Fracture risk after deprescription of bisphosphonates: Application of real-world data in primary care.

PURPOSE: To compare the effect of discontinuing bisphosphonate treatment on fracture risk in postmenopausal women at high versus low risk of fracture. DESIGN: Retrospective, longitudinal and population-based cohort study. SETTING: Barcelona City Primary Care. Catalan Health Institute. PARTICIPANTS: All women attended by primary care teams who in January 2014 had received bisphosphonate treatment for at least five years were included and followed for another five years. INTERVENTION: Patients were classified according to their risk of new fractures, defined as those who had a history of osteoporotic fracture and/or who received treatment with an aromatase inhibitor, and the continuity or deprescription of the bisphosphonate treatment was analyzed over fiver year follow-up. MAIN MEASUREMENTS: The cumulative incidence of fractures and the incidence density were calculated and analyzed using logistic regression and Cox models. RESULTS: We included 3680 women. There were no significant differences in fracture risk in high-risk women who discontinued versus continued bisphosphonate treatment (hazard ratio [HR] 1.17, 95% confidence interval [CI] 0.87-1.58 for total osteoporotic fractures). However, discontinuers at low risk had a lower incidence of fracture than continuers. This difference was significant for vertebral fractures (HR 0.64, 95% CI 0.47-0.88) and total fractures (HR 0.77, 95% CI 0.64-0.92). CONCLUSION: Our results suggest that deprescribing bisphosphonates in women who have already received five years of treatment does not increase fracture risk. In low-risk women, continuing this treatment might could even favor the appearance of new osteoporotic fractures.

Glycemic control and the risk of tuberculosis in patients with diabetes: A cohort study in a Mediterranean city.

Background: Diabetes mellitus (DM) is one of the leading chronic diseases globally and one of the most common causes of death, morbidity, and poor quality of life. According to the WHO, DM is also one of the main risk factors for developing active tuberculosis (TB). Subjects with DM are at a higher risk of infections, in addition to frequent micro and macrovascular complications, and therefore sought to determine whether poor glycemic control is linked to a higher risk of developing TB. Methods: We used a retrospective cohort of diabetic subjects to predict the incidence of TB. All DM patients were recruited from Ciutat Vella (the inner-city of Barcelona) from January 2007 until December 2016, with a follow-up period until December 2018 (≥2 years). Data were extracted from Barcelona's Primary Care medical record database - SIDIAP, and linked to the Barcelona TB Control Program. The incidence of TB and the impact of glycemic control were estimated using time-to-event curves analyzed by Cox proportional hazard regression. Hazard ratios (HRs) and 95% confidence intervals (CIs), unadjusted and adjusted by potential confounding variables, were also assessed, which included age, sex, diabetes duration, macrovascular and microvascular signs, BMI, smoking habit, alcohol consumption and geographical origin. Results: Of 8,004 DM patients considered for the study (equating to 68,605 person-years of follow-up), 84 developed TB [incidence rate = 70 (95% CI: 52-93) per 100,000 person-years]. DM subjects with TB were younger (mean: 52.2 vs. 57.7 years old), had higher values of glycosylated hemoglobin (HbA1c) (7.66 vs. 7.41%) and total triglycerides (122 vs. 105 mg/dl), and had twice the frequency of diabetic nephropathy (2.08 vs. 1.18%). The calculated incidence rate increased with increasing HbA1c: 120.5 (95% CI 77.2-179.3) for HbA1c ≥ 7.5%, 143 (95% CI 88.3-218.1) for HbA1c ≥ 8% and 183.8 (95% CI 105-298) for HbA1c ≥ 9%. An increase in the risk of TB was also observed according to a poorer optimization of glycemic control: adjusted HR 1.80 (95% CI 0.60-5.42), 2.06 (95% CI 0.67-6.32), and 2.82 (95% CI 0.88-9.06), respectively. Conclusion: Diabetic subjects with worse glycemic control show a trend toward a higher risk of developing TB.

Serum Selenium and Incident Cardiovascular Disease in the PREvención con DIeta MEDiterránea (PREDIMED) Trial: Nested Case-Control Study.

