[A multifaceted implementation strategy to enhance the uptake of evidence-based nursing recommendations in Spain: implementation project protocol]. / Estrategia de implantación multifacética para promover los cuidados basados en la evidencia: protocolo de investigación en implantación.

OBJECTIVE: It is necessary to facilitate the implementation of evidence-based practice in clinical practice to improve patients' health results. Sumamos Excelencia® is an implementation project led by nurses that aims to improve the evidence-based practice uptake. Building on the first edition, we have improved the project design and proposed new intervention topics. The objective is to evaluate the effects of the implementation of evidence-based recommendations through a multifaceted implementation strategy. METHODS: This study is an implementation research with a quasi-experimental, multicentre, before-and-after design and audits for data collection at baseline, 3, 6, and 12 months. It will be developed in hospital units, primary care centres, and nursing homes. Units choose to implement recommendations of one of these topics: assessment and management of pain, conservative management of urinary incontinence, prevention of childhood obesity, or breastfeeding promotion. All units will implement recommendations about hand hygiene. Audits will assess changes in process and patient outcomes, barriers and strategies, and evidence-based practice competencies through specific questionnaires and clinical records data. Analysis will be descriptive and inferential. CONCLUSIONS: Sumamos Excelencia® will aim to improve the use of evidence-based practice in the Spanish National Health System and to advance implementation science. This study will also provide important insight into the barriers that nurses face to implementing evidence-based practice in clinical practice and the strategies that they can use to overcome them. This generated knowledge can be used in other evidence-based practice implementation projects in a similar context to enhance adherence to evidence-based recommendations.

OBJECTIVE: Es necesario facilitar la implantación de la evidencia científica en la práctica clínica para mejorar los resultados de salud de los pacientes. Sumamos Excelencia® es un proyecto de implantación liderado por enfermeras para aumentar el uso de prácticas basadas en la evidencia en la práctica clínica. En base a la primera edición, se ha mejorado el diseño del proyecto y desarrollado nuevos paquetes de intervención clínica. El objetivo es evaluar los efectos de la implantación de recomendaciones basadas en evidencia en la práctica clínica mediante una estrategia de implantación multifacética. METHODS: Investigación en implantación con diseño cuasi-experimental multicéntrico antes-después sin grupo control, auditorías a los 0, 3, 6 y 12 meses. Realizado en unidades hospitalarias, centros de atención primaria y centros sociosanitarios. Las unidades eligen buenas prácticas sobre una intervención clínica: evaluación y manejo del dolor, manejo conservador de la incontinencia urinaria, prevención de la obesidad infantil o promoción de la lactancia materna. Todas implantarán recomendaciones sobre higiene de manos. Las auditorías evaluarán cambios en procesos y resultados, barreras y estrategias, y competencias de práctica basada en evidencia mediante cuestionarios específicos y registros clínicos. Análisis descriptivo e inferencial. CONCLUSIONS: Sumamos Excelencia® pretende mejorar el uso de la práctica basada en evidencia y aportar conocimiento a la ciencia de la implantación. Proporcionará información sobre las barreras para implantar prácticas basadas en evidencia en la práctica clínica y las estrategias para superarlas. El conocimiento generado puede utilizarse en otros proyectos de implantación para mejorar la adherencia a las recomendaciones basadas en evidencia.

A espessura da gordura epicárdica está associada à restenose de stent coronariano? Uma revisão sistemática e metanálise / Is epicardial fat thickness associated with coronary stent restenosis? A systematic review and meta-analysis

INTRODUÇÃO: Os fatores relacionados ao paciente que contribuem para a restenose do stent ainda não estão claros. A espessura da gordura epicárdica é proposta como um marcador potencial para pacientes de maior risco. MÉTODOS: Realizamos uma revisão sistemática e metanálise comparando a média da espessura da gordura medida por ecocardiografia em pacientes que desenvolveram versus pacientes que não desenvolveram restenose intrastent durante o acompanhamento após intervenção coronariana percutânea. Foram pesquisados PubMed, Cochrane e Embase. Um modelo de efeitos aleatórios foi usado para calcular as diferenças médias (MDs), com intervalos de confiança (IC) de 95%. As análises estatísticas foram realizadas usando o Review Manager 5.4.1. RESULTADOS: Quatro estudos observacionais compreendendo 820 pacientes foram incluídos, dos quais 61,3% eram do sexo masculino e 25,6% desenvolveram restenose; a idade média variou de 57,6 a 63,0 anos. O período médio de acompanhamento foi de 12 meses. A espessura média da gordura epicárdica variou de 3,8 a 10,4 mm no grupo de restenose e de 3,2 a 7,9 mm no grupo sem restenose. Pacientes que desenvolveram restenose do stent coronariano durante o acompanhamento mostraram uma espessura basal significativamente maior da gordura epicárdica do que aqueles sem restenose (MD = 1,02 mm; IC 95% 0,23; 1,80; p= 0,01). CONCLUSÃO: Nossos resultados apontam para uma associação significativa entre o aumento da espessura da gordura epicárdica e a incidência de restenose intrastent coronariana. Dada a possível relevância prognóstica dessa medida, recomendamos sua consideração para inclusão nos relatórios de exames, especialmente em pacientes com doença aterosclerótica.

