1
|
Lin Y, Shi X, Huang L, Chen A, Zhu H. Frailty Index was Associated With Adverse Outcomes in Admitted Elderly Patients With Type 2 Diabetes Mellitus. INQUIRY : A JOURNAL OF MEDICAL CARE ORGANIZATION, PROVISION AND FINANCING 2023; 60:469580231201022. [PMID: 37724847 PMCID: PMC10510342 DOI: 10.1177/00469580231201022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 07/20/2023] [Accepted: 08/28/2023] [Indexed: 09/21/2023]
Abstract
We aimed to investigate the role of the laboratory frailty index (LFI) in diabetic complications and incident disability in admitted older patients with type 2 diabetes mellitus (T2DM). We retrospectively collected the clinical data of older patients with T2DM from December 2018 to May 2020. Frailty was quantified using the LFI, which considers the accumulation of 27 items of abnormal laboratory outcomes. Univariate and multivariate analyses were performed to evaluate the relationship between LFI and diabetes-related adverse outcomes. In total, 293 consecutive older patients with T2DM were recruited for this study. According to the predefined LFI criteria, 110 (37.5%) participants were non-frail, 131 (44.7%) were prefrail, and 52 (17.8%) were frail. Univariate and multivariate analysis revealed that LFI was associated with the diabetic microangiopathy complications (odds ratio for prefrail [ORprefrail] 1.760, 95% confidence interval for prefrail [CIprefrail] 1.019-3.041, P = .043; ORfrail 4.667, 95% CIfrail 2.012-10.826, P < .001) and activities of daily living (ADL) disability (ORprefrail 2.323, 95% CIprefrail 1.209-4.463, P = .011; ORfrail 9.367, 95% CIfrail 4.030-21.775, P < .001), but not with the diabetic macroangiopathy complications and diabetic peripheral neuropathy. Frailty, as determined by the LFI, was proven to be an effective tool for the prediction of diabetic microangiopathy complications and ADL disability.
Collapse
Affiliation(s)
- Yi Lin
- Department of Endocrinology, The Third Affiliated Hospital of Shanghai University, Wenzhou People’s Hospital, Zhejiang, China
| | - Xiaochong Shi
- Department of Endocrinology, The Third Affiliated Hospital of Shanghai University, Wenzhou People’s Hospital, Zhejiang, China
| | - Lingling Huang
- Department of Endocrinology, The Third Affiliated Hospital of Shanghai University, Wenzhou People’s Hospital, Zhejiang, China
| | - Aixia Chen
- Department of Endocrinology, The Third Affiliated Hospital of Shanghai University, Wenzhou People’s Hospital, Zhejiang, China
| | - Haihui Zhu
- Department of Endocrinology, The Third Affiliated Hospital of Shanghai University, Wenzhou People’s Hospital, Zhejiang, China
| |
Collapse
|
2
|
Long-term Outcomes Among Young Adults With Type 2 Diabetes Based on Durability of Glycemic Control: Results From the TODAY Cohort Study. Diabetes Care 2022; 45:2689-2697. [PMID: 36190810 PMCID: PMC9679266 DOI: 10.2337/dc22-0784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 08/19/2022] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To examine the effect of different patterns of durable glycemic control on the development of comorbidities among youth with type 2 diabetes (T2D) and to assess the impact of fasting glucose (FG) variability on the clinical course of T2D. RESEARCH DESIGN AND METHODS From the Treatment Options for Type 2 Diabetes in Adolescents and Youth (TODAY) study, 457 participants (mean age, 14 years) with mean diabetes duration <2 years at entry and a minimum study follow-up of 10 years were included in these analyses. HbA1c, FG concentrations, and β-cell function estimates from oral glucose tolerance tests were measured longitudinally. Prevalence of comorbidities by glycemic control status after 10 years in the TODAY study was assessed. RESULTS Higher baseline HbA1c concentration, lower β-cell function, and maternal history of diabetes were strongly associated with loss of glycemic control in youth with T2D. Higher cumulative HbA1c concentration over 4 years and greater FG variability over a year within 3 years of diagnosis were related to higher prevalence of dyslipidemia, nephropathy, and retinopathy progression over the subsequent 10 years. A coefficient of variability in FG ≥8.3% predicted future loss of glycemic control and development of comorbidities. CONCLUSIONS Higher baseline HbA1c concentration and FG variability during year 1 accurately predicted youth with T2D who will experience metabolic decompensation and comorbidities. These values may be useful tools for clinicians when considering early intensification of therapy.
Collapse
|
3
|
Gómez-Peralta F, Carrasco-Sánchez FJ, Pérez A, Escalada J, Álvarez-Guisasola F, Miranda-Fernández-Santos C, Mediavilla-Bravo JJ, Gómez-Huelgas R. Executive summary on the treatment of type 2 diabetes mellitus in elderly or frail individuals. 2022 update of the 2018 consensus document "Treatment of type 2 diabetes mellitus in the elderly". Rev Clin Esp 2022; 222:496-499. [PMID: 35753941 DOI: 10.1016/j.rceng.2022.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Accepted: 03/17/2022] [Indexed: 10/17/2022]
Abstract
The population with type 2 DM (DM2) is highly heterogeneous, representing an important challenge for healthcare professionals. The therapeutic choice should be individualized, considering the functional status, frailty, the occurrence of comorbidities, and the preferences of patients and their caregivers. New evidence on the cardiovascular and renal protection of specific therapeutic groups and on the usefulness of new technologies for DM2 management, among other aspects, warrant an update of the consensus document on the DM2 in the elderly that was published in 2018.
