Relationship between body mass index and depression in women: A 7-year prospective cohort study. The APNA study.

BACKGROUND: The association between body mass index (BMI) and depression is complex and controversial. The present study examined the relationship between BMI and new-onset depression during 7 years of follow-up in 20,212 adult women attending Primary Health Care Centres in Navarra, Spain. METHODS: The Atención Primaria de Navarra (APNA) study is a dynamic prospective cohort study. A total of 20,212 women aged 18-99 years (mean age: 50.7 ± 18.5 years) without depression at baseline were selected from 2004 to 2011. We estimated the incidence of depression. We used the Kaplan-Meier analysis to predict the survival curve. The risk of depression onset according to different measures of BMI at baseline was assessed using Cox regression analyses. RESULTS: During the 7 years of follow-up, depression appeared in 8.9% (95% CI 8.5-9.3). The highest rates of depression incidence at follow-up occurred in underweight and obese women (9.8% [95% CI 7.3-12.9] and 10.3% [95% CI 9.5-11.1] respectively). The distribution of depression incidence by weight category was U-shaped. The risk of depression increased over time with an observed Kaplan-Meier estimation of 6.67. After adjusting for age, underweight and obese women at baseline have increased risk of depression onset during the follow-up period compared with normal weight women (HR=1.48, 95% CI=1.09-2.00 and HR=1.14, 95% CI=1.01-1.29 respectively). CONCLUSIONS: In this 7-year prospective study in the APNA women population, depression emerged in 8.9%. Being underweight or obese (not overweight) at baseline is significantly associated with future onset of depression.

Cirugía oncológica de párpado y la región orbitaria / Oncologic Surgery of the Eyelid and Orbital Region

La cirugía oncológica del párpado y de la región orbitaria supone un reto en cirugía dermatológica, ya que en esta región se encuentran dificultades y posibles complicaciones que no hay en otras localizaciones, como podrían ser el ectropión, la epífora, exposición corneal, queratitis, conjuntivitis o lagoftalmos, entre otros. Para conseguir una correcta cirugía oncológica, unida a un resultado lo más funcional y cosmético posible, es necesario el correcto conocimiento de las estructuras anatómicas de los párpados, así como su vascularización, inervación y anatomía del aparato lacrimal. Presentamos varios ejemplos de técnicas quirúrgicas reconstructivas tras exéresis tumorales quirúrgicas, tanto en el párpado superior como en el inferior, con diversos colgajos o injertos, que se han realizado en nuestro servicio en los últimos años, y revisamos las posibles técnicas quirúrgicas según el tamaño y la localización de las lesiones

Oncologic surgery of the eyelid and orbital region is a challenge in dermatologic surgery. This region presents difficulties and possible complications that do not exist at other sites, including ectropion, epiphora, corneal exposure, keratitis, conjunctivitis, and lagophthalmos. Adequate oncologic surgery associated with the best possible functional and cosmetic result requires extensive knowledge of the anatomy, innervation, and blood supply of the eyelid and anatomy of the lacrimal apparatus. We present examples of reconstructive surgical techniques that can be used after the excision of tumors of the upper or lower eyelid, with descriptions of the different flaps and grafts employed in our department in recent years. We also review the surgical techniques according to the site and size of the lesions

Oncologic surgery of the eyelid and orbital region.

Oncologic surgery of the eyelid and orbital region is a challenge in dermatologic surgery. This region presents difficulties and possible complications that do not exist at other sites, including ectropion, epiphora, corneal exposure, keratitis, conjunctivitis, and lagophthalmos. Adequate oncologic surgery associated with the best possible functional and cosmetic result requires extensive knowledge of the anatomy, innervation, and blood supply of the eyelid and anatomy of the lacrimal apparatus. We present examples of reconstructive surgical techniques that can be used after the excision of tumors of the upper or lower eyelid, with descriptions of the different flaps and grafts employed in our department in recent years. We also review the surgical techniques according to the site and size of the lesions.

