[Update on the use of insulins for the primary care physician]. / Actualización en el uso de insulinas para el médico de familia.

Insulin treatment in type 2 diabetes mellitus patients is still essential and its usage has increased during recent years. Despite this, the level of control continues to be very poor. Insulin treatment is initiated with control levels above the recommendations set by the Clinical Practice Guidelines (CPG) and patients are exposed to very high blood glucose levels during long periods of time. This paper reviews the role of insulin in the different CPG, the criteria for therapy initiation and intensification, the beginning of the intensification and the different types of insulin which are commercialized in our country. Moreover, we discuss insulinization in special situations such as corticosteroid treatment, fragile elderly patients, palliative care situations, chronic kidney disease or during Ramadan. Finally, the problem of therapeutic inertia in insulinization is also addressed.

Freezing of gait in Parkinson's disease: functional neuroimaging studies of the frontal lobe.

OBJECTIVE: The objective of the study is to study a group of patients with Parkinson's disease (PD) with and without freezing of gait (FOG) and analyze neuropsychological differences, especially regarding executive functions, according to their performance in a set of tests, and potential anomalies in functional positron emission tomography with 2-deoxy-2-[fluorine-18]fluoro-d-glucose integrated with computed tomography (18F-FDG PET/CT) neuroimaging results of the frontal lobe. METHODS: The study recruited 23 patients. We performed an 18F-FDG PET/CT scan for 17 patients (9 with FOG and 8 without FOG) and 6 controls. Frontal functions were evaluated in all the patients during their 'on' situation. RESULTS: In FDG PET studies, PD patients differed from controls in that they presented hypometabolic areas in the parietal and bilateral occipital regions, as well as in the bilateral frontal region, especially on the right side. Compared to patients without FOG, patients with FOG displayed more pronounced frontal and predominantly right-sided hypometabolism. Both groups of patients displayed a poorer performance than the control population in the frontal cognitive tests. A greater executive disfunction was found in patients with FOG. CONCLUSIONS: Our study revealed greater hypometabolism in FDG PET studies, predominantly in right-sided-specific motor regions of the frontal lobe in FOG patients and greater frontal disfunction in neuropsychological tests in PD patients with FOG. These data suggest that FOG may be related to functional impairment of the circuits connecting the frontal lobe and the basal ganglia.

Uso de inhibidores de la dipeptidil peptidasa 4 en pacientes con diabetes / No disponible

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Introducción: Uso de inhibidores de la dipeptidil peptidasa 4 en pacientes con diabetes / No disponible

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ZODIAC: Consenso para la prevención del herpes zóster en personas con diabetes mellitus / ZODIAC: Consensus on herpes zoster prevention in persons with diabetes mellitus

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Prevalence of depression in patients with type 2 diabetes attended in primary care in Spain.

OBJECTIVES: To estimate the prevalence of known and undiagnosed depression in patients with type 2 diabetes attended in primary care setting in Spain, and to determine the factors associated with the presence of depression. METHODS: This was a cross-sectional and multicenter study performed in a random sample of patients with type 2 diabetes attended in 21 primary care centers. Depressive symptoms were measured with the self-administered Patient Health Questionnaire (PHQ-9). RESULTS: A total of 411 patients were analyzed (mean age 70.8 (SD 10.3) years; 53.8% women). 29.2% of patients met the diagnostic criteria of depression, of whom 17% had known depression and 12.2% undiagnosed depression (PHQ-9 score ≥10, without a previous diagnosis of depression). Depression was more common in women (43.4%; 95% confidence interval [CI] 34.5-52.3%), widow (33.3%; 95% CI 27.9-38.7%), and hypothyroidism (12.5%; 95% CI 8.7-16.3%). Cardiovascular risk factors, the degree of control, complications related to diabetes, antidiabetic therapy and the number of drugs were not associated with the presence of depression. CONCLUSIONS: The prevalence of depression was high in patients with type 2 diabetes. However, in approximately 40% of patients depression was undiagnosed. The complications related to diabetes and antidiabetic therapy were not associated with the presence of depression.

