Patient safety climate research in primary care dentistry: A systematic scoping review

BACKGROUND

Patient safety climate constitutes an important element for quality improvement. Its current evidence base has been generated in hospital settings in developed countries. Studies in dentistry are limited.

OBJECTIVE

To systematically explore the evidence regarding assessing patient safety climate in dentistry.

METHODS

We developed a search strategy to explore MEDLINE, SCOPUS, and Web of Science databases from January 1st, 2002, to December 31st, 2022, to include observational studies on patient safety culture or patient safety climate assessment. Methodological features and item data concerning the dimensions employed for assessment were extracted and thematically analyzed. Reported scores were also collected.

RESULTS

Nine articles out of 5584 were included in this study. Most studies were generated from high-income economies. Our analysis revealed methodological variations. Non-randomized samples were employed (ranging from 139 to 656 participants), and response rates varied from 28% to 93.7%. Three types of measurement instruments have been adapted to assess patient safety climate. These mainly consisted of replacing words or rewording sentences. Only one study employed an instrument previously validated through psychometric methods. In general, patient safety climate levels were either low or neutral. Only one study reported scores equal to or greater than 75.

DISCUSSION

Despite diverse assessment tools, our two-decade analysis reveals a lag compared with medicine, resulting in methodological variations for assessing patient safety climate. Collaboration is vital to elevate standards, prioritize patient safety across oral healthcare services, and advocate for integrating safety climate into local and national quality and patient safety strategies.

Interventions for preventing keratinocytic cancer in patients with a history of a previous keratinocytic carcinoma: A systematic review

Keratinocyte cancer (KC) is the most common cancer worldwide. It is important to analyze the actual interventions that are available for the prevention of patients with a previous history of a KC. We aim to review the existent literature to assess the efficacy and safety of interventions to prevent KC in patients with a history of previous KC. We searched clinical trials in which the main outcome was the prevention of KC in patients with a previous history of KC using the strategy published in the International Prospective Register of Systematic Reviews (PROSPERO registry), CRD42016045981. We analyzed 18 clinical trials from which eight reported a benefit with their respective intervention but had methodological flaws and a variable risk of bias. Two clinical trials (regarding celecoxib and oral supplementation with nicotinamide) seemed to have the most beneficial results reducing the incidence of KC in treated groups. However, all of the studies are highly heterogeneous, which does not allow a meta-analysis to be performed. New studies with greater epidemiological value should be conducted.

Quality of life in children and adolescents with vitiligo

The assessment of the quality of life (QoL) in vitiligo patients is essential to quantify the psychological burden of the disease. The effect of vitiligo on the QoL has been reported extensively in adults; however, there is a lack of information in Mexican children. To assess the QoL in children and adolescents with vitiligo and their association with affected body surface area (BSA) and age. A cross-sectional study was conducted in vitiligo patients aged between 5 and 17 years. The study was approved by our institutional review board and informed consent was obtained from all participants and their parents. Participants with psychiatric and neurological disease were excluded. Vitiligo was clinically diagnosed by an experienced dermatologist, and the following variables were registered: sex, age, origin, education, treatment, time and response to treatment, age of onset, clinical type, affected body areas and skin phototype. All participants were requested to complete the CDLQI questionnaire, those aged from 5 to 10 years filled the cartoon format and those from 11 to 17 years filled the text version. The measure of the disease extent was done using the Vitiligo Extent Score (VES). A total of 223 participants were recruited, 102 males (46·2%) and 120 females (53·8%) with a mean age of 9·86 (SD 3·02) years. The mean age of onset of vitiligo was before the first decade of life, of 7·12 (SD 3·66) years. The most frequent type of vitiligo was nonsegmental 53·8% (n = 120), followed by segmental 46·2% (n = 103). The most affected area was head 63·7% (n = 142), followed by trunk 56·1% (n = 125). The median of body surface affected area was 0·7797 with a minimum of 0·0060 and a maximum of 22·285, of these 84·3% (n = 188) had lesions that covered <1% of the BSA and 15·7% (n = 35) >1% BSA. Phototype III was the most frequent in half of the population, followed by phototype IV. The mean duration of the treatment was 11·32 (SD 18) months; 62·3% (n = 139) of them showed good response to treatment. The mean value of the CDLQI questionnaire was 4·95 (SD 4·57) points, with a minimum of 0 and a maximum of 30 points. The participants were classified according to CDLQI results in the following groups: 22·9% (n = 51) showed no effect of vitiligo in their QoL, 50·7% (n = 113) had a small effect, 19·3% (n = 43) a moderate effect, 4·9% (n = 11) a very large effect and only 2·2% (n = 5) an extremely large effect. A total CDLQI score between 0 and 9 was obtained from 85·2% (n = 190) of the participants and 14·8% (n = 33) had a score >10 points. Differences between subgroups were found; children older than 10 years had a lower CDLQI score (mean of 4·13 points), and children under this age had a higher CDLQI score (mean of 5·54 points), and this difference was significant, P = 0·026. Regarding the affected BSA, patients with CDLQI in ranges between 0 and 9 points had a median VES index of 0·1905, while children with CDLQI >10 points had a median VES index of 0·4781, P = 0·024. No significant differences were found when we analysed the rest of the variables in relation to quality-of-life results. The effect of vitiligo on the QoL in Mexican children and adolescents with vitiligo was similar to that of previous studies. We found a higher prevalence of patients with moderate effect on the QoL. The lower the age and the BSA affected, the greater the impact on the QoL.

