El papel de la Medicina de Familia en el Grado

At the beginning of this decade, several authors, the scientific societies of Family Medicine / Primary Care, as well as the National Commission (CN) of Family and Community Medicine claimed about the lack of continuity between undergraduate and specialized training in Family Medicine. According to various reports, recent graduates accumulate many specific knowledge, few generic or essential skills and they are not aware of the most prevalent and general problems,  including clinical preventive medicine. They do not handle well with key skills and attitudes in professional competence. This article offers a reflection about how studying Family Medicine by medical students impacts on their education and future choices as doctors.Al inicio de esta década, diversos autores, las sociedades científicas de medicina de familia/Atención Primaria, así como la propia Comisión Nacional (CN) de Medicina Familiar y Comunitaria (MFyC) llamaron la atención sobre la falta de continuidad entre formación de grado y la formación especializada en MFyC. Según diversos informes los recién licenciados acumulan muchos conocimientos muy específicos, tienen pocos conocimientos genéricos o esenciales y sus conocimientos son reducidos sobre los problemas más prevalentes y generales y sobre la medicina preventiva clínica. No se manejan bien con habilidades y actitudes claves en la competencia profesional. Este artículo ofrece una reflexión acerca del impacto del estudio de MFyC por los estudiantes de Grado en Medicina

¿Los estudios de prevalencia de zona básica de salud tienen sentido en medicina familiar y comunitaria? A propósito de un caso: la enfermedad pulmonar obstructiva crónica

ResumenObjetivoDeterminar la prevalencia de EPOC y tabaquismo en nuestra Zona Básica de Salud (ZBS) y su correlación con la prevalencia extrapolada y la morbilidad registrada. Conocer el perfil personal, familiar y social. Determinar la validez del test de función pulmonar.DiseñoEstudio de prevalencia.EmplazamientoZBS urbana.ParticipantesDocientas treinta y tres personas de 40 a 75años seleccionadas aleatoriamente.Mediciones principalesEdad, sexo, paquetes/año, espirometría, pulsioximetría, medicación, ingresos. Tests: Fagerström, Richmond, MOS, APGAR y función pulmonar.ResultadosEdad media: 53,7±7,6años; 57,9% mujeres. EPOC: morbilidad registrada 1,2% (0,5-3,9%). Prevalencia: 4,7% (1,5% mujeres, 9,2% hombres); prevalencia extrapolada: 10,2%. Tabaquismo: morbilidad registrada: 10,7% (1-19,4%); prevalencia: 18,5% (20% mujeres, 16,3% hombres); prevalencia extrapolada: 23,95%. Test de función pulmonar: cociente de probabilidad positivo: 3,18, y negativo: 0,1. Alta probabilidad de EPOC (59,5%) si >30paquetes/año. Los fumadores fuman como media 20,8paquetes/año. Dependencia física más alta en mujeres (36% versus 21,4%). Mayor probabilidad de deshabituación tabáquica en hombres (57,1% versus 44%). El 14,7% percibe disfunción familiar. El 6,9% tienen bajo apoyo social y el 9,1% en EPOC. El 70% de los pacientes EPOC nunca han ingresado. El 10% son polimedicados versus el 60% de los EPOC.ConclusionesLas prevalencias de EPOC y de tabaquismo (indicador de morbilidad evitable imputable a atención primaria) son sustancialmente inferiores a las prevalencias extrapoladas. El test de función pulmonar es válido. La variablidad interprofesional es elevada. Las mujeres fuman más, tienen más dependencia y menos motivación para el abandono. Su percepción familiar y social es peor. Estas investigaciones son fundamentales para la intervención comunitaria y la planificación operativa.AbstractObjectiveTo determine the prevalence of COPD and smoking in a Health District, to correlate real, registered, and extrapolated morbidity. To determine personal, family and social profiles. To determine the validity of the lung function questionnaire.DesignPrevalence study.LocationUrban District Health.ParticipantsRandom selection of 233 people aged 40-75years.Main measurementsAge, sex, pack/years, spirometry, pulse-oximetry, medication, income. Tests: Fagerström, Richmond, MOS, APGAR, and lung function.ResultsMean age was 53.7+7.6years, with 57.9% women. Registered morbidity for COPD 1.2% (0.5-3.9%). Prevalence 4.7% (1.5% female, 9.2% male), extrapolated prevalence: 10.2%. Registered morbidity for Smoking 10.7% (1-19.4%); prevalence: 18.5% (20% female, 16.3% male), extrapolated prevalence 23.95%. Lung function questionnaire: positive likelihood ratio 3.18; negative 0.1. High probability of COPD (59.5%) in >30 packs/year smokers. Smokers consume a mean of 20.8 packs/year. Women showed higher physical dependence (36% versus 21%). More probability of achieving successful smoking cessation in men (57.1% versus 44%). There was 14.7% perceived family dysfunction; 6.9% have a low global index of social support, and 9.1% in COPD subjects. More than two-thirds (70%) of COPD patients had never been hospitalized. There were 10% polymedicated patients compared to 60% in identified COPDs.ConclusionsPrevalence of COPD and smoking (indicator of avoidable morbidity attributable to primary care) are substantially lower than the reference data. The lung function questionnaire is valid. There was evidence of inter-professional variability. Women smoke more, are more dependent and are less motivated to quit. Their family and social perception is worse. These investigations are essentials for community intervention and operational planning

