¿Qué experiencias internacionales se han desarrollado en la implementación de servicios/hospitales de alta complejidad en neurología/neurocirugía y cuáles son sus características? / What international experiences have been developed in the implementation of highly complex services / hospitals in neurology / neurosurgery and what are their characteristics?

INTRODUCCIÓN: El Instituto de Neurocirugía Alfonso Asenjo (INCA) de Chile es un hospital de referencia a nivel nacional de alta complejidad para pacientes adultos y pediátricos, creado en el año 1942(1). Es un Establecimientos Autogestionado en Red, es decir, que está integrado a la red asistencial, entrega atención de alta complejidad técnica, desarrollo de especialidades, tiene atribuciones para organizarse internamente, administrar sus recursos y cuenta con un alto número de prestaciones(2). El actual Instituto se encuentra en un edificio de construcción del año 1953 por lo que a lo largo de estos años ha tenido cierto deterioro en su materialidad, en relaciones funcionales y necesidades clínicas. En la cuenta pública del 2019, el INCA menciona que es imprescindible su reposición ya que no es posible mejorar las actuales condiciones y pensar en un proyecto a futuro en el actual edificio. Para ello se está trabajando en un proyecto de pre-inversión hospitalario para el nuevo INCA y se espera para principios del año 2021 tener la aprobación para pasar a la etapa de anteproyecto(3). En este contexto la División de Gestión de Redes Asistencial (DIGERA) del Ministerio de Salud ha solicitado información en torno a las experiencias de implementación de servicios u hospitales de alta complejidad en neurocirugía reportadas a nivel internacional con el fin de tener información actualizada de los modelos de atención y gestión de centros de este tipo. RESUMEN DE HALLAZGOS: Siguiendo con la metodología de síntesis rápidas de evidencia se hizo una búsqueda de Revisiones Sistemáticas (RS), al no encontrarse ninguna que respondiera a la pregunta de investigación se realizó una búsqueda de estudios primarios (EP). Se incluyeron todo tipo de publicaciones: artículos de investigación, experiencias, cartas al editor u otro medio de comunicación que describiera la forma de organización, experiencias de trabajo o implementación de servicios u hospitales de alta complejidad, en neurocirugía u otra especialidad neurológica. Se incluyeron todo tipo de experiencias, independiente de la población de atención del centro o del tipo de financiamiento. No se utilizaron filtros por idioma, país o fecha de publicación. De acuerdo a las necesidades del solicitante, se excluyeron publicaciones que tuvieran como objetivo describir las características de pacientes hospitalizados o ambulatorios; publicaciones que describieran o propusieran una intervención sin haberla implementado; publicaciones que tuvieran como objetivo describir o justificar la incorporación de nuevas tecnologías a sus centros; y publicaciones que se desarrollaran en un contexto de atención primaria en salud. Al realizar la búsqueda, los títulos y resúmenes fueron seleccionados por dos revisoras independientes, discutiendo cada uno de los disensos encontrados. Se encontraron inicialmente 173 EP. De éstos, se excluyeron 133 por disenso o duplicados. Luego de la revisión a texto completo de 40 EP, se excluyeron 20 por no cumplir con los criterios de inclusión descritos anteriormente. De esta forma, se utilizaron 20 estudios primarios(4,5,14­23,6­13) publicados entre 2012 y 2020. Los estudios incluidos corresponden a siete de diseño de cohorte(7,10­12,15,22,23), un estudio ecológico(8), una descripción sobre la historia de un centro(21), dos estudiostransversales(4,20), cuatro estudios cuasi