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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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

Background and Objective: To determine whether in the Mexican population the spouses of patients with type 2 diabetes mellitus (DM2) have an increased risk of any degree of glucose intolerance compared with spouses of subjects without diabetes., Subjects and Method: An analytical cross-sectional study was made in the Family Medicine Unit number 62 of the Mexican Institute of Social Security, located in the State of México. A random sample of 87 spouses of patients with DM2 (group ED) was compared with 87 spouses of subjects with a normal glucose tolerance (group ENOD). Risk factors for DM2 were investigated; spouses in both groups underwent oral glucose tolerance test, and total cholesterol, triglycerides, blood pressure, body mass index and waist circumference were measured. The frequency of impaired fasting glucose, impaired glucose tolerance and DM2 were compared in both groups and the odds ratio was calculated., Results: In the group ED there were 38 (43.7%) subjects with any degree of glucose intolerance vs. 23 (26.4%) in the ENOD group -odds ratio = 2.16 (95% confidence interval, 1.14-4.08) in the bivariate analysis, and odds ratio = 2.37 (95% confidence interval, 1.14-4.91) in the logistic regression-. In the group ED a higher systolic blood pressure was observed (P=.02). There were no significant differences in age, sex, body mass index, waist circumference, total cholesterol, triglycerides and diastolic blood pressure. The frequency of risk factors for diabetes was similar in both groups., Conclusions: In the Mexican population, the spouses of subjects with DM2 have a higher risk of any alteration in the glucose tolerance than spouses of subjects with a normal glucose metabolism.

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.

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.

Objectives: To estimate the frequency of asymptomatic bacteriuria in pregnant women attended in Family Medicine Units of the Instituto Mexicano del Seguro Social and to determine the in vitro sensitivity rate of the microorganisms to ampicillin, trimethoprim-sulfamethoxazole, nitrofurantoin and amikacin., Patients and Methods: We carried out an observational, prospective and transversal study at Family Medicine Units 62 and 64 of the Mexico State Delegation, located in the urban area of Mexico City. Women with lesser than 32 weeks of pregnancy without urinary tract symptoms were included. Urine culture of a midstream urine specimen with > or = 10(5) colony forming units/mL urine of an only germen was used as the gold standard. The in vitro antimicrobial sensitivity was established according to the Bauer Kirby technique., Results: 874 pregnant women were included and 73 had a positive urine culture, with a frequency of 8.4%, IC 95% = 6.6 - 10.2%, of asymptomatic bacteriuria. Escherichia coil was the most frequent isolated agent (77%). In vitro sensitivity to ampicillin of the microorganisms isolated was of 27%, IC 95% = 16 - 38%; to trimethoprim-sulfamethoxazole of 40%, IC95% = 29 - 51%; to amikacin of 68%, IC 95% = 57 - 79%, and to nitrofurantoin of 79%, IC 95% = 70 - 88%., Conclusions: The frequency of asymptomatic bacteriuria in the studied population is similar to the reported by the literature. The in vitro sensitivity rates of E. coil to ampicillin and to trimethoprim-sulfamethoxazole are very low. The best sensitivity corresponded to the nitrofurantoin. The treatment of the asymptomatic bacteriuria must be based on the local patterns of antimicrobial sensitivity and resistance.

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.

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.

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.

Background: Surgical wound infection after cesarean section varies from 2.5 to 16.1%, thus the utilization of antibiotic prophylaxis has increased routinely and irrationally. Despite this, we can still see cases of infections., Objective: To determine if the antibiotic prophylaxis with cefotaxime is associated with the decreased incidence of wound infection in patients submitted to cesarean section without risk factors., Patients and Methods: This study was carried out as a randomized clinical trial in patients submitted to cesarean section. Two groups were formed: in the first group we administered cefotaxime and the other one did not receive prophylaxis. The follow-up lasted 30 days to evaluate clinical data of infection., Results: We performed 3,300 cesarean in the studied period; 1,000 patients had the inclusion criteria to participate in the study. A surgical wound infection was observed in 31 (0.96%) patients without risk factors. In 14 of these patients we administered cefotaxime, and in 17 patients we did not use prophylaxis. The highest frequency of infection was observed in the group of 24 to 30 years old, with 16 patients (51.6%). The clinical data of infection were: dehiscence in 29 patients (93.5%), pus secretion in 23 (74.2%), and fever in only 3 (9.7%) of them. The hospital stay after the infection was of five days in 75% of the cases. When the use of cefotaxime as prophylaxis was analyzed in both groups we had an odds ratio of 0.82, which was not significant., Discussion: The use of cefotaxime in patients operated of cesarean does not have great transcendence since it does not reduce the infection incidence. The use of antibiotics in an irrational way implies a high cost, since the majority of the post-operation infections are not complicated, involving exclusively the skin and cellular subcutaneous tissue. Then, the cases with risk factors should be analyzed carefully for the cefotaxime administration.

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.

Objective: To determine the clinical significance and optimal cutting points of laboratory tests more frequently used in patients with pre-eclampsia of recent diagnosis., Materials and Methods: We made an analytic cross-sectional study for evaluation of diagnostic test. Non probabilistic sampling. Sample size 400 patients. We used the American College of Obstetricians and Gynecologists criteria as gold standard. Laboratory personnel was blinded to the clinical classification of the patients., Results: We studied 192 patients without pre-eclampsia, 63 with mild and 153 with severe pre-eclampsia. Hematocrits, prothrombin time, partial thromboplastin time, aspartate aminotransferase, alanine aminotransferase and bilirubins did not show significative differences among groups. Platelets counting showed low sensitivity. Lactic dehydrogenase showed 71% sensitivity (65-85 CI95%), specificity 74% (68-80 CI95%) positive likelihood ratio 2.7 and negative 0.4. Uric acid showed sensitivity of 75% (69-81 CI95%) specificity 79% (73-85 CI95%) positive likelihood ratio of 3.5 and negative of 0.3. Seric creatinine with sensitivity of 81% (76-86 CI95%) specificity of 60% (53-67 CI95%) positive likelihood ratio of 2 and negative of 0.3., Conclusions: Seric uric acid, seric creatinine and lactic dehydrogenase are useful for diagnosis and severity classification of pre-eclampsia. Platelets counting is not useful for diagnosis but is useful for severity classification. In patients with thrombocytopenia prothrombin time is useful for severity classification.