Utilidad de la ecografía de la vaina del nervio óptico en pacientes con cese de flujo cerebral / Usefulness of the optic nerve sheath ultrasound in patients with cessation of cerebral flow

La ecografía del diámetro de la vaina del nervio óptico (DVNO), ha demostrado ser una herramienta útil para la detección de hipertensión intracraneal (HIC). Los valores del DVNO en pacientes con cese del flujo sanguíneo cerebral (CFSC), todavía no han sido definidos. Objetivo: Establecer asociación entre el DVNO y el CFSC en pacientes neurocríticos ingresados en una unidad de uidados intensivos (UCI). Pacientes y métodos: Estudio transversal de pacientes ingresados en una UCI polivalente de tercer nivel, con patología neurológica, entre abril de 2017 y abril de 2018. Se incluyeron en el estudio pacientes con signos de HIC o riesgo de desarrollarla, neurocríticos con alteraciones clínico radiológicas. Se realizó una ecografía del DVNO en las primeras 24 h de ingreso, que se repitió en aquellos pacientes con evolución a CFSC, establecido mediante Doppler transcraneal. Se compararon los valorares de DVNO de los pacientes con y sin diagnóstico de CFSC. Resultados: Se incluyeron 99 pacientes de los cuales 29 mostraron CFSC por Doppler transcraneal. La medición del DVNO no mostró diferencias significativas entre ambos grupos, 6,59 ± 0,75 en el grupo con CSFC y 6,39 ± 0,56 en el grupo sin CSFC, p = 0,141. Conclusión: En nuestro estudio, no se identificaron valores de DVNO capaces de diagnosticar el CFS (AU)

Optic nerve sheath diameter (ONSD) ultrasound has proven to be a useful tool for the detection of intracranial hypertension (IH). The ONSD values, in patients with cessation of cerebral blood flow (CCBF), has not been clarified yet. Objective: Establish an association between ONSD and CCBF in neurocritical patients admitted to an ICU. Patients and methods: Cross-sectional study of patients admitted in a third level ICU, between April 2017 and April 2018, with neurological pathology. ONSD ultrasound was performed in the first 24 hours and as the patient was diagnosed of CCBF. The ONSD values of patients with and without diagnosis of CCBF were compared. Results: 99 patients were included, 29 of whom showed CCBF in transcranial Doppler. The ONSD measurement did not demonstrate significant differences between both groups, 6,59 ± 0,75 in the group with CCBF and 6,39 ± 0,56 in the group without CCBF p=0.141. Conclusion: In our study, ONSD values capable of recognizing CCBF were not identified (AU)

Do internists know what limitation of therapeutic effort means?

OBJECTIVES: To ascertain whether internists know what limitation of therapeutic effort (LTE) means and whether training in palliative care affects this understanding. METHODS: A survey was administered to Spanish internists on their knowledge of LTE and training in palliative care. RESULTS: A total of 273 respondents completed the survey (mean age, 42±12 years), 80.2% of whom were associates. Some 23.8% of the respondents identified the complete definition of LTE. The most frequently selected responses were "not starting an active treatment" (85.0%) and "withdrawing an active treatment" (65.9%). Forty-three percent of the respondents lacked training in palliative care, 73.3% considered their level of understanding to be good or very good, 62.3% stated that they became anxious when addressing planning for end-of-life care with a patient, and 81.3% stated that they had experienced some conflict with their LTE decisions. CONCLUSIONS: Only 1 of every 4 internists knew the proper definition of LTE, with no association with the level of training in palliative care.

¿Saben los internistas qué es la limitación del esfuerzo terapéutico? / Do internists know what limitation of therapeutic effort means?

Objetivos Averiguar si los internistas saben qué es la limitación del esfuerzo terapéutico (LET) y si la formación en cuidados paliativos condiciona dicho conocimiento. Métodos Encuesta a los internistas españoles sobre el conocimiento de la LET y la formación en cuidados paliativos. Resultados Se recibieron 273 encuestas; edad media de los que respondieron 42±12 años; el 80,2% eran adjuntos. El 23,8% identificó la definición completa de la LET; las opciones más escogidas fueron «no iniciar un tratamiento activo» (85,0%) y «retirar un tratamiento activo» (65,9%). El 43% carece de formación en cuidados paliativos, el 73,3% considera que su nivel de conocimiento es bueno o muy bueno, al 62,3% le genera ansiedad afrontar la planificación de cuidados al final de la vida con el paciente y el 81,3% ha tenido algún conflicto con sus decisiones de la LET. Conclusiones Solo 1 de cada 4internistas conoce bien la definición de la LET, sin asociación con el grado de formación en cuidados paliativos (AU)

