[Reasons and determining factors for referrals between primary and specialised care]. / Motivos y condicionantes de la interconsulta entre atención primaria y especializada.

OBJECTIVES: To determine the reasons and characteristics of referrals from Primary to Specialised Care in the Health Area of Toledo (Spain). MATERIAL AND METHODS: A descriptive, cross-sectional study was conducted by reviewing a sample of the referrals to specialists made by 26 general practitioners from eight Teaching Health Centres during February 2011. All of them completed a questionnaire which recorded patient data, and reason and characteristics of the referral. RESULTS: A total of 332 referrals were recorded; the mean age of the patients was 51.3 years (SD; 17.9); 60.1% females; 30.7% pensioners; 54.8% had a chronic disease; 85.8% were from an urban environment. The most consulted specialists were: Traumatology (63), Gynaecology (53), and Ophthalmology (41). More than three-quarters (78.9%) were by the normal route, and 47.4% were first consultations. Around 12.7% were scheduled reviews, with a majority (51.4%) by a hospital specialist. More than two thirds (69.8%, 95% CI; 64.5-74.7%) required follow-up or treatment by the specialist. More than half (57.7%, 95% CI; 52.3-63.1%) required special diagnostic tests, and in 29.8% (95% CI; 25.0-35.1%) there was no clear diagnosis. There was a history of a repeated consultation for the same symptomatology in 28.9% of the referrals. Around 38.4% (95% CI; 33.0-43.7%) were requested specifically by the family or patient. Around 5.4% had a poor relationship with the patient. CONCLUSIONS: The majority of referrals are made by the normal route, and to surgical specialities. The need for hospital specialist follow-up and/or treatment, or the impossibility to request specific tests from Primary Care were the main reasons for requesting care from a second health care level. There were a high percentage of referrals requested by the family/patient.

Motivos y condicionantes de la interconsulta entre atención primaria y especializada / Reasons and determining factors for referrals between primary and specialised care

Objetivos. Conocer los motivos y características de las derivaciones desde atención primaria a especializada en el área de Salud de Toledo. Material y métodos. Estudio de tipo descriptivo transversal. Se revisó una muestra de las interconsultas a especializada realizadas por 26 médicos de familia, pertenecientes a 8 centros de salud docentes, en febrero de 2011. Por cada una, se cumplimentó un cuestionario que recogía datos del paciente, motivo y características de la derivación. Resultados. Se recogieron 332 interconsultas; la edad media de los pacientes fue de 51,3 años (DE 17,9); el 60,1% mujeres; el 30,7% pensionistas; el 54,8% presentaban patología crónica; el 85,8% procedía del medio urbano. Las especialidades más consultadas fueron: Traumatología (63), Ginecología (53) y Oftalmología (41). El 78,9% fueron vía normal y 47,4% fueron primeras consultas. Un 12,7% eran revisiones programadas, en su mayoría (51,4%) por el especialista hospitalario. El 69,8% (IC95% 64,5–74,7%) precisaba seguimiento o tratamiento por el especialista. El 57,7% (IC95% 52,3–63,1%) requería pruebas diagnósticas especiales. En el 29,8% (IC95% 25,0–35,1%) no estaba claro el diagnóstico. En el 28,9% de las derivaciones había antecedentes de consulta reiterada por esa sintomatología. En el 38,4% (IC95% 33,0–43,7%) hubo solicitud expresa por familia o paciente. El 5,4% tenía mala relación con el paciente. Conclusiones. La mayoría de las derivaciones se hacen por vía normal y a especialidades quirúrgicas. La necesidad de seguimiento y/o tratamiento por parte del especialista hospitalario o la imposibilidad de solicitar determinadas pruebas desde atención primaria fueron los principales motivos para solicitar la atención del segundo nivel asistencial. Existe un alto porcentaje de interconsultas inducidas por la familia/paciente(AU)

Objectives. To determine the reasons and characteristics of referrals from Primary to Specialised Care in the Health Area of Toledo (Spain). Material and methods. A descriptive, cross-sectional study was conducted by reviewing a sample of the referrals to specialists made by 26 general practitioners from eight Teaching Health Centres during February 2011. All of them completed a questionnaire which recorded patient data, and reason and characteristics of the referral. Results. A total of 332 referrals were recorded; the mean age of the patients was 51.3 years (SD; 17.9); 60.1% females; 30.7% pensioners; 54.8% had a chronic disease; 85.8% were from an urban environment. The most consulted specialists were: Traumatology (63), Gynaecology (53), and Ophthalmology (41). More than three-quarters (78.9%) were by the normal route, and 47.4% were first consultations. Around 12.7% were scheduled reviews, with a majority (51.4%) by a hospital specialist. More than two thirds (69.8%, 95% CI; 64.5–74.7%) required follow-up or treatment by the specialist. More than half (57.7%, 95% CI; 52.3–63.1%) required special diagnostic tests, and in 29.8% (95% CI; 25.0-35.1%) there was no clear diagnosis. There was a history of a repeated consultation for the same symptomatology in 28.9% of the referrals. Around 38.4% (95% CI; 33.0–43.7%) were requested specifically by the family or patient. Around 5.4% had a poor relationship with the patient. Conclusions. The majority of referrals are made by the normal route, and to surgical specialities. The need for hospital specialist follow-up and/or treatment, or the impossibility to request specific tests from Primary Care were the main reasons for requesting care from a second health care level. There were a high percentage of referrals requested by the family/patient(AU)

