Efficiency as a determinant of loyalty among users of a community of clinical practice: a comparative study between the implementation and consolidation phases

A community of clinical practice called the Online Communication Tool between Primary and Hospital Care (ECOPIH) was created to enable primary care and specialist care professionals to communicate with each other in order to resolve real clinical cases, thereby improving communication and coordination between care levels. The present work seeks to analyse whether ECOPIH makes it possible to reduce the number of referrals. To that end, the objectives are: (1) To find out the degree of loyalty among ECOPIH users, by comparing the medical professionals' profiles in the tool's implementation phase to those in its consolidation phase. (2) To evaluate the degree of fulfilment of users' expectations, by establishing the determining factors that had an influence on the physicians' intention to use ECOPIH in the implementation phase and observing whether its use had an effective, direct impact on the number of patient referrals that primary care physicians made to specialist care professionals. Two studies were conducted. Based on a survey of all the physicians in a Primary Care area, Study 1 was a descriptive study in ECOPIH's implementation phase. Study 2 was a randomised intervention study of ECOPIH users in the tool's consolidation phase. The results from both studies were compared. Various bivariate and multivariate statistical techniques (exploratory factor analysis, cluster analysis, logistic regression analysis and ANOVA) were used in both studies, which were conducted on a sample of 111 and 178 physicians, respectively. We confirmed the existence of an ECOPIH user profile stable across both phases: under-50-year-old women. Regarding the second objective, there were two particular findings. First, the discriminant factors that had an influence on greater ECOPIH use were habitual Social media website and app use and Perceived usefulness for reducing costs. Second, PC professionals who were ECOPIH members made fewer referrals to SC professionals in Cardiology, Endocrinology and Gastroenterology than older PC professionals who were not ECOPIH members. The use of a community of clinical practice by primary care and specialist care professionals helps to reduce the number of referrals among medical professionals

The Moderating Role of Intellectual Humility in the Adoption of ICT: A Study Across Life-Span

Literature has shown age-related differences in the adoption process. In this way, it is very important to encourage the adoption of ICT by the elderly, in order to maintain their independence in daily life. However, some specific cognitive variables were not considered in theoretical models until a decade ago. One of the emerging fields in this area is the science of learnable intelligence, which investigates the role of thinking dispositions. The variable which we have focused on is intellectual humility. For this propose, a sample of 306 participants from 18 to 87 years was selected. Age was selected as a predictor variable. Intellectual humility was tested as a moderator between aging and ICT adoption, more precisely computer and mobile devices. The model fitted the theoretical proposal. However, the subscale known as Independence of the intellect and ego was the only one to fulfill all the requirements for the moderational analysis. The findings suggest a moderational effect that might enhance the ICT adoption. These results are of interest in the field of personal development and training purposes in life-span

Direct-acting Antivirals for the Treatment of Kidney Transplant Patients With Chronic Hepatitis C Virus Infection in Spain: A Long-term Prospective Observational Study

Background: Direct-acting antivirals (DAA) allow effective and safe eradication of hepatitis C virus (HCV) in most patients. There are limited data on the long-term effects of all-oral, interferon-free DAA combination therapies in kidney transplant (KT) patients infected with HCV. Here we evaluated the long-term tolerability, efficacy, and safety of DAA combination therapies in KT patients with chronic HCV infection. Methods: Clinical data from KT patients treated with DAA were collected before, during, and after the treatment, including viral response, immunosuppression regimens, and kidney and liver function. Results: Patients (N = 226) were mostly male (65.9%) aged 56.1 +/- 10.9 years, with a median time from KT to initiation of DAA therapy of 12.7 years and HCV genotype 1b (64.6%). Most patients were treated with sofosbuvir-based therapies. Rapid virological response at 1 month was achieved by 89.4% of the patients and sustained virological response by week 12 by 98.1%. Liver function improved significantly after DAA treatment. Tacrolimus dosage increased 37% from the beginning of treatment (2.5 +/- 1.7 mg/d) to 1 year after the start of DAA treatment (3.4 +/- 1.9 mg/d, P < 0.001). Median follow-up was 37.0 months (interquartile range, 28.4-41.9) and death-censored graft survival was 91.1%. Adverse events resulting from DAA treatment, especially anemia, were reported for 31.0% of the patients. Conclusions: Chronic HCV infection can be treated efficiently and safely with DAA therapy in KT patients. Most patients retained stable kidney function and improved liver function. Tacrolimus dose had to be increased in most patients, potentially as a result of better liver function