Objectives To ascertain whether internists know what limitation of therapeutic effort (LTE) means and whether training in palliative care affects this understanding. Methods A survey was administered to Spanish internists on their knowledge of LTE and training in palliative care. Results A total of 273 respondents completed the survey (mean age, 42±12 years), 80.2% of whom were associates. Some 23.8% of the respondents identified the complete definition of LTE. The most frecuently selected responses were «not starting an active treatment»(85.0%) and «withdrawing an active treatment» (65.9%). Forty-three percent of the respondents lacked training in palliative care, 73.3% considered their level of understanding to be good or very good, 62.3% stated that they became anxious when addressing planning for end-of-life care with a patient, and 81.3% stated that they had experienced some conflict with their LTE decisions. Conclusions Only 1 of every 4 internists knew the proper definition of LTE, with no association with level of training in palliative care (AU)

Do internists know what limitation of therapeutic effort means? / ¿Saben los internistas qué es la limitación del esfuerzo terapéutico?

OBJECTIVES: To ascertain whether internists know what limitation of therapeutic effort (LTE) means and whether training in palliative care affects this understanding. METHODS: A survey was administered to Spanish internists on their knowledge of LTE and the training in palliative care. RESULTS: A total of 273 respondents completed the survey (mean age, 42±12 years), 80.2% of whom were associates. Some 23.8% of the respondents identified the complete definition of LTE. The most often chosen responses were «not starting an active treatment¼(85.0%) and «withdrawing an active treatment¼ (65.9%). Forty-three percent of the respondents lacked training in palliative care, 73.3% considered their level of understanding to be good or very good, 62.3% stated that they became anxious when addressing the planning for end-of-life care with the patient, and 81.3% stated that they had had some conflict with their LTE decisions. CONCLUSIONS: Only 1 of every 4 internists knew the proper definition for LTE, with no association with the level of training in palliative care.

Limitación del esfuerzo terapéutico en pacientes hospitalizados en servicios de medicina interna / Limitation of therapeutic effort in patients hospitalised in departments of internal medicine

Introducción. Existe escasa información sobre la limitación del esfuerzo terapéutico (LET) en pacientes ingresados en unidades de hospitalización de medicina interna. Objetivos. Describir las pautas de LET indicadas en los servicios de medicina interna y las características de los pacientes que las reciben. Pacientes y métodos. Estudio observacional descriptivo y retrospectivo de 4 hospitales de la Comunidad de Madrid. Se recogieron datos demográficos, de comorbilidad y las órdenes de LET pautadas en todos los pacientes fallecidos en un periodo de 6 meses. Resultados. Se incluyeron 382 pacientes cuya edad media fue de 85±10 años; 204 eran mujeres (53,4%) y 222 (58,1%) procedían de su domicilio. El 51,1% eran enfermos terminales, el 43,2% tenían demencia moderada/grave y el 95,5% presentaban comorbilidad al menos moderada. En 318 pacientes (83,7%) se realizó algún tipo de LET, siendo las más frecuentes las órdenes de «no reanimación cardiopulmonar» (292 enfermos, 76,4%; IC 95%: 72,1-80,8), «no usar medidas agresivas» (113 pacientes, 16,4%; IC 95%: 13,7-19,4) y «no ingresar en unidad de cuidados intensivos» (102 casos, 14,8%; IC 95%: 12,3-17,7). Conclusiones. La LET es muy frecuente en los pacientes que fallecen en medicina interna. Las pautas más utilizadas son «no reanimación cardiopulmonar» y la expresión poco concreta de «no usar medidas agresivas». Los pacientes son de edad avanzada, con importante comorbilidad, enfermedad terminal y demencia avanzada (AU)

Introduction. There is little information on the limitation of therapeutic effort (LTE) in patients admitted to hospital internal medicine units. Objectives. To describe the indicated LTE regimens in the departments of internal medicine and the characteristics of the patients who undergo them. Patients and methods. An observational, descriptive retrospective study was conducted on 4 hospitals of the Community of Madrid. The study collected demographic and comorbidity data and the LTE orders prescribed for all patients who died during a period of 6 months. Results. The study included 382 patients with a mean age of 85±10 years; 204 were women (53.4%) and 222 (58.1%) came from their homes. Some 51.1% of the patients were terminal, 43.2% had moderate to severe dementia, and 95.5% presented at least moderate comorbidity. Some type of LTE was performed in 318 patients (83.7%); the most common orders were «No cardiopulmonary resuscitation» (292 patients, 76.4%; 95% CI 72.1-80.8), «Do not use aggressive measures» (113 patients, 16.4%; 95% CI 13.7-19.4) and «Do not transfer to an intensive care unit» (102 cases, 14.8%, 95% CI 12.3-17.7). Some type of LTE was performed in 318 patients (83.7%); the most common orders were «No cardiopulmonary resuscitation» (292 patients, 76.4%; 95% CI 72.1-80.8), «Do not use aggressive measures» (113 patients, 16.4%; 95% CI 13.7-19.4) and «Do not transfer to an intensive care unit» (102 cases, 14.8%, 95% CI 12.3-17.7). Conclusions. LTE is common among patients who die in Internal Medicine. The most widely used regimens were «No CPR» and the unspecific statement «Do not use aggressive measures». The patients were elderly and had significant comorbidity, terminal illness and advanced dementia (AU)

