Determinación de arteriopatía periférica mediante diferentes métodos en Atención Primaria / Determination of peripheral arteriopathy by different methods in Primary Care

OBJETIVOS: determinar el grado de acuerdo en la identificación de alteraciones arteriales en pacientes con diabetes mellitus (DM) tipo 2, mediante los signos de palpación de pulsos pedios (PP), isquemia plantar (IP)y repleción venosa capilar (RVC) y el valor de referencia índice tobillobrazo (ITB), así como el valor pronóstico de estos signos y la relación entre RVC y complicaciones microvasculares diabéticas establecidas en población estudiada. DISEÑO: estudio descriptivo multicentrico. Ámbito: 16 centros de Atencion Primaria. Población diana 5.524 pacientes con DM2 y muestreo probabilístico de 804 enfermos de ambos sexos, seleccionados mediante llamada telefónica, mayores de 40 años. Se ha descartado la existencia de criterios de exclusion. Analisis descriptivo en porcentajes. T de Student para variables continuas,χ2 para categóricas. Sensibilidad (S), especificad (E), valor predictivo positivo(VPP) y valor predictivo negativo (VPN).RESULTADOS: el 58,8% eran hombres; edad media 67,5 años (DE ± 9,76).ITB alterado en 226 (28,1%) (IC 95% 25%-31%); PP alterados 62 (p=< 0,001); S 27,4%; E 89,8%, VPP 51,2%, VPN 76%. RVC alterada 53(p= < 0,001), S 23,5%; E 90,7%; VPP 49,5%; VPN 75,2%. IP presente88 (p= 0,035), S 38,9%; E 68.9%; VPP 32,8%; VPN 74,3%. RVC alterada frente a neuropatía: 16 de 36 (p= < 0,001); a nefropatía 19 de 75 (p = 0,001); a retinopatía 15 de 74 (p= 0,064).CONCLUSIONES: los signos son directamente proporcionales en estenosis e inversamente en calcificaciones. Son necesarios más estudios para asegurar que la RVC alterada representa alteración microvascular (AU)

OBJECTIVES: to determine the level of agreement in identification of arterial alterations in patients with Type 2 Diabetes Mellitus (DM), through the signs of Pedal Pulse (PP) palpation, Plantar Ischemia (PI) and Venous Capillary Refill (VCR), and the reference value of Ankle-Arm Index(AAI), as well as the prognostic value of these signs and the connection between VCR and diabetic microvascular complications established in the studied population. DESIGN: multicenter descriptive study. SETTING: 16 Primary Care centers. Target population: 5524 patients with DM2, and probabilistic sampling of 804 patients of both genders, over 40-year-old, selected through phonecall. The presence of exclusion criteria has been ruled out. Descriptive analysis in percentages. Student's t-test for continuous variables, χ2 test for categorical variables. Sensitivity (S), specificity (SP),Positive Predictive Value (PPV) and Negative Predictive Value (NPV).RESULTS: 58% of the sample were men, median age 67.5 years (DE ± 9,76). Altered AAI in 226 (28.1%) (CI 95% 25%-31%); altered PP in 62(p= < 0.001); S 27.4%; SP 89,8%, PPV 51,2%, NPV 76%. Altered VCR in 53 (p= < 0.001), S 23.5%; SP 90.7%; PPV 49.5%; NVP 75.2%. PI present in 88 (p = 0.035), S 38.9%; SP 68.9%; PPV 32.8%; NPV 74.3%.Altered VCR vs. neuropathy: 16 of 36 (p= < 0.001); vs. nephropathy: 19of 75 (p= 0.001); vs. retinopathy 15 of 74 (p= 0.064).CONCLUSIONS: signs are directly proportional to stenosis and inversely proportional in calcifications. More studies are needed in order to ensure that altered VCR represents microvascular alteration (AU)

Level of distress, somatisation and beliefs on health-disease in newly arrived immigrant patients attended in primary care centres in Catalonia and definition of professional competences for their most effective management: PROMISE Project.