Collapse
Affiliation(s)
- F Gómez-Peralta
- Unidad de Endocrinología y Nutrición, Hospital General de Segovia, Segovia, Sociedad Española de Diabetes (SED), Spain
| | - F J Carrasco-Sánchez
- Servicio de Medicina Interna, Hospital Juan Ramón Jiménez, Huelva, Sociedad Española de Medicina Interna (SEMI), Spain
| | - A Pérez
- Servicio de Endocrinología y Nutrición, Hospital de la Santa Creu i Sant Pau, Institut d'Investigació Biomèdica Sant Pau, Barcelona, Universitat Autònoma de Barcelona y Centro de Investigación Biomédica en Red de Diabetes y Enfermedades Metabólicas Asociadas (CIBERDEM), Barcelona, Sociedad Española de Diabetes (SED), Spain
| | - J Escalada
- Departamento de Endocrinología y Nutrición, Clínica Universidad de Navarra, Pamplona, España, Sociedad Española de Endocrinología y Nutrición (SEEN), CIBER Fisiopatología de la Obesidad y Nutrición (CIBERobn), Instituto de Salud Carlos III, Madrid, Spain
| | - F Álvarez-Guisasola
- Centro de Salud Ribera del Órbigo, León, Grupo de trabajo de diabetes, Sociedad Española de Medicina de Familia y Comunitaria (semFYC), Spain
| | - C Miranda-Fernández-Santos
- Centro de Salud Buenavista Toledo, Toledo, Área Cardiovascular y Diabetes de la Sociedad Española de Médicos Generales y de Familia (SEMG), Spain
| | - J J Mediavilla-Bravo
- Centro de Salud Burgos Rural, Burgos, Sociedad Española de Médicos de Atención Primaria (SEMERGEN), Spain
| | - R Gómez-Huelgas
- Servicio de Medicina Interna, Hospital Regional Universitario de Málaga, Málaga, Instituto de Investigación Biomédica de Málaga (IBIMA), CIBER de Obesidad y Nutrición (CIBEROBN), Instituto de Salud Carlos III, Madrid, Sociedad Española de Medicina Interna (SEMI), Spain.
| |
Collapse
|
4
|
Gómez-Huelgas R, Gómez-Peralta F, Cos F. Evaluación de conocimientos, barreras y actitudes en el manejo de la diabetes tipo 2 en pacientes de edad avanzada: estudio Delphi en atención primaria y hospitalaria. Rev Clin Esp 2022. [DOI: 10.1016/j.rce.2021.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
5
|
Cardiovascular prevention in elderly patients. J Geriatr Cardiol 2022; 19:377-392. [PMID: 35722032 PMCID: PMC9170910 DOI: 10.11909/j.issn.1671-5411.2022.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
In recent decades, life expectancy has been increasing significantly. In this scenario, health interventions are necessary to improve prognosis and quality of life of elderly with cardiovascular risk factors and cardiovascular disease. However, the number of elderly patients included in clinical trials is low, thus current clinical practice guidelines do not include specific recommendations. This document aims to review prevention recommendations focused in patients ≥ 75 years with high or very high cardiovascular risk, regarding objectives, medical treatment options and also including physical exercise and their inclusion in cardiac rehabilitation programs. Also, we will show why geriatric syndromes such as frailty, dependence, cognitive impairment, and nutritional status, as well as comorbidities, ought to be considered in this population regarding their important prognostic impact.
Collapse
|
6
|
Resumen ejecutivo sobre el tratamiento de la diabetes mellitus tipo 2 en personas de edad avanzada o frágiles. Actualización 2022 del documento de consenso 2018 «Tratamiento de la diabetes mellitus tipo 2 en el paciente anciano». Rev Clin Esp 2022. [DOI: 10.1016/j.rce.2022.03.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
|
7
|
Molist-Brunet N, Sevilla-Sánchez D, Puigoriol-Juvanteny E, Bajo-Peñas L, Cantizano-Baldo I, Cabanas-Collell L, Espaulella-Panicot J. Individualized Medication Review in Older People with Multimorbidity: A Comparative Analysis between Patients Living at Home and in a Nursing Home. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19063423. [PMID: 35329110 PMCID: PMC8955931 DOI: 10.3390/ijerph19063423] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 03/10/2022] [Accepted: 03/11/2022] [Indexed: 01/27/2023]
Abstract
(1) Background: aging is associated with complex and dynamic changes leading to multimorbidity and, therefore, polypharmacy. A periodic medication review (MR) in frail older people leads to optimizing medication use. The aims of the study were to perform a comparative analysis of the impact of place of residence (own home versus nursing home) in a cohort of older patients on the characteristics of the baseline therapeutic plan and characteristics of the therapeutic plan after an MR; (2) Methods: Study with paired pre- and post-MR data based on person-centred prescription, with a follow-up assessment at three months. Patients who lived either in their own home or in a nursing home were recruited. We selected patients of 65 years or more with multimorbidity whose General Practitioner identified difficulties with the prescription management and the need for an MR. Each patient’s treatment was analysed by applying the Patient-Centred Prescription (PCP) model; (3) Results: 428 patients. 90% presented at least one inappropriate prescription (IP) in both settings. In nursing homes, a higher number of implemented optimization proposals was detected (81.6% versus 65.7% (p < 0.001)). After the MR, nursing-home patients had a greater decrease in their mean number of medications, polypharmacy prevalence, therapeutic complexity, and monthly drug expenditure (p < 0.001); (4) Conclusions: PCP model detected a high number of IP in both settings. However, after an individualized MR, nursing-home patients presented a greater decrease in some pharmacological parameters related to adverse events, such as polypharmacy and therapeutic complexity, compared to those living at home. Nursing homes may be regarded as a highly suitable scenario to carry out a periodic MR, due to its high prevalence of frail people and its feasibility to apply the recommendations of an MR. Prospective studies with a robust design should be performed to demonstrate this quasi-experimental study along with a longitudinal follow-up on clinical outcomes.
