Comparative efficacy of two interventions to discontinue long-term benzodiazepine use: cluster randomised controlled trial in primary care.

BACKGROUND: Benzodiazepines are extensively used in primary care, but their long-term use is associated with adverse health outcomes and dependence. AIMS: To analyse the efficacy of two structured interventions in primary care to enable patients to discontinue long-term benzodiazepine use. METHOD: A multicentre three-arm cluster randomised controlled trial was conducted, with randomisation at general practitioner level (trial registration ISRCTN13024375). A total of 532 patients taking benzodiazepines for at least 6 months participated. After all patients were included, general practitioners were randomly allocated (1:1:1) to usual care, a structured intervention with follow-up visits (SIF) or a structured intervention with written instructions (SIW). The primary end-point was the last month self-declared benzodiazepine discontinuation confirmed by prescription claims at 12 months. RESULTS: At 12 months, 76 of 168 (45%) patients in the SIW group and 86 of 191 (45%) in the SIF group had discontinued benzodiazepine use compared with 26 of 173 (15%) in the control group. After adjusting by cluster, the relative risks for benzodiazepine discontinuation were 3.01 (95% CI 2.03-4.46, P<0.0001) in the SIW and 3.00 (95% CI 2.04-4.40, P<0.0001) in the SIF group. The most frequently reported withdrawal symptoms were insomnia, anxiety and irritability. CONCLUSIONS: Both interventions led to significant reductions in long-term benzodiazepine use in patients without severe comorbidity. A structured intervention with a written individualised stepped-dose reduction is less time-consuming and as effective in primary care as a more complex intervention involving follow-up visits.

Predicting the onset of major depression in primary care: international validation of a risk prediction algorithm from Spain.

BACKGROUND: The different incidence rates of, and risk factors for, depression in different countries argue for the need to have a specific risk algorithm for each country or a supranational risk algorithm. We aimed to develop and validate a predictD-Spain risk algorithm (PSRA) for the onset of major depression and to compare the performance of the PSRA with the predictD-Europe risk algorithm (PERA) in Spanish primary care. METHOD: A prospective cohort study with evaluations at baseline, 6 and 12 months. We measured 39 known risk factors and used multi-level logistic regression and inverse probability weighting to build the PSRA. In Spain (4574), Chile (2133) and another five European countries (5184), 11 891 non-depressed adult primary care attendees formed our at-risk population. The main outcome was DSM-IV major depression (CIDI). RESULTS: Six variables were patient characteristics or past events (sex, age, sex×age interaction, education, physical child abuse, and lifetime depression) and six were current status [Short Form 12 (SF-12) physical score, SF-12 mental score, dissatisfaction with unpaid work, number of serious problems in very close persons, dissatisfaction with living together at home, and taking medication for stress, anxiety or depression]. The C-index of the PSRA was 0.82 [95% confidence interval (CI) 0.79-0.84]. The Integrated Discrimination Improvement (IDI) was 0.0558 [standard error (s.e.)=0.0071, Zexp=7.88, p<0.0001] mainly due to the increase in sensitivity. Both the IDI and calibration plots showed that the PSRA functioned better than the PERA in Spain. CONCLUSIONS: The PSRA included new variables and afforded an improved performance over the PERA for predicting the onset of major depression in Spain. However, the PERA is still the best option in other European countries.

Características sociodemográficas y psicopatológicas del paciente hiperfrecuentados en atención primaria / Sociodemographic and psychopathological features of frequent attenders in Primary Care

Objetivo. Determinar las características sociodemográficas, clínicas y psicopatológicas de un grupo de pacientes hiperfrecuentadores comparándolo con otro grupo de normofrecuentadores en tres centros de atención primaria. Método. La muestra está compuesta por 232 hiperfrecuentadores (definidos por un número de consultas igual o superior a 12 en el último año) y 93 normofrecuentadores. Los instrumentos utilizados son: un cuestionario de elaboración propia para la evaluación de las características sociodemográficas y clínicas y el Cuestionario de Salud General de Goldberg en su versión de 28 ítems (GHQ-28).Resultados. La regresión logística muestra que el aumento de edad, un nivel educativo bajo, la presencia de enfermedad crónica (diabetes e hipertensión), un diagnóstico psiquiátrico y presencia de sintomatología psicopatológica «menor» establecen diferencias significativas en el grupo de hiperfrecuentadores frente al grupo de normofrecuentadores. No existen diferencias significativas entre hombres y mujeres. Conclusión. Los pacientes hiperfrecuentadores presentan altas tasas de quejas físicas, mentales y sociales. La edad, determinadas enfermedades crónicas y la psicopatología son los factores más importantes en relación a la hiperfrecuentación (AU)

Objective. To determine the sociodemographic and clinical characteristics of frequent attenders and compare them with another group of routine attenders in three primary care centers. Method. The sample is composed by 232 frequent attenders (defined by number of consultations in the last year of 12 or more) and 93 routine attenders. The instruments used are: a questionnaire for the evaluation of the sociodemographic and clinical characteristics and the 28-item Goldberg General Health Questionnaire (GHQ-28).Results. The logistic regression shows that increase of age, low level of education, presence of chronic disease, psychiatric diagnosis and presence of psychopathological «minor» symptomatology establish significant differences in the group of frequent attenders in relation to the routine attenders group. There are no significant differences between men and women. Conclusion. Frequent attenders present higher rates of physical, mental and social complaints. Age, some chronic conditions and psychopathology are the most important factors for frequent attendance (AU)

Sociodemographic and psychopathological features of frequent attenders in Primary Care.

