[Should hydration and artificial nutrition be accepted as a palliative care?]. / Se considera la hidratación y la nutrición artificial como un cuidado paliativo?

BACKGROUND: Ethical considerations are becoming more and more common in clinical practice. There is no unanimous agreement on which measures should be deemed as basic care, specially regarding hydration and artificial nutrition. AIM: To know the opinion of lay people and health professionals, stratified according to their university degree, about which palliative measures, including hydration and artificial nutrition, should be judged as palliative care. METHODS: A descriptive transversal study has been designed to know the opinion of 256 subjects: 91 users of the National Health System (NHS), 80 nurses, 47 pharmacists and 38 physicians. A questionnaire examined which of the following measures should be considered as palliative care: hygiene, analgesia, pressure ulcer care, position change, sedation, oxygen administration, urinary catheter, hydration, enteral and parenteral nutrition. RESULTS: More than 50% of the participants think that all the proposed measures can be considered as a palliative care, except parenteral nutrition. There is unanimous agreement to accept analgesia, pressure ulcer care, position change and enteraL nutrition as basic care, but there is disagreement in relation to hygiene (p = 0.000), sedation (p = 0.005), oxygen administration (p = 0.007), urinary catheter (p = 0.011) and parenteral nutrition (p = 0.000). There were not differences of opinion after adjusting for age, sex, religious beliefs, and length of professional experience among the individuals that answered the questionnaire. CONCLUSION: There is no agreement on which measures should be considered as palliative care. Opinions differ regarding hygiene, sedation, oxygen administration, urinary catheterisation and parenteral nutrition. In comparison to enteral nutrition, many responders believe that parenteral nutrition is a therapeutic option. The opinions shown in this questionnaire were independent from the demographic characteristics of the subjects that answered it.

¿Se considera la hidratación y la nutrición artificial como un cuidado paliativo? / Should hydration and artificial nutrition be accepted as a palliative care?

Fundamento: Cada vez son más frecuentes los dilemas éticos en la práctica clínica. No existe acuerdo unánime, en especial en lo relativo a la hidratación y nutrición artificial, sobre que medida debe ser considerada como un cuidado básico. Objetivo: Conocer la opinión del personal sanitario, diferenciando la titulación universitaria, sobre que medidas de cuidado paliativo, incluyendo la hidratación y la nutrición artificial, deben ser consideradas como cuidado paliativo. Material y metodos: Se ha diseñado un estudio de campo descriptivo transversal, en el que se analiza la opinión de 256 individuos mediante las respuestas a un cuestionario: 91 usuarios del Sistema Nacional de Salud, 80 enfermeras, 38 médicos y 47 farmacéuticos sobre qué medida de las siguientes debe ser considerada como cuidado paliativo: higiene, analgesia, cuidado de las escaras, cambios posturales, sedación, oxigenoterapia, sondaje urinario, hidratación intravenosa, nutrición enteral y nutrición parenteral. Resultados: Más del 50% de los encuestados valora todas las medidas interrogadas como paliativas, a excepción de la nutrición parenteral. Entre los diversos grupos no existen diferencias en considerar a la analgesia, cuidado de escaras, cambios posturales, sueroterapia y administración de nutrición enteral como un cuidado básico, pero sí existen diferencias de opinión sobre la higiene (p = 0,000), sedación (p = 0,005), oxigenoterapia (p = 0,007), sondaje urinario (p = 0,011) y nutrición parenteral (p = 0,000). La edad, sexo, creencia religiosa y años de experiencia profesional en el ámbito sanitario del encuestado no influyen los resultados obtenidos. Conclusiones: No existe unanimidad entre los individuos, en qué medida debe ser considerada como cuidado paliativo. Se discrepa en relación a la higiene, la sedación, la oxigenoterapia, el sondaje urinario y la nutrición parenteral. Esta última medida se considera más como una opción terapéutica que la nutrición enteral. La opinión no depende de las características sociodemográficas de la población estudiada (AU)

