Search

Background Chronic conditions are one of the main determinants of frailty, functional disability, loss of quality of life and the number one cause of death worldwide. This study aimed to describe the survival of patients with chronic conditions who were followed up in primary care according to the level of risk by adjusted morbidity groups and to analyse the effects of sex, age, clinician and care factors on survival. Methods This was a longitudinal observational study of a retrospective cohort of patients with chronic conditions identified by the adjusted morbidity group stratifier of the electronic medical records in a primary health centre of the Region of Madrid, which has an assigned population of 18,107 inhabitants. The follow-up period was from June 2015 to June 2018. A description of survival according to the Kaplan–Meier method and Cox proportional hazards multivariate regression model was used to analyse the effects of sex, age, clinician and care factors. Results A total of 9,866 patients with chronic conditions were identified; 77.4% (7,638) had a low risk, 18.1% (1,784) had a medium risk, and 4.5% (444) had a high risk according to the adjusted morbidity groups. A total of 477 patients with chronic conditions died (4.8%). The median survival was 36 months. The factors associated with lower survival were age over 65 years (hazard ratio [HR] = 1.3; 95% confidence interval [CI] = 1.1–1.6), receiving palliative care (HR = 3.4; 95% CI = 2.6–4.5), high versus low risk level (HR = 2.4; 95% CI = 1.60–3.7), five chronic conditions or more (HR = 1.5; 95% CI = 1.2-2), complexity index (HR = 1.01; 95% CI = 1.02–1.04) and polymedication (HR = 2.6; 95% CI = 2.0-3.3). Conclusions There was a gradual and significant decrease in the survival of patients with chronic conditions according to their level of risk as defined by adjusted morbidity groups. Other factors, such as older age, receiving palliative care, high number of chronic conditions, complexity, and polymedication, had a negative effect on survival. The adjusted morbidity groups are useful in explaining survival outcomes and may be valuable for clinical practice, resource planning and public health research.

Puntos para una lectura rapida • Los pacientes en tratamiento con IECA o ARAII no tienen mayor riesgo de infeccion por SARS-COVID, ni mayor riesgo de COVID-19 grave ni de mortalidad. Por ello, deben continuar con el tratamiento, y solo estaria justificada su retirada por motivos clinicos. • Los pacientes con COVID-19 en tratamiento con hipolipemiantes deben continuar con ellos, especialmente aquellos con alto riesgo de enfermedad cardiovascular. Se suspenderan si hay riesgo hepatico o renal o si esta impedida la via oral. Se valorara el cambio de estatina si hay interaccion con el tratamiento para la infeccion. • En pacientes diabeticos con COVID-19 se recomienda suspender los iSGLT-2 (gliflozinas o uricosuricos) en caso de fiebre o diarrea, y vigilar funcion renal y glucemia por si es necesario ajustar el resto de los antidiabeticos. La insulina es el tratamiento de eleccion en caso de retirada del resto de farmacos. • Los medicamentos psicotropicos pueden interactuar con los farmacos utilizados para la COVID-19 y algunos de sus efectos adversos, especialmente los relacionados con la depresion respiratoria, pueden empeorar la evolucion de la infeccion. • No se ha encontrado asociacion entre el uso de inhibidores de la bomba de protones o anti-H2 y la aparicion de COVID-19. La evidencia actual no indica la necesidad de retirar el omeprazol en los casos con clara indicacion. • No hay evidencia cientifica que relacione el uso de antiinflamatorios no esteroideos (AINE) con el empeoramiento de la COVID-19, por lo que pueden usarse en el tratamiento sintomatico de la infeccion y/u otras comorbilidades asociadas. • No se deben interrumpir los tratamientos cronicos con AINE u opiaceos que estan bien indicados. Se recomienda elegir opioides con menos efecto inmunosupresor. • Durante la COVID-19 se recomienda suspender temporalmente los anticonceptivos y continuar con los anticoagulantes o antiagregantes que tomase previamente.