Background: Selenium is an essential trace mineral with potential interest for cardiovascular disease (CVD) prevention owing to its antioxidant properties. Epidemiological data on selenium status and CVD remain inconsistent. The objective of this study was to ascertain whether low serum selenium (SSe) concentrations are related to an increased risk of a first CVD event in a population at high cardiovascular risk. Methods: We undertook a case-control study nested within the "PREvención con DIeta MEDiterránea" (PREDIMED) trial. A total of 207 participants diagnosed with CVD (myocardial infarction, stroke, or cardiovascular death) during the follow-up period (2003−2010) were matched by sex, age, and intervention group to 436 controls by incidence density sampling. Median time between serum sample collection and subsequent CVD event occurrence was 0.94 years. SSe levels were determined using inductively coupled plasma mass spectrometry analysis. Covariates were assessed through validated questionnaires, in-person interviews, and medical record reviews. Conditional logistic regression was used to calculate multivariable-adjusted odds ratios (ORs). Results: Among women, the mean SSe concentration was lower in cases than in controls (98.5 µg/L vs. 103.8 µg/L; p = 0.016). In controls, SSe levels were directly associated with percentage of total energy intake from proteins and fish intake (p for linear trend < 0.001 and 0.049, respectively), whereas SSe concentrations were inversely associated with age, body mass index, and percentage of total energy intake from carbohydrates (p for linear trend < 0.001, 0.008 and 0.016 respectively). In the total group, we observed an inverse dose−response gradient between SSe levels and risk of CVD in the fully-adjusted model (highest vs. lowest quartile: OR = 0.47, 95% CI: 0.27−0.81; ptrend = 0.003). Conclusions: Among elderly individuals at high cardiovascular risk, high SSe concentrations within population reference values are associated with lower first CVD incidence.

Does Influenza Vaccination Reduce the Risk of Contracting COVID-19?

The concurrent timing of the COVID-19 pandemic and the seasonal occurrence of influenza, makes it especially important to analyze the possible effect of the influenza vaccine on the risk of contracting COVID-19, or in reducing the complications caused by both diseases, especially in vulnerable populations. There is very little scientific information on the possible protective role of the influenza vaccine against the risk of contracting COVID-19, particularly in groups at high-risk of influenza complications. Reducing the risk of contracting COVID-19 in high-risk patients (those with a higher risk of infection, complications, and death) is essential to improve public well-being and to reduce hospital pressure and the collapse of primary health centers. Apart from overlapping in time, COVID-19 and flu share common aspects of transmission, so that measures to protect against flu might be effective in reducing the risk of contracting COVID-19. In this study, we conclude that the risk of contracting COVID-19 is reduced if patients are vaccinated against flu, but the reduction is small (0.22%) and therefore not clinically important. When this reduction is analysed based on the risk factor suffered by the patient, statistically significant differences have been obtained for patients with cardiovascular problems, diabetics, chronic lung and chronic kidney disease; in all four cases the reduction in the risk of contagion does not reach 1%. It is worth highlighting the behaviour that is completely different from the rest of the data for institutionalized patients. The data for these patients does not suggest a reduction in the risk of contagion for patients vaccinated against the flu, but rather the opposite, a significant increase of 6%. Socioeconomic conditions, as measured by the MEDEA deprivation index, explain increases in the risk of contracting COVID-19, and awareness campaigns should be increased to boost vaccination programs.

[Frailty impact on COVID-19 disease in an older cohort from the city of Barcelona]. / Impacto de la fragilidad y COVID-19 en una cohorte de gente mayor de la ciudad de Barcelona.

Objetive To describe the incidence and mortality of the first wave of COVID-19 in the elderly population of Barcelona, according to their previous levels of frailty. DESIGN: Retrospective cohort study. SETTING AND PARTICIPANTS: Population aged 65 or over assigned to the Barcelona Primary Care centres of the Institut Català de la Salut, followed between March and June 2020. MAIN MEASUREMENTS: Frailty was calculated at baseline from the computerised medical records. Results during follow-up: diagnosis of COVID-19, possible or confirmed with PCR and all-cause mortality. RESULTS: 251788 patients over 64 years of age were analysed, 61.3% had some level of frailty, 27.8% moderate or severe. The incidence of COVID-19 was 3.13 cases per 100 inhabitants (N=7883) and the mortality from COVID-19 was 21.5% (N=1691). Both the incidence and mortality from COVID-19 were higher at older age, in men, at greater deprivation and at a higher level of frailty. Individuals with mild, moderate, and severe frailty had an adjusted Hazard Ratio (HR) for COVID-19 disease of 1.47, 2.08, and 3.50, respectively. Among subjects with COVID-19, those with mild, moderate, and severe frailty had an adjusted HR for COVID-19 mortality of 1.44, 1.69, and 2.47, respectively. CONCLUSIONS: We consider it necessary to address frailty also in a pandemic situation, since it is a treatable condition and in turn a more serious risk factor for COVID-19, where the role of primary care is essential, due to its accessibility and longitudinal character.

Subjects With Diabetes Mellitus Are at Increased Risk for Developing Tuberculosis: A Cohort Study in an Inner-City District of Barcelona (Spain).