Glycemic control and use of A1c in primary care patients with type 2 diabetes mellitus.

AIMS: To evaluate the degree of glycemic control and its relationship with disease characteristics and antidiabetic treatment in patients with type 2 diabetes mellitus (DM), as well as the frequency of A1c use. METHODS: For this purpose, an observational, cross-sectorial, and multicenter study was performed. A total of 443 patients were monitored in 17 Spanish primary healthcare centers. Demographic and clinical variables were recorded from the clinical history of patients. RESULTS: Mean age was 68.9±12.0 years. Time of evolution of DM was 9.2±6.4 years. Mean A1c was 7.38±1.34% and 45% of patients achieved A1c <7%. There was a no significant relationship between the degree of control and time of evolution of DM. In 16% of patients no A1c determination was performed in the previous twelve months. In those patients in whom A1c was determined, 95% received pharmacologic treatment, and 31% insulin therapy. 66% of patients on monotherapy attained A1C <7%, compared with 39% and 23% of those receiving double- and triple-oral therapy, respectively (p<0.001). Only 21% of patients on insulin therapy achieved A1c <7%. The worst-controlled patients were those receiving oral antidiabetic agents and insulin (24% had A1c levels ≥9%). CONCLUSIONS: A large proportion of patients are poorly controlled. Poor control increases according to complexity of treatment. A1c is underdetermined in many patients, likely related to clinical inertia.

Introducción: Revisión de las últimas guías de patología cardiometabólica. Introducción / No disponible

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Guías en el manejo de la diabetes mellitus tipo 2 / Guidelines for the management of diabetes mellitus type 2

La publicación en los últimos años de nuevos estudios en diabetes, junto a la aparición de nuevos fármacos para el tratamiento de la hiperglucemia, ha llevado a la actualización de las más prestigiosas guías de práctica clínica para el tratamiento de la diabetes. Así, en abril de 2012 se publicó el documento de consenso de la American Diabetes Association y de la European Association for the Study of Diabetes sobre el tratamiento de la hiperglucemia en la diabetes tipo 2. Al año siguiente, 2013, aparece la actualización de una de las guías basada en la evidencia promovida por la Canadian Diabetes Association, y este mismo año 2014 aparece el consenso de la redGDPS, cuyas guías son las que mayor seguimiento tienen entre los médicos de atención primaria de nuestro país. Las 3 guías destacan la necesidad de una individualización del abordaje de la diabetes mellitus tipo 2, marcando tanto objetivos de control como pautas de tratamiento diferenciadas según las características de los pacientes, evolución de la enfermedad y presencia de comorbilidades o complicaciones de esta. En lo referente al tratamiento, las 3 destacan la trascendencia de tomar en cuenta las opiniones de los pacientes, la importancia de aplicar modificaciones del estilo de vida para un buen control de la enfermedad y marcan como primer fármaco a utilizar la metformina, a la que se añaden otros agentes hipoglucemiantes en caso de no obtener los objetivos marcados (AU)

In the last few years, the publication of new studies in diabetes, together with the development of new classes of blood glucose-lowering medications, have led to updates of the most prestigious clinical practice guidelines for the treatment of diabetes. Thus, a consensus statement from the American Diabetes Association and the European Association for the Study of Diabetes on the management of hyperglycemia in type 2 diabetes was published in April 2012. An update of one of the evidence-based guidelines issued by the Canadian Diabetes Association appeared in 2013 and this year, 2014, saw the publication of the consensus document of the redGDPS, whose guidelines are those most closely followed by primary care physicians in Spain. The three guidelines highlight the need for an individualized approach to type 2 diabetes mellitus, outlining both target glycemic goals and distinct treatment regimens based on patient characteristics, disease stage and the presence of comorbidities or complications. In the treatment of the disease, the three guidelines also stress the importance of considering patients’ opinions and of recommending lifestyle modifications to achieve good disease control. Metformin is identified as the first-line drug, with the addition of other glucose-lowering agents if necessary (AU)

Evaluación de la realización del cribado del pie diabético en Atención Primaria / Evaluation of diabetic foot screening in Primary Care

