[Polypharmacy in psychiatric patients as an alternative to limited mental health resources]. / La polimedicación de los pacientes psiquiátricos como alternativa a la escasez de recursos asistenciales.

INTRODUCTION: Polypharmacy with psychoactive drugs is an increasingly common and debatable contemporary practice in clinical psychiatry more probably based on experience than evidence. The objective of this study was to evaluate the prevalence and estimators of polypharmacy in psychiatric patients living in an area with very limited mental health resources. METHOD: All patients (n = 352) with mental disorders receiving psychotropic medication living in La Gomera were studied through an audit of case records and a second phase confirmation strategy through personal interviews. RESULTS: The mean number of psychoactive drugs prescribed was 2.22 +/- 0.70 (range: 1-6). The rate of polypharmacy was 67 %, with 34.1 % of patients receiving two drugs, 20.5 % receiving three drugs and 12.5 % of the patients receiving four or more psychotropic drugs at the same time. Multiple regression analysis shows that none of the variables considered (age, sex, marital status, educational level, work activity and diagnosis) had predictive value in regards to the number of psychotropic drug used. Benzodiazepines were the most prevalent drugs in single drug therapy, while antidepressants and antipsychotics were the most used in combination with other treatment. A questionably very high degree of same-class polypharmacy was observed, while multiclass, adjunctive and augmentation polypharmacy seems to be more appropriate. CONCLUSION: The psychiatric clinical practice needs to develop indicators for an appropriate polypharmacy of mental disorders. More research is still needed to identify patients at risk of polypharmacy in order to develop interventions that minimize the risks associated to this treatment alternative.

Functional recovery of skilled forelimb use in rats obliged to use the impaired limb after grafting of the frontal cortex lesion with homotopic fetal cortex.

The long-term effect of transplanting embryonic frontal cortex into a unilateral frontal cortex lesion has been studied in adult rats. Before surgery, activity in an open field, muscular strength of both forelimbs, and performance in a paw-reaching-for-food task were scored in 26 rats. In 21 animals a unilateral cortex lesion was then made in the forelimb motor area of the hemisphere contralateral to the preferred paw in the paw-reaching-for-food task, while the other 5 animals were sham-operated. On retesting, the lesion animals changed the preferred paw. A solid homotopic transplant of embryonic tissue (embryonic day 17) was then placed in the lesion cavity in 11 of the lesion rats. Three months later neither lesion alone nor lesion plus transplantation affected open field behavior and muscular strength, but the lesion permanently affected performance in the paw-reaching-for-food task, as shown by a change of preferred paw and a functional deficit in the paw contralateral to the lesion. Transplantation ameliorated the deficits caused by the lesion, but this was only evident when animals were forced to reach with the paw contralateral to the lesion plus transplant. The behavioral results were independent of the size of the lesion and graft. Connections between graft and host tissue were studied by means of the fluorescent tracer 1,1'-dioctadecyl-3,3,3'3'-tetramethylindocarbocyanine perchlorate (DiI). A dense array of labeled fibers was found in the host cortex adjacent to the transplant. The results suggest that functional recovery depends on grafting but is only evident when the animal is obliged to use the affected limb.

The Severity of Dependence Scale (SDS) as screening test for benzodiazepine dependence: SDS validation study.

AIMS: To assess the validity of the Severity of Dependence Scale (SDS) as a screening test to detect benzodiazepine dependence in regular benzodiazepine users. METHOD: One hundred regular benzodiazepine users, recruited from neurotic benzodiazepine users attending the Mental Health Outpatient Services of the Canary Islands Health Service, were administered the SDS and responses were compared with the Composite International Diagnostic Interview (CIDI) diagnosis of benzodiazepine dependence. Receiver Operating Characteristic (ROC) analysis was used to determine which cut-off score on SDS allowed the best trade-off between sensitivity and specificity. RESULTS: SDS was shown to have high diagnostic utility, and a score higher than six on the scale appears to be an appropriate threshold for problematic benzodiazepine use. The SDS had a specificity of 94.2% and a sensitivity of 97.9%, and the area under the curve was of 0.991. CONCLUSION: The SDS was found to be a valid brief self-report questionnaire for the assessment of benzodiazepine dependence in patients using benzodiazepines.

Prescribed daily doses and 'risk factors' associated with the use of benzodiazepines in primary care.

OBJECTIVE: To assess the extent, characteristics and determinants of benzodiazepine prescription in outpatient Primary Health Care. METHODS: A clinical audit of a stratified random sample of Primary Health Care Centres in the seven islands and 1.6 million inhabitants region of 'Canarias' in Spain was carried out. From those centres, a random sample of 1045 clinical records was reviewed and information on diagnosis, prescription and prescribed dosages was collected in a structured questionnaire. A multivariate logistic regression analysis was performed in order to determine the 'risk factors' for the use of benzodiazepines. RESULTS: Benzodiazepine prescription was recorded in 23.4% of all clinical records; 87.7% of these were for benzodiazepines classified as anxiolytics (N05B) and 12.3% for hypnotics (N05C2). Benzodiazepine prescription was more common for women, elderly, widowed, divorced, low educational background, housewives and retired people. Using multivariate logistic regression, the probability of benzodiazepine prescription was found to be closely related to age, gender and employment status, but not with educational level. Prescribed Daily Doses were lower than Defined Daily Doses (DDD) in 77.1% of all anxiolytic prescriptions, but were in agreement with DDD in 90% of hypnotic prescriptions. The duration of treatment recorded in the clinical records was 25+/-21 months, with a range of 1 and 144 months. General Practitioners were responsible for 67% of all benzodiazepine prescription. Anxiolytics were prescribed as a single daily dose in 57% of the cases, and only 'at supper' in 48.6%. CONCLUSION: In the general population attending Primary Health Care Centres of the Canary Islands Health System the prescription of benzodiazepines is higher for women and the elderly, and the most common use is chronic, with a duration of over 2 years in most cases. Anxiolytics are prescribed in doses which are much lower than those used as DDD and were used only 'at night' in almost half of the cases. This could represent an overlapping of the indications with hypnotics, and explain part of the huge difference in the use of anxiolytics in Spain compared with other figures in Europe. This fact must also be taken into account when making inferences of benzodiazepine use from sales statistics, which are very imprecise measures of drug use.

