Telemental Health Services Usage and Association with Health Care Utilization and Expenditures Among Vulnerable Medicare Beneficiaries in 2019: A Comparative Study Using Propensity Score Matching.

Background: Telemental health (TMH) offers a promising approach to managing major depressive disorder (MDD). The objective of our work was to evaluate TMH usage among a vulnerable population of MDD Medicare beneficiaries and its association with health care utilization and expenditures. Methods: This cohort study analyzed 2019 Mississippi Medicare fee-for-service data for adult beneficiaries with MDD. Subjects were matched by the use of TMH following 1:1 propensity score matching. Comparisons between TMH and non-TMH cohorts were made on health care utilization and expenditure outcomes, adjusting for provider types postmatching. Results: Among 7,673 identified beneficiaries, 551 used TMH and 7,122 did not. Prematching, TMH cohort showed greater proportions of dual beneficiaries, rural residents, subjects with income below $40,000, those with disability entitlement, and higher Charlson comorbidity index scores, compared to the non-TMH cohort (all p < 0.001). Moreover, the TMH cohort had fewer outpatient visits, but more inpatient admissions, emergency department (ED) visits, and higher medical, pharmacy, and total expenditures (all p < 0.001). Postmatching, TMH was associated with a 25% reduction in outpatient visits (p < 0.001) and a 20% reduction in pharmacy expenditures (p = 0.01), with no significant effect on inpatient admissions, ED visits, medical expenditures, or total expenditures. Conclusions: These results underscore the potential of TMH in enhancing accessible health care services for vulnerable populations and affordable services for Medicare. Our results provide a robust baseline for future policy discussions concerning TMH. Future studies should consider identifying barriers to TMH use among vulnerable populations and ensuring equitable and high-quality patient care.

Medical deserts in Spain-Insights from an international project.

INTRODUCTION: Medical deserts are a growing phenomenon across many European countries. They are usually defined as (i) rural areas, (ii) underserved areas or (iii) by applying a measure of distance/time to a facility or a combination of the three characteristics. The objective was to define medical deserts in Spain as well as map their driving factors and approaches to mitigate them. METHODS: A mixed methods approach was applied following the project "A Roadmap out of medical deserts into supportive health workforce initiatives and policies" work plan. It included the following elements: (i) a scoping literature review; (ii) a questionnaire survey; (iii) national stakeholders' workshop; (iv) a descriptive case study on medical deserts in Spain. RESULTS: Medical deserts in Spain exist in the form of mostly rural areas with limited access to health care. The main challenge in their identification and monitoring is local data availability. Diversity of both factors contributing to medical deserts and solutions applied to eliminate or mitigate them can be identified in Spain. They can be related to demand for or supply of health care services. More national data, analyses and/or initiatives seem to be focused on the health care supply dimension. CONCLUSIONS: Addressing medical deserts in Spain requires a comprehensive and multidimensional approach. Effective policies are needed to address both the medical staff education and planning system, working conditions, as well as more intersectoral approach to the population health management.

Proxy measures for the assessment of psychotic and affective symptoms in studies using electronic health records.

BACKGROUND: There is a lack of standardised psychometric data in electronic health record (EHR)-based research. Proxy measures of symptom severity based on patients' clinical records may be useful surrogates in mental health EHR research. AIMS: This study aimed to validate proxy tools for the short versions of the Positive and Negative Syndrome Scale (PANSS-6), Young Mania Rating Scale (YMRS-6) and Montgomery-Åsberg Depression Rating Scale (MADRS-6). METHOD: A cross-sectional, multicentre study was conducted in a sample of 116 patients with first-episode psychosis from 12 public hospitals in Spain. Concordance between PANSS-6, YMRS-6 and MADRS-6 scores and their respective proxies was evaluated based on information from EHR clinical notes, using a variety of statistical procedures, including multivariate tests to adjust for potential confounders. Bootstrapping techniques were used for internal validation, and an independent cohort from the Treatment and Early Intervention in Psychosis Program (TIPP-Lausanne, Switzerland) for external validation. RESULTS: The proxy versions correlated strongly with their respective standardised scales (partial correlations ranged from 0.75 to 0.84) and had good accuracy and discriminatory power in distinguishing between patients in and not in remission (percentage of patients correctly classified ranged from 83.9 to 91.4% and bootstrapped optimism-corrected area under the receiver operating characteristic curve ranged from 0.76 to 0.89), with high interrater reliability (intraclass correlation coefficient of 0.81). The findings remained robust in the external validation data-set. CONCLUSIONS: The proxy instruments proposed for assessing psychotic and affective symptoms by reviewing EHR provide a feasible and reliable alternative to traditional structured psychometric procedures, and a promising methodology for real-world practice settings.

