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Background: Evidence supports a causal relationship between circadian disturbance and impaired glucose homeostasis. Method: To determine the effect of a nursing educational intervention on improving healthy sleep, a parallel, open-label clinical trial in subjects with Impaired Fasting Glucose (IFG) or Type 2 Diabetes Mellitus (T2DM) and 18 and older was performed. Study variables were sex, age, fasting glucose, glycated hemoglobin A1c (HbA1c), Pittsburgh Sleep Quality Index (PSQI), sleep duration and efficiency, BMI, antidiabetic treatment and diet and physical exercise. An individual informative educational intervention was carried out following a bidirectional feedback method. It was intended to develop skills to improve sleep through 9 simple tips. An analysis of covariance was performed on all the mean centered outcome variables controlling for the respective baseline scores. Results: After the intervention, in the experimental group, PSQI dropped, the duration and quality of sleep increased. Further, a decrease in fasting glucose and in HbA1c levels was observed. Conclusion: The proposed intervention has proven to be effective to improve sleep quality, time, and efficiency and in only 3 months, to achieve a decrease in fasting glucose and HbA1c levels. These findings support the importance of sleep and circadian rhythms education focused on improving in T2DM or IFG.

Background: The usefulness of Lung Ultrasound (LUS) for the diagnosis of interstitial syndrome caused by COVID-19 has been broadly described. The aim of this study was to evaluate if LUS may predict the complications (hospital admission) of COVID-19 pneumonia in primary care patients. Methods: This observational study collects data from a cohort of 279 patients with clinical symptoms of COVID-19 pneumonia who attended the Balaguer Primary Health Care Area between 16 March 2020 and 30 September 2020. We collected the results of LUS scans reported by one general practitioner. We created a database and analysed the absolute and relative frequencies of LUS findings and their association with hospital admission. We found that different LUS patterns (diffuse, attenuated diffuse, and predominantly unilateral) were risk factors for hospital admission (p &lt, 0.05). Additionally, an evolutionary pattern during the acute phase represented a risk factor (p = 0.0019). On the contrary, a normal ultrasound pattern was a protective factor (p = 0.0037). Finally, the presence of focal interstitial pattern was not associated with hospital admission (p = 0.4918). Conclusion: The lung ultrasound was useful to predict complications in COVID-19 pneumonia and to diagnose other lung diseases such as cancer, tuberculosis, pulmonary embolism, chronic interstitial pneumopathy, pleuropericarditis, pneumonia or heart failure.

Puntos clave • Se estima que un 10% de la poblacion adulta padece insomnio cronico. • Ante un paciente que consulta por insomnio de reciente aparicion, el medico de familia debe plantearse su tratamiento etiologico. • Es importante realizar una correcta anamnesis de la persona con insomnio para poder saber que es lo que puede estar causando el insomnio. • El insomnio es causa, efecto y comorbilidad frecuente de padecimientos medicos, psiquiatricos y de consumo de sustancias. • El insomnio puede ser el resultado del tratamiento de otros padecimientos. • La intervencion terapeutica temprana es crucial para limitar las consecuencias negativas que puede suponer la cronificacion del insomnio. • El primer paso del tratamiento del insomnio consiste en informar al paciente, para que comprenda el origen de su problema y para que conozca las medidas que se pueden llevar a cabo para resolverlo. • Los hipnoticos son de utilidad si se usan en la dosis minima efectiva y por el menor tiempo necesario. Su funcion es el alivio sintomatico y prevenir la accion de los factores perpetuantes. • El tratamiento del insomnio cronico es complejo y debe incluir obligatoriamente metodos no farmacologicos, en especial la explicacion de habitos correctos de sueno. • La terapia cognitivo-conductual (TCC) ha demostrado ser, al menos, tan efectiva como los farmacos, y sus beneficios se mantienen en el tiempo una vez que finaliza la administracion activa de la TCC.