Keratosis Pilaris Treatment: Evidence from Intervention Studies

Keratosis pilaris is a common dermatosis observed in daily dermatologic practice. The diagnosis is clinical and usually asymptomatic, although sometimes patients may complain of mild pruritus and its cosmetic appearance. Few reports exist about its treatment. There are clinical trials assessing topical treatments and laser surgery, but no systematic reviews on its management were found in literature. An online research was conducted to identify evidence-based recommendations. Lactic acid, salicylic acid, and the 1064-nm Nd:YAG laser seem to be the most effective and safe treatment options for keratosis pilaris among patients aged 12 years and older; however, high-quality randomized controlled trials with long-term outcomes are required. (SKINmed. 2022;20:258-271).

Short- and long-term prognostic factors associated with functional recovery in elderly patients with hip fracture: A systematic review

This systematic review aimed to identify short- and long-term associated factors to functional recovery of elderly hip fracture patients after discharge. We identified 43 studies reporting 74 associated factors to functional recovery; most of them were biological, sociodemographic, or inherent factors to patients' baseline characteristics, including their pre-facture functional capacity.

PURPOSE

This systematic review aimed to identify short- and long-term associated factors to functional recovery of elderly hip fracture patients after hospital discharge. We assessed the use of the hip fracture core-set and key-performance indicators for secondary fracture reduction.

METHODS

A search was performed in seven electronic databases. Observational studies reporting predictors after usual care of elderly patients with hip fracture diagnoses receiving surgical or conservative treatment were included. Primary outcomes considered were part of the domains corresponding to functional capacity.

RESULTS

Of 3873 references identified, and after the screening and selection process, 43 studies were included. Sixty-one functional measures were identified for ten functional outcomes, including BADLs, IADLs, ambulation, and mobility. Biological characteristics such as age, sex, comorbidities, cognitive status, nutritional state, and biochemical parameters are significantly associated. Determinants such as contact and size of social network and those related to institutional care quality are relevant for functional recovery at six and 12 months. Age, pre-fracture function, cognitive status, and complications continue to be associated five years after discharge. We found 74 associated factors to functional recovery of elderly hip fracture patients. Ten of the studies reported rehabilitation programs as suggested in KPI 9; none used the complete hip fracture core-set.

CONCLUSION

Most of the associated factors for functional recovery of elderly hip fracture were biological, sociodemographic, or inherent factors to patients' baseline characteristics, including their pre-facture functional capacity. For the core-set and KPI's, we found an insufficient use and report. This study reports 61 different instruments to measure functional capacity.

REGISTRATION NUMBER

PROSPERO (CRD42020149563).

Development and Validation of a New Scoring Tool to Evaluate the Clinical Evolution of Adult Patients with Nonsegmental Vitiligo

BACKGROUND

Vitiligo has an unpredictable course and a variable response to treatment. Furthermore, the improvement of some vitiligo lesions cannot be considered a guarantee of a similar response to the other lesions. Instruments for patient-reported outcome measures (PROM) can be an alternative to measure complex constructions such as clinical evolution.

OBJECTIVE

The aim of this study was to validate a PROM that allows to measure the clinical evolution of patients with nonsegmental vitiligo in a simple but standardized way that serves to gather information for a better understanding of the disease.

METHODS

The instrument was created through expert consensus and patient participation. For the validation study, a prospective cohort design was performed. The body surface area affected was measured with the Vitiligo Extension Score (VES), the extension, the stage, and the spread by the evaluation of the Vitiligo European Task Force assessment (VETFa). Reliability was determined with test-retest, construct validity through hypothesis testing, discriminative capacity with extreme groups, and response capacity by comparing initial and final measurements.

RESULTS

Eighteen semi-structured interviews and 7 cognitive interviews were conducted, and 4 dermatologists were consulted. The instrument Clinical Evolution-Vitiligo (CV-6) was answered by 119 patients with a minimum of primary schooling. A wide range was observed in the affected body surface; incident and prevalent cases were included. The average time to answer the CV-6 was 3.08 ± 0.58 min. In the test-retest (n = 53), an intraclass correlation coefficient was obtained: 0.896 (95% CI 0.82-0.94; p < 0.001). In extreme groups, the mean score was 2 (2-3) and 5 (4-6); p < 0.001. The initial CV-6 score was different from the final one and the change was verified with VES and VETFa (p < 0.05, n = 92).

