La evaluación de la capacidad de resolución de la atención primaria y su contribución a la efectividad del sistema de salud.La hospitalización por ambulatory care sensitive conditions como medida

La 'Hospitalización por Ambulatory Care Sensitive Conditions (ACSC)' es un indicador de medida indirecta de la capacidad de resolución de la Atención Primaria de Salud (APS). El indicador mide el volumen de hospitalizaciones potencialmente evitables mediante una APS óptima y ha sido propuesto por varios autores, tanto nacionales como internacionales, para evaluar la efectividad de la APS. Las ACSC son códigos de diagnóstico de alta hospitalaria clasificados según la CIE-9-CM (Clasificación Internacional de Enfermedades, 9ª revisión) que se obtienen del sistema de información sanitaria hospitalario, el Conjunto Mínimo Básico de Datos de Alta Hospitalaria (CMBD-AH). Muchas cuestiones emergen de la propuesta de evaluar la APS mediante un indicador generado con datos hospitalarios, cuestiones relacionadas con los aspectos conceptuales, metodológicos, de interpretación de los resultados y sobre su aplicabilidad para el sistema de salud. Las respuestas breves a estas cuestiones constituyen los puntos clave para la lectura rápida del mismo

Education stategies in european context: a survey of teaching learning approaches, tools and assessment among physiotherapy teachers

Background: The context of education in the health professions has been influenced by the same tendencies of development of knowledge and technology that society faces. It is therefore important that educational institutions are capable of promoting an evolutionary profile of professionals that is adapted to the needs of the future society. Purpose: One of the aims of the European Network of Physioth erapy in Higher Education (ENPHE) is to bring together and enhance collaboration between european institutes and physiotherapy educational institutions in the european region in order to encourage and support standards of high quality education in physiotherapy in accordance with the recommendations of the World Confederation for Physical Therapy (WCPT and ER-WCPT). Methods: In the context of the ENPHE group “Facilitation of Learning” and based on the literature, an online questionnaire was constructed regarding teaching approaches. After a pilot study within 5 institutions, the final version of the survey was disseminated during the ENPHE 2018 seminar. Results: We h ad 143 survey responses from 19 countrys, most of the respondents were fulltime lecturers (54%) at Bachelor´s level (89%). The responses indicated that the most commonly used Learning. Approaches included, Problem Solving (86%) and Content Focus activities (83%) using mainly lectures (78%) and practical training in class (83%) and the most popular tools used were aimed to facilitate retrieving, recalling or recognising knowledge (97%), using written (86%) and/or practical examination (77%) as assessment strategies. Conclusion(s): The results still reflect a classic approach to teaching and learning as shown by the selection of approaches, tools and assessment strategies. Implications: The results have provided some insight and also could guide the ENPHE in devising strategies to facilitate the use of more student inclusive and active learning strategies in Physiotherapy education.N/

Mapping education strategies in european context: a survey of teaching-learning approaches, tools and assessment among ENPHE members

Purpose The context of education in the health professions has been influenced by the same tendencies of development of knowledge and technology that society faces. It is therefore important that educational institutions are capable of promoting an evolutionary profile of professionals that is adapted to the needs of the future society. Subjects Lecturers from Higher education institutions belonging to the ENPHE Network Material / Methods In the context of the ENPHE group “Facilitation of Learning” and based on the literature, an online questionnaire was constructed regarding teaching approaches. After a pilot study within 5 institutions, the final version of the survey was disseminated during the ENPHE 2018 seminar and until July 2018 by email. Results We had 143 survey responses from 19 country's, most of the respondents were fulltime lecturers (54%) at Bachelor´s level (89%). The responses indicated that the most commonly used Learning Approaches included, Problem Solving (86%) and Content Focus activities (83%) using mainly lectures (78%) and practical training in class (83%) and the most popular tools used were aimed to facilitate retrieving, recalling or recognizing knowledge (97%), The use written (86%) and/or practical examination (77%) as assessment strategies. Conclusions The results still reflect a classic approach to teaching and learning as shown by the selection of approaches, tools and assessment strategies. Educational relevance. The results have provided some insight and also could guide ENPHE devising strategies to facilitate the use of more student inclusive and active learning strategies in Physiotherapy education.N/

Clinical characteristics and outcome of Spanish patients with ANCA-associated vasculitides: Impact of the vasculitis type, ANCA specificity, and treatment on mortality and morbidity

Spain; ANCA; VasculitidesEspanya; ANCA; VasculitisEspaña; ANCA; VasculitisThe aim of this study was to describe the clinical characteristics of ANCA-associated vasculitides (AAV) at presentation, in a wide cohort of Spanish patients, and to analyze the impact of the vasculitis type, ANCA specificity, prognostic factors, and treatments administered at diagnosis, in the outcome.A total of 450 patients diagnosed between January 1990 and January 2014 in 20 Hospitals from Spain were included. Altogether, 40.9% had granulomatosis with polyangiitis (GPA), 37.1% microscopic polyangiitis (MPA), and 22% eosinophilic granulomatosis with polyangiitis (EGPA). The mean age at diagnosis was 55.6 ± 17.3 years, patients with MPA being significantly older (P < 0.001). Fever, arthralgia, weight loss, respiratory, and ear-nose-throat (ENT) symptoms, were the most common at disease onset. ANCAs tested positive in 86.4% of cases: 36.2% C-ANCA-PR3 and 50.2% P-ANCA-MPO. P-ANCA-MPO was significantly associated with an increased risk for renal disease (OR 2.6, P < 0.001) and alveolar hemorrhage (OR 2, P = 0.010), while C-ANCA-PR3 was significantly associated with an increased risk for ENT (OR 3.4, P < 0.001) and ocular involvement (OR 2.3, P = 0.002). All patients received corticosteroids (CS) and 74.9% cyclophosphamide (CYC). The median follow-up was 82 months (IQR 100.4). Over this period 39.9% of patients suffered bacterial infections and 14.6% opportunistic infections, both being most prevalent in patients with high-cumulated doses of CYC and CS (P < 0.001). Relapses were recorded in 36.4% of cases with a mean rate of 2.5 ± 2.3, and were more frequent in patients with C-ANCA-PR3 (P = 0.012). The initial disease severity was significantly associated with mortality but not with the occurrence of relapses. One hundred twenty-nine (28.7%) patients (74 MPA, 41 GPA, 14 EGPA) died. The mean survival was 58 months (IQR 105) and was significantly lower for patients with MPA (P < 0.001). Factors independently related to death were renal involvement (P = 0.010), cardiac failure (P = 0.029) and age over 65 years old (P < 0.001) at disease onset, and bacterial infections (P < 0.001). An improved outcome with significant decrease in mortality and treatment-related morbidity was observed in patients diagnosed after 2000, and was related to the implementation of less toxic regimens adapted to the disease activity and stage, and a drastic reduction in the cumulated CYC and CS dose

Non-linear dynamic analysis of RR signals in patients with and without excessive daytime sleepiness

Linear and non-linear measures applied to heart rate variability (HRV) can be used to quantify modulation of the sympathetic and parasympathetic branches of the autonomic nervous system. RR signals were obtained from the ECG recorded during five Maintenance of Wakefulness (MWT) and Multiple Sleep Latency (MSLT) tests alternated throughout the day from patients suffering sleep disturbance. Two different end-points were considered: Study A, excessive daytime sleepiness (EDS) versus without daytime sleepiness (WDS); Study B, Pre-CPAP versus Post-CP AP (continuous positive airway pressure therapy) in EDS. Measures obtained from spectral analysis (PSD), time-frequency representation (TFR), auto-correntropy (ACORR) and auto-mutual-information function (AMIF) were applied to describe autonomic nervous system activity and RR regularity. Statistical differences between EDS and WDS groups were found in MSLT events. During MSLT, the parasympathetic activity and RR regularity in EDS were affected by CPAP therapy. Non-linear measures obtained from EDS in Post-CPAP differed from Pre-CPAP (p-value<0.05) and tended to be similar to WDS.Peer ReviewedPostprint (published version

Modeling the Effect of Propofol and Remifentanil Combinations for Sedation-Analgesia in Endoscopic Procedures Using an Adaptive Neuro Fuzzy Inference System (ANFIS)

