Features and frequency of use of electronic health records in primary care across 20 countries: a cross-sectional study.

OBJECTIVES: Variation exists in the capabilities of electronic healthcare records (EHRs) systems and the frequency of their use by primary care physicians (PCPs) from different settings. We aimed to examine the factors associated with everyday EHRs use by PCPs, characterise the EHRs features available to PCPs, and to identify the impact of practice settings on feature availability. STUDY DESIGN: Cross-sectional study. METHODS: PCPs from 20 countries completed cross-sectional online survey between June and September 2020. Responses which reported frequency of EHRs use were retained. Associations between everyday EHRs use and PCP and practice factors (country, urbanicity, and digital maturity) were explored using multivariable logistic regression analyses. The effect of practice factors on the variation in availability of ten EHRs features was estimated using Cramer's V. RESULTS: Responses from 1520 out of 1605 PCPs surveyed (94·7%) were retained. Everyday EHRs use was reported by 91·2% of PCPs. Everyday EHRs use was associated with PCPs working >28 h per week, having more years of experience using EHRs, country of employment, and higher digital maturity. EHRs features concerning entering, and retrieving data were available to most PCPs. Few PCPs reported having access to tools for 'interactive patient education' (37·3%) or 'home monitoring and self-testing of chronic conditions' (34·3%). Country of practice was associated with availability of all EHRs features (Cramer's V range: 0·2-0·6), particularly with availability of tools enabling patient EHRs access (Cramer's V: 0·6, P < 0.0001). Greater feature availability of EHRs features was observed with greater digital maturity. CONCLUSIONS: EHRs features intended for patient use were uncommon across countries and levels of digital maturity. Systems-level research is necessary to identify the country-specific barriers impeding the implementation of EHRs features in primary care, particularly of EHRs features enabling patient interaction with EHRs, to develop strategies to improve systems-wide EHRs use.

One consensual depression diagnosis tool to serve many countries: a challenge! A RAND/UCLA methodology.

OBJECTIVE: From a systematic literature review (SLR), it became clear that a consensually validated tool was needed by European General Practitioner (GP) researchers in order to allow multi-centred collaborative research, in daily practice, throughout Europe. Which diagnostic tool for depression, validated against psychiatric examination according to the DSM, would GPs select as the best for use in clinical research, taking into account the combination of effectiveness, reliability and ergonomics? A RAND/UCLA, which combines the qualities of the Delphi process and of the nominal group, was used. GP researchers from different European countries were selected. The SLR extracted tools were validated against the DSM. The Youden index was used as an effectiveness criterion and Cronbach's alpha as a reliability criterion. Ergonomics data were extracted from the literature. Ergonomics were tested face-to-face. RESULTS: The SLR extracted 7 tools. Two instruments were considered sufficiently effective and reliable for use: the Hospital Anxiety and Depression Scale and the Hopkins Symptoms Checklist-25 (HSCL-25). After testing face-to-face, HSCL-25 was selected. A multicultural consensus on one diagnostic tool for depression was obtained for the HSCL-25. This tool will provide the opportunity to select homogeneous populations for European collaborative research in daily practice.

Which DSM validated tools for diagnosing depression are usable in primary care research? A systematic literature review.

INTRODUCTION: Depression occurs frequently in primary care. Its broad clinical variability makes it difficult to diagnose. This makes it essential that family practitioner (FP) researchers have validated tools to minimize bias in studies of everyday practice. Which tools validated against psychiatric examination, according to the major depression criteria of DSM-IV or 5, can be used for research purposes? METHOD: An international FP team conducted a systematic review using the following databases: Pubmed, Cochrane and Embase, from 2000/01/01 to 2015/10/01. RESULTS: The three databases search identified 770 abstracts: 546 abstracts were analyzed after duplicates had been removed (224 duplicates); 50 of the validity studies were eligible and 4 studies were included. In 4 studies, the following tools were found: GDS-5, GDS-15, GDS-30, CESD-R, HADS, PSC-51 and HSCL-25. Sensitivity, Specificity, Positive Predictive Value, Negative Predictive Value were collected. The Youden index was calculated. DISCUSSION: Using efficiency data alone to compare these studies could be misleading. Additional reliability, reproducibility and ergonomic data will be essential for making comparisons. CONCLUSION: This study selected seven tools, usable in primary care research, for the diagnosis of depression. In order to define the best tools in terms of efficiency, reproducibility, reliability and ergonomics for research in primary care, and for care itself, further research will be essential.