Índice de perfusión en una reanimación con riesgo biológico, como medida de mala tolerancia fisiológica

Introduction: Perform a cardiopulmonary resuscitation requires technical knowledge and minimal physical conditions. Perform this resuscitation a team of individual protection against biological risks level D placed increases the overexertion that encourage rescuers are subjected.The objective of this study is to prove the existence of a pattern of poor physiological tolerance to the use of personal protective equipment level D, category 4-5-6B for action in incidents with biological risk objectified by measuring the perfusion index before and after a simulated resuscitation.Material and methods: We have performed a quasiexperimental not controlled on 96 volunteers chosen through a random sampling, stratified by sex, level of education and professional category, medical and nursing students and professionals doctors and nurses.A decision of the perfusion index before performing the resuscitation and other simulated after resuscitation.Results: A 15% of the volunteers presented a perfusion index lower back to baseline, which translates into a situation of peripheral vasoconstriction after the completion of the physical exercise that involved the clinical case, when expected was a vasodilatation to Increase perfusion.Conclussion: Extrapolating these data, we can conclude that, in the sample for the study, the volunteers who have less perfusion index at the end of that at the beginning do not tolerate well the effort involved in the case.Introducción: Realizar de una forma adecuada una reanimación cardiopulmonar precisa unos conocimientos técnicos y unas mínimas condiciones físicas. Realizar esta reanimación un equipo de protección individual frente a riesgos biológicos nivel D colocado aumenta el sobresfuerzo al que se ven sometidos los reanimadores.El objetivo de este estudio es comprobar la existencia de un patrón de mala tolerancia fisiológica al uso de los equipos de protección nivel D, categoría 4-5-6B para la actuación en incidentes con riesgo biológico objetivado mediante la medición del índice de perfusión antes y después de una reanimación simulada.Material y métodos: Se ha realizado un estudio cuasiexperimental no controlado sobre 96 voluntarios elegidos mediante un muestreo aleatorio estratificado por sexo, nivel de formación y categoría profesional, estudiantes de Medicina y Enfermería y profesionales Médicos y Enfermeros. Se realizó una toma del índice de perfusión antes de realizar la reanimación y otra después de la reanimación simulada.Resultados: Un 15% de los voluntarios presentaron un índice de perfusión posterior más bajo al basal, lo que se traduce en una situación de vasoconstricción periférica después de la realización del ejercicio físico que supuso el caso clínico, cuando lo esperable era una vasodilatación para aumentar la perfusión.Conclusiones: Extrapolando estos datos, podemos concluir que, en la muestra de estudio que nos ocupa, los voluntarios que presentan menos índice de perfusión al finalizar que al comenzar no toleran bien el esfuerzo que supone el caso clínico. &nbsp

Conditional expression of HGAL leads to the development of diffuse large B-cell lymphoma in mice

Diffuse large B-cell lymphomas (DLBCLs) are clinically and genetically heterogeneous tumors. Deregulation of diverse biological processes specific to B cells, such as B-cell receptor (BCR) signaling and motility regulation, contribute to lymphomagenesis. Human germinal center associated lymphoma (HGAL) is a B-cell–specific adaptor protein controlling BCR signaling and B lymphocyte motility. In normal B cells, it is expressed in germinal center (GC) B lymphocytes and promptly downregulated upon further differentiation. The majority of DLBCL tumors, primarily GC B-cell types, but also activated types, express HGAL. To investigate the consequences of constitutive expression of HGAL in vivo, we generated mice that conditionally express human HGAL at different stages of hematopoietic development using 3 restricted Cre-mediated approaches to initiate expression of HGAL in hematopoietic stem cells, pro-B cells, or GC B cells. Following immune stimulation, we observed larger GCs in mice in which HGAL expression was initiated in GC B cells. All 3 mouse strains developed DLBCL at a frequency of 12% to 30% starting at age 13 months, leading to shorter survival. Immunohistochemical studies showed that all analyzed tumors were of the GC B-cell type. Exon sequencing revealed mutations reported in human DLBCL. Our data demonstrate that constitutive enforced expression of HGAL leads to DLBCL development