Abordaje terapéutico del insomnio / Therapeutic approach to insomnia

El insomnio es la incapacidad para conciliar o mantener el sueño o la sensación de no haber tenido un sueño reparador que ocasiona disfunción diurna. Repercute de forma importante en la salud y la calidad de vida de quien lo presenta. Pese a ello, hasta el 10% de los pacientes insomnes no reciben el tratamiento adecuado. Debe realizarse un abordaje integral tratando las causas o desencadenantes y sus síntomas y valorando su repercusión en el paciente. El tratamiento debe basarse en estrategias de modificación de conductas y cambios en el estilo de vida a las que se asociará, cuando se considere necesario, tratamiento farmacológico. Los principales hipnóticos son las benzodiacepinas y los fármacos Z o hipnóticos no benzodiacepínicos, sin que se hayan encontrado evidencias de diferencias clínicamente significativas sobre la utilización de unas u otros. Ambos grupos terapéuticos son eficaces en el tratamiento del insomnio a corto plazo pero no se dispone de evidencia sobre su eficacia a largo plazo en este cuadro (AU)

Insomnia is the inability to reconcile or maintain sleep or the feeling of not having a good night's sleep, resulting in daytime dysfunction. It affects health and the quality of life of patients who suffer from it. However, up to 10% of insomniac patients do not receive an adequate treatment. Insomnia requires an integrated approach, treating the causes or triggers and symptoms, and assessing their impact on the patient. Treatment must be based on strategies of changing behaviour and changes in lifestyle that are associated, and when deemed necessary, pharmacological treatment. The main hypnotics are benzodiazepines and Z drugs or non-benzodiazepine hypnotics, on not finding any evidence of clinically significant differences between the use of one or the other. Both therapeutic groups are effective in the treatment of insomnia in the short term, but there is no evidence on their long-term effectiveness (AU)

[Therapeutic approach to insomnia]. / Abordaje terapéutico del insomnio.

Insomnia is the inability to reconcile or maintain sleep or the feeling of not having a good night's sleep, resulting in daytime dysfunction. It affects health and the quality of life of patients who suffer from it. However, up to 10% of insomniac patients do not receive an adequate treatment. Insomnia requires an integrated approach, treating the causes or triggers and symptoms, and assessing their impact on the patient. Treatment must be based on strategies of changing behaviour and changes in lifestyle that are associated, and when deemed necessary, pharmacological treatment. The main hypnotics are benzodiazepines and Z drugs or non-benzodiazepine hypnotics, on not finding any evidence of clinically significant differences between the use of one or the other. Both therapeutic groups are effective in the treatment of insomnia in the short term, but there is no evidence on their long-term effectiveness.

Conductas relacionadas con el acoso escolar en un instituto de educación secundaria / School harassment related behaviors in a secondary education school

INTRODUCCIÓN. El acoso escolar (bullying) es una conducta agresiva, intencional y persistente entre escolares. El objetivo de este estudio fue explorar la frecuencia y las características de los comportamientos agresivos en el ámbito escolar y la vivencia de los propios adolescentes de dichas conductas. MATERIAL Y MÉTODOS. Estudio observacional descriptivo, realizado entre alumnos de primero a cuarto de Enseñanza Secundaria Obligatoria en un instituto de Toledo, mediante encuesta anónima y autocumplimentada, elaborada ad hoc. RESULTADOS. Se incluyeron en el estudio 124 jóvenes entre 13 y 17 años, de los que el 51,6% correspondía a varones. El 16,9% reconoce haberse sentido acosado, rechazado o perseguido alguna vez por sus compañeros (intervalo de confianza del 95%: 11,0-24,9). Este porcentaje es mayor en chicas (22,0 frente a 11,5; p = 0,121). El 49,2% afirmó conocer algún caso de acoso. Aunque el lugar más habitual donde tiene lugar el acoso es la calle, un 40,7% lo situó en las propias aulas y un 36,6% en el patio. Las conductas de acoso más frecuentemente observadas fueron las físicas (87,4%), seguidas de las verbales (75,8%) y el aislamiento (63,7%). Globalmente, el 78,2% reconoció haber realizado algún comportamiento relacionado con el bullying alguna vez, sin diferencias entre sexos. Un 22,6% refiere que ¿en caso de sufrir acoso¿ no lo comentaría con nadie. CONCLUSIONES. El acoso escolar, en mayor o menor grado, es un fenómeno frecuente entre adolescentes. Sorprende el alto porcentaje que reconoce la propia clase como emplazamiento en el que tienen lugar acciones de este tipo. Tanto los profesionales de la enseñanza como los sanitarios debemos actuar para prevenir, detectar y poner soluciones a este problema (AU)

