Opioides fuertes y dolor crónico no oncológico en Cataluña. Análisis del patrón de prescripción por parte de los médicos de familia / Strong opioids and non-cancer chronic pain in Catalonia. An analysis of the family physicians prescription patterns

OBJETIVO: Conocer los patrones de prescripción de opioides fuertes en dolor crónico no oncológico por parte de médicos de familia. MATERIAL Y MÉTODOS: diseño: estudio descriptivo mediante cuestionario autoadministrado por correo electrónico. EMPLAZAMIENTO: todos los centros de salud de Cataluña. PARTICIPANTES: 3.602 médicos de familia socios de la Sociedad Catalana de Medicina Familiar y Comunitaria. INTERVENCIONES: administración de la encuesta por correo electrónico a los médicos de familia catalanes. MEDICIONES PRINCIPALESs: datos demográficos, número de pacientes que consultan por dolor crónico no oncológico tratados con opioides fuertes, opioides utilizados e indicación, patrones de prescripción, relación con la Unidad del Dolor. RESULTADOS: se obtuvieron 551 respuestas de 3.602 cuestionarios enviados (tasa de respuesta del 15,3%): 480 facultativos (87%) prescriben opioides fuertes para dolor músculo-esquelético; 268 (48,6%) prescriben fentanilo ultrarrápido; 434 (78,7%) disminuyen las dosis de benzodiacepinas al prescribir opioides fuertes. Los efectos adversos más habituales son estreñimiento y náuseas. Las principales dificultades observadas en la prescripción son su manejo (341, 71%) y la resistencia de pacientes y profesionales (87, 18,1%). La valoración de la interrelación con las Unidades de Dolor fue 2+/-1 (escala 1 al 5), siendo los problemas en la comunicación (271, 52,2%) y en la accesibilidad (141, 27,1%) los principales puntos de mejora. CONCLUSIONES: los patrones de prescripción se adecuan mayoritariamente a las guías clínicas en algunos aspectos (disminución de benzodiacepinas o titulación de dosis). Sin embargo, existen áreas de mejora como son el poco uso de laxantes o el uso de opioides ultrarrápidos para indicaciones no autorizadas y sin tratamiento opioide de base. Los médicos de familia demandan formación, perciben resistencias en su prescripción y creen necesario mejorar la relación con las Unidades del Dolor

OBJECTIVE: To identify family doctor prescription patterns for strong opioids for chronic, non-cancer-related pain. MATERIALS AND METHODS: Design A descriptive study based on a self-administered email questionnaire. LOCATION: All primary health care centres in Catalonia. PARTICIPANTS: 3,602 family doctors, all members of the Catalan Society of Family and Community Medicine. INTERVENTIONS: Email survey of Catalan family doctors. MAIN MEASUREMENTS: Demographic data, number of patients treated with potent opioids for chronic non-cancer pain, type of opioid used and indications, prescribing patterns and relationship with the Pain Management Unit. RESULTS: A total of 551 answers were obtained from 3,602 questionnaires sent (response rate of 15.3%), in which 480 physicians (87%) prescribed strong opioids for musculoskeletal pain, 268 (48.6%) prescribed ultra-rapid fentanyl and 434 (78.7%) reduced benzodiazepines dosage when prescribing potent opioids. The most common adverse effects were constipation and nausea. The main problems related with opioid prescription were improper use (341, 71%) and patient and/or practitioner reluctance (87, 18.1%). The assessment of the relationship with Pain Management Units was 2+/-1 (on a 1 to 5 scale), with communication (271, 52.2%) and accessibility (141, 27.1%) being the areas most in need of improvement. CONCLUSIONS: Opioid prescribing patterns generally follow clinical guidelines (e.g. reduction of benzodiazepine use or dose titration). However, there are some areas of improvement, such as sparse use of laxatives or use of ultra-rapid opioids for unapproved indications and in patients with no background opioid therapy. Family doctors perceive patient reluctance to adhere to the prescribed treatment, and call for specific training and better relationships with Pain Management Units

Hypoglycemia in noncritically ill patients receiving total parenteral nutrition: a multicenter study. (Study group on the problem of hyperglycemia in parenteral nutrition; Nutrition area of the Spanish Society of Endocrinology and Nutrition).

