Adecuación de la prescripción de vitamina D en Atención Primaria / Adequacy of the prescription of vitamin D in Primary Care

Objetivos: Evaluar la adecuación del tratamiento con vitamina D, basada en la evidencia clínica, en un centro de Atención Primaria, así como analizar diversas características de las prescripciones realizadas. Materiales y métodos: Estudio descriptivo transversal. Atención Primaria. Pacientes mayores de 14 años con prescripción de vitamina D. Variable principal fue la adecuación terapéutica con compuestos de vitamina D (se consideró adecuación cuando había indicación clínica de tratamiento y niveles séricos de vitamina D<20 ng/ml). Se recogieron otras variables clínicas. Para el análisis estadístico se utilizaron medidas de frecuencia y asociación. Se consideró un nivel de significación<0,05. Resultados: Cuatrocientos treinta pacientes, 346 mujeres (80,5%, IC-95%=77-84). Registro de valores de vitamina D en 216 (50,2%, IC-95%=45-55). Indicaciones para realizar cribado/tratamiento en 219 pacientes (50,9%, IC-95%=46-56), de los que en 150 (68,5%, IC-95%=62-75) constaban valores de vitamina D, media (±DE) de 21,22±12 ng/ml, criterios de deficiencia en 86 (57,3%, IC-95%=51-64), insuficiencia en 37 (24,7%, IC- 95%=19-30) y suficiencia en 27 (18%, IC-95%=13-23). En 86 pacientes (20%, IC-95%=16-24) había adecuación de tratamiento (indicación de tratamiento sumado a un déficit de vitamina D), sin diferencias entre sexos. Conclusiones: Solo el 20% de los pacientes tratados con vitamina D tenían una buena adecuación terapéutica (indicación para tratamiento junto con un déficit de vitamina D). Había más mujeres con tratamiento. Poco más de la mitad presentaron indicación para cribado analítico de valores serológicos de vitamina D y/o para iniciar tratamiento con fármacos con compuestos de vitamina D. La mitad de los pacientes tenían registro de vitamina D (AU)

Objectives: To evaluate the adequacy of vitamin D treatment based on clinic evidence in a Primary Care Center as well as to analyze some characteristics of the prescriptions made. Materials and methods: Descriptive cross-sectional study. Primary Care. Patients above 14 years old with vitamin D prescription. Main variable was the therapeutic adequacy with vitamin D compounds (adequacy was considered when there was a clinical indication for treatment and blood vitamin D levels below 20ng/ml). Other clinical variables were collected. Frequency and association measures were used for statistical analysis. Level of statistical significance was considered <0.05. Results: 430 patients, 346 women (80.5%, 95% CI=77–84). Record of vitamin D values in 216 (50.2%, 95% CI=45–55). Screening/treatment indications in 219 patients (50.9%, 95% CI=46–56), of those in 150 patients vitamin D values were recorded (68.5%, 95% CI=62–75), average (±SD) was 21.22±12ng/ml, deficiency criteria in 86 (57.3%, 95% CI=51–64), insufficiency in 37 (24.7%, 95% CI=19–30) and sufficiency in 27 (18%, 95% CI=13–23). 86 patients (20%, 95% CI=16–24) had treatment indications plus vitamin D deficiency with no differences between genders. Conclusions: Only 20% of the patients had treatment indications plus vitamin D deficiency. Female predominance. Just over half had indications for screening of serological vitamin D values and/or indications for treatment with vitamin D compounds (AU)

[Adequacy of the prescription of vitamin D in Primary Care]. / Adecuación de la prescripción de vitamina D en Atención Primaria.

OBJECTIVES: To evaluate the adequacy of vitamin D treatment based on clinic evidence in a Primary Care Center as well as to analyze some characteristics of the prescriptions made. MATERIALS AND METHODS: Descriptive cross-sectional study. Primary Care. Patients above 14 years old with vitamin D prescription. Main variable was the therapeutic adequacy with vitamin D compounds (adequacy was considered when there was a clinical indication for treatment and blood vitamin D levels below 20ng/ml). Other clinical variables were collected. Frequency and association measures were used for statistical analysis. Level of statistical significance was considered <0.05. RESULTS: 430 patients, 346 women (80.5%, 95% CI=77-84). Record of vitamin D values in 216 (50.2%, 95% CI=45-55). Screening/treatment indications in 219 patients (50.9%, 95% CI=46-56), of those in 150 patients vitamin D values were recorded (68.5%, 95% CI=62-75), average (±SD) was 21.22±12ng/ml, deficiency criteria in 86 (57.3%, 95% CI=51-64), insufficiency in 37 (24.7%, 95% CI=19-30) and sufficiency in 27 (18%, 95% CI=13-23). 86 patients (20%, 95% CI=16-24) had treatment indications plus vitamin D deficiency with no differences between genders. CONCLUSIONS: Only 20% of the patients had treatment indications plus vitamin D deficiency. Female predominance. Just over half had indications for screening of serological vitamin D values and/or indications for treatment with vitamin D compounds.