INTRODUCTION. Bullying in the school is an aggressive,intentional and persistent behavior among students. Thisstudy has aimed to discover the frequency and characteristicsof these aggressive behaviors in the school and the experienceof teenagers regarding the mentioned behaviors.MATERIALS AND METHODS. This is an observationaldescriptive study performed among pupils from first gradeto fourth grade of Compulsory Secondary Education in aschool in Toledo with an anonymous and self-completed survey,elaborated ad hoc.RESULTS. One hundred twenty four youths between 13and 17 years of age, 51.6% males, were included. Of these,16.9% admitted they had felt bullied, rejected or abusedby their schoolmates at one time or another (CI 95%: 11.0-24.9). This percentage was higher among girls (22.0 vs 11.5;p = 0.121). A total of 49.2% stated they know about some casesof harassment.Although the most common place where bullying takesplace is in the street, 40.7% located it in their own classroomsand 36.6% in the playground. The most frequently observedbullying behaviors were physical (87.4%), followedby verbal (75.8%) and isolation (63.7%). Globally, 78.2% admittedthey had done some bullying-related activity at one timeor another, without differences between the genders.“In case of suffering from harassment”, 22.6% stated thatthey would not comment on it with anybody.CONCLUSIONS. Bullying, to a lesser or greater degree, isa frequent phenomenon among teenagers. The high percentageof students who admit that the classroom is the placewhere this type of action occurs is surprising. Both educationand health professionals must act to anticipate, detectand come up with solutions to this problem (AU)

[Diurnal variability of intraocular pressure]. / Variabilidad diurna de la presión intraocular.

OBJECTIVE: To assess whether there are variations in the intraocular pressure (IOP) between the morning and afternoon in healthy subjects. METHODS: This study was carried out in a Primary Care Health Center among usual patients of general practitioners. Two measurements of the intraocular pressure were assessed on the same day (between 8 and 9 a.m. and between 5 and 6 p.m.) using a Perkins applanation tonometer. The subjects (119 females and 101 males) had a mean age of 46.3 years, with ages ranging between 14 and 83 years. They were proportionally distributed among 4 age groups (14-24, 25-44, 45-64 and >65 years). RESULTS: The IOP mean values were: right eye, morning time and afternoon, 13.29 and 11.81 mm Hg, respectively (p<0.001); left eye, morning time and afternoon, 13.48 and 12.04 mm Hg (p<0.001). The IOP was significantly higher in males than in females, and showed a weak association with age. CONCLUSIONS: We found a diurnal variation of IOP of approximately 1.5 mm Hg. The time of day when the IOP is measured needs to be considered as a variable in research in ocular hypertension and glaucoma.

Variabilidad diurna de la presión intraocular / Diurnal variability of intraocular pressure

Objetivo: Comprobar y cuantificar la posible variación de los valores de presión intraocular (PIO) en sujetos sanos, entre la mañana y la tarde. Métodos: Estudio descriptivo y transversal realizado en un Centro de Salud entre los consultantes habituales de una consulta de medicina general. Se realizaron dos tomas de presión intraocular el mismo día (la primera entre las 8 y las 9 horas y la segunda entre las 17 y las 18 horas) utilizando un tonómetro de aplanación tipo Perkins. Los sujetos (119 mujeres y 101 hombres, edad media de 46,3 años con un rango entre 14 y 83) estaban distribuidos proporcionalmente en cuatro grupos de edad (14-24, 25-44, 45-64 y >65 años). Resultados: Los valores medios de PIO fueron: Ojo derecho en la mañana y en la tarde 13,29 y 11,81 (p<0,001) respectivamente y Ojo izquierdo en la mañana y en la tarde 13,48 y 12,04 (p<0,001). La PIO fue significativamente mayor en hombres que en mujeres, teniendo una correlación muy débil con la edad. Conclusiones: Constatamos una diferencia en los valores de PIO entre la mañana y la tarde, de aproximadamente 1,5 mmHg. El momento del día en que se determina la PIO debería contemplarse como una variable más en los estudios de hipertensión ocular y glaucoma que la determinan

Objective: To assess whether there are variations in the intraocular pressure (IOP) between the morning and afternoon in healthy subjects. Methods: This study was carried out in a Primary Care Health Center among usual patients of general practitioners. Two measurements of the intraocular pressure were assessed on the same day (between 8 and 9 a.m. and between 5 and 6 p.m.) using a Perkins applanation tonometer. The subjects (119 females and 101 males) had a mean age of 46.3 years, with ages ranging between 14 and 83 years. They were proportionally distributed among 4 age groups (14-24, 25-44, 45-64 and >65 years). Results: The IOP mean values were: right eye, morning time and afternoon, 13.29 and 11.81 mm Hg, respectively (p<0.001); left eye, morning time and afternoon, 13.48 and 12.04 mm Hg (p<0.001). The IOP was significantly higher in males than in females, and showed a weak association with age. Conclusions: We found a diurnal variation of IOP of approximately 1.5 mm Hg. The time of day when the IOP is measured needs to be considered as a variable in research in ocular hypertension and glaucoma

