POS0749 ASSOCIATION BETWEEN IMMUNE-SEROLOGICAL PROFILE AND PULMONARY MANIFESTATIONS IN COLOMBIAN PATIENTS WITH SYSTEMIC LUPUS ERYTHEMATOSUS (LES)

Background:

Pulmonary involvement is common in Systemic Lupus Erythematosus (SLE) patients with varying degrees of parenchymal, vascular, and pleural compromise. In GLADEL, pulmonary involvement was reported in 28.4% of the cohort, but its occurrence ranges between 30-90% due to diversity in populations and the methods used to define it.

Objectives:

To describe the immune-serological profile of a Colombian cohort of SLE patients and to establish its association with pulmonary manifestations.

Methods:

Retrospective analysis of observational data from the follow-up of a cohort of adult patients with SLE. We included 559 patients that fulfilled the SLICC 2012 classification criteria with at least 6 months of disease history and being treated in a rheumatology specialized medical center between 2015 and 2018. The immuno-serological profile was characterized, and pulmonary involvement was monitored for 1 year. Diagnosis of pulmonary involvement was performed with the rheumatologist report in the clinical chart. Prevalence of pulmonary manifestations and immune-serological profile was determined, and logistic regression was performed afterward adjusted by age, sex, and level of education to establish the association between pulmonary manifestations and a positive auto-antibodies profile.

Results:

The median age of the cohort was 45 years, 96.5% were female. Pulmonary involvement was documented in 113 patients (20.5%) at the beginning of the study. Their frequency was: pleuritis (14.3%), lupus pneumonitis (3.6%), pulmonary hypertension (3.2%), interstitial lung disease (ILD) (2.3%), pulmonary embolism (2.3%), lung fibrosis (2.14%), alveolar hemorrhage (1.4%), shrinking lung (0.2%). At 1 year of follow up. there were no statistically significant differences in the frequency of pulmonary manifestations. As for the immune-serological profile, there were positive ANA in 92%, anti-dsDNA in 53.1%, anti-B2GP IgM 15.2%, anti- B2GP IgG in 17.2%, and ENA in 97.2%; as for the ENA 41.7% had positive anti-RNP, 40.2% anti-Ro, 36.4% anti-SM and 16.5% anti-La. Low complement levels was characterized as follows: C3 53.1% and C4 29.2%. In the logistic regression adjusted by age, sex and level of education, there was an association between anti-SM and pulmonary manifestations with an adjusted OR of 1.85; 95% CI 1.13-3.01.

Conclusion:

An association between anti-SM positivity and pleuro-pulmonary manifestations was found. In other cohorts with a greater size, anti-La and anti-RNP have been associated with pulmonary involvement (OR 2.51; 95% CI 1.39-4.57 and OR 1.32; 95% CI 1-1.75 respectively). Anti-RNP positivity has been associated in particular with ILD, pulmonary hypertension and shrinking lung. Although these manifestations prevalence was similar in our cohort, an association with this antibody was not found (OR 1.01, 95% CI: 0.2-4.9). This could be explained by the smaller sample size. As for anti-La positivity, its prevalence in our cohort was less than what was found in the GLADEL cohort (16.5% vs 24.3% respectively). It is possible that this could explain the poor association between anti-La positivity with the presence of pulmonary manifestations in our study compared with those of the GLADEL cohort. There are data that indicates that anti-SM and anti-RNP simultaneous positivity is related mainly to pleuritis OR 1.98 (95% CI: 1.31-3); and this kind of involvement was found to be more frequent in our study. Our results suggest an association between positive anti-SM and pulmonary manifestations in Colombian patients with SLE, pleuritis in particular.

References:

[1]Haye Salinas MJ, Caeiro F, Saurit V et al. Pleuropulmonary involvement in patients with systemic lupus erythematosus from a Latin American inception cohort (GLADEL). Lupus. 2017;26(13):1368–77.

[2]Emad Y, Gheita T, Darweesh H, Klooster P, et al. Antibodies to extractable nuclear antigens (ENAS) in systemic lupus erythematosus patients: Correlations with clinical manifestations and disease activity. Reumatismo. 2018;70(2):85–91.

Disclosure of Interests:

None declared

AB0336 PULMONARY MANIFESTATIONS IN A COLOMBIAN COHORT OF PATIENTS WITH SYSTEMIC LUPUS ERYTHEMATOSUS

Background:

Pulmonary manifestations are frequent in systemic lupus erythematosus (SLE) with a frequency of 30-90% that depends on the cohort and the methods used for their identification. The association of this compromise with mortality highlights its importance and the need for biomarkers to adequately predict this complication. We describe the prevalence of pulmonary manifestations, and the clinic and immunoserological characteristics of 551 Colombian patients with SLE

Objectives:

We performed an observational and analytic study of a retrospective cohort with adult SLE patients who fulfilled the 2012 SLICC classification criteria and that had a history of at least 6 months of the disease. These patients were treated in a specialized center of rheumatology with presence in six cities of Colombia between 2015 and 2018. We excluded pregnant patients and those with incomplete data for our survey. The first clinic consult occurred between 2015 and 2018, being defined as moment one. The follow up one year later was defined as moment two. We obtained 710 registries that were potentially eligible and analyzed 465 patients at moment two after applying the exclusion criteria

Methods:

In 465 eligible patients, 20,5% had pulmonary compromise (93.8% female) with a median age of 42,4 years. The average SLICC Damage Index of 551 patients with SLE was 0,9 in women and 1.05 in men, while the average SDI of patients with pulmonary compromise was 1. The most frequent manifestation was pleural (14.3%), followed by Lupus pneumonitis (3.6%) and pulmonary hypertension (3.2%). Other manifestations and serological characteristics are recorded in Table 1. Of note, ANA homogeneous pattern was the most common (34.5%), anti-RNP positivity was 41.7%, anti-dsDNA positivity was 53.1% and 53.1% had hypocomplementemia.

