[Interlevel incident management: The experience of a primary care district]. / Gestión de incidencias interniveles. La experiencia de un distrito de atención primaria.

AIM: Determine the prevalence and define the profile of interlevel incidences (ININ) between primary care (PC) and hospital (HC). DESIGN: Multicenter cross-sectional descriptive study. SITE: Primary care. PARTICIPANTS: Professionals from a Health District and its reference hospitals. INTERVENTIONS: ININ are errors in communication between PC and HC professionals derived from administrative, pharmaceutical or clinical procedures not resolved during the formal interlevel communication processes, which requires a coordinated and validated response from the health care directions to not overload the family physician. MAIN MEASUREMENTS: ININ by category, hospital services and health centers, total and validated, relative to the total number of referrals, and the reason for the ININ. RESULTS: We detected 2011 ININs (3.36%) among the 59.859 referrals, although only 1684 were validated (83.7%). Most were administrative (59.5%), followed by pharmaceutical (24.2%), clinical (10.2%) and reverse (6.1%). 41.3% of the clinical ININs were grouped around 5 hospital specialties, and 45.9% in 5 health centers. The main reasons for clinical ININ were non-prescription of the recommended pharmacological treatment in outpatient clinics or on hospital discharge (27.3%), request for referral to another hospital specialist (27.9%), or request to referral in person to patients who had already been referred by teleconsultation (17.8%). CONCLUSIONS: 3.36% of interlevel referrals are accompanied by incidents and 83.7% are validated and processed. It is necessary to develop ININ management tools to guarantee safe healthcare and debureaucratize PC.

Efectividad del Decálogo de prevención cardiovascular en diabéticos / Effectiveness of a Decalogue for cardiovascular prevention in diabetics

INTRODUCCIÓN: Evaluar la efectividad en conocimiento, percepción de control y mejora del riesgo cardiovascular (RCV) mediante la entrega de un Decálogo visual. MATERIAL Y MÉTODOS: Ensayo clínico de intervención educativa, no farmacológico, con grupo control paralelo, aleatorizado, evaluado a ciegas, en pacientes diabéticos tipo 2, realizado en Atención Primaria de Salud. Ambos grupos recibieron una intervención educativa sobre RCV y su grado de control, y el de intervención además un Decálogo visual con los factores de RCV modificables que reflejaba visualmente su grado de control. Incluimos 50 pacientes en cada grupo para detectar una mejora del conocimiento multifactorial del RCV del 50%. Todos los pacientes recibieron un recuerdo telefónico a los 2 meses, evaluando enmascaradamente el conocimiento y la percepción de control del RCV, y al cabo de 6 meses se evaluó de nuevo presencialmente el conocimiento y el control real del RCV. RESULTADOS: Seleccionamos 51 hombres y 49 mujeres, de 62,9 años de edad media, 9,2 años de evolución y escaso nivel educativo (32% sin estudios y 52% estudios primarios). Basalmente, el conocimiento, la percepción y el control del RCV fueron del 55,0, 80,4 y 65,9%, respectivamente. A los 2 meses, el conocimiento aumentó en el grupo del Decálogo un 16,5% más que en el grupo de educación convencional (73,6% vs. 63,2%; p < 0,05); la percepción sobreestimada de control mejoró un 34,5% en el total de la muestra (p < 0,001) sin diferencias entre grupos, aunque mejoró más la concordancia en el grupo del Decálogo. A los 6 meses aumentó el conocimiento globalmente en un 25,6% (p < 0,001), desapareciendo las diferencias iniciales entre grupos. El control final del RCV aumentó globalmente y en el grupo del Decálogo en un 6,4% (p < 0,005) y un 9,4% (p < 0,001), respectivamente. El riesgo SCORE disminuyó significativamente de forma global y en ambos grupos, sin diferencias entre ambos. CONCLUSIONES: La intervención educativa mejora globalmente el conocimiento, la percepción y el control del RCV. El Decálogo de RCV incrementa rápidamente el conocimiento y disminuye la falsa percepción subjetiva de control del RCV, aunque el beneficio se equipara a los 6 meses si las intervenciones educativas persisten

