Symptom attribution and stress level in patients with medically unexplained symptoms in a Mexican emergency department.

Background: Patients who come to the emergency department are different from those seen in outpatient clinics. The former suffer greater stress. Aim: Establish an association between the attribution of the symptoms (psychosocial or organic) by the patient and the level of perceived stress in patients with Medically Unexplained Physical Symptoms (MUS) in an emergency department. Methods: A correlational cross-sectional study was conducted in 138 patients with MUS in the emergency department of a 3rd level public hospital where the psychosocial or organic attribution of nonspecific symptom(s) by patients and the perceived stress were measured with validated scales. Bivariate analysis was performed with Chi square for categorical variables, and a Spearman correlation, p <0.05. Results: 75% of patients with psychosocial attribution have higher stress compared to patients with organic symptom attribution (25%). In Spearman's correlation, a medium but statistically significant correlation was obtained. Conclusions: The psychosocial attribution of the patient's complaint might coexist in MUS patients with higher level of perceived stress by the patients. Health professionals might need to address both psychosocial attributions and stress in MUS patients.

[Epidemiological and clinical characteristics of the COVID-19 epidemic in Mexico: Quintana Roo case]. / Características epidemiológicas y clínicas de la epidemia COVID-19 en México: caso Quintana Roo.

Objective: Identify risk factors for severe outcome in Mexican patients with COVID-19 in the population of Quintana Roo. Material and methods: Study of 5,916 who met the criteria for suspected cases of COVID-19, 2,531 confirmed by qrTPCR-Sars-CoV-2 tests, of which 1,486 were positive, among which they were classified as hospitalized (severe COVID-19) and outpatients. Multivariate logistic regression analysis was performed to explore the factors associated with the severity of COVID-19 and death as clinical outcomes. The basic reproduction number (R0) was calculated Statistical analysis) Endorsement of the ethics committee 2301. Results: SARS-CoV-2 positive patients presented a high prevalence of hypertension 29.1%, diabetes 23.5%, obesity 24%, and 48.5% have at least one chronic disease. There is a high risk of severity for COVID-19 in patients with diabetes OR=3.14, hypertension OR=1.88, obesity OR=1.68, kidney disease OR=3.2, older than 65 years OR=13.6 and men OR=1.7. These factors also increase the risk of death up to 7.7 times. The maximum R0 during the epidemic was 2.4. Conclusion: Liver and kidney disease, diabetes, hypertension, and obesity are significantly associated with severe COVID-19 and death.

Objetivo: identificar factores de riesgo para desenlace a COVID-19 grave en pacientes mexicanos con de COVID-19 en población en Quintana Roo. Material y métodos: estudio de 5,916 quienes cumplieron criterios de casos sospechosos de COVID-19, 2,531 confirmados por pruebas qrTPCR-Sars-CoV-2 de los cuales 1,486 fueron positivos entre los cuales se clasifico en hosptializados (COVID-19 grave) y ambulatorios. Se realizó análisis de regresión logística multivariada para explorar los factores asociados con la gravedad de COVID-19 y defunción como desenlaces clínicos. Se calculó el número básico de reproducción (R0) Análisis estadístico) Aval del comité de ética 2301. Resultados: pacientes positivos a SARS-CoV-2 presentaron alta prevalencia de hipertensión 29.1%, diabetes 23.5%, obesidad 24%, y 48.5% tiene al menos una enfermedad crónica. Existe alto riesgo de severidad para COVID-19 en pacientes con diabetes OR=3.14; hipertensión OR=1.88, obesidad OR=1.68, enfermedad renal OR=3.2, mayores de 65 años OR=13.6 y hombres OR=1.7. Estos factores también incrementan el riesgo de defunción hasta 7.7 veces. El R0 máximo durante la epidemia fue de 2.4. Conclusión: la enfermedad hepática, renal, diabetes, hipertensión y obesidad se asocian significativamente a COVID-19 severo y defunción.

Auto- medicación y auto-prescripción en el personal de salud del primer nivel de atención de México, Bolivia y Ecuador / Selfmedication and selfprescription in health care workers in primary care in Mexico, Bolivia and Ecuador

Introducción. La prevalencia general de la automedicación en la población general fluctúa de 27.3% a 61.3%. En trabajadores de la salud está menos documentado (Definido como auto prescripción), así como su frecuencia y las características del personal médico. Material y métodos. Se trata de un estudio comparativo transversal de 3 países, México (178), Bolivia (250) y Ecuador (130) en población de Médicos Familiares y Médicos Generales de Primer nivel de atención en salud; sexo y edad indistintos, activos en consulta pública o institucional. El muestreo fue por conveniencia calculado por fórmula. Se usó una encuesta con datos demográficos, Frecuencia de automedicación y auto prescripción, patologías donde se usaron, y razones de uso y fuentes de información. Se capturaron y analizaron en SPSS versión 20. Se utilizaron estadísticas descriptivas e inferenciales como ji-cuadrada y Kruskal Wallis. Aprobado por el comité de ética de dos países. Resultados. De los participantes 58.0% son médicos familiares, la mayoría femeninas (p<.05), con pareja, y con promedio de edad de 39.3. Laboran en el sistema público 42.2%. Se automedicaron y auto prescribieron más medicamentos los médicos en México y menos en Ecuador (p<.0001). En general, en el último mes, 61.5% de los profesionales estudiados se auto medicó (media 2.99 veces), y menor porcentaje se auto prescribió 35.8%, (media 1.28 veces) principalmente analgésicos y antibióticos (p<.0001) y por patologías respiratorias (p<.05). Las variables numéricas no cumplieron los supuestos de normalidad. Conclusión. Más de la mitad de los profesionales estudiados se auto medicó y más de un tercio se auto prescribió (antibióticos y analgésicos), esto más en México (AU)