[Adherence to healthy lifestyle behaviours in patients with type 2 diabetes in Spain]. / Adherencia a un estilo de vida saludable en pacientes con diabetes mellitus tipo 2 en España.

OBJECTIVES: The aim of this study was to report on the main lifestyle components and related factors in adults with diabetes type 2 treated in Primary Care clinics in Spain. MATERIAL AND METHODS: A cross-sectional and multicentre study was performed on a consecutive sample of patients with type 2 diabetes attending 25 Primary Care clinics between April 2018 and April 2019. Data were collected by auditing the computerised medical records, and an interview. An analysis was carried out on adherence to 4 healthy lifestyle trends (Mediterranean diet, regular exercise, not smoking, and emotional well-being). RESULTS: A total of 412 patients were included in the analysis (mean age 69 (SD 8.65) years; 50.2% men). Only a minority was highly adherent to the Mediterranean diet, 92 (22.3%). Regular physical activity was carried out by 189 (45.8%). A total of 361 (87.6%) were non-smoking, and 259 (62.8%) felt emotional well-being. A small number (9, 2.1%) of patients had not followed any of the healthy lifestyle recommendations, with 87 (21.1%) following one, 145 (35.1%) two, 128 (31%) three, and 43 (10.4%) all 4 healthy habits: diet, exercise, not smoking, and emotional well-being. Healthy lifestyle adherence was related to gender. Obesity is poorly associated with adherence to diet and physical activity. The results for age, time with the disease, socioeconomic status, and treatment regimen were not consistent. CONCLUSIONS: This study suggest that adherence to a healthy lifestyle pattern in DM2 is low. Less than a quarter follow a healthy diet, and less than a half practice regular exercise. Gender is the variable that most influences a healthy lifestyle in DM2, but not age, time with the disease, or treatment regimen.

Conocimientos y actitudes de los médicos de Atención Primaria de Andalucía (España) sobre la detección de personas con riesgo elevado de cáncer de mama y colorrectal / Knowledge and attitude among general practitioners in Andalusia (Spain) on the identification of subjects at high risk of breast and colorectal cancer

OBJETIVOS: Explorar los conocimientos y las actitudes de los médicos de Atención Primaria de Andalucía sobre la detección de personas con riego elevado de cáncer de mama y colorrectal y el cáncer hereditario. MÉTODOS: Estudio descriptivo transversal a partir de una encuesta de opinión on line. Cuestionario de 24 preguntas. Para el análisis estadístico se emplearon medidas de frecuencia y de asociación. Se estableció un nivel de significación para una p < 0,05. RESULTADOS: Tasa de respuesta del 32%, 224 encuestas válidas, un 56% de varones, edad media ± DE de 46 ± 12 años. Los criterios de riesgo alto de cáncer de mama eran conocidos por el 71,4% [IC 95% 65-76], peor en los hábitats mayores (p = 0,014). Podían solicitar mamografía en tumoraciones y en riesgo moderado o elevado el 86%. Respecto al cáncer colorrectal, conocen los criterios de riesgo el 87,9%. Ante un paciente con criterios de sospecha podían solicitar colonoscopia directamente el 58,2% [IC 95% 49-62] y las zonas más pobladas tenían mayor acceso a la petición de colonoscopias (p < 0,0001). Desconocían la existencia de consultas de consejo genético 133 médicos (59,4% [IC 95% 52-65]). CONCLUSIONES: El programa de cribado de cáncer de mama es bien conocido y el acceso a la mamografía es satisfactorio. La mayoría de los médicos consideran adecuado el seguimiento de las personas con alto riesgo de cáncer colorrectal, aunque la mitad de los encuestados refieren dificultades para solicitar la colonoscopia directamente. Los conocimientos sobre cáncer hereditario son deficitarios y variables según las zonas y hay un desconocimiento generalizado sobre la existencia de unidades de consejo genético y cáncer hereditario

