[Evaluation of the collaboration between Primary and Hospital Care in order to improve inappropriate prescription]. / Evaluación de la colaboración entre atención primaria y hospitalaria para mejorar la polimedicación inapropiada.

INTRODUCTION AND OBJECTIVES: To evaluate the implementation of a collaborative experience between Primary (PC) and Hospital Care (HC) aimed at reducing potentially inappropriate prescribing (PIP) in patients with polypharmacy. MATERIALS AND METHODS: Collaborative experience including a controlled before-after intervention study, carried out in the Donostialdea Integrated Health Organization (IHO), with Bilbao Basurto IHO as control group, Osakidetza, Basque Health Service. Participant were 227 PC physicians and physicians from 7 hospital services, and patients with 5 or more drugs meeting at least one PIP criteria. The intervention consisted of communication and knowledge between professionals, PC-HC consensus, training, identification of patients at risk, medication review, evaluation and feed-back. The collaboration process (agreements, consensus documents, training activities) and the change in the prevalence of PIP in polymedicated patients (using computerised health records) were evaluated. RESULTS: A total of 21 PIP criteria and 6 recommendation documents were agreed. An analysis was performed on 15,570 PIP from OSI Donostialdea and 24,866 from the control group. The prevalence of PIP in polymedicated patients was reduced by -4.53% (95% CI: -4.71 to -4.36, P< .0001) in comparison with the control group. The before-after differences were statistically significant across the 7 services. CONCLUSIONS: PC-HC collaboration is feasible and, along with other intervention components, reduces inappropriate polypharmacy in the context of a recently integrated healthcare organisation. The collaboration process is complex and requires continuous monitoring, policy involvement, leadership that encourages health professional participation, and intensive use of information systems.

Toward personalized medicine in renal transplantation.

BACKGROUND: The pharmacokinetics of tacrolimus (TRL) are clearly affected by genetic polymorphisms in drug-metabolizing enzymes, which lead to large interindividual differences in dose-response relations. In addition, TRL has a narrow therapeutic index requiring monitoring of blood levels. The objective of the present observational, retrospective study was to associate maintenance TRL doses with various genetic markers seeking to guide optimization of the initial dose. METHODS: Results of DNA samples from 15 kidney transplant patients were correlated retrospectively with clinical information from medical records. Samples were genotyped using PHARMAchip. Association studies were performed with χ2 and Pearson tests and by analysis of variance. The study was carried out in accordance with international ethical standards of the Helsinki Declaration and approved by our ethics committee. RESULTS: Two patient groups were identified to show a difference in TRL dose requirements: a control (0.014-0.10 mg/kg/per day) and an high-dose group (0.14-0.15 mg/kg/per day). The presence of CYP3A5*1 and the null allele in GSTM1 were significantly associated (P=.01 and P=.04) with the need for higher immunosuppressive doses (>0.10 mg/kg/per day). There were no differences in plasma levels of TRL or other clinical variables between the patient groups. CONCLUSION: Determination of the CYP3A5 genotype might be used to predict initial TRL requirements, although other genetic variants also provide important information to adjust the drug dose.

The intricate relationship between evidence and clinical practice in kidney transplantation.

Clinical practice is supposed to be evidence-based but it always conveys underlying values, judgements, moral principles or axioms. We explore the evidence-based nature of clinical practice in the fast-changing field of kidney transplantation and its relationship with values in five different interventions: those well supported on evidence, focussed on the use of immunosuppressant drugs like cyclosporine, mycophenolate mofetil and tacrolimus, and the elective withdrawal of cyclosporine or steroids; disputable interventions where evidence, focussed on anti-lymphocyte antibodies, is strong but not strong enough to be applied on the majority of occasions; interventions not supported by randomised controlled trials with focus on primary treatment of vascular graft rejection and rescue treatment for acute graft rejection; interventions not widely applied despite strong evidence from sources other than randomised controlled trials, with focus on HLA-matched kidney transplants in cadaver donor and living donor transplants; and finally, a variety of interventions when evidence is lacking. Being aware of the factors influencing every clinical decision we can make the strength of evidence and the nature of the values underlying them explicit and we will find it easier to improve the process of transferring evidence into practice and openly face and acknowledge the values involved.

Sobre el razonamiento y la interpretación mediante la estadística en las Ciencias Biomédicas

Nuestro trabajo sensibiliza al profesional de la salud con la compresión científica de la estadística como método idóneo en la investigación social, sus funciones e interpretaciones de términos usados.(AU)

Algunas consideraciones sobre el Microstat, utilización en las Ciencias Médicas

El trabajo que nos hemos propuesto desarrollar, pretende poder acercar distintos especialistas y estudiantes, a una de las posibilidades que brindan las microcomputadoras, la explotación de sistemas, se trata en particular del sistema Estadístico Microstat, este es un conjunto de programas sobre los principales métodos estadísticos aplicados a las investigaciones sociales y biomédicas. (AU)

Algunas consideraciones sobre el Microstat, utilización en las Ciencias Médicas

El trabajo que nos hemos propuesto desarrollar, pretende poder acercar distintos especialistas y estudiantes, a una de las posibilidades que brindan las microcomputadoras, la explotación de sistemas, se trata en particular del sistema Estadistico Microstat, este es un conjunto de programas sobre los principales métodos estadísticos aplicados a las investigaciones sociales y biomédicas. (AU)