OBJETIVO: Conocer si se realiza el cribado del pie diabético en pacientes con diabetes tipo 2 atendidos en Atención Primaria y analizar qué factores relacionados con el paciente y el centro de salud se asocian a la cumplimentación de dicho cribado. MATERIAL Y MÉTODO: Estudio epidemiológico, transversal y multicéntrico. Se revisaron las historias clínicas de una muestra representativa (n = 443) de pacientes con diabetes tipo 2 que habían sido seguidos en Atención Primaria como mínimo en los 12 meses previos. Se registraron variables demográficas, de proceso asistencial y características del centro. RESULTADOS: El 51,2% de los pacientes recibieron educación sanitaria sobre el autocuidado del pie, al 56,4% se le realizó inspección de los pies, el 39,5% fueron explorados con monofilamento, y en el 45,8 y 10,1% se realizó palpación de pulsos periféricos e índice tobillo-brazo, respectivamente. El cribado del pie diabético (inspección, exploración de sensibilidad con monofilamento y palpación de pulsos periféricos) fue efectuado al 37% de los pacientes estudiados, y la estratificación del riesgo de úlceras se determinó en el 12,4% de los casos. Existe asociación entre realización del cribado y presencia de deformidades en el pie (p < 0,001), antecedentes de neuropatía (p = 0,005) y arteriopatía periférica (p < 0,05). También se asocia a algunas características del centro: recibir información sobre consecución de objetivos (p < 0,001), y percepción de incentivos económicos por cumplimiento de los mismos (p < 0,001). CONCLUSIONES: Se constata una deficiente atención a las personas con diabetes tipo 2 respecto a la prevención del pie diabético, pues no se realiza de forma rutinaria cribado y estratificación de riesgo

AIM: To ascertain whether patients with type 2 diabetes are screened for diabetic foot, and to analyze the factors related to patients and centers associated to performance of such screening. MATERIAL AND METHODS: A multicenter, epidemiological, cross-sectional study was conducted. The clinical records of 443 patients with type 2 diabetes monitored at Primary Care for at least 12 months were reviewed. Demographic and healthcare variables and characteristics of the primary care center were recorded. RESULTS: In the previous year, 51.2% of patients had been trained on foot self-care, 56.4% had undergone foot inspection, 39.5% had been examined with a monofilament, and palpation of peripheral pulses and measurement of the ankle-brachial index were performed in 45.8 and 10.1% of patients, respectively. Diabetic foot screening (inspection, monofilament testing, and palpation of peripheral pulses) was performed in 37% of study patients. Ulcer risk stratification was done in 12.4% of patients. A significant association was found between diabetic foot screening and presence of foot deformities (P < .001), history of neuropathy (P = .005), and history of peripheral artery disease (P < .05). Screening was also associated to some characteristics of the center, such as reception of information about goal achievement (P < .001) and economic incentives for goal attainment (P < .001). CONCLUSIONS: Compliance with diabetic foot screening and ulcer risk stratification in patients with type 2 diabetes in Primary Care was poor

Introducción: Abordaje de factores de riesgo cardiovacular en el anciano / No disponible

No disponible

Evaluation of diabetic foot screening in Primary Care.

AIM: To ascertain whether patients with type 2 diabetes are screened for diabetic foot, and to analyze the factors related to patients and centers associated to performance of such screening. MATERIAL AND METHODS: A multicenter, epidemiological, cross-sectional study was conducted. The clinical records of 443 patients with type 2 diabetes monitored at Primary Care for at least 12 months were reviewed. Demographic and healthcare variables and characteristics of the primary care center were recorded. RESULTS: In the previous year, 51.2% of patients had been trained on foot self-care, 56.4% had undergone foot inspection, 39.5% had been examined with a monofilament, and palpation of peripheral pulses and measurement of the ankle-brachial index were performed in 45.8 and 10.1% of patients, respectively. Diabetic foot screening (inspection, monofilament testing, and palpation of peripheral pulses) was performed in 37% of study patients. Ulcer risk stratification was done in 12.4% of patients. A significant association was found between diabetic foot screening and presence of foot deformities (P<.001), history of neuropathy (P=.005), and history of peripheral artery disease (P<.05). Screening was also associated to some characteristics of the center, such as reception of information about goal achievement (P<.001) and economic incentives for goal attainment (P<.001). CONCLUSIONS: Compliance with diabetic foot screening and ulcer risk stratification in patients with type 2 diabetes in Primary Care was poor.

