Aspectos metodológicos de los procesos asistenciales integrados (PAI) / Methodological aspects of integrated care pathways

Un proceso asistencial integrado (PAI) es una herramienta cuyo propósito es aumentar la efectividad de las actuaciones clínicas a través de una mayor coordinación y garantía de continuidad asistencial. Los PAI sitúan al paciente como el eje central de la organización asistencial. Se definen como el conjunto de actividades que realizan los proveedores de la atención sanitaria con la finalidad de incrementar el nivel de salud y el grado de satisfacción de la población que recibe los servicios. La elaboración de un PAI precisa analizar el flujo de actividades, la interrelación entre profesionales y dispositivos asistenciales y las expectativas del paciente. En este artículo se presenta y se discute la metodología para la elaboración de un PAI, así como los factores de éxito para su definición y su efectiva implantación. Se explica también, a modo de ejemplo, el reciente PAI para hipoglucemias en personas con diabetes mellitus tipo 2 elaborado por un equipo multidisciplinar y avalado por varias sociedades científicas (AU)

An Integrated Healthcare Pathway (PAI) is a tool which has as its aim to increase the effectiveness of clinical performance through greater coordination and to ensure continuity of care. PAI places the patient as the central focus of the organisation of health services. It is defined as the set of activities carried out by the health care providers in order to increase the level of health and satisfaction of the population receiving services. The development of a PAI requires the analysis of the flow of activities, the inter-relationships between professionals and care teams, and patient expectations. The methodology for the development of a PAI is presented and discussed in this article, as well as the success factors for its definition and its effective implementation. It also explains, as an example, the recent PAI for Hypoglycaemia in patients with Type 2 Diabetes Mellitus developed by a multidisciplinary team and supported by several scientific societies (AU)

[Methodological aspects of integrated care pathways]. / Aspectos metodológicos de los procesos asistenciales integrados (PAI).

An Integrated Healthcare Pathway (PAI) is a tool which has as its aim to increase the effectiveness of clinical performance through greater coordination and to ensure continuity of care. PAI places the patient as the central focus of the organisation of health services. It is defined as the set of activities carried out by the health care providers in order to increase the level of health and satisfaction of the population receiving services. The development of a PAI requires the analysis of the flow of activities, the inter-relationships between professionals and care teams, and patient expectations. The methodology for the development of a PAI is presented and discussed in this article, as well as the success factors for its definition and its effective implementation. It also explains, as an example, the recent PAI for Hypoglycaemia in patients with Type 2 Diabetes Mellitus developed by a multidisciplinary team and supported by several scientific societies.

Appropriateness of colonoscopy requests according to EPAGE-II in the Spanish region of Catalonia.

BACKGROUND: In a context of increasing demand and pressure on the public health expenditure, appropriateness of colonoscopy indications is a topic of discussion. The objective of this study is to evaluate the appropriateness of colonoscopy requests performed in a primary care (PC) setting in Catalonia. METHODS: Cross-sectional descriptive study. Out-patients >14 years of age, referred by their reference physicians from PC or hospital care settings to the endoscopy units in their reference hospitals, to undergo a colonoscopy. Evaluation of the appropriateness of 1440 colonoscopy requests issued from January to July 2011, according to the EPAGE-II guidelines (European Panel on the Appropriateness of Gastrointestinal Endoscopy). RESULTS: The most frequent indications of diagnostic suspicion requests were: rectal bleeding (37.46 %), abdominal pain (26.54 %), and anaemia study (16.78 %). The most frequent indications of disease follow-up were adenomas (58.1 %), and CRC (31.16 %). Colonoscopy was appropriate in 73.68 % of the cases, uncertain in 16.57 %, and inappropriate in 9.74 %. In multivariate analysis, performed colonoscopies reached an OR of 9.9 (CI 95 % 1.16-84.08) for qualifying as appropriate for colorectal cancer (CRC) diagnosis, 1.49 (CI 95 % 1.1-2.02) when requested by a general practitioner, and 1.09 (CI 95 % 1.07-1.1) when performed on women. CONCLUSIONS: Appropriateness of colonoscopy requests in our setting shows a suitable situation in accordance with recognized standards. General practitioners contribute positively to this appropriateness level. It is necessary to provide physicians with simple and updated guidelines, which stress recommendations for avoiding colonoscopy requests in the most prevalent conditions in PC.

Association of neurexin 3 polymorphisms with smoking behavior.