Avaliação prognóstica de parâmetros ecocardiográficos em pacientes com Doença de Chagas: uma revisão sistemática e metanálise / Prognostic evaluation of echocardiographic parameters in patients with Chagas disease: a systematic review and meta-analysis

CONTEXTO: A doença de Chagas continua sendo uma das principais causas não isquêmicas de cardiomiopatia na América Latina. No entanto, nossa compreensão dos parâmetros ecocardiográficos prognósticos além da fração de ejeção do ventrículo esquerdo (FEVE) permanece limitada. Objetivo: Conduzir uma revisão sistemática e metanálise para avaliar a relação entre o strain longitudinal global do ventrículo esquerdo (GLS-VE), o diâmetro diastólico final do ventrículo esquerdo (DDFVE) e a FEVE com o risco de mortalidade por todas as causas, transplante cardíaco ou necessidade de dispositivo de assistência ventricular mecânica. MÉTODOS: Realizamos uma busca sistemática nas bases de dados Elsevier, PubMed e Cochrane por estudos que avaliassem GLS-VE, DDFVE e FEVE em pacientes com doença de Chagas, abrangendo tanto as fases indeterminada quanto de cardiomiopatia. A análise estatística foi realizada utilizando o RevMan 5.1.7, e a heterogeneidade foi avaliada usando estatísticas I². Calculamos razões de risco (HR) combinadas com intervalos de confiança (IC) de 95% sob um modelo de efeitos aleatórios. Também realizamos uma análise de subgrupos de análises multivariáveis para minimizar o efeito de variáveis de confusão. RESULTADOS: Incluímos 1.277 pacientes de 10 estudos observacionais, com idade média variando de 53 a 66 anos, sendo 60,3% do sexo masculino. Desses pacientes, 1.138 (89%) apresentavam cardiomiopatia chagásica, enquanto 139 estavam na fase indeterminada. A FEVE média variou de 26% a 52%. A redução do GLS-VE (HR 1,14; IC 95% 1,01-1,29; p= 0,04; Figura 1A) e o aumento do DDFVE (HR 1,07; IC 95% 1,02-1,12; p< 0,0001; Figura 1B) foram associados a maior risco de mortalidade por todas as causas, transplante cardíaco ou necessidade de dispositivo de assistência ventricular mecânica. Em contrapartida, maiores índices de FEVE foram associados a menor risco desse desfecho composto (HR 0,93; IC 95% 0,90-0,96; p= 0,002), o que permaneceu estatisticamente significativo após análise de subgrupos com apenas resultados ajustados por multivariáveis (HR 0,95; IC 95% 0,91- 0,99; p= 0,001; Figura 1C). CONCLUSÃO: Nesta revisão sistemática e metanálise de pacientes com doença de Chagas, a redução do GLS-VE e o aumento do DDFVE foram associados a maior risco de mortalidade por todas as causas, transplante cardíaco ou necessidade de dispositivo de assistência ventricular mecânica, enquanto o aumento da FEVE foi fator protetor prognóstico independente para esse desfecho.

Assessment and management of post-surgical pain in adult patients undergoing thoracic surgery: a best practice implementation project.

INTRODUCTION AND OBJECTIVES: Effectiv. e management of post-operative pain improves the condition of patients and reduces their hospital stay. This, in turn, has an impact on caregivers, professionals, and institutions and, as such, is considered a primary indicator of quality. The aim of this project was to improve the assessment and management of post-surgical pain in thoracic surgery patients. METHODS: This implementation project was conducted in a thoracic surgery unit of a tertiary hospital in Spain. The project was guided by the JBI Evidence Implementation Framework, which is grounded in an audit, feedback, and re-audit strategy. A baseline audit was conducted with 44 patients, and barriers to best practice were identified. Strategies were then implemented to improve the assessment and management of post-operative pain. Three follow-up audits were performed using nine audit criteria with 34, 40, and 46 patients, respectively. RESULTS: The baseline audit revealed poor compliance with best practices. After implementing strategies to address areas of non-compliance, health education for patients and caregivers improved up to 80%, while the measurement of pain upon admission and post-surgery rose to 91%. However, patients undergoing pre-operative assessment to guide their post-operative pain management at hospital discharge remained below 50%. CONCLUSIONS: Using a methodology to implement best practices, together with clinical audits, improved compliance with the use of validated scales to assess and manage pain. A multidisciplinary approach improves the quality of care received by patients and contributes to their recovery. SPANISH ABSTRACT: http://links.lww.com/IJEBH/A240.