Collapse
Affiliation(s)
- Núria Molist-Brunet
- Geriatric Department, Hospital Universitari de la Santa Creu de Vic, 08500 Vic, Spain; (L.B.-P.); (I.C.-B.); (J.E.-P.)
- Central Catalonia Chronicity Research Group (C3RG), Centre for Health and Social Care Research (CESS), Universitat de Vic—University of Vic-Central University of Catalonia (UVIC-UCC), 08500 Vic, Spain;
- Correspondence: ; Tel.: +34-938-833-300
| | - Daniel Sevilla-Sánchez
- Central Catalonia Chronicity Research Group (C3RG), Centre for Health and Social Care Research (CESS), Universitat de Vic—University of Vic-Central University of Catalonia (UVIC-UCC), 08500 Vic, Spain;
- Pharmacy Department, Parc Sanitari Pere Virgili, 08023 Barcelona, Spain
| | - Emma Puigoriol-Juvanteny
- Epidemiology Department, Hospital Universitari de Vic, 08500 Vic, Spain;
- Tissue Repair and Regeneration Laboratory (TR2Lab), Research Group, University of Vic, 08500 Vic, Spain
| | - Lorena Bajo-Peñas
- Geriatric Department, Hospital Universitari de la Santa Creu de Vic, 08500 Vic, Spain; (L.B.-P.); (I.C.-B.); (J.E.-P.)
| | - Immaculada Cantizano-Baldo
- Geriatric Department, Hospital Universitari de la Santa Creu de Vic, 08500 Vic, Spain; (L.B.-P.); (I.C.-B.); (J.E.-P.)
| | | | - Joan Espaulella-Panicot
- Geriatric Department, Hospital Universitari de la Santa Creu de Vic, 08500 Vic, Spain; (L.B.-P.); (I.C.-B.); (J.E.-P.)
- Central Catalonia Chronicity Research Group (C3RG), Centre for Health and Social Care Research (CESS), Universitat de Vic—University of Vic-Central University of Catalonia (UVIC-UCC), 08500 Vic, Spain;
- Geriatric and Palliative Care Department, Hospital Universitari de Vic, 08500 Vic, Spain
| |
Collapse
|
8
|
Evaluation of knowledge, barriers, and attitudes in the management of type 2 diabetes in elderly patients: A Delphi study on primary and hospital care. Rev Clin Esp 2022; 222:385-392. [PMID: 35300934 DOI: 10.1016/j.rceng.2021.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Accepted: 11/23/2021] [Indexed: 11/21/2022]
Abstract
OBJECTIVES This work aims to explore attitudes regarding the management of elderly or frail patients with type 2 diabetes mellitus in the routine clinical practice of a multidisciplinary group of physicians in Spain. METHODS A mixed survey was used that included both Delphi and opinion, attitude, and behaviour (OAB) questions. Perceptions in primary care (n = 211) and hospital care (n = 80) were compared. RESULTS Consensus was obtained on all statements. Eighty-seven percent of participants considered that severe psychiatric disorders conditioned antidiabetic treatment and 72% that a psychocognitive assessment is as relevant as the assessment of other comorbidities. Hospital care physicians more frequently considered that comorbidity affects self-care (95.0% vs. 82.9%), that a lack of de-intensification is a form of therapeutic inertia (88.8% vs. 76.3%), that classifying older adults as frail is fundamental to choosing targets (96.3% vs. 87.7%), that de-intensification of antidiabetic treatment and control of cardiovascular risk factors should be considered in those over 80 years of age (90.0% vs. 78.7%), and that type 2 diabetes mellitus predisposes patients to sarcopenia (86.3% vs. 71.6%). The usefulness of clinical guidelines was more highly valued among primary care participants (79.1% vs. 72.5%). CONCLUSIONS There is room for improvement on several aspects of managing elderly or frail patients with type 2 diabetes mellitus, including inertia in treatment de-intensification, conducting a psychocognitive assessment, or the identification of frailty and sarcopenia.
Collapse
|
9
|
Molist-Brunet N, Sevilla-Sánchez D, Puigoriol-Juvanteny E, Espaulella-Ferrer M, Amblàs-Novellas J, Espaulella-Panicot J. Factors Associated with the Detection of Inappropriate Prescriptions in Older People: A Prospective Cohort. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:11310. [PMID: 34769827 PMCID: PMC8582657 DOI: 10.3390/ijerph182111310] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Revised: 10/11/2021] [Accepted: 10/22/2021] [Indexed: 11/24/2022]
Abstract
(1) Background: Ageing is associated with complex and dynamic changes leading to multimorbidity and, therefore, polypharmacy. The main objectives were to study an older community-dwelling cohort, to detect inappropriate prescriptions (IP) applying the Patient-Centred Prescription model, and to evaluate the most associated factors. (2) Methods: This was a prospective, descriptive, and observational study conducted from June 2019 to October 2020 on patients ≥ 65 years with multimorbidity who lived in the community. Demographic, clinical and pharmacological data were assessed. Variables assessed were: degree of frailty, using the Frail-VIG index; therapeutical complexity and anticholinergic and sedative burden; and the number of chronic drugs to determine polypharmacy or excessive polypharmacy. Finally, a medication review was carried out through the application of the Patient-Centred Prescription model. We used univariate and multivariate regression to identify the factors associated with IP. (3) Results: We recruited 428 patients (66.6% women; mean age 85.5, SD 7.67). A total of 50.9% of them lived in a nursing home; the mean Barthel Index was 49.93 (SD 32.14), and 73.8% of patients suffered some degree of cognitive impairment. The prevalence of frailty was 92.5%. Up to 90% of patients had at least one IP. An increase in IP prevalence was detected when the Frail-VIG index increased (p < 0.05). With the multivariate model, the relationship of polypharmacy with IP detection stands out above all. (4) Conclusions: 90% of patients presented one IP or more, and this situation can be detected through the PCP model. Factors with higher association with IP were frailty and polypharmacy.