AIMS: To assess the knowledge and attitude among general practitioners in Andalusia on the identification of subjects with elevated risk for breast cancer, colorectal cancer, and hereditary cancers, as well as to detect barriers to accessibility to the screening programs. METHODS: A descriptive, cross-sectional study was conducted based on an online survey of 24 questions. Data are shown as frequencies, and association tests were statistically used. The level of significance was set at <.05. RESULTS: Survey response rate was 32%, of which 224 were valid, and included 56% men, and a mean age±DE of 46±12 years. Established criteria for high risk breast cancer were already known by 71.4% [95% CI 65-76], being worst in those living in big cities (P <.014). Among general practitioners, 86% were allowed to order mammography in women with lumps or at moderate to high risk for breast cancer. As regards colorectal cancer, 87.9% of general practitioners knew the risk factors. Among general practitioners, 58.2% [95% CI 49-62] were allowed to order a colonoscopy if clinical suspicion was present, especially if they lived in large cities (P < .0001). CONCLUSIONS: The screening program for breast cancer is well-known by general practitioners, and the access to mammography is successful. Most of the general practitioners consider the follow-up program for persons at high risk for colorectal cancer appropriate, although half of those surveyed had some barriers to ordering colonoscopy. Knowledge on hereditary cancer is limited and varies among areas. There is also a general lack of awareness on hereditary cancer and genetic counselling units

[Knowledge and attitude among general practitioners in Andalusia (Spain) on the identification of subjects at high risk of breast and colorectal cancer]. / Conocimientos y actitudes de los médicos de Atención Primaria de Andalucía (España) sobre la detección de personas con riesgo elevado de cáncer de mama y colorrectal.

AIMS: To assess the knowledge and attitude among general practitioners in Andalusia on the identification of subjects with elevated risk for breast cancer, colorectal cancer, and hereditary cancers, as well as to detect barriers to accessibility to the screening programs. METHODS: A descriptive, cross-sectional study was conducted based on an online survey of 24 questions. Data are shown as frequencies, and association tests were statistically used. The level of significance was set at<.05. RESULTS: Survey response rate was 32%, of which 224 were valid, and included 56% men, and a mean age±DE of 46±12 years. Established criteria for high risk breast cancer were already known by 71.4% [95% CI 65-76], being worst in those living in big cities (P<.014). Among general practitioners, 86% were allowed to order mammography in women with lumps or at moderate to high risk for breast cancer. As regards colorectal cancer, 87.9% of general practitioners knew the risk factors. Among general practitioners, 58.2% [95% CI 49-62] were allowed to order a colonoscopy if clinical suspicion was present, especially if they lived in large cities (P<.0001). CONCLUSIONS: The screening program for breast cancer is well-known by general practitioners, and the access to mammography is successful. Most of the general practitioners consider the follow-up program for persons at high risk for colorectal cancer appropriate, although half of those surveyed had some barriers to ordering colonoscopy. Knowledge on hereditary cancer is limited, and varies among areas. There is also a general lack of awareness on hereditary cancer and genetic counselling units.

Impacto de la inercia terapéutica y del grado de adherencia al tratamiento en los objetivos de control en personas con diabetes / The impact of therapeutic inertia and the degree of the medication adherence on the control goals for patients with diabetes

Objetivo: El objetivo de este estudio fue analizar el impacto de la baja adherencia terapéutica (AT) y la inercia terapéutica de los profesionales (IT) sobre el mal control glucémico y de los factores de riesgo cardiovasculares en personas con DM2. Material y métodos: Estudio transversal realizado en atención primaria. Se incluyeron 320 personas con DM2. Se valoró si cumplían los objetivos de control (HbA1c≤7%, PA≤130/80mmHg, LDL≤100mg/dl). Se consideró falta de AT la retirada de farmacia <80% de las recetas prescritas e IT la no modificación del tratamiento en personas mal controladas. Resultados: Presentaron buen control de HbA1c, PA y cLDL el 62,5, el 40,9 y el 35,9%, respectivamente. Las personas mal controladas presentaron cifras de AT menores y la IT no se relacionó con la AT. En sujetos mal controlados para HbA1c, presentaban IT el 25,8%, el 24,8% mala AT y el 11,9% estaban afectados por ambos comportamientos. Para cLDL, el 3,6% presentaban mala AT, el 70,4% IT y el 16,0% mala AT e IT (p<0,001). Respecto a la PA, el 3,5% tenían mala AT, el 54,6% IT y el 21,5% presentaban mala AT e IT (p<0,01). Conclusiones: La falta de AT y la IT han estado implicadas en un porcentaje elevado de personas con DM2 mal controladas. La IT ha resultado de gran relevancia en el presente estudio

