Familiar Dermatologic Drugs as Therapies for COVID-19. / Fármacos de uso frecuente en dermatología como terapia para COVID-19.

Researchers the world over are working to find the treatments needed to reduce the negative effects of coronavirus disease 2019 (COVID-19) and improve the current prognosis of patients. Several drugs that are often used in dermatology are among the potentially useful treatments: ivermectin, antiandrogenic agents, melatonin, and the antimalarial drugs chloroquine and hydroxychloroquine. These and other agents, some of which have proven controversial, are being scrutinized by the scientific community. We briefly review the aforementioned dermatologic drugs and describe the most recent findings relevant to their use against COVID-19.

Rifampin pharmacokinetics in tuberculosis-diabetes mellitus patients: a pilot study from Baja California, Mexico.

BACKGROUND: Worldwide, there has been an increase in type 2 diabetes mellitus (DM2) as a comorbidity of tuberculosis (TB), which is characterized by alterations in the pharmacokinetics of drugs used for TB treatment.OBJECTIVE: To characterize the pharmacokinetics of rifampin in patients with TB and TB-DM2.METHODS: Blood samples were collected in two hospitals in Baja California, Mexico from March through December 2017. Sampling was not random and included 14 patients with TB and 16 with TB-DM2. High-performance liquid chromatographic (HPLC) was carried out to determine the concentration of rifampin in human serum.RESULTS: On average, the highest concentration of rifampin for both groups was registered at 2.5 h after ingestion (3.5 ± 2.64 µg/ml). The maximum difference in concentration (Cmax) of rifampin between TB and TB-DM2 group was not significant (P > 0.05). Importantly however, the analysis showed suboptimal levels of Cmax in a high proportion of both groups of patients studied.CONCLUSION: The study suggests that under the currently recommended rifampin dose, suboptimal Cmax levels are reached in a high proportion of patients, regardless of whether they have diabetes or not. It may therefore be necessary to use higher doses of rifampin and perform routine monitoring of serum levels. However, further work is needed to confirm these findings.

Toward healthy aging through empowering self-care during the climacteric stage.

BACKGROUND: While they progress through the climacteric stage, women often develop physical and psychological health needs, calling for innovative health-care services that can be translated into preventive programs and empowerment towards self-care. OBJECTIVE: To identify the changes in women's discourse regarding their concerns and needs about the climacteric stage and self-care after they had participated in an integrative women-centered health-care model with empowerment for self-care. METHODS: Women's narratives during counseling group sessions were analyzed using qualitative inductive thematic analysis. RESULTS: A total of 121 women between 45 and 59 years of age participated. At the beginning of the counseling group sessions, we identified the following themes: (1) Lack of information about changes during the climacteric stage and self-care; (2) Tradition: the climacteric stage as a taboo subject; (3) Life's changes and transitions: the complexity of the climacteric experience; (4) Stigma of menopause; (5) Relationship between the traditional gender role and the lack of self-care. At the end of the counseling group sessions, the themes were: (1) The climacteric as a natural stage; (2) Expectations for old age; (3) Empowerment and the change of awareness for self-care; (3) De-medicalization of the climacteric; (4) The richness of group work; (5) Empowerment as motivation to convey acquired knowledge. CONCLUSION: Women in the climacteric stage require more information about their physical, psychological and social needs, as well as the potential impact on their health during old age. Empowerment during the climacteric can contribute to improving the perception about this stage as well as the importance of self-care.

Mutations in rpoB and katG genes in Mycobacterium isolates from the Southeast of Mexico.

