Characterizing the implementation of performance management interventions in a primary health care system: a case study of the Salud Mesoamerica Initiative in El Salvador.

Performance management (PM) reforms have been introduced in health systems worldwide to improve accountability, transparency and learning. However, gaps in evidence exist regarding the ways in which PM contributes to organizational-level outcomes. Between 2015 and 2017, the government of El Salvador and the Salud Mesoamerica Initiative (SMI) introduced team-based PM interventions in the country's primary health care (PHC) system including target setting, performance measurement, provision of feedback and in-kind incentives. The programme's evaluation showed widespread improvements in performance for community outreach and service timeliness, quality and utilization. The current study characterizes how the implementation of team-based PM interventions by SMI implementers contributed to PHC system performance improvements. We used a descriptive, single-case study design informed by a programme theory (PT). Data sources included qualitative in-depth interviews and SMI programme documents. We interviewed the members of four PHC teams (n = 13), Ministry of Health (MOH) decision makers (n = 8) and SMI officials (n = 6). Coded data were summarized, and thematic analysis was employed to identify broader categories and patterns. The outcomes chain in the PT was refined based on empirical findings that revealed the convergence of two processes: (1) increased social interactions and relationships among implementers that enhanced communication and created opportunities for social learning and (2) cyclical performance monitoring that generated novel flows of information. These processes contributed to emergent outcomes including the uptake of performance information, altruistic behaviours in service delivery and organizational learning. Through time, the cyclical nature of PM appears to have led to the spread of these behaviours beyond the teams studied here, thus contributing to system-wide effects. Findings illustrate the social nature of implementation processes and describe plausible pathways through which lower-order implementation programme effects can contribute to higher-order changes in system performance.

Microbiological assessment of arterial allografts processed in a tissue bank.

The transmission of microbial infection through tissue allografts is one of the main risks that must be controlled in tissue banks. Therefore, microbiological monitoring controls and validated protocols for the decontamination of tissues during processing have been implemented. This study is based on the evaluation of data from microbiological cultures of arteries (mainly long peripheral arteries) processed in the tissue bank of Valencia (Spain). Donors' profile, pre- and post-disinfection tissue samples were assessed. The presence of residual antibiotics in disinfected tissues was determined and the antimicrobial potential of these tissues was tested. Our overall contamination rate was 23.69%, with a disinfection rate (after antibiotic incubation) of 87.5%. Most (76.09%) of the microbial contaminants were identified as Gram positive. Arterial allografts collected from body sites affected by prior organ removal showed higher risk of contamination. Only vancomycin was detected as tissue release. The antimicrobial effect on Candida albicans was lower than that for bacterial species. Risk assessment for microbial contamination suggested the donor's skin and the environment during tissue collection as the main sources for allograft contamination. Antibiotic-disinfected arterial allografts showed antimicrobial potential.

¿Qué haría usted ante un paciente con fibrilación auricular no valvular en tratamiento con anticoagulantes orales de acción directa que tiene que hacerse una gastroscopia o colonoscopia? / What would you do with a patient with non-valvular atrial fibrillation treated with direct-acting oral anticoagulants who had to undergo gastroscopy or colonoscopy?

En España aproximadamente el 25% de los pacientes anticoagulados por fibrilación auricular no valvular llevan un anticoagulante de acción directa (ACOD). Es previsible que la mayor parte de ellos en algún momento de su vida deban someterse a procedimientos invasivos o tratamientos quirúrgicos, por lo que el manejo del ACOD en estas situaciones es esencial para realizar el procedimiento con la máxima seguridad y minimizar al máximo el riesgo de hemorragia y de trombosis. El manejo de esta situación se basa en la valoración del riesgo hemorrágico del paciente y del procedimiento que se va a realizar, del riesgo de tromboembolia del paciente, su función renal y de las características farmacocinéticas de los ACOD, especialmente su vida media, el grado de eliminación renal y su pico de acción