Complete versus partial revascularization for older adults with acute coronary syndrome: a meta-analysis and systematic review of randomized and multivariable adjusted data

BACKGROUND Evidence from randomized studies support complete over culprit-only revascularization for patients with acute coronary artery syndrome (ACS) and multivessel coronary artery diseases (MVD). Whether these findings extend to elderly patients, however, has not been thoroughly explored. METHODS We conducted a systematic review and meta-analysis comparing clinical outcomes of elderly individuals (defined as age ≥75 years) with ACS and MVD submitted to complete vs partial-only percutaneous coronary intervention (PCI). PubMed, Embase, and Cochrane were searched. We computed pooled hazard ratios with 95% confidence intervals (CI) to preserve time time-to-event data. RESULTS We included 7 studies, of which 2 were RCT and 5 were multivariable adjusted cohorts, comprising a total 10 147, of whom 43.8% underwent complete revascularization. As compared with partial-only PCI, complete revascularization was associated with a lower all-cause mortality (hazard ratio 0.71; 95% CI 0.60­0.85; P < 0.01), cardiovascular mortality (hazard ratio 0.64; 95% CI 0.52­0.79; P < 0.01), and recurrent myocardial infarction (hazard ratio 0.65; 95% CI 0.50­0.85; P < 0.01). There was no significant difference between groups regarding the risk of revascularizations (hazard ratio 0.80; 95% CI 0.53­1.20; P = 0.28). CONCLUSION Among elderly patients with ACS and multivessel CAD, complete revascularization is associated with a lower risk of all-cause mortality, cardiovascular mortality, and recurrent myocardial infarction.

Complete versus partial revascularization for older adults with acute coronary syndrome: a meta-analysis and systematic review of randomized and multivariable adjusted data.

BACKGROUND: Evidence from randomized studies support complete over culprit-only revascularization for patients with acute coronary artery syndrome (ACS) and multivessel coronary artery diseases (MVD). Whether these findings extend to elderly patients, however, has not been thoroughly explored. METHODS: We conducted a systematic review and meta-analysis comparing clinical outcomes of elderly individuals (defined as age ≥75 years) with ACS and MVD submitted to complete vs partial-only percutaneous coronary intervention (PCI). PubMed, Embase, and Cochrane were searched. We computed pooled hazard ratios with 95% confidence intervals (CI) to preserve time time-to-event data. RESULTS: We included 7 studies, of which 2 were RCT and 5 were multivariable adjusted cohorts, comprising a total 10 147, of whom 43.8% underwent complete revascularization. As compared with partial-only PCI, complete revascularization was associated with a lower all-cause mortality (hazard ratio 0.71; 95% CI 0.60-0.85; P < 0.01), cardiovascular mortality (hazard ratio 0.64; 95% CI 0.52-0.79; P < 0.01), and recurrent myocardial infarction (hazard ratio 0.65; 95% CI 0.50-0.85; P < 0.01). There was no significant difference between groups regarding the risk of revascularizations (hazard ratio 0.80; 95% CI 0.53-1.20; P = 0.28). CONCLUSION: Among elderly patients with ACS and multivessel CAD, complete revascularization is associated with a lower risk of all-cause mortality, cardiovascular mortality, and recurrent myocardial infarction.

Pain assessment and management among adult patients in a gynecology ward: a best practice implementation project.

OBJECTIVES: This project aimed to improve compliance with evidence-based practice in pain assessment and management in a gynecology ward. INTRODUCTION: Effective pain control is important to prevent the negative consequences of pain that is poorly managed. However, it remains undervalued and inadequately treated. Applying evidence-based practices to correctly evaluate and manage pain is essential to improve pain relief. METHODS: This project followed the JBI Evidence Implementation Framework. A baseline audit of 41 women admitted to the gynecology ward was conducted and measured against 5 best practice criteria, along with a patient satisfaction questionnaire. Targeted strategies were then implemented and a follow-up audit was conducted using the same criteria, methods, and sample size as the baseline audit. RESULTS: The baseline audit revealed gaps between current and best practice. Barriers to implementation were identified and strategies to resolve the barriers were designed and implemented (nurse education, informative materials, electronic patient records system improvements). Comprehensive pain assessment, including dynamic and static pain assessment, use of a validated tool, and education provided to patients and carers, improved in the follow-up audit. There was no change in patient satisfaction levels; however, the discrepancy between pain measured by nurses and pain measured by patients was reduced. CONCLUSIONS: The JBI methodology was useful in improving compliance with evidence-based practice criteria. It also facilitated adaptation to new barriers, such as the COVID-19 pandemic. Improving nurses' knowledge of pain assessment can lead to more accurate assessment. Inadequate records systems also made it difficult to record the care that was provided. Subsequent audits will assess sustainability and the project will be escalated to other wards.

