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Endocrinology and Nutrition

moderated by Dr Ricardo Correa Márquez


Oral communications

The influence of nutritional risk in elderly patients hospitalized for bone fracture

Drs María José Calero-García, Ana Raquel Ortega Martínez, Elena Navarro González, María Dolores Calero García

Introduction: Bone fractures in older adults involve hospitalization and surgical intervention, aspects that have been related to functional and cognitive impairment. Several variables have been studied as moderators in how these patients evolve, such as nutritional status. However the implications of nutritional status in the subsequent evolution of the hospitalized elderly, has not been studied to date. Objective: In the present study the authors analyze the relationship between the nutritional status, and diferent variables related to the evolution of older adults who have undergone surgery after a bone fracture.
Method and instruments: One hundred-seventy six elderly (aged 65–105 years; 138 females and 38 males) participated in the study. Participants’ consent was obtained according to the Declaration of Helsinki. The following questionnaires were administered: Phototest, Auditory Verbal Learning Test of Learning Potential (AVLT-PA) and Mini Nutritional Assessment (MNA). The questionnaires was administered at the three months of the hospitalization. Results. The elders`s nutritional state showed a significant relationship with cognitive decline at home (r=.171, p=.038), and with cognitive plasticity (r=.238, p<.010). Furthermore, those elderly patients at risk of malnutrition have a higher cognitive decline at the three months of the hospitalization (t= -3.808, p=.000) and worse cognitive plasticity (t= -3.096, p=.004). No differences were noted among regarding functional.


C-Reactive Protein in patientes with type-2 Diabetes Mellitus

Dr Athar Memon

OBJECTIVE: To determine the frequency of raised C-reactive protein (CRP) in patients with type 2 diabetes mellitus
PATIENTS AND METHODS: This cross sectional descriptive study of six months study was conducted at Liaquat University Hospital Hyderabad from March 2013 to August 2013. All diabetic patients of ≥35 years age of either gender for >01 year duration visited at OPD were evaluated for C-reactive protein and their glycemic status by hemoglobin A1c. The data was analyzed in SPSS and the frequency and percentage was calculated.
RESULTS: During six month study period, total 100 diabetic patients were evaluated for C-reactive protein. Majority of patients were from urban areas 75/100 (75%). The mean ±SD for age of patients with diabetes mellitus was 51.63±7.82. The mean age ±SD of patient with raised CRP was 53±7.21. The mean ±SD for HbA1c in patients with raised CRP is 9.55±1.73. The mean random blood sugar level in patients with raised CRP was 247.42 ± 6.62. The majority of subjects from 50-69 years of age group with female predominance (p = 0.01) while the CRP was raised in 70(70%) patients in relation to age (p=0.02) and gender (p=0.01) respectively. Both HbA1c and CRP was raised in 64.9% (p = 0.04) in patients with type 2 diabetes mellitus. The mean ±SD of CRP was 5.8±1.21 while for male and female individuals with raised CRP was 3.52±1.22 and 5.7±1.63 respectively
CONCLUSION: The raised CRP was observed in patients with type 2 diabetes mellitus
Refractory hypertension due to lack of treatment compliance in a 37 year old woman

Drs Sara Quintana Arroyo, Carmen Acosta Calero, Claudia Arnas Leon, Ana Delia Santana Suarez, Esperanza Perdomo Herrera, Alba Tocino, Francisco Javier Martinez Martin

BACKGROUND: Therapeutic inertia and lack of compliance are the main barriers to hypertension control
OBJECTIVES: Presentation of a case illustrating the importance of proper adherence to blood pressure and a detailed anamnesis in patients with apparent refractory hypertension.
METHODS: Review of the clinical record.
RESULTS: A female patient had been diagnosed of hypertension 3 years ago, with SBP around 150-160 mmHg and DBP around 90-100 mmHg. Ambulatory Blood Pressure Monitoring (AMBP) was performed while untreated, showing a normal dipper pattern, with average BP 141/93mmHg (diurnal) and 115/69mmHg (nocturnal); the respective HR were 81 and 68 bpm. The peak SBP was156 mmHg (2:30 p.m.). No cause of secondary hypertension or target organ damage had been found.
The patient never achieved adequate BP control despite multiple permutations and combinations of drugs. She was prescribed up to 12 different patterns of antihypertensive treatment; the final combination before referral to our Hypertension Clinic was: Cardesartan 16 mg + Torasemide 10 mg + Amlodipine10mg + Doxazosin 10 mg + Bisoprolol 10mg +Spironolactone 50 mg. Reinterrogating the patient in order to clarify the inefficiency of the antihypertensive treatment, she finally admitted that she had never taken it regularly and had taken at most one tablet daily. An agrrement was made: She would take only one daily pill (Valsartan 80 mg) avoiding omissions. After 2 weeks the ABPM was repeated and the results were: average BP 123/83mmHg (diurnal) and 116/73mmHg (nocturnal); the respective HR were 75 and 77 bpm. It clearly showed that she had a pseudorefractory hypertension, caused by lack of compliance.
CONCLUSIONS: This case illustrates that in patients with hypertension labeled as refractory it is essential to obtain a detailed anamnesis and assessment of the level of compliance, before prescribing drugs and explorations which can entail high costs and side effects.
Presentation of adrenal oncocitoma with hirsutism in a 24 year old woman

Drs Carmen Acosta Calero, Pablo Benito Pedrianes Martin, Claudia Arnas Leon, Sara Quintana Arroyo, Ana Delia Santana Suarez, Alba Tocino, Esperanza Perdomo Herrera, Francisco Javier Martinez Martin