Open data for monitoring COVID-19 in Spain: Descriptive study.

BACKGROUND: The indicators of the pandemic have been based on the total number of diagnosed cases of COVID-19, the number of people hospitalized or in intensive care units, and deaths from the infection. The aim of this study is to describe the available data on diagnostic tests, health service used for the diagnosis of COVID-19, case detection and monitoring. METHOD: Descriptive study with review of official data available on the websites of the Spanish health councils corresponding to 17 Autonomous Communities, 2 Autonomous cities and the Ministry of Health. The variables collected refer to contact tracing, technics for diagnosis, use of health services and follow-up. RESULTS: All regions of Spain show data on diagnosed cases of COVID-19 and deaths. Hospitalized cases and intensive care admissions are shown in all regions except the Balearic Islands. Diagnostic tests for COVID-19 have been registered in all regions except Madrid region and Extremadura, with scarcely information on what type of test has been performed (present in 7 CCAA), requesting service and study of contacts. CONCLUSIONS: The information available on the official websites of the Health Departments of the different regions of Spain are heterogeneous. Data from the use of health service or workload in Primary Care, Emergency department or Out of hours services are almost non-existent.

Study of the Direct Costs of Asthma at a Healthcare Service Provider in Bogotá, Colombia.

OBJECTIVES: This study aimed to describe clinical characteristics and direct medical costs associated with disease treatment in Colombia patients with asthma from 1 healthcare provider. METHODS: This was a descriptive study with a retrospective data collection from a healthcare provider's electronic medical records in Colombia. A clinical, demographic, and healthcare resource utilization profile was developed over a 12-month observation period after the identification of eligible patients. To determine the mean cost per patient per year, the total frequencies of resource utilization were added, and the result was multiplied by the unit cost of each of them. RESULTS: A total of 7919 patients were included in the analysis. The mean ± SD cost per patient per year ranged from $189.5 ± $1.900.6 to $240.2 ± $1.903.6 depending on the price guidebook. The total cost had been driven by the medication use (79% of total cost) and by the outpatient visits (20% of total cost). CONCLUSIONS: In the population analyzed, the mean total direct cost per patient per year of asthma was $189.5 and $240.2, depending on the cost source. Direct medical costs were higher in cases classified as severe and in the adult and elderly population. When comparing the sources of resource utilization, it was found that the mean cost per patient obtained from real-life data is lower than the theoretical cost obtained from the bottom-up method with quantification of resources from experts. It is important to consider limitations related to study design and the evolving landscape of asthma treatments.

Telemental Health Use Is Associated With Lower Health Care Spending Among Medicare Beneficiaries With Major Depression.

BACKGROUND: Some policymakers are concerned that expanding telehealth coverage may increase Medicare expenditures. However, there is limited evidence on the association of telehealth use with utilization and spending among Medicare beneficiaries with major depression. OBJECTIVE: To examine the differences in spending and utilization among telemental health users and non-telemental health users with major depression. METHODS: We examined 2014-2019 traditional Medicare claims data for beneficiaries aged ≥50 years with major depression in Texas. Multivariable generalized linear models were used to assess the relationships between telemental health use and Medicare spending and utilization while adjusting for patient demographics and programmatic and clinical factors. RESULTS: In each of the years between 2014 and 2019, an average of 4.6% Medicare beneficiaries with major depression had at least 1 telemental health visit. Compared with beneficiaries without a telemental health visit, those who had a telemental health visit were significantly more likely to be enrolled in Medicaid, be Medicare eligible due to a disability, live in a lower income area or in a rural area, and have a higher comorbidity index. Beneficiaries utilizing telemental health services incurred higher unadjusted Medicare spending than those not receiving telemental health services. However, this difference appeared due to beneficiary and programmatic characteristics rather than telemental health use. Adjusting for model covariates, the telemental health group had lower overall per member per year predicted spending, inpatient admissions, and emergency department visits than non-telemental health users. CONCLUSION: Our findings suggest that telemental health care use may improve access to mental health care without increasing Medicare spending among telemental health users in Texas.

