[Depressive symptoms as a risk factor for polypharmacy in patients over 60 years of age]. / Síntomas depresivos como factor de riesgo para polifarmacia en pacientes mayores de 60 años.

OBJECTIVE: To determine the association between depressive symptoms not identified by the family physician and polypharmacy in patients over 60 years old. METHODS: A case-control design with non-probabilistic sampling. INCLUSION CRITERIA: > or = 60 years old both sexes, without disease or with one disease-balanced illness, and with reliable recording in chart by the last 12 month. EXCLUSION CRITERIA: cognitive deterioration, obstructive chronic lung disease, cardiopathy, infarct record, alcoholism, smoking addiction and functional dependence's. Elimination criteria: depression's previous diagnoses and hospitalization during a year before the study. The cases were patients who have simultaneously received 4 o more pharmacologic prescriptions in 5 of 6 last medical visits. The controls were patients who have simultaneously received 3 o less pharmacologic prescriptions in 5 of 6 last medical visits. Depressive symptoms: grading > or = 6 (Yesavage and Brink scale). RESULTS: 200 patients per group, aged 69 +/- 6 years agreed to participate. Logistics regression (OR;CI(95%)): hypertension (6.0;3.6-10.3), diabetes mellitus type 2 (3.7;2.3-5.9), depression (2.1;1.2-3.4), and female sex (1.7;1.1-2.7). CONCLUSIONS: Hypertension, diabetes mellitus type 2, depressive symptoms not identified by the family physician, and female sex are risk factors for polypharmacy in the elderly.

Síntomas depresivos como factor de riesgo para polifarmacia en pacientes mayores de 60 años / Depressive symptoms as a risk factor for polypharmacy in patients over 60 years of age

Objetivo: Determinar la asociación entre los síntomas depresivos no identificados por el médico de atención primaria y la polifarmacia en pacientes mayores de 60 años. Material y métodos: Se diseñó un estudio de casos y controles con muestreo no probabilístico de casos consecutivos. Los criterios de inclusión fueron: pacientes de ambos sexos con 60 o más años de edad, con un máximo de una enfermedad, sin descompensaciones agudas, con registros confiables en sus expedientes durante los últimos 12 meses. Los criterios de exclusión fueron: deterioro cognitivo, artritis reumatoide, endocrinopatías (excepto diabetes mellitus), alcoholismo, tabaquismo, dependencia funcional, antecedentes de automedicación. Los criterios de eliminación fueron: diagnóstico previo de depresión o síntomas depresivos y hospitalización en los últimos 12 meses. Se seleccionaron como casos pacientes a quienes, por lo menos, en 5 de las 6 últimas consultas recibidas, se hayan prescrito 4 o más fármacos en forma simultánea. Se incluyeron en el grupo de los controles pacientes los a quienes al menos en 5 de las 6 últimas consultas recibidas, se haya prescrito un máximo de 3 fármacos en forma simultánea. Resultados: Participaron 200 pacientes por grupo, con edad promedio de 69 ± 6 años con los siguientes resultados: regresión logística (RM; IC95%) hipertensión arterial (6.0;3.6-10.3), diabetes mellitus 2 (3.7;2.3-5.9), síntomas depresivos (2.1;1.2-3.4), sexo femenino (1.7;1.1-2.7). Conclusiones: La presencia de hipertensión arterial, diabetes mellitus, síntomas depresivos no identificados por el médico y el sexo femenino favorecen la presencia de polifarmacia en el adulto mayor que acude a una unidad de medicina familiar.