Valoración de la idoneidad de los criterios STOPP/START en el ámbito de atención primaria en España por el método RAND / Assessment of the appropriateness of STOPP/START criteria in primary health care in Spain by the RAND method

Introducción. Pretendemos valorar la idoneidad de los criterios STOPP/START para su utilización en el ámbito de atención primaria (AP) en España. Material y método. Estudio observacional transversal con metodología RAND a 2 rondas realizado en la Gerencia de AP de Vigo con 582.968 habitantes (24% ≥>= 65 años). El grupo de expertos fue constituido por la comisión de farmacia del área, con 12 miembros de diversas especialidades. En una primera ronda, se proporciona a la comisión bibliografía relevante y un cuestionario con los criterios STOPP/START para puntuar la idoneidad en AP con una escala Likert del 1-9 (mínimo, máximo). Cada criterio se clasifica en función de la mediana de las puntuaciones obtenidas y su grado de acuerdo. En una segunda ronda, los expertos debaten los criterios dudosos y las sugerencias aportadas. Resultados. La mayoría de los criterios se consideran apropiados, proponiendo una nueva versión AP2012 con las siguientes diferencias: eliminar START E2 «Bifosfonatos en pacientes que reciben corticoesteroides orales a dosis de mantenimiento»; eliminar START F3 «Antiagregantes plaquetarios en la diabetes mellitus si coexisten uno o más factores mayores de riesgo cardiovascular»; modificar STOPP A9, A15, A16, A17 y E5 y START A1 y A2, por referirse solo a la warfarina y se añade acenocumarol, habitual en nuestro medio, e introducir STOPP C6 «Uso de inhibidores de la bomba de protones (IBP) fuera de sus indicaciones autorizadas». Conclusiones. Los criterios STOPP/START son adecuados para su uso en el ámbito de AP pero es necesaria su adaptación y actualización periódica (AU)

Introduction: A new screenings tool called STOPP/START has been formulated to identify potentially inappropriate prescribing in older people. This study aimed to assess the appropriateness of STOPP/START criteria in primary health care (PHC) in Spain. Material and method: The RAND Appropriateness Method was used to obtain agreement on STOPP/START criteria with two rounds in Vigo PHC with 582.968 inhabitants (24% >=65 years). The pharmacotherapy committee of Vigo PHC area was identified as expert panel, with 12 members from different specialties. In the first round, the committee was provided with relevant literature and a questionnaire with STOPP/START criteria to rate their applicability in PHC with a 9-point Likert scale. Then, each of the criteria was classified according to the median scores and the degree of agreement. In the second round, the experts discussed the undecided criteria and suggestions. Results: Most of the criteria were appropriate. We present a new version with the following differences: to remove START E2 «Biphosphonates in patients taking maintenance oral corticosteroid therapy»; to remove START F3 «Antiplatelet therapy in diabetes mellitus with coexisting major cardiovascular risk factors»; to modify STOPP A9, A15, A16, A17 and E5; and START A1 and A2, adding acenocoumarol to all of them because acenocoumarol is the most used anticoagulant in our country and they only refer to warfarin, and to introduce STOPP C6: «Use of proton pump inhibitors without authorized indication». Conclusions: Criteria STOPP/START are suitable for use PHC but it is necessary to adapt and update them periodically (AU)

[Assessment of the appropriateness of STOPP/START criteria in primary health care in Spain by the RAND method]. / Valoración de la idoneidad de los criterios STOPP/START en el ámbito de atención primaria en España por el método RAND.

INTRODUCTION: A new screenings tool called STOPP/START has been formulated to identify potentially inappropriate prescribing in older people. This study aimed to assess the appropriateness of STOPP/START criteria in primary health care (PHC) in Spain. MATERIAL AND METHOD: The RAND Appropriateness Method was used to obtain agreement on STOPP/START criteria with two rounds in Vigo PHC with 582.968 inhabitants (24% ≥ 65 years). The pharmacotherapy committee of Vigo PHC area was identified as expert panel, with 12 members from different specialties. In the first round, the committee was provided with relevant literature and a questionnaire with STOPP/START criteria to rate their applicability in PHC with a 9-point Likert scale. Then, each of the criteria was classified according to the median scores and the degree of agreement. In the second round, the experts discussed the undecided criteria and suggestions. RESULTS: Most of the criteria were appropriate. We present a new version with the following differences: to remove START E2 «Biphosphonates in patients taking maintenance oral corticosteroid therapy¼; to remove START F3 «Antiplatelet therapy in diabetes mellitus with coexisting major cardiovascular risk factors¼; to modify STOPP A9, A15, A16, A17 and E5; and START A1 and A2, adding acenocoumarol to all of them because acenocoumarol is the most used anticoagulant in our country and they only refer to warfarin, and to introduce STOPP C6: «Use of proton pump inhibitors without authorized indication¼. CONCLUSIONS: Criteria STOPP/START are suitable for use PHC but it is necessary to adapt and update them periodically.

