Colaboración interdisciplinaria para la mejora de la adherencia y la seguridad del paciente en atención primaria / Interdisciplinary collaboration to improve adherence and patient safety in primary care

JUSTIFICACIÓN: se estima que aproximadamente la mitad de los pacientes crónicos en países desarrollados no son adherentes al tratamiento, lo que supone un problema de salud pública muy prevalente, pues afecta al éxito del tratamiento. Esta falta de adherencia, unida a la inercia clínica puede comprometer la seguridad del paciente. Ante esta situación, los grupos GIS y Seguridad del paciente de SEMERGEN y SEFAC respectivamente entendieron que la situación se presentaba como una oportunidad para que ambas profesiones sanitarias, médicos y farmacéuticos, participasen en una formación conjunta. De esta manera se puso en marcha el curso “Reto Adherencia terapéutica y Seguridad del paciente”(6,6 créditos de formación continuada), actividad basada en el concepto de gamificación donde los participantes obtienen puntos por cada entregable y tema superado, adquiriendo conocimientos y estableciéndose una clasificación con los mejores participantes semana a semana.OBJETIVO: mejorar el conocimiento de las diferentes competencias, así como buscar líneas de mejora conjuntas entre medicina y farmacia, logrando a su vez un mejor control de las patologías de nuestros pacientes.MATERIAL Y MÉTODOS: se han incluido 8 retos en total, 1 tema por semana, entre enero y marzo del año en curso, incluyendo temas relacionados con concepto, prevalencia e importancia de la adherencia, métodos de diagnóstico, propuestas de mejora, inercia clínica, gestión del medicamento: conciliación y de prescripción, seguridad del paciente: conceptos generales y herramientas para la seguridad del paciente; seguridad del paciente en el uso de los medicamentos, coordinación asistencial en adherencia y seguridad. Además de contenidos teóricos y la bibliografía de apoyo. (AU)

Phase singularity point tracking for the identification of typical and atypical flutter patients: A clinical-computational study.

Atrial Flutter (AFL) termination by ablating the path responsible for the arrhythmia maintenance is an extended practice. However, the difficulty associated with the identification of the circuit in the case of atypical AFL motivates the development of diagnostic techniques. We propose body surface phase map analysis as a noninvasive tool to identify AFL circuits. Sixty seven lead body surface recordings were acquired in 9 patients during AFL (i.e. 3 typical, 6 atypical). Computed body surface phase maps from simulations of 5 reentrant behaviors in a realistic atrial structure were also used. Surface representation of the macro-reentrant activity was analyzed by tracking the singularity points (SPs) in surface phase maps obtained from band-pass filtered body surface potential maps. Spatial distribution of SPs showed significant differences between typical and atypical AFL. Whereas for typical AFL patients 70.78 ±â€¯16.17% of the maps presented two SPs simultaneously in the areas defined around the midaxialliary lines, this condition was only satisfied in 5.15 ±â€¯10.99% (p < 0.05) maps corresponding to atypical AFL patients. Simulations confirmed these results. Surface phase maps highlights the reentrant mechanism maintaining the arrhythmia and appear as a promising tool for the noninvasive characterization of the circuit maintaining AFL. The potential of the technique as a diagnosis tool needs to be evaluated in larger populations and, if it is confirmed, may help in planning ablation procedures.

Minimal configuration of body surface potential mapping for discrimination of left versus right dominant frequencies during atrial fibrillation.

BACKGROUND: Ablation of drivers maintaining atrial fibrillation (AF) has been demonstrated as an effective therapy. Drivers in the form of rapidly activated atrial regions can be noninvasively localized to either left or right atria (LA, RA) with body surface potential mapping (BSPM) systems. This study quantifies the accuracy of dominant frequency (DF) measurements from reduced-leads BSPM systems and assesses the minimal configuration required for ablation guidance. METHODS: Nine uniformly distributed lead sets of eight to 66 electrodes were evaluated. BSPM signals were registered simultaneously with intracardiac electrocardiograms (EGMs) in 16 AF patients. DF activity was analyzed on the surface potentials for the nine leads configurations, and the noninvasive measures were compared with the EGM recordings. RESULTS: Surface DF measurements presented similar values than panoramic invasive EGM recordings, showing the highest DF regions in corresponding locations. The noninvasive DFs measures had a high correlation with the invasive discrete recordings; they presented a deviation of <0.5 Hz for the highest DF and a correlation coefficient of >0.8 for leads configurations with 12 or more electrodes. CONCLUSIONS: Reduced-leads BSPM systems enable noninvasive discrimination between LA versus RA DFs with similar results as higher-resolution 66-leads system. Our findings demonstrate the possible incorporation of simplified BSPM systems into clinical planning procedures for AF ablation.