CONCLUSIONS

The CV-6 instrument allows patient collaboration, it is simple and brief, and it makes it easier for the doctor to focus attention on injuries that present changes at the time of medical consultation.

Spanish Version of the System Usability Scale for the Assessment of Electronic Tools: Development and Validation

Background

The System Usability Scale (SUS) is a common metric used to assess the usability of a system, and it was initially developed in English. The implementation of electronic systems for clinical counseling (eHealth and mobile health) is increasing worldwide. Therefore, tools are needed to evaluate these applications in the languages and regional contexts in which the electronic tools are developed.

Objective

This study aims to translate, culturally adapt, and validate the original English version of the SUS into a Spanish version.

Methods

The translation process included forward and backward translation. Forward translations were made by 2 native Spanish speakers who spoke English as their second language, and a backward translation was made by a native English speaker. The Spanish SUS questionnaire was validated by 10 experts in mobile app development. The face validity of the questionnaire was tested with 10 mobile phone users, and the reliability testing was conducted among 88 electronic application users.

Results

The content validity index of the new Spanish SUS was good, as indicated by a rating of 0.92 for the relevance of the items. The questionnaire was easy to understand, based on a face validity index of 0.94. The Cronbach α was .812 (95% CI 0.748-0.866; P<.001).

Conclusions

The new Spanish SUS questionnaire is a valid and reliable tool to assess the usability of electronic tools among Spanish-speaking users.

Prognostic Factors in Mexican Patients with Patchy and Other Types of Alopecia Areata

Introduction

Some clinical features have been associated with the progression and remission of alopecia areata (AA). We aim to determine possible prognostic factors in Mexican patients with AA.

Methods

This prospective study of a 1-year follow-up included Mexican patients with a clinical diagnosis of AA. We evaluated disease activity with the SALT score at the first visit and 1-year follow-up; progression, no progression, and remission were defined according to score changes. We used multiple linear regression model to detect factors associated with progression and remission.

Results

One hundred and four patients concluded the study. Ninety-seven patients (93.3%) had patchy AA. Fifteen patients showed disease progression and 89 no progression, of which 35 patients had remission. Body hair involvement was related to disease progression and adherence to treatment with disease remission and progression.

Conclusions

Body hair involvement is related to poor prognosis. Adherence to treatment is a modifiable prognostic factor associated with the course of AA in Mexican patients.

Diagnostic Accuracy of Dermoscopy of Actinic Keratosis: A Systematic Review

INTRODUCTION

Dermoscopy is a tool that aids clinicians in the diagnosis of actinic keratosis; however, few diagnostic accuracy studies have determined its sensitivity and specificity for this diagnosis.

OBJECTIVE

Determine the diagnostic accuracy of dermoscopy on actinic keratosis.

METHODS

A systematic review was conducted on EMBASE, PubMed, Scopus and the Cochrane Central Registry of Controlled Trials from inception to August 2019.

RESULTS

We screened 485 titles and abstracts. Two studies comprising 219 actinic keratoses were eligible for qualitative analysis. The number and heterogeneity of included studies limited a quantitative analysis.

CONCLUSIONS

Studies that focus specifically on the diagnostic accuracy of dermoscopy for actinic keratosis are lacking.

Psychological Profile and Quality of Life of Patients with Alopecia Areata

Alopecia areata (AA) is a nonscarring alopecia with an autoimmune etiology, unpredictable course, multiple presentations, and variable psychological distress. We conducted a cross-sectional study which included 126 patients with AA. A complete medical history was documented using the Severity Alopecia Tool (SALT) to assess the severity of the disease, and the following questionnaires were applied to the participants: the Dermatology Life Quality Index (DLQI), Hospital Anxiety and Depression Scale (HADS), Plutchik Suicide Risk Scale, and the Perceived Stress Scale (PSS-14) for adults. The Child Dermatology Life Quality Index (cDLQI) and the Birleson Depression Self-Rating Scale questionnaires were applied for children. Quality of life (QoL) disturbance was detected in 77.6% of adult participants, 65.9% of them had signs of depression or anxiety, and 12.8% were at risk of committing suicide. The PSS-14 average score for adults was 24.5. QoL disturbance was detected in 76.7% of children participants, and 6.3% of them showed signs of depression with the Birleson Depression Self-Rating Scale. We conclude that patients with AA could experience changes in their QoL and signs of depression, anxiety, and suicide risk, mainly in the adult population, during the course of the disease.