Introduction. The general prevalence of selfmedication in the general population fluctuates from 27.3% to 61.3%. It is less documented in health workers (denominated as selfprescription), as well as its frequency and the characteristics of medical personnel. Material and methods. This is a cross- sectional, comparative study of 3 countries, Mexico (178), Bolivia (250) and, Ecuador (130) in the population of Family Physicians and General Practitioners of the first level of care; indistinct sex and age, active practice in public or institutional consultation. Sampling was for convenience calculated by a formula. A survey with demographic data, II Frequency of self-medication and self-prescription, pathologies where they were used, reasons for use and, sources of information were used. They were captured and analyzed in SPSS version 20. Descriptive and inferential statistics such as chi-square and Kruskal Wallis were used. It was approved by the ethic committee from two countries. Results. Of the participants, 58.0% are family doctors, the majority female (p <.05), with a partner, and with an average age of 39.3 years; 42.2% work in the public system. More physicians in Mexico and fewer in Ecuador used self-medicated and self- prescribed medications (p <.0001). In general in the last month, 61.5% of the professionals self-medicated (average 2.99 times), and a lower percentage (35.8%,)self-prescribed (average 1.28 times) mainly pain relievers and antibiotics (p <.0001) and for respiratory pathologies (p <.05). The numerical variables did not meet the assumptions of normality. Conclusion. More than half of the professionals studied practice self-medication and more than third antibiotics and analgesics as self-prescription this more in Mexico (AU)

Validación de Shared Decision Making Questionnaire - physician version (SDM-Q-Doc) en español / Validation of the Shared Decision Making Questionnaire - physician version (SDM-Q-Doc) in Spanish

OBJETIVO: Validar Shared Decision Making Questionnaire - physician version (SDM-Q-Doc) en español. DISEÑO: Estudio transversal, multicéntrico y de validación clinimétrica. EMPLAZAMIENTO: Unidades de Atención Primaria. PARTICIPANTES: En la fase de adaptación transcultural fueron 31 médicos de familia y en la de validación 219, todos activos en la práctica médica a nivel institucional y/o privado. MEDICIONES PRINCIPALES: Adaptación transcultural (traducción directa, síntesis y conciliación de la versión por un comité de expertos, traducción inversa, conciliación de la traducción inversa con autores del cuestionario original, análisis de comprensión en una muestra de pacientes) y aspectos psicométricos (fiabilidad y validez). RESULTADOS: Se realizó la adaptación transcultural, la pregunta guía 2 se homologó al SDM-Q-9. No se observaron valores negativos en la correlación de item corregido - con la correlación total; todos son mayores que 0,80. El Alfa de Cronbach fue de 0,963. El item 1 explicó una varianza del 77,2 %. La prueba de Kaiser-Meyer-Olkin (KMO) fue de 0,924 con una esfericidad de Barlett estadísticamente significativa. La matriz de correlación de Pearson demuestra una correlación positiva; en general la relación inter-item es mayor a 0,606. CONCLUSIONES: Se ha validado un cuestionario útil, corto y accesible para aplicarse en Atención Primaria, para medir la toma de decisiones compartidas desde la perspectiva del médico

OBJECTIVE: To validate the Shared Decision Making Questionnaire - physician version (SDM-Q- Doc) in Spanish. DESIGN: Cross-sectional, multicenter, clinimetric validation study. SETTING: Primary Care Units. PARTICIPANTS: In the cross-cultural adaptation phase there were 31 family doctors, and in the validation phase there were 219, all active medical professionals at the institutional and / or private level. MAIN MEASURES: Cross-cultural adaptation (direct translation, synthesis and reconciliation of the version by an expert committee, reverse translation, reconciliation of the reverse translation with authors of the original questionnaire, comprehension analysis in a sample of patients) and psychometric aspects (reliability and validity). RESULTS: Cross-cultural adaptation was performed, guide question 2 was homologated to SDM-Q-9. No negative values were observed in the corrected item-total correlation- with the total correlation; all are higher than 0.80. Cronbach's Alpha was 0.963. Item 1 explained a variance of 77.2%. The Kaiser-Meyer-Olkin (KMO) test was 0.924 with a statistically significant Barlett Sphericity. Pearson's correlation matrix shows a positive correlation; in general the inter-item relationship is greater than 0.606. CONCLUSIONS: A useful, short and accessible questionnaire to be applied in Primary Care has been validated to measure shared decision-making from the physician's perspective

Actitudes de los médicos familiares mexicanos sobre el uso de placebos en la práctica clínica.