Delirium risk screening and assessment among older patients in general wards and the emergency department: a best practice implementation project.

OBJECTIVES: The aim of this project was to improve compliance with evidence-based criteria regarding risk of delirium and the assessment of delirium among older patients in the general hospitalization wards and the emergency department. INTRODUCTION: More than 50% of older hospitalized patients experience delirium. Some studies have highlighted the need to implement an orientation protocol in the emergency department and to continue this in the general wards, with the aim of decreasing the delirium rate among older patients admitted to hospital. METHODS: The project followed the JBI evidence implementation framework. We conducted a baseline audit, a half-way audit, and final audit of 50 patients at risk of delirium admitted to the emergency department and the general wards, respectively. The audits measured compliance with eight criteria informed by the available evidence. RESULTS: In the final audit, three of the eight criteria achieved more than 50% compliance in the general wards: pressure injury screening (96%); monitoring changes (74%); and performing interventions (76%). In the emergency department, worse results were reported because of the service conditions. The exception was the criterion on the training of nurses on the topic, with 98%. The integration of a tool to screen for delirium in older patients in the hospital's electronic clinical history records increased the percentage of compliance with audit criteria regarding the use of the scale and delirium detection (rising from 0% to 32% in the final audit in the general wards). CONCLUSION: Through the implementation of this project, validated and evidence-based evaluation will ensure that nurses are supported through appropriate measures to reduce patient confusion and aggression resulting from delirium.

Lenalidomide and dexamethasone maintenance with or without ixazomib, tailored by residual disease status in myeloma.

From November 2014 to May 2017, 332 patients homogeneously treated with bortezomib, lenalidomide, and dexamethasone (VRD) induction, autologous stem cell transplant, and VRD consolidation were randomly assigned to receive maintenance therapy with lenalidomide and dexamethasone (RD; 161 patients) vs RD plus ixazomib (IRD; 171 patients). RD consisted of lenalidomide 15 mg/d from days 1 to 21 plus dexamethasone 20 mg/d on days 1 to 4 and 9 to 12 at 4-week intervals, whereas in the IRD arm, oral ixazomib at a dose of 4 mg on days 1, 8, and 15 was added. Therapy for patients with negative measurable residual disease (MRD) after 24 cycles was discontinued, whereas those who tested positive for MRD remained on maintenance with RD for 36 more cycles. After a median follow-up of 69 months from the initiation of maintenance, the progression-free survival (PFS) was similar in both arms, with a 6-year PFS rate of 61.3% and 55.6% for RD and IRD, respectively (hazard ratio, 1.136; 95% confidence interval, 0.809-1.603). After 2 years of maintenance, treatment was discontinued in 163 patients with negative MRD, whereas 63 patients with positive MRD continued with RD therapy. Maintenance discontinuation in patients tested negative for MRD resulted in a low progression rate (17.2% at 4 years), even in patients with high-risk features. In summary, our results show the efficacy of RD maintenance and support the safety of maintenance therapy discontinuation in patients with negative MRD at 2 years. This trial was registered at www.clinicaltrials.gov as #NCT02406144 and at EudraCT as 2014-00055410.

Definition and Clinical Significance of the Monoclonal Gammopathy of Undetermined Significance-Like Phenotype in Patients With Monoclonal Gammopathies.

PURPOSE: The existence of patients with multiple myeloma (MM) and light-chain (AL) amyloidosis who present with a monoclonal gammopathy of undetermined significance (MGUS)-like phenotype has been hypothesized, but methods to identify this subgroup are not standardized and its clinical significance is not properly validated. PATIENTS AND METHODS: An algorithm to identify patients having MGUS-like phenotype was developed on the basis of the percentages of total bone marrow (BM) plasma cells (PC) and of clonal PC within the BM PC compartment, determined at diagnosis using flow cytometry in 548 patients with MGUS and 2,011 patients with active MM. The clinical significance of the algorithm was tested and validated in 488 patients with smoldering MM, 3,870 patients with active MM and 211 patients with AL amyloidosis. RESULTS: Patients with smoldering MM with MGUS-like phenotype showed significantly lower rates of disease progression (4.5% and 0% at 2 years in two independent series). There were no statistically significant differences in time to progression between treatment versus observation in these patients. In active newly diagnosed MM, MGUS-like phenotype retained independent prognostic value in multivariate analyses of progression-free survival (PFS; hazard ratio [HR], 0.49; P = .001) and overall survival (OS; HR, 0.56; P = .039), together with International Staging System, lactate dehydrogenase, cytogenetic risk, transplant eligibility, and complete remission status. Transplant-eligible patients with active MM with MGUS-like phenotype showed PFS and OS rates at 5 years of 79% and 96%, respectively. In this subgroup, there were no differences in PFS and OS according to complete remission and measurable residual disease status. Application of the algorithm in two independent series of patients with AL predicted for different survival. CONCLUSION: We developed an open-access algorithm for the identification of MGUS-like patients with distinct clinical outcomes. This phenotypic classification could become part of the diagnostic workup of MM and AL amyloidosis.