Global assessment of marine plastic exposure risk for oceanic birds

Plastic pollution is distributed patchily around the world’s oceans. Likewise, marine organisms that are vulnerable to plastic ingestion or entanglement have uneven distributions. Understanding where wildlife encounters plastic is crucial for targeting research and mitigation. Oceanic seabirds, particularly petrels, frequently ingest plastic, are highly threatened, and cover vast distances during foraging and migration. However, the spatial overlap between petrels and plastics is poorly understood. Here we combine marine plastic density estimates with individual movement data for 7137 birds of 77 petrel species to estimate relative exposure risk. We identify high exposure risk areas in the Mediterranean and Black seas, and the northeast Pacific, northwest Pacific, South Atlantic and southwest Indian oceans. Plastic exposure risk varies greatly among species and populations, and between breeding and non-breeding seasons. Exposure risk is disproportionately high for Threatened species. Outside the Mediterranean and Black seas, exposure risk is highest in the high seas and Exclusive Economic Zones (EEZs) of the USA, Japan, and the UK. Birds generally had higher plastic exposure risk outside the EEZ of the country where they breed. We identify conservation and research priorities, and highlight that international collaboration is key to addressing the impacts of marine plastic on wide-ranging species

Global assessment of marine plastic exposure risk for oceanic birds

Plastic pollution is distributed patchily around the world’s oceans. Likewise, marine organisms that are vulnerable to plastic ingestion or entanglement have uneven distributions. Understanding where wildlife encounters plastic is crucial for targeting research and mitigation. Oceanic seabirds, particularly petrels, frequently ingest plastic, are highly threatened, and cover vast distances during foraging and migration. However, the spatial overlap between petrels and plastics is poorly understood. Here we combine marine plastic density estimates with individual movement data for 7137 birds of 77 petrel species to estimate relative exposure risk. We identify high exposure risk areas in the Mediterranean and Black seas, and the northeast Pacific, northwest Pacific, South Atlantic and southwest Indian oceans. Plastic exposure risk varies greatly among species and populations, and between breeding and non-breeding seasons. Exposure risk is disproportionately high for Threatened species. Outside the Mediterranean and Black seas, exposure risk is highest in the high seas and Exclusive Economic Zones (EEZs) of the USA, Japan, and the UK. Birds generally had higher plastic exposure risk outside the EEZ of the country where they breed. We identify conservation and research priorities, and highlight that international collaboration is key to addressing the impacts of marine plastic on wide-ranging species

Spatiotemporal Characteristics of the Largest HIV-1 CRF02_AG Outbreak in Spain: Evidence for Onward Transmissions

Background and Aim: The circulating recombinant form 02_AG (CRF02_AG) is the predominant clade among the human immunodeficiency virus type-1 (HIV-1) non-Bs with a prevalence of 5.97% (95% Confidence Interval-CI: 5.41–6.57%) across Spain. Our aim was to estimate the levels of regional clustering for CRF02_AG and the spatiotemporal characteristics of the largest CRF02_AG subepidemic in Spain.Methods: We studied 396 CRF02_AG sequences obtained from HIV-1 diagnosed patients during 2000–2014 from 10 autonomous communities of Spain. Phylogenetic analysis was performed on the 391 CRF02_AG sequences along with all globally sampled CRF02_AG sequences (N = 3,302) as references. Phylodynamic and phylogeographic analysis was performed to the largest CRF02_AG monophyletic cluster by a Bayesian method in BEAST v1.8.0 and by reconstructing ancestral states using the criterion of parsimony in Mesquite v3.4, respectively.Results: The HIV-1 CRF02_AG prevalence differed across Spanish autonomous communities we sampled from (p < 0.001). Phylogenetic analysis revealed that 52.7% of the CRF02_AG sequences formed 56 monophyletic clusters, with a range of 2–79 sequences. The CRF02_AG regional dispersal differed across Spain (p = 0.003), as suggested by monophyletic clustering. For the largest monophyletic cluster (subepidemic) (N = 79), 49.4% of the clustered sequences originated from Madrid, while most sequences (51.9%) had been obtained from men having sex with men (MSM). Molecular clock analysis suggested that the origin (tMRCA) of the CRF02_AG subepidemic was in 2002 (median estimate; 95% Highest Posterior Density-HPD interval: 1999–2004). Additionally, we found significant clustering within the CRF02_AG subepidemic according to the ethnic origin.Conclusion: CRF02_AG has been introduced as a result of multiple introductions in Spain, following regional dispersal in several cases. We showed that CRF02_AG transmissions were mostly due to regional dispersal in Spain. The hot-spot for the largest CRF02_AG regional subepidemic in Spain was in Madrid associated with MSM transmission risk group. The existence of subepidemics suggest that several spillovers occurred from Madrid to other areas. CRF02_AG sequences from Hispanics were clustered in a separate subclade suggesting no linkage between the local and Hispanic subepidemics