Background: Ethical considerations are becoming more and more common in clinical practice. There is no unanimous agreement on which measures should be deemed as basic care, specially regarding hydration and artificial nutrition. Aim: To know the opinion of lay people and health professionals, stratified according to their university degree, about which palliative measures, including hydration and artificial nutrition, should be judged as palliative care. Methods: A descriptive transversal study has been designed to know the opinion of 256 subjects: 91 users of the National Health System (NHS), 80 nurses, 47 pharmacists and 38 physicians. A questionnaire examined which of the following measures should be considered as palliative care: hygiene, analgesia, pressure ulcer care, position change, sedation, oxygen administration, urinary catheter, hydration, enteral and parenteral nutrition. Results: More than 50% of the participants think that all the proposed measures can be considered as a palliative care, except parenteral nutrition. There is unanimous agreement to accept analgesia, pressure ulcer care, position change and enteraL nutrition as basic care, but there is disagreement in relation to hygiene (p = 0.000),sedation (p = 0.005), oxygen administration (p = 0.007), urinary catheter (p = 0.011) and parenteral nutrition (p = 0.000). There were not differences of opinion after adjusting for age, sex, religious beliefs, and length of professional experience among the individuals that answered the questionnaire. Conclusion: There is no agreement on which measures should be considered as palliative care. Opinions differ regarding hygiene, sedation, oxygen administration, urinary catheterisation and parenteral nutrition. In comparison to enteral nutrition, many responders believe that parenteral nutrition is a therapeutic option. The opinions shown in this questionnaire were independent from the demographic characteristics of the subjects that answered it (AU)

Consideraciones sobre la calidad de vida profesional en los trabajadores de atención primaria de Madrid / Considerations on the professional quality of life of primary care workers in Madrid

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[Cross-cultural adaptation of a questionnaire for measuring the quality of life of patients taking oral anticoagulants]. / Adaptación transcultural de un cuestionario para medir la calidad de vida de los pacientes con anticoagulación oral.

OBJECTIVE: To adapt to Spanish culture and language a questionnaire developed to evaluate the quality of life of patients taking oral anticoagulation treatment (OAT) and to measure its validity. DESIGN: A descriptive observation study to validate an instrument to measure health-related quality of life. SETTING: Primary and specialist care. PARTICIPANTS: 225 patients, all the patients at our centre who were on OAT and a consecutive sample of patients on OAT from the referral hospital's haemotology service. MAIN MEASUREMENTS: Direct translation, back-translation, and pilot study. Factor analysis and item-dimension grouping, internal consistency analysis and analysis of the item-total correlation of the definitive version of the questionnaire in Spanish. RESULTS: Mean age was 65 (SD=13 years); 51% were women; 45.8% were monitored in PC. Validity study: factor analysis extracted 5 factors that explained 41.62% of total variance value and obtained a grouping different from the original; Cronbach's alpha was .82 overall and ran from .56 to .74 in the various dimensions; and item-total correlation analysis had statistically significant values, except for question 29. CONCLUSIONS: After adaptation to Spanish culture and language of a questionnaire developed to evaluate the quality of life of patients taking OAT, it was found to be a useful instrument, valid for use in our milieu.

¿Se debe limitar el esfuerzo terapéutico en nutrición artificial? / Should the therapeutic effort in artificial nutrition be limited?

Fundamento. Existe acuerdo general entre los expertos en Bioética en no mantener un tratamiento si éste es considerado fútil. Sin embargo, no existe unanimidad sobre si la sueroterapia, la nutrición enteral (NE) y la parenteral (NP) son medidas terapéuticas o forman parte del concepto de cuidado paliativo. Objetivo. Conocer la opinión de usuarios y trabajadores sanitarios del Sistema Nacional de Salud (SNS) en estas cuestiones. Diseño. Estudio descriptivo transversal. Ámbito. Atención Primaria y especializada. Métodos. Se distribuyó una encuesta a 219 individuos (84 usuarios del SNS, 135 trabajadores sanitarios), que incluía variables sociodemográficas, la opinión sobre diferentes aspectos de ética y soporte nutricional y qué medidas se consideran como cuidado paliativo. Resultados. La mayoría de los encuestados opinan que la NE (70,8 por ciento; IC 95 por ciento: 64,2-76,8) y NP (54,8 por ciento; IC 95 por ciento: 47,9-61,6) forman parte de los cuidados básicos, con diferencias entre el personal sanitario y los usuarios del SNS. El 50,2 por ciento considera que no existen diferencias entre instaurar o retirar soporte nutricional. El 71,3 por ciento de los profesionales sanitarios responden que esta decisión depende del médico y el 60,5 por ciento de los usuarios del SNS opinan que depende del propio enfermo y/o familiares. Todas las medidas interrogadas se consideran como cuidados básicos, independientemente de las características del encuestado. Conclusiones. La nutrición artificial se entiende como un cuidado básico, independientemente de la situación y calidad de vida del paciente. Mientras los profesionales sanitarios opinan que la decisión de iniciar/retirarlas depende del médico, los usuarios del SNS consideran que depende del enfermo/familia en caso de incapacidad de éste (AU)

[Should the therapeutic effort in artificial nutrition be limited?]. / Se debe limitar el esfuerzo terapéutico en nutrición artificial?