Resumen: Objetivo: Estudiar el efecto del tipo de seguimiento según la cartera de servicios y de otros factores asociados en la disminución de las cifras de HbA1c en personas con diabetes mellitus tipo 2, nuevo diagnóstico y con mal control inicial. Diseño: Estudio observacional analítico de una cohorte en condiciones de práctica clínica habitual. Emplazamiento: 262 centros de salud de Atención Primaria de Madrid. Participantes: 1838 personas mayores de 18 años con nuevo diagnóstico de diabetes y cifras de HbA1c inicial ≥ 7% o ≥ 8,5% si tienen más de 75 años. Intervenciones: La variable exposición fue el tipo de seguimiento según la cartera, categorizado en mínimo, medio y óptimo, según el número de intervenciones realizadas y periodicidad por tipo de plan terapéutico-farmacológico. Mediciones principales: Se estudiaron comorbilidad, plan terapéutico-farmacológico, consejos dieta y ejercicio, índice de privación. La variable resultado principal fue la diferencia entre la HbA1c final e inicial. Resultados: Tras 2 años de seguimiento se produjo una disminución media de la HbA1c de –1,7 puntos porcentuales (IC del 95%: –1,6; –1,8), siendo 0,39 puntos mayor en los pacientes con tipo de seguimiento óptimo: –2,1 (IC del 95%: –1,7; –2,4). Los factores asociados a la disminución fueron: tipo de seguimiento óptimo –0,29 (IC del 95%: –0,5; –0,1) y medio –0,26 (IC del 95%: –0,5; –0,0), y valor de la HbA1c inicial –0,9 (IC del 95%: –0,9; –0,9) y los factores asociados al aumento: tratamiento con insulina y vivir en zonas socialmente desfavorecidas. Conclusiones: Los pacientes con diagnóstico reciente de diabetes en los que se realiza un seguimiento óptimo según la cartera de servicios mejoran el control glucémico. Abstract: Objective: To study the effect of the type of follow-up according to Service Portfolio and other associated factors, in the reduction of HbA1c levels in people with a new diagnosis of type 2 diabetes and poor initial control. Design: Analytical observational study of a cohort under routine clinical practice conditions. Location: 262 Primary Health Care Centres in Madrid. Participants: 1,838 individuals older than 18 years with a new diagnosis of type 2 DM and initial HbA1c levels ≥ 7%, or ≥ 8.5% if older than 75 years. Interventions: The exposure variable was the type of follow-up according to Portfolio, categorised as minimum, medium, and optimal, according to the number of interventions performed and periodicity of type of therapeutic-pharmacological plan. Main measurements: A study was made of the comorbidity, therapeutic-pharmacological plan, diet - exercise advice and deprivation index. The main outcome was the difference between the final and initial HbA1c. Results: After 2 years of follow-up there was a mean decrease in HbA1c by -1.7 percentage points (95% CI: -1.6;-1.8), which was 0.36 points higher in patients with optimal follow-up: -2.1 (95% CI: -1.7;-2.4). The factors associated with a decrease in HbA1c were the optimal follow-up -0.29 (95% CI: -0.5;-0.1), the medium follow-up -0.26 (95% CI: -0.5; -0.0), and the initial HbA1c value -0.9 (95% CI: -0.9; -0.9. The factors associated with the increase were insulin treatment and living in socially disadvantaged areas. Conclusions: Glycaemic control was improved in patients with a new diagnosis of diabetes in which optimal follow-up is performed as proposed in the Service Portfolio.

Background: Clinical practice guidelines (CPGs) have great teaching potential for health professionals in training, although their use is limited. The objective of this study was to evaluate the effectiveness and adherence to e-EDUCAGUIA teaching strategy using educational game with simulated clinical scenarios to implement a CPG on antimicrobial therapy compared to the usual dissemination strategies in improving the knowledge and skills of family medicine residents.Methods: This was a multicentre cluster-randomized clinical trial in 7 teaching units in Madrid (Spain). Intervention: educational games based on CPG recommendations, compared with the passive dissemination of the guideline. Main outcome variable: knowledge and skills questionnaire scores one month after the intervention. The difference in mean scores between the intervention and control groups at one month was determined, along with the 95% CI using generalized linear models.Results: A total of 202 residents participated (104 in the intervention group and 98 in the control group). One hundred residents performed the post-test at one month (45 in the intervention group vs. 55 in the control group). The differences favoured the intervention group in terms of both the final scores at month (11.4, 95% CI 6.9–15.9) and the change from baseline scores (11.9, 95% CI 5.9–17.9), with estimated effect sizes of 0.88 for the between-groups difference and 0.75 for the change in baseline difference. For each additional hour of training in evidence-based medicine there was a an increase of 0.28 points (95 % CI 0.15–0.42). Conclusions: The e-EDUCAGUIA strategy improves the knowledge and skills of medicine residents for clinical decision-making during short-term antimicrobial therapy. Adherence to educational games in the absence of specific incentives is moderate.Trial registration: ClinicalTrials.gov Identifier: NCT02210442. Registered 6 August 2014, https://www.clinicaltrials.gov/ct2/show/NCT02210442

Confinement due to the COVID-19 pandemic has had a major impact on the living habits and health of the population, notably in the pre-frail elderly. This study aimed to study the effect of the COVID-19 pandemic on the physical function, mental function (cognition and mood), and quality of life of pre-frail elderly individuals over 70 years of age following confinement as well as to analyze the variables associated with the observed changes. Methods: Observational study of a cohort of pre-frail community-dwelling older adults over 70 years of age during the COVID-19 pandemic conducted in primary care. Variables: The main outcome variables were recorded during face-to-face interviews between December 14 of 2020 and August 12 of 2021 using scales for the evaluation of physical function (Short Physical Performance Battery), cognition (Lobo's Mini-Examen Cognoscitivo), depressive mood (Geriatric Depression Scale), and quality of life (EuroQol-5D-3L). Covariates: sociodemographic data and variables related to the pandemic and general health (social support network, COVID-19 infection, exercising, and leisure activities) were also collected. Analysis: The Student's t-test for paired samples and multivariate linear regression models were employed for the statistical analyses. Results: Ninety-two subjects were included in the study. Physical function, cognition, and depressive mood improved during the pandemic, whereas no changes were observed in quality of life. Suffering from COVID-19 was associated with deterioration of the cognitive function (−1.460; CI95%: −2.710 to −0.211). Conclusion: Confinement due to the COVID-19 pandemic was not associated with a decline in physical function, cognition, depressive mood, or quality of life in pre-frail individuals over 70 years of age, This study has been partially funded by the Instituto de Salud Carlos III (ISCIII) (project ref.: PI17/01887) and co-funded by the European Union. The study also received funds from the Foundation for Biosanitary Research and Innovation in Primary Care (FIIBAP) and the Regional Health Ministry of the Community of Madrid through non-refundable grants from the credits awarded to the Community of Madrid by the Spanish Government Fund COVID-19, included in Law HAC/667/2020. The funders had no role in the study design or decision to publish this article