INTRODUCTION: The use of placebo has spread in clinical practice despite being controversial. In Mexico, the practice of family medicine is predominantly institutional and works with an essential medications list. OBJECTIVE: To determine the frequency and family doctor attitude regarding the use of placebos in clinical practice. METHOD: Cross-sectional, observational, multicenter study of 307 family doctors with active practice in 27 states of the Mexican Republic. A questionnaire was used with sociodemographic data and consensus-developed questions about frequency of use and attitudes. For analysis, the square-chi test was used. RESULTS: 75% used placebos (95% CI=69.7-79.4%); 122 (39.7%) used pure placebos, mainly water (p < 0.05), and 220 (71.6%), impure placebos, mainly vitamins and laboratory tests. They were used more in patients with medically unexplained physical symptoms (178, 45.5%), including 122 (31.2%) "healthy worried" patients, or who had chronic conditions (40, 12.5%). Reasons for prescription: 249 (81%) for the psychological effect, when they showed benefit (176, 57%), even when it implied deceiving (78, 25%) or insufficient evidence of efficacy (57, 19%). The main reason was because of patient insistence. CONCLUSIONS: More impure placebos were used, mainly in healthy worried patients and in those with chronic conditions.

INTRODUCCIÓN: El uso de placebo se ha extendido en la práctica a pesar de ser polémico. En México, la práctica de medicina familiar es predominante institucional y trabaja con un cuadro básico de medicamentos. OBJETIVO: Determinar la frecuencia y actitud del médico familiar en la utilización de placebos en la práctica clínica. MÉTODO: Estudio transversal, observacional, multicéntrico, en 307 médicos familiares con práctica activa, en 27 estados de la República Mexicana. Se usó cuestionario con datos sociodemográficos, preguntas sobre frecuencia de uso y actitudes elaboradas por consenso. Se analizó con chi cuadrada. RESULTADOS: 75 % utilizó placebos (IC 95 % = 69.7-79.4 %); 122 (39.7 %) placebos puros, principalmente agua (p < 0.05), y 220 (71.6 %) placebos impuros, principalmente vitaminas y exámenes de laboratorio. Los usaron más en pacientes con síntomas físicos no explicados médicamente (178, 45.5 %), incluidos 122 (31.2 %) pacientes "sanos preocupados" o con padecimientos crónicos (40, 12.5 %). Motivos de prescripción: 249 (81 %) por el efecto psicológico, cuando demostraron beneficio (176, 57 %), aun cuando implicara engaño (78, 25 %) o evidencia de eficacia insuficiente (57, 19 %). El principal motivo fue por insistencia del paciente. CONCLUSIONES: Se utilizaron más placebos impuros, principalmente en pacientes sanos preocupados y en aquellos con padecimientos crónicos.

Actitudes de los médicos familiares mexicanos sobre el uso de placebos en la práctica clínica / Attitudes of Mexican family physicians on the use of placebos in clinical practice

Resumen Introducción: El uso de placebo se ha extendido en la práctica a pesar de ser polémico. En México, la práctica de medicina familiar es predominante institucional y trabaja con un cuadro básico de medicamentos. Objetivo: Determinar la frecuencia y actitud del médico familiar en la utilización de placebos en la práctica clínica. Método: Estudio transversal, observacional, multicéntrico, en 307 médicos familiares con práctica activa, en 27 estados de la República Mexicana. Se usó cuestionario con datos sociodemográficos, preguntas sobre frecuencia de uso y actitudes elaboradas por consenso. Se analizó con chi cuadrada. Resultados: 75 % utilizó placebos (IC 95 % = 69.7-79.4 %); 122 (39.7 %) placebos puros, principalmente agua (p < 0.05), y 220 (71.6 %) placebos impuros, principalmente vitaminas y exámenes de laboratorio. Los usaron más en pacientes con síntomas físicos no explicados médicamente (178, 45.5 %), incluidos 122 (31.2 %) pacientes “sanos preocupados” o con padecimientos crónicos (40, 12.5 %). Motivos de prescripción: 249 (81 %) por el efecto psicológico, cuando demostraron beneficio (176, 57 %), aun cuando implicara engaño (78, 25 %) o evidencia de eficacia insuficiente (57, 19 %). El principal motivo fue por insistencia del paciente. Conclusiones: Se utilizaron más placebos impuros, principalmente en pacientes sanos preocupados y en aquellos con padecimientos crónicos.

Abstract Introduction: The use of placebo has spread in clinical practice despite being controversial. In Mexico, the practice of family medicine is predominantly institutional and works with an essential medications list. Objective: To determine the frequency and family doctor attitude regarding the use of placebos in clinical practice. Method: Cross-sectional, observational, multicenter study of 307 family doctors with active practice in 27 states of the Mexican Republic. A questionnaire was used with sociodemographic data and consensus-developed questions about frequency of use and attitudes. For analysis, the square-chi test was used. Results: 75% used placebos (95% CI=69.7-79.4%); 122 (39.7%) used pure placebos, mainly water (p < 0.05), and 220 (71.6%), impure placebos, mainly vitamins and laboratory tests. They were used more in patients with medically unexplained physical symptoms (178, 45.5%), including 122 (31.2%) “healthy worried” patients, or who had chronic conditions (40, 12.5%). Reasons for prescription: 249 (81%) for the psychological effect, when they showed benefit (176, 57%), even when it implied deceiving (78, 25%) or insufficient evidence of efficacy (57, 19%). The main reason was because of patient insistence. Conclusions: More impure placebos were used, mainly in healthy worried patients and in those with chronic conditions.