OBJECTIVE: To determine the association between depressive symptoms not identified by the family physician and polypharmacy in patients over 60 years old. METHODS: A case-control design with non-probabilistic sampling. Inclusion criteria: > or = 60 years old both sexes, without disease or with one disease-balanced illness, and with reliable recording in chart by the last 12 month. Exclusion criteria: cognitive deterioration, obstructive chronic lung disease, cardiopathy, infarct record, alcoholism, smoking addiction and functional dependence's. Elimination criteria: depression's previous diagnoses and hospitalization during a year before the study. The cases were patients who have simultaneously received 4 o more pharmacologic prescriptions in 5 of 6 last medical visits. The controls were patients who have simultaneously received 3 o less pharmacologic prescriptions in 5 of 6 last medical visits. Depressive symptoms: grading > or = 6 (Yesavage and Brink scale). RESULTS: 200 patients per group, aged 69 +/- 6 years agreed to participate. Logistics regression (OR;CI(95%)): hypertension (6.0;3.6-10.3), diabetes mellitus type 2 (3.7;2.3-5.9), depression (2.1;1.2-3.4), and female sex (1.7;1.1-2.7). CONCLUSIONS: Hypertension, diabetes mellitus type 2, depressive symptoms not identified by the family physician, and female sex are risk factors for polypharmacy in the elderly.

[Characterizing the prescription of non-steroidal anti-inflammatory drugs among the elderly]. / Características de la prescripcion de analgésicos antiinflamatorios no esteroideos en adultos mayores.

OBJECTIVE: Determine prescription characteristics of non-steroidal anti-inflammatory drugs among the elderly attending primary medical care. MATERIAL AND METHODS: Setting, Family Health Unit 52, Mexican Institute of Social Security. DESIGN: Prospective, cross-sectional, descriptive, with randomized sampling. PARTICIPANTS: 400 patients; aged 60 and older, male and female, without cognitive impairment. Those without clinical records were excluded. Every patient was interviewed and examined and their clinical record and prescription were assesed. RESULTS: NSAIDs were prescribed in 312 patients (78% 95% CI 74-82), one type of NSAIDs was prescribed in 188 (60% 95% CI 55-65), two types in 117 (38% 95% CI 33-43) and three types in 7 (2% 95% CI 0.0-4). Of the 443 prescriptions, Acetylsalicylic acid was prescribed in 200 cases (45% 95% CI 40-50) and Naproxen in 100 (23% IC 95% 19-26). Reasons for prescribing included cardiovascularprophylaxis in 46% (IC 95% 7-13)pain management in 40% (95% CI 31-49), anti-inflammatory cases 4% (95% CI 2-6), and non-specified in 10% of cases (95% CI 7-13). Treatment duration was not specified for 253 patients (81% 95% CI 77-85). We noted drug-drug interaction in 228 cases (73% 95% CI 67-77) and a potential drug-disease interaction in 247 (79% 95% CI 77-81). The gastro-esophageal prescription was not more frequent among patients taking NSAIDs compared with non-users OR = 1 (95% CI 0.53-1.75; p = 0.89). CONCLUSIONS: NSAIDs prescription prevalence is high: although diagnoses do not justify their use and gastro-esophageal protection is often not sufficient. Prostaglandins inhibitors are favored without taking into account drug-disease interaction.

Características de la prescripcion de analgésicos antiinflamatorios no esteroideos en adultos mayores / Characterizing the prescription of non-steroidal anti-inflammatory drugs among the elderly

