Offerings and User Demands of eHealth Services in Spain: National Survey.

BACKGROUND: The accelerated development of information and communication technologies has made health care one of the pioneering fields in the incorporation of these tools. As new technologies have been applied, existing technologies have been sophisticated and improved and the concept of eHealth has expanded. However, these advances and expansion of eHealth do not seem to have served to adapt the supply of services to users' demands; rather, supply seems to be governed by other variables. OBJECTIVE: The main objective of this work was to review the existing differences between user demands and the supply of eHealth services in Spain and their causes. The aim is to provide information on the level of use of the services and the causes of the variation in demand for these services, which can be useful in correcting existing differences and adapting them to the needs of users. METHODS: A survey, "Use and Attitudes Toward eHealth in Spain," was applied by telephone to a sample of 1695 people aged 18 years and over, taking into account sociodemographic profile characteristics (sex, age, habitat, educational level). The confidence level was set at 95% and the margin of error was ±2.45 for the whole sample. RESULTS: The survey results showed that the online doctor's appointment service is the most frequently used eHealth service by users: 72.48% of respondents used this service at some point and 21.28% stated that they use it regularly. The other services showed significantly lower percentages of use, including "managing health cards" (28.04%), "consulting medical history" (20.37%), "managing test results" (20.22%), "communicating with health professionals" (17.80%), and "requesting a change of doctor" (13.76%). Despite this low usage, a large majority of respondents (80.00%) attach great importance to all the services offered. Overall, 16.52% of the users surveyed were willing to make new service requests to the regional websites, with 9.33% of them highlighting services such as "the availability of a complaints and claims mailbox," "the possibility of consulting medical records," and "the availability of more detailed information on medical centers (location, medical directory, waiting lists, etc)." Other outstanding requests (8.00%) were to simplify the procedures for using certain existing services. CONCLUSIONS: The data from the survey show that eHealth services are widely known and highly valued by users, but not all services are used with the same frequency or intensity. It appears that users find it difficult to suggest new services that might be useful to them in terms of demand for new services that do not currently exist. It would be useful to use qualitative studies to gain a deeper understanding of currently unmet needs and the possibilities of eHealth. The lack of access to and use of these services and the unmet needs particularly affect more vulnerable populations who have the greatest difficulty in meeting their needs through alternative means to eHealth.

Sliding ureteral inguinal hernia: An uncommon embryological trick. Case report and literature review.

INTRODUCTION: Inguinoscrotal herniation of the bladder is a rare clinical entity, with a frequency between 0.5% and 4% of all inguinal hernias. When the whole bladder and ureters migrate into the scrotum, it may cause urinary disorders as hydronephrosis. CASE REPORT: A 77-year-old male patient suffering from hypertrophic obstructive cardiomyopathy, obesity and diabetic disease presented with urinary disorders and left-sided inguinoscrotal hernia. Under clinical suspicion of sigmoid colon involvement in the inguinal canal, abdominal and pelvic computed tomography (CT scan) with endovenous contrast was performed, revealing a left inguinoscrotal hernia, containing the sigmoid colon and the left pelvic ureter causing left hydronephrosis. DISCUSSION: Without create urinary bladder wall leakage, the content of the hernial sac was reduced into the abdominal cavity. Previous subarachnoid anesthesia a left hernioplasty was performed by means of Lichtenstein's method with self-fixating mesh (Bard Adhesix) and subsequent complete resolution of the hydronephrosis. CONCLUSION: Ureter involvement should be suspected when a clinical inguinal hernia is diagnosed concurrently with unexplained hydronephrosis, renal failure, or urinary tract infection, as in the case described. When suspected, the preoperative diagnosis, particularly with CT scan, is essential to avoid complications and to reduce risk of bladder and ureter injuries during hernia repair.

The Present and Future of eHealth in Spain From a Health Management Perspective.

eHealth has grown significantly over the last decade. The aim of this study was to determine the level of use of information and communication technologies for health care in Spain and identify the main barriers to development. We used a qualitative study based on data obtained from 8 Spanish autonomous communities through semi-structured, in-depth interviews with key informants in eHealth management and planning. Programs present varying degrees of implementation. Services such as electronic prescriptions, digital medical records, and appointment requests via the Internet are advanced and widespread; others, such as digital imaging, are advanced but not fully deployed; and some, such as telecare programs, are experimental. The study also revealed diverse levels of interoperability and barriers to the expansion of these technologies, which can be classified into 4 fields: technological, organizational, human, and economic. eHealth might evolve more slowly in the coming years. Unless the payoff is clearly seen, major budget cuts in the current economic climate will prevent the implementation of new projects. Programs that help reduce health spending are more likely to be implemented, to the detriment of projects involving simple techniques or even clear health care improvements.

eHealth and mHealth Development in Spain: Promise or Reality?

