Eficacia a largo plazo de una intervención para la deshabituación del consumo crónico de benzodiazepinas / Long-term effectiveness of an intervention to discontinue chronic benzodiazepine use

Introducción. Se evalúa la efectividad a largo plazo de una intervención para la deshabituación del consumo crónico de benzodiazepinas. Métodos. Diseño: seguimiento posterior al cierre de un ensayo clínico aleatorizado. Ámbito: tres centros de salud que cubren una población de 82.000 habitantes. Sujetos: 135 pacientes finalizaron el ensayo clínico previo (66 del grupo intervención, 63 del grupo control y 6 habían fallecido). Intervención-mediciones: el ensayo clínico previo comparó la eficacia de una intervención basada en una entrevista estructurada y reducción gradual de dosis frente a un grupo control con seguimiento clínico habitual. Los resultados fueron evaluados a los 12 meses. La variable principal es consumo o no de benzodiazepinas 3 años tras finalizar el estudio, principio activo y motivo de consumo. Resultados. Tras 3 años de seguimiento, 25/66 del grupo de intervención y 14/63 del grupo control no consumen benzodiazepinas. La probabilidad de abandonar el consumo de benzodiazepinas entre los pacientes que recibieron intervención era un 41% más elevada que en el grupo control. Riesgo relativo: 1,41 (intervalo de confianza del 95%: 0,98-1,66). En el grupo intervención, 16 de los 31 (51,6%) que abandonaron el consumo a los 12 meses siguen sin consumir. La benzodiazepina más prescrita es lorazepam (27,9%)seguida de alprazolam (12,4%), y el principal motivo de prescripción es ansiedad (16,3 %) seguido de trastorno mixto ansiosodepresivo (10,9%).Conclusiones. A pesar de la importante tasa de recaída, la intervención para reducir el consumo crónico de benzodiacepinas mantiene su eficacia a largo plazo (AU)

Introduction. We establish the long-term effectiveness of a brief intervention to withdraw from chronic benzodiazepine use. Methods. Follow-up after a randomized clinical trial. Setting: Three health care centers covering 82,000 inhabitants. Subjects: 135 patients who completed the previous clinical trial (66 from the intervention group,63 from the control group, 6 had died). Intervention measurements: the previous clinical trial compared an intervention consisting of standardized advice and a dose tapering schedule against a control group followed by usual care. Results were evaluated at 12 months. Main outcome: benzodiazepine use three years after the end of the clinical trial, type of drug and the reason for prescription. Results. After 3 years of follow up, 25/66 (37.9%) subjects from the intervention group and 14/63 (22.2%) from the control group were benzodiazepine free. The probability of withdrawal from benzodiazepine between patients in the intervention group was 41% higher than in the control group. Relative risk: 1.41 (95% confidence interval:0.98-1.66). In the intervention group, 16 from 31 (51.6%) patients who had withdrawn at 12 months were benzodiazepine free after 3 years. The most prescribed benzodiazepine is lorazepam (27.9%), followed by alprazolam (12.4 %) and the main reason for prescription is anxiety (16.3%) followed by anxious-depressive disorder (10.9%).Conclusions. Even though there is a substantial relapse rate, the intervention to reduce chronic benzodiazepine use remains effective in the long-term (AU)

[Long-term effectiveness of an intervention to discontinue chronic benzodiazepine use]. / Eficacia a largo plazo de una intervención para la deshabituación del consumo crónico de benzodiazepinas.