[Diagnóstico tardío de psoriasis: motivos y consecuencias]

BACKGROUND

Psoriasis is an autoimmune skin disease that may be associated with articular manifestations, and the most common clinical presentation is the variety "in plaques". In Mexico, in the Centro Dermatológico Pascua, it is the eighth leading cause of consultation. The aim of this study was to determine the diagnostic process of patients in a reference center for diseases of the skin.

METHODS

Performing an analytical cross-sectional study that included 100 patients where the diagnostic process was questioned, clinimetric scales were applied and evaluated anthropometric.

RESULTS

It was found that 70% of patients had taken over a month to get medical care (median: 3 months; IQR: 11 months), having consulted in 61% to a general physician as a doctor of first contact and 89% being diagnosed by a dermatologist. Eighty-eight percent of the patients were overweight or obese. We found as a factor of delay, a partnership with the variable of having an Institutional Medical Service (p = 0.019; U = 695.5).

CONCLUSION

it is necessary to design a system to shorten the diagnostic process, not only in psoriasis, in addition to emphasizing dermatological education.

Impact of Vitiligo on Quality of Life

INTRODUCTION AND OBJECTIVE

Vitiligo is a chronic autoimmune skin disease caused by the destruction of melanocytes. Although quality of life (QOL) in vitiligo has been studied in different countries, it has not yet been investigated in Mexico. The aim of this study was to assess the QOL of Mexican patients with vitiligo.

MATERIAL AND METHOD

We conducted a cross-sectional study at the research unit of Centro Dermatológico Dr. Ladislao de la Pascua in Mexico City. We included adults with vitiligo and excluded those with other pigmentation disorders or a neurological or psychiatric disorder. Patients on psychoactive medications were also excluded. All the patients were administered the Dermatology Life Quality Index (DLQI), a vitiligo-specific quality of life instrument (the VitiQoL), and the Beck Depression and Anxiety Inventories.

RESULTS

We studied 150 patients with vitiligo (103 women [68.7%] and 47 men [31.3%]). The median (interquartile range) age was 38 (20) years. The mean (SD) scores on the DLQI and VitiQoL were 5.2 (5.4) and 32.1 (22.7) out of total possible scores of 30 and 90, respectively. The correlation between questionnaire scores was 0.675 (P<.001). Patients with genital involvement scored significantly worse on the VitiQoL than those without lesions in this area (43.95 [28.4]) vs. 28.98 [20.08], P<.001). The prevalence of depression and anxiety was 34% and 60%, respectively.

CONCLUSION

Vitiligo has a minimal impact on the QOL of our patients. QOL was worse in patients with genital lesions.

[Insulin levels in teenagers with comedonal acne]

INTRODUCTION

Acne is considered a multifactorial skin disease secondary to an obstructive process of pilosebaceous units. Some studies suggest a relationship between insulin levels and the presence of acne, but this has not yet been demonstrated.

OBJECTIVE

To compare the levels of insulin in patients with and without comedonal acne.

MATERIAL AND METHODS

From January to July 2012, we conducted a cross-sectional study in the Dr. Ladislao de la Pascua Dermatologic Center in Mexico city. We recruited men and women from 14 to 25 years old with and without comedonal acne. We measured the insulin levels in all patients with DXI 800 Beckman Coulter equipment in a blood sample.

RESULTS

Twenty patients with acne and 20 patients without acne were studied, with an average age of 17 (±3) and 19 (±4) years, respectively. Both groups were different in terms of gender. Body mass index was similar in both groups. We did not find a difference in insulin levels between groups (p=0.818). The average level of insulin was 7.15±4.7 uU/ml for the acne group and 7.85±3.3 uU/mL for the control group.

CONCLUSION

Insulin levels are similar in patients with and without comedonal acne. There is no direct relationship between hyperinsulinemia and acne.

[Validation of a questionnaire to quantify the risk for skin cancer]

INTRODUCTION

Currently, strategies are needed to identify the population at risk for skin cancer in order to implement prevention and for early diagnosis. There are no validated Spanish language instruments to measure skin cancer risk.

OBJECTIVES

To design and validate a self-applied questionnaire to quantify the risk of melanoma and non-melanoma skin cancer in a Mexican population.

METHODS

A self-applied questionnaire was designed to measure risk factors for skin cancer. Face and content validity was assessed by five experts in skin cancer. The value of each item was weighted according to the relative risk of the risk factors. The questionnaire was applied to extreme groups in order to measure the construct validity. Reliability was evaluated using test-retest method two weeks after the first application.

RESULTS

The questionnaire was applied to patients with (n = 147) and without (n = 249) skin cancer from the Dermatologic Center "Dr. Ladislao de la Pascua". The total score of the questionnaire was different in both groups (U = 2,104.5, p = 0.0001) and ROC curve determined that five points or more equals high risk for skin cancer (area 0.964; 95% CI: 0.946-0.981; p = 0.0001). The reliability of the instrument was 0.971 (95% CI: 0.943-0.986; p = 0.0001).