[Guidelines for the management of diabetes mellitus type 2]. / Guías en el manejo de la diabetes mellitus tipo 2.

In the last few years, the publication of new studies in diabetes, together with the development of new classes of blood glucose-lowering medications, have led to updates of the most prestigious clinical practice guidelines for the treatment of diabetes. Thus, a consensus statement from the American Diabetes Association and the European Association for the Study of Diabetes on the management of hyperglycemia in type 2 diabetes was published in April 2012. An update of one of the evidence-based guidelines issued by the Canadian Diabetes Association appeared in 2013 and this year, 2014, saw the publication of the consensus document of the redGDPS, whose guidelines are those most closely followed by primary care physicians in Spain. The three guidelines highlight the need for an individualized approach to type 2 diabetes mellitus, outlining both target glycemic goals and distinct treatment regimens based on patient characteristics, disease stage and the presence of comorbidities or complications. In the treatment of the disease, the three guidelines also stress the importance of considering patients' opinions and of recommending lifestyle modifications to achieve good disease control. Metformin is identified as the first-line drug, with the addition of other glucose-lowering agents if necessary.

Evolución del burnout y variables asociadas en los médicos de atención primaria / Evolution of burnout and associated factors in primary care physicians

Objetivo: Analizar la evolución del burnout y elaborar un modelo explicativo. Diseño: Estudio prospectivo de cohorte dinámica. Emplazamiento: Todos los centros de AP de Burgos. Sujetos: Todos los médicos de AP excepto urgencias, pediatría y residentes. Mediciones principales: Cuestionario anónimo autoadministrado: Maslach Burnout Inventory (MBI) y variables relacionadas. Análisis mediante la t de Student, el test de la x2 y regresión logística. Resultados: Respuesta del 47,76% en 2007, inferior a la del 2005.Existieron diferencias significativas entre 2005 y 2007, para los incrementos en el porcentaje de médicos fumadores, formación postgrado, especialidad vía MIR, y los que consideran que la coordinación con enfermería y atención especializada y comunicación institucional son adecuadas. Aumenta la prevalencia de burnout casi un punto con respecto a 2005, disminuye el desgaste máximo; disminuyó el cansancio emocional (CE) y aumentó la realización personal (RP) y despersonalización (DP). Densidad de incidencia de burnout de 1/113,5 médicos de atención primaria por año. La existencia de burnout se asocia a la utilización de medicación crónica e inadecuada coordinación con enfermería y CE además con elevada presión asistencial. Conclusiones: El aumento de la prevalencia hallado es compatible con la idea del burnout como desarrollo dinámico y el modelo teórico descrito. El empleo estable y de calidad es una vía para mitigar indirectamente (favoreciendo la comunicación interna) el desgaste profesional. En el análisis multivariado la variable más determinante en la aparición de burnout es la inadecuada coordinación con enfermería(AU)

Purpose: To analyse the course of burnout and develop an explanatory model. Design: Prospective cohort dynamics. Site: All primary health care centres in Burgos. Subjects: All physicians except medical emergencies, paediatrics and residents. Main measurements: Anonymous self-report questionnaire: Maslach Burnout Inventory (MBI) and related variables. An analysis was performed using the Student-t, X2 test and logistic regression. Results: The response rate was 47.76% in 2007, which was lower than that of 2005. There were significant differences between 2005 and 2007, for increases in the percentage of physicians who smoked, postgraduate training, residency, and those who believe that coordination with nursing and specialist care and institutional communication is appropriate. There was an increase in the prevalence of burnout by almost one point compared with 2005, a decrease in maximum burnout and emotional exhaustion (EC), and an increase in depersonalisation (DP) and personal accomplishment (RP). The incidence density of burnout was 1/113. 5 primary care physicians per year. The existence of burnout is associated with the use of chronic medication and inadequate coordination between nursing and EC, and also with the high workload. Conclusions: The increase in the prevalence found is consistent with the idea of burnout as a dynamic development and the theoretical model described. Stable and quality employment is one way to indirectly mitigate (by encouraging internal communication) professional burnout. In the multivariate analysis, the most critical variable in the onset of burnout is the inadequate coordination with nursing(AU)