Limitation of therapeutic effort in patients hospitalised in departments of internal medicine. / Limitación del esfuerzo terapéutico en pacientes hospitalizados en servicios de medicina interna.

INTRODUCTION: There is little information on the limitation of therapeutic effort (LTE) in patients admitted to hospital internal medicine units. OBJECTIVES: To describe the indicated LTE regimens in the departments of internal medicine and the characteristics of the patients who undergo them. PATIENTS AND METHODS: An observational, descriptive retrospective study was conducted on 4 hospitals of the Community of Madrid. The study collected demographic and comorbidity data and the LTE orders prescribed for all patients who died during a period of 6 months. RESULTS: The study included 382 patients with a mean age of 85±10 years; 204 were women (53.4%) and 222 (58.1%) came from their homes. Some 51.1% of the patients were terminal, 43.2% had moderate to severe dementia, and 95.5% presented at least moderate comorbidity. Some type of LTE was performed in 318 patients (83.7%); the most common orders were "No cardiopulmonary resuscitation" (292 patients, 76.4%; 95% CI 72.1-80.8), "Do not use aggressive measures" (113 patients, 16.4%; 95% CI 13.7-19.4) and "Do not transfer to an intensive care unit" (102 cases, 14.8%, 95% CI 12.3-17.7). Some type of LTE was performed in 318 patients (83.7%); the most common orders were "No cardiopulmonary resuscitation" (292 patients, 76.4%; 95% CI 72.1-80.8), "Do not use aggressive measures" (113 patients, 16.4%; 95% CI 13.7-19.4) and "Do not transfer to an intensive care unit" (102 cases, 14.8%, 95% CI 12.3-17.7). CONCLUSIONS: LTE is common among patients who die in Internal Medicine. The most widely used regimens were "No CPR" and the unspecific statement "Do not use aggressive measures". The patients were elderly and had significant comorbidity, terminal illness and advanced dementia.

The natural history of Parkinson's disease in the province of Segovia: mortality in a longitudinal study (20-year follow-up).

OBJECTIVE: We determined mortality rates and predictors of survival in 273 patients with Parkinson's disease based on a 20-year follow-up longitudinal study. MATERIAL AND METHODS: We examined 273 patients with Parkinson's disease during a 20-year follow-up, recruited between 1978 and 1998. All patients were regularly followed at the Department of Neurology until December 31, 1998, or death. RESULTS: By then, 69 patients had died, crude mortality was rate 4.43, and standardized mortality ratio for the total patient group was 1.39 (95% CI, 1.10-1.50). As Parkinson's disease is a chronic progressive disorder in adult life, disease-related mortality would be expected to increase in later stages after 15 or 20 years. Mean age at death in our cohort was 78.27 (95% CI, 76.90-79.20). Median time of death was 11 years (95% CI, 9.50-12.49). Independent predictors of mortality during the follow-up were age at onset (hazard ratio, 1.05; 95% CI, 1.01-1.09; P = 0.01), clinical form - akinesia and rigidity (hazard ratio, 2.20; 95% CI, 1.06-4.88; P = 0.03) - and treatment with dopaminergic agonist (hazard ratio, 0.49; 95% CI, 0.23-1.03; P = 0.06). Cardiovascular disease was the most frequent cause of death in 42%. CONCLUSIONS: This study suggests a link between mortality with age of onset and treatment without dopamine agonists as initial treatment. So, there is an association between decreased mortality and tremor as initial clinical forms at onset.

Latex allergy in primary care providers.

