Effectiveness of a nurse-led case management home care model in Primary Health Care. A quasi-experimental, controlled, multi-centre study.

BACKGROUND: Demand for home care services has increased considerably, along with the growing complexity of cases and variability among resources and providers. Designing services that guarantee co-ordination and integration for providers and levels of care is of paramount importance. The aim of this study is to determine the effectiveness of a new case-management based, home care delivery model which has been implemented in Andalusia (Spain). METHODS: Quasi-experimental, controlled, non-randomised, multi-centre study on the population receiving home care services comparing the outcomes of the new model, which included nurse-led case management, versus the conventional one. Primary endpoints: functional status, satisfaction and use of healthcare resources. Secondary endpoints: recruitment and caregiver burden, mortality, institutionalisation, quality of life and family function. Analyses were performed at base-line, and at two, six and twelve months. A bivariate analysis was conducted with the Student's t-test, Mann-Whitney's U, and the chi squared test. Kaplan-Meier and log-rank tests were performed to compare survival and institutionalisation. A multivariate analysis was performed to pinpoint factors that impact on improvement of functional ability. RESULTS: Base-line differences in functional capacity - significantly lower in the intervention group (RR: 1.52 95%CI: 1.05-2.21; p = 0.0016) - disappeared at six months (RR: 1.31 95%CI: 0.87-1.98; p = 0.178). At six months, caregiver burden showed a slight reduction in the intervention group, whereas it increased notably in the control group (base-line Zarit Test: 57.06 95%CI: 54.77-59.34 vs. 60.50 95%CI: 53.63-67.37; p = 0.264), (Zarit Test at six months: 53.79 95%CI: 49.67-57.92 vs. 66.26 95%CI: 60.66-71.86 p = 0.002). Patients in the intervention group received more physiotherapy (7.92 CI95%: 5.22-10.62 vs. 3.24 95%CI: 1.37-5.310; p = 0.0001) and, on average, required fewer home care visits (9.40 95%CI: 7.89-10.92 vs.11.30 95%CI: 9.10-14.54). No differences were found in terms of frequency of visits to A&E or hospital re-admissions. Furthermore, patients in the control group perceived higher levels of satisfaction (16.88; 95%CI: 16.32-17.43; range: 0-21, vs. 14.65 95%CI: 13.61-15.68; p = 0,001). CONCLUSION: A home care service model that includes nurse-led case management streamlines access to healthcare services and resources, while impacting positively on patients' functional ability and caregiver burden, with increased levels of satisfaction. TRIAL REGISTRATION: ISRCTN44054549.

Effectiveness of Food-Based Fortification in Older People. A Systematic Review and Meta-Analysis.

BACKGROUND: Early intervention with nutritional support has been found to stop weight loss in older people malnourished or at risk of malnutrition. Enriched food could be a more attractive alternative to improve meals, than conventional oral nutritional supplements. AIMS: To determine the effectiveness of food-based fortification to prevent risk of malnutrition in elderly patients in community or institutionalized elderly patients. METHODS: A systematic review was conducted of randomized controlled trials, quasi-experimental, and interrupted time series including a longitudinal analysis. PARTICIPANTS: Elderly patients who are institutionalized, hospitalized or community-dwelling, with a minimum average age of 65 years. All type of patient groups, with the exception of people in critical care, or those who were recovering from cancer treatment, were included. INTERVENTION: Studies had to compare food-based fortification against alternatives. Studies that used oral nutritional supplementation such as commercial sip feeds, vitamin or mineral supplements were excluded. The search was conducted in Cochrane, CINAHL, PubMed, EMBASE, LILACS, and Cuiden. An independent peer review was carried out. RESULTS: From 1011 studies obtained, 7 were included for the systematic review, with 588 participants. It was possible to perform meta-analysis of four studies that provided results on caloric and protein intake. Food-based fortification yielded positive results in the total amount of ingested calories and protein. Nevertheless, due to the small number of participants and the poor quality of some studies, further high quality studies are required to provide reliable evidence. IMPLICATIONS FOR PRACTICE: Despite the limited evidence, due to their simplicity, low cost, and positive results in protein and calories intake, simple dietary interventions based on the food-based fortification or densification with protein or energy of the standard diet could be considered in patients at risk of malnutrition.

[The use of 125I-fibrinogen in the diagnosis of deep venous thrombosis in medical practice (author's transl)]. / El uso del fibrinógeno-125I en el diagnóstico de la trombosis venosa profunda en clínica médica.

A series of 38 "high risk" selected cases of deep venous thrombosis were studied in an internal Medicine Department. Fibrinogen-125I was used. Phlebographic verification was sought in those cases with a positive response to the fibrinogen. From the 38 cases 13 turned out to be positive; in 8 the venous thrombus was identify by venography. In two cases the dorsal venous arch could not be filled. In one case the phlebography could not be carried out. In the remaining two cases the venography did not show a thrombus but there was a pathologic fracture with hematoma and an ossifying myositis, respectively. Both cases were interpreted as false positives to the radioactive fibrinogen. One of them had suggestive clinical manifestations of deep venous thrombosis. Of the eight cases which were positive to the venography and radioactive fibrinogen only four showed a clinical picture suggestive of deep venous thrombosis. If the three cases with negative venographies are included only 36.3 percent of the patients had clinical manifestations. Among the 25 cases which were negative to the radioactive fibrinogen none of them had a clinical picture of deep venous thrombosis, although in 64 percent of them at least one of the clinical signs collected during the physical examination was positive. The correlation between fibrinogen-125I and phlebography turned out to be 80 percent.