BACKGROUND: The adrenal oncocytoma is a rare entity, and only a small minority of the patients present with endocrine disorders.
OBJECTIVES: Presentation of a case illustrating a rare cause of hirsutism.
METHODS: Review of the Clinical Record.
FINDINGS: A young woman was referred to our Endocrinology Clinic six years after developing severe hirsutism (facial, periareolar, in the lower back and the linea alba). The patient always had regular menses, with no other signs or symptoms. She had received therapy with oral contraceptives and antiandrogens (cyproterone acetate) without improvement. The only relevant findings in the physical examination were hirsutism and mild hepatomegaly (2-3 cm). Lab investigations showed normal routine biochemistry and CBC but clearly high free testosterone, Δ-4-androstendione and 17-α-OH-progesterone (>3x upper normal limit). Unexpectedly, abdominal ultrasound and computed tomography revealed a well defined mass (15 cm maximum diameter) in the right adrenal gland with coarse calcifications, displacing and deforming the right hepatic lobe and the kidney. With the presumptive diagnosis of an androgen-secreting adrenal adrenocarcinoma, the patient underwent right adrenalectomy. The tumor was diagnosed as a well-encapsulated oncocytic adreno-cortical neoplasm with no extension. One year later the hirsutism had resolved, plasma androgens were normal and the patient had a successful pregnancy. Eight years later the patient remains asymptomatic without treatment, with no radiological findings except postsurgical changes.
CONCLUSIONS: Hirsutism is common in young women, but high androgen levels and the lack of response to the usual hormonal therapy suggest a tumoral cause. Androgen-secreting adrenal oncocitomas are rare, but they should be included in the differential diagnosis along with adrenocarcinoma and ovarian neoplasms.
Patient with Metabolic Syndrome Rejected for Bariatric Surgery

Drs Alba Lucia Tocino Hernandez, Esperanza Perdomo Herrera, Sara Quintana Arroyo, Claudia Arnas Leon, Carmen Acosta Calero, Ana Delia Santana Suarez, Francisco Javier Martinez Martin

Background: Bariatric surgery is currently advocated as an elective treatment of severe obesity and its associated comorbidities
Objective: Presentation of a case demonstrating the effectiveness of lifestyle changes as an alternative to bariatric surgery.
Method: Review of the Clinical Record.
Results: A 47 year old woman with long-standing severe obesity was diagnosed of essential hypertension, mixed dyslipidemia, nonalcoholic steatohepatitis and type 2 diabetes. Three years ago she had an episode of deep venous thrombosis and pulmonary thromboembolism and was diagnosed of Factor V Leiden thrombophilia. Her treatment included standard doses of Acenocoumarol, Irbesartan, Manidipine, Torasemide, Atorvastatin, Metformin and Sitagliptin. However the patient was sedentary with inadequate eating habits and her comorbidities were uncontrolled. She was referred for bariatric surgery but was rejected due to her thrombophilia. Physical examination: Weight 102.3 kg, height 166 cm, BMI 37.3 kg/m2, waist circumference 126 cm. BP 129/76 mmHg, HR 68 bpm. Lab tests: HbA1c 8.3%, Glucose 168, total cholesterol 212, HDL 41, LDL 116, trigl. 274 (mg/dL); AST 55, ALT 43, GGT 87 (U/L); normal GFR, ions, TSH and CBC. Evolution: Upon rejection for surgery, she began a 1250 Kcal diet and a low-impact exercise program. After six months she lost 38 kg achieving a normal BMI (23.4) and a waist perimeter of 92 cm. Antihypertensive medication was withdrawn due to symptomatic hypotension. At present she is normotensive, with normal hepatic enzymes, good glycemic control (Glucose 78, HbA1c 5.9%) and lipid profile (total cholesterol 147, HDL 52, LDL 72, trigl. 116) without any medication except Acenocoumarol
Conclusions: With good compliance, the conservative treatment of severe obesity with lifestyle modifications can be as effective as bariatric surgery, being able to resolve both the obesity and its comorbidities. This option should be seriously tried before referral for bariatric surgery.

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Making Sense of Insulin

Drs Francisco Javier Martinez-Martin, Carmen Acosta-Calero, Esperanza Perdomo-Herrera, Alba Lucia Tocino-Hernandez, Sara Quintana-Arroyo, Claudia Arnas-Leon, Ana Delia Santana-Suarez

BACKGROUND: Insulin-related peptides are found in Cnidaria (the most ancient metazoa with differentiated tissues including a nervous system, dating from about 600 million years ago) and their nucleotide sequence has been highly preserved ever since. In mammals the binding of insulin to its receptor causes a cascade of actions,the main one being translocation of GLUT4 glucose transporters to the plasma membrane allowing influx of glucose into the adipose and striated muscle cells. But the fact that glucose can freely enter most other tissues (via non insulin-dependent glucose transporters) and that in non-chordates the glucose influx is unrelated to insulin raises the question: Why did fat and muscle need to have GLUT4 and therefore insulin dependency? Better yet, what is the sense of having insulin?
METHODS: Review of the literature with emphasis in the insulin phylogeny.
FINDINGS: The familiar glucocentric functions of insulin appear with protochordates; however insulin-related peptides play an essential role in invertebrates activating growth, differentiation, metamorphosis, sexual activity and in general regulating the allocation of energy resources. In the well-studied nematode Caenorhabditis elegans the presence of nutrients releases an insulin-like peptide that activates metabolic and reproductive developments and shortens the lifespan, while the lack of this peptide triggers a long-lasting dormant state (dauer).
CONCLUSIONS: The insulin receptor and insulin are lock and key. But having a lock and key in a door only makes sense if sometimes we need to close it. We need insulin, not to allow glucose influx in muscle and fat (in the postprandial state), but in order to be able to close it (in the fasting state) saving glucose for non-dependent tissues. Therefore insulin is the main switch between the anabolic and the catabolic state. This function predates allowing glucose influx by hundreds of millions of years and is well preserved along the evolutionary tree.