Highlights • La ecografía clínica es una herramienta que complementa a la anamnesis y a la exploración física, lo que facilita y agiliza la toma de decisiones en cualquier entorno de atención médica • El médico de familia es el especialista que más se puede beneficiar del empleo de la ecografía porque debe ser competente en todos los terrenos de la enfermedad • El estudio mediante ecografía, por su fiabilidad, seguridad, reproducibilidad y bajo coste debe estar accesible para su empleo en atención primaria, tanto en el ámbito de la atención normal como la urgente • Esta técnica, aplicada en escenarios concretos y con una sistemática de estudio definida, confirma o descarta enfermedades, lo que orienta el diagnóstico con elevada fiabilidad, así como sustenta de modo eficaz la conducta del profesional • Este artículo revisa la fiabilidad y la utilidad de la ecografía clínica en escenarios como la enfermedad cervical, y en diferentes situaciones de urgencia, como sospecha de trombosis venosa profunda en la extremidad inferior, traumatismo toracoabdominal, inestabilidad hemodinámica o parada cardiaca, Resumen La ecografía es una herramienta de gran valor para el diagnóstico y el manejo de una gran variedad de situaciones clínicas cotidianas. El médico de familia como especialista generalista debe ser competente para el abordaje de prácticamente cualquier problema de salud que afecte a su población, por lo que, en sus manos, esta herramienta puede proporcionar un elevado impacto sobre la calidad y la eficacia del proceso asistencial. Este es el último artículo de una serie dedicada a mostrar la aplicabilidad de la ecografía clínica en nuestras manos, en la que hemos revisado la mayoría de sus aplicaciones, como la ecografía clínica abdominal, la nefrourológica, la musculoesquelética, la cardiaca o la pulmonar. Queremos terminar con escenarios como la afección del cuello o su uso en situaciones de urgencia, en las que proporciona datos definitivos para la orientación diagnóstica, el manejo clínico e incluso la supervivencia del paciente, tales como el paciente con sospecha de trombosis venosa profunda en miembros inferiores, traumatismo toracoabdominal, compromiso hemodinámico o parada cardiaca.

Resumen Fundamento y objetivo Analizar las diferencias en la incidencia de fractura de femur en mayores de 65 anos en las 17 comunidades autonomas (CC. AA.) del estado espanol en el periodo de 1997-2010. Material y metodos Estudio ecologico, observacional y retrospectivo que incluye a las personas ≥ 65 anos que han presentado una fractura del tercio proximal de femur en Espana durante 14 anos. Estos registros provienen del conjunto minimo basico de datos de los pacientes atendidos en el conjunto de hospitales de Espana. Resultados Se analizan 534.043 fracturas de femur en personas ≥ 65 anos (414.518 en mujeres y 119.525 en varones). En ≥ 75 anos ocurrieron el 85,4% (86,7% en mujeres; 80,7% en varones). La tasa ajustada/100.000/ano fue de 722,6 en mujeres y 284,8 en varones. Por encima de la media en mujeres hay 7 CC. AA., y destacan: Cataluna, Comunidad Valenciana y Castilla-La Mancha. Por debajo de la media hay 6 CC. AA., y destacan: Canarias y Galicia. La diferencia entre CC. AA. con mayor y menor tasa de fractura ajustada por poblacion es un 44% menor en mujeres (Canarias frente a Castilla-La Mancha) y un 50% menor en varones (Galicia frente a Cataluna). Conclusiones La incidencia de fractura de femur en Espana en ≥ 65 anos muestra una importante variabilidad entre CC. AA. y, por tanto, entre zonas geograficas. Excepto en Canarias, esta variabilidad es dificil de explicar solo por factores como la edad de la poblacion, la exposicion solar o el gradiente norte-sur. Son necesarios estudios que analicen las causas de estas importantes diferencias entre CC. AA. espanolas.

Resumen El médico de familia está incorporando la ecografía clínica como técnica de exploración y diagnóstico en su actividad asistencial, del mismo modo que el resto de los especialistas. Su papel generalista lo convierte en un potencial utilizador de todas las posibles aplicaciones de esta técnica, lo cual puede causar un elevado impacto en su capacidad de manejar, enfocar y resolver un gran número de situaciones clínicas. En este artículo nos dedicamos a valorar la utilidad y la efectividad de la ecografía clínica por parte del médico de familia en sus aspectos más novedosos, como son la ecocardiografía clínica y la ecografía pulmonar.