CONCLUSION

This is the first Spanish language questionnaire valid to measure risk of skin cancer, whose application at the population level would be useful to identify high-risk individuals who need preventative interventions.

[Clinical practice guideline. Drug prescription in elderly]

The process of prescribing a medication is complex and includes: deciding whether it is indicated, choosing the best option, determining the dose and the appropriate management scheme to the physiological condition of the patient, and monitoring effectiveness and toxicity. We have to inform patients about the expected side effects and indications for requesting a consultation. Specific clinical questions were designed based on the acronym PICOST. The search was made in the specific websites of clinical practice guidelines, was limited to the population of older adults, in English or Spanish. We used 10 related clinical practice guidelines, eight systematic reviews and five meta-analyses. Finally, we made a search of original articles or clinical reviews for specific topics. The development and validation of clinical practice guidelines for "rational drug prescriptions in the elderly" is intended to promote an improvement in the quality of prescription through the prevention and detection of inappropriate prescribing in the elderly and, as a result of this, a decrease in the adverse events by drugs, deterioration of health of patients and expenditure of resources.

[Inappropriate prescribing in older adults with chronic-degenerative disease]

BACKGROUND

potentially inappropriate prescribing (IP) includes the use of drugs that represent greater risk than benefit to the patient, the STOPP-START instrument, allows its detection, the aim was to evaluate its utility.

METHODS

a descriptive cross-sectional study was performed. Randomly selecting records of older adults with at least one chronic degenerative disease, as last query had more than two months and have completed their monthly meeting at least four citations in the last 6 months were analyzed.

RESULTS

the files from 285 patients were reviewed, females were 60 %, and the mean age was 74 ± 6 years. A total of 1749 prescriptions included 126 different drugs. The prevalence of inappropriate prescribing was 55 % (95 % CI = 49-61) and 87 % polypharmacy (95 % CI = 83-91). The cardiovascular, endocrine and skeletal muscle system diseases had the highest number of prescriptions and inappropriate prescribing. It was detected the omission of one or more drugs listed in 72 % of 75 % specific clinical circumstances.

CONCLUSIONS

the STOPP-START instrument is useful for detecting inappropriate prescribing. Also, the omission of indicated preventive treatments required for older adults with chronic degenerative diseases.

[Clinical guideline. Preeclampsia-eclampsia]

Preeclampsia remains a major cause of worldwide pregnancy related maternal and neonatal mortality and morbidity, it accounts for more than 50,000 maternal deaths each year. The World Health Organization estimates that at least one woman dies every 7 minutes from a complication of preeclampsia. It is the main cause of maternal death in Mexico and Latin America. Standarized assessment and surveillance of women with preeclampsia is associated with reduced maternal risk. Standarized sequence was established to search for practice guidelines from the clinical questions raised on diagnosis and treatment of preeclampsia-eclampsia. The working group selected clinical practice guidelines found in the Cochrane Library, Medline and PubMed. The results were expressed as levels of evidences and grade of recommendation. Evidence suggests, that treatment of severe hypertension, seizures prophylaxis with magnesium sulfate, and management by experienced health-care professionals will improve maternal, fetal and neonatal outcomes. Treatment remains supportive with pregnancy termination being the only definitive cure.

[Clinical guide practice. Patent ductus arteriosus]

Patent ductus arteriosus (PDA) is the most common congenital heart disease in Mexico. The clinical manifestations of the PCA are from asymptomatic patients to the presence of heart failure. Its management should be individualized based on clinical, hemodynamic data and presence of pulmonary hypertension. Our objective was to provide current medical recommendations based on the best, available scientific evidence for the diagnosis, study and therapeutic decisions of the PCA. Established a standardized sequence to search for Practice Guidelines, based on the clinical questions about PCA diagnosis and treatment. Most of the recommendations were taken from selected guidelines and supplemented with the remaining material. The information is expressed in levels of evidence (E) and grade of recommendation (R) according to the characteristics of the study design and type of publications. Currently produces large amounts of medical information in a relatively short period of time which is necessary to have evidence-based CPG to facilitate and standardize the diagnostic decision-treatment to provide better care for children and adults with PCA.