Results:

The prevalence of pulmonary manifestations in our cohort was 20,5%, which is lower that in the previous described GLADEL cohort (28,4%). This could be explained by the regional differences of ethnicities in Latin America and in immune-serological profiles. Anti-RNP positivity was frequent (41.7%) and new pulmonary compromise for one year follow-up was rare. Of not, the mean damage index for our patients with pulmonary manifestations was 1, this could highlight the importance of this organ as a causa of higher damage accrual and mortality, which we will explore in the future

Conclusion:

The prevalence of pulmonary manifestations in our cohort was 20,5%, which is lower that in the previous described GLADEL cohort (28,4%). This could be explained by the regional differences of ethnicities in Latin America and in immune-serological profiles. Anti-RNP positivity was frequent (41.7%) and new pulmonary compromise for one year follow-up was rare. Of not, the mean damage index for our patients with pulmonary manifestations was 1, this could highlight the importance of this organ as a causa of higher damage accrual and mortality, which we will explore in the future

References:

[1]G. Aguilera-Pickens, C. Abud-Mendoza. Pulmonary Manifestations in Systemic Lupus Erythematosus: Pleural Involvement, Acute Pneumonitis, Chronic Interstitial Lung Disease and Diffuse Alveolar Hemorrhage. Reumatol Clin. 2018;14(5):294–300.

[2]Haye Salinas MJ, Caeiro F, Saurit V. Pleuropulmonary involvement in patients with systemic lupus erythematosus from a Latin American inception cohort (GLADEL). Lupus (2017) 0, 1–10.

[3]Santamaria-Alza Y, Sanchez-Bautista J, Fajardo-Rivero J. Acute respiratory involvement in Colombian patients with systemic lupus erythematosus undergoing chest computed tomography. Int J Rheum Dis. 2019;00:1–7.

Table 1.

clinical and immunoserological characteristics

n%Women10693,8Global mortality468,3Pulmonary compromise mortality87,1ANA10492Anti-DNA6053,1ENAS97,2Ro35/8740,2La14/8516,5SM32/8836,4RNP35/8441,7Follow up 1 %Follow up 2 %P Value *Pulmonary hypertension3,22,80,28Pulmonary fibrosis2,142,61Shrunken lung0,20,21Pleuritis14,315,050,42Lupus pneumonitis3,63,010,85Alveolar hemorrhage1,41,30,76Pulmonary embolism2,31,930,72

Disclosure of Interests:

None declared

AB0335 SURVIVAL ASSESSMENT IN PATIENTS WITH SLE AND PULMONARY MANIFESTATIONS IN A COLOMBIAN COHORT WITH 2-YEAR FOLLOW-UP

Background:

Systemic lupus erythematosus (SLE) is a multisystemic autoimmune disease with heterogenous and variable behavior. The frequency of pulmonary involvement ranges from 10-90%, with this variability in occurrence attributed to differences in populations and heterogeneity in detection methods and study designs.

Objectives:

To analyze survival in patients with SLE and the presence of pulmonary manifestations according to clinical and demographic characteristics in a cohort of patients in Colombia

Methods:

Observational-analytical, retrospective, follow-up study of a cohort of adult patients with SLE. We included 559 adult patients who fulfilled the 2012 SLICC SLE classification criteria and with at least 6 months of disease evolution, treated in a medical center specialized in rheumatology with locations in 6 cities in Colombia between 2015 and 2018. Pregnant patients and those who had incomplete data or visits were excluded. Immunoserological profile was characterized and pulmonary involvement was followed for 1 year. The diagnosis of pulmonary involvement was obtained from the rheumatology report in the clinical chart. The prevalence of pulmonary manifestations and the immunoserological profile were determined and subsequently a logistic regression adjusted for age, sex and level of education was performed to establish the association between pulmonary manifestations and a positive autoantibody profile

Results:

Median age was 44.5 ± 14 years, 96.6% were women. In patients with pulmonary compromise 9.7% were smokers, 12.4% had an active alcohol intake, 58.4% had a low socioeconomic status, 38.1% medium and 4.7% high. Pulmonary involvement was present in 20% of patients, the most common manifestations were pleuritis (14.3%), lupus pneumonitis (3.6%), pulmonary hypertension (3.2%), interstitial lung disease (2.3%), pulmonary embolism (2.3%), pulmonary fibrosis (2.14%), alveolar hemorrhage (1.4%), shrinking lung (0.2%). there was no significant difference in the follow up at one year. Immunoserological characteristics shows ANA positivity in 92%, anti-DNA in 53%, ENAS in 97%, with anti-RNP being the most common (41.7%), and low complement levels in 53%. Mortality for pulmonary compromise was 1.4%, and survival at 2 years did not have a statistically significant difference (p=0.155)

Conclusion:

Survival was not found to be lower in patients with SLE and pulmonary involvement (p=0.155) when compared to SLE patients without pulmonary involvement after 2-year follow-up. This finding was independent of age, gender, and educational level. Previous large cohorts like GLADEL and RELESSER describe an association between pulmonary involvement and lower survival HR 2,79 (95% CI: 1,80-4,31), p <0,001 and HR 3.13, (95% IC: 1.56– 6.28, P = 0.00 respectively. In the RELESSER cohort pleural involvement and pulmonary embolism was found to have low to minimal impact on survival.

In our cohort pleuritis was the most common finding whereas the other pulmonary manifestations were reported in less than 4% of patients. This difference could explain our differences with other cohorts. Other causes for this difference are a smaller sample size and a short follow-up.

The results of our study do not suggest that there is an association between pulmonary involvement and mortality in Colombian patients with SLE during a 2-year follow-up. We will continue to monitor and report in this regard

References:

[1]Narváez J, Borrell H, Sánchez-Alonso F, Rúa-Figueroa I, López-Longo FJ, Galindo-Izquierdo M, et al. Primary respiratory disease in patients with systemic lupus erythematosus. (RELESSER) cohort. Arthritis Res Ther. 2018;20(1):1–10.

[2]Keane MP, Lynch JP. Pleuropulmonary manifestations of systemic lupus erythematosus. Vol. 55, Thorax. Thorax; 2000. p. 159–66.