BACKGROUND: The increasing demand for anesthetic procedures in the gastrointestinal endoscopy area has not been followed by a similar increase in the methods to provide and control sedation and analgesia for these patients. In this study, we evaluated different combinations of propofol and remifentanil, administered through a target-controlled infusion system, to estimate the optimal concentrations as well as the best way to control the sedative effects induced by the combinations of drugs in patients undergoing ultrasonographic endoscopy. METHODS: One hundred twenty patients undergoing ultrasonographic endoscopy were randomized to receive, by means of a target-controlled infusion system, a fixed effect-site concentration of either propofol or remifentanil of 8 different possible concentrations, allowing adjustment of the concentrations of the other drug. Predicted effect-site propofol (C(e)pro) and remifentanil (C(e)remi) concentrations, parameters derived from auditory evoked potential, autoregressive auditory evoked potential index (AAI/2) and electroencephalogram (bispectral index [BIS] and index of consciousness [IoC]) signals, as well as categorical scores of sedation (Ramsay Sedation Scale [RSS] score) in the presence or absence of nociceptive stimulation, were collected, recorded, and analyzed using an Adaptive Neuro Fuzzy Inference System. The models described for the relationship between C(e)pro and C(e)remi versus AAI/2, BIS, and IoC were diagnosed for inaccuracy using median absolute performance error (MDAPE) and median root mean squared error (MDRMSE), and for bias using median performance error (MDPE). The models were validated in a prospective group of 68 new patients receiving different combinations of propofol and remifentanil. The predictive ability (P(k)) of AAI/2, BIS, and IoC with respect to the sedation level, RSS score, was also explored. RESULTS: Data from 110 patients were analyzed in the training group. The resulting estimated models had an MDAPE of 32.87, 12.89, and 8.77; an MDRMSE of 17.01, 12.81, and 9.40; and an MDPE of -1.86, 3.97, and 2.21 for AAI/2, BIS, and IoC, respectively, in the absence of stimulation and similar values under stimulation. P(k) values were 0.82, 0.81, and 0.85 for AAI/2, BIS, and IoC, respectively. The model predicted the prospective validation data with an MDAPE of 34.81, 14.78, and 10.25; an MDRMSE of 16.81, 15.91, and 11.81; an MDPE of -8.37, 5.65, and -1.43; and P(k) values of 0.81, 0.8, and 0.8 for AAI/2, BIS, and IoC, respectively. CONCLUSION: A model relating C(e)pro and C(e)remi to AAI/2, BIS, and IoC has been developed and prospectively validated. Based on these models, the (C(e)pro, C(e)remi) concentration pairs that provide an RSS score of 4 range from (1.8 μg·mL(-1), 1.5 ng·mL(-1)) to (2.7 μg·mL(-1), 0 ng·mL(-1)). These concentrations are associated with AAI/2 values of 25 to 30, BIS of 71 to 75, and IoC of 72 to 76. The presence of noxious stimulation increases the requirements of C(e)pro and C(e)remi to achieve the same degree of sedative effects

Structure versus function: correlation between outer retinal and choroidal thicknesses measured by swept-source OCT with multifocal electroretinography and visual acuity

