¿Es útil la prueba de la marcha durante 6 min en Atención Primaria? / Is the 6-min walk test useful in primary care?

Introducción La enfermedad pulmonar obstructiva crónica (EPOC) constituye una importante causa de muerte y discapacidad y un frecuente motivo de consulta en Atención Primaria. Pretendemos estudiar la utilidad y seguridad de la prueba de la marcha durante 6 min (PM6M) para valorar el estado funcional de los pacientes. Material y métodos Estudio de valoración de una prueba funcional en atención primaria con 94 pacientes (media: 72,34 años; el 77,77% eran hombres) con EPOC que realizaron la PM6M. Resultados Nuestros pacientes caminaron una media de 360,39m, la distancia correlacionó significativamente con el volumen espiratorio forzado en un segundo en litros (r=0,423), la probabilidad de supervivencia a los 10 años (r=0,403), con la talla (r=0,236), la saturación de oxígeno (r=0,226) y el porcentaje del volumen espiratorio forzado en un segundo (r=0,214); observamos correlaciones inversas significativas con la edad (r=−0,458), el índice de Charlson ajustado (r=−0,290) y el estadio de su enfermedad (r=−0,215). Tanto la frecuencia cardiaca que pasó de 78,26 a 85,70ppm como la saturación de oxígeno (del 94,07 al 95,84%), la presión arterial sistólica (de 146,82 a 158,77mmHg), la presión arterial diastólica (80,79 a 83,78mmHg), así como la sensación de disnea (de 0,72 a 2,83) y el cansancio (0,69–2,36) medidas con la escala de Borg aumentaron de forma muy significativa en el transcurso de la prueba (p<0,0001). No hubo complicaciones y todos los pacientes, menos uno, finalizaron correctamente el test. Conclusión Los pacientes más mayores con otras patologías y en un estadio avanzado de EPOC conseguían caminar distancias significativamente menores; la PM6M resultó una prueba útil para valorar la gravedad de la enfermedad, resultando además ser sencilla y segura (AU)

Introduction Given the frequency and importance of COPD, we need to know the functional performance of our patients. Therefore we have sought to evaluate their exercise capacity using the 6-min walk test (6MWT), evaluating its utility and safety. Material and methods An evaluation study of a functional test in Primary Care with 94 COPD patients (mean, 72.34 years; 77.77%, men) who performed the 6MWT. Results Our patients walked a mean of 360.39 meters. The distance significantly correlated with the FEV1 in liters (r=0.423), with the 10-year likelihood of survival (r=0.403), with height (r=0.236), with O2 saturation (r=0.226) and with FEV1% (r=0.214). Significant inverse correlations were observed with age (r=−0.458), adapted Charlson index (r=−0.290), and with their disease stage (r=−0.215). Heart rate, that went from 78.26 to 85.70bpm, and oxygen saturation (94.07% to 95.84%), systolic blood pressure (146.82mmHg to 158.77), diastolic blood pressure (80.79mmHg to 83.78) and the sensation of dyspnea (from 0.72 to 2.83) and tiredness (0.69 to 2.36) measured with the Borg scale significantly increased during the test (p<0.0001). There were no complications and all the patients, except for one, correctly completed the test. Conclusion The older patients with other conditions and with an advanced COPD stage were able to walk significantly shorter distances. The 6MWT was a useful test to evaluate the severity of the disease, and was also easy and safe (AU)

¿Es útil la prueba de la marcha durante 6min en Atención Primaria? / Is the 6-min walk test useful in primary care?

Introducción: La enfermedad pulmonar obstructiva crónica (EPOC) constituye una importante causa de muerte y discapacidad y un frecuente motivo de consulta en Atención Primaria. Pretendemos estudiar la utilidad y seguridad de la prueba de la marcha durante 6 min (PM6M) para valorar el estado funcional de los pacientes. Material y métodos: Estudio de valoración de una prueba funcional en atención primaria con 94 pacientes (media: 72,34 años; el 77,77% eran hombres) con EPOC que realizaron la PM6M. Resultados: Nuestros pacientes caminaron una media de 360,39m, la distancia correlacionó significativamente con el volumen espiratorio forzado en un segundo en litros (r=0,423), la probabilidad de supervivencia a los 10 años (r=0,403), con la talla (r=0,236), la saturación de oxígeno (r=0,226) y el porcentaje del volumen espiratorio forzado en un segundo (r=0,214); observamos correlaciones inversas significativas con la edad (r=−0,458), el índice de Charlson ajustado (r=−0,290) y el estadio de su enfermedad (r=−0,215). Tanto la frecuencia cardiaca que pasó de 78,26 a 85,70ppm como la saturación de oxígeno (del 94,07 al 95,84%), la presión arterial sistólica (de 146,82 a 158,77mmHg), la presión arterial diastólica (80,79 a 83,78mmHg), así como la sensación de disnea (de 0,72 a 2,83) y el cansancio (0,69–2,36) medidas con la escala de Borg aumentaron de forma muy significativa en el transcurso de la prueba (p<0,0001). No hubo complicaciones y todos los pacientes, menos uno, finalizaron correctamente el test. Conclusión: Los pacientes más mayores con otras patologías y en un estadio avanzado de EPOC conseguían caminar distancias significativamente menores; la PM6M resultó una prueba útil para valorar la gravedad de la enfermedad, resultando además ser sencilla y segura (AU)