INTRODUCTION: We establish the long-term effectiveness of a brief intervention to withdraw from chronic benzodiazepine use. METHODS: Follow-up after a randomized clinical trial. SETTING: Three health care centers covering 82,000 inhabitants. SUBJECTS: 135 patients who completed the previous clinical trial (66 from the intervention group, 63 from the control group, 6 had died). Intervention-measurements: the previous clinical trial compared an intervention consisting of standardized advice and a dose tapering schedule against a control group followed by usual care. Results were evaluated at 12 months. main outcome: benzodiazepine use three years after the end of the clinical trial, type of drug and the reason for prescription. RESULTS: After 3 years of follow up, 25/66 (37.9%) subjects from the intervention group and 14/63 (22.2%) from the control group were benzodiazepine free. The probability of withdrawal from benzodiazepine between patients in the intervention group was 41% higher than in the control group. Relative risk: 1.41 (95% confidence interval: 0.98-1.66). In the intervention group, 16 from 31 (51.6%) patients who had withdrawn at 12 months were benzodiazepine free after 3 years. The most prescribed benzodiazepine is lorazepam (27.9%), followed by alprazolam (12.4%) and the main reason for prescription is anxiety (16.3%) followed by anxious-depressive disorder (10.9%). CONCLUSIONS: Even though there is a substantial relapse rate, the intervention to reduce chronic benzodiazepine use remains effective in the long-term.

Los maletines de emergencias de los centros de salud de un área sanitaria / The emergency bags in the Health Care Centres

Objetivos: El médico de atención primaria (AP) presta atención domiciliaria urgente y necesita un equipamiento clínico y terapéutico completo y manejable. Este estudio pretende conocer los maletines de emergencias (ME) de nuestra área. Métodos: Revisión de la literatura de los 10 años previos. Consenso por grupo de expertos. Ámbito: los 39 centros de salud (CS) de Mallorca. Visita sin anunciar a los CS donde, de manera anónima y previo consentimiento, se analizaron una muestra de 24 ME. Resultados: Ningún ME llevaba todos los elementos recomendados por el consenso. La mitad de ME no podrían tomar los signos vitales al faltar algún elemento. Sólo el 50% llevaba laringoscopio y ninguno desfibrilador portátil. Uno llevaba todo el material de curas. Casi todos los ME llevaban adrenalina y atropina, y pocos midazolam y succinilcolina. Antídotos como naloxona, flumazenilo y glucosa al 50% estaban presentes en más del 80% de los ME. La medicación para el síndrome coronario agudo presente fue nitroglicerina en el 80% y ácido acetilsalicílico en el 79,2%; pero sólo el 37% disponían de cloruro mórfico. Hemos detectado alguna medicación caducada en 12 ME (50%). Conclusiones: Falta una revisión y mantenimiento del contenido del ME porque en menos de la mitad de casos no sería posible tomar unos signos vitales o reemplazar la medicación caducada. Casi todos los ME estaban preparados para atender intoxicaciones por drogas. Se debería conseguir una guía básica de material imprescindible de los ME y garantizar la homogeneidad del contenido del mismo (AU)

Aims: The primary care physician lends urgent domiciliary attention and needs a complete and manageable clinical and therapeutic equipment. This study tries to know emergencies kits (ME) of our area. Methods: Revision of the literature of the 10 previous years. Consensus by a group of experts. Scope: 39 health centers (CS) of Majorca. Visit without announcing to the CS where, of anonymous way and previous consent, analyzed a sample of 24 ME. Results: No ME took all the elements recommended by the consensus. Half ME could not take the vital constants because it lacks some elements. Only 50% of ME contained laryngoscope and none portable desfibrilador. Only one took all the material to cures. Almost all ME took adrenalin and atropine, and only a few midazolam and succinilcolin. Antidotes like naloxon, flumazenil and glucose to 50% were present in more of 80% of ME. Coronary acute syndrome treatment present in ME was nitroglycerin in 80% and acetilsalicilic acid in 79.2%; but only 37% had morfic chloride. We have detected some medication expired in 12 ME (50%). Conclusions: A revision and maintenance of the content of ME is needed because in less than half of cases it wouldn’t be possible to take vital constants or to replace the expired medication. Almost all of ME were prepared to take care of poisonings by drugs. A basic guide of essential material of ME would be due to obtain, and also to guarantee the homogeneity of the content of this (AU)

[Family practice and diagnosis of cancer]. / El médico de atención primaria y el diagnóstico de los pacientes con cáncer.