Background: Tuberculosis is the leading cause of mortality from lung infectious disease worldwide in recent years, and its incidence has re-emerged in large cities in low-incidence countries due to migration and socioeconomic deprivation causes. Diabetes mellitus and tuberculosis are syndemic diseases, with diabetes being considered a risk factor for developing tuberculosis. Objective: To investigate whether diabetic patients were at increased risk of tuberculosis living in an inner-district of a large city of northeastern Spain. Methods: Observational matched retrospective cohort study based on clinical records from the population of the lowest socioeconomic status in Barcelona (Ciutat Vella district). A cohort including patients with type 1 and type 2 diabetes mellitus in 2007 and new cases until 2016 (8004 subjects), matched 1:1 by sex and age with a non-diabetic cohort. Follow-up period was until December 31st 2018. We evaluated the risk of developing tuberculosis in diabetic patients compared to non-diabetic patients during the follow up period. We used time-to-event analysis to estimate the incidence of tuberculosis, and competing risks regression by clusters and conditional Cox regression models to calculate the hazard ratio (HR) and its 95% confidence intervals (CI). Results: Among the 16,008 included subjects, the median follow-up was 8.7 years. The mean age was 57.7 years; 61.2% men and 38.8% women in both groups. The incidence of tuberculosis was 69.9 per 100,000 person-years in diabetic patients, and 40.9 per 100,000 person-years in non-diabetic patients (HR = 1.90; CI: 1.18-3.07). After adjustment for the country of origin, chronic kidney disease, number of medical appointments, BMI, alcoholism and smoking, the risk remained higher in diabetic patients (1.66: CI 0.99-2.77). Additionally, subjects from Hindustan or with a history of alcohol abuse also showed a higher risk of developing tuberculosis (HR = 3.51; CI:1.87-6.57, and HR = 2.73; CI:1.22-6.12 respectively). Conclusion: People with diabetes mellitus were at higher risk of developing tuberculosis in a large cohort recruited in an inner-city district with a high incidence for this outcome, and low socioeconomic conditions and high proportion of migrants. This risk was higher among Hindustan born and alcohol abusers.

[Characteristics and factors associated with the severity of COVID-19 in Primary Care professionals followed in a Basic Prevention Unit.] / Características y factores asociados a la gravedad de COVID-19 en profesionales de Atención Primaria seguidos en una Unidad Básica de Prevención.

OBJECTIVE: 24.1% of COVID-19 cases reported in Spain from the start of the COVID-19 alert until 29 May 2020 were in healthcare workers. The aim was to describe the demographic, clinical and epidemiological characteristics of Primary Care professionals notified for suspected or contact COVID-19 and to know the factors associated with the severity of the disease. This will allow the development of risk prevention strategies in Primary Care professionals. METHODS: We included all Primary Care professionals of the Territorial Management of Barcelona (GTBCN) notified as suspicion or contact with COVID-19 between March 15 and June 15, 2020. Demographic, clinical and epidemiological variables of the professionals and episodes reported were collected, as well as possible risk factors associated with severity. Descriptive and logistic regression analysis were performed. RESULTS: 1,511 episodes corresponding to 1,427 professionals (31.3% of the GTBCN staff) were reported. 76.4% were women, with a mean age of 45.32 years. Of the professionals reported, 28.5% presented COVID-19 in some episode, and of these 18.2% presented severe symptomatology. Risk factors associated with severity were: respiratory pathology (OR: 2.54, 95%CI: 1.16-5.56) and neoplasia (OR: 4.48, 95%CI: 1.38-14.55). CONCLUSIONS: The proportion of professionals notified due to suspicion or contact with COVID-19 is similar to that observed in other studies, being mostly concentrated in the care categories of primary care teams. The factors associated with symptom severity were previous respiratory disease and neoplasia.

OBJETIVO: El 24,1% de los casos de COVID-19 notificados en España desde el inicio de la alerta por COVID-19 hasta el 29 de mayo 2020 fue en trabajadores de la salud. El objetivo de este trabajo fue describir las características demográficas, clínicas y epidemiológicas de los profesionales de Atención Primaria notificados por sospecha o contacto COVID-19 y conocer los factores asociados a la gravedad de la enfermedad. Esto permitirá desarrollar estrategias de prevención de riesgos en los profesionales de Atención Primaria. METODOS: Se incluyeron todos los profesionales de Atención Primaria de la Gerencia Territorial de Barcelona (GTBCN) del Institut Català de la Salut notificados como sospecha o contacto con COVID-19 entre el 15 de marzo y el 15 de junio de 2020. Se recogieron variables demográficas, clínicas, epidemiológicas de los profesionales y episodios notificados, así como posibles factores de riesgo asociados a gravedad. Se realizó análisis descriptivo y de regresión logística. RESULTADOS: Se notificaron 1.511 episodios correspondientes a 1.427 profesionales (31,3% de la plantilla de la GTBCN). El 76,4% fueron mujeres, con una edad media de 45,32 años. El 28,5% de los profesionales notificados presentaron COVID-19 en algún episodio, y de estos 18,2% presentó sintomatología grave. Los factores de riesgo asociados a gravedad fueron: patología respiratoria (OR: 2,54, IC95%: 1,16-5,56) y neoplasia (OR: 4,48, IC95%: 1,38-14,55). CONCLUSIONES: El porcentaje de profesionales afectados por sintomatología compatible o contacto con COVID-19 es similar al observado en otros estudios concentrándose mayoritariamente en las categorías asistenciales de los equipos de atención primaria. Los factores asociados con la gravedad de los síntomas son enfermedad respiratoria previa y neoplasia.

