Similitudes en el deterioro cognitivo de pacientes con esquizofrenia de inicio reciente y pacientes crónicos: una consideración sobre la hipótesisdel neurodesarrollo / Similarities in cognitive impairment between recent-onset and chronic schizophrenia patients: a consideration for the neurodevelopmental hypothesis

Se ha descrito la presencia de déficits cognitivos en pacientes con esquizofrenia, dichas alteraciones pueden observarse en fases tempranas y crónicas de la enfermedad.Sin embargo, los hallazgos respecto a los déficits en estas fases aún mantienen el debate sobre si la esquizofrenia es una condición neurodegenerativa que cursa con un deterioro continuo o si los déficits permanecen estables, como sugiere la hipótesis del neurodesarrollo. En el presente estudio se compara el rendimiento cognitivo de pacientes con esquizofrenia de inicio reciente (RO) y pacientes crónicos (CH) con la finalidad de contrastar la hipótesis del neurodesarrollo con la perspectiva neurodegenerativa. Método. Se incluyeron 20 participantes de RO (< 5 años desde el primer episodio psicótico) y 30 pacientes de CH (>5 años desde el primer episodio psicótico). Para la evaluación cognitiva se utilizó la Batería Cognitiva Consensuada MATRICS (MCCB), la Prueba Torre de Londres, la Prueba de Clasificación de Tarjetas de Wisconsin y la Prueba de Stroop. Se utilizó ANCOVA para las comparaciones de grupos. Resultados. No hubo diferencias entre los grupos en la mayoría de las pruebas cognitivas. Se observó una diferencia significativa en la prueba de span espacial del MCCB. Conclusiones. Los déficits cognitivos permanecen estables a lo largo del tiempo; nuestros hallazgos son consistentes con la hipótesis del neurodesarrollo de la esquizofreniamás que con el enfoque neurodegenerativo. (AU)

Impairment in attention, memory, processing speed and executive functions have been described in patients with schizophrenia. Such impairments can be observed in early stages of the disease and in chronic patients; discrepancy in findings regarding the cognitive deficits at different stages of the illness keeps the debate about schizophrenia as a neurodegenerative condition which courses with continuous deterioration, or if deficits remain stable, as the neurodevelopmental hypothesis suggests. The aim of the present study was to compare the cognitive performance of recent-onset (RO) and chronic (CH) schizophrenia patients to contrast the neurodevelopmental hypothesis against the neurodegenerative approach. Methods. Twenty RO participants (< 5 years from first psychotic episode) and 30 CH patients (> 5 years from first psychotic episode) were included in the sample. The MATRICS Consensus Cognitive Battery (MCCB), Tower of London test (ToL), Wisconsin Card Sorting Test (WCST) and Stroop Test were used for cognitive evaluation. ANCOVA analysis was performed for group comparisons. Results. No differences between RO and CH patients were identified on most cognitive tests. However, a significant difference was observed in the visual spatial span test from MCCB. Conclusions. We conclude that cognitive deficits remain stable over the course of the disease. Our findings are consistent with the neurodevelopmental hypothesis of schizophrenia rather than the neurodegenerative approach. (AU)

Patrón inflamatorio de las vías aéreas en pacientes fumadores con enfermedad pulmonar obstructiva crónica / Inflammatory pattern of the airways in COPD smokers

Introducción: La enfermedad pulmonar obstructiva crónica cursa con un patrón inflamatorio en la vía aérea que incluye neutrófilos, macrófagos, linfocitos, los cuales se pueden obtener mediante un cepillado bronquial citológico. Objetivos: Identificar patrón inflamatorio según células inflamatorias presentes en la vía aérea, mediante el cepillado bronquial citológico e índice tabáquico de paquetes/año en pacientes con enfermedad pulmonar obstructiva crónica. Métodos: Se realizó un estudio descriptivo transversal en pacientes con enfermedad pulmonar obstructiva crónica, que concurrieron al Hospital Neumológico Benéfico-Jurídico, en el período comprendido de junio de 2018 a junio de 2019, con indicación para la realización de fibrobroncoscopía con cepillado bronquial. Resultados: El 53,1 por ciento de los pacientes corresponden al sexo masculino. Un 46,1 por ciento presentó un índice tabáquico de paquetes/año entre 21-40. Predominaron las criptas y estrías como hallazgos broncoscópicos con un 51 por ciento y 40,8 por ciento respectivamente en pacientes con índice paquetes/año mayor que 40. De los pacientes con índice paquetes/año mayor de 40 (13 para un 26,5 por ciento) presentaron hiperplasia de células basales. El 46,9 por ciento de los pacientes presentaron un patrón inflamatorio neutrofílica. Conclusiones: Se identificaron a los pacientes con EPOC que presentaron patrón inflamatorio neutrofílica en la vía aérea y elevado índice tabáquico y desde el punto de vista broncoscópico tienen varios hallazgos que sugieren cronicidad(AU)

Introduction: Chronic obstructive pulmonary disease presents with an inflammatory pattern in the airway that includes neutrophils, macrophages, and lymphocytes, which can be obtained by cytological bronchial brushing. Objectives: To identify inflammatory pattern according to inflammatory cells present in the airway, through cytological bronchial brushing and smoking rate of packs/year in patients with chronic obstructive pulmonary disease. Methods: A cross-sectional descriptive study was carried out in patients with chronic obstructive pulmonary disease, who attended Benefico-Jurídico Pneumological Hospital, from June 2018 to June 2019, with an indication for fiberoptic bronchoscopy with bronchial brushing. Results: 53.1percent of the patients correspond to the male sex. 46.1percent ad a smoking rate of packs/year between 21-40. Crypts and striae predominated as bronchoscopic findings with 51percent and 40.8percent respectively in patients with a pack/year index greater than 40. Patients with a pack/year index greater than 40 (13 for 26.5percent) showed basal cell hyperplasia. 46.9percent of the patients had a neutrophilic inflammatory pattern. Conclusions: Patients with COPD who had a neutrophilic inflammatory pattern in the airway and high smoking index were identified, and from the bronchoscopic point of view they have several findings that suggest chronicity(AU)

La docencia sobre cronicidad en las facultades de Medicina: una revisión de la situación actual / Teaching about chronicity in medical schools — A review of the current situation