Stages of Change for Mammography Among Mexican Women and a Decisional Balance Comparison Across Countries.

An analysis of the adoption of secondary preventive behaviors is significant in regions with disparities in mammography use and breast cancer survival. Therefore, we determined the cognitive factors and the degree to which they differentiate stages of change in mammography among Mexican women. We also compared the decisional balance performance at Mexico, Switzerland, South Korea, and the USA. A cross-sectional study was designed for women in the stages of precontemplation (n = 240), contemplation (n = 243), action (n = 205), maintenance (n = 311), and relapse (n = 348). We only considered those ≥40 years with no cancer history. We measured the pros, cons, and self-efficacy, among other components. The decisional balance was estimated, and the result was transformed into T-scores. Odds ratios (OR) and 95% confidence intervals (CI) were estimated with multinomial logistic regression using precontemplation as the reference group. The decisional balance distinguished stages partially: in contemplation, the OR was 1.26 (95%CI 1.08, 1.47) and in maintenance, 1.34 (95%CI 1.13, 1.59); in action and relapse, the statistical significance was marginal (p < 0.10). The decisional balance T-score performance registered variations among countries. Additionally, the effect of self-efficacy progressively ascended from contemplation to action and maintenance (OR = 1.29 [95%CI 1.05, 1.58], 1.53 [95%CI 1.20, 1.96], and 2.48 [95%CI 1.82, 3.39], respectively). Furthermore, risk perception and severity did not have an effect on stages of change among Mexican women. Recognition of what provokes action in a population is a key factor in the efficacy of screening programs. Variations among countries highlight the necessity for importance of investigating cognitive determinants for mammography in specific areas.

Strategies for Increasing the Role of Family Medicine in Mexican Health Care Reform.

There is little or no role for primary care and family medicine in current health reforms in Mexico. However, robust evidence shows that primary care helps prevent morbidity and mortality and increases health equity. Mexico has participated in several international meetings sponsored by the World Organization of National Colleges, Academies and Academic Associations and the North American Primary Care Research Group that are aimed at increased understanding of national health systems and the need to strengthen primary care for improved health outcomes. From 1 of these meetings the Cancún Manifesto emerged, with a strategic plan to increase the stature and impact of the Mexican College of Family Physicians (COLMEXAC) in strengthening primary care in Mexico. We aim to describe this strategic plan and discuss its early implementation, and for this account to serve as a possible formula for other countries. The 5 specific strategies discussed are 1) the need for consensus on the leading role of the Mexican family physician in the national health system; 2) health ecology research; 3) to improve the perception of patients about the benefits of primary care and family medicine; 4) to organize meetings of health providers, users, and other stakeholders; and 5) to promote the professionalization of COLMEXAC as a legal entity.

Randomized clinical trial of the safety and immunogenicity of the Tdap vaccine in pregnant Mexican women.

Immunization with the tetanus, diphtheria, and pertussis (Tdap) vaccine raises controversies on immunogenicity and possible antibody interference. We performed an experimental, double-blind, parallel group controlled clinical trial to evaluate the safety and immunogenicity of the Tdap vaccine in 204 pregnant women and their children and to determine its interference in antibody production. Pregnant women 18 to 38 y of age with 12 to 24 weeks gestation, a low obstetric risk, and without serious disease were randomly selected. The experimental group received 0.5 mL IM of Tdap and the control group normal saline. Six blood samples were drawn before and after solution application, and from the umbilical cord of the infants and at 2, 4, and 6 months of age. Pertactin and Pertussis toxin antibodies and possible interference of maternal antibodies with the vaccine were determined. In the experimental group, antibodies against Bordetella pertussis pertactin (anti-PRN) (112 E/mL 95% CI 89.9-139.9) and antibodies against pertussis toxin (anti-PT) (24.0 E/mL, 95% CI 18.3-31.4) were elevated in the mother before vaccination. These were higher in the umbilical cord and descended in the infant at 2 months (71.4 (95% CI 56.8-89.7 and 10.9; 95% CI 8.7-13.7, respectively). Anti-PT showed a delay in production. Tdap safety was confirmed with only mild local pain at 24 and 48 hours. Anti-PRN and anti-PT antibodies in the infant descend at 2 months of age. There is a delay in anti-PT in children of immunized mothers. Further studies are needed to elucidate its clinical significance.

Health care utilization of mexican patients with medically unexplained physical symptoms.

