Pilot study of a brief psychological intervention for reducing emotional exhaustion and secondary traumatic stress among physicians of intensive care units in Mexico / Estudio piloto de una intervención psicológica breve para reducir el agotamiento emocional y el estrés traumático secundario en personal médico de las unidades de cuidados intensivos en México

Abstract Introduction Physicians of Intensive Care Units (ICU) have a potential risk to develop negative outcomes such as emotional exhaustion and secondary traumatic stress (STS). Specifically, job demands in these units (i.e., work stressors and emotional effort) may positively predict these outcomes, whereas personal resources such as harmonious passion and self-compassion may diminish them. Objetive To design a specific intervention for physicians in ICU and provide preliminary evidence of its effectiveness. Method A brief intervention of five weekly sessions (two hour-sessions) was carried out with four physicians in ICU in a hospital in Mexico. Other four physicians were selected as a control group. The intervention was aimed at reducing emotional exhaustion and STS by increasing harmonious passion and self-compassion, and diminishing the emotional effort. Results The intervention group showed a significant reduction in: a) work stressors (2/4 physicians; RCI = .21); emotional effort (1/4 physicians; (RCI = .60); emotional exhaustion (2/4 physicians; RCI = .34); and STS (3/4 physicians; RCI = .26). One physician experienced a significant increase in harmonious passion (RCI = 1.00), but the intervention seems to maintain high levels of this and self-compassion in comparison with the control group. The control group showed a worse result in its outcomes. Discussion and conclusion Despite the limitations, this study provides preliminary evidence for effectively reducing emotional exhaustion and STS. Our findings highlight the individual analysis of the effective tools per physician and address interventions focused on harmonious passion and self-compassion. This study calls for future research concerning intervention proposals in ICU with follow-up measures to diminish the negative consequences in the long-term.

Resumen Introducción Los médicos de las unidades de Cuidados Intensivos (UCI) presentan un riesgo de desarrollar agotamiento emocional y estrés traumático secundario (ETS). Las demandas laborales en estas unidades (estresores laborales y esfuerzo emocional) pueden predecir positivamente estos resultados, mientras que los recursos personales como la pasión armoniosa y la autocompasión pueden disminuirlos. Objetivo Diseñar una intervención específica para médicos de UCI y proporcionar evidencia preliminar de su efectividad. Método Se realizó una intervención de cinco sesiones semanales (de dos horas de duración cada una) con cuatro médicos de una UCI en un hospital de México. Otros cuatro médicos fueron seleccionados como grupo control. El objetivo fue reducir el agotamiento emocional y el ETS mediante el aumento la pasión armoniosa y la autocompasión; y la disminución del esfuerzo emocional. Resultados En el grupo de intervención se halló una disminución significativa en: a) estresores laborales (2/4 médicos; RCI = .21); esfuerzo emocional (1/4 médicos; RCI = .60); agotamiento emocional (2/4 médicos; RCI = .34); y ETS (3/4 médicos; RCI = .26). Un médico experimentó un aumento significativo en la pasión armoniosa (RCI = 1.00), en tanto que el resto mantuvo altos niveles de ésta y autocompasión en comparación con el grupo control. Discusión y conclusión A pesar de las limitaciones, este estudio proporciona evidencia preliminar para reducir el agotamiento emocional y el ETS. Nuestros hallazgos destacan el análisis individual de las herramientas efectivas y destaca las intervenciones centradas en la pasión armoniosa y la autocompasión. Nuestro estudio recalca la importancia de desarrollar investigaciones futuras sobre intervenciones en UCI con medidas de seguimiento que puedan disminuir las consecuencias negativas a largo plazo.