In the last decades, the use of Information and Communication Technologies (ICTs) has progressively spread to society and public administration. Health is one of the areas in which the use of ICTs has more intensively developed through what is now known as eHealth. That area has recently included mHealth. Spanish health system has stood out as one of the benchmarks of this technological revolution. The development of ICTs applied to health, especially since the outbreak of the pandemic caused by SARS Cov-2, has increased the range of health services delivered through smartphones and the development of subsequent specialized apps. Based on the data of a Survey on Use and Attitudes regarding eHealth in Spain, the aim of this research was to conduct a comparative analysis of the different eHealth and mHealth user profiles. The results show that the user profile of eHealth an mHealth services in Spain is not in a majority. Weaknesses are detected both in the knowledge and use of eHealth services among the general population and in the usability or development of their mobile version. Smartphones can be a democratizing vector, as for now, access to eHealth services is only available to wealthy people, widening inequality.

Injerto de hueso medular de tibia como alternativa para relleno de defectos óseos maxilofaciales / Tibial bone graft as an option for filling maxillofacial bone defects

Objetivos: Demostrar la utilidad y la facilidad técnica del injerto tibial en defectos óseos orales y maxilofaciales, para tenerlo como un recurso alternativo en la práctica general del cirujano oral y maxilofacial. Caso clínico: Se presenta un caso clínico con el uso de injerto óseo autólogo de tibia para el relleno de un defecto óseo a raíz de una lesión quística. Se realizó la exéresis de la patología quística por medio de un abordaje oral y posteriormente se recolectó hueso medular tibial a través de un abordaje medio al tubérculo anterior de la tibia, para poder colocarlo en el defecto óseo. Conclusión: El injerto de hueso medular de epífisis tibial representa un sitio de recolección de fácil acceso, del que se puede obtener una cantidad de hueso ideal para defectos de pequeño y mediano tamaño de la región maxilofacial, de baja morbilidad y con muy pocas complicaciones post-operatorias, lo que lo convierte en una alternativa para rellenos de cavidades óseas de gran utilidad (AU)

Objective: To demonstrate the utility and technical ease of the tibial graft in oral and maxillofacial bone defects so as to have it as an alternative resource in the general practice of the oral and maxillofacial surgeon. Case report: A clinical case is shown with the use of an autologous tibial bone graft to fill a bone defect as a result of a cystic lesion. The cyst was excised by an oral approach and the medial tibial bone was collected through a middle approach to the anterior tubercle of the tibia, to place it in the bone defect. Conclusion: The tibial epiphysis medullary bone graft represents an easily accessible collection site, from which an ideal amount of bone can be obtained for small and mediumsized defects of the maxillofacial region, with low morbidity and very few post-operative complications, which makes it a useful option for bone cavity filling (AU)

Equity policies in health plans: accessibility and something more?

OBJECTIVE: To examine the approach adopted by the health plans of the autonomous communities of Spain, verifying the weight given to the concept of equity; to detect referenced communities or situations, as well as to distinguish the perspective of approaching it, from access, equity or equalization. METHODS: Qualitative study, of content analysis using Nvivo12, carried out in 2020 on health plans in force since 2019 in the different regions (autonomous communities) of Spain. Sixteen current regional health plans were compiled to establish base categories (equity, accessibility and equality) and determine associated terms using Nvivo12, from which a content analysis was performed. RESULTS: The concept of equity is not emphasized in the regional health plans and its relevance is surpassed by the concepts of accessibility and equality. The use of these three concepts is associated with various categories indicating circumstances, conditions or groups to which the plans give greater attention. CONCLUSIONS: The results obtained coincide with previous studies on the contents and orientation of health plans, revealing a discrete presence of the concept of equity in the approaches adopted, although this does not undermine the alignment of health policies with the visions emanating from transnational organizations. It is detected the existence of a group to which special attention is given from the accessibility approach, the population with functional diversity.

Genome-wide association study of stage III/IV grade C periodontitis (former aggressive periodontitis) in a Spanish population.

AIM: To identify loci associated with stages III/IV, grade C periodontitis (PIII/IV-C) through a genome-wide association study (GWAS). MATERIALS AND METHODS: 441 Caucasian Spanish PIII/IV-C cases from the SEPA Network of Research Clinics and 1141 controls from the Banco Nacional de ADN were genotyped with "Axiom Spain Biobank Array," which contains 757836 markers, including rare and low-frequency Spanish variants. The analysis of the individual association and subsequently the gene-level analysis with Sequence Kernel Association Test (SKAT) were carried out adjusting for age, sex and PC1 covariates. Pathway Analysis was additionally performed with Ingenuity Pathway Analysis (IPA) software on the top associated genes. RESULTS: In the individual analyses, no genome-wide significant signals were detected. However, 8 SNPs of 8 loci reached suggestive evidence of association with PIII/IV-C, including FAT3 rs35709256, CSNK1G2 rs4807188, MYH13 rs2074872, CNTN2 rs116611488, ANTXR1 rs4854545, 8p23.2 rs78672540, ANGPT1 rs13439823 and PLEC rs11993287 (p < 5 × 10-6 ). SKAT analysis identified other interesting signals at CNTN2, FBXO44, AP1M2, RSPO4, KRI1, BPIFB1 and INMT, although their probability does not exceed the multiple-test correction. IPA indicated significant enrichment of pathways related to cAMP, IL-2, CD28, VDR/RXR and PI3K/Akt.  CONCLUSIONS: GWAS found no SNPs significantly associated with PIII/IV-C.