Objective: The purpose of this study was to analyse both the impact of low therapeutic adherence (TA) and therapeutic inertia (TI) on poor blood glucose control and on risk factors for heart disease in patients with DM2. Material and methods: A cross-sectional study was conducted in a Primary Halth Care centre. A total of 320 patients with DM2 were included and an assessment was made of control goals (HbA1c≤7%, blood pressure ≤130/80mmHg, and LDL-cholesterol≤100mg/dl). A pharmacy retrieval <80% was considered as a lack of TA and the non-modification of treatment in badly controlled patient as TI. Results: The percentage of patients with good control of HbA1c, blood pressure and LDL-cholesterol was 62.5%, 40.9%, and 35.9%, respectively. Lower figures of TA were present in poorly controlled patients, and TI was not found to be related to TA. In the patients with poor HbA1c control, 25.8% had TI, 24.8% poor TA, and 11.9% had both of them. As regards LDL-cholesterol, 3.6% presented poor TA, 70.4% showed TI, and 16% with poor TA and TI (P<.001). As for blood pressure, 3.5% of patients had poor TA, 54.6% had TI, and 21.5% of them had poor TA as well as TI (P<.01). Conclusions: Lack of therapeutic adherence and therapeutic inertia were found in a high percentage of poorly-controlled DM2 patients with bad control. Therapeutic inertia was found to be of great relevance in this study

[The impact of therapeutic inertia and the degree of the medication adherence on the control goals for patients with diabetes]. / Impacto de la inercia terapéutica y del grado de adherencia al tratamiento en los objetivos de control en personas con diabetes.

OBJECTIVE: The purpose of this study was to analyse both the impact of low therapeutic adherence (TA) and therapeutic inertia (TI) on poor blood glucose control and on risk factors for heart disease in patients with DM2. MATERIAL AND METHODS: A cross-sectional study was conducted in a Primary Halth Care centre. A total of 320 patients with DM2 were included and an assessment was made of control goals (HbA1c≤7%, blood pressure ≤130/80mmHg, and LDL-cholesterol≤100mg/dl). A pharmacy retrieval <80% was considered as a lack of TA and the non-modification of treatment in badly controlled patient as TI. RESULTS: The percentage of patients with good control of HbA1c, blood pressure and LDL-cholesterol was 62.5%, 40.9%, and 35.9%, respectively. Lower figures of TA were present in poorly controlled patients, and TI was not found to be related to TA. In the patients with poor HbA1c control, 25.8% had TI, 24.8% poor TA, and 11.9% had both of them. As regards LDL-cholesterol, 3.6% presented poor TA, 70.4% showed TI, and 16% with poor TA and TI (P<.001). As for blood pressure, 3.5% of patients had poor TA, 54.6% had TI, and 21.5% of them had poor TA as well as TI (P<.01). CONCLUSIONS: Lack of therapeutic adherence and therapeutic inertia were found in a high percentage of poorly-controlled DM2 patients with bad control. Therapeutic inertia was found to be of great relevance in this study.

Satisfacción de las personas con diabetes mellitus tipo 2 tras iniciar tratamiento con insulina / Satisfaction of patients with type 2 diabetes mellitus after starting treatment with insulin

Objetivos. El 'miedo al pinchazo' de muchos pacientes con diabetes tipo 2 (DM2) puede retrasar el inicio del tratamiento con insulina. Nuestro objetivo es valorar si superar dicha barrera e iniciar el tratamiento con insulina mejora el control clínico y produce mayor satisfacción del paciente con su tratamiento. Material y métodos. Estudio observacional, multicéntrico, de pacientes con DM2 —realizado en atención primaria— con un mal control glucémico (A1c≥8%), en tratamiento con antidiabéticos orales y a los que se aplicó una intervención motivacional para vencer el miedo al pinchazo y se inició el tratamiento con insulina. Se valoró el grado de satisfacción con el tratamiento mediante el Diabetes Treatment Satisfaction Questionnaire (DTSQ). Resultados. Quinientos setenta y tres pacientes, 64±10 años. Puntuación global media del cuestionario DTSQs de 18,3±6,3. El cambio de tratamiento produjo una mejoría de la satisfacción del paciente con respecto al tratamiento anterior (puntuación media DTSQc 8,8±5,9). La A1c descendió desde 8,7% (desviación típica 0,8) hasta 7,5% (desviación típica 0,7) (p<0,001). La frecuencia de hiperglucemia percibida fue significativamente menor después de superar el miedo al pinchazo (35,6% frente a 11,5%; p<0,001), sin encontrar diferencias estadísticamente significativas en la frecuencia de hipoglucemias (32% frente a 35%; p=0,059). Conclusión. En pacientes con DM2 mal controlados con antidiabéticos orales, vencer el miedo al pinchazo e iniciar el tratamiento con insulina se asoció a una mejoría global de la satisfacción con el tratamiento, y disminuyó la percepción de episodios de hiperglucemia. El control glucémico y el perfil metabólico de los pacientes también mejoraron de forma estadísticamente significativa (AU)