Anticoncepción en la adolescencia / Contraceptives in adolescence

La edad no es razón suficiente para descartar ningún método anticonceptivo, pero los aspectos socioconductuales de los adolescentes deben ser considerados a la hora de recomendar uno, siendo muy importante valorar su aceptabilidad y motivación, para asegurar un adecuado cumplimiento. Los métodos naturales son baratos e inocuos, pero requieren un elevado grado de motivación, resultando poco recomendables en adolescentes. Los de barrera ofrecen protección también frente a enfermedades de transmisión sexual (ETS), por lo que están especialmente indicados en la adolescencia, bien solos o en doble protección. Los anticonceptivos orales se consideran actualmente seguros en la adolescencia. Tampoco existen problemas para el uso en adolescentes de anticoncepción combinada inyectable, parches transdérmicos o anillos vaginales, de fácil uso y buen grado de cumplimiento. Respecto a la anticoncepción con progestágenos solos, el patrón de sangrado errático que producen es, con frecuencia, motivo de abandono del método en adolescentes. La minipíldora exige una pauta estricta, por lo que las adolescentes no son buenas candidatas para ella. Sin embargo, la inyección o los implantes de progestágeno solo son de elección cuando se requiere alta eficacia y/o se sospecha mal cumplimiento. El dispositivo intrauterino (DIU) con levonorgestrel está muy discutido en adolescentes. Finalmente, para la anticoncepción de emergencia en adolescentes es preferible la pauta de progestágeno solo, por su mayor efectividad y menor frecuencia de efectos secundarios. Hay que dejar muy claro que no es un sustituto de la anticoncepción habitual, además de no proteger de las ETS

Age is not a sufficient reason to rule out any contraceptive method, but the social-behavioral aspects of the adolescents should be considered when recommending one. It is very important to assess its acceptability and motivation, to assure adequate compliance. Natural methods are cheap and harmless, but require elevated degree of motivation, and are not very recommendable in adolescents. Barrier methods also offer protection against STD, so that they are especially indicated in adolescence, either alone or in double protection. Oral contraceptives are presently considered safe in adolescence. There are also no problems for the use of injectable combined contraceptive, transdermal patches or vaginal rings, of easy use and good degree of compliance, in adolescents. Regarding contractive method with progestagens alone, the erratic bleeding pattern it produces is frequently a reason to discontinue the method in adolescents. The mini pill requires strict regimen, so that adolescents are not good candidates for it. However, progestagen injection or implants are only of choice when high efficacy is required and/or poor compliance is suspected. The IUD with levonorgestrel is very debatable in adolescents. Finally, for emergency contractive method in adolescents, progestagen regimen alone is preferable, due to its greater effectiveness and less frequency of side effects. It must be made clear that it is not a substitute for usual contraceptive method and does not protect against STD

Investigación en atención primaria: 1994-2003 / Research in primary care: 1994-2003

Objetivos. Conocer las características de los artículos originales publicados en la revista Atención Primaria en los últimos 10 años. Diseño. Estudio bibliométrico. Emplazamiento. Atención primaria de salud. Participantes. Artículos originales publicados en Atención Primaria entre 1994 y 2003. Mediciones principales. La categoría profesional de los autores, si se trataba de un estudio multidisciplinario y si era multicéntrico, la comunidad autónoma de procedencia, el tema, el tipo de estudio y si constaba alguna beca o ayuda. Resultados. Se han revisado 1.229 artículos. En el 40,0% figura la autoría de un médico de familia. El 31,4% se puede considerar multidisciplinario y el 20,5% multicéntrico. Las comunidades valenciana, madrileña, andaluza y catalana acaparan más del 60% del volumen de publicaciones. El tema más común es el relacionado con la prestación y organización de los servicios sanitarios (40,5%). Sólo un 4,3% de los diseños es experimental. En el 16,2% de los artículos consta alguna beca o ayuda. Conclusiones. Aunque la situación respecto a años anteriores no ha variado demasiado, algunos hallazgos positivos, como la emergencia de grupos de investigadores, la presencia cada vez mayor de estudios multicéntricos y multidisciplinarios, el mayor acceso a fuentes de financiación, etc., sugieren que estamos en un proceso de mejora de la calidad investigadora en atención primaria

Objectives. To analyse the characteristics of the original articles published in the journal Atención Primaria (Primary Care) during the last 10 years. Design. Literature study. Setting. Primary health care. Participants. Original articles published in Atención Primaria between 1994 and 2003. Main measurements. The professional category of the authors, whether it was a multidisciplinary or multicentred study, the autonomous community of origin, the topic, the type of study, and if it had a grant or financial assistance. Results. 1229 articles have been reviewed. In 40.0% of them a family doctor is included in the authorship. 31.4% can be considered multidisciplinary and 20.5% multicentred. The Communities of Valencia, Madrid, Andalusia, and Catalonia took up 60% of the volume of publications. The most common topic is the provision and organisation of the health services (40.5%). Only 4.3% of the designs are experimental. A grant or financial aid is stated in 16.2% of the articles. Conclusions. Although the situation as regards the previous years has not varied too much, some positive findings, such as the emergence of research groups, increasing presence of multicentre and multidisciplinary studies, better access to sources of finance, etc, suggest that we are in a process of improving the quality of research in primary care

[Alcohol consumption in Toledo schoolchildren: reasons and alternatives]. / Consumo de alcohol en escolares toledanos: motivos y alternativas.