Predictive model for atrial fibrillation in hypertensive diabetic patients.

BACKGROUND: Several scores to identify patients at high risk of suffering atrial fibrillation have been developed. Their applicability in hypertensive diabetic patients, however, remains uncertain. Our aim is to develop and validate a diagnostic predictive model to calculate the risk of developing atrial fibrillation at five years in a hypertensive diabetic population. METHODS: The derivation cohort consisted of patients with both hypertension and diabetes attended in any of the 52 primary healthcare centres of Barcelona; the validation cohort came from the 11 primary healthcare centres of Terres de l'Ebre (Catalonia South) from January 2013 to December 2017. Multivariable Cox regression identified clinical risk factors associated with the development of atrial fibrillation. The overall performance, discrimination and calibration of the model were carried out. RESULTS: The derivation data set comprised 54 575 patients. The atrial fibrillation rate incidence was 15.3 per 1000 person/year. A 5-year predictive model included age, male gender, overweight, heart failure, valvular heart disease, peripheral vascular disease, chronic kidney disease, number of antihypertensive drugs, systolic and diastolic blood pressure, heart rate, thromboembolism, stroke and previous history of myocardial infarction. The discrimination of the model was good (c-index = 0.692; 95% confidence interval, 0.684-0.700), and calibration was adequate. In the validation cohort, the discrimination was lower (c-index = 0.670). CONCLUSIONS: The model accurately predicts future atrial fibrillation in a population with both diabetes and hypertension. Early detection allows the prevention of possible complications arising from this disease.

Long-term effectiveness of an intervention to enhance mirabegron use revision and its deprescribing: 36-month follow-up of a quasi-experimental trial in primary care.

OBJECTIVE: This is a follow-up study from a multicenter, prospective, before-and-after quasi-experimental, controlled trial to assess effectiveness at 36 months of an intervention designed to promote the revision and deprescribing of mirabegron in primary care in patients with overactive bladder. METHODS: Intervention included patients who attended in 17 PHCs located in North Barcelona; control included patients who attended in the other 34 PHCs located in South, East and West Barcelona. The primary endpoint was mirabegron review and deprescribing when GPs considered appropriate, which was measured by the percentage of change of the number of patients with treatment at 36 months compared to the baseline. The intervention consisted of meetings with all the directors of the PHCs; distribution of the infographic to the GPs; providing information regarding the intervention for urologist and gynaecologist; and review of the treatments by the GPs. A monthly follow-up was done during the first year, and every three months thereafter until month 36. RESULTS: Overall, 1932 patients were included, mean age 71.6 years (female 53.8%). A total of 540 patients included in the intervention discontinued mirabegron at some point during the 36 months follow-up (540/762, 70.8%) compared to 759 patients in the control (759/1170, 64.9%), (p < 0.001). A total of 324/433 patients (74.8%) who discontinued mirabegron use at 12 months remained without pharmacological treatment at 36 months. With respect to the baseline cohort, there was a lower introduction of new patients with mirabegron in the intervention (546/762, 71.6%) compared to the control (1246/1170, 106.5%), (p < .001). Regarding the treated patients, there was an increase of 41.6% in the control and a slight increase of 0.8% in the intervention at 36 months, (p < .001). CONCLUSION: Our data indicate that an intervention can enhance the review use of mirabegron in the primary care setting, and promote their deprescribing.

Relationship between the place of living and mortality in patients with advanced heart failure.