Objetivo. Determinar las características de la prescripción de AINEs en pacientes de 60 años y más. Material y métodos. El estudio se realizó en 400 pacientes entre agosto y septiembre 2003 en una Unidad de Medicina Familiar (UMF), con base en un diseño prospectivo, transversal analítico y un muestreo aleatorio simple. Los criterios de inclusión fueron: tener 60 años o más, ser de ambos sexos sin deterioro cognitivo. Se excluyeron los que no contaban con información confiable en su expediente. Se interrogaron y exploraron a los pacientes, revisando sus expedientes y recetas. Resultados. Se prescribió AINEs a 312 de los 400 pacientes incluidos en el estudio (78% IC al 95% 74-82) de los cuales a 188 (60% IC al 95% 55-65) se recetó solamente un AINE, a 117 (38% IC al 95% 33- 43) dos y a 7 (2% IC al 95% 0.0-4) tres. El total de prescripciones fue 443. Los tipos más frecuentemente prescritos fueron el ácido acetil salicílico en 200 prescripciones (45% IC al 95% 40-50) y el naproxeno en 100 (23% IC al 95%19- 26). El ácido acetil salicílico fue recetado principalmente para profilaxis cardiovascular, mientras que el naproxeno lo fue como analgésico. La duración del tratamiento no estaba especificado en 253 pacientes (81% IC al 95% 77-85). En 228 de ellos (73% IC al 95% 68-77) se presentó interacción potencial fármaco–fármaco y en 247 (79% IC al 95% 77-81) interacción potencial fármacoenfermedad. La prescripción de una protección farmacológica gastroesofágica no se relacionó con la prescripción de AINEs (OR = 1; IC al 95% 0.53-1.75; p = 0.89). Conclusiones. La prescripción de AINEs a adultos mayores es muy frecuente; se prefiere el naproxeno como analgésico, el cual no se acompaña de protección gastroesofágica. La probabilidad de interacciones fármaco-fármaco y fármaco-enfermedad es alta.

OBJECTIVE: Determine prescription characteristics of non-steroidal anti-inflammatory drugs among the elderly attending primary medical care. MATERIAL AND METHODS: Setting, Family Health Unit 52, Mexican Institute of Social Security. DESIGN: Prospective, cross-sectional, descriptive, with randomized sampling. PARTICIPANTS: 400 patients; aged 60 and older, male and female, without cognitive impairment. Those without clinical records were excluded. Every patient was interviewed and examined and their clinical record and prescription were assesed. RESULTS: NSAIDs were prescribed in 312 patients (78% 95% CI 74-82), one type of NSAIDs was prescribed in 188 (60% 95% CI 55-65), two types in 117 (38% 95% CI 33-43) and three types in 7 (2% 95% CI 0.0-4). Of the 443 prescriptions, Acetylsalicylic acid was prescribed in 200 cases (45% 95% CI 40-50) and Naproxen in 100 (23% IC 95% 19-26). Reasons for prescribing included cardiovascularprophylaxis in 46% (IC 95% 7-13)pain management in 40% (95% CI 31-49), anti-inflammatory cases 4% (95% CI 2-6), and non-specified in 10% of cases (95% CI 7-13). Treatment duration was not specified for 253 patients (81% 95% CI 77-85). We noted drug-drug interaction in 228 cases (73% 95% CI 67-77) and a potential drug-disease interaction in 247 (79% 95% CI 77-81). The gastro-esophageal prescription was not more frequent among patients taking NSAIDs compared with non-users OR = 1 (95% CI 0.53-1.75; p = 0.89). CONCLUSIONS: NSAIDs prescription prevalence is high: although diagnoses do not justify their use and gastro-esophageal protection is often not sufficient. Prostaglandins inhibitors are favored without taking into account drug-disease interaction.

[Frequency of gastroesophageal reflux disease in elderly patients attending a family medicine clinic]. / Frecuencia de síntomas de ERGE en adultos mayores que acuden a una unidad de medicina familiar.

OBJECTIVES: To ascertain the prevalence of gastroesophageal reflux disease (GERD) in elderly people attending to family medicine clinics. MATERIAL AND METHODS: the study was conducted by using a prospective design in which participants were randomly selected from a family medicine clinic located in Mexico City. The study was run from August to September 2003, and included patients aged sixty years or older, regardless of gender. They should not have cognitive damage, which was ascertained by the Folstein Mini Mental State Examination. Those patients that did not accept to participate and those having incomplete or illegible medical records were excluded. The socio-demographic characteristics test and Carlsson-Dent test were applied. The information about diagnosis, drugs prescriptions, and pharmacological and no pharmacological gastroesophageal protection was obtained from the medical charts and prescriptions. RESULTS: 400 elderly patients were evaluated by using the Carlsson-Dent test. GERD prevalence was 25% (CI 95% 21-29) the average age of patients with and without GERD was 68 +/- 7 years and 70 +/- 7 years respectively (p = .002). Women suffered GERD more frequently than men (p = 0.001). GERD diagnosis was not found in any of the reviewed medical charts. Antacids, histamine-2 receptor antagonists (H2 As) and prokinetics were prescribed in 39% (CI 95% 34-44) of patients with GERD and in 18% (CI 95% 15-21) without GERD. CONCLUSIONS: Elderly patients attending to primary care facilities often have GERD symptoms, but they are not properly diagnosed or followed up. The Carlsson-Dent questionnaire is an alternative to identify GERD patients.