[3]Haye Salinas MJ, Caeiro F, Saurit V, Alvarellos A, Wojdyla D, Scherbarth HR, et al. Pleuropulmonary involvement in patients with systemic lupus erythematosus from a Latin American inception cohort (GLADEL). Lupus. 2017;26(13):1368–77

Disclosure of Interests:

None declared

Mef2 induction of the immediate early gene Hr38/Nr4a is terminated by Sirt1 to promote ethanol tolerance

Drug naïve animals given a single dose of ethanol show changed responses to subsequent doses, including the development of ethanol tolerance and ethanol preference. These simple forms of behavioral plasticity are due in part to changes in gene expression and neuronal properties. Surprisingly little is known about how ethanol initiates changes in gene expression or what the changes do. Here we demonstrate a role in ethanol plasticity for Hr38, the sole Drosophila homolog of the mammalian Nr4a1/2/3 class of immediate early response transcription factors. Acute ethanol exposure induces transient expression of Hr38 and other immediate early neuronal activity genes. Ethanol activates the Mef2 transcriptional activator to induce Hr38, and the Sirt1 histone/protein deacetylase is required to terminate Hr38 induction. Loss of Hr38 decreases ethanol tolerance and causes precocious but short‐lasting ethanol preference. Similarly, reduced Mef2 activity in all neurons or specifically in the mushroom body α/β neurons decreases ethanol tolerance; Sirt1 promotes ethanol tolerance in these same neurons. Genetically decreasing Hr38 expression levels in Sirt1 null mutants restores ethanol tolerance, demonstrating that both induction and termination of Hr38 expression are important for behavioral plasticity to proceed. These data demonstrate that Hr38 functions as an immediate early transcription factor that promotes ethanol behavioral plasticity.

A novel method to recover DD fusion proton CR-39 data corrupted by fast ablator ions at OMEGA and the National Ignition Facility

CR-39 detectors are used routinely in inertial confinement fusion (ICF) experiments as a part of nuclear diagnostics. CR-39 is filtered to stop fast ablator ions which have been accelerated from an ICF implosion due to electric fields caused by laser-plasma interactions. In some experiments, the filtering is insufficient to block these ions and the fusion-product signal tracks are lost in the large background of accelerated ion tracks. A technique for recovering signal in these scenarios has been developed, tested, and implemented successfully. The technique involves removing material from the surface of the CR-39 to a depth beyond the endpoint of the ablator ion tracks. The technique preserves signal magnitude (yield) as well as structure in radiograph images. The technique is effective when signal particle range is at least 10 μm deeper than the necessary bulk material removal.

Impact of x-ray dose on the response of CR-39 to 1-5.5 MeV alphas

The CR-39 nuclear track detector is used in many nuclear diagnostics fielded at inertial confinement fusion (ICF) facilities. Large x-ray fluences generated by ICF experiments may impact the CR-39 response to incident charged particles. To determine the impact of x-ray exposure on the CR-39 response to alpha particles, a thick-target bremsstrahlung x-ray generator was used to expose CR-39 to various doses of 8 keV Cu-Kα and Kβ x-rays. The CR-39 detectors were then exposed to 1-5.5 MeV alphas from an Am-241 source. The regions of the CR-39 exposed to x-rays showed a smaller track diameter than those not exposed to x-rays: for example, a dose of 3.0 ± 0.1 Gy causes a decrease of (19 ± 2)% in the track diameter of a 5.5 MeV alpha particle, while a dose of 60.0 ± 1.3 Gy results in a decrease of (45 ± 5)% in the track diameter. The reduced track diameters were found to be predominantly caused by a comparable reduction in the bulk etch rate of the CR-39 with x-ray dose. A residual effect depending on alpha particle energy is characterized using an empirical formula.

Empirical assessment of the detection efficiency of CR-39 at high proton fluence and a compact, proton detector for high-fluence applications

CR-39 solid-state nuclear track detectors are widely used in physics and in many inertial confinement fusion (ICF) experiments, and under ideal conditions these detectors have 100% detection efficiency for ∼0.5-8 MeV protons. When the fluence of incident particles becomes too high, overlap of particle tracks leads to under-counting at typical processing conditions (5 h etch in 6N NaOH at 80 °C). Short etch times required to avoid overlap can cause under-counting as well, as tracks are not fully developed. Experiments have determined the minimum etch times for 100% detection of 1.7-4.3-MeV protons and established that for 2.4-MeV protons, relevant for detection of DD protons, the maximum fluence that can be detected using normal processing techniques is ≲3 × 10(6) cm(-2). A CR-39-based proton detector has been developed to mitigate issues related to high particle fluences on ICF facilities. Using a pinhole and scattering foil several mm in front of the CR-39, proton fluences at the CR-39 are reduced by more than a factor of ∼50, increasing the operating yield upper limit by a comparable amount.

Hypoglycaemia and somnambulism: a case report

Sleepwalking (somnambulism) is a sleep disorder classified as a parasomnia. Sleepwalkers develop motor activities that may be simple or complex: they can get out of bed, walk, urinate and even leave the house while remaining unconscious and unable to communicate. It is difficult to wake a sleepwalker, but it is not dangerous - as many people think. Sleepwalking cases have been caused by jet lag, the consumption of narcotics, sedatives and alcohol, cardiac problems such as arrhythmias, and other medical conditions, including epilepsy, asthma and apnoea. In a quick search of the literature, only one case due to hypoglycaemia has been reported, describing a patient with type 1 diabetes whose sleepwalking was triggered by nocturnal hypoglycaemia. Our present case was similar, and our report also describes how it occurred and how the condition was remedied.

[Evaluation of the efficacy of a comprehensive programme of secondary prevention of cardiovascular disease in primary care: the PREseAP Study]

OBJECTIVES

To assess the efficacy of a comprehensive secondary prevention programme to reduce morbidity and mortality in patients who have suffered a cardiovascular (CV) event; to control CV risk factors and prophylactic treatment in order to prevent recurrence; and to improve the quality of life of patients with cardiovascular disease.

DESIGN

Randomised, pragmatic, open clinical trial in primary care.

SETTING

A total of 42 primary care centres of 8 different areas in Spain.

PARTICIPANTS

Men and women below 86 years old, diagnosed with coronary disease and/or stroke and/or peripheral vascular disease in the preceding year, and who have no serious or terminal disease.

INTERVENTION

Primary care centres will be randomised to following usual care (control group), or to following a comprehensive programme of secondary prevention (intervention group).

MAIN MEASUREMENTS

Cardiovascular fatal events, cardiovascular non-fatal events, total mortality and health-related quality of life (SF-36).