In recent decades, progressive population aging in developed countries has led to a significant increase in the number of people with at least one chronic medical condition. As a result, acquiring knowledge about chronicity in medical school is key for physicians to be able to provide proper management for these patients. However, the presence of chronicity in educational curricula is scarce and highly variable. On the one hand, this work consisted of a review of the educational programs of the main medical schools on each continent with the aim of identifying whether they included chronicity and, on the other, a literature review focused on identifying educational projects in the field of chronicity. The presence of chronicity in most medical schools’ curricula is marginal and only a few universities include specific skills or competences linked to chronicity. In most cases, this topic appears as a global, cross-curricular competence that students are supposed to acquire over the course of their entire education. The literature review retrieved 21 articles on innovative teaching projects on chronicity. Direct contact with chronic patients, most times as “health mentors,” the role of the student as a teacher, and continuous evaluation and feedback from all participants are the main characteristics of the projects analyzed. Some previously published experiences support the usefulness of innovative methodologies for better approaching this capital field in current medical practice. Despite the current situation in which chronic patients consume most healthcare resources, the presence of chronicity in medical schools is marginal. However, a literature review did identify some useful experiences for improving education on chronicity in medical schools. Medical schools should change their academic curricula and redirect them towards providing students all the necessary tools for improving their knowledge on chronicity (AU)

En las últimas décadas, el progresivo envejecimiento de la población en los países desarrollados ha provocado un aumento significativo del número de personas con al menos una enfermedad crónica. Como consecuencia, es fundamental que la formación pregrado en Medicina aporte conocimientos sobre la cronicidad, de forma que los médicos puedan proporcionar un manejo adecuado a estos pacientes. A pesar de ello, la presencia de la cronicidad en los currículos formativos de las facultades de Medicina es escasa y muy variable. Este trabajo consistió, por un lado, en una revisión de los programas formativos de las principales facultades de Medicina de cada continente, con el objetivo de identificar si incluían aspectos relacionados con la cronicidad y, por otro, en una revisión bibliográfica enfocada a identificar proyectos educativos en el campo de la cronicidad. La presencia de la cronicidad en los planes de estudio de la mayoría de las facultades de Medicina es marginal y solo unas pocas universidades incluyen habilidades o competencias específicas vinculadas a este campo. En la mayoría de los casos en los que sí aparece, este tema se refleja como una competencia global y transversal que los estudiantes deben adquirir a lo largo de toda su formación. La revisión bibliográfica identificó 21 artículos sobre proyectos docentes innovadores sobre cronicidad. Las principales características de los proyectos analizados son: el contacto directo con pacientes crónicos, la mayoría de las veces como «mentores de salud», el papel del estudiante como profesor y la evaluación y retroalimentación continuas de todos los participantes. Algunas experiencias previamente publicadas avalan la utilidad de metodologías innovadoras para una mejora en el abordaje de este campo en la práctica médica diaria. A pesar de la situación actual, en la que los pacientes crónicos consumen la mayor parte de los recursos sanitarios, la presencia de la cronicidad en las facultades de Medicina es marginal (AU)

Teaching about chronicity in medical schools - A review of the current situation.

In recent decades, progressive population aging in developed countries has led to a significant increase in the number of people with at least one chronic medical condition. As a result, acquiring knowledge about chronicity in medical school is key for physicians to be able to provide proper management for these patients. However, the presence of chronicity in educational curricula is scarce and highly variable. On the one hand, this work consisted of a review of the educational programs of the main medical schools on each continent with the aim of identifying whether they included chronicity and, on the other, a literature review focused on identifying educational projects in the field of chronicity. The presence of chronicity in most medical schools' curricula is marginal and only a few universities include specific skills or competences linked to chronicity. In most cases, this topic appears as a global, cross-curricular competence that students are supposed to acquire over the course of their entire education. The literature review retrieved 21 articles on innovative teaching projects on chronicity. Direct contact with chronic patients, most times as "health mentors," the role of the student as a teacher, and continuous evaluation and feedback from all participants are the main characteristics of the projects analyzed. Some previously published experiences support the usefulness of innovative methodologies for better approaching this capital field in current medical practice. Despite the current situation in which chronic patients consume most healthcare resources, the presence of chronicity in medical schools is marginal. However, a literature review did identify some useful experiences for improving education on chronicity in medical schools. Medical schools should change their academic curricula and redirect them towards providing students all the necessary tools for improving their knowledge on chronicity.

Epidemiología de la anemia en adultos: estudio observacional de base poblacional / Epidemiology of anemia in adults: A population based study

Objetivo Determinar la prevalencia de la anemia y las características definitorias de los individuos que la padecen. Diseño Estudio observacional descriptivo de base poblacional. Variables extraídas de la base de datos informatizada de historias clínicas de atención primaria. Emplazamiento El presente estudio se realizó en la región sanitaria Metropolitana Nord, Barcelona. Participantes Pacientes con anemia evaluada mediante hemoglobina durante el año 2019. Criterios inclusión: mayores de 14 años, con determinaciones de hemoglobina por debajo del valor recomendado por la OMS. Criterio exclusión: no realizar seguimiento por la sanidad pública. Mediciones principales Variables demográficas, variables clínicas (fármacos, diagnóstico de anemia, paciente crónico complejo o enfermedad crónica avanzada. Variables consumo de recursos (número de visitas a atención primaria, número de ingresos hospitalarios y número de consultas a urgencias). Las variables demográficas y clínicas se evaluaron mediante frecuencias y porcentajes, media y desviación estándar para las variables cuantitativas. Las características de los diferentes subgrupos se compararon con la t de Student. Resultados La prevalencia de la anemia fue del 3,78%. Media de edad 64,5 años, el 60,8% mujeres. El 15,8% identificados como pacientes crónicos complejos. La hipertensión arterial presente en el 51,46%. El 50,97% fueron anemias ferropénicas. Consultaron al médico de familia 2,25 veces de media y a la enfermera de familia 1,49 veces. De las personas con criterios analíticos de anemia, solo el 46,57% tenían registrado un diagnóstico de anemia. Conclusiones En el territorio estudiado se ha objetivado un infraregistro del diagnóstico de anemia. Se observan diferencias en la caracterización por género y edad (AU)

Objective To determine the prevalence of anemia and the defining characteristics of the individuals who suffer from it. Design Population-based descriptive observational study. Variables extracted from the computerized database of primary care medical records. Setting This study was conducted in the Metropolitana Nord health region, Barcelona. Participants Patients with anemia evaluated by hemoglobin, during the year 2019. Inclusion criteria: older than 14 years, with hemoglobin determinations below the value recommended by the WHO. Exclusion criteria: no follow-up by public health. Main measurements Demographic variables, clinical variables (drugs, diagnosis of anemia, complex chronic patient or advanced chronic disease. Resource consumption variables (number of visits to primary care, number of hospital admissions, and number of visits to the emergency room). The variables demographic and clinical variables were evaluated using frequencies and percentages, mean and standard deviation for quantitative variables. The characteristics of the different subgroups were compared with Student's t-test. Results The prevalence of anemia was 3.78%. Mean age 64.5 years and 60.8% women. 15.8% identified as complex chronic patients. Arterial hypertension present in 51.46%. 50.97 were iron deficiency anemias. They consulted the family doctor 2.25 times on average and the family nurse 1.49. Of the people with analytical criteria for anemia, only 46.57 had a registered diagnosis of anemia. Conclusions In the territory studied, an under-reporting of the diagnosis of anemia has been observed. Differences are observed in the characterization by gender and age (AU)

[Epidemiology of anemia in adults: A population based study]. / Epidemiología de la anemia en adultos: estudio observacional de base poblacional.

OBJECTIVE: To determine the prevalence of anemia and the defining characteristics of the individuals who suffer from it. DESIGN: Population-based descriptive observational study. Variables extracted from the computerized database of primary care medical records. SETTING: This study was conducted in the Metropolitana Nord health region, Barcelona. PARTICIPANTS: Patients with anemia evaluated by hemoglobin, during the year 2019. INCLUSION CRITERIA: older than 14 years, with hemoglobin determinations below the value recommended by the WHO. EXCLUSION CRITERIA: no follow-up by public health. MAIN MEASUREMENTS: Demographic variables, clinical variables (drugs, diagnosis of anemia, complex chronic patient or advanced chronic disease. Resource consumption variables (number of visits to primary care, number of hospital admissions, and number of visits to the emergency room). The variables demographic and clinical variables were evaluated using frequencies and percentages, mean and standard deviation for quantitative variables. The characteristics of the different subgroups were compared with Student's t-test. RESULTS: The prevalence of anemia was 3.78%. Mean age 64.5 years and 60.8% women. 15.8% identified as complex chronic patients. Arterial hypertension present in 51.46%. 50.97 were iron deficiency anemias. They consulted the family doctor 2.25 times on average and the family nurse 1.49. Of the people with analytical criteria for anemia, only 46.57 had a registered diagnosis of anemia. CONCLUSIONS: In the territory studied, an under-reporting of the diagnosis of anemia has been observed. Differences are observed in the characterization by gender and age.

Protocolo de validación de la herramientade desprescripción LESS-CHRON en pacientespluripatológicos. Proyecto LESS-CHRON-VALIDATION / Validation protocol of the LESS-CHRON deprescription tool in multimorbidity patients. LESS-CHRON-VALIDATION Project

Objetivo: La desprescripción se considera una de las principales estrategias disponibles para el abordaje del plan terapéutico individualizado enpacientes pluripatológicos o crónicos complejos. Sin embargo, a pesar deser una práctica ya instaurada desde hace algunos años, se reclama lanecesidad de estudios que avalen la obtención de buenos resultados ensalud, además de herramientas que ayuden a su desarrollo en la prácticaclínica habitual. El objetivo de este proyecto es analizar el impacto en ladisminución de la farmacoterapia mediante la desprescripción de fármacos,aplicando la herramienta LESS-CHRON, en una población de pacientes deedad avanzada, polimedicada y con múltiples patologías.Método: Estudio cuasiexperimental, pre-post, multicéntrico. Las variables aanalizar se dividirán en dos grandes grupos: referidas a la esfera farmacológica y referidas a resultados en salud. Se recogerán en el momento basal,a los 3 y a los 6-12 meses. Se realizará una primera fase de screening paralocalizar a los pacientes candidatos, que permitirá obtener la informaciónrelativa a las oportunidades de desprescripción identificadas. La segundaconstituirá la fase de intervención, en la que se aplicará la herramientaLESS-CHRON y se llevará a cabo la desprescripción real de los fármacos.(AU)

Objective: Deprescribing is considered one of the main strategies available for preparing an individualized therapeutic plan in patients withmultiple pathologies or complex chronic conditions. However, despite thepractice has been in place for some years, there is a need for studies thatsupport the achievement of satisfactory health outcomes, as well as toolsthat help implement deprescribing in routine clinical practice. The objective of this project is to analyze the impact of reducing polypharmacy,through the LESS-CHRON deprescribing tool, on a population of elderlypolymedicated patients with multiple conditions.Method: This will be a quasi-experimental, pre-and-post interventionmulticenter cohort study. The variables to be analyzed will be dividedinto two large groups: those related to pharmacology and those related to health outcomes. They will be collected at baseline, at 3 and at6-12 months. A first screening phase will be carried out to recruit candidate patients and obtain information about the identified deprescribingopportunities. The second phase will constitute the intervention phase,where the LESS-CHRON tool will be applied and the actual deprescribingof the drugs will be carried out. (AU)

Digoxina: alternativas a la pauta de descanso / Digoxin: alternatives to the rest regimen

Introducción: La digoxina se caracteriza por estrecho margen terapéutico que hace dificultosa su dosificación y sea necesaria una monitorización de sus niveles séricos. Esto se hace más complejo en pacientes con nefropatía crónica que precisan de un mayor ajuste de dosis.Desarrollo de la experiencia:Presentamos el caso de una mujer de 88 años admitida en nuestra unidad en tratamiento con digoxina oral por insuficiencia cardiaca crónica con pauta de 1 comprimido diario con descanso los fines de semana, que presenta mal control de síntomas y niveles séricos de digoxina infraterapéuticos en controles. Al cambiar la formulación a jarabe oral pediátrico (Lanacordin® 0,05mg/mL) se consiguió un mejor nivel de los niveles del fármaco y del control de síntomas.Conclusiones:La utilización de la digoxina en jarabe oral puede ser una alternativa a la formulación con comprimidos, sobre todo en pacientes en los que el control de los niveles del fármaco puede resultar complejo por sus comorbilidades. (AU)