Frailty is an increasing problem among the elderly people and it is more frequent in women. Physical activity improves either the function and quality of life. Given the diferences reported by the literature about the quality of life perception and the physical activity practice between men and women, the aim of this study is to analyze the association between health related quality of life (HRQoL) and physical activity in a pre-frail population and to study its relationship with gender.Descriptive study in pre-frail individuals over 70 years old assigned to twelve primary care health centers carried out between 2018 Jun and 2020 March in Madrid. The studied variables were registered by clinical interview: Physical activity (Yale), HRQoL (EQ-5D-3L), sociodemographic and clinical variables (comorbidity, depression and pain). Descriptive analysis and multiple linear regression for the whole population and stratified by gender, using the quality of life as dependent variable.The study involved 206 pre-frail individuals (152 women) wih an average age of 78 years. Women had less comorbidity (32.3% versus 55.6%) but more pain (60.5% versus 44.4%) than men. The median of physical activity was 40 points (55.9% of that score was attributable to relaxed walk). HRQoL was 0.74 in utility score and 68 in the EQ-VAS. No differences were found by gender. To walk more than 5 hours a week was found associated with better quality of life by EQ-5D utility score (0.08, IC95%: 0.03 to 0.14), and by EQ-VAS score (5.38, IC95%: 0.25 to 10.51).Physical activity was associated to better quality of life in a pre-frail population of individuals older than 70 years old.La fragilidad es un problema de creciente magnitud entre los mayores que afecta en mayor proporción a mujeres. La actividad física mejora tanto la funcionalidad como la calidad de vida. Dadas las diferencias en la percepción de la calidad de vida y en la práctica de actividad física entre hombres y mujeres, se planteó como objetivo analizar la asociación entre calidad de vida y actividad física en mayores de 70 años prefrágiles y su relación con el sexo.Estudio descriptivo en mayores de 70 años prefrágiles realizado entre junio de 2018 y marzo de 2020 en 12 centros de salud de Madrid. Se recogieron mediante entrevista clínica, variables de actividad física (cuestionario de Yale), calidad de vida (Euroqol-5D); variables sociodemográficas y de salud (comorbilidad, depresión y dolor). Se realizó análisis descriptivo y modelos de regresión lineal múltiple con calidad de vida como variable dependiente (total población y por sexo).Participaron en el estudio 206 individuos (152 mujeres), con una edad media de 78 años. Las mujeres presentaron menos comorbilidad (32,3% versus 55,6%) y más dolor (60,5% versus 44,4%) que los hombres. La media de actividad física fue de 40 puntos (55,9% de la puntuación corresponde a pasear relajadamente). La calidad de vida fue de 0,74 segun utilidades y de 68 en la EVA-EQ5D, sin diferencias según sexo. Pasear más de 5 horas/semana se asoció a mejor calidad de vida según utilidades (0,08, IC95%: 0,03 a 0,14), y según EVA (5,38, IC95%: 0,25 a 10,51).La actividad física se asoció a una mejor calidad de vida en población prefrágil mayor de 70 años.

Resumen: Objetivo: Estudiar si en pacientes mayores de 65 años con tratamientos antihipertensivos e hipolipemiantes los cambios de fármacos bioequivalentes con diferente apariencia se asocian a un aumento de errores de uso y pérdida de adherencia al tratamiento. Diseño: Estudio observacional, longitudinal, prospectivo, de cohorte de 1 año de seguimiento entre el 1 de enero de 2013 y el 31 de diciembre de 2014. Emplazamiento: Centros de Salud de la Comunidad de Madrid. Participantes: Pacientes ≥ 65 años con diagnóstico de HTA (CIAP K86) y/o dislipidemia (CIAP T93) en tratamiento con enalapril y/o amlodipino y/o simvastatina. Mediciones principales: Se recogieron mediante entrevista en consulta variables sociodemográficas (edad, sexo, nivel de estudios), clínicas, adherencia (test de Morisky-Green y recuento directo), errores de medicación (número y tipo), cambios de fármacos y número, parámetros bioquímicos (colesterol total, colesterol HDL, colesterol LDL, triglicéridos) y variable combinada (error y/o adherencia). Se realizaron 5 visitas: una basal y 4 trimestrales. Resultados: Se incluyeron 274 pacientes, edad media 72 (6,6) años, 47,8% mujeres. Presentaron algún cambio de medicamento 134 pacientes (48,9%), con una mediana de cambios de 3 (RIQ 1-5) y máximo de 11. El riesgo de presentar algún error o disminuir la adherencia estaba aumentado en expuestos a cambios en todas las visitas con RR 1,14 (1,16-1,69) al año de seguimiento. El error más frecuente fue la pérdida de dosis. Por cada cambio la probabilidad de un evento combinado aumenta en un 41%. Conclusiones: Los cambios realizados entre fármacos bioequivalentes con diferente apariencia podrían aumentar el número de errores de medicación y disminuir la adherencia. Habría que realizar más estudios para valorar en qué medida afecta al control de la enfermedad.No se contempla el apartado intervención por tratarse de un estudio observacional. Abstract: Objective: To study whether the changes in bioequivalent drugs with different appearances are associated with an increase in lack of adherence and medication use errors, in patients > 65 years old treated with antihypertensive and lipid-lowering medications. Design: Observational longitudinal prospective cohort study with a one-year follow-up period between 1 January 2013 and 31 December 2014. Location: Primary Healthcare Centres in the Community of Madrid. Participants: Patients ≥ 65 years-old with a diagnosis of hypertension and/or dyslipidaemia receiving treatment with Enalapril and/or Amlodipine and/or Simvastatin. Main measurements: Variables collected during a Primary Care consultation by means of a personal interview were: sociodemographic (age, gender, level of education), clinical variables, adherence (Morisky-Green test and direct counting), medication errors (number and type), medication changes and number, analytical (total cholesterol, HDL-cholesterol, LDL-cholesterol, triglycerides) and combined variable (error and/or adherence). There were 1 baseline and 4 quarterly visits. Results: The study included 274 patients with a mean age 72 (6.6) years, of whom 47.8% were female. Some medication changes were observed in 134 patients (48.9%), with a median of 3 (IQR 1-5) and a maximum of 11 changes. The risk of presenting with a medication use error or decreased adherence was increased in patients exposed to changes in all visits with RR 1.14 (1.16-1.69) at one year of follow-up. The most frequent error was the loss of dose. For each change in medication, the probability of a combined event increases by 41%. Conclusions: The changes made in bioequivalent drugs with different appearance could increase the number of medication use errors and decrease the adherence. More studies should be carried out to assess how much this affects the control of the disease.The intervention section is not considered because it is an observational study. Palabras clave: Isoapariencia, Medicamentos genéricos, Hipertensión, Dislipidemia, Cumplimiento, Adherencia, Error medicación, Keywords: Medication appearance, Generic drugs, Hypertension, Dyslipidaemia, Compliance, Adherence, Medication error

