Effectiveness of a strategy that uses educational games to implement clinical practice guidelines among Spanish residents of family and community medicine (e-EDUCAGUIA project):A clinical trial by clusters

This study was funded by the Fondo de Investigaciones Sanitarias FIS Grant Number PI11/0477 ISCIII.-REDISSEC Proyecto RD12/0001/0012 AND FEDER Funding.Background: Clinical practice guidelines (CPGs) have been developed with the aim of helping health professionals, patients, and caregivers make decisions about their health care, using the best available evidence. In many cases, incorporation of these recommendations into clinical practice also implies a need for changes in routine clinical practice. Using educational games as a strategy for implementing recommendations among health professionals has been demonstrated to be effective in some studies; however, evidence is still scarce. The primary objective of this study is to assess the effectiveness of a teaching strategy for the implementation of CPGs using educational games (e-learning EDUCAGUIA) to improve knowledge and skills related to clinical decision-making by residents in family medicine. The primary objective will be evaluated at 1 and 6months after the intervention. The secondary objectives are to identify barriers and facilitators for the use of guidelines by residents of family medicine and to describe the educational strategies used by Spanish teaching units of family and community medicine to encourage implementation of CPGs. Methods/design: We propose a multicenter clinical trial with randomized allocation by clusters of family and community medicine teaching units in Spain. The sample size will be 394 residents (197 in each group), with the teaching units as the randomization unit and the residents comprising the analysis unit. For the intervention, both groups will receive an initial 1-h session on clinical practice guideline use and the usual dissemination strategy by e-mail. The intervention group (e-learning EDUCAGUIA) strategy will consist of educational games with hypothetical clinical scenarios in a virtual environment. The primary outcome will be the score obtained by the residents on evaluation questionnaires for each clinical practice guideline. Other included variables will be the sociodemographic and training variables of the residents and the teaching unit characteristics. The statistical analysis will consist of a descriptive analysis of variables and a baseline comparison of both groups. For the primary outcome analysis, an average score comparison of hypothetical scenario questionnaires between the EDUCAGUIA intervention group and the control group will be performed at 1 and 6months post-intervention, using 95% confidence intervals. A linear multilevel regression will be used to adjust the model. Discussion: The identification of effective teaching strategies will facilitate the incorporation of available knowledge into clinical practice that could eventually improve patient outcomes. The inclusion of information technologies as teaching tools permits greater learning autonomy and allows deeper instructor participation in the monitoring and supervision of residents. The long-term impact of this strategy is unknown; however, because it is aimed at professionals undergoing training and it addresses prevalent health problems, a small effect can be of great relevance. Trial registration: ClinicalTrials.gov: NCT02210442.Publisher PDFPeer reviewe

Association Between Preexisting Versus Newly Identified Atrial Fibrillation and Outcomes of Patients With Acute Pulmonary Embolism

Background Atrial fibrillation (AF) may exist before or occur early in the course of pulmonary embolism (PE). We determined the PE outcomes based on the presence and timing of AF. Methods and Results Using the data from a multicenter PE registry, we identified 3 groups: (1) those with preexisting AF, (2) patients with new AF within 2 days from acute PE (incident AF), and (3) patients without AF. We assessed the 90-day and 1-year risk of mortality and stroke in patients with AF, compared with those without AF (reference group). Among 16 497 patients with PE, 792 had preexisting AF. These patients had increased odds of 90-day all-cause (odds ratio [OR], 2.81; 95% CI, 2.33-3.38) and PE-related mortality (OR, 2.38; 95% CI, 1.37-4.14) and increased 1-year hazard for ischemic stroke (hazard ratio, 5.48; 95% CI, 3.10-9.69) compared with those without AF. After multivariable adjustment, preexisting AF was associated with significantly increased odds of all-cause mortality (OR, 1.91; 95% CI, 1.57-2.32) but not PE-related mortality (OR, 1.50; 95% CI, 0.85-2.66). Among 16 497 patients with PE, 445 developed new incident AF within 2 days of acute PE. Incident AF was associated with increased odds of 90-day all-cause (OR, 2.28; 95% CI, 1.75-2.97) and PE-related (OR, 3.64; 95% CI, 2.01-6.59) mortality but not stroke. Findings were similar in multivariable analyses. Conclusions In patients with acute symptomatic PE, both preexisting AF and incident AF predict adverse clinical outcomes. The type of adverse outcomes may differ depending on the timing of AF onset.info:eu-repo/semantics/publishedVersio

Outcomes from elective colorectal cancer surgery during the SARS-CoV-2 pandemic

This study aimed to describe the change in surgical practice and the impact of SARS-CoV-2 on mortality after surgical resection of colorectal cancer during the initial phases of the SARS-CoV-2 pandemic

Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

Abstract Background Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres. Methods This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low–middle-income countries. Results In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of ‘single-use’ consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low–middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia. Conclusion This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high– and low–middle–income countries

Influencia del gradiente de Na+ y K+ en la contractilidad del músculo liso

El músculo liso está presente en el tracto respiratorio (tráquea y bronquios), gastrointestinal (esófago, estómago e intestino), genito-urinario (útero y vejiga de la orina) o sistema vascular (arterias y venas) y juega un papel central en el desarrollo de la mayoría de las funciones vitales. Las alteraciones en los mecanismos de contracción/relajación del músculo liso constituyen, junto a las que se producen en la capacidad proliferativa, la principal causa de enfermedad en el mundo occidental. Por este motivo, muchos de los fármacos empleados actualmente en clínica tienen como diana el músculo liso. Ello también explica la necesidad de desarrollar nuevos fármacos de mayor actividad y selectividad a este nivel. En los últimos años se han producido grandes avances en el conocimiento de los procesos de contracción y relajación muscular. Tras el aumento de la concentración intracelular de Ca2+, el paso último y necesario para que se desencadene la contracción es la fosforilación de una proteína, la miosina. La defosforilación de la misma por una proteína fosfatasa conduce a la relajación. El descubrimiento de inhibidores selectivos de esta fosfatasa ha sido esencial para observar que la sensibilidad de la maquinaria contráctil al Ca2+ varía en función del estímulo que genera la respuesta. Sin embargo, en el caso concreto de la musculatura de fibra lisa uterina, los factores involucrados en el control de la motilidad son, aun, poco conocidos, y ello a pesar del carácter esencial de este músculo en la pervivencia de nuestra especie y los crecientes problemas de infertilidad de nuestra sociedad. Además, lo que sí está bien establecido es el importante papel que juegan las hormonas ováricas en la regulación de la reactividad uterina, lo que añade complejidad al ya de por sí complicado mecanismo de contracción muscular e implica la imposibilidad de extrapolar al útero los resultados obtenidos en otros músculos lisos. Dentro de nuestro proyecto de investigación, el presente trabajo de Tesis Doctoral ha tenido como objetivo profundizar en el estudio de los mecanismos capaces de modular (aumentar o disminuir) la sensibilidad al Ca2+ de la maquinaria contráctil del miometrio. Los estudios se han llevado a cabo en ratas no preñadas en distintas fases del ciclo hormonal y en ratas preñadas en diferentes estadíos del periodo de gestación. CONCLUSIONES 1. El útero de rata es altamente sensible a los cambios en la concentración extracelular e intracelular de K+. el nivel de contractilidad esta directamente relacionado con la concentración intracelular de potasio, [K+]i. 2. La contracción inducida por KCl (30-210 mM) es independiente de la activación del Complejo Ca2+-calmodulina y no está mediada por activación de la proteína kinasa C ó ácido araquidónico y sus derivados. El mecanismos por el que el que se produce la contracción permanece inaclarado pero implica, al menos en parte, una alteración del equilibrio entre la kinasa de la cadena ligera de miosina, MLCK, y la fosfatasa de la miosina, MLCPP. 3. El gradiente de Na+ y K+ a través de membrana modula la sensibilidad de la maquinaria contráctil al Ca2+ a través de un proceso que parece implicar la activación de proteínas G sensibles al fluoruro de aluminio. Ello proporciona un mecanismo mediante el cual la bomba de Na+/K+, la ATPasa de membrana responsable del mantenimiento de los gradientes de estos iones, participa en el control de la sensibilidad de la maquinaria contráctil del útero. 4. El gradiente de Na+ y K+ a través de membrana modula la sensibilidad de la maquinaria contráctil uterina al ácido okadaico de una manera compleja y diferentes del efecto sobre el KCl, la OXY y el VAN. 5. Las hormonas ováricas, que modulan los niveles intracelulares de Na+ y K+, juegan un importante papel en la regulación de la sensibilidad de la maquinaria contráctil uterina, que es particularmente evidente en el curso de la preñez. Esta regulación está mediada, al menos en parte, por un cambio en la exposición de la fosfatasa de la miosina, MLCPP. 6. Los agentes que aumentan el AMPc o abren canales de K+ son capaces de inducir una desensibilización de la maquinaria contráctil uterina. Al contrario de lo que ocurre en la mayoría de los músculos lisos, las isoformas de proteína kinasa C sensibles a ésteres de forbol ejercen una acción inhibidora sobre la sensibilidad de las proteínas contráctiles uterinas. El GMPc se muestra prácticamente incapaz de modificar dicha sensibilidad. 7. El péptido relacionado con el gen de la calcitonina, CGRP, ejerce una acción inhibidora que esta parcialmente mediada por la apertura de canales de K+, pero no parece relacionada con el aumento de los niveles de AMPc. A pesar de su acción inhibidora, el CGRP produce un aumento en la concentración intracelular de Ca2+