Radon Dynamics and Effective Dose Estimation in a Touristic Volcanic Cave: La Cueva del Viento, Tenerife (Canary Islands, Spain).

La Cueva del Viento is a volcanic lava tube located in Tenerife Island (Canary Islands, Spain). Its touristic section, 180 m long, receives more than 28,200 visitants each year. According to the European and Spanish legislation, a radon monitoring program is required to minimize the radon exposition of workers, tourists, and cavers. In this work, we studied the radon concentration dynamics in the touristic section of the cave for ca. 1 year, using both passive and active radon detectors. Pluviometry and external air temperature played an important role in the seasonal and daily variations of indoor radon concentrations. Daily fluctuations during the dry season were analyzed using time series (Box-Jenkins methodology) and frequency analysis (Fourier and Wavelet transforms) methods. The experimental radon time-series was well-fitted using a seasonal autoregressive integrated moving average model: Seasonal Auto-Regressive Integrated Moving Average (2,0,1) (2,1,0)24, and its value, in a short-time window (ca. 1 week) was conveniently forecasted. Finally, this work revealed that the annual effective doses received, during the observation period (1 year), by the touristic guides and visitors was ca. 2 mSv/yr and 4 µSv/hr, respectively. We concluded that the touristic exploitation of La Cueva del Viento is safe for both tourists and guides. However, based on our results, La Cueva del Viento had to be classified as a "Monitoring zone" and a regular monitoring program should be implemented.

Experiencia en la generación de estrategias de monitorización y evaluación en la implantación de Guías de Práctica Clínica en España / Experience Generating Evaluation and Monitoring Strategies in the Implementation of Clinical Practice Guidelines in Spain / Experiência na geração de estratégias de monitoramento e avaliação na implementação de manuais de prática clínica na Espanha

Introducción. La monitorización de la utilización del conocimiento y la evaluación de resultados permiten conocer la aplicación de la evidencia, cambios en los conocimientos y actitudes, el impacto en resultados de salud y la integración y el mantenimiento de las prácticas adoptadas. Existen debilidades relacionadas con la falta de sistematización, limitaciones de los registros y calidad del proceso. El objetivo de este artículo es describir la experiencia en la generación de estrategias de monitorización y evaluación de resultados de implantación de Guías de Buenas Prácticas en España. División de temas tratados. En primer lugar, se revisan los procesos de medición de resultados en la implantación de Guías, en el marco del Programa Best Practice Spotlight Organizations®, cuya herramienta para liderar el cambio incluye la monitorización y evaluación como una de las seis fases del ciclo de acción. En segundo lugar, se analizan las estrategias de monitorización y evaluación propuestas en la literatura, destacando la Asociación Profesional de Enfermeras de Ontario. Finalmente, se analizan las estrategias de monitorización y evaluación generadas por dos instituciones españolas participantes en el programa, centradas en adecuación de registros, explotación y análisis de indicadores, desarrollo de herramientas, procedimientos de evaluación y mecanismos de difusión y retroalimentación. Conclusiones. La definición de estrategias de monitorización y evaluación planificada de forma temprana contribuye a la viabilidad de la evaluación de la implantación y su sostenibilidad. Es necesario adaptarlas al contexto, con estrategias transversales que alcancen a toda la institución, facilitadas por la institución. Palabras clave: Ciencia de la Implementación; Práctica Clínica Basada en la Evidencia; Evaluación de Resultado en la Atención de Salud; Mecanismos de Evaluación de la Atención de Salud; Indicadores de Calidad de la Atención de Salud

Introduction. Monitoring the usage of knowledge and evaluating results permits one to know the application of the evidence, knowledge, and attitude changes, the impact on health results, integration, and maintenance of the adopted practices. There exist weaknesses related to lack of systematization, limitation of the records, and quality of the process. This article's objective is to describe the experience generating monitoring strategies and evaluation of the results regarding the implementation of good practice guides in Spain. Topics for Reflection. In the first place, the measurement process of the results regarding the implementation of guides are reviewed, in the Best Practice Spotlight Organizations® program frame, whose tool to lead the change includes monitoring and evaluation as one of the sixth phases of the action cycle. In the second place, monitoring and evaluation strategies proposed in the literature are analyzed, highlighting the Professional Nurses Association of Ontario. Finally, the monitoring and evaluation strategies are analyzed by two Spanish institutions participating in the program, focused on the adequation of records, exploitation and indicator analysis, tools development, evaluation procedures, dissemination, and feedback mechanisms. Conclusions: The definition of monitoring and evaluation strategies planned in advance contributes to the viability of the evaluation regarding the implementation and its sustainability. Is necessary to adapt them to the context, with transversal strategies that reach the whole institution, facilitated by the institution. Keywords: Implementation Science; Evidence-Based Practice; Outcome Assessment, Health Care; Health Care Evaluation Mechanisms; Quality Indicators, Health Care

