Clinical experience of plasmapheresis for neuromyelitis optica patients in Mexico.

BACKGROUND: Neuromyelitis optica spectrum disorders (NMOSDs) are a group of chronic immune-mediated demyelinating diseases of the central nervous system. Their pathophysiology dependent on humoral mediated responses caused by autoreactive IgG antibodies against aquaporin-4 water channels (AQP4-IgG) or myelin oligodendrocyte glycoprotein (MOG-IgG). Plasma exchange (PLEX) has proved to be a beneficial therapy in patients with severe relapses. We present the largest series of Latin American patients treated with PLEX for acute NMOSDs relapses. METHODS: A retrospective study was conducted. Selection included patients diagnosed with NMOSDs who received PLEX between 2010-2019, irrespective of their AQP4-IgG serostatus. All patients received 5 grams of IV methylprednisolone. PLEX therapy could be initiated simultaneously or after IV steroids. Baseline and post-PLEX therapy Expanded Disability Status Scale (EDSS) was measured to identify acute response to therapy. Comparison between responders and non-responders was also conducted. Subgroup analysis stratified response by serostatus, type of clinical relapse and time to PLEX. RESULTS: A total of 89 patients were included. Mean age at onset was 38 ± 12.97 years. 49 (55.1%) patients were AQP4-IgG seropositive. Most patients had unilateral optic neuritis (34.8%) or longitudinally extensive transverse myelitis (33.7%). Mean time from onset to PLEX initiation was 20.9 ± 18.1 days. Response rate was 39.3% and mean decline in EDSS was 0.7 ± 0.9 (p <0.001). Decline in EDSS and response rate were independent of serostatus, type of clinical relapse or time to PLEX initiation. CONCLUSION: PLEX appears to be an effective therapy for NMOSDs relapses even in limited resources setting where treatment initiation may be delayed. The benefit seems to be independent of the type of clinical relapse and AQP4 IgG serostatus.

Implantación del cribado de retinopatía diabética mediante retinografía digital en atención primaria / Implementation of diabetic retinopathy screening using digital retinography in primary care

Objetivo: Mejorar la detección precoz y el seguimiento de la retinopatía diabética (RD) en 2 centros de salud mediante retinografía no midriática (RNM). Diseño: Estudio descriptivo longitudinal prospectivo. Emplazamiento: Área 11 de atención primaria (AP) de Madrid. Participantes: Pacientes diabéticos adultos (DM) sin exploración de fondo de ojo (FO) en los 2 últimos años. Intervenciones: Proceso de implantación del cribado de RD mediante RNM en AP. Fotografía digital de la retina efectuada por personal de enfermería. Interpretación de retinografías por el oftalmólogo. Mediciones: Número de DM con FO. Número de pacientes con RD. Grado de control metabólico en los últimos 2 años (HbA1c). Periodo de estudio: Septiembre de 2009 a septiembre de 2011. Resultados: El número de DM aumentó de 2.850 a 3.357. La proporción de pacientes con FO ascendió del 6,7% (IC 95%: 5,7-7,6%) al 32,4% (IC 95%: 30,8-34,0%) (p<0,001). La prevalencia de RD aumentó de 3,85% (IC 95%: 3,14-4,58%) a 4,3% (IC 95%: 3,59-4,99%). El porcentaje de pacientes con FO y RD disminuyó del 60% (IC 95%: 52,77-67,23%) al 14% (IC 95%: 11,87-16,09%) (p<0,001). La proporción de DM con HbA1c aumentó del 21,9% (IC 95%: 20,36-23,43%) al 52,4% (IC 95%: 50,69-54,10%) (p<0,001). El valor medio de HbA1c en pacientes con RD fue 7,8 (IC 95%: 7,50-8,06) y sin RD, 7,1 (IC 95%: 7,08-7,22) (p<0,001). Conclusiones: La RNM en AP se acompaña de un incremento del número de diabéticos con exploración de FO. Es posible implementar el cribado de RD mediante RNM si se dispone de los recursos necesarios, de la motivación de los profesionales implicados y del compromiso directivo. Un seguimiento más prolongado permitirá conocer su impacto en la tasa de interconsultas a oftalmología, llegando a derivar solo las imágenes dudosas(AU)