OBJECTIVE: To determine the prevalence of medically unexplained physical symptoms and the characteristics and use of health services in a group of patients with medically unexplained physical symptoms and a group of patients with other illnesses. METHODS: This was a cross-sectional, retrospective and multicenter study. We included 1,043 patients over 18 years of age from 30 primary care units of a government health institution, in 11 states of Mexico, attended by 39 family physicians. The prevalence of medically unexplained physical symptoms was determined and both groups with or without symptoms were compared with regard to drug use, laboratory and other studies, leaves of absence, and referrals in the last six months. The group with medically unexplained physical symptoms was diagnosed using the Patient Health Questionnaire and the diagnostic criteria of Reid et al. Emergency or terminal illnesses were excluded. The chi square test was used with a statistical significance of p < 0.05. RESULTS: Medically unexplained physical symptoms was diagnosed in 73 patients (7.0%). The majority were women (91.8%); their predominant symptom was from the gastrointestinal system in 56 (76.7%). This group had a greater use of clinical studies and referrals to other services (mean 1.1 vs. 0.5; p <0.0001 and 0.6 vs. 0.8; p < 0.01, respectively). CONCLUSIONS: The prevalence of medically unexplained physical symptoms was low, but with a greater impact on some health services. This could represent an overload in medical costs. OBJETIVO: Determinar la prevalencia de Síntomas Físicos Medicamente No Explicables y las características y uso de los servicios de salud entre el grupo de pacientes con Síntomas Físicos Medicamente No Explicables, y el grupo con otras enfermedades. MÉTODOS: Estudio transversal, retroprospectivo y multicéntrico. Se incluyeron a 1,043 pacientes mayores de 18 años, en 30 unidades de atención primaria de una institución gubernamental en salud, en 11 estados de la República Mexicana, atendidos por 39 médicos familiares. Se estimó la prevalencia de Síntomas Físicos Medicamente No Explicables y se compararon los dos grupos con y sin estos síntomas, en cuanto al uso de medicamentos, estudios de laboratorio, de gabinete, incapacidades y referencias en los últimos seis meses. El grupo de Síntomas Físicos Medicamente No Explicables fue diagnosticado por el Patient Health Questionnaire (son los síntomas físicos más comúnmente referidos por estos pacientes en el primer nivel de atención), además de criterios diagnósticos de Reid et al. Se excluyeron urgencias o con enfermedad terminal. Se utilizó prueba Chi cuadrada con p <0.05 para significancia estadística. RESULTADOS: El 7.0% (73) se diagnosticó como Síntomas Físicos Medicamente No Explicables, la mayoría mujeres (91.8%); el síntoma predominante pertenece al sistema gastrointestinal con 76.7% (56). Este grupo demandó mayor uso de estudios de gabinete y referencias a otros servicios (media 1.1 vs. 0.5; p <0.0001 y 0.8 vs 0.6; p <0.01, respectivamente). CONCLUSIONES: La prevalencia de Síntomas Físicos Medicamente No Explicables fue baja, pero con impacto significativo en el uso de algunos servicios de salud. Esto pudiera representar un mayor costo comparado con otro grupo de pacientes.

Investigación en Medicina Familiar y Comunitaria en Iberoamérica / Research in Family and Community Medicine in Ibero-America / Pesquisa em Medicina de Família e Comunidade na Ibero-América

El grupo de trabajo # 4 de la VI Cumbre Iberoamericana de Medicina Familiar en San José, Costa Rica, 2016 se conformó para lograr contribuir al desarrollo de la investigación en Medicina Familiar y Atención Primaria en Iberoamérica, así como para consolidar la Red IBIMEFA. Estuvo integrado por 54 médicos de 21 países. Se nombraron 2 coordinadores generales y 10 coordinadores para dirigir los cinco subgrupos. El trabajo realizado por este grupo durante ocho meses, obtuvo como resultado la identificación de líneas activas y prioritarias de investigación en medicina familiar, la necesidad de realizar estrategias para promover la producción científica, tales como: a) desarrollo de pasantías de investigación en diferentes regiones; b) identificación de fuentes de financiamiento; c) lograr una plataforma virtual, soporte para asesorías y foros de investigación coordinados por IBIMEFA.

In order to contribute to the development of research in Family Medicine and Primary Care in Ibero-America and the consolidation of the IBIMEFA Network, the Work Group #4 was created for the VI Ibero-American Summit of Family Medicine in San José, Costa Rica, 2016, which was composed by a group of 54 family physicians from 21 countries. Two general coordinators and 10 subgroup coordinators were designated. The work developed by this group throughout an 8-month period has resulted in the identification of both active and priority research lines in Family Medicine and the need to develop strategies for the promotion of scientific production, such as: a) the development of research internships across the different regions, b) the identification of sources of financing; c) the design of a virtual platform with support for consultancy and research forums coordinated by IBIMEFA

O grupo de trabalho nº 4 da VI Cúpula Ibero-Americana de Medicina Familiar em San Jose, Costa Rica de 2016 se organizou para colaborar com o desenvolvimento da pesquisa em Medicina de Família e Atenção Primaria na Ibero-América, assim como consolidar a Rede IBIMEFA. Foi composto por 54 médicos de 21 países. Dois coordenadores gerais e 10 sub-coordenadores foram nomeados para organizar os cinco subgrupos. O trabalho realizado durante oito meses por este grupo obteve como resultado a identificação de linhas ativas e prioritárias de pesquisa em Medicina de Família e a necessidade de serem estabelecidas estratégias para promover a produção científica tais como: a) implementação de estágios de pesquisa em diferentes regiões; b) identificação de fontes de financiamento; c) desenvolver uma plataforma virtual, dar suporte para consultoria e realizar fóruns de pesquisa coordenados pela IBIMEFA.