The effect of inhaled drugs in community-acquired pneumonia (CAP) is unclear. This case-control study was designed to determine whether inhaled drugs were risk factors for CAP. All incident cases of confirmed CAP that occurred over 1 yr in patients with chronic bronchitis (CB), chronic obstructive pulmonary disease (COPD) or asthma were included, as well as CB, COPD and asthma controls. Risk factors for CAP and inhaled treatment were recorded during a personal interview. An effect of inhaled drugs on the risk of CAP was observed in COPD and asthma patients after adjusting for the effect of other respiratory diseases and their concomitant treatments. In COPD patients, inhaled steroids had a risk OR of 3.26 (95% CI 1.07-9.98) and in asthma patients inhaled anticholinergics had a risk OR of 8.80 (95% CI 1.02-75.7). In CB patients, no association with CAP was observed for any inhaler. These effects were independent of adjusting variables related to severity and other respiratory and non-respiratory risk factors for CAP, including vaccines. Inhaled β(2)-adrenergic agonists did not show a significant effect on the risk of CAP in any of the respiratory diseases. Inhaled steroids may favour CAP in COPD patients, whereas anticholinergics may favour CAP in asthma patients. It is difficult to differentiate the effect of inhaled therapy from the effect of COPD or asthma severity on the risk of CAP, and these relationships may not be causal, but could call attention to inhaled therapy in COPD and asthma patients.

The aim of the present study was to identify risk factors for community-acquired pneumonia (CAP), with special emphasis on modifiable risk factors and those applicable to the general population. A population-based, case-control study was conducted, with a target population of 859,033 inhabitants aged >14 yrs. A total of 1,336 patients with confirmed CAP were matched to control subjects by age, sex and primary centre over 1 yr. In the univariate analysis, outstanding risk factors were passive smoking in never-smokers aged >65 yrs, heavy alcohol intake, contact with pets, households with >10 people, contact with children, interventions on the upper airways and poor dental health. Risky treatments included amiodarone, N-acetylcysteine and oral steroids. Influenza and pneumococcal vaccine, and visiting the dentist were protective factors. Multivariable analysis confirmed cigarette smoking, usual contact with children, sudden changes of temperature at work, inhalation therapy (particularly containing steroids and using plastic pear-spacers), oxygen therapy, asthma and chronic bronchitis as independent risk factors. Interventions for reducing community-acquired pneumonia should integrate health habits and lifestyle factors related to household, work and community, together with individual clinical conditions, comorbidities and oral or inhaled regular treatments. Prevention would include vaccination, dental hygiene and avoidance of upper respiratory colonisation.

Fundamento y objetivo Los objetivos del estudio han sido estimar la prevalencia de hipertension arterial (HTA) en los ancianos institucionalizados en Espana y por comunidad autonoma, y describir el perfil del anciano hipertenso atendido en estos centros. Pacientes y metodo Se ha realizado un estudio transversal de prevalencia de HTA, de ambito estatal. Se incluyo a personas mayores de 65 anos institucionalizadas. Se excluyo a las ingresadas en unidades de cuidados paliativos. Se consideraron criterios de HTA para el estudio los siguientes: diagnostico de HTA en la historia clinica, tratamiento farmacologico antihipertensivo y valor mas alto de presion arterial en el ultimo ano de 140/90 mmHg o superior. Resultados Se incluyo a 13.272 pacientes de 223 centros, pertenecientes a las 17 comunidades autonomas y a la ciudad autonoma de Melilla, con una media (desviacion estandar) de edad de 82,9 (7,5) anos; el 70,6% eran mujeres. Cumplian al menos un criterio de HTA 8.242 pacientes (62,1%; intervalo de confianza del 95%, 61,3-62,9%). La HTA se asociaba a obesidad en el 26,3% de los casos, a diabetes en el 25,7% y a dislipemias en el 23,8%. La comorbilidad mas frecuente fue la demencia (37,1%), seguida de la insuficiencia vascular periferica (28,3%), el ictus (26,0%) y la insuficiencia cardiaca (25,1%). El 69,7% de los hipertensos (intervalo de confianza del 95%, 68,7-70,6%) recibia tratamiento farmacologico antihipertensivo. Los antihipertensivos mas utilizados eran los diureticos (46,3%) y los inhibidores de la enzima de conversion de la angiotensina (34,6%). La ultima determinacion de la presion arterial efectuada en el centro fue inferior a 140/90 mmHg en el 60,4% de los hipertensos. Conclusiones Los ancianos institucionalizados en nuestro entorno presentan una elevada prevalencia de HTA, con una comorbilidad notable y una proporcion de tratamiento farmacologico antihipertensivo similar a las publicadas en otros paises.

