Evaluación de la realización del cribado del pie diabético en Atención Primaria

AimTo ascertain whether patients with type 2 diabetes are screened for diabetic foot, and to analyze the factors related to patients and centers associated to performance of such screening.Material and methodsA multicenter, epidemiological, cross-sectional study was conducted. The clinical records of 443 patients with type 2 diabetes monitored at Primary Care for at least 12 months were reviewed. Demographic and healthcare variables and characteristics of the primary care center were recorded.ResultsIn the previous year, 51.2% of patients had been trained on foot self-care, 56.4% had undergone foot inspection, 39.5% had been examined with a monofilament, and palpation of peripheral pulses and measurement of the ankle-brachial index were performed in 45.8 and 10.1% of patients, respectively. Diabetic foot screening (inspection, monofilament testing, and palpation of peripheral pulses) was performed in 37% of study patients. Ulcer risk stratification was done in 12.4% of patients. A significant association was found between diabetic foot screening and presence of foot deformities (P < .001), history of neuropathy (P = .005), and history of peripheral artery disease (P < .05). Screening was also associated to some characteristics of the center, such as reception of information about goal achievement (P < .001) and economic incentives for goal attainment (P < .001).ConclusionsCompliance with diabetic foot screening and ulcer risk stratification in patients with type 2 diabetes in Primary Care was poor.     

Viabilidad de una intervención psicológica individualizada para personas mayores con demencia y discapacidad visual

IntroductionThe ageing of the population has led to a progressive increase in age-related diseases, such as dementia or visual impairment, due to chronic diseases. This work describes and analyses the efficacy and feasibility of an individualised intervention carried out with two male users of a day-care centre with a diagnosis of dementia and a severe visual impairment, which made it difficult for them to take part in the regular activities of the centre.Material and methodThe intervention process had a time frame of three months, and had an assessment phase before and after the intervention. For the assessment, use was made of the Mini-Mental State Examination, Geriatric Depression Scale, and an observational tool based on the Dementia Categorization Recording Observational System. The intervention lasted for eight weeks, and consisted of different dynamics adjusted to the preferences of the participants.Results and conclusionsAfter the intervention, a clinically significant reduction in the depressive symptomatology was observed for both participants, along with a reduction in the frequency of apathetic behaviour during the time they spent in the centre. Furthermore, an increase was observed in the prosocial behaviour and on the engagement with the task. The results show that the personalisation of the activities for particular users increases the stimulation of the participants, improving their well-being through small and inexpensive adaptations to the interventions that are carried out in the centres.     

Evaluación funcional y cognitiva en una población urbana de mayores de 89 años. Estudio NonaSantFeliu

Introductionthe increase in life expectancy should be characterized by an increase in disability-free life. We assessed functional and cognitive capacity in an urban population older than 89 years, as well as possible gender variations.Material and methodsthe NonaSantFeliu study is a longitudinal, observational, population-based study. We present the first crosssectional survey of 186 inhabitants older than 89 years in a city. Sociodemographic data were gathered. We assessed basic activities of daily living with the Barthel Index (BI), instrumental activities with the Lawton Index (LI), cognitive status with the Mini-Mental State Examination (MMSE) and comorbidity with the Charlson Index (CI).Resultsof 186 examined nonagenarians, 143 (76.5%) were women. The mean age SD was 93.1 ± 3.1 years. One-hundred forty nine (80.2%) were widowed and 26% were institutionalized. The mean BI was 60.8 ± 30; 56% were functionally independent or had slight dependence. The mean LI was 2.1 ± 2.8. The mean MMSE score was 21 ± 11; 56% had an MMSE score higher than 23. The mean CI was 1.4 ± 1.7. No significant differences were found by gender.Conclusionsdespite their advanced age, most of the nonagenarians showed mild functional and cognitive impairment with low comorbidity. No significant differences were observed by gender. Future studies should help to detect nonagenarians at high risk of rapid impairment to allow early initiation of interventions to delay the development of further incapacity.     