Objectives. The objective of this study is to evaluate if overcoming the barrier of starting treatment with insulin can lead to better clinical control and a higher level of patient satisfaction with their treatment. Material and methods. This is an observational, multicentre study of patients diagnosed with DM2 who attended primary care centres with poor glycaemic control (A1c≥8%) under treatment with oral antidiabetic drugs (OADs), and who were given motivational treatment to overcome their fear of injections, and started treatment with insulin. The level of satisfaction with the treatment was evaluated using the Diabetes Treatment Satisfaction Questionnaire (DTSQ). The questionnaire was used before initiating the treatment with insulin and in the follow-up visit (3-4 months from the beginning of treatment with basal insulin). Results. A total of 573 patients with a mean age of 64±10 years were recruited. The overall mean score from the DTSQs satisfaction questionnaire was 18.3±6.3, and the change of treatment led to an improvement in patient satisfaction compared to the previous treatment (DTSQc mean score 8.8±5.9). A1c dropped from an initial value of 8.7% (SD 0.8) to 7.5% (SD 0.7) (P<.001). The frequency of hyperglycaemic episodes perceived by the patients was significantly lower after they overcame their fear of injections (35.6% compared to 11.5%; P<.001), but no statistically significant differences were found in the frequency of hypoglycaemic episodes (32% compared to 35%; P=.059). Conclusion. In patients with DM2 poorly controlled with OADs, overcoming a fear of injections and starting treatment with insulin was associated with an overall improvement in satisfaction with the new treatment, and decreased the perception of hyperglycaemic episodes. Glycaemic control and the metabolic profile of the patients also improved to a statistically significant degree with the change of treatment (AU)

[Satisfaction of patients with type 2 diabetes mellitus after starting treatment with insulin]. / Satisfacción de las personas con diabetes mellitus tipo 2 tras iniciar tratamiento con insulina.

OBJECTIVES: The objective of this study is to evaluate if overcoming the barrier of starting treatment with insulin can lead to better clinical control and a higher level of patient satisfaction with their treatment. MATERIAL AND METHODS: This is an observational, multicentre study of patients diagnosed with DM2 who attended primary care centres with poor glycaemic control (A1c≥8%) under treatment with oral antidiabetic drugs (OADs), and who were given motivational treatment to overcome their fear of injections, and started treatment with insulin. The level of satisfaction with the treatment was evaluated using the Diabetes Treatment Satisfaction Questionnaire (DTSQ). The questionnaire was used before initiating the treatment with insulin and in the follow-up visit (3-4 months from the beginning of treatment with basal insulin). RESULTS: A total of 573 patients with a mean age of 64±10 years were recruited. The overall mean score from the DTSQs satisfaction questionnaire was 18.3±6.3, and the change of treatment led to an improvement in patient satisfaction compared to the previous treatment (DTSQc mean score 8.8±5.9). A1c dropped from an initial value of 8.7% (SD 0.8) to 7.5% (SD 0.7) (P<.001). The frequency of hyperglycaemic episodes perceived by the patients was significantly lower after they overcame their fear of injections (35.6% compared to 11.5%; P<.001), but no statistically significant differences were found in the frequency of hypoglycaemic episodes (32% compared to 35%; P=.059). CONCLUSION: In patients with DM2 poorly controlled with OADs, overcoming a fear of injections and starting treatment with insulin was associated with an overall improvement in satisfaction with the new treatment, and decreased the perception of hyperglycaemic episodes. Glycaemic control and the metabolic profile of the patients also improved to a statistically significant degree with the change of treatment.

Effects of a long-term lifestyle intervention program with Mediterranean diet and exercise for the management of patients with metabolic syndrome in a primary care setting.