IIntroduction: Chronic obstructive pulmonary disease ( COPD) is a major cause of death and disability and a frequent reason for consultation in primary care. We intend to study the usefulness and safety of walking test for 6 min ( 6MWT ) to assess the functional status of patients. Material and methods: assessment of a functional test in primary care with 94 patients (mean : 72.34 years , 77.77 % were men) with COPD who performed the 6MWT . Results : Our patients walked an average of 360.39 m, the distance significantly correlated with forced expiratory volume in one second in liters ( r = 0.423 ) , the probability of survival at 10 years ( r = 0.403 ) , with size ( r = 0.236) , oxygen saturation ( r = 0.226 ) and the percentage of forced expiratory volume in one second ( r = 0.214 ), observed significant inverse correlations with age ( r = -0.458 ) , adjusted Charlson index ( r = -0.290 ) and the stage of their disease ( r = -0.215 ) . Both heart rate which rose from 78.26 to 85.70 ppm oxygen saturation (from 94.07 to 95.84 % ) , systolic blood pressure (from 146.82 to 158.77 mmHg ) , diastolic blood pressure ( 80.79 to 83.78 mmHg ) , and the sensation of dyspnea ( from 0.72 to 2.83) and fatigue ( 0.69 to 2.36 ) measured with the Borg scale very significantly increased in the course of the test ( p < 0.0001 ) . There were no complications and all patients but one test completed successfully . Conclusion : Older patients with other diseases and in an advanced stage of COPD getting significantly less walking distances , the 6MWT was a useful test for assessing the severity of the disease , resulting also be simple and safe (AU)

Pocos ensayos clínicos y con resultados mal comunicados. Réplica / Few clinical trials, and these with poorly reported results. Reply

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[Is the technique used to collect urine important in avoiding contamination of samples?]. / 'Es importante la técnica de recogida de la orina para evitar la contaminación de las muestras?

OBJECTIVE: To appraise the efficacy of hygienic standards in preventing the contamination of urine samples. DESIGN: Randomised clinical trial. 515 women assigned at random: 279 to the Intervention group and 236 to Control. SETTING: Population registered with 4 doctors at 2 health centres. PARTICIPANTS: Women from 15 to 65 who attended the clinic for on-demand care. Criteria for exclusion from the trial were: permanent bladder catheter, anomalies in genito-urinary apparatus, antibiotic treatment in the 7 previous days and inability to understand instructions. INTERVENTION: Verbal instructions on hygienic standards for collecting the sample and explanatory leaflet, as against the customary guidelines. MAIN MEASUREMENTS: The main result was the combination of contamination levels and infection. Analysis by intention to treat. RESULTS: Irregularities in the urine culture in 113 (41%) patients from the Intervention group and in 133 (56%) from the Control group (P<.001), with RRR of 28% (95% CI, 14%-40%) and NNT of 6 (95% CI, 4-14). Taking only serious contamination or urinary infection, we had 14 in the Intervention group and 36 in the Control (P<.0001), with RRR of 67% (95% CI, 41%-82%) and NNT of 10 (95% CI, 6-20). CONCLUSIONS: Providing an explanatory leaflet and giving verbal instructions on hygienic standards for urine collection reduces contamination of the samples.

[What are Gypsies like and what do they suffer from?]. / Cómo son y de qué padecen los gitanos.

OBJECTIVE: To find and compare the social and demographic features and health status of two different ethnic and cultural groups, gypsies and payos (non-gypsies). DESIGN: Observational, descriptive, crossover study. SETTING: Primary care. PARTICIPANTS: The 121 gypsy patients > 14 registered at the centre and 121 controls who were matched for age. INTERVENTIONS: Social and demographic variables, risk factors, chronic illnesses and involvement in preventive and health promotion programmes were gathered. MEASUREMENTS AND MAIN RESULTS: On the basis of a questionnaire that was filled out with data from the primary care health histories, we saw that there were significant differences in educational background, jobs and work situation (p < 0.0005). Among the gypsies there were more alcohol consumers, intravenous drug users and patients at social-health risk. Hb, Hc and HIV affected gypsies significantly more (the two groups were included in preventive programmes and activities). Mean age of death among gypsies was early (40.6 years vs. 73). Paradoxically, gypsies used private medicine more. CONCLUSIONS: There were significant social-health differences between the two groups studied. The gypsies on our health centre lists need greater care from the primary care team, so that they can achieve better health status.

