Medicina personalizada en atención primaria / Personalized medicine in primary care

No disponible

Práctica clínica en el manejo de la hipertensión y la diabetes en Atención Primaria: estudio ATENCION / Management of hypertension and diabetes in Primary Care clinical practice: ATENCION study

Fundamento y objetivo. Las enfermedades cardiovasculares constituyen la principal causa de muerte en la población española. La detección y control de los factores de riesgo cardiovascular es fundamental para prevenirlas. Este estudio tiene como objetivos fundamentales analizar la actitud y las decisiones terapéuticas de los médicos de Atención Primaria (AP) ante la hipertensión arterial (HTA) y la diabetes mellitus tipo 2 (DM2), con el fin de conocer la realidad y proponer estrategias de mejora para su correcto manejo. Material y método. Estudio ecológico de encuesta, descriptivo, transversal y multicéntrico, de ámbito nacional, con participación de médicos de AP, realizado en 2013. Se solicitó la participación en el estudio a 1.028 médicos. Resultados. El 92,9 y el 91,4% de los investigadores consultados sigue las guías para la evaluación, el tratamiento y el diagnóstico de HTA y DM2, respectivamente. Esta última se diagnostica sobre todo casualmente, y la HTA por búsqueda activa en pacientes con otros factores de riesgo. La terapia combinada tarda más de 6 meses en instaurarse en pacientes hipertensos y entre 8-9 meses en diabéticos. El porcentaje de incumplimiento es similar (10-40%) en ambas dolencias. Aproximadamente la mitad de los encuestados consideran buena o excelente la interacción con el especialista (46 y 57,3% en HTA y DM2, respectivamente). Conclusiones. La práctica clínica en AP en HTA y DM2 tiene criterios básicos comunes. La interacción entre la AP y el especialista es buena. No obstante, existe margen de mejora en el tratamiento de estos factores de riesgo, particularmente en lo relativo a intensificar la terapia precozmente (AU)

Background and objective. Cardiovascular diseases are the main cause of death in the Spanish population. The detection and control of cardiovascular risk factors are fundamental in the prevention of cardiovascular disease. The main objectives of this study are to analyse the attitudes and therapeutic decisions of Primary Care (PC) physicians when treating hypertension (HT) and diabetes mellitus type 2 (DM2), with the aim of establishing the situation and eventually proposing improvement strategies. Material and method. A national ecological, multicentre, cross-sectional, and descriptive study was conducted in 2013. A questionnaire was used and 1,028 PC physicians took part in the study. Results. A total of 92.9% of the investigators consulted have indicated that they follow the guidelines for evaluation, treatment, and diagnosis of HT, and 91.4% in the case of diabetes. The latter is diagnosed as a casual finding, while HT is diagnosed through active investigation in patients with other risk factors. Combined therapy takes more than 6 months to take effect in patients with HT, and between 8 and 9 months in diabetic patients. The percentage of non-compliance is similar (10-40%) in both pathologies. Around half the physicians questioned considered interaction with the specialist to be good or excellent (46% HT and 57.3% DM2). Conclusions. Clinical practices in PC for HT and DM2 have some basic criteria in common. The interaction with the specialist is good, but there is a considerable margin for improvement (AU)

Acute myeloid leukemia derived from lympho-myeloid clonal hematopoiesis.

We studied acute myeloid leukemia (AML) patients with lympho-myeloid clonal hematopoiesis (LM-CH), defined by the presence of DNA methyltransferase 3A (DNMT3A) mutations in both the myeloid and lymphoid T-cell compartment. Diagnostic, complete remission (CR) and relapse samples were sequenced for 34 leukemia-related genes in 171 DNMT3A mutated adult AML patients. AML with LM-CH was found in 40 patients (23%) and was associated with clonal hematopoiesis of indeterminate potential years before AML, older age, secondary AML and more frequent MDS-type co-mutations (TET2, RUNX1 and EZH2). In 82% of AML patients with LM-CH, the preleukemic clone was refractory to chemotherapy and was the founding clone for relapse. Both LM-CH and non-LM-CH MRD-positive AML patients who achieved CR had a high risk of relapse after 10 years (75% and 75%, respectively) compared with patients without clonal hematopoiesis in CR with negative MRD (27% relapse rate). Long-term survival of patients with LM-CH was only seen after allogeneic hematopoietic stem cell transplantation (HSCT). We define AML patients with LM-CH as a distinct high-risk group of AML patients that can be identified at diagnosis through mutation analysis in T cells and should be considered for HSCT.