OBJECTIVES: To describe the types of cancer identified in primary health care, their clinical presentation, management until diagnosis and delay in diagnosis. DESIGN: Descriptive study based on secondary information from medical records. SETTING: Two urban health care centres in Mallorca, Spain. PARTICIPANTS: Patients over 14 years old diagnosed with cancer between 1994 and 1998. MEASUREMENTS: Age, sex, location of tumour, symptoms, role of family doctor, specialist referral, care environment, time from first symptom to diagnosis, and stage of tumour. RESULTS: We identified 408 cancers. Mean age at diagnosis was 66.5 years (95% CI, 65.3-67.7); 237 (58.1%) were male. The most frequent tumours were colorectal, lung, prostate, breast and bladder, and the most common symptom was pain (33.1%; 95% CI, 28-38.3). The family doctor was involved in 63% of diagnoses (95% CI, 58.2-67.8). Mean delay from first symptom until diagnosis was 90 days, of which 26 were attributed to the patient and 55 to primary health care services. For colorectal, lung and prostate cancers, delay was shorter. The tumour was less advanced at diagnosis when family doctors were involved. CONCLUSIONS: Family doctors are involved in the diagnosis of most cancers. In colorectal, lung and prostate cancers, their contribution could improve prognosis. More studies are needed to confirm these findings.

El médico de atención primaria y el diagnóstico de los pacientes con cáncer / Family practice and diagnosis of cancer

Objetivos. Describir los tipos de cáncer identificados en atención primaria, su forma de presentación clínica, el proceso asistencial seguido hasta su diagnóstico y los tiempos de demora diagnóstica. Diseño. Estudio descriptivo basado en la recogida de información secundaria a partir de la historia clínica. Emplazamiento. Dos centros de salud urbanos de Mallorca. Participantes. Cánceres diagnosticados, entre 1994 y 1998, en usuarios mayores de 14 años. Mediciones. Edad, sexo, localización, desencadenantes, intervención del médico de familia, tipo de derivación, ámbito de actuación, intervalos de tiempo desde el inicio de síntomas hasta el diagnóstico y estadio. Resultados. Se identificaron 408 cánceres. La media de edad en el momento del diagnóstico fue de 66,5 años (intervalo de confianza [IC] del 95%, 65,3-67,7), 237 (58,1%) en varones. Los más frecuentes fueron colorrectal, pulmón, próstata, mama y vejiga. El síntoma más frecuente fue el dolor, que se presenta en el 33,1% (IC del 95%, 28-38,3). El médico de familia intervino en el 63,0% (IC del 95%, 58,2-7,8). La demora total fue de 90 días de mediana, mientras que en atención primaria fue de 55 días y la debida al paciente de 26 días. En los casos en que intervino el médico de familia, la demora fue menor y se llegó al diagnóstico en estadios más precoces para el cáncer colorrectal, de pulmón y de próstata, pero no en el resto de las localizaciones. Conclusiones. El médico de AP interviene en el diagnóstico de la mayoría de los cánceres. Su intervención podría mejorar el pronóstico en el cáncer colorrectal, de pulmón y de próstata. Deben realizarse estudios que confirmen estos hallazgos

Objectives. To describe the types of cancer identified in primary health care, their clinical presentation, management until diagnosis and delay in diagnosis. Design. Descriptive study based on secondary information from medical records. Setting. Two urban health care centres in Mallorca, Spain. Participants. Patients over 14 years old diagnosed with cancer between 1994 and 1998. Measurements. Age, sex, location of tumour, symptoms, role of family doctor, specialist referral, care environment, time from first symptom to diagnosis, and stage of tumour. Results. We identified 408 cancers. Mean age at diagnosis was 66.5 years (95% CI, 65.3-67.7); 237 (58.1%) were male. The most frequent tumours were colorectal, lung, prostate, breast and bladder, and the most common symptom was pain (33.1%; 95% CI, 28-38.3). The family doctor was involved in 63% of diagnoses (95% CI, 58.2-67.8). Mean delay from first symptom until diagnosis was 90 days, of which 26 were attributed to the patient and 55 to primary health care services. For colorectal, lung and prostate cancers, delay was shorter. The tumour was less advanced at diagnosis when family doctors were involved. Conclusions. Family doctors are involved in the diagnosis of most cancers. In colorectal, lung and prostate cancers, their contribution could improve prognosis. More studies are needed to confirm these findings

¿Cómo deben ser el maletín de domicilios y el maletín de urgencias del médico de atención primaria?