A catalogue of molecular, physiological and symbiotic properties of soybean-nodulating rhizobial strains from different soybean cropping areas of China.

We have analysed 198 fast-growing soybean-nodulating rhizobial strains from four different regions of China for the following characteristics: generation time; number of plasmids; lipopolysaccharide (LPS), nodulation factors (LCOs) and PCR profiles; acidification of growth medium; capacity to grow at acid, neutral, and alkaline pH; growth on LC medium; growth at 28 and 37 degrees C; melanin production capacity; Congo red absorption and symbiotic characteristics. These unbiased analyses of a total subset of strains isolated from specific soybean-cropping areas (an approach which could be called "strainomics") can be used to answer various biological questions. We illustrate this by a comparison of the molecular characteristics of five strains with interesting symbiotic properties. From this comparison we conclude, for instance, that differences in the efficiency of nitrogen fixation or competitiveness for nodulation of these strains are not apparently related to differences in Nod factor structure.

Soils of the Chinese Hubei province show a very high diversity of Sinorhizobium fredii strains.

Biodiversity studies of native soybean-nodulating rhizobia in soils from the Chinese Hubei province (Honghu county; pH 8, alluvial soil) have been carried out. Inoculation of an American (Williams) and an Asiatic (Peking) soybean cultivar with eleven soil samples led to the isolation of 167 rhizobia strains. The ratio (%) of slow-/fast-growing isolates was different depending on the trap plant used. All isolates were able to nodulate both cultivars, although the N2-fixation efficiency (measured as plant-top dry weight) was different among them. A total of thirty-three isolates were selected for further characterisation on the basis of physiological parameters, PCR-RFLP of symbiotic genes and Low Molecular Weight RNA, lipopolysaccharide, protein and plasmid profiles. Low Molecular Weight RNA profiling indicates that all the isolates belong to species Sinorhizobium fredii. The dendrogram obtained with the physiological parameters has been useful to classify the isolates at strain level, although plasmid profiling was the most discriminating technique to detect differences among the analysed soybean-rhizobia isolates, showing there is not two isolates identical each other. Plasmid profile analyses also revealed that some of the investigated strains contain low molecular weight plasmids (7-8-kb). They are, to our knowledge, the smallest ever found in rhizobia and they could be the starting point for the construction of the first group of vectors based on a native rhizobia replicon.

Determination of the chemical structure of the capsular polysaccharide of strain B33, a fast-growing soya bean-nodulating bacterium isolated from an arid region of China.

We have determined the structure of a polysaccharide from strain B33, a fast-growing bacterium that forms nitrogen-fixing nodules with Asiatic and American soya bean cultivars. On the basis of monosaccharide analysis, methylation analysis, one-dimensional 1H- and 13C-NMR and two-dimensional NMR experiments, the structure was shown to consist of a polymer having the repeating unit -->6)-4-O-methyl-alpha-D-Glcp-(1-->4)-3-O-methyl-beta-D-GlcpA-(1--> (where GlcpA is glucopyranuronic acid and Glcp is glucopyranose). Strain B33 produces a K-antigen polysaccharide repeating unit that does not have the structural motif sugar-Kdx [where Kdx is 3-deoxy-D-manno-2-octulosonic acid (Kdo) or a Kdo-related acid] proposed for different Sinorhizobium fredii strains, all of them being effective with Asiatic soya bean cultivars but unable to form nitrogen-fixing nodules with American soya bean cultivars. Instead, it resembles the K-antigen of S. fredii strain HH303 (rhamnose, galacturonic acid)n, which is also effective with both groups of soya bean cultivars. Only the capsular polysaccharide from strains B33 and HH303 have monosaccharide components that are also present in the surface polysaccharide of Bradyrhizobium elkanii strains, which consists of a 4-O-methyl-D-glucurono-L-rhamnan.