 Global Health & Nursing

moderated by Simon Downes

Oral communications

Sustainability of the Public Health Service in Spain: An Approach to Governance

D. Miguel Angel Moyano Santiago, Dª Juana M Rivera Lirio

Background, Aim & Objectives: The health system sustainability is a key topic in Spain’s political debates. What a sustainable heath system should be poses a big concern for citizens and politicians. Foremost for managers and political actors, to ascertain the right way to build a good mid- and large-term financial model of sustainability is critical as well. However, to link exclusively the financial sustainability of the health system with a political objective could be a limited overview. Issues that affect the national health system have an impact on the entire society and its processes and activities result in environmental externalities.
Methods/Study Design: The analysis focuses on the triple bottom line: economic, social and environmental; displaying a wider view of the Spanish health models and their future strategies. Likewise, it needs to be understood whether the concept of sustainability goes beyond. The economical concerns in the plans of the health authority and their financial budgets, and come to terms with the expectations of citizens and the political speech, considering that the health budgets of Spain and other OECD countries show a weakness point in this regard. This article analyzes the challenges of the health system and its critical points from the perspective of the health authority through a cualitative research by survey and interviews.
Results: Most leaders working at Spanish’s health system are focus on economical concerns and social and environmental issues are put then in a second place. The sustainability view is limited in terms of the concept of triple bottom line.
Socio-demographic factors and health seeking behaviour of clients: a retrospective analysis of HIV data in rural Ghana

Dr Paschal Apanga

Background: HIV/AIDS care, treatment and prevention is critical in controlling the HIV menace in Ghana. This study investigated the socio-demographic factors, diagnostic criteria and health seeking pattern of HIV clients in rural Ghana.
Methods: This was a retrospective longitudinal study that analysed secondary data from 102 HIV clients in Talensi District Hospital collected between February and April, 2015 in rural Ghana. HIV data was analysed descriptively using Epi Info 7.
Results: The analysis revealed that more females, 69.6% (71/102) and married couples, 51.9% (53/102) were infected than their male, 30.3% (31/102) and single, 19.6% (20/102) counterparts respectively. Most of the clients had primary/no education, 87.3% (89/102) whilst 12.7% (13/102) of the clients had secondary/higher education. 68.6% (70/102) of clients became aware of their status through diagnostic HIV testing with only 2% (2/102) of clients who became aware of their status by walk in voluntary counselling and testing. Majority of the clients had medical insurance, 76.4 % (78/102) with 22.6% (23/102) of clients who made payment out of their pocket for treatment. Majority of the clients came from neighbouring communities, 62.7% (64/102) to seek care although such services were rendered at their respective communities.
Conclusion: This study has provided evidence on the need for health facilities in rural Ghana to intensify education on HIV preventive methods to rural communities as well as discourage the stigmatization of people living with HIV/AIDS. It is also important to educate people in rural communities on the availability of voluntary counselling and testing centres and encourage them to know their status.


Safe Hands: Teaching Innovation Project to Improve Hand Hygiene in Health Sciences

Jacobo Cambil-Martin

Background: Since 2004, the World Alliance for Patient Safety brings proposing hand hygiene as the key measure of its international strategy in the fight against healthcare-associated infections. In Spain the Safe Hands Distinction of the Patient Safety Observatory recognizes the good practices on improving hand hygiene of the World Health Organization.
Objectives: Apply the WHO multimodal strategy to improve hand hygiene at the Faculty of Health Sciences and maintain the culture of Patient Safety on hand hygiene by students and staff.
Methods: A teaching innovation project called “Safe Hands” was developed in the Nursing Degree at the Faculty of Health Sciences of the University of Granada during the academic period 2013-2015. The tool “Guide to the Implementation of the WHO Multimodal Hand Hygiene Improvement Strategy” served to develop and plan the program to improve hand hygiene according to its five phases. Parallelly, activities were implemented according to the three stages of the accreditation process “Safe Hands Distinction”.
Results: The Faculty of Health Sciences has become a dynamic secure environment that provides alcoholic gel for practice and training on hand hygiene, disseminates information and updated signage, reinforces the training of students and staff, and reinforces the quality assurance project.
Study Limitations: It is necessary to complete the five years cycle of continuous improvement in quality of the WHO guide to establish an optimal strategy for improving hand hygiene.
Conclusion: Safe Hands has launched the WHO multimodal strategy in an academic context. The Faculty of Health Sciences has got credited the Safe Hands Distinction, becoming the first Higher Education Center accredited in Spain to improve hand hygiene.
Codes of conduct for nursing students: bioethical commitment to higher education in Spain

Jacobo Cambil-Martin

Background: As a profession, Nursing has its own code of ethics and codes of conduct which establish personal and professional behavior expected on Nursing professionals and students to be competent in their practice, learning and development. The Nursing and Midwifery Council has a Code of Professional Conduct for students of Nursing and Midwife. Considering that the diversity of values is a fact in the university community, it is necessary to explore the validity and meaning to implement Codes of Professional Conduct for Nursing students in the teaching and learning process.
Objective: To identify and assess codes of conduct aimed at Nursing students to understand the commitment to Bioethics training of higher education in Spain.
Methods: A literature review was conducted. Main elements of ethical codes and the dimensions of the attitudinal assessment template for Nursing students in clinical practice with the code of conduct of the English Council were compared.
Results: The literature review brings two articles in Spanish language and according to the selection criteria. The journal “Etica de los cuidados” -indexed in “Cuiden” database- collects these studies reporting that both professionals and students know the Spanish Code of Ethics for Nursing and there is a need to establish a new teaching and learning framework in Bioethics; however, no specific articles provide knowledge about codes of conduct for Nursing students in Spain.
Conclusion: In general, the standards of conduct for students of the Nursing and Midwifery Council are already implicit in the ethical rules, rights and duties of the Spanish code of professional ethics. So it is still necessary to consider the Code of Conduct of the Spanish Nursing Council and the White Paper of the Nursing Degree to understand the commitment to Bioethics training on Nursing.
Reiki therapy in a colorectal cancer patient

Jonatan Fernández Ruiz, Keyla Vargas Román, Francisco Delgado Díaz, Noelia Galiano Castillo, Irene Cantarero Villanueva, Lourdes Díaz Rodríguez

Background: Patients diagnoses with colorectal cancer show physiological and psychological changes due to the disease itself and the side effects of the cancer treatment. Reiki is an energy therapy, which uses a specific sequence of hand positions to channel the universal life force for recharging, realigning, and rebalancing the human energy field.
Aim & Objectives: The main objective of this study was to develop an individualized care plan in a patient with adenocarcinoma of the rectum in stage IIIC undergoing neoadjuvant radiotherapy treatment, using the NANDA, NOC and NIC taxonomy, whose main intervention was the NIC (1520) Reiki.
Methods/Study Design: The diagnostic labels included in this care plan were (000155) Risk for falls and (00050) Disturbed energy field, evaluating the level of fatigue (Piper Fatigue Scale), anxiety (State-Trait Anxiety Inventory), depression (Beck questionnaire), heart rate variability (ECG, NoravHolter) and blood pressure (validated automatic oscillometric device).
Results/Findings: Results showed a decrease in heart rate, blood pressure, anxiety, depression and fatigue after each Reiki session, and also an increase in heart rate variability. Furthermore, it was observed an improvement of fatigue and vagal activity as well as a decrease in anxiety and depression at the end of the radiotherapy treatment, reaching the target score of each indicator of the selected NOC.
Conclusion: Thus, it is suggested that Nursing professional should be trained in NIC (1520) Reiki to apply integral care to cancer patients and improve their quality of life.
Coping strategies in colorectal cancer patients

Keyla Vargas Román, Jonatan Fernández Ruiz, Francisco Delgado Díaz, Lydia Martín Martín, Carolina Fernández Lao, Lourdes Díaz Rodríguez

Background: According to the World Health Organization, the leading cause of death worldwide in 2012 was cancer and a substantial increase of 19.3 million new cases per year by 2025 will rise due to population growth and a progressive aging population. In Spain, with the highest incidence cancer is colorectal (15%) 32,240 new cases diagnosed each year and 14,700 deaths. One of the complementary therapies to conventional cancer treatment to improve the quality of life of patients after diagnosis of cancer is the coping strategies so that the person learns to focus and have better tailored to the new situation.
Aim & Objectives: The objective of this study was to analyze the scientific evidence of the use of coping strategies in patients older than 65 with colorectal cancer.
Methods: The literature search was performed in PubMed, American Search Premier and EBSCOT the search data was till April 30th, 2015. The selection between the articles were randomized controlled trials, controlled trials and/or quasi-experimental studies written in English, that were applying the strategies of coping in patients older than 65 with colorectal cancer.
Results: Of the initial 78 items, 23 potentially eligible studies were identified by reviewing the full text. After a thorough analysis, seven studies met the inclusion criteria. All of them showed a significant improvement in the study variables such as distress, depression, anxiety and quality of life.
Conclusions: We suggest that coping strategies in patients with colorectal cancer are effective in improving the patient’s adaptation to the new situation; therefore, we recommend that health professionals, especially nurses working with cancer patients, receive training in these therapies to implement a comprehensive care to improve the quality of life of cancer patients.
Impact of the level of dependence on functionality and health of institutionalized older adults

Dr. Lydia M Martín-Martín, Mr Mario Lozano-Lozano, Dr. Noelia Galiano-Castillo, Dr. Irene Cantarero-Villanueva, Mss. Angélica Ariza-Garcia, Dr. Lourdes Díaz-Rodríguez

Background. The population ageing can be considered both a medical success and a challenge to our society. According to the World Health Organization, people aged 60 or more will reach to 2,000 million in 2050, this is, 22% of the world population. Therefore, it is expected an increased amount of institutionalized elderly in the coming years.
Objectives: our study was aimed to assess and describe the functionality, health, and quality of life of institutionalized older adults as well as to analyze the influence of their dependence level on these variables.
Methods. A cross-sectional study was carried out. Institutionalized older adults over 60 years were included. The study variables were the level of dependence (Barthel index), the level of functionality (TUG), the state of balance and gait (Tinetti), the level of physical activity (IFIS), quality of life (SF questionnaire 36), sleep quality index (Pittsburgh) and the level of anxiety and depression (HADS).
Results. 35 older adults were included. The results showed that those who had a better dependence level also exhibited better functionality, balance and gait, level of physical activity and quality of life, and lower anxiety and depression levels.
Conclusions. Institutionalized older adults with total or severe dependence had significantly worse levels of functionality and health.