Objetivo. Establecer un consenso sobre cómo debe ser el maletín para domicilios (MD) del médico de familia y el maletín de urgencias (MU) del centro de salud. Métodos. Revisión bibliográfica y búsqueda de consenso mediante un panel de expertos compuesto por 9 médicos (farmacólogo clínico, anestesista, intensivista, 6 médicos de familia), realizado en atención primaria de Mallorca. A partir de la revisión bibliográfica se elaboró un listado exhaustivo sobre las características y contenidos del MD y del MU, de acuerdo con la medicación, los instrumentos diagnósticos, el material de curas y los impresos. En el panel de expertos se decidió si cada uno de los elementos era imprescindible, opcional o innecesario para el MD y el MU. Resultados. La revisión identificó 191 elementos. Se consideró que 33 eran imprescindibles para el MD y 72 para el MU. De los 94 principios activos identificados, 17 se consideraron imprescindibles para el MD y 26 para el MU. De los 17 instrumentos diagnósticos, 5 se consideraron imprescindibles para el MD y 9 para el MU. De los 67 materiales de curas, 8 se consideraron imprescindibles para el MD y 31 para el MU. Finalmente, de los 13 impresos, 3 se incluyeron como imprescindibles para el MD y 6 para el MU. Conclusiones. Se cuenta con un consenso sobre el contenido para el MD y para el MU (AU)

Análisis de la actividad asistencial pediátrica del Punto de Atención Continuada (PAC) de Calvià / Analysis of pediatric health care activity in the Continuing Health Care Point of Calvià

Objetivos: establecer las características de la demanda pediátrica en urgencias. Diseño: revisión de los informes de asistencia en urgencias. Emplazamiento: zona Básica de Salud de Calvià (Mallorca), durante 1998.Pacientes: novecientos diez niños que han sido atendidos en horario de PAC. Resultados: la población pediátrica supone 1/3 de la presión asistencial, el 92 por ciento son residentes en Calvià, produciéndose una mayor demanda durante los meses de invierno, su frecuencia es de 0,97 visitas/niño/año; no hay diferencias significativas por sexo o edad. La presión asistencial no difiere entre los días de la semana. Los motivos de consulta más frecuentes son fiebre (29 por ciento), naúseas-vómitos (11 por ciento), resfriado (9 por ciento), tos (9 por ciento), dolor de oídos (9 por ciento) y contusiones (5 por ciento). Los diagnósticos más frecuentes son infección de vías respiratorias altas (17 por ciento), amigdalitis aguda (12 por ciento), otitis media aguda (7 por ciento) y contusión (5 por ciento); en el 11 por ciento no constaba ningún diagnóstico. Se remitieron al hospital el 3,3 por ciento de las demandas. Conclusiones: la población pediátrica produce un tercio de la demanda de urgencias y reside mayoritariamente en el mismo municipio, a pesar de la importante afluencia turística. El elevado poder resolutivo podría ser mayor si se dispusiera de medios de radiodiagnóstico en el PAC. Los motivos de consulta no difieren de los de cita previa (AU)

Management of terminal cancer patients: attitudes and training needs of primary health care doctors and nurses.

The objective of the study was to ascertain the attitudes and training needs of primary health care (PHC) professionals regarding the management of terminal cancer patients. A cross-sectional study involving 30 PHC teams (15 urban and 15 rural) in the health district of Majorca (Spain) was carried out. Out of the 224 doctors and 186 nurses initially included, 157 and 156, respectively, completed a questionnaire designed to elicit the participant's opinions on the role of PHC in palliative care, their needs in terms of training and their management of clinical and psychological symptoms. Forty percent of professionals considered that terminal care should be the responsibility of PHC, whereas 59.5% thought it preferable for such care to be given either in Palliative Care Units or by oncologists. All kinds of relationships between PHC professionals and specialists were highly valued. Seventy-five percent of general practitioners referred to pain control, and 83% of doctors and nurses provided emotional support. Most health professionals felt training in emotional aspects would be the most desirable. One group of professionals considered palliative care to be an asset in PHC, whereas another group thought that patient care should be provided by specialists. The majority of doctors and nurses pinpointed the need for improving co-ordination with specialists. A need for tuition in palliative care was clearly stated. In conclusion, the planning of palliative care should take into account the attitudes and opinions of PHC doctors and nurses.