[Clinical guideline for detection and diagnosis of hypertensive pregnancy disease]

Hypertensive disorders in pregnancy (HDP) are the main complication and cause of maternal and perinatal death. Pre-eclampsia represents a 34%, according to the Secretaría de Salud de México. To offer the family physicians tools for the opportune detection and diagnosis of HDP a clinical guideline was developmented. Clinical questions were formulated and structured. A standardized sequence to search for Practice Guidelines, based on the key words: hypertensive disorders in pregnancy, pre-eclampsia. Tripdatabase, MDConsult, National Guideline Clearinghouse, Scottish Intercollegiate Guidelines Network, National Institute for Health and Clinical Excellence were used. In addition, Cochrane Library Plus, Science Direct and OVID were used. Most of the recommendations were taken from guidelines selected and supplemented with the remaining material. The information is expressed in levels of evidence and grade of recommendation according to the characteristics of the study design and type of publications. To reduce morbidity and mortality from HDP health professionals should identify risk factors; conduct a close monitoring and early diagnosis. It is essential to provide information to the pregnant patient on alarm data and behavior to follow. This clinical practice guide offers current evidence for screening and diagnosis of HDP in primary care.

[A clinical guideline for diagnosis and treating of diabetes during pregnancy]

BACKGROUND

Metabolic disturbance commonly occurs during pregnancy and perinatal outcome harms, with increased maternal-fetal morbidity. The prevalence of diabetes during pregnancy in Mexico is 7%.

OBJECTIVE

To develop a guideline available to the staff of the first, second and third level of care, that includes recommendations based on the best available evidence.

METHODS

Clinical questions were formulated and structured. Standardized sequence was established to search for practice guidelines from the clinical questions raised on diagnosis and treatment of diabetes and pregnancy. The working group selected clinical practice guidelines. We found eleven guidelines which took many of the recommendations. For recommendations not included in the reference guides the search process was conducted in PubMed and Cochrane Library. The results were expressed as levels of evidence and grade of recommendation.

CONCLUSIONS

Diabetes mellitus during pregnancy increases perinatal morbidity and mortality. The recommendations in this evidence-based guide will help to make diagnosis and treatment standardized to reduce the consequences of disease.

[The clinical guidelines of practice project at the Instituto Mexicano del Seguro Social]

The advance in the knowledge and technology is growing quickly and greater quantity, so it is difficult for the health professional to access to whole information that is generated every day on diagnostic and therapeutic strategies more effective, so the clinic practice guidelines (CPG) is a resource to support the updating of the health professional and support them in making clinical decisions. The CPG is also a better support to the manager of health services in making decisions regarding the strategies that have performed for the patient and less risk to the individual and collective health. They also support the response capacity of the medical units and hospitals and guide the planning of services to the optimization of the resources. This paper summarizes the methodology of a national project for the development of GPC coordinated by the Mexican Social Security Institute with the collaboration of more than 1200 health professionals of the institution in a great effort institutional update and make information accessible to the entire health sector, which also defines the steps to upgrade and maintain the updating of knowledge and technology expressed in them.

[Immunization and bacterial pathogens in the oropharynx as risk factors for alopecia areata]

INTRODUCTION

Alopecia areata is an autoimmune inflammatory disease affecting the hair follicles. Researchers are currently interested in whether the presence of bacterial pathogens and/or a history of immunization can trigger an autoimmune response in patients who are genetically predisposed.

OBJECTIVES

This study aimed to determine whether there is an association between the development of alopecia areata and throat carriage of bacterial pathogens or a history of immunization.

MATERIAL AND METHODS

Sixty-five men and women with alopecia areata and 65 control patients with other skin diseases were studied at the Dr Ladislao de la Pascua Dermatology Clinic between September 2008 and February 2009. The patients ranged in age from 18-59 years. Patients with scalp diseases were excluded from the control group. In all cases, the patient was questioned about immunizations received in the previous 6 months, and a throat swab was cultured.

RESULTS

A history of immunization (odds ratio [OR], 3.3; 95% confidence interval [CI], 1.6-6.7; P=.001), the presence of bacterial pathogens in the oropharynx (OR, 2.6; 95% CI, 1.1-6.2; P=.033), and being a carrier of Streptococcus pyogenes (OR, 2.1; 95% CI, 1.7-2.5; P=.042) were risk factors for alopecia areata. Klebsiella pneumoniae, S. pyogenes, Pseudomonas aeruginosa, Streptococcus pneumoniae, Serratia marcescens and Escherichia coli were isolated from cultures.

CONCLUSIONS

This is the first study to show an association between alopecia areata and throat carriage of bacterial pathogens or history of immunization, as risk factors for development of the disease. Given the characteristics of our study population, the association appears valid for patients with less than 25% hair loss and a course of disease under 1 year.

[Usefulness of a clinical questionnaire for screening osteopenia and osteoporosis in post-menopausal women]

BACKGROUND

The prevalence of osteoporosis in post-menopausal women (PMW) is 30 %, and bone densitometry (BD) is the gold standard. This is not recommended as a screening test because of its cost. Instead, the SCORE index (Simple Calculated Osteoporosis Risk Estimation) is proposed. The objective is to determine the sensitivity and specificity of this test in the population and the optimization of BD.