Elevada capacidad de localización ecográfica de adenomas paratiroideos en endocrinología (estudio ETIEN 4) / High capacity of ultrasound for locating parathyroid adenomas in endocrinology (the ETIEN 4 study)

OBJETIVO: Evaluar el rendimiento diagnóstico de la ecografía de localización de adenomas de paratiroides realizada por endocrinólogos en pacientes con hiperparatiroidismo primario (HPTP). METODOLOGÍA: Estudio observacional retrospectivo en 135 pacientes (74,8% mujeres; edad media: 60,0±12,3 años) atendidos en consultas de endocrinología por HPTP (calcemia media: 11,3±1,2 mg/dl y PTH plasmática media: 240,4±346,8 pg/ml) a los cuales se realiza eco cervical en consulta de endocrinología y se solicita gammagrafía 99mTc-MIBI previamente a la cirugía. Se calcula sensibilidad, especificidad y valor predictivo de ambas pruebas en el subgrupo de pacientes intervenidos. RESULTADOS: Un total de 98 pacientes fueron intervenidos de HPTP y se curaron el 97,8% a 6 meses. La ecografía de localización tuvo una sensibilidad del 85% (IC 95: 75,7-91,2%) y un valor predictivo positivo (VPP) del 95,2% (IC 95%: 87,5-98,4%) para localizar adenomas de paratiroides de 1,7±0,9 cm de diámetro medio máximo (69,4% en glándulas inferiores), presentando una elevada correlación (r = 0,661 y r = 0,716) con el diámetro máximo y el volumen del adenoma extirpado. El 60% presentaba patología nodular tiroidea (64,2% bilateral con un diámetro máximo medio nodular de 1,5±0,9 cm) y se realizaron tiroidectomías en el 31,6%. El mayor rendimiento diagnóstico se observó con la combinación de eco cervical y gammagrafía 99mTc-MIBI (sensibilidad: 96,8% y VPP: 95,8%). CONCLUSIÓN: En nuestro medio, la ecografía de localización de adenomas de paratiroides en pacientes con HPTP realizada por endocrinólogos tiene una elevada capacidad diagnóstica y permite detectar la presencia de patología tiroidea en el 60% de los pacientes

OBJECTIVE: To assess the diagnostic performance of neck ultrasound examination performed by endocrinologists to locate parathyroid adenomas in patients with primary hyperparathyroidism (PHPT). METHODOLOGY: A retrospective observational study in 135 patients (mean age, 60.0 ± 12.3 years; 74.8% females) seen at endocrinology for PHPT (mean calcium level, 11.3 ± 1.2 mg/dL mean PTH level, 240.4 ± 346.8 pg/mL) who underwent neck ultrasound examinations at the endocrinology department. 99mTc-MIBI parathyroid scintigraphy was performed before surgery in all patients. Sensitivity, specificity, positive predictive value, and negative predictive value were calculated in surgical patients. RESULTS: Ninety-eight patients underwent surgery for PHPT and 97.8% were cured at 6 months. Parathyroid ultrasound had a sensitivity of 85% (95% CI: 75.7%-91.2%) and a positive predictive value (PPV) of 95.2% (95% CI: 87.5%-98.4%) to locate parathyroid adenomas 1.7 ± 0.9 cm in maximum diameter (69.4% in smaller glands), showing a high correlation (r = 0.661 and r = 0.716) with maximum diameter and volume of the excised adenoma. Sixty percent of patients had nodular thyroid disease (64.2% bilateral nodules with mean maximum diameter of 1.5 ± 0.9cm), and thyroidectomy was performed in 31.6%. The highest diagnostic performance was seen with a combination of neck ultrasound and 99mTc-MIBI scintigraphy (sensitivity: 96.8% and PPV: 95.8%). CONCLUSIÓN: In our area, parathyroid adenoma localization with ultrasound performed by endocrinologists has a high diagnostic yield and allows for detecting nodular thyroid disease in 60% of patients

Rendimiento diagnóstico del sistema de evaluación de riesgo ecográfico del nódulo tiroideo de la American Thyroid Association en endocrinología (estudio ETIEN 3) / Diagnostic performance of the American Thyroid Association ultrasound risk assessment of thyroid nodules in endocrinology (the ETIEN 3 study)