The most frequent mutations associated with rifampin and isoniazid resistance in Mycobacterium are the substitutions at codons 531 and 315 in the rpoB and katG genes, respectively. Hence, the aim of this study was to characterize these mutations in Mycobacterium isolates from patients suspected to be infected with drug-resistant (DR) pulmonary tuberculosis (TB) in Veracruz, Mexico. Drug susceptibility testing of 25 clinical isolates revealed that five were susceptible while 20 (80%) were DR (15% of the annual prevalence for Veracruz). Of the DR isolates, 15 (75%) were resistant to rifampin, 17 (85%) to isoniazid and 15 (75%) were resistant to both drugs (MDR). Sequencing analysis performed in the isolates showed that 14 (93%) had mutations in the rpoB gene; seven of these (47%) exhibited a mutation at 531 (S-->L). Ten (58%) of the 20 resistant isolates showed mutations in katG; nine (52%) of these 10 exhibited a mutation at 315 (S-->T). In conclusion, the DR profile of the isolates suggests a significant number of different DR-TB strains with a low frequency of mutation at codons 531 and 315 in rpoB and katG, respectively. This result leads us to consider different regions of the same genes, as well as other genes for further analysis, which is important if a genetic-based diagnosis of DR-TB is to be developed for this region.

Mutations in rpoB and katG genes in Mycobacterium isolates from the Southeast of Mexico

The most frequent mutations associated with rifampin and isoniazid resistance in Mycobacterium are the substitutions at codons 531 and 315 in the rpoB and katG genes, respectively. Hence, the aim of this study was to characterize these mutations in Mycobacterium isolates from patients suspected to be infected with drug-resistant (DR) pulmonary tuberculosis (TB) in Veracruz, Mexico. Drug susceptibility testing of 25 clinical isolates revealed that five were susceptible while 20 (80 percent) were DR (15 percent of the annual prevalence for Veracruz). Of the DR isolates, 15 (75 percent) were resistant to rifampin, 17 (85 percent) to isoniazid and 15 (75 percent) were resistant to both drugs (MDR). Sequencing analysis performed in the isolates showed that 14 (93 percent) had mutations in the rpoB gene; seven of these (47 percent) exhibited a mutation at 531 (S[L). Ten (58 percent) of the 20 resistant isolates showed mutations in katG; nine (52 percent) of these 10 exhibited a mutation at 315 (S[T). In conclusion, the DR profile of the isolates suggests a significant number of different DR-TB strains with a low frequency of mutation at codons 531 and 315 in rpoB and katG, respectively. This result leads us to consider different regions of the same genes, as well as other genes for further analysis, which is important if a genetic-based diagnosis of DR-TB is to be developed for this region.

Body condition and protein supplementation positively affect periovulatory ovarian activity by non LH-mediated pathways in goats.

Effects of rumen undegradable intake protein (UIP) supplementation on ovarian activity and serum insulin, GH, and LH were evaluated in goats having low or high body condition (BC). Goats with either low BC (n=16, 28.7+/-0.8 kg BW, BC=2.1+/-0.3) or high BC (n=16, 38.4+/-0.8 kg, BC=3.2+/-0.3) received, during 40-days, one of the two protein supplementation levels: without UIP or with UIP (120 g goat(-1)d(-1)). Oestrus was synchronized with two i.m. doses of PGF(2alpha), and jugular blood samples were collected from 36 to 42 h after the second prostaglandin injection at 15 min intervals. Serum concentrations of insulin, LH, and GH were measured The number of preovulatory follicles and the number of corpora lutea (CL) were evaluated by transrectal ultrasonography at 1 and 4 days after the second prostaglandin dose, respectively. Does with higher BC had more CL than those in the lower condition group (2.8+/-0.2 versus 1.8+/-0.2, P<0.05). Similarly, goats receiving UIP supplementation had more follicles (2.6+/-0.2 versus 1.9+/-0.2, P<0.05) and tended to have more CL (2.6+/-0.2 versus 2.0+/-0.2, P=0.05) than does not receiving UIP. Neither BCS nor UIP supplementation affected serum GH or LH concentrations, pulsatility, or area under the curve. High BC does produced more insulin (1.92+/-0.17 versus 0.81+/-0.17 ng/mL, P<0.01 ng/mL) than lower BC goats; the same for UIP-supplemented (1.69+/-0.18 versus 1.04+/-0.18, P<0.05). Results suggest that the increased ovarian activity observed in both UIP-supplemented and higher BC goats was not the result of changes in LH or GH, suggesting effects at a local level, through changes in insulin in a non-GnRH-gonadotrophin dependent manner.

Intron retention as an alternative splice variant of the rat urocortin 1 gene.