METHODS

The SCORE Index is a pre-screening questionnaire; it was used in PMW to compare with BD, registering the total score of the questionnaire, densitometry diagnosis, the fracture risk and the site of osteoporosis. The sensitivity and specificity of SCORE Index and chi(2) of Mantel-Hanszel were calculated.

RESULTS

We studied 201 patients, mean age 55.70 years. Osteoporosis was recognized in 22.8 %, osteopenia in 68.3 % and 8.9 % was normal. The sensitivity of the SCORE index was 87 % (95 % CI = 77-97) and specificity was 34.6 % (95 % CI = 27-42) with p = 0.000. A positive probability quotient of 1.33 (95 % CI = 1.1-1.7).

CONCLUSIONS

Osteoporosis is a frequent disease in PMW. It is mandatory to have cheap and easy-tools which can detect osteoporosis cases.

[Frequency of gastroesophageal reflux disease in elderly patients attending a family medicine clinic]

OBJECTIVES

To ascertain the prevalence of gastroesophageal reflux disease (GERD) in elderly people attending to family medicine clinics.

MATERIAL AND METHODS

the study was conducted by using a prospective design in which participants were randomly selected from a family medicine clinic located in Mexico City. The study was run from August to September 2003, and included patients aged sixty years or older, regardless of gender. They should not have cognitive damage, which was ascertained by the Folstein Mini Mental State Examination. Those patients that did not accept to participate and those having incomplete or illegible medical records were excluded. The socio-demographic characteristics test and Carlsson-Dent test were applied. The information about diagnosis, drugs prescriptions, and pharmacological and no pharmacological gastroesophageal protection was obtained from the medical charts and prescriptions.

RESULTS

400 elderly patients were evaluated by using the Carlsson-Dent test. GERD prevalence was 25% (CI 95% 21-29) the average age of patients with and without GERD was 68 +/- 7 years and 70 +/- 7 years respectively (p = .002). Women suffered GERD more frequently than men (p = 0.001). GERD diagnosis was not found in any of the reviewed medical charts. Antacids, histamine-2 receptor antagonists (H2 As) and prokinetics were prescribed in 39% (CI 95% 34-44) of patients with GERD and in 18% (CI 95% 15-21) without GERD.

CONCLUSIONS

Elderly patients attending to primary care facilities often have GERD symptoms, but they are not properly diagnosed or followed up. The Carlsson-Dent questionnaire is an alternative to identify GERD patients.

[Depressive symptoms as a risk factor for polypharmacy in patients over 60 years of age]

OBJECTIVE

To determine the association between depressive symptoms not identified by the family physician and polypharmacy in patients over 60 years old.

METHODS

A case-control design with non-probabilistic sampling.

INCLUSION CRITERIA

> or = 60 years old both sexes, without disease or with one disease-balanced illness, and with reliable recording in chart by the last 12 month.

EXCLUSION CRITERIA

cognitive deterioration, obstructive chronic lung disease, cardiopathy, infarct record, alcoholism, smoking addiction and functional dependence's. Elimination criteria: depression's previous diagnoses and hospitalization during a year before the study. The cases were patients who have simultaneously received 4 o more pharmacologic prescriptions in 5 of 6 last medical visits. The controls were patients who have simultaneously received 3 o less pharmacologic prescriptions in 5 of 6 last medical visits. Depressive symptoms: grading > or = 6 (Yesavage and Brink scale).

RESULTS

200 patients per group, aged 69 +/- 6 years agreed to participate. Logistics regression (OR;CI(95%)): hypertension (6.0;3.6-10.3), diabetes mellitus type 2 (3.7;2.3-5.9), depression (2.1;1.2-3.4), and female sex (1.7;1.1-2.7).

CONCLUSIONS

Hypertension, diabetes mellitus type 2, depressive symptoms not identified by the family physician, and female sex are risk factors for polypharmacy in the elderly.

[Differences of risk factors for peripheral arterial disease in type 2 diabetes patients in urban and suburban populations]

OBJECTIVES

To determine the prevalence of peripheral arterial disease (PAD) in type 2 diabetes patients and to measure the strength of the association of selected risk factors.

METHODOLOGY

A cross-sectional study including two hundred and fifty-two type 2 diabetes patients older than 40 years was conducted in three family medicine clinics, one clinic located within the city and two clinics in the suburb. PAD was diagnosed by Doppler pulsed in the patients with an ankle/arm index < 0.9. CLINICAL VARIABLES: Serum cholesterol and triglycerides levels, body mass index (BMI), waist-hip index (WHI), blood pressure (BP) and fasting blood glucose average of the last six months. To ascertain the differences in the prevalence of PAD, chi(2) test was used; t test was used for quantitative variables; and to estimate the risks the odds ratios were calculated.