BASIS: There exists general agreement among the experts in Bioethics in order not to maintain a treatment if it is considered that it is useless. However, there is no unanimity about if serotherapy, enteral nutrition (EN), and parenteral nutrition (PN) are really therapeutic measures or else they are measures that they are part of the concept of palliative care. OBJECTIVE: Know the opinion of users and health workers of National Health System (NHS) in these issues. DESIGN: Cross-sectional descriptive study. AREA: Primary and specialized care. METHODS: A survey was distributed to 219 individuals (84 users of the NHS, 135 health workers), that it included sociodemographic parameters, the opinion on different aspects of ethics and nutritional support, and the measures regarded as palliative care. RESULTS: The majority of the respondents think that the EN (70.8%; 95% IC: 64.2-76.8) and PN (54.8%; 95% IC: 47.9-61.6) are part of the basic care, with differences between the health personnel and the users of the NHS. 50.2% considers that there are no differences between applying or removing nutritional support. 71.3% of the health professionals answer that this decision depends on the medical, 60.5% of the users of the NHS thinks that it depends on the patient himself and/or its family members. All the evaluated measures are regarded as basic care, regardless of the characteristics of the respondent. CONCLUSIONS: Artificial nutrition is understood as a basic care, regardless of the situation and quality of life of the patient. While the health professionals think that the decision to initiate/to retire artificial nutrition depends on the physician, the users of the NHS consider that it depends on the patient/family in case of disability of this.

Calidad de vida profesional de los trabajadores de Atención Primaria del Área 10 de Madrid / Professional quality of life in sanitary personnel of Primary Health Care Area 10 in Madrid

Objetivo: conocer la calidad de vida profesional (CVP) percibida por los trabajadores de Atención Primaria de nuestra área de salud, identificando los principales componentes de la misma. Diseño: estudio descriptivo transversal. Material y métodos: ámbito: Atención Primaria (Área 10; Madrid). Participantes: todos los profesionales de Atención Primaria (n=419). Mediciones: encuesta anónima autoadministrada que incluye el cuestionario CVP-35, además de variables demográficas y laborales. Resultados: tasa de respuesta: 57,5 por ciento. Edad media: 39 ñ7 años; mujeres:172 (71,4 por ciento); propietarios: 116 (48,1 por ciento); turno de mañana: 121 (50,2 por ciento); antigüedad media: 12 ñ7 años. La CVP media fue 5,2 ñ1,8. Los ítems con puntuación más baja fueron "posibilidad de promoción" (2,34 ñ 1,57) y "conflictos con otras personas" (3,38 ñ2,16). Los ítems con puntuación más alta fueron "estoy capacitado para realizar mi trabajo" (8,38 ñ 1,27) y "cantidad de trabajo" (8,19 ñ 1,28). La percepción de la CVP es significativamente peor entre el personal médico que en el resto de profesionales (p<0,05). No encontramos diferencias al analizar la CVP por el resto de variables. Conclusiones: encontramos un nivel medio de CVP entre los trabajadores de nuestra área, aun- que la valoración es peor entre los médicos. Se percibe excesiva carga de trabajo y pocos recursos aportados por la organización (AU)

[Quality control of the monitoring of normal pregnancy in primary care]. / Control de calidad del seguimiento del embarazo normal en atención primaria.

OBJECTIVES: GENERAL: to increase the quality of mother-baby care in our population. SPECIFIC: to improve by at least 10% the record of activities with poorest compliance at the first evaluation on the quality cycle. DESIGN: Quality cycle of the normal pregnancy monitoring programme in primary care (PC). The scientific-technical dimension of quality was the one studied. There was a retrospective, crossed evaluation, on internal initiative, about the clinical records of the pregnant women. SEQUENCE: first evaluation of pregnancies in 1994-95; application of corrective measures in 1996; second evaluation of pregnancies in 1997-98. SETTING: Primary care. PATIENTS: All the pregnancies monitored by our PC team during the periods described. MEASUREMENTS AND MAIN RESULTS: CRITERIA EVALUATED: care activities of the programme for monitoring normal pregnancies in Area 10. First evaluation (n = 54): 11.5% overall non-compliance. The criteria with under 80% compliance were: folic acid supplement, counselling, diagnosis of pregnancy diabetes and attendance in the month after delivery. Second evaluation (n = 69): 6.3% overall non-compliance. All activities surpassed 80% compliance except obstetric examination on the first visit, attendance a week after delivery and attendance a month after delivery. CONCLUSIONS: After introducing certain simple corrective measures, we achieved overall improvement of over 40% and increased compliance in most activities, except for attendance after delivery and obstetric examination on the first visit. We think a continuous cycle of quality improvement needs to be maintained in order to achieve adequate mother-baby care.