Cómo son y de qué padecen los gitanos / What are gypsies like and what do they suffer from?

Objetivo. Conocer y comparar las características sociodemográficas y el estado de salud de 2 grupos étnicos y culturales distintos (payos y gitanos). Diseño. Estudio observacional, descriptivo, transversal. Emplazamiento. Atención primaria. Participantes. Los 121 pacientes de cultura gitana mayores de 14 años adscritos al centro y 121 controles apareados por edad. Intervenciones. Se recogieron variables sociodemográficas, factores de riesgo, enfermedades crónicas y adscripción a programas preventivos y de promoción de la salud. Mediciones y resultados principales. A partir de un cuestionario que se rellenó con datos de las historias de salud de atención primaria, vimos que había diferencias significativas en cuanto al nivel de instrucción, profesión y situación laboral (p < 0,0005). Había mayor número de consumidores de alcohol, de tóxicos vía parenteral y superior número de pacientes con riesgo sociosanitario entre los gitanos. VHB, VHC y VIH inciden significativamente más sobre los gitanos (ambos grupos incluidos en programas y actividades preventivas). Se detecta una temprana edad media de muerte en la población gitana (40,6 años frente a 73,3 entre los payos). Paradójicamente, se da una mayor utilización de la medicina privada entre los gitanos. Conclusiones. Existen diferencias sociosanitarias significativas entre ambos grupos estudiados. La población gitana de nuestro centro de salud requiere mayor atención por parte del equipo de atención primaria, para conseguir un mejor estado de salud en este grupo (AU)

[Differences between knowledge and attitudes to AIDS in adolescents]. / Diferencias entre conocimientos y actitudes frente al sida en población adolescente.

OBJECTIVES: To relate knowledge about AIDS to the worry and fear caused by normal everyday situations, in which someone seropositive or with AIDS is involved, but when the virus cannot be transmitted. To find the discrimination that exists towards HIV carriers and people with AIDS. DESIGN: A basically descriptive crossover observation study. SETTING: Educational centres in the city of Castellón. PARTICIPANTS: 628 adolescents found by multi-stage conglomerate sampling. MEASUREMENTS AND RESULTS: A self-filled questionnaire was used. The items involving behaviour through which the virus was not transmitted, and for which the knowledge, worry and fear generated were evaluated, were described analytically. Items concerning discriminatory attitudes were analysed. Although we detected a lack of knowledge, the worry and fear generated by each situation was greater. In over 75% of those polled we observed discriminatory attitudes. CONCLUSIONS: We detected important divergences between knowledge about paths of non-transmission, and the anxiety and fear generated. Perhaps the preventive campaigns have contributed knowledge about the paths of contagion, but it is clear that they have not helped to modify discriminatory attitudes towards people with HIV or AIDS.

[Profile of primary care physicians in a health area: a cluster analysis]. / Perfil de los médicos de atención primaria en un área de salud: un análisis de clusters.

OBJECTIVES: To discover characteristics of primary care doctors. To find homogeneous groups of doctors. DESIGN: A basically descriptive crossover observational study. SETTING: Primary care doctors from a health area. PARTICIPANTS: The following variables were recorded on the 99 doctors who worked in Castellon Area 03 during 1992: age, gender, fixed or temporary post, rural or urban area, MIR training, primary care model, patient load, sole employment, drugs expenditure, number of pensioners and total number of patients registered. MEASUREMENTS AND MAIN RESULTS: We found a first group of older doctors, working mainly in the old model, for whom PC was not their sole employment; another younger group without MIR training and with an average patient load; the third group was women in temporary posts with a somewhat higher drugs expenditure; the fourth was doctors working in rural areas with a very low patient load; the fifth, final and youngest group was family doctors, with an average patient load, low expenditure and a high number of patients registered. We observed highly significant differences between groups. CONCLUSIONS: Doctors' age and gender divide them into different groupings; family doctors form one group. Multivariable, descriptive methods proved useful in finding, describing and classifying doctors and centres, etc., and could be of use in resource and action planning.

[Factors determining costs of drug prescriptions in primary health care]. / Factores determinantes del gasto por prescripción farmacéutica en atención primaria.

