Trends and area variations in Potentially Preventable Admissions for COPD in Spain (2002-2013): A significant decline and convergence between areas

Background: Potentially Preventable Hospitalizations (PPH) are hospital admissions for conditions which are preventable with timely and appropriate outpatient care being Chronic Obstructive Pulmonary Disease (COPD) admissions one of the most relevant PPH. We estimate the population age-sex standardized relative risk of admission for COPD-PPH by year and area of residence in the Spanish National Health System (sNHS) during the period 2002–2013. Methods: The study was conducted in the 203 Hospital Service Areas of the sNHS, using the 2002 to 2013 hospital admissions for a COPD-PPH condition of patients aged 20 and over. We use conventional small area variation statistics and a Bayesian hierarchical approach to model the different risk structures of dependence in both space and time. Results: COPD-PPH admissions declined from 24.5 to 15.5 per 10, 000 persons-year (Men: from 40.6 to 25.1; Women: from 9.1 to 6.4). The relative risk declined from 1.19 (19 % above 2002–2013 average) in 2002 to 0.77 (30 % below average) in 2013. Both the starting point and the slope were different for the different regions. Variation among admission rates between extreme areas dropped from 6.7 times higher in 2002 to 4.6 times higher in 2013. Conclusions: COPD-PPH conditions in Spain have undergone a strong decline and a reduction in geographical variation in the last 12 years, suggesting a general improvement in health policies and health care over time. Variability among areas still remains, with a substantial room for improvement

Effectiveness of an intervention for improving drug prescription in primary care patients with multimorbidity and polypharmacy:Study protocol of a cluster randomized clinical trial (Multi-PAP project)

This study was funded by the Fondo de Investigaciones Sanitarias ISCIII (Grant Numbers PI15/00276, PI15/00572, PI15/00996), REDISSEC (Project Numbers RD12/0001/0012, RD16/0001/0005), and the European Regional Development Fund ("A way to build Europe").Background: Multimorbidity is associated with negative effects both on people's health and on healthcare systems. A key problem linked to multimorbidity is polypharmacy, which in turn is associated with increased risk of partly preventable adverse effects, including mortality. The Ariadne principles describe a model of care based on a thorough assessment of diseases, treatments (and potential interactions), clinical status, context and preferences of patients with multimorbidity, with the aim of prioritizing and sharing realistic treatment goals that guide an individualized management. The aim of this study is to evaluate the effectiveness of a complex intervention that implements the Ariadne principles in a population of young-old patients with multimorbidity and polypharmacy. The intervention seeks to improve the appropriateness of prescribing in primary care (PC), as measured by the medication appropriateness index (MAI) score at 6 and 12months, as compared with usual care. Methods/Design: Design:pragmatic cluster randomized clinical trial. Unit of randomization: family physician (FP). Unit of analysis: patient. Scope: PC health centres in three autonomous communities: Aragon, Madrid, and Andalusia (Spain). Population: patients aged 65-74years with multimorbidity (≥3 chronic diseases) and polypharmacy (≥5 drugs prescribed in ≥3months). Sample size: n=400 (200 per study arm). Intervention: complex intervention based on the implementation of the Ariadne principles with two components: (1) FP training and (2) FP-patient interview. Outcomes: MAI score, health services use, quality of life (Euroqol 5D-5L), pharmacotherapy and adherence to treatment (Morisky-Green, Haynes-Sackett), and clinical and socio-demographic variables. Statistical analysis: primary outcome is the difference in MAI score between T0 and T1 and corresponding 95% confidence interval. Adjustment for confounding factors will be performed by multilevel analysis. All analyses will be carried out in accordance with the intention-to-treat principle. Discussion: It is essential to provide evidence concerning interventions on PC patients with polypharmacy and multimorbidity, conducted in the context of routine clinical practice, and involving young-old patients with significant potential for preventing negative health outcomes. Trial registration: Clinicaltrials.gov, NCT02866799Publisher PDFPeer reviewe

Erratum to: 36th International Symposium on Intensive Care and Emergency Medicine

[This corrects the article DOI: 10.1186/s13054-016-1208-6.]

