Evidence supporting the best clinical management of patients with multimorbidity and polypharmacy: a systematic guideline review and expert consensus.

The complexity and heterogeneity of patients with multimorbidity and polypharmacy renders traditional disease-oriented guidelines often inadequate and complicates clinical decision making. To address this challenge, guidelines have been developed on multimorbidity or polypharmacy. To systematically analyse their recommendations, we conducted a systematic guideline review using the Ariadne principles for managing multimorbidity as analytical framework. The information synthesis included a multistep consensus process involving 18 multidisciplinary experts from seven countries. We included eight guidelines (four each on multimorbidity and polypharmacy) and extracted about 250 recommendations. The guideline addressed (i) the identification of the target population (risk factors); (ii) the assessment of interacting conditions and treatments: medical history, clinical and psychosocial assessment including physiological status and frailty, reviews of medication and encounters with healthcare providers highlighting informational continuity; (iii) the need to incorporate patient preferences and goal setting: eliciting preferences and expectations, the process of shared decision making in relation to treatment options and the level of involvement of patients and carers; (iv) individualized management: guiding principles on optimization of treatment benefits over possible harms, treatment communication and the information content of medication/care plans; (v) monitoring and follow-up: strategies in care planning, self-management and medication-related aspects, communication with patients including safety instructions and adherence, coordination of care regarding referral and discharge management, medication appropriateness and safety concerns. The spectrum of clinical and self-management issues varied from guiding principles to specific recommendations and tools providing actionable support. The limited availability of reliable risk prediction models, feasible interventions of proven effectiveness and decision aids, and limited consensus on appropriate outcomes of care highlight major research deficits. An integrated approach to both multimorbidity and polypharmacy should be considered in future guidelines.

[Brain natriuretic peptide in primary care: diagnostic value in heart failure]. / Péptido cerebral natriurético en atención primaria: valor diagnóstico en la insuficiencia cardíaca.

OBJECTIVE: To determine the validity and usefulness of brain natriuretic peptide (BNP) for diagnosing left ventricular dysfunction (LVD). DESIGN: Prospective, descriptive, multi-centred study to validate the diagnostic test. SETTING: Primary care centres in the Community of Madrid, Spain. PARTICIPANTS: Consecutive sample of patients at high risk of presenting with LVD. INTERVENTIONS: Data will be gathered from anamnesis, physical examination, ECG, and chest x-ray to find the risk factor(s) for LVD and the presence or absence of symptoms of congestive heart failure according to the Framingham scale. BNP will be determined at PC clinics in all patients who meet the inclusion criteria, using the "triage BNP test." All patients included in the study will be referred to an echocardiography service for an echocardiogram, which will be the gold standard test. Two independent cardiologists will evaluate the echocardiograph without knowing the BNP values. MAIN MEASUREMENTS: BNP concentrations will be compared against the kind and degree of LVD. ROC curves analysis will test the capacity of BNP to diagnose LVD. Optimal sensitivity and specificity value will be calculated by means of the position on the curve resulting from the minimum distance at the cut-off point for best sensitivity and specificity. Then, sensitivity, specificity, and positive and negative predictive values will be calculated. DISCUSSION: BNP can complement the information provided by other diagnostic tests. It should be included as an important factor in the taking of clinical-therapeutic decisions.

Revisión sistemática de las intervenciones educativas grupales en pacientes diabéticos tipo 2 / Systematic review of group educational interventions in type-2 diabetes patients

Objetivo. Evaluar el efecto de las intervenciones educativas grupales en pacientes diabéticos tipo 2. Analizar qué tipo de intervención grupal produce mayores efectos a largo plazo. Diseño. Revisión sistemática. Fuente de datos. Revisión de bases electrónicas: CENTRAL, MEDLINE, EMBASE, CINAHL y PASCAL, así como de las citas bibliográficas de los estudios seleccionados. Contactos con expertos para localizar artículos no publicados. Selección de los estudios. Ensayos clínicos aleatorizados, controlados y estudios cuasiexperimentales que evalúen intervenciones educativas grupales dirigidas a pacientes diabéticos tipo 2, mayores de 18 años, de cualquier duración, realizada en cualquier ámbito, cuya meta sea mejorar la calidad de vida, el autocontrol o el control metabólico. El grupo de comparación incluye intervenciones educativas individuales y no intervenciones. Variables resultado. Calidad de vida, autocontrol y control diabético (HbA1c, colesterol, triglicéridos, presión arterial y consumo de tabaco). Métodos de revisión. Selección de los ensayos realizada por 3 grupos, con 3 investigadores cada uno, que de forma independiente revisan los títulos, abstracts y palabras clave de todos los ensayos identificados para decidir sobre su elegibilidad. La calidad de los ensayos se evalúa usando los criterios definidos por el Cochrane Metabolic and Endocrine Disorders Group. Los investigadores evalúan de forma independiente los artículos y las discrepancias se resuelven por discusión y consenso

Objectives. To evaluate the effect of group educational interventions in type-2 diabetes patients. To analyse what kind of group intervention has the best long-term effects. Design. Systematic review. Data sources. Review of electronic data bases: CENTRAL, MEDLINE, EMBASE, CINAHL, and PASCAL, and of the bibliographic references of the studies selected. Contacts with experts to locate non-published articles. Selection of studies. Randomised clinical studies with controls and quasi-experimental studies that evaluate group education interventions aimed at type-2 diabetes patients over 18 years old. These interventions were of any length and in any context, and their target was to improve quality of life, self-control, or metabolic control. The comparison group included individual educational interventions and non-interventions. Variables result. Quality of life, self-control, and diabetes control (HbA1c, cholesterol, triglycerides, blood pressure, and smoking). Review methods. Trial selection by 3 groups with 3 researchers in each, who independently reviewed headings, abstracts and key words of all the identified trials to decide on their eligibility. The quality of trials was evaluated by the criteria defined by the Cochrane Metabolic and Endocrine Disorders Group. Researchers assessed the articles independently; and discrepancies were resolved by discussion and consensus

[Primary care doctors needs for information: analysis of questions and how they were answered]. / Necesidades de información de los médicos de atención primaria: análisis de preguntas y su resolución.

OBJECTIVE: To assess what information primary care doctors from 5 health areas of Madrid need, through the description of the frequency and kind of clinical questions that arise, the pattern of search for the answers and how well they were answered. DESIGN: Descriptive, observational study. Setting. Primary care consultations in health areas 1, 3, 8, 9, and 10, Madrid, Spain. PARTICIPANTS: Randomised sample, stratified by zone, and kind of doctor, of 125 doctors from each area (Madrid). Residents, locums, and university teachers were excluded. INTERVENTIONS: Doctors will be invited to be observed by video camera for about four hours of on-demand consultation. They will be asked between patients to specify the questions that arise and the sources of information used in the consultation. Unresolved questions will be followed up by means of phone contact 2 weeks later, to see whether they had found answers and what methods they used to find them. MAIN VARIABLES: number of recognised clinical questions formulated and their answers; number of clinical questions not recognised (as observed by video); each question's theme and kind of information; time used to look for answers; information resources used. Other variables: characteristics of the PC professionals taking part, consultations, health centres, and case-loads. DISCUSSION: Restrictions: Hawthorne effect or bias in the person observed and participants stage fright. Applicability: the results of the research will be used to plan the resources needed for doctors to enjoy and put into practice the best scientific knowledge.

Necesidades de información de los médicos de atención primaria: análisis de preguntas y su resolución / Primary care doctors’ needs for information: analysis of questions and how they were answered

Objetivo. Determinar las necesidades de información de los médicos de atención primaria de 5 áreas de salud de Madrid mediante la descripción de la frecuencia y el tipo de preguntas clínicas, el patrón de búsqueda y nivel de resolución de éstas. Diseño. Estudio observacional descriptivo. Emplazamiento. Consultas de atención primaria. Áreas de salud 1, 3, 8, 9 y 10 de Madrid. Participantes. Muestra aleatoria, estratificada por zona y tipo de médico, de 125 médicos de cada una de las áreas (Madrid). Se excluye a los médicos residentes, a los suplentes y a los que realizan actividades de enseñanza universitaria. Intervenciones. Se invitará a los médicos a ser observados mediante cámara de vídeo durante aproximadamente 4 h de consulta a demanda. Se les pedirá que especifiquen, entre paciente y paciente, las preguntas que surjan y las fuentes de información utilizadas dentro de la consulta. Las preguntas sin resolver serán seguidas mediante contacto telefónico 2 semanas después para determinar si se han obtenido respuestas y los métodos utilizados. Mediciones principales. Variables principales: número de preguntas clínicas formuladas reconocidas y sus respuestas; número de preguntas clínicas no reconocidas (observadas a través del vídeo); tema y tipo de información de cada pregunta; tiempo utilizado en buscar respuestas; recursos de información utilizados. Otras variables: características de los profesionales de atención primaria participantes, consultas, centros de salud y presión asistencial. Discusión. Una limitación es el efecto Hawthorne o sesgo del observado y miedo escénico de los participantes. En cuanto a la aplicabilidad de los resultados de la investigación, servirán para planificar los recursos necesarios para que los médicos dispongan y apliquen la mejor evidencia científica

Objective. To assess what information primary care doctors from 5 health areas of Madrid need, through the description of the frequency and kind of clinical questions that arise, the pattern of search for the answers and how well they were answered. Design. Descriptive, observational study. Setting. Primary care consultations in health areas 1, 3, 8, 9, and 10, Madrid, Spain. Participants. Randomised sample, stratified by zone, and kind of doctor, of 125 doctors from each area (Madrid). Residents, locums, and university teachers were excluded. Interventions. Doctors will be invited to be observed by video camera for about four hours of on-demand consultation. They will be asked between patients to specify the questions that arise and the sources of information used in the consultation. Unresolved questions will be followed up by means of phone contact 2 weeks later, to see whether they had found answers and what methods they used to find them. Main measurements. Main variables: number of recognised clinical questions formulated and their answers; number of clinical questions not recognised (as observed by video); each question's theme and kind of information; time used to look for answers; information resources used. Other variables: characteristics of the PC professionals taking part, consultations, health centres, and case-loads. Discussion: Restrictions: Hawthorne effect or bias in the person observed and participants´ stage fright. Applicability: the results of the research will be used to plan the resources needed for doctors to enjoy and put into practice the best scientific knowledge

[Systematic review of group educational interventions in type-2 diabetes patients]. / Revisión sistemática de las intervenciones educativas grupales en pacientes diabéticos tipo 2.

OBJECTIVES: To evaluate the effect of group educational interventions in type-2 diabetes patients. To analyse what kind of group intervention has the best long-term effects. DESIGN: Systematic review. DATA SOURCES: Review of electronic data bases: CENTRAL, MEDLINE, EMBASE, CINAHL, and PASCAL, and of the bibliographic references of the studies selected. Contacts with experts to locate non-published articles. Selection of studies. Randomised clinical studies with controls and quasi-experimental studies that evaluate group education interventions aimed at type-2 diabetes patients over 18 years old. These interventions were of any length and in any context, and their target was to improve quality of life, self-control, or metabolic control. The comparison group included individual educational interventions and non-interventions. VARIABLES RESULT: Quality of life, self-control, and diabetes control (HbA1c, cholesterol, triglycerides, blood pressure, and smoking). REVIEW METHODS: Trial selection by 3 groups with 3 researchers in each, who independently reviewed headings, abstracts and key words of all the identified trials to decide on their eligibility. The quality of trials was evaluated by the criteria defined by the Cochrane Metabolic and Endocrine Disorders Group. Researchers assessed the articles independently; and discrepancies were resolved by discussion and consensus.

Epidemiología de la infección por elVIH en la población de Getafe / Epidemiology of HIV infection in the town of Getafe

No disponible

[Effectiveness of non-pharmacological primary care methods for giving up tobacco dependency]. / Efectividad de los métodos no farmacológicos para la deshabituación tabáquica en atención primaria.

OBJECTIVE: To determine the effectiveness of a systematic and intensive programme of tobacco counselling, as against brief anti-tobacco counselling. DESIGN: Controlled and randomised clinical trial. SETTING: Primary care medical and nursing clinics at an urban Health Centre in Getafe. PARTICIPANTS: Smokers who request health care at the medical clinics for any reason during the recruitment period, who satisfy the inclusion criteria and who want to take part in the study. The inclusion criteria are: 18 years old or more, people who have smoked daily during the previous month any amount of cigarettes, and high motivation (score over 7 on the Richmond test). INTERVENTION: The 110 patients recruited by each doctor will be included, depending on the clinic they come from, in the control group (brief counselling) or the intervention group (intensive counselling). For the patients in the intervention group, monitoring visits will be programmed for 6 months after giving up. Both groups will be called by phone after a year to see if they are still smoking. MAIN MEASUREMENTS: Abstinence at 12 months. SECONDARY MEASUREMENTS: a) Recorded at the start: personal details, medical history and smoking history; b) recorded at the consultations: abstinence, date of first giving up and symptoms of withdrawal syndrome. DISCUSSION: The study will define the role of nursing professionals in taking patients off tobacco and will help define the effectiveness of non-medical methods to achieve this.

Efectividad de los métodos no farmacológicos para la deshabituación tabáquica en atención primaria / Effectiveness of nonpharmacological primary care methods for giving up tobacco dependency

Objetivo. Determinar la efectividad de un programa de consejo antitabaco intensivo sistemático frente al consejo antitabaco breve. Diseño. Ensayo clínico controlado y aleatorizado. Emplazamiento. Consultas de medicina y enfermería de atención primaria de un centro de salud urbano de Getafe. Participantes. Fumadores que demandan asistencia por cualquier motivo en las consultas de medicina durante el período de captación y que, cumpliendo los criterios de inclusión, quieran participar en el estudio. Los criterios de inclusión son: edad igual o superior a 18 años, personas que han fumado diariamente durante el último mes cualquier cantidad de cigarrillos y motivación alta (puntuación del test de Richmond mayor de 7).Intervención. Los pacientes captados por cada médico, que en total son 110, se incluirán, según la consulta de la que procedan, en el grupo control (consejo breve) o en el grupo intervención (consejo intensivo). Para los pacientes del grupo intervención se programarán visitas de seguimiento hasta completar 6 meses desde la deshabituación. A los miembros de ambos grupos se les llamará por teléfono al año para preguntarles si siguen fumando. Mediciones principales. Abstinencia a los 12 meses. Mediciones secundarias. a) Registradas al inicio (datos personales, antecedentes médicos y antecedentes tabáquicos), y b) registradas en las visitas (abstinencia, fecha de inicio de abandono y síntomas del síndrome de abstinencia).Discusión. El estudio definirá el papel de los profesionales de enfermería en la deshabituación tabáquica y ayudará a definir la efectividad de los métodos no farmacológicos en ésta (AU)

Ácido fólico y defectos del tubo neural en Atención Primaria / Folic acid and neural tube defects in Primary

Los defectos del tubo neural (DTN) son malformaciones graves y relativamente comunes que se originan al comienzo de la gestación. La suplementación con folatos se ha demostrado como una medida eficaz en la prevención primaria de dichos DTN. La evidencia sobre la prevención del primer episodio y la recurrencia de estas malformaciones es tal, que las recomendaciones sobre la oferta de ácido fólico rutinaria a mujeres en edad fértil son apoyadas por las autoridades sanitarias. Los médicos de Atención Primaria, como responsables del primer escalón de atención a la población de mujeres, deben conocer cuáles son esas recomendaciones y cómo se pueden llevar a cabo (AU)

[Prophylaxis of neural tube defects with folic acid in pregnant women from a health district]. / Profilaxis de los defectos del tubo neural con folatos en las mujeres gestantes del Area 10 de Madrid.

OBJECTIVES: To evaluate the knowledge about the prophylaxis of neural tube defects (NTD) with supplements of folic acid and the correct therapeutic compliance. DESIGN: Observational, descriptive study. PARTICIPANTS: 346 pregnant women attending to deliver at the department of obstetrics and gynaecology, university hospital. MATERIAL AND METHODS: The following outcomes were gathered through a questionnaire: demographic variables, previous personal or family history of a pregnancy affected by a NTD, planning of pregnancy, knowledge about the value of the use of folic acid, health professional who prescribed it, and the beginning and duration of the prophylaxis. RESULTS: 95% of the participants used supplements of folic acid during their pregnancy. A 34% was able to describe folic acid as an efficacious method to diminish the incidence of NTD. The percentage of women who used correctly the prophylaxis was significantly greater when it was prescribed by a family physician (P=.003). CONCLUSIONS: A great proportion of women from our health district take folic acid during pregnancy, but just a small percent accomplishes the treatment correctly. The lack of awareness among women about the need for periconceptional folic acid supplements and how it should be taken following the recommendations to prevent NTD are the main reasons for not accomplishing a correct prophylaxis. Family physicians could play an important role as health educators.

Profilaxis de los defectos del tubo neural con folatos en las mujeres gestantes del Área 10 de Madrid / Prophylaxis of neural tube defects with folic acid in pregnant women from a health district

Objetivo. Evaluar el conocimiento sobre la profilaxis de los defectos del tubo neural (DTN) con la toma de suplementos de folatos así como el cumplimiento terapéutico. Diseño. Estudio observacional, descriptivo, transversal. Emplazamiento. Unidad de obstetricia de un hospital de segundo nivel. Participantes. Un total de 346 mujeres gestantes que acuden para dar a luz a la unidad de obstetricia de un hospital de segundo nivel. Mediciones principales. A través de un cuestionario autocumplimentable se recogieron variables sociodemográficas, antecedentes familiares y personales de DTN, planificación del embarazo, conocimiento del valor de los suplementos de folatos, profesional sanitario que los prescribió, comienzo y duración de toma de dichos suplementos. Resultados. El 95 per cent de las mujeres consumió suplementos de folatos durante la gestación, pero sólo un 17 per cent los tomó de la manera apropiada. El 34 per cent señaló el ácido fólico como método eficaz para reducir la incidencia de los DTN. El porcentaje de mujeres que realizó la profilaxis de forma idónea fue significativamente superior entre las que recibieron la prescripción por parte de su médico de atención primaria (p = 0,003).Conclusiones. Aunque se ha obtenido una buena proporción de gestantes de nuestra área de salud que han consumido suplementos de ácido fólico durante el embarazo, la idoneidad de dicha profilaxis ha sido baja. La principal razón para que la profilaxis de los DTN no sea adecuada es el desconocimiento que las mujeres en edad fértil tienen sobre los beneficios de los suplementos del ácido fólico y cómo debe realizarse su toma. El médico de atención primaria podría representar un papel muy importante como educador sanitario (AU)