Post–COVID-19 Conditions Among Children 90 Days After SARS-CoV-2 Infection

IMPORTANCE Little is known about the risk factors for, and the risk of, developing post-COVID-19 conditions (PCCs) among children. OBJECTIVES To estimate the proportion of SARS-CoV-2-positive children with PCCs 90 days after a positive test result, to compare this proportion with SARS-CoV-2-negative children, and to assess factors associated with PCCs. DESIGN, SETTING, AND PARTICIPANTS This prospective cohort study, conducted in 36 emergency departments (EDs) in 8 countries between March 7, 2020, and January 20, 2021, included 1884 SARS-CoV-2-positive children who completed 90-day follow-up; 1686 of these children were frequency matched by hospitalization status, country, and recruitment date with 1701 SARS-CoV-2-negative controls. EXPOSURE SARS-CoV-2 detected via nucleic acid testing. MAIN OUTCOMES AND MEASURES Post-COVID-19 conditions, defined as any persistent, new, or recurrent health problems reported in the 90-day follow-up survey. RESULTS Of 8642 enrolled children, 2368 (27.4%) were SARS-CoV-2 positive, among whom 2365 (99.9%) had index ED visit disposition data available; among the 1884 children (79.7%) who completed follow-up, the median age was 3 years (IQR, 0-10 years) and 994 (52.8%) were boys. A total of 110 SARS-CoV-2-positive children (5.8%; 95% CI, 4.8%-7.0%) reported PCCs, including 44 of 447 children (9.8%; 95% CI, 7.4%-13.0%) hospitalized during the acute illness and 66 of 1437 children (4.6%; 95% CI, 3.6%-5.8%) not hospitalized during the acute illness (difference. 5.3%; 95% CI, 2.5%-8.5%). Among SARS-CoV-2-positive children, the most common symptom was fatigue or weakness (21 [1.1%]). Characteristics associated with reporting at least 1 PCC at 90 days included being hospitalized 48 hours or more compared with no hospitalization (adjusted odds ratio [aOR], 2.67 [95% CI, 1.63-4.38]); having 4 or more symptoms reported at the index ED visit compared with 1 to 3 symptoms (4-6 symptoms: aOR, 2.35 [95% CI, 1.28-4.31]; >= 7 symptoms: aOR, 4.59 [95% CI, 2.50 8.44]); and being 14 years of age or older compared with younger than 1 year (aOR, 2.67 [95% CI, 1.43-4.99]). SARS-CoV-2-positive children were more likely to report PCCs at 90 days compared with those who tested negative, both among those who were not hospitalized (55 of 1295 [4.2%; 95% CI, 3.2%-5.5%] vs 35 of 1321[2.7%; 95% CI, 1.9%-3.7%]; difference, 1.6% [95% CI, 0.2%-3.0%]) and those who were hospitalized (40 of 391[10.2%; 95% CI, 7.4%-13.7%] vs 19 of 380 [5.0%; 95% CI, 3.0%-7.7%]; difference, 5.2% [95% CI, 1.5%-9.1%]). In addition, SARS-CoV-2 positivity was associated with reporting PCCs 90 days after the index ED visit (aOR, 1.63 [95% CI, 1.14-2.35]), specifically systemic health problems (eg, fatigue, weakness, fever; aOR, 2.44 [95% CI, 1.19-5.00]). CONCLUSIONS AND RELEVANCE In this cohort study, SARS-CoV-2 infection was associated with reporting PCCs at 90 days in children. Guidance and follow-up are particularly necessary for hospitalized children who have numerous acute symptoms and are older.This studywas supported by grants from the Canadian Institutes of Health Research (operating grant: COVID-19-clinical management); the Alberta Health Services-University of Calgary-Clinical Research Fund; the Alberta Children's Hospital Research Institute; the COVID-19 Research Accelerator Funding Track (CRAFT) Program at the University of California, Davis; and the Cincinnati Children's Hospital Medical Center Division of Emergency Medicine Small Grants Program. Dr Funk is supported by the University of Calgary Eyes-High PostDoctoral Research Fund. Dr Freedman is supported by the Alberta Children's Hospital Foundation Professorship in Child Health andWellness

Keys to success of a community of clinical practice in primary care : a qualitative evaluation of the ECOPIH project

The current reality of primary care (PC) makes it essential to have telemedicine systems available to facilitate communication between care levels. Communities of practice have great potential in terms of care and education, and that is why the Online Communication Tool between Primary and Hospital Care was created. This tool enables PC and non-GP specialist care (SC) professionals to raise clinical cases for consultation and to share information. The objective of this article is to explore healthcare professionals' views on communities of clinical practice (CoCPs) and the changes that need to be made in an uncontrolled real-life setting after more than two years of use. A descriptive-interpretative qualitative study was conducted on a total of 29 healthcare professionals who were users and non-users of a CoCP using 2 focus groups, 3 triangular groups and 5 individual interviews. There were 18 women, 21 physicians and 8 nurses. Of the interviewees, 21 were PC professionals, 24 were users of a CoCP and 7 held managerial positions. For a system of communication between PC and SC to become a tool that is habitually used and very useful, the interviewees considered that it would have to be able to find quick, effective solutions to the queries raised, based on up-to-date information that is directly applicable to daily clinical practice. Contact should be virtual - and probably collaborative - via a platform integrated into their habitual workstations and led by PC professionals. Organisational changes should be implemented to enable users to have more time in their working day to spend on the tool, and professionals should have a proactive attitude in order to make the most if its potential. It is also important to make certain technological changes, basically aimed at improving the tool's accessibility, by integrating it into habitual clinical workstations. The collaborative tool that provides reliable, up-to-date information that is highly transferrable to clinical practice is valued for its effectiveness, efficiency and educational capacity. In order to make the most of its potential in terms of care and education, organisational changes and techniques are required to foster greater use. The online version of this article (10.1186/s12875-018-0739-0) contains supplementary material, which is available to authorized users

Enfermedad linfoproliferativa difusa postrasplante renal: estudio longitudinal de 21.546 receptores durante 2 décadas en España

Article disponible en anglès: http://hdl.handle.net/10230/60097Introducción: La enfermedad linfoproliferativa difusa postrasplante (ELPD) es un grupo heterogéneo de enfermedades que se caracteriza por una proliferación de linfocitos después de un trasplante de órgano sólido y que presenta un espectro que comprende desde hiperplasias a agresivos linfomas. Material y métodos: Hemos evaluado, en un estudio observacional multicéntrico retrospectivo que incluye 21.546 receptores adultos de trasplante renal simple trasplantados en España de 1990 al 2009, la incidencia de ELPD durante un periodo de 22 años, su relación con el virus de Epstein-Barr, los factores de riesgo clásico y su pronóstico. Resultados: Un total de 275 receptores desarrollaron ELPD durante el seguimiento (1,2%), siendo 195 varones (70,9%) y 80 mujeres (29,1%), con una mediana de edad al diagnóstico de 59,2 (p25 44,7; p75 68) años. Doscientos cuarenta y cinco (89,0%) eran primeros trasplantes y 269 (97,8%) fueron de donante cadáver. Se objetivó virus de Epstein-Barr en el tejido proliferativo de 94 de los 155 casos estudiados (60,6%) y el 86,0% de las proliferaciones eran linfocitos B. La mediana del tiempo de desarrollo después del trasplante fue de 42 (p25 12; p75 77,5) meses. Un total de 188 receptores de 275 (68,3%) tenían algún factor de riesgo clásico. La incidencia anual fue de 0,14% el primer año y de 0,98% la acumulada en 10 años postrasplante. El periodo de seguimiento postrasplante de los receptores fue de 3 a 22 años. Durante el seguimiento 172 pacientes murieron (62,5%) y 103 (37,5%) tuvieron remisión completa. La causa de muerte más frecuente fue la progresión (n=91, 52,9%), seguida de la sepsis (n=24, 13,9%). La supervivencia del paciente después del diagnóstico fue del 51% al año, del 44% al segundo año y del 39% al quinto año. La supervivencia del injerto fue de 48, 39 y 33%, respectivamente. Conclusión: Este estudio muestra una baja incidencia de ELPD en receptores de trasplante renal en un periodo de 22 años. La mayoría de las proliferaciones se asocian a linfocitos B y presentan una importante relación con el virus de Epstein-Barr. La entidad puede desarrollarse en ausencia de factores de riesgo clásicos y su incidencia es mayor en el primer año postrasplante, presentando un mal pronóstico principalmente en los primeros meses de la enfermedad que condiciona una mala supervivencia del paciente que, si sobrevive, puede mantener su injerto