BACKGROUND: Social and environmental factors in advanced heart failure (HF) patients may be crucial to cope with the end stages of the disease. This study analyzes health inequalities and mortality according to place of residence (rural vs urban) in HF patients at advanced stages of the disease. METHODS: Population-based cohort study including 1148 adult patients with HF attended in 279 primary care centers. Patients were followed for at least 1 year after reaching New York Heart Association IV functional class, between 2010 and 2014. Data came from primary care electronic medical records. Cox regression models were applied to determine the hazard ratios (HR) of mortality. RESULTS: Mean age was 81.6 (SD 8.9) years, and 62% were women. Patients in rural areas were older, particularly women aged > 74 years (p = 0.036), and presented lower comorbidity. Mortality percentages were 59 and 51% among rural and urban patients, respectively (p = 0.030). Urban patients living in the most socio-economically deprived neighborhoods presented the highest rate of health service utilization, particularly with primary care nurses (p-trend < 0.001). Multivariate analyses confirmed that men (HR 1.60, 95% confidence interval (CI) 1.34-1.90), older patients (HR 1.05, 95% CI 1.04-1.06), Charlson comorbidity index (HR 1.16, 95% CI 1.11-1.22), and residing in rural areas (HR 1.35, 95% CI 1.09 to 1.67) was associated with higher mortality risk. CONCLUSIONS: Living in rural areas determines an increased risk of mortality in patients at final stages of heart failure.

Effectiveness of a comprehensive care protocol in patients with new diagnoses of type 2 diabetes mellitus and associated comorbidities in primary care: study protocol of a quasi-experimental trial.

INTRODUCTION: Type 2 diabetes mellitus (T2DM) is a highly prevalent chronic disease in the Spanish population. Typically, T2DM is associated with other chronic conditions. Intensive medication at the time of diagnosis has proven effective in reducing cardiovascular risk, improving glycaemic control and preventing T2DM complications. However, it has not yet been demonstrated that a comprehensive and intensive health education protocol at the time of diagnosis has the benefits described previously. Currently, there is great variability in the practices of primary care nurses regarding health education at the time of disease diagnosis.We aimed to evaluate the effectiveness of a systematic protocol with a comprehensive care programme in people with newly diagnosed T2DM with associated comorbidities. METHODS AND ANALYSIS: A multicentre quasi-experimental design comparing a group of individuals taking part in the intervention (intervention group (IG)) with a similar group receiving standard diabetes care (comparison group (CG)) is planned. The intervention will take place during the 3 months after study enrolment. Data will be collected at baseline and at 3, 6 and 12 months. Ten primary care centres in Barcelona city will be selected for participation: 5 for the IG and 5 for the CG. The IG will include five structured individual visits postdiagnosis with the primary care nurse, during which aspects of diabetes education will be discussed with the patient and his/her family. The results will be measured in terms of health-related quality of life and the change in main outcomes (glycated haemoglobin and weight). ETHICS AND DISSEMINATION: The study fully met the requirements of the Ethical Committee of Clinical Investigation of the IDIAP Jordi Gol (approval code: P13/118). Patients will be informed that their data are confidential, and they have the right to withdraw at any time without penalty. Dissemination will include publishing the findings in peer-reviewed journals and sharing our findings at scientific conferences. TRIAL REGISTRATION NUMBER: NCT03990857; Pre-results.

Short-term mortality in end-stage heart failure patients.

OBJECTIVES: This study is aimed at analyzing the impact of the main factors contributing to short and long-term mortality in patients at final stages of heart failure (HF). SETTING: Patients attended at any of the 279 primary health care centers belonging to the Institut Català de la Salut, in Catalonia (Spain). PARTICIPANTS: Patients with Advanced HF. DESIGN: Multicenter cohort study including 1148 HF patients followed for one-year after reaching New York Heart Association (NYHA) IV. MAIN MEASUREMENTS: The primary outcome was all-cause mortality. Multivariate logistic regression models were performed to assess the outcomes at 1, 3, 6, and 12 months. RESULTS: Mean age of patients was 82 (SD 9) years and women represented 61.7%. A total of 135 (11.8%) and 397 (34.6%) patients died three months and one year after inclusion, respectively. Male gender, age, and decreased body mass index were associated with higher mortality at three, six and twelve months. In addition, low systolic blood pressure levels, severe reduction in glomerular filtration, malignancy, and higher doses of loop diuretics were related to higher mortality from 6 to 12 months. The most important risk factor over the whole period was presenting a body mass index lower than 20kg/m2 (three months OR 3.06, 95% CI: 1.58-5.92; six months OR 4.42, 95% CI: 2.08-9.38; and 12 months OR 3.68, 95% CI: 1.76-7.69). CONCLUSIONS: We may conclude that male, age, and decreased body mass index determined higher short-term mortality in NYHA IV. In addition, low systolic blood pressure, reduced glomerular filtration, malignancy, and higher doses of loop diuretics contribute to increasing the risk of mortality at medium and long-term. Such variables are easily measurable and can help to decide the best way to face the most advances stages of the disease.

[Evaluation of a training model for health professionals in the care of critical patients: AIPCAP Study]. / Evaluación de un modelo formativo para profesionales sanitarios en la atención del paciente crítico: Estudio AIPCAP.