A reliable method for rhythm analysis during cardiopulmonary resuscitation.

Interruptions in cardiopulmonary resuscitation (CPR) compromise defibrillation success. However, CPR must be interrupted to analyze the rhythm because although current methods for rhythm analysis during CPR have high sensitivity for shockable rhythms, the specificity for nonshockable rhythms is still too low. This paper introduces a new approach to rhythm analysis during CPR that combines two strategies: a state-of-the-art CPR artifact suppression filter and a shock advice algorithm (SAA) designed to optimally classify the filtered signal. Emphasis is on designing an algorithm with high specificity. The SAA includes a detector for low electrical activity rhythms to increase the specificity, and a shock/no-shock decision algorithm based on a support vector machine classifier using slope and frequency features. For this study, 1185 shockable and 6482 nonshockable 9-s segments corrupted by CPR artifacts were obtained from 247 patients suffering out-of-hospital cardiac arrest. The segments were split into a training and a test set. For the test set, the sensitivity and specificity for rhythm analysis during CPR were 91.0% and 96.6%, respectively. This new approach shows an important increase in specificity without compromising the sensitivity when compared to previous studies.

Response to methylphenidate by adult and pediatric patients with attention-deficit/hyperactivity disorder: the Spanish multicenter DIHANA study.

BACKGROUND: The purpose of this multicenter Spanish study was to evaluate the response to immediate-release methylphenidate by children and adults diagnosed with attention-deficit/hyperactivity disorder (ADHD), as well as to obtain information on current therapy patterns and safety characteristics. METHODS: This multicenter, observational, retrospective, noninterventional study included 730 patients aged 4-65 years with a diagnosis of ADHD. Information was obtained based on a review of medical records for the years 2002-2006 in sequential order. RESULTS: The ADHD predominantly inattentive subtype affected 29.7% of patients, ADHD predominantly hyperactive-impulsive was found in 5.2%, and the combined subtype in 65.1%. Overall, a significant lower Clinical Global Impression (CGI) score and mean number of DSM-IV TR (Diagnostic and Statistical Manual of Mental Disorders Fourth Edition, Text Revision) symptoms by subtype were found after one year of treatment with immediate-release methylphenidate; CGI decreased from 4.51 to 1.69, symptoms of inattention from 7.90 to 4.34, symptoms of hyperactivity from 6.73 to 3.39, and combined subtype symptoms from 14.62 to 7.7. Satisfaction with immediate-release methylphenidate after one year was evaluated as "very satisfied" or "satisfied" by 86.90% of the sample; 25.75% of all patients reported at least one adverse effect. At the end of the study, 41.47% of all the patients treated with immediate-release methylphenidate were still receiving it, with a mean time of 3.80 years on therapy. CONCLUSION: Good efficacy and safety results were found for immediate-release methylphenidate in patients with ADHD.

Reappraisal of classical electrocardiographic criteria in detecting accessory pathways with a strict para-Hisian location.