experimentales antes-después (13,14,17,19), dos cartas al editor(16,18), una serie de casos(5), un ensayo controlado no aleatorizado(6) y un estudio cualicuantitativo: análisis de contenido inductivo y comparación antes-después de la intervención(9). CONSIDERACIONES DE IMPLEMENTACIÓN: Consideraciones de Aplicabilidad: La evidencia aquí contemplada proviene de documentos publicados en distintos países en 4 continentes, con los que se pudieran identificar similitudes con Chile. Por ejemplo, el tema de respuesta ante la pandemia de COVID-19 al cual tuvieron que adaptarse los hospitales a nivel mundial o el tipo de ingreso per cápita al que pertenece cada país, ya que algunos países como Canadá, EEUU, Alemania y España que, al igual que Chile, pertenecen a la OCDE y son catalogados de ingresos altos, sin embargo, esto no es un indicativo de una asignación de recursos adecuada para un buen funcionamiento hospitalario. Por otro lado, los estudios no informan respecto del tipo de financiamiento que posee cada institución mencionada. Tampoco se menciona el tipo de población cubierta, el porcentaje, ni el tipo de sistemas de salud en los que están insertos los servicios/hospitales mencionados. Dicho lo anterior, se recomienda un análisis profundo y cauteloso de los datos o características de interés para evaluar su posible aplicabilidad al contexto chileno. Por otro lado,cabe destacar que en este resumen incluyó documentos de distintos tipos de publicaciones (cartas al editor, artículos científicos, documentos narrativos), sin asignar un valor ni la graduación de la calidad a estos resultados. Consideraciones Económicas: Solamente un documento hizo referencia a los costos de los procedimientos neuroquirúrgicos de un hospital de alto volumen vs uno de bajo volumen, concluyendo que los hospitales de alto volumen son más rentables(8). No se mencionan costos directos o indirectos del resto de los procesos o intervenciones mencionados. Consideraciones de Equidad: Si bien no se pueden realizar comparaciones entre los hospitales, se puede mencionar que la los estudios muestran una diversidad en las estructuras hospitalarias y recursos tanto económicos, estructurales y de RRHH, por ejemplo, ante la misma pandemia COVID-19 el Departamento de Neurocirugía de la Universidad del Sur de Florida, pudo implementar un protocolo específico, que incluye entre otras cosas, dividir el personal en 3 equipos para que cada equipo trabaje 1 semana y cumpla 2 semanas de cuarentena, y otorgar equipamiento de protección personal adecuado, mientras que el Hospital Mayo en Lahoreno (Pakistán) no contaba con un protocolo, las medidas de protección eran básicas (mascarilla, toma de temperatura) y reasignó el personal de neurología a la atención de urgencias(18). Otro ejemplo sería el Centro Médico Hadassah (Israel), que cuenta con un grupo de enfermeras que dan atención personalizada y de acompañamiento a los pacientes(20) mientras el Centro Médico Bugando (Tanzania)(5) se encuentra en estado de precariedad y no cuenta con RRHH suficientes para dar atención de pacientes, estos cuatro ejemplos son todos hospitales de tercer nivel y de referencia en sus países. Consideraciones de Monitoreo y Evaluación: No se encontraron revisiones sistemáticas que respondan esta pregunta de investigación y los estudios primarios encontrados presentan información poco especifica. Sin embargo, estos resultados pueden ayudar a identificar un hospital, país o sistema de referencia sobre la cual se desee seguir profundizando. Además, es necesario monitorear la publicación de nueva evidencia que evalúe de manera más específica intervenciones o características requeridas para la implementación del nuevo INCA y la población hará uso de este hospital.