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BENECA project: Energy Balance on Cancer. Feasibility of a e-health system in patients diagnosed with cancer

Mr Mario Lozano-Lozano, Dr Lydia Martín-Martín, Dr Noelia Galiano-Castillo, Dr Lourdes Díaz-Rodríguez, Dr Carolina Fernández-Lao, Dr Manuel Arroyo-Morales

BACKGROUND: The energy imbalance (excess in energy intake (diet) or low physical activity), is a key to the increased risk of some of the most prevalent cancer processes currently, being determinants of the risk of recurrence, second cancers and cancer mortality.
Recent research reveal that, even knowing the benefits of interventions aimed at promoting energy balance among cancer survivors, it is unrealistic to expect that most of them, with a strong sedentary habit, comply with the current guidelines of good practice.
AIM AND OBJECTIVES: The main objective of this project is to design, implement and validate in a real clinical setting an on-line monitoring system energy balance on cancer survivors (BENECA system).
STUDY DESIGN: A descriptive crossover design and a prospective design with one arm (pre and post-intervention) will be used to meet the first objective (design and feasibility study of the application) and to evaluate the effect of the intervention, respectively. The goal is to keep recruiting study for 12 months. It is anticipated that approximately 96 cancer patients will be sent to the program during this time.
BENECA System asks users to register food and drinks, and the different activities carried out during the previous day. With an open structure and four time periods, after entering the information the application detects if there is an energy imbalance and will provide to patient their level of energy balance and general recommendations on physical activity (according to the American College of Sports Medicine), and substituting foods considered potentially carcinogenic by others with protective capacity against cancer (following guidelines of the American Cancer Society).
CONCLUSIONS: The aim of this poster is to present the BENECA project to the scientific community. In this study we hope to overcome the specific barriers identified to facilitate the inclusion of exercise and healthy diet programs within supportive care for cancer survivors.

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Identification of inequality in the territorial distribution of physicians in primary health care and its relationship to community health indicators in Chile

Dr Germán Camilo Bass del Campo, Mr Carlos Barría León

Health reform raised to an unprecedented boost to the Primary Health Care. However, there are not addressed problems that threaten the success of this process. Analyze the territorial distribution of physicians in primary care Community Health in Chile. To estimate the association between the rate of medical hours per commune and some indicators of community health. Ecological design type of comparison group was used as the unit of analysis taking the communes. Comparing the availability of medical hours, with national and international standards. Furthermore, the association with health indicators was estimated. Among the 261 communes of the study, it is shown that the territorial distribution of physicians in primary care Community Health is uneven, an average of 3.11 per 10,000 medical time equivalents people in large communities is observed rate and 2.24 for small municipalities. There is a serious shortage of medical hours in most of the communes. For the standard of the Ministry of Health there is a gap of 8.37%. For the standard 2,000 people, a 45.01% and every 1,200 people, with a 67.01%. In the correlation analysis would have a statistically significant association with most of the outcome variables (General Mortality Rate, Adjusted General Mortality Rate, Infant Mortality Rate Late, Mortality rate 20-44 years, 45-64 years Mortality rate, mortality rate 65 and 79 and 80 and Mortality Rate). Regarding the purpose of the present research, this study may contribute, along with a few made about medical resource of Primary Health Care in Chile, to a better understanding of our health situation and therefore, the development of public policies in the field of human resources for health, that a greater attraction, retention and better distribution of medical resources in primary care guidance. Thus, contribute to strengthening the Integral Health Care Model Approach to Family and Community, currently being implemented.

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Out-of-Hospital Emergency Medical Service. Detection of Child Abuse

Prof Carmen Cardós, Dr Antonio Sáez, Dr Santiago Apilluelo, Dr Jose L. del Pino

Background: Child Abuse has become a worried trouble in public health. Its detection is difficult and hard because child abuse usually happens in child`s home and moreover is committed by relatives.
Objective: The aim of this study is to carry out an approximation to ability detection of child abuse by an out of hospital emergency medical service (SUMMA-112).
Methods: Descriptive statistical analysis. Observational study of raw data from the whole pediatric medical histories, diagnostic codes CIE-10 of child abuse, collected from 2008 to 2011.
Results: Prevalence of Child Abuse detected by SUMMA-112 was 0.83%. Male 38.3% (n=41); Female 61.7% (n=66). The most frequent diagnostic code in our survey was emotional mistreatment. On the contrary, in-hospital most frequent diagnostic codes are physical mistreatment and sexual abuse and the lesser diagnostic code detected is the neglect.