[Bringing in equity to health. An analysis of the autonomous communities health plans.] / Incorporando la equidad a la salud. Un análisis de los planes autonómicos sanitarios.

OBJECTIVE: The debate on equity in health, with long history and wide understanding, is more relevant today when considering the transcendence of this area. In the context of our system, it is appropriate to know the approach adopted by the autonomous communities. By analysing regional health plans in Spain it was intended to detect the perspectives applied in the search for equity, as well as to know the main goals of the plans and those groups or circumstances they try to deal with. METHODS: Based on the procedure of constant comparative analysis and content analysis, whose statistical treatment was conducted with Nvivo software (v12) and the analysis of Jaccard and Pearson correlation indexes, along with the triangulation of methods, data and researchers, the most recent regional health plans in progress (fourth quarter of 2019) were screened. RESULTS: Analized plans brought out that the search for equity is not given sufficient relevance. However, there are specific circumstances that standed out among the references to equity in the plans. Accessibility arised as a key category to understand the setup of health care as a public policy. CONCLUSIONS: The main paradigm found in regional health plans is that of equality or equity in access to health. To a lesser extent, it is also present a search for equal opportunities for various specific groups, such as people suffering from mental illness, people with functional diversity or who face some of the barriers or difficulties associated with the gender gap. Other items or groups considered by the regional administrations in a more reduced way, but also in a different manner, are immigration, rural habitat and infrastructures and elderly people.

OBJETIVO: El debate sobre la equidad en salud, con amplia trayectoria e interpretaciones, cobra más vigencia en la actualidad al considerar la trascendencia de esta área. En el contexto de nuestro sistema, resulta pertinente conocer la aproximación adoptada por las comunidades autónomas. Mediante el análisis de los planes de salud autonómicos se persiguió el objetivo de detectar las perspectivas que se habían aplicado a la búsqueda de la equidad en España, así como conocer sus principales metas y los colectivos o condiciones tomados en consideración. METODOS: Mediante el análisis comparativo constante y del análisis de contenido, cuyo tratamiento estadístico se realizó con el software Nvivo (v12) y el análisis de los índices de correlación de Jaccard y Pearson, junto con la triangulación de métodos, datos e investigadores, fueron examinados los planes generales de salud autonómicos más recientes a fecha del cuarto trimestre de 2019. RESULTADOS: Los planes analizados revelaron que no se otorga a la búsqueda de la equidad suficiente importancia, si bien se detectaron circunstancias específicas que destacan entre las referencias a la equidad recogidas por los planes. La accesibilidad emergió como categoría clave a la hora de entender la configuración de la sanidad como política pública. CONCLUSIONES: El principal paradigma presente en los planes de salud autonómicos es el de la igualdad o equidad en cuanto al acceso a la salud, seguido del de la búsqueda de igualdad de oportunidades para colectivos concretos, como son las personas que padecen enfermedades mentales, personas con diversidad funcional o que presentan alguna de las barreras o dificultades asociadas a la brecha de género. Otros ítems o colectivos contemplados en menor medida, pero de forma desigual entre las comunidades autónomas, son la inmigración, el hábitat rural e infraestructuras y el colectivo de personas mayores.

Equity policies in health plans: accessibility and something more? / Políticas de equidad en los planes de salud: accesibilidad ¿y algo más?

ABSTRACT OBJECTIVE: To examine the approach adopted by the health plans of the autonomous communities of Spain, verifying the weight given to the concept of equity; to detect referenced communities or situations, as well as to distinguish the perspective of approaching it, from access, equity or equalization. METHODS: Qualitative study, of content analysis using Nvivo12, carried out in 2020 on health plans in force since 2019 in the different regions (autonomous communities) of Spain. Sixteen current regional health plans were compiled to establish base categories (equity, accessibility and equality) and determine associated terms using Nvivo12, from which a content analysis was performed. RESULTS: The concept of equity is not emphasized in the regional health plans and its relevance is surpassed by the concepts of accessibility and equality. The use of these three concepts is associated with various categories indicating circumstances, conditions or groups to which the plans give greater attention. CONCLUSIONS: The results obtained coincide with previous studies on the contents and orientation of health plans, revealing a discrete presence of the concept of equity in the approaches adopted, although this does not undermine the alignment of health policies with the visions emanating from transnational organizations. It is detected the existence of a group to which special attention is given from the accessibility approach, the population with functional diversity.