Collapse
Affiliation(s)
- Núria Molist-Brunet
- Hospital Universitari de la Santa Creu de Vic, 08500 Vic, Spain; (M.E.-F.); (J.A.-N.); (J.E.-P.)
- Central Catalonia Chronicity Research Group (C3RG), Centre for Health and Social Care Research (CESS), Universitat de Vic. University of Vic-Central University of Catalonia (UVIC-UCC), 08500 Vic, Spain;
| | - Daniel Sevilla-Sánchez
- Central Catalonia Chronicity Research Group (C3RG), Centre for Health and Social Care Research (CESS), Universitat de Vic. University of Vic-Central University of Catalonia (UVIC-UCC), 08500 Vic, Spain;
- Pharmacy Department, Parc Sanitari Pere Virgili, 08023 Barcelona, Spain
| | - Emma Puigoriol-Juvanteny
- Epidemiology department. Hospital Universitari de Vic, 08500 Vic, Spain;
- Tissue Repair and Regeneration Laboratory (TR2Lab), University of Vic-Central University of Catalonia (UVIC-UCC), Fundació Hospital Universitari de la Santa Creu de Vic, and Hospital Universitari de Vic, 08500 Vic, Spain
| | - Mariona Espaulella-Ferrer
- Hospital Universitari de la Santa Creu de Vic, 08500 Vic, Spain; (M.E.-F.); (J.A.-N.); (J.E.-P.)
- Tissue Repair and Regeneration Laboratory (TR2Lab), University of Vic-Central University of Catalonia (UVIC-UCC), Fundació Hospital Universitari de la Santa Creu de Vic, and Hospital Universitari de Vic, 08500 Vic, Spain
| | - Jordi Amblàs-Novellas
- Hospital Universitari de la Santa Creu de Vic, 08500 Vic, Spain; (M.E.-F.); (J.A.-N.); (J.E.-P.)
- Central Catalonia Chronicity Research Group (C3RG), Centre for Health and Social Care Research (CESS), Universitat de Vic. University of Vic-Central University of Catalonia (UVIC-UCC), 08500 Vic, Spain;
- Chair of Palliative Care, University of Vic, 08500 Vic, Spain
| | - Joan Espaulella-Panicot
- Hospital Universitari de la Santa Creu de Vic, 08500 Vic, Spain; (M.E.-F.); (J.A.-N.); (J.E.-P.)
- Central Catalonia Chronicity Research Group (C3RG), Centre for Health and Social Care Research (CESS), Universitat de Vic. University of Vic-Central University of Catalonia (UVIC-UCC), 08500 Vic, Spain;
| |
Collapse
|
10
|
López-Simarro F, Cols-Sagarra C, Mediavilla Bravo JJ, Cañís-Olivé J, Hernández-Teixidó C, González Mohíno Loro MB. [Update on the use of insulins for the primary care physician]. Semergen 2021; 48:54-62. [PMID: 34266759 DOI: 10.1016/j.semerg.2021.04.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2021] [Revised: 04/23/2021] [Accepted: 04/28/2021] [Indexed: 11/25/2022]
Abstract
Insulin treatment in type 2 diabetes mellitus patients is still essential and its usage has increased during recent years. Despite this, the level of control continues to be very poor. Insulin treatment is initiated with control levels above the recommendations set by the Clinical Practice Guidelines (CPG) and patients are exposed to very high blood glucose levels during long periods of time. This paper reviews the role of insulin in the different CPG, the criteria for therapy initiation and intensification, the beginning of the intensification and the different types of insulin which are commercialized in our country. Moreover, we discuss insulinization in special situations such as corticosteroid treatment, fragile elderly patients, palliative care situations, chronic kidney disease or during Ramadan. Finally, the problem of therapeutic inertia in insulinization is also addressed.
Collapse
Affiliation(s)
- Flora López-Simarro
- Médico de Familia. CAP Martorell Urbano, Barcelona, España; Miembro del grupo de trabajo de diabetes, Semergen España.
| | - Celia Cols-Sagarra
- Miembro del grupo de trabajo de diabetes, Semergen España; Médico de Familia. CAP Martorell Rural, Barcelona, España
| | - José Javier Mediavilla Bravo
- Miembro del grupo de trabajo de diabetes, Semergen España; Médico de Familia. Centro de Salud Burgos Rural, Burgos, España
| | - Judit Cañís-Olivé
- Miembro del grupo de trabajo de diabetes, Semergen España; Médico de Familia. EAP Vilafranca Nord. Vilafranca del Penedès. Barcelona, España
| | - Carlos Hernández-Teixidó
- Miembro del grupo de trabajo de diabetes, Semergen España; Médico de Familia. CS San Roque, Badajoz, España
| | | |
Collapse
|
11
|
Carrasco-Sánchez FJ, Fernández-Rodríguez JM, Ena J, Gómez-Huelgas R, Carretero-Gómez J. Medical treatment of type 2 diabetes mellitus: Recommendations of the Diabetes, Obesity and Nutrition Group of the Spanish Society of Internal Medicine. Rev Clin Esp 2021; 221:101-108. [PMID: 32674850 DOI: 10.1016/j.rce.2020.06.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Revised: 06/04/2020] [Accepted: 06/05/2020] [Indexed: 02/08/2023]
Abstract
Type 2 diabetes mellitus is a major health problem with high prevalence, morbidity and mortality, and its medical treatment is growing in complexity due to patients' diverse clinical conditions. This article presents a consensus document by the Diabetes, Obesity and Nutrition Group of the Spanish Society of Internal Medicine, with recommendations for the medical treatment of type 2 diabetes mellitus. The main objective of this article is to facilitate the therapeutic decision-making process to improve the care of patients with diabetes. The document prioritises treatments with cardiovascular benefits, especially those that benefit patients with heart and renal failure.
Collapse
Affiliation(s)
- F J Carrasco-Sánchez
- Área de Insuficiencia Cardíaca, Diabetes y Riesgo Vascular, Unidad de Gestión Clínica de Medicina Interna y Cuidados Paliativos, Hospital Universitario Juan Ramón Jiménez, Huelva, España.
| | - J M Fernández-Rodríguez
- Servicio de Medicina Interna, Hospital Carmen y Severo Ochoa, Cangas de Narcea, Asturias, España
| | - J Ena
- Servicio de Medicina Interna, Hospital Marina Baixa, Alicante, España
| | - R Gómez-Huelgas
- Centro de Investigación Biomédica en Red de Fisiopatología de la Obesidad y Nutrición (CIBEROBN), Instituto de Salud Carlos III, Servicio de Medicina Interna, Hospital Regional Universitario de Málaga, Instituto de Investigación Biomédica de Málaga (IBIMA), Universidad de Málaga, Málaga, España
| | - J Carretero-Gómez
- Servicio de Medicina Interna, Hospital de Zafra, Zafra, Badajoz, España
| |
Collapse
|
12
|
Statement of the Spanish Interdisciplinary Vascular Prevention Committee on the updated European Cardiovascular Prevention Guidelines. CLINICA E INVESTIGACION EN ARTERIOSCLEROSIS 2021; 33:85-107. [PMID: 33495044 DOI: 10.1016/j.arteri.2020.11.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 11/16/2020] [Indexed: 11/24/2022]
Abstract
We present the adaptation for Spain of the updated European Cardiovascular Prevention Guidelines. In this update, greater stress is laid on the population approach, and especially on the promotion of physical activity and healthy diet through dietary, leisure and active transport policies in Spain. To estimate vascular risk, note should be made of the importance of recalibrating the tables used, by adapting them to population shifts in the prevalence of risk factors and incidence of vascular diseases, with particular attention to the role of chronic kidney disease. At an individual level, the key element is personalised support for changes in behaviour, adherence to medication in high-risk individuals and patients with vascular disease, the fostering of physical activity, and cessation of smoking habit. Furthermore, recent clinical trials with PCSK9 inhibitors are reviewed, along with the need to simplify pharmacological treatment of arterial hypertension to improve control and adherence to treatment. In the case of patients with type 2 diabetes mellitus and vascular disease or high vascular disease risk, when lifestyle changes and metformin are inadequate, the use of drugs with proven vascular benefit should be prioritised. Lastly, guidelines on peripheral arterial disease and other specific diseases are included, as is a recommendation against prescribing antiaggregants in primary prevention.
Collapse
|
13
|
Medical treatment of type 2 diabetes mellitus: Recommendations of the Diabetes, Obesity and Nutrition Group of the Spanish Society of Internal Medicine. Rev Clin Esp 2020; 221:101-108. [PMID: 33998485 DOI: 10.1016/j.rceng.2020.06.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Accepted: 06/05/2020] [Indexed: 11/21/2022]
Abstract
Type 2 diabetes is a big health concern due to its high prevalence and morbi-mortality. Medical treatment has a growing complexity which is focus on patients' clinical situations. This article contains a consensus statement about recommendations on medical treatment of type-2 diabetes from the Working Group of Diabetes, Obesity and Nutrition of Spanish Society of Internal Medicine. The aim of this consensus is to facilitate therapeutic decision-making to improve the diabetes patients care. The document prioritizes treatments with cardiovascular, especially heart failure, and real benefits.
Collapse
|
14
|
Armario P, Brotons C, Elosua R, Alonso de Leciñana M, Castro A, Clarà A, Cortés O, Díaz Rodriguez Á, Herranz M, Justo S, Lahoz C, Pedro-Botet J, Pérez Pérez A, Santamaria R, Tresserras R, Aznar Lain S, Royo-Bordonada MÁ. [Statement of the Spanish Interdisciplinary Vascular Prevention Committee on the updated European Cardiovascular Prevention Guidelines]. HIPERTENSION Y RIESGO VASCULAR 2020; 38:21-43. [PMID: 33069629 DOI: 10.1016/j.hipert.2020.07.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Accepted: 07/29/2020] [Indexed: 12/23/2022]
Abstract
We present the adaptation for Spain of the updated European Cardiovascular Prevention Guidelines. In this update, greater stress is laid on the population approach, and especially on the promotion of physical activity and healthy diet through dietary, leisure and active transport policies in Spain. To estimate vascular risk, note should be made of the importance of recalibrating the tables used, by adapting them to population shifts in the prevalence of risk factors and incidence of vascular diseases, with particular attention to the role of chronic kidney disease. At an individual level, the key element is personalised support for changes in behaviour, adherence to medication in high-risk individuals and patients with vascular disease, the fostering of physical activity, and cessation of smoking habit. Furthermore, recent clinical trials with PCSK9 inhibitors are reviewed, along with the need to simplify pharmacological treatment of arterial hypertension to improve control and adherence to treatment. In the case of patients with type 2 diabetes mellitus and vascular disease or high vascular disease risk, when lifestyle changes and metformin are inadequate, the use of drugs with proven vascular benefit should be prioritised. Lastly, guidelines on peripheral arterial disease and other specific diseases are included, as is a recommendation against prescribing antiaggregants in primary prevention.