The Neurexin 3 gene (NRXN3) has been associated with dependence on various addictive substances, as well as with the degree of smoking in schizophrenic patients and impulsivity among tobacco abusers. To further evaluate the role of NRXN3 in nicotine addiction, we analyzed single nucleotide polymorphisms (SNPs) and a copy number variant (CNV) within the NRXN3 genomic region. An initial study was carried out on 157 smokers and 595 controls, all of Spanish Caucasian origin. Nicotine dependence was assessed using the Fagerström index and the number of cigarettes smoked per day. The 45 NRXN3 SNPs genotyped included all the SNPs previously associated with disease, and a previously described deletion within NRXN3. This analysis was replicated in 276 additional independent smokers and 568 controls. Case-control association analyses were performed at the allele, genotype and haplotype levels. Allelic and genotypic association tests showed that three NRXN3 SNPs were associated with a lower risk of being a smoker. The haplotype analysis showed that one block of 16 Kb, consisting of two of the significant SNPs (rs221473 and rs221497), was also associated with lower risk of being a smoker in both the discovery and the replication cohorts, reaching a higher level of significance when the whole sample was considered [odds ratio = 0.57 (0.42-0.77), permuted P = 0.0075]. By contrast, the NRXN3 CNV was not associated with smoking behavior. Taken together, our results confirm a role for NRXN3 in susceptibility to smoking behavior, and strongly implicate this gene in genetic vulnerability to addictive behaviors.

Análisis de costes del tratamiento de la diabetes mellitus tipo 2 con insulina glargina o detemir / Costs analysis of type 2 diabetes mellitus treatment with insulin glargine or detemir

Introducción: Diversos estudios publicados han revelado que algunos pacientesque inician el tratamiento con insulina detemir, cuya administraciónrecomendada es de una vez al día, requieren finalmente una administracióndos veces al día para optimizar el control de la glucosa sanguínea. Los resultadosclínicos se han evaluado en esta población seleccionada mediante unensayo clínico aleatorizado. Objetivo: Comparar los costes de dos tratamientoscon insulina (glargina y detemir) en la diabetes mellitus tipo 2 en pacientesno controlados con antidiabéticos orales. Métodos: Análisis de compensaciónde costes sanitarios, modelizado desde la perspectiva del Sistema Nacional deSalud español (considerando únicamente los costes directos sanitarios). Sesimuló la utilización de los recursos asociados al tratamiento de la diabetestipo 2 con glargina y detemir, respecto a las dosis de insulina administradas, lautilización de tiras reactivas para el autoanálisis de la glucemia y el consumode agujas desechables. Las dosis de glargina y detemir se obtuvieron de unensayo clínico que comparó ambas insulinas durante 24 semanas. La utilizaciónde tiras reactivas y de agujas desechables se estimó de acuerdo con lapráctica clínica en España. Los costes unitarios se tomaron de fuentes y basesde datos españolas. Resultados: En los pacientes tratados con glargina seadministró una menor dosis diaria de insulina que con detemir y, por tanto, seprodujo un menor coste diario del tratamiento insulínico, así como un menorconsumo de tiras reactivas y agujas. En consecuencia, la utilización de glarginaen lugar de detemir se asociaría a un ahorro anual de 765,03 € por pacientecon diabetes tipo 2, lo que supone un ahorro de un 43,3% con glarginafrente a detemir. En el análisis de sensibilidad, el ahorro anual por pacientetratado con glargina osciló entre 646,05 y 810,55 €(AU)

Conclusiones: Deacuerdo con el presente modelo, en la población estudiada la insulina glarginaes un tratamiento de la diabetes tipo 2 más coste-efectiva que la insulina detemiry se asocia a unos menores costes anuales de tratamiento(AU)

Introduction: Large published data suggested that some patients initiatingwith the recommended once daily insulin detemir administration require twicedaily dosing to optimise blood glucose control. Therefore the clinical outcomein this selected population was tested in a randomized controlled trial. Objective:To compare the costs of two treatments of type 2 diabetes mellitus, insulinglargine and insulin detemir, in patients with type 2 diabetes not controlledwith oral antidiabetic agents. Methods: Costs-offset analysis was modelledfrom the Spanish National Health System perspective, taking into account thehealth direct costs. A simulation of resources use related with glargine and detemirin type 2 diabetes treatment was performed, taking into account insulinadministered doses, utilization of test strips for glycemia control and disposableneedles used. The glargine and detemir doses were obtained from one clinicaltrial comparing both insulins for 24 weeks. The test strips and disposableneed les use were estimated from the Spanish clinical practice. Unit costs weretaken from Spanish sources and databases. Results: Lower daily doses were administeredwith glargine than with detemir. Therefore, the use of glargine insteaddetemir would result in a lower daily cost of insulin treatment, and alower use of test strips and disposable needles. As a consequence, the glargineuse would result in an annual saving of 765.03 € for a patient with type 2diabetes, 43.3% savings with glargine versus detemir. According to the sensitivityanalysis, the annual saving for a patient treated with glargine was between646.05 and 810.55 €. Conclusions: According to this model, in the abovementioned population, glargine insulin is a more cost-effective treatment thandetemir insulin, with lower annual treatment costs(AU)

