[Family and community medicine: The most chosen specialty in the MIR]. / Medicina familiar y comunitaria: la especialidad más elegida en el MIR.

Family and Community Medicine is the most offered and chosen specialty in the MIR (Spanish medical residency examination), however, every year its attractiveness is questioned due to not all offered positions being filled and a certain number of resident doctors deciding not to continue in this specialty once started. In this context, some of the proposals to address the problem focus on increasing the supply when the facts show that the challenge lies in addressing the demand by making the specialty and its professional scope more attractive. The problem and its determinants are analyzed in this context by focusing on four elements that may be influencing it: the vocational aspects of medical graduates who pursue specialization, the characteristics of the specialty program and the teaching units where training is carried out, the presence of family medicine in the university as a key element for knowledge and affinity to this specialty from undergraduate studies, and finally, the situation of primary care as the space where training is materialized and the priority setting for the professional practice of future specialists.

[The new program of the Family and Community Medicine specialty: An opportunity not to be missed]. / El nuevo programa de la especialidad de medicina familiar y comunitaria: una oportunidad que no se debe perder.

The training program for the Family and Community Medicine specialty (MFyC), which has been in effect since 2005, is currently undergoing a review and update process. This article proposes contributions to deepen the specific contents of the specialty in order to guide towards a more significant competency development. To carry out values-oriented training, it is suggested to deploy the values function and promote the creation of care spaces where the daily experience of those values is possible. It is proposed to establish a scale of values where the two essential values of the family physician are, in this order, a commitment to the individual person, and a commitment to the group of people under their care. Additionally, it is proposed to reorganize the competency map around five competency integrators or meta-competencies: patient-centered clinical method, population-based clinical governance, primary care oriented to the community, health promotion or community health based on assets, and research in the family and community field.

Obstructive sleep apnoea in the elderly: role of continuous positive airway pressure treatment.

Almost all the information about the effect of continuous positive airway pressure (CPAP) in patients with obstructive sleep apnoea (OSA) comes from clinical trials involving only middle-aged patients. The objective of this study was to assess the effect of CPAP treatment in elderly patients with severe OSA on clinical, quality-of-life and neurocognitive spheres. We performed an open-label, randomised, multicentre clinical trial in a consecutive clinical cohort of 224 elderly (≥70 years old) patients with confirmed severe OSA (apnoea-hypopnea index ≥30) randomised to receive CPAP (n=115) or no CPAP (n=109) for 3 months. A sleep study was performed by either full polysomnography or respiratory polygraphy. CPAP titration was performed by an autoCPAP device. The primary endpoint was quality of life (Quebec Sleep Questionnaire) and secondary endpoints included sleep-related symptoms, presence of anxiety/depression, office-based blood pressure and some neurocognitive tests. The mean±sd age was 75.5±3.9 years. The CPAP group achieved a greater improvement in all quality-of-life domains (p<0.001; effect size: 0.41-0.98), sleep-related symptoms (p<0.001; effect size 0.31-0.91) as well as anxiety (p=0.016; effect size 0.51) and depression (p<0.001; effect size: 0.28) indexes and some neurocognitive tests (digit symbol test (p=0.047; effect size: 0.20) and Trail Making Test A (p=0.029; effect size: 0.44)) in an intention-to-treat analysis. In conclusion, CPAP treatment resulted in an improvement in quality of life, sleep-related symptoms, anxiety and depression indexes and some neurocognitive aspects in elderly people with severe OSA.

[Palliative care regulation and assisted death]. / Regulación de los cuidados paliativos y muerte asistida.

This article analyzes the Mexican regulation on palliative care and its relationship with the public debate on assisted death or suicide. This paper focuses on the rights that people with incurable diseases have, given the current contents of the General Health Statute and other applicable rules. Its main purpose is to activate the public debate on these matters.

Effects of overmilking and liner type and characteristics on teat tissue in small ruminants.

