Impact of the Southwark and Lambeth Integrated Care Older People's Programme on hospital utilisation and costs: controlled time series and cost-consequence analysis.

OBJECTIVES: To estimate the impact on hospital utilisation and costs of a multi-faceted primary care intervention for older people identified as being at risk of avoidable hospitalisation. DESIGN: Observational study: controlled time series analysis and estimation of costs and cost consequences of the Programme. General practitioner (GP)'s practice level data were analysed from 2009 to 2016 (intervention operated from 2012 to 2016). Mixed-effect Poisson regression models of hospital utilisation included comparisons with control practices and background trends in addition to within-practice comparisons. Cost estimation used standard tariff values. SETTING: 94 practices in Southwark and Lambeth and 263 control practices from other parts of England. MAIN OUTCOME MEASURES: Hospital utilisation: emergency department attendance, emergency admissions, emergency admissions for ambulatory sensitive conditions, outpatient attendance, elective admission and length of stay. RESULTS: By the fourth year of the Programme, there were reductions in accident and emergency (A&E) attendance (rate ratio 0.944, 95% CI 0.913 to 0.976), outpatient attendances (rate ratio 0.938, 95% CI 0.902 to 0.975) and elective admissions (rate ratio 0.921, 95% CI 0.908 to 0.935) but there was no evidence of reduced emergency admissions. The costs of the Programme were £149 per resident aged 65 and above but savings in hospital costs were only £86 per resident aged 65 and above, equivalent to a net increase in health service expenditure of £64 per resident though the Programme was nearly cost neutral if set-up costs were excluded. Holistic assessments carried out by GPs and consequent Integrated Care Management (ICM) plans were associated with increases in elective activity and costs; £126 increase in outpatient attendance and £936 in elective admission costs per holistic assessment carried out, and £576 increase in outpatient and £5858 in elective admission costs per patient receiving ICM. CONCLUSIONS: The Older People's Programme was not cost saving. Some aspects of the Programme were associated with increased costs of elective care, possibly through the identification of unmet need.

Rapid Detection of Antibiotic Resistance in Gram-Negative Bacteria Through Assessment of Changes in Cellular Morphology.

Rapid antimicrobial susceptibility testing has the potential to improve patient outcomes and reduce healthcare-associated costs. In this study, a novel assay based on bacterial cell elongation after exposure to an antibiotic (ceftazidime) was evaluated for its ability to rapidly detect resistance in Gram-negative bacteria. The assay was used to detect resistance in a large collection of strains containing 320 clinical isolates of Acinetobacter baumannii, 171 clinical isolates of Klebsiella pneumoniae, and 212 clinical isolates of Pseudomonas aeruginosa, and the results were compared to those obtained using standard antimicrobial susceptibility testing methods. The assay identified ceftazidime-resistant strains with 100% sensitivity and 100% specificity for A. baumannii, 100% sensitivity and 97.2% specificity for K. pneumoniae, and with 82.3% sensitivity and 100% specificity for P. aeruginosa. Importantly, results were obtained in 1 hour 15 minutes from exponentially growing cultures. This study demonstrates that changes in cell length are highly correlated with phenotypic antibiotic susceptibility determined using standard susceptibility testing methods. This study therefore provides proof-of-concept that changes in cell morphology can be used as the basis for rapid detection of antibiotic resistance and provides the basis for the development of novel rapid diagnostics for the detection of antibiotic resistance.

Del lado de allá y del lado de acá. ¿Qué pueden aprender mutuamente los países emergentes latinoamericanos y España para mejorar sus perfiles del médico de familia? / From one side of the ocean to the other. What can emerging latinamerican countries and Spain learn from each other to improve their family physician profile?