[Sleep disorders and the consumption of hypnotics on the island of Mallorca]. / Trastornos del sueño y consumo de hipnóticos en la isla de Mallorca.

OBJECTIVE: To estimate the frequency and characteristic of sleep disorders and consumption of hypnotic drugs in a population attended by primary care physicians (PC). METHODS: Interviewing a population of 602 patients at the office exit of 87 PC physicians in 32 institution in Mallorca 1994. Questionnaire on sleep: hypnotic drugs and scale hospital anxiety-depression, others. RESULTS: 17.4% (95% CI: 14.4%-20.5%) sleepless (DSM-III-R), 27.0% (95% CI: 23.5%-30.6%) complained from poor sleep quality and 16.4% (95% CI: 13.4%-19.4%) usually consumed hypnotic drugs (56.7%, for longer than one year). CONCLUSION: The high frequency of both sleep disorders and chronic consumption of hypnotic drugs represents a relevant health problem.

[Use of antibiotics in primary care: treatment of urinary infection]. / Uso de antibióticos en atención primaria: tratamiento de la infección urinaria.

OBJECTIVES: To analyse the primary care therapeutic approach to urinary tract infections (UTI), and, a secondary objective, to obtain information on the microbiological profile and resistance to antibiotics in this field, with the aim of making therapeutic recommendations. DESIGN: The UTI diagnosed through systematic checking of sediment and/or culture, requests from health centres are described. SETTING: 9 Health Centres in Palma (Mallorca) during November 1992. PATIENTS AND OTHER PARTICIPANTS: Out of 2,484 requests for sediment and/or uroculture, clinical history was found in 2,033. At the end there were 232 patients whose request for analysis was for suspected UTI, among whom there were 43 recurring cases, which meant a total of 275 cases. MEASUREMENTS AND MAIN RESULTS: The most frequent germ was Escherichia coli. 68% had complicated UTI. Empirical treatment was carried out in 60.7%. Treatment of the first episode of UTI was with quinolones in 73.3% of cases, with norfloxacine in 44.1%. There was a higher percentage of resistance of Escherichia coli to cotrimoxazole (49.0%), ampicilline-sulbactam (46.4%), ampicilline (42.0%) and cephalexin (31.4%). In 50 cases there was therapeutic failure, due (among the most commonly used drugs) to norfloxacine in 12.4%, to cotrimoxazole in 28.6%, to norfloxacine in 27.3% and to pipemidic in 18.9%. CONCLUSIONS: There are many more specific than empirical treatments as well as excessive use of drugs not recommended as first choice in primary care. The level of resistance to the new quinolones is considerable and is greater still for some antimicrobial drugs used for UTI.

[Network of research units and primary health care]. / La red de unidades de investigación y la atención primaria de salud.