Validación de un cuestionario de mejora de la satisfacción laboral (CMSL ) en profesionales de atención primaria / Validation of a questionnaire on improving work satisfaction (CMSL) in primary care professionals

Fundamento. La satisfacción laboral de los profesionales sanitarios se considera un indicador de calidad en la gestión del sistema, estando relacionado con la eficacia de los servicios ofrecidos. El objetivo del estudio es la validación de un cuestionario para evaluar la mejora de la satisfacción laboral (CMSL) en una población de profesionales sanitarios de atención primaria en Navarra. Metodología. Se realizó un estudio descriptivo con cuestionarios autocumplimentados, siendo la población diana todos los profesionales de atención primaria (médicos, pediatras y personal de enfemería) de los centros de salud de Navarra. Se utilizó la escala Lickert para la medición de los ítems. Se recogieron datos descriptivos de sexo, años de ejercicio profesional, satisfacción laboral, estamento profesional, centro de salud y 47 ítems sobre mejora de satisfacción laboral. Se calculó la fiabilidad mediante el coeficiente alfa de Cronbach y se halló la validez de constructo mediante un análisis factorial con rotación varimax, agrupando los ítems en 9 dimensiones. Resultados. Se recogieron un total de 414 cuestionarios. Se obtuvo el coeficiente alfa de Cronbach, con un valor global de 0,933. Entre 5 dimensiones se explica el 41,287% de la varianza total. La dimensión "relaciones con los pacientes" presentó la media (4,087) más alta de mejora de la satisfacción laboral y el ítem "Si pudiera eliminar la demanda injustificada" presentó una media de 4,21.Conclusiones. El cuestionario diseñado es un instrumento válido para la evaluación integral de la mejora de la satisfacción laboral de los profesionales de atención primaria. Los resultados obtenidos pueden orientar sobre qué áreas de mejora se deben implantar para mejorar la satisfacción de los profesionales(AU)

Background. Job satisfaction of health professionals is considered to be a quality indicator, as it is related to the efficacy of the services. The aim of the study is to validate a questionnaire for evaluating job satisfaction improvement in a population of health professionals in primary care in Navarre. Methodology. Descriptive study with self-completed questionnaires; the target population was all health care professionals (family doctors, pediatricians and nurses)of primary health centers of Navarre. A Lickert scale was used for measuring the items. Other variables measured were: sex, years in the profession, job satisfaction, professional status, health center, and 47 items on improving job satisfaction. Cronbach's alpha coefficient was used to evaluate reliability, and to evaluate construct validity factor analysis with varimax rotation, grouping the items in 9 dimensions was used. Results. A total of 414 questionnaires were collected. Cronbach's alpha coefficient was 0.933. Forty-one point two eight seven percent (41.287%) of total variance was explained by five dimensions. The dimension "relations with patients" presented the highest average (4.087) of improvement in job satisfaction, and the item "If it were possible to eliminate unjustified demand" showed an average of 4.21. Conclusions. The questionnaire designed is a valid instrument for a comprehensive evaluation of the improvement in the job satisfaction of primary care professionals. The results obtained can indicate which areas of improvement should be implemented in order to improve the satisfaction of the professionals(AU)

[Validation of a questionnaire on improving work satisfaction (CMSL) in primary care professionals]. / Validación de un cuestionario de mejora de la satisfacción laboral (CMSL) en profesionales de atención primaria.

BACKGROUND: Job satisfaction of health professionals is considered to be a quality indicator, as it is related to the efficacy of the services. The aim of the study is to validate a questionnaire for evaluating job satisfaction improvement in a population of health professionals in primary care in Navarre. METHODOLOGY: Descriptive study with self-completed questionnaires; the target population was all health care professionals (family doctors, pediatricians and nurses) of primary health centers of Navarre. A Lickert scale was used for measuring the items. Other variables measured were: sex, years in the profession, job satisfaction, professional status, health center, and 47 items on improving job satisfaction. Cronbach's alpha coefficient was used to evaluate reliability, and to evaluate construct validity factor analysis with varimax rotation, grouping the items in 9 dimensions was used. RESULTS: A total of 414 questionnaires were collected. Cronbach's alpha coefficient was 0.933. Forty-one point two eight seven percent (41.287%) of total variance was explained by five dimensions. The dimension "relations with patients" presented the highest average (4.087) of improvement in job satisfaction, and the item "If it were possible to eliminate unjustified demand" showed an average of 4.21. CONCLUSIONS: The questionnaire designed is a valid instrument for a comprehensive evaluation of the improvement in the job satisfaction of primary care professionals. The results obtained can indicate which areas of improvement should be implemented in order to improve the satisfaction of the professionals.

[Identification of problems and proposals for improving outpatient emergency care in Navarre: a Delphi study]. / Identificación de problemas y propuestas para mejorar la atención de las urgencias extrahospitalarias en Navarra: un estudio Delphi.

BACKGROUND: Two years ago there were alterations to outpatient A and E departments in Navarre; in particular, a rural A and E service (Servicio de Urgencias Rural- SUR) was set up, which coexists geographically with the normal A and E service. The aim of this study is to determine the opinion of experts on problems and recommendations for improvements that affect outpatient A and E services. METHODOLOGY: A Delphi study was carried out with the participation of 37 experts (doctors and nurses). Three successive rounds of questionnaires were completed using email. The final questionnaire identified degree of agreement with the group's ideas, and the 15 most relevant problems and recommendations were identified; those ideas that were selected achieved at least 50% agreement and their priority was above 25%. We grouped the ideas using a hierarchic cluster analysis. RESULTS: Four cluster problems were identified; the most outstanding amongst them being "the population uses A and E for banal pathologies, just like any other consultation" with a score of 297 points. Outstanding amongst the recommendations, with 3 identified clusters, were the "need to design a strategic plan for A and E care with resources appropriate to the needs" (310 priority points) and "sending clear messages to the population on the correct use of A and E" (192 priority points). CONCLUSION: The Delphi method identifies problems and improvement areas through consensus.

La coordinación de esfuerzos en casos clínicos complejos: un valor añadido de cuidados paliativos en un hospital universitario / Coordinating efforts in complex clinical cases: added value of palliative care at a university teaching hospitalpcuth

Los cuidados paliativos se entienden generalmente en el contexto de la atención a pacientes terminales ingresados en hospitales o en unidades de hospitales de larga estancia. Sin embargo, cada vez son más frecuentes estas unidades en hospitales de alto nivel de desarrollo. Presentamos el caso de una paciente de especial complejidad, diagnosticada de carcinoma de recto en la que confluían cuatro problemas de difícil abordaje: dolor neuropático descontrolado a pesar de opioides, infección con repercusión sistémica, herida quirúrgica abierta y desánimo completo. Mostramos las medidas que se adoptaron y cómo una excelente colaboración inter-departamental, bajo la coordinación del equipo de medicina paliativa, sirvió para solucionar una situación que en un punto llegó aparecer insostenible (AU)

Palliative care is generally understood on caring for terminal patients in chronic settings but more recently these units are developing also in acute caresettings or university hospitals as consultants teams. We report the case of a complex patient with rectal adenocarcinoma and four problems of difficult approach: uncontrolled neuropathic pain despite opioids treatment, systemic infection, depression with intense demoralisation and open surgery wound. We show the measures adopted and how an excellent inter-departmental collaboration under the co-ordination of palliative medicine consultant team helped to resolve the untenable situation (AU)

[Coordinating efforts in complex clinical cases: added value of palliative care at a university teaching hospital]. / La coordinación de esfuerzos en casos clínicos complejos: un valor añadido de cuidados paliativos en un hospital universitario.

Palliative care is generally understood on caring for terminal patients in chronic settings but more recently these units are developing also in acute care settings or university hospitals as consultants teams. We report the case of a complex patient with rectal adenocarcinoma and four problems of difficult approach: uncontrolled neuropathic pain despite opioids treatment, systemic infection, depression with intense demoralisation and open surgery wound. We show the measures adopted and how an excellent inter-departmental collaboration under the co-ordination of palliative medicine consultant team helped to resolve the untenable situation.

[Effectiveness of primary health care in the diagnosis and treatment of arterial hypertension]. / Efectividad de la atención primaria de salud en el diagnóstico y tratamiento de la hipertensión arterial.

Arterial hypertension (AHT) is a significant public health problem due to its high cardiovascular morbidity and mortality and its economic and social costs. Background. To identify the prevalence of AHT detected in primary care and its degree of control; to determine the types of treatment used and factors associated with its control. Patients and methods. Transversal comparative study of two years in the Villava Health Centre. The computerised clinical history data for the years 2003 and 2006 was analysed. The following variables were studied: age, gender, systolic and diastolic arterial pressure, total cholesterol, HDL, LDL, triglycerides, tobacco use, body mass index in both years. Hypotensor treatment in the year 2006. The variables for the year 2006 associated with good control were identified through logistic regression. Results. AHT prevalence detected in (3)18 year olds: 2003: 11.6% (CI:10.9-12.3); 2006: 16.6% (CI:15.8-17.4) (p<0.001). Control of hypertense persons with a register of arterial tension (AP:<140/90) in 2003: 45.1% (CI: 41.0-48.0) and in 2006: 40.4% (CI: 37.7-43.2) (p<0.05). Variables associated with good control: being male [OR 1.60 (IC: 1.26-2.03)] treatment with ARA II [OR 2.16 (CI: 1.50-3.09)] and being diabetic [OR 1.50 (CI: 1.10-2.03]. Associated with poor control: presenting cerebral vascular disease, peripheral vasculopathy and treatment with ACE inhibitors. Conclusions. A low prevalence of AHT was detected. The level of control was higher for the DAP than for the SAP. Treatment with AIIRA, being male and being diabetic were associated with a better control. Peripheral vasculopathy, ichaemic cardiopathy, cerebral vascular disease, ACE inhibitors use and age were associated with a poorer control.

[Acral keratoses and inverted follicular keratosis presenting Cowden disease]. / Queratosis acras y queratosis folicular invertida como manifestación de la enfermedad de Cowden.

Cowden disease is a rare genetic disorder characterized by the presence of multiple hamartomas in the skin, thyroid, breast, nervous system and gastrointestinal tract. Mucocutaneous lesions are the most constant and characteristic finding. Breast and thyroid neoplasms (benign and malignant) develop in up to two thirds of patients. Inverted follicular keratosis as the presenting feature of Cowden disease is rare as the disease is usually suspected by the appearance of multiple facial trichilemmomas, oral mucosal papillomatosis and acral keratoses.

Queratosis acras y queratosis folicular invertida como manifestación de la enfermedad de Cowden / Acral keratoses and inverted follicular keratosis presenting as Cowden disease

La enfermedad de Cowden es un trastorno genético poco frecuente caracterizado por la presencia de múltiples tumores hamartomatosos en piel, tiroides, mama, sistema nervioso y tracto gastrointestinal. Las lesiones mucocutáneas son el hallazgo más constante y característico. Las neoplasias (tanto benignas como malignas) de la mama y del tiroides aparecen hasta en dos tercios de los pacientes. La queratosis folicular invertida como forma de presentación de una enfermedad de Cowden es rara, ya que suelen ser los triquilemomas faciales múltiples, las lesiones papilomatosas de la mucosa oral y las queratosis acras la que suelen hacer sospechar esta enfermedad

Cowden disease is a rare genetic disorder characterized by the presence of multiple hamartomas in the skin, thyroid, breast, nervous system and gastrointestinal tract. Mucocutaneous lesions are the most constant and characteristic finding. Breast and thyroid neoplasms (benign and malignant) develop in up to two thirds of patients. Inverted follicular keratosis as the presenting feature of Cowden disease is rare as the disease is usually suspected by the appearance of multiple facial trichilemmomas, oral mucosal papillomatosis and acral keratoses

[Models to explain and predict medical case-loads: their use in calculating the maximum family medicine list that allows at least ten minutes per consultation]. / Modelos explicativos y predictivos de la carga asistencial médica: aplicación para el cálculo del cupo máximo en medicina de familia que permita un mínimo de diez minutos por consulta.

OBJECTIVE: To calculate the maximum family medicine list that gives at least ten minutes per consultation.Design. Transversal. SETTING: Three health centres. SUBJECTS: 45 826 inhabitants. MEASUREMENTS: We used the appointments made at three centres to calculate the annual time employed per patient and we adjusted it to allocate a minimum of ten minutes per consultation. We established a cubic regression model to predict the mean case-load per age of patient in general medicine and calculated the maximum list if 70% of the working day were dedicated to care. The results contrasted two centres with greater nursing involvement and one with less. We showed the R2 coefficients. We calculated the maximum lists for the health centres of Navarra and showed them in five clusters worked out on the basis of the percentage of patients >=65. RESULTS: Age explained 86.1% of variability in mean case-load at each age (84% in children and 93.5% in adults). According to the mean percentage of those >=65 years old, the average maximum lists for centres with more or less nursing involvement are as follows: 7.0%>=65 (2025 and 1989); 14.0% (1834 and 1715); 21.2% (1691 and 1558); 27.0% (1648 and 1460), 34.0% (1560 and 1340). CONCLUSION: To a great extent, age explains the variability in case-load and lets us calculate the maximum number of patients on the list that still ensures a minimum time for each consultation.

Modelos explicativos y predictivos de la carga asistencial médica: aplicación para el cálculo del cupo máximo en medicina de familia que permita un mínimo de diez minutos por consulta / Models to explain and predict medical case-loads: their use in calculating the maximum family medicine list that allows at least ten minutes per consultation

Objetivo. Estimar el cupo máximo en medicina familiar que permita consultas mínimas de 10 min. Diseño. Transversal. Ámbito. Tres centros de salud. Sujetos. Un total de 45.826 habitantes. Mediciones. A partir de las citas de tres centros estimamos el tiempo anual empleado por paciente y lo ajustamos asignando un tiempo mínimo de 10 min por consulta. Establecemos un modelo de regresión cúbica predictor de la carga de trabajo asistencial media por edad en medicina general y estimamos el cupo máximo si se dedica un 70 por ciento de la jornada laboral a la asistencia. Exponemos los resultados para dos centros con mayor implicación de enfermería en la atención de los pacientes, y otro en que ésta es menor. Presentamos los coeficientes R2. Estimamos los cupos máximos para los centros de salud de Navarra y los mostramos en cinco grupos elaborados a partir del porcentaje de población de 65 años o más. Resultados. La edad explica el 86,1 por ciento de la variabilidad en la carga asistencial media en cada edad (un 84 por ciento en niños y un 93,5 por ciento en adultos). Según el porcentaje promedio de sujetos 65 años de edad los cupos máximos promedios para centros con mayor o menor implicación de enfermería son los siguientes: 7 por ciento (2.025 y 1.989); 14 por ciento (1.834 y 1.715); 21,2 por ciento (1.691 y 1.558); 27 por ciento (1.648 y 1.460); 34 por ciento (1.560 y 1.340). Conclusiones. La edad explica en gran medida la variabilidad de la carga asistencial y permite estimar el cupo máximo de pacientes que asegure un tiempo mínimo por consulta (AU)

La informatización de atención primaria (II) / Computerising primary care (II)

No disponible

Informatización en la atención primaria (I) / Computerising primary care (I)

No disponible

[A proposal for capitation payment, based on age, chronicity, and gender, using management databases]. / Una propuesta para el pago capitativo, a partir de edad, cronicidad y género, utilizando bases de datos administrativas.

OBJECTIVES: To propose a case-mix methodology for primary care, based on chronicity, type and age. To describe the explanatory value of these variables in the variability of the medical case-load. DESIGN: Observation, descriptive and retrospective study. SETTING: Primary care. Rochapea Health Centre, Pamplona. MATERIAL AND METHODS: Computer records of all the consultations between January 1996 and June 1997. Dependent variable: case-load. INDEPENDENT VARIABLES: age, type, chronic pathologies (diabetes, lipaemia, chronic neurological diseases, COPD-asthma, chronic psychiatric illnesses, cardiopathy, hypertension, alcohol and other drug abuse). The Kruskal-Wallis test was used to compare work-loads by age groups; and multiple linear regression analysis to calculate the predictive power of the independent variables. RESULTS: Significant differences were observed for age groups. In the multivariate model used for general practitioners, all the variables could be included. They explained 24.2% of the variability in work load (R2). For paediatricians, age and asthma, explaining 23.48%, could also be included. CONCLUSIONS: Age, type and chronicity are useful variables for predicting case load from administrative data bases. They can be used in adjustments for case load applicable to capitation payment systems.

Una propuesta para el pago capitativo, a partir de edad, cronicidad y género, utilizando bases de datos administrativas / A proposal for a capitation payment based on age, chronicity and type, using administrative data bases

Objetivo. Proponer una metodología de case-mix para atención primaria, basada en edad, cronicidad y género. Describir el valor explicativo de estas variables en la variabilidad de la carga de trabajo asistencial médica. Diseño. Estudio observacional, descriptivo, retrospectivo. Emplazamiento. Atención primaria. Centro de Salud Rochapea de Pamplona. Material y métodos. Registros informáticos de todas las consultas entre enero de 1996 y junio de 1997. Variable dependiente: carga de trabajo. Variables independientes: edad, género, patologías crónicas (diabetes, dislipemias, enfermedades neurológicas crónicas, EPOC-asma, enfermedades psiquiátricas crónicas, cardiopatías, hipertensión arterial, abuso alcohol y otras drogas). Se utilizó la prueba de Kruskal-Wallis para comparar cargas de trabajo por grupos de edad y análisis de regresión lineal múltiple para calcular el poder predictivo de las variables independientes. Resultados. Se observaron diferencias significativas por grupos de edad. En el modelo multivariante aplicado a médicos de familia se pudieron incluir todas las variables, explicando un 24,2 por ciento de la variabilidad de la carga de trabajo (R2). Para los pediatras se pudieron incluir la edad y asma, explicando un 23,48 por ciento. Conclusiones. Edad, cronicidad y género son variables útiles para predecir, a partir de bases de datos administrativas, la carga de trabajo asistencial. Permiten su utilización en ajustes por carga asistencial aplicables a sistemas retributivos capitativos (AU)

[Risk of pregnancy in adolescence]. / El riesgo de embarazo en la adolescencia.

OBJECTIVE: To describe the frequency and distribution of sexual conduct with risk of pregnancy, the degree of information on sexuality and contraceptive methods. To analyze the relationship between sexual conduct with risk of pregnancy and the most relevant variables of social surroundings of the adolescent: family, friends, school, etc. DESIGN: Descriptive survey by means of a questionnaire. LOCATION: Basic Neighbourhood Health Zone (Gran Canaria). TARGET GROUP: Teenage students aged between 14 and 19. Measurements and main results 21% of the population in the survey have sexual relationships, and out of these, 88% run a high risk of becoming pregnant. The information they have is basically theoretical, and practical knowledge is low. Older adolescents (OR, 1,4/year), males (OR 2.08), those with parents with no qualifications (OR 1.88) and those with parents of a high income bracket (OR 4.11) have the most high-risk sexual relationships. CONCLUSIONS: The importance of high-risk sexual conduct in adolescence is underlined, plus the need for information of adolescents, although it does not seem enough, in order to face sexuality with guarantees.