Introdução. Monitorizar a utilização do conhecimento e avaliar os resultados permite-nos conhecer a aplicação das evidências, as mudanças nos conhecimentos e atitudes, o impacto nos resultados de saúde e a integração e manutenção das práticas adotadas. Existem fragilidades relacionadas à falta de sistematização, limitações de registros e qualidade do processo. O objetivo deste artigo é descrever a experiência na geração de estratégias de monitoramento e avaliação dos resultados da implementação de Manuais de Boas Práticas na Espanha. Divisão dos temas abordados. Em primeiro lugar, são revistos os processos de medição de resultados na implementação dos Manuais, no âmbito do Programa Best Practice Spotlight Organizations®, cuja ferramenta para liderar a mudança inclui a monitorização e avaliação como uma das seis fases do ciclo de ação. Em segundo lugar, são analisadas as estratégias de monitoramento e avaliação propostas na literatura, com destaque para a Associação Profissional de Enfermeiros de Ontário. Por fim, são analisadas as estratégias de monitoramento e avaliação geradas por duas instituições espanholas participantes do programa, focadas na adaptação de registros, exploração e análise de indicadores, desenvolvimento de ferramentas, procedimentos de avaliação e mecanismos de divulgação e feedback. Conclusões. A definição de estratégias de monitoramento e avaliação planeadas antecipadamente contribui para a viabilidade da avaliação da implementação e para a sua sustentabilidade. É necessário adaptá-los ao contexto, com estratégias transversais que alcancem toda a instituição, facilitadas pela instituição. Palavras-chave: Ciência da Implementação; Prática Clínica Baseada em Evidências; Avaliação de Resultados em Cuidados de Saúde; Mecanismos de Avaliação da Assistência à Saúde; Indicadores de Qualidade em Assistência à Saúde

Prognostic Value of Serum Paraprotein Response Kinetics in Patients With Newly Diagnosed Multiple Myeloma.

INTRODUCTION: Response kinetics is a well-established prognostic marker in acute lymphoblastic leukemia. The situation is not clear in multiple myeloma (MM) despite having a biomarker for response monitoring (monoclonal component [MC]). MATERIALS AND METHODS: We developed a mathematical model to assess the prognostic value of serum MC response kinetics during 6 induction cycles, in 373 NDMM transplanted patients treated in the GEM2012Menos65 clinical trial. The model calculated a "resistance" parameter that reflects the stagnation in the response after an initial descent. RESULTS: Two patient subgroups were defined based on low and high resistance, that respectively captured sensitive and refractory kinetics, with progression-free survival (PFS) at 5 years of 72% and 59% (HR 0.64, 95% CI 0.44-0.93; P = .02). Resistance significantly correlated with depth of response measured after consolidation (80.9% CR and 68.4% minimal residual disease negativity in patients with sensitive vs. 31% and 20% in those with refractory kinetics). Furthermore, it modulated the impact of reaching CR after consolidation; thus, within CR patients those with refractory kinetics had significantly shorter PFS than those with sensitive kinetics (median 54 months vs. NR; P = .02). Minimal residual disease negativity abrogated this effect. Our study also questions the benefit of rapid responders compared to late responders (5-year PFS 59.7% vs. 76.5%, respectively [P < .002]). Of note, 85% of patients considered as late responders were classified as having sensitive kinetics. CONCLUSION: This semi-mechanistic modeling of M-component kinetics could be of great value to identify patients at risk of early treatment failure, who may benefit from early rescue intervention strategies.

[Limited Reuse and Extended Use of Filtering Facepiece Respirators]. / Reutilización limitada y uso extendido de mascarillas de media-alta filtración.

AIM: Personal protective equipment (PPE), including respirators, is essential in a pandemic like COVID-19, which has required, on many occasions, the reuse of material due to its shortage. The aim of this review is to summarize available evidence on the reuse and extended use of filtering facepiece respirator. METHOD: Scoping review. Search through natural language in PUBMED and Centers, Agencies and Organizations for Disease Control. Limited to articles published between 2010-2020 in English and Spanish. RESULTS: 83 articles were located, 14 were selected, plus 5 recommendations. The topics included in this study are classified in 7 sections: expiration, extended use and reuse of masks, handling techniques, sealing, physical-psychological effects and compliance, contamination and decontamination of respirators. CONCLUSIONS: The reuse of masks is not recommended by official organizations or manufacturers, and is only accepted in extraordinary cases, such as pandemics. The studies are characterized by having small samples, using different models of respirators adjusting their recommendation to the model.