Evaluación del grado de consecución de objetivos de control metabólico en pacientes con diabetes mellitus tipo 2

ObjectiveTo evaluate the extent to which metabolic targets in type 2 diabetes (DM-2) are achieved in the Endocrinology and Clinical Nutrition Unit of the Hospital Puerta del Mar in Cadiz (Spain) from 2005 to 2008.MethodThe database included in the computer application HP-Doctor used for all patients attended in our unit (admissions, consultations and peripheral centers) was analyzed. All patients with a principal or secondary diagnosis of DM-2 were included. Clinical characteristics, chronic complications, drug treatment and the percentage of patients who achieved annual mean targets of glycosylated hemoglobin (HbA1c) and low-density lipoprotein cholesterol (LDLc) were analyzed.ResultsFrom 2005 to 2008, the number of DM-2 patients with computerized records increased by 108.7%. In 2008, 1,177 patients were evaluated. A total of 10.8% were active smokers, 53% had hypertension, and 51.2% and 12.6% presented with retinopathy and cardiovascular disease, respectively. During the study period, the percentage of patients with a mean HbA1c <7% was similar (2005: 31.7% 2008: 30.4%), those with LDLc <100 mg/dl increased from 19.2% to 25.6% and only 9.2% of patients achieved both targets, HbA1c <7% and LDLc <100 mg/dl.ConclusionsIn 2008, only 30% of DM-2 patients achieved a mean HbA1c < 7% and only 25% had LDLc < 100 mg/dl. Metabolic control in DM-2 patients should be improved.     

Atención a pacientes COVID-19 durante la primera ola de la pandemia en un hospital de media estancia. Variables asociadas con mortalidad en ingresados en situación aguda

Background and objectiveSpain has been one of the countries most affected by the SARS-CoV-2 pandemic. The objective of this study is to describe the characteristics of the patients treated for COVID-19 at Guadarrama Hospital and to identify the associated mortality factors in those admitted in an acute situation.Material and methodsRetrospective observational study of COVID-19 patients admitted from 3/15 to 5/15/2020. Sociodemographic, mental, functional, analytical, clinical, radiological and therapeutic variables were collected. Factors associated with mortality were analysed using a bivariate and multivariate study.ResultsTwo hundred eleven patients were included: 102 (48.3%) in an acute situation and 109 (51.7%) in the convalescent phase, the median (interquartile range) age was 82 (72, 85) years. The most frequent symptoms were fever, cough and respiratory failure. The 89.9% had pneumonia.An acute mortality rate of 26.5% (27/102) was detected and the associated factors were: respiratory failure (P 0.002), Charlson index (ChI)≥3 (P<0.001), CURB≥2 (P 0.011), low SatO₂/FiO₂ ratio (<0.001), elevated urea (P<0.001) and creatinine (P 0.036), hypoproteinemia (P 0.037) and age (P<0.018). The deceased had a worse functional situation than the survivors (P 0.025). In the multivariate analysis, SatO₂/FiO₂ ratio (OR: 2.23; 95% CI: 1.07-4.63; P 0.031) and ChI≥3 (OR: 4.25; 95% CI: 1.06-17.04; P 0.041) were independent factors of mortality.ConclusionsThe COVID-19 patients treated were mostly severe cases. The variables associated with mortality were age, respiratory failure, comorbidity, kidney failure, and malnutrition. Respiratory failure and comorbidity outweigh age as independent risk factors for mortality.     

Valoración de la musculatura isquiosural en personas mayores

Objectiveto evaluate hamstring flexibility in older adults.Materials and methodsa total of 177 subjects (13 men and 164 women) aged between 43 and 80 years old (mean age = 63.4 ± 6.7 years) who attended fitness classes were evaluated. The mean height was 161 ± 10 cm and the mean weight was 74 ± 5.6 kg. Hamstring flexibility was evaluated using the straight leg raise test.Resultsthe mean flexion in the right hip was 72° ± 13.2° and the mean flexion of the left hip was 72.4° ± 13.8°. No significant differences were found in the values obtained from the straight leg raise test in the left and right legs. For the right leg, 48.02% of the subjects’ values were within the normal range, while 28.81% showed grade I shortness, and 23.61% showed grade II shortness. For the left leg, 49.94% showed normal values, 29.94% showed grade I shortness, and 22.03% showed grade II shortness.Conclusionshalf of the adults and elderly individuals that took part in the present study had hamstring shortness, which increased in frequency with age.     