Introducción: Hasta la actualidad no se ha publicado en nuestro país ningún estudio sobre la utilidad del sistema de evaluación del riesgo ecográfico del nódulo tiroideo de la American Thyroid Association (ATA) aplicada por endocrinólogos. Objetivos: Evaluar el rendimiento diagnóstico de la clasificación ATA del nódulo tiroideo aplicada por endocrinólogos respecto a los resultados histológicos. Metodología: Estudio observacional retrospectivo de 317 pacientes (51,7 ± 13,7 años de edad media; 83,3% mujeres) con nódulos tiroideos (diámetro máximo: 3,2 ± 1,4 cm) evaluados en consulta de eco-PAAF de endocrinología entre octubre de 2015 y diciembre de 2018, a los cuales se les aplicó la clasificación ATA y que fueron intervenidos. Se evalúan los criterios de calidad de la clasificación ecográfica prequirúrgica respecto a los resultados histológicos. Resultados: El 61,2% de los nódulos evaluados fueron clasificados como benignos (n = 3), de muy baja (n = 60) o de baja sospecha (n = 131), el 11,7% como sospecha intermedia (n = 37) y el 27,1% como alta sospecha (n = 86). Se detectaron 260 casos de enfermedad nodular benigna y 57 cánceres de tiroides. Hubo 14 microcarcinomas papilares incidentales. La clasificación de nódulos de alta sospecha presentó un elevado rendimiento diagnóstico para identificar nódulos malignos (sensibilidad 87,7%, especificidad 86,2% y valor predictivo negativo 97,0%), mejorando la sensibilidad (93,0%) y reduciéndose la especificidad (73,1%) al considerar de riesgo los nódulos de sospecha alta e intermedia. Conclusiones: La aplicación por endocrinólogos del sistema de evaluación de riesgo ecográfico del nódulo tiroideo de la ATA presenta un elevado rendimiento diagnóstico para identificar prequirúrgicamente nódulos tiroideos malignos

Introduction: No study has been published to date in Spain about the value of the American Thyroid Association (ATA) ultrasound risk assessment of thyroid nodules applied by endocrinologists. Objectives: To assess the diagnostic performance of ATA thyroid nodule risk classification applied by endocrinologists with respect to histological results. Methods: A retrospective, observational study of 317 patients (mean age, 51.7 ± 13.7 years; 83.3% women) with thyroid nodules (maximum diameter: 3.2 ± 1.4 cm) who underwent US-guided FNA in endocrinology between October 2015 and December 2018, were classified based on the ATA ultrasound risk assessment. Surgery was performed in all of them. Quality criteria of the ultrasound classification were assessed as compared to histological results. Results: Overall, 61.2% of nodules assessed were classified as benign (n = 3) and very low (n = 60) or low suspicion (n = 131), 11.7% as intermediate suspicion (n = 37), and 27.1% as high suspicion (n = 86). Benign nodular disease was found in 260 patients, and thyroid cancer in 57 patients. There were 14 incidental papillary microcarcinomas. Classification of thyroid nodules as high suspicion showed a high diagnostic performance to identify malignant nodules (87.7% sensitivity, 86.2% specificity, negative predictive value 97.0%), improving sensitivity (93.0%) and reducing specificity (73.1%) when considering high and intermediate suspicion nodules as a risk for thyroid cancer. Conclusions: Application by endocrinologists of the ATA ultrasound risk assessment of thyroid nodules shows a high diagnostic performance to identify malignant thyroid nodules before surgery

High capacity of ultrasound for locating parathyroid adenomas in endocrinology (the ETIEN 4 study). / Elevada capacidad de localización ecográfica de adenomas paratiroideos en endocrinología (estudio ETIEN 4).

OBJECTIVE: To assess the diagnostic performance of neck ultrasound examination performed by endocrinologists to locate parathyroid adenomas in patients with primary hyperparathyroidism (PHPT). METHODOLOGY: A retrospective observational study in 135 patients (mean age, 60.0±12.3 years; 74.8% females) seen at endocrinology for PHPT (mean calcium level, 11.3±1.2mg/dL mean PTH level, 240.4±346.8pg/mL) who underwent neck ultrasound examinations at the endocrinology department. 99mTc-MIBI parathyroid scintigraphy was performed before surgery in all patients. Sensitivity, specificity, positive predictive value, and negative predictive value were calculated in surgical patients. RESULTS: Ninety-eight patients underwent surgery for PHPT and 97.8% were cured at 6 months. Parathyroid ultrasound had a sensitivity of 85% (95% CI: 75.7%-91.2%) and a positive predictive value (PPV) of 95.2% (95% CI: 87.5%-98.4%) to locate parathyroid adenomas 1.7±0.9cm in maximum diameter (69.4% in smaller glands), showing a high correlation (r=0.661 and r=0.716) with maximum diameter and volume of the excised adenoma. Sixty percent of patients had nodular thyroid disease (64.2% bilateral nodules with mean maximum diameter of 1.5±0.9cm), and thyroidectomy was performed in 31.6%. The highest diagnostic performance was seen with a combination of neck ultrasound and 99mTc-MIBI scintigraphy (sensitivity: 96.8% and PPV: 95.8%). CONCLUSION: In our area, parathyroid adenoma localization with ultrasound performed by endocrinologists has a high diagnostic yield and allows for detecting nodular thyroid disease in 60% of patients.