Evolución del cultivo probiótico y el color de manzanas impregnadas con bacteria ácido lácticas / Evolution of probiotic content and color of apples impregnated with lactic acid

Un importante tema relacionado con el desarrollo de alimentos funcionales es la estabilidad componentes fisiológicamente activos como vitaminas, minerales, bacterias probióticas y otros, los cuales pueden ser muy sensibles al proceso tecnológico de obtención. El objetivo de este trabajo es evaluar la viabilidad de una cepa probiótica (Lactobacillus rhamnosus) en el interior de una matriz alimentaria (manzana Granny smith) y los parámetros de color (L* a* b*) en cilindros de manzana impregnados alvacío durante el almacenamiento bajo refrigeración y congelación. Los resultados muestran una viabilidad de la bacteria probiótica en el interior de la matriz alimentaria, manteniendo los valores mínimos para ser considerados como alimentos funcionales probióticos (106 UFC/g) y los parámetros de color son críticos en las muestras refrigeradas durante el almacenamiento.

Neumomediastino en niño de tres años en su primera crisis de broncospasmo / Pneumomediastinum in a three-year-old boy during his first episode of bronchial asthma

Se presenta el caso de un niño de tres años, sin antecedentes previos de asma, que padeció un neumomediastino en su primera crisis de broncos pasmo. El tratamiento fue conservador, con resolución del neumomediastino a las 24 horas

We report the case of a three-year-old boy, with no previous history of asthma, who developed pneumomediastinum during his first episode of bronchial asthma. It resolved in 24 hours with conservative treatment

[Degree of satisfaction of primary health workers regarding a consultancy-based specialty care model]. / Grado de satisfacción de los profesionales de Atención Primaria con un modelo de actividad especializada basado en la consultoría.

OBJECTIVE: To evaluate the degree of satisfaction of primary health care workers with a model of specialty care based on consultancy. METHODS: A questionnaire was delivered to the nurses and physicians of a Primary Care centre, in order to assess their satisfaction with the different activities in the specialty of endocrinology (1-5 points). RESULTS: The consultancy activity itself was given 4.41 +/- 0.89 points by the nurses (n = 39) and 3.60 +/- 0.97 by physicians (n = 32) (p < 0.05), clinical sessions, 4.21 +/- 0.74 and 3.82 +/- 1.02, and diagnostic and therapeutic protocols, 4.12 +/- 0.71 points (physicians) (p < 0.05 vs consultancy). Global scores was 4.33 +/- 0.70 and 3.76 +/- 0.89 points, respectively. 74% and 80% of the nurses and 58% and 69% of the physicians considered the present model appropriate for other specialties and primary care center, respectively. CONCLUSIONS: The health care workers at the primary care center assesse show a high degree of satisfaction with this model of specialised care based on consultancy.

A prospective study of antibodies to beta2-glycoprotein I and prothrombin, and risk of thrombosis.

Antiphospholipid syndrome (APS) is a clinical autoimmune disorder characterized by thrombosis/pregnancy morbidity associated with the persistence of lupus anticoagulant (LA) and/or anticardiolipin (aCL) antibodies. We assessed the contribution of antibodies to beta2-glycoprotein I (anti-beta2GPI) and prothrombin (anti-PT) to the thrombotic risk in a cohort of 194 consecutive patients with persistent LA and/or aCL. Median follow-up was 45 months. A total of 39 patients (20.1%) had one documented episode of thrombosis during follow-up. Eleven of these patients had no previous thrombosis before enrollment in the study and 28 had recurrences of thrombosis. There were 21 venous and 18 arterial thrombotic events and the overall incidence of thrombosis was 5.6% per patient-year. After multivariate analysis, the male sex (P = 0.025), a previous thrombosis (P < 0.01), the presence of anti-beta2GPI (P = 0.001), and the presence of anti-PT (P = 0.03) remained as independent risk factors for recurrent thrombosis. Only IgG anti-beta2GPI and anti-PT were associated with an increased risk of thrombosis (P < 0.01 and P = 0.005). Patients testing positive for anti-beta2GPI had a higher rate of thrombosis than did antiphospholipid patients without anti-beta2GPI (8.0% vs. 3.1% per patient-year). Similarly, a higher rate of thrombosis was found in patients with positive anti-PT compared with patients without anti-PT (8.6% vs. 3.5% per patient-year). Considering only the group of 142 LA positive patients, the highest incidence of thrombosis was found in LA patients positive for both anti-beta2GPI and anti-PT (8.4% per patient-year). In conclusion, the presence of IgG anti-beta2GPI and anti-PT in patients with LA and/or aCL and mainly in those with LA predicts a higher risk of thromboembolic events.