RESUMEN OBJETIVO: Examinar el enfoque adoptado por los planes de salud de las comunidades autónomas de España verificando el peso otorgado al concepto de equidad; detectar a qué colectivos o situaciones se hace referencia; así como distinguir la perspectiva de abordaje del mismo, desde el acceso, la igualación o la equiparación. MÉTODOS: Estudio cualitativo, de análisis de contenido mediante Nvivo12, realizado en 2020 sobre planes de salud en vigencia a fecha de 2019 en las diferentes regiones (comunidades autónomas) de España. Se han recopilado 16 planes de salud regionales vigentes para establecer categorías base (equidad, accesibilidad e igualdad) y determinar términos asociados a través de Nvivo12, a partir de los que se realizó un análisis de contenido. RESULTADOS: El concepto de equidad no resulta destacado por los planes de salud autonómicos y su relevancia es superada por los conceptos de accesibilidad e igualdad. El empleo de estos tres conceptos está asociado a diversas categorías que connotan circunstancias, condiciones o colectivos a los que los planes prestan mayor atención. CONCLUSIONES: Los resultados obtenidos coinciden con estudios previos sobre los contenidos y orientación de los planes de salud, revelando una presencia discreta del concepto de equidad en los enfoques adoptados, sin que ello menoscabe el alineamiento de las políticas de salud respecto de las visiones emanadas de organizaciones transnacionales. Se detecta la existencia de un colectivo al que se presta especial atención desde el enfoque de accesibilidad, la población con diversidad funcional.

Opinión de los facultativos y usuarios sobre avances de la e-salud en atención primaria / Opinion of doctors and users on e-health advances in primary care

OBJETIVO: Explorar las opiniones de los usuarios y de los facultativos sobre el avance de la e-salud en atención primaria. DISEÑO: Grupos focales realizados entre el 1 de mayo y el 25 de septiembre de 2018. Emplazamiento: Nivel de atención primaria en los servicios autonómicos de salud. PARTICIPANTES: Un total de 29 usuarios y 33 facultativos vinculados a atención primaria contactados, respectivamente, a través de asociaciones de usuarios y por medio del servicio autonómico de salud. MÉTODO: Análisis inductivo de las transcripciones de grupos focales en torno a los siguientes temas: accesibilidad y seguridad; eficiencia; problemas de información y técnicos; potencialidades. RESULTADOS: Los servicios de salud en línea son positivamente valorados por usuarios y facultativos de atención primaria en términos de ahorro de costes. No obstante, la interacción presencial sigue considerándose clave en la calidad de servicio. Se comparte la preocupación por la seguridad de los datos y por las deficiencias formativas de usuarios y de facultativos en el acceso y la provisión de servicios de e-salud. El diseño adecuado de las aplicaciones constituye un condicionante para la aceptación y la difusión de las tecnologías que sostienen la salud en línea. CONCLUSIONES: La administración sanitaria debería intensificar la utilización de las nuevas tecnologías con un enfoque facilitador de la labor del facultativo, simplificando tareas burocráticas, aportando seguridad diagnóstica, prescriptiva y de protección de datos. Mientras los sistemas generen fallos y desconfianza continuarán percibiéndose como un complemento pero no como alternativa al modelo de atención tradicional

OBJECTIVE: To find out the opinions of users and primary care doctors on the progress of e-health in primary care. DESIGN: Focus groups set up between 1st May and 25th September 2018. LOCATION: Primary care level in regional online health services. PARTICIPANTS: A total of 29 users and 33 primary care doctors linked to primary care that were contacted, through user associations and regional public health services, respectively. METHOD: Inductive analysis of transcripts from focus groups about the following issues: accessibility and security; efficiency; information and technical problems; potentialities. RESULTS: Online health services are positively valued in terms of cost savings both by users and doctors of primary care. Nevertheless, face-to-face interaction is still considered a key factor in the quality of service. When it comes to the access and provision of e-health services, there is shared concern for the security of the data and for the training deficiencies of users and doctors. An adequate design of the applications becomes a condition for the acceptance and diffusion of technologies that support online health. CONCLUSIONS: Health authorities should intensify the use of new technologies oriented towards easing the work of doctors, simplifying bureaucratic tasks, providing diagnostic and prescription security, and protecting data. As long as systems generate failures and mistrust, new technologies will remain to be perceived as a complement, but not as an alternative to the traditional care model

Effects of high-energy photon beam radiation therapy on Jarvik 2000 LVAD: in vitro evaluation.