[Management of hypertension and diabetes in Primary Care clinical practice: ATENCION study]. / Práctica clínica en el manejo de la hipertensión y la diabetes en Atención Primaria: estudio ATENCION.

BACKGROUND AND OBJECTIVE: Cardiovascular diseases are the main cause of death in the Spanish population. The detection and control of cardiovascular risk factors are fundamental in the prevention of cardiovascular disease. The main objectives of this study are to analyse the attitudes and therapeutic decisions of Primary Care (PC) physicians when treating hypertension (HT) and diabetes mellitus type 2 (DM2), with the aim of establishing the situation and eventually proposing improvement strategies. MATERIAL AND METHOD: A national ecological, multicentre, cross-sectional, and descriptive study was conducted in 2013. A questionnaire was used and 1,028 PC physicians took part in the study. RESULTS: A total of 92.9% of the investigators consulted have indicated that they follow the guidelines for evaluation, treatment, and diagnosis of HT, and 91.4% in the case of diabetes. The latter is diagnosed as a casual finding, while HT is diagnosed through active investigation in patients with other risk factors. Combined therapy takes more than 6 months to take effect in patients with HT, and between 8 and 9 months in diabetic patients. The percentage of non-compliance is similar (10-40%) in both pathologies. Around half the physicians questioned considered interaction with the specialist to be good or excellent (46% HT and 57.3% DM2). CONCLUSIONS: Clinical practices in PC for HT and DM2 have some basic criteria in common. The interaction with the specialist is good, but there is a considerable margin for improvement.

Boceprevir plus pegylated interferon/ribavirin to re-treat hepatitis C virus genotype 1 in HIV-HCV co-infected patients: final results of the Spanish BOC HIV-HCV Study.

INTRODUCTION: Boceprevir (BOC) was one of the first oral inhibitors of hepatitis C virus (HCV) NS3 protease to be developed. This study assessed the safety and efficacy of BOC+pegylated interferon-α2a/ribavirin (PEG-IFN/RBV) in the retreatment of HIV-HCV co-infected patients with HCV genotype 1. METHODS: This was a phase III prospective trial. HIV-HCV (genotype 1) co-infected patients from 16 hospitals in Spain were included. These patients received 4 weeks of PEG-IFN/RBV (lead-in), followed by response-guided therapy with PEG-IFN/RBV plus BOC (a fixed 44 weeks was indicated in the case of cirrhosis). The primary endpoint was the sustained virological response (SVR) rate at 24 weeks post-treatment. Efficacy and safety were evaluated in all patients who received at least one dose of the study drug. RESULTS: From June 2013 to April 2014, 102 patients were enrolled, 98 of whom received at least one treatment dose. Seventy-three percent were male, 34% were cirrhotic, 23% had IL28b CC, 65% had genotype 1a, and 41% were previous null responders. The overall SVR rate was 67%. Previous null-responders and cirrhotic patients had lower SVR rates (57% and 51%, respectively). Seventy-six patients (78%) completed the therapy scheme; the most common reasons for discontinuation were lack of response at week 12 (12 patients) and adverse events (six patients). CONCLUSIONS: Response-guided therapy with BOC in combination with PEG-IFN/RBV led to an overall SVR rate of 67%, but an SVR rate of only 51% in patients with cirrhosis. The therapy was generally well tolerated. Although the current standards of care do not include BOC+PEG-IFN/RBV, the authors believe that this combination can be beneficial in situations where new HCV direct antiviral agent interferon-free therapies are not available yet.

Three-dimensional cone beam computed tomography analysis of maxillary sinus and alveolar bone anatomy in the restorative axis of dental implants using radiopaque drill guides.

