[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.

Examining the continuum of psychosis: Frequency and characteristics of psychotic-like symptoms in relatives and non-relatives of patients with schizophrenia.

BACKGROUND: A key finding underlying the continuum of psychosis concept is the presence of psychotic-like experiences (PLEs) in healthy subjects. However, it remains uncertain to what extent these experiences are related to the genetic risk for schizophrenia and how far they actually resemble attenuated forms of psychotic symptoms. METHODS: Forty-nine adults with no history of mental illness in first-degree relatives and 59 siblings of patients with schizophrenia were rated on the psychosis section of the Computerized Diagnostic Interview Schedule IV (C DIS-IV) and the Rust Inventory of Schizotypal Cognitions (RISC). Those who rated positive on the CDIS-IV were re-interviewed using the lifetime version of the Present State Examination 9th edition (PSE-9) and the Structured interview for Schizotypy (SIS). RESULTS: Seventeen (34.69%) of the non-relatives and 22 (37.29%) of the relatives responded positively to one or more of the psychosis questions on the DIS. This difference was not significant. RISC scores were also similar between the groups. At follow-up interview with the PSE-9, 13/40 PLEs (32.50%) in the non-relatives were classified as possible or probable psychotic symptoms compared to 11/46 (23.91%) in the relatives. Using liberal symptom thresholds, 5 of those who attended the follow-up interview (2 non-relatives and 3 relatives) met SIS criteria for schizotypal personality disorder. CONCLUSIONS: Rates of PLEs, however considered, do not differ substantially between relatives and non-relatives of patients with schizophrenia. Only a minority of PLEs picked up by screening interviews resemble attenuated forms of psychotic symptoms.

Failure of deactivation in the default mode network: a trait marker for schizophrenia?

BACKGROUND: Functional imaging studies in relatives of schizophrenic patients have had inconsistent findings, particularly with respect to altered dorsolateral prefrontal cortex activation. Some recent studies have also suggested that failure of deactivation may be seen. METHOD: A total of 28 patients with schizophrenia, 28 of their siblings and 56 healthy controls underwent functional magnetic resonance imaging during performance of the n-back working memory task. An analysis of variance was fitted to individual whole-brain maps from each set of patient-relative-matched pair of controls. Clusters of significant difference among the groups were then used as regions of interest to compare mean activations and deactivations among the groups. RESULTS: In all, five clusters of significant differences were found. The schizophrenic patients, but not the relatives, showed reduced activation compared with the controls in the lateral frontal cortex bilaterally, the left basal ganglia and the cerebellum. In contrast, both the patients and the relatives showed significant failure of deactivation compared with the healthy controls in the medial frontal cortex, with the relatives also showing less failure than the patients. Failure of deactivation was not associated with schizotypy scores or presence of psychotic-like experiences in the relatives. CONCLUSIONS: Both schizophrenic patients and their relatives show altered task-related deactivation in the medial frontal cortex. This in turn suggests that default mode network dysfunction may function as a trait marker for schizophrenia.

Aprendiendo de los errores: fenómeno EDTA / Learning from errors: EDTA phenomenon

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Donor kidney volume and outcomes following live donor kidney transplantation.

Pre-donation kidney volume and function may be crucial factors in determining graft outcomes in kidney transplant recipients. We measured living donor kidney volumes by 3D helical computed tomography scanning and glomerular filtration rate (GFR) by (125)I-iothalamate clearances in 119 donors, and correlated these values with graft function and incidence of acute rejection at 2 years post-transplantation. Kidney volume strongly correlated with GFR (Pearson r= 0.71, p < 0.001). Body size and male gender were independent correlates of larger kidney volumes, and body size and age were predictors of kidney function. The effects of transplanted kidney volume on graft outcome were studied in 104 donor-recipient pairs. A transplanted kidney volume greater than 120 cc/1.73 m(2) was independently associated with better estimated GFR at 2 years post-transplant when compared to recipients of lower transplanted kidney volumes (64 +/- 19 vs. 48 +/- 14 mL/min/1.73 m(2), p < 0.001). Moreover, recipients of lower volumes had a higher incidence of acute cellular rejection (16% vs. 3.7%, p = 0.046). In conclusion, kidney volume strongly correlates with function in living kidney donors and is an independent determinant of post-transplant graft outcome. The findings suggest that (1) transplantation of larger kidneys confers an outcome advantage and (2) larger kidneys should be preferred when selecting from otherwise similar living donors.