Background and Aim: Consensus has been reached on the need to integrate palliative care in the follow-up examinations of chronic obstructive pulmonary disease (COPD) patients. We analyzed the survival from the initiation of follow-up by a palliative home care team (PHCT) and described the needs and end-of-life process. Setting and Design: This study was a prospective observational cohort study of advanced COPD patients referred to a PHCT. Sociodemographic variables, survival from the start date of follow-up using the Kaplan–Meier model, health resource consumption, perceived quality of life, main symptomatology, opioid use, and advanced care planning (ACP) were analyzed. Results: Sixty patients were included. The median survival was 8.3 months. Forty-two patients died at the end of the study (85% at home or in palliative care units). The most frequent cause of death was respiratory failure in 39 patients (93%), with 29 of these patients requiring sedation (69%). Dyspnea at rest, with an average of 5 (standard deviation [SD] 2) points, was the main symptom. Fifty-five patients (91%) required opioids for symptom control. The median score in the St. George's Respiratory Questionnaire was 72 (SD 13). The mean number of visits by the home team was 7 (SD 6.5). The mean number of admissions during the monitoring period was 1.5 (SD 0.15). Conclusions: The characteristics of the cohort appear suitable for a PHCT. The follow-up care provided by our multidisciplinary unit decreased the number of hospitalizations, favored the development of ACP, and enabled death at home or in palliative care units.

Objective: To analyze trends in urinary tract infection hospitalization (cystitis, pyelonephritis, prostatitis and non-specified UTI) among patients over 65 years in Spain from 2000-2015. Methods: We conducted a retrospective observational study using the Spanish Hospitalization Minimum Data Set (CMBD), with codifications by the International Classification of Diseases (ICD-9). We collected data on sex, age, type of discharge, main diagnosis, comorbid diagnosis, length of stay, and global cost. All the hospitalizations were grouped by age into three categories: 65-74 years old, 75-84 years old, and 85 years old and above. In the descriptive statistical analysis, crude rates were defined as hospitalizations per 1,000 inhabitants aged ≥65. To identify trends over time, we performed a Joinpoint regression. Results: From 2000-2015, we found 387,010 hospitalizations coded as UTIs (54,427 pyelonephritis, 15,869 prostatitis, 2643 cystitis and 314,071 non-specified UTI). The crude rate of hospitalization for UTIs between 2000 and 2015 ranged from 2.09 in 2000 to 4.33 in 2015 Rates of hospitalization were higher in men than in women, except with pyelonephritis. By age group, higher rates were observed in patients aged 85 years or older, barring prostatitis-related hospitalizations. Joinpoint analyses showed an average annual percentage increase (AAPC) in incidence rates of 4.9% (95% CI 3.2;6.1) in UTI hospitalizations. We observed two joinpoints, in 2010 and 2013, that found trends of 5.5% between 2000 and 2010 (95% CI 4.7;6.4), 1.5% between 2010 and 2013 (95% CI -6.0;9.6) and 6.8% between 2013 and 2015 (95% CI -0.3;14.4). Conclusions: The urinary infection-related hospitalization rate in Spain doubled during the period 2000-2015. The highest hospitalization rates occurred in men, in the ≥85 years old age group, and in non-specified UTIs. There were increases in all types of urinary tract infection, with non-specified UTIs having the greatest growth. Understanding these changing trends can be useful for health planning. This study has been funded by Instituto de Salud Carlos III through the project “PI19/01700”, as part of the Plan Estatal de I+D+I 2017-2020 co-funded by European Regional Development Fund (ERDF) “A way of shaping Europe”. In addition, the principal investigator JRS received support to increase his research activities and to publish this manuscript from the 2020 funding program of the Fundación de Investigación e Innovación Biosanitaria en Atención Primaria (FIIBAP), Community of Madrid. Sí

