Evaluación de la eficacia de dos intervenciones educativas a corto plazo sobre las técnicas ed inhalación en pacientes con enfermedad pulmonar obstructiva crónica. Estudio TECEPOC

En diversos estudios se ha observado que más del 85% de los pacientes no utiliza los inhaladores correctamente y que el entrenamiento repercute positivamente en su uso. Objetivos: Evaluar la eficacia de dos intervenciones educativas para mejorar la técnica de inhalación en 465 pacientes con EPOC (Enfermedad Pulmonar Obstructiva Crónica) de 9 centros de salud del Distrito Sanitario de Málaga-Guadalhorce y del Área Sanitaria Málaga Este-Axarquía. Evaluar la influencia de las preferencias sobre la mejora en la técnica de inhalación. Metodología: Diseño: Ensayo clínico de preferencias parcialmente aleatorizado o diseño de cohorte comprensivo. Los pacientes fueron asignados inicialmente a uno de los dos grupos del estudio (Preferencia y Aleatorización) y dentro de cada grupo a uno de los brazos establecidos (Intervención A, Intervención B, Control). Después de explicarle las dos intervenciones que se iban a realizar en cada grupo, se preguntó al paciente si tenía preferencia por alguna de ellas. Si mostraba preferencia se asignaba directamente al grupo de preferencias en el brazo de Intervención A (BPA) o Brazo de intervención B (BPB). Si no era así se asignaba aleatoriamente a un brazo dentro del grupo de aleatorización (Brazo Control o BAC, Brazo de Intervención A o BAA y Brazo de Intervención B o BAB). Los dos grupos tuvieron el mismo seguimiento y visitas durante 3 meses. Intervenciones: Las dos intervenciones educativas diseñadas corresponden a las que han mostrado más eficacia según la bibliografía y están recogidas en el consenso SEPAR-ALAT (Sociedad Española de Neumología y Cirugía Torácica-Asociación Latinoamericana del Tórax) sobre terapia inhalada. Intervención A: Se entregó a los pacientes un folleto explicativo con información sobre la correcta técnica de inhalación de los dispositivos usados más frecuentemente en nuestra área (Handihaler®, Accuhaler®, Turbuhaler® y cartucho presurizado), describiéndose la técnica paso a paso, incluyendo imágenes ilustrativas. A los participantes de este grupo se les pidió que mostraran cómo realizaban la técnica de inhalación mediante dispositivos placebo, anotando el entrevistador los fallos cometidos. Posteriormente se les entregaba el folleto explicativo invitándoles a que lo leyeran para las siguientes visitas. Intervención B (información escrita mediante folleto explicativo más instrucción por monitor) se realizó en tres pasos. Primero, los pacientes realizaban la demostración mediante dispositivos placebo, anotando los errores cometidos, posteriormente se realizaba la demostración mediante el monitor preguntándole por los errores percibidos, y finalmente se entrenaba al paciente hasta que realizaba adecuadamente la técnica de inhalación. Como instrumento de evaluación de la correcta técnica de inhalación se utilizó una plantilla de pasos necesarios para realizar adecuadamente la técnica de inhalación especialmente diseñada para el estudio y basada en las recomendaciones SEPAR vigentes en el momento del estudio. Tamaño muestral: 465 pacientes con EPOC para el estudio. Variables. Variable resultado principal: realización correcta de la técnica de inhalación según recomendaciones de la SEPAR. Variables resultado secundarias: Espirometría forzada (patrón y severidad), pico de flujo inhalatorio, índice de disnea basal (IDB), escala de disnea modificada del Medical Research Council (mMRC), test EuroQuol-5-D, cuestionario respiratorio St. George, cuestionario SeguiEPOC. Variables independientes: edad, sexo, IMC, nivel educativo, estado civil, hábito tabáquico, comorbilidades, criterios diagnósticos de EPOC, número de reagudizaciones de EPOC en último año, número de visitas al centro de salud, especialista, urgencias de servicios sanitarios, ingresos en UCI, hospital y planta, medicación prescrita en el momento del estudio para su EPOC, instrucción de la técnica de inhalación, tiempo de instrucción de la técnica, método de instrucción, número de dispositivos, Mini Mental Test, test de APGAR familiar y el test de Duke-UNC Análisis estadístico: Descriptivo de todas las variables contempladas en el estudio. Se realizó también un análisis bivariante de cada variable para la comparación entre los brazos y grupos del estudio y además un análisis multivariante mediante regresión múltiple para valorar la asociación significativa entre las diferentes variables con la correcta técnica de inhalación, a través de las diferencias encontradas en la realización de los análisis previos. Resultados: 1. 92.9% de tasa de error en las técnicas de inhalación al inicio del estudio predominando los errores relacionados con una falta de preparación del paciente ante la maniobra de inhalación: no exhalar previamente a la inspiración de la medicación y no realizar apnea tras la inspiración. Por dispositivo el que presentó un mayor porcentaje de error fue el cartucho presurizado (91.7%), seguido del Handihaler® (91.3%), Turbuhaler® (89.5%) y Accuhaler® (85.6%). 2. La técnica de inhalación mejoró desde la primera visita para los sujetos que recibieron instrucción con monitor (intervención B), tanto en el grupo aleatorizado como en el de preferencias. Los sujetos que recibieron sólo un folleto (intervención A) se comportaron de forma similar a los controles, aunque se detectaron diferencias significativas en el grupo aleatorizado respecto al brazo control. 3. El paciente con preferencias tiene mayor afectación clínico-espirométrica por la EPOC, menor número de reagudizaciones en el año previo, mayor afectación de la calidad de vida relacionada con actividades cotidianas y menor nivel educativo. 4. No se ha detectado efecto significativo de las preferencias sobre la realización de una correcta técnica de inhalación. 5. La instrucción con monitor consigue aumentar entre un 43% (en el grupo de preferencias) y un 35% (en el grupo aleatorizado) el número de personas que hacen una técnica de inhalación correcta con respecto a la entrega de un folleto, es decir, por cada 2 o 3 pacientes que entrenamos con monitor en la realización correcta de la técnica, conseguimos que uno la aprenda y la realice bien. 6. Realizar una correcta técnica de inhalación se asocia con: recibir una instrucción utilizando una demostración con dispositivo placebo (intervención B), tener un pico de flujo inhalatorio alto y usar los dispositivos Accuhaler® y Turbuhaler®. Mientras que tener más de un dispositivo y mayor deterioro cognitivo empeoran la técnica de inhalación. Conclusión: El entrenamiento con monitor en técnicas de inhalación mejora significativamente el correcto uso de los inhaladores en pacientes con EPOC. Las preferencias no influyen significativamente en la mejora de la técnica de inhalación