Structural determination of a 5-acetamido-3,5,7, 9-tetradeoxy-7-(3-hydroxybutyramido)-L-glycero-L-manno-nonulos onic acid-containing homopolysaccharide isolated from Sinorhizobium fredii HH103.

The structure of a polysaccharide from Sinorhizobium fredii HH103 has been determined. This polysaccharide was isolated by following the protocol for lipopolysaccharide extraction. On the basis of monosaccharide analysis, methylation analysis, fast atom bombardment MS, matrix-assisted laser desorption ionization MS, electron-impact high-resolution MS, one-dimensional (1)H-NMR and (13)C-NMR and two-dimensional NMR experiments, the structure was shown to consist of a homopolymer of a 3:1 mixture of 5-acetamido-3,5,7, 9-tetradeoxy-7-[(R)- and (S)-3-hydroxybutyramido]-l-glycero-l-manno-nonulosonic acid. The sugar residues are attached via a glycosidic linkage to the OH group of the 3-hydroxybutyramido substituent and thus the monomers are linked via both glycosidic and amidic linkages. In contrast with the Sinorhizobium K-antigens previously reported, which are composed of a disaccharide repeating unit, the K-antigen polysacharide of S. fredii HH103 is a homopolysaccharide.

Structural determination of a 5-O-methyl-deaminated neuraminic acid (Kdn)-containing polysaccharide isolated from Sinorhizobium fredii.

The structure of a polysaccharide from Sinorhizobium fredii SVQ293, a thiamine auxotrophic mutant of S. fredii HH103, has been determined. This polysaccharide was isolated following the protocol for lipopolysaccharide extraction. On the basis of monosaccharide analysis, methylation analysis, fast atom bombardment MS, collision-induced dissociation tandem MS, one-dimensional 1H and 13C NMR and two-dimensional NMR experiments, the structure was shown to consist of the following trisaccharide repeating unit-->2)-alpha-d-Galp-(1-->2)-beta-d-Ribf-(1-->9)-alpha-5-O-Me-++ +Kdnp- (2-->, in which Kdn stands for deaminated neuraminic acid; 25% of the Kdn residues are not methylated. The structure of this polysaccharide is novel and this is the first report of the presence of Kdn in a rhizobial polysaccharide, as well as being the first structure described containing 5-O-Me-Kdn. This Kdn-containing polysaccharide is not present in the wild-type strain HH103, which produces a 3-deoxy-d-manno-2-octulosonic acid (Kdo)-rich polysaccharide. We conclude that it is likely that the appearance of this new Kdn-containing polysaccharide is a consequence of the mutation.

Association of spontaneous anterior fossa CSF rhinorrhea and congenital perilymphatic fistula in a patient with recurrent meningitis.

A case of recurrent meningitis associated with spontaneous cerebrospinal fluid (CSF) rhinorrhea and left sensorineural hearing loss in a 4-year-old boy was found to be due to simultaneous congenital defects. High resolution CT examination clearly showed an anterior fossa defect and an inner ear malformation, including demineralization in the region of the footplate of the stapes, and thus provided clear guidance for the surgeon.

Melanotic neuroectodermal tumor of infancy: a case report.

A male patients, two months of age, was affected by a rapidly growing tumor on the left side of the mandible. There were no other clinical or pathological signs. A thorough examination, as well as radiographic, tomographic and tomodensitometric tests showed the presence of a tumor on the maxilla. It was of low density, encapsulated and shifting the germinal teeth. Surgical removal revealed a melanotic neuroectodermal tumor typical of that in children. The tumor recurred in the same location and was actually larger, less than a month after the operation. A new screening was done for vanilmandelic acid and radiographies of the skull base and skeletal series were negative. The patient was operated on again, with the same histological diagnosis. The diagnosis and treatment are discussed.

Melanin production by Rhizobium strains.

Different Rhizobium and Bradyrhizobium strains were screened for their ability to produce melanin. Pigment producers (Mel) were found among strains of R. leguminosarum biovars viceae, trifolii, and phaseoli, R. meliloti, and R. fredii; none of 19 Bradyrhizobium strains examined gave a positive response. Melanin production and nod genes were plasmid borne in R. leguminosarum biovar trifolii RS24. In R. leguminosarum biovar phaseoli CFN42 and R. meliloti GR015, mel genes were located in the respective symbiotic plasmids. In R. fredii USDA 205, melanin production correlated with the presence of its smallest indigenous plasmid.