Effectiveness and Safety of Treatments for Degenerative Ataxias: A Systematic Review

The aim of this study was to determine the effectiveness and safety of available treatment alternatives for degenerative ataxias (DA). We systematically reviewed studies that assess pharmacological, rehabilitative, or psychological treatments in patients with DA. Studies were included if they fulfilled prespecified criteria. All included clinical trials were scored for methodological quality. Main outcome measures were clinical status of neurological disorder, adverse events, and patient‐based factors. Twenty‐five studies were included. Most studies were of small sample sizes, wide age variations, and low scientific validity. Only one study gave information on physical rehabilitation and none on psychological therapy. The remaining 24 studies reported on the effects of different pharmacological treatments. Outcomes such as functional capacity and psychological functioning of patients were evaluated by few studies. Some evidence supports that 5‐hydroxytryptophan is more effective than placebo improving neurological symptoms in patients with Friedreich ataxia (FA), olivopontocerebellar atrophy, or cerebellar atrophy. Idebenone is more effective than placebo for halting and reversing the hypertrophic cardiomyopathy associated with FA, but it seems unable to improve neurological semiology. Limited evidence for other therapies was found. No relevant side effects for drugs that shown some degree of effectiveness were reported. Availability of quality studies to evaluate the safety and efficacy of treatments for most DA is scarce. No valid information on the actual value of physical rehabilitation and psychological support as treatments for DA is available. Further investigations with improved trial designs are necessary.Peer reviewe

Hormonal regulation of the contractile response induced by okadaic acid in the rat uterus. J Pharmacol Exp Ther 296: 841–848

ABSTRACT The contractile effect of okadaic acid (OA), a highly selective inhibitor of protein serine/threonine phosphatases, was analyzed in the rat uterus during the estrous cycle and during the course of pregnancy. Contractile effects were related to circulating levels of estrogen and progesterone and to mRNA levels of myosin light chain kinase (MLCK) and of myosin light chain protein phosphatase catalytic (PP1-␦) and larger regulatory subunit (MYPT). Both in nonpregnant and pregnant uteri, OA (20 M) induced a transient contraction, which after plateauing, slowly decreased. In the nonpregnant uterus, the amplitude of this contraction varied at different stages of the estrous cycle, being higher at proestrus and lower at diestrus. In the pregnant uterus, the contraction to OA increased significantly during the course of pregnancy, reaching a maximum in day 21 pregnant rats, and declined after delivery. Whatever the day of pregnancy, the amplitude of the contraction to OA was not significantly modified when obtained in Ca 2ϩ -free solution. The magnitude of the OA-induced contraction in spontaneously cycling and pregnant rats was positively correlated to the ratio of estrogen/progesterone serum levels. Reverse transcriptionpolymerase chain reaction assays on myometrial tissue demonstrated that mRNA expression of PP1-␦ and MYPT was higher at early (day 3) than at late (day 21) pregnancy. MLCK mRNA levels were similar in day 3 and day 21 pregnant rats. These data suggest that changes in the expression and activity of myosin phosphatase may contribute to modulating the level of uterine contractile force during the estrous cycle, pregnancy, and labor