Health care utilization of mexican patients with medically unexplained physical symptoms / Uso de los servicios de salud de pacientes mexicanos con síntomas físicos medicamente inexplicables

Abstract Objective: To determine the prevalence of medically unexplained physical symptoms and the characteristics and use of health services in a group of patients with medically unexplained physical symptoms and a group of patients with other illnesses. Methods: This was a cross-sectional, retrospective and multicenter study. We included 1,043 patients over 18 years of age from 30 primary care units of a government health institution, in 11 states of Mexico, attended by 39 family physicians. The prevalence of medically unexplained physical symptoms was determined and both groups with or without symptoms were compared with regard to drug use, laboratory and other studies, leaves of absence, and referrals in the last six months. The group with medically unexplained physical symptoms was diagnosed using the Patient Health Questionnaire and the diagnostic criteria of Reid et al. Emergency or terminal illnesses were excluded. The chi square test was used with a statistical significance of p < 0.05. Results: Medically unexplained physical symptoms was diagnosed in 73 patients (7.0%). The majority were women (91.8%); their predominant symptom was from the gastrointestinal system in 56 (76.7%). This group had a greater use of clinical studies and referrals to other services (mean 1.1 vs. 0.5; p <0.0001 and 0.6 vs. 0.8; p < 0.01, respectively). Conclusions: The prevalence of medically unexplained physical symptoms was low, but with a greater impact on some health services. This could represent an overload in medical costs....au

Resumen Objetivo: Determinar la prevalencia de Síntomas Físicos Medicamente No Explicables y las características y uso de los servicios de salud entre el grupo de pacientes con Síntomas Físicos Medicamente No Explicables, y el grupo con otras enfermedades. Métodos: Estudio transversal, retroprospectivo y multicéntrico. Se incluyeron a 1,043 pacientes mayores de 18 años, en 30 unidades de atención primaria de una institución gubernamental en salud, en 11 estados de la República Mexicana, atendidos por 39 médicos familiares. Se estimó la prevalencia de Síntomas Físicos Medicamente No Explicables y se compararon los dos grupos con y sin estos síntomas, en cuanto al uso de medicamentos, estudios de laboratorio, de gabinete, incapacidades y referencias en los últimos seis meses. El grupo de Síntomas Físicos Medicamente No Explicables fue diagnosticado por el Patient Health Questionnaire (son los síntomas físicos más comúnmente referidos por estos pacientes en el primer nivel de atención), además de criterios diagnósticos de Reid et al. Se excluyeron urgencias o con enfermedad terminal. Se utilizó prueba Chi cuadrada con p <0.05 para significancia estadística. Resultados: El 7.0% (73) se diagnosticó como Síntomas Físicos Medicamente No Explicables, la mayoría mujeres (91.8%); el síntoma predominante pertenece al sistema gastrointestinal con 76.7% (56). Este grupo demandó mayor uso de estudios de gabinete y referencias a otros servicios (media 1.1 vs. 0.5; p <0.0001 y 0.8 vs 0.6; p <0.01, respectivamente). Conclusiones: La prevalencia de Síntomas Físicos Medicamente No Explicables fue baja, pero con impacto significativo en el uso de algunos servicios de salud. Esto pudiera representar un mayor costo comparado con otro grupo de pacientes...au

Adult community health-promoting interventions in primary health care: A systematic review.

OBJECTIVE: To examine evidence on the effectiveness of health-promoting community interventions carried out in primary health care. METHODS: Systematic review of originals and systematic reviews of health-promoting community interventions with the participation of primary health care. A working definition of community activities was used in the inclusion criteria. Databases searched up to 2013: PUBMED, EMBASE, CINHAL, Web of SCIENCE, IBECS, IME, and PSICODOC. No restrictions on year of publication or design. Articles were reviewed by separate researchers to identify risks of bias. RESULTS: Fifty-one articles published between 1966 and 2013 were included: 11 systematic reviews and 40 originals that described 39 community interventions. There is evidence on the effectiveness of community interventions in reducing cardiovascular risk factors, encouraging physical exercise, preventing falls and improving self-care among chronic patients compared with usual individual care. The effectiveness of some interventions increases when the community is involved in their development. Most assessments show positive results despite design limitations. CONCLUSIONS: The community approach may be more effective than the individual in usual preventive interventions in primary care. There is a lack of evidence on many community interventions in primary care and further research is needed.