Background: To correlate retina-choroidal anatomy as assessed via swept-source OCT (SS-OCT) with retinal function as determined by best-corrected visual acuity (BCVA) and multifocal electroretinogram (mfERG). Methods: Thirty-three eyes from 33 patients including 16 with neovascular AMD (nvAMD) and 17 controls were included. Patients were included in the present study after a complete ophthalmologic examination, including BCVA, slit-lamp study, intraocular pressure measurement, dilated fundus examination after tropicamide instillation, SD-OCT, SS-OCT, fundus photographs and mfERG. Age, sex, BCVA, number of anti-VEGF intravitreal injections in the nvAMD group, were recollected. Outer retinal and choroidal thickness were determined at the fovea and 500 μm temporal, superior, nasal and inferior. First-order response from mfERG was collected. P1 amplitude was recorded in R1, R2 and the average of R1 + R2. The measurements recollected from the SS-OCT, mfERG and BCVA were compared. Results: Better BCVA was found with thicker outer retina foveal thickness (r = 0.349; P = 0.047), with thicker subfoveal choroidal thickness (r = 0.443; P = 0.010), and with higher amplitude in P1 at R1 (r = 0.346; P = 0.037). Outer retina foveal thickness did not correlate with P1 amplitude at R1 (r = 0.072; P = 0.692), R2 (r = 0.265; P = 0.137) either with the average P1 amplitude at R1 + R2 (r = 0.253; P = 0.156). A thicker subfoveal choroidal thickness was related with higher amplitude in P1 at R1 (r = 0.383; P = 0.028), R2 (r = 0.409; P = 0.018) and the average of R1 + R2 (r = 0.419; P = 0.015). Conclusions: Choroidal thickness demonstrated a positive correlation with retinal function in the sample studied, so a thicker choroid is related to a better retinal function measured with mfERG and BCVA

Atomic-level passivation mechanism of ammonium salts enabling highly efficient perovskite solar cells.

The high conversion efficiency has made metal halide perovskite solar cells a real breakthrough in thin film photovoltaic technology in recent years. Here, we introduce a straightforward strategy to reduce the level of electronic defects present at the interface between the perovskite film and the hole transport layer by treating the perovskite surface with different types of ammonium salts, namely ethylammonium, imidazolium and guanidinium iodide. We use a triple cation perovskite formulation containing primarily formamidinium and small amounts of cesium and methylammonium. We find that this treatment boosts the power conversion efficiency from 20.5% for the control to 22.3%, 22.1%, and 21.0% for the devices treated with ethylammonium, imidazolium and guanidinium iodide, respectively. Best performing devices showed a loss in efficiency of only 5% under full sunlight intensity with maximum power tracking for 550 h. We apply 2D- solid-state NMR to unravel the atomic-level mechanism of this passivation effect

IRF4 and IRGs Delineate Clinically Relevant Gene Expression Signatures in Systemic Lupus Erythematosus and Rheumatoid Arthritis

Introduction: Overactivation of the type I interferon (IFN) signature has been observed in several systemic autoimmune conditions, such as Systemic Lupus Erythematosus (SLE) or Rheumatoid Arthritis (RA). Impaired control of Interferon-Responding Genes (IRGs) expression by their regulatory mechanisms, including Interferon Regulatory Factors (IRFs), may underlie these findings and it may explain the heterogeneity observed among these conditions. In the present study we aimed to evaluate the associations between IRF4 gene expression and those of IRGs in SLE and RA patients to gain insight about its links with the IFN signature as well as to explore the potential clinical relevance of these associations.Methods: The gene expression of IRF4 and IRGs (IFI44, IFI44L, IFI6, and MX1) in peripheral blood was analyzed in 75 SLE patients, 98 RA patients, and 28 healthy controls. A group of 13 biological-naïve RA patients was prospectively followed upon TNFα-blockade. The associations among IRF4 and IRGs were evaluated by principal component analyses (PCA), correlations and network analyses. Publicly available datasets were used for replication.Results: A broad activation of IRGs was observed in autoimmune patients, although certain heterogeneity can be distinguished, whereas IRF4 was only upregulated in RA. The differential expression of IRF4 in RA was then confirmed in publicly available gene expression datasets. PCA revealed different associations among IRF4 and IRGs in each condition, which was later confirmed by correlation and network analyses. Cluster analysis identified 3 gene expression signatures on the basis of IRF4 and IRGs expression which were differentially used by SLE and RA patients. Cluster III was associated with markers of disease severity in SLE patients. Cluster II, hallmarked by IRF4 upregulation, was linked to clinical stage and mild disease course in RA. TNFα-blockade led to changes in the association between IRF4 and IRGs, whereas increasing IRF4 expression was associated with a good clinical outcome in RA.Conclusions: The differential expression of IRF4 and IRGs observed in SLE and RA can delineate gene expression signatures associated with clinical features and treatment outcomes. These results support a clinically-relevant phenomenon of shaping of the IFN signature by IRF4 in autoimmune patients