Incidence and risk factors associated with urinary tract infection in diabetic patients with and without asymptomatic bacteriuria

In order to compare the incidence of symptomatic urinary tract infection (UTI) in diabetic patients with and without asymptomatic bacteriuria (ASB), and to identify other risk factors for these infections, 289 females and 168 males were studied over a 12-month period. Symptomatic UTI occurred in 69.2% of patients with ASB (67.6% female and 76.5% male) versus 9.8% without ASB (14.9% female and 2.6% male). ASB and urinary incontinence were associated with symptomatic UTI in both women and men. Other risk factors included previous antimicrobial treatment and macrovascular complications in women and obesity and prostatic syndrome in men. The presence of ASB was found to be the major risk factor for developing symptomatic urinary tract infection. Further prospective randomized clinical trials of diabetic patients with risk factors for UTI who are receiving or not receiving treatment may be considered.

Multifactorial approach and adherence to prescribed oral medications in patients with type 2 diabetes

The aims of this study were to assess adherence to oral hypoglycaemic/cardiovascular drugs and determine non-adherence predictors in type 2 diabetes patients. It was designed as a population-based cross-sectional study in which 90 patients from a primary care setting were studied. Pill count and self-report methods were used to measure adherence. Logistic regression analysis was performed to predict factors related to non-adherence. Adequate adherence to all drugs was found in 29 patients (35.4%; 95% confidence interval (CI) 25.0-45.7). Variables associated with non-adherence were HbA1c odds ratio (OR) 2.32 (95% CI: 1.09-4.95), systolic blood pressure OR 1.68 (95% CI: 1.08-2.62), total cholesterol OR 1.34 (95% CI: 1.08-1.66), number of pills OR 1.80 (95% CI: 1.26-2.55) and duration of disease OR 0.44 (CI 95%: 0.24-0.83). In conclusion, one in three patients had adequate adherence. Factors associated with non-adherence were duration of disease, complexity of drug regimen and inadequate control of cardiovascular risk factors.

The effect of written information on adherence to antibiotic treatment in acute sore throat

A randomised clinical trial was conducted to establish whether written instructions, in addition to verbal ones, significantly improve adherence to antibiotic treatment for acute sore throat in comparison with verbal instructions only. Patients were selected by consecutive sampling at seven primary healthcare surgeries. The pill count average was 87.4+/-25.2% and it was higher in the intervention group (93.7+/-24.5%) than in the control group (81.1+/-24.5%) (P < 0.05). Absolute risk reduction was 14% (95% confidence interval (CI), -3.77 to 26.56); relative risk reduction was 24.9% (95% CI, -11.04 to 58.28); the number needed to treat was 8.77. Written instructions, in addition to verbal ones, significantly improve compliance with antibiotic treatment in tonsillitis of acute sore throat in comparison with verbal instructions only.

Identificación de las variables de influencia en los tiempos de espera en atención especializada

OBJECTIVE

To identify the variables influencing waiting time for specialized care (waiting lists) through multiple regression analysis and to analyze the health districts with long waiting times according to these variables.

DESIGN

Descriptive, cross sectional and retrospective study of waiting times for access to specialized care between 1997 and 1998.

SETTING

Area 20 of the Health Department of the Autonomous Community of Valencia (Spain) consisting of 12 health districts with 204,424 inhabitants.

INTERVENTIONS

The following variables were gathered: variables influencing demand: type of municipality, aging and indexes of dependent population, and percentage of pensioners; variables influencing supply: age, sex, training and professional stability of the doctor, and size of the patient list; variables influencing resource consumption: percentage of referrals to specialized care per thousand inhabitants, mean WT for access to specialized care (in natural days) by district and year, number of consultations, and workload. A multiple regression model was constructed through (backward) elimination, taking the mean WT as the dependent variable and the remaining variables as independent variables. The resulting equation enabled calculation of the expected WT per health district and the deviation of the real WT from the expected WT. A district was considered to have a high WT when its deviation was above the mean plus one standard deviation of the distribution.

RESULTS

The mean WT for access to specialized care was 37 days in 1997 and 34 days in 1998. A significant correlation (p < 0.005) was found between WT and the percentage of the population aged less than 14 years (r = 0.693), the percentage of the population aged between 14-65 years (r = 0.517), the number of consultations (r = 0.689), and coastal population (r = 0.470). Our final model included: percentage of the population aged less than 14 years, number of consultations, and coastal population (F = 41.803; p < 0.000; r = 0.945; r2 = 0.893). Three districts (37.5%) with high WTs were identified.

CONCLUSIONS

The number of consultations, the percentage of the pediatric population, and proximity to the coast were closely correlated with WT for specialized care, with a consequent influence on waiting lists.

Clinical study of an outbreak of Legionnaire's disease in Alcoy, Southeastern Spain

The aim of this study was to identify the clinical features of Legionnaires' disease, sudden outbreaks of which demand a quick and flexible clinical approach, particularly with regard to diagnosis and therapy. A prospective and comparative study based on a clinical protocol was performed during an outbreak of Legionnaires' disease in Alcoy, Spain. The outbreak was environmental in origin, linked to cooling towers. Data about epidemiological and clinical features, blood chemistry values, radiological and microbiological findings, and characteristics related to the clinical course of Legionnaires' disease were obtained for 357 patients admitted to hospital with community-acquired pneumonia (177 with Legionella pneumonia). Patients with Legionnaires' disease were younger (mean age, 65.3+/-16.5 years) and more likely to be smokers compared with patients with other types of pneumonia (28.8% vs. 11.1%; P<0.01). Moreover, they had not been admitted to any hospital because of pneumonia in the previous year. Patients with Legionnaires' disease had higher fever, more severe headache, and less expectoration as well as lower sodium blood levels (mean, 132.6+/-4.8 mmol/l vs. 135.7 mmol/l; P<0.01). Radiological studies also showed that fewer patients with Legionnaires' disease had pleural effusion (9% vs. 19.4% of those with non- Legionella pneumonia). The presence of headache, high fever, hyponatremia, scanty or null expectoration, and current cigarette smoking provides physicians with important clues for a high suspicion of Legionella pneumonia before the results of confirmatory laboratory tests are available.