The trial was financed by Ministerio de Sanidad y Consumo Español through their call for independent clinical research, Orden Ministerial SAS/2377, 2010 (EC10-115, EC10-116, EC10-117, EC10-119, EC10-122); CAIBER—Spanish Clinical Research Network, Instituto de Salud Carlos III (ISCIII) (CAI08/010044); and Gerencia Asistencial de Atención Primaria de Madrid. This study is also supported by the Spanish Clinical Research Network (SCReN), funded by ISCIII-Subdirección General de Evaluación y Fomento de la Investigación, project number PT13/0002/0007, within the National Research Program I+D+I 2013-2016 and co-funded with European Union ERDF funds (European Regional Development Fund). This project received a grant for the translation and publication of this article from the Foundation for Biomedical Research and Innovation in Primary Care (FIIBAP) Call 2017 for grants to promote research programs. Objectives To compare the effectiveness of oral versus intramuscular (IM) vitamin B12 (VB12) in patients aged ≥65 years with VB12 deficiency. Design Pragmatic, randomised, non-inferiority, multicentre trial in 22 primary healthcare centres in Madrid (Spain). Participants 283 patients ≥65 years with VB12 deficiency were randomly assigned to oral (n=140) or IM (n=143) treatment arm. Interventions The IM arm received 1 mg VB12 on alternate days in weeks 1–2, 1 mg/week in weeks 3–8 and 1 mg/month in weeks 9–52. The oral arm received 1 mg/day in weeks 1–8 and 1 mg/week in weeks 9–52. Main outcomes Serum VB12 concentration normalisation (≥211 pg/mL) at 8, 26 and 52 weeks. Non-inferiority would be declared if the difference between arms is 10% or less. Secondary outcomes included symptoms, adverse events, adherence to treatment, quality of life, patient preferences and satisfaction. Results The follow-up period (52 weeks) was completed by 229 patients (80.9%). At week 8, the percentage of patients in each arm who achieved normal B12 levels was well above 90%; the differences in this percentage between the oral and IM arm were −0.7% (133 out of 135 vs 129 out of 130; 95% CI: −3.2 to 1.8; p>0.999) by per-protocol (PPT) analysis and 4.8% (133 out of 140 vs 129 out of 143; 95% CI: −1.3 to 10.9; p=0.124) by intention-to-treat (ITT) analysis. At week 52, the percentage of patients who achieved normal B12 levels was 73.6% in the oral arm and 80.4% in the IM arm; these differences were −6.3% (103 out of 112 vs 115 out of 117; 95% CI: −11.9 to −0.1; p=0.025) and −6.8% (103 out of 140 vs 115 out of 143; 95% CI: −16.6 to 2.9; p=0.171), respectively. Factors affecting the success rate at week 52 were age, OR=0.95 (95% CI: 0.91 to 0.99) and having reached VB12 levels ≥281 pg/mL at week 8, OR=8.1 (95% CI: 2.4 to 27.3). Under a Bayesian framework, non-inferiority probabilities (Δ>−10%) at week 52 were 0.036 (PPT) and 0.060 (ITT). Quality of life and adverse effects were comparable across groups. 83.4% of patients preferred the oral route. Conclusions Oral administration was no less effective than IM administration at 8 weeks. Although differences were found between administration routes at week 52, the probability that the differences were below the non-inferiority threshold was very low. Publisher PDF

PURPOSE: Uncertainty exists regarding the best way to communicate cardiovascular risk (CVR) to patients, and it is unclear whether the comprehension and perception of CVR varies according to the format used. The aim of the present work was to determine whether a strategy designed for communicating CVR information to patients with poorly controlled high blood pressure (HBP), but with no background of cardiovascular disease, was more effective than usual care in the control of blood pressure (BP) over the course of a year. METHODS: A pragmatic, two-arm, cluster-randomized controlled trial was performed. Consecutive patients aged 40-65 years, all diagnosed with HBP in the last 12 months, and all of whom showed poor control of their condition (systolic BP ≥140 mmHg and/or diastolic BP ≥90 mmHg), were recruited at 22 primary healthcare centres. Eleven centres were randomly assigned to the usual care arm, and 11 to the informative intervention arm (Educore arm). At the start of the study, the Educore arm subjects were shown the "low risk SCORE table", along with impacting images and information pamphlets encouraging the maintenance of good cardiovascular health. The main outcome variable measured was the control of HBP; the secondary outcome variables were SCORE table score, total plasma cholesterol concentration, use of tobacco, adherence to prescribed treatment, and quality of life. RESULTS: The study participants were 411 patients (185 in the Educore arm and 226 in the usual care arm). Multilevel logistic regression showed that, at 12 months, the Educore intervention achieved better control of HBP (OR = 1.57; 1.02 to 2.41). No statistically significant differences were seen between the two arms at 12 months with respect to the secondary outcomes. CONCLUSIONS: Compared to usual care, the Educore intervention was associated with better control of HBP after adjusting for age, baseline SBP and plasma cholesterol, at 12 months. This study was funded by the Spanish Ministry of Science and Innovation via the Instituto de Salud Carlos III, Subprograma de Proyectos de Investigación en Evaluación de Tecnologías Sanitarias y Servicios de Salud (PI 09/90354), and the Fundación de Investigación e Innovación Biomédica en Atención Primaria (FIIBAP). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript Sí

Background Community-acquired pneumonia (CAP) is a lung infection that can be acquired during day-to-day activities in the community (not while receiving care in a hospital). Community-acquired pneumonia poses a significant public health burden in terms of mortality, morbidity, and costs. Shorter antibiotic courses for CAP may limit treatment costs and adverse effects, but the optimal duration of antibiotic treatment is uncertain. Objectives To evaluate the efficacy and safety of short-course versus longer-course treatment with the same antibiotic at the same daily dosage for CAP in non-hospitalised adolescents and adults (outpatients). We planned to investigate non-inferiority of short-course versus longer-term course treatment for efficacy outcomes, and superiority of short-course treatment for safety outcomes. Search methods We searched CENTRAL, which contains the Cochrane Acute Respiratory Infections Group Specialised Register, MEDLINE, Embase, five other databases, and three trials registers on 28 September 2017 together with conference proceedings, reference checking, and contact with experts and pharmaceutical companies. Selection criteria Randomised controlled trials (RCTs) comparing short- and long-courses of the same antibiotic for CAP in adolescent and adult outpatients. Data collection and analysis We planned to use standard Cochrane methods. Main results Our searches identified 5260 records. We did not identify any RCTs that compared short- and longer-courses of the same antibiotic for the treatment of adolescents and adult outpatients with CAP.We excluded two RCTs that compared short courses (five compared to seven days) of the same antibiotic at the same daily dose because they evaluated antibiotics (gemifloxacin and telithromycin) not commonly used in practice for the treatment of CAP. In particular, gemifloxacin is no longer approved for the treatment of mild-to-moderate CAP due to its questionable risk-benefit balance, and reported adverse effects. Moreover, the safety profile of telithromycin is also cause for concern.We found one ongoing study that we will assess for inclusion in future updates of the review. Authors' conclusions We found no eligible RCTs that studied a short-course of antibiotic compared to a longer-course (with the same antibiotic at the same daily dosage) for CAP in adolescent and adult outpatients. The effects of antibiotic therapy duration for CAP in adolescent and adult outpatients remains unclear.