In Spain, approximately 25% of patients anticoagulated due to non-valvular atrial fibrillation use a direct-acting anticoagulant (DOAC). It is foreseeable that most of them at some point in their lives should undergo invasive procedures or surgical treatments. This makes the management of DOAC in these situations essential in order to perform the procedure with maximum safety and minimise the risk to the maximum of haemorrhage and thrombosis. The management of this situation is based on the evaluation of the haemorrhagic risk of the patient, and the procedure to be performed, the risk of thromboembolism, and renal function. The pharmacokinetic characteristics of the DOAC also should be taken into account, especially its half-life, the degree of renal elimination and its peak action

[What would you do with a patient with non-valvular atrial fibrillation treated with direct-acting oral anticoagulants who had to undergo gastroscopy or colonoscopy?] / ¿Qué haría usted ante un paciente con fibrilación auricular no valvular en tratamiento con anticoagulantes orales de acción directa que tiene que hacerse una gastroscopia o colonoscopia?

In Spain, approximately 25% of patients anticoagulated due to non-valvular atrial fibrillation use a direct-acting anticoagulant (DOAC). It is foreseeable that most of them at some point in their lives should undergo invasive procedures or surgical treatments. This makes the management of DOAC in these situations essential in order to perform the procedure with maximum safety and minimise the risk to the maximum of haemorrhage and thrombosis. The management of this situation is based on the evaluation of the haemorrhagic risk of the patient, and the procedure to be performed, the risk of thromboembolism, and renal function. The pharmacokinetic characteristics of the DOAC also should be taken into account, especially its half-life, the degree of renal elimination and its peak action.

Impact of Maintenance Therapy for the Prevention of Peri-implant Diseases: A Systematic Review and Meta-analysis.

At the present time, peri-implantitis has become a global burden that occurs with a frequency from 1% to 47% at implant level. Therefore, we aimed herein at assessing the impact of peri-implant maintenance therapy (PIMT) on the prevention of peri-implant diseases. Electronic and manual literature searches were conducted by 3 independent reviewers using several databases, including MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, and Cochrane Oral Health Group Trials Register, for articles up to June 2015 without language restriction. Articles were included if they were clinical trials aimed at demonstrating the incidence of peri-implant diseases under a strict regime or not of PIMT. Implant survival and failure rate were studied as secondary outcomes. A meta-analysis was conducted to evaluate the influence of PIMT and other reported variables upon peri-implant diseases. Thirteen and 10 clinical trials were included in the qualitative and quantitative analysis, respectively. Mucositis was affected by history of periodontitis and mean PIMT at implant and patient levels, respectively. Similarly, significant effects of history of periodontal disease were obtained for peri-implantitis for both implant and patient levels. Furthermore, mean PIMT interval was demonstrated to influence the incidence of peri-implantitis at implant but not patient level. PIMT interval showed significance at both levels. For implant survival, implants under PIMT have 0.958 the incident event than those with no PIMT. Within the limitations of the present systematic review, it can be concluded that implant therapy must not be limited to the placement and restoration of dental implants but to the implementation of PIMT to potentially prevent biologic complications and hence to heighten the long-term success rate. Although it must be tailored to a patient's risk profiling, our findings suggest reason to claim a minimum recall PIMT interval of 5 to 6 mo. Additionally, it must be stressed that even in the establishment of PIMT, biologic complications might occur. Thus, patient-, clinical-, and implant-related factors must be thoroughly explored.

New piophilid in town: the first Palaearctic record of Piophila megastigmata and its coexistence with Piophila casei in central Spain.

The genus Piophila Fallén (Diptera: Piophilidae) is known from only two species: Piophila casei (L.) is a major pest, a cosmopolitan species and is commonly used as a forensic indicator, whereas Piophila megastigmata McAlpine has until now only been recorded in a natural environment in South Africa. The present work reports the first occurrence of P. megastigmata in the Palaearctic region from specimens collected by carrion-baited traps throughout different natural habitats of central Spain. Furthermore, the species was also collected with P. casei on corpses of domestic pigs used in a carrion succession study in a periurban habitat in central Spain. Both species occurred on carrion in different seasons, but P. megastigmata was more abundant than P. casei in autumn, arriving earlier at the carcasses and persisting for a longer period. The contrary pattern was observed in spring. The presence of P. megastigmata in different localities in central Spain and its coexistence with P. casei in a periurban habitat make it a potentially useful new tool for legal medicine in Europe; thus this species must be considered in forensic entomology studies.