Objetivo: Se realizó un estudio cualitativo con el objetivo de encontrar factores estratégicos en medicina de familia que impliquen oportunidades de aprendizaje que los países del Norte desarrollado puedan utilizar de los países del Sur emergentes, y viceversa. Diseño, emplazamiento y participantes: A partir de un muestreo no aleatorio, intencionado, seguido de muestra en bola de nieve, hasta la saturación de los datos, se realizaron por parte médicos de familia de atención primaria de Toledo y Tenerife en España, y Paraguay, México, y Perú, diarios de campo de un día habitual y su contexto socio-sanitario, y se evaluaron mediante análisis del contenido y un estudio DAFO (Debilidades, Amenazas, Fortalezas y Oportunidades). Mediciones principales y resultados: Se obtuvieron 24 diarios de un día normal (9 médicos en España, 7 en México, 4 en Paraguay, y 4 en Perú). Se encontraron "fortalezas" del Sur en la coexistencia de trabajo ambulatorio y hospitalario, en el amplio rango de tareas asistenciales, en el mayor peso de actividades de promoción y educación para la salud dirigidas a la población, en la presencia de actividades comunitarias de campo, en la integración de la medicina tradicional, en la mejor relación médico-paciente, y percepción más positiva de la carga de trabajo. Y "fortalezas" del Norte en las actividades de prevención, promoción y educación para la salud integradas en la asistencia por enfermedades en el centro de salud, y en la mayor existencia de recursos materiales. Conclusiones: Hay áreas donde podría aprender el médico de familia español del latinoamericano y viceversa (AU)

Objective: A qualitative study was carried out with the aim to find strategic factors involving learning opportunities that northern developed countries could use from emerging countries in the South and vice versa. Design, setting and participants: A non-random intentional sampling, followed by a snowball sampling until data saturation were carried out by a group of primary health care family physicians in Toledo and Tenerife in Spain and Paraguay, Mexico and Peru. Field diaries of a normal day and its health and social care context were kept and analyzed, and a SWOT study (strengths weaknesses, opportunities and threats) was performed. Main measures and results: Twenty-four diaries of a normal day were obtained (9 physicians in Spain, 7 in Mexico, 4 in Paraguay and 4 in Peru). Some strengths were found in the South in the coexistence of ambulatory care and hospital work, in the wide range of care tasks, in the greater weight of health promotion and educational activities targeted to the population, in the presence of community field activities, in the integration of traditional medicine, in the better patient-doctor relationship and a more positive perception of the workload. And the strengths in northern countries were: more prevention, health promotion and educational actions integrated in visits to the family physician in primary care settings and more material resources available. Conclusions: There are some areas in which the Spanish family physician could learn from the latinamerican physician and vice versa (AU)

[Open vacuum-pack abdomen. An ideal technique for deferred temporary abdominal closure in complications after cytoreduction surgery and intraperitoneal chemotherapy with hyperthermia due to peritoneal cancer]. / Open vacuum-pack, técnica ideal del cierre abdominal temporal diferido en las complicaciones tras cirugía citorreductora y quimioterapia intraperitoneal con hipertermia por carcinomatosis peritoneal.

INTRODUCTION: The use of a new therapeutic alternative involving cytoreductive surgery with perioperative intraperitoneal chemotherapy in the treatment of patients suffering from peritoneal carcinomatosis represents a new challenge for the multidisciplinary teams caring for these patients. Their post-operative progress and care needs, apart from differing from those of conventional patients, have not yet been completely defined or protocolised. In this presentation we explain the special characteristics of these patients compared to the usual surgical patients, the possible physiopathological mechanisms which may give rise to the different types of complications, the circumstances when a temporary abdominal closure is necessary, the ideal conditions required for an optimal technique, and finally our experience with the open vacuum abdomen technique in the treatment of the complications that appear in patients treated by this new triple combined therapy. PATIENTS AND METHODS: Based on our personal experience in the treatment of 110 cytoreductions carried out between February 1997 and February 2007 on 71 patients suffering from peritoneal carcinomatosis of various origins. Of the 71 patients, 50 (70%) suffered some kind of complication during their postoperative evolution, 28 of them requiring re-operation for a Grade III-IV postoperative complication. The abdominal situation made a temporary closure desirable in 17 patients, having applied an open vacuum abdomen technique on every occasion. We study this group of patients according their original type of tumour and stage of the disease at the cytoreductive procedure, peritonectomies and visceral resections required, type of postoperative complications, treatment applied and evolution. RESULTS: A total of 52 open vacuum abdomen procedures were required (median, 2.8 per patient; range, 1-10) before the abdominal complication could be completely kept under control in these 17 patients. Only 2 postoperative intestinal fistulas were directly related to this technique, and a primary closure of the whole abdominal wall was possible in 11 of these patients (66%). All but one of them left the hospital alive and well. CONCLUSIONS: As a consequence of this experience, in our opinion, the open vacuum abdomen is the ideal election technique to be employed in any temporary closure of the abdominal cavity for whatever reason it is required, including the worst possible surgical scenario, as we have demonstrated in the treatment of surgical complications after cytoreductive procedures and intraperitoneal chemohyperthermia.