[Social inequalities in health in the city of Málaga]. / Desigualdades sociales en salud en la ciudad de Málaga.

Social inequalities and health inequalities are closely related, and their reduction is the goal of international organizations and governments as well. In order to better understand the territorial distribution of social inequalities in the city of Málaga (Spain) and compare them with measured health differences, a descriptive study was done using different sources of information. Using the city's neighbourhoods as the unit of analysis, a cluster analysis was carried out based on a set of demographic, socioeconomic and standard of living indicators. This led to the configuration of six social areas within the city. In these areas, as defined by socially homogeneous criteria, diverse health indicators have been measured, leading the verification of important health differences among them. For example, clear differences in mortality rates between Area IV (socioeconomically deprived) and Area III (with a higher standard of living) are observed: the ratio between their respective "years of potential life lost" was 1.79, and between standardized mortality rates, 1.42. A similar disadvantage in low birth weight was confirmed notably so in adolescent pregnancies (five times higher). In conclusion, those areas of the city with a lower socio-economic status also had the lowest health levels.

Accuracy of teleradiology in skeletal disorders: solitary bone lesions and fractures.

To evaluate the diagnostic accuracy of digitized film radiography and digital teleradiology for detecting bone fractures and for studying solitary bone lesions, we examined 633 single radiographs from 373 patients (159 with solitary bone lesions, 123 with fractures and 91 without pathology). Radiographs were digitized using a commercial teleradiology workstation and transmitted to a local hospital over a standard telephone line. Images were reviewed by two groups of three experienced radiologists. Receiver operating characteristic (ROC) curves were analysed for conventional films, digitized images and transmitted teleradiology images. No significant differences were found among readers for the evaluation of bone fractures and solitary bone lesions. Teleradiology systems permit remote expert consultation, and telediagnosis therefore is a powerful tool in telemedicine.

[Biological parameters of virilism in women]. / Paramètres biologiques du virilisme féminin.

Comparative results of the suppression-stimulation test by dexamethasone and chorionic gonadotropin, chromatographic separation of 17-ketosteroids, and plasma testosterone levels in the ovarian and adrenal veins, in cases of virilism in women. Thirteen patients with hirsutism and virilization were investigated as follows: 1. measurement of plasma testosterone (T) levels by radioimmunoassay (RIA) during suppression-stimulation tests by the administration of Dexamethasone (DXM) and chorionic Gonadotropin (HCG). 2. chromatographic determination of urinary 17-ketosteroids, pregnanediol (P2), and pregnanetriol (P3). An attempt was made to classify virilism as "ovarian" or "adrenal" based on the results of 1. and 2. 3. bilateral ovarian and adrenal venous catheterization through the femoral vein to measure T (RIA) levels. 4. laparotomy with bilateral wedge resections of the ovaries for therapeutic and biopsy purposes. Surgical catheterization of the ovarian veins was carried out during the operation. The results of these tests show that: a) the dynamic DXM-HCG test can be used to separate those cases in which the ovary is not involved in T formation from those in which, apparently, it is involved. b) chromatographic determination of urinary steroids has no aetiological value, as the variations in the different fractions are not significant. c) in all patients, the principal source of T is the adrenals and not the ovaries, even when there is an increase in T in the ovarian efferent blood vessels.

[Nursing consultation for chronic patients]. / Consulta de enfermería para pacientes crónicos.

Nursing consultation for chronic patients forms part of the list of primary health care services for the coverage provided and due to the general public's satisfaction. However, the content and the results offered can be improved and the need to reorient this service has been proposed for quite some time. Strategies to succeed in developing a pure nursing contribution vis-a-vis our patients' health, that which we call an independent dimension in nursing, pass through the construction of a nursing vision which many of us lack as a consequence of a structured professional development along the lines of the biomedical model in which the nursing paradigm was transmitted more in the theoretical field than in the practical. By referring to Doka and Riopelle, we analyze the stages through which a patient afflicted by a physical disease passes and the tasks which he and his family should fulfill, in order to find an equivalence between these and some of the nursing diagnoses published by the North American Nursing Diagnosis Association (NANDA). The nursing diagnoses so obtained are compared to those which a panel of experts, belonging on Methodology Commission of the Malaga Sanitary District, by consensus identified as the most prevalent among this population. The degree of coincidences was high, which encourages us to continue along this vein in the nursing consultations for chronic patients.

The association between nursing diagnoses, resource utilisation and patient and caregiver outcomes in a nurse-led home care service: longitudinal study.