Evaluación de la efectividad del tratamiento con glucocorticoides intravenosos en la oftalmopatía de Graves

ObjectiveTo assess the efficacy of intermittent, high-dose treatment with intravenous glucocorticoids (IV GCs) in moderate to severe Graves’ ophthalmopathy (GO).Materials and methodsPatients with GO treated with IV GCs from August 2007 to August 2011 at the Endocrinology Department of Reina Sofía Hospital were enrolled into the study. IV pulse prednisolone (7.5 mg/kg/day) was administered twice weekly every two weeks for 6 weeks, and at half the dose for 6 additional weeks.ResultsEighteen patients (mean age, 43+/-11 years) with moderate to severe GO were analyzed (83.3% females). Four were active smokers, five former smokers, and the rest had never smoked. Hyperthyroidism due to Graves’ disease was found in 66.7% of patients, 41.6% of whom had received radioiodine therapy. Response to treatment was satisfactory in 72.2%, partial in 11.1%, and poor in 16.7%. Mild side effects were reported by 5 patients. Before treatment, 83.3% had diplopia, 33.3% eyelid retraction, 72.2% eye pain, and 44.4% exophthalmos. After treatment, only 33.3% had diplopia (P = .004), 5.6% eyelid retraction (P = .063), 16.7% eye pain (P = .002), and 11.1% exophthalmos (P = .031). Response to treatment was not related to the underlying disease (P = .866), prior radioiodine treatment (P = .447), or smoking status (P = .368).ConclusionsIntravenous glucocorticoid therapy decreased activity in patients with moderate to severe active GO, with major improvement occurring in diplopia, eye pain, and exophthalmos. Side effects were mild and uncommon. Treatment response was independent from the underlying disease, prior radioiodine treatment, or smoking status.     

Programas para combatir la soledad en las personas mayores en el ámbito institucionalizado: una revisión de la literatura científica

Loneliness is a problem that affects a very high percentage of older people, and can lead to physical and/or mental illness. This article aims to present a systematic review of programs to combat loneliness directed towards the institutionalised elderly. Experimental and quasi-experimental articles published between 2000 and 2016 were included in the review. An analysis was carried out on the quality of the methodological evidence of each of the articles. The programs analysed included animal-assisted, contacts with families through videoconferencing, gardening and/or horticulture workshops, reminiscence therapies, humour therapies, and cognitive interventions. The results show that intervention programs are effective to reduce the feeling of loneliness. The methodological limitations of the studies are discussed and future research is recommended.     

Evaluación de la utilización de las prestaciones específicas de los sistemas de infusión subcutánea de insulina y su relación con el control metabólico en pacientes con diabetes tipo 1

Background and objectivePatients with type 1 diabetes (T1DM) treated with continuous subcutaneous insulin infusion (CSII) have available several specific features of these devices. The aim of this study was to evaluate the relationship between real use of them and the degree of glycemic control in patients using this therapy.Patients and methodsForty-four T1DM patients on CSII therapy with or without real-time continuous glucose monitoring (CGM) were included. Data from 14 consecutive days were retrospectively collected using the therapy management software CareLink Personal/Pro^® and HbA1c measurement performed at that period. The relationship between the frequency of usie of specific features of insulin pumps (non-sensor augmented or sensor-augmented) and glycemic control was analyzed.ResultsMean HbA1c in the group was 7.5 ± .8%. Mean daily number of boluses administered was 5.1 ± 1.8, with 75.4% of them being bolus wizards (BW). Daily number of boluses was significantly greater in patients with HbA1c < 7.5% than in those with HbA1c > 7.5% (5.3 ± 1.6 vs. 4.3 ± 1.6, P = .056). There was a trend to greater use of BW in patients with better control (82.8 ± 21.4% vs. 69.9 ± 29.1%, P = .106). HbA1c was lower in patients using CGM (n = 8) as compared to those not using sensor-augmented pumps (7.6 ± .8 vs 7.1 ± .7, P = .067), but the difference was not statistically significant.ConclusionsMore frequent use of BW appears to be associated to better metabolic control in patients with T1DM using pump therapy. In standard clinical practice, augmentation of insulin pump with CGM may be associated to improved glycemic control.     