Grado de satisfacción de los profesionales de Atención Primaria con un modelo de actividad especializada basado en la consultoría / Degree of satisfaction of Primary Health workers regarding a consultancy-based specialty care model

Objetivo. Evaluar el grado de satisfacción de los profesionales de un centro de Atención Primaria con un modelo de asistencia especializada basada en la consultoría. Métodos. Se realizó una encuesta a médicos y enfermería que valoraba cada una de las actividades de Endocrinología en el centro de Atención Primaria y una valoración global (1-5 puntos). Resultados. La consultoría se valoró en 4,41 ± 0,89 por las enfermeras (n = 39) y 3,60 ± 0,97 por los médicos (n = 32) (p < 0,05), las sesiones clínicas en 4,21 ± 0,74 y 3,82 ± 1,02 y los protocolos diagnóstico-terapéuticos en 4,12 ± 0,71 (médicos) (p < 0,05 frente a interconsultas). La puntuación global fue de 4,33 ± 0,70 y 3,76 ± 0,89, respectivamente. El 74% y 80% de las enfermeras y 58% y 69% de los médicos consideran a este modelo apropiado para otras especialidades y centros de Atención Primaria, respectivamente. Conclusiones. Los profesionales del Centro de Atención Primaria Maragall muestran un alto grado de satisfacción con este modelo de atención especializada basado en la consultoría

Objective. To evaluate the degree of satisfaction of Primary Health care workers with a model of specialty care based on consultancy. Methods. A questionnaire was delivered to the nurses and physicians of a Primary Care centre, in order to assess their satisfaction with the different activities in the specialty of Endocrinology (1-5 points). Results. The consultancy activity itself was given 4.41 ± 0.89 points by the nurses (n = 39) and 3.60 ± 0.97 by physicians (n = 32) (p < 0.05), clinical sessions, 4.21 ± 0.74 and 3.82 ± 1.02, and diagnostic and therapeutic protocols, 4.12 ± 0.71 points (physicians) (p < 0.05 vs consultancy). Global scores was 4.33 ± 0.70 and 3.76 ± 0.89 points, respectively. 74% and 80% of the nurses and 58% and 69% of the physicians considered the present model appropriate for other specialties and Primary Care center, respectively. Conclusions. The health care workers at the Primary Care center assesse show a high degree of satisfaction with this model of specialised care based on consultancy

Alimentos funcionales: una historia con mucho presente y futuro / Functional foods: a history with a lot of present and future

La evolución de los hábitos nutricionales ha sido muy variable a través del tiempo, pero siempre soportada con el criterio básico de mantener la salud. Cada día las exigencias de los consumidores se dirigen más a la búsqueda de nuevos productos con propiedades funcionales que puedan proporcionar además del valor nutritivo, otros componentes con actividad fisiológica que permitan un mejor estado tanto físico como mental, reduciendo así el riesgo de enfermedades y alargando la vida al mismo tiempo que manteniendo su calidad. Esta revisión describe aspectos importantes de alimentos e ingredientes con características funcionales, a través del pasado, presente y futuro

[Evaluation of the process and the outcomes of care for the diabetic patients in a hospital]. / Evaluación del proceso y los resultados de la atención a los pacientes diabéticos en un hospital.

For the purpose of establishing a specific information system in order to identify the diabetic patients looked after in the hospital and evaluate the processes and the clinical outcomes obtained, a prospective descriptive study was designed--in the Corporació Parc Taulí of Sabadell (Barcelona)--about the diabetic patients cared starting in January 1998, through a clinical registry and other hospital sources of information. Seven hundred and fifty-five patients were identified, and the completeness of the registry was 98%. It was feasible the integration of the registry of admissions with that of the laboratory, that of the discharges from hospital, that of pharmacy and the specific clinical registry. An evaluation of the glycemic control was made in around 90% of the patients, and the registry of the organic explorations was higher than 87%. Although it was not possible in this study, the incorporation of the information from the primary care would complete the follow-up of the patients.