The objectives were to assess the sinus anatomy and alveolar ridge dimensions and to identify clinical factors and morphological relationships that may predict the characteristics of the sinus anatomy. A total 336 edentulous molar and 168 edentulous premolar regions were analyzed. The mediolateral maxillary sinus (5mm and 10mm above alveolar bone), lateral maxillary sinus wall, ostium height, and alveolar ridges were measured. Measurement regions were defined by radiopaque simulation of the restoration goal. Mean molar mediolateral dimensions were >10mm: first molar, 11.8mm (range 3.8-21.1mm); second molar, 12.2mm (range 7.9-20.1mm). The extent of the sinus differed significantly between premolars and molars (P<0.001). The first molar region had the highest mean value for the lateral sinus wall (2.4mm, range 0.2-7.9mm) and the greatest distance between the alveolar crest and simulated restorative goal (8.1mm, range 1.1-16.3mm). Septum prevalence was 46% in the molar region and 27% in the premolar region. A lower alveolar ridge height was associated with a wider transverse extent of maxillary sinus and consequently longer distances between the crest and restorative goal. Systematic three-dimensional analysis of the maxillary sinus yields precise preoperative information about sinus configurations. There were significant variations and relationships among characteristics of the maxillary sinus, ridge, and the restorative goal.

Prevalence of orthostatic hypotension in non-institutionalised elderly aged 80 and over. A diagnostic study using an oscillometric device / Prevalencia de hipotensión ortostática en ancianos mayores de 80 años no institucionalizados. Estudio de diagnóstico clínico mediante aparato de presión oscilométrico

Background: Orthostatic hypotension (OH) is a common disorder, and possibly underdiagnosed. In the elderly, OH has been considered a common cause of falls, fractures, and fear of falling. Its prevalence increases with age, probably related to the number of drug treatments, decreased fluid intake, and the progressive dysfunction of the autonomic nervous system. Objectives: To evaluate the prevalence of OH in a non-institutionalised population ≥80 years, according to different criteria based on sequential measurements taken at minute 0, 1, 3 and 5 of standing. Methods design: A diagnostic accuracy study using an oscillometric device. Setting and participants: Convenience sampling of 176 people ≥80 years attended in an urban Primary Health Care Centre. Measurements: Supine and standing blood pressure (BP) measurements, at minutes 0, 1, 3 and 5 using the OMRON 705-CP blood pressure device. OH definition: decrease ≥20 mmHg in systolic BP (SBP) and/or ≥10 mmHg in diastolic BP (DBP). Results: Mean age (Standard Deviation) was 85.2 (3.7) years, and 60.2% were women. Prevalence of OH: 30.7% at minute 0; 19.3% at minute 1; 18.2% at minute 3; and 20.5% at minute 5. Age, sedentary life, smoking, diabetes and SBP values were significantly associated with a greater BP decrease at minute 0. Conclusion: A third of the sample had OH, with a maximum prevalence at minute 0. From a clinical point of view, it is suggested that the definition of OH is prioritized according to the BP at minute 0

Introducción: La hipotensión ortostática (HO) es un fenómeno muy común posiblemente infradiagnosticado. En ancianos, la HO puede causar caídas, fracturas y miedo a caerse. Su prevalencia aumenta con la edad, seguramente en relación con el número fármacos prescritos, la disminución de ingesta de líquidos y la disfunción progresiva de su sistema nervioso autónomo. Objetivos: Evaluar la prevalencia de OH en ancianos mayores de 80años no institucionalizados según el criterio diagnóstico de HO en medidas secuenciales tomadas en los minutos 0, 1, 3 y 5 de bipedestación. Sujetos y métodos: Diseño: estudio de diagnóstico mediante aparato de presión oscilométrico. Muestra: muestreo a conveniencia de 176 pacientes ≥80 años atendidos en un centro de atención primaria urbano. Medidas: Presión Arterial (PA) en supinación y a los minutos 0, 1, 3 y 5 mediante un tensiómetro OMRON 705-CP. Definición de HO: descenso ≥20 mmHg en la PA sistólica (PAS) y/o ≥10 mmHg en la PA diastólica. Resultados: La media de edad (desviación estándar) fue de 85,2 (3,7) años, y el 60,2% fueron mujeres. Prevalencia de HO: 30,7% al minuto 0; 19,3% al minuto 1; 18,2% al minuto 3; 20,5% al minuto 5. Edad, sedentarismo, tabaquismo, diabetes y valores de PAS mostraron una asociación significativa con un mayor descenso de la PA en el minuto 0. Conclusión: Un tercio de la muestra presenta HO, con un máximo de prevalencia en el minuto 0. Desde el punto de vista clínico parece recomendable priorizar la definición de la HO según la PA en el minuto 0

Prevalence of orthostatic hypotension in non-institutionalised elderly aged 80 and over. A diagnostic study using an oscillometric device.