BACKGROUND: Health care workers represent one of the major risk groups for developing latex allergy. Most studies have examined hospital workers. The aims of this study were to analyze the prevalence of latex allergy in primary care providers and to describe the characteristics of health care workers who are allergic to latex. MATERIAL AND METHODS: A self-administered questionnaire on work activity, history of symptoms, and allergic reactions to latex products was completed by a sample of primary care workers. Skin prick tests were performed with a commercial latex extract, and serum specific immunoglobulin (Ig) E to latex and its main allergens was determined. RESULTS: Of the 620 workers contacted, 341 completed the questionnaire and 170 were tested with latex allergens. The prevalence of latex allergy was 5.9% (95% confidence interval 2.4%-9.4%). Most allergic workers with a previous diagnosis of latex allergy showed negative or lowered specific IgE levels and a reduced wheal size to latex in comparison with the previous tests. We found 3 cases with elevated latex-specific IgE due to cross-reactivity with pollen profilin, although the results were not clinically relevant. Allergy to latex was associated with the number of surgical interventions and with allergy to kiwi, banana, chestnuts, and avocado. CONCLUSIONS: The prevalence of latex allergy in this study was 5.9%. The importance of a firm diagnosis at the onset of symptoms should be stressed, since reducing contact with latex can yield negative test results. Assessment of IgE reactivity to the individual latex allergens (component-resolved diagnosis) can detect sensitization to panallergens such as profilin and help to clarify the diagnosis.

Aplicación de la CIF para el estudio y evaluación del funcionamiento y la discapacidad en depresión unipolar en el ámbito de atención primaria / Applicability of the ICF in measuring functioning and disability in unipolar depression in Primary Care settings

Introducción. Se emplea el modelo biopsicosocial de la Clasificación Internacional del Funcionamiento, la Discapacidad y la Salud (CIF) para: a) estudiar el perfil de funcionamiento en depresión unipolar tratada en atención primaria; b) determinar variables predictoras y mediadoras de discapacidad en depresión, y c) analizar la eficacia del tratamiento psicofarmacológico habitual en la remisión funcional de pacientes con depresión. Diseño. Naturalístico, longitudinal, prospectivo. Emplazamiento. Estudio multicéntrico en atención primaria. Centros del Área 2 de la Comunidad de Madrid. Participantes. Pacientes adultos con diagnóstico de depresión unipolar que inician tratamiento con inhibidores selectivos de la recaptación de serotonina en centros de atención primaria. Se excluirán los pacientes con historia de trastorno bipolar, trastornos psicóticos, demencias y con historia de dependencia de sustancias adictivas. Medidas principales. Nivel de discapacidad en distintas áreas de funcionamiento evaluado con instrumentos desarrollados a partir de la CIF. Sucesos vitales estresantes, apoyo social y esquemas cognitivos serán explorados como variables mediadoras del funcionamiento. Características sociodemográficas y clínicas y el tratamiento psicofarmacológico son tratados como factores independientes. Discusión y aplicabilidad clínica. Sesgo en la representatividad y selección de la muestra podrían afectar a la generalización de resultados. Se aplica por primera vez en España el modelo biopsicosocial de la CIF y la metodología desarrollada en el estudio de la depresión en atención primaria. Se espera una mejor comprensión de factores ligados a discapacidad funcional en pacientes con depresión. El proyecto se suma a una de las líneas prioritarias de investigación en la UE (proyecto MHADIE)

Introduction. We use the biopsychosocial model of the International Classification of Functioning, Disability, and Health (ICF): a) to analyze functioning and disability patterns in unipolar depression cases attended in primary care settings; b) to study predictive and mediator variables related to disability in depression, and c) to determine the impact of traditional interventions in depression cases using functional remission as outcome measure. Design. Naturalistic, prospective, longitudinal. Setting. Multicenter study in primary care. Health Area 2. Region of Madrid. Participants. Adult patients with a diagnosis of unipolar depression who initiate psychopharmacological treatment with selective serotonin reuptake inhibitor (SSRI) in primary care sites. Patients with history of bipolar disorders, psychotic disorders, dementias, and dependence of toxic substances will be excluded. Main measurements. Level of functioning and disability in different domains of well-being assessed through ICF related instruments. Stressful life events, social support and cognitive schemes will be analyzed as mediator variables. Socio-demographic and clinical characteristics, psychopharmacological treatment and treatment compliance are considered independent factors. Discussion and practical use. Selection bias may affect the generalization of the results. The biopsychosocial model underlying the ICF and its methodology are applied to the study of depression in primary care settings for the first time in Spain. Improving our understanding of disability related factors in depressive patients is expected. This study is one of the main research priorities of the EU (MHADIE project)

[Applicability of the ICF in measuring functioning and disability in unipolar depression in Primary Care settings]. / Aplicación de la CIF para el estudio y evaluación del funcionamiento y la diacapacidad en depresión unipolar en el ámbito de atención primaria.

