Antonio R. Villa

Deterioro cognoscitivo y factores asociados en adultos mayores en México

OBJECTIVE: To determine the prevalence of cognitive impairment in the elderly and its relation with sociodemographic and health factors in the Mexican population. MATERIAL AND METHODS: From the first wave data of the National Aging and Health Study, collected in 2001 in Mexico, subjects 65 years or older and who had completed a cognitive assessment were selected. Subjects were classified according to two groups: with and without cognitive impairment, based on the cutoff point corresponding to the 10th percentile of the total cognitive assessment score, adjusted for age and educational level. All subjects with cognitive impairment that also had difficulty with one of the activities of daily living were classified as a third group: with cognitive impairment and functional dependency. Prevalence rates were calculated, and an association with demographic and health variables was established through regression analysis. RESULTS: Seven percent of the population had cognitive impairment while 3.3% had both conditions. The probability of cognitive impairment was not significantly associated with any demographic or health variables. Cognitive impairment and functional dependency indicated an association with gender, age, marital status, diabetes, stroke, heart disease and depression. CONCLUSIONS: The high prevalence of cognitive impairment and its relation with chronic disease frequently observed in the Mexican elderly suggest the need to increase early identification of both conditions in the population.

NONADHERENCE TO INSULIN THERAPY IN LOW-INCOME, TYPE 2 DIABETIC PATIENTS

OBJECTIVEnTo evaluate the psychosocial barriers to insulin use in low-income, type 2 diabetic patients; the clinical characteristics of these patients; and the possible causes of nonadherence to insulin regimens months after prescription.nnnMETHODSnWe studied a prospective cohort of low-income patients with type 2 diabetes mellitus, aged 45 to 75 years, attending a tertiary health care center in Mexico City, Mexico. Patients were eligible if their diabetes was not controlled with oral agents, and they were excluded if they had type 1 diabetes mellitus, a secondary cause of diabetes, had been admitted to the hospital within the month before study commencement, had been previously treated with insulin, had severe diabetic complications, or had a chronic or disabling medical illness. All patients were prescribed 6 to 10 units of neutral protamine Hagedorn insulin before bedtime and received a referral to visit with a diabetes nurse educator. The main outcome was adherence or nonadherence to insulin therapy, and it was correlated with several variables including attitudes toward insulin, diabetes self-management, diabetes-related knowledge, depression, and diabetes-related distress. Brief medical history, complete battery of questionnaires, and laboratory workup were obtained at baseline and 1 to 3 months after insulin prescription.nnnRESULTSnTwenty-nine consecutive patients were included. Mean age (+/- standard deviation) was 59 +/- 8 years, 18 (62%) were women, mean diabetes duration was 14 +/- 9 years, and mean hemoglobin A1c level was 10.8 +/- 1.4%. Negative attitudes toward insulin were very common, particularly in patients with less education and poorer diabetes-related knowledge (odds ratio, 6.2; 95% confidence interval, 1.04-47.3; P = .02). Even when they received precise recommendations, 12 patients (41%) did not adhere to insulin treatment. Patients who did not adhere to therapy were most commonly women and were depressed (P = .05). Improved adherence was significantly associated with the additional support of a diabetes nurse educator (odds ratio, 6.6; 95% confidence interval, 1.0-55.7; P = .02).nnnCONCLUSIONSnImproving patient perception and acceptance of insulin with the help of diabetes educators can facilitate earlier and more aggressive intervention and thus optimize glycemic control.

Incidence of Delirium, Risk Factors, and Long-Term Survival of Elderly Patients Hospitalized in a Medical Specialty Teaching Hospital in Mexico City

BACKGROUNDnWe determined the incidence, probable risk factors, causes, and long-term survival of delirium in patients hospitalized in a medical specialty teaching hospital in Mexico City.nnnMETHODnFrom June to December 1995, 667 elderly patients 60 years and older were hospitalized and assessed within 48 hours, excluding those with delirium at admission, those sedated, on respiratory support, or unable to speak.nnnRESULTSnTwelve percent of the population developed delirium, identified by means of the daily application of the Confusion Assessment Method; its appearance was attributed in 50% to two or more causes, in 10% to an insufficient control of pain, in 7.5% to a preceding surgical event, and in the rest to other causes. Each case was compared randomly with three nonpaired control patients of the same cohort who did not develop delirium. There was a significant increase in the number of cases of delirium in patients older than 75 years (p < .001), those with low schooling (p = .04), those with greater comorbidity (p < .001), those with a hematocrit lower than 30% (relative risk [RR] 2.1, confidence interval [CI] 1.2-4.1), and those with a glucose level greater than 140 mg/dl (RR 2.1, CI 1.2-3.6). Patients with delirium remained hospitalized longer than controls (p = .02). There was no significant difference in the intrahospital mortality of both groups, although during 5 years follow-up, survivors demonstrated a significant increase in mortality (p = .03) in the group of individuals with delirium during the hospital stay when compared to controls.nnnCONCLUSIONnIn this geriatric population of Mexican patients, delirium incidence was similar to that previously reported in the worldwide literature. Its incidence is associated with longer hospital stay and greater mortality. Age, low level of schooling, greater comorbidity, high glucose levels, poor pain control, and hematocrit lower than 30% were independently associated with a greater incidence of delirium.