BACKGROUND: Newly arrived immigrant patients who frequently use primary health care resources have difficulties in verbal communication. Also, they have a system of beliefs related to health and disease that makes difficult for health care professionals to comprehend their reasons for consultation, especially when consulting for somatic manifestations. Consequently, this is an important barrier to achieve optimum care to these groups. The current project has two main objectives: 1. To define the different stressors, the level of distress perceived, and its impact in terms of discomfort and somatisation affecting the main communities of immigrants in our area, and 2. To identify the characteristics of cross-cultural competence of primary health care professionals to best approach these reasons for consultation. METHODS/DESIGN: It will be a transversal, observational, multicentre, qualitative-quantitative study in a sample of 980 people from the five main non-European Union immigrant communities residing in Catalonia: Maghrebis, Sub-Saharans, Andean South Americans, Hindustanis, and Chinese. Sociodemographic data, level of distress, information on the different stressors and their somatic manifestations will be collected in specific questionnaires. Through a semi-structured interview and qualitative methodology, it will be studied the relation between somatic manifestations and particular beliefs of each group and how these are associated with the processes of disease and seeking for care. A qualitative methodology based on individual interviews centred on critical incidents, focal groups and in situ questionnaires will be used to study the cross-cultural competences of the professionals. DISCUSSION: It is expected a high level of chronic stress associated with the level of somatisations in the different non-European Union immigrant communities. The results will provide better knowledge of these populations and will improve the comprehension and the efficacy of the health care providers in prevention, communication, care management and management of resources.

¿A quién medir el índice tobillo-brazo? / Who should have the ankle-arm index measured?

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Infradiagnóstico de la arteriopatía periférica en la población española. Estudio ARTPER / Underdiagnosis of peripheral arterial disease in the spanish population. ARTPER study

Fundamento y objetivo: Aunque la arteriopatía periférica (AP) es un importante marcador de morbimortalidad cardiovascular, desconocemos cuántos pacientes están infradiagnosticados. El objetivo es conocer el infradiagnóstico de la AP y estudiar los factores asociados.Pacientes y método: Se estudió a 3.786 pacientes mayores de 49 años, seleccionados aleatorizadamente. Se definió AP si el índice tobillo-brazo (ITB) era inferior a 0,9. Se consideró infradiagnóstico si era inferior a 0,9 y no estaban diagnosticados de AP en la historia clínica, se determinó también la presencia de claudicación intermitente (CI) mediante el cuestionario de Edinburgh. Resultados: El 7,6% tenía un ITB inferior a 0,9 (intervalo de confianza [IC] del 95% de 6,7–8,4). De estos pacientes, estaba infradiagnosticado el 80,7%, a pesar de que el 29,3% presentaba clínica de CI. El infradiagnóstico fue inferior en fumadores o ex fumadores (odds ratio [OR] de 0,20; IC del 95% de 0,07–0,59), si existía CI (OR de 0,40; IC del 95% de 0,18–0,89), si el ITB estaba entre menos de 0,7 y 0,5 o más (OR de 0,36; IC del 95% de 0,16–0,81) o si era inferior a 0,5 (OR de 0,04; IC del 95% de 0,01–0,20); fue superior en los pacientes de 70 años de edad o más (OR de 3,12; IC del 95% de 1,12–8,67). Conclusiones: El infradiagnóstico de AP es elevado, especialmente en los pacientes de edad avanzada. Es necesario consensuar criterios para la práctica del ITB en la población general (AU)

Background and objectives: Although peripheral arterial disease (PA) is an important clinical marker of cardiovascular morbimortality, the rate of under-diagnosis is unknown. Our aimed to know the proportion of patients underdiagnosed of PA and the associated factors. Patients and methods: 3786 patients >49 years old, randomly selected, were studied. PA was diagnosed by means of the ankle-brachial index (ABI<0, 9). Underdiagnosed was considered when ABI<0,9 and when they were not diagnosed of PA in the clinical record. We also determined the presence of intermittent claudication (IC) defined by Edinburgh's questionnaire.Results: 7,6% had an ABI <0, 9 (IC95% 6,7–8, 4). Of these patients 80.7%, were underdiagnosed, although the 29,3% had IC. PA underdiagnosis was low in current smokers or former smokers (OR 0.20; IC95% 0,07–0,59), if IC (OR 0.40; IC95% 0,18–0,89), if ABI between <0.7 and 0.5 (OR 0.36; IC95% 0,16–0,81) or <0,5 (OR 0,04; IC95 % 0,01–0,20), being higher in >70 years (OR 3,12; IC95% 1,12–8,67). Conclusions: PA underdiagnosis is high, especially in old patients. It is necessary to reach consensus criteria for the practice of the ABI in the general population (AU)

[Underdiagnosis of peripheral arterial disease in the Spanish population. ARTPER study]. / Infradiagnóstico de la arteriopatía periférica en la población española. Estudio ARTPER.

BACKGROUND AND OBJECTIVES: Although peripheral arterial disease (PA) is an important clinical marker of cardiovascular morbimortality, the rate of under-diagnosis is unknown. Our aimed to know the proportion of patients underdiagnosed of PA and the associated factors. PATIENTS AND METHODS: 3786 patients >49 years old, randomly selected, were studied. PA was diagnosed by means of the ankle-brachial index (ABI<0, 9). Underdiagnosed was considered when ABI<0, 9 and when they were not diagnosed of PA in the clinical record. We also determined the presence of intermittent claudication (IC) defined by Edinburgh's questionnaire. RESULTS: 7,6% had an ABI <0, 9 (IC95% 6.7-8.4). Of these patients 80.7%, were underdiagnosed, although the 29.3% had IC. PA underdiagnosis was low in current smokers or former smokers (OR 0.20; IC95% 0.07-0.59), if IC (OR 0.40; IC95% 0.18-0.89), if ABI between <0.7 and 0.5 (OR 0.36; IC95% 0.16-0.81) or <0,5 (OR 0.04; IC95 % 0.01-0.20), being higher in >70 years (OR 3.12; IC95% 1.12-8.67). CONCLUSIONS: PA underdiagnosis is high, especially in old patients. It is necessary to reach consensus criteria for the practice of the ABI in the general population.

Dyspnea--a bad prognosis symptom at the end of life.

PURPOSES: Dyspnea as refractory symptom leading to sedation at the end of life and the place of death. Survival study in population with dyspnea. METHODS: Longitudinal study of terminally ill patients in a year (n = 195). We divided populations as (a) population with dyspnea: prevalent and incident dyspnea and (b) population without dyspnea. We used the statistical program Stata9 (Kaplan-Meier and Cox logistic regression models). RESULTS: The probability of being sedated was 5 times higher in population with dyspnea. Dying in hospital odds ratio was 2.13 in patients with dyspnea. The average survival time was 52 days in patients with dyspnea and 69 in non-dyspnea patients. The average survival was similar between both groups. Patients with incident dyspnea showed a higher average survival than those with prevalent dyspnea. CONCLUSIONS: The connection between dyspnea and sedation was clearly shown. There were significant differences between prevalent dyspnea and incident dyspnea groups.

[Medium-term effectiveness of a group educational intervention on foot care in patients with type 2 diabetes]. / Efectividad a medio plazo de una intervención educativa grupal dirigida al cuidado de los pies en pacientes con diabetes tipo 2.

AIM: To evaluate the medium-term effectiveness of a group educational intervention in primary care aimed at improving attitudes and skills in self-care of the feet in patients with type 2 diabetes, and to determine the optimal time for reintervention. METHOD: We performed a before-after intervention study with a 24-month follow-up. The sample consisted of 76 patients with type 2 diabetes who underwent two group education sessions. Sociodemographic variables and variables related to the neurovascular status of the foot and with hygiene and self-care habits were measured. To compare the results, McNemar's test for paired data was used. RESULTS: The mean age was 66 years and 51% were men. Skills performance before-after (8 months) the intervention were as follows: correct hygiene 41%-86%, good-medium hydration 80%-97%, daily foot washing 42%-68%, proper tools use 41%-79%, proper shoes 9%-33%, proper nails 26%-74% (all differences with p < 0.001). Among patients that improved due to the sessions, skills were still correct at 24 months in 76% (95% CI: 61%-90%) for hygiene, 100% for hydration, 70% for daily foot washing (95% CI: 51%-90%), 74% for proper tools use (95% CI: 58-90%), 55% for proper shoes (95% CI: 34%-77%) and 81% for proper nails (95% CI: 68%-94%). CONCLUSIONS: The intervention improved all the skills studied. The effects of the sessions were still evident after 24 months in more than 70% of patients for all the variables studied except proper shoe use. Group education favors skills improvement. We suggest repeating the intervention every 24 months.

Esteatosis hepática no alcohólica. Puesta al día / Non-alcoholic hepatic steatosis. An update

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