OBJECTIVE: To evaluate the validity, acceptability, and impact on the level of knowledge and skills of Primary Care health professionals of a training model aimed at improving the care of critical patients. DESIGN: A quasi-experimental interventional, multicentre study. LOCATION: Eight health care teams in Barcelona. PARTICIPANTS: A total of 272 professionals. INTERVENTIONS: A training program consisting of 48 simulations of acute myocardial infarction and stroke. MAIN MEASUREMENTS: A checklist was used to evaluate critical patient skills, effect of training on the knowledge of the participants, and a satisfaction survey. The training was carried out after 2 series of simulations (AMI+Stroke). In the second series, 3evaluations were made: in situ, one week after, and at 3weeks. Concordance and reliability were measured. The differences in means were analysed using the Student t test for paired data. RESULTS: A total of 449 knowledge tests were answered, with a higher score being obtained at the end of each simulation (3.89 -SD 1.01 vs. 3.21 -SD 1.09). Doctors obtained better medical scores than nurses (3.81 - SD 0.87 vs. 3.32 - SD 1.15), and professionals with a specialty completed scored more than those in training (MIR) (3.6 - SD 1.08 vs. 3.4 - SD 1.18). The mean score was 7.7 points (SD 1.56) in the first evaluation, and improved to 9.1 points (SD 0.78). The kappa index was greater than 0.40 in all cases. CONCLUSIONS: A training methodology in the management of emergencies in Primary Care based on simulations is valid, reliable and well accepted, achieving an improvement in the level of knowledge and skills of the participating professionals.

Self-perception of leadership styles and behaviour in primary health care.

BACKGROUND: The concept of leadership has been studied in various disciplines and from different theoretical approaches. It is a dynamic concept that evolves over time. There are few studies in our field on managers' self-perception of their leadership style. There are no pure styles, but one or another style is generally favoured to a greater or lesser degree. In the primary health care (PHC) setting, managers' leadership style is defined as a set of attitudes, behaviours, beliefs and values. The objectives of this study were to describe and learn about the self-perception of behaviours and leadership styles among PHC managers; to determine the influence of the leadership style on job satisfaction, efficiency, and willingness to work in a team; and to determine the relationship between transformational and transactional styles according age, gender, profession, type of manager years of management experience, and the type of organization. METHODS: To describe leadership styles as perceived by PHC managers, a cross sectional study was performed using an 82 items-self-administered Multifactor Leadership Questionnaire (MLQ). This questionnaire measures leadership styles, attitudes and behaviour of managers. The items are grouped into three first order variables (transformational, transactional and laissez-faire) and ten second order variables (which discriminate leader behaviours). Additionally, the questionnaire evaluates organizational consequences such as extra-effort, efficiency and satisfaction. RESULTS: One hundred forty responses from 258 managers of 133 PHC teams in the Barcelona Health Area (response rate: 54.26 %). Most participants were nurses (61.4 %), average age was 49 years and the gender predominantly female (75 %). Globally, managers assessed themselves as equally transactional and transformational leaders (average: 3.30 points). Grouped by profession, nurses (28.57 % of participants) showed a higher transactional leadership style, over transformational leadership style, compared to physicians (3.38 points, p < 0.003). Considering gender, men obtained the lowest results in transactional style (p < 0.015). Both transactional and transformational styles correlate with efficiency and job satisfaction (r = 0.724 and r = 0.710, respectively). CONCLUSIONS: PHC managers' self-perception of their leadership style was transactional, focused on the maintenance of the status quo, although there was a trend in some scores towards the transformational style, mainly among nurse managers. Both styles correlate with satisfaction and willingness to strive to work better.

Glucemia basal alterada y riesgo de diabetes mellitus a los 10 años. Estudio de cohorte / Impaired fasting glucose and risk of diabetes mellitus at 10 years. Cohort study

Fundamento y objetivo: El objetivo del estudio fue conocer la incidencia de diabetes mellitus tipo 2 en pacientes con glucemia basal alterada y su asociación con factores de riesgo. Pacientes y método: Se incluyeron 115 pacientes > 18 años, seleccionados aleatoriamente en un Centro de Salud, diagnosticados de glucemia basal alterada con los criterios de la Asociación Americana de Diabetes de 1997 y seguidos durante 10 años. Como factores predictivos para desarrollar diabetes mellitus se consideraron: edad, sexo, tabaquismo, hipertensión arterial, hipercolesterolemia, antecedentes familiares de diabetes mellitus tipo 2, antecedente de diabetes gestacional y obesidad. Resultados: En 10 años de seguimiento evolucionaron a diabetes mellitus 33 pacientes (28,7%; intervalo de confianza del 95% [IC 95%] 20,4-37,0%), a normoglucemia 57 pacientes (49,6%; IC 95% 40,4-58,7%), permaneciendo como glucemia basal alterada 25 pacientes (21,7%; IC 95% 14,2-29,3%). Solo la obesidad se asoció con la progresión a diabetes mellitus (hazard ratio ajustada 2,01; IC 95% 1,00-4,03, p=0,050).Conclusiones: La mitad de los pacientes con glucemia basal alterada normalizaron su glucemia y el 28,7% desarrollaron diabetes mellitus, especialmente si tenían obesidad. Estos resultados sugieren una historia natural diferente respecto a la intolerancia a la glucosa (AU)