Training of Tunisian future urologists: how to improve it ?

BACKGROUND: The lack of continuous evaluation of training tools in medicine, especially in developing countries, represents a brake to the development of the latter. AIM: To establish an inventory of the training facilities available to residents in urology in Tunisia, to assess their satisfaction and their expectations, and to propose solutions to improve residents training. METHODS: An anonymous questionnaire was sent by E-mail in 2015 to all residents in urology in Tunisia. The questionnaire addressed demographic characteristics, educational resources used and desired, the current medical and university curriculum and evaluation of the training. RESULTS: Among 33 residents, 66.6% responded to the survey. Medical staff, courses organized by the national college of urology, reading french-language articles and daily activity in operating room were the most used pedagogic resources. Training was judged unsatisfactory by 59.1% of respondents because of a lack of theoretical training in 18.1% of cases, a lack of practical training in 13.6% of cases and both of them in 27.2% of cases. Training on animals and simulator, creation of an educational booklet, use of online course materials, and the institution of a mentoring process during residency were rated favorable by the majority of respondents. CONCLUSION: The majority of residents in urology in Tunisia believe their training is unsatisfactory. The E-learning, improved access to surgical training in animals and simulator, better information on existing resources and strengthening of companionship through tutoring should enhance satisfaction.

Hospitals admitting at least 100 patients with stroke a year should have a stroke unit: a case study from Australia.

BACKGROUND: Establishing a stroke unit (SU) in every hospital may be infeasible because of limited resources. In Australia, it is recommended that hospitals that admit ≥100 strokes per year should have a SU. We aimed to describe differences in processes of care and outcomes among hospitals with and without SUs admitting at least 100 patients/year. METHODS: National stroke audit data of 40 consecutive patients per hospital admitted between 1/7/2010-31/12/2010 and organizational survey for annual admissions were used. Descriptive analyses and multilevel regression were used to compare patient outcomes. Sensitivity analysis including only hospitals meeting all of the Australian SU criteria (e.g., co-location of beds; inter-professional team; weekly meetings; regular training) was performed. RESULTS: Two thousand eight hundred ninety-eight patients from 72/108 eligible hospitals completing the audit (SU = 60; patients: 2,481 [mean age 76 years; 55% male] and non-SU patients: 417 [mean age 77; 53% male]). Hospitals with SUs had greater adherence to recommended care processes than non-SU hospitals. Patients treated in a SU hospital had fewer new strokes while in hospital (OR: 0.20; 95% CI 0.06, 0.61) and there was a borderline reduction in the odds of dying in hospital compared to patients in non-SU hospitals (OR 0.57 95%CI 0.33, 1.00). Among SU hospitals meeting all SU criteria (n = 59; 91%) the adjusted odds of having a poor outcome was further reduced compared with patients attending non-SU hospitals. CONCLUSION: Hospitals annually admitting ≥100 patients with acute stroke should be prioritized for establishment of a SU that meet all recommended criteria to ensure better outcomes.

Reinventing the community hospital: a retrospective population-based cohort study of a natural experiment using register data.

OBJECTIVES: To investigate whether implementation of municipal acute bed units (MAUs) resulting from the Norwegian Coordination Reform (2012) was associated with reductions in hospital admissions, particularly for the elderly. DESIGN: A municipality-based retrospective comparative cohort study using monthly population-based registry data analysed with fixed-effects log-log regressions. SETTING: Norwegian municipalities and hospitals. POPULATION: All patients admitted to secondary hospital care in Norway between 2010 and 2014, excluding psychiatric admissions, with additional focus on admission type and elderly age subgroups. MAIN OUTCOME MEASURES: Monthly admission rates in total and by age group for all patients, patients admitted with acute conditions and with acute conditions at internal medicine departments. RESULTS: The introduction of MAUs was associated with a small yet significant overall negative effect on hospital admissions. The reduction in all admissions was significant for the entire population (-1.2%, 95% CI -2.0% to -0.0%) and slightly stronger for those aged 80 years and above (-1.9%, 95% CI -3.0% to -1.0%). The more detailed analysis of the elderly population aged 80 years and above revealed that effects were affected by the institutional characteristics of the MAUs. The significant effects ranged between -1.6% and -8.6%, depending on the availability of physicians on duty at the MAUs, the MAUs location or combinations thereof. CONCLUSIONS: Introduction of MAUs following implementation of the Norwegian Coordination Reform in 2012 was associated with a significant reduction in hospital admissions primarily for the elderly. Our findings suggest that this type of intermediate care is a viable option in an effort to alleviate the burden on hospitals by reducing the acute secondary care admission volume. Further examinations focused on cost-effectiveness, health status of patients, number of patients treated at the MAUs and comparing other intermediate care alternatives would all add important perspectives to the issue.

Epilepsy services in Saudi Arabia. Quantitative assessment and identification of challenges.