BACKGROUND: Orthostatic hypotension (OH) is a common disorder, and possibly underdiagnosed. In the elderly, OH has been considered a common cause of falls, fractures, and fear of falling. Its prevalence increases with age, probably related to the number of drug treatments, decreased fluid intake, and the progressive dysfunction of the autonomic nervous system. OBJECTIVES: To evaluate the prevalence of OH in a non-institutionalised population ≥80 years, according to different criteria based on sequential measurements taken at minute 0, 1, 3 and 5 of standing. METHODS DESIGN: A diagnostic accuracy study using an oscillometric device. SETTING AND PARTICIPANTS: Convenience sampling of 176 people ≥80 years attended in an urban Primary Health Care Centre. MEASUREMENTS: Supine and standing blood pressure (BP) measurements, at minutes 0, 1, 3 and 5 using the OMRON 705-CP blood pressure device. OH definition: decrease ≥20mmHg in systolic BP (SBP) and/or ≥10mmHg in diastolic BP (DBP). RESULTS: Mean age (Standard Deviation) was 85.2 (3.7) years, and 60.2% were women. Prevalence of OH: 30.7% at minute 0; 19.3% at minute 1; 18.2% at minute 3; and 20.5% at minute 5. Age, sedentary life, smoking, diabetes and SBP values were significantly associated with a greater BP decrease at minute 0. CONCLUSION: A third of the sample had OH, with a maximum prevalence at minute 0. From a clinical point of view, it is suggested that the definition of OH is prioritized according to the BP at minute 0.

Minimum spread of the new Swedish variant of Chlamydia trachomatis and distribution of C. trachomatis ompA genotypes in three geographically distant areas of Spain, 2011-2012.

PURPOSE: The aim of this study was to determine the presence of the new Swedish Chlamydia trachomatis (C. trachomatis) variant (nvCT) and the distribution of C. trachomatis ompA genotypes in three geographically distant regions of Spain. METHODS: The genotypes of strains causing 624 episodes of infection (January 2011-September 2012) were studied using a nested PCR that amplifies a fragment of the ompA gene, followed by sequencing. To detect nvCT, a real-time PCR was used that amplifies a fragment of the cryptic plasmid with a 377 base pair deletion, which identifies the nvCT. RESULTS AND CONCLUSION: The ompA genotype was identified in 565 (90.5%) episodes. Eleven genotypes were detected, of which nine were found in all three regions. Only one nvCT strain was detected (0.4%), despite the predominance of genotype E (41%). Other frequent genotypes were genotypes D (19%), F (13%), G (11 %), and J (7%). Genotype L2b, causing lymphogranuloma venereum, was detected in men who have sex with men (MSM) in all three regions. Genotypes E and F were more frequent in women and heterosexual men, and genotypes D, G, J and L2b in MSM. In men, the main factor causing differences in the distribution of C. trachomatis was sexual behavior (MSM versus heterosexual men), while the distribution of C. trachomatis genotypes was similar in women and heterosexual men.

Terahertz plastic compound lenses.

We present terahertz (THz) lenses made of highly refracting polymeric compounds which provide a better focusing performance and an increased functionality in comparison to conventional THz lenses. Using mixtures consisting of polypropylene (PP) and alumina as well as PP and zinc sulfide allows a significant increase of the refractive index while simultaneously keeping a low extinction and dispersion. With these new material combinations, lenses with an increased focusing capability are realized. This is evaluated by focal plane measurements using a fiber coupled THz time-domain spectrometer.

i.lect, a pre-graduate education model of implantology.

