Una experiencia de grupo de reflexión para el manejo de entrevistas clínicas difíciles / A reflection group’s experience in handling hard clinical encounters

Fundamento. Se presenta la experiencia de un grupo de reflexión para valorar si la metodología llevada a cabo, ayuda a los profesionales sanitarios a entenderlos encuentros difíciles (ED), a mejorar su satisfacción profesional y la comunicación con el paciente. Material y método. Se siguió una metodología de reestructuración cognitiva con registro escrito para analizar, primero individualmente, los ED con los pacientes y comentarlos luego en el grupo de reflexión. Resultados. Los ED se referían principalmente a: solicitudes vividas como inapropiadas, cuestionamiento de competencia profesional, y cambio inesperado de médico. Las emociones surgidas, antes y después de “volver a pensar”, cambiaron de intensidad de forma significativa (p<0,001). Los pensamientos irracionales se agruparon en 9 tipos de distorsiones cognitivas, siendo las más frecuentes “razonamiento emocional” y “falacias de control”. Las pautas explicativas constructivas que surgieron después de “volver a pensar”, en su mayoría estaban relacionados con la necesidad de mejorar la comunicación. El grupo reconoció muchas aportaciones positivas. Ni las encuestas utilizadas para valorar el desgaste profesional (MBI), ni la encuesta diseñada para la evaluación, presentaron diferencias significativas, comparando al inicio y final del trabajo. Conclusiones. El empleo conjunto de una metodología cognitivo-conductual en el marco de un grupo de reflexión, se complementan mutuamente, y posibilitan el trabajo engrupo sin precisar un conductor profesional. La reflexión escrita y el trabajo con los pensamientos irracionales y “volver a pensar” con la perspectiva de comentarlo en el grupo, es una experiencia aplicable en el contexto de Atención Primaria y ayuda al manejo de los encuentros difíciles (AU)

Background. We present the experience of a reflection group to evaluate whether the methodology carried out helps health professionals to understand difficult encounters and improve their professional satisfaction and communication with the patient. Method. We followed a cognitive restructuring methodology with a written record in order to analyze difficult encounters with patients, first individually and then followed by comments in the reflection group. Results. Difficult encounters mainly involved: requests felt to be inappropriate, questioning of professional competence, and unexpected change of doctor. The emotions arising, before and after “rethinking”, changed in intensity in a significant way (p<0.001). Irrational thoughts were grouped in 9 types of cognitive distortions, with the most frequent being “emotional reasoning” and “control fallacies”. The majority of constructive explanatory patterns that emerged after “rethinking” were related to the need for improving communication. The group recognized many positive contributions. Neither the surveys used to evaluate occupational burnout, nor the survey designed for the evaluation showed significant differences, comparing the beginning and end of the work. Conclusions. The joint use of a cognitive-behavioral methodology in the framework of a reflection group is mutually complementary, and enables group work without the need for professional direction. Written reflection and work with irrational thoughts and “rethinking” with the perspective of group comment is an experience that is applicable in the context of Primary Care and helps in handling difficult encounters (AU)

[A reflection group's experience in handling difficult clinical encounters]. / Una experiencia de grupo de reflexión para el manejo de entrevistas clínicas difíciles.

BACKGROUND: We present the experience of a reflection group to evaluate whether the methodology carried out helps health professionals to understand difficult encounters and improve their professional satisfaction and communication with the patient. METHOD: We followed a cognitive restructuring methodology with a written record in order to analyze difficult encounters with patients, first individually and then followed by comments in the reflection group. RESULTS: Difficult encounters mainly involved: requests felt to be inappropriate, questioning of professional competence, and unexpected change of doctor. The emotions arising, before and after "rethinking", changed in intensity in a significant way (p<0.001). Irrational thoughts were grouped in 9 types of cognitive distortions, with the most frequent being "emotional reasoning" and "control fallacies". The majority of constructive explanatory patterns that emerged after "rethinking" were related to the need for improving communication. The group recognized many positive contributions. Neither the surveys used to evaluate occupational burnout, nor the survey designed for the evaluation showed significant differences, comparing the beginning and end of the work. CONCLUSIONS: The joint use of a cognitive-behavioral methodology in the framework of a reflection group is mutually complementary, and enables group work without the need for professional direction. Written reflection and work with irrational thoughts and "rethinking" with the perspective of group comment is an experience that is applicable in the context of Primary Care and helps in handling difficult encounters.