OBJECTIVE: Hypoglycemia is a common problem among hospitalized patients. Treatment of hyperglycemia with insulin is potentially associated with an increased risk for hypoglycemia. The aim of this study was to determine the prevalence and predictors of hypoglycemia (capillary blood glucose <70 mg/dL) in hospitalized patients receiving total parenteral nutrition (TPN). METHODS: This prospective multicenter study involved 19 Spanish hospitals. Noncritically ill adults who were prescribed TPN were included, thus enabling us to collect data on capillary blood glucose and insulin dosage. RESULTS: The study included 605 patients of whom 6.8% (n = 41) had at least one capillary blood glucose <70 mg/dL and 2.6% (n = 16) had symptomatic hypoglycemia. The total number of hypoglycemic episodes per 100 d of TPN was 0.82. In univariate analysis, hypoglycemia was significantly associated with the presence of diabetes, a lower body mass index (BMI), and treatment with intravenous (IV) insulin. Patients with hypoglycemia also had a significantly longer hospital length of stay, PN duration, higher blood glucose variability, and a higher insulin dose. Multiple logistic regression analysis showed that a lower BMI, high blood glucose variability, and TPN duration were risk factors for hypoglycemia. Use of IV insulin and blood glucose variability were predictors of symptomatic hypoglycemia. CONCLUSIONS: The occurrence of hypoglycemia in noncritically ill patients receiving PN is low. A lower BMI and a greater blood glucose variability and TPN duration are factors associated with the risk for hypoglycemia. IV insulin and glucose variability were predictors of symptomatic hypoglycemia.

Nutrition-related risk indexes and long-term mortality in noncritically ill inpatients who receive total parenteral nutrition (prospective multicenter study).

BACKGROUND: Malnutrition in hospitalized patients is associated with an increased risk of death, in both the short and the long term. AIMS: The purpose of this study was to determine which nutrition-related risk index predicts long-term mortality better (three years) in patients who receive total parenteral nutrition (TPN). METHODS: This prospective, multicenter study involved noncritically ill patients who were prescribed TPN during hospitalization. Data were collected on Subjective Global Assessment (SGA), Nutritional Risk Index (NRI), Geriatric Nutritional Risk Index (GNRI), body mass index, albumin and prealbumin, as well as long-term mortality. RESULTS: Over the 1- and 3-year follow-up periods, 174 and 244 study subjects (28.8% and 40.3%) respectively, died. Based on the Cox proportional hazards survival model, the nutrition-related risk indexes most strongly associated with mortality were SGA and albumin (<2.5 g/dL) (after adjustment for age, gender, C-reactive protein levels, prior comorbidity, mean capillary blood glucose during TPN infusion, diabetes status prior to TPN, diagnosis, and infectious complications during hospitalization). CONCLUSIONS: The SGA and very low albumin levels are simple tools that predict the risk of long-term mortality better than other tools in noncritically ill patients who receive TPN during hospitalization.

Absceso cerebral por Mycobacterium tuberculosis / Brain abscess due to Mycobacterium tuberculosis

No disponible

Rigidified calixarenes bearing four carbamoylmethylphosphineoxide or carbamoylmethylphosphoryl functions at the wide rim

Conformationally rigidified tetraCMPO derivatives have been prepared from calix[4]arene bis(crown ether) 4a in which adjacent oxygens are bridged at the narrow rim by two diethylene glycol links. Acylation of the tetraamine 4c with the CMPO-active ester 5b gave the tetraphosphine oxide 6a, while the tetraphosphinate 6b and the tetraphosphonate 6c were obtained by Arbuzov reaction of tetrabromoacetamido derivative 7 with PhP(OEt)2 or P(OEt)3. The extraction ability of these CMPO derivatives was checked for selected lanthanides and actinides and compared with the analogous compounds 1b, 10b and 10d derived from calix[4]arene tetrapentyl ether. All rigidified bis(crown ether) ligands are more effective extractants than their pentyl ether counterparts and require only 1/10 of the concentration (cL= 10 4M) to obtain the same distribution coefficients, while with CMPO itself a 2,000-fold concentration is necessary. This could be a consequence of a better preorganisation of the ligating functions owing to the rigidity which on the other hand did not change the observed selectivity for americium (DAm/DEu=9-19) and for light lanthanides over heavy ones. NMR relaxivity titration curves show that the complex of Gd3+ with ligand 6a is highly oligomerised in anhydrous acetonitrile over a large range of ligand:metal concentration ratios. Nuclear magnetic relaxation dispersion (NMRD) profiles also showed that large oligomers were formed, and their mean tumbling times were deduced from the Solomon-Bloembergen-Morgan equations. The NMR spectra of dia- and paramagnetic lanthanide complexes with 6a agreed with the presence of two conformers with an elongated calix[4]arene skeleton in which the distances between opposite methylene groups are different. Contrary to what was observed with ligand 2a, the addition of nitrate ions does not labilize the metal complexes, presumably because of the rigidification effect of the ether bridges. Single-crystal X-ray structures were obtained for the active ester 5b and for diphenylphosphorylacetic acid 5a.

Involving Adolescent Males in Pregnancy and STD Prevention Programs.

The principal barriers responsible for lack of male involvement in sexuality programs and in STD and pregnancy prevention programs are discussed and strategies are offered to help attract and keep males in sexual and reproductive health programs.