Atención psicomédica a personas transexuales en España en la era de la despatologización de la transexualidad como trastorno mental. Una revisión global

ObjectiveTo identify the strengths and weaknesses of Spanish healthcare protocols for transsexual persons and to compare them to current international protocols. To review the current status as regards transsexuality etiology and prevalence. To suggest measures to optimize care to achieve a significant improvement, including options for saving financial resources.MethodsA comparison of the contents of texts related to transsexualism in the ICD-10, DSM-IV, and guidelines of the Spanish gender units with international standards of care for transgender persons and the last draft version of the DSM-5. Systematic revision of the literature related to the etiology and prevalence of transsexualism.ResultsSignificant discrepancies have been found as regards the minimum time period for diagnosis, access to hormone replacement therapy and to genital surgery, and the requirement of the so-called real-life experience. Impact of sex hormones on the etiology of transsexualism and underestimation of its prevalence was confirmed.ConclusionsThe access to hormonal and surgical treatment requires a profound review, and decentralization of transsexual care is recommended, because all university hospitals haves psychiatrists, clinical psychologists, and endocrinologists available. Although gender reassignment surgery also requires plastic surgery specialists, plastic surgeons currently receive training in this field.     

Evaluación de la utilidad diagnóstica de la biopsia ungueal en las onicomicosis

BackgroundOnychomycosis affects between 2% to 30% of the world population. Nail biopsy may help in making a diagnosis and can distinguish between invasion and colonisation.AimsTo evaluate the diagnostic usefulness of nail biopsy with Periodic acid–Schiff (PAS) staining for onychomycosis, compared to direct KOH examination, culture and its combination in a reference laboratory in Colombia.MethodsThe study included 66 patients in whom a blind and independent reading of the three tests was performed. The usefulness was defined based on the validity (sensitivity, specificity, Youden's index, likelihood ratios), performance (predictive values) efficiency (proportion of correctly diagnosed patients), and reproducibility (kappa coefficient).ResultsThe mean age of the patients was 55 ± 16 years, and included 76% women. The direct tests with KOH were positive in 66.7% (n = 44), 62.1% (n = 41) were positive with culture, and 56.1% (n = 37) with the biopsy. The main causal agents were non-dermatophytes moulds in 36.4% (n = 24). The most frequent species were Neoscytalidium dimidiatum (n = 11), Trichophyton rubrum (n = 11), and Candida parapsilosis (n = 13). The sensitivity of nail biopsy, when compared to the standard (KOH and/or culture), was 71%, specificity 83%, Youden's index 0.54, positive likelihood ratio 4.25, negative likelihood ratio 0.35, positive predictive value 92%, negative predictive value 52%, efficiency 74% and kappa coefficient 0.45. When biopsy was evaluated only in patients with onycholysis of the nail plate greater than 50%, all the parameters of diagnostic usefulness increased.ConclusionsThe overall usefulness of the biopsy was moderate for patients with more severe symptomatology, which makes its use advisable in cases of extensive onycholysis, and when discriminating colonisation from invasion is required.     

Expresión sexual y regulación de la sexualidad en residencias de personas mayores

Objectives

The study had three objectives: (a) To determine how staff perceives the frequency of different sexual expressions in long-term care facilities for older people; (2) to quantify policies aimed at guaranteeing residents’ sexual rights in such institutions, and (3) to determine factors influencing the presence of these kind of policies.

Análisis de la sedación paliativa en pacientes mayores hospitalizados: efectividad de un protocolo

