Evolución de la relación entre atención primaria y especializada 1992-2001: estudio Delphi

ObjetivoValorar la tendencia en la relación de atención primaria (AP) y especializada (hospital) en 2 momentos diferentes de la reforma sanitaria, al inicio (1992) y tras una fase de consolidación (2001).DiseñoEstudio cualitativo basado en la técnica Delphi modificada.EmplazamientoComunidad Valenciana.ParticipantesSe seleccionó a un total de 196 profesionales de la Comunidad Valenciana (103 coordinadores de AP, 43 directores médicos hospitalarios y de AP, y 50 jefes de servicio de medicina interna/urgencias).ResultadosSe enviaron 196 cuestionarios, con una tasa de respuesta del 38%. Desde AP los problemas se mantienen, con un empeoramiento en la desmotivación del personal sanitario (+1,34), la falta de visión integral del paciente (+1,10) y la masificación asistencial (+1,06), y un mejoría en la presencia de especialistas de ambulatorio no integrados (–1,32). Desde el ámbito hospitalario empeora la falta de visión integral del paciente (+0,51), pero destaca la mejoría generalizada de los problemas, sobre todo la falta de comunicación y diálogo (–1,14). Las soluciones que aumentan su demanda desde AP son una historia clínica única informatizada (+1,50), la elaboración de protocolos comunes (+0,86) y las rotaciones periódicas de los médicos de AP (MAP) por servicios hospitalarios (+0,85), con una disminución de las derivaciones burocráticas a AP (–0,60) y la necesidad de especialistas en AP como consultores (–0,36). Desde el ámbito hospitalario, todas las soluciones disminuyen su valoración y entre ellas destaca facilitar el acceso de MAP para el seguimiento de los pacientes ingresados (–2,44) y la realización de guardias hospitalarias por MAP (–2,30).ConclusionesLos problemas y las soluciones siguen siendo los mismos que en 1992, pero en AP se observa una tendencia a empeorar y en el ámbito hospitalario se detecta una visión más positiva.AimTo evaluate the trends in the inter-professional relationship between primary health care (PHC) and secondary care (hospital) at 2 different moments of the health reform, at its start in 1992 and after a phase of consolidation (2001).DesignObservational study based on modified Delphi technique.SettingValencia Community, Spain.ParticipantsOne hundred and ninety six professionals from Valencia Community were selected (103 PH centre administrators, 43 hospital and PC medical directors, and 50 heads of internal medicine or emergency services).ResultsOne hundred and ninety six questionnaires were sent out, with a response rate of 38%. In PHC problems remained the same, but the following got worse: “lack of motivation” (+1.34), “lack of overall vision of patients” (+1.10), and “overuse of medical services” (+1.06). The existence of non-integrated out-patient specialists got better (–1.32). In hospitals, “lack of overall vision of patients” got worse (+0.51), but in general problems got better, especially in “lack of communication and dialogue” (–1.14). PC increased its demand for “a single computerized clinical record” (+1.50), drawing up of common protocols (+0.86), and periodic rotations of PC doctors through hospitals (+0.85), but bureaucratic referrals to PC (–0.60) and the need for specialists in PC as consultants (-0.36) diminished. In hospitals all solutions showed lower scores, particularly access of PC doctors to monitoring of admitted patients (–2.44) and PC doctors doing hospital cover (–2.30).ConclusionsProblems and solutions from PHC and hospitals remain the same, but there is a trend to the worse in PHC, whereas in hospitals the trend is more positive

Listado de especies espinosas de Solanum L. (Leptostemonum, Solanaceae)

Solanum is one of the largest flowering-angiosperm genera with 1500 species approximately. Five clados are recognized in Solanum, Leptostemonum is the largest group with 350-450 species distributed in the Old and Neotropic world. In the Neotropic 200 species are recognized. This study is an initial base for posterior studies of taxonomic and evolution diversity of Leptostemonum. The checklist of the names presented here is the result of the study of herbaria COL, COAH, FMB, HUA, JAUM, UPTC, INPA and MG collections and the revision of data bases as International Plant Name Index, Solanaceae Source, The New York virtual Herbarium and Tropicos. There were found 54 valid and effective-published names, 12 of these names associated to 14 synonyms in Colombia.Solanum es uno de los géneros mas grandes de angiospermas con flores con cerca de 1500 especies. En Solanum se reconocen cinco clados, siendo Leptostemonum el mas grande, con 350-450 especies, distribuidas en el Viejo mundo y en el Neotrópico. Para el Neotrópico se reconocen cerca de 200 especies. El trabajo que se presenta aquí es un punto de partida para abordar posteriormente estudios sobre la diversidad taxonómica y evolutiva de Leptostemonum. El listado de nombres obtenido es el resultado del estudio de las colecciones depositados en los herbarios de COL, COAH, FMB, HUA, INPA, JAUM, UPTC y MG, y la consulta de bases de datos, International plant name index, Solanaceae source, The New York Virtual Herbarium y Tropicos. Se encontraron 54 nombres válidamente y efectivamente publicados, 12 de esos nombres asociados a 14 sinónimos

Gestión clínica de la consulta: previsibilidad y contenido clínico (estudio SyN-PC)

ObjetivoDescribir la actividad asistencial en función de la naturaleza de la consulta (previsibilidad) y las necesidades de los pacientes (contenido clínico). Analizar la relación con las características de la consulta, del paciente y del centroDiseñoEstudio observacional descriptivo multicéntricoEmplazamientoAtención primaria. Área 17 de la Conselleria de Sanidad de la Comunidad Valenciana. Población de 197.316 habitantes. Trece centros de saludParticipantesRecogida de información en tiempo real por un observador externo. Muestreo aleatorio estratificado de 2.051 pacientes que ocasionaron 3.008 motivos de consulta médicaMediciones principalesConsulta previsible (Pr): se puede prever su contenido (revisiones, recogida de resultados). Consulta imprevisible (Ip): no podemos prever su contenido (problemas agudos) y surgen inesperadamente. Engloba la consulta urgente. Consulta administrativa (Ad): tareas burocráticas (recetas, partes de confirmación, certificados). Consulta asistencial (As): prevenir, diagnosticar y tratar la enfermedad, o realizar seguimiento de ésta. Variables del paciente, el centro y la consultaResultadosEl 60% (n=1.809; IC del 95%, 58,69–61,59%) de los motivos fueron previsibles y el 40% (n=1.199; IC del 95%, 36,6–43,12%), imprevisibles. El 50% (n=1.509; IC del 95%, 47,26–53,06%) fueron consultas asistenciales y el 50% (n=1.499; IC del 95%, 46,34–53,39%), administrativas. El 40% (n=1.189; IC del 95%, 37,78–41,28%) fueron previsibles-administrativas y tan sólo un 21% (n=620; IC del 95%, 19,16– 22,06%) resultaron de carácter previsible-asistencial. El 30% (n=889; IC del 95%, 27,92–31,18%) fueron de carácter imprevisible–asistencial y el 10% (n=310; IC del 95%, 9,22– 11,4%), imprevisibles-administrativas. En los pacientes con un único motivo, el 48% (n=577; IC del 95%, 44,25–52,05%) fueron consultas previsibles-administrativas. Los centros docentes o informatizados tienen menos carga de consultas previsibles-administrativas. Éstas aumentan con la edad del paciente y con la presión asistencialConclusionesCasi un 40% de los motivos de consulta son previsibles-administrativos, lo que implica una gestión clínica inadecuada. Sería necesaria una intervención que permitiera liberar tiempo médico consumido en asuntos burocráticos para dedicarlo a la tarea asistencial propiamente dichaObjectivesTo describe care activity as a function of the nature of the consultation (predictability) and the needs of the patients (clinical content). To analyse the relationship of these with the characteristics of the consultation, of the patient and of the centreDesignMulti-centre, descriptive, observational study.SettingPrimary care. Area 17 of the Health Department of the Community of Valencia, with 197 316 inhabitants and 12 health centresParticipantsInformation gathering in real time by outside observer. Stratified randomised sampling of 2051 patients who gave rise to 3008 reasons for medical consultationMain measurementsPredictable consultations (Pr): their content can be foreseen (check-ups, picking up results). Unpredictable consultations (Unp): we cannot predict their content (acute problems may arise unexpectedly). These include urgent consultations. Administrative consultations (Ad): bureaucratic tasks (prescriptions, repeat sick-notes, sick certificates). Care consultations (Car): prevention, diagnosis and treatment of the illness, or monitoring of it. Variables here are the patient, the doctor and the consultationResults60% (1809) (95% CI, 58.69%–61.59%) of the reasons were Pr and 40% (1199) (95% CI, 36.6%–43.12%) were Unp. 50% (1509) (95% CI, 47.26%–53.06%) were Car, and 50% Ad (1499) (95% CI, 46.34%–53.39%). 40% (1189) (95% CI, 37.78%–41.28%) were Pr-Ad and only 21% (620) (95% CI, 19.16%–22.06%) were Pr-Car. 30% (889) (95% CI, 27.92%–31.18%) were Unp–Car, and 10% (310) (95% CI, 9.22%– 11.4%) Unp-Ad. 48% of patients with a single reason for attendance were Pr-Ad (577) (95% CI, 44.25%–52.05). Teaching centres and computerised ones had less Pr-Ad load. Pr-Ad consultations increased with patient´s age and with case-load.ConclusionsAlmost 40% of the reasons for consultation are Pr-Ad, which implies inadequate clinical management. An intervention is needed to free up medical time consumed by bureaucratic questions, so that this time can be devoted fully to health-care task

Analysing the concept of diagnostic inertia in hypertension: a cross-sectional study

Aims The aim of this study was to quantify diagnostic inertia (DI) when the physician fails to diagnose hypertension and determine its associated factors. Methods This cross-sectional, observational study involved all patients without a diagnosis of hypertension who had their blood pressure (BP) measured at least three times during the second half of 2010 (N = 48,605). Patients with altered mean BP figures (≥ 140/90 mmHg) were considered to experience DI. Secondary variables: gender, atrial fibrillation, diabetes mellitus, dyslipidemia, cardiovascular disease, age and the physician having attended a cardiovascular training course (ESCARVAL). Associated factors were assessed by multivariate logistic regression analysis. Results Diagnostic inertia was present in 6450 patients (13.3%, 95% CI: 13.0–13.6%). Factors significantly associated with DI were: male gender (OR = 1.46, 95% CI: 1.37–1.55, p < 0.001), atrial fibrillation (OR = 0.73, 95% CI: 0.58–0.92, p = 0.007), the ESCARVAL cardiovascular course (OR = 0.88, 95% CI: 0.81–0.96, p = 0.005), diabetes mellitus (OR = 0.93, 95% CI: 0.87–0.99, p = 0.016), cardiovascular disease (OR = 0.77, 95% CI: 0.67–0.88, p < 0.001) and older age (years) (18–44[RIGHTWARDS ARROW]OR = 1; 45–59[RIGHTWARDS ARROW]OR = 12.45, 95% CI: 11.11–13.94; 60–74[RIGHTWARDS ARROW]OR = 18.11, 95% CI: 16.30–20.12; ≥ 75[RIGHTWARDS ARROW]OR = 20.43, 95% CI: 18.34–22.75; p < 0.001). The multivariate model had an area under the ROC curve of 0.81 (95% CI: 0.80–0.81, p < 0.001). Conclusions This study will help clinical researchers differentiate between the two forms of DI (interpretation of a positive screening test and interpretation of positive diagnostic criteria). The results found here in patients with hypertension suggest that this problem is prevalent, and that a set of associated factors can explain the outcome well (AUC>0.80)

Internacionalización de la obra del artista Octavio Torres: Affordable Art Fair New York

Octavio Torres es un talentoso escultor nacido en Guadalajara, Jalisco el 10 de octubre de 1974. Escultor egresado de la escuela de artes plásticas del centro universitario de arte, arquitectura y diseño de la Universidad de Guadalajara años de 1994 - 1999. También egresó como restaurador de bienes muebles en la escuela de conservación y restauración de los años 2005-2010. Octavio cuenta con una especialización en conservación de monumentos de piedra hecha en Argentina y un diplomado en historia del arte mexicano. Las exposiciones más destacadas de Octavio han sido en el museo del premio nacional de cerámica en Tlaquepaque, Jalisco. Participó en Gallery Weekend en la Ciudad de México con una exposición titulada “Motor de impulso” y también participó en el Bienal de las Artes en la Habana, Cuba. Uno de los objetivos de Octavio es poder aumentar el número de espectadores, así como poder generar más contactos para comercializar un número mayor de esculturas. Los objetivos de Octavio son concretos y alcanzables ya que la feria nos da un amplio repertorio de contactos y puede lograr un alcance bastante grande con todas las personas que se encuentran viendo las obras. Lo que se busca es que Octavio pueda tener pedidos a futuro de personas interesadas en sus esculturas. Estamos seguros que su cartera de clientes va a crecer, desde personas que quieren las piezas para su hogar o personas que quieren sus piezas para hoteles o negocios.ITESO, A.C

Cost-Effectiveness Analysis of Insulin Detemir Compared to Neutral Protamine Hagedorn (NPH) in Patients with Type 1 and Type 2 Diabetes Mellitus in Spain

Introduction: An Excel® (Microsoft Corporation) model was adapted to estimate the short-term (1-year) cost effectiveness of insulin detemir (IDet) versus neutral protamine Hagedorn (NPH) insulin in patients initiating insulin treatment with type 1 diabetes mellitus (T1DM) and type 2 diabetes mellitus (T2DM) in Spain. Methods: Clinical benefits included the non-severe hypoglycemia rate for T1DM and T2DM, and weight change for T2DM. Three scenarios were included with different hypoglycemia rates estimated on the basis of clinical trials and observational studies. Costs, estimated from perspective of the Spanish Public Healthcare System (Euros 2014), included insulin treatment and non-severe hypoglycemia management costs. Non-severe hypoglycemia, defined as a self-managed event, implied the use of extra glucose testing strips and a general practitioner visit during the week following the event for 25% of patients. An average disutility value was associated to non-severe hypoglycemia events and, for T2DM, to one body mass index unit gain to calculate quality-adjusted life years (QALYs). Results: For the three scenarios a range of 0.025–0.076 QALYs for T1DM and 0.014–0.051 QALYs for T2DM were gained for IDet versus NPH due to non-severe hypoglycemia and weight gain avoidance, in return of an incremental cost of €145–192 for T1DM and €128–206 for T2DM. This resulted in the IDet versus NPH incremental cost-effectiveness ratio (ICER) ranging between €1910/QALY and €7682/QALY for T1DM and €2522/QALY and €15,009/QALY for T2DM. Conclusion: IDet was a cost-effective alternative to NPH insulin in the first year of treatment of patients with T1DM and patients with T2DM in Spain, with ICERs under the threshold value commonly accepted in Spain (€30,000/QALY)

FUMEPOC: Early detection of chronic obstructive pulmonary disease in smokers

<p>Abstract</p> <p>Background</p> <p>Currently is not feasible using conventional spirometry as a screening method in Primary Care especially among smoking population to detect chronic obstructive pulmonary disease in early stages. Therefore, the FUMEPOC study protocol intends to analyze the validity and reliability of Vitalograph COPD-6 spirometer as simpler tool to aid screening and diagnosis of this disease in early stages in primary care surgery.</p> <p>Methods / Design</p> <p>Study design: An observational, descriptive study of diagnostic tests, undertaken in Primary Care and Pneumology Outpatient Care Centre at San Juan Hospital and Elda Hospital. All smokers attending the primary care surgery and consent to participate in the study will undergo a test with Vitalograph COPD-6 spirometer. Subsequently, a conventional spirometry will be performed in the hospital and the results will be compared with those of the Vitalograph COPD-6 test.</p> <p>Discussion</p> <p>It is difficult to use the spirometry as screening for early diagnose test in real conditions of primary care clinical practice. The use of a simpler tool, Vitalograph COPD-6 spirometer, can help in the early diagnose and therefore, it could improve the clinical management of the disease.</p

Total and Subtypes of Dietary Fat Intake and Its Association with Components of the Metabolic Syndrome in a Mediterranean Population at High Cardiovascular Risk

Background: The effect of dietary fat intake on the metabolic syndrome (MetS) and in turn on cardiovascular disease (CVD) remains unclear in individuals at high CVD risk. Objective: To assess the association between fat intake and MetS components in an adult Mediterranean population at high CVD risk. Design: Baseline assessment of nutritional adequacy in participants (n = 6560, men and women, 55-75 years old, with overweight/obesity and MetS) in the PREvención con DIeta MEDiterránea (PREDIMED)-Plus randomized trial. Methods: Assessment of fat intake (total fat, monounsatured fatty acids: MUFA, polyunsaturated fatty acids: PUFA, saturated fatty acids: SFA, trans-fatty acids: trans-FA, linoleic acid, α-linolenic acid, and ω-3 FA) using a validated food frequency questionnaire, and diet quality using 17-item Mediterranean dietary questionnaire and fat quality index (FQI). Results: Participants in the highest quintile of total dietary fat intake showed lower intake of energy, carbohydrates, protein and fiber, but higher intake of PUFA, MUFA, SFA, TFA, LA, ALA and ω-3 FA. Differences in MetS components were found according to fat intake. Odds (5th vs. 1st quintile): hyperglycemia: 1.3-1.6 times higher for total fat, MUFA, SFA and ω-3 FA intake; low high-density lipoprotein cholesterol (HDL-c): 1.2 higher for LA; hypertriglyceridemia: 0.7 lower for SFA and ω-3 FA intake. Conclusions: Dietary fats played different role on MetS components of high CVD risk patients. Dietary fat intake was associated with higher risk of hyperglycemia

Complement component C4 structural variation and quantitative traits contribute to sex-biased vulnerability in systemic sclerosis

Altres ajuts: Fondo Europeo de Desarrollo Regional (FEDER), "A way of making Europe".Copy number (CN) polymorphisms of complement C4 play distinct roles in many conditions, including immune-mediated diseases. We investigated the association of C4 CN with systemic sclerosis (SSc) risk. Imputed total C4, C4A, C4B, and HERV-K CN were analyzed in 26,633 individuals and validated in an independent cohort. Our results showed that higher C4 CN confers protection to SSc, and deviations from CN parity of C4A and C4B augmented risk. The protection contributed per copy of C4A and C4B differed by sex. Stronger protection was afforded by C4A in men and by C4B in women. C4 CN correlated well with its gene expression and serum protein levels, and less C4 was detected for both in SSc patients. Conditioned analysis suggests that C4 genetics strongly contributes to the SSc association within the major histocompatibility complex locus and highlights classical alleles and amino acid variants of HLA-DRB1 and HLA-DPB1 as C4-independent signals

Mortality from gastrointestinal congenital anomalies at 264 hospitals in 74 low-income, middle-income, and high-income countries: a multicentre, international, prospective cohort study

Summary Background Congenital anomalies are the fifth leading cause of mortality in children younger than 5 years globally. Many gastrointestinal congenital anomalies are fatal without timely access to neonatal surgical care, but few studies have been done on these conditions in low-income and middle-income countries (LMICs). We compared outcomes of the seven most common gastrointestinal congenital anomalies in low-income, middle-income, and high-income countries globally, and identified factors associated with mortality. Methods We did a multicentre, international prospective cohort study of patients younger than 16 years, presenting to hospital for the first time with oesophageal atresia, congenital diaphragmatic hernia, intestinal atresia, gastroschisis, exomphalos, anorectal malformation, and Hirschsprung’s disease. Recruitment was of consecutive patients for a minimum of 1 month between October, 2018, and April, 2019. We collected data on patient demographics, clinical status, interventions, and outcomes using the REDCap platform. Patients were followed up for 30 days after primary intervention, or 30 days after admission if they did not receive an intervention. The primary outcome was all-cause, in-hospital mortality for all conditions combined and each condition individually, stratified by country income status. We did a complete case analysis. Findings We included 3849 patients with 3975 study conditions (560 with oesophageal atresia, 448 with congenital diaphragmatic hernia, 681 with intestinal atresia, 453 with gastroschisis, 325 with exomphalos, 991 with anorectal malformation, and 517 with Hirschsprung’s disease) from 264 hospitals (89 in high-income countries, 166 in middleincome countries, and nine in low-income countries) in 74 countries. Of the 3849 patients, 2231 (58·0%) were male. Median gestational age at birth was 38 weeks (IQR 36–39) and median bodyweight at presentation was 2·8 kg (2·3–3·3). Mortality among all patients was 37 (39·8%) of 93 in low-income countries, 583 (20·4%) of 2860 in middle-income countries, and 50 (5·6%) of 896 in high-income countries (p<0·0001 between all country income groups). Gastroschisis had the greatest difference in mortality between country income strata (nine [90·0%] of ten in lowincome countries, 97 [31·9%] of 304 in middle-income countries, and two [1·4%] of 139 in high-income countries; p≤0·0001 between all country income groups). Factors significantly associated with higher mortality for all patients combined included country income status (low-income vs high-income countries, risk ratio 2·78 [95% CI 1·88–4·11], p<0·0001; middle-income vs high-income countries, 2·11 [1·59–2·79], p<0·0001), sepsis at presentation (1·20 [1·04–1·40], p=0·016), higher American Society of Anesthesiologists (ASA) score at primary intervention (ASA 4–5 vs ASA 1–2, 1·82 [1·40–2·35], p<0·0001; ASA 3 vs ASA 1–2, 1·58, [1·30–1·92], p<0·0001]), surgical safety checklist not used (1·39 [1·02–1·90], p=0·035), and ventilation or parenteral nutrition unavailable when needed (ventilation 1·96, [1·41–2·71], p=0·0001; parenteral nutrition 1·35, [1·05–1·74], p=0·018). Administration of parenteral nutrition (0·61, [0·47–0·79], p=0·0002) and use of a peripherally inserted central catheter (0·65 [0·50–0·86], p=0·0024) or percutaneous central line (0·69 [0·48–1·00], p=0·049) were associated with lower mortality. Interpretation Unacceptable differences in mortality exist for gastrointestinal congenital anomalies between lowincome, middle-income, and high-income countries. Improving access to quality neonatal surgical care in LMICs will be vital to achieve Sustainable Development Goal 3.2 of ending preventable deaths in neonates and children younger than 5 years by 2030