Objective: To improve early detection and monitoring of diabetic retinopathy (DR) in two primary care centers (PCC) using a non-mydriatic retinal camera (NMRC). Design: Prospective longitudinal descriptive study. Location: Area 11 Primary Care, Madrid. Participants: Adult patients with diabetes (DM) without funduscopic examination in the last two years (FO). Interventions: Implementation process of screening for DR by NMRC in PCC. Digital photography of the retina made by nursing staff. Interpretation of retinal images by an ophthalmologist. Measurements: Number of DM with FO. Number of patients with DR. Metabolic control in the last two years (HbA1c). Study period: September 2009-September 2011. Results: DM increased from 2850 to 3357. The proportion of patients with FO increased from 6.7% (95% CI: 5.7-7.6%) to 32.4% (95% CI: 30.8-34.0%) (P<0.001). The prevalence of DR increased from 3.85% (95% CI: 3.14-4.58%) to 4.3% (95% CI: 3.59-4.99%). The percentage of patients with FO and DR decreased from 60% (95% CI: 52.77-67.23%) to 14% (95% CI: 11.87-16.09%) (P<.001).The proportion of DM with HbA1c increased from 21.9% (95% CI: 20.36-23.43%) to 52.4% (95% CI: 50.69-54.10%) (P<0.001). The mean HbA1c in patients with DR and without DR was 7.8 (95% CI: 7.50-8.06) and 7.1 (IC95% CI: 7.08-7.22) (P<0.001), respectively. Conclusions: NMRC in PCC is accompanied by an increase in the number of diabetics with FO examination. The implementing of DR screening is possible if an NMRC is available, along with available resources, the motivation of the professionals involved and management commitment. A longer follow-up is required to determine its impact on referral rates to ophthalmology service, and to only refer those with dubious images(AU)

[Implementation of diabetic retinopathy screening using digital retinography in primary care]. / Implantación del cribado de retinopatía diabética mediante retinografía digital en atención primaria.

OBJECTIVE: To improve early detection and monitoring of diabetic retinopathy (DR) in two primary care centers (PCC) using a non-mydriatic retinal camera (NMRC). DESIGN: Prospective longitudinal descriptive study. LOCATION: Area 11 Primary Care, Madrid. PARTICIPANTS: Adult patients with diabetes (DM) without funduscopic examination in the last two years (FO). INTERVENTIONS: Implementation process of screening for DR by NMRC in PCC. Digital photography of the retina made by nursing staff. Interpretation of retinal images by an ophthalmologist. MEASUREMENTS: Number of DM with FO. Number of patients with DR. Metabolic control in the last two years (HbA1c). STUDY PERIOD: September 2009-September 2011. RESULTS: DM increased from 2850 to 3357. The proportion of patients with FO increased from 6.7% (95% CI: 5.7-7.6%) to 32.4% (95% CI: 30.8-34.0%) (P<.001). The prevalence of DR increased from 3.85% (95% CI: 3.14-4.58%) to 4.3% (95% CI: 3.59-4.99%). The percentage of patients with FO and DR decreased from 60% (95% CI: 52.77-67.23%) to 14% (95% CI: 11.87-16.09%) (P<.001). The proportion of DM with HbA1c increased from 21.9% (95% CI: 20.36-23.43%) to 52.4% (95% CI: 50.69-54.10%) (P<.001). The mean HbA1c in patients with DR and without DR was 7.8 (95% CI: 7.50-8.06) and 7.1 (IC95% CI: 7.08-7.22) (P<.001), respectively. CONCLUSIONS: NMRC in PCC is accompanied by an increase in the number of diabetics with FO examination. The implementing of DR screening is possible if an NMRC is available, along with available resources, the motivation of the professionals involved and management commitment. A longer follow-up is required to determine its impact on referral rates to ophthalmology service, and to only refer those with dubious images.

Implementing an action protocol on prostatic disease in primary care and impact on referrals to urology.