Background and objective To analyze differences in the incidence of hip fracture in people older than 65 years in the 17 autonomous communities (AA. CC.) (regions) of the Spanish state in the 1997–2010 period. Material and methods Ecological, observational and retrospective study that includes people ≥ 65 year old who have suffered a hip fracture in Spain over 14 years. These records are taken from the minimum basic data set of patients treated in all hospitals of Spain. Results The analysis include 534,043 hip fractures in ≥ 65 year olds (414,518 women and 119,525 men). A percentage of 85.4 of hip fractures occurred in people ≥ 75 years (86.7% women; 80.7% men). The adjusted hip fracture rate/100,000/year was 722.6 in women and 284.8 in men. AA. CC. with women above the average of the country were 7, including Catalonia, Comunidad Valenciana and Castilla-La Mancha. Six AA. CC. had patients below the average, including Canary Islands and Galicia. In AA. CC. with highest and lowest adjusted hip fracture rate/100,000/year, the difference was 44% lower in women (Canary vs. Castilla-La Mancha) and 50% lower in men (Galicia vs. Catalonia). Conclusions The analysis of the incidence of hip fracture in Spain in people ≥65 year old shows a significant variability between AA. CC. Except in Canary Islands, this variability is difficult to explain only by factors such as population age, sun exposure or north-south gradient. Additional studies are needed to analyze the causes of these important differences between Spanish AA. CC.

Resumen El envejecimiento comporta un incremento de la dependencia en la realizacion de las actividades de vida diaria y, por ello, un aumento de la necesidad de atencion a largo plazo El objetivo de este trabajo es conocer el grado de dependencia de las personas de 65 anos o mas de una area rural y comparar las escalas de valoracion de las actividades de la vida diaria (AVD) de Katz y de Barthel Realizamos un estudio observacional con una muestra de 195 individuos con historia clinica abierta en la ABS. Los resultados obtenidos fueron: a ) el incremento de edad es directamente proporcional a la perdida de funcion, y b ) no hay diferencias significativas entre la valoracion con el indice de Katz o con el de Barthel Creemos en la necesidad de aplicar estas escalas a la poblacion mayor de 65 anos para identificar la dependencia y valorar el tipo de ayuda que requiere el anciano en las actividades de la vida diaria en concreto y prevenir las posibles complicaciones

