La educación terapéutica de personas con diabetes. Experiencia del Servicio de Endocrinología y Nutrición del Hospital Universitario «Carlos Haya» de Málaga / Therapeutic education in people with diabetes. Experience from the Endocrinology and Nutrition Department of Carlos Haya University Hospital in Málaga, Spain

En la segunda mitad del siglo XX, la medicina ha cambiado más que en toda su historia anterior. Este cambio ha sido la consecuencia no sólo de los avances científicos y técnicos, sino también de los cambios del modelo social. Los pacientes han dejado de ser personas pasivas y han pasado a disfrutar de un creciente protagonismo en la toma de decisiones: es la manera de llevar a la práctica el principio de autonomía, que, junto con los principios de beneficencia y de justicia, constituyen los pilares básicos de la ética médica. Pero la autonomía no es real si el paciente no disfruta de los instrumentos para ejercerla realmente. La educación terapéutica es el mejor instrumento para transferir información desde el médico y el sistema sanitario hacia el paciente. La diabetes mellitus es el prototipo de enfermedad crónica susceptible de beneficiarse de la participación activa del paciente. Los programas de educación de pacientes diabéticos han pasado a formar parte de los espacios establecidos de atención clínica de la diabetes. Por lo general, hasta no hace mucho los servicios clínicos carecían de experiencia en la introducción de la educación como parte de la terapéutica clínica. No es sorprendente, pues, que la manera de organizar la educación de los pacientes haya sido muy diversa: dependía de la capacidad de cada servicio para dar respuesta a los nuevos retos, pero también, y sobre todo, de la sensibilidad y la cultura que se tuviera sobre la relación médico-enfermo. Así, aunque se ha hecho un esfuerzo por estandarizar la educación terapéutica, lo cierto es que ha habido tantos programas como espacios donde se ha puesto en marcha. En el presente artículo se reflexiona sobre la educación de pacientes desde la experiencia de más de 20 años en un servicio de endocrinología y nutrición

In the second half of the 20th century, the field of «Medicine» underwent more changes than throughout its entire previous history. This transformation has been the consequence not only of scientific and technical advances, but of changes in the social model as well. Patients have gone from being passive individuals to having an increasingly prominent role in the decision-making process. This is the manner of putting into practice the principle of autonomy, which, together with the principles of beneficence and justice, is a mainstay of medical ethics. However, this autonomy is not real if the patient is not provided with the tools he or she needs to actually exercise it. Therapeutic education is the best tool for transferring information from the physician and health care system to the patient. Diabetes mellitus represents the prototype of the chronic diseases that could benefit from the active participation of the patient. Education programs for diabetic patients have become a part of the conventional ambit of clinical care in diabetes. The staffs of clinical services generally lack experience in the introduction of education as a part of clinical therapeutics. Thus, it is not surprising that the approach to organizing patient education has varied widely. It has depended on the capacity of each service to respond to the new challenges, but, above all, on the existing sensitivity and culture with respect to the physician-patient relationship, as well. Although there has been an effort to standardize therapeutic education, the truth is that there have been as many programs as settings in which they have been introduced. In the present article, the authors reflect on patient education, following more than twenty years of experience in an endocrinology and nutrition department

Diagnóstico de bocio en los estudios poblacionales de déficit de yodo: ¿palpación o ecografía? / Diagnosing goitre in population studies of iodine deficiency: palpation or ultrasound?

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Adipose tissue fatty acids and size and number of fat cells from birth to 9 years of age--a cross-sectional study in 96 boys.