RESULTS

Among urban population the prevalence of PAD was of 25.6% while for those living in the suburb was 9.8 % (p = 0.002). Serum levels of blood glucose and cholesterol were lower in the latter (p = 0.01 and p = 0.001 respectively). PAD was associated with serum blood glucose levels higher than 140 mg/dL (OR = 3.1; 95% CI: 1-9.7); total cholesterol higher than 200 mg/dL (OR = 2.8; 95% CI: 1.1-7.4); proteinuria (OR = 4.9; 95% CI: 1.7-30.6) and blood pressure higher than 140/90 mm Hg (OR = 2.11; 95% CI: 1.08-4.14).

CONCLUSIONS

Prevalence of PAD was higher in type 2 diabetes patients receiving care in urban clinics when compared to those cared for at suburban family medicine clinics and its corresponding risk factors showed significant values.

[Professional burnout in family physicians and its association with social demographic and labor factors]

OBJECTIVE

To determinate the prevalence of burnout in family physicians of the Family Medicine Units in the Estado de México and its association with labor and socio demographics factors.

MATERIAL AND METHODS

A transversal study was made in five Family Medicine Units. 154 physicians of both sex participated in this study. The Maslach Burnout Inventory (MBI) which measures the burnout in its three dimensions: emotional fatigue (EC), depersonalization (DP) and personal realization (PR), was applied by self-administration. Socio-demographic and labor details were obtained.

RESULTS

Response rate was 85. A high CE was significantly associated to inadequate physical area, OR 3.9 CI 95% 1.5-10.6; to work load OR 7.6 CI 95% 1.6-50.7 and to lack of labor incentives OR 4.4 CI 95% 1.7-11.9 depersonalization was associated only with salary OR 2.6 CI 95% 1.05-6.4.

CONCLUSIONS

Family physicians of Mexican Institute of Social Security have labor factors that are associated with burnout that can affect patient's attention.

[Depression prevalence and risk factors found in women attended by a family physician]

OBJECTIVES

Determine the prevalence of depressive symptoms in adult woman who was attended by family physician, to explore risk factors for depression and estimate how often depression is registered as a diagnosis by the family physician.

MATERIALS AND METHODS

We did a prospective, analytic, and transversal study with simple randomized sampling at a Mexico City Family Medicine Clinic from March to December 2004. The size of the study was 384 patients. It includes women from 20 to 59 years of age. We excluded women without a clinical file for at least 1 year of reliable information. The Center for Epidemiologic Studies Depression Scale (CES-D) and the Family Apgar Scale were applied.

RESULTS

The survey included a total of 400 patients with the following characteristics: average age, 39 +/- 11 years; married, 74%; homemakers, 68%, and women with education level of high school or less were 79%. Prevalence of depressive symptoms was 52% (95% confidence interval [95% CI], 47-57). In women between 20 and 39 years of age, there was an association between depression and family dysfunction; the average number of healthcare appointments for the year prior to the study was significantly higher in patients 40 years old or more.

CONCLUSIONS

There is a high prevalence of depressive symptoms in adult women, and depression diagnosis is frequently omitted. Depression-associated factors differ according to chronological age. In young women, family dysfunction is the main risk factor.

[Usefulness of establishing diagnosis and severity of the most frequent signs and symptoms in preeclamptic patients]

OBJECTIVE

Our aim was to determine that signs and symptoms are tools in establishing diagnosis and severity of preeclampsia.

MATERIALS AND METHODS

Our study design was prolective, comparative, cross-sectional for evaluation of diagnosis. Our sample included 408 patients. The study employed classification criteria of the American College of Obstetricians and Gynecologists. One blinded family physician interrogated and examined each patient. The sample included patients with recent diagnosis and without treatment. Patients with HELLP syndrome, eclampsia, and those in Intensive Care were excluded. Clinical signs evaluated included headache, Phosphenes, acuphenes, tinnitus, vomiting, epigastric pain, right hypochondrium pain, ecchymosis, hematomas,and hyperreactive reflexes.

RESULTS

A total of 192 patients without preeclampsia, 63 with mild, and 153 with severe preeclampsia were included. Clinical manifestations were absent in 60, 21 and 8% respectively of patients in each group. Presence of three or more signs or symptoms had sensitivity of 60% (CI95% 53-67), specificity of 84% (CI95% 79-89), and positive likelihood ratio of 3.8 and negative, 0.48. Most usefulness data for diagnosis of preeclampsia are hyperreactive reflexes, phosphenes, acuphenes, right hypochondrium pain, and epigastric pain.

CONCLUSIONS

The symptoms and signs taken alone are tools for evaluation of severity but not for detection of preeclampsia. There is necessary to develop new way for it's diagnosis during prenatal care.