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moderated by Dr John Bennett

Short teaching course

Non-motor symptoms of Parkinson's disease

Dr AQ Rana


Oral communications

Planimetry of the Medial Temporal Lobe is a Feasible Method for Supporting the Diagnosis of Alzheimer’s disease in Daily Clinical Practice

Manuel Menéndez-González, Aníbal Fernández Oliveira, Francisco Conejo Bayón, Jesús Maese, Tamara Mesas, Estíbaliz Herrera de la Llave, Tania Álvarez Avellón

Background: Albeit a disproportionate rate of atrophy in the medial temporal lobe (MTA) represents a reliable marker of AD, the measurement of MTA is not being widely used in daily clinical practice. This is mainly because the methods available to date are sophisticated and difficult to implement (volumetric methods) or lack objectivity (visual rating scales). Here, we aimed to compare the results of one of a planimetric method (the yearly rate of absolute atrophy of the Medial Temporal Lobe, 2D-yrA-MTL) with the results of using semi-automated volumetry of the hippocampus (the yearly rate of absolute atrophy of the Hippocampus, 3D-yrA-H) on a collection of MRIs from patients with Alzheimer’s disease (AD), Mild Cognitive Impairment (MCI) and matched controls. We also aimed to assess the reproducibility of computing the 2D-yrA-MTL and the efforts needed to start using the 2D-yrA-MTL correctly.
Methods: A series of 1.5T-MRI studies from 120 subjects ranging 65–85 years old, including patients with AD (n=40), MCI (n=30) and matched controls (n=50) were examined by two subgroup of researchers (one 3D and one 2D). Each subgroup was blinded to the results of the other. In the 2D-subgroup of researchers there were experienced tracers (ET) and inexperienced tracers (IT).
Results: IT needed to train with 3 cases before being able to compute the 2D-yrA-MTL on their own correctly. After training, IT needed 5 minutes to examine a new case. In the differential diagnosis of AD against controls 3D-yrA-H performed significantly better than 2D-yrA-MTL The intrarater and interrater reproducibility of 2D-yrA-MTL was good.
Conclusion: although planimetry of the MTL is not as good as volumetry of the hippocampus in the diagnosis of AD, the 2D-yrA-MTL is a simple, objective and reproducible method that could be easily implemented in clinical practice.


Brain neurotransmitters in Parkinson’s induced rats

Dr Nitin Kumar

Neurotransmitters play a vital role in the functioning of brain. Our study aimed to investigate the changes in brain Neurotransmitters in Wistar rat models of Parkinson’s disease
Parkinson’s disease (PD) is a neurodegenerative disease and a movement disorder characterized by loss of dopaminergic neurons in the substantia nigra causing dopamine depletion in the striatum. Neurodegeneration in PD occurs due to multiple pathways including oxidative stress, mitochondrial damage, protein aggregation.
Objectives: Neurotransmitters play a vital role in the functioning of brain. Our study aimed to investigate the changes in brain Neurotransmitters in Wistar rat models of Parkinson’s disease
Parkinson’s disease (PD) is a neurodegenerative disease and a movement disorder characterized by loss of dopaminergic neurons in the substantia nigra causing dopamine depletion in the striatum. Neurodegeneration in PD occurs due to multiple pathways including oxidative stress, mitochondrial damage, protein aggregation.
Methods: Determination of brain norepinephrine, dopamine and serotonin was carried out using high performance liquid chromatography (HPLC) system, Agilent technologies 1100 series.
Results: The mean values of brain norepinephrine, dopamine and serotonin levels in Parkinsons induced rat brain were significantly increased compared to control group.
Conclusion: Neurotransmitters play a vital role in brain functioning and also have important function in Parkinson’s disease status.


NRF2 attenuates levodopa-induced dyskinesias through the modulation of DARPP-32/ERK phosphorylation signaling pathway

PhD Julio Tobon, MSc Aldrin Martínez, MSc Celeste Santamaría, MSc José García

The long-term levodopa replacement therapy in Parkinson’s disease is accompanied by AIMs, known as levodopa-induced dyskinesia, and it´s associated with hyperphosphorylation of the DARPP-32/ERK-1/2 signaling by D1R activation. We analyzed the involvement of oxidative stress in this pathway by using mice deficient in the transcription factor NRF2. Here, we show that the modulation of L-DOPA-induced phosphorylation in Thr34-DARPP-32 and ERK-1/2 by NRF2. L-DOPA more increased the phosphorylation of two markers of DA signaling in NRF2-knockout, and Nrf2 inducer by SFN attenuated DA signaling in wild type mice. These results indicate the relevance of redox homeostasis in L-DOPA/DA signaling and the crucial role of NRF2 in modulation of this process. Finally, we modulated NRF2 activity in two dyskinetic mouse models that combined the parkinsonism induced by 6-OHDA delivery with the development of AIMs induced by chronic administration of L-DOPA. Consequently, we observed that the activation of the way of DARRP-32 and ERK-1/2 is required for the induction of FosB/Δ-FosB expression, which are implicated in LID. We SFN attenuated LID in wild type but not in Nrf2-null mice by decrease of the phosphorylation on T34-DARPP-32 and reduce the concomitant activations of ERK-1/2 and FosB/Δ-FosB signaling. These studies demonstrate that expression of ERK-1/2 and FosB/Δ-FosB induced by L-DOPA, requires activation of DARPP-32, and modulation of this pathway suggest a major role of NRF2 in the regulation of L-DOPA/DA signaling through the regulation of redox activity and the potential use of Nrf2 as a new target of reduce L-DOPA-induced diskynesias.