Background and objective: The aim of this study was to define the incidence of type 2 diabetes mellitus in patients with impaired fasting glucose and its association with risk factors.Patients and method: 115 patients aged > 18 years old, randomly selected in a Healthcare Center, diagnosed of impaired fasting glucose with 1997 American Diabetes Association criteria, followed 10 years. Predictive factors for developing diabetes mellitus were: age, sex, smoking, hypertension, hypercholesterolemia, family history of type 2 diabetes mellitus, antecedent of diabetes in pregnancy, and obesity.Results: During the 10 years of follow-up, 33 patients developed type 2 diabetes mellitus (28.7%; 95% CI 20.4-37.0%), 57 patients progressed to normoglycaemia (49.6%; 95% CI 40.4-58.7%), and 25 patients remained with an impaired fasting glucose (21.7%; 95% CI 14.2-29.3%). Only obesity was associated with progression to type 2 diabetes mellitus (adjusted hazard ratio 2.01; 95% CI 1.00-4.03, p=0.050).Conclusions: Half of the patients with impaired fasting glucose normalized their glycaemia, and 28.7% developed diabetes mellitus, especially patients with obesity. These results suggest a different natural history to respect glucose intolerance (AU)

[Characterization of patients with rheumatoid arthritis according to the health care level]. / Caracterización de pacientes con artritis reumatoide según el nivel asistencial.

OBJECTIVE: To characterize rheumatoid arthritis patients seen in Rheumatology Units at different health care levels. MATERIAL AND METHODS: Questionnaire and clinical examination of rheumatoid arthritis patients seen as outpatients in Rheumatology Units from Primary Care, county Hospitals and Reference Hospitals. Demographic, social, labour and disease data were collected. Statistical study included a description of the variables and a multiple correspondence analysis to define patient profiles. RESULTS: Eight hundred and twelve patients with rheumatoid arthritis were included. There were significant differences in patient profiles at the different care level. In Primary Care, patients were older, with basic studies, and with short duration and generally mild rheumatoid arthritis. In local hospitals the typical patient was a man, qualified worker, with low income, and an erosive disease with extraarticular manifestations. At reference Hospitals prevailing patients were young women with a long duration disease and requiring biological therapy. CONCLUSION: There are significant differences in rheumatoid arthritis patient profiles at different health care levels.

[Comparison of the SCORE and REGICOR models for calculating cardiovascular risk in cardiovascular disease-free individuals at a healthcare center in Barcelona, Spain]. / Comparación de los modelos SCORE y REGICOR para el cálculo del riesgo cardiovascular en sujetos sin enfermedad cardiovascular atendidos en un centro de salud de Barcelona.

BACKGROUND: No studies have been published to date comparing SCORE, REGICOR and Framingham models. This study is aimed at analyzing how the REGICOR and SCORE functions classify cardiovascular risk, their correlation and concordance with Framingham (1998) and whether any differences exist among them with regard to the cardiovascular risk factors in high-risk groups. METHODS: Descriptive cross-sectional study conducted in primary care. A total of 851 individuals within the 35-74 age range, free of cardiovascular diseases and selected by simple random sampling were included. A study was made of the percentage of high-risk patients with Framingham (> or = 20% ten-year risk), SCORE (> or = 5% ten-year risk) and REGICOR with cutoff points > or = 20%, > or = 15%, > or = 10% and > or = 5% at 10 years, given that with REGICOR > or = 20% there are hardly any high-risk cases. A comparison was drawn between the correlation (Pearson's r) and concordance (Kappa index) of the REGICOR and SCORE high-risk individuals as compared to Framingham. RESULTS: The high-risk percentages respectively found were: 23.3% with Framingham; 15.2%; with SCORE; and 1.4%, 5.8%, 17.6% and 57.0% with REGICOR with the cutoff points described. REGICOR has a 0.99 correlation, SCORE a 0.78 correlation. REGICOR > or = 10% showed a better concordance (Kappa 0.83) than SCORE (Kappa 0.61). On comparing the cardiovascular risk factors of the high-risk cases (> or = 20% Framingham, > or = 5% SCORE and > or = 10% REGICOR), SCORE showed higher prevalence of diabetes and a lower prevalence of hypercholesterolemia (p<0.05). CONCLUSIONS: REGICOR showed a good correlation with Framingham. With the > or = 10% cutoff point, it classifies a number of individuals as high-risk similar to SCORE and fewer than Framingham. The SCORE model would treat a number of patients similar to the REGICOR > or =10% model with hypolipemiant drugs, however showing lesser evidence of effectiveness of the treatment.