Assessment of diaphragmatic function through surface electromyography in healthy individuais. A cross-section observational study

Introduction: Diaphragmatic surface electromyography is a procedure designed to assess the diaphragm. The physiological values of the electrical activity may have potential use in rehabilitation, sports training, ventilatory support withdrawal in critical care units and follow-up of respiratory disease. Objective: To assess and describe the diaphragmatic function through surface electromyography in a population of individuals during spontaneous and forced breathing. Methods: Observational, exploratory cross-sectional study including subjects with no comorbidities. Diaphragmatic surface EMG was performed measuring the mean quadratic root during tidal volume and vital capacity breathing. The body composition of the participants was also assessed. Results: 28 males and 22 females were included in the study. The mean quadratic root of the tidal volume for two minutes was 13.94 nV for females and 13.31 nV for males. The vital capacity was 23.24 nV for males and 22.4 nV for females. A correlation was identified between the mean quadratic root, weight, and body surface. Conclusions: Mean quadratic root values of tidal volume in two minutes in healthy females and males have been documented. The mean quadratic root values are correlated with the physiological and functional characteristics of the participants.

Introducción: La electromiografía de superficie diafragmática es un procedimiento para la evaluación diafragmática. Los valores fisiológicos de la actividad eléctrica tendrían aplicaciones potenciales en rehabilitación, entrenamiento deportivo, en el retiro ventilatorio en unidades de cuidado crítico y en el seguimiento a patologías respiratorias. Objetivo: Evaluar y describir la función diafragmática a través de electromiografía de superficie diafragmática en una población de sujetos durante la respiración espontánea y la respiración forzada. Métodos: Estudio observacional exploratorio de corte transversal en el que se incluyeron sujetos sin comorbilidades. Se realizó electromiografía de superficie diafragmática midiendo la raíz cuadrática media durante respiraciones de volumen corriente y capacidad vital. Adicionalmente, se valoró la composición corporal de los participantes. Resultados: Se incluyeron 28 hombres y 22 mujeres. La raíz cuadrática media de volumen corriente por dos minutos fue de 13,94 µV para mujeres y 13,31 µV para hombres, mientras que la capacidad vital fue 23,24 µV para hombres y 22,4 µV para mujeres. Se encontró una correlación entre la raíz cuadrática media, el peso y la superficie corporal. Conclusiones: Se han documentado los valores de la raíz cuadrática media de volumen corriente por dos minutos en mujeres y hombres sanos. Los valores de la raíz cuadrática media se correlacionan con características fisiológicas y funcionales de los participantes.

Addressing health inequity during the COVID-19 pandemic through primary health care and public health collaboration: a multiple case study analysis in eight high-income countries.

BACKGROUND: The COVID-19 pandemic substantially magnified the inequity gaps among vulnerable populations. Both public health (PH) and primary health care (PHC) have been crucial in addressing the challenges posed by the pandemic, especially in the area of vulnerable populations. However, little is known about the intersection between PH and PHC as a strategy to mitigate the inequity gap. This study aims to assess the collaboration between PHC and PH with a focus on addressing the health needs of vulnerable populations during the COVID-19 pandemic across jurisdictions. METHODS: We analyzed and compared data from jurisdictional reports of COVID-19 pandemic responses in PHC and PH in Belgium, Canada (Ontario), Germany, Italy, Japan, the Netherlands, Norway, and Spain from 2020 to 2021. RESULTS: Four themes emerge from the analysis: (1) the majority of the countries implemented outreach strategies targeting vulnerable groups as a means to ensure continued access to PHC; (2) digital assessment in PHC was found to be present across all the countries; (3) PHC was insufficiently represented at the decision-making level; (4) there is a lack of clear communication channels between PH and PHC in all the countries. CONCLUSIONS: This study identified opportunities for collaboration between PHC and PH to reduce inequity gaps and to improve population health, focusing on vulnerable populations. The COVID-19 response in these eight countries has demonstrated the importance of an integrated PHC system. Consequently, the development of effective strategies for responding to and planning for pandemics should take into account the social determinants of health in order to mitigate the unequal impact of COVID-19. Careful, intentional coordination between PH and PHC should be established in normal times as a basis for effective response during future public health emergencies. The pandemic has provided significant insights on how to strengthen health systems and provide universal access to healthcare by fostering stronger connections between PH and PHC.