Introduction: Digoxin is characterized by narrow therapeutic margin which makes its dosing difficult and monitoring of its serum levels necessary. This becomes more complex in patients with chronic nephropathy who require a greater dose adjustment.Development of the experience:We present the case of an 88-year-old woman admitted to our unit under treatment with oral digoxin for chronic heart failure with a regimen of 1 tablet daily with rest at weekends, who presented poor symptom control and subtherapeutic serum digoxin levels in controls. Changing the formulation to pediatric oral syrup (Lanacordin® 0.05mg/mL) resulted in better drug levels and symptom control.Conclusions:The use of digoxin in oral syrup may be an alternative to tablet formulation, especially in patients in whom drug level control may be complex due to their comorbidities. (AU)

Dispensación excepcional. Resultados según tipo de farmacia / Exceptional dispensing. Results by type of pharmacy

JUSTIFICACIÓN: la farmacia comunitaria (FC) se enfrenta a diario con situaciones que impiden la dispensación adecuada del medicamento y que están relacionadas con la forma farmacéutica, el tamaño del envase, la idoneidad de una presentación determinada, el extravío de la medicación por parte del paciente, etc. en las que el farmacéutico se ve obligado a derivar al médico de Atención Primaria (AP) debido a que su intervención, si hiciera esa dispensación, superaría sus competencias profesionales.OBJETIVOS: estimar el número de incidencias que impiden dispensar el fármaco adecuado y que podrían ser susceptibles de resolución por parte del farmacéutico comunitario, pero que por la normativa actual precisan obligatoriamente de la intervención del médico prescriptor.Material y Métodos se han clasificado las FC en función del número de habitantes que contiene la localidad en la que se encuentran, y son:-Urbana: más de 50.000-Semiurbana: entre 5.000-50.000 -Rural: menos de 5000 Se ha registrado mediante un cuestionario alojado en una plataforma web, aquellas incidencias detectadas según los FR, en horario habitual de la farmacia, durante el periodo del 8-21 noviembre 2021, en FC de Aragón y Asturias. Para calcular el tamaño muestral se partió de los resultados del piloto realizado en Asturias en octubre de 2020.RESULTADOS: una vez depurada la base de datos se incorporaron al estudio 138.697 dispensaciones, correspondientes a 87 FC, que cumplimentaron adecuadamente los registros. Un 44,37 % proceden de farmacias urbanas, 39,94 % farmacias semiurbanas y 15,69 % rurales. (AU)

Cronicidad y deprescripción colaborativa de los tratamientos con Benzodiacepinas / Chronicity and collaborative deprescribing of benzodiazepine treatments

JUSTIFICACIÓN: las Benzodiacepinas (BZD) son psicofármacos con indicaciones clínicas para ansiedad e insomnio, entre otras. Las guías clínicas son muy claras en relación a la duración de los tratamientos (4-12 semanas incluyendo el periodo de retirada), su uso prolongado es habitual y se asocia con tolerancia y dependencia, síndrome de abstinencia y factores de riesgo asociados. La deprescripción propone “el proceso de desmontaje de la prescripción de medicamentos por medio de su revisión, que concluye con la modificación de dosis, sustitución oelimin ación de unos fármacos o adición de otros”. Objetivos: Evaluar la duración de los planes de tratamientos con BZD en una Farmacia Comunitaria de Tenerife e identificar variables asociadas a la cronificación de los tratamientos con BZD como son la polimedicación y la revisión del plan de tratamiento y una posible derivación al médico para la deprescripción. Método: La cronicidad ha sido estudiada en 127 pacientes entrevistados en una Farmacia Comunitaria de Santa Cruz de Tenerife desde agosto 2020-febrero 2021 mediante preguntas incluidas en el CRD del estudio prospectivo observacional, descriptivo y transversal con código: DAA-CLO-2020-01, clasificado por la AEMPS y aprobado por el CEIm del Hospital Universitario de Canarias y el del Servicio de Ordenación Farmacéutica del Servicio Canario de la Salud.RESULTADOS: los pacientes estudiados presentan una media de 6,5 años en tratamiento con BZD si bien el rango es de 0,2-40 años. Al preguntar por el tipo de tratamiento en el 71,65 % de los pacientes es crónico, frente al 28,35 % que lo reciben de manera puntual. (AU)

La esclerosis lateral amiotrófica (ELA) desde la Atención Primaria. Epidemiología y características clínico-asistenciales / Amyotrophic lateral sclerosis (ALS) from the perspective of Primary Care. Epidemiology and clinical-care characteristics

La ELA es una enfermedad poco frecuente en atención primaria (AP), representa un desafío para el médico de familia especialmente en atención domiciliaria. Objetivo: Conocer la incidencia y prevalencia de la ELA en un área de gestión de AP, las características clínicas y la utilización de recursos sanitarios. Diseño: Estudio observacional. Emplazamiento: Dirección de AP Costa de Ponent, Región Sanitaria Metropolitana Sur, Barcelona, Cataluña, España. Participantes: Pacientes con ELA ≥18 años diagnosticados hasta el 01/03/2017. Mediciones principales: Edad, sexo, características: forma de inicio (espinal, bulbar, otras), intervalo entre inicio de síntomas y diagnóstico, portadores gastrostomía percutánea, ventilación no invasiva o invasiva. Identificación en AP como paciente crónico complejo o con necesidades paliativas. Inclusión en programas de atención domiciliaria (PAD). Modelo de atención hospitalario. Resultados: Ochenta y un pacientes, edad media 65,6 años (±11,7), varones 49,4%. Forma de inicio: espinal 69%, bulbar 21%, otras 4%. Intervalo entre inicio de síntomas y diagnóstico 12 meses. Identificados como paciente crónico complejo o con necesidades paliativas 13,6%, incluidos en PAD 29 pacientes (35,8%). Atendidos en modelo hospitalario integral 79 pacientes (97,5%). Prevalencia 6,1/100.000 habitantes en 2017. Incidencia anual entre 1,2 casos/100.000 habitantes/año en 2012 y 3,5 casos/100.000 habitantes/año en 2016. Conclusiones: Utilizar gastrostomía percutánea en la ELA favorece la identificación como paciente crónico complejo o con necesidades paliativas e inclusión en PAD. Utilizar ventilación no invasiva favorece la inclusión en PAD. Los datos de incidencia y prevalencia de ELA son superiores a los descritos previamente en la misma área. Es necesaria la identificación precoz de estos pacientes en los modelos de atención a la cronicidad en equipos de AP.(AU)

Amyotrophic Lateral Sclerosis (ALS) is a rare disease in primary care (PC), it represents a challenge for the family doctor, especially in home care. Objective: To know the incidence and prevalence of ALS in an area of ??PA management, the clinical characteristics and use of health resources. Design: Observational study. Location: PC-Direction Costa de Ponent, South Metropolitan Health Region, Barcelona, Catalonia, Spain. Participants: Patients with ALS ≥18 years diagnosed until 03/01/2017. Main measurements: Age, sex, characteristics: form of appearance (spinal, bulbar, others), interval between onset of symptoms and diagnosis, percutaneous gastrostomy carriers, ventilation non-invasive or invasive. Identification in PC as a Complex Chronic Patient or with palliative needs (CCP). Inclusion in home care programs (PAD). Model of attention hospitable. Results: 81 patients, mean age 65.6 years (± 11.7), men 49.4%. Shape of onset: spinal 69%, bulbar 21%, another 4%. Interval between the onset of symptoms and diagnosis 12 months. Identified as a CCP 13.6%, 29 patients (35.8%) included in PAD. Attended in comprehensive hospital model 79 patients (97.5%). Prevalence 6.1/100,000 inhabitants in 2017. Annual incidence between 1.2 cases/100,000 inhabitants/year in 2012 and 3.5 cases/100,000 inhabitants/year in 2016. Conclusions: The use of percutaneous gastrostomy in ALS favors the identification as CCP or with palliative needs and inclusion in PAD. The use of non-invasive ventilation favors inclusion in PAD. The incidence and prevalence data for ALS are higher than those described above in the same area. Early identification is necessary of these patients in the chronic care models in PC teams.(AU)

[Amyotrophic lateral sclerosis (ALS) from the perspective of Primary Care. Epidemiology and clinical-care characteristics]. / La esclerosis lateral amiotrófica (ELA) desde la Atención Primaria. Epidemiología y características clínico-asistenciales.

Amyotrophic Lateral Sclerosis (ALS) is a rare disease in primary care (PC), it represents a challenge for the family doctor, especially in home care. OBJECTIVE: To know the incidence and prevalence of ALS in an area of ??PA management, the clinical characteristics and use of health resources. DESIGN: Observational study. LOCATION: PC-Direction Costa de Ponent, South Metropolitan Health Region, Barcelona, Catalonia, Spain. PARTICIPANTS: Patients with ALS ≥18 years diagnosed until 03/01/2017. Main measurements Age, sex, characteristics: form of appearance (spinal, bulbar, others), interval between onset of symptoms and diagnosis, percutaneous gastrostomy carriers, ventilation non-invasive or invasive. Identification in PC as a Complex Chronic Patient or with palliative needs (CCP). Inclusion in home care programs (PAD). Model of attention hospitable. RESULTS: 81 patients, mean age 65.6 years (± 11.7), men 49.4%. Shape of onset: spinal 69%, bulbar 21%, another 4%. Interval between the onset of symptoms and diagnosis 12 months. Identified as a CCP 13.6%, 29 patients (35.8%) included in PAD. Attended in comprehensive hospital model 79 patients (97.5%). Prevalence 6.1/100,000 inhabitants in 2017. Annual incidence between 1.2 cases/100,000 inhabitants/year in 2012 and 3.5 cases/100,000 inhabitants/year in 2016. CONCLUSIONS: The use of percutaneous gastrostomy in ALS favors the identification as CCP or with palliative needs and inclusion in PAD. The use of non-invasive ventilation favors inclusion in PAD. The incidence and prevalence data for ALS are higher than those described above in the same area. Early identification is necessary of these patients in the chronic care models in PC teams.

Specific model for the coordination of primary and hospital care for patients with diabetes mellitus. Evaluation of two-year results (2015-2017).

INTRODUCTION: Diabetes mellitus (DM) is one of the most prevalent chronicdiseases and has a significant health and social impact. Strict control of blood glucose levels and other risk factors for vascular disease (VD) reduces complications and mortality and is related to the quality of care received. Although care should be interdisciplinary, based on the coordination of primary care (PC) and hospital care (HC), little information is available on the effectiveness of the different existing intervention models. OBJECTIVE: To assess, in a population with DM from a healthcare area, the impact on health, quality of care, and effectiveness in the use of resources of a specific model of shared management of patients with DM (Instrument for Evaluation of Models of Chronic Care in Diabetes Mellitus; IEMAC-DM). PATIENTS AND METHODS: A quasi-experimental before-after intervention study in patients with DM in the Cádiz-San Fernando Healthcare Area (Andalusia, Spain) that allows for identifying the capacity of the program to improve the quality indicators both in the whole population with DM and in that referred to HC. For this, a working group consisting of healthcare professionals of different profiles and care levels was set up. An initial self-assessment was done using the IEMAC-DM tool and, after analysis of the preliminary results, improvement strategies were established and implemented. Finally, the clinical and resource management results were assessed before and two years after the implementation of the model. RESULTS: During the study period, no significant changes were seen in process indicators related to laboratory practices or examinations in the health area. The proportion of patients with acceptable metabolic control [glycosylated hemoglobin (HbA1c) level < 8%] was 49% in 2015 and 45% in 2017. The number of admissions related to acute myocardial infarction (AMI) and stroke remained constant, but there was an increase in the standardized ratio of major lower limb amputations (1.5 vs. 1.9). Of the 295 patients referred from PC to HC, the proportion of adequate referrals increased from 40% in 2015 to 76% in 2017 (P = .001). In the referred patients, a significant improvement was seen in the mean difference in glycosylated hemoglobin levels (HbA1c; 1.14 ± 1.73%; 95% CI: 0.73-1.55; P = .0001) and cholesterol (11.28 ± 40 mg/dL; 95% CI: 2.07-20.48; P = .012). CONCLUSIONS: This study shows that an intervention based on a chronicity care model adapted to patients with DM improves certain aspects related to the quality of care and the degree of metabolic control. Improving health outcomes will require long-term evaluation and, probably, other additional interventions.