ResumenLa investigación es una de las funciones básicas que debe desarrollarse en atención primaria. La información clínica almacenada en distintos registros y que deriva de la atención médica constituye una herramienta fundamental para esta actividad. El uso de los datos de carácter personal con fines de investigación está legitimado por nuestra legislación, sin embargo, esta información debe ser tratada de forma confidencial en todo momento. Para esto, se ofrecen dos alternativas, o bien la obtención del consentimiento informado del paciente o bien el tratamiento disociado de la información. Pero, en algunos supuestos, el cumplimiento de las exigencias legales a la hora de obtener datos para investigar se hace realmente difícil, planteándose una serie de dificultades que en muchos casos imposibilita el desarrollo de la investigación. En este documento marcaremos una orientación sobre el acceso a la información contenida en registros, respetando los derechos de los pacientes y la legislación vigente.AbstractResearch is one of the fundamental functions that have to be carried out in Primary Care. The clinical information stored in different records arising from medical care is a basic tool for this activity. The use of personal data for the purposes of research is legitimate according to our laws; however, this information must be treated confidentially at all times. Two alternatives are available for this. One is to obtain the informed consent of the patient, and the other is to dissociate the handling of the information. But in some situations, the compliance to legal demands when obtaining data for research is not easy, there being a series of obstacles which in many cases makes it impossible to carry out research. In this article, we will give guidance on how to access the information contained in records while respecting the rights of the patient and the current legislation.

ResumenObjetivoDeterminar la validez y utilidad del BNP en atención primaria para detectar la disfunción ventricular en pacientes asintomáticos con alto riesgo de insuficiencia cardiaca (IC).DiseñoEstudio descriptivo prospectivo y multicéntrico de validación de prueba diagnóstica.EmplazamientoConsultas de atención primaria de 7 centros de salud de la comunidad de Madrid.ParticipantesMuestra consecutiva de 204 pacientes asintomáticos con riesgo elevado de presentar IC (estadios A y B de la American Heart Association).Mediciones principalesSe recogieron datos de la anamnesis, exploración física, electrocardiograma, factores de riesgo de IC y tratamiento actual. Se determinó el BNP en sangre venosa en la propia consulta mediante Triage BNP Test® (Biosite®) realizándose en las siguientes 72h un ecocardiograma (prueba de referencia). Comparamos los niveles de BNP según presencia o ausencia de disfunción ventricular, tipo (sistólica/diastólica) y grado. Se calcularon la sensibilidad, especificidad y los valores predictivos para el mejor punto de corte en la curva ROC.ResultadosLos valores de BNP fueron más altos (p 96%).AbstractObjectiveThe aim of this study was to determine the accuracy of BNP test for early diagnosis of left ventricular dysfunction in patients at high-risk for heart failure.DesignCross-sectional descriptive study.Setting7 Primary Care Centres in Madrid (Spain).ParticipantsA consecutive sample of 204 consecutive asymptomatic patients with high risk for heart failure (Stages A-B, AHA/ACC Classification).Main measurementsBNP plasma levels were measured in the clinical setting using Triage BNP Test® (Biosite®) and an echocardiography was performed in the following 3 days in a single hospital unit as a reference standard. Plasma BNP levels were compared depending on the presence/absence of left ventricular dysfunction (LVD), type and severity degree. Sensitivity, specificity, positive and negative predictive values, and Área under the receiver operating characteristic curve (ROC) for BNP assay were calculated.ResultsBNP values were significantly higher (P

The number of aggressions towards health care professionals has risen over the past few years. There are no previous studies in primary care covering an entire region and to all professional categories. The aim of this study was to characterize aggressions in Primary Care in the Community of Madrid.Multicenter cross-sectional study. Analysis of a Registration System that reports any type of aggression suffered by Primary Care workers, in the Community of Madrid. The study variables included sociodemographic characteristics of the aggressor and the victim, the type of aggression (verbal or physical abuse), its causes and consequences. We described median, intercuartilic range and frequencies. Logistic regression was performed calculating odds ratio and their 95% confidence intervals.1,157 assaults were reported, 53.07% suffered by doctors. Physical assault occurred in 4.7% of the cases. The main reason was dissatisfaction with the care (36.1%). The non-medical staff showed less risk of being physically assaulted (OR: 0.38; CI95%: 0.17-0.86). The perpetrator profile was male (56.8%), aged between 31-40 (26.8%) years. Health care victim profile was female (84%), aged between 45-60 years. 10% of professionals reported some form of aggression, 5,9% of aggression were submitted to court.The risk of assault is higher in health personnel, particularly physicians. There were significant differences by gender and age, both in the profile of the aggressor and the victim.