Collapse
Affiliation(s)
- Pedro Armario
- Sociedad Española-Liga Española para la Lucha contra la Hipertensión Arterial, Madrid, España.
| | - Carlos Brotons
- Sociedad Española de Medicina de Familia y Comunitaria, Barcelona, España
| | | | | | - Almudena Castro
- Sociedad Española de Cardiología-Coordinadora Nacional Sección de Prevención, Madrid, España
| | - Albert Clarà
- Sociedad Española de Angiología y Cirugía Vascular, Madrid, España
| | - Olga Cortés
- Asociación Española Pediatría de Atención Primaria, Madrid, España
| | | | - María Herranz
- Federación de Asociaciones de Enfermería Comunitaria y Atención Primaria-FAECAP, Madrid, España
| | | | - Carlos Lahoz
- Sociedad Española de Medicina Interna, Madrid, España
| | | | | | | | - Ricard Tresserras
- Sociedad Española de Salud Pública y Administración Sanitaria-SESPAS, Barcelona, España
| | - Susana Aznar Lain
- Facultad de Ciencias del Deporte, Universidad Castilla La Mancha, Toledo, España
| | | |
Collapse
|
15
|
Arévalo Lorido J, Carretero Gómez J, Gómez Huelgas R, Quirós López R, Dávila Ramos M, Serrado Iglesias A, Ruiz Laiglesia F, González Franco A, Cepeda Rodrigo J, Montero-Pérez-Barquero M. Comorbidity in patients with type 2 diabetes mellitus and heart failure with preserved ejection fraction. Cluster analysis of the RICA registry. Opportunities for improvement. Rev Clin Esp 2020. [DOI: 10.1016/j.rceng.2019.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
|
16
|
Prescription patterns of antihyperglycemic drugs in elderly patients in Spain: A national cross-sectional study. Rev Clin Esp 2020; 220:155-161. [PMID: 31326081 DOI: 10.1016/j.rce.2019.05.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Revised: 05/06/2019] [Accepted: 05/07/2019] [Indexed: 11/22/2022]
Abstract
BACKGROUND AND OBJECTIVE Elderly patients with type 2 diabetes represent a growing and heterogeneous group of subjects where treatment targets and antihyperglycemic drugs prescriptions should be tailored according to coexisting illnesses, functional and social domains. METHODS We carried-out a national cross-sectional study (from February 2014 to December 2014) to assess prescription patterns and treatment inadequacy in patients with type 2 diabetes older than 65 years with at least 6 months of treatment with antihyperglycemic drugs. RESULTS We included a total of 4,917 patients cared by 2,100 family physicians and 450 specialists. Diabetes prescriptions were monotherapy (21.2%), dual therapy (58.1%) and triple therapy (20.6%). The most common prescription patterns were metformin in monotherapy (66.5%), metformin plus DPP4 inhibitors in dual therapy (77.3%) and, in triple therapy, oral drugs (45.5%) and oral drugs plus insulin (45.8%). A total of 1,272 (25.9%) patients were at risk of serious hypoglycemia, 643 of them due to treatment with secretagogues (25%) or treatment with human insulin types (25.6%). CONCLUSIONS Elderly patients with type 2 diabetes often receive antihyperglycemic therapy with higher risk of hypoglycemia. Substitution of secretagogues and human insulin therapy for safer medication could significantly reduce the adverse effects of diabetes treatment in this population.
Collapse
|
17
|
Tratamiento de la diabetes tipo 2 en el paciente anciano: la seguridad es una prioridad. Rev Clin Esp 2020; 220:184-185. [DOI: 10.1016/j.rce.2019.06.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Accepted: 06/24/2019] [Indexed: 12/12/2022]
|
18
|
Gómez-Huelgas R, González D, Abadias M, Puig J, Ena J. Prescription patterns of antihyperglycemic drugs in elderly patients in Spain: A national cross-sectional study. Rev Clin Esp 2020. [DOI: 10.1016/j.rceng.2019.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
|
19
|
Treatment for type 2 diabetes in elderly patients: safety is a priority. Rev Clin Esp 2020. [DOI: 10.1016/j.rceng.2019.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
|
20
|
Arévalo Lorido JC, Carretero Gómez J, Gómez Huelgas R, Quirós López R, Dávila Ramos MF, Serrado Iglesias A, Ruiz Laiglesia F, González Franco A, Cepeda Rodrigo JM, Montero-Pérez-Barquero M. Comorbidity in patients with type 2 diabetes mellitus and heart failure with preserved ejection fraction. Cluster analysis of the RICA registry. Opportunities for improvement. Rev Clin Esp 2020; 220:409-416. [PMID: 31932045 DOI: 10.1016/j.rce.2019.10.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Revised: 09/19/2019] [Accepted: 10/01/2019] [Indexed: 01/14/2023]
Abstract
AIM The heterogeneity of patients with heart failure and preserved ejection fraction (HFpEF) is high, thusthis entity tends to be grouped into phenotypes to act with precision. Within these groups, patients with type 2 diabetes mellitus (T2DM) hold this heterogeneity. Our aim is to describe subgroups of patients with HFpEF and T2DM based on other comorbidities. MATERIAL AND METHODS Patients were recruited from the national registry of heart failure (RCIA). Patients with ejection fraction greater than or equal to 50% without valvular disease and with T2DM were included. A hierarchical agglomerative analysis was performed with Ward's method including the following variables: dyslipidemia, liver disease, Chronic obstructive pulmonary disease (COPD), dementia, cerebrovascular disease, arrhythmia, systolic blood pressure, body mass index (BMI), estimation of glomerular filtration and hemoglobin. RESULTS 1934 patients with ICFEP were included, of which 907 (46.9%) had T2DM with a predominance of women (60.9%) and with a BMI of 31.1 (5.9) Kg / m2. Four groups were obtained, two with high vascular risk (one with arrhythmia and the other without it) with 263 patients the first and 201 the second. A third group had a predominance of COPD (140 patients) and a last group with 303 patients older but with less comorbidity. CONCLUSIONS In our patients with ICFEP and T2DM, obesity and female sex predominated. All four groups offered treatment chances to improve their prognosis not only based on the use of new antidiabetic drugs but also on other options that may be a starting point for further research.
Collapse
Affiliation(s)
| | | | - R Gómez Huelgas
- Medicina Interna, Complejo Hospitalario Universitario de Málaga, Málaga, España
| | - R Quirós López
- Medicina Interna, Hospital Costa del Sol, Marbella, Málaga, España
| | - M F Dávila Ramos
- Medicina Interna, Hospital Universitario Nuestra Señora de la Candelaria, Santa Cruz de Tenerife, España
| | - A Serrado Iglesias
- Medicina Interna, Hospital Municipal de Badalona, Badalona, Barcelona, España
| | - F Ruiz Laiglesia
- Medicina Interna, Hospital Clínico Universitario Lozano Blesa, Zaragoza, España
| | - A González Franco
- Medicina Interna, Hospital Universitario Central de Asturias, Oviedo, Asturias, España
| | - J M Cepeda Rodrigo
- Medicina Interna, Hospital Vega Baja, San Bartolomé-Orihuela, Alicante, España
| | | | | |
Collapse
|
21
|
García Díaz E, Alonso Ramírez J, Herrera Fernández N, Peinado Gallego C, Pérez Hernández DDG. Effect of strength exercise with elastic bands and aerobic exercise in the treatment of frailty of the elderly patient with type 2 diabetes mellitus. ENDOCRINOL DIAB NUTR 2019. [DOI: 10.1016/j.endien.2019.01.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
|
22
|
Efecto del ejercicio de fuerza muscular mediante bandas elásticas combinado con ejercicio aeróbico en el tratamiento de la fragilidad del paciente anciano con diabetes mellitus tipo 2. ENDOCRINOL DIAB NUTR 2019; 66:563-570. [DOI: 10.1016/j.endinu.2019.01.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2018] [Revised: 01/16/2019] [Accepted: 01/20/2019] [Indexed: 02/07/2023]
|
23
|
[Diabetes mellitus and risk of hip fracture. A systematic review]. Rev Esp Geriatr Gerontol 2019; 55:34-41. [PMID: 31668564 DOI: 10.1016/j.regg.2019.08.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Revised: 07/22/2019] [Accepted: 08/25/2019] [Indexed: 01/27/2023]
Abstract
BACKGROUND AND OBJECTIVES It has been reported that the risk of fracture is increased in patients with diabetes mellitus (DM). The aim of this study was to investigate the possible relationship between DM and hip fracture, as well as any associated risk factors, by means of a systemic review of the literature. METHODS PubMed and SCOPUS databases were used to search for relevant studies published from January 2001 to August 2018. Retrospective and prospective cohort studies were selected in which the estimated risk of hip fracture was demonstrated by comparing groups of diabetic patients with non-diabetics. A search was also made for risk factors independent from the association between DM and hip fracture. RESULTS A total of 27 articles that fulfilled the inclusion criteria were included. A clear association was observed in diabetic patients (women and men) compared to non-diabetics patients. Among the risk factors, the most important ones were the fact that diabetes was type 1, probably associated with greater risk to a longer duration of DM, and being a female. CONCLUSIONS There is an increased risk of hip fracture in patients diagnosed with DM. This association is more significant in diabetes type 1 and women.