OBJECTIVE: To assess the epilepsy services and identify the challenges in hospitals without epilepsy monitoring units (EMUs). In addition, comparisons between governmental and private sectors, as well as between regions, are to be performed. METHODS: A cross sectional study conducted using an online questionnaire distributed to the secondary and tertiary hospitals without EMUs throughout the Kingdom of Saudi Arabia (KSA). The study was conducted from September 2013 to September 2015 and regular updates from all respondents were constantly made. Items in the questionnaire included the region of the institution, the number of pediatric and adult neurologists and neurosurgeons along with their subspecialties, the number of beds in the Neurology Department, whether they provide educational services and have epilepsy clinics and if they refer patients to an EMU or intend to establish one in the future. RESULTS: Forty-three institutions throughout the Kingdom responded, representing a response rate of 54%. The majority of hospitals (58.1%) had no adult epileptologists. A complete lack of pediatric epileptologists was observed in 72.1% of hospitals. Around 39.5% were utilizing beds from internal medicine. Hospitals with an epilepsy clinic represented 34.9% across all regions and sectors. Hospitals with no intention of establishing an EMU represented 53.5%. Hospitals that did not refer their epileptic patients to an EMU represented 30.2%. CONCLUSION: Epilepsy services in KSA hospitals without EMUs are underdeveloped.

Health workforce and hospital network in the 9th health region of Paraná / Força de trabalho em saúde e rede hospitalar na 9ª região de saúde do paraná / Fuerza de trabajo en salud y red hospitalariaen la 9ª región de salud de paraná

RESUMO A rede hospitalar e a força de trabalho em saúde se distribuem de maneira desigual no territorio nacional, refletindo o modelo de atenção hegemônico e a organização a partir da oferta de serviços. O estudo teve por objetivo analisar a rede hospitalar e a composição e distribuição da força de trabalho em saúde dos hospitais da 9ª Região de Saúde do Paraná. Pesquisa descritiva, quantitativa que teve como fonte de dados o Cadastro Nacional de Estabelecimentos de Saúde. A estatística descritiva revelou que 84,62% dos hospitais são privados; 61,54% de pequeno porte; existem 2.307 ocupações cadastradas e destas 57,91% são de nível superior; 69,27% dos vínculos de trabalho são precários e 23,50% dos trabalhadores apresentavam mais que um vínculo empregatício. Identificou-se, ainda, menor jornada de trabalho semanal e maior precarização entre as ocupações de nível superior. Conclui-se pela necessidade de maior participação do Estado na regulação das instituições públicas e privadas, sobretudo na gestão do trabalho, e no planejamento da distribuição da força de trabalho em saúde.

RESUMEN La red hospitalaria y la fuerza del trabajo en salud se distribuyen de forma desigual en el país, lo que refleja el modelo de atención hegemónico y la organización a partir de la oferta de servicios. El objetivo del estudio fue analizar la red hospitalaria y la composición y distribución de la fuerza de trabajo en salud de los hospitales de la 9ªRegión de Salud de Paraná-Brasil. Investigación descriptiva, cuantitativa que tuvo como fuente de datos el Registro Nacional de Establecimientos de Salud. La estadística descriptiva mostró que 84,62% de los hospitales son privados; 61.54% pequeño porte; hay 2.307 ocupaciones registradas y de estas 57,91% son de nivel superior; 69.27% de los vínculos laborales son precarios y 23,50% de los trabajadores tenían más de un empleo. También fueron identificadas menos horas de trabajo semanal y más relaciones precarias entre las ocupaciones de nivel superior. Los resultados confirmaron la necesidad de una mayor participación del Estado en la regulación de las instituciones públicas y privadas, sobre todo en la gestión del trabajo, y la planificación de la distribución de la fuerza de trabajo en salud.

ABSTRACT The hospital network and health workforce are distributed unevenly in the country, reflecting the hegemonic model of attention and organization as from the services offer. The study aimed to analyze the hospital network and its composition and distribution of health workforce of the 9th Health Region hospitals of Paraná. Descriptive, quantitative research had as data source the National Register of Health Facilities. The statistics showed that 84.62% of hospitals are private; 61.54% are small; there are 2,307 registered occupations and, of these, 57.91% are educated level; 69.27% of the working relations are precarious and out of them, 23.50% of workers had more than one job. It was also identified shorter week working hours and higher precariousness among the educated level occupations. The results confirmed the need for greater participation of the state in the regulation of public and private institutions, particularly in work management, and planning the distribution of the health workforce.

[How to convince the head of department and managing director of the importance of specialised headache clinics]. / Como convencer al jefe de servicio y al gerente de la importancia de las unidades/consultas especializadas de cefaleas.