[Agreement among ophthalmologists and primary care physicians in the evaluation of retinographies of diabetic patients]. / Concordancia en el estudio de retinografías en diabéticos: oftalmólogos vs médicos de familia.

PURPOSE: To assess the extent of agreement in the evaluation of non-mydriatic retinographies of diabetic patients among ophthalmologists and a group of primary care physicians with previous training. METHODS: The study was divided in two phases. In the first phase, the four participants were instructed in the interpretation of retinographies. The second phase involved the evaluation of 1000 images of 200 patients, 100 without retinopathy and 100 with signs of diabetic retinopathy. The four participants had to decide if the images did or did not show evidence of diabetic retinopathy. Kappa index was used to assess the extent of agreement. A percentage disagreement of 15% with a precision of 5% (+/-5%) with a confidence level of 95% was considered adequate. RESULTS: The percentage of coincident diagnoses among ophthalmologists and primary care physicians was between 89 and 97.5%. With respect to the assessment of the agreement, the kappa index was between 80 and 95%. In all cases the confidence interval was at least 85%. CONCLUSIONS: After an adequate training process, the reliability of evaluation of non-mydriatic retinographies of diabetic patients by primary care physicians was very high. This could allow the establishment of screening for diabetic retinopathy at the primary care level. Advantages of this system include a greater involvement of primary care physicians in the global management of diabetic patients and a lower demand for ophthalmic attention.

Concordancia en el estudio de retinografías en diabéticos: oftalmólogos vs médicos de famlia / Agreement among ophthalmologists and primary care physicians in the evaluation of retinographies of diabetic patients

Objetivo: Determinar la concordancia en la interpretación de retinografías no midriáticas de pacientes diabéticos entre oftalmólogos y un grupo de médicos de atención primaria previamente sometidos a un proceso de adiestramiento. Métodos: El estudio fue dividido en dos fases. En la primera se adiestró a los participantes en la interpretación de imágenes retinográficas. La segunda fase se realizó sobre 1000 imágenes correspondientes a 200 pacientes, 100 sin retinopatía diabética y 100 con retinopatía. Los participantes debían decidir si las imágenes presentaban o no signos de retinopatía diabética. Para la valoración de la concordancia se utilizó el índice kappa. Se estimó como adecuado un porcentaje de desacuerdo del 15% con una precisión del 5% (±5%) con un nivel de confianza del 95%. Resultados: El porcentaje de diagnósticos coincidentes entre oftalmólogos y médicos de atención primaria está entre 89 y 97,5%. Por lo que respecta a la evaluación de la concordancia, el índice kappa se sitúa entre 80 y 95%. En todos los casos el intervalo de confianza incluye el 85%. Conclusiones: Después de un adecuado adiestramiento, la fiabilidad de facultativos de atención primaria en interpretar retinografías no midriáticas de diabéticos es muy alta. Esto permitiría establecer en atención primaria el filtro para el cribado de la retinopatía diabética. Las ventajas de esta medida serían una mayor implicación de atención primaria en el manejo global de los diabéticos y una disminución de la demanda de atención oftalmológica

Purpose: To assess the extent of agreement in the evaluation of non-mydriatic retinographies of diabetic patients among ophthalmologists and a group of primary care physicians with previous training. Methods: The study was divided in two phases. In the first phase, the four participants were instructed in the interpretation of retinographies. The second phase involved the evaluation of 1000 images of 200 patients, 100 without retinopathy and 100 with signs of diabetic retinopathy. The four participants had to decide if the images did or did not show evidence of diabetic retinopathy. Kappa index was used to assess the extent of agreement. A percentage disagreement of 15% with a precision of 5% (±5%) with a confidence level of 95% was considered adequate. Results: The percentage of coincident diagnoses among ophthalmologists and primary care physicians was between 89 and 97.5%. With respect to the assessment of the agreement, the kappa index was between 80 and 95%. In all cases the confidence interval was at least 85%. Conclusions: After an adequate training process, the reliability of evaluation of non-mydriatic retinographies of diabetic patients by primary care physicians was very high. This could allow the establishment of screening for diabetic retinopathy at the primary care level. Advantages of this system include a greater involvement of primary care physicians in the global management of diabetic patients and a lower demand for ophthalmic attention (Arch Soc Esp Oftalmol 2008; 83: 527-532)

[Population-based epidemiology of colorectal cancer: causality review]. / Epidemiología poblacional de cáncer colorrectal: revisión de la causalidad.

