologic assessment includes six principal health priorities in older people (loss of vision, difficulty to hear, falls or problems walking, nutritional disorders, memory difficulties, and sleep disorders); additionally, another four components for assessment are revised (medication use, physical functionality, quality of life, and social support). Simple recommendations for detection, diagnosis and management of these problems in primary care settings are presented.

Design and validation of a critical pathway for hospital management of patients with severe traumatic brain injury.

BACKGROUND: Critical pathways for the management of patients with severe traumatic brain injury (STBI) may contribute to reducing the incidence of hospital complications, length of hospitalization stay, and cost of care. Such pathways have previously been developed for departments with significant resource availability. In Mexico, STBI is the most important cause of complications and length of stay in neurotrauma services at public hospitals. Although current treatment is designed basically in accordance with the Brain Trauma Foundation guidelines, shortfalls in the availability of local resources make it difficult to comply with these standards, and no critical pathway is available that accords with the resources of public hospitals. The purpose of the present study was to design and to validate a critical pathway for managing STBI patients that would be suitable for implementation in neurotrauma departments of middle-income level countries. METHODS: The study comprised two phases: design (through literature review and design plan) and validation (content, construct, and appearance) of the critical pathway. RESULTS: The validated critical pathway for managing STBI patients entails four sequential subprocesses summarizing the hospital's care procedures, and includes three components: (1) nodes and criteria (in some cases, indicators are also included); (2) health team members in charge of the patient; (3) maximum estimated time for compliance with recommendations. CONCLUSIONS: This validated critical pathway is based on the current scientific evidence and accords with the availability of resources of middle-income countries.

[Guideline for diagnosis and treatment of urinary incontinence in elderly]. / Guía para el diagnóstico y tratamiento de la incontinencia urinaria en adultos mayores.

Urinary incontinence is a frequent geriatric syndrome, characterized by involuntary urine losses that have a negatively influence on the health, their functionality and social relationships in whom suffered it. Nevertheless, most of these patients are not diagnosed and they do not receive treatment. The objective of this clinical guideline is to provide recommendations based on the best scientific evidence available for diagnosis and treatment of the urinary incontinence in the elderly, at primary care attention. Articles of clinical relevance were selected based on clinical evidence and analyzed by two family physicians, one geriatrician, one gerontologist and two experts in methods for elaboration of clinical guidelines. To verify comprehension and clinical applicability, 4 workshops including 35 family physicians were carried out, and the corresponding adjustments were made. The clinical guideline can be a tool for physicians at primary care attention to classify urinary incontinence and to provide pharmacologic and nonpharmacologic treatment. Additionally, the guideline presents recommendations for identification of patients who need specialized care.

Guía de práctica clínica para el diagnóstico y tratamiento de depresión en los adultos mayores