[Burnout and reaction to stress]. / Burnout y reactividad al estrés.

The recent flurry of attention to burnout syndrome still leaves numerous questions unanswered. One of them is the relationship between individual factors and the development of burnout. An understanding of the individual factors underlying burnout must include an assessment of the individual reactivity to stress. The occurrence, distribution and relationship with stress reactivity of the three dimensions of the burnout syndrome (emotional exhaustion, depersonalization and lowered feelings of personal accomplishment) were studied among a representative sample of the different professionals involved in the Primary Care Health System. Our results indicate that stress reactivity could be a variable that modulates the experienced psychopathology, suggesting a predisposition that increases the susceptibility to the development of burnout.

[The factors related to the research activities of primary care physicians]. / Factores relacionados con la actividad investigadora de los médicos de atención primaria.

OBJECTIVE: To find the factors related with the research activities of primary care (PC) doctors in Catalonia, especially their motivation and the obstacles to research perceived by the doctors themselves. DESIGN: An observational, crossover study. SETTING: Primary care doctors in Catalonia. PARTICIPANTS: The number of doctors (1,286) was divided into two: a) doctors who had published between 1989 and 1994 (n = 146), b) doctors who had not published. INTERVENTIONS: A survey concerning personal and workplace variables was carried out by post. RESULTS: The reply percentage was 49.5% (63.7% among those who had published and 44.85% among those who had not). The multivariant analysis showed a significant link between publishing and postgraduate residence training (MIR), the fact of working in a teaching centre and working in a centre with more than ten doctors. CONCLUSIONS: Research is close related to postgraduate residence training (MIR), work in a teaching unit and PC centres with over ten doctors. Care load, lack of time and difficulty in getting financing were the main obstacles to research given by the doctors polled.

Endovascular treatment of external carotid-jugular fistulae in the parotid region.

A series of eight patients with large arteriovenous fistulae involving the external carotid artery and the jugular vein that were treated with the endovascular technique are reviewed. The origin of the fistula was congenital in six patients, spontaneous in one, and iatrogenic in one. All the fistulae were located in the parotid region, and single channel arteriovenous shunts were evident in all the cases. Endovascular treatment was performed with a detachable balloon. All the patients were cured, and no complications were observed. No recurrences were observed after a clinical follow-up of 6 months to 12 years (mean, 5 yr). Endovascular treatment offers the advantage of being less traumatic because it avoids facial scars and injury to the facial nerve. This is especially important in children, who most commonly have this condition. In our group, endovascular treatment is considered first in the management of external carotid-jugular fistulae.

[Review of the original articles published by primary care professionals in Catalonia]. / Revisión de los artículos originales publicados por profesionales de atención primaria en Cataluña.

OBJECTIVE: To describe the characteristics of the research work published by Primary Care professionals in Catalonia between 1989 and 1991, with an analysis of the preferred research areas, design type and different bibliometric features, with the aim of finding what is the real state of Primary Care research in Catalonia. DESIGN: Descriptive study based on checking all the original articles published between January 1989 and December 1991 in nine Spanish journals in the Primary Care, internal medicine and paediatrics fields. SETTING: Included were studies carried out by Primary Care professionals in Catalonia, either working alone or in collaboration, and which were relevant to Primary Care. MEASUREMENTS AND MAIN RESULTS: A total of 63 articles were surveyed. The average number of authors per article was 5.8 +/- 2.4. The majority of the signatories were Family and Community Medicine (FCM) specialists. 65.1% of articles were by professionals from FCM teaching units. The most common research areas were epidemiology, clinics and prevention. 74.6% of the articles were descriptive. 69.8% used some technique of inferential statistics. The average number of bibliographical quotations was 18.9 +/- 10.4: with the journal Atención Primaria the most quoted. CONCLUSIONS: This study revealed the type of research being undertaken in the Primary Care field in Catalonia.

[Program for helping the smoker in primary care. Preliminary evaluation]. / Programa de ayuda al fumador para la atención primaria. Evaluación preliminar.

The program of help to the smoker (PHS) consists of a systematic intervention upon the whole of the demanding population, identifying the smokers and acting on them with a short, concise advise in all visits. The results after 2 months of operation of the PHS in a primary care center are reported. Among 483 persons 104 smokers were detected (23.65%). 27% showed a favorable disposition towards quitting smoking within a short term; only 17% declared to be against quitting. The best response (36.8% of favorable responses) was obtained in the group smoking 20 cigarettes per day or more. The reported data suggest that the PHS could be useful both in heavy and in minimal or moderate smokers. We consider these data as a preliminary evaluation; assessment with data of long term cessation from smoking is required.