Urocortin 1, highly conserved metazoan gene of the corticotropin-releasing hormone family, is a simple gene structured in two exons and the corresponding intron. The urocortin 1 prepropeptide is entirely coded in the second exon. Preliminary non-isotopic in situ hybridization experiments with an oligonucleotide complementary to an intron sequence of the urocortin 1 gene showed a significant cytoplasmic-like staining, suggesting the occurrence of an intron-retained urocortin 1 transcript. This observation prompted us to study whether the urocortin 1 gene presents alternative splicing by intron retention event. Confocal fluorescent in situ hybridization for urocortin 1 RNA and the use of the specific DNA dye TOPRO-3 allowed us to show significant expression of the intron-retained urocortin 1 transcript that did not colocalize with TOPRO-3 staining indicating a cytoplasmic localization for the intron-retained urocortin 1 transcript. The natural occurrence of a polyadenylated intron-retained urocortin 1 RNA was further documented by reverse transcriptase polymerase chain reaction (PCR), primed with oligo(dT), of total RNA extracted from three brain regions, a midbrain region containing the Edinger-Westphal nucleus, cerebellum and prefrontal cortex. In the three brain regions studied, it was possible to amplify both intron-less as well as intron-retained urocortin 1 transcripts. The use of PCR primers that simultaneously amplify both urocortin 1 transcripts allowed us to show that the expression of both urocortin 1 transcripts differs among the brain regions analyzed, suggesting a tissue specific regulation of this alternative splicing. In silico analysis of the five known mammalian urocortin 1 genomic sequences showed high conservation of the urocortin 1 intron sequence. Further studies should investigate the regulation of this intron retention event and its consequence for the functionality of the urocortin 1 gene.

The primary care clinic as a setting for continuing medical education: program description.

The Mexican Institute of Social Security (IMSS) is Mexico's Largest state-financed health care system, providing care to 50 million people. This system comprises 1450 family medicine clinics staffed by 14,000 family physicians, as well as 240 secondary care hospitals and 10 tertiary care medical centres. We developed a program of continuing medical education (CME) for IMSS family physicians. The program had 4 stages, which were completed over a 7-month period: development of clinical guidelines, training of clinical instructors, an educational intervention (consisting of interactive workshops, individual tutorials and peer group sessions), and evaluation of both physicians' performance and patients' health status. The pilot study was conducted in an IMSS family medicine clinic providing care to 45,000 people; 20 family physicians and 4 clinical instructors participated. The 2 main reasons for visits to IMSS family medicine clinics are acute respiratory infections and type 2 diabetes mellitus. Therefore, patients being treated at the clinic for either of these illnesses were included in the study. The sources of data were interviews with physicians and patients, clinical records and written prescriptions. A 1-group pretest-posttest design was used to compare physicians' performance in treating the 2 illnesses of interest. We found that the daily activities of the clinic could be reorganized to accommodate the CME program and that usual provision of health care services was maintained. Physicians accepted and participated actively in the program, and their performance improved over the course of the study. We conclude that this CME strategy is feasible, is acceptable to family physicians and may improve the quality of health care provided at IMSS primary care facilities. The effectiveness and sustainability of the strategy should be measured through an evaluative study.

Immunization promotion activities: are they effective in encouraging mothers to immunize their children?