BACKGROUND: Identification of electrocardiographic (ECG) criteria for para-Hisian accessory pathways (APs) is based on a small series of patients. The presence of a negative delta wave in leads V(1) and V(2) has been suggested as an ECG marker of this AP location. OBJECTIVE: To validate these ECG findings in a large series of patients with strict invasive criteria for that location. METHODS: We included 105 patients (39 women, 66 men; mean age 26 ± 12 years, range 5-82 years) with an ECG pattern compatible with preexcitation through an anteroseptal or midseptal AP following established ECG criteria. A para-Hisian AP was defined when the location of its successful catheter ablation coincided with either the largest recordable His bundle electrogram or a His bundle potential of>0.1 mV. Patients without that definition were included in the control group. RESULTS: A para-Hisian location of the AP was found in 52 patients. AP locations of the remaining 53 patients (control group) were anteroseptal (n = 39), midseptal (n = 9), and fasciculoventricular (n = 5). A negative delta wave in leads V(1) and V(2) was observed in 13 patients with para-Hisian APs (sensitivity 25%; specificity 92%). However, the sum of initial r-wave amplitudes in those leads was<0.5 mV in 44 of the patients with para-Hisian APs and in 13 patients of the control group (sensitivity 85%; specificity 75.5%; area under receiver-operator characteristic curve 0.85). CONCLUSIONS: The presence of negative delta waves in leads V(1) and V(2) indicates a poor sensitivity and high specificity to detect APs with a strict definition of para-Hisian location. The sum of initial r-wave amplitudes in those ECG leads could be a useful, adjunctive marker in the noninvasive identification of these challenging APs.

Trastornos neuropsiquiátricos en la epilepsía con punta-onda continua durante el sueño lento (EPOCS) / Neuropsychiatry disorders in epilepsy with continuous spikes and waves during slow-wave sleep

La epilepsia con punta-onda continua durante el sueño lento (EPOCS) es un síndrome epiléptico que resulta de la asociación de varios tipos de crisis epilépticas parciales y/o generalizadas durante el sueño con un patrón electroencefalográfico característico (complejos de punta-onda continuos) junto con ausencias atípicas en vigilia1. Es conocido en la bibliografía que los síntomas psíquicos que aparecen en la epilepsia son muy abundantes2. La asociación entre psicosis y epilepsia es un hecho que ha sido reconocido desde antiguo2. Así, acompañando al cuadro clínico epiléptico, pueden existir otros trastornos neuro-psiquiátricos asociados, tales como: Trastornos del lenguaje, disminución más o menos marcada del cociente intelectual (CI)3, trastornos de conducta con hiperactividad4, sintomatología psicótica5, etc. A continuación se describen dos casos clínicos de EPOCS en los que junto a la clínica epiléptica existen hallazgos neuro-psicopatológicos comórbidos que siguen un curso independiente a las crisis

Epilepsy with continuous spikes and waves during slow-wave sleep is an epileptic syndrome that results from the association of various types of partial seizures and / or generalized during sleep with an EEG pattern typical (spike-wave complexes continued) with atypical absence in waking1. It is known in the literature that psychological symptoms that appear in epilepsy are most abundant2. The association between psychosis and epilepsy is a fact that has been recognized since antiquity2. Thus, accompanying clinical epileptic, there may be other associated neuro- psychiatric disorders such as disorders of language, more or less pronounced decrease of CI3, conduct disorder with hyperactivity4, psychotic symptoms5, etc. Here are two clinical cases in which epilepsy with continuous spikes and waves during slow-wave sleep by the clinical findings are neuro-epileptic comorbid psychopathology following an independent course to the crisis

Cardiac electrophysiological effects of remifentanil: study in a closed-chest porcine model.

BACKGROUND: Remifentanil has been implicated as causing intraoperative bradyarrhythmias, but little information is available regarding its cardiac electrophysiological effects. Thus, we evaluated the cardiac electrophysiological properties before and after remifentanil in a closed-chest porcine model. METHODS: Eighteen Landrace-Large pigs were premedicated with ketamine and anaesthetized with propofol (4.5 mg kg(-1) bolus followed by 13 mg kg(-1) h(-1)). After instrumentation, an electrophysiological evaluation was performed under propofol and repeated after remifentanil (bolus of 1 microg kg(-1), followed by an infusion of 0.5 microg kg(-1) min(-1)). We evaluated sinus node function [sinus node recovery time (SNRT) and sinoatrial conduction time (SACT)], atrioventricular (AV) nodal function [AH intervals during sinus rhythm (SR) and atrial pacing, Wenckebach cycle length (WCL), and effective refractory periods (ERP)], atrial, His-Purkinje, and ventricular conduction and refractoriness. Significant changes between 'propofol protocol' and 'propofol+remifentanil protocol' were evaluated. RESULTS: Remifentanil caused a significant increase in sinus cycle length (21%, P=0.001) and a significant prolongation of SNRT (43%, P=0.001), corrected SNRT (136%, P=0.003), SACT (40%, P=0.005), AH interval during SR (17%, P=0.02), AH interval during atrial pacing (25%, P=0.01), and ventricular ERP (12%, P=0.004). There was a tendency towards a prolongation of WCL and AV nodal refractoriness. Similar significant changes were observed in a reference group of seven animals in which sevoflurane was used instead of propofol. No significant changes were observed in atrial parameters, His-Purkinje function, parameters of intraventricular conduction, and QT intervals. CONCLUSIONS: Remifentanil depresses sinus node function and most parameters of AV nodal function. This contributes to an explanation for clinical observations of remifentanil-related severe bradyarrhythmias.