La reforma de los sistemas sanitario y social: desarrollo del espacio asistencial sociosanitario / atención intermedia / The reform of the health and social systems: development of the socio-health care space / intermediate care

La pandemia por Covid-19 ha puesto de manifiesto de manera muy evidente y dolorosa, la fragilidad de nuestro sistema sanitario (Hospital de Agudos y Atención primaria) y social (ámbito residencial) en la atención a la cronicidad, especialmente la compleja y en la mayoría de los casos ligada a la edad avanzada.Proponemos la creación/desarrollo/reconocimiento de un espacio asistencial sociosanitario, especializado en la atención integral a la cronicidad compleja, como atención intermedia entre sistema sanitario y social, e integrada en ambos sistemas. (AU)

The pandemic by Covid-19 has shown in a very evident and painful way, the fragility of our health system (Hospital of Acutes and Primary Care) and social (residential area) in the attention to chronicity, especially complex and in most cases linked to advanced age. We propose the creation/development/recognition of a partner health and social space specialized in complex chronicity as an intermediate care between health and social system, as a specialized intermediate care integrated into both systems. (AU)

Group family psychotherapy during relapse. Case report of a novel intervention for severe and enduring anorexia nervosa / Psicoterapia familiar grupal durante la recaída. Caso clínico de una intervención novedosa para la anorexia nerviosa grave y duradera

Abstract Background Anorexia nervosa is a complex and highly variable disorder. Preventing patients from becoming resistant to treatments is fundamental since an important percentage develops a severe and enduring disorder; and because relapse is highly associated with psychiatric comorbidity, poor prognosis, and serious medical consequences due to malnutrition. Contemporary treatments for anorexia nervosa support the benefits of involving the family in treatment, and although the gold standard of family psychotherapy offers an excellent option for anorexia nervosa, that intervention is aimed at early stages, and therapeutic options for later stages of the disorder are reduced and not clearly established. Objective Expose the therapeutic effect of the protocol for severe and enduring cases of anorexia nervosa at relapse, used at the Clinic of Eating Behavior of the National Institute of Psychiatry, Ramón de la Fuente Muñiz, whose theoretical foundation is systemic therapy. Method To develop this case report, we carried out an in-depth review of the clinical records, and of the clinic attendance records of the case presented here. CARE clinical case report guidelines format were used. Results The case shows how a young woman, diagnosed with anorexia nervosa with clinical signs of severe and enduring anorexia nervosa (SE-AN), was able to achieve symptomatic remission after her parents, but not her, were administered the protocol for SE-AN. Discussion and conclusion Here we present an emblematic case showing the importance of getting the parents involved in the treatment of anorexia nervosa.

Resumen Antecedentes La anorexia nervosa es un trastorno complejo y muy variable. Evitar que los pacientes se vuelvan resistentes a los tratamientos es fundamental, pues un porcentaje importante desarrolla un trastorno grave y duradero; adicionalmente, la recaída está muy asociada con una alta comorbilidad psiquiátrica, un mal pronóstico y graves consecuencias médicas debido a la desnutrición. El tratamiento actual de la anorexia nervosa respalda los beneficios de involucrar a la familia en el tratamiento, y, aunque el estándar de oro en psicoterapia familiar ofrece una excelente opción para la anorexia nervosa, dicha intervención está orientada a etapas tempranas y las opciones para las etapas tardías del trastorno son reducidas, además de no estar claramente establecidas. Objetivo Exponer el efecto terapéutico del protocolo para casos graves y duraderos de anorexia nervosa en recaída, de la Clínica de Trastornos de la Conducta Alimentaria (CTA) del Instituto Nacional de Psiquiatría Ramón de la Fuente Muñiz, cuya base teórica es la terapia sistémica. Método Para integrar este caso, realizamos una revisión a fondo del expediente clínico y de los registros asistenciales del caso que aquí presentamos. Se utilizó el formato de reporte de caso de las guías CARE. Resultados El caso muestra cómo una joven, con signos clínicos de anorexia nervosa grave y duradera (AN-GD), pudo lograr remisión sintomatológica después de que sus padres, pero no ella, recibieran tratamiento con el protocolo para AN-GD. Discusión y conclusión Aquí presentamos un caso emblemático que muestra la importancia de involucrar a los padres en el tratamiento de la anorexia nervosa.

Specific model for the coordination of primary and hospital care for patients with diabetes mellitus. Evaluation of two-year results (2015-2017). / Modelo específico de coordinación entre atención primaria y hospitalaria para la atención a pacientes con diabetes mellitus. Evaluación de resultados a dos años (2015-2017).

INTRODUCTION: Diabetes mellitus (DM) is one of the most prevalent chronic diseases and has a significant health and social impact. Strict control of blood glucose levels and other risk factors for vascular disease reduces complications and mortality and is related to the quality of care received. Although care should be interdisciplinary, based on the coordination of primary care (PC) and hospital care (HC), little information is available on the effectiveness of the different existing intervention models. OBJECTIVE: To assess, in a population with DM from a healthcare area, the impact on health, quality of care, and effectiveness in the use of resources of a specific model of shared management of patients with DM (Instrument for Evaluation of Models of Chronic Care in Diabetes Mellitus; IEMAC-DM). PATIENTS AND METHODS: A quasi-experimental before-after intervention study in patients with DM in the Cádiz-San Fernando Healthcare Area (Andalusia, Spain) that allows for identifying the capacity of the program to improve the quality indicators both in the whole population with DM and in that referred to HC. For this, a working group consisting of healthcare professionals of different profiles and care levels was set up. An initial self-assessment was done using the IEMAC-DM tool and, after analysis of the preliminary results, improvement strategies were established and implemented. Finally, the clinical and resource management results were assessed before and two years after the implementation of the model. RESULTS: During the study period, no significant changes were seen in process indicators related to laboratory practices or examinations in the health area. The proportion of patients with acceptable metabolic control [glycosylated hemoglobin (HbA1c) level<8%] was 49% in 2015 and 45% in 2017. The number of admissions related to acute myocardial infarction and stroke remained constant, but there was an increase in the standardized ratio of major lower limb amputations (1.5 vs. 1.9). Of the 295 patients referred from PC to HC, the proportion of adequate referrals increased from 40% in 2015 to 76% in 2017 (p=0.001). In the referred patients, a significant improvement was seen in the mean difference in glycosylated hemoglobin levels (HbA1c; 1.14±1.73%; 95% CI: 0.73-1.55; p=0.0001) and cholesterol (11.28±40mg/dL; 95% CI: 2.07-20.48; p=0.012). CONCLUSIONS: This study shows that an intervention based on a chronicity care model adapted to patients with DM improves certain aspects related to the quality of care and the degree of metabolic control. Improving health outcomes will require long-term evaluation and, probably, other additional interventions.