We studied interrelations between the size and number of fat cells and the composition of fatty acids in 96 boys from birth to 9 years of age. The size of fat cells increased during the first months of life and decreased over the second 6 months, in parallel with the tissue fat concentration and the skinfold thickness of subcutaneous fat. From the end of the first year of life, the size of the fat cell increased slowly. The number of fat cells did not begin to increase until the end of the first year of life, maintaining a continuous increase until 9 years of age. During the first years of life, important changes occurred in the concentration of adipose tissue fatty acids. Palmitic acid had the greatest concentration in adipose tissue at the moment of birth and then decreased, becoming stabilized from the age of 2 or 3 years. The concentrations of lauric, myristic, and myristoleic acids followed a course similar to that of adipocyte growth, probably reflecting changes in the accumulation of fat by the adipocyte. At the moment of birth, the concentrations of linoleic acid (C18:2), an essential fatty acid not synthesized by the organism, were low, increasing from the very first months of life. This increase correlated with the increase in fat cell size and number. These interrelations between the size and number of fat cells and the composition of adipose tissue fatty acids suggest the important role dietary fat can play in the childhood endowment of adipocytes.

[Scientific investigation in biomedicine and health sciences in Andalusia]. / La investigación científica en Biomedicina y Ciencias de la Salud en Andalucía.

OBJECTIVES: To evaluate the scientific output in Biomedicine and Health Sciences in Andalusia in the context of the published works on the national scientific output in the last few years. MATERIAL: Descriptive study with seven different information sources: a) final Report of the Experts Committee on Documentation from the Consejería de Salud de la Junta de Andalucía (IME: Indice Médico Español) suplemento internacional: 1980-1994; b) MEDLINE (Comprehensive Medline Ebsco, 1987-1993); c) EMBASE (Excerpta Medica; Elsevier Science Publisher) (1986-1994); d) IME, mechanized version: 1974-1993; Anales del FIS (1989-1993); e) Memoria REUNI: 1993-1994, and f) call for and resolution of research projects from the Consejería de Salud de la Junta de Andalucía (1994). RESULTS AND CONCLUSIONS: Scientific output in health sciences in Andalusia has gown in parallel with the national output from other communities. Nevertheless, in absolute terms this output is scant and the big difference compared with Catalonia and Madrid--the two Autonomous Communities with the largest scientific output--remains unchanged. Grenada is the Andalusian province with the largest output, with Seville, Cordoba and Malaga ranking next. The output in the other Andalusian provinces is very small. The output is apparently independent from the number of inhabitants or the historic presence of a Medicine School. In contrast with Catalonia and Madrid, where the largest output originates in hospitals, the largest output in Andalusia comes from Universities; this fact suggests relevant differences in scientific sub-structure. This suggestion is also endorsed by the lower competition of Andalusia to obtain resources and the lower number of research scholarships. With these results in mind a scientific policy of positive discrimination is proposed which allows the Andalusian Autonomous Community to reach the standard of scientific output in biomedicine and health sciences according to its socioeconomic status.

[Diet and hypertriglyceridemia: influence of dietary modifications on plasma lipids, lipoproteins and apoproteins in patients with primary hypertriglyceridemia]. / Dieta e hipertrigliceridemia: influencia de las modificaciones dietéticas sobre los lípidos, lipoproteínas y apoproteínas plasmáticas en pacientes con hipertrigliceridemia primaria.

BACKGROUND: To investigate the influence of dietary changes on plasma lipoproteins and apoproteins in 10 patients with hypertriglyceridemia (plasma triglycerides greater than 1000 mg/dl). METHODS: A sequential study with three periods was designed: 1) Inclusion with uncontrolled free diet; 2) Two weeks of a diet with about 1000 calories/day, controlled with a daily survey; and 3) One week of "free" diet of about 2000 calories. At the end of the three periods the following were measured in each patient: weight, glycemia, plasma IRI and C-peptide, plasma, triglycerides, cholesterol, chylomicron, VLDL, LDL and HDL cholesterol. At the end of the second and third periods the caloric and immediate principles intake were individually considered. RESULTS: A reduction in plasma cholesterol and triglycerides was observed in all cases after the caloric reduction, and also a disappearance of chylomicrons. The reduction of triglycerides took place in all lipoproteins. By contrast, after the low-calorie diet only the VLDL-cholesterol was reduced, while LDL- and HDL-cholesterol increased. The apo C-III/apo C-II ratio was significantly reduced after the low-calorie diet. The plasma glycemia, IRI and C-peptide were negatively correlated with LDL-cholesterol and with the apo C-III/apo C-II ratio. The best model to explain the oscillations of plasma triglycerides depending on the diet was that including the three ingested immediate principles together with the total diet calories. CONCLUSIONS: During the caloric restriction there would be an increased catabolism of VLDL to LDL. This reduction would be mediated by C-III and C-II apoproteins, probably through the oscillations of plasma IRI.