INTRODUCTION: We use the biopsychosocial model of the International Classification of Functioning, Disability, and Health (ICF): a) to analyze functioning and disability patterns in unipolar depression cases attended in primary care settings; b) to study predictive and mediator variables related to disability in depression, and c) to determine the impact of traditional interventions in depression cases using functional remission as outcome measure. DESIGN: Naturalistic, prospective, longitudinal. SETTING: Multicenter study in primary care. Health Area 2. Region of Madrid. PARTICIPANTS: Adult patients with a diagnosis of unipolar depression who initiate psychopharmacological treatment with selective serotonin reuptake inhibitor (SSRI) in primary care sites. Patients with history of bipolar disorders, psychotic disorders, dementias, and dependence of toxic substances will be excluded. MAIN MEASUREMENTS: Level of functioning and disability in different domains of well-being assessed through ICF related instruments. Stressful life events, social support and cognitive schemes will be analyzed as mediator variables. Socio-demographic and clinical characteristics, psychopharmacological treatment and treatment compliance are considered independent factors. DISCUSSION AND PRACTICAL USE: Selection bias may affect the generalization of the results. The biopsychosocial model underlying the ICF and its methodology are applied to the study of depression in primary care settings for the first time in Spain. Improving our understanding of disability related factors in depressive patients is expected. This study is one of the main research priorities of the EU (MHADIE project).

[Evaluation of referrals in primary care]. / Evaluación de la demanda derivada en atención primaria.

OBJECTIVE: To study the process of referral from primary care in a health area in Madrid. The second objective was to evaluate the trends in the referral process. DESIGN: Observational, descriptive and cross-sectional study. SETTING: Three urban health centers in the Area 2. PARTICIPANTS: All referrals made by 13 doctors during 3 consecutive weeks. The total number of visits attended were 6012. The study was realized between February 2002 and January 2003. MAIN MEASUREMENTS: Patient, doctor and referral characteristics on every referral. RESULTS: 349 referrals were studied. The rate of referral 5.8% (5.21-6.39). The referred patients, 65.5% women, medium age 50.6+/-21. The specialties that received more referrals are gynecologist, ophthalmology, dermatology, otorhinolaryngology, rehabilitation, orthopedic surgeon and general surgeon. The most common conditions referred, 25.6% of all referrals, are gynecologist check, blindness, other illnesses of subcutaneous cellular tissue, arthrosis, joint pain, diabetes, benign neoplasm of skin, depression and hypoacusis. 92.3% of the referrals were sent to the specialist center. 89.7% were normal (no urgent). The reason for referral was to accede to the patient's request in 18.3% of the referrals. CONCLUSIONS: The process of referral is similar to previous studies. Although people are more participative, have more information and the defensive medicine is increasing, the process of referral have not changed.

Evaluación de la demanda derivada en atención primaria / Evaluation of referrals in primary care

Objetivo. Analizar el patrón de derivación en consultas de atención primaria de un área de salud de Madrid. Un segundo objetivo es analizar los cambios que se hayan producido en dicho patrón. Diseño. Estudio observacional, descriptivo y transversal de la demanda derivada. Emplazamiento. Tres centros de salud urbanos del Área 2. Participantes. Se han seleccionado todas las derivaciones realizadas durante 3 semanas consecutivas por 13 médicos que atendieron a un total de 6.012 visitas en ese período. El estudio se realizó entre febrero de 2002 y marzo de 2003. Mediciones principales. En cada derivación se determinaron los datos del paciente, del médico y de la derivación. Resultados. Se estudiaron 349 derivaciones, lo que supone una tasa de derivación del 5,8% (5,21-6,39). De los pacientes derivados, el 65,5% era mujer, con una edad media ± desviación estándar (DE) de 50,6 ± 21 años. Las especialidades que han recibido más derivaciones son ginecología, oftalmología, dermatología, otorrinolaringología, rehabilitación, traumatología y cirugía general. Los diagnósticos más frecuentes derivados, el 25,6% del total, son revisión ginecológica, disminución de la agudeza visual, otras enfermedades de la piel y el tejido celular subcutáneo, artrosis, dolor articular, diabetes, neoplasia benigna de la piel, depresión y sordera. Un 92,3% de las derivaciones fueron dirigidas a un centro de especialidades, el 89,7% de forma normal. En el 18,3%, el médico sintió algún grado de presión por parte del paciente para derivarlo. Conclusiones. El patrón de derivación es similar al de estudios anteriores. El hecho de que la población tenga una actitud más participativa y un mayor acceso a la información, y el aumento de la medicina defensiva no parecen haber modificado el patrón de derivación

Objective. To study the process of referral from primary care in a health area in Madrid. The second objective was to evaluate the trends in the referral process. Design. Observational, descriptive and crosssectional study. Setting. Three urban health centers in the Area 2. Participants. All referrals made by 13 doctors during 3 consecutive weeks. The total number of visits attended were 6012. The study was realized between February 2002 and January 2003. Main measurements. Patient, doctor and referral characteristics on every referral. Results. 349 referrals were studied. The rate of referral 5.8% (5.21-6.39). The referred patients, 65.5% women, medium age 50.6±21. The specialties that received more referrals are gynecologist, ophthalmology, dermatology, otorhinolaringology, rehabilitation, orthopedic surgeon and general surgeon. The most common conditions referred, 25.6% of all referrals, are gynecologist check, blindness, other illnesses of subcutaneous cellular tissue, arthrosis, joint pain, diabetes, benign neoplasm of skin, depression and hypoacusis. 92.3% of the referrals were sent to the specialist center. 89.7% were normal (no urgent). The reason for referral was to accede to the patient’s request in 18.3% of the referrals. Conclusions. The process of referral is similar to previous studies. Although people are more participative, have more information and the defensive medicine is increasing, the process of referral have not changed

[Factors affecting drug expenditure in the primary care centre in a health area]. / Factores condicionantes del gasto en farmacia en los centros de atención primaria de un área de salud.

OBJECTIVE: To identify the factors affecting drug expenditure.Design. Cross-sectional study.Setting. Madrid Primary Care area. PARTICIPANTS: 21 health centres. MEASUREMENTS: Association of the drug expenditure per inhabitant of each health centre during 1999 with the characteristics of its staff and operation of the centre. MAIN RESULTS: Expenditure on drugs per inhabitant, 14360 plus minus 3040 pesetas (86.31 plus minus 18.27; general practitioners, 19.62 plus minus 23.8%; doctors working as locums, 40.48 plus minus 20.72%; women doctors, 59.76 plus minus 13.36%; family doctors, 38.57 plus minus 21.35%; team nurses, 86.6 plus minus 18.27%; population over 65, 18.03 plus minus 7.73%; patients per day attended by each general practitioner, 32.82 plus minus 3.81; number of sessions per year on prescription profiles, 5 plus minus 3.91; prescription avoidable because of health card: 3106 plus minus 808 pesetas (18.67 plus minus 4.86 ); compliance with service offer, 1.7 plus minus 3.78. Drug expenditure per inhabitant dropped when sessions on prescription profiles (p = 0.013), the percentage of women doctors (p = 0.067) and the percentage of family doctors (p = 0.035) increased; and it dropped too when the over-65 population (p = 0.099) and the amount of prescription avoidable through the card (p = 0.034) dropped. In the multivariate analysis, the sessions on prescription profiles (ss = -843), the percentage of nurses in the reformed model (ss = -155), the percentage of family doctors (ss = -142) and the percentage of doctors from the traditional model (ss = -121) explain 71.2% of the variability in drug expenditure per inhabitant (F = 6.909; p = 0.002). CONCLUSIONS: The sessions to discuss prescription profiles, the presence of nurses from the reform model, postgraduate medical training and the employment of doctors under the traditional model are the factors that our study finds are linked to lower drug expenditure per inhabitant.

Factores condicionantes del gasto en farmacia en los centros de atención primaria de un área de salud / Factors affecting drug expenditure in the primary care centres in a health area

Objetivo. Identificar factores condicionantes del gasto en farmacia. Diseño. Estudio transversal. Emplazamiento. Área de atención primaria de Madrid. Participantes. Un total de 21 centros de salud. Mediciones. Asociación del gasto en farmacia/habitante durante 1999 de cada centro de salud con sus características de personal y funcionamiento del centro. Resultados principales. Gasto en farmacia/habitante, 14.360 ñ 3.040 pts.(86,31 ñ 18,27 e); médicos de cupo, 19,62 ñ 23,8 por ciento; médicos interinos, 40,48 ñ 20,72 por ciento; médicos mujeres, 59,76 ñ 13,36 por ciento; médicos de familia, 38,57 ñ 21,35 por ciento; enfermeras de equipo, 86,6 ñ 18,27 por ciento; población > 65 años, 18,03 ñ 7,73 por ciento; pacientes/día atendidos por cada médico general, 32,82 ñ 3,81; número de sesiones anuales sobre perfiles de prescripción, 5 ñ 3,91; prescripción evitable por tarjeta sanitaria, 3.106 ñ 808 pts. (18,67 ñ 4,86 e), y cumplimiento de cartera, 1,7 ñ 3,78. El gasto en farmacia/habitante disminuía al aumentar las sesiones sobre perfiles de prescripción (p = 0,013), el porcentaje de mujeres médicos (p = 0,067), el de médicos de familia (p = 0,035) y al disminuir el porcentaje de población > 65 años (p = 0,099) y la cuantía de la prescripción evitable por tarjeta (p = 0,034).En el análisis multivariante las sesiones sobre perfiles de prescripción ( = -843), el porcentaje de enfermeras de modelo reformado ( = -155), el de médicos de familia ( = -142) y el de médicos de modelo tradicional ( = -121) explican un 71,2 por ciento de la variabilidad del gasto en farmacia/habitante (F = 6,909; p = 0,002).Conclusiones. Las sesiones de discusión de perfiles de prescripción, la presencia de enfermeras de modelo reformado, la formación de posgrado de los médicos y el contrato de los médicos según modelo tradicional son los factores asociados en nuestro trabajo a un menor gasto farmacéutico/habitante (AU)