Mass media communication is an important strategy for increasing parental uptake and to promote community participation when large-scale immunization activities are carried out. In Mexico, the National Vaccination Council (CONAVA) launches three immunization campaigns every year accompanied by three vaccination promotion campaigns. This study was conducted to assess whether communication activities to promote CONAVA's Second National Health Week (SNHW) were effective in providing information to mothers about the importance of immunizing their children under five years of age and in prompting them to seek immunization services. A probability sample of mothers living in the metropolitan area of Mexico City and having at least one child under five years old was selected for the study. Four outcome variables were defined as measuring the impact of the campaign: (1) mothers' knowledge about the SNHW; (2) mothers' comprehension indicating how well they understood the campaign messages (aware, partly aware and unaware); (3) mothers' motivation, i.e. whether or not they sought out immunizations for their children under the age of five and (4) mothers' opinion of how well they liked the messages. A total of 935 mothers were interviewed; 88.2% knew about the SNHW, 64.3% were aware that the campaign aimed to provide immunizations, and most held a favorable opinion about the messages. Among aware mothers, 87.5% of their children received immunizations. In this group 72.1% were prompted by the information in the campaign to seek immunizations for their children while 27.9% had to be personally invited to participate in the campaign. The latter occurred either when health workers or volunteers visited mothers in their homes or by soliciting mothers' participation as they visited or passed by immunization health posts. In the unaware mothers group, 72.7% of their children received immunizations; 62.5% of the mothers took their children because of information they received through the campaign while 37.5% had to be personally invited to immunize their children. Mothers with better socioeconomic status were more aware of the campaign, but a high percentage of them did not seek immunizations, while mothers with middle and lower socioeconomic status were motivated to immunize their children through the campaign. Promotion activities and messages communicated through the mass media were appropriate to inform and motivate mothers to seek immunization services for their children.

The day care center as a risk factor for acute respiratory infections.

BACKGROUND: This study was conducted to assess the magnitude of the risk of high morbidity (> or = 7 episodes/year) for acute respiratory infections (ARI) in infants attending day care centers (DCC), and to compare the incidence, duration, and severity of ARI in children staying at home (Home). METHODS: Using a cohort design, 282 infants (DCC, 138 and Home, 144) were followed for a year. Age at entry into the study ranged from 43 days to 4 months. During follow-up, social workers interviewed the mothers weekly to register whether the infants had an ARI. Also, infant health conditions and physical growth were updated monthly. RESULTS: ARI incidence was 14 episodes per child/year among DCC infants with a median of 74 sick days, while among children at home, the ARI incidence was 6 episodes, and the median was 40 days. The incidence density ratio for DCC children was 2.33 (95% CI, 2.13-2.54); after adjusting for other covariates, the relative risk increased to 5.27 (95% CI, 3.54-7.83). CONCLUSIONS: Infants attending DCCs will suffer ARI more frequently than children cared for at home. We did not find seasonal variations in the incidence rates among DCC infants. The quality of care provided at these facilities should be analyzed in more depth for proposing measures to decrease ARI incidence.

[Design and applicability of a clinical guide for appropriate attention in acute respiratory infections]. / Diseño y aplicabilidad de una guía clínica para la atención apropiada en las infecciones respiratorias agudas.

Clinical guidelines provide continuing education and help physicians in the clinical decision-making process. Clinical guidelines to manage acute respiratory infections (ARI) were developed comprehensively from a perspective where prevention, diagnosis, treatment and the patient's education were considered. Methodology. The guideline development process was comprised of two stages: 1. The building stage consisted of several steps: definition of the problem, definition of the potential users of the guidelines, and the appropriate level of care; review of updated bibliographies, and validation using the Delphi technique. 2. The start-up stage consisted of evaluating the guidelines applicable to out-patient settings. Twenty family physicians participated, using the guidelines with 115 patients. Agreement between the family physicians' diagnosis and the criteria stated in the guidelines was tested using unweighted kappa. Differences in the use of the guidelines to manage ARI patients were tested by using the X2 test or the exact Fisher test. Results. Development of guidelines considered the patient's age group. Therefore, guidelines to manage patients under five years of age and to manage patients above this age were constructed. The application of the guidelines was increased from 40 to 60%. As a result, inappropriate prescribing of antibiotics and cough syrups decreased. Although the guidelines could be helpful in treating ARI, its efficacy and effectiveness remain to be tested.

[Impact of health services, sanitation and literacy in the mortality of children under 5 years of age]]. / Impacto de los servicios de salud, el saneamiento y la alfabetización en la mortalidad de menores de cinco años.