The relationship between professional tournament structure on the national level and success in men's professional tennis.

This article discusses the relationship between a nation's men's professional tennis tournament structure and that nation's success in the international men's game. The 2002 men's professional tennis tournament calendar provided the distribution of events on the top thirty nations. Criteria for a nation's success in men's professional tennis were: nation's number of players with ATP points, nation's number of players in the top 200 ranking, and the combined ATP ranking of a nation's top 5 male players. Pearson correlations were performed between the number of tournaments and each criterion. Results showed a considerable variation in the number of events ranging between 67 (United States) and 4 (Sweden). On the other hand, 29 of the 30 countries had Internationally ranked male player/s and 22 had player/s ranked inside the top 200. Results also showed that: 1. nations with a high number of men's professional events are best positioned to provide for more professionally ranked players, 2. nations with more professional men's tournaments are likely to experience success in the men's international game, and 3. having a high number of tournaments is not a prerequisite to having a group of players ranked among the game's elite. It can be concluded that competition is an important factor in player development and that countries who want to be successful at the professional level should try to provide best competitive progression for their players.

Risk stratification in heart failure using artificial neural networks.

Accurate risk stratification of heart failure patients is critical to improve management and outcomes. Heart failure is a complex multisystem disease in which several predictors are categorical. Neural network models have successfully been applied to several medical classification problems. Using a simple neural network, we assessed one-year prognosis in 132 patients, consecutively admitted with heart failure, by classifying them in 3 groups: death, readmission and one-year event-free survival. Given the small number of cases, the neural network model was trained using a resampling method. We identified relevant predictors using the Automatic Relevance Determination (ARD) method, and estimated their mean effect on the 3 different outcomes. Only 9 individuals were misclassified. Neural networks have the potential to be a useful tool for making prognosis in the domain of heart failure.

Satisfaction with life scale: analysis of factorial invariance for adolescents and elderly persons.

The purpose of this work is to analyze the factorial invariance of the Satisfaction With Life Scale across samples of adolescents and elderly persons. Data from 266 subjects were analyzed. Half were Spanish junior high-school students (65 girls and 68 boys) and the other half were Spanish elderly people (68 women and 65 men). Single-group analyses showed an acceptable one-factor model for both adolescent and elderly groups. Sequential multigroup analyses to test the equivalence of factor structures for adolescent and elderly groups showed that factor loadings and variances are not invariant. The scale is sensitive to age in these groups.

[Psychiatric morbidity associated to enuresis in children]. / Morbilidad psiquiátrica asociada a enuresis infantil.

AIMS: The objective of the study was to know the clinical and epidemiological features, including associated psychiatric morbidity, of the children seeking help for enuresis in a public child and adolescent mental health unit. SUBJECTS AND METHOD: Within an exploratory, retrospective, and observational study, we reviewed the clinical charts of all the children (N= 2,315) attending the unit during a five-year period (January 1992-December 1997), collecting information on gender, age, type of enuresis, associated psychiatric morbidity, and social and family characteristics. Both the enuresis and the associated psychiatric disorders were diagnosed according to the DSM-IV criteria. RESULTS: Enuresis was the reason for admission in 230 children (9.9%), whose mean (+/- SD) age was 9.0 (+/- 2.9) years (range: 5-18). The condition of single-parent family, the perception of economic difficulties, and a poor academic achievement were not associated to any type of enuresis. A 19.5 per cent of the patients with enuresis presented a co-morbid psychiatric disorder, which was significantly associated to both male gender in subjects younger than 9 and enuresis of the type secondary or mixed. DISCUSSION: Most children with enuresis referred for psychiatric consultation do not present an associated psychiatric disorder. Our results on children with enuresis, in a clinical sample, are similar to those of previous studies conducted in the general population. This may mean that these patients are sent to child psychiatry services for reasons of traditional health delivery uses rather than for their psychopathological characteristics.