[Effectiveness of acupuncture in the treatment of pain from osteoarthritis of the knee]. / Efectividad de la acupuntura en el tratamiento del dolor en la artrosis de rodilla.

AIM: To determine the effectiveness of acupuncture in controlling pain from arthritis of the knee. DESIGN: Systematic review. DATA SOURCES: MedLine, the Cochrane Library. STUDY SELECTION: Of the 9 studies located, only 4 met the inclusion criteria. All were controlled, randomized clinical trials that studied the effect of acupuncture only in the knee joint. DATA EXTRACTION: Primary outcome variables were intensity of pain, overall measure (general improvement, proportion of patients who recovered, subjective improvement in symptoms) and functional status. As secondary outcome measures we used objective physiological measures (range of knee movement, muscle strength, time needed to walk a certain distance, time needed to climb a certain number of stairs), general health status, and other information such as medication needed and side effects. RESULTS: There was moderately strong evidence that acupuncture was more effective in treating knee joint pain than no treatment. The difference can be explained by its marked placebo effect. CONCLUSIONS: There is currently insufficient evidence to recommend acupuncture as a treatment for pain from osteoarthritis of the knee. Additional, better designed studies are needed to determine the actual role of acupuncture in this disease.

Efectividad de la acupuntura en el tratamiento del dolor en la artrosis de rodilla / Effectiveness of acupuncture in the treatment of pain from osteoarthritis of the knee

Objetivo. Determinar la efectividad de la acupuntura en el control del dolor de la artrosis de rodilla. Diseño. Revisión sistemática. Fuentes de datos. MEDLINE, The Cochrane Library. Selección de estudios. De los 9 estudios encontrados, sólo 4 superaron los criterios de selección. Se trata de ensayos clínicos controlados aleatorios que estudian el efecto de la acupuntura únicamente en la articulación de la rodilla. Extracción de datos. Los indicadores de resultado primarios valorados son: intensidad del dolor, medición global (mejoría general, proporción de pacientes recuperados, mejoría subjetiva de los síntomas) y estado funcional. Son considerados indicadores de resultado secundarios: mediciones fisiológicas objetivas (amplitud del movimiento de la rodilla, fuerza muscular, tiempo para caminar una determinada distancia, tiempo para escalar una altura determinada), estado general de salud y otros datos, como la necesidad de utilizar medicación o los efectos secundarios. Resultados. Existe una evidencia moderada sobre la efectividad de la acupuntura en el tratamiento del dolor de la gonartrosis frente al no tratamiento, que puede ser explicada por su fuerte efecto placebo. Conclusiones. En la actualidad no existe suficiente evidencia para recomendar la acupuntura como tratamiento del dolor de la gonartrosis. Son necesarios nuevos estudios, y mejor diseñados, para determinar el verdadero papel de la acupuntura en esta enfermedad (AU)

[The frequency of illnesses attended and its relationship with the maintenance of the family doctor's skill]. / La frecuencia de las enfermedades atendidas y su relación con el mantenimiento de la destreza del médico de familia.

OBJECTIVE: To describe the incidence of health problems dealt with less often in primary care medical consultations, and to discuss its relationship with the maintenance of professional skill, with in-work training and case-load planning. DESIGN: A prospective observational study based on a year's recording. SETTING: The clinics of 44 primary care doctors from 10 autonomous communities. PATIENTS: 418,98 people were attended. INTERVENTIONS: The unit of analysis was the care episode. The incidence per 1000 people attended, in total and by demographic mean, of the less common health complaints (incidence less than 1/1000) was calculated. RESULTS: Primary care doctors attended at greater frequency than 1/1000 all diseases of eyes, ears, mastoids (except salpingitis) and menstrual disorders codifiable under the classification CIPSAP; almost all the respiratory, skin and locomotive diseases, and more than half of the circulatory, genito-urinary, digestive and endocrine-metabolic diseases. Incidence was less than 1/1000 in all the malignant tumours and contagious diseases, except viral hepatitis and tuberculosis in the urban setting. CONCLUSIONS: Primary care doctors do not often attend certain serious diseases, which are nevertheless present in many differential diagnoses (malignant tumours). This should be borne in mind in the training strategies aimed at maintaining doctor's diagnostic skills.

[Episodes of sickness attended by general/family physicians according to demographic context. 2. Utilization]. / Episodios de enfermedad atendidos en medicina general/de familia, según medio demográfico (y II): Utilización.

OBJECTIVES: To describe the use of consultations, the place where care is given and referral demand, in function of episodes of illness and the demographic context. DESIGN: An observational, prospective study based on a year-long record. SETTING: 43 practices spread over 10 Autonomous Communities. INTERVENTIONS: Identification, date of birth and sex of each patient attended, date of their first consultation and the number of consultations per episode, the health problem, place of consultation and existence or otherwise of referral, were all recorded. RESULTS: 74.57% in the rural areas, 56.21% in the urban and 56.74% in the mixed saw the doctor over the year. In the rural context there were 2.26 consultations per episode and 5.41 consultations per person, against 1.88 and 4.55 in the urban context. Figures for the mixed context were in between. In all the illness groups (except that for accidents) the number of consultations per episode in the urban context: 13.90% against 10.74 in the rural. CONCLUSIONS: Greater use of the doctor in rural areas could be because of the lower population/doctor ratio and easier access. Higher referral rates in urban areas could be due to the closeness of the second care level. A low percentage of home consultations was observed.

[Episodes of disease taken care of in general practice/family medicine according to demographic context (I): morbidity]. / Episodios de enfermedad atendidos en medicina general/de familia, según medio demográfico (I): morbilidad.

OBJECTIVES: To identify the population seen at general/family medical practices and quantity the episodes of illnesses attended, in function of the demographic context. DESIGN: An observational, prospective study based on a year-long record. SETTING: 43 practices spread over 10 autonomous communities. INTERVENTIONS: Identification, sex and date of birth of each patient attended, the type of episode, health problem and date of their first consultation, were all recorded. Standardisation by the indirect method was used to compare morbidity rates. RESULTS: 2.39 episodes per person seen were attended in rural areas, 2.42 in urban ones, and 2.45 in mixed areas. The rural context had rates below 15% of the standard rate for neoplasias, endocrine diseases, neurological illness and additional categories; and over 15% for digestive tract diseases, traumas and side-effects. The urban context had higher rates for neoplasias, endocrine, blood and neurological diseases, and additional categories; and lower for respiratory system illnesses. In the mixed areas, rates were higher for contagious, neurological, respiratory system and congenital diseases. CONCLUSIONS: The morbidity attended varies in function of context. Some differences could be due to age distribution (younger in the mixed areas) or accidents (greater in rural areas). Others could be affected by use or problem-solving criteria varying according to the demographic context.

[Analysis of repeat prescriptions in chronic treatments at a health center]. / Análisis de la prescripción repetida para tratamientos crónicos en un centro de salud.

OBJECTIVES: To describe the social-health profile of the population attending for the renewal of prescriptions for long-term treatments; to quantify the possible pharmacological interactions; to measure cognitive function in a sample of this population. DESIGN: Crossover study. SETTING: Urban Health Centre. PARTICIPANTS: All the patients (359) who were seen during a one month period at any of the centre's nursing stations for the renewal of long-term treatment prescriptions. MEASUREMENTS AND RESULTS: All the social-health data of every patient were collected on a form. Cognitive function was assessed in one of every three cases by means of Folstein's Minimental test. Average age was 64 +/- 0.76; 37% were men and 63% women. The mean number of chronic diagnoses per patient was 3.2 +/- 0.08 and of medicines per patient 2.9 +/- 0.09. 15% medicated themselves. Pharmacological interactions were possible in 41% of the patients who took more than one medicine. 8% were illiterate and 16% only knew how to read or write. 24.54% displayed overall cognitive deterioration and 48%, lapses in memory. CONCLUSIONS: Patients seen at our Centre for renewal of prescriptions were an elderly population group, with pluripathology, taking several medicines, with a low cultural level and deterioration in their cognitive functions. The risk of pharmacological interactions is very high. Repeat prescriptions for long-term treatments should not just be an administrative function: it should be performed by trained health staff.