OBJECTIVE: In 2008, a consensus meeting of the Association for Dental Education in Europe stated that dental implant treatment represents a popular treatment alternative and, therefore, it should be an integral part of dental student pre-graduate education. In 2009, the Friedrich-Alexander University, Erlangen-Nuremberg implemented a voluntary, structured, education program for pre-graduate dental students, called 'i.lect'. The present study evaluated the effectiveness of the i.lect program. METHODS: Concurrent to the dental curriculum, the i.lect program provides 200 hours in 3 years of theoretical and practical education on all aspects of modern dental implantology. We recruited dental students in the i.lect program and additionally students from 15 other universities that voluntarily participated in a single, 3-day implantology camp (R = 58). To demonstrate their knowledge on dental implant issues, both student groups completed a written examination that covered 'Basic information and materials of implantology', 'Implant planning' and 'Soft tissue management'. RESULTS: The students in the i.lect program achieved higher scores than students from the implantology camp on questions concerning 'basic implantology' and 'implant planning'. CONCLUSION: The results indicated that the structured i.lect undergraduate curriculum enhanced individual knowledge in the specific field of implantology. This program could have pilot character for use in other universities.

Evolución de las opciones terapéuticas en el tratamiento de la hipertensión arterial / Evolution of therapeutic options in the treatment of hypertension

Desde el año 1978 las recomendaciones sobre el tratamiento de la hipertensión arterial han experimentado una serie de cambios sucesivos como consecuencia, en primer lugar, de los resultados de los numerosos ensayos clínicos de morbimortalidad y metaanálisis publicados en revistas de alto impacto y, en segundo lugar, por el esfuerzo de síntesis y consenso realizado por los autores de las guías de práctica clínica. El tratamiento escalonado fue la primera propuesta de un comité de expertos de la Organización Mundial de la Salud en la que los diuréticos y los bloqueadores beta configuraban el primer escalón. Posteriormente se fueron incorporando el resto de clases terapéuticas hasta constituir el complejo «diamante» de las guías conjuntas de la Sociedad Europea de Hipertensión y de la Sociedad Europea de Cardiología del año 2003. Documentos posteriores han apostado por una simplificación del esquema terapéutico cuyo máximo exponente es la polémica Guía británica del National Institute for Clinical Excelence, si bien el «triángulo» formado por inhibidores de la enzima de conversión de la angiotensina y antagonistas de los receptores de la angiotensina II en un vértice y antagonistas del calcio y diuréticos ocupando los otros 2, pueden ser una propuesta razonable con objeto de simplificar el tratamiento y facilitar los objetivos de control de la hipertensión arterial (AU)

Since 1978, recommendations on the treatment of hypertension have undergone a series of changes. These changes have been due firstly to the results of numerous clinical trials on morbidity and mortality and meta-analyses published in high-impact journals and, secondly, to the efforts of the authors of clinical practice guidelines to synthesis information and reach consensus. Stepwise treatment was the first proposal of the expert committee of the World Health Organization in which diuretics and beta-blockers are the first step. Subsequently, the remaining therapeutic classes were gradually incorporated into the 2003 European Society of Hypertension–European Society of Cardiology guidelines for the management of arterial hypertension, which recommended six drug groups. Subsequent documents have proposed simplification of therapeutic regimens, principally the controversial British guidelines of the National Institute for Clinical Excellence, although the “triangle” composed of an angiotensin-converting enzyme inhibitor and an angiotensin II receptor blocker on one side and calcium channel blockers and diuretics on the remaining sides could be a reasonable proposal to simplify treatment and achieve blood pressure targets (AU)

Possibilities and limitations of implant placement by virtual planning data and surgical guide templates.

The use of computer-aided surgical systems for dental implant bed preparation and implant placement results in an average precision within 1 mm of implant position and within 5 degrees of deviation for implant inclination. The accuracy of axis and implant position is significantly more precise with the three-dimensional surgical guide than with the free-hand method. The three-dimensional assessment of the restorative goal (radiopaque simulation of prosthesis with scanning template) allows virtual planning of implants, which enables optimized positioning of implants with surgical guide templates in oral surgery. If there is a clear indication for three-dimensional diagnostics, it should always be checked whether the data can be used as planning data for a surgical guide template, otherwise the chance for guided surgery remains unused. Since uncertainties still exist despite the use of a drilling template, it is recommended that the minimum safety distance from adjacent structures be maintained. The successful use of surgical guide templates requires comprehensive knowledge of and experience in using three-dimensional information for the virtual planning of implant position.