Tumor cells in light-chain amyloidosis and myeloma show distinct transcriptional rewiring of normal plasma cell development.

Although light-chain amyloidosis (AL) and multiple myeloma (MM) are characterized by tumor plasma cell (PC) expansion in bone marrow (BM), their clinical presentation differs. Previous attempts to identify unique pathogenic mechanisms behind such differences were unsuccessful, and no studies have investigated the differentiation stage of tumor PCs in patients with AL and MM. We sought to define a transcriptional atlas of normal PC development in secondary lymphoid organs (SLOs), peripheral blood (PB), and BM for comparison with the transcriptional programs (TPs) of tumor PCs in AL, MM, and monoclonal gammopathy of undetermined significance (MGUS). Based on bulk and single-cell RNA sequencing, we observed 13 TPs during transition of normal PCs throughout SLOs, PB, and BM. We further noted the following: CD39 outperforms CD19 to discriminate newborn from long-lived BM-PCs; tumor PCs expressed the most advantageous TPs of normal PC differentiation; AL shares greater similarity to SLO-PCs whereas MM is transcriptionally closer to PB-PCs and newborn BM-PCs; patients with AL and MM enriched in immature TPs had inferior survival; and protein N-linked glycosylation-related TPs are upregulated in AL. Collectively, we provide a novel resource to understand normal PC development and the transcriptional reorganization of AL and other monoclonal gammopathies.

Impact of the implementation of best practice guidelines on nurse's evidence-based practice and on nurses' work environment: Research protocol.

AIM: To determine the impact of the Best Practice Spotlight Organization® initiative on nurses' perception of their work environment and their attitudes to evidence-based practice. DESIGN: Quasi-experimental, multicentre study. The intervention is the participation in Best Prectice Spotilight Organizations to implement Best Practice Guidelines. METHODS: The study will include seven centres in the interventional group and 10 in the non-equivalent control group, all of them belonging to the Spanish national health system. The Practice Environment Scale of the Nursing Work Index, and the Health Sciences Evidence-Based Practice Questionnaire will be administered to a sample of 1,572 nurses at the beginning of the programme and at 1 year. This 3-year study started in April 2018 and will continue until December 2021. Statistical analyses will be carried out using the SPSS 25.0. This project was approved by the Drug Research Ethics Committee of the Parc de Salut Mar and registered in Clinical Trials. DISCUSSION: The study findings will show the current state of nurses' perception of their work environment and attitudes to evidence-based practice, and possible changes in these parameters due to the programme. IMPACT: The findings could provide a strong argument for health policymakers to scale up the Best Practice Spotlight Organization® initiative in the Spanish national health system.

[Nursing mothers satisfaction with the promotion of breastfeeding and professionals adherence to the recommendations. Multi-center study.] / Satisfacción de madres lactantes con la promoción de la lactancia materna y adherencia de los profesionales a las recomendaciones. Estudio multicéntrico.

OBJECTIVE: The Baby-friendly Hospital Initiative or clinical practice guideline implementation programs have a positive impact on the promotion of breastfeeding (BF). There are knowledge gaps regarding the perceptions of new mothers towards these initiatives, and their degree of satisfaction. Our objective was to describe the satisfaction of BF mothers and adherence to the recommendations of the "Breastfeeding" guide from the Registered Nurses' Association of Ontario (RNAO). METHODS: Between 2018-2019, in 9 Spanish hospitals that implemented the guide, 2,397 nursing mothers were surveyed who met inclusion criteria. A self-administered survey was designed with sociodemographic data, mother-child, BF promotion interventions carried out and degree of satisfaction. Descriptive and bivariate analysis was performed. RESULTS: The recommendations for skin-to-skin contact, help in breastfeeding, observation of a breastfeeding session and resolution of doubts presented adhesions >84%. Information about support groups, rooming-in and recognize signs of baby satisfaction obtained adhesions <40%. The exclusive BF rate at discharge was 77.5%. The mean satisfaction with skin-to-skin contact and the percentage of satisfaction at discharge were 5.8 and 96.8% respectively. The differences were significant between the degree of satisfaction and the educational level, age, work situation, type of delivery and type of hospital (p<0.05). CONCLUSIONS: According to puerperal women, adherence to the recommendations of the Clinical Practice Guide is good for most interventions and the degree of satisfaction is high.