Impacto de una intervención psicosocial en la carga del cuidador de niños con parálisis cerebral / Impact of a psychosocial intervention in caregiver burden of children with cerebral palsy

OBJETIVO: Demostrar que la terapia de resolución de problemas es eficaz para disminuir la carga en los cuidadores de niños con parálisis cerebral. DISEÑO: Ensayo clínico aleatorizado. Emplazamiento: Consulta de atención primaria dentro de una asociación privada no lucrativa. Participantes: Ciento cuarenta cuidadores divididos en un grupo control (GC) y un grupo experimental (GE). Intervenciones: Se realizó en ambos grupos una intervención psicosocial con una frecuencia de una sesión por semana durante 3 semanas a completar 120 min. En el GE se realizó una forma acortada de terapia de resolución de problemas con enfoque en la carga del cuidador y en el GC se realizó una intervención educativa con enfoque en enfermedades respiratorias. Mediciones principales: La variable respuesta corresponde a la puntuación obtenida mediante el cuestionario Zarit. La variable independiente correspondió a la intervención psicosocial. RESULTADOS: En el GE, de acuerdo con la puntuación del cuestionario Zarit, se obtuvo un promedio preintervención de 45,0 puntos contra 45,3 puntos en el GC; tras la intervención se obtuvo un promedio Zarit de 29,8 puntos en el GE y de 44,3 puntos en el GC (p < 0,0001). Se catalogó a los grupos según su puntuación Zarit en carga: nula, leve, moderada y severa, encontrando diferencias del impacto de la intervención en los diversas categorías (prueba de Wilcoxon Z = -6,281, p < 0,00001). CONCLUSIONES: La terapia de resolución de problemas es efectiva para disminuir la carga en los cuidadores de niños con parálisis cerebral

OBJECTIVE: To demonstrate that problem-solving therapy is effective in reducing the burden on caregivers of children with cerebral palsy. DESIGN: Randomized clinical trial. Location: Check primary care within a private nonprofit association. Participants: 140 caregivers divided into control group (CG) and experimental group (EG).Interventions: We performed in both groups a psychosocial intervention with a frequency of one session per week for three weeks to complete 120 minutes. In the EG performed a shortened form of problem-solving therapy with a focus on caregiver burden and the CG performed an educational intervention focusing on respiratory diseases. Main measures: The response variable corresponds to the score obtained by Zarit questionnaire. The independent variable accounted for psychosocial intervention. RESULTS: In the EG according to Zarit questionnaire score was obtained by averaging 45.0 points pre intervention against 45.3 points in the CP after intervention Zarit was obtained by averaging 29.8 points in the EG and 44.3 points in the CG (P <0.0001). The catalog groups according to their score Zarit in charge: none, mild, moderate and severe impact differences were found in the different intervention categories (Wilcoxon test Z = 6.281, P < 0.00001). CONCLUSIONS: Problem solving therapy is effective in reducing the burden on caregivers of children with cerebral palsy

[Impact of a psychosocial intervention in caregiver burden of children with cerebral palsy]. / Impacto de una intervención psicosocial en la carga del cuidador de niños con parálisis cerebral.

OBJECTIVE: To demonstrate that problem-solving therapy is effective in reducing the burden on caregivers of children with cerebral palsy. DESIGN: Randomized clinical trial. LOCATION: Check primary care within a private nonprofit association. PARTICIPANTS: 140caregivers divided into control group (CG) and experimental group (EG). INTERVENTIONS: We performed in both groups a psychosocial intervention with a frequency of one session per week for three weeks to complete 120minutes. In the EG performed a shortened form of problem-solving therapy with a focus on caregiver burden and the CG performed an educational intervention focusing on respiratory diseases. MAIN MEASURES: The response variable corresponds to the score obtained by Zarit questionnaire. The independent variable accounted for psychosocial intervention. RESULTS: In the EG according to Zarit questionnaire score was obtained by averaging 45.0 points pre intervention against 45.3 points in the CP after intervention Zarit was obtained by averaging 29.8 points in the EG and 44.3 points in the CG (P<.0001). The catalog groups according to their score Zarit in charge: none, mild, moderate and severe impact differences were found in the different intervention categories (Wilcoxon test Z=6.281, P<.00001). CONCLUSIONS: Problem solving therapy is effective in reducing the burden on caregivers of children with cerebral palsy.

Absence of antibodies against Bordetella pertussis in pregnant women and newborns in the state of Nuevo Leon.

AIMS: To assess placental transfer of antibodies to the child at birth and at 2 months of age. MATERIALS AND METHODS: For the quantification of anti-PT IgG antibodies, we used an indirect enzyme-linked immunosorbent assay standardized by The National Institute of Epidemiologic Diagnosis and Reference (InDRE). Samples were considered negative from 0 to 48 IU/mL, indeterminate from 49 to 93 IU/mL and positive at ≥94 IU/mL. We performed a cross-sectional assessment of anti-PT IgG antibody levels in the mother, umbilical cord, and child. RESULTS: There was a higher concentration of IgG anti-TP in the umbilical cord (4.3%) and in the mother (1.4%), but a total absence was observed in the child (0%). CONCLUSION: The vulnerability of children to Bordetella pertussis shows the need to implement effective immunization strategies, whether actively, in the child, or passively through the mother, adolescents, and adults who are in contact with the child.