[Water immersion for adjuvant treatment of refractory ascites in patients with liver cirrhosis]. / Inmersión en agua para el tratamiento adyuvante de la ascitis refractaria en pacientes con cirrosis hepática.

BACKGROUND: Head-out water immersion has been proposed as an adjuvant treatment in refractory ascites and hepatorenal syndrome. We undertook this study to present the results of management of patients with refractory ascites. METHODS: We included 10 patients with diagnosis of hepatic cirrhosis and refractory ascites. Variables were measured in four stages: stage I (basal); II (at the end of water immersion); III (72 h after water immersion); IV (1 week after water immersion concludes). Clinical and laboratory variables were measured and included general exams and renal function tests. Friedman test was used for statistics to establish differences between variables at the end of stage IV. We considered statistical significance when p<0.05. RESULTS: Median age was 53.8 years, corresponding to seven men and three women with a Child's classification of B or C. Statistically significant variables were weight (p=0.02) and abdominal circumference (p=0.003), as a result of an increased urine output (p=0.03) and glomerular filtration rate (p<0.002). Renal plasma rate increased until stage III, returning to basal level in stage IV. Serum potassium levels decreased but the difference was marginal (p=0.052). During follow-up, two patients died as a consequence of liver insufficiency. CONCLUSIONS: Head-out water immersion showed a decrease in weight and abdominal circumference, which means reduction of ascites. There was a transitory improvement in renal function. No collateral events were reported. Water immersion could be proposed as an adjuvant treatment in patients with refractory ascites and liver cirrhosis.

Ozonoterapia combinada en el tratamiento del paciente portador de hernia discal lumbar: estudio preliminar / Combined ozone therapy in the treatment of the patient with lumbar herniated disc: preliminary study

Se estudió el efecto de la ozonoterapia por vía rectal e intramuscular (paravertebral) sobre variables clínicas y hallazgos imagenológicos en pacientes portadores de hernia discal lumbar. Es conocido que la hernia discal lumbar es causa de sacrolumbalgia y en muchos de los casos llega a invalidar al paciente, constituyendo un problema de salud importante en el mundo actual. A pesar de que existen diferentes esquemas de tratamientos (conservadores y quirúrgicos) para abordar el paciente con hernia discal, muchas veces estos fracasan. Teniendo en cuenta, por otra parte, las propiedades de la ozonoterapia sobre el metabolismo del oxígeno y sobre mediadores de la inflamación, fue objetivo de este trabajo valorar el efecto de la ozonoterapia sobre la calidad de vida en pacientes con hernia discal lumbar. Para desarrollar este estudio se utilizó una muestra de 37 pacientes portadores de hernia discal lumbar, a estos se les midió por escala la fuerza muscular y el grado de reflectividad osteotendinosa, así como la intensidad del dolor antes y al finalizar el tratamiento con ozono, además se realizaron estudios imagenológicos antes y después de haber concluido el esquema terapéutico. Los resultados mostraron que la terapia con ozono reflejo un efecto beneficioso en las variables clínicas estudiadas en estos pacientes además de incidir significativamente en el mejoramiento desde el punto de vista imagenológico.