Economic evaluation and costs of remote patient monitoring for cardiovascular disease in the United States: a systematic review.

BACKGROUND: Remote patient monitoring (RPM) has emerged as a viable and valuable care delivery method to improve chronic disease management. In light of the high prevalence and substantial economic burden of cardiovascular disease (CVD), this systematic review examines the cost and cost-effectiveness of using RPM to manage CVD in the United States. METHODS: We systematically searched databases to identify potentially relevant research. Findings were synthesized for cost and cost-effectiveness by economic study type with consideration of study perspective, intervention, clinical outcome, and time horizon. The methodological quality was assessed using the Joanna Briggs Institute Checklist for Economic Evaluations. RESULTS: Thirteen articles with fourteen studies published between 2011 and 2021 were included in the final review. Studies from the provider perspective with a narrow scope of cost components identified higher costs and similar effectiveness for the RPM group relative to the usual care group. However, studies from payer and healthcare sector perspectives indicate better clinical effectiveness of RPM relative to usual care, with two cost-utility analysis studies suggesting that RPM relative to usual care is a cost-effective tool for CVD management even at the conservative $50,000 per Quality-Adjusted Life-Year threshold. Additionally, all model-based studies revealed that RPM is cost-effective in the long run. CONCLUSIONS: Full economic evaluations identified RPM as a potentially cost-effective tool, particularly for long-term CVD management. In addition to the current literature, rigorous economic analysis with a broader perspective is needed in evaluating the value and economic sustainability of RPM.

Prognostic significance of incorporating exercise tissue doppler mitral annular early diastolic velocity in exercise diastolic dysfunction assessment.

BACKGROUND: The existing algorithm for defining exercise-induced diastolic dysfunction incorporates resting e' velocity as a surrogate of myocardial relaxation. The additive prognostic value of incorporating post-exercise e' velocity in definition of exercise-induced diastolic dysfunction is poorly studied. AIM: To define the additive prognostic value of post-exercise e' septal velocity in the assessment of exercise-induced diastolic dysfunction compared to the traditional approach. METHODS: This retrospective study included 1409 patients undergoing exercise treadmill echocardiography with available full set of diastolic variables. Doppler measures of diastolic function included resting septal e' velocity, post-exercise septal e' velocity, post-exercise E/e' ratio, and post-exercise tricuspid regurgitant jet velocity. Approaches incorporating resting septal e' velocity and post-exercise septal e' velocity were compared in defining exercise-induced diastolic dysfunction, and for association with adverse cardiovascular outcomes. RESULTS: The mean age of study subjects was 56.3 ± 16.5 years and 791 (56%) patients were women. A total of 524 patients had disagreement between resting and post exercise septal e' velocities, and these values showed only weak agreement (kappa statistics: .28, P = .02). All categories of the traditional exercise-induced DD approach incorporating resting septal e' velocity witnessed reclassification when exercise septal e' velocity was used. When both approaches were compared, increased event rates were only evident when both approaches agreed on exercise-induced diastolic dysfunction (HR: 1.92, P < .001, 95% CI: 1.37-2.69). This association persisted after multivariable adjustment and propensity score matching for covariates. CONCLUSION: Incorporation of post-exercise e' velocity into the set of variables defining exercise-induced diastolic dysfunction can improve the prognostic utility of diastolic function assessment.

Cost of remote patient monitoring for cardiovascular disease: a systematic review protocol.

OBJECTIVE: This review aims to evaluate the costs and cost-effectiveness of remote patient monitoring for cardiovascular disease in the United States. INTRODUCTION: Cardiovascular disease is a leading public health concern in the United States, resulting in a substantial economic burden. Remote patient monitoring has emerged as a viable and valuable care delivery method to improve cardiovascular disease management at home. However, there is limited systematic research of the cost and cost-effectiveness of using remote patient monitoring to manage the disease. INCLUSION CRITERIA: This review will consider all studies evaluating the cost of remote patient monitoring for cardiovascular disease management in the United States. The population of interest includes all individuals with various types of chronic cardiovascular disease in the United States. METHODS: The search strategy will locate both published and unpublished studies. Systematic searches will be completed in PubMed, Embase, Web of Science, CINAHL, Scopus, Cochrane Central Register of Controlled Trials, ClinicalTrials.gov, National Health Service Economic Evaluation Database, and the Cost-Effectiveness Analysis Registry. Two reviewers will independently screen titles and abstracts, followed by a full-text review against the inclusion criteria. Disagreements will be resolved through discussion between all study members. The JBI checklist for economic evaluations will be utilized to evaluate the methodological quality of studies. Data will be extracted using a modified version of the JBI data extraction form for economic evaluations. Reviewers will summarize studies and cost-related metrics. The Dominance Ranking Matrix will be used to synthesize full economic evaluation. SYSTEMATIC REVIEW REGISTRATION NUMBER: PROSPERO CRD42021270621.

Frequency and estimated costs of ten low-value practices in the Spanish primary care: a retrospective study.

BACKGROUND: The frequency of low-value practices (LVPs) in the healthcare system is a worldwide challenge. This study aimed to evaluate the LVPs trend in Spanish primary care (PC), its frequency in both sexes, and estimate its related extra cost. METHODS: A multicentric, retrospective, and national research project was conducted. Ten LVPs highly frequent and potentially harmful for patients were analyzed (majority of them related to prescription). Algorithms were applied to collect the data from 28,872,851 episodes registered into national databases (2015-2017). RESULTS: LVPs registered a total of 7,160,952 (26.5%) episodes plus a total of 259,326 avoidable PSA screening tests. In adults, a high frequency was found for inadequate prescription of paracetamol antibiotics, and benzodiazepines . Women received more jeopardizing practices (p ≤ 0.001). Pediatrics presented a downward of antibiotic and paracetamol-ibuprofen prescription combination. The estimated extra cost was close to €292 million (2.8% of the total cost in PC). CONCLUSION: LVPs reduction during the analyzed period was moderate compared to studies following 'Choosing Wisely list' of LVPs and must improve to reduce patient risk and the extra related costs.

[The Global Patient Safety Action Plan 2021-2030: Identifying actions for safer primary health care]. / El Plan de acción mundial para la seguridad del paciente 2021-2030: identificando acciones para una atención primaria más segura.

The 74th World Health Assembly adopted in May 2021 the "Global Patient Safety Action Plan: 2021-2030" to enhance patient safety as an essential component in the design, procedures and performance evaluation of health systems worldwide. It is a strategic plan that guides country governments, health sector entities, health organisations and the World Health Organisation secretariat on how to implement the assembly's patient safety resolution. Deployment of the plan will strengthen the quality and safety of health systems worldwide by spanning the entire continuum of people's health care from diagnosis to treatment and care, reducing the likelihood of harm in the course of care. The Declaration on Primary Health Care during the Global Conference on Primary Health Care in Astana, 2018, urged countries to strengthen their primary health care systems as an essential step towards achieving universal health coverage and providing access to safe, quality care without financial loss. The deployment of the Global Patient Safety Action Plan in primary care is therefore a high-priority health policy action. The Action Plan is structured into 6 strategic objectives with 35 strategic actions. We present an analysis of the strategic actions regarding healthcare organizations and the challenges ahead for their particular deployment in primary health care settings.