Mortality from gastrointestinal congenital anomalies at 264 hospitals in 74 low-income, middle-income, and high-income countries: a multicentre, international, prospective cohort study

Summary Background Congenital anomalies are the fifth leading cause of mortality in children younger than 5 years globally. Many gastrointestinal congenital anomalies are fatal without timely access to neonatal surgical care, but few studies have been done on these conditions in low-income and middle-income countries (LMICs). We compared outcomes of the seven most common gastrointestinal congenital anomalies in low-income, middle-income, and high-income countries globally, and identified factors associated with mortality. Methods We did a multicentre, international prospective cohort study of patients younger than 16 years, presenting to hospital for the first time with oesophageal atresia, congenital diaphragmatic hernia, intestinal atresia, gastroschisis, exomphalos, anorectal malformation, and Hirschsprung’s disease. Recruitment was of consecutive patients for a minimum of 1 month between October, 2018, and April, 2019. We collected data on patient demographics, clinical status, interventions, and outcomes using the REDCap platform. Patients were followed up for 30 days after primary intervention, or 30 days after admission if they did not receive an intervention. The primary outcome was all-cause, in-hospital mortality for all conditions combined and each condition individually, stratified by country income status. We did a complete case analysis. Findings We included 3849 patients with 3975 study conditions (560 with oesophageal atresia, 448 with congenital diaphragmatic hernia, 681 with intestinal atresia, 453 with gastroschisis, 325 with exomphalos, 991 with anorectal malformation, and 517 with Hirschsprung’s disease) from 264 hospitals (89 in high-income countries, 166 in middleincome countries, and nine in low-income countries) in 74 countries. Of the 3849 patients, 2231 (58·0%) were male. Median gestational age at birth was 38 weeks (IQR 36–39) and median bodyweight at presentation was 2·8 kg (2·3–3·3). Mortality among all patients was 37 (39·8%) of 93 in low-income countries, 583 (20·4%) of 2860 in middle-income countries, and 50 (5·6%) of 896 in high-income countries (p<0·0001 between all country income groups). Gastroschisis had the greatest difference in mortality between country income strata (nine [90·0%] of ten in lowincome countries, 97 [31·9%] of 304 in middle-income countries, and two [1·4%] of 139 in high-income countries; p≤0·0001 between all country income groups). Factors significantly associated with higher mortality for all patients combined included country income status (low-income vs high-income countries, risk ratio 2·78 [95% CI 1·88–4·11], p<0·0001; middle-income vs high-income countries, 2·11 [1·59–2·79], p<0·0001), sepsis at presentation (1·20 [1·04–1·40], p=0·016), higher American Society of Anesthesiologists (ASA) score at primary intervention (ASA 4–5 vs ASA 1–2, 1·82 [1·40–2·35], p<0·0001; ASA 3 vs ASA 1–2, 1·58, [1·30–1·92], p<0·0001]), surgical safety checklist not used (1·39 [1·02–1·90], p=0·035), and ventilation or parenteral nutrition unavailable when needed (ventilation 1·96, [1·41–2·71], p=0·0001; parenteral nutrition 1·35, [1·05–1·74], p=0·018). Administration of parenteral nutrition (0·61, [0·47–0·79], p=0·0002) and use of a peripherally inserted central catheter (0·65 [0·50–0·86], p=0·0024) or percutaneous central line (0·69 [0·48–1·00], p=0·049) were associated with lower mortality. Interpretation Unacceptable differences in mortality exist for gastrointestinal congenital anomalies between lowincome, middle-income, and high-income countries. Improving access to quality neonatal surgical care in LMICs will be vital to achieve Sustainable Development Goal 3.2 of ending preventable deaths in neonates and children younger than 5 years by 2030