OBJECTIVE: To analyze differences of the impact of health care services, sanitation and literacy on the mortality rates of children under five years of age, in two Mexican states with marked socioeconomic differences: Chiapas and Nuevo Leon. MATERIAL AND METHODS: The study design was ecologic, based on a retrospective analysis of data published by the Health Ministry (Secretaría de Salud), National Institute of Statistics, Geography and Informatics (Instituto Nacional de Estadística, Geografía e Informática) and the National Population Council (Consejo Nacional de Población), on the tendencies of mortality among children under five years and on the changes of selected indicators corresponding to the period 1990-1997. STUDY DESIGN: ecologic study. This was based on a retrospective analysis of data published by Secretaría de Salud, Instituto Nacional de Estadística e Informática and Consejo Nacional de Población, about the tendencies of mortality among children under five years, and about the changes of selected indicators. The analysis was carried out in the period comprised between 1990-1997. For both states the registered variations were calculated and the trends were determined through analysis of simple linear regression; the independent variable corresponded to the study years. Partial correlation analysis between the various mortality trends studies and between and the selected indicators, were calculated. RESULTS: During the studied period there was a steady decline of children mortality, which was more marked in Chiapas. In both entities, this decrease was closely related to the decline in mortality due to acute diarrhea, and also correlated with a descent in measles and acute respiratory infections. In Chiapas, the indicators which correlated more significantly with this decline in mortality were vaccination coverage and literacy. In Nuevo Leon, the indicators with greater correlation were the increase in the number of nurses, of lodgings with piped water and vaccination coverage. CONCLUSIONS: During the analyzed period, the mortality rate of children under five years of age decreased in the states of Chiapas and Nuevo Leon. To sustain or accelerate the decline in childhood mortality it is mandatory to continue with the currently implemented programs, and in Chiapas, and similar states, to increase the available infrastructure to provide health care.

[Maternal and perinatal morbidity-mortality in pregnant women with renal transplant]. / "Morbimortalidad materna y perinatal en pacientes embarazadas con trasplante renal".

The outcome of 32 pregnancies in renal allograft recipients is reported. The mean age at the time of conception was 27.3 years (range, 20 to 37) with an average interval of 47 months from the time of transplantation to conception (range, 2 to 163). Twenty-nine patients received the graft from a living related donor, one from a living no related donor an 2 from cadaver donors. All patients continued their immunosuppressive regimen during pregnancy and only 6 patients were taking cyclosporine A. Hypertension during pregnancy was observed in 10 patients (31%), superimposed preeclampsia in 4 (14%), preterm labor in 4 (14%) and premature rupture of membranes in 2 (7%). Twenty-eight pregnancies resulted in 28 liveborn infants and there were 4 miscarriages. Cesarean section was performed in 17 cases and 11 had vaginal delivery. Intrauterine growth retardation was observed in 4 cases (14%), fetal distress in 2 (7%) and one neonatal death due to multiple malformations. There was not significative impairment of renal function in this group.

Proposal to institutionalize criteria and quality standards for cervical cancer screening within a health care system.

The uterine cervix is the most common cancer site for females. Approximately 52,000 new cases occur annually in Latin America, thus the need to improve efficiency and effectiveness of Cervical Cancer Screening Programs (CCSP) is mandatory to decrease the unnecessary suffering women must bear. This paper is addressing essential issues to revamp the CCSP as proposed by the Mexican official norm. A general framework for institutionalizing CCSP is outlined. Furthermore, strategies to strengthen CCSP performance through managerial strategies and quality assurance activities are described. The focus is on the following activities: 1) improving coverage; 2) implementing smear-taking quality control; 3) improving quality in interpretation of Pap test; 4) guaranteeing treatment for women for whom abnormalities are detected; 5) improving follow-up; 6) development of quality control measures and 7) development of monitoring and epidemiological surveillance information systems. Changes within the screening on cervical cancer may be advocated as new technologies present themselves and shortcomings in the existing program appear. It is crucial that these changes should be measured through careful evaluation in order to tally up potential benefits.

Antibiotic noncompliance and waste in upper respiratory infections and acute diarrhea.