Resumen: Introducción La depresión cada día cobra mayor importancia, y se estima que en el año 2020 será la segunda causa de años de vida saludable perdidos a escala mundial y la primera en países desarrollados, por lo que el diagnóstico adecuado y oportuno permitirá brindar un manejo integral que incluya psicoterapia y tratamiento médico adecuado, lo que mejorará de manera significativa la calidad de vida y el pronóstico de estas personas. En atención primaria existe sub diagnóstico y retraso en la identificación de la depresión, por lo que, desde el inicio del tratamiento, impacta negativamente en el bienestar de los individuos, en la salud pública y en los costos directos e indirectos de los servicios sanitarios. Es frecuente que el médico de atención primaria considere como "causa" de la depresión las quejas de la vida cotidiana, la incapacidad para hacer frente al estrés familiar, el aislamiento social o el cambio de roles y los problemas financieros; por lo tanto la considera "justificada" y evita proporcionar tratamiento, cuando en realidad esta incapacidad suele ser ocasionada por la misma depresión. La depresión es uno de los padecimientos psicogeriátricos más frecuentes y en México su prevalencia global es de 9.5% en mujeres y 5% en hombres mayores de 60 años. En la mayoría de los casos no es diagnosticada por la presentación atípica de la misma o por la falsa creencia de que forma parte del envejecimiento normal, puesto que en el adulto mayor la depresión se puede esconder en síntomas somáticos, ya sea como manifestaciones del síndrome depresivo o porque a causa de éste se acentúan los síntomas de otras enfermedades concomitantes. Los síntomas cognitivos secundarios se presentan con más frecuencia en este grupo etario. Objetivo Proporcionar a los médicos de primer nivel de atención, una guía de práctica clínica con los elementos técnico-médicos suficientes que faciliten el diagnóstico y tratamiento integral de adultos mayores con depresión. Usuarios. La guía está dirigida a los médicos del primer nivel de atención. Población blanco. Hombres y mujeres de 60 años de edad en adelante. Método El estudio comprendió dos fases: el diseño y la validación de la guía clínica. Selección de evidencia 1. Las palabras clave para la búsqueda fueron: Depresión, adulto mayor, guías clínicas, prevalencia, atención primaria, valoración, tratamiento, riesgo de suicidio. 2. Bases de datos consultadas: Cochrane, Pub-Med y Medline, en el período de 1990-2006. 3. Se encontraron 26 referencias para depresión mayor en adulto mayor: ocho meta análisis de estudios clínicos aleatorizados, dos clínicos aleatorizados, uno de cohorte, 12 descriptivos no experimentales y tres artículos de libros (DSM-IV TR; CIE 10, Manual de psicogeriatría). 4. Categoría de evidencia y fuerza de recomendación, indica al usuario el origen de las recomendaciones emitidas. En el algoritmo de la guía clínica se identifican los conceptos o el sustento de cada una de las recomendaciones. En la presente guía el diagnóstico de depresión se fundamenta en la CIE 10 y su gradación podría ser comparable con la depresión mayor del DSM IV TR. Se incluye el diagnóstico diferencial, los criterios de referencia al psiquiatra, los lineamientos para el tratamiento farmacológico, psicoterapéutico y psicosocial; fase de inicio y fase de mantenimiento. Conclusión La guía de práctica clínica propuesta se basa en metodología rigurosa, da al médico elementos suficientes para realizar el diagnóstico oportuno, así como el tratamiento integral en adultos mayores con depresión, e incorpora criterios con base en evidencia científica que permitirán actualizarla y evaluar su solidez ante el surgimiento de nueva evidencia, manteniendo así su validez.

Summary: Introduction Depression is growing in importance every day. It is estimated that by the year 2020 it will be worldwide the second cause for the loss of healthy life years and the first in developed countries. Considering this, an adequate and opportune diagnosis will allow for a complete handling of the disorder. This should include adequate psychotherapy and medical treatment which will in turn improve significantly the prognosis and life quality of depressed individuals. In the primary care area, sub-diagnosis and delays to identify depression are common. These have a negative effect on the individuals' well-being, in public health and in the direct and indirect costs of health services. It is not uncommon for primary care practitioners to consider everyday complaints, the inability to cope with family stress, social isolation, role change and money problems as «causes ¼ for depression. Thus, they deem depression «justified ¼ and fail to offer treatment when actually this very inability is often caused by depression. Depression is among the most frequent psycho-geriatric ailments. In Mexico, its overall prevalence is 9.5% in women and 5% in men age 60 or more. In most instances, it goes undiagnosed given its atypical expression or the false belief which considers it part of the normal aging process. In the elderly, depression may conceal somatic symptoms, be it as expressions of the depressive syndrome or because these same symptoms aggravate symptoms from other concomitant diseases. Secondary cognitive symptoms are more frequent among this age group. Objective To provide physicians at primary care a guideline with enough technical-medical elements to facilitate the timely diagnosis and integral treatment of elderly with depression. Method This study comprised two phases: design and validation of the guideline. Evidence selection 1. Key words for search: depression, elderly, clinical guidelines, prevalence, primary care, assessment, treatment, suicide risk. 2. Data bases used: Cochrane, Pub-Med and Medline for the 1990-2006 period. 3. Twenty-six references for major depression in the elderly were found: eight random meta-analysis, two random clinical, one cohort, twelve descriptive non-experimental, and three book articles (DSM-IV[HRM1] TR; CIE 10, Psycho-geriatrics Manual). 4. Evidence category and strength of recommendation. This indicates the user about the origin of recommendations issued. In the algorithm from the clinical guide, the concepts or support for each recommendation are identified. In this guide, the diagnosis of depression is based on the CIE-10 and its ranking may be comparable to that for major depression in the DSM-IV TR. Differential diagnosis; criteria for referring a patient to the psychiatrist; guidelines for pharmacological, psychotherapeutic and psychosocial treatment; onset phase and maintenance phase are included. Thus, the clinical practice guide proposed is based on a strict methodology. It offers enough elements for the general practitioner to assess an opportune and complete treatment for elderly people with depression. In addition, it incorporates criteria based on scientific evidence, which will allow updating it, and evaluating its solidity in the face of new evidence, which will in turn maintain its validity.