OBJECTIVE: To determine the sociodemographic and clinical characteristics of frequent attenders and compare them with another group of routine attenders in three primary care centers. METHOD: The sample is composed by 232 frequent attenders (defined by number of consultations in the last year of 12 or more) and 93 routine attenders. The instruments used are: a questionnaire for the evaluation of the sociodemographic and clinical characteristics and the 28-item Goldberg General Health Questionnaire (GHQ-28). RESULTS: The logistic regression shows that increase of age, low level of education, presence of chronic disease, psychiatric diagnosis and presence of psychopathological <> symptomatology establish significant differences in the group of frequent attenders in relation to the routine attenders group. There are no significant differences between men and women. CONCLUSION: Frequent attenders present higher rates of physical, mental and social complaints. Age, some chronic conditions and psychopathology are the most important factors for frequent attendance.

[Minimally invasive surgery of the inguinal hernia]. / Cirugía mínimamente invasiva de la hernia inguinal.

The minimally invasive approach to the inguinal hernia shows advantages with respect to previous conventional approaches in bilateral and recurrent inguinal hernias; while the initial results were bad, new problems were added deriving from the laparoscopic approach. The aim of this article is to describe the surgical technique and analyse the preliminary results of our series of 600 totally extra-peritoneal hernioplasties, performed at the University Clinic of Navarra. The most frequent complication (25.7%) was the accidental rupture of the peritonea. There were no associated intra-abdominal complications. In the follow-up there were 9 relapses (1.5%) and 13 reinterventions. Eleven (1.8%) of the patients developed transitory neuropathic pain in the femoral cutaneous area. In our experience the totally extra-peritoneal approach is a technique that is especially indicated in relapsed and bilateral hernias. The advantages present, in terms of pain and postoperative discomfort, recovery of physical and labour activity, and the good results with respect to relapses and neuropathic pains, encourage us to indicate it not only in relapsed or bilateral inguinal hernias but also in primary ones.

Cirugía mínimamente invasiva de la hernia inguinal / Minimally invasive surgery of the inguinal hernia

El abordaje mínimamente invasivo de la hernia inguinal presenta ventajas respecto a los abordajes convencionales anteriores en las hernias inguinales bilaterales y recurrentes, si bien los resultados iniciales fueron malos, se sumaron nuevos problemas derivados del abordaje laparoscópico.El objetivo de este artículo es describir la técnica quirúrgica y analizar los resultados preliminares de nuestra serie de 600 hernioplastias totalmente extraperitoneales realizadas en la Clínica Universitaria de Navarra.La complicación intraoperatoria más frecuente (25,7%) fue la apertura accidental del peritoneo. No hubo complicaciones intrabdominales asociadas. En el seguimiento hubo 9 (1,5%) recidivas y 13 reintervenciones. Once (1,8%) pacientes desarrollaron dolor neuropático transitorio en el territorio del fémoro-cutáneo. En nuestra experiencia el abordaje totalmente extraperitoneal es una técnica especialmente indicada en hernias recidivadas y bilaterales. Las ventajas presentes en cuanto a dolor y disconfort postoperatorio, recuperación de la actividad física y laboral, y los buenos resultados en cuanto a recidivas y dolor neuropático nos animan a indicarla no sólo en las hernias inguinales recidivadas o bilaterales sino en las primarias

The minimally invasive approach to the inguinal hernia shows advantages with respect to previous conventional approaches in bilateral and recurrent inguinal hernias; while the initial results were bad, new problems were added deriving from the laparoscopic approach. The aim of this article is to describe the surgical technique and analyse the preliminary results of our series of 600 totally extra-peritoneal hernioplasties, performed at the University Clinic of Navarra. The most frequent complication (25.7%) was the accidental rupture of the peritonea. There were no associated intra-abdominal complications. In the follow-up there were 9 relapses (1.5%) and 13 reinterventions. Eleven (1.8%) of the patients developed transitory neuropathic pain in the femoral cutaneous area. In our experience the totally extra-peritoneal approach is a technique that is especially indicated in relapsed and bilateral hernias. The advantages present, in terms of pain and postoperative discomfort, recovery of physical and labour activity, and the good results with respect to relapses and neuropathic pains, encourage us to indicate it not only in relapsed or bilateral inguinal hernias but also in primary ones

[Application of extracorporeal lithotripsy in intestinal subocclusion caused by a clam shell]. / Aplicación de la litotricia extracorpórea en la suboclusión intestinal por valva de molusco.

A patient with intestinal obstruction secondary to a foreign body (clam shell) impacted in the ileocecal valve was treated by extracorporeal shock wave lithotripsy. The resolution of ileus without complications was obtained.

[Suicide attempt with diltiazem]. / Intento de autólisis con diltiacem.

We report a case of a patient, with no conduction abnormalities, who had took 1,800 mg of diltiazem in an attempted suicide. We haven't come across a similar case, which is not associated with other drugs, in bibliography we have consulted. She had conduction abnormalities at different levels, such as atrioventricular block and sinoatrial block, but after a few hours sinus rhythm returned without more complicated treatment. Serial electrocardiograms showed the different types of block. Although we didn't make an electrophysiologic study, we made vagal tests which were normal.