ResumenObjetivoRecientes publicaciones han concluido que existen desigualdades sociales en salud en las personas mayores de 65 años en España, que afectan principalmente a mujeres y personas con bajo nivel socioeconómico. La salud autopercibida se ha relacionado con la prevalencia de enfermedades crónicas, la utilización de los servicios sanitarios y la mortalidad. El objetivo de este trabajo es valorar las desigualdades en la salud autopercibida de los mayores en relación con la edad, el género, los factores socioeconómicos y el nivel de dependencia.MétodosSe diseñó una revisión sistemática de la literatura siguiendo los criterios PRISMA. Se realizó una búsqueda exhaustiva en PubMed, WOK, Science Direct, EMBASE, IME, Cochrane, JSTOR, Ovid, Proquest y BMJ Group, y en bases electrónicas de tesis doctorales españolas hasta abril de 2013. La calidad de los estudios se evaluó por dos revisores de forma independiente mediante el instrumento desarrollado por Berra.ResultadosSe seleccionaron 20 documentos concordantes en señalar el empeoramiento de la salud autopercibida en los individuos de mayor edad (excepto en los más longevos), en los que tienen dependencia funcional, pertenecen a un nivel socioeconómico bajo y al género femenino.ConclusionesEsta revisión muestra que entre las personas mayores persiste la desigualdad de género y de nivel socioeconómico con respecto a la salud autopercibida. Son necesarios futuros estudios para aclarar los factores que hacen que persistan las desigualdades en los mayores, y así poder diseñar políticas de salud específicas para este sector de la población.AbstractObjectiveRecent publications have concluded that there are social health inequalities in people older than 65 years in Spain, especially among women and people with low socioeconomic status. Self-perceived health is an indicator that is related to the possibility of chronic disease, the use of health services, and mortality. The aim of this study was to assess inequalities in self-perceived health in relation to age, gender, socioeconomic factors, and functional dependence.MethodsA systematic review was conducted following the PRISMA criteria. An exhaustive search was performed in PubMed, WOK, Science Direct, EMBASE, IME, Cochrane, JSTOR, Ovid, Proquest, the BMJ Group and in Spanish doctoral theses up to April 2013. The quality of the studies was assessed by two independent editors through the Berra Tool.ResultsA total of 20 documents were selected. These studies were in agreement in the deterioration of self-perceived health among older people (except the oldest), in those with functional dependence, lower socioeconomic status, and in women.ConclusionsThis review shows that, among older people, inequalities in self-perceived health due to socioeconomic status and gender have persisted in time. Future research is needed to cast light on the factors determining the persistence of these inequalities among older people, so that specific health policies can be designed for this sector of the population.

Background The oral administration of vitamin B12 offers a potentially simpler and cheaper alternative to parenteral administration, but its effectiveness has not been definitively demonstrated. The following protocol was designed to compare the effectiveness of orally and intramuscularly administered vitamin B12 in the treatment of patients ≥65 years of age with vitamin B12 deficiency. Methods/design The proposed study involves a controlled, randomised, multicentre, parallel, non-inferiority clinical trial lasting one year, involving 23 primary healthcare centres in the Madrid region (Spain), and patients ≥65 years of age. The minimum number of patients required for the study was calculated as 320 (160 in each arm). Bearing in mind an estimated 8-10% prevalence of vitamin B12 deficiency among the population of this age group, an initial sample of 3556 patients will need to be recruited. Eligible patients will be randomly assigned to one of the two treatment arms. In the intramuscular treatment arm, vitamin B12 will be administered as follows: 1 mg on alternate days in weeks 1 and 2, 1 mg/week in weeks 3–8,and 1 mg/month in weeks 9–52. In the oral arm, the vitamin will be administered as: 1 mg/day in weeks 1–8 and 1 mg/week in weeks 9–52. The main outcome variable to be monitored in both treatment arms is the normalisation of the serum vitamin B12 concentration at weeks 8, 26 and 52; the secondary outcome variables include the serum concentration of vitamin B12 (in pg/ml), adherence to treatment, quality of life (EuroQoL-5D questionnaire), patient 3satisfaction and patient preferences. All statistical tests will be performed with intention to treat and per protocol. Logistic regression with random effects will be used to adjust for prognostic factors. Confounding factors or factors that might alter the effect recorded will be taken into account in analyses. Discussion The results of this study should help establish, taking quality of life into account, whether the oral administration of vitamin B12 is an effective alternative to its intramuscular administration. If this administration route is effective, it should provide a cheaper means of treating vitamin B12 deficiency while inducing fewer adverse effects. Having such an alternative would also allow patient preferences to be taken into consideration at the time of prescribing treatment. Trial registration This trial has been registered with ClinicalTrials.gov, number NCT 01476007, and under EUDRACT number 2010-024129-20.