INTRODUCTION: To assess the effects of a visual Decalogue aid on the degree of knowledge, control perception and improvement in cardiovascular risk factors (CVRF). MATERIAL AND METHODS: A Primary care randomised non-pharmacological trial of an educational intervention with a parallel control group, and blind evaluation in type 2 diabetic patients. Both groups received an educational intervention on the management of CVRF. The intervention group also received a visual Decalogue aid that showed the level of control patients have over the modifiable CVRF. A total of 50 patients were included in each group in order to identify an improvement of 50% in the multifactorial knowledge of CVRF. All patients received a reminder telephone call at 2 months, with masked evaluation of knowledge and CVRF control perception. In a 6 months visit the level of knowledge and real control of CVRF were re-evaluated. RESULTS: The study included 51 males and 49 females, with mean age of 62.9 years, a mean disease duration of 9.2 years, and low educational level. The level of knowledge, control perception, and real control at baseline was 55%, 80.4%, and 65.9%, respectively. After 2 months the level of knowledge in the Decalogue group increased by 16.5% more than in the conventional education group (73.6% vs. 63.2%; P < .05) and the overestimated control perception improved by 34.5% (P < .001) with no differences between groups, although concordance was better in the Decalogue group. At 6 months there was an overall increase 25.6% (P < .001) in the level of knowledge, with the previous difference between groups levelling off. The final CVRF control improved overall and in the Decalogue group by 6.4% (P < .005) and 9.4% (P < .001), respectively. The SCORE risk significantly decreased overall with no differences between groups. CONCLUSIONS: The educational intervention improves the overall level of knowledge, perception and control of CVRF. The CVRF Decalogue quickly increases the level of knowledge, and decreases the false subjective risk control perception. The benefit, however, becomes equal at 6 months with ongoing education interventions

[Effectiveness of a Decalogue for cardiovascular prevention in diabetics]. / Efectividad del Decálogo de prevención cardiovascular en diabéticos.

INTRODUCTION: To assess the effects of a visual Decalogue aid on the degree of knowledge, control perception and improvement in cardiovascular risk factors (CVRF). MATERIAL AND METHODS: A Primary care randomised non-pharmacological trial of an educational intervention with a parallel control group, and blind evaluation in type 2 diabetic patients. Both groups received an educational intervention on the management of CVRF. The intervention group also received a visual Decalogue aid that showed the level of control patients have over the modifiable CVRF. A total of 50 patients were included in each group in order to identify an improvement of 50% in the multifactorial knowledge of CVRF. All patients received a reminder telephone call at 2 months, with masked evaluation of knowledge and CVRF control perception. In a 6 months visit the level of knowledge and real control of CVRF were re-evaluated. RESULTS: The study included 51 males and 49 females, with mean age of 62.9 years, a mean disease duration of 9.2 years, and low educational level. The level of knowledge, control perception, and real control at baseline was 55%, 80.4%, and 65.9%, respectively. After 2 months the level of knowledge in the Decalogue group increased by 16.5% more than in the conventional education group (73.6% vs. 63.2%; P<.05) and the overestimated control perception improved by 34.5% (P<.001) with no differences between groups, although concordance was better in the Decalogue group. At 6 months there was an overall increase 25.6% (P<.001) in the level of knowledge, with the previous difference between groups levelling off. The final CVRF control improved overall and in the Decalogue group by 6.4% (P<.005) and 9.4% (P<.001), respectively. The SCORE risk significantly decreased overall with no differences between groups. CONCLUSIONS: The educational intervention improves the overall level of knowledge, perception and control of CVRF. The CVRF Decalogue quickly increases the level of knowledge, and decreases the false subjective risk control perception. The benefit, however, becomes equal at 6 months with ongoing education interventions.