Costo humano oculto en la experiencia vivida de un cuidador de adulto mayor con alzhéimer / Human Cost Hidden in Caregiver Life Experience of an Alzheimer's Elderly

Introducción: El ser cuidador de un paciente crónico con alzhéimer aumenta el riesgo de repercutir en la calidad de vida. Lo anterior se puede observar con el costo humano oculto: las implicaciones negativas en lo social, salud emocional, salud física y problemas económicos que conlleva a ser cuidador informal. Objetivo: Explorar el fenómeno de costo humano oculto de la experiencia de vida de un cuidador informal de adulto mayor con alzhéimer. Métodos: Estudio de caso de aproximación fenomenológica. Se aplicó entrevista semiestructurada con una pregunta generadora y cinco para profundizar en el fenómeno del cuidar a un adulto mayor con alzhéimer grave. Se analizaron datos de forma artesanal. El rigor científico utilizado fue la credibilidad y auditabilidad. Resultados: El participante fue un hombre de 53 años, cuidador desde hace siete años de una adulta mayor con alzhéimer. De la experiencia de vida emergieron una metacategoría, y dos categorías. La primera categoría fue el costo humano oculto en el cuidador, que consiste en el impacto de cuidar en sus relaciones sociales, sobrecarga y dificultad económica, la segunda fue el afrontamiento implementado por el cuidador a través de actividades recreativas, religión y recordar la razón del cuidado. Conclusiones: El conocer el costo humano oculto de ser cuidador permitirá proporcionar evidencias para establecer futuras intervenciones y atender a las necesidades para el cuidado biológico, psicológico, social y espiritual de este grupo vulnerable(AU)

Introduction: Being the caregiver of a chronic patient with Alzheimer's increases the risk of affecting the quality of life. The hidden human cost is seen in the negative implications in social, emotional health, physical health and economic problems that lead to being an informal caregiver. Objective: To explore the phenomenon of hidden human cost of the life experience of an informal caregiver of the elderly with Alzheimer's. Methods: We report a case study of phenomenological approach. We carried out a semi-structured interview with one generating question and five to delve into the phenomenon of caring for an older adult with severe Alzheimer's. Data were analyzed in an artisanal way. The scientific rigor used was credibility and auditability. Results: The participant was a 53-year-old man, who was a caregiver for an older adult with Alzheimer's disease for seven years. From life experience, a meta-category and two categories emerged. The first category was the hidden human cost in the caregiver, consisting of the caring impact on his social relationships, overload and economic difficulty. The second was the coping implemented by the caregiver through recreational activities, religion and remembering the reason for caring. Conclusions: Knowing the hidden human cost of being a caregiver will provide evidence to establish future interventions and to meet the needs for biological, psychological, social and spiritual care of this vulnerable group(AU)

Effectiveness of New Tools to Define an Up-to-Date Patient Safety Risk Map: A Primary Care Study Protocol.

BACKGROUND: Reducing incidents related to health care interventions to improve patient safety is a health policy priority. To strengthen a culture of safety, reporting incidents is essential. This study aims to define a patient safety risk map using the description and analysis of incidents within a primary care region with a prior patient safety improvement strategy organisationally developed and promoted. METHODS: The study will be conducted in two phases: (1) a cross-sectional descriptive observational study to describe reported incidents; and (2) a quasi-experimental study to compare reported incidents. The study will take place in the Camp de Tarragona Primary Care Management (Catalan Institute of Health). In Phase 1, all reactive notifications collected within one year (2018) will be analysed; during Phase 2, all proactive notifications of the second and third weeks of June 2019 will be analysed. Adverse events will also be assessed. Phases 1 and 2 will use a digital platform and the proactive tool proSP to notify and analyse incidents related to patient safety. EXPECTED RESULTS: To obtain an up-to-date, primary care patient safety risk map to prioritise strategies that result in safer practices.

Comprehensive assessment of respiratory function, a step towards early weaning from the ventilator.

Methods for assessing diaphragmatic function can be useful in determining the functional status of the respiratory system and can contribute to determining an individual's prognosis, depending on their pathology. They can also be a useful tool for making objective decisions regarding mechanical ventilation weaning and extubation. Esophageal and transdiaphragmatic pressure measurement, diaphragm ultrasound, diaphragmatic excursion, surface electromyography (sEMG) and some serum biomarkers are of increasing interest and use in clinical and intensive care settings to offer a more objective process for withdrawing mechanical ventilation; especially in the situation that we are experiencing with the increased demand for mechanical ventilation to treat patients with Covid-19-associated viral pneumonia. In this literature review, we updated the clinical and physiological indicators with more evidence to improve ventilator withdrawal techniques. We concluded that, to ensure successful extubation in a way that is useful, cost-effective, practical for health personnel and non-invasive for the patient, further studies of novel techniques such as surface electromyography should be implemented.