OBJECTIVES: To determine the impact of implementing a joint action protocol on prostatic disease on the referrals to Urology from Primary Care in a health care area. METHODS: We drafted a protocol for managing patients consulting for clinical signs and symptoms associated to benign prostatic hyperplasia (BPH) and to test PSA in asymptomatic males. At the same time, three e-mail addresses were opened for consultations generated from Primary Care, and joint sessions were carried out in the primary health care centers. We measured the impact of the protocol by assessing the adequacy of prostatic disease referrals to Urology, as well as by determining the course of the total number of referrals in three peripheral specialized health care centers (PSHCC). RESULTS: From January 2011, a better compliance to the referrals to Urology protocol for prostatic disease has been produced, going from 47% (assessment prior to implementing the protocol) to 64%. These results are especially good when we consider referrals associated to PSA, which went from a compliance of 33% to 84%. Regarding the course of the referrals to Urology, the referral rate (referrals per 1000 inhabitants) has decreased by 15% (from 13,8 to 11,7). CONCLUSIONS: The collaboration between Urology and Primary health care, by means of implementing joint protocols, and also by establishing new communication channels (e-mail, joint sessions), achieves a better adequacy of patients referred for prostatic disease, as well as a reduction in the total number of referrals.

Implantación de un protocolo de actuación en patología prostática en atención primaria e impacto en las derivaciones a urología / Implementing an action protocol on prostatic disease in primary care and impact on referrals to urology

OBJETIVO: Determinar el impacto sobre las derivaciones a Urología desde Atención Primaria, de un protocolo de actuación conjunta en patología prostática en un área sanitaria. MÉTODOS: Se elaboró un protocolo para el manejo del paciente que consulta por clínica relacionada con hiperplasia prostática y para la realización de PSA en varón asintomático. Al mismo tiempo, se abrieron tres direcciones de correo electrónico para consultas generadas desde Atención Primaria y se realizaron sesiones conjuntas en los Centros de Salud. Medimos el impacto del protocolo valorando la adecuación de las derivaciones a Urología por patología prostática, así como determinando la evolución del número total de derivaciones en tres centros de especialidades periféricas. RESULTADOS: Desde enero de 2011, se ha producido una mejor adecuación de las derivaciones a Urología por patología prostática, que han pasado de un 47% de adecuación (valoración previa a la implantación del protocolo) a un 64%. Estos resultados son especialmente buenos cuando consideramos las derivaciones relacionadas con el PSA, que han pasado de un 33% a un 84% de adecuación. En cuanto a la evolución de las derivaciones a Urología, la tasa de derivación (derivaciones por 1000 habitantes) ha descendido en un 15% (de 13,8 a 11,7). CONCLUSIONES: La colaboración entre Urología y Atención Primaria, mediante la implantación de protocolos conjuntos, así como estableciendo nuevos medios de comunicación (correo electrónico, sesiones conjuntas), consigue una mejor adecuación de los pacientes derivados por patología prostática, así como una disminución en el número total de derivaciones (AU)

OBJECTIVES: To determine the impact of implementing a joint action protocol on prostatic disease on the referrals to Urology from Primary Care in a health care area. METHODS: We drafted a protocol for managing patients consulting for clinical signs and symptoms associated to benign prostatic hyperplasia (BPH) and to test PSA in asymptomatic males. At the same time, three e-mail addresses were opened for consultations generated from Primary Care, and joint sessions were carried out in the primary health care centers. We measured the impact of the protocol by assessing the adequacy of prostatic disease referrals to Urology, as well as by determining the course of the total number of referrals in three peripheral specialized health care centers (PSHCC). RESULTS: From January 2011, a better compliance to the referrals to Urology protocol for prostatic disease has been produced, going from 47% (assessment prior to implementing the protocol) to 64%. These results are especially good when we consider referrals associated to PSA, which went from a compliance of 33% to 84%.Regarding the course of the referrals to Urology, the referral rate (referrals per 1000 inhabitants) has decreased by 15% (from 13,8 to 11,7). CONCLUSIONS: The collaboration between Urology and Primary health care, by means of implementing joint protocols, and also by establishing new communication channels (e-mail, joint sessions), achieves a better adequacy of patients referred for prostatic disease, as well as a reduction in the total number of referrals (AU)

Medidas organizativas y práctica asistencial. Una perspectiva desde los centros de salud / Organizational procedures and health care management. A point of view from primary care centres