Nurses' perceptions of aids and obstacles to the provision of optimal end of life care in ICU

Contains fulltext : 172380.pdf (publisher's version ) (Open Access

The DUNE far detector vertical drift technology. Technical design report

DUNE is an international experiment dedicated to addressing some of the questions at the forefront of particle physics and astrophysics, including the mystifying preponderance of matter over antimatter in the early universe. The dual-site experiment will employ an intense neutrino beam focused on a near and a far detector as it aims to determine the neutrino mass hierarchy and to make high-precision measurements of the PMNS matrix parameters, including the CP-violating phase. It will also stand ready to observe supernova neutrino bursts, and seeks to observe nucleon decay as a signature of a grand unified theory underlying the standard model. The DUNE far detector implements liquid argon time-projection chamber (LArTPC) technology, and combines the many tens-of-kiloton fiducial mass necessary for rare event searches with the sub-centimeter spatial resolution required to image those events with high precision. The addition of a photon detection system enhances physics capabilities for all DUNE physics drivers and opens prospects for further physics explorations. Given its size, the far detector will be implemented as a set of modules, with LArTPC designs that differ from one another as newer technologies arise. In the vertical drift LArTPC design, a horizontal cathode bisects the detector, creating two stacked drift volumes in which ionization charges drift towards anodes at either the top or bottom. The anodes are composed of perforated PCB layers with conductive strips, enabling reconstruction in 3D. Light-trap-style photon detection modules are placed both on the cryostat's side walls and on the central cathode where they are optically powered. This Technical Design Report describes in detail the technical implementations of each subsystem of this LArTPC that, together with the other far detector modules and the near detector, will enable DUNE to achieve its physics goals

Applying spatio-temporal models to assess variations across health care areas and regions: Lessons from the decentralized Spanish National Health System

<div><p>Objective</p><p>To illustrate the ability of hierarchical Bayesian spatio-temporal models in capturing different geo-temporal structures in order to explain hospital risk variations using three different conditions: Percutaneous Coronary Intervention (PCI), Colectomy in Colorectal Cancer (CCC) and Chronic Obstructive Pulmonary Disease (COPD).</p><p>Research design</p><p>This is an observational population-based spatio-temporal study, from 2002 to 2013, with a two-level geographical structure, Autonomous Communities (AC) and Health Care Areas (HA).</p><p>Setting</p><p>The Spanish National Health System, a quasi-federal structure with 17 regional governments (AC) with full responsibility in planning and financing, and 203 HA providing hospital and primary care to a defined population.</p><p>Methods</p><p>A poisson-log normal mixed model in the Bayesian framework was fitted using the INLA efficient estimation procedure.</p><p>Measures</p><p>The spatio-temporal hospitalization relative risks, the evolution of their variation, and the relative contribution (fraction of variation) of each of the model components (AC, HA, year and interaction AC-year).</p><p>Results</p><p>Following PCI-CCC-CODP order, the three conditions show differences in the initial hospitalization rates (from 4 to 21 per 10,000 person-years) and in their trends (upward, inverted V shape, downward). Most of the risk variation is captured by phenomena occurring at the HA level (fraction variance: 51.6, 54.7 and 56.9%). At AC level, the risk of PCI hospitalization follow a heterogeneous ascending dynamic (interaction AC-year: 17.7%), whereas in COPD the AC role is more homogenous and important (37%).</p><p>Conclusions</p><p>In a system where the decisions loci are differentiated, the spatio-temporal modeling allows to assess the dynamic relative role of different levels of decision and their influence on health outcomes.</p></div

Interaction of photosystem I from Phaeodactylum tricornutum with plastocyanins as compared with its native cytochrome c6: Reunion with a lost donor

In the Phaeodactylum tricornutum alga, as in most diatoms, cytochrome c6 is the only electron donor to photosystem I, and thus they lack plastocyanin as an alternative electron carrier. We have investigated, by using laser-flash absorption spectroscopy, the electron transfer to Phaeodactylum photosystem I from plastocyanins from cyanobacteria, green algae and plants, as compared with its own cytochrome c6. Diatom photosystem I is able to effectively react with eukaryotic acidic plastocyanins, although with less efficiency than with Phaeodactylum cytochrome c6. This efficiency, however, increases in some green alga plastocyanin mutants mimicking the electrostatics of the interaction site on the diatom cytochrome. In addition, the structure of the transient electron transfer complex between cytochrome c6 and photosystem I from Phaeodactylum has been analyzed by computational docking and compared to that of green lineage and mixed systems. Taking together, the results explain why the Phaeodactylum system shows a lower efficiency than the green systems, both in the formation of the properly arranged [cytochrome c6-photosystem I] complex and in the electron transfer itself.Peer reviewe

Conhecimentos, atitudes e práticas diante da limitação de esforços terapêuticos em pessoal de saúde de um hospital universitário