Are auditory warnings in the intensive care unit properly adjusted?

The purpose of this study was to determine whether auditory warnings in the intensive care unit (ICU) were properly adjusted. An intervention study (before- and-after assessment) was conducted in a 12-bed medical-surgical ICU of an acute-care teaching hospital in Barcelona, Spain. A total of 100 patients with stable haemodynamic and respiratory parameters were included. In the first 3-month phase of the study, minimum and maximum alarm parameters of breathing rate, expired volume/min, airway pressure, SaO(2), arterial blood pressure and heart rate were recorded. In the second 12-month phase of the study, the same alarm parameters were recorded every 4 hours in the patient's medical record. In the third 3-month phase of the study, alarm readings were recorded again as in the first phase. The change throughout coefficient of variation (CV) and the 95% confidence interval (CI) for each alarm were calculated. Following the intervention, there was a statistically significant improvement in alarm readings for expired volume, heart rate and systolic blood pressure, so that alarms had been more properly adjusted to the patient's real value. Nursing staff should be aware that auditory warnings in ICU stable patients are frequently set very far from suitable values. Recording of alarm parameters in the patient's medical record as a routine daily activity was an effective intervention for improving adjustment of auditory warnings.

[Variability in working systems in intensive care units]. / La variabilidad en las sistemáticas de trabajo en los Servicios de Medicina Intensiva.

INTRODUCTION: Patients attended in Intensive Medicine Services (IMS) require a high therapeutic support. To do so, each IMS elaborates a work system (monitoring of constants, insertion of catheters,...) aiming to respond to these high necessities of therapy. The objective of this study is to describe the variability among different IMS. METHODS: The study was performed in 15 hospitals in Catalonia between April and May 1995. In the end two of them did not participate in the study. In each hospital 180 pieces of data were collected referring to their material and human resources, graphics of data collection, monitoring of respiratory system (mechanical ventilator, aspirations of secretions, tracheostomy care), techniques of catheterization of artery and venous via vesical probing, prevention of pressure ulcers , hygiene of patients, nutrition, family treatment and data about medical orders and nursing courses. Similarly, the fact whether the work system was justified by studies from the same IMS, other centres, or whether it was simply unknown, was also evaluated. RESULTS: There was a great variability among the IMS studied, oscillating significatively according to assigned resources, frequency of action and cost. According to the procedure 61% of IMS did not justify the work systems depending on scientific data. CONCLUSION: it is necessary to unify the different work systems. To do so, and in our opinion, scientific societies should establish common norms, guidelines and protocols so as to obtain a higher efficiency of IMS.

[The evaluation of noncompliance in an anti-influenza vaccination program]. / Evaluación del incumplimiento en un programa de vacunación antigripal.

The article presents an evaluation of an anti-influenza vaccination programme in a population at risk, with a special study of the general characteristics of the group of non-complying patients, and the possible relation of these characteristics with their conduct. Moreover, a study was made of the possible motives for not complying with the vaccination programme by means of a survey carried out by post and telephone in a representative sample of 108 individuals. A 34.77% of the registered population did not receive the anti-influenza vaccine, corresponding largely with the youngest age group (15 to 44 years) and there were no significant differences determined by sex or risk factor or doctor. A positive response was received from 75% of those surveyed, and the basic conclusions drawn were a low proportion of information error attributable to the programme (2.94%), and patient refusal as the principal cause of non-compliance (54.41%), followed by "other reasons" (hospitalisation, absence from home, etc.) (32.35%). The strategies that may be followed in the face of this problem require definition of the group of non-compliers, further understanding of the motives for their conduct, and educational measures to change their attitude. 95.9%). Incidence of hypertension and hyperlipemia was 56.2% and 47.3%. Late vascular events varied between 2.6% (nephropathy) and 19.5% (retinopathy). A total of 101 patients (44.6%) were unaware of the existence of diabetic health education programmes. Moreover, 68 (30.3%) declared that they had never received any previous information about their diabetes. Practical skills were evaluated on an individual basis.