La Entomología Forense en España: pasado, presente y perspectivas de futuro / Forensic Entomology in Spain: past, present and future perspectives

La entomología forense -estudio de los insectos que aparecen en los cadáveres- es una disciplina relativamente joven en cuanto a su aplicación. En España ha evolucionado lentamente, experimentando un notable crecimiento en las últimas décadas, tanto en el número de trabajos como en el de grupos de investigación dedicados a ello, adquiriendo un estatus cada vez más importante como disciplina forense. En este trabajo se presentan los resultados de una revisión bibliográfica en la que se ha analizado con detalle la evolución de las publicaciones relacionadas con la entomología forense en España. Se incluye además un anexo con las referencias de todos los artículos recopilados, clasificados según sus características (divulgación científica, educación o formación, aplicación en casos reales e investigación en entomología forense). Finalmente se analiza el estado actual de esta disciplina en nuestro país, considerando la faceta educativa, así como los principales lugares donde se investiga y aquellos donde se aplica la entomología forense en la resolución de casos reales

Forensic Entomology- the study of insects appearing in corpses- is a relatively young discipline regarding its application. In Spain it has evolved slowly showing a great development in the last decades, both regarding the publications number and the people involved, gaining a higher status as a forensic discipline. The results of a bibliographical revision in which evolution of the number of Spanish Forensic Entomology publications has been analyzed in detail are presented. Moreover, an annexe with the references of all the compiled publications classified according to the type (scientific popularization, education and training, application in real cases and investigation in Forensic Entomology) is enclosed. Finally, the current state of the discipline in our country is also presented, taking into consideration education aspects as well as main places where there are people researching or applying forensic entomology in the resolution of real cases

[Behavior disorder of the REM sleep in 2 documented cases with polysomnography]. / Trastorno conductual del sueño REM en dos casos documentados con polisomnografía.

We report a 69 years old male with a parkinsonian syndrome and a 50 years old female without neurological problems who showed violent behavior during REM sleep. Polysomnography showed that both bad tonic or phasic muscular activity during REM sleep and a REM sleep behavior disorder was diagnosed. Clonazepam was used in both, with good clinical response. This condition is frequently unrecognized and confused with nightmares, nocturnal delirium or other parasomnias.

Mutaciones del gen supresor de tumor p53 en adenocarcinoma gástrico / Mutations of p53 suppressor gene in gastric adenocarcinoma

Background: We have shown numeric alterations such as hyperploidy and hypoploidy with loss of chromosome 17 in primary gastric cancer. This chromosome maps p53 suppressor gene that induces the transcription of genes related to cellular cycle control, DNA synthesis and repair, cellular differentiation and apoptosis. Aim: To analyze, at a molecular level, the possible alterations of p53 suppressor gene in samples of gastric cancer and non tumoral mucosa. Material and methods: Tissue samples of gastric carcinoma and non tumoral gastric mucosa coming from 26 patients subjected to a total gastrectomy were analyzed. The mutation of p53 suppressor gene exons 7 to 9 were determined using a conformational polymorphism analysis in single strands of the gene and indirect sequencing in some cases. Results: Alterations in p53 gene were found in 77 percent of tumoral and 19 percent of non tumoral samples. T insertions in codons 260, 317 and 321, G insertion in codon 328 and G-T transvertion in codon 302 were found. Aminoacid sequence analysis of p53 protein obtained with sequencing data showed that T insertion in codon 260 could translate three erroneous aminoacids after the mutation and produce a truncated protein due to the creation of a stop codon. No associations between alterations of p53 gene and clinical or pathological variables such as age, sex, tumor localization, histological type and presence of Iymph node metastases were observed

Hemorragias mucocutáneas: evaluación clínica, secuencia de estudio y frecuencia relativa de enfermedades hereditarias de la hemostasia en población chilena / Mucocutaneous hemorrhages: clinical evaluation, study sequency and related frequency of hemostatic hereditary disases in Chilean population