Cronicidad, violencia y longitud de trayectoria criminal. Hombres detenidos por violencia doméstica / Chronicity, violence and criminal trajectory length. Men arrested for domestic violence

Resumen Los delincuentes crónicos resultan ser los responsables de la mayor parte de la actividad criminal, además de ser los más persistentes y violentos. Existe escasa evidencia longitudinal que permita conocer cómo se manifiesta la cronicidad en agresores de violencia doméstica. El objetivo de esta investigación es identificar el criterio más adecuado para diferenciar a los hombres crónicos y establecer la relación que existe entre cronicidad, violencia, versatilidad y duración de la carrera criminal en 10 505 hombres chilenos detenidos por delitos de violencia en el ámbito familiar en el 2007, con base en todas las nuevas detenciones producidas los siguientes diez años. El diseño es longitudinal pseudoprospectivo, tal como si correspondiera a un estudio longitudinal prospectivo. Los resultados muestran que tres o más delitos bastan para identificar adecuadamente carreras criminales crónicas, y que un 12.7% del total de hombres pueden considerarse graves, violentos y crónicos, al presentar una trayectoria criminal de entre ocho y diez años, ser responsables de más del 37% del total de las reincidencias, alcanzar un promedio de delitos significativamente alto y versátiles, así como una elevada prevalencia en delitos violentos.

Abstract Chronical criminals turn out to be responsible of most of the criminal activity, in addition to being the most persistent and violent. There exists limited longitudinal evidence that allows knowing how chronicity manifests itself in domestic violence aggressors. The objective of this investigation is to identify the most appropriate criteria to differentiate chronic men and establish the relationship between chronicity, violence and duration of the criminal career in 10 505 Chilean men arrested for domestic violence crimes in 2007, based on all new arrests produced the next 10 years. The design is a longitudinal pseudo-prospective, as if it corresponded to a prospective longitudinal study. The results show that three or more crimes are enough to properly identify chronic criminal careers, and that 12.7% of all men can be considered as serious, violent and chronic, presenting a criminal trajectory between eight and ten years, being responsible for more than 37% of total recidivism, reach a significantly high average of crimes and high prevalence of violent crimes.

Social Profile of Patients Admitted for COPD Exacerbations. A Gender Analysis. / Perfil social de los pacientes que ingresan por una agudización de EPOC. Un análisis desde una perspectiva de género.

OBJECTIVE: To describe and compare from a gender perspective the social profile of patients admitted to a respiratory unit for COPD exacerbations (COPDE). METHODOLOGY: A cross-sectional study in patients with serious COPDE in which demographic, clinical, and social data (economic situation, care, dependency for basic and instrumental activities, social risk, caregiver overload, use of social services) were collected using questionnaires and indices such as Barthel, Lawton-Brody, Zarit, Barber, and Gijón. A descriptive analysis was made of patients' social and healthcare situation, compared on the basis of gender. RESULTS: We included 253 patients, aged 68.9±9.8years, 58 (23%) women, FEV1 42.1±14.2%, and Charlson index 1.8±0.9; 37.9% were active smokers. In total, 55.2% had an income of less than €800/month, 46.2% had some dependency for basic activities, and 89.3% for instrumental activities, 89% presented social fragility, while 64% were in a situation of social problem/risk; 49% had a caregiver, 83% in a non-formal arrangement, 90.9% of whom were women, with some overload reported by 69.2%. A total of 21.4% lived alone, and 22.9% had contacted social services. Women with COPDE are younger, smoke more actively, and have fewer comorbidities. They have more scant economic resources and assistance and are in a poorer socio-familiar situation, but they are less dependent for some activities. CONCLUSIONS: The social profile of patients with serious COPDE admitted to respiratory units is very unfavorable, especially among women. These inequalities appear to go beyond differences in the expression of COPD, and are associated with gender.

La promoción de salud en la escuela como estrategia para el abordaje de la cronicidad en España / Health promotion in schools as a strategy for addressing chronic disease in Spain / A promoção da saúde na escola como estratégia para controlar a cronicidade em Espanha / La promotion de la santé à l'école comme stratégie pour faire face á la chronicité en Espagne

Resumen Objetivo: Este artículo aborda los temas que sirvieron de referencia teórica de una disertación de tesis doctoral. Se pretende analizar las principales conductas y factores de patologías crónicas que avalan la necesidad del enfoque promocional de salud en la escuela y a lo del todo el curso de vida, así como su impacto en la mejora de la salud global de la población y la reducción del gasto público en España. Material y métodos: Se ha utilizado una perspectiva crítica desde la que se hace una revisión reflexiva sobre dichos factores en el contexto español, estudiando la necesidad de abordaje temprano. Los factores analizados han estado relacionados con la alimentación y actividad física, salud bucodental, consumo de sustancias tóxicas, seguridad vial, sexualidad y bienestar emocional. Resultados: Se observa un descenso de actividad física en la etapa escolar. Tres de cada diez niños/as tienen sobrepeso u obesidad. La prevalencia de afecciones bucodentales ronda el 40% a los 6 años. El cannabis es la tercera droga más consumidas por los escolares de 14-18 años, después del tabaco y el alcohol. Más de la mitad de los fallecimientos por accidente de tráfico entre los jóvenes (18-24 años) fue durante la noche y fin de semana. España se consolida como tercer país de la Unión Europea con mayor número de abortos. Las infecciones de transmisión sexual afectan de forma desproporcionada a las adolescentes. Los trastornos de salud mental están entre los cuatro problemas más prevalentes de los niños/as menores de 15 años Conclusiones: Se concluye que las acciones educativas realizadas en la escuela desde las edades más tempranas sobre los factores y conductas pueden reducir considerablemente los costes individuales, económicos y sociales que acarrean las enfermedades crónicas, convirtiéndose en una necesidad estratégica para el abordaje de la cronicidad, que es uno de los mayores retos a los que se enfrenta el sistema sanitario español.