Assessment of quality of life in patients with chest pain and normal coronary arteriogram (syndrome X) using a specific questionnaire.

BACKGROUND: Prognosis in patients with syndrome X (chest pain and normal coronary arteriograms) is good; however, persistent chest pain and functional disability are common in these patients. Accurate assessment of quality of life may be useful for patient management. AIM: The quality of life status in patients with syndrome X was assessed using a specific questionnaire. This questionnaire was developed and validated for the assessment of quality of life in patients with typical chest pain despite normal coronary arteriograms. METHODS: Ninety consecutive patients were invited to complete both the questionnaire (on two occasions within 2 weeks) and a standardized angina dairy. Fully completed questionnaires were received from 66 (73%) patients (mean age 58 +/- 8 years, 55 women). RESULTS: Answers were scored according to a grading system where higher scores indicate worse quality of life. We observed that total scores increased with severity of angina (Canadian Class I, 38 +/- 16, II: 93 +/- 29, III-IV, 119 +/- 23; p < 0.001) and correlated with both the number and the severity of chest pain episodes (r = 0.50-0.66: p < 0.001). In patients who remained clinically stable (n = 37) during the 2-week assessment, test-retest analysis showed no score differences (87 +/- 30 vs. 81 +/- 30; p = 0.1), while total score increased in patients (n = 24) whose symptoms worsened (108 +/- 31 vs. 116 +/- 31; p < 0.02) and was reduced in those (n = 5) whose symptoms improved (55 +/- 37 vs. 39 +/- 28; p < 0.04). CONCLUSION: Our study shows that quality of life is significantly impaired in patients with syndrome X and that the specific questionnaire used for assessment is a reliable and sensitive tool for the evaluation of quality of life in patients with chest pain and normal coronary arteriograms.

Video modeling and imaging training on performance of tennis service of 9- to 12-year-old children.

The purpose of this work is to analyze, in a pilot study, the effects of video modeling and imagery training over 24 weeks on tennis service performance. Three groups of 9- to 12-yr.-old tennis players participated: (a) a physical practice group, who received physical training, (b) a physical practice + video group who received physical training plus watched a video modeling mental training, and (c) a physical practice + video + imagery group who received physical training plus video modeling and imagery mental training. The results for the intragroup pre-post-test comparisons showed that tennis performance did not significantly improve for the physical training group. The groups given mental training showed improvement from pre- to postintervention. Finally, the posttest comparison between groups indicated that there were significant differences between the group given physical training only compared to the groups given mental training but that the latter two did not differ significantly from each other.

Angiographic progression in patients with angina pectoris and normal or near normal coronary angiograms who are restudied due to unstable symptoms.

BACKGROUND: Syndrome X patients commonly remain symptomatic during follow-up and may be readmitted with unstable anginal symptoms. Angiographic disease progression must be considered as a possible mechanism for instability, particularly where multiple coronary risk factors are present and an interval of several years has elapsed since previous angiography. METHODS AND RESULTS: We reviewed data from 139 consecutive patients with chest pain and normal or near normal coronary angiograms (101 patients with completely normal angiograms and 38 patients with minimal lumenal irregularities). During a 5-year period, 24 patients (19 women, median age 56 years) underwent repeat angiography due to primary unstable angina (median interval between angiograms 58 months (range 8-130 months)). This group included three patients with minimal lumenal irregularities and four patients with left bundle branch block. Only two patients had progression to significant angiographic stenosis (> 30% diameter reduction); both were male patients with minimal irregularities at baseline angiography, left bundle branch block and multiple coronary risk factors. However, overall only two of 18 (11%) patients with one or more conventional coronary risk factors had angiographic progression. CONCLUSIONS: Unstable symptoms in patients with chest pain and previously normal or near normal coronary arteriograms are rarely due to angiographic disease progression. However, the presence of minimal lumenal irregularities at baseline angiography and LBBB may identify a sub-group at increased risk.

Recovery curve and concealed conduction in the His-Purkinje system of the rabbit heart: effects of radiofrequency modification of the low AV junction.