Evaluation of tooth preparations - a comparative study between faculty members and pre-clinical students.

INTRODUCTION: Preparation of teeth is a basic technique for dental treatment and plays an essential role in pre-clinical education. The purpose of this study was to evaluate whether undergraduate students' evaluations of prepared teeth were consistent with faculty assessments and correlated with students' performance in test preparations. MATERIALS AND METHODS: Thirty four of 52 dental students having attended a pre-clinical course on basic prosthodontic topics including tooth preparation volunteered to participate in this study. The students were given 10 casts each containing one tooth with an intentionally applied preparation fault of a certain type prepared by an experienced clinician. The students were asked to mark on a list the fault type found in every tooth. The association of students' ratings with their performance during the course was analysed by means of a contingency table, and a generalised linear model was used to compare students' and faculty ratings (α = 0.05). RESULTS: No significant difference between students' and faculty ratings could be found by analysis of deviance (P = 0.953). Significant deviations of fault detection probabilities from their group mean were found for six of ten fault types. No significant association between students' performance in test preparations and students ratings could be found (P = 0.564). DISCUSSION: It was possible to achieve a level of calibration within the group of students, which was comparable to that in the group of faculty members. CONCLUSIONS: Calibration of both students and examiners remains to be an issue with the teaching concepts applied in this study.

Student attitudes towards computer-aided testing.

INTRODUCTION: Computer-aided learning (CAL) is a viable alternative to traditional teaching methods. While CAL is used for teaching only, computer-aided testing (CAT) can be applied as a computer-based examination method. The aim of the present study was to evaluate students' attitude towards CAT as compared to written multiple choice tests. MATERIALS AND METHODS: Forty-one undergraduate dental students underwent a mock examination consisting of 15 written multiple choice questions and 15 questions delivered using the interactive MobiTed® system. A questionnaire based on an eight-item seven-point Likert scale was used to evaluate the students' attitude towards CAT. The students' performance in both tests was analysed using paired t-tests. Correlations between test performance and questionnaire were expressed by Pearson correlation coefficients. RESULTS: Despite study-design-related differences, students' test performance between written multiple choice and MobiTed® was comparable. No correlations between test results and questionnaire could be set up. Students rated MobiTed® to be equivalent to written multiple choice and had no difficulties with the CAT set up. The pre-defined sequence of questions with each question being shown only once was considered to be a major disadvantage of the CAT system. Complex questions should be displayed longer compared to short questions. DISCUSSION: Computer-aided testing appeared to be equivalent to written multiple choice tests not only in terms of student performance but also to their perception. This is consistent with previous studies. CONCLUSIONS: Interactive multiple choice tests may provide an alternative to written tests, but should allow examinees to have control over the sequence, as well as the length of time the questions are displayed.

[Comparison of laparoscopic splenectomy in supine position with hanging-spleen technique in idiopathic thrombocytopenic purpura]. / Vergleich der laparoskopischen Splenektomie in Steinschnittlage mit der Hanging-Spleen-Technik bei idiopathischer thrombozytopenischer Purpura.

BACKGROUND: Laparoscopic splenectomy has become the gold standard intervention for elective splenectomy. Several techniques have been described, which differ in trocar localisations and patient positions. The hanging-spleen technique was examined in comparison to the conventional laparoscopic splenectomy in the supine position among the patient population in our institution over a period of 8 years. PATIENTS AND METHODS: On the basis of a retrospective analysis, data were collected on all patients who underwent elective laparoscopic splenectomy for idiopathic thrombocytopenic purpura between May 1994 and April 2002 and were examined for operation time, blood loss and peri-operative complications. Two types of operation were compared, the conventional laparoscopic splenectomy in the supine position (group A) and the hanging-spleen technique (group B). Finally, the costs of materials of the two operation techniques were compared. RESULTS: For 51 patients (43.1 % men, 56.9 % women) (mean age: 45.5 ± 17.5 years) the mean operation times were 134.2 ± 47.3 min (group A) and 9.8 ± 39.9 min (group B). The mean blood losses were 691.3 ± 544.4 mL in group A and 638.3 ± 1050.6 mL in group B. The perioperative complications were 38.8 % in group A and 21.2 % in group B. There was no significant difference found for operation time, blood loss and perioperative complications in a multivariate analysis. The cost of materials was reduced in group B (use of Endo-GIA 42.4 % in group B, 100 % in group A). In group A 4 incisions, in group B 3 incisions were necessary. CONCLUSIONS: Regarding operation time, blood loss and perioperative complications the 2 laparoscopic techniques for splenectomy do not differ significantly. Merely reduced material costs and a reduction of incisions were found in patients -operated with the hanging-spleen technique. Whether the hanging-spleen technique is the method of choice will have to be shown by further prospective studies.