Effects of Memantine and One-on-One Caregiver Contact on Antipsychotic Medication Prescribed to Elderly Veterans with Dementia

Dr Abimbola Farinde

Background: Dementia is a neurological disorder that manifests with cognitive impairments as well as behavioral and neuropsychiatric symptoms.Behavioral and neuropsychiatric symptoms can be include inappropriate behavior, combativeness, agitation, aggression,hallucinations, delusions, and depression.Dementia patients can be placed on pharmacological and
nonpharmacological interventions to manage the behavioral and neuropsychiatric symptoms. Co-therapy with a cholinesterase inhibitor, memantine, and one-on- one contact in reducing prescribed antipsychotic medications in
dementia patients has not been explored.Elderly veterans with dementia represent an important population for this study due to utilization of antipsychotic medication and associated suffering, morbidity, and mortality.
Objectives: The purpose of this research study is to investigate whether one-on-one contact, memantine, and a cholinesterase inhibitor might be associated with a lower average daily dosage of antipsychotic medications given in elderly veteran dementia patients.
Research Questions: What is the effect of the addition of memantine and caregiver one-on-one contact co-therapy to antipsychotic medication therapy on the average daily dosage of anti-psychotic therapy in elderly outpatient veterans with dementia? To what extent does patient age have on the effect of the addition of the memantine and co-therapy on average daily dosage of anti-psychotic medication? To what extent does severity of dementia have on the effect of the addition of memantine and co-therapy on average daily dosage of anti-psychotic medication?


moderated by Dr. Jaume Cañellas Galindo


Psychiatric disorders in Prader-Willi syndrome: a case report about psychotic symptoms

Drs Marta Herrera Durán, Carlos Gómez Sánchez-Lafuente

Background: Psychiatric symptoms are prevalent in patients with Prader-Willi syndrome (PWS), mainly behaviour disorders (temper tantrums and stubbornness) and manipulative behaviour, obsessive-compulsive characteristics in relation with food. True psychosis is evident in young adulthood in approximately 5-10% of patients.
Aim & Objectives: review of psychotic symptoms in patients with a diagnosis of PWS to purpose of a case.
Methods/Study Design: a PWS case report with psychotic symptoms treated with Aripiprazole.
Results/Findings: PWS patients have an increased risk of psychotic disorder or affective illness with a psychotic component, especially young adult patients and those with the maternal uniparental disomy as opposed to paternal deletion.
Conclusion: Behavioural and psychiatric problems interfere the most with quality of life in adulthood. These should be detected early and treated appropriately with parental education and psychotropic medication if it was necessary. Serotonin agonists have been the most successful in reducing temper outbursts and improving compulsivity. Psychosis is treated in a standard manner.

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Oral communications

Decompressive craniectomy in traumatic brain injury: Systematic review

Drs Luis Rafael Moscote-Salazar and Andres M. Rubiano

Intracranial hypertension is the leading cause of mortality in patients with head injuries. At present, the TBI is a public health problem worldwide. Decompressive craniectomy emerges as a treatment strategy for patients with intracranial hypertension refractory to medical management. This procedure requires careful and exquisite surgical technique, we present an updated systematic review procedure.


Pilomyxoid astrocytoma of the fourth ventricle in an adult: case report

Drs Sayoa Alvarez de Eulate-Beramendi, Marco Alvarez-Vega, Javier Sol-Álvarez, Antonio López-García

Pilomyxoid astrocytoma has been identify as a variant of pilocytic astrocytoma, although due to his poor prognosis, it corresponds to WHO grade II. They are usually limited to the hypothalamic or chiasmatic region, and pediatric patients. Only a few cases have been reported of a pilomyxoid astrocytoma in the fourth ventricle in an adult.
A 19-year-old boy presented with headache of 7-month duration. As he complained of diplopia since two months, an ophthalmological exam was performed, showing papiledema. On examination, he had no other neurological deficits. A TC revealed a mass in the IV ventricle with obstructive hydrocephalus. The brain MRI revealed a heterogeneously enhanced mass in the fourth ventricle. He first underwent endoscopic vetriculostomy to treat hydrocephalus and a suboccipital craniotomy was performed to remove the tumour. The macroscopic appearance showed a gelatinous and reddish mass, vascularised and infiltrating the floor of the fourth ventricle. Partial resection was performed to minimize neurological disturbances. Postoperatively, the patient presented oculomotor paresis and left incomplete facial palsy. The histopathological analysis showed bipolar tumour cells with myxoid background, vascular proliferation and angiocentric arrangement of piloid cells. No Rosenthal fibers or eosinophilic granular bodies were found. Glial fibrillary acid protein and S-100 were positive, the synaptophysin was negative, and a diagnosis of pilomyxoid astrocytoma was made.
Conclusions: Pilomyxoid astrocytomas are a more aggressive variant of pilocytic astrocytoma. Rare examples have been described in adults. Histopathologically it shows a monophasic pattern with myxoid background with angiocentric arrangement, without Rosenthal fibers and eosinophilic granular bodies. Post-operative adjuvant treatments are controversial, however in adults who have subtotal resection they can improve prognosis and decrease CSF dissemination rate.

Physical Medicine

moderated by Prof. Erna Navarrete


Role of Physical Therapy in the treatment of pain in patients with articular prosthesis. Physical Therapy program in total knee arthroplasty, a case study

Miss Eloísa Delgado-Delgado, Miss Mª Magdalena Moral-Castro, Mr Jonatan Fernández-Ruiz, Dr Lydia Martín-Martín, Dr Manuel Arroyo-Morales, Dr Noelia Galiano-Castillo