Collapse
|
24
|
Morillas C, Escalada J, Palomares R, Bellido D, Gómez-Peralta F, Pérez A. Treatment of Type 2 Diabetes by Patient Profile in the Clinical Practice of Endocrinology in Spain: Delphi Study Results from the Think Twice Program. Diabetes Ther 2019; 10:1893-1907. [PMID: 31359366 PMCID: PMC6778580 DOI: 10.1007/s13300-019-0671-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Indexed: 12/18/2022] Open
Abstract
INTRODUCTION The aim of this Delphi study is to unveil the management of patients with type 2 diabetes (T2D) and different levels of complexity in the clinical practice in Spain. METHODS Based on the common management practices of T2D profiles reported by Spanish endocrinologists, a Delphi questionnaire of 55 statements was developed and responded to by a national panel (n = 101). RESULTS A consensus was reached for 30 of the 55 statements. Regarding overweight patients inadequately controlled with metformin, treatment with a sodium-glucose transport protein 2 inhibitor (SGLT2-I) is preferred over treatment with a dipeptidyl peptidase-4 inhibitor (DPP4-I). If the patient is already being treated with a DPP4-I, an SGLT2-I is added on to the treatment regimen rather than replacing the DPP4-I. Conversely, if the treatment regimen includes a sulfonylurea, it is usually replaced by other antihyperglycemic agents. Current treatment trends in uncontrolled obese patients include the addition of an SGLT2-I or a glucagon-like peptide-1 receptor agonist (GLP1-RA) to background therapy. When the glycated hemoglobin target is not reached, triple therapy with metformin + GLP1-RA + SGLT2-I is initiated. Although SGLT2-Is are the treatment of choice in patients with T2D and heart failure or uncontrolled hypertension, no consensus was reached regarding the preferential use of SGLT2-Is or GLP1-RAs in patients with established cardiovascular disease. CONCLUSION Consensus has been reached for a variety of statements regarding the management of several T2D profiles. Achieving a more homogeneous management of complex patients with T2D may require further evidence and a better understanding of the key drivers for treatment choice. FUNDING Logistic support was provided by ESTEVE Pharmaceuticals S.A Spain.
Collapse
Affiliation(s)
| | | | | | - Diego Bellido
- Hospital Arquitecto Marcide, Complejo Hospitalario Universitario de Ferrol [CHUF], El Ferrol, Spain
| | | | - Antonio Pérez
- Hospital de la Santa Creu i Sant Pau, CIBERDEM, c/de Sant Quintí, Barcelona, Spain
| |
Collapse
|
25
|
Gomez-Peralta F, Escalada San Martín FJ, Menéndez Torre E, Mata Cases M, Ferrer García JC, Ezkurra Loiola P, Ávila Lachica L, Fornos Pérez JA, Artola Menéndez S, Álvarez-Guisasola F, Rica Echevarría I, Girbés Borrás J. Recomendaciones de la Sociedad Española de Diabetes (SED) para el tratamiento farmacológico de la hiperglucemia en la diabetes tipo 2: Actualización 2018. ENDOCRINOL DIAB NUTR 2018; 65:611-624. [DOI: 10.1016/j.endinu.2018.08.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Revised: 08/10/2018] [Accepted: 08/16/2018] [Indexed: 12/25/2022]
|
26
|
Gomez-Peralta F, Abreu C, Gomez-Rodriguez S, Barranco RJ, Umpierrez GE. Safety and Efficacy of DPP4 Inhibitor and Basal Insulin in Type 2 Diabetes: An Updated Review and Challenging Clinical Scenarios. Diabetes Ther 2018; 9:1775-1789. [PMID: 30117055 PMCID: PMC6167285 DOI: 10.1007/s13300-018-0488-z] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Indexed: 12/18/2022] Open
Abstract
The safety and efficacy of dipeptidyl peptidase-4 (DPP4) inhibitors as monotherapy or in combination with other oral antidiabetic agents or basal insulin are well established. DPP4 inhibitors stimulate glucose-dependent insulin secretion and inhibit glucagon production. As monotherapy, they reduce the hemoglobin A1c level by about 0.6-0.8%. The addition of a DPP4 inhibitor to basal insulin is an attractive option, because they lower both postprandial and fasting plasma glucose concentrations without increasing the risk of hypoglycemia or weight gain. The present review summarizes the extensive evidence on the combination therapy of DPP4 inhibitors and insulin-based regimens in patients with type 2 diabetes. We focus our discussion on challenging clinical scenarios including patients with chronic renal impairment, elderly persons and hospitalized patients. The evidence indicates that these drugs are highly effective and safe in the elderly and in the presence of mild, moderate and severe renal failure improving glycemic control with low risk of hypoglycemia. In addition, several randomized-controlled trials have shown that the use of DPP4 inhibitors in combination with basal insulin represents an alternative to the basal-bolus insulin regimen in hospitalized patients with type 2 diabetes.
Collapse
Affiliation(s)
| | - Cristina Abreu
- Endocrinology and Nutrition Unit, Segovia General Hospital, Segovia, Spain
| | | | | | | |
Collapse
|
27
|
Carretero Gómez J, Miramontes González JP, Varela Aguilar JM, Ena J, Arévalo Lorido JC. Use of degludec insulin in chronic complex patients. Eur J Intern Med 2018; 52:e27-e29. [PMID: 29576381 DOI: 10.1016/j.ejim.2018.03.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Revised: 03/18/2018] [Accepted: 03/19/2018] [Indexed: 11/15/2022]
Affiliation(s)
- J Carretero Gómez
- Dpt. Internal Medicine, Hospital Comarcal de Zafra, Zafra, Badajoz, Spain.
| | - J P Miramontes González
- Dpt. Internal Medicine, Hospital Clínico Universitario de Salamanca, Instituto de investigación biomédica de Salamanca, IBSAL, Salamanca, Spain
| | - J M Varela Aguilar
- Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP), Hospital Virgen del Rocío, Sevilla, Spain
| | - J Ena
- Dpt. Internal Medicine, Hospital Marina Baixa, La Vila Joiosa, Alicante, Spain
| | - J C Arévalo Lorido
- Dpt. Internal Medicine, Hospital Comarcal de Zafra, Zafra, Badajoz, Spain
| |
Collapse
|
28
|
Javier J, Bravo M. Introducción. Semergen 2018; 44 Suppl 1:1-2. [DOI: 10.1016/s1138-3593(18)30368-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
|
29
|
Recomendaciones de las principales guías de práctica clínica. Semergen 2018; 44 Suppl 1:3-9. [DOI: 10.1016/s1138-3593(18)30369-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
|