ObjetivoConocer la utilización de medidas organizativas relacionadas con la práctica asistencial de los centros de salud (CS) a través de la valoración de las comisiones directivas.DiseñoEstudio multicéntrico, descriptivo, transversal.EmplazamientoÁrea 11 Atención Primaria, Madrid.ParticipantesComisiones Directivas de los Equipos de Atención Primaria (n=38).MedicionesSe utilizó un cuestionario semiestructurado autoadministrado con 21 preguntas principales sobre procedimientos y utilización de medidas organizativas internas relacionadas con la práctica asistencial en los CS, agrupadas en 5 apartados: consultas previsibles y no previsibles (carácter asistencial o administrativo) y gestión de agendas/atención al usuario.ResultadosTasa de respuesta 100%. El 69% dispone de circuito interno y/o aplicación informática para renovación de recetas crónicas y el 55% para incapacidad temporal. En el 71%, las consultas de enfermería participan en emisión y entrega de recetas crónicas. El 42% realiza trámites administrativos atribuibles a atención especializada. El 21% no se ajusta a la frecuencia recomendada de visitas de seguimiento en los programas asistenciales y el 29% duplica la actividad entre medicina y enfermería. El 97% dispone de circuito específico interno para atención urgente. El 84% facilita citación autoconcertada desde las consultas y un 29% tiene agenda disponible para un período superior a 6 meses.ConclusionesExiste variabilidad en la utilización de determinadas medidas organizativas y procedimientos relacionados con la práctica asistencial en los centros de salud. Sería recomendable una mayor investigación para determinar si los cambios organizativos y del profesional pudieran contribuir a una mejor eficiencia y satisfacción del paciente(AU)

ObjectiveWe aimed to know how the directive teams perceive the implementation of organizational procedures in relation with the health care management in the primary care setting.DesignMulticentre cross-sectional descriptive study.SettingArea 11 Madrid Primary Care Service, Spain.ParticipantsAll directive teams of primary care centres (PCC) (n=38).MeasurementsData were collected with a self-administered semiestructured questionnaire which included 21 main questions about procedures and use of internal organizational measures relating to the health care management in PCC, grouped in five sections: predictable and non predictable consultations(clinical and administrative), clinical schedules and office management.Results100% response rate. 69% of PCC use internal procedures and computerized applications for the renewal of medical chronic prescriptions and 55% for temporary disability. 71% show nurse involvement in terms of dispensing medical prescriptions during clinical consultations. 42% keep on performing administrative procedures of specialized care. 21% don’t get compliance with routine control of programs and in 29% of consultations duplicity of visits among medicine and nursing are expected. 97% follow a specific process for urgent attention. 84% request subsequent appointment in the previous clinical consultation. 29% have open schedules availables for 6 months.ConclusionsA wide variability of the implementation of organizational procedures in PCC was observed. Further research is needed to determine whether any organizational and professional changes could contribute to improve efficiency and patient satisfaction(AU)

[Organizational procedures and health care management. A point of view from primary care centres]. / Medidas organizativas y práctica asistencial. Una perspectiva desde los centros de salud.

OBJECTIVE: We aimed to know how the directive teams perceive the implementation of organizational procedures in relation with the health care management in the primary care setting. DESIGN: Multicentre cross-sectional descriptive study. SETTING: Area 11 Madrid Primary Care Service, Spain. PARTICIPANTS: All directive teams of primary care centres (PCC) (n=38). MEASUREMENTS: Data were collected with a self-administered semiestructured questionnaire which included 21 main questions about procedures and use of internal organizational measures relating to the health care management in PCC, grouped in five sections: predictable and non predictable consultations(clinical and administrative), clinical schedules and office management. RESULTS: 100% response rate. 69% of PCC use internal procedures and computerized applications for the renewal of medical chronic prescriptions and 55% for temporary disability. 71% show nurse involvement in terms of dispensing medical prescriptions during clinical consultations. 42% keep on performing administrative procedures of specialized care. 21% don't get compliance with routine control of programs and in 29% of consultations duplicity of visits among medicine and nursing are expected. 97% follow a specific process for urgent attention. 84% request subsequent appointment in the previous clinical consultation. 29% have open schedules availables for 6 months. CONCLUSIONS: A wide variability of the implementation of organizational procedures in PCC was observed. Further research is needed to determine whether any organizational and professional changes could contribute to improve efficiency and patient satisfaction.