PURPOSE: Left ventricular assist device (LVAD) is considered a standard care for patients with advanced heart failure. The aim of this work was to study in vitro the effects of direct exposure of the Jarvik 2000 LVAD to 10-MV photon beams. METHODS: Jarvik 2000 pump was immersed in a siliconized box filled with deionized water. A 30 × 30 × 15 cm RW3 slabs were added forth and back to the box. A treatment plan consisting of a single direct 10 × 10 cm2 field size beam was used to deliver 1000 MU at the center of the pump. During irradiation, the external Flow Maker controller and the lithium battery were positioned away from the beam. Pump parameter data (included voltage, current and frequency) were measured, recorded and analyzed for changes in pump function among baseline, pre-irradiation, during irradiation, post-irradiation and after 6 months. The whole session lasted 6 months. The Mann-Whitney U test was used to compare the repeated measurements. X-ray radiation attenuation was also studied. RESULTS: The parameters investigated remained stable over the 6 months; that is, no pump stops, alarms, events, operational changes or abnormalities during the discharge rate of the connected power sources, were encountered, confirmed by the Mann-Whitney U test applied to all sessions (p > 0.1). The measured X-ray attenuation differed from the calculated one by TPS by 34%. CONCLUSION: The Jarvik 2000 resulted stable under direct X-ray beam of 10-MV energy. Its strong attenuation, however, can affect dose deposition in the pump in TPS, and it must be taken into account.

[Opinion of doctors and users on e-health advances in primary care]. / Opinión de los facultativos y usuarios sobre avances de la e-salud en atención primaria.

OBJECTIVE: To find out the opinions of users and primary care doctors on the progress of e-health in primary care. DESIGN: Focus groups set up between 1st May and 25th September 2018. LOCATION: Primary care level in regional online health services. PARTICIPANTS: A total of 29 users and 33 primary care doctors linked to primary care that were contacted, through user associations and regional public health services, respectively. METHOD: Inductive analysis of transcripts from focus groups about the following issues: accessibility and security; efficiency; information and technical problems; potentialities. RESULTS: Online health services are positively valued in terms of cost savings both by users and doctors of primary care. Nevertheless, face-to-face interaction is still considered a key factor in the quality of service. When it comes to the access and provision of e-health services, there is shared concern for the security of the data and for the training deficiencies of users and doctors. An adequate design of the applications becomes a condition for the acceptance and diffusion of technologies that support online health. CONCLUSIONS: Health authorities should intensify the use of new technologies oriented towards easing the work of doctors, simplifying bureaucratic tasks, providing diagnostic and prescription security, and protecting data. As long as systems generate failures and mistrust, new technologies will remain to be perceived as a complement, but not as an alternative to the traditional care model.

La eSalud en España: evolución, estado actual y perspectivas de futuro / eHealth in Spain: evolution, current status and future prospects

Resumen Ofrecer un análisis pormenorizado de la evolución e implantación de las Tecnologías de la Información y la Comunicación (TIC) en el ámbito sanitario -eSalud- en España, atendiendo a los principales servicios implementados, su situación actual y sus perspectivas de futuro, así como a su posible impacto en el sistema sanitario y particularmente en sus usuarios. Se ha revisado la literatura científica sobre eSalud para identificar los servicios implementados más extendidos y sus características. En función de esa información se ha diseñado y administrado una encuesta a nivel estatal a usuarios del sistema nacional de salud de España (SNS) para conocer su percepción sobre los servicios recibidos y los obstáculos existentes para su pleno desarrollo. Los resultados fueron contrastados con otras fuentes secundarias. Existen servicios plenamente implementados y con un elevado nivel de uso; otros todavía permanecen en una fase más inicial. Se confirma una asimetría en los servicios ofertados por las administraciones de salud de las Comunidades Autónomas. Se confirma que el sistema sanitario español ha experimentado un importante avance tecnológico, orientando la eSalud hacia la oferta de servicios centrados en la equidad, la calidad y la eficiencia, aunque todavía subsisten obstáculos a superar.

Abstract This article aims to offer a detailed analysis of the evolution and implementation of Information and Communications Technology (ICT) in the health sector -eHealth- in Spain. Considering the main services implemented, their current situation and future prospects, as well as their possible impact on the health system and particularly on their users. The scientific literature on eHealth has been reviewed to identify the most widely implemented services and their characteristics. Based on this information, a statewide survey has been designed and administered to users of the Spanish National Health System (SNS) to learn about their perception of the services received and the existing obstacles to their full development. The results were contrasted with other secondary sources. Some services are fully implemented and have a high level of use; others are still at an early stage. It is also confirmed an asymmetric evolution of services delivered by Spanish regional health organizations. It is confirmed that the Spanish health system has experienced an important technological improvement, focusing eHealth towards the delivery of services which highlight equity, quality and efficiency, although there are still obstacles to overcome.

Are we ready for a paradigm shift from high-dose conventional to moderate hypofractionated radiotherapy in intermediate-high risk prostate cancer? A systematic review of randomized controlled trials with trial sequential analysis.

AIM: to evaluate efficacy and late toxicity of moderate hypofractionated (HFRT) over high-dose (>76 Gy) conventional radiotherapy (CRT) in a non-inferiority perspective. METHODS: Randomized controlled trials (RCTs) were included. HFRT regimens were deemed non-inferior to high-dose CRT if the computed CI for the overall RR did not exceed the non-inferiority margin of 7%. RESULTS: When the prespecified margin, corresponding to a critical RR of 0.930 for CCS, OS and BFS, was used all efficacy outcomes satisfied the criteria for the non-inferiority analysis indicating the non-inferiority of HFRT regimens over high-dose CRT in the medium term period. Differently, the evidence concerning the late toxicity was inconclusive. CONCLUSIONS: Noninferiority analysis indicates that moderate HFRT regimes are non-inferior over high-dose CRT in the medium-term. Inconclusive is the evidence for the late toxicity. Longer follow-up will provide a more clear answer concerning the non-inferiority of HFRT regimens in the long-term period.

Lipoprotein (a) levels and outcomes in stable outpatients with symptomatic artery disease.

BACKGROUND AND AIMS: Although genetic and epidemiological studies support that people with high lipoprotein (a) [Lp(a)] levels are at an increased risk for arterial disease, its prognostic value in patients with established artery disease has not been consistently evaluated. METHODS: FRENA is a prospective registry of consecutive outpatients with coronary, cerebrovascular or peripheral artery disease. We assessed the risk for subsequent myocardial infarction, ischemic stroke or limb amputation according to Lp(a) levels at baseline. RESULTS: As of December 2016, 1503 stable outpatients were recruited. Of these, 814 (54%) had levels <30 mg/dL, 319 (21%) had 30-50 mg/dL and 370 (25%) had ≥50 mg/dL. Over a mean follow-up of 36 months, 294 patients developed subsequent events (myocardial infarction 122, ischemic stroke 114, limb amputation 58) and 85 died. On multivariable analysis, patients with Lp(a) levels of 30-50 mg/dL were at a higher risk for myocardial infarction (hazard ratio [HR]: 4.67; 95%CI: 2.77-7.85), ischemic stroke (HR: 8.27; 95%CI: 4.14-16.5) or limb amputation (HR: 3.18; 95%CI: 1.36-7.44) than those with normal levels. Moreover, patients with levels ≥50 mg/dL were at increased risk for myocardial infarction (HR: 19.5; 95%CI: 10.5-36.1), ischemic stroke (HR: 54.5; 95%CI: 25.4-116.7) or limb amputation (HR: 22.7; 95%CI: 9.38-54.9). CONCLUSIONS: Stable outpatients with symptomatic artery disease and Lp(a) levels >30 mg/dL were at a 5-fold higher risk for subsequent myocardial infarction, stroke or limb amputation. Those with levels >50 mg/dL were at an over 10-fold higher risk.

A Feasibility Study for in vivo Dosimetry Procedure in Routine Clinical Practice.

PURPOSE: The aim of the in vivo dosimetry, during the fractionated radiation therapy, is the verification of the correct dose delivery to patient. Nowadays, in vivo dosimetry procedures for photon beams are based on the use of the electronic portal imaging device and dedicated software to elaborate electronic portal imaging device images. METHODS: In total, 8474 in vivo dosimetry tests were carried out for 386 patients treated with 3-dimensional conformal radiotherapy, intensity-modulated radiotherapy, and volumetric modulated arc therapy techniques, using the SOFTDISO. SOFTDISO is a dedicated software that uses electronic portal imaging device images in order to (1) calculate the R index, that is, the ratio between daily reconstructed dose and the planned one at isocenter and (2) perform a γ-like analysis between the signals, S, of a reference electronic portal imaging device image and that obtained in a daily fraction. It supplies 2 indexes, the percentage γ% of points with γ < 1 and the mean γ value, γmean. In γ-like analysis, the pass criteria for the signals agreement ΔS% and distance to agreement Δd have been selected based on the clinical experience and technology used. The adopted tolerance levels for the 3 indexes were fixed in 0.95 ≤ R ≤ 1.05, γ% ≥ 90%, and γmean ≤ 0.5. RESULTS: The results of R ratio, γ-like, and a visual inspection of these data reported on a monitor screen permitted to individuate 2 classes of errors (1) class 1 that included errors due to inadequate standard quality controls and (2) class 2, due to patient morphological changes. Depending on the technique and anatomical site, a maximum of 18% of tests had at least 1 index out of tolerance; once removed the causes of class-1 errors, almost all patients (except patients with 4 lung and 2 breast cancer treated with 3-dimensional conformal radiotherapy) presented mean indexes values ([Formula: see text], [Formula: see text]%, and [Formula: see text] ) within tolerance at the end of treatment course. Class-2 errors were found in some patients. CONCLUSIONS: The in vivo dosimetry procedure with SOFTDISO resulted easily implementable, able to individuate errors with a limited workload.

Hippocampal sparing approach in fractionated stereotactic brain VMAT radio therapy: A retrospective feasibility analysis.