[What lines of action should the Valencia Society of Family and Community Medicine adopt over the next 4 years?]

OBJECTIVE

To identify the areas of activity in which the Valencia Society of Family and Community Medicine (SVMFyC) should become involved over the next four years.

DESIGN

Qualitative research.Setting. SVMFyC members.

PATIENTS AND OTHER PARTICIPANTS

27 experts belonging to the SVMFyC took part.

INTERVENTIONS

Qualitative consensus-seeking techniques. Reliability and validity of the technique were ensured through triangulation and the selection of experts from among the different professional groups within the SVMFyC.

MEASUREMENTS AND MAIN RESULTS

To determine the recommended lines of action, productivity, spontaneous representativity, intensity of recommendation and degree of agreement were analysed. The priority lines recommended were: defending the MIR path, proposing reforms in undergraduate study plans, watching over the transparency of job selection procedures and the annual OPE selection, promoting the professional degree course, creation of posts for teachers in family and community medicine, defining the size of the population registered with a doctor, proposing an incentives list and studying alternatives to uniform salaries in the form of target-linked remuneration.

CONCLUSIONS

The lines of action recommended by the experts were established.

[The variability in the care for diabetic and hypertensive patients as a function of the styles of a physician's practice]

OBJECTIVES

To analyse the variability of certain indicators of the procedure and outcome of medical care in the clinical records of diabetic and hypertense patients, and their relationship with the doctor's style of practice.

DESIGN

An observational, descriptive study.

SETTING

Seven health centres in the public network.

PARTICIPANTS

40 primary care doctors (all the doctors).

MEASUREMENTS AND MAIN RESULTS

By means of stratified systematic random sampling, 20 clinical histories for each doctor were chosen (10 for patients diagnosed with diabetes mellitus and 10 with hypertension). The deviation ratio was used as the measurement of variability. Doctors' styles of medical practice were evaluated through the Australia questionnaire. Great variability was found in the frequency with which the different indicators of the two pathologies were recorded (deviation ratio: weight > 90.02% in DM, 81.37% in HT; height > 84.01% in DM, 77.10% in HT), and in the absolute figures (patients with HT, wide variability in all outcome indicators; patients with DM, in last figures, total and HDL cholesterol, and HbA1c). The styles of practice were shown to be related to the frequency of appearance of some indicators in the clinical records and with the quality of particular outcome indicators. The age of the doctor correlated significantly, and negatively, with the recording of almost all the indicators and their quality.

CONCLUSIONS

Variability of medical practice in the care of the chronically ill seen in primary care does exist. The use of clinical practice guides is emphasised.

[Relationship between medical treatment compliance and the degree of control in patients with high blood pressure, non-insulin dependent diabetes mellitus and dyslipidemia]

BACKGROUND

To study the relationship between therapeutic compliance and the control of arterial hypertension, non insulin dependent diabetes mellitus and hyperlipidemia.

PATIENTS AND METHODS

Prospective study performed on 174 hypertensive patients, 107 with diabetes and 107 with hyperlipidemia evaluating compliance by counting of tablets in two home visits.

RESULTS

34% hypertensive patients, 20% diabetics and 37% hyperlipidemics that took medication as instructed or more than they should were badly controlled.

CONCLUSIONS

The control grade of high blood pressure, non insulin dependent diabetes mellitus and hyperlipidemia not only depends on improving compliance but also in adapting pharmacologic prescriptions.

[Validation of an instrument for identifying styles of the professional practice of the primary care doctor]

OBJECTIVE

To elaborate and validate a questionnaire for identifying common styles of Primary Care doctors' practice.

SETTING

Primary Health Care. Public sector in Spain.

DESIGN

This was a study to validate a questionnaire administered in two phases with different samples. In the first phase, the items (item-total correlation, using Alpha on eliminating item), validity of construction, empirical validity and internal consistency, were analysed. In the second, discriminatory validity and reliability of the questionnaire (test-retest) were calculated.

MEASUREMENTS AND MAIN RESULTS

81.5% of the doctors replied in the first phase; and 100% in the second. Two factors were isolated with the Principal Components procedure, which confirmed the validity of the questionnaire's construction (52% variance explained). Internal consistency (Alphas ranged between 0.55 and 0.75) and reliability (ranging between 0.50 and 0.95 in function of the time elapsed) were also demonstrated.

CONCLUSIONS

This instrument could be used to differentiate two styles in practice, characterised by focusing on the physical illness vs the psycho-social aspects of the disease process. The instrument is also useful because it gives the feeling of control over the task.

[Factors involved in noncompliance with drug treatment in non-insulin dependent diabetes mellitus]

OBJECTIVE

To find the level of non-compliance with treatment with oral hypoglycemics, its causes and the profile of non-compliant patients.

DESIGN

Prospective study.

SETTING

Primary Care Centres in the province of Alicante.

PATIENTS

107 diabetics not dependent on insulin on the lists of five General Medicine practices and all receiving pharmacological treatment.

MEASUREMENTS AND MAIN RESULTS

The method used to value compliance was a surprise count of pills in the patient's home. Patients achieving 80-110% compliance were considered compliant. The level of non-compliance was 51.5% (C.I. 42.1%-61%), 36.5% being hypocompliers and 15% hypercompliers. Forgetting (40.7%) and lack of knowledge (29.5%) were the most frequent reasons for non-compliance. The factors associated with non-compliance were: over four years evolution of the disease (p = 0.02), the diet not properly observed (p = 0.03), over a year in regular treatment (p = 0.006), poor control of the disease valued by HbA1C (p = 0.003).

CONCLUSIONS

A high level of non-compliance with pharmacological treatment was found for patients with Diabetes Mellitus not dependent on insulin. Its causes were identified and factors associated with poor compliance were profiled.

[Factors involved in noncompliance with pharmacological treatment in arterial hypertension]

OBJECTIVES

To find the amount of non-compliance with medical treatment for Hypertension and its causes, and to describe the profile of non-compliant patients.

DESIGN

A crossover study performed on two home visits.

SETTING

A rural Health Centre at Calpe, Alicante.

PATIENTS

The sample was obtained from the census of medically treated hypertense patients. 174 of the 200 patients chosen completed the study.