A prospective cohort study was conducted to analyze factors associated with antibiotic noncompliance and waste among patients suffering acute respiratory infection (ARI) and acute diarrhea (AD). The study took place in four primary health care clinics in Mexico City, two belonging to the Ministry of Health (MoH) and two to the Mexican Social Security Institute (IMSS). Two hundred twenty-two patients with ARI and 155 with AD were included. Data about study variables and the assessment of compliance were obtained through patient interviews and direct observation. Factors associated with noncompliance were assessed through a multiple logistic regression procedure. Noncompliance was 60% for ARI and 55.5% for AD in both health care systems. Prescription of an antibiotic was justified only in 13.5% of cases. Associated factors were: increased duration of illness (OR 2.95; 95% CI, 1.17-7.41); complexity of the treatment: 3 or more doses per day (OR 2.47; 95% CI, 1.56-3.92), and treatment for more than 7 days (OR 1.94; 95% CI, 1.16-3.26); younger age of patient (OR 1.89; 95% CI, 1.18-3.02); and an inadequate physician-patient relationship (OR 1.87; 95% CI, 1.16-3.02). Antibiotic waste was higher in IMSS (ARI 39.3%, AD 32.6%), than in the MoH (ARI 21.2%, AD 16.4%). Educational strategies to modify physician prescribing practices and strengthen physician-patient relationships might improve compliance and decrease drug waste.

Infant mortality due to acute respiratory infections: the influence of primary care processes.

A population-based case control study was conducted to ascertain whether the process of primary care can be a determinant of infant mortality due to Acute Respiratory Infection (ARI). Cases were 118 infants who died from ARI, individually matched with 118 infants who suffered an ARI episode and recovered. Information was gathered through interviewing mothers. Study variables were assembled into five subsets: children's characteristics; mothers' characteristics; access to medical services; process of primary care, and; sociodemographic variables. An index per subset was built to analyze the independent influence of each on ARI death risk. The index was constructed upon the weighted sum of the adjusted odds ratios (OR) within each subset. Then, the values of each index were collapsed into high/low values with the 50 percentile as a cut-off value. Next, by means of a conditional logistic regression procedure, an explanatory model of ARI mortality was obtained. The final multivariate model included the indexes that showed an independent effect: I) Process of care (OR 9.68, CI 95% 3.59-26.1): inadequate referral, attention provided by more than one physician and being attended by a private physician; II) children's characteristics (OR 7.22, CI 95% 2.35-22.2): perinatal history, lack of breast-feeding and incomplete immunization scheme; III) access to medical services (OR 5.27, CI 95% 2.02-13.7): geographic and economic barriers, lack of confidence in public health services, and; IV) mothers' characteristics (OR 4.03, CI 95% 1.18-13.8), mainly represented by untimely care seeking. We conclude that the management of the disease is a key determinant in which factors relating to the mother and the health services are strongly related. Our study reveals untimely care seeking, difficult access and inadequate disease treatment as important factors which deserve careful attention in the future. We also confirm the importance of biological determinants previously described. A main strategy to reduce infant mortality due to ARI should be to encourage training of primary care physicians, including private practitioners, focused on providing effective case management and emphasizing the education to mothers.

PIP: Findings are reported from a case-control study conducted to determine whether the process of primary care can be a determinant of infant mortality due to acute respiratory infection (ARI). 118 infants who died from ARI were individually matched with 118 infants who experienced an ARI episode and recovered. Information was collected through interviews with the children's mothers. Multivariate analysis identified the independent effects of the process of care, children's characteristics, access to medical services, and mothers' characteristics upon ARI-related infant mortality. Managing disease is a key determinant to survival in which factors relating to the mother and health services are strongly related. Untimely care seeking, difficult access, and inadequate disease treatment deserve close attention in the future. A strategy to reduce the level of infant mortality due to ARI would be to encourage the training of primary care physicians, including private practitioners, focusing upon providing effective case management and emphasizing the education of mothers.

Mothers' health-seeking behaviour in acute diarrhoea in Tlaxcala, Mexico.