Lymphoproliferative disorders after renal transplantation along 2 decades: a large longitudinal study of 21.546 recipients

Article disponible en castellà: http://hdl.handle.net/10230/60098Introduction: Post transplant lymphoproliferative disorders (PTLD) are heterogeneous lymphoid proliferations in recipients of solid organs which seem to be related to Epstein Barr Virus (EBV). The use of antilymphocyte antibodies, EBV seronegativity in the recipient,acute rejection and CMV infection have been identified as classical risk factors. Material y methods: We have studied in a retrospective observational study, the incidence of PTLD in a period of 22 years, its relationship with EBV, presence of classical risk factors and outcome in 21546 simple adult renal transplant recipients from cadaveric and living donors, transplanted in 21 hospitals from 1990 to 2009. Results: A total of 275 recipients developed PTLD (1,2%),195 males (70,9%), 80 females (29,1%) aged 59.2 (p25 44.7 p75 68)years. Two hundred forty-five (89.0%) were 1st transplant recipients and 269 (97,8%) from cadaveric donors. EBV in the tissue was reported in 94 out of the 155 studied recipients (60.6%) and 86.0% of the proliferations were due to B lymphocytes. PTLD median appearance after transplant were 42.months (p25, 75, 12, 77, 5). One hundred eighty-eight recipients out of 275 patients (68.3%) had any classical risk factor and the use of antilymphocyte antibodies was the most frequent. During the follow-up, 172 patients died (62,5%) and 103 (37,5%) had a complete remission. The main cause of death was PTLD progression (n = 91, 52,9%), followed by sepsis (n = 24, 13,9%). The follow-up period post-transplant of the recipients was between 3 and 22 years. The incidence was 0,14% during the first year post-trasplant and 0.98% the cumulative incidence at 10 years. Patient survival after diagnosis was 51%, 44% and 39% after 1, 2 and 5 years, respectively. Finally, overall graft survival was 48%, 39% and 33% at the same periods. Conclusion: PTLD has a low incidence in renal transplant recipients. Most of the proliferations are due to B lymphocytes and seem to have a close relationship with EBV. PTLD can develop in the absence of classical risk factors. The prognosis is poor, mainly due to PTLD progression, but the survivors can even maintain their grafts

Paricalcitol versus calcifediol for treating hyperparathyroidism in kidney transplant recipients