Abstract Object: This article focuses on the topics that served as theoretical reference of a doctoral dissertation. The aim is to analyze the main behaviors and factors of chronic pathologies that support the need of the promotional approach of health in the school and the whole life course, as well as its impact in the improvement of the global health of the population and the reduction of the public spending in Spain. Materials and methods: A critical perspective has been used from which a reflexive review of these factors in the Spanish context has been carried out, studying the need of an early approach. Factors related to diet and physical activity, oral health, toxic substance use, road safety, sexuality and emotional well-being have been analyzed. Results: There was a decrease in physical activity in the school stage. Three out of ten children are overweight or obese. The prevalence of oral diseases is around 40% at 6 years. Cannabis is the third most consumed drug by schoolchildren aged 14-18, after tobacco and alcohol. More than half of the deaths due to traffic accidents among young people (18-24 years old) occurred during the night and weekend. Spain is consolidated as the third country in the European Union with the highest number of abortions. Sexually transmitted infections disproportionately affect teenagers. Mental health disorders are among the four most prevalent problems of children under 15 years of age. Conclusions: It is concluded that educational actions carried out in schools from the earliest ages on behavioral risk factors can considerably reduce the individual, economic and social costs of chronic diseases, becoming a strategic necessity for dealing with chronic diseases, which is one of the greatest challenges facing the Spanish health system.

Resumo Objetivo: Este artigo aborda os temas que foram usados como referência teórica numa tese de doutoramento. Pretendeu-se analisar os principais comportamentos e fatores relacionados com as patologias crónicas que suportam a necessidade de uma abordagem de promoção de saúde na escola e em todo o ciclo de vida, bem como o seu impacto na melhoria da saúde global da população e na redução das despesas públicas em Espanha. Materiais e métodos: Utilizou-se uma perspectiva crítica a partir de uma revisão reflexiva sobre esses fatores no contexto espanhol, estudando a necessidade de intervenção precoce. Os fatores analisados foram relacionados com a alimentação, a atividade física, a saúde bucal, o consumo de substâncias tóxicas, a segurança rodoviária, a sexualidade e o bem-estar emocional Resultados: Observou-se uma diminuição da atividade física em crianças de idade escolar. Três em cada dez crianças sofrem excesso de peso ou obesidade. A prevalencia de doenjas bucais é de cerca de 40% aos 6 anos. A Cannabis é a terceira droga mais consumida por alunos dos 14 a 18 anos, depois do consumo de tabaco e álcool. Mais da metade das mortes por acidentes rodoviários dos jovens entre os 18 e 24 anos ocorreram durante a noite e no fim-de-semana. A Espanha é o terceiro país da Uniao Europeia com mais número de abortos. As infecções sexualmente transmissíveis afetam desproporcionalmente as adolescentes. Os transtornos mentais estao entre os quatro problemas mais prevalentes em crianças menores de 15 anos de idade. Conclusões: Conclui-se que as ações educativas realizadas na escola, em idades precoces, sobre os fatores de risco comportamentais, podem reduzir consideravelmente os custos individuais, económicos e sociais que as doenjas crónicas acarretam, transformando-se numa necessidade estratégica para a abordagem da cronicidade, que é um dos maiores desafios que o sistema de saúde espanhol enfrenta.

Résumé Objectif: Cet article se centre sur les sujets qui ont servi de référence théorique pour une thése de doctorat. L'objectif est d'analyser les principaux comportements et facteurs de pathologies chroniques qui supportent le besoin de l'approche promotionnelle de la santé á l'école et tout au long de la vie, ainsi que son impact sur l'amélioration de la santé globale de la population et la réduction du dépenses publiques en Espagne. Matériaux et méthodes: Une perspective critique a été utilisée á partir de laquelle une revue réflexive est faite sur ces facteurs dans le contexte espagnol, en étudiant la nécessité d'une approche précoce. Les facteurs analysés ont été liés á l'alimentation et á l'activité physique, á la santé bucco-dentaire, á la consommation de substances toxiques, á la sécurité routiére, á la sexualité et au bien-etre émotionnel. Résultats: Il y a une diminution de l'activité physique au stade scolaire. Trois enfants sur dix sont en surpoids ou obéses. La prévalence des maladies buccales est d'environ 40% á 6 ans. Le cannabis est la troisiéme drogue la plus consommé par les écoliers agés de 14 á 18 ans, aprés le tabac et l'alcool. Plus de la moitié des décés dus aux accidents de la circulation chez les jeunes (18-24 ans) ont eu lieu pendant la nuit et le week-end. L'Espagne est consolidée comme le troisiéme pays de l'Union européenne avec le plus grand nombre d'avortements. Les infections sexuellement transmissibles touchent de maniére disproportionnée les adolescentes. Les troubles de santé mentale sont parmi les quatre problémes les plus courantes chez les enfants de moins de 15 ans. Conclusion: Les actions éducatives menées á l'école dés le plus jeune age sur les facteurs et les comportements peuvent réduire considérablement les coúts individuels, économiques et sociaux qu'apportent les maladies chroniques, devenant une nécessité stratégique pour l'approche de la chronicité, qui est l'un des plus grands défis du systéme de santé espagnol.

Are planets lined up for nurses to cross the mirror? / ¿Están alineados los planetas para que las enfermeras crucen el espejo?

Since the publication in 2010 of the document 'Nursing in front of the mirror: myths and realities', the nursing profession has worked hard to study and recognise its myths and realities. Now is the time to ask whether the profession is yet in a position to stop standing in front the looking glass and, like Alice, cross through.