BACKGROUND: The information generated by nurses through standardised nursing languages is insufficiently evaluated and exploited, mainly in home care services, as is its potential impact on outcomes. OBJECTIVES: To find out how often nursing diagnoses are made during nursing home care visits, and to explore their relation with use of resources, mortality, institutionalisation and satisfaction. DESIGN: Observational, longitudinal follow-up study. SETTINGS: Home care services delivered by Primary Healthcare Districts in Málaga, Costa del Sol, Almería and Granada, in Spain. PARTICIPANTS: Patients and caregivers who initiated the Home Care Programme. METHODS: The accumulated incidence of nursing diagnosis was analysed over 34 months of follow-up. Diagnoses were made by nurse case managers in their daily practice. Several regression models were devised to analyse their linkage with the use of resources, mortality, institutionalisation and satisfaction. RESULTS: Two hundred and forty-seven subjects were included (129 patients and 118 caregivers). 93.8 had been diagnosed (2.8 diagnoses per subject). Risk of caregiver strain and mobility impairment accounted for 40% of total home visits (p=0.033). Significant differences were observed in the use of physiotherapy and rehabilitation services. The home visits for caregivers were, in 78% of cases, due to the recipient's baseline functional status. No relation was detected for institutionalisation or for patient satisfaction. There was a higher rate of anxiety diagnosed in the caregiver when the recipient was at greater risk for mortality (RR: 2.08 CI 95%: 1.26-3.42) (p=0.012). CONCLUSIONS: These data confirm results from other studies which find nursing diagnoses to be sound predictors of resources use. Their synergy with other case-mix systems in home care should be investigated.

Comparative study of propofol versus midazolam in the sedation of critically ill patients: results of a prospective, randomized, multicenter trial.

OBJECTIVES: To compare the effectiveness, characteristics, duration of action, hemodynamic and biochemical effects, and side effects of propofol and midazolam used for continuous intravenous sedation of ventilated critically ill patients. DESIGN: Multicenter, prospective, randomized, nonblinded study. SETTING: Nine Spanish general intensive care units (ICUs). PATIENTS: Ninety-eight patients admitted to the ICU who were mechanically ventilated and required sedation for a minimum of 48 hrs. INTERVENTIONS: Propofol or midazolam was used for induction and maintenance of continuous intravenous sedation for a maximum of 5 days. The effectiveness of those two regimens was assessed according to their effects on ventilatory management and the presence of agitation. MEASUREMENTS AND MAIN RESULTS: In 93% of the patients studied, there was a medical cause necessitating mechanical ventilation. The mean (+/-SD) duration of sedation was 81 +/- 25 hrs and 88 +/- 27 hrs for the propofol and midazolam groups, respectively. The induction dose was 2.24 +/- 0.43 mg/kg over 318 +/- 363 secs for propofol, and 0.22 +/-0.07 mg/kg over 33 +/-29 secs for midazolam. The maintenance dose was 2.8 +/-1.1 mg/kg/hr for propofol and 0.14 +/- 0.10 mg/kg/hr for midazolam. There was no difference regarding the opiate and muscle relaxant requirements between the two groups. Sedation with propofol was more effective in achieving patient-ventilator synchrony than that with midazolam after the first hour of treatment (p < .01). Patients sedated with propofol awoke more rapidly and with less variability that those patients sedated with midazolam (23 +/- 16 mins vs. 137 +/- 185 mins, respectively, p < .05), particularly in those patients requiring deep sedation (27 +/- 16 mins vs. 237 +/- 222 mins, respectively, p < .01). No hemodynamic or biochemical changes were detected in any of the treatment groups. During induction, five patients in the propofol group and two patients in the midazolam group had hypotension. CONCLUSIONS: In this population of critically ill patients, propofol is an effective and safe alternative for sedation, with some advantages, such as short duration of action and high effectiveness over the conventional regimen with benzodiazepines and opiates.

[Current study of Cushing's syndrome, apropos of 3 cases]. / Exploración actual del síndrome de Cushing; a propósito de tres casos

The authors describe three cases of Cushing' syndrome, due to nodular hyperplasia, simple hyperplasia and adenocarcinoma respectively, and the most useful approaches (dexamethasone, metopirona, insulinic hypoglycemia, cortisol rhythm, catheterism and assessment of urinary free cortisol) for diagnosis and etiology of Cushing's syndrome.

[Comments on the current treatment of fulminant liver failure]. / Comentarios sobre el tratamiento actual del fallo hepático fulminante.

The current treatment of fulminant liver failure, underscoring substitutive liver therapy, is reviewed. The usefulness of hemodialysis and hemofiltration with a high-permeability membrane, hemoperfusion with activated carbon, hemoperfusion with resins, plasma exchange, artificial cells and the combination of various techniques for the same patients has been studied. Finally, the indications for utility of these techniques and the role of liver transplantation are considered. Early onset of treatment is essential for achieving satisfactory results.

Recursos humanos en los Servicios de Salud: ¿decisiones políticas o política de decisiones? / Health care staff: political decisions or policy of decision making?

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