OBJECTIVE: To describe and explain the annual pharmaceutical expenditure generated by the professionals in a Health Area. DESIGN: An observational crossover study. SETTING: Primary Care. Doctors in a Health Area. PARTICIPANTS: 99 general practitioners who worked during 1992 in Area 3, Castellón. INTERVENTIONS: We used as a variable reply the pharmaceutical expenditure of each doctor during 1992, the expenditure per inhabitant and the expenditure per inhabitant standardised for the percentage of passives. We gathered as explanatory variables of the same: age, gender, whether the post was provisional or permanent, rural or urban area, MIR (resident) training or not, the model of Primary Care, frequency of attendance, whether the doctors worked there exclusively, the number of pensioners and the number of patients at work registered. MEASUREMENTS AND RESULTS: In the bivariant analysis we found a significant association of expenditure with being provisional in the post, the old model of primary care, an urban area, greater age of the doctor, greater frequency of attendance, non-exclusivity and the number of patients registered. These associations varied in line with the variable reply used. In the different models of multiple linear regression obtained, the influence of the number, non-exclusivity, gender and work-place characteristics predominated. CONCLUSIONS: Greater pharmaceutical expenditure appears to be related to the number of patients registered, the absence of exclusivity, doctors being women and the features of the town where they work.

[The validity and reliability of arterial pressure measurement in a health center]. / Validez y fiabilidad de la medición de la tensión arterial en un centro de salud.

OBJECTIVE: To evaluate the validity of blood pressure measurement by studying the presence of preference bias in last digits and also of the bias which tends to situate measurements below the established limit. To evaluate the interobserver (doctor-nurse) reliability of the measurements. DESIGN: A cross-sectional [correction of crossover] observation study with descriptive and analytic components. SETTING: A nursing station in the Health Centre. PATIENTS: The patients who attended the nursing station by appointment during the months of September and October 1993. MEASUREMENTS AND MAIN RESULTS: The patients who attended the nursing station by appointment had their blood pressure measured by a doctor or nurse in a random fashion. We detected a preference in last digits, which was very significant for both systolic and diastolic pressure (p < 0.0001). The tendency to reduce diastolic figures to below the preestablished limit of pressure was also very significant (p < 0.05). The nurse found lower figures than the doctor, with a very significant difference for diastolic pressure (p < 0.001). The index of kappa concordance between nurse and doctor on evaluating whether pressure was high or not was 0.4864, with a C.I. of 95%, from 0.3530 to 0.6198. CONCLUSIONS: The existence of two important biases in the measurements of pressure questions their validity. Additionally the significant difference between the pressure averages and the low concordance poses a serious question over the interobserver reliability and should make us restate blood pressure measurement and the treatment of patients suffering Hypertension.

[A quality evaluation in requests for thoracic radiology in chronic pathology at a health center]. / Evaluación de la calidad en la solicitud de radiología de tórax en patología crónica en un centro de salud.

OBJECTIVE: To improve the quality of thoracic x-ray requests during chronic illness, presenting criteria for indication in HTA, LCFA and TBC. DESIGN: Intervention study of quality improvement. SETTING: Can Misses Health Centre in Ibiza. PARTICIPANTS: The General Practitioners at the above centre. MEASUREMENTS AND MAIN RESULTS: In this study we proposed to evaluate the work of the doctors at our Health Centre in correctly requesting x-ray explorations on the basis of two explicit, standard criteria: 1) the reason for the thorax x-ray request must be stated in the clinical notes. 2) Thorax x-rays requested for LCFA, HTA and TBC must be correctly indicated. CONCLUSION: The use of structured criteria in thorax x-ray requests for chronic patients appears to lead to greater quality in requests for this complementary exploration.

[The prescription of intramuscular injectable drugs: a comparative study]. / La prescripción de inyectables por vía intramuscular: estudio comparativo.

AIMS: To find out the personal characteristics of patients who receive intra-muscular medication. To examine those illnesses where this treatment is used. To compare the number of intra-muscular treatments prescribed with the nature of the medication, according to a model of Primary Care and to the doctors training. DESIGN: We are dealing with an observational study, in which a questionnaire was used to find patients' characteristics and the prescription given. SITE. The present study was carried out in the Ibiza Health Centre and two old-fashioned out-patient clinics in our Health Area. PATIENTS AND OTHER PARTICIPANTS: The population under study consisted of all those patients above the age of 7 who received intramuscular treatment during the period of the study (October, November and December, 1990). INTERVENTIONS: There were no interventions, as this was an observational study. MEASUREMENTS AND MAIN FINDINGS: The intra-muscular method of administration was used more in women, people over 50 and those with a very low cultural level. The majority of patients (59.66%) believed that this method was superior to enteric treatments. This method was more often used in out-patient clinics than in the Health Centre (p < 0.01). In the Health Centre less medication treating the Locomotive System (p < 0.001) and more dealing with the Centre Nervous System (p < 0.02) was prescribed. In out-patient clinics more antibiotics, either in combination with each other or with other products, were prescribed (p < 0.01). CONCLUSIONS: In the Health Centre the intra-muscular method was used less. Additionally, a smaller proportion of the medication given was intrinsically useless or of unacceptably low value.