Diagnostic performance of the American Thyroid Association ultrasound risk assessment of thyroid nodules in endocrinology (the ETIEN 3 study). / Rendimiento diagnóstico del sistema de evaluación de riesgo ecográfico del nódulo tiroideo de la American Thyroid Association en endocrinología (estudio ETIEN 3).

INTRODUCTION: No study has been published to date in Spain about the value of the American Thyroid Association (ATA) ultrasound risk assessment of thyroid nodules applied by endocrinologists. OBJECTIVES: To assess the diagnostic performance of ATA thyroid nodule risk classification applied by endocrinologists with respect to histological results. METHODS: A retrospective, observational study of 317 patients (mean age, 51.7±13.7 years; 83.3% women) with thyroid nodules (maximum diameter: 3.2±1.4cm) who underwent US-guided FNA in endocrinology between October 2015 and December 2018, were classified based on the ATA ultrasound risk assessment. Surgery was performed in all of them. Quality criteria of the ultrasound classification were assessed as compared to histological results. RESULTS: Overall, 61.2% of nodules assessed were classified as benign (n=3) and very low (n=60) or low suspicion (n=131), 11.7% as intermediate suspicion (n=37), and 27.1% as high suspicion (n=86). Benign nodular disease was found in 260 patients, and thyroid cancer in 57 patients. There were 14 incidental papillary microcarcinomas. Classification of thyroid nodules as high suspicion showed a high diagnostic performance to identify malignant nodules (87.7% sensitivity, 86.2% specificity, negative predictive value 97.0%), improving sensitivity (93.0%) and reducing specificity (73.1%) when considering high and intermediate suspicion nodules as a risk for thyroid cancer. CONCLUSIONS: Application by endocrinologists of the ATA ultrasound risk assessment of thyroid nodules shows a high diagnostic performance to identify malignant thyroid nodules before surgery.

Impacto asistencial y económico de la ecografía tiroidea en acto único en consultas de endocrinología (estudio ETIEN 1) / Care and economic impact of thyroid ultrasound examination at single visits to endocrinology clinics (the ETIEN 1 study)

OBJETIVO: La realización de ecografía tiroidea en consultas en acto único está escasamente implantada en nuestro país. El objetivo de este estudio fue evaluar el impacto asistencial y económico de la utilización de la ecografía tiroidea en consultas de endocrinología en acto único. MÉTODOS: Se trata de un estudio prospectivo, observacional y descriptivo en el que se analizaron los datos de 2.274 pacientes (edad media: 59 +/- 16 años; 83% mujeres) a los cuales se les realizó al menos una ecografía tiroidea en acto único en consultas de endocrinología durante 2013 y 2014. Se evaluaron el número de consultas de acto único, consultas con alta directa y la variación en el número de ecografías solicitadas y realizadas en radiodiagnóstico durante el período de estudio. RESULTADOS: En 2013 y 2014 se realizaron 2.558 ecografías tiroideas en consultas de endocrinología en acto único, siendo el 42,2% consultas de alta directa sin revisión de resultados, con un ahorro estimado de 58.946,40 €. En 2013 y 2014 se redujo el número de ecografías solicitadas a radiodiagnóstico en un 43,3% y 86,0%, respectivamente. De forma global se realizaron en radiodiagnóstico un 28,1% y un 68,3% menos ecografías tiroideas respecto al año 2012, estimándose un ahorro económico de 94.441,36 euros. CONCLUSIONES: La realización de ecografías tiroideas en consultas de endocrinología en acto único permite reducir tanto el número de revisiones de recogida de resultados como las ecografías tiroideas realizadas en radiodiagnóstico, lo cual disminuye el número de desplazamientos innecesarios de pacientes y favorece un ahorro económico considerable