Ozonoterapia combinada en el tratamiento del paciente portador de hernia discal lumbar: estudio preliminar / Combined ozone therapy in the treatment of the patient with lumbar herniated disc: preliminary study

Se estudió el efecto de la ozonoterapia por vía rectal e intramuscular (paravertebral) sobre variables clínicas y hallazgos imagenológicos en pacientes portadores de hernia discal lumbar. Es conocido que la hernia discal lumbar es causa de sacrolumbalgia y en muchos de los casos llega a invalidar al paciente, constituyendo un problema de salud importante en el mundo actual. A pesar de que existen diferentes esquemas de tratamientos (conservadores y quirúrgicos) para abordar el paciente con hernia discal, muchas veces estos fracasan. Teniendo en cuenta, por otra parte, las propiedades de la ozonoterapia sobre el metabolismo del oxígeno y sobre mediadores de la inflamación, fue objetivo de este trabajo valorar el efecto de la ozonoterapia sobre la calidad de vida en pacientes con hernia discal lumbar. Para desarrollar este estudio se utilizó una muestra de 37 pacientes portadores de hernia discal lumbar, a estos se les midió por escala la fuerza muscular y el grado de reflectividad osteotendinosa, así como la intensidad del dolor antes y al finalizar el tratamiento con ozono, además se realizaron estudios imagenológicos antes y después de haber concluido el esquema terapéutico. Los resultados mostraron que la terapia con ozono reflejo un efecto beneficioso en las variables clínicas estudiadas en estos pacientes además de incidir significativamente en el mejoramiento desde el punto de vista imagenológico(AU)

Ozonoterapia en la glomerulonefritis tóxica experimental por adriamicina / Ozone therapy in the experimental toxic glomerulonephritis due to adriamicine

Se estudió el efecto del ozono por vía rectal a diferentes dosis sobre variables de función renal y la presión arterial sistólica en un modelo de glomerulonefritis tóxica experimental por adriamicina. La glomerulonefritis experimental es causa de insuficiencia renal, caracterizada por un daño renal progresivo. Existen diferentes esquemas de tratamiento, los cuales son muy caros y producen inmunosupresión, que afecta la calidad de vida del paciente. Para desarrollar este trabajo se utilizaron 40 ratas hembras Wistar de 200 g de peso, divididas en 4 grupos, uno control, otro control positivo, que recibieron adriamicina durante un período de 10 semanas, y otros 2 que recibieron terapia con ozono. A todos se les determinó la proteinuria, presión arterial sistólica y diuresis de 24 h. Los resultados mostraron que la terapia con ozono a una dosis de 0,3 mg/kg tuvo efecto renoprotector

Ozonoterapia en la glomerulonefritis tóxica experimental por adriamicina / Ozone therapy in the experimental toxic glomerulonephritis due to adriamicine

Se estudió el efecto del ozono por vía rectal a diferentes dosis sobre variables de función renal y la presión arterial sistólica en un modelo de glomerulonefritis tóxica experimental por adriamicina. La glomerulonefritis experimental es causa de insuficiencia renal, caracterizada por un daño renal progresivo. Existen diferentes esquemas de tratamiento, los cuales son muy caros y producen inmunosupresión, que afecta la calidad de vida del paciente. Para desarrollar este trabajo se utilizaron 40 ratas hembras Wistar de 200 g de peso, divididas en 4 grupos, uno control, otro control positivo, que recibieron adriamicina durante un período de 10 semanas, y otros 2 que recibieron terapia con ozono. A todos se les determinó la proteinuria, presión arterial sistólica y diuresis de 24 h. Los resultados mostraron que la terapia con ozono a una dosis de 0,3 mg/kg tuvo efecto renoprotector(AU)

Correlación de los diagnósticos clínicos y patológicos e autopsias / Correlation of the clinical and patologyc diagnostic in autopsies

Se revisaron 100 autopsias en forma consecutiva, realizadas en la Unidad de Anatomía Patológica del Hospital de Clínicas de la ciudad de La Paz, entre 1994 y 2003; con datos clínicos adecuados y protocolos patológicos completos, según un diseño cuasi experimental en serie de tiempos, para establecer correlación entre los diagnósticos clínicos y patológicos. En el 80 por ciento de dichas autopsias la correlación fue buena, mientras no hubo correlación entre ambos diagnóstios en el 20 por ciento de los casos. Este estudio señala la importancia de la realización de las utopsias como el instrumento para el control de la calidad en la práctica médica conforme lo señala la literatura; especialmente en enfermedades infecto contagiosas, como la tuberculosis, donde no se sospecha dichas afecciones, por último parece necesario mejorar la documentación tanto a nivel de las historias clinicas como de los protocolos de autopsia para que no sean excluidas y nos permita realizar una adecuada correlación clínico patológica.