Adapting a home telemonitoring intervention for underserved Hispanic/Latino patients with type 2 diabetes: an acceptability and feasibility study.

BACKGROUND: Home telemonitoring is a promising approach to optimizing outcomes for patients with Type 2 Diabetes; however, this care strategy has not been adapted for use with understudied and underserved Hispanic/Latinos (H/L) patients with Type 2 Diabetes. METHODS: A formative, Community-Based Participatory Research approach was used to adapt a home telemonitoring intervention to facilitate acceptability and feasibility for vulnerable H/L patients. Utilizing the ADAPT-ITT framework, key stakeholders were engaged over an 8-month iterative process using a combination of strategies, including focus groups and structured interviews. Nine Community Advisory Board, Patient Advisory, and Provider Panel Committee focus group discussions were conducted, in English and Spanish, to garner stakeholder input before intervention implementation. Focus groups and structured interviews were also conducted with 12 patients enrolled in a 1-month pilot study, to obtain feedback from patients in the home to further adapt the intervention. Focus groups and structured interviews were approximately 2 hours and 30 min, respectively. All focus groups and structured interviews were audio-recorded and professionally transcribed. Structural coding was used to mark responses to topical questions in the moderator and interview guides. RESULTS: Two major themes emerged from qualitative analyses of Community Advisory Board/subcommittee focus group data. The first major theme involved intervention components to maximize acceptance/usability. Subthemes included tablet screens (e.g., privacy/identity concerns; enlarging font sizes; lighter tablet to facilitate portability); cultural incongruence (e.g., language translation/literacy, foods, actors "who look like me"); nursing staff (e.g., ensuring accessibility; appointment flexibility); and, educational videos (e.g., the importance of information repetition). A second major theme involved suggested changes to the randomized control trial study structure to maximize participation, including a major restructuring of the consenting process and changes designed to optimize recruitment strategies. Themes from pilot participant focus group/structured interviews were similar to those of the Community Advisory Board such as the need to address and simplify a burdensome consenting process, the importance of assuring privacy, and an accessible, culturally congruent nurse. CONCLUSIONS: These findings identify important adaptation recommendations from the stakeholder and potential user perspective that should be considered when implementing home telemonitoring for underserved patients with Type 2 Diabetes. TRIAL REGISTRATION: NCT03960424; ClinicalTrials.gov (US National Institutes of Health). Registered 23 May 2019. Registered prior to data collection. https://www.clinicaltrials.gov/ct2/show/NCT03960424?term=NCT03960424&draw=2&rank=1.

[Health, incidence and differences in the territorial vulnerability city of Madrid]. / Salud e incidencia y diferencias en vulnerabilidad territorial de la ciudad de Madrid.

OBJECTIVE: Territoriality is configured as an important axis of inequality. The objective of this study was to determine the level of association between territory and vulnerability, specifying proposals for territorial intervention using key socio-health indicators. METHODS: Analytical cross-sectional study, which combined the analysis of the Health Survey Madrid City 2017 (n=9,513) and the vulnerability-ranking indicator of the same year (n=2,780,197), popu-lation of the city of Madrid in 2017, from the Data Bank of the Madrid City Council), prepared with the hierarchical analysis technique. Sociodemographic and health variables were included, such as self-perception of health status, quality of life in relation to health, tobacco consumption, alcohol, obesity, sedentary lifestyle and mental health (GHQ-12). The relationships were assessed with DE, 95% CI, Spearman correlation, B and ß coefficients of multiple linear regression and the pair-point technique. RESULTS: The links between health and vulnerability were: in health-self-perceived and HRQL, as global health variables, p<0.01 for women with territory and vulnerability; sedentary lifestyle for both sexes, was interpreted with 60-80% by territory and vulnerability; obesity was slightly linked to the te-ritory in women and explained 77%; mental health was not territorially related for the group, but it was significantly related to women, due to 64% of the variance; in tobacco there was a significant territorial link in men and vulnerability in 57%; finally, alcohol had a significant difference in men at the territorial level and explained in 72% in both sexes, inverted. CONCLUSIONS: The results support the behavior of global and specific health indicators with vulnerability, with a disaggregation by sex, which will allow planning adapted to the territory.