This study, a cross-sectional survey, was conducted to assess how mothers take care of their children with diarrhoea and to develop a model of health-care seeking behaviour. Multistage sampling was used. Mothers whose children aged less than five years had suffered from diarrhoea in the last fortnight were included. Nurses interviewed the mothers to collect data. Variables included in the interview were: mothers' characteristics, children's characteristics, clinical data, treatment given by the mother, maternal health-seeking behaviour and mothers' information about diarrhoea and dehydration. Variables corresponding to the clinical data were grouped to identify dehydration signs and the need for medical care. Dehydration was defined as the presence of two or more of the following reported signs: thirst, sunken eyes, sunken fontanelle, or scanty urine. The need for medical care was defined as the presence of one or more of the following characteristics: illness lasting more than three days, vomiting, fever, bloody diarrhoea or dehydration. A sample of 747 mothers was obtained. Household treatments consisted of herbal teas to stop diarrhoea (52.3%), liquids to prevent dehydration (92.2%), symptomatic drugs (35.2%) and changes in feeding patterns (36.3%), which consisted in suppressing milk and dairy products and interrupting breast feeding (12.2%). Mothers sought medical assistance when they perceived a worsening of clinical conditions. Clinical signs statistically associated with their decision were: bloody diarrhoea, vomiting, illness longer than three days, weight loss, and fever. The signs of dehydration were not associated with health care-seeking because the mother did not recognise them. It is concluded that maternal educational programmes should emphasise, besides the proper use of oral rehydration therapy, teaching mothers to identify signs of dehydration as an indication to seek timely medical care.

Improving physician prescribing patterns to treat rhinopharyngitis. Intervention strategies in two health systems of Mexico.

To improve prescribing practices for rhinopharyngitis, an interactive educational intervention and a managerial intervention were carried out in 18 primary care facilities in metropolitan Mexico City. Four family medicine clinics of the Mexican Social Security Institute (IMSS) and 14 health centres of the Ministry of Health (SSA) were included. A quasi-experimental design was employed. One hundred and nineteen physicians (IMSS 68, SSA 51) participated. Sixty-five physicians (IMSS 32, SSA 33) were in the study group, while 54 were in the control group (IMSS 36, SSA 18). The study had four stages: (I) baseline, to evaluate the physicians' prescribing behaviour for rhinopharyngitis; (II) intervention, using an interactive educational workshop and a managerial peer review committee; (III) post-intervention evaluation of short-term impact; and (IV) follow-up evaluation of long-term effect 18 months after the workshop. The control group did not receive any intervention but was evaluated at the same time as the study group. At baseline, most patients in both institutions received antibiotic prescriptions (IMSS 85.2%, SSA 68.8%). After the workshop, the percentage of patients receiving antibiotic prescriptions in the IMSS went from 85.2% to 48.1%, while in the SSA it went from 68.8% to 49.1%. Appropriateness of treatment was analyzed using the physician as the unit of analysis. At baseline, 30% of IMSS physicians in the study group treated their patients appropriately. After the intervention, this percentage increased to 57.7%, and at the 18-month follow-up it was 54.2%. The SSA study group increased the appropriate use of antibiotics from 35.7% to 46.2%, with this percentage falling to 40.9% after the 18-month follow-up period. In the control group there were no significant changes in prescribing patterns with respect to either the prescribing of antibiotics or the appropriateness of treatment. The intervention strategies were successful in both institutions. Forty per cent of physicians improved their prescribing practices after the workshop, with this change remaining in 27.5% of them throughout the follow-up period. On the other hand, 42.5% of the physicians did not change their prescribing practices after the intervention. The rest (17.5%) showed appropriate prescribing practices during all the stages of the study. We conclude that it is possible to improve the physicians' prescribing practices through interactive educational strategies and managerial interventions. This type of intervention can be an affordable way to provide continuing medical education to primary care physicians who do not have access to continuing educational activities, and to improve the quality of care they provide.

[An operative primary health care services model including physicians and technicians]. / Un modelo operativo de servicios de atención primaria a la salud con médicos y técnicos.

The operative Model of Primary Health Care, was developed to offer health services to a population living under conditions of extreme poverty in the municipality of Chimalhuacán, State of México. This article describes the theorical framework, organization and operationalization of an innovative model, changing the current paradigm of clinical practice to include allied health personnel with and especial training. At the core of the model is the Basic Unit of Primary Care that includes one physician and five allied health technicians for each 15,000 habitants. This model offer an alternative to improve the utilization of available personnel and infrastructure. Finally this paper emphasizes the importance of the permanece, surveillance and evaluation of the model.