In spite that headache is, by far, the most frequent reason for neurological consultation and that the diagnosis and treatment of some patients with headache is difficult, the number of headache clinics is scarce in our country. In this paper the main arguments which should allow us, as neurologists, to defend the necessity of implementing headache clinics are reviewed. To get this aim we should first overcome our internal reluctances, which still make headache as scarcely appreciated within our specialty. The facts that more than a quarter of consultations to our Neurology Services are due to headache, that there are more than 200 different headaches, some of them actually invalidating, and the new therapeutic options for chronic patients, such as OnabotulinumtoxinA or neuromodulation techniques, oblige us to introduce specialised headache attendance in our current neurological offer. Even though there are no definite data, available results indicate that headache clinics are efficient in patients with chronic headaches, not only in terms of health benefit but also from an economical point of view.

TITLE: Como convencer al jefe de servicio y al gerente de la importancia de las unidades/consultas especializadas de cefaleas.A pesar de que la cefalea es, con diferencia, el principal motivo neurologico de consulta, y de la complejidad diagnostica y terapeutica de algunos pacientes, el numero de consultas monograficas de cefalea (CC) y de unidades de cefalea (UC) es muy reducido en nuestro pais. En este articulo pasaremos revista a los principales argumentos que nos permitan, como neurologos, defender la necesidad de la implementacion de una CC/UC, dependiendo de la poblacion que se debe atender, en todos nuestros servicios de neurologia. Para ello deberemos, en primer lugar, vencer las reticencias internas, que hacen que la cefalea sea aun poco apreciada y atractiva dentro de nuestra especialidad. El hecho de que la cefalea justifique mas de un cuarto de las consultas a un servicio de neurologia estandar de nuestro pais y de que existan mas de 200 cefaleas diferentes, algunas de ellas realmente invalidantes, y las nuevas opciones de tratamiento para pacientes cronicos, como la OnabotulinumtoxinA para la migraña cronica o las tecnicas de neuromodulacion, obligan a introducir dentro de nuestras carteras de servicios la asistencia especializada en cefaleas. Aunque no disponemos de datos incontrovertibles, existen ya datos suficientes en la literatura que indican que esta atencion es eficiente en pacientes con cefaleas cronicas no solo en terminos de salud, sino tambien desde el punto de vista economico.

[Positioning of headache units in the field of neurology: the importance of OnabotulinumtoxinA and other therapies in the treatment of headaches]. / Posicionamiento de las unidades de cefalea en el ambito de la neurologia: la importancia de la OnabotulinumtoxinA y otras terapias en el tratamiento de la cefalea.

Chronic migraine is a disease that affects 0.5-2.5% of the population, depending on the statistics that are analysed and the definition of chronic migraine that is used. It is extraordinarily disabling, since it does not allow the sufferer to carry out any of their scheduled personal, professional or social activities, and it has a great impact on the patients' quality of life, as measured on disability, quality of life and impact on daily activities scales. Yet, nowadays there are treatments that have proven to be effective in cases of chronic migraine, such as OnabotulinumtoxinA. It is a treatment that is well tolerated and with a high rate of efficacy. Yet it is not only a therapeutic tool, but in the world of headaches it has also opened up the doors to invasive treatments, to the learning of techniques and, in short, to placing headaches in referral units that are usually located in tertiary care hospitals. Furthermore, it has also helped to overcome the idea that patients with headache should be visited exclusively by primary care physicians or general neurologists. This is an opportunity to redefine the field of study and the care for headaches that must be seized. In the future, this is going to be complemented by novel treatments with neurostimulation and probably with monoclonal antibodies against the calcitonin gene-related peptide. A revolution has begun in our knowledge and capacity to act. It is our duty to give it the importance and usage it deserves both for our patients and for us as specialists.