Intervalos de referencia de la tirotropina durante la gestación en la provincia de Huelva / Thyrotropin reference ranges during pregnancy in the province of Huelva, Spain

Objetivo: El diagnóstico correcto de hipotiroidismo gestacional requiere determinar los intervalos de referencia trimestrales locales de la TSH. En su ausencia las guías recomiendan utilizar como límites superiores 2,5-3,0-3,0μU/ml para el 1.°-2.°-3.° trimestre. Nuestro objetivo es calcular el rango de referencia para nuestra población. Material y métodos: Estudio observacional de base poblacional realizado en gestantes sanas de 11 centros de salud de la provincia de Huelva incluidas consecutivamente durante el año 2016 en el proceso de embarazo. Excluimos las gestantes con antecedentes de enfermedad tiroidea o médica, malos antecedentes obstétricos, embarazo gemelar, autoinmunidad tiroidea y TSH en valores extremos (<0,4μU/ml o>10μU/ml), así como las que durante el estudio iniciaron tratamiento con levotiroxina por disfunción tiroidea. Resultados: Seleccionamos 186 gestantes de 30,7 años (IC 95%: 29,8-31,6) e IMC de 23,6 (IC 95%: 23,2-24,0) que mayoritariamente se hicieron la 1.ª analítica con anterioridad a la 11.ª semana de gestación. Fueron válidas para el análisis 145-105-67 gestantes en el 1.°-2.°-3.° trimestre, respectivamente, tras excluir sucesivamente abortos (18,9%), autoinmunidad (6,5%), hipo/hipertiroidismos (2,2%) y tratamientos con levotiroxina durante el 2.°/3.° trimestre (18,6%). El percentil 97,5 de la TSH para el 1.°-2.°-3.° trimestre, respectivamente, fue de 4,68-4,83-4,57μU/ml. Durante el estudio se detectaron 80 gestantes con disfunción tiroidea (55,2%), recibiendo 33 de ellas tratamiento con levotiroxina (22,7%); con los nuevos criterios la prevalencia de disfunción tiroidea se reduciría al 6,2% y la necesidad de tratamiento al 4,1%. Conclusión: El rango de normalidad de TSH de nuestra población difiere del propuesto en las guías. Un 18,6% de las gestantes fueron tratadas innecesariamente

Objective: The correct diagnosis of hypothyroidism during pregnancy requires knowledge of the local trimester-specific thyrotropin (TSH) reference ranges. When these are not available, the guidelines recommend upper limits of 2.5, 3.0, and 3.0μU/ml for the 1st, 2nd, and 3rd trimesters, respectively. The aim is to establish the reference range for our local population. Material and methods: A population-based observational study was performed on healthy pregnant women from 11 healthcare centres in the province of Huelva. Women were recruited consecutively during 2016 through the pregnancy process. Women were excluded who had a history of thyroid or medical disease, a poor obstetric history, multiple pregnancy, thyroid autoimmunity, and extreme TSH values (<0.4μU/ml or>10μU/ml), as well as women treated with levothyroxine for thyroid dysfunction. Results: The study included a total of 186 pregnant women, with a mean age of 30.7 years (95% CI: 29.8-31.6) and a body mass index (BMI) of 23.6 (95% CI: 23.2-24.0). Most of them had the first laboratory tests performed before week 11 of pregnancy. Valid subjects for analysis were 145, 105, and 67 pregnant women in the 1st, 2nd, and 3rd trimesters, respectively, after excluding those due to abortion (18.9%), autoimmunity (6.5%), hypo/hyperthyroidism (2.2%), and levothyroxine treatment during the 2nd/3rd trimester (18.6%). The 97.5% TSH percentile for the 1st, 2nd, and 3rd trimester was 4.68, 4.83, and 4.57μU/ml, respectively. Thyroid dysfunction was identified in 80 women (55.2%), 33 of whom received treatment with Levothyroxine (22.7%). With the new criteria, thyroid dysfunction prevalence would be reduced to 6.2%, and the need for treatment to 4.1%. Conclusion: The reference range for TSH in our population differs from that proposed by the guidelines. Unnecessary treatment was being given to 18.6% of pregnant women

[Thyrotropin reference ranges during pregnancy in the province of Huelva, Spain]. / Intervalos de referencia de la tirotropina durante la gestación en la provincia de Huelva.