OBJETIVO: La Iniciativa para la Humanización de la Asistencia al Nacimiento y la Lactancia (IHAN) o programas de implantación de Guías de Práctica Clínica tienen impacto positivo en la promoción de la lactancia materna (LM). Existen lagunas respecto a percepciones de las puérperas hacia estas iniciativas y el grado de satisfacción. Nuestro objetivo fue describir la satisfacción de las madres lactantes y la adherencia a las recomendaciones de la guía "Lactancia Materna" de la Registered Nurses´Association of Ontario (RNAO). METODOS: Entre 2018-2019, en 9 hospitales españoles que implantaban la guía se encuestaron 2.397 madres lactantes que cumplieron criterios de inclusión. Se diseñó una encuesta autoadministrada con datos sociodemográficos madre-hijo, intervenciones de promoción de LM realizadas y grado de satisfacción. Se realizó análisis descriptivo y bivariado. RESULTADOS: Las recomendaciones de contacto piel-con-piel, ayuda en el amamantamiento, observación de la toma y resolución de dudas presentaron adherencias >84%. La información sobre grupos de apoyo, alojamiento conjunto y reconocer signos de satisfacción del bebé obtuvieron adherencias <40%. La tasa de LM exclusiva al alta fue 77,5%. La satisfacción media con el contacto piel con piel y el porcentaje de satisfacción al alta fueron 5,8 y 96,8% respectivamente. Las diferencias fueron significativas entre el grado de satisfacción y el nivel de estudios, la edad, la situación laboral, tipo de parto y tipo de hospital (p<0,05). CONCLUSIONES: Según las puérperas, la adherencia a las recomendaciones de la Guía de Práctica Clínica es buena para la mayoría de intervenciones y el grado de satisfacción elevado.

Cronoterapia antihipertensiva en pacientes diabéticos tipo 2: grado de implantación en una zona de salud del centro de España / Antihypertensive chronotherapy in type 2 diabetes mellitus: application degree in a community health center in central Spain

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Techo de cristal y desigualdades de género en la carrera profesional de las mujeres académicas e investigadoras en ciencias biomédicas / Glass ceiling and gender inequalities in the careers of women academics in biomedical sciences

OBJETIVO: Identificar, en la literatura científica internacional, los obstáculos y factores potencialmente favorecedores para el avance durante su carrera profesional de las mujeres académicas e investigadoras en ciencias biomédicas. MÉTODO: Se realizó una búsqueda sistemática en PubMed, Scopus, CinahlPlus, Cochrane Database of Systematic Reviews, PsycInfo y Sociological Abstracts de artículos publicados en inglés y español entre enero de 2006 y diciembre de 2016 sobre el fenómeno del techo de cristal en mujeres académicas e investigadoras en ciencias biomédicas. El cribado se llevó a cabo por revisoras independientes. RESULTADOS: Se encontraron 2254 estudios, de los cuales se incluyeron 23 en la revisión. Los obstáculos identificados para la promoción de las mujeres académicas o investigadoras en ciencias biomédicas son los sesgos de género en la evaluación de la investigación, el individualismo y la falta de colaboración, la falta de influencia de las mujeres, las desigualdades de género en la contratación y la promoción, la percepción de sexismo y discriminación en el clima laboral, y las dificultades de conciliación. Los elementos que favorecen son los ejemplos de mujeres en puestos de liderazgo, la mentorización, facilitar la conciliación, la transparencia en la contratación, la participación en la toma de decisiones, realizar auditorías de género en la evaluación de la investigación, la conciencia de las desigualdades de género, promover la colaboración y la equidad salarial. CONCLUSIONES: Potenciar los elementos que favorecen la promoción de las mujeres académicas en ciencias biomédicas contribuiría a reducir el fenómeno del techo de cristal en esta área, al aumentar su participación, representación y liderazgo. Se requiere un cambio de valores organizacional e institucional

OBJECTIVE: To identify in the international scientific literature the obstacles and potential promoters for the advancement of women academics and researchers in biomedical sciences during their professional careers. METHOD: PubMed, Scopus, CinahlPlus, Cochrane Database of Systematic Reviews, PsycInfo and Sociological Abstracts were systematically searched for articles published in English and Spanish between January 2006 and December 2016 on the phenomenon of the glass ceiling in women academics and researchers in biomedical sciences. The screening was carried out by independent reviewers. RESULTS: A total of 2254 studies were found, of which 23 were included in the review. The obstacles identified for the promotion of women academics and/or researchers in biomedical sciences are: gender bias in the evaluation of research results, individualism and lack of collaboration, women's lack of influence, the existence of gender inequalities in access to employment. The perception of sexism and discrimination in the work environment, and the difficulties in reconciling work and family life. The promoting elements are: examples of women in leadership positions, mentoring, facilitating conciliation, transparency in recruitment, participation in decision-making, gender assessment of research, awareness of gender inequalities in institutions, promoting collaboration, and pay equity. CONCLUSIONS: By enhancing the elements favouring the promotion of academic women in biomedical sciences would help to reduce the glass ceiling in the career paths of women academics and health science researchers by increasing their participation, leadership and representation. A change of organizational and institutional values is required to achieve this