[The response of the growth hormone to acute effort is a function of training]. / La respuesta de la hormona de crecimiento al esfuerzo agudo está en función del entrenamiento.

BACKGROUND: The increase of the growth hormone (GH) during exercise is known although the relationship of this response with other hormones, the type and intensity of the exercise, nutritional state and with the degree of training are reasons for discussion. The aim of this investigation was to study the response of the HG on a group of young adults with different degrees of training, according to the maximum consumption of oxygen (VO2 max) achieved over a short period of time. METHODS: Thirty-nine healthy subjects who underwent maximum effort on the treadmill were grouped according to VO2 max reached (less than 3,000 ml/min; 3,000-4,500 ml/min and greater than 4,500 ml/min). Systolic blood pressure (SBP) and diastolic blood pressure (DBP), respiratory quotient (RQ), O2 pulse, cardiac frequency (CF) respiratory equivalence (RE), glycemia, plasma insulin (PI), C peptide, lactic acid, venous pH, plasma renin activity (PRA), plasma aldosterone, thyrotropine (TSH), triodothyronine (T3), thyroxine (T4), adrenocorticotropine (ACTH), cortisol and GH were measured basally and following achievement of VO2 max. RESULTS: The GH was only increased in those subjects with a VO2 max higher than 3,000 ml/min with a significant positive correlation found between the GH and VO2 max and a significant negative correlation was found between the GH and lactic acid at the end of the test. The increase of glycemia at the end of the test correlated with the VO2 max. The PI and C peptide increased at the end of the test in the subjects with greater VO2 max capacity and correlated positively with the VO2 max and with the GH upon completion of the exercise. CONCLUSIONS: These results suggest that the response of the growth hormone to exercise is a function of maximum oxygen consumption although this only explains 24% of the variants of the growth hormone. Despite important hormonal and metabolic mobilization during exercise, no model of multiple regression has been found which substantially improves the association found between the growth hormone and maximum oxygen consumption.

[Computerized tomography of the pituitary gland in the diagnosis of prolactinoma: a concordance study]. / La tomografía computadorizada de hipófisis en el diagnóstico de los prolactinomas: estudio de concordancia.

BACKGROUND: The diagnostic capacity of computed tomography (CT) of the pituitary gland in the diagnosis of prolactinomas is difficult to define in terms of specificity and sensitivity since, up to the present, there is no definite diagnostic test for prolactin producing tumors. The aim of this study is to establish the consistency of CT of the hypophysis in the diagnosis of the prolactinomas based on a concordance design. METHODS: In the follow-up study of 48 patients diagnosed as affected of prolactinoma a concordance study was carried out on the blind lecture of 35 pituitary gland CT by two radiologists. RESULTS: The degree of concordance for all the diagnosis (kappa = 0.58) was greater than what might be expected by chance. The degree of concordance was also different for the different diagnosis given by the two radiologists: empty sella turcica, kappa = 0.84 (p less than 0.01); macroprolactinoma, kappa = 0.68 (p less than 0.01); microprolactinoma, kappa = 0.45 (p less than 0.01) and normal sella turcica, kappa = 0.28 (NS). CONCLUSIONS: CT of the hypophysis must be less sensitive (more false negatives) in cases of high prolactin due to microprolactinomas and less specific (more false positives) in cases of high prolactin due to a cause other than pituitary tumor, thereby making it a complementary diagnostic test to clinical evaluation and to prolactin determinations.