Volumetric Modulated Arc Therapy (VMAT) techniques for fractioned stereotactic brain radiotherapy (FSBRT) can achieve highly conformal dose distribution to intracranial lesions. However, they can potentially increase the dose to hippocampus (H) causing neurocognitive toxicity during the first four months after irradiation. The purpose of this study was to assess the feasibility of hippocampal-sparing (HS) treatment plans in 22 patients with brain metastasis treated with VMAT technique. Firstly, we retrospectively analyzed hippocampal doses in all 22 VMAT original (not hippocampal-sparing, NHS) plans. Plans with hippocampal dose exceeding constraints (9 out of 22) were re-planned considering dose constraints on the hippocampus (H) and on hippocampal avoidance zone (HAZ) generated using 5 mm isotropic margin to the hippocampus. Conformity (CI) and homogeneity indexes (HI) on the target and MUs, were maintained as close as possible to the original plans. Mean CINHS and CIHS obtained were: 0.79 ± 0.11 and 0.81 ± 0.10, respectively (P = 0.75); mean HINHS and HIHS were 1.05 ± 0.02 and 1.04 ± 0.01 respectively (P = 0.72). In both sets of plans, the mean MU values were similar: 1033 ± 275 and 1022 ± 234 for NHS and HS respectively. In HS plans, the mean hippocampal dose was decreased by an average of 35%. After replanning, the Dmax (21.3 Gy) for HAZ and H was met by 45% (4/9) and 78% (7/9) of the NHS plans, respectively. The worst results were obtained for cases with target volumes extention closer than 12 mm to H, because of the difficulty to spare hippocampus without compromising target coverage. After replanning D40% constraint value (7.3 Gy) was met by all the 9 NHS plans. In conclusion, this study suggests that an hippocampal-sparing approach to FSBRT is feasible resulting in a decrease in the dose to the hippocampus without any loss in conformity or increase in treatment time.

Raised Fibrinogen Levels and Outcome in Outpatients With Peripheral Artery Disease.

The influence of raised fibrinogen levels on outcome in stable outpatients with peripheral arterial disease (PAD) has not been consistently investigated. We used data from the Factores de Riesgo y ENfermedad Arterial (FRENA) registry to compare ischemic events, major bleeding, and mortality in stable outpatients with PAD, according to their baseline plasma fibrinogen levels. Of 1363 outpatients with PAD recruited in FRENA, 558 (41%) had fibrinogen levels >450 mg/100 mL. Over 18 months, 43 patients presented with acute myocardial infarction, 37 had an ischemic stroke, 51 underwent limb amputation, 19 had major bleeding, and 90 died. Compared to patients with normal levels, those with raised fibrinogen levels had an over 2-fold higher rate of ischemic stroke (rate ratio [RR]: 2.30; 95% confidence interval [CI]: 1.19-4.59), limb amputation (RR: 2.58; 95% CI: 1.46-4.67), or death (RR: 2.27; 95% CI: 1.49-3.51) and an over 3-fold higher rate of major bleeding (RR: 3.90; 95% CI: 1.45-12.1). On multivariate analysis, patients with raised fibrinogen levels had an increased risk of developing subsequent ischemic events (hazard ratio [HR]: 1.61; 95% CI: 1.11-2.32) and major bleeding (HR: 3.42; 95% CI: 1.22-9.61). Stable outpatients with PAD and raised plasma fibrinogen levels had increased rates of subsequent ischemic events and major bleeding.

[CLINICAL CASES-TREATED WITH TECHNOLOGY LIPID COLLOIDAL (TLC)]. / Casos clinicos tratados con La tecnologia lipido coloidal (TLC).

INTRODUCTION: This study presents clinical cases collecting etiologies that are more frequent in the field of complex wounds. All require a specific approach, as well as the interdisciplinary participation of different members of the team. But in general, established local cure plans may be quite similar. Applies them technology lipid colloidal (TLC) which consists of the combination of particles of hydrocolloid (carboxymethylcellulose) with lipid components. Products with a technology designed for every moment of healing. OBJECTIVE: Show our experience in the use of products with TLC in patients with ulcers of different etiologies. METHOD: The following products depending on the case have been used to treat: UrgoTul Absorb Border, Urgoclean (rope or plate), UrgoStart, UrgoK2 and UrgoK2 LITE. These products were applied in patients presenting four different etiologies of ulcer: hypertensive, traumatic, venous and ischemic ulcer. The use of Urgoclean rope favored cleaning the bed ulceral and applied Urgoclean plate with reinforced alginate to control the abundant exudates, with coverage of UrgoTul ABsorb Border. Once clean beds pass UrgoStart and at all times UrgoK2 bandage, cases that required compressive therapy. Intolerance to that kind of compression applied to patients presenting bandage UrgoK2 LITE (which tolerated without problem) which significantly reduced edema, favoring the control of exudate. Patients with ulcer of long evolution, at the start were reluctant to the application of new technologies, but after the first cures and sensing a good evolution, we get their confidence and commitment to the resolution. RESULTS: Are displayed clinical cases of different etiologic and personal contexts that an integral and interdisciplinary approach together with the application of products with TLC, managed to solve the problem. CONCLUSION: The materials used have been satisfactory in all cases, with a direct involvement in the resolution of lesions which carries a long unresolved, and in any of them, even with a diagnosis of poor prognosis. In the clinical practice of the wound care knowledge and research of new materials that improve the quality of life of patients, reducing the time evolution of the lesions is very important. Not to mention that education for the prevention of their health should be one of the objectives to prevent recurrences.