OBJECTIVE: To know the consumption of alcohol in Toledo schoolchildren, to find out the reasons which cause them to drink and the alternatives proposed. DESIGN: Descriptive, transverse study. LOCATION: 2 zones in the Toledo health area. PARTICIPANTS: A total of 625 adolescents between 13 and 18 years, in the third and fourth years of Obligatory Secondary Education and first year in High School (Bachillerato) of 2 secondary education institutions in Torrijos and 1 in Toledo capital. MAIN MEASUREMENTS: Using an ad hoc designed anonymous questionnaire, with 32 items, the following data was collected: age, sex, alcohol consumption (personal, family, and friends), how much (standard drink units), knowledge and sources of information on alcohol, taking of other drugs, reasons for consuming, and the alternatives. RESULTS: 47.27% of those questioned were male. The mean age was 15.4 +/- (-)1.3 years. 93.4% had tried alcohol (95% CI, 91.1-95.2). 52.0% had been drunk at some time, which was more frequent in rural areas than in the city. 58.1% considered alcohol as a drug. Among the reasons mentioned for drinking, the main ones were "enjoyment" (46.3%), "to forget problems" (30.7%), and "curiosity" (24.6%). The alternatives to drinking which were proposed were related to computers and sport. CONCLUSIONS: The consumption of alcohol is a common habit among adolescents and its pattern differs between urban and rural areas, where it is much earlier and more intense in the latter. It forms part of their lifestyle, they use it as a means of enjoyment and a large percentage consider that alcohol is a drug. Against "street binge drinking," their proposals are computer activities and sport.

Consumo de alcohol en escolares toledanos: motivos y alternativas / Alcohol consumption in Toledo schoolchildren: reasons and alternatives

Objetivo. Describir el consumo de alcohol en escolares toledanos, conocer los motivos que les inducen a beber y las alternativas que proponen. Diseño. Estudio descriptivo, transversal. Emplazamiento. Dos zonas de salud del área sanitaria de Toledo. Participantes. Un total de 625 adolescentes de entre 13 y 18 años, de tercero y cuarto de Educación Secundaria Obligatoria y primero de Bachillerato de 2 institutos de educación secundaria de Torrijos y uno de Toledo capital. Mediciones principales. Mediante cuestionario anónimo diseñado ad hoc, con 32 ítems, se recogieron los siguientes datos: edad, sexo, consumo de alcohol (personal, familiar y de amigos), cuantía (unidades de bebida estándar), conocimientos y fuentes de información sobre el alcohol, consumo de otras drogas, motivaciones de consumo y alternativas. Resultados. Un 47,27% de los encuestados son varones. La media de edad (± desviación estándar) es de 15,4 ± 1,3 años. El 93,4% ha probado el alcohol (intervalo de confianza del 95%, 91,1-95,2). Un 52,0% se ha emborrachado alguna vez, dato más frecuente en el medio rural que en el urbano (el 53,5 frente al 39,3%; p < 0,05). Un 69,6% bebe los fines de semana. El 58,1% considera que el alcohol es una droga. Entre los motivos aludidos para el consumo destacan «diversión» (46,3%), «olvidar problemas» (30,7%) y «curiosidad» (24,6%). Las alternativas al consumo que proponen están relacionadas con la informática y el deporte. Conclusiones. El consumo de alcohol es un hábito generalizado entre adolescentes y su patrón difiere entre el medio urbano y el rural, donde es más temprano e intenso. Forma parte de su estilo de vida, lo utilizan como medio de diversión y un gran porcentaje considera que el alcohol es una droga. Frente al «botellón», sus propuestas son actividades informáticas y deportivas

Objective. To know the consumption of alcohol in Toledo schoolchildren, to find out the reasons which cause them to drink and the alternatives proposed. Design. Descriptive, transverse study. Location. 2 zones in the Toledo health area. Participants. A total of 625 adolescents between 13 and 18 years, in the third and fourth years of Obligatory Secondary Education and first year in High School (Bachillerato) of 2 secondary education institutions in Torrijos and 1 in Toledo capital. Main measurements. Using an ad hoc designed anonymous questionnaire, with 32 items, the following data was collected: age, sex, alcohol consumption (personal, family, and friends), how much (standard drink units), knowledge and sources of information on alcohol, taking of other drugs, reasons for consuming, and the alternatives. Results. 47.27% of those questioned were male. The mean age was 15.4±-1.3 years. 93.4% had tried alcohol (95% CI, 91.1-95.2). 52.0% had been drunk at some time, which was more frequent in rural areas than in the city. 58.1% considered alcohol as a drug. Among the reasons mentioned for drinking, the main ones were "enjoyment" (46.3%), "to forget problems" (30.7%), and "curiosity" (24.6%). The alternatives to drinking which were proposed were related to computers and sport. Conclusions. The consumption of alcohol is a common habit among adolescents and its pattern differs between urban and rural areas, where it is much earlier and more intense in the latter. It forms part of their lifestyle, they use it as a means of enjoyment and a large percentage consider that alcohol is a drug. Against "street binge drinking," their proposals are computer activities and sport

Motivos de interconsulta entre atención primaria y el segundo nivel / Reasons for consultation between primary care and the second level