Introduction; Secondary hyperparathyroidism (SHPT) and vitamin D deficiency are common at kidney transplantation and are associated with some early and late complications. This study was designed to evaluate whether paricalcitol was more effective than nutritional vitamin D for controlling SHPT in de novo kidney allograft recipients. Methods: This was a 6-month, investigator-initiated, multicenter, open-label, randomized clinical trial. Patients with pretransplantation iPTH between 250 and 600 pg/ml and calcium 110 pg/ml at 6 months. Secondary endpoints were bone mineral metabolism, renal function, and allograft protocol biopsies. Results: The primary outcome occurred in 19.6% of patients in the PAR group and 36.2% of patients in the CAL group (P = 0.07). However, there was a higher percentage of patients with iPTH <70 pg/ml in the PAR group than in the CAL group (63.4% vs. 37.2%; P = 0.03). No differences were observed in bone turnover biomarkers and bone mineral density. The estimated glomerular filtration rate was significantly higher in the CAL group than in the PAR group without differences in albuminuria. In protocol biopsies, interstitial fibrosis and tubular atrophy tended to be higher in the PAR group than in the CAL group (48% vs. 23.8%; P = 0.09). Both medications were well tolerated. Conclusion: Both PAR and CAL reduced iPTH, but PAR was associated with a higher proportion of patients with iPTH <70 pg/ml. These results do not support the use of PAR to treat posttransplantation hyperparathyroidism

Paricalcitol versus calcifediol for treating hyperparathyroidism in kidney transplant recipients

Introduction; Secondary hyperparathyroidism (SHPT) and vitamin D deficiency are common at kidney transplantation and are associated with some early and late complications. This study was designed to evaluate whether paricalcitol was more effective than nutritional vitamin D for controlling SHPT in de novo kidney allograft recipients. Methods: This was a 6-month, investigator-initiated, multicenter, open-label, randomized clinical trial. Patients with pretransplantation iPTH between 250 and 600 pg/ml and calcium 110 pg/ml at 6 months. Secondary endpoints were bone mineral metabolism, renal function, and allograft protocol biopsies. Results: The primary outcome occurred in 19.6% of patients in the PAR group and 36.2% of patients in the CAL group (P = 0.07). However, there was a higher percentage of patients with iPTH <70 pg/ml in the PAR group than in the CAL group (63.4% vs. 37.2%; P = 0.03). No differences were observed in bone turnover biomarkers and bone mineral density. The estimated glomerular filtration rate was significantly higher in the CAL group than in the PAR group without differences in albuminuria. In protocol biopsies, interstitial fibrosis and tubular atrophy tended to be higher in the PAR group than in the CAL group (48% vs. 23.8%; P = 0.09). Both medications were well tolerated. Conclusion: Both PAR and CAL reduced iPTH, but PAR was associated with a higher proportion of patients with iPTH <70 pg/ml. These results do not support the use of PAR to treat posttransplantation hyperparathyroidism

Outcome of kidney transplants from viremic and non-viremic hepatitis C virus positive donors into negative recipients: results of the Spanish registry

Historically, donor infection with hepatitis-C virus (HCV) has been a barrier to kidney transplantation. However, in recent years, it has been reported that HCV positive kidney donors transplanted into HCV negative recipients offer acceptable mid-term results. However, acceptance of HCV donors, especially viremic, has not broadened in the clinical practice. This is an observational, multicenter, retrospective study including kidney transplants from HCV positive donors into negative recipients reported to the Spanish group from 2013 to 2021. Recipients from viremic donors received peri-transplant treatment with direct antiviral agents (DAA) for 8–12 weeks. We included 75 recipients from 44 HCV non-viremic donors and 41 from 25 HCV viremic donors. Primary non function, delayed graft function, acute rejection rate, renal function at the end of follow up, and patient and graft survival were not different between groups. Viral replication was not detected in recipients from non-viremic donors. Recipient treatment with DAA started pre-transplant avoids (n = 21) or attenuates (n = 5) viral replication but leads to non-different outcomes to post-transplant treatment with DAA (n = 15). HCV seroconversion was more frequent in recipients from viremic donors (73% vs. 16%, p < 0.001). One recipient of a viremic donor died due to hepatocellular carcinoma at 38 months. Donor HCV viremia seems not to be a risk factor for kidney transplant recipients receiving peri-transplant DAA, but continuous surveillance should be advised