[Risk of Suffering from Cardiovascular Diseases because of the Clustering of the Modifiable Cardiovascular Risk Factors in the Population Older than 15 years of a Health Care Center in Barcelona]. / riesgo de presentación de eventos cardiovasculares según la agrupación de los factores de riesgo modificables en la población mayor de 15 de años de un centro de salud de barcelona.

OBJECTIVE: Over recent decades, the death rate due to cardiovascular diseases has shown a downward trend in developed countries, as has also been the case in Spain. However, are still the leading cause of death. This study is aimed at studying the relationship between cardiovascular diseases and different modifiable cardiovascular risk factors related to their clustering. METHODS: Descriptive cross-sectional study conducted at an urban healthcare center, which included 2248 individuals ages 15 and above selected by simple random sampling of the medical record files. The risk of having some cardiovascular disease (ischemic cardiopathy, cerebrovascular disease or peripheral arteriopathy of lower limbs) was calculated in the form of an odds ration (OR) in relation to the clustering of the risk factors of smoking, high blood pressure,hypercholesterolemia, hypertriglyceridemia and diabetes mellitus,adjusted by age, sex and risk factors. RESULTS: The individuals studied had 224 cardiovascular diseases.For smoking, the OR as an isolated risk factor was 1.5 (95% CI:1.0-2.2) and 1.6 (95% CI: 0.9-2.5) with the clustering with the other four risk factors; with high blood pressure, respectively of 2.1 (95% CI: 1.5-2.9) and 1.7 (95% CI: 1.1-2.6); with hypercholesterolemia, respectively of 1.7 (95% CI: 1.2-2.4) and 1.6 (95% CI: 1.1-2.4); and with hypertriglyceridemia, respectively of 1.8(95% CI: 1.2-2.8) and 1.3 (95% CI: 0.8-2.1). The OR's showed a similar behavior on layering by each cardiovascular disease, although the highest OR's (2.4 - 3.1 range) corresponded to the clustering of diabetes mellitus and smoking. CONCLUSIONS: The risk of having cardiovascular diseasesremains high with the clustering of cardiovascular risk factors,although differences among them are found to exist.

OBJETIVO: En la últimas décadas la mortalidad por enfermedades cardiovasculares ha mostrado una tendencia decreciente en los países desarrollados, confirmada asimismo en España. No obstante siguen siendo la principal causa de mortalidad El objetivo de este trabajo es estudiar la asociación entre las enfermedades cardiovasculares y diversos factores de riesgo cardiovascular modificables en relación a su agrupación (clustering). METODOS: Estudio descriptivo transversal realizado en un centro de salud urbano, que incluyó a 2.248 personas de 15 o más años, seleccionadas por muestreo aleatorio simple del archivo de historias clínicas. Se calculó en forma de odds ratio (OR) el riesgo de tener alguna enfermedad cardiovascular (cardiopatía isquémica, enfermedad cerebrovascular o arteriopatia periférica de extremidades inferiores)en relación al clustering de los factores de riesgo tabaquismo,hipertensión arterial, hipercolesterolemia, hipertrigliceridemia y diabetes mellitus, ajustado por edad, sexo y factores de riesgo. RESULTADOS: Las personas estudiadas tenían 224 enfermedades cardiovasculares. En el tabaquismo la OR como factor de riesgo aislado fue de 1,5 (IC95%: 1,0-2,2) y de 1,6 (IC95%: 0,9-2,5) con el clustering con los otros 4 factores de riesgo; con la hipertensión arterial de 2,1 (IC95%: 1,5-2,9) y de 1,7 (IC95%: 1,1-2,6), respectivamente; con la hipercolesterolemia de 1,7 (IC95%: 1,2-2,4) y de 1,6 (IC95%: 1,1-2,4), respectivamente; con la diabetes de 2,5 (IC95%: 1,7-3,5) y 2,0 (IC95%: 1,3-3,0), respectivamente y con la hipertrigliceridemia de 1,8 (IC95%: 1,2-2,8) y 1,3 (IC95%: 0,8-2,1), respectivamente. Las OR se comportaron de manera similar al estratificar por cada enfermedad cardiovascular, aunque las OR más elevadas (entre 2,4 y 3,1) correspondieron al clustering de diabetes mellitus y tabaquismo. CONCLUSIONES: El riesgo de tener enfermedades cardiovasculares sigue siendo elevado con el clustering de factores de riesgo cardiovascular,aunque se observan diferencias entre ellos.