[Infusional therapy: an alternative for shouder pain post-laparoscopy]. / Terapia infusional: una alternativa en dolor de hombro post laparoscopia

INTRODUCTION: Neuraxial anesthesia in upper abdominal laparoscopic surgery decreases perioperative morbidity and mortality. However, shoulder pain is common and difficult to control. Use of a major opioid (e.g., fentanyl) for the control of this event may depress respiratory function. This is why we believe that a safe and effective therapeutic control of this disease pain is a multimodal analgesic scheme which we have called infusional therapy. OBJECTIVE: To compare various schemes for controlling shoulder pain secondary to pneumoperitoneum. METHODS: Nonrandomized clinical trial with 56 patients ASA I-II divided into four groups undergoing laparoscopic cholecystectomy. Group I (n= 15) managed with ketorolac 1 mg kg, group II (n = 12) ketoprofen 100 mg, group III (n = 14) ketoprofen 50 mg + 50 mg tramadol, and group IV (n = 15) ketoprofen 100 mg + 100 mg tramadol. The following ariables were analyzed: presence and intensity of pain, analgesia rescue and operative time. RESULTS: Group I had more shoulder pain events compared to other groups (p= 0.002) in the same way the group IV required less rescue analgesia (p= 0.034). CONCLUSION: preemptive analgesia to infusional therapy with ketoprofen-tramadol at doses of 100 mg each is safe for laparoscopic surgery.

Antecedentes: en cirugía laparoscópica del hemiabdomen superior la anestesia neuroaxial disminuye la morbilidad y mortalidad perioperatorias; sin embargo, el dolor de hombro es una afección frecuente de difícil control. Puesto que los fármacos opioides mayores (fentanilo) para el control del dolor deprimen la función respiratoria, consideramos que la terapia infusional es un tratamiento seguro y eficaz. Objetivo: comparar diversos esquemas analgésicos para el control del dolor de hombro secundario al neumoperitoneo. Material y método: ensayo clínico no aleatorizado, efectuado en 56 pacientes ASA I-II en cuatro grupos con colecistectomía laparoscópica. El grupo I (n= 15) se trató con ketorolaco 1 mg/kg, el grupo II (n= 12) con ketoprofeno 100 mg, el grupo III (n= 14) con ketoprofeno 50 mg más tramadol 50 mg, y el grupo IV (n= 15) con ketoprofeno 100 mg más tramadol 100 mg. Las variables analizadas fueron: dolor y su intensidad, analgesia de rescate y tiempo quirúrgico. Resultados: en el grupo I hubo más episodios de dolor de hombro que en el resto de los grupos (p= 0.002); el grupo IV requirió menos analgesia de rescate (p= 0.034). Conclusión: la analgesia preventiva con terapia infusional con ketoprofeno-tramadol, a dosis de 100 mg, es segura para pacientes intervenidos mediante cirugía laparoscópica.

Acupuncture in patients with acute low back pain: a multicentre randomised controlled clinical trial.

Reviews of the efficacy of acupuncture as a treatment for acute low back pain have concluded that there is insufficient evidence for its efficacy and that more research is needed to evaluate it. A multicentre randomized controlled trial was conducted at 4 primary-care centres in Spain to evaluate the effects of acupuncture in patients with acute nonspecific low back pain in the context of primary care. A total of 275 patients with nonspecific acute low back pain (diagnosed by their general practitioner) were recruited and assigned randomly to 4 different groups: conventional treatment either alone or complemented by 5 sessions over a 2-week period of true acupuncture, sham acupuncture, or placebo acupuncture per patient. Patients were treated from February 2006 to January 2008. The primary outcome was the reduction in Roland Morris Disability Questionnaire scores of 35% or more after 2weeks' treatment. The patients in the 3 types of acupuncture groups were blinded to the treatments, but those who received conventional treatment alone were not. In the analysis adjusted for the total sample (true acupuncture relative risk 5.04, 95% confidence interval 2.24-11.32; sham acupuncture relative risk 5.02, 95% confidence interval 2.26-11.16; placebo acupuncture relative risk 2.57 95% confidence interval 1.21-5.46), as well as for the subsample of occupationally active patients, all 3 modalities of acupuncture were better than conventional treatment alone, but there was no difference among the 3 acupuncture modalities, which implies that true acupuncture is not better than sham or placebo acupuncture.

Correction of nonvertex presentation with moxibustion: a systematic review and metaanalysis.

We searched systematically for randomized controlled trials, comparing moxibustion with a nonmoxibustion control group or other methods such as external cephalic version, postural methods, and acupuncture in databases, both Western and Chinese, up to June 2007. Six studies, with 1087 subjects and a high degree of heterogeneity, compared moxibustion vs observation or postural methods and reported a rate of cephalic version among the moxibustion group of 72.5% vs 53.2% in the control group (relative risk, 1.36; 95% confidence interval, 1.17-1.58); the number needed to treat was 5 (95% confidence interval, 4-7). In terms of safety, no significant differences were found in the comparison of moxibustion with other techniques. Moxibustion at acupuncture point BL67 has been shown to produce a positive effect, whether used alone or in combination with acupuncture or postural measures, in comparison with observation or postural methods alone, for the correction of nonvertex presentation, although these results should be viewed with caution, given the considerable heterogeneity found among studies.