TITLE: Posicionamiento de las unidades de cefalea en el ambito de la neurologia: la importancia de la OnabotulinumtoxinA y otras terapias en el tratamiento de la cefalea.La migraña cronica es una enfermedad que afecta al 0,5-2,5% de la poblacion segun las estadisticas que se analicen y la definicion de migraña cronica que se adopte. Es extraordinariamente incapacitante, ya que no permite realizar las actividades personales, profesionales o sociales programadas, y tiene un gran impacto sobre la calidad de vida de los pacientes, medido en escalas de discapacidad, calidad de vida e impacto en la actividad diaria. Sin embargo, actualmente se dispone de tratamientos que han demostrado eficacia en la migraña cronica, como la OnabotulinumtoxinA. Es un tratamiento bien tolerado y con una tasa de eficacia elevada. Pero no es solo una herramienta terapeutica, sino que ha abierto las puertas en el mundo de la cefalea a la realizacion de tratamientos invasivos, al aprendizaje de tecnicas y, en definitiva, a situar la cefalea en unidades de referencia ubicadas, habitualmente, en hospitales de tercer nivel. Ademas, ha ayudado a eliminar el concepto de que los pacientes con cefalea deben ser atendidos exclusivamente por medicos de atencion primaria o neurologos generales. Esta es una oportunidad que debe aprovecharse para redimensionar el campo del estudio y asistencia de la cefalea. En el futuro, esto va a complementarse con novedosos tratamientos con neuroestimulacion y, probablemente, con anticuerpos monoclonales contra el peptido relacionado con el gen de la calcitonina. Se ha iniciado una revolucion en nuestro conocimiento y capacidad de actuacion. Es nuestro deber darle la importancia y uso que se merecen tanto para nuestros pacientes como para nosotros como especialistas.

[Organisation of headache units from a multidisciplinary point of view]. / Organizacion de las unidades de cefalea desde un punto de vista multidisciplinar.

Headache units have come into being to respond to the need to address the treatment of patients with complex headaches in a multidisciplinary manner. Although headaches are one of the most prevalent medical pathologies, it is surprising how little is being done to foster the development of such units. Within the multidisciplinary organisation, the role of the neurologist with adequate training in this field is essential. He or she is the person responsible for receiving, directing, supervising and coordinating the treatment, together with other medical specialties. The basic core of the team should consist of a psychiatrist, psychologist and physiotherapist. Their joint coordinated action generates an objective improvement in the pain over and beyond that achieved with each isolated treatment.

TITLE: Organizacion de las unidades de cefalea desde un punto de vista multidisciplinar.Las unidades de cefaleas surgen ante la necesidad de abordar de forma multidisciplinar el tratamiento de pacientes con dolores de cabeza complejos. A pesar de que las cefaleas son una de las patologias medicas mas prevalentes, es llamativa la poca promocion que existe para su desarrollo. Dentro de la organizacion multidisciplinar, el papel del neurologo debidamente formado en este campo es crucial. Es la persona encargada de recibir, dirigir, supervisar y coordinar el tratamiento, junto con otras especialidades medicas. Se debe contar con la participacion del psiquiatra, del psicologo y del fisioterapeuta como nucleo basico. Su actuacion conjunta y coordinada genera de forma objetiva una mejoria del dolor frente a cada tratamiento de forma aislada.

[Creation and enhancement of headache units: the view of neurologists and heads of neurology departments]. / Creacion y potenciacion de las unidades de cefalea: vision de los neurologos y jefes de servicio de neurologia.

Headache is the most common reason for visiting in neurology. Almost a third of all patients surveyed in this specialty visit for this reason. The gradual increase in the complexity of the care afforded to patients with headaches requires neurologists to become more specialised and leads to the creation of specialised units where this more complex care can be implemented. The heads of the neurology department are responsible for structuring and coordinating the different care units. This article shows the findings of a survey carried out on a group of heads of neurology departments in order to determine the current state of headache units, that is, their opinion regarding the creation, functioning and development of headache units in Spanish hospitals, and the parameters of their efficacy and effectiveness.

TITLE: Creacion y potenciacion de las unidades de cefalea: vision de los neurologos y jefes de servicio de neurologia.La cefalea constituye el motivo de consulta mas frecuente en neurologia. Casi la tercera parte de pacientes consultados en esta especialidad lo hace por este motivo. El gradual incremento en la complejidad de asistencia a pacientes con cefalea hace necesaria una mayor especializacion por parte de los neurologos y propicia la creacion de unidades especializadas donde desarrollar esta actividad asistencial mas compleja. La estructuracion y coordinacion de las distintas unidades asistenciales corresponde a los jefes de servicio de neurologia. En este articulo se recogen los resultados de una encuesta realizado a un grupo de jefes de servicio de neurologia para conocer el estado actual de las unidades de cefalea: su opinion sobre la creacion, funcion y desarrollo de unidades de cefalea en los hospitales españoles, y los parametros de eficacia y eficiencia de estas.