The aim of this work was to study the effect on teat wall thickness and canal length in sheep and goats of overmilking for 2 min (OM+2) and of milking with used (AL; +3000 milkings) and twisted (TL; 45°) liners in sheep and goats, as well as the effect of milking goats with liners designed for sheep (SL, shorter length and diameter than liners for goats). To this end, we performed four experiments in goats and three in sheep, in a Latin square design with two experimental periods. During the experimental period 4 controls were carried out, performing ultrasound scans before and immediately after milking to determine the teat wall thickness (TWT), teat wall area (TWA), teat end area (TEWA) and teat canal length (TCL). OM+2 caused a significant increase in TWT, TWA, TEWA and TCL in goats and in TWA, TEWA and TCL in sheep. Liner features had a strong influence on the variables studied; aged liners caused significant changes in TWT and TCL in goats and in TWT in sheep; twisted liners produced a significant effect on the increase of TWT and TCL in goats, without reaching significance level in sheep; and milking goats with sheep liners led to a significant increase in TWT, TWA, TEWA and TCL. In practice, it is therefore important to avoid overmilking and the use of worn-out liners. It is also necessary to use liners designed for the morphological features of each species, taking special care to carry out periodic liner positioning revisions to ensure the benefits of pulsation on the teat end. Finally, it would be necessary to carry out long-term experiments to study whether the increase in thickness observed in some experiments is sufficient to affect milking efficiency and mammary gland health status.

How does the milk removal method affect teat tissue and teat recovery in dairy ewes?

The aim of this work was to study how machine milking (MM) carried out in suitable conditions affects teat wall thickness and teat canal length and their return after milking to pre-milking conditions, in comparison with other milk extraction methods considered biological referents: lamb suckling (LS), milk removal by catheter (RC) and hand milking (HM). Three Latin square experiments were designed, using 11 ewes in the first experiment (LS), 13 in the second (RC) and 12 in the third (HM). Each of the Latin squares was divided into two periods: in the first, the left gland of each animal was machine milked and the corresponding treatment (LS, RC and HM) was applied to the right gland. Subsequently, in the second period the extraction methods were interchanged. During the experimental period, 4 sampling days were carried out (2 in each experimental period), where ultrasound scans were taken before (B) and immediately after milking (A) and at 1 (1 h), 2 (2 h), 3 (3 h), 4 (4 h), 6 (6 h), 8 (8 h) and 10 (10 h) hours after milking finished. Teat wall thickness (TWT), teat wall area (TWA), teat end area (TEWA) and teat canal length (TCL) were measured in all the ultrasound images. MM increased TWT after milking compared with RC. TWT, TWA, TEWA and TCL were lower (P<0.05) in HM than in MM. No significant differences (P>0.05) were found between LS and MM for any variable. The extraction method affected the recovery time of the variables, with total teat recovery at 6 h after RC and 4 h after HM. In the case of LS, the TEWA and TCL values were recovered sooner, as of 3 h. Teat recovery time after MM was similar to the extraction method with which it was compared in each experiment. Thus, considering the similar increase in wall thickness and their recovery time compared with the reference methods, it was concluded that machine milking, carried out in optimum conditions and respecting the time interval between milkings usually applied on sheep farms (8-12 h), would not affect teat integrity. Moreover, given the variability observed in teat thickness recovery time between the different experiments, further research should be carried out to study which factors intrinsic and extrinsic to the animal may affect the teat wall thickness and recovery time after machine milking.

[Constitutional analysis of Mexican Official Norm NOM-174-SSA1-1998 for the handling of obesity]. / Análisis Constitucional de la Norma Oficial Mexicana NOM-174-SSA1-1998, Para el Manejo Integral de la Obesidad.

The First Chamber of the Mexican Supreme Court of Justice decided, by a majority of four votes, on a case where it had to be evaluated if some articles of a Mexican Official Norm (NOM) on obesity violated human rights. The majority in the chamber concluded that the restrictions went against Medics' prescribing or therapeutic rights, and therefore their freedom to work. Justice Cossío Díaz voted against the judgment and wrote a separate opinion where he holds, first of all, that the prescribing right works as a guideline for the medical profession and is not an essential element of the freedom to work. Secondly, he points out that the freedom to work is not an absolute right, for it has certain limits permitted by the Constitution. Consequently, experts' opinions should have been consulted for them to be able to determine if the NOM´s requirements were in accordance with the Constitution. Finally, he considers that the judgment should have introduced a balancing test between freedom to work and the patient's health rights, since this last-mentioned right was what the NOM intended to protect.

Effect of the Onset of Intramammary Infection on the Electrical Conductivity of Ewe's Milk and Study of Various Algorithms for Its On-Line Detection.

The aim of this study was to determine the effect of the onset of intramammary infection (IMI) on the electrical conductivity (EC) of ewe milk and assess the detection capability of various algorithms based on daily glandular milk EC measurement. An experiment was carried out with 26 Manchega sheep located at the farm of the Miguel Hernández University, Elche, Spain. The variables in milk from the gland (production, EC) were monitored daily for 2 weeks during the morning and evening milking; once infection was established in the gland, the variables were measured for a further 4 weeks. In addition, the SCC, sodium, potassium, chloride and milk macro-compositions were analysed. The sensitivity, specificity and positive and negative predictive values for IMI detection of different algorithms were calculated using the EC variable. It was observed that the onset of IMI resulted in an increase in SCC and a significant decrease in yield, and EC rose significantly when infection occurred bilaterally. The best results for IMI detection were obtained with the algorithm that detected deviations greater than 3σ of the conductivity ratio between collateral glands with respect to a moving average calculated with a time horizon of 10 days (50% sensitivity and 100% specificity).

Long-Term Feeding of Dairy Goats with 40% Artichoke by-Product Silage Preserves Milk Yield, Nutritional Composition and Animal Health Status.

The aim of this work is to study the effect of 40% inclusion of artichoke by-product silage (AB) in dairy goat diets on milk yield, composition and animal health status during a full lactation period compared to an isoenergetic and isoproteic mixed ration based on alfalfa hay and a cereal and legume mixture. Milk yield was not affected by the dietary treatments, and neither was body weight. AB treatment reduced whey protein (0.38 vs. 0.42%, p < 0.05) and milk urea concentrations (687 vs. 773 mg/L, respectively, p < 0.001), and did not affect total true protein (3.22 vs. 3.24% p > 0.05) or other macro-composition variables. AB treatment showed higher milk concentrations of Ca (p < 0.05), Mn (p < 0.01), Cu (p < 0.01) and Zn (p < 0.001) compared to the control group (C). Slight differences were observed in milk fatty acid profile without any negative effects (p > 0.05) on the blood cholesterol and glucose of goats. The AB group reduced blood urea due to its high dietary total phenol content. However, it had a positive effect on ß-hydroxybutyrate (p < 0.05) and nonesterified fatty acids (p > 0.05). It was concluded that 40% artichoke by-product inclusion in dairy goat feed for the whole lactation period (23 weeks) is a sustainable solution, reducing feeding cost by 12.5% per kg of dry matter, contributing to a better circular economy without any negative repercussions on the productivity and health of Murciano-Granadina dairy goats.

Optimal Parameters to Milk Murciano-Granadina Goats in Mid and Low-Line Milking Parlours.

Recent short-term studies on Murciano-Granadina goats have established that the optimal parameters to set up the milking machines are different according to the milk pipes height. Two groups of 52 fresh goats each were employed in 2 different experiments to confirm during an entire lactation period the best combinations of system vacuum pulsation rate and pulsator ratio in low-line and mid-line milking parlours. The experiment performed in the low-line milking parlour included one group milked with 40 KPa vacuum system level, 90 puls/min pulsation rate and 60/40 pulsation and a second group milked with 38 KPa vacuum system level, 90 puls/min pulsation rate and 60/40 pulsation ratio. The experiment carried out in mid-line included one group milked with 40 KPa vacuum system level, 90 puls/min pulsation rate and 60/40 pulsation ratio and a second group milked with 40 KPa vacuum system level, 120 puls/min pulsation rate and 60/40 pulsation ratio. Variables studied included milking efficiency, milk composition, cortisol, SCC and intramammary infections, teat-end oedema after milking and vacuum dynamics during milking. Considering the results of an entire lactation period, it was confirmed that when milking in mid-line, the combination of 40 KPa system vacuum, 90 cycles/min pulsation rate and 60/40 pulsator ratio showed optimal results of the above-mentioned variables. On the other hand, the use of 40 KPa in a low-line system increased the milk cortisol values (0.34 ± 0.1 vs. 0.44 ± 0.1 ng/mL) without any other advantage. Thus, the recommendation is to use a combination of 38 KPa system vacuum, 90 cycles/min pulsation rate and 60/40 pulsator ratio to enhance animal welfare.

Effect of mid-line or low-line milking systems on milking characteristics in goats.

Two experiments were carried out to compare mechanical milking in mid-level (ML) and low-level (LL) milkline in goats. The first trial used 40 intramammary infection (IMI)-free goats that had been milked in ML during a pre-experimental period of 4±1 weeks post partum. These animals were divided into two groups (n=20), randomly assigning each group to ML or LL milking for a 17-week experimental period. During this period, several strategies were applied to increase teat exposure to pathogens in both experimental groups. The IMI rate was the same in both experimental groups (30% of goats), although the majority of new infections appeared earlier in ML (weeks 1-5) than in LL (weeks 7-16). Teat-end vacuum range (maximum minus minimum vacuum) was higher in ML than in LL, but no significant differences were found in the remaining variables [milk production and composition, somatic cell count (SCC), frequency of liner slips+teatcups fall off]. In the second experiment, in a crossover design (54 goats in fourth month of lactation; 2 treatments, ML and LL, in 2 experimental periods each lasting 1 week) it was observed that both the milk fractioning (reduced machine milk and increased machine stripping) and average machine milk flow worsened slightly in ML milking; in contrast, no differences were observed in total milking time or teat thickness changes after milking. It was concluded that the differences found between ML and LL are not sufficiently important to discourage breeders from using ML in goat milking.

Evaluation of commercial probes for on-line electrical conductivity measurements during goat gland milking process.

The measurement of the milk electrical conductivity (EC) during mechanical milking has been widely studied for mastitis detection on cows because its improving of welfare and animal health, although research about small ruminants is scarce. The aim of this study was to evaluate the performance of three commercial conductimeters to be used during mechanical milking of small ruminant halves, especially Murciano-Granadina goats. The objective of this research was to integrate the probes on the milking unit and to check the suitability of the probe selected. The results presented in this research have guided authors to discard the commercial probes and to establish the requirements of a new probe design that is briefly outlined in the conclusions of this contribution.

Quality and Functional Parameters of Fermented Milk Obtained from Goat Milk Fed with Broccoli and Artichoke Plant By-Products.

Large amount of vegetal by-products are generated during production and processing steps. Introducing silage from vegetable by-products into dairy goat feed would be of great interest from the point of view of reducing costs and supporting the circular economy. The aim of this research was to study the effect of 40% inclusion of silage broccoli by-products and artichoke plant by-products in the diet of Murciano-Granadina goats throughout the lactation to establish milk suitability for fermented milks production. The novelty of this study is the use of milk from goats fed for a long term with a high inclusion of silages from artichoke plant and broccoli by-products, being the first one on broccoli inclusion. Two starter cultures thermophilic (YO-MIXTM300), and, mesophilic (MA400) were used and fermented milks were analyzed at two storage times after fermentation. Fermentation enhances antioxidant properties of fermented milks from all diets (p < 0.05), especially when mesophilic starter cultures are used. The main findings are that long term inclusion of 40% silage from broccoli and artichoke plant by-products in balanced diets of dairy goats yields milk suitable for fermentation by yogurt and cheese cultures, the inclusion of broccoli silage enhances antioxidant properties (p < 0.05), and, the inclusion of plant artichoke enhances fatty acids health indexes (p < 0.05).

Multicomponent, high-intensity, and patient-centered care intervention for complex patients in transitional care: SPICA program.