Background: In 2020, the osteoarthritis will be the fourth leading cause of disability worldwide. Nowadays, according to the World Health Organization (WHO), this impairment affects 80% of the population older than 65 years. The treatment in advanced stages is the total knee arthroplasty (TKA). After surgery procedure, it is essential the early beginning of a program of physiotherapy to recover the physical and functional capacity of the patients.
Objectives: The objective of this study was to perform an 8-week physical therapy program (3 sessions per week) to recover the functionality to a patient who underwent TKA.
Methods: A case study of TKA for secondary osteoarthritis was carried out. The variables were measured at baseline, 4, 6 and 8 weeks. This analysis was performed using percentages of change with respect to baseline assessment for the following variables: joint balance, muscle balance, circumferential data, Tinetti test, Timed Up and Go test, Flamingo test, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Hospital Anxiety and Depression Scale (HADS), Visual Analogue Scale (VAS), Short Form-36 Health Survey (SF-36) and Barthel Index.
Results: The physical therapy program was well tolerated with an adherence rate of 100%. There were improvements in all variables, highlighting the joint balance where were obtained ranges between 46.66-120%.
Conclusions: The results obtained have been beneficial. We found important improvements in all variables assessed. It has improved quality of life, functional capacity and pain. Subsequent studies would be required to approach the patterns of miofascial pain associated with this intervention due to the results found in this study.

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Effectiveness of the Physical Therapy in women with fibromyalgia: a systematic review

Miss Mª Magdalena Moral-Castro, Miss Eloísa Delgado-Delgado, Dr Lydia Martín-Martín, Dr Irene Cantarero-Villanueva, Dr Carolina Fernández-Lao, Dr Noelia Galiano-Castillo

Background: The fibromyalgia is a frequent problem. Its prevalence varies according to the studied population, ranging between 0.7 and 20% in clinical practice. Furthermore, it is the most common cause of generalized and chronic musculoskeletal pain.
Objectives: To revise the main scientific evidences in order to determine the effectiveness of the physical therapy in women with fibromyalgia.
Methods: A search of randomized controlled clinical trials was carried out in Pubmed, Physiotherapy Evidence Database (PEDro) and Web of Science (WOS) using Fibromyalgia, Physiotherapy and Physical Therapy as descriptors and restricting the results to those published from 2010 to date in English or Spanish. The PEDro and Jadad scales were used to evaluate the quality of the studies.
Results: A total of 1,405 studies were found, of which 11 were selected according to the inclusion and exclusion criteria and classified into eight groups taking into account the type of procedure: multidisciplinary therapy, vibration, physical exercise, transcutaneous electrical nerve stimulation (TENS), balneotherapy, yoga, myofascial release and belly dancing.
Conclusions: This systematic review found evidence for the effectiveness of the physical therapy in women diagnosed with fibromyalgia. It is shown that complementary therapies such as yoga or belly dancing are effective, which suggests that these should be used for the physiotherapists in women with fibromyalgia.

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Iliohypogastric Nerve Block for Chronic Pelvic Pain Treatment: Ultrasound-Guide Technique Description and Cases Series

Ms Marta Linares Gago, Mr Cano Plasencia, Ms Inmaculada Díaz-Cano Carmona, Mr Jorge Rodríguez García, Mr Luis Eduardo Alarcón Mora

Background Aim and Objetives: To describe the technique of the Iliohyogastric Nerve (IPN) block with ultrasound-guide (UG) and show and show its utility and safety in a physical medicine and rehabilitation consulting room.
Methods: we present three consecutive patients with a chronic pelvic pain difficult to manage with NSAIDS or analgesics. All this patientes suffered more than six months of burning and lancinating pelvic pain that get worse with trunk movements and when the patient is seated or walking. Due to symthoms and physical examination, the patients were diagnosed of iliohypogastric neuropathy and we decided to perform an ultrasound guided iliohypogastric nerve block in all cases.
Results: The VAS punctuation were improved after each nerve blockade in three patients at the finally of follow-up, decreasing VAS 3.5 points (P50) in compare with before start the treatment. Any secondary effects were reported.
Discussion: There is little literature concerning this procedure which shows, such our study, that in blockades were used a local anesthetic and the nerve is located with ultrasound-guide. The results show partial improvement of the symptoms after the treatment.
Although our sample is small and the follow up is short, we continue the study with the aim of improving the technique and provide statistically significant results.
Conclusion: The iliohypogastric nerve block is easily repoducible in the clinical setting and offers an advancement for patients with pelvic pain, that could be an initial option of treatment to improve the pain and delay other treatment as surgery.

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Knee and Ankle Surgery

Short Teaching Course

moderated by Dr Seyed Mohamad Mehdi Daneshpoor

Total ankle replacement and the options for ankle arthritis

Dr Selene Parekh

Ankle arthritis is a painful and debilitating condition that often times requires surgery.  Ankle fusion has been the standard treatment method, but in the last 10 years, advances in total ankle replacements has allowed patients to keep motion. With the same pain relief, a better quality of life can be achieved with surgery. This presentation highlights the benefits of total ankle replacement and other therapeutic options for ankle arthritis.


ACL (Anterior Cruciate Ligament) insufficient in Athlete: my favorite technique

 Prof. Pedro Guillén

I am outstandingly glad we gather together to talk about the Knee, which is such an amazing joint. We are going to talk specifically about the Anterior Cruciate Ligament insufficiency. The knee is especially vulnerable on account of to its particular location and biomechanics. It was classically thought to opens itself like a book or a hinge, in an only plane. However, it also makes a rotational movement, to which much of the knee vulnerability is due.

In this short conference we will deal with ACL insufficiency in elite athletes and its complications. Firstly, we will discuss the problems that might arise during the treatment. Secondly, I will describe my favorite technique, using gracilis and semitendinosus tendons, in which we have a 6000thousand cases experience. Finally, we will try to clarify the athlete’s hesitations on the long recovery path, which takes them no less than 6-7 months.