Casos clínicos tratados con la tecnología lípido coloidal (TLC) / Clinical cases treated with tecjnology lipid colloidal (TLC)

Introducción. En este estudio se exponen casos clínicos que recogen las etiologías más frecuentes en el campo de las heridas complejas. Todas requieren un abordaje específico, además de la participación interdisciplinar de diferentes miembros del equipo. Sin embargo, en general, los planes de cura locales establecidos pueden ser bastante similares. Se les aplica la tecnología lípido coloidal (TLC) que consiste en la combinación de partículas de hidrocoloide (carboximetilcelulosa) con componentes lipídicos. Son productos con una tecnología diseñada para cada momento de la cicatrización. Objetivo. Dar a conocer nuestra experiencia en la utilización de productos con TLC en pacientes con úlceras de diferentes etiologías. Método. Se han utilizado los siguientes productos dependiendo del caso que tratar: UrgoTul® Absorb Border, Urgoclean® (mecha o placa), UrgoStart®, UrgoK2® y UrgoK2 LITE®. Estos productos se aplicaron en pacientes que presentaban cuatro etiologías de úlcera diferentes: úlcera hipertensiva, traumática, venosa e isquémica (arterial). La utilización de Urgoclean® mecha favoreció la limpieza del lecho ulceral y se aplicó Urgoclean® placa con alginato reforzado para controlar los exudados abundantes, con cobertura de UrgoTul® Absorb Border. Una vez limpios los lechos, pasamos a UrgoStart® y usamos en todo momento vendaje UrgoK2®, en los casos que precisaban terapia compresiva. A los pacientes que presentaban intolerancia a ese tipo de compresión se les aplicó el vendaje UrgoK2 LITE® (que toleraron sin problema), lo que redujo notablemente el edema y favoreció el control del exudado. Los pacientes con heridas de larga evolución se mostraron al inicio reticentes a la aplicación de nuevas tecnologías, pero, trascurridas las primeras curas, y al percibir una buena evolución, confiaron y se adhirieron al tratamiento hasta la resolución. Resultados. Se muestran casos clínicos de diferentes contextos etiológicos y personales, de los que, con un abordaje integral e interdisciplinar, junto con la aplicación de productos con TLC, se consiguió resolver la problemática. Conclusión. Los materiales utilizados han sido satisfactorios en todos los casos, con una implicación directa en la resolución de las lesiones que conllevaban un largo tiempo sin resolver y, en alguno de ellos, incluso con un diagnóstico de mal pronóstico. En la práctica clínica del cuidado de las heridas es muy importante el conocimiento y la investigación de nuevos materiales que mejoren la calidad de vida de los pacientes y reduzcan el tiempo de evolución de las lesiones. Sin olvidar que la educación para la prevención de su salud debe ser uno de los objetivos para evitar las recidivas (AU)

Introduction. This study presents clinical cases collecting etiologies that are more frequent in the field of complex wounds. All require a specific approach, as well as the interdisciplinary participation of different members of the team. But in general, established local cure plans may be quite similar. Applies them technology lipid colloidal (TLC) which consists of the combination of particles of hydrocolloid (carboxymethylcellulose) with lipid components. Products with a technology designed for every moment of healing. Objective. Show our experience in the use of products with TLC in patients with ulcers of different etiologies. Method. The following products depending on the case have been used to treat: UrgoTul® Absorb Border, Urgoclean® (rope or plate), UrgoStart®, UrgoK2® and UrgoK2 LITE®. These products were applied in patients presenting four different etiologies of ulcer: hypertensive, traumatic, venous and ischemic ulcer. The use of Urgoclean® rope favored cleaning the bed ulceral and applied Urgoclean® plate with reinforced alginate to control the abundant exudates, with coverage of UrgoTul ABsorb Border®. Once clean beds pass UrgoStart® and at all times UrgoK2® bandage, cases that required compressive therapy. Intolerance to that kind of compression applied to patients presenting bandage UrgoK2 LITE® (which tolerated without problem) which significantly reduced edema, favoring the control of exudate. Patients with ulcer of long evolution, at the start were reluctant to the application of new technologies, but after the first cures and sensing a good evolution, we get their confidence and commitment to the resolution. Results. Are displayed clinical cases of different etiologic and personal contexts that an integral and interdisciplinary approach together with the application of products with TLC, managed to solve the problem. Conclusion. The materials used have been satisfactory in all cases, with a direct involvement in the resolution of lesions which carries a long unresolved, and in any of them, even with a diagnosis of poor prognosis. In the clinical practice of the wound care knowledge and research of new materials that improve the quality of life of patients, reducing the time evolution of the lesions is very important. Not to mention that education for the prevention of their health should be one of the objectives to prevent recurrences (AU)