Multimorbidity is increasingly present in our environment. Besides, this is accompanied by a deterioration of social and environmental conditions and affects the self-care ability and access to health resources, worsening health outcomes and determining a greater complexity of care. Different multidisciplinary and multicomponent programs have been proposed for the care of complex patients around hospital discharge, and patient-centered coordination models may lead to better results than the traditional ones for this type of patient. However, programs with these characteristics have not been systematically implemented in our country, despite the positive results obtained. Hospital Universitario de Canarias cares for patients from the northern area of Tenerife and La Palma, Spain. In this hospital, a multicomponent and high-intensity care program is carried out by a multidisciplinary team (made up of family doctors and nurses together with social workers) with complex patients in the transition of care (SPICA program). The aim of this program is to guarantee social and family reintegration and improve the continuity of primary healthcare for discharged patients, following the patient-centered clinical method. Implementing multidisciplinary and high-intensity programs would improve clinical outcomes and would be cost-effective. This kind of program is directly related to the current clinical governance directions. In addition, as the SPICA program is integrated into a Family and Community Care Teaching Unit for the training of both specialist doctors and specialist nurses, it becomes a place where the specific methodology of those specialties can be carried out in transitional care. During these 22 years of implementation, its continuous quality management system has allowed it to generate an important learning curve and incorporate constant improvements in its work processes and procedures. Currently, research projects are planned to reevaluate the effectiveness of individualized care plans and the cost-effectiveness of the program.

Analysis and evaluation of the operational characteristics of a new photodynamic therapy device.

One of the key aspects of photodynamic therapy is the light source that is used to irradiate the lesion to be treated. The devices used must ensure that their emission spectrum matches the absorption spectrum of the photosensitizer, so that treatment radiation is delivered only on the target area, without irradiating healthy tissue at superficial or deep levels. Irradiance values must be adequate in order to avoid thermal damage, exceed the oxygen replenishment rate and avoid long treatment times. Furthermore, the device should be user-friendly, inexpensive, and able to be adapted to different photosensitizers. We have developed an easy-to-use and highly customizable device based on LED technology. Its innovative geometric design allows radiation to be delivered to a small treatment surface, since the LEDs are arranged in three arms, the configuration of which directs their radiation on the treatment point. Different high-power color LEDs are disposed on the arms, and can be independently selected based on the most effective wavelengths for exciting the different photodynamic therapy photosensitizers. We have tested the prototype in 5 different patients (1 actinic keratose, 1 actinic cheilitis, 1 superficial basal cell carcinoma and 2 Bowen's disease) and after 1-2 sessions of total cumulative dose of 25-50 J / cm2, 100% clearance of lesions were obtained. Our device can be used by any professional in the field, whether for medical or research purposes. It facilitates the development of treatment protocols and trials with different photosensitizers.

[Epilepsy as a cause of removal from the Armed Forces]. / La epilepsia como causa de inutilidad en las Fuerzas Armadas.

Recently, the First Chamber of the Supreme Court of Justice decided two important cases where the Ministers were urged to evaluate whether a provision of the Social Security Institute for the Mexican Armed Forces Statute making"epilepsy and other forms of seizures or equivalents" a cause of removal from the Army on the basis of "uselessness in the service" violates the equality and non-discrimination principle laid down in article 1 of the Federal Constitution. Four Supreme Court Ministers declared that the provision was constitutional. Justice Minister Cossío Díaz disagreed and wrote a separate opinion where he holds that the aforementioned provision is unconstitutional, since its excessively wide and undetermined language opens the door to declarations of "uselessness for the service" without ensuring this rests in every case in a genuine incapacity to develop a job in the Army.Before reaching this conclusion Justice Minister Cossío asked for information to the National Institute of Neurology and Neurosurgery. It was on these basis that he sustained that the aforementioned legal provision does not satisfy an adequate means-end correlation, since it allows the Army to withdraw from service ­on the basis of "uselessness"­persons whose medical condition is sometimes episodic; others curable; others, if not curable, pharmaceutically controlled; and, in cases where it does limit the kinds of activity, that the person can develop, it does so in a way that can only be determined by an intensely individualized basis.