OBJECTIVE: Routine thyroid ultrasound examination in a single medical appointment is rarely performed in Spain. The objective of this study was to evaluate the care and economic impact of thyroid US examination in a single endocrine appointment. METHODS: A prospective, observational, descriptive study was conducted to analyze data from 2274 patients (mean age, 59 ± 16 years; 83% females) performed at least one thyroid US in a single visit to an endocrinology clinic during 2013 and 2014. The number of endocrine acts with thyroid US, single endocrine and US acts without review, and the change in the number of thyroid US requested by endocrinologists to the radiology department and total thyroid US examinations performed at the radiology department during the study period were assessed. RESULTS: In 2013 and 2014, 2558 endocrine acts with thyroid US were performed, of which 42.2% were single endocrine and US appointments without a second endocrine act, with estimated savings of €58,946.40. As compared to 2012, the number of thyroid US requested by endocrinologists to the radiology department decreased by 43.3% and 86.0% in 2013 and 2014 respectively, and total thyroid US performed by the radiology department decreased by 28.1% and 68.3% respectively, with estimated savings of €94,441.36. CONCLUSIONS: Thyroid US examination in a single endocrine appointment allows for decreasing the number of both second endocrine acts and thyroid US examinations performed at the radiology department, thus reducing the number of unnecessary clinic visits and promoting considerable economic savings

Care and economic impact of thyroid ultrasound examination at single visits to endocrinology clinics (the ETIEN 1 study).

OBJECTIVE: Routine thyroid ultrasound examination in a single medical appointment is rarely performed in Spain. The objective of this study was to evaluate the care and economic impact of thyroid US examination in a single endocrine appointment. METHODS: A prospective, observational, descriptive study was conducted to analyze data from 2274 patients (mean age, 59±16 years; 83% females) performed at least one thyroid US in a single visit to an endocrinology clinic during 2013 and 2014. The number of endocrine acts with thyroid US, single endocrine and US acts without review, and the change in the number of thyroid US requested by endocrinologists to the radiology department and total thyroid US examinations performed at the radiology department during the study period were assessed. RESULTS: In 2013 and 2014, 2558 endocrine acts with thyroid US were performed, of which 42.2% were single endocrine and US appointments without a second endocrine act, with estimated savings of €58,946.40. As compared to 2012, the number of thyroid US requested by endocrinologists to the radiology department decreased by 43.3% and 86.0% in 2013 and 2014 respectively, and total thyroid US performed by the radiology department decreased by 28.1% and 68.3% respectively, with estimated savings of €94,441.36. CONCLUSIONS: Thyroid US examination in a single endocrine appointment allows for decreasing the number of both second endocrine acts and thyroid US examinations performed at the radiology department, thus reducing the number of unnecessary clinic visits and promoting considerable economic savings.

Web-based telemedicine system is useful for monitoring glucose control in pregnant women with diabetes.

OBJECTIVE: The aim of this study was to examine the impact of a Web-based telemedicine system for monitoring glucose control in pregnant women with diabetes on healthcare visits, metabolic control, and pregnancy outcomes. SUBJECTS AND METHODS: A prospective, single-center, interventional study with two parallel groups was performed in Puerto Real University Hospital (Cadiz, Spain). Women were assigned to two different glucose monitoring groups: the control group (CG), which was managed only by follow-ups with the Gestational Diabetes Unit (GDU), and the telemedicine group (TMG), which was monitored by both more spaced GDU visits and a Web-based telemedicine system. The number of healthcare visits, degree of metabolic control, and maternal and neonatal outcomes were evaluated. RESULTS: One hundred four pregnant women with diabetes (77 with gestational diabetes, 16 with type 1 diabetes, and 11 with type 2 diabetes) were included in the TMG (n=40) or in the CG (n=64). There were no significant differences in mean glycated hemoglobin level during pregnancy or after delivery, despite a significantly lower number of visits to the GDU (3.2±2.3 vs. 5.9±2.3 visits; P<0.001), nurse educator (1.7±1.3 vs. 3.0±1.7 visits; P<0.001), and general practitioner (3.7±2.0 vs. 4.9±2.8 visits; P<0.034) in the TMG. There were no significant differences between groups in maternal or neonatal outcomes. CONCLUSIONS: A Web-based telemedicine system can be a useful tool facilitating the management of pregnant diabetes patients, as a complement to conventional outpatient clinic visits.