OBJECTIVES: To find the connections between Primary Health Care (PHC) and Research Units (RU) and the participation of PHC professionals in Research Committees (RC) and Clinical Research Ethical Committees (CREC). To evaluate RUs' PHC-related research activities, analyse the RUs and how much they are used by PHC. DESCRIPTION: A descriptive, crossover study, with data collected by means of a mailed questionnaire. SETTING: The 110 units which were part of the RU network by the end of 1993. PARTICIPANTS: Representatives of RUs. INTERVENTIONS: In May 1994 a self-filled questionnaire containing 29 items was sent out to RUs. During October/November 1994 non-repliers were recontacted. MEASUREMENTS AND MAIN RESULTS: 80 RUs replied. 30 RUs were connected with PHC; 14 were totally dependent on PHC; and 16 were partially linked to PHC. A minority of PHC professionals took part in RCs, except in the cases of those totally dependent on PHC. Participation in the CRECs was unusual. RUs had little connection with Family & Community Medicine teaching units, although this figure was higher for RUs connected to PHC. 86.2% of RUs were open to PHC professionals, although involvement was generally low. 71.4% of RUs stated they had carried out some project of their own related to PHC; and 77.6% had collaborated in at least one PHC project. CONCLUSIONS: PHC has paid little attention to the creation of RUs and has participated little in RCs and CRECs. Teaching units should tighten their relationship with RUs, which do an important amount of PHC research. PHC researchers offered a wide range of services, which were little-used. Teaching units should publicise their existence more and extend their times of availability.

[Childhood accidents in primary health care]. / Accidentes infantiles en atención primaria.

BACKGROUND: Accidents in childhood are an important health problem, mainly in situations of social and environmental risk. Additionally, the lack of studies in primary health care, encouraged us to set up a study in order to establish the characteristics of accidents in childhood attended in a health center, their relation with the child's socio-familiar situation and medical care delivered. METHODS: We describe children's accidents occurred in our area (2,543 children 0-14 years old, 788 of them living in deprived neighbourhoods) during 1992 attended in the health center. Study data was collected from data included in emergencies and medical records of the health center. We included information on: age, sex, socio-familiar situation, accident, lesion, and health care delivered characteristics. RESULTS: We include 623 accidents: annual cumulated incidence = 245/1,000 children; males were more affected (58.4%); the accidents occurred mainly in the household (35.6%); the most frequent causes were blows (39.9%) and falls (30.5%); the most frequent lesions were injuries (29.7%) and blows (25.7%). Location of the lesions were the superior limbs (33.5%) and head and neck (25.98%). About 12.5% were delivered to the hospital, 17.8% of them required inpatient care, one died. Children of deprived boroughs have a relative risk of being attended for accident in our center of 4.2 (CI 95% = 3.64-4.84) compared with the rest of the area. 79 children have had repeated accidents, they occurred mainly in only 27 families, 92.6% of whom live in deprived areas. CONCLUSIONS: Our health center is attending a high frequency of children's accidents, most of them can be treated in the health center, the cases are concentrated in deprived boroughs and in risk families.

[The resident in family and community medicine views his specialization. II]. / El residente de Medicina Familiar y Comunitaria ante su especialización (II).

A questionnaire was submitted to the third year residents of Family and Community Medicine. Its aim was to know their opinion, respecting the different aspects of their specialty. We obtained a high rate of response (49.5%). The majority of residents are male and 37 por 100 had finished their degree before joining the program. The fact of choosing a residence in the Family and Community Medicine program is related to the place obtained in the ranking of Internal Resident Doctors and to the lack of vacancies in fields thought to be more interesting. About a third of those polled state that their main reason for choosing Family and Community Medicine is vocational. If one compared their preference for the specialty before and after the resident period, this increased. Still, the specialty's allure is low. The majority prefer working in Public Medicine and in tasks related to medical care and the urban milieu. We put forward some suggestions that could improve this situation.

[The family and community medicine resident facing his/her specialization (I)]. / El residente de medicina familiar y comunitaria ante su especialización (I).

A questionnaire was sent out to the interns in Family and Community Medicine throughout the country in the last month of training. The objective was to find out the degree of fulfillment and the evaluation of the Official Program of the Specialty as far as courses, rotations and duty periods were concerned. We received 170 questionnaires (response rate: 49.8%). The obligatory courses are overwhelmingly attended, but not so the optional ones. What stands out especially is the incorrect length of rotation among Internal Medicine, Pediatrics, and Primary Health Care. The specializations which draw the most interest due to their eventual use are Internal Medicine, Pediatrics, and Primary Health Care, and the least interesting are Gynaecology, Otorhinolaryngology and Ophthalmics. Roughly half have not had any duty watches in Surgery and Primary Care. With these results in hand, we recommend some changes be made in the specialization programs.