11 páginasLimitation of therapeutic efforts refers to the decision not to initiate or to withdraw medical treatment for a patient (with or without the ability to decide) who will not benefit clinically from it. What justifies this behavior is the sense of disproportion between the end and the therapeutic means. The purpose of this article is to describe the attitudes, knowledge and practices of health professionals working at a university hospital. A descriptive, transversal study was conducted in which a number of health professionals who work at the hospital in question were asked to complete a questionnaire on their knowledge, attitudes and practices concerning the limi- tation of therapeutic efforts for hospitalized patients. A total of 412 persons responded to the questionnaire, Fifty percent (50%) of those surveyed were nursing aids and 25 % were physicians. Only 14.6% knew what “limitation of therapeutic efforts” means, and 62.4 % of the physicians admitted having difficulty making such decisions. Despite the importance of this bioethical issue and the controversy it provokes from a personal and professional standpoint, health professionals know little about it. More training and awareness in this respect are needed.  El término limitación de esfuerzos terapéuticos se refiere al hecho de no iniciar o retirar un tratamiento médico a un paciente (con o sin capacidad de decidir) que no se beneficia clínicamente de él. Lo que justifica este tipo de conducta es el sentido de despro- porción entre los fines y los medios terapéuticos. Describir las actitudes, los conocimientos y las prácticas de profesionales del área de la salud que laboran en un hospital universitario. Estudio descriptivo, de corte transversal. Se les pidió a diferentes profesionales del área de la salud que realizan labores en dicho hospital que respondieran una encuesta sobre los conocimientos, las actitudes y las prácticas que tienen frente a la limitación de esfuerzos terapéuticos en pacientes hospitalizados. 412 personas respondieron la encuesta. El 50 % de los encuestados eran auxiliares de enfermería y 25 % médicos. Solo el 14,6 % conocía el significado de limi- tación de esfuerzos terapéuticos y el 62,4 % de los médicos admitieron tener dificultad para tomar estas decisiones. No obstante la importancia y la polémica que este asunto plantea desde el punto de vista personal y profesional, es bajo el nivel de conocimiento que poseen los profesionales de la salud frente a este importante tema de la bioética. Se requiere mayor capacitación y sensibiliza- ción frente al tema. A expressão limitação de esforços terapêuticos se refere ao fato de não iniciar ou retirar um tratamento médico a um paciente (com ou sem capacidade de decidir) que não se beneficia clinicamente dele. O que justifica esse tipo de conduta é o sentido de despro- porção entre os fins e os meios terapêuticos. O objetivo do presente artigo é descrever as atitudes, os conhecimentos e as práticas de profissionais da área da saúde que trabalham em um hospital universitário. Consiste de um estudo descritivo, de corte transversal, no qual foi pedido a diferentes profissionais da área de saúde que realizam trabalhos nesse hospital que respondessem a uma pesquisa sobre os conhecimentos, as atitudes e as práticas que eles têm diante da limitação de esforços terapêuticos em pacientes hospita- lizados. Um total de 412 pessoas respondeu a pesquisa. 50% dos entrevistados eram auxiliares de enfermagem e 25%, médicos. Somente 14,6% conheciam o significado de limitação de esforços terapêuticos e 62,4% dos médicos admitiram ter dificuldade para tomar essas decisões. Contudo, a importância e a polêmica que esse assunto apresenta, sob o ponto de vista pessoal e profissional, é baixo o nível de conhecimento que os profissionais de saúde possuem ante esse importante tema da bioética. Requer-se maior capacitação e sensibilização sobre o tema

Assessing the SNR influence in the estimation of the mean frequency of lower limbs sEMG signals

La frecuencia media del espectro de potencia (MNF) se usa comúnmente para describir el contenido de frecuencia de una señal electromiográfica (EMG). El objetivo de este estudio es determinar el valor mínimo / deseable de la relación señal a ruido (SNR) para lograr una medición confiable de la MNF en señales EMG superficiales (sEMG) de las extremidades inferiores durante la marcha. Para este fin, las mediciones de MNF y SNR se tomaron en nueve músculos de 21 sujetos, y las señales registradas se contaminaron con diferentes niveles de ruido. El umbral mínimo de una SNR deseable se determinó utilizando el algoritmo K-means. Se determinó un límite inferior de 5,51 dB como el valor de SNR para la adquisición de sEMG, mientras que 12,28 dB es el valor de SNR deseable para registrar señales de sEMG.The mean frequency of the power spectrum (MNF) is commonly used to describe the frequency content of an electromyographic (EMG) signal. The objective of this study is to determine the minimum/desirable signal to noise ratio (SNR) value to achieve a reliable measurement of the MNF in superficial EMG (sEMG) signals of lower limbs during gait. To this end, measurements of MNF and SNR were taken in nine muscles of 21 subjects, and recorded signals were contaminated with different noise levels. The minimum threshold of a desirable SNR was determined using the K-means algorithm. A lower bound of 5.51 dB was determined as the SNR value for sEMG acquisition, while 12.28 dB is the desirable SNR value for recording sEMG signals. The methodology presented throughout this paper helps in the determination of the minimum SNR value necessary to validate the sEMG acquisition process that can be used, for example, as a control signal for identifying motion intention in the development of control systems devoted for a lower limb exoskeleton