Patients and methods: Five hundred eighty nine patients whose main symptom was the presence of mucocutaneous hemorrhages were studied. Bleeding time, platelet count, coagulant activity of factor VIII (FVIII:C), FvW: Ag and FvW:CoRis and ABO blood group were measured in all patients in a first stage. According to the results of these tests, further studies were decided. Results: In patients younger than 13 years old, males predominated and, in older patients, females consulted with higher frequency. There was a higher proportion of individuals with O blood type than in the normal population. Bleeding time was abnormal in 330 patients (56 percent). One hundred ten patients (19 percent) had von Willebrand disease and, among them, one third had a normal bleeding time. Isolated reduction of factor VIII activity was found in 66 patients (11 percent, 51 males) and 32 of these had normal bleeding time. Eighty one patients (14 percent) were considered to have an hereditary platelet function defect. A precise diagnosis was not achieved in 332 patients (56 percent). Conclusions: Among patients consulting for mucocutaneous hemorrhages, 19 percent had von Willebrand disease, 11 had an isolated reduction of factor VIII activity, 14 percent had platelet function defects and in 56 percent, a precise diagnosis was not reached

[Foramen ovale electrodes in the study of temporal lobe epilepsy]. / Electrodos de foramen oval en la investigación de las epilepsias del lóbulo temporal.

Corticograms of the mesial structures of the temporal lobe may be obtained with the recently developed foramen ovale electrodes. Since their installation is easy and of low risk, they will probably displace other invasive techniques routinely used up to the moment for the localization and lateralization of epileptic foci originated in the temporal lobe. For the first time in our country, we have used this technique in 7 patients with medically intractable complex partial epilepsy. In all the patients, the study allowed to clear doubts about the laterality of the start of ictal activity and to define irritative foci not found with conventional continuous superficial electroencephalographic recordings. The procedure was uneventful and the implanted electrodes were optimally tolerated. Foramen ovale electrodes are an effective diagnostic method for temporal lobe epilepsies and their features are specially appropriate for our milieu.

Activación plaquetaria en el síndrome hipertensivo inducido por el embarazo / Platelet activation in hypertensive syndrome due to pregnancy

Para evaluar la activación y agregación plaquetaria en tres grupos de 18 pacientes (mujeres sanas no embarazadas, embarazadas normales y embarazadas con síndrome hipertensivo del embarazo), se determinaron los valores de factor plaquetario-4 en plasma y serotonina intraplaquetaria. Los estudios de variancia y comparaciones múltiples no revelaron diferencias significativas entre los distintos grupos. La alteración de la función plaquetaria no sería un hecho relevante al inicio de la enfermedad hipertensiva del embarazo o, sí ésta existe, no sería reflejada a nivel sistémico. Se discute así la falta de fundamentos para el uso de antiagregantes plaquetarios para la prevención o control de esta enfermedad

Actividad electrica amigdalino-piriforme registrada con tecnica estereotaxica. / Amygdala-pyriform electric activity registered with stereotaxic technic

Se presenta una serie de registros en area piriforme y nucleo amigdalino realizados en 26 pacientes sometidos a operacion estereotaxica por diferentes causas. El modo particular de actividad electrica espontanea detectada en esas regiones se supone relacionado con una funcion convergente de potenciales aferentes, sin connotacion patologica

[Sleep stages and growth hormone in manganese poisoning. Effects of L dopa]. / Etapas de sueño y hormona de crecimiento en intoxicación por manganeso. Efecto de L Dopa.

Sleep characteristics are studied in 7 patients with sequelae of manganese intoxication and in 8 controls. A reduction in the length of the REM stage was observed, which could be prolonged by L Dopa administration, but without achieving values comparable to the controls. No changes were noted in the non-REM stage of sleep. These results are similar to the ones obtained in Parkinson's disease, suggesting clinical and probably biochemical similarities between the 2 conditions. The blood concentrations of growth hormone during sleep in the manganic patients was lower than in the control group, and no significant variations were noted after L Dopa administration.