Evaluación del proceso y los resultados de la atencióna los pacientes diabéticos en un hospital* / Evaluation of the process and the outcomes of care for the diabetic patients in a hospital

Con el fin de establecer un sistema de información específico para identificar a los pacientes diabéticos atendidos en el hospital y evaluar los procesos y los resultados clínicos obtenidos se diseñó un estudio descriptivo prospectivo en la Corporació Parc Taulí de Sabadell (Barcelona) de los pacientes diabéticos atendidos a partir de enero de 1998 mediante un registro clínico y otras fuentes de información hospitalarias. Se identificaron 755 pacientes siendo la exhaustividad del registro del 98 por ciento. Fue factible la integración del registro de admisiones con el de laboratorio, las altas hospitalarias, el de farmacia y el registro clínico específico. Se realizó una evaluación del control glucémico en alrededor del 90 por ciento de los pacientes y el registro de las exploraciones orgánicas fue superior al 87 por ciento. Aunque no fue posible en este proyecto, la incorporación de la información procedente de la asistencia primaria completaría el seguimiento de los pacientes (AU)

Gender-related differences in clinical and pathological characteristics and therapy of bladder cancer.

OBJECTIVE: To confirm the very high male:female ratios previously observed among Spanish bladder cancer patients and to assess gender differences in tumoral characteristics, diagnostic procedures, and treatment in a large series of consecutive bladder cancer patients. PATIENTS AND METHODS: All newly diagnosed bladder cancer patients (n=615) in 17 Spanish hospitals, between 1997-2000, were included. Information was collected both through personal interviews to patients and from medical records using a structured form. RESULTS: Seventy-six percent of tumours were superficial. The male:female ratio was 6.7 and it was similar for superficial and infiltrating tumours. Women were older than men at the diagnosis of bladder cancer (68.2+/-9.4 years versus 65.7+/-9.7 years, p=0.01). Ten percent of superficial tumours in women, versus 3% in men, were classified as "other histological types" (p=0.008). T1GIII tumours were more frequent among men (17% versus 7%, p=0.047). On the other hand, women were more likely to present with 0a-stage tumours (48.6% versus 35.5%, p=0.04), multiple tumours (50% versus 29%, trend test: 0.005), multi-centric tumours (54% versus 38%, p=0.019), and larger infiltrating masses (5.2 cm versus 3.8 cm, p=0.03) than men. Among 0a-stage tumours, only 23% of women compared to 54% of men received transurethral resection (TUR) alone (p=0.002). Women were almost five-fold more likely to receive additional therapies to TUR (p=0.004) after adjusting for age, geographical area, stage, tumoral size, nuclear grade, and multiplicity. CONCLUSION: The study confirms the very high male:female ratio of bladder cancer in Spain. We found substantial differences in the pathological characteristics of tumours from men and women. There was a tendency for women to receive more frequently non-standard, more aggressive, therapy than men.

Demolition of a hospital building by controlled explosion: the impact on filamentous fungal load in internal and external air.

The demolition of a maternity building at our institution provided us with the opportunity to study the load of filamentous fungi in the air. External (nearby streets) and internal (within the hospital buildings) air was sampled with an automatic volumetric machine (MAS-100 Air Samplair) at least daily during the week before the demolition, at 10, 30, 60, 90,120, 180, 240, 420, 540 and 660 min post-demolition, daily during the week after the demolition and weekly during weeks 2, 3 and 4 after demolition. Samples were duplicated to analyse reproducibility. Three hundred and forty samples were obtained: 115 external air, 69 'non-protected' internal air and 156 protected internal air [high efficiency particulate air (HEPA) filtered air under positive pressure]. A significant increase in the colony count of filamentous fungi occurred after the demolition. Median colony counts of external air on demolition day were significantly higher than from internal air (70.2 cfu/m(3) vs 35.8 cfu/m(3)) (P < 0.001). Mechanical demolition on day +4 also produced a significant difference between external and internal air (74.5 cfu/m(3) vs 41.7 cfu/m(3)). The counts returned to baseline levels on day +11. Most areas with a protected air supply yielded no colonies before demolition day and remained negative on demolition day. The reproducibility of the count method was good (intra-assay variance: 2.4 cfu/m(3)). No episodes of invasive filamentous mycosis were detected during the three months following the demolition. Demolition work was associated with a significant increase in the fungal colony counts of hospital external and non-protected internal air. Effective protective measures may be taken to avoid the emergence of clinical infections.