Intense physical activity is associated with better metabolic control in patients with type 1 diabetes.

OBJECTIVES: To analyze the association between adherence to physical activity guideline recommendations and metabolic control in patients with type 1 diabetes (DM1). METHODS: An observational, cross-sectional study was conducted in 130 adult DM1 patients from Spain with a mean age of 33.9±11.5 years and disease duration of 16.5±9.5 years. We analyzed several clinical, anthropometric and laboratory variables together with information obtained from the Minnesota Leisure Time Physical Activity Questionnaire. RESULTS: Evaluated patients reported an average of 850.6±493.2min of physical activity per week, being classified as light (567.4±425.4min/week), moderate (169.9±212.1min/week) and intense activities (120.6±184.2). Patients who dedicated more time to intense physical activity were younger, had university studies and were males more often than those who spent none or less time on intense physical activity. We observed no differences in HbA1c levels in relation to time dedicated to moderate physical activities. However, patients who dedicated more than 150min to intense physical activity per week had lower levels of HbA1c (HbA1c: 7.2±1.0% versus 7.8±1.1% versus 8.0±1.0% in more than 149min, between 0 and 149min or 0min of intense physical activity per week, respectively). CONCLUSION: Performing more than 150min of intense physical activity a week is associated with better metabolic control in type 1 Spanish patients. No positive impact in metabolic control was observed in relation to the time spent in moderate physical activity.

Linfoma de tipo B difuso de células grandes primario rectal que simula un adenocarcinoma de recto / Primary diffuse large B-cell lymphoma of the rectum simulating a rectal adenocarcinoma

El linfoma colorrectal es una entidad extremadamente infrecuente, representando menos del 0,5% del total de las neoplasias colorrectales primarias. La localización colorrectal supone el 15–20% del total de los linfomas gastrointestinales, tras el estómago y el intestino delgado. Debido a la inespecificidad de los síntomas, la enfermedad suele estar avanzada en el momento del diagnóstico. Primordial interés tienen los criterios de Dawson para diferenciar la afectación colorrectal primaria de la afectación del tracto gastrointestinal secundaria a un linfoma sistémico, dadas sus diferentes connotaciones pronósticas y terapéuticas. Presentamos el caso de un linfoma no hodgkiniano tipo B de localización rectal, de difícil diagnóstico, tratado con esquema poliquimioterapéutico con ciclofosfamida, adriamicina, vincristina, prednisona y rituximab, cuya evolución fue desfavorable (AU)

Colorectal lymphoma is an extremely infrequent entity, representing less than 0.5% of all primary colorectal neoplasms. Colorectal localization accounts for 15–20% of all gastrointestinal lymphomas, after the stomach and small intestine. Because the symptoms are non-specific, this disease is usually diagnosed in the advanced stages. Dawson's criteria are highly useful in the differential diagnosis between primary colorectal involvement and gastrointestinal tract involvement secondary to systemic lymphoma, which is important due to the distinct prognosis and treatment of these entities. We report the case of a B-cell non-Hodgkin's lymphoma that was difficult to diagnose and was treated with R-CHOP polychemotherapy. Outcome was poor (AU)

[Primary diffuse large B-cell lymphoma of the rectum simulating a rectal adenocarcinoma]. / Linfoma de tipo B difuso de células grandes primario rectal que simula un adenocarcinoma de recto.

Colorectal lymphoma is an extremely infrequent entity, representing less than 0.5% of all primary colorectal neoplasms. Colorectal localization accounts for 15-20% of all gastrointestinal lymphomas, after the stomach and small intestine. Because the symptoms are non-specific, this disease is usually diagnosed in the advanced stages. Dawson's criteria are highly useful in the differential diagnosis between primary colorectal involvement and gastrointestinal tract involvement secondary to systemic lymphoma, which is important due to the distinct prognosis and treatment of these entities. We report the case of a B-cell non-Hodgkin's lymphoma that was difficult to diagnose and was treated with R-CHOP polychemotherapy. Outcome was poor.