Survey on the state of otoneurology in Spain.

Otoneurology is a subspecialty of otolaryngology-neurology, which has experienced extraordinary progress in the last 50 years and is currently fully consolidated in our environment. Through this study, prepared by the Otoneurology Commission of the Spanish Society of Otorhinolaryngology (SEORL), we have attempted to design an approach to provide information on what the current situation regarding the exercise in Spain is, trying to determine who practice it and where, what resources are available and what the teaching and scientific productions are. The results obtained are generally satisfactory and reflect the strength of the exercise of otoneurology. The number of centres with otoneurology units is significant and the majority of centres that lack such a unity consider it necessary. However, there are aspects to establish related to minimum requirements for its performance in satisfactory conditions, as well as determining future guidelines to ensure improved teaching and increased scientific production.

Lost in hospital: a qualitative interview study that explores the perceptions of NHS inpatients who spent time on clinically inappropriate hospital wards.

BACKGROUND: Prior research suggests that the placement of patients on clinically inappropriate hospital wards may increase the risk of experiencing patient safety issues. OBJECTIVE: To explore patients' perspectives of the quality and safety of the care received during their inpatient stay on a clinically inappropriate hospital ward. DESIGN: Qualitative study using semi-structured interviews. PARTICIPANTS AND SETTING: Nineteen patients who had spent time on at least one clinically inappropriate ward during their hospital stay at a large NHS teaching hospital in England. RESULTS: Patients would prefer to be treated on the correct specialty ward, but it is generally accepted that this may not be possible. When patients are placed on inappropriate wards, they may lack a sense of belonging. Participants commented on potential failings in communication, medical staff availability, nurses' knowledge and the resources available, each of which may contribute to unsafe care. CONCLUSIONS: Patients generally acknowledge the need for placement on inappropriate wards due to demand for inpatient beds, but may report dissatisfaction in terms of preference and belonging. Importantly, patients recount issues resulting from this placement that may compromise their safety. Hospital managers should be encouraged to appreciate this insight and potential threat to safe practice and where possible avoid inappropriate ward transfers and admissions. Where such admissions are unavoidable, staff should take action to address the gaps in safety of care that have been identified.

Where we come from and where we are going in terms of peritoneal dialysis: identifying barriers and strategies for the future.

Despite the 40 years history, the comparable survival of Hemodialysis and Peritoneal Dialysis (PD), and the improved PD technique survival, the percentage of patients performing PD is low. After a short history review and data description, we analyze the many non-medical factors (“the vicious circle”) that contribute to the underutilization of PD: inadequate medical training, lack of infrastructures, small PD units, inadequate patient education for choice of dialysis modality, lack of multidisciplinary end-stage renal disease units, the proliferation of hemodialysis centers, or the trends in government reimbursement. Several of these factors are modifiable, and we propose future strategies to increase the use of PD.

Stroke rehabilitation services in New Zealand: a survey of service configuration, capacity and guideline adherence.

AIM: To provide an up-to-date account of stroke rehabilitation services in all District Health Boards (DHB) in New Zealand in 2013. METHOD: An online survey was completed by clinicians at all 38 facilities in New Zealand providing rehabilitation services following acute stroke. RESULTS: There was some evidence of stroke rehabilitation specialisation, particularly in larger DHBs (seven of eight large DHBs provided a dedicated stroke rehabilitation unit or designated beds). Capacity was generally satisfactory with units accommodating all (68% of units) or most (further 29%) of stroke patients needing rehabilitation. Most units had guidelines for the management of common problems following stroke, apart from depression screening (7%), but intensity of therapy input remains below recommended levels. Post-discharge rehabilitation services are available in the majority of areas but significant delays (mean 14 days) are common in accessing these services. The results for New Zealand stroke rehabilitation services are broadly comparable with those from the recent Australian stroke rehabilitation service audit. CONCLUSION: Compared to previous surveys, New Zealand stroke rehabilitation services have shown progress. To maximise outcomes for stroke patients, improvements are still needed in provision of dedicated stroke rehabