Comunicación interna en atención primaria

ObjetivosEstudiar la comunicación interna entre los profesionales de la atención primaria.DiseñoEstudio descriptivo, transversal.EmplazamientoÁmbito de Atención Primaria Costa de Ponent del Institut Català de la Salut.ParticipantesTodos los trabajadores del ámbito (n=3.565).MedicionesEncuesta dividida en 3 partes: a) preguntas sociodemográficas; b) preguntas que valoraban del 0 al 10 la importancia y el funcionamiento actual de diferentes cuestiones, y c) preguntas sobre nuevas herramientas de comunicación.ResultadosRespondieron un 39% de los encuestados (n=1.388), con una edad media de 43,2 años (intervalo de confianza [IC] del 95%, 42,75-43,65), y el 28,9% eran varones. Las mayores diferencias entre importancia y actualidad se dieron a «enterarse de los proyectos antes de que se publiquen en los medios de comunicación», «conocerlos por vía oficial y no por rumores» y «conocer los proyectos de otros equipos». Las menores diferencias se produjeron en la comunicación dentro de los equipos. Los medicos consideran más importante la comunicación ascendente. Los médicos son los que valoran mejor la comunicación dentro de los equipos, y los profesionales de la unidad de atención al usuario (UAU), los que la valoran peor. Los médicos son los que más importancia dan a enterarse a tiempo de los proyectos. El 55% de los encuestados no utiliza el servicio de intranet, la mayor parte por falta de tiempo. El segundo motivo de esta falta de uso es su dificultad. Un 62% lee el correo electrónico más de 2-3 veces por semana El 89% de los encuestados querría tener un boletín electrónico. Los trabajadores de más edad usan menos las nuevas tecnologías.ConclusionesEs necesario mejorar la comunicación descendente, ascendente y transversal, especialmente la ascendente de los médicos, y la de los equipos para los profesionales de la UAU. Debe dotarse a la intranet de instrumentos que agilicen el trabajo y ofrecerse formación en el manejo de las nuevas tecnologías.ObjectivesTo study internal communication between primary care health professionalsDesignCross-sectional, descriptive.SettingCatalan Health Institute Costa de Ponent Primary Care Area, Spain.ParticipantsAll workers in the area (n=3565).MeasurementsThree part questionnaire: a) sociodemographic questions; b) questions scoring from 0 to 10 the current importance and operation of certain aspects; and c) questions on new communication tools.ResultsOf those sent a questionnaire, 39% (n=1388) responded, with a mean age of 43.2 years (95% CI, 42.75- 43.65), 28.9% being male.The major differences between importance and current events were said to be “to be informed of projects before they appear in the communication media,” “by official routes and not by rumour,” and “to be aware of projects of other teams.” The least communicated within teams. The doctors considered upward communication to be more important. Doctors are those who appreciate communication within teams better and the professionals of the users services unit (UAU) less so. Doctors are the ones who give more importance to being informed of projects at the time.55% do not use the intranet, mainly due lack of time. The second reason is that they find it difficult.Sixty-two per cent read e-mail >2-3 times per week. Eighty-nine per cent want an electronic bulletin. The older workers use new technologies less.ConclusionsDownward, upward, and sideways communication needs to be improved, particularly upwards by doctors, and that of the teams for the UAU professionals. Intranet tools must be provided that make the work easier and training in handling new technologies must be offered

Reestructuración del funcionamiento de la Unidad de Hospitalización a Domicilio del Hospital Universitario Germans Trias i Pujol para el manejo de pacientes COVID y no COVID ingresados durante la pandemia del COVID-19 en España

Introduction: The COVID-19 pandemic made that the Home Care Unit of the Germans Trias i Pujol University Hospital implement strategies for the management of patients admitted with or without COVID-19, optimizing health care resources.Method: A descriptive study of patients with and without COVID-19 was conducted between March 14th and May 31th, 2020. An increase in the number of virtual beds, as well as extension of working hour and incorporation of personnel health (doctor/nurses) was necessary, activating 2 telemedicine platforms for monitoring of patients (COVIDApp for COVID patients and Revita for non-COVID patients).Results: A total of 781 patients referred from the hospitalization, emergency and primary care were included, 584 (74.8%) admitted with a diagnosis of COVID-19 (by PCR) and 197 (25.2%) patients admitted by other pathologies (non-COVID) from the Nord Metropolitan area of Barcelona and Maresme. 24.6% of non-COVID patients and 2.5% of COVID patients were complex chronic patients. The percentage of hospital readmission was higher in non-COVID patients (11.6%) than in COVID patients (4.28%). The percentage of discharges from the UHAD increased to 35.34%. Both platforms allowed for close monitoring of patients.Conclusions: The COVID-19 pandemic has highlighted the need to optimize and restructure the resources of the health system, with the Telemedicine platforms COVIDApp and Revita as innovative tools.Introducción: La Unidad de Hospitalización a Domicilio del Hospital Universitari Germans Trias i Pujol, ante la grave situación sanitaria generada por el COVID-19 optó por varias estrategias para la atención de los pacientes ingresados con o sin diagnóstico de COVID optimizando los recursos de atención sanitaria.Método: Estudio descriptivo sobre la reorganización de la Unidad de Hospitalización a Domicilio (UHAD) durante la pandemia del COVID-19 en el período comprendido entre el 14 de Marzo y 31 de Mayo del 2020. Una ampliación del número de camas virtuales, así como de los turnos e incorporación de personal sanitario (médico/enfermeros) fue necesario, activándose paralelamente 2 plataformas de telemedicina para monitorización y contacto con los pacientes (COVIDApp para los pacientes COVID y Revita para los pacientes no COVID).Resultados: Un total de 781 pacientes referidos del área de hospitalización, urgencias y atención primaria fueron incluidos, 584 (74,8%) ingresados con diagnóstico de COVID-19 (por PCR = polymerase chain reaction) y 197 (25,2%) pacientes ingresados por otras patologías (no-COVID) provenientes de la zona Metropolitana Nord de Barcelona y Maresme. Un 24,6% de los pacientes no-COVID y un 2,5% de los pacientes COVID eran pacientes crónicos complejos. El porcentaje de reingreso hospitalario fue mayor en los pacientes no-COVID (11.6%) que en los pacientes COVID (4,28%). El porcentaje de altas de la UHAD aumentó hasta un 35,34%. Ambas plataformas permitieron realizar seguimiento estrecho de los pacientes.Conclusiones: La pandemia del COVID-19 ha remarcado la necesidad de optimizar y reestructurar los recursos del sistema sanitario, siendo las plataformas de Telemedicina COVIDApp y Revita de ayuda como herramientas innovadoras

Fractal dimension analysis of malignant and benign endobronchial ultrasound nodes

Background: Endobronchial ultrasonography (EBUS) has been applied as a routine procedure for the diagnostic of hiliar and mediastinal nodes. The authors assessed the relationship between the echographic appearance of mediastinal nodes, based on endobronchial ultrasound images, and the likelihood of malignancy.; Methods: The images of twelve malignant and eleven benign nodes were evaluated. A previous processing method was applied to improve the quality of the images and to enhance the details. Texture and morphology parameters analyzed were: the image texture of the echographies and a fractal dimension that expressed the relationship between area and perimeter of the structures that appear in the image, and characterizes the convoluted inner structure of the hiliar and mediastinal nodes.; Results: Processed images showed that relationship between log perimeter and log area of hilar nodes was lineal (i.e. perimeter vs. area follow a power law). Fractal dimension was lower in the malignant nodes compared with non-malignant nodes (1.47(0.09), 1.53(0.10) mean(SD), Mann-Whitney U test p < 0.05)).; Conclusion: Fractal dimension of ultrasonographic images of mediastinal nodes obtained through endobronchial ultrasound differ in malignant nodes from non-malignant. This parameter could differentiate malignat and non-malignat mediastinic and hiliar nodes.Peer ReviewedPostprint (published version

Transbronchial biopsy results according to diffuse interstitial lung disease classification. Cryobiopsy versus forceps: MULTICRIO study

Background In recent years, transbronchial cryobiopsy (TBCB) has come to be increasingly used in interventional pulmonology units as it obtains larger and better-quality samples than conventional transbronchial lung biopsy (TBLB) with forceps. No multicenter studies have been performed, however, that analyse and compare TBCB and TBLB safety and yield according to the interstitial lung disease (ILD) classification. Objectives We compared the diagnostic yield and safety of TBCB with cryoprobe sampling versus conventional TBLB forceps sampling in the same patient. Method Prospective multicenter clinical study of patients with ILD indicated for lung biopsy. Airway management with orotracheal tube, laryngeal mask and rigid bronchoscope was according to the protocol of each centre. All procedures were performed using fluoroscopy and an occlusion balloon. TBLB was followed by TBCB. Complications were recorded after both TBLB and TBCB. Results Included were 124 patients from 10 hospitals. Airway management was orotracheal intubation in 74% of cases. Diagnostic yield according to multidisciplinary committee results for TBCB was 47.6% and for TBLB was 19.4% (p<0.0001). Diagnostic yield was higher for TBCB compared to TBLB for two groups: idiopathic interstitial pneumonias (IIPs) and ILD of known cause or association (OR 2.5; 95% CI: 1.4-4.2 and OR 5.8; 95% CI: 2.3-14.3, respectively). Grade 3 (moderate) bleeding after TBCB occurred in 6.5% of patients compared to 0.8% after conventional TBLB. Conclusions Diagnostic yield for TBCB was higher than for TBLB, especially for two disease groups: IIPs and ILD of known cause or association. The increased risk of bleeding associated with TBCB confirms the need for safe airway management and prophylactic occlusion-balloon use. Trial registration clinicaltrials.gov identifier: NCT02464592

Tenofovir vs lamivudine plus adefovir in chronic hepatitis B: TENOSIMP-B study

AIM To demonstrate the non-inferiority (15% non-inferiority limit) of monotherapy with tenofovir disoproxil fumarate (TDF) vs the combination of lamivudine (LAM) plus adefovir dipivoxil (ADV) in the maintenance of virologic response in patients with chronic hepatitis B (CHB) and prior failure with LAM. METHODS This study was a Phase IV prospective, randomized, open, controlled study with 2 parallel groups (TDF and LAM+ADV) of adult patients with hepatitis B e antigen (HBeAg)-negative CHB, prior failure with LAM, on treatment with LAM+ADV for at least 6 mo, without prior resistance to ADV and with an undetectable viral load at the start of the study, in 14 Spanish hospitals. The follow-up time for each patient was 48 wk after randomization, with quarterly visits in which the viral load, biochemical and serological parameters, adverse effects, adherence to treatment and consumption of hospital resources were analysed. RESULTS Forty-six patients were evaluated [median age: 55.4 years (30.2-75.2); 84.8% male], including 22 patients with TDF and 24 with LAM+ADV. During study development, hepatitis B virus DNA (HBV-DNA) remained undetectable, all patients remained HBeAg negative, and hepatitis B surface antigen (HBsAg) positive. Alanine aminotransferase (ALT) values at the end of the study were similar in the 2 groups (25.1 ± 7.65, TDF vs 24.22 ± 8.38, LAM+ADV, P = 0.646). No significant changes were observed in creatinine or serum phosphorus values in either group. No significant differences between the 2 groups were noted in the identification of adverse effects (AEs) (53.8%, TDF vs 37.5%, LAM+ADV, P = 0.170), and none of the AEs which occurred were serious. Treatment adherence was 95.5% and 83.3% in the TDF and the LAM+ADV groups, respectively (P = 0.488). The costs associated with hospital resource consumption were significantly lower with the TDF treatment than the LAM+ADV treatment (€4943 ± 1059 vs €5811 ± 1538, respectively, P < 0.001). CONCLUSION TDF monotherapy proved to be safe and not inferior to the LAM+ADV combination therapy in maintaining virologic response in patients with CHB and previous LAM failure. In addition, the use of TDF generated a significant savings in hospital costs

Smoking cessation opportunities in severe mental illness (tobacco intensive motivational and estimate risk — TIMER—): study protocol for a randomized controlled trial

There is an increased risk of premature death in people with severe mental illness (SMI). Respiratory disorders and cardiovascular disease are leading causes of increased mortality rates in these patients, and tobacco consumption remains the most preventable risk factor involved. Developing new tools to motivate patients towards cessation of smoking is a high priority. Information on the motivational value of giving the lung age and prevention opportunities is unknown in this high-risk population. In the context of community care, screening and early detection of lung damage could potentially be used, together with mobile technology, in order to produce a prevention message, which may provide patients with SMI with a better chance of quitting smoking.This study receives funding by the Spanish Ministry of Economy, Industry and Competitiveness, Instituto Carlos III (FIS PI16/00802)

Role of age and comorbidities in mortality of patients with infective endocarditis

[Purpose]: The aim of this study was to analyse the characteristics of patients with IE in three groups of age and to assess the ability of age and the Charlson Comorbidity Index (CCI) to predict mortality. [Methods]: Prospective cohort study of all patients with IE included in the GAMES Spanish database between 2008 and 2015.Patients were stratified into three age groups:<65 years,65 to 80 years,and ≥ 80 years.The area under the receiver-operating characteristic (AUROC) curve was calculated to quantify the diagnostic accuracy of the CCI to predict mortality risk. [Results]: A total of 3120 patients with IE (1327 < 65 years;1291 65-80 years;502 ≥ 80 years) were enrolled.Fever and heart failure were the most common presentations of IE, with no differences among age groups.Patients ≥80 years who underwent surgery were significantly lower compared with other age groups (14.3%,65 years; 20.5%,65-79 years; 31.3%,≥80 years). In-hospital mortality was lower in the <65-year group (20.3%,<65 years;30.1%,65-79 years;34.7%,≥80 years;p < 0.001) as well as 1-year mortality (3.2%, <65 years; 5.5%, 65-80 years;7.6%,≥80 years; p = 0.003).Independent predictors of mortality were age ≥ 80 years (hazard ratio [HR]:2.78;95% confidence interval [CI]:2.32–3.34), CCI ≥ 3 (HR:1.62; 95% CI:1.39–1.88),and non-performed surgery (HR:1.64;95% CI:11.16–1.58).When the three age groups were compared,the AUROC curve for CCI was significantly larger for patients aged <65 years(p < 0.001) for both in-hospital and 1-year mortality. [Conclusion]: There were no differences in the clinical presentation of IE between the groups. Age ≥ 80 years, high comorbidity (measured by CCI),and non-performance of surgery were independent predictors of mortality in patients with IE.CCI could help to identify those patients with IE and surgical indication who present a lower risk of in-hospital and 1-year mortality after surgery, especially in the <65-year group

Why Are Outcomes Different for Registry Patients Enrolled Prospectively and Retrospectively? Insights from the Global Anticoagulant Registry in the FIELD-Atrial Fibrillation (GARFIELD-AF).