Control de calidad del seguimiento del embarazo normal en atención primaria / Quality control of the monitoring of normal pregnancy in primary care

Objetivos. General: aumentar la calidad de la atención materno-infantil en nuestra población. Específico: mejorar al menos un 10 por ciento el registro de las actividades con peor cumplimiento en la primera evaluación del ciclo de calidad. Diseño. Ciclo de calidad del programa de seguimiento de embarazo normal en atención primaria (AP).Dimensión de calidad estudiada: científico-técnica. Evaluación retrospectiva, cruzada, por iniciativa interna y sobre las historias clínicas de las gestantes. Marco temporal: primera evaluación sobre gestaciones de 1994-1995; aplicación de medidas correctoras durante 1996; segunda evaluación sobre gestaciones de 1997-1998.Ámbito. Atención primaria. Sujetos. Todas las gestaciones seguidas en nuestro equipo de AP durante los períodos descritos. Mediciones y resultados principales. Criterios evaluados: actividades asistenciales del programa de seguimiento del embarazo normal del Área 10. Primera evaluación (n = 54): incumplimiento global del 11,5 por ciento; los criterios con cumplimiento inferior al 80 por ciento fueron suplemento con ácido fólico, consejos a la gestante, detección de diabetes gestacional y visita al mes posparto. Segunda evaluación (n = 69): incumplimiento global del 6,3 por ciento; todas las actividades superaron el 80 por ciento excepto la exploración obstétrica en la primera visita, la visita a la semana posparto y la visita al mes posparto. Conclusiones. Tras la introducción de unas medidas correctoras sencillas, logramos una mejoría global superior al 40 por ciento y un aumento en el cumplimiento de la mayor parte de las actividades, excepto en las visitas posparto y la exploración obstétrica en la primera visita. Creemos que es necesario mantener un ciclo continuo de mejora de calidad para conseguir una adecuada asistencia materno-infantil (AU)

[Role of the primary care physician in the diagnosis and treatment of thyroid diseases]. / Papel del médico de atención primaria en el diagnóstico y seguimiento de la patología tiroidea.

OBJECTIVE: To determine the participation of the primary care physician in the diagnosis and follow-up of thyroid pathology. DESIGN: A descriptive study of a crossover type. SETTING: The Isabel II Health centre at Parla (Madrid). PATIENTS: All those diagnosed with thyroid pathology registered with the two primary care teams at the Isabel II Health Centre up to august 1992. Data were obtained from the morbidity records and the District's Endocrinology Clinic. MAIN RESULTS: 196 patients, with 250 diagnoses overall, were located. The main ones were: hypothyroidism (27.6%), normally functioning goitres (24.4%) and hyperthyroidism (23.2%). The general practitioner was aware of the illness in 87% of cases, as against the specialist in 97%. The provisional diagnosis was carried out at the primary care level in 56% of cases; the final one only in 18%. With respect to patients' subsequent treatment, it was exclusively specialist in 72% of cases and joint in 19%. CONCLUSIONS: The primary care doctor is aware of the majority of his/her patients' thyroid illnesses, but not all. We recommend greater participation of primary care in the initial diagnostic approach to these conditions; and, in particular, a closer involvement in the treatment of these pathologies, which requires that the primary care doctor must have access to precise diagnostic methods.

[Epidemiology of acute poisoning: a study of 851 cases detected in the southern area of the Madrid community in 1990]. / Epidemiología de la intoxicación aguda: estudio de 851 casos habidos en 1990 en el área sur de la Comunidad de Madrid.

Epidemiology of acute intoxication (AI) must be reviewed periodically to know its trends, therefore, following a line of RESEARCH, we have studied the AI's attended on the Emergency Ward of Internal Medicine at Hospital Doce de Octubre (Madrid). We found that most of them are voluntary (93%): in females being predominant the suicide attempt and in males the AI secondary to illegal drugs use. Toxic drugs have been used in 96% on suicide attempts; the relative incidence of each drug does not vary, but AI with more than one toxic diminish. Within the non-drug toxics, illegal drugs come first, followed by alcohol. Drug-addiction is the numerically most frequent antecedent; depression is predominant in suicide attempts, alcoholism is infrequent in ethyl AI. ICU admissions represent an intermediate figure in our country, mortality (most of them due to overdose) is similar to those of non-Spanish series.