ObjectiveTo measure changes in the practice of palliative sedation during agony in hospitalised elderly patients before and after the implementation of a palliative sedation protocol.Material and methodsA retrospective before-after study was performed in hospitalised patients over 65 years old who received midazolam during hospital admission and died in the hospital in two 3-month periods, before and after the implementation of the protocol. Non-sedative uses of midazolam and patients in intensive care were excluded. Patient and admission characteristics, the consent process, withdrawal of life-sustaining treatments, and the sedation process (refractory symptom treated, drug doses, assessment and use of other drugs) were recorded. Association was analysed using the Chi² and Student t tests.ResultsA total of 143 patients were included, with no significant differences between groups in demographic characteristics or symptoms. Do not resuscitate (DNR) orders were recorded in approximately 70% of the subjects of each group, and informed consent for sedation was recorded in 91% before vs. 84% after the protocol. Induction and maintenance doses of midazolam followed protocol recommendations in 1.3% before vs 10.4% after the protocol was implemented (P=.02) and adequate rescue doses were used in 1.3% vs 11.9% respectively (P=.01). Midazolam doses were significantly lower (9.86 mg vs 18.67 mg, P<.001) when the protocol was used than when it was not used. Ramsay sedation score was used in 8% vs. 12% and the Palliative Care Team was involved in 35.5% and 16.4% of the cases (P=.008) before and after the protocol, respectively.ConclusionsUse of midazolam slightly improved after the implementation of a hospital protocol on palliative sedation. The percentage of adequate sedations and the general process of sedation were mostly unchanged by the protocol. More education and further assessment is needed to gauge the effect of these measures in the future.     

Atención de pacientes adultos con crisis epilépticas en servicios de urgencias (Registro ACESUR). Diferencias en función de la edad ≥ 75 años

ObjectivesTo determine whether there are differences in the profile and in the care of adult patients with epileptic seizures in emergency department according to age ≥ 75 years, and if this is independently associated with results in the emergency department and 30 days after discharge.Material and methodsACESUR is a multicentre, prospective, observational cohort multipurpose register that was carried out in 2017. The distribution of the variables corresponding to the clinical presentation and care according to age ≥ 75 years were compared. Subsequently, logistic regression models were performed with the objective of evaluating the effect of age ≥ 75 years on the outcome variables.ResultsA total of 541 (81.5%) cases younger than 75 years were analysed compared to 123 adult patients (18.5%) of ≥ 75 years or more. In the group of long-lived it was observed significantly greater probability of dependence, co-morbidity, polypharmacy, a previous visit to the hospital emergency department, arrived by ambulance, first seizures and a symptomatic aetiopathogenic classification. In the multivariate analysis, after adjusting for the above variables, it is observed that age > 75 years is associated independently with a higher incidence of specific supplementary tests (OR: 2.31; 95% CI: 1.21-4.44), but not pharmacological intervention (OR: 1.63; 95% CI: 0.96-2.80), or hospitalisation or extended stay in emergency departments (OR: 1.56; 95% CI: 0.94-2.59). On adjusting for all previous variables, age > 75 years is associated with lower incidence of adverse events at 30 days (OR: 0.43; 95% CI: 0.25-0.77).ConclusionsIn the ACESUR Registry, differences in clinical presentation and in the care of patients with seizures in emergency departments were identified when comparing those patients > 75 years with those < 75 years. Age ≥ 75 years is not independently associated with a higher incidence of intervention in emergency departments, or with more adverse outcomes at 30 days after discharge.     

Innovando en la toma de decisiones compartida con pacientes hospitalizados: descripción y evaluación de una herramienta de registro de nivel de intensidad terapéutica

Background and aimShared decision-making between patients and healthcare professionals is crucial to guarantee adequate coherence between patient values and preferences, caring aims and treatment intensity, which is key for the provision of patient-centred healthcare. The assessment of such interventions are essential for caring continuity purposes. To do this, reliable and easy-to-use assessment systems are required. This study describes the results of the implementation of a hospital treatment intensity assessment tool.Material and methodsThe pre-implementation and post-implementation results were compared between two cohorts of patients assessed for one month.ResultsSome record of care was registered in 6.1% of patients in the pre-implementation group (n = 673) compared to 31.6% of patients in the post-implementation group (n = 832) (P < .01), with differences between services. Hospital mortality in both cohorts is 1.9%; in the pre-implementation group, 93.75% of deceased patients had treatment intensity assessment.ConclusionsIn hospital settings, the availability of a specific tool seems to encourage very significantly shared decision-making processes between patients and healthcare professionals —multiplying by more than 5 times the treatment intensity assessment. Moreover, such tools help in the caring continuity processes between different teams and the personalisation of caring interventions to be monitored. More research is needed to continue improving shared decision-making for hospital patients