Background: Retrospective and prospective observational studies are designed to reflect real-world evidence on clinical practice, but can yield conflicting results. The GARFIELD-AF Registry includes both methods of enrolment and allows analysis of differences in patient characteristics and outcomes that may result. Methods and Results: Patients with atrial fibrillation (AF) and ≥1 risk factor for stroke at diagnosis of AF were recruited either retrospectively (n = 5069) or prospectively (n = 5501) from 19 countries and then followed prospectively. The retrospectively enrolled cohort comprised patients with established AF (for a least 6, and up to 24 months before enrolment), who were identified retrospectively (and baseline and partial follow-up data were collected from the emedical records) and then followed prospectively between 0-18 months (such that the total time of follow-up was 24 months; data collection Dec-2009 and Oct-2010). In the prospectively enrolled cohort, patients with newly diagnosed AF (≤6 weeks after diagnosis) were recruited between Mar-2010 and Oct-2011 and were followed for 24 months after enrolment. Differences between the cohorts were observed in clinical characteristics, including type of AF, stroke prevention strategies, and event rates. More patients in the retrospectively identified cohort received vitamin K antagonists (62.1% vs. 53.2%) and fewer received non-vitamin K oral anticoagulants (1.8% vs . 4.2%). All-cause mortality rates per 100 person-years during the prospective follow-up (starting the first study visit up to 1 year) were significantly lower in the retrospective than prospectively identified cohort (3.04 [95% CI 2.51 to 3.67] vs . 4.05 [95% CI 3.53 to 4.63]; p = 0.016). Conclusions: Interpretations of data from registries that aim to evaluate the characteristics and outcomes of patients with AF must take account of differences in registry design and the impact of recall bias and survivorship bias that is incurred with retrospective enrolment. Clinical Trial Registration: - URL: http://www.clinicaltrials.gov . Unique identifier for GARFIELD-AF (NCT01090362)

Risk profiles and one-year outcomes of patients with newly diagnosed atrial fibrillation in India: Insights from the GARFIELD-AF Registry.

BACKGROUND: The Global Anticoagulant Registry in the FIELD-Atrial Fibrillation (GARFIELD-AF) is an ongoing prospective noninterventional registry, which is providing important information on the baseline characteristics, treatment patterns, and 1-year outcomes in patients with newly diagnosed non-valvular atrial fibrillation (NVAF). This report describes data from Indian patients recruited in this registry. METHODS AND RESULTS: A total of 52,014 patients with newly diagnosed AF were enrolled globally; of these, 1388 patients were recruited from 26 sites within India (2012-2016). In India, the mean age was 65.8 years at diagnosis of NVAF. Hypertension was the most prevalent risk factor for AF, present in 68.5% of patients from India and in 76.3% of patients globally (P < 0.001). Diabetes and coronary artery disease (CAD) were prevalent in 36.2% and 28.1% of patients as compared with global prevalence of 22.2% and 21.6%, respectively (P < 0.001 for both). Antiplatelet therapy was the most common antithrombotic treatment in India. With increasing stroke risk, however, patients were more likely to receive oral anticoagulant therapy [mainly vitamin K antagonist (VKA)], but average international normalized ratio (INR) was lower among Indian patients [median INR value 1.6 (interquartile range {IQR}: 1.3-2.3) versus 2.3 (IQR 1.8-2.8) (P < 0.001)]. Compared with other countries, patients from India had markedly higher rates of all-cause mortality [7.68 per 100 person-years (95% confidence interval 6.32-9.35) vs 4.34 (4.16-4.53), P < 0.0001], while rates of stroke/systemic embolism and major bleeding were lower after 1 year of follow-up. CONCLUSION: Compared to previously published registries from India, the GARFIELD-AF registry describes clinical profiles and outcomes in Indian patients with AF of a different etiology. The registry data show that compared to the rest of the world, Indian AF patients are younger in age and have more diabetes and CAD. Patients with a higher stroke risk are more likely to receive anticoagulation therapy with VKA but are underdosed compared with the global average in the GARFIELD-AF. CLINICAL TRIAL REGISTRATION-URL: http://www.clinicaltrials.gov. Unique identifier: NCT01090362