BACKGROUND: The impact of a lifestyle intervention (LSI) program for the long-term management of subjects with metabolic syndrome in a primary care setting is not known. METHODS: This 3-year prospective controlled trial randomized adult subjects with metabolic syndrome to receive intensive LSI or to usual care in a community health centre in Malaga, Spain. LSI subjects received instruction on Mediterranean diet and a regular aerobic exercise program by their primary care professionals. Primary outcome included changes from baseline on different components of metabolic syndrome (abdominal circumference, blood pressure, HDL-cholesterol, fasting plasma glucose and triglycerides). RESULTS: Among the 2,492 subjects screened, 601 subjects with metabolic syndrome (24.1%) were randomized to LSI (n = 298) or to usual care (n = 303); of them, a 77% and a 58%, respectively, completed the study. At the end of the study period, LSI resulted in significant differences vs. usual care in abdominal circumference (-0.4 ± 6 cm vs. + 2.1 ± 6.7 cm, p < 0.001), systolic blood pressure (-5.5 ± 15 mmHg vs. -0.6 ± 19 mmHg, p = 0.004), diastolic blood pressure (-4.6 ± 10 mmHg vs. -0.2 ± 13 mmHg, p < 0.001) and HDL-cholesterol (+4 ± 12 mg/dL vs. + 2 ± 12 mg/dL, p = 0.05); however, there were no differences in fasting plasma glucose and triglyceride concentration (-4 ± 35 mg/dl vs. -1 ± 32 mg/dl, p = 0.43 and -0.4 ± 83 mg/dl vs. +6 ± 113 mg/dl, p = 0.28). CONCLUSION: Intensive LSI counseling provided by primary care professionals resulted in significant improvements in abdominal circumference, blood pressure and HDL-cholesterol but had limited effects on glucose and triglyceride levels in patients with metabolic syndrome.

Recomendaciones de buena práctica en el tratamiento de la dislipemia en la diabetes / Consensus document on the treatment of dyslipidemia in diabetes

Las personas con diabetes mellitus tipo 2 tienen un riesgo de desarrollar enfermedad cardiovascular de 2 a 4 veces superior al observado en la población general de similar edad y sexo. Este riesgo se mantiene después de ajustar para otros factores clásicos de riesgo cardiovascular. La dislipidemia asociada a la diabetes mellitus tipo 2 se encuentra presente en hasta un 60% de las personas con diabetes y contribuye en gran medida al incremento de riesgo cardiovascular y de morbimortalidad que presentan estos pacientes. La dislipidemia diabética es una alteración del metabolismo lipídico que se caracteriza por un exceso de triglicéridos, un déficit del colesterol HDL y una alteración de la composición de las lipoproteínas que consiste sobre todo en un exceso de partículas LDL pequeñas y densas. Múltiples ensayos clínicos han demostrado los beneficios del tratamiento farmacológico de la dislipidemia (principalmente estatinas), para prevenir eventos cardiovasculares y mortalidad en personas con diabetes tanto en prevención primaria como secundaria. El presente documento de consenso elaborado por médicos de familia, integrantes del Grupo de Diabetes de la Sociedad Española de Médicos de Atención Primaria (SEMERGEN), pretende servir de ayuda en el manejo de las personas con diabetes y dislipidemia a la vista de las recomendaciones más actualizadas (AU)

People with type 2 diabetes mellitus have a 2 to 4 times higher risk of developing cardiovascular diseases when compared to general population of similar age and sex. This risk remains after adjustment of other traditional cardiovascular risk factors. The dyslipidemia associated with type 2 diabetes mellitus is present in up to 60% of people with diabetes and contributes greatly to increased cardiovascular, morbidity and mortality risk in these patients. Diabetic dyslipidemia is a disorder of lipid metabolism characterized by an excess of triglycerides, a decrease in HDL-cholesterol and altered lipoprotein composition, consisting mainly in an excess of small, dense LDL particles. Multiple clinical trials have demonstrated the benefits of drug treatment of dyslipidemia (mainly statins) to prevent cardiovascular events and mortality in people with diabetes, both in primary and secondary prevention. This consensus document, developed by general practitioners, members of the Diabetes Group of the Spanish Society of Primary Care Physicians (SEMERGEN), aims to assist in the management of patients with diabetes and dyslipidemia in accordance with the most recent recommendations (AU)

[Consensus document on the treatment of dyslipidemia in diabetes]. / Recomendaciones de buena práctica en el tratamiento de la dislipemia en la diabetes.

People with type 2 diabetes mellitus have a 2 to 4 times higher risk of developing cardiovascular diseases when compared to general population of similar age and sex. This risk remains after adjustment of other traditional cardiovascular risk factors. The dyslipidemia associated with type 2 diabetes mellitus is present in up to 60% of people with diabetes and contributes greatly to increased cardiovascular, morbidity and mortality risk in these patients. Diabetic dyslipidemia is a disorder of lipid metabolism characterized by an excess of triglycerides, a decrease in HDL-cholesterol and altered lipoprotein composition, consisting mainly in an excess of small, dense LDL particles. Multiple clinical trials have demonstrated the benefits of drug treatment of dyslipidemia (mainly statins) to prevent cardiovascular events and mortality in people with diabetes, both in primary and secondary prevention. This consensus document, developed by general practitioners, members of the Diabetes Group of the Spanish Society of Primary Care Physicians (SEMERGEN), aims to assist in the management of patients with diabetes and dyslipidemia in accordance with the most recent recommendations.

[Use of glucose-lowering drugs in a primary care setting in Malaga during the years 2008-2012]. / Utilización de fármacos hipoglucemiantes en el ámbito de la atención primaria de Málaga durante los años 2008-2012.

INTRODUCTION: The aim of the study is to describe the pattern of use of hypoglycemic agents in a primary health care district of Málaga between the years 2008-2012. MATERIAL AND METHOD: Cross-sectional descriptive study. Málaga health district. Population of 609,781 inhabitants; 42,060 people in the diabetes process. Therapeutic sub-group A10 (drugs used in diabetes). Data is presented as defined daily dose (DDD). Years 2008-2012. Measures of frequency. RESULTS: The population grew by 0.4% and the people included in the diabetes process, by 19%. The hypoglycemic agents have increased from 12,453,443 to 14,144,817 DDD (13.5%). Oral antidiabetics increased by 13.8% and insulin by 9.7%. Metformin is the most used oral antidiabetic (6,655,923 DDD) and the iDDP4 was the one that had increased more (from 63,882 DDD to 1,482,574). The growth in insulin use was mainly due to the long-acting (38%) and the shorter-acting one (40%). The most used insulin doses are the long-acting ones, followed by the pre-mixed. The proportion of insulin use as regards the use of ADOs has remained stable (31%)., Long-acting (36%) insulin has become the most used, followed by pre-mixed (34%), shorter-acting (16%), and the intermediate-acting (12%). CONCLUSIONS: There is an increase in the use of hypoglycemic agents., Metformin and iDPP4 are the antidiabetics oral with the greatest growth., There is an increase in shorter-acting and long-acting insulins with a decrease in intermediate-acting and pre-mixed., The proportion of oral antidiabetics/insulins has remained stable.

Role of an intermittent claudication questionnaire for the diagnosis of PAD in ambulatory patients with type 2 diabetes.

AIM: In epidemiological studies, peripheral arterial disease is assessed by the measurement of the ankle/brachial index (ABI), thus enabling detection of asymptomatic disease. Our aim was to evaluate the diagnostic accuracy of a validated questionnaire on intermittent claudication for peripheral arterial disease in a clinical setting. METHODS: We administered the Edinburgh questionnaire on intermittent claudication and measured ABI using a portable Doppler in 456 outpatients with type 2 diabetes. Subjects with intermittent claudication and an ABI above 0.9 were examined with color Doppler ultrasound imaging. Peripheral arterial disease was considered to be present when the ABI was <0.9 or the color Doppler arterial waveform was monophasic. RESULTS: Thirty-five (7.6%) of the 456 patients had intermittent claudication. Of these, 22 (63%) had an ABI <0.9 and the remaining 13 (37%) had an ABI >0.9. Of these latter, 12 were reexamined and 3 (25%) were found to have monophasic waveforms in color Doppler, thus being diagnosed with peripheral arterial disease. The overall accuracy of intermittent claudication for peripheral arterial disease was 75% (95% CI, 71-79). CONCLUSION: Among patients with type 2 diabetes, a normal ABI does not rule out peripheral arterial disease; the use of an intermittent claudication questionnaire is able to identify correctly the disease in 3 out of 4 patients with diabetes. Our results suggest incorporating the intermittent claudication questionnaire into the general consultation instead of the general screening of the ABI.

Fasting apolipoprotein B48 is a marker for peripheral arterial disease in type 2 diabetes.