Background: The WHO has recently published the FRAX tool to determine the absolute risk of osteoporotic fracture at 10 years. This tool has not yet been validated in Spain. Methods/design: A prospective observational study was undertaken in women in the FRIDEX cohort (Barcelona) not receiving bone active drugs at baseline. Baseline measurements: known risk factors including those of FRAX and a DXA. Follow up data on self-reported incident major fractures (hip, spine, humerus and wrist) and verified against patient records. The calculation of absolute risk of major fracture and hip fracture was by FRAX website. This work follows the guidelines of the STROBE initiative for cohort studies. The discriminative capacity of FRAX was analyzed by the Area Under Curve (AUC), Receiver Operating Characteristics (ROC) and the Hosmer-Lemeshow goodness-of-fit test. The predictive capacity was determined using the ratio of observed fractures/expected fractures by FRAX (ObsFx/ExpFx). Results: The study subjects were 770 women from 40 to 90 years of age in the FRIDEX cohort. The mean age was 56.8 ± 8 years. The fractures were determined by structured telephone questionnaire and subsequent testing in medical records at 10 years. Sixty-five (8.4%) women presented major fractures (17 hip fractures). Women with fractures were older, had more previous fractures, more cases of rheumatoid arthritis and also more osteoporosis on the baseline DXA. The AUC ROC of FRAX for major fracture without bone mineral density (BMD) was 0.693 (CI 95%; 0.622-0.763), with T-score of femoral neck (FN) 0.716 (CI 95%; 0.646-0.786), being 0.888 (CI 95%; 0.824-0.952) and 0.849 (CI 95%; 0.737-0.962), respectively for hip fracture. In the model with BMD alone was 0.661 (CI 95%; 0.583-0.739) and 0.779 (CI 95%; 0.631-0.929). In the model with age alone was 0.668 (CI 95%; 0.603-0.733) and 0.882 (CI 95%; 0.832-0.936). In both cases there are not significant differences against FRAX model. The overall predictive value for major fracture by ObsFx/ExpFx ratio was 2.4 and 2.8 for hip fracture without BMD. With BMD was 2.2 and 2.3 respectively. Sensitivity of the four was always less than 50%. The Hosmer-Lemeshow test showed a good correlation only after calibration with ObsFx/ExpFx ratio. Conclusions: The current version of FRAX for Spanish women without BMD analzsed by the AUC ROC demonstrate a poor discriminative capacity to predict major fractures but a good discriminative capacity for hip fractures. Its predictive capacity does not adjust well because leading to underdiagnosis for both predictions major and hip fractures. Simple models based only on age or BMD alone similarly predicted that more complex FRAX models.

Background: Osteoporosis is a serious health problem that worsens the quality of life and the survival rate of individuals with this disease on account the osteoporotic fractures. Studies have long focused on women, and its presence in men has been underestimated. While many studies conducted in different countries mainly assess health-related quality of life and identify fracture risks factors in women, few data are available on a Spanish male population. Methods/Design: Observational study. Study population: Men ≥ 40 years of age with/without diagnosed osteoporosis and with/without osteoporotic fracture included by their family doctor. Measurements: The relationship between customary clinical risk factors for osteoporotic fracture and healthrelated quality of life in a Spanish male population. A telephone questionnaire on health-related quality of life is made. Statistical analysis: The association between qualitative variables will be assessed by the Chi-square test. The distribution of quantitative variables by Student’s t-test. If the conditions for using this test are not met, the nonparametric Mann-Whitney’s U test will be used. The validation of the results obtained by the FRAX™ tool will be performed by way of the Hosmer-Lemeshow test and by calculating the area under the Receiver Operating Characteristic (ROC) curve (AUC). All tests will be performed with a confidence intervals set at 95%. Discussion: The applicability and usefulness of Health-related quality of life (HRQOL) studies are well documented in many countries. These studies allow implementing cost-effective measures in cases of a given disease and reducing the costly consequences derived therefrom. This study attempts to provide objective data on how quality of life is affected by the clinical aspects involved in osteoporosis in a Spanish male population and can be useful as well in cost utility analyses conducted by health authorities. The sample selected is not based on a high fracture risk group. Rather, it is composed of men in the general population, and accordingly comparisons should not lead to erroneous interpretations. A possible bias correction will be ensured by checking reported fractures against healthcare reports and X-rays, or by consulting health care centers as applicable.