Counselling following diagnosis of a fetal abnormality : Comparison of different clinical specialists in Mexico

Most geneticists agree that counselling should be nondirective, and studies report that genetic counselling by geneticists is performed largely in a neutral style. However, couples at risk of having a child with a genetic condition may seek the advice of other physicians. The purpose of the present study was to describe the answers of four groups of specialists from Mexico City (internists, pediatricians, obstetricians, and neurologists) regarding how they would counsel a couple when prenatal diagnosis has shown that a fetus is affected by one of 17 different genetic disorders and to analyze the role of several variables in the development of their opinion. Our results show that physicians in these specialties are more likely to counsel directively than neutrally. Other variables did not influence the directiveness. With respect to direction of influence, internists, pediatricians, and neurologists are more likely to counsel terminating affected pregnancies than are obstetricians (P = 0.0002). Similarly, clinicians older than 37 years of age and those reporting that religion is not important to them counsel terminating affected pregnancies (P = 0.005 and P = 0.003, respectively). Physicians gender and clinical experience with genetic diseases did not show statistically significant differences. Strong consensus among specialists was reached only on terminating pregnancies in anencephaly. A lowered and moderate consensus (51-75% agreement) was reached on continuing pregnancies with cleft lip and plate. A moderate measure of consensus for nondirective counselling was found among obstetricians regarding 14 of the 17 diseases in the study, whereas neurologists expressed a moderate measure of consensus on counselling the termination of pregnancies when the fetus was affected by neurological disorders. Hence, the approach to counselling was related in part to the fetal condition and in part to the clinicians specialty and age and the self-reported importance of religion. The data presented herein may not be representative of all Mexican physicians within the selected specialties; however, it is important to gather their opinions because they are involved in the care and treatment of genetic diseases and may have an important influence on the demand and availability of prenatal diagnosis and abortion.

Emotional dysfunction associated with diabetes in Mexican adolescents and young adults with type-1 diabetes

OBJECTIVEnTo assess the emotional dysfunction associated with diabetes in Mexican young individuals with type-1 diabetes.nnnMATERIAL AND METHODSnA cross-sectional survey was conducted to perform a complete clinical and psychosocial evaluation of 93 consecutive type-1 diabetes patients, and 14 to 30 years.nnnRESULTSnAdolescents had higher scores of emotional dysfunction related to diabetes and a diminished knowledge in diabetes-related areas. A multivariate logistic regression model showed that an inadequate emotional response to diabetes (high problem areas in diabetes or PAID scores) was mainly associated with a poor glycemic control (OR = 2.9, 95% CI 0.9-9.7, p = 0.09). Apprehension about the future and the possibility of serious complications had the highest mean PAID score in all age groups.nnnCONCLUSIONSnNew strategies should be developed to improve the routine care and support of young individuals with type-1 diabetes.

Attitudes of Mexican geneticists towards prenatal diagnosis and selective abortion.

Prenatal diagnosis (PD) provides the physician information on whether the unborn fetus has a genetic or chromosomal disorder, and offers patients a new option: selective abortion. In the present study, we analyzed the answers Mexican geneticists provided to a few selected questions from a multinational survey designed by Wertz and Fletcher [1988: Am J Hum Genet 42:592-600]. The selected questions were related to the use of PD, the acceptance of selective abortion, and the self-reported directiveness of counselling following the diagnosis of a fetal anomaly. Our results show that the great majority of Mexican geneticists participating in the study agree with PD when medically indicated, but not on free demand. Specific cases stimulated the group on thinking more than the general statements provided in the survey. Although the majority agreed that PD should be available to all women, when faced with cases of nonmorbid maternal anxiety, paternity testing, and sex selection, the proportion of geneticists willing to perform the test decreased substantially. When counselling patients on a fetal anomaly, the minority would be as unbiased as possible, and this seems to be the tendency in developing countries where counselling, as stated in the respondents comments, reflects the belief that the goal of genetics is the prevention of or opposition to abortion. Counselling was influenced by the severity of the disorder. The geneticists personal attitude toward abortion in the same situations was stronger than when counselling others. Analysis of directiveness in counselling for fetal anomaly showed that older geneticists, with more years of experience in medical genetics, were more likely to be neutral. When counselling directively, the group showed an overall direction toward continuing affected pregnancies. However, older geneticists and those with more than 10 years of practice were more likely than their younger counterparts to counsel towards terminating affected pregnancies. In personal situations of fetal disorder, the general tendency was to abort; however, geneticists seeing more than 5 patients per week, and those who believe that religion is important, were more likely to reject abortion. The sample is representative of Mexican geneticists, and the main limitation of this study is that the geneticists have very little experience in PD, and that their responses were mostly based on theory. However, their opinions may influence the demand and the availability of PD and abortion, as well as the possibility of legalization of abortion on the basis of a fetal defect.