Crack origin and detection in thin cristallyne solar cells in a production line

In order to reduce cost and make up for the rising price of silicon, silicon wafers are sliced thinner and wider,eading to weaker wafers and increased breakage rates during fabrication process. In this work we have analysed different cracks origins and their effect on wafer’s mechanical strength. To enhance wafer’s strength some etching methods have been tested. Also, we have analysed wafers from different points of an entire standard production process. Mechanical strength of the wafers has been obtained via the four line bending test and detection of cracks has been tested with Resonance Ultrasonic Vibration (RUV) system, developed by the University of South Florida

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

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

Study protocol for a randomized, controlled trial comparing the efficacy of two educational interventions to improve inhalation techniques in patients with chronic obstructive pulmonary disease (COPD): TIEPOC Study.

Background: An appropriate inhalation technique and adherence to treatment are both critical determinants of the success of chronic obstructive pulmonary disease (COPD) management. We have observed that up to 75% of patients do not use a successful inhalation technique. Knowledge evaluation and frequent reassessment of inhaler use, together with education of patients and healthcare professionals, can significantly improve the benefits that patients with COPD will derive from inhaler therapy. The objective of this study is to test the efficacy of two educational interventions to improve inhalation techniques in patients with COPD. Methods: Multicenter randomized controlled trial with 296 patients diagnosed with COPD selected by a non-probabilistic method of sampling from seven Spanish Primary Care Centers. The patients will be divided into three groups by block randomization. The three groups are: 1) control; 2) Intervention A; and 3) Intervention B. The control group will comprise patients with no explanations or written information; the Intervention A group will comprise patients to whom we give written information only; and the Intervention B group will comprise patients to whom we give written information plus instructor training. Every patient in each group will be visited four times during the year of the study at the health centers. Discussion: Our hypothesis is that the application of educational interventions (A or B) in patients with COPD who use inhaler therapy will increase the number of patients who perform a correct inhalation technique by at least 25%. We will evaluate the effectiveness of these interventions on patient inhalation technique improvement, where feasible within the context of clinical practice. post-index period

Efficacy of an educational intervention in primary health care in inhalation techniques: study protocol for a pragmatic cluster randomised controlled trial.

Chronic obstructive pulmonary disease (COPD) accounts for 10-12 % of primary care consultations, 7 % of hospital admissions and 35 % of chronic incapacity related to productivity. The misuse of inhalers is a significant problem in COPD because it is associated with reduced therapeutic drug effects leading to lack of control of both symptoms and disease. Despite all advice, health care professionals' practice management of inhalation treatments is usually deficient. Interventions to improve inhaler technique by health care professionals are limited, especially among primary care professionals, who provide the most care to patients with COPD. The aim of this study is to evaluate the efficacy of an educational intervention to train general practitioners (GPs) in the right inhalation technique for the most commonly used inhalers. We are conducting a pragmatic cluster randomised controlled trial. The sample population is composed of 267 patients diagnosed with COPD using inhalation therapy selected from among those in 20 general practices, divided into two groups (control and intervention) by block randomisation at 8 primary care centres. The sample has two levels. The first level is patients with COPD who agree to participate in the trial and receive the educational intervention from their GPs. The second level is GPs who are primary health care professionals and receive the educational intervention. The intervention is one session of the educational intervention with a monitor given to GPs for training in the right inhalation technique. The primary outcome is correct inhalation technique in patients. Secondary outcomes are functional status (spirometry) and quality of life. The follow-up period will be 1 year. GPs will have two visits (baseline and at the 1-year follow-up visit. Patients will have four visits (at baseline and 3, 6 and 12 months). Analysis will be done on an intention-to-treat basis. We carried out three previous clinical trials in patients with COPD, which showed the efficacy of an educational intervention based on monitor training to improve the inhalation technique in patients. This intervention is suitable and feasible in the context of clinical practice. Now we are seeking to know if we can improve it when the monitor is the GP (the real care provider in daily practise). ISRCTN Registry identifier ISRCTN93725230 . Registered on 18 August 2014