Background High blood pressure (HBP) is a major risk factor for cardiovascular disease (CVD). European hypertension and cardiology societies as well as expert committees on CVD prevention recommend stratifying cardiovascular risk using the SCORE method, the modification of lifestyles to prevent CVD, and achieving good control over risk factors. The EDUCORE (Education and Coronary Risk Evaluation) project aims to determine whether the use of a cardiovascular risk visual learning method - the EDUCORE method - is more effective than normal clinical practice in improving the control of blood pressure within one year in patients with poorly controlled hypertension but no background of CVD; Methods/Design This work describes a protocol for a clinical trial, randomised by clusters and involving 22 primary healthcare clinics, to test the effectiveness of the EDUCORE method. The number of patients required was 736, all between 40 and 65 years of age (n = 368 in the EDUCORE and control groups), all of whom had been diagnosed with HBP at least one year ago, and all of whom had poorly controlled hypertension (systolic blood pressure ≥ 140 mmHg and/or diastolic ≥ 90 mmHg). All personnel taking part were explained the trial and trained in its methodology. The EDUCORE method contemplates the visualisation of low risk SCORE scores using images embodying different stages of a high risk action, plus the receipt of a pamphlet explaining how to better maintain cardiac health. The main outcome variable was the control of blood pressure; secondary outcome variables included the SCORE score, therapeutic compliance, quality of life, and total cholesterol level. All outcome variables were measured at the beginning of the experimental period and again at 6 and 12 months. Information on sex, age, educational level, physical activity, body mass index, consumption of medications, change of treatment and blood analysis results was also recorded; Discussion The EDUCORE method could provide a simple, inexpensive means of improving blood pressure control, and perhaps other health problems, in the primary healthcare setting; Trial registration The trial was registered with ClinicalTrials.gov, number NCT01155973 [http://ClinicalTrials.gov].

Background Different studies have investigated the effects that changes in drug appearance have on the control of chronic diseases and drug safety. The main objective of the proposed study is to evaluate if changes in the appearance of the packaging and presentation of drugs having the same active ingredient are related to a decrease in adherence and an increase in usage errors for chronic treatment using antihypertensive (enalapril and amlodipine) and hypolipidemic agents (simvastatin) in patients ≥65 years old, over a one-year follow-up period. Methods/Design We propose a multicentric observational longitudinal cohort study with a one-year follow-up period in 8 primary health care centers (PHCC) in the Community of Madrid. 259 patients who are ≥65 years old, hypertensive and/or dyslipidemic, undergoing treatment with enalapril and/or amlodipine and/or simvastatin, and under formal follow-up of chronic patients in primary health care will be selected by simple random sampling. The main outcome variable will be a final combined variable (adherence and medication usage errors). Other included variables will be: sociodemographic and clinical variables of the patient, degree of disease control, drug taken, number of changes in the appearance of each drug by the pharmacy, and the type and frequency of both avoidable and non-avoidable adverse effects during the follow-up period. A descriptive and a multivariate analysis of the variables will be carried out by means of a logistic regression model, using the final combined variable as the dependent variable (error and/or inadequate usage of the drug), and variables shown to be related to it during the bivariate analysis as the independent variables. Discussion For drugs of the same active ingredient, the effect that different package appearances and presentation may have on the safety of patients undergoing chronic treatments is unknown under the new legislative framework. There are various initiatives that promote the iso-appearance of drugs: “If they are the same, make them look the same”. It is to be expected that older, multi-medicated patients with chronic pathologies will be the ones under a greater risk of suffering from this problem.

Introduction: The acid-suppressive medications are used frequently in hospitalized patients, but some studies suggests that their are overused, especially in the treatment of stress ulcer prophylaxis in low-risk patients. This research determine the frequency of use and indications of acid-suppressive medications in hospitalized patients in a internal medical service. Materials and methods: A at random and retrospective revision of 209 medical records of 661 hospitalized patients during the year 2000 in the V Internal Medical Service of the General University Hospital of Gregorio Maranon (Cantoblanco). Definitions: Use: any prescription of an acid-suppressive medication, regardless of dosage regimen, in which the patient received at least one dose. Appropriated indication: endoscopical criteria: treatment of active ulcer disease, esophagitis or gastritis. Medical criteria: symptomatic gastroesophageal reflux, dyspepsia, prolonging of previous treatment, as a part of a treatment regimen for H. pylori, relief of dyspepsia caused by nonsteroidal anti-inflammatory drugs, stress ulcer prophylaxis in high risk patients. Inappropriate indication: any other uses were considered not indicated. Results: Of the 209 patients, a total of 157 (75,1%) received acidsuppressive therapy, average age 76 years old, 89 women (56,7%) and 68 men (43,3%). The admitting diagnoses for the admission were: CHF 34 (21,7%), Pneumonia ( 16,6%), UTI (15,3%) y COPD 18 (11,5%). The use in hospital ward was 84,7% (133), with inappropriate use 72,2% (96), the cause of prescription “no reason” 52,1% (50), and received proton pump inhibitors 46, 9% (45). Conclusions: This study show a high frequency of incorrect use of acid-suppressive medications in hospitalized patients.

Background Vaginitis is a common complaint in primary care. In uncomplicated candidal vaginitis, there are no differences in effectiveness between oral or vaginal treatment. Some studies describe that the preferred treatment is the oral one, but a Cochrane's review points out inconsistencies associated with the report of the preferred way that limit the use of such data. Risk factors associated with recurrent vulvovaginal candidiasis still remain controversial. Methods/Design This work describes a protocol of a multicentric prospective observational study with one year follow up, to describe the women's reasons and preferences to choose the way of administration (oral vs topical) in the treatment of not complicated candidal vaginitis. The number of women required is 765, they are chosen by consecutive sampling. All of whom are aged 16 and over with vaginal discharge and/or vaginal pruritus, diagnosed with not complicated vulvovaginitis in Primary Care in Madrid. The main outcome variable is the preferences of the patients in treatment choice; secondary outcome variables are time to symptoms relief and adverse reactions and the frequency of recurrent vulvovaginitis and the risk factors. In the statistical analysis, for the main objective will be descriptive for each of the variables, bivariant analysis and multivariate analysis (logistic regression).. The dependent variable being the type of treatment chosen (oral or topical) and the independent, the variables that after bivariant analysis, have been associated to the treatment preference. Discussion Clinical decisions, recommendations, and practice guidelines must not only attend to the best available evidence, but also to the values and preferences of the informed patient.