School food in Mexican children

OBJECTIVEnTo establish the school eating habits of Mexican children, who are prone to obesity and later to high rates of adult chronic diseases.nnnDESIGNnQuestionnaires for students and parents with staff questionnaires and interviews.nnnSETTINGnRandomly sampled schools in a socio-economically representative district of Mexico City.nnnSUBJECTSnSubjects were 1504 adolescents aged 10-19 years attending schools in Mexico City, 27 teachers and seven headmasters, sampled from both public and private schools and from the full range of socio-economic groups.nnnRESULTSnFoods brought from home were of a higher nutritional quality than those purchased at school, where purchases were dominated by crisps, soft drinks and other items with high energy density. Girls were more inclined to purchase inappropriately; those from poorer homes purchased less. Private-school students irrespective of socio-economic grade brought more food from home and purchased more expensive food at school. School policies allowed food and drink vendors to market any products within the schools, which benefited financially from these activities.nnnCONCLUSIONSnCurrent school food policies are conducive to amplifying the current epidemic of obesity and related adult chronic diseases, and need to change.

Prevalence of Codependence in Young Women Seeking Primary Health Care and Associated Risk Factors

Codependence as a relational problem that often, but not necessarily always, occurs in conjunction with familial alcoholism. Previous research has shown that various etiological factors resulting from recurring stressful circumstances experienced in childhood or adulthood may contribute to this relation. Another factor arises out of the submission script that may be assumed by women living within a culture that typically promotes unequal power between women and men. To examine the prevalence of codependence and its predictors, a cross-sectional study was conducted among a population of 845 young women seeking primary health care in Mexico City. Odds ratio prevalence (ORP) was used to estimate the strength of possible association between codependence and exposure to several factors. A prevalence of 25% of codependence was found. Multivariate analysis revealed that women with a submissive cultural script were nearly eight times more likely to develop codependence than those without this programming. Other relevant factors were having a partner with probable alcohol dependence, a father with alcohol problems, physical and sexual mistreatment by a partner, and a history of emotional mistreatment.

The Efficacy of Adipokines and Indices of Metabolic Syndrome as Predictors of Severe Obesity-Related Hepatic Steatosis

The aim of this study was to investigate adiponectin, leptin, and metabolic syndrome as predictors of the severity of obesity-related steatosis. By ultrasonography steatosis-positive (cases) subjects (n=141) were compared with controls (n=111). Demographic and anthropometric data and serum concentrations of adiponectin, leptin, and insulin were measured. The impact of several criteria of metabolic syndrome, serum adiponectin concentrations, and serum leptin concentrations were tested using a multivariate logistic regression analysis. The frequency of metabolic syndrome was higher in cases (44.0% versus 9.2%; Pu2009<u2009.0001). Cases were older and had higher insulin resistance, waist circumference, and lower concentrations of adiponectin (all Pu2009<u2009.001). The upper adiponectin quartile was associated with a lesser grade of steatosis. Metabolic syndrome and adiponectin concentrations were independently associated with the probability of steatosis. In conclusion, adipokines and metabolic syndrome are useful indices for the prediction of the severity of obesity-related steatosis.

Physician-assisted Death. Opinions of a Sample of Mexican Physicians

BACKGROUNDnThere is insufficient information on what Mexicans think of physician-assisted death, a problem that is currently being discussed in our legislative bodies. This paper discusses the findings among a sample of physicians.nnnMETHODSnThe sample was formed by 2097 physicians from several specialties employed by a Mexican government health system, distributed throughout the country. Each physician received a structured questionnaire exploring what they thought of two different scenarios related to physician-assisted death: 1) intolerable suffering of patients; and 2) persistent vegetative state (PVS). Questions included data on several personal characteristics of the respondents and two open-ended questions asking the reasons why they answered the main questions as they did.nnnRESULTSnThere was an overall response rate of 47.3%. Approximately 40% agreed with physicians helping terminally ill patients request to die because of intolerable suffering caused by incurable diseases, whereas 44% said no and the rest were undecided. This was statistically different from the answers to the scenario where the relatives of a patient in a PVS ask their physician to help him or her die, where 48% of respondents said yes, and 35% said no. The main reasons to say yes in both scenarios were respect for patients or family autonomy and to avoid suffering, whereas those opposed cited other ethical and mainly religious considerations.nnnCONCLUSIONSnThe variable with the highest probability to approve both scenarios was of a legal nature, whereas strong religious beliefs were against accepting physician-assisted death. The group was evenly divided with approximately 40% each between those for and against the idea of helping die a patient and approximately 20% were undecided.