The estimated number of new cases of colorectal cancer per year in Spain (no. 19,166) is higher than other tumour locations. 1.56 times more cases of colon cancer are registered than of the rectum, and there are 1.44 times more cases in men than in women. Incidence and mortality are lower than the average for European countries; in historical series (1973-1999) an increase can be observed by age, period and birth cohorts between 1898 and 1932. On the contrary, in the USA a reduction of mortality can be observed from 1973 to 1999 (-20.8%) and of incidence from 1985 to 1999 (-7.4%). In Spain, the average duration of the disease in years is 4.29, lower than that of the European Community (4.57), and 72% of the figure for the most favourable country (5.93). Relative survival after five years in Spain is lower than in the USA (61.9% vs. 54%). Several dietary, environmental and lifestyle factors appear to be associated with colorectal cancer, but the risk or protection of these factors are of little weight and the results of studies are at times contradictory. The reduction of incidence in the USA indicates that intervention is possible to bring about a change of trend, predictably by means of secondary prevention.

Epidemiología poblacional de cáncer colorrectal: revisión de la causalidad / Population-based epidemiology of colorectal cancer: causality review

El número de casos nuevos estimados al año de cáncer colorrectal en España (19.166) es superior al del resto de localizaciones tumorales. Se registran 1,56 veces más de cáncer de colon que de recto y 1,44 veces más en hombres que en mujeres. La incidencia y la mortalidad son inferiores al promedio de los países europeos; en series históricas (1973-1999) se observa un incremento según la edad, el período y las cohortes de nacimiento entre 1898 y 1932. Por el contrario, en EE.UU. se observa una reducción de la mortalidad desde 1973 a 1999 (-20,8%) y de la incidencia (-7,4%) desde 1985 a 1999. En España, la duración promedio en años de la enfermedad es de 4,29, inferior a la de la comunidad europea (4,57) y el 72% respecto al país más favorable (5,93). Varios factores dietéticos, ambientales y de estilos de vida se muestran asociados al cáncer colorrectal, pero el riesgo o la protección de tales factores son de escasa fuerza y los resultados de los estudios son a veces contradictorios. La reducción de la incidencia en EE.UU. plantea que es posible la intervención para un cambio de la tendencia, previsiblemente a través de la prevención secundaria (AU)

The estimated number of new cases of colorectal cancer per year in Spain (no. 19,166) is higher than other tumour locations. 1.56 times more cases of colon cancer are registered than of the rectum, and there are 1.44 times more cases in men than in women. Incidence and mortality are lower than the average for European countries; in historical series (1973-1999) an increase can be observed by age, period and birth cohorts between 1898 and 1932. On the contrary, in the USA a reduction of mortality can be observed from 1973 to 1999 (-20.8%) and of incidence from 1985 to 1999 (-7.4%). In Spain, the average duration of the disease in years is 4.29, lower than that of the European Community (4.57), and 72% of the figure for the most favourable country (5.93). Relative survival after five years in Spain is lower than in the USA (61.9% vs. 54%). Several dietary, environmental and lifestyle factors appear to be associated with colorectal cancer, but the risk or protection of these factors are of little weight and the results of studies are at times contradictory. The reduction of incidence in the USA indicates that intervention is possible to bring about a change of trend, predictably by means of secondary prevention (AU)

Programa de trastornos mentales / Mental disorders programme

No disponible

Early prognosis in severe sepsis via analyzing the monocyte immunophenotype.

OBJECTIVE: To analyze the early discriminative predictive information regarding the immunophenotype components of patients with sepsis, and its potential use as a prognosis tool. DESIGN: Observational prospective clinical study. SETTING: Intensive care unit (ICU) in a University Hospital. PATIENTS: Thirty-five patients admitted with severe sepsis. MEASUREMENTS: Analysis of peripheral blood on admission and 48 h later of the absolute white cell count and the immunophenotype of lymphocyte (CD3, CD3-HLADR, CD4, CD8, CD4/CD8 ratio, CD19, and CD25) and monocyte (CD13, CD13-HLADR, CD14, CD14-HLADR, CD13-CD14, and CD4) subpopulations. RESULTS: Due to its high correlation, the immunophenotypic profile studied at admission and 48 h later showed the same prognosis power regardless of the time of performance. The univariate analysis between groups (survival versus death) confirmed the prognostic significance of the total monocyte count and its subpopulations; significant differences were observed from the beginning only in the CD19 lymphocyte subpopulation. Multivariate analysis was performed using logistic regression with survival as the dependent variable. The final model comprised monocytes beta = 0.002 (P = 0.025) and CD13-HLADR beta = 0.016 (P = 0.029). The monocytes receiver operating characteristic (ROC) area obtained was 0.819 (confidence interval 0.663-0.976 at 95 %), the CD13-HLADR ROC area was 0.810 (confidence interval 0.658-0.963), and the monocytes + CD13-HLADR ROC area was 0.918 (confidence interval 0.807-1.000). CONCLUSIONS: A single blood sample test obtaining the absolute monocyte and CD13-HLADR subpopulation count in the first days of admission could contribute to simplifying the classification of patients with severe sepsis into high- and low-mortality risk.