An earlier study showed that fasting and postprandial concentrations of apolipoprotein B48 were raised in patients with type 2 diabetes (DM2) and peripheral arterial disease (PAD) as compared with persons without DM2 or persons with DM2 but not PAD. The aim of this study was to confirm the association of PAD and B48 in a larger group of patients with DM2 and the relation of B48 with the preheparin lipoprotein lipase (LPL) mass. We studied 456 patients with DM2. PAD was defined as an ankle-brachial index (ABI) <0.9. Apolipoprotein B48 was quantified by ELISA. Apo B48 was significantly higher in the group with an ABI <0.9 than the groups with ABI of 0.9-1.3 and >1.3 (10.7 ± 6.28 vs. 9.24 ± 5.5 vs. 9.17 ± 8.8 mg/L, ANOVA test, p < 0.05). B48 was independently associated with an ABI <0.9 (OR 1.053; 95 % CI, 1.013-1.094; p < 0.05), together with smoking and duration of diabetes. The preheparin LPL mass was similar in the patients with and without PAD. In conclusion, we confirmed that fasting B48 is an independent marker of PAD in patients with DM2, unrelated to the preheparin LPL mass, statin therapy or glucose lowering treatment.

Compliance with cardiovascular drug prevention measures in a general population: the Multidisciplinary Intervention in Primary Care (IMAP) study.

AIMS: To evaluate adherence to guideline-recommended drug therapies for primary and secondary cardiovascular prevention in a general Mediterranean population. SUBJECTS AND METHODS: A cross-sectional study was conducted in a random sample of 2270 individuals (18-80 years) assigned to a health centre in Malaga (Spain). The appropriate use was analysed of statins, antithrombotics, beta-blockers, and angiotensin-converting enzyme inhibitors (ACEI) or angiotensin II type 1 receptor blockers (ARB), based on the criteria of the European Guidelines on Cardiovascular Prevention and the European Society of Hypertension-European Society of Cardiology. RESULTS: The prescription rate of statins, antithrombotics, beta-blockers, and ACEI/ARB was 7.8%, 5.1%, 3.3%, and 11%, respectively. The prescription of these drugs was inappropriate in 36.2%, 22.4%, 64.5%, and 0%, respectively. Overtreatment was more frequent in subjects with greater comorbidity or ≥ 2 vascular risk factors (p < 0.001). The percentage of individuals with prescription criteria but who did not receive the treatment was 19.5%, 4.7%, 2%, and 9.3%, respectively, increasing significantly with age, Charlson index, and the presence of ≥ 2 risk factors (p < 0.001). Only 11% of patients in secondary prevention received combination therapy with statins, antithrombotics, and ACEI/ARB. Patients with ischaemic heart disease, as compared to non-coronary vascular patients, more frequently received statins (56.1% vs. 25.6%; p = 0.0001) and antithrombotic drugs (66.7% vs. 56.4%; p = 0.02). CONCLUSIONS: We detected a low adherence to existing pharmacological guidelines for the prevention of cardiovascular disease. A priority is to establish appropriate training and dissemination of cardiovascular prevention guidelines in the field of primary care.

HbA(1c) in adults without known diabetes from southern Europe. Impact of the new diagnostic criteria in clinical practice.

AIMS: To analyse the differences in the prevalence of diabetes and dysglycaemia using fasting plasma glucose and HbA(1c) criteria. METHODS: Analytical cross-sectional study undertaken in a random sample of 2144 individuals (age 18-80 years) without known diabetes from the primary care setting in Malaga (Spain). Dysglycaemia was defined as fasting plasma glucose 5.6-6.9 mmol/l or HbA(1c) 39-46 mmol/mol (5.7-6.4%) and diabetes as fasting plasma glucose ≥ 7.0 mmol/l or HbA(1c)≥ 48 mmol/mol (≥ 6.5%). RESULTS: The proportion of subjects who were normoglycaemic was significantly higher using fasting plasma glucose than HbA(1c) (83.5 vs. 65%) (P < 0.0001). Compared with fasting plasma glucose, HbA(1c) detects more cases of dysglycaemia (32 vs. 14.8%) (P < 0.0001) and diabetes (3 vs. 1.7%) (P < 0.0001). CONCLUSIONS: In our environment, using HbA(1c) for the diagnosis of pre-diabetes and diabetes could increase the target population for preventive and therapeutic measures. Further cost-effectiveness studies are needed before the widespread diagnostic use of HbA(1c) can be recommended.