OBJECTIVE: The correct diagnosis of hypothyroidism during pregnancy requires knowledge of the local trimester-specific thyrotropin (TSH) reference ranges. When these are not available, the guidelines recommend upper limits of 2.5, 3.0, and 3.0µU/ml for the 1st, 2nd, and 3rd trimesters, respectively. The aim is to establish the reference range for our local population. MATERIAL AND METHODS: A population-based observational study was performed on healthy pregnant women from 11 healthcare centres in the province of Huelva. Women were recruited consecutively during 2016 through the pregnancy process. Women were excluded who had a history of thyroid or medical disease, a poor obstetric history, multiple pregnancy, thyroid autoimmunity, and extreme TSH values (<0.4µU/ml or>10µU/ml), as well as women treated with levothyroxine for thyroid dysfunction. RESULTS: The study included a total of 186 pregnant women, with a mean age of 30.7 years (95% CI: 29.8-31.6) and a body mass index (BMI) of 23.6 (95% CI: 23.2-24.0). Most of them had the first laboratory tests performed before week 11 of pregnancy. Valid subjects for analysis were 145, 105, and 67 pregnant women in the 1st, 2nd, and 3rd trimesters, respectively, after excluding those due to abortion (18.9%), autoimmunity (6.5%), hypo/hyperthyroidism (2.2%), and levothyroxine treatment during the 2nd/3rd trimester (18.6%). The 97.5% TSH percentile for the 1st, 2nd, and 3rd trimester was 4.68, 4.83, and 4.57µU/ml, respectively. Thyroid dysfunction was identified in 80 women (55.2%), 33 of whom received treatment with Levothyroxine (22.7%). With the new criteria, thyroid dysfunction prevalence would be reduced to 6.2%, and the need for treatment to 4.1%. CONCLUSION: The reference range for TSH in our population differs from that proposed by the guidelines. Unnecessary treatment was being given to 18.6% of pregnant women.

Seguimiento de la hipertransaminasemia en las consultas de atención primaria / Monitoring of hypertransaminasaemia in primary care clinics

No disponible

Comparison of intravenous flecainide, propafenone, and amiodarone for conversion of acute atrial fibrillation to sinus rhythm.

In a prospective, single-blind trial, we randomized 150 consecutive symptomatic patients with acute (< or = 48 hours' duration) atrial fibrillation to receive intravenous flecainide, propafenone, or amiodarone. Flecainide and propafenone were administered as a bolus dose of 2 mg/kg in 20 minutes. A second bolus dose of 1 mg/kg in 20 minutes was administered if conversion to sinus rhythm was not achieved after 8 hours. Amiodarone was administered as a bolus of 5 mg/kg in 20 minutes followed by a continuous infusion of 50 mg/hour. By the end of a 12-hour observation period, conversion to sinus rhythm was achieved in 45 patients (90%) in the flecainide group, 36 (72%) in the propafenone group, and 32 (64%) in the amiodarone group (p = 0.008 for the overall comparison, p = 0.002 for flecainide vs amiodarone, p = 0.022 for flecainide vs propafenone, and p = 0.39 for propafenone vs amiodarone). When compared with amiodarone, this higher reversion rate with flecainide was present from the first hour of the study period. However, only after administering the second bolus was there a significant difference between flecainide and propafenone. Median time to conversion to sinus rhythm was different among groups (p < 0.001), and it was lower in the flecainide (25 minutes; range 4 to 660) and propafenone (30 minutes; range 10 to 660) groups than in the amiodarone group (333 minutes; range 15 to 710; p < 0.001 for both comparisons). Flecainide, at the doses administered in this study, is more effective than propafenone and amiodarone for conversion of acute atrial fibrillation to sinus rhythm. Propafenone and amiodarone have similar conversion rates, although propafenone was faster in achieving the conversion to sinus rhythm.