Evaluación de la situación actual del cumplimiento terapéutico en la hipertensión arterial en España, en opinión de los pacientes. Proyecto Cumplex II / No disponible

OBJETIVOS. Evaluar la opinión de los hipertensos españoles sobre diferentes aspectos relacionados con el cumplimiento terapéutico. METODOLOGÍA. Estudio descriptivo transversal mediante una encuesta a pacientes hipertensos en tratamiento antihipertensivo estable, realizada en centros de Atención Primaria de España. Se recogieron datos demográficos, se midió el cumplimiento mediante los cuestionarios de Batalla, Morisky-Green y Haynes-Sackett, y se interrogó sobre las causas por las que dejaban de tomar los comprimidos en alguna ocasión, la causa que consideraban más frecuente de incumplimiento y las estrategias que desearían que su médico o enfermera realizasen para mejorar el cumplimiento. RESULTADOS. Se incluyeron 4.952 pacientes (91,9%)(edad media: 62,6 años; desviación estándar [DE] 10,7 y47,2% mujeres). Fueron cumplidores el 90,3% (intervalo de confianza [IC] 99% = 89,2-91,4) mediante el cuestionario de Haynes-Sackett, el 11,3% (IC 99%=10,1-12,5) según Morisky-Green y el 69,5% (IC 99% = 67,8-71,2) según el de Batalla. Las causas más frecuentes por las cuales dejaron de tomar alguna vez la medicación fueron los olvidos involuntarios(77,4% [IC 99% = 67,8-71,2]) quedarse sin medicación(45,4% [IC 99% = 43,6-47,2]) y no encontrarse bien (34,5%[IC 99% = 32,8-36,2]). La causa de incumplimiento considerada como principal fueron los olvidos (80,3% [IC 99% =78,8-81,8]). Entre las estrategias que los pacientes deseaban para mejorar el cumplimiento, las preferencias oscilaron entre el 88,6% (IC 99% = 87,4-89,8) para la prescripción del menor número posible de comprimidos y el 10,8% (IC 99%= 9,7-11,9) para el contacto con el médico por correo electrónico. CONCLUSIONES. La principal causa de incumplimiento son los olvidos casuales, la estrategia preferida es la simplificación del tratamiento y los pacientes encuestados muestran escasas preferencias por el uso de nuevas tecnologías (AU)

OBJECTIVE. To evaluate the opinion of Spanish hypertensive patients regarding different aspects of treatment adherence. METHODS. Descriptive, cross-sectional study conducted by surveying hypertensive patients on stable anti-hypertensive treatment in Spanish Primary Care centres. Demographic data were collected and compliance was measured using the Batalla, Morisky-Green and Haynes-Sackett tests; the patients were asked why they had not taken the tablets on some occasion, what they considered to be the most common cause of non-compliance and which adherence-enhancing strategies they would like their doctor or nurse to adopt. RESULTS. A total of 4,952 patients (91.9%) were included in the study (mean age: 62.6 years [SD 10.7]; 47.2%women). Compliance was estimated to be 90.3% (CI 99%= 89.2-91.4), 11.3% (CI 99% = 10.1-12.5) and 69.5% (CI99% = 67.8-71.2) according to the Haynes-Sackett, Morisky-Green and Batalla test, respectively. The most common reasons for not taking the medication were forgetfulness(77.4% [CI 99% = 67.8-71.2]), running out of medication(45.4% [CI 99% = 43.6-47.2]) and not feeling well (34.5%[CI 99% = 32.8-36.2]). Forgetfulness was considered to be the primary cause of non-compliance (80.3% [CI 99% =78.8-81.8]). The patients’ preferred strategies for improving adherence varied between 88.6% (CI 99% = 87.4-89.8) for the prescription of the least number of tablets possible and 10.8% (CI 99% = 9.7-11.9) for e-mail contact with the physician. CONCLUSIONS. The main cause of non-compliance is forgetfulness; the preferred strategy for patients is the simplification of treatment regimens and there is little interest in using new technologies (AU)

Biopsychosocial correlations in patients with chronic oro-facial pain. Part II. Experiences of pain and dramatic events before the 16th year of life.