[Incidence of idiopathic and secondary Parkinson disease in Navarre. Population-based case registry]. / Incidencia de la enfermedad de Parkinson idiopática y secundaria en Navarra. Registro poblacional de casos.

AIM: To determine the incidence of Parkinson's disease in Navarra, province of Spain. PATIENTS AND METHODS: All patients diagnosed as suffering from Parkinson's disease or related disorders for the neurologists of the region during the period 1994-1995 inclusive were referred to the study. EUROPARKINSON protocol and an epidemiological questionnaire were employed for the assessment. RESULTS: A total of 132 cases of idiopathic (86) and secondary (45) Parkinson's disease were diagnosed during that period. Among men the age adjusted incidence of idiopathic Parkinson's disease was 10.06 x 10(5), while for women it was 4.92 x 10(5). Total adjusted incidence was 7.36 x 10(5). The average age at onset was 67.5 years in men and 72.6 years in women (p < or = 0.007). Men showed an age adjusted incidence of secondary parkinsonism of 3.34 x 10(5) and women of 4.23 x 10(5). Age at onset was earlier in women than in men (71.2 and 74.8 years, respectively). CONCLUSIONS: The incidence of idiopathic Parkinson's disease in Navarra is higher in men than in women, also supported for an earlier age at onset in men. The epidemiological pattern of secondary Parkinson's disease differs from that of the idiopathic disease.

Priorities in healthcare: a perspective from Spain.

The aim of this paper is to describe the process of transformation over the past two decades in the Spanish healthcare system. The main emphasis is on priority setting and rationing at different levels. On the supply side, the policies have focused on limiting the scope of pharmaceutical benefits in the system, and establishing a guaranteed healthcare package. On the consumer side, the main measures reviewed are copayments. Finally, a discussion of the research that has been done on public opinion about rationing is presented.

[Inverse association between smoking and idiopathic Parkinson's disease]. / Asociación inversa entre consumo de tabaco y enfermedad de Parkinson idiopática.

An evaluation is made of the effect of smoking during the period of life between 20 and 50 years of age and idiopathic Parkinson's disease in a case-control study carried out in Navarra. An inverse association is observed: for the number of smokers (OR = 0.66, CI 90% 0.41-1.05); for the number of years smoking (OR =0.22, CI 90% 0.05-0.97); and for the quantity of cigarettes smoked (z = 2.2298, p = 0.02). Likewise, a dose-response relationship exists between the number of cigarettes consumed and the risk of Parkinson's disease (p = 0.01). The same effect is maintained on analysing the data by matching 1:1 (OR = 0.59, CI 90% 0.31-1.10). All of this contributes to giving consistency to the protective effect of smoking against idiopathic Parkinson's disease. The anti-oxidant status, measured by means of different parameters in peripheral blood, is lower in the cases than in the tests for reduced glutathione (GSH) (p = 0.001) and is an independent variable with respect to smoking.

Depression in three populations in the Basque country--a comparison with Britain.

A psychiatric survey in three regions of the Basque Autonomous Community aimed to replicate two British surveys, in London and a rural area of Scotland, investigating both prevalence of psychiatric disorder and its relationship with certain key psychosocial factors. The Spanish rural-urban differences in rates of depression and anxiety closely paralleled the earlier British results. As in Britain, Spanish rural rates of depression were lower among those most integrated into the traditional family ways of life, but in contrast to Britain the urban rates did not vary with social class or the presence of children at home. As in Britain, severe life event and major difficulties were associated with onset of depression, and varied in prevalence and type with degree of integration with the traditional lifestyle. The protective role of intimate confiding with a partner against depressive onset was confirmed among non-churchgoers in Bilbao, but not among churchgoers, while in the rural samples there was only a nonsignificant trend.