MEASUREMENTS AND MAIN RESULTS

Compliance was evaluated by a surprise count of pills in the patient's home. Patients complying between 80 and 110% were considered compliant. There was 47.7% non-compliance (C.I. 95%: 40.3-55.1), with 31% under-compliers and 16.7% over-compliers. Lack of information (39.8%) and forgetfulness (28.9%) were the most common causes of non-compliance.

CONCLUSIONS

A high amount of non-compliance was shown, including an important number of over-compliers. Its causes were defined along with other reasons predicting non-compliance.

[The validity of 6 indirect methods for assessing compliance with pharmacological treatment in dyslipidemias]

OBJECTIVE

To validate six indirect methods of identifying patients who do not comply with their treatment with hypolipaemiant drugs.

DESIGN

A prospective study.

SETTING

Primary care centres in the province of Alicante.

PATIENTS

107 lipaemic patients, on the lists of 5 General Medical practices and on drugs treatment.

MEASUREMENTS AND MAIN RESULTS

The most accurate way to assess compliance was the surprise counting of pills in patients' homes. Patients who had between 80 and 110% compliance were defined as compliant. The six indirect methods validated were: Communication of self-compliance (CS), Attendance at appointments (AA), Doctor's judgment (DJ), Information about the illness (II), the Morisky-Green test (MG) and the grade of control (GC). AA, DJ and CS were the methods with highest specificity (91.2%-89.5%). GC and II were the most sensitive (88%-82%). GC obtained the greatest negative predictive value (77.7%), and DJ the greatest positive predictive value (73.6%). The concordance index (kappa) ranged from 0.23 for GC and -0.002 for II.

CONCLUSIONS

GC, DJ and CS are the methods with the best validity indicators and concordance. They could, therefore, be used together in clinical practice to identify patients not complying with their hypolipemiant treatment.

[The validity of 6 indirect methods for assessing drug treatment compliance in arterial hypertension]

OBJECTIVE

To validate six indirect methods, which were simple and easy to apply in clinical practice, of identifying patients who did not comply with drugs treatment for hypertension.

DESIGN

A prospective study based on two visits to patient's home.

SETTING

rural health centre at Calpe, Alicante.

PATIENTS

174 patients (58 men and 116 women) were included. They were chosen at random from the centre's records of hypertense patients.

MEASUREMENTS AND MAIN RESULTS

Compliance was assessed by the method of a surprise counting of pills in the patient's home. Patients who had between 80 and 110% compliance were defined as compliant. The six indirect methods validated were: communication of self-compliance (CS), attendance at appointments (AA), doctor's judgment (DJ), information about the illness (II), hypertension control (HC) and the Morisky-Green test (MG). II was the most sensitive (81.9%). CS reached the highest specificity (93.4%), the best positive predictive value (81.8%) and the best concordance index (kappa, 0.26).

CONCLUSIONS

II and CS are the indirect methods with the best validity indicators and could be used together to assess compliance with drugs treatment for hypertension.

[The validity of basal blood glucose in the control of non-insulin-dependent diabetic patients]

BACKGROUND

To validate basal glucemia as a control method for non-insulin dependent diabetes mellitus, and to determine the cut-off point that best characterizes good control.

PATIENTS AND METHODS

A transversal, observational study of 256 patients who participated in a diabetes mellitus follow-up program during 1993. In the study, glucemia validity indicators were evaluated after making 2 X 2 tables and ROC (receiver operating characteristic) curves for the different values. Control values of glycated hemoglobin was used as to define a good (< 6.5%) and moderate (< 8%).

RESULTS

The values of glucemia considered to be "good" as regards control (from 80 to 110 mg/dl, 4.4-6.05 mmol/dl) have good sensitivity (from 97.3% to 100%) and negative predictive values (from 85.7% to 100%) but extremely bad specificity (from 3.8% to 22.7%) and only moderate positive predictive values (from 59.5% to 64.1%) in reference to values of glycated hemoglobin of 6.5%. The same occurs for 8% as regards sensitivity (from 98.6% to 100%), negative predictive value (from 96.4% to 100%) and specificity from 2.1% to 14.5%). Positive predictive value worsens (from 27.8% to 30.3%). The most effective and most accurate values of glucemia in the ROC curves are 150 mg/dl (8.25 mmol/l) if the control of glycated hemoglobin is good, and 170 mg/dl (9.35 mmol/l) if it is moderate.

CONCLUSIONS

The glucemia control figures recommended by consensus produce false positives when they are compared to glycated hemoglobin. In the analysis of effectiveness and ROC curves greater accuracy is obtained with glucemia values that are slightly higher than those recommended.

[Quality of drug prescriptions by the Spanish internal medicine services]

Many registered drugs in different countries not always have been tested by clinical assays and their efficacy has no definitively proved. Good clinical practice must assume the prescription of the more efficacy drugs. The aim of this study is to evaluate the quality of the drugs prescribed by spanish general internists. We analyze the treatments prescribed by general internists using their hospital medical records. The records were offered by the Heads of the Internal Medecine Departments of Spanish hospitals with 250 beds or more when required by the Spanish Society of Internal Medecine. A random sample, stratified by the hospital size, was obtained from the whole of the Spanish hospitals. Quality of the drugs was determined using two criteria: A. Their intrinsic value; it was decided it was high if clinical assays showed their efficacy and security, and low of it was not B. The number of different chemical substances in the drug; we considered a high quality criteria if only one chemical substance, or two with proved synergistic efficacy were present, and low if it was more than two, or without proved synergistic efficacy. The sample was 250 clinical records, with 1022 different prescriptions; the records were collected between February and July 1994. We found that 94.06 +/- 1.45 of evaluated treatments have a high intrinsic value, and 96.93 +/- 1.06 have only one chemical component. The drugs without a high intrinsic value were: oral hypoglycaemics, some including several combinations of vit B, drugs acting on the cerebral blood flow and some mucolitics. Spanish general Internists usually prescribed monocomponent drugs with proved efficacy and safety.

[Importance of HDL cholesterol determination in the evaluation of coronary risk in clinical practice]

OBJECTIVE

To validate to what extent the isolated determination of total Cholesterol (TC) is effective when seeking to predict coronary risk.

DESIGN

An observational crossover study of the analytic determinations of the clinics which systematically request TC and HDL-Cholesterol (HDL)--case-finding method.

SETTING

Health Centre.

PARTICIPANTS

631 analytic determinations, with samples from people who attended a Health Centre between May and November 1992, were studied.

MEASUREMENTS AND MAIN RESULTS

As proof of certainty the Atherogenic Index (AI) was used for the relative risks (RR) of suffering a coronary event in line with the Framingham study. The confidence limits (CL) were calculated to 95% in order to quantify random error and permit comparison. On varying the cut-off points of TC the indicators changed, being more sensitive (S) and less specific (E) with the lower figures: 180 mg/dl, RR > 1, S = 97.5% (CL: 100-94.7) and E = 30.5% (36.8-24.2); RR > 2, S = 100%, E = 22.1% (26.9-17.3) and RR > 3, S = 100%, E = 20.8% (25.3-16.3). As values of TC increase, S diminishes and E increases: 250 mg/dl, RR > 1, S = 48.3% (57.2-39.4), E = 87.2% (91.8-82.6); RR > 2, S = 58.6% (76.5-40.7), E = 77.2% (82-72.4) and RR > 3, S = 63.6% (92-35.2), E = 75.3% (80.1-70.5).

CONCLUSIONS

HDL must be determined if TC is -200 mg/dl. If everyone with RR > 2 is to be detected, HDL-cholesterol from TC > or = 180 mg/dl must be measured.

[Diabetes mellitus mortality in Spain: a comparative analysis between Spanish provinces in the period of 1981-1986]

OBJECTIVE

To find and compare mortality because of diabetes mellitus (DM) among the different provinces of Spain in the 1981 to 1986 period.

SETTING

The natural movement of population figures of the National Institute of Statistics (INE) and the census of 1981 and register of 1986 were used.

DESIGN

A descriptive observation study of a crossover type. Standardisation of rates by the indirect method. Calculation of the ratio of standardised mortality for each province.

RESULTS

At the national level, the Communities with an excess of mortality in 1981 were Andalusia, Melilla, the Community of Valencia, Murcia, the Balearics, the Canaries and Extremadura, as well as the provinces of Tarragona, Gerona, Ciudad Real and Albacete. In 1986 the following still had excess of mortality: Andalusia, the Community of Valencia, Murcia, the Balearics, the Canaries, Asturias and Cantabria, along with the provinces of Badajoz and Pontevedra.

CONCLUSIONS

The provinces with an excess mortality because of diabetes mellitus are geographically grouped (with some exceptions) in the south and south-east of Spain and the island communities.

[Opinion of university professors on the suitability of specific primary care training in medical students]

OBJECTIVE

To find the opinion of teachers at the University of Alicante about the appropriateness of a Primary Care Theory-Practice programme within the Medicine curriculum.

DESIGN

A descriptive observation study of a crossover nature.

SETTING

Teachers of the Departments of Medicine and Public Health who had had contact with the Primary Care Theory-Practice programme.

PARTICIPANTS

44 out of 71 teachers (62%) replied.

INTERVENTION

An 11-question survey was answered anonymously between October 1993 and June 1994.

MEASUREMENTS AND MAIN RESULTS

77.3% (95% Confidence Interval 64.9-89.7%) considered appropriate the theoretical content at undergraduate level, where there was an average 18.5 hours teaching (C.I. 15.8-21.2); and 95.5% (C.I.89.4-100%), the practicals at a Health Centre, where there was an average 65.2 hours (C.I. 43.1-87.3) work. 43.9% thought it was appropriate to form a separate subject and 39% favored integrating these themes into other subjects. Theoretical contents would be basically teaching general information about Primary Care; and practical work would be clinical activities. The greatest advantages regarding carrying out practical work in Health Centres were: the student finds pathology more prevalent and learns to provide practical answers. The greatest disadvantages were: the low methodological knowledge and teaching preparation of the Teams.

CONCLUSIONS

Those interviewed considered that the teaching at undergraduate level of a Primary Care subject with theoretical-practical content would be useful. The advantages, its contents and some difficulties were noted.

[An analysis of domiciliary medical care in 7 health centers of Alicante Province]

OBJECTIVE

To know the characteristics of medical care at home done by the doctor and to what extent it is justified.

DESIGN

An observational, descriptive-prospective study. Form filled out by the doctor after completing the visit.

SETTING

Outpatients, 7 hospitals in area 17 of the Valencian Community.

PATIENTS

188 different patients attended in February 1993 by 15 family doctors. The statistical tests used were ji-squared test, Student's t-test and Anova.

MEASUREMENTS AND MAIN RESULTS

An average of 0.4 visits/doctor/day were made. Less than 2 hours/week/doctor were needed. 80.5% of the cases were resolved using usual means available in the doctors emergency briefcase. 64.5% of the patients attended were over the age of 65.66% of the visits were considered to be justified.

CONCLUSIONS

66% of medical care at home was considered justified and did not require excessive time. Elderly patients are the ones who most require medical care at home.

[An opinion/satisfaction survey on 2 models of clinical histories used in primary care]

OBJECTIVE

We aimed to discover the opinion of primary care doctors regarding the structure, usefulness and problems when using two models of clinical records employed consecutively in the same health centres.

DESIGN

A double crossover study. An opinion poll (with 22 closed questions and one open), filled out in 1988 (evaluating the type A clinical record) and then in 1992 (for type B), was used. Chi squared statistical analysis with Yates corrections and Fisher test.

SETTING AND PARTICIPANTS

Staff doctors and third-year family and community medicine interns at their teaching centres in Alicante province. In 1988, 49 doctors took part, and in 1992, 68: 70 and 75% respectively of the target group.

RESULTS

The new record was an improvement over the earlier one. It was broader and corresponded more closely to the actual case. But problems of completion and legibility persisted, as did the difficulties in filling out socio-economic data and work/school history. Model B favoured use by all the team members. It was better for new patients and when doing later checks, although it did not avoid the accumulation of inactive documentation. The need for specific documents for preventive activities was detected. Computerisation would improve manageability. For both models lack of time was the main reason for under-recording.

CONCLUSIONS

The new model is better than the earlier one but is lacking in the areas of manageability and difficulty in retrieving information. The methodology employed shows its use for evaluating health-care innovations and detecting insufficiencies, as well as allowing user-satisfaction to be more easily identified.

[Medicine at the primary care level (optional undergraduate subject at the University of Alicante): 2 years of experience]

OBJECTIVE

We want to put on record two years' experience of undergraduate teaching of an optional subject, "Medicine at the Primary Care level". This was given to sixth-year students by Family and Community Medicine specialist doctors within the Department of Medicine.

DESIGN AND SETTING

A crossover study carried out at the University of Alicante.

PARTICIPANTS

In the first year, 73 out of the 102 students making up the complete course took part (71.6%); and in the second year, 33 out of 93 (35.5%).

MEASUREMENTS AND MAIN RESULTS

The methodology employed, the teaching staff and the documents handed out were given high marks by the students in both cases; as were the course contents in the second year. Deficiencies were noted in the presentation of practical hypotheses. In the first course the students criticised the lack of certain points, basically the tackling of the more common chronic pathologies, something which was corrected in the second year. The survey identified students' wishes to spend longer on the subject.

CONCLUSIONS

The students valued positively the existence of a theoretical content specific to Primary Care Medicine. In particular, they requested to be taught performance patterns for prevalent pathologies and for seminars to be organised around practical hypotheses.

[An evaluation study of a scale of diabetological education in primary care]

OBJECTIVE

To devise and evaluate a scale of measurement which would permit evaluation at primary care level, of the knowledge that diabetic patients have of diabetes. Secondly, to ascertain the level of knowledge of the sample of diabetic patients attending the Xixona Health Centre.

DESIGN

Non-longitudinal, observational, descriptive study.

SETTING

Primary health care (health centre).

MEASUREMENTS AND MAIN RESULTS

The degree of internal consistency of the diabetes scale of knowledge (DISK) attained a Cronbach Alpha value of 0.87. The coefficients of correlation of each of the factors--defined a priori (general knowledge, diet, exercise, hygiene and self-regulation)--oscillated between 0.77 and 0.83. The Garret index of corrected difficulty was at 0.64. The homogeneity of each item with the questionnaire showed values above 0.31. The reliability measured by means of the KR20 index was 0.86. The odd-even coefficient of reliability was at 0.89. The mean level of correct answers was 70%. A relation was found between the level of knowledge and the variables age and years the patient had been subject to the condition. No relation was found with the treatment, sex, glycaemia or HbA1C level, nor educational level.

CONCLUSIONS

The indices obtained by the scale can be considered to be judiciously acceptable, both in terms of their internal consistency and their ability to characterise. The DISK (ECODI) is, then, a valuable tool in the field of primary health care.

[Undergraduate training in primary health care: 6 years' experience at the University of Alicante]

OBJECTIVE

To assess the opinion of medical students on the teaching offered in the Primary Care context (TOPC).

DESIGN

Observational and crossover study. The assessment used an opinion questionnaire.

PARTICIPANTS

296 sixth-year medical students between 1987 and 1992.

INTERVENTIONS

The TOPC consisted of four weeks stay in a Health Centre with an eminently practical programme. However this also included hour-long theoretical seminars on the most important Primary Care questions and the student's completion of a research project related to Primary Care.

RESULTS

The students expressed satisfaction with the TOPC (average score of 4 out of 5). Moreover this satisfaction increased over the five years (from 3.7 to 4.6, p = 0.0001). They believed the TOPC to be useful (3.6 to 4.7, p = 0.0001) and relevant to their future professional activity (3.1 to 4.6, p = 0.0001). They thought that the tutors were very competent (4 out of 5, with no significant variation) and the Health Centres' teaching facilities suitable (3.8 to 4, with no significant variation). Finally, they considered that TOPC should become a compulsory undergraduate subject (3.9 out of 5).

CONCLUSIONS

Medical students give a positive rating to the Primary Care teaching offered and believe it should be integrated into the Medicine syllabus as a compulsory subject.

Slowing of mortality rates at older ages in large medfly cohorts

It is generally assumed for most species that mortality rates increase monotonically at advanced ages. Mortality rates were found to level off and decrease at older ages in a population of 1.2 million medflies maintained in cages of 7,200 and in a group of approximately 48,000 adults maintained in solitary confinement. Thus, life expectancy in older individuals increased rather than decreased with age. These results cast doubt on several central concepts in gerontology and the biology of aging: (i) that senescence can be characterized by an increase in age-specific mortality, (ii) that the basic pattern of mortality in nearly all species follows the same unitary pattern at older ages, and (iii) that species have absolute life-span limits.

[The satisfaction of the primary care consumer: a comparison between distinct models of care]

The results of a questionnaire about satisfaction in the users of an urban health area of the city of Alicante, where the traditional model of primary care (the clinic, C), the new model (the health center, HC) and private practice (P) coexist are reported. The questionnaires were administered by staff unrelated with the health center. In general, satisfaction was significantly greater (p = 0.001) in users of HC and P than in C users. no significant difference was found between HC and P. The specific satisfaction was also greater (p less than 0.05) for all services in HC than in C: General practice (GP), nursing care (N), pediatrics (PED), and administration-information (ADMON). The general satisfaction did not correlate with sociodemographic variables; it was weakly correlated with the service use variables, and was clearly correlated (p less than 0.001) with the specific satisfaction with the use of services such as GP (r = 0.57), PED (r = 0.49), ADMON (r = 0.56), and N (r = 0.58).

[The validation and usefulness of a questionnaire for evaluating the infrastructure of health centers]

A questionnaire was distributed in all the health centers of the Comunidad Valenciana to establish its validity and usefulness for the evaluation of the physical structure of the health centers. Subsequently, the results were validated by direct verification in 30% of centers. The results of the first part of the questionnaire, related to the type of premises that should be available, and of the second, about the characteristics of such premises, were significantly related with the satisfaction degree (r = -0.724, p less than 0.01), as well as with the criterion of previous planning (p less than 0.001) and the inclusion in structures of a traditional model (p less than 0.001). The 75th percentile of the results of the first and second part of the questionnaire are proposed to select those centers with an unacceptable structure, and, as a quick method, it is recommended to test the parameters of satisfaction degree, previous planning, and inclusion within traditional model structures.