Objetivo. Identificar los motivos que provocan mayor número de derivaciones desde atención primaria a otras especialidades en nuestra área de salud. En segundo lugar, analizamos la calidad en la cumplimentación de los partes de interconsulta (PIC). Diseño. Estudio observacional, descriptivo. Emplazamiento. Atención primaria del Área de Salud de Toledo. Población. PIC emitidos por los médicos de 17 equipos de atención primaria durante 2 semanas de noviembre de 2002. Mediciones. Edad y sexo del paciente, equipo de atención primaria, tipo de derivación (nueva consulta o revisión), modo de derivación (normal o preferente), especialidad, motivo de derivación, calidad de los PIC. Resultados principales. Se analizaron 1.610 PIC de 125 médicos. El 64,6% pertenecían a mujeres; la edad media era de 43,5 años (intervalo de confianza [IC] del 95%, 42,4-44,6). El 74,6% (IC del 95%, 72,2-76,5) fueron nuevas consultas y el 12,9% (IC del 95%, 11,3-14,7), derivaciones preferentes. Las especialidades con más derivaciones fueron: ginecología (20,2%), traumatología (17,4%) y oftalmología (14,9%). Globalmente, el diagnóstico temprano de cáncer ginecológico (13,01%; IC del 95%, 11,4-14,8), la disminución de la agudeza visual (6,95%; IC del 95%, 5,8-8,3) y las tumoraciones benignas de la piel (4,18%; IC del 95%, 3,3-5,3), fueron los 3 motivos que provocaron más derivaciones. La calidad de los PIC se consideró buena en el 13,1%, aceptable en el 82,8% y mala en el 4,1%. Conclusiones. Un elevado número de derivaciones se debe a motivos que podrían resolverse en el primer nivel asistencial. La mayor parte de las interconsultas se realizan a especialidades médico-quirúrgicas. La calidad de los PIC tiene todavía un importante margen de mejora

Objective. To identify the reasons causing most referrals from primary care to specialist clinics in our health area. In addition, we analysed the quality of compliance in the inter-clinic forms. Design. Descriptive and observational study. Setting. Primary care in the Toledo Health Area. Population. Inter-clinic forms (ICF) issued by doctors in 17 primary care teams (PCTs) during 2 weeks in November 2002. Measurements. Age and sex of patient, PCT, type of referral (first time, check-up), referral path (normal, preferential), speciality, reason for referral, ICF quality. Main results. 1610 ICFs from 125 doctors were analysed. 64.6% belonged to women. Average age was 43.5 (95% confidence interval [CI], 42.4­44.6). 74.6% (95% CI, 72.2­76.5) were new consultations. 12.9% (95% CI, 11.3­14.7) were preferential referrals. Specialities with most referrals were: Gynaecology (20.2%), traumatology (17.4%), and Ophthalmology (14.9%). The early diagnosis of gynaecological cancer (13.01%; 95% CI, 11.4­14.8), reduction in visual sharpness (6.95%; 95% CI, 5.8­8.3) and benign skin tumours (4.18%; 95% CI, 3.3-5.3) were the 3 reasons for most referrals. ICF quality was thought good in 13.1% of cases, acceptable in 82.8%, and poor in 4.1%. Conclusions. A high number of referrals were due to reasons that could be resolved at the primary care level. Most inter-clinical referrals were to medical-surgical specialists. Inter-clinical forms are still open to considerable improvement

[Reasons for consultation between primary care and the second level]. / Motivos de interconsulta entre atención primaria y el segundo nivel.

OBJECTIVE: To identify the reasons causing most referrals from primary care to specialist clinics in our health area. In addition, we analysed the quality of compliance in the inter-clinic forms. DESIGN: Descriptive and observational study. SETTING: Primary care in the Toledo Health Area. POPULATION: Inter-clinic forms (ICF) issued by doctors in 17 primary care teams (PCTs) during 2 weeks in November 2002. Measurements. Age and sex of patient, PCT, type of referral (first time, check-up), referral path (normal, preferential), specialty, reason for referral, ICF quality. MAIN RESULTS: 1610 ICFs from 125 doctors were analysed. 64.6% belonged to women. Average age was 43.5 (95% confidence interval [CI], 42.4-44.6). 74.6% (95% CI, 72.2-76.5) were new consultations. 12.9% (95% CI, 11.3-14.7) were preferential referrals. Specialties with most referrals were: Gynaecology (20.2%), traumatology (17.4%), and Ophthalmology (14.9%). The early diagnosis of gynaecological cancer (13.01%; 95% CI, 11.4-14.8), reduction in visual sharpness (6.95%; 95% CI, 5.8-8.3) and benign skin tumours (4.18%; 95% CI, 3.3-5.3) were the 3 reasons for most referrals. ICF quality was thought good in 13.1% of cases, acceptable in 82.8%, and poor in 4.1%. CONCLUSIONS: A high number of referrals were due to reasons that could be resolved at the primary care level. Most inter-clinical referrals were to medical-surgical specialists. Inter-clinical forms are still open to considerable improvement.