Before the sixteenth year of life, biopsychosocial influences such as self-experienced and observed accidents/illnesses, adverse medical/dental treatments, dangerous events and self-experienced or observed force seem to affect the manifestation of chronic pain in the oro-facial area in the forms of temporomandibular disorder (TMD) and psychogenic denture-intolerance (PDI)/somatoform oro-facial pain (SOP). We evaluated the occurrence of these types of events before the age of 16 years in 50 TMD patients, 55 PDI/SOP patients and 55 randomly selected pain-free control group (CG) using the medical questionnaire 'Physical well-being and traumatic experiences (PTE). A separate dental questionnaire determined the effects of previous experiences of pain or force on the emotional self-assessment of the patients (pain localization and body feeling). The TMD group was significantly more likely to have experienced an accident and an illness before the age of 16 years than were the other two groups (PDI/SOP and CG) (P < 0.039). Temporomandibular disorder and PDI/SOP patients suffered frequent backaches significantly more than CG patients (P < 0.028). The PDI/SOP patients were least likely to report having felt threatened before or after the age of 16 years (P < 0.003) compared with the PDI/SOP and CG group. Sociodemographic parameters, experiencing an accident, previous medical incidents, experiences of force and emotional self-assessment influence the biopsychosocial dynamics that directly influence oro-facial symptoms with psychogenic components. Similar to medical history, age seems to play a decisive role in the manifestation of oro-facial psychic symptoms.

Objetivos de presión arterial en diversas situaciones clínicas en pacientes con diabetes / Blood pressure targets in various clinical situations in diabetic patients

El objetivo de este trabajo es revisar las evidencias que avalan las recomendacionesde las guías de práctica clínica sobre la hipertensiónarterial y la diabetes mellitus en relación con los objetivos de controlde la presión arterial (PA). En la actualidad, la práctica totalidad de lasguías coinciden, con algunos matices, en que los objetivos son alcanzary mantener unas cifras de presión arterial sistólica (PAS) <130mmHg y de presión arterial diastólica <80 mmHg. Con alguna excepción(la nefropatía diabética con proteinuria superior a 1 g/24 h es laúnica), estos objetivos no varían en función de la presencia de otraspatologías asociadas a la diabetes. La revisión de los ensayos clínicospermite concluir que la reducción de las cifras de PA es, sin duda, beneficiosa. Sin embargo, incluso en las condiciones de los ensayosclínicos, muy apartadas de la realidad práctica de la atención primaria,un porcentaje considerable de pacientes no alcanzan los objetivos decontrol propuestos en las guías, especialmente de PAS, a pesar de lautilización de combinaciones de dos o más fármacos antihipertensivos(AU)

The objective of this paper is to review the evidence that supports therecommendations of the Clinical Practice Guidelines on arterial hypertensionand diabetes mellitus with regard to blood pressure controltargets. Nearly all the Guidelines currently state, with certain nuances,that the targets are to achieve and maintain a systolic blood pressureof <130 mmHg and a diastolic blood pressure of <80 mmHg. Apartfrom certain exceptions –diabetic nephropathy with proteinuria greaterthan 1 g/24 hours is the only one– those targets do not vary accordingto the presence of other pathologies associated with diabetes. Thereview of the clinical trials makes it possible to conclude that bloodpressure lowering is, without a doubt, benefi cial. Nevertheless, even inthe conditions of the clinical trials, which are very far removed from thepractical reality of Primary Health Care, a substantial percentage ofpatients do not achieve the control targets recommended in the guidelines;this is especially true in the case of systolic blood pressure, despitethe use of combinations of two or more antihypertensive drugs(AU)