[Adaptation and validation of quality of life instrument Diabetes 39 for Mexican patients with type 2 diabetes mellitus]. / Adaptación y validación del instrumento de calidad de vida Diabetes 39 en pacientes mexicanos con diabetes mellitus tipo 2.

OBJECTIVE: To adapt and validate the Spanish language version of the Diabetes 39 instrument, which measures quality of life,for Mexican patients with type 2 diabetes mellitus (DM-2). MATERIALS AND METHODS: The Spanish language version of the instrument was adapted to make it more comprehensible to Mexican patients. In a cross-sectional survey, the instrument was administered on two different days to 260 patients with type DM-2. Glycated hemoglobin (HbAic), total cholesterol, triglycerides, blood pressure, body mass index and waist/hip ratio were measured. Information about age, sex, time since diagnosis of diabetes, diabetes related complications and comorbidity was obtained. RESULTS: A total of 249 subjects completed the study, 62.7% of which were women. Cronbach's alpha coefficient was > or = 0.80 for the domains and 0.95 for the total score. The test-retest consistency for the total score was r = 0.82, p = 0.01. The median of the total score was 29 (on a scale of 0-100), which was considered the cutoff value for defining "better" (<29) and "worse" > or =29) quality of life.A worse quality of life was associated with diabetes related complications > or =1 (OR = 1.73; IC 95% 1.05-3.06); total cholesterol >240 mg/dL (OR = 4.43; IC 95% 1.23-16.26); comorbidity > or =2 diseases (OR = 2.36; IC 95% 1.31-4.28); diabetes longer than 10 years (OR = 2.19; IC 95% 1.2-3.78), and HbA(IC) >8% (OR = 1.81; IC 95% 1.09-2.99). The last three were identified as predictor variables for worse quality of life by logistic regression (p < 0.05). CONCLUSIONS: The adapted Spanish language version of Diabetes 39 is a reliable and valid instrument for measuring the quality of life of Mexican patients with DM-2.

Adaptación y validación del instrumento de calidad de vida Diabetes 39 en pacientes mexicanos con diabetes mellitus tipo 2 / Adaptation and validation of quality of life instrument Diabetes 39 for Mexican patients with type 2 diabetes mellitus

OBJETIVO: Adaptar y validar la versión al español del cuestionario Diabetes 39, que mide calidad de vida, en pacientes mexicanos con diabetes mellitus tipo 2 (DM-2) MATERIAL Y MÉTODOS: Encuesta transversal realizada en una unidad de medicina familiar. Un panel de investigadores adaptó el instrumento, que se aplicó en dos ocasiones, por autoadministración, a una muestra de 260 pacientes con DM-2. Se midieron la hemoglobina glucosilada (HbA1C), colesterol total, triglicéridos, tensión arterial, índice de masa corporal e índice cintura/cadera. Se obtuvieron datos sobre edad, sexo, tiempo de evolución, complicaciones diabéticas y comorbilidad RESULTADOS: Completaron el estudio 249 sujetos de los cuales 62.7 por ciento fueron mujeres. El alfa de Cronbach fue >0.80 para los dominios. La consistencia test-retest para la calificación total tuvo una r= 0.82, p= 0.01. La mediana de la puntuación total fue de 29 puntos (escala de 0 a 100) y se tomó como punto de corte para definir mejor (<29) y peor (>29) calidad de vida. En el análisis bivariado, una peor calidad de vida se asoció con complicaciones tardías de la diabetes >1 (RM= 1.73; IC95 por ciento 1.05-3.06); colesterol total >240 mg/dL (RM= 4.43; IC95 por ciento 1.23-16.26); comorbilidad >2 enfermedades (RM= 2.36; IC95 por ciento 1.31-4.28); evolución mayor a 10 años (RM= 2.19; IC95 por ciento 1.27-3.78) y HbA1C >8 por ciento (RM= 1.81; IC95 por ciento 1.09-2.99). Las tres últimas fueron predictoras de peor calidad de vida en la regresión logística (p< 0.05) CONCLUSIONES: La versión adaptada en idioma español del Diabetes 39 es un instrumento válido y confiable para medir la calidad de vida en los pacientes mexicanos con DM-2.

[Family-physician factors associated with glycemic control of patients with diabetes mellitus]. / Factores de los médicos familiares asociados al control glucémico de sus pacientes con diabetes mellitus.

INTRODUCTION: Metabolic control of patients with diabetes is determined by several factors, among others competence level, performance, and attitudes of primary-care physicians. OBJECTIVE: On objective was to determinate family physician factors associated with glycemic control in subjects with diabetes in two Family Medicine Units (FMU). DESIGN: Cross-sectional comparative study. SETTING: Two Family Medicine Units of the Mexican Institute Social Security. INTERVENTIONS: Family physician demographic factors were measured (age, sex, job seniority, time of university graduation, and had to have studied a specialty residence studied). Two validated instruments were applied to measure attitude level and handling competence of DM 2, and we determined glycemic level in the previous months of five diabetic patients by consulting room. RESULTS: Forty family physicians were evaluated, mean age 43.9 years, 57.5% with a residence in Family Medicine. Better glycemic control was associated with job seniority, OR 2.49 (CI 0.96-6.6), time of university graduation > 10 years with OR 2.11 (CI 1.4-2.9), to have at least one course related with diabetes in the previous year with OR 4.8 (IC 0.39-22), and competence level OR 2.02 (CI 0.36-11.3) CONCLUSIONS: There association between better glycemic control and more professional experience and training on diabetes in the previous year.

[Comparison of fasting and 2 hours postprandial blood glucose in the control of patients with type 2 diabetes]. / Comparación de la glucemia en ayuno y dos horas postprandial en el control de pacientes con diabetes tipo 2.

BACKGROUND: Fasting glycemia is a questionable control test for subjects with diabetes mellitus. 2-h postprandial glycemia is an element that must be considered as complementary in controlling the disease. OBJECTIVES: Compare usefulness of fasting glycemia and 2-h postprandial glycemia as control tests in patients with type 2 diabetes mellitus. DESIGN: Study of diagnostic test. MATERIAL AND METHODS: 112 patients were included in the study, age mean 59 +/- 10.9 and evolution of diagnosis 10.2 +/- 8.3 years. We calculated the mean of three fasting glycemias at the beginning of the study and three determinations of 2-h postprandial glycemia. The habitual drug administration was continued. Sensibility, specificity, predictive values, and precision of each measurement were calculated in relation to HbA1C as a Gold Standard. RESULTS: Correlation of fasting glycemia was 0.74 p < 0.01, and correlation of postprandial glycemia was 0.79 p < 0.01. Fasting glycemia had a sensibility of 0.71 and a specificity of 98. 2-h postprandial glycemia had a sensibility of 0.79 and a specificity of 0.86. When combining fasting glycemia and postprandial glycemia, sensibility was 0.85 and specificity was 1. CONCLUSION: 2-h postprandial glycemia level is more precise than fasting glycemia. Both determinations used together increase usefulness in controlling blood glucose level when lacks hemoglobin A1C.

[Construction and validation of a clinical diagnostic-therapeutic guide for the hospitable management of patients with type 2 diabetes mellitus]. / Construcción y validación de una guía clínica diagnóstico-terapéutica para el manejo hospitalario de pacientes con diabetes mellitus tipo 2.

OBJECTIVE: To develop and validate a diagnostic-therapeutic guideline (DTG) for the management of hospitalized diabetic patients, and apply it to a sample of medical files. MATERIAL AND METHODS: The DTG was constructed and then validated by a consensus of internist physicians, afterwards it was applied to a sample of 97 randomly selected medical files of diabetic patients discharged from a internal medicine service. Hospitalization time, studies requested, average glycemia, glycemic prior to the discharge, time for to achieve glycemic control and mortality were compared at different percentages of the DTG's application. The results were analyzed by U of Mann-Whitney and ANOVA of Kruskal-Wallis. RESULTS: The intra-class correlation coefficient among the physicians for the guide validation was 0.94, with minimal modifications of content and format. The time, in hours, to achieve glycemic control was minor with a higher application percentage of the complete guide, p < 0.001, and also of the therapeutic domain, p = 0.05. The last glycemic prior to the discharge was lower with a higher application than 75% of the diagnostic domain, p < 0.001. A higher application percentage of the entire guide was found in living subjects more than in deceased subjects, p = 0.001, and also of the therapeutic domain, p = 0.008, and of the diagnostic domain p = 0.05. CONCLUSIONS: A higher level of application of the DTG is associated with a shorter time to achieve glycemic control, lower glycemic prior to the discharge and lower mortality.

Indice glúcemico de alimentos mezclados indicados en el IMSS para la dieta del diabético / Glycemic index of mixed meals indicated for diabetic patients at the IMSS

Introducción: la selección de alimentos para la dieta recomendada al diabético se basa principalmente en el contenido de nutrimentos y el aporte calórico que proporcionan, más que en el índice glucémico (IG).Objetivo: determinar el índice glucémico y la magnitud de la respuesta glucémica a las dos horas de ingestión de algunos alimentos prescritos a pacientes diabéticos tipo 2, en el Instituto Mexicano del Seguro Social.Diseño: descriptivo, transversal comparativo.Material y métodos: se midió IG de 12 alimentos mezclados y de un alimento industrializado para pacientes con diabetes. El alimento que se utilizó como referencia para comparar la magnitud de la elevación glucémica y el IG fue el pan blanco de caja. Cada uno de los alimentos fue administrado a no menos de cinco sujetos, en una cantidad calculada con base en 25 g de hidratos de carbono.Resultados: sólo en cuatro alimentos se observó IG bajo, considerando un punto de corte de 70. Existe correlación entre IG con el cálculo obtenido del área bajo la curva de la glucosa, con la glucemia a los 120 minutos y la magnitud de su elevación. No hubo correlación con el contenido de nutrimentos, tiempo de consumo, o grado de obesidad de los pacientes.Conclusiones: el índice glucémico de los alimentos debe considerarse al diseñar la dieta para el paciente diabético.

Respuesta de la glucemia a la administración de insulina sublingual / Sublingual insuline in diabetes type 2

Se presentan los resultados de un estudio para evaluar la respuesta de la glucemia después a la administración de una dosis de insulina por vía sublingual en un grupo de pacientes dabéticos tipo 2. Se seleccionaron 10 sujetos del Hospital General Regional No. 72 y 50 sujetos del Hospital de Solidaridad de Jimiltepec Oaxaca. Todos los sujetos suspendieron el tratamiento antidiabético 24 horas previas. Se administró una dosis de insulina regular dentro de cápsulas de gelatina a razón de 16 unidades en promedio. Se tomaron muestras sanguíneas a los 0 y 15, 30, 45, 60, 90 y 120 minutos. La glucemia se determinó por técnica de glucosa-oxidasa. En el grupo de Insulina se observa disminución de la glucemia inicial a los 120 minutos; no hubo modificación de los niveles de glucemia con placebo. La insulina administrada en cápsulas por vía sublingual disminuye los niveles de glucemia en sujetos con diabetes mellitus tipo 2