Background The development of FRAX ® has been useful to simplify the fracture risk assessment of patients, although several studies have shown that this tool underestimates the real risk of fracture in Spanish population. Objectives To develop an accurate model of fracture risk assessment based on FRAX ®, using a cohort of Spanish women followed over a 10 year period and to establish the best thresholds for indication of DXA and indication of treatment (high-risk patients). Methods Longitudinal multicenter study. Women between 40-90 years from FRIDEX cohort (35,000 people in the Barcelona with DXA and extensive questionnaire on risk factors for fracture at baseline), who had been followed during a 10 year period and who had not received any treatment for osteoporosis were selected. New self-reported osteoporotic fractures contrasted with electronic records or clinical reports were collected.The risk of major osteoporotic fracture for Spanish population based on FRAX was assessed in all women. We calculated the Area Under the ROC curve (AUC) for both DXA and 10-year risk of major fracture by FRAX. Results We selected 816 women, mean age 56.8±8.2 years. After 10 years, 76 women (9.3%) had suffered 95 osteoporotic fractures, of which 49 (6%) were major (15 hip, 4 vertebral, 13 humerus and 17 distal radio). Women who suffered a major osteoporotic fracture during the follow-up were significantly older (p 7.5%). In women with intermediate risk the model reassess the probability of fracture including the T-score of femoral neck by DXA in the FRAX tool and classify these patients as low or high risk for fracture. The application of this model could save 82% of DXA scans and avoid up to 31% of unnecessary treatments. Conclusions The FRIDEX model, compared with DXA based model, has a better discriminative ability to detect women who will suffer osteoporotic fractures over a 10-year period. This model could save unnecessary DXA and osteoporotic treatments. Disclosure of Interest R. Azagra Grant/Research support from: Sponsored by FEDER, IS Carlos III Grant. Spanish Ministry of Science., E. Casado: None Declared, G. Encabo: None Declared, A. Aguye: None Declared, J. Pujol-Salud: None Declared, J. C. Martin-Sanchez: None Declared, E. Gene: None Declared, M. Zwart: None Declared, M. Iglesias: None Declared, F. Lόpez-Expόsito: None Declared, G. Roca: None Declared, S. Guell: None Declared

Background: The COVID-19 pandemic rapidly strained healthcare systems worldwide. The reference standard for diagnosis is a positive reverse transcription polymerase chain reaction (RT-PCR) test, but results are not immediate and sensibility is variable. Aim: To evaluate the diagnostic accuracy of lung ultrasound compared to chest X-ray for COVID-19 pneumonia. Design and Setting: A retrospective analysis of symptomatic patients admitted into one primary care centre in Spain between March and September 2020. Method: Patients’ chest X-rays and lung ultrasounds were categorized as normal or pathologic. RT-PCR confirmed COVID-19 infection. Pathologic lung ultrasound images were further categorized as showing either local or diffuse interstitial disease. McNemar and Fisher tests were used to compare diagnostic accuracy. Results: Most of the 212 patients presented fever at admission, either as a standalone symptom (37.74% of patients) or together with others (72.17% of patients). The positive predictive value of the lung ultrasound was 90% for the diffuse interstitial pattern and 46.92% for local pattern. The lung ultrasound had a significantly higher sensitivity (82.75%) (p &lt, 0.001), but lower specificity (71%) than the chest X-ray (54.02% and 86%, respectively) (p = 0.008) for identifying interstitial lung disease. Moreover, sensitivity of the lung ultrasound for severe interstitial disease was 100%, and was significantly higher than the chest X-ray (58.33%) (p = 0.002). Conclusion: The lung ultrasound is more accurate than the chest X-ray for identifying patients with COVID-19 pneumonia and it is especially useful for those presenting diffuse interstitial disease.

Introducción: Numerosos estudios han establecido tanto la hipertensión arterial como la hipertensión de bata blanca como factores de riesgo cardiovascular. Un ritmo circadiano anómalo de la presión arterial podría aumentar el riesgo cardiovascular. Objetivo: Determinar la existencia de una relación clínicamente relevante entre un ritmo circadiano anómalo de la presión arterial y un incremento del riesgo cardiovascular en pacientes con hipertensión arterial o hipertensión de bata blanca. Material y Método: Estudio descriptivo en 166 pacientes mayores de 18 años del Área Básica de Salud de Balaguer que tuvieran una monitorización ambulatoria de la presión arterial realizada entre junio de 2014 y marzo de 2018 y cumplieran los criterios de inclusión y exclusión. Se realizó un análisis univariado y bivariado de las variables. Resultados: Se obtuvo que en casi todos los promedios de presión arterial nocturna destaca el patrón riser mostrando que el 25% tenía un riesgo cardiovascular mayor o igual al 10%, seguido del dipper extremo 16,67%, dipper 9,4% y no dipper 8,27%. Conclusión: Un ritmo circadiano alterado se relaciona con un riesgo cardiovascular más elevado y un peor control de los factores que conllevan al mismo.