[Use of ineffective practices in Primary Health Care: professional opinions]. / Utilización de prácticas inefectivas en atención primaria: opinión de los profesionales.

OBJECTIVE: To estimate the frequency of ineffective practices in Primary Health Care (PHC) based on the opinions of clinical professionals from the sector, and to assess the significance, implications and factors that may be contributing to their continuance. MATERIAL AND METHODS: An on line survey of opinion from a convenience sample of 575 professionals who had published articles over the last years in Atención Primaria and Semergen medical journals. RESULTS: A total of 212 professionals replied (37%). For 70.6% (95% confidence interval [CI] 64.5 to 73.3) the problem of ineffective practices is frequent or very frequent in PHC, and rate their importance with an average score of 7.3 (standard deviation [SD]=1.8) out of 10. The main consequences would be endangering the sustainability of the system (48.1%; 95% CI, 41.2 to 54.9) and harming patients (32.1%; 95% CI, 25.7 to 38.5). These ineffective practices are the result of the behaviour of the patients themselves (28%; 95% CI, 22.6 to 35.0) workload (26.4%; 95% CI, 20.3 to 32.5), and the lack of the continuous education (19.3%; 95% CI, 13.9 to 24.7). Clinical procedures of greatest misuse are the prescribing of antibiotics for certain infections, the frequency of cervical cancer screening, rigorous pharmacological monitoring of type 2 diabetes in patients over 65 years, the use of psychotropic drugs in the elderly, or the use of analgesics in patients with hypertension or renal failure. CONCLUSIONS: The use of ineffective procedures in PHC is considered a very important issue that negatively affects many patients and their treatment, and possibly endangering the sustainability of the system and causing harm to patients.

[Amenable mortality as indicator of effectiveness of health care services in Spain before and after transferences]. / Mortalidad reducible como indicador de efectividad de los servicios sanitarios en España antes y después de las transferencias.

OBJECTIVE: To describe the evolution of amenable mortality (MRASS) in Spain and to evaluate differences in trend patterns before and after health care services were transferred to local authorities. METHODS: MRASS was defined from a list of causes of death used in other studies. We analyzed the change in sex-age-standardized death rates of MRASS in two periods: 1999-2001 and 2006-2008, just before, and five years after, the health care transfers were completed. RESULTS: MRASS represented 24% of deaths in persons from 0 to 74 years old. MRASS has seen a reduction (19.4%) between the two periods over and above other causes of mortality (14.5%). The group of causes of mortality which showed most reduction: ischemic heart disease (28%), other vascular disease (27%), surgical conditions and surgical-medical errors (26%), and diabetes (22.5%). Although there were differences between the districts, health care transfers have not created significant variations in MRASS. Navarra and Madrid showed lower rates of MRASS, and the Canary Islands, Asturias, Andalusia, Ceuta and Melilla had higher rates. The Balearic Islands showed the greatest reduction in MRASS. CONCLUSIONS: MRASS constitutes an important proportion of trends of mortality in persons between 0-74 years. It has declined in all districts. Even though there were large differences between districts, there does not appear to be any direct influence due to health care transfer in amenable mortality trends. In spite of limitations, MRASS is an indicator to be considered when monitoring and detecting weaknesses in the effectiveness of health care systems.

Transmission of trans effects in dinuclear complexes.

The substitution of a terminal hydride ligand in the complexes [Ir(2)(mu-H)(mu-Pz)(2)H(3)(L)P(i)Pr(3))(2)] (L = NCCH(3) (1) or pyrazole (3)) by chloride provokes a significant change in the lability of the L ligand, despite the fact that the substituted hydride and the L ligand lie in opposite extremes of the diiridium(III) complexes. Detailed structural studies of complex 3 and its chloro-trihydride analogue [Ir(2)(mu-H)(mu-Pz)(2)H(2)Cl(HPz)(P(i)Pr(3))(2)] (4) have shown that this behavior is a consequence of the transmission of ligand trans effects from one extreme of the molecule to the other, with the participation of the bridging hydride. Extended Hückel calculations on model diiridium complexes have suggested that such trans effect transmissions are due to the formation of molecular orbitals of sigma symmetry extended along the backbones of the complexes. This is also an expected feature for metal-metal bonded complexes. The feasibility of the transmission of ligand trans effects and trans influences through metal-metal bonds and its relevance to the understanding of both the reactivity and structures of metal-metal bonded dinuclear compounds have been substantiated through structural studies and selected reactions of the diiridium(II) complexes [Ir(2)(mu-1,8-(NH)(2)naphth)I(CH(3))(CO)(2)(P(i)Pr(3))(2)] (isomers 6 and 7) and their cationic derivatives [Ir(2)(mu-1,8-(NH)(2)naphth)(CH(3))(CO)(2)(P(i)Pr(3))(2)](CF(3)SO(3)) (isomers 8 and 9).

Synthesis of paramagnetic tetranuclear rhodium and iridium complexes with the 2,6-pyridinedithiolate ligand. Redox-induced degradation to diamagnetic triiridium compounds.