UNLABELLED: The aim of this study was to analyze the recovery curve and concealed conduction in the normal His-Purkinje system and after delivering radiofrequency current in the low AV junction, in the perfused rabbit heart. Twenty-one rabbit hearts were studied. Radiofrequency current (5 W) was delivered in the low AV junction to induce an incomplete His-Purkinje AV block (HV prolongation with 1:1 AV conduction); this was achieved in 9 experiments (Group I), while 12 experiments developed a complete block (Group II). Atrial stimulation was performed in both Groups at baseline, and in Group I after radiofrequency delivery, as follows: (1) pacing at increasing rates to determine the His-Purkinje AV block cycle length; (2) atrial extrastimulus test (A1A2) to calculate the His-Purkinje effective refractory period and the fitting of the recovery curve (H1H2 vs H2V2) to the exponential equation delta HV = a.e(-b)x(H1H2); (3) concealed conduction protocol (in 15 experiments) consisting of an atrial extrastimulus test with an interposed beat (A1-A0-A2) at a fixed A1A0 coupling interval. The baseline recovery curve fitted an exponential equation in 17 experiments (with a 93% +/- 42% maximum H2V2 increase at the shortest H1H2), but did not in 4 experiments (the maximum H2V2 increase being only 22% +/- 7%). Radiofrequency application prolonged the HV interval (25 +/- 6 ms vs 46 +/- 16 ms; P = 0.001) and His-Purkinje effective refractory period (167 +/- 28 ms vs 217 +/- 57 ms; P = 0.02). The percentage increment was greater for HV than for refractory period (99% +/- 65% vs 35% +/- 32%; P = 0.02); however, the increment of the His-Purkinje block cycle length (77% +/- 74%) only correlated with that of the refractory period (r = 0.95; P = 0.0001). The recovery curve after radiofrequency delivery fitted an exponential equation in all experiments, showing a rightward shift expressed by an increment of the constant ln a (2.7 +/- 1.9 vs 5.5 +/- 5.5; P = 0.02). Concealed conduction appeared in only three experiments at baseline. After radiofrequency, however, it was observed in all experiments, producing a rightward shift of the recovery curve and an ln a increase (2.87 +/- 1.2 vs 9.9 +/- 2.7; P = 0.0001). When Ho was conducted, the curve rightward shift and ln a increase (26 +/- 7.5; P = 0.0001) were greater. CONCLUSION: (1) His-Purkinje physiology, as in AV nodal physiology, can be described by a recovery curve that fits an exponential equation, especially if conduction becomes depressed with radiofrequency current. (2) Radiofrequency application in the low AV junction modifies His-Purkinje conduction more than refractoriness, though the refractoriness increase determines the degree of block at fast atrial rates. (3) Concealed conduction is uncommon in the normal His-Purkinje system during atrial pacing, but very frequent after modifying the low AV junction with radiofrequency current.

Factor analysis and reliability of the Movement Imagery Questionnaire.

The purpose of this work was to analyze the factor structure, estimate reliability of the Movement Imagery Questionnaire of Hall and Pongrac, and examine differences between men and women on factor scores. The results for 63 men and 47 women supported the bifactorial structure and reliability of this self-report and its adequacy in comparisons of visual and kinesthetic imagery scores.

Amino acid and enzyme studies of brain and other tissues in an infant with argininosuccinic aciduria.

Amino acid contents were measured in four regions of autopsied brain from an infant who presented in coma at the age of 7 weeks and died with argininosuccinic aciduria. Argininosuccinic acid lyase activity was greatly reduced in liver, kidney and cultured skin fibroblasts; incorporation of [14C]citrulline into protein by fibroblasts was minimal. Argininosuccinic acid lyase activity in brain was only slightly lower than that in control infant brain. Nevertheless, the brain showed extensive microscopic changes and a marked accumulation of argininosuccinic acid, varying between regions from 1.8 to 4.4 mmol/l. Brain contents of glutamine, glutamic acid, and alpha-amino-n-butyric acid were also greatly elevated, with a lesser elevation of citrulline, and a normal arginine content. These studies suggest genetic heterogeneity of tissue enzymes in argininosuccinic aciduria and offer some clues about pathogenesis of the neurological damage often seen in this disorder.