[Evolution of burnout and associated factors in primary care physicians]. / Evolución del burnout y variables asociadas en los médicos de atención primaria.

PURPOSE: To analyse the course of burnout and develop an explanatory model. DESIGN: Prospective cohort dynamics. SITE: All primary health care centres in Burgos. SUBJECTS: All physicians except medical emergencies, paediatrics and residents. MAIN MEASUREMENTS: Anonymous self-report questionnaire: Maslach Burnout Inventory (MBI) and related variables. An analysis was performed using the Student-t, X(2) test and logistic regression. RESULTS: The response rate was 47.76% in 2007, which was lower than that of 2005. There were significant differences between 2005 and 2007, for increases in the percentage of physicians who smoked, postgraduate training, residency, and those who believe that coordination with nursing and specialist care and institutional communication is appropriate. There was an increase in the prevalence of burnout by almost one point compared with 2005, a decrease in maximum burnout and emotional exhaustion (EC), and an increase in depersonalisation (DP) and personal accomplishment (RP). The incidence density of burnout was 1/113. 5 primary care physicians per year. The existence of burnout is associated with the use of chronic medication and inadequate coordination between nursing and EC, and also with the high workload. CONCLUSIONS: The increase in the prevalence found is consistent with the idea of burnout as a dynamic development and the theoretical model described. Stable and quality employment is one way to indirectly mitigate (by encouraging internal communication) professional burnout. In the multivariate analysis, the most critical variable in the onset of burnout is the inadequate coordination with nursing.

Documento de consenso sobre el tratamiento al alta hospitalaria del paciente con hiperglucemia / Consensus document on the management after hospital discharge of patient with hyperglycaemia

En el presente documento se pretende adaptar las recomendaciones generales establecidas en un consenso para la elaboración del informe de alta hospitalaria en especialidades médicas a las necesidades específicas de la población diabética hospitalizada. La diabetes es una enfermedad con un coste sanitario muy elevado, siendo el riesgo global de muerte entre personas con diabetes casi el doble que entre personas sin diabetes, lo que justifica que esta patología constituya uno de los diagnósticos más frecuentes en los pacientes hospitalizados y el creciente interés sobre el tratamiento de la hiperglucemia durante la hospitalización y al alta. Para establecer un plan de tratamiento al alta adecuado a cada paciente, los elementos más importantes a tener en cuenta son la etiología y el tratamiento previo de la hiperglucemia, la situación clínica del paciente y el grado de control glucémico. Debido a la inestabilidad del control glucémico también es necesario prever las necesidades educativas de cada paciente, así como establecer las pautas de monitorización y seguimiento al alta, y un adecuado plan de tratamiento al alta (AU)

The present document intends to adapt the general recommendations set up in a consensus to elaborate the hospital discharge report in medical specialties to the specific needs of the hospitalized diabetic population. Diabetes is an illness with a very high health cost, being the global risk of death in people with diabetes almost double than in non-diabetes people, justifying the fact that diabetes constitutes one of the most frequent diagnoses in hospitalized patients and the growing interest upon hyperglycaemia management during hospitalization and at discharge. To set up an adequate treatment plan at discharge suitable for each patient, the most important elements to take into account are the etiology and prior hyperglycaemia treatment, the patient's clinical situation and the degree of glycaemia control. Due to instability of glycaemia control, it is also needed to anticipate the educational needs for each patient, as well as to set up the monitoring schedule and follow-up at discharge, and an adequate treatment plan at discharge (AU)