Efectividad del consejo antitabaco en fumadores con espirometría normal y con espirometría obstructiva (EPOC) / Effectiveness of antitobacco advise in smokers with normal spirometry and obstructive spirometry (COPD)

Objetivos: El objetivo de este estudio es valorar la efectividad delconsejo médico antitabaco (CMA) en dos poblaciones de fumadores,una con espirometría normal (EN) y otra con espirometría obstructiva(EPOC).Pacientes y métodos: Estudio descriptivo transversal en el ámbitode Atención Primaria. Se realizó espirometría a fumadores mayoresde 40 años. A los que tenían EN se les daba consejo antitabaco durante3-5 minutos, mientras que a los del grupo EPOC se les dedicaban 8-10minutos. Al año se contactó telefónicamente y se les interrogó sobresu hábito tabáquico en ese momento, intentos de abandono y utilizaciónde otros métodos para intentar la abstinencia.Resultados: La muestra la formaban 217 sujetos (176 EN y 41EPOC) con edad media de 50,5 años. El 57,1% eran varones. Hubo 70intentos de abandono (53,7% del grupo EPOC vs 27,3% del grupo EN;χ2 = 10,59; p < 0,001), consiguiendo abandonarlo 19 del grupo EN y 13del grupo EPOC (10,8 vs 31,7%; OR 3,86; IC95% 1,7-8,6). En el análisismultivariante, el sexo masculino, el índice tabáquico, la realización deintentos de deshabituación previa y la alteración en la espirometría fueronlas variables asociadas a mayor frecuencia de abandono.Conclusiones: Los fumadores a los que se diagnostica de EPOCy se les da CMA durante 8-10 minutos abandonan significativamentemás el tabaco que aquellos otros con espirometría normal y un consejode menor duración. Creemos que, en Atención Primaria, debe potenciarsela realización de CMA

Foundation: Fighting against nicotine poisoning is a fundamentalobjective for a Sanitary System. The target of this survey is to assess theeffectiveness of smoking cessation counseling over two samples of smokers,one of them with a normal spirometry (NS) and the other, with apathologic spirometry (COPD).Patients and methodology: Transversal descriptive survey, carriedout within the primary attention area. Smoking patients over their 40’shad a spirometry made. Those patients who smoked and had a normalspirometry (NS group) were given anti-smoking counsel for 3-5 minutes,while those patients with an obstructive spirometry (COPD group),received counsel for 8-10 minutes. One year later, all of them were contactedon the phone and were asked about: their smoking habit in thatmoment, attempts to quit smoking and use of other resources or methodsto reach abstinence.Results: The sample was finally composed of 217 patients (176 NSand 41 COPD) with an average age of 50.5 years; 57.1% of them weremales. There were 70 attempts to quit smoking (53.7% within the COPDgroup vs. 27.3% within the NS group; χ2 = 10.59; p < 0.001); 19 patientsin the NS group and 13 in the COPD group succeeded in giving up smoking(10.8% vs. 31.7%; OR 3.86; IC95% 1.7–8.6 ). In the multi-variantanalysis, the variables which associate with a higher frequency in givingup smoking are: the masculine gender, the tobacco habit indicator, theprevious attempting to break oneself of the habit of smoking and the alterationin the spirometry.Conclussions: Smokers with a COPD diagnosis who receive medicalanti-smoking counsel for 8-10 minutes, give up smoking more significantlythan patients with a normal spirometry and a shorter medicalcounsel. We believe that within the primary attention frame,anti-smoking counsel should be promoted

[Information given to patients and their participation in clinical decision-making]. / La información al paciente y su participación en la toma de decisiones clínicas.

OBJECTIVES: To evaluate the information provided by physicians during consultations, the information requested by patients, and patients' participation in decision-making. DESIGN: Descriptive, cross-sectional study based on observations of visits to the doctor's office and subsequent telephone interview. SETTING: Primary care centers in Toledo, Spain.Participants. 152 clinical interviews.Interventions. Questionnaire with items on age, sex, types of information provided by the physician, information requested by the patient, and evaluation of the patient's participation in decision-making and degree of satisfaction. MAIN MEASURES AND RESULTS: Mean age of the patients was 41.1 years, and 55.9% were women. The type of information given most frequently to patients was related to treatment (88.3%). Of the 152 patients whose visits were observed, 55 (36.2%) did not request additional information. The information requested most frequently when not provided spontaneously by the physician concerned treatment (35.3%) and cause of the symptoms (29.7%). Almost all patients (94.0%) considered the information received to be sufficient. However, 22.7% stated that when they left the doctor's office there was something they wished they had asked about, and 18.6% said they understood the doctor's explanations "in part." According to the observers, 69.4% of the patients did not take part in the decision about their treatment. CONCLUSIONS: The information provided by the physician was not as complete as it might have been. Patients usually ask few questions, and a large percentage of patients had something they wished they had asked about, or did not fully understand the information. Patients' participation in decision-making was low.

La información al paciente y su participación en la toma de decisiones clínicas / Information given to patients and their participation in clinical decision-making

Objetivos. Valorar la información aportada por el médico en consulta, la información solicitada por el paciente y su participación en la toma de decisiones. Diseño. Descriptivo, transversal, basado en la observación en las consultas y la posterior entrevista telefónica. Emplazamiento. Atención Primaria de Toledo. Participantes. Un total de 152 pacientes a los que se realizó una entrevista clínica.Intervenciones. Cuestionario que incluía la edad, el sexo, la información proporcionada por el médico y solicitada por el paciente sobre diversos aspectos de la entrevista, la valoración de la participación del paciente en la toma de decisiones y su grado de satisfacción. Mediciones principales y resultados. La edad media de los pacientes fue de 41,1 años y un 55,9 por ciento era mujer. La información proporcionada con más frecuencia al paciente estuvo relacionada con el tratamiento (88,3 por ciento). De los 152 casos observados, en 55 (36,2 por ciento) el paciente no solicitó información. La demanda de información al médico por el paciente cuando aquél no la proporciona de forma espontánea es sobre todo acerca del tratamiento (35,3 por ciento) y de la causa del cuadro (29,7 por ciento). El 94,0 por ciento consideró suficiente la información recibida; no obstante, el 22,7 por ciento manifestó haber salido de la consulta con ganas de preguntar algo y el 18,6 por ciento dijo comprender "parcialmente" la explicación. Según los observadores, un 69,4 por ciento de los pacientes no participó en la toma de decisiones sobre el tratamiento. Conclusiones. La información que el médico proporciona no es todo lo completa que debiera. El paciente suele preguntar poco al médico; un alto porcentaje de ellos se quedan con ganas de preguntar y/o no comprenden totalmente la información. La participación del paciente en la toma de decisiones es escasa (AU)

Prevalencia y factores de riesgo de EPOCen fumadores y ex fumadores / Prevalence of Chronic Obstructive Pulmonary Disease and Risk Factors in Smokers and Ex-smokers

OBJETIVO: Estimar la prevalencia de enfermedad pulmonar obstructiva crónica (EPOC) en fumadores y ex fumadores mayores de 40 años y describir los factores asociados. MATERIAL Y MÉTODOS: Se realizó un estudio descriptivo transversal en el ámbito de la atención primaria. En él se incluyo a 444 personas de 40 años de edad o mayores que fumaban o habían fumado. A todos se les realizó una espirometría. Si la relación volumen espiratorio forzado en el primer segundo/porcentaje de la capacidad vital forzada era menor del 70 por ciento, se realizaba una prueba de broncodilatación y se repetía la espirometría a los 15-20 min tras dos inhalaciones de terbutalina (500 µg/dosis). Si la relación volumen espiratorio forzado en el primer segundo/porcentaje de la capacidad vital forzada seguía siendo inferior al 70 por ciento y el volumen espiratorio forzado en el primer segundo menor del 80 por ciento del teórico, se diagnosticaba EPOC. También se recogieron edad, sexo, consumo de tabaco, edad de inicio, índice tabáquico (paquetes/día × años de consumo) e intentos de abandono. RESULTADOS: La edad media de los pacientes era de 53,5 años, y un 65,8 por ciento eran varones. En el momento del realizar el estudio fumaban 248 sujetos (55,9 por ciento). La mediana de inicio del consumo resultó de 16,5 años, y la del índice tabáquido fue de 26,7. El 72,1 por ciento había realizado al menos un intento de abandono. Se diagnosticó de EPOC a 70 personas (24 ya conocidas), lo que supone una prevalencia del 16,4 por ciento (intervalo de confianza del 95 por ciento, 12,9-19,9). Un 10 por ciento eran casos graves. Tras el análisis multifactorial resultaron significativamente asociadas a EPOC la edad y el índice tabáquico. CONCLUSIONES: La prevalencia de EPOC hallada es ligeramente superior a la de otros estudios, si bien puede existir un sesgo en los resultados obtenidos al no haber podido establecer contacto con el 11,9 por ciento de la población objeto del estudio. Casi dos tercios de los casos eran desconocidos. Son claros factores de riesgo la edad y el consumo acumulado de tabaco (AU)

[Prevalence of chronic obstructive pulmonary disease and risk factors in smokers and ex-smokers]. / Prevalencia y factores de riesgo de EPOC en fumadores y ex fumadores.

OBJECTIVE: To estimate the prevalence of chronic obstructive pulmonary disease (COPD) in smokers and ex-smokers over 40 years of age and describe the associated risk factors. MATERIAL AND METHODS: A cross-sectional descriptive study at primary care level in which 444 current or ex-smokers 40 years of age or older were enrolled. Spirometry was performed with all subjects. If the ratio of forced expiratory volume in 1 second to forced vital capacity (FEV1/FVC) was less than 70%, a bronchodilator test was performed and spirometry was repeated after 2 inhalations of terbutaline (500 g/dose). If the FEV1/FVC ratio continued to be less than 70% and FEV1 less than 80% of predicted, COPD was diagnosed. Age, sex, smoking, age smoking began, index of smoking history (packs per day x year) and attempts to quit smoking were also recorded. RESULTS: The patients' mean age was 53.5 years and 65.8% were men. At the time of the study, 248 subjects (55.9%) were current smokers. The median age smoking began was 16.5 years and the median pack-years index was 26.7. At least 1 attempt to quit had been made by 72.1% of the patients. COPD was diagnosed in 70 subjects (24 with the diagnosis previously established), representing a prevalence of 16.4% (95% confidence interval, 12.9-19.9). COPD was serious in 10%. A multifactorial analysis indicated that age and smoking history in pack-years were significantly associated with COPD. CONCLUSIONS: The prevalence of COPD in our study is slightly higher than in other studies, although selection bias may have affected our results given that we were unable to contact 11.9% of the population sample. Almost two thirds of cases had not been previously diagnosed. Two major risk factors are age and cumulative tobacco consumption.

Ganancia ponderal tras el abandono del hábito tabáquico / Weight gain after giving up tobacco

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