The tetranuclear complexes [M4(mu-PyS2)2(diolefin)4] [PyS2 = 2,6-pyridinedithiolate; M = Rh, diolefin = cod (1,5-cyclooctadiene) (1), tfbb (tetrafluorobenzo[5,6]bicyclo[2.2.2]octa-2,5,7-triene) (2); M = Ir, diolefin = cod (3), tfbb (4)] exhibit two one-electron oxidations at a platinum disk electrode in dichloromethane at potentials accessible by chemical reagents. The rhodium tetranuclear complexes were selectively oxidized to the monocationic complexes [Rh4(mu-PyS2)2(diolefin)4](+) (1(+), 2(+)) by mild one-electron oxidants such as [Cp2Fe](+) or [N(C6H4Br-4)3](+) and isolated as the PF6(-), BF4(-), and ClO4(-) salts. Silver salts behave as noninnocent one-electron oxidants for the reactions with the rhodium complexes 1 and 2 since they give sparingly soluble coordination polymers. The complex [Ir4(mu-PyS2)2(cod)4](+) (3(+)) was obtained as the tetrafluoroborate salt by reaction of 3 with 1 molar equiv of AgBF4, but the related complex 4(+) could not be isolated from the chemical oxidation of [Ir4(mu-PyS2)2(tfbb)4] (4) with AgBF4. Oxidation of 3 and 4 with 2 molar equiv of common silver salts resulted in the fragmentation of the complexes to give the diamagnetic triiridium cations [Ir3(mu-PyS2)2(diolefin)3](+). The molecular structure of [Ir3(mu-PyS2)2(cod)3]BF4, determined by X-ray diffraction methods, showed the three metal atoms within an angular arrangement. Both 2,6-pyridinedithiolate tridentate ligands bridge two metal-metal bonded d(7) centers in pseudo octahedral environments and one d(8) square-planar iridium center. An interpretation of the EPR spectra of the 63-electron mixed-valence paramagnetic tetranuclear complexes suggests that the unpaired electron is delocalized over two of the metal atoms in the complexes 1(+)-3(+).

Key factors determining the course of methyl iodide oxidative addition to diamidonaphthalene-bridged diiridium(I) and dirhodium(I) complexes.

The course of methyl iodide oxidative addition to various nucleophilic complexes, [Ir2(mu-1,8-(NH)2naphth)(CO)2(PiPr3)2] (1), [IrRh(mu-1,8-(NH)2naphth)(CO)2(PiPr3)2] (2), and [Rh2(mu-1,8-(NH)2naphth)(CO)2(PR3)2] (R = iPr, 3; Ph, 4; p-tolyl, 5; Me, 6), has been investigated. The CH3I addition to complex 1 readily affords the diiridium(II) complex [Ir2(mu-1,8-(NH)2naphth)I(CH3)(CO)2(PiPr3)2] (7), which undergoes slow rearrangement to give a thermodynamically stable stereoisomer, 8. The reaction of the Ir-Rh complex 2 gives the ionic compound [IrRh(mu-1,8-(NH)2naphth)(CH3)(CO)2(PiPr3)2]I (10). The dirhodium compounds, 3-5, undergo one-center additions to yield acyl complexes of the formula (Rh2(mu-1,8-(NH)2naphth)I(COCH3)(CO)(PR3)2] (R = iPr, 12; Ph, 13; p-tolyl, 14). The structure of 12 has been determined by X-ray diffraction. Further reactions of these Rh(III)-Rh(I) acyl derivatives with CH3I are productive only for the p-tolylphosphine derivative, which affords the bis-acyl complex [Rh2(mu-1,8-(NH)2naphth)(CH3CO)2I2(P(p-tolyl)3)2] (15). The reaction of the PMe3 derivative, 6, allows the isolation of the bis-methyl complex [Rh2(mu-1,8-(NH)2naphth)(mu-I)(CH3)2(CO)2(PMe3)2]I (16a), which emanates from a double one-center addition. Upon reaction with methyl triflate, the starting materials, 1, 2, 3, and 6, give the isostructural cationic methyl complexes 9, 11, 17, and 18, respectively. The behavior of these cationic methyl compounds toward CH3I, CH3OSO2CF3, and tetrabutylamonium iodide is consistent with the role of these species as intermediates in the SN2 addition of CH3I. Compounds 18 and 17 react with an excess of methyl triflate to give [Rh2(mu-1,8-(NH)2naphth)(mu-OSO2CF3)(CH3)2(CO)2(PMe3)2][CF3SO3] (19) and [Rh2(mu-1,8-(NH)2naphth)(OSO2CF3)(COCH3)(CH3)(CO)(PiPr3)2][CF3SO3] (20), respectively. Upon treatment with acetonitrile, complexes 17 and 18 give the isostructural cationic acyl complexes [Rh2(mu-1,8-(NH)2naphth)(COCH3)(NCCH3)(CO)(PR3)2][CF3SO3] (R = iPr, 21; Me, 22). A kinetic study of the reaction leading to 21 shows that formation of these complexes involves a slow insertion step followed by the fast coordination of the acetonitrile. The variety of reactions found in this system can be rationalized in terms of three alternative reaction pathways, which are determined by the effectiveness of the interactions between the two metal centers of the dinuclear complex and by the steric constraints due to the phosphine ligands.