OBJETIVO: La territorialidad se configura como un eje importante de desigualdad. El objetivo de este estudio fue determinar el nivel de asociación entre territorio y vulnerabilidad, concretando propuestas de intervención territorial mediante indicadores clave socio-sanitarios. METODOS: Se realizó un estudio transversal analítico, que combinó el análisis de la Encuesta de Salud de la Ciudad de Madrid de 2017 (n=9.513) y el indicador de vulnerabilidad-ranking del mismo año (n=2.780.197, población de la ciudad de Madrid en 2017, procedente del Banco de Datos del Ayuntamiento de Madrid), elaborado con la técnica de análisis jerárquico. Se incluyeron variables sociodemográficas y de salud, como autopercepción del estado de salud, calidad de vida en relación con la salud, consumo de tabaco, alcohol, obesidad, sedentarismo y salud mental (GHQ-12). Las relaciones se valoraron con DE, IC 95%, correlación de Spearman, coeficientes B y ß de regresión lineal múltiple y la técnica de pares de puntos. RESULTADOS: Los vínculos entre salud y vulnerabilidad fueron: en salud-autopercibida y CVRS, como variables globales de salud, p<0,01 para las mujeres con territorio y vulnerabilidad; en sedentarismo para ambos sexos, se interpretó con el 60-80% por el territorio y vulnerabilidad; la obesidad se vinculó levemente con el territorio en las mujeres y explicó el 77%; la salud mental no se relacionó territorialmente para el conjunto, pero sí de forma significativa en las mujeres, por el 64% de la varianza; en tabaco hubo vínculo significativo territorial en hombres y vulnerabilidad en el 57%; finalmente, el alcohol tuvo una diferencia significativa en hombres a nivel territorial y explicó en el 72% en ambos sexos, de forma invertida. CONCLUSIONES: Los resultados avalan el comportamiento de los indicadores globales y específicos de salud con la vulnerabilidad, con una desagregación por sexos, lo cual permitirá una planificación adaptada al territorio.

Immunohistochemical assessment of basal and luminal markers in non-muscle invasive urothelial carcinoma of bladder.

The Cancer Genome Atlas project introduced genomic taxonomy of basal and luminal molecular subtypes in muscle invasive bladder cancer. Fewer studies have addressed the molecular classification in non-muscle invasive bladder cancer (NMIBC). Our aim is to assess the applicability of the proposed phenotypic classification for NMIBC. Three TMAs were constructed from 193 TURBT specimens of 60 bladder cancer patients treated at one of the authors' institutions (1998-2008). Follow-up data on recurrence, grade, or stage progression was obtained. Immunohistochemistry was performed using an automated Ventana System for markers indicative of luminal (GATA3, CK20, ER, Uroplakin II, and HER2/neu) and basal (CK5/6 and CD44) phenotype. Marker expression was evaluated by 3 urologic pathologists. Using unadjusted logistic regression, we found significant association between tumor recurrence at next biopsy and CD44 expression (OR = 2.51, P = 0.03), tumor recurrence at any subsequent biopsy and ER expression (OR = 0.24, P = 0.04), and tumor grade progression at any subsequent biopsy and HER2/neu expression (OR = 0.24, P = 0.04). After adjusting for pathologic stage, we found a significant association between CK5/6 expression and tumor stage progression at either next or any subsequent biopsy (OR = 0.94, P = 0.006; and OR = 0.97, P = 0.02, respectively). Our findings suggest that individual immunohistochemical markers may be of value as prognostic factors in NMIBC.

[Conflicts of interest in the medical profession]. / Conflictos de interés en la profesión médica.

In the last decades the world of medicine has become familiar with the disclosure of conflicts of interest (CDI). The requirement for authors to declare their CDIs concerning their publications is a common issue. Another topic for CDI is related to the medical decision making on prescription. Finally, professionals being in positions of responsibility in professional societies or associations and healthcare institutions are asked to show their disclosure of CDI. These debates show up the interest of democratic societies for justice and social ethics that demand fair play in making decisions that may affect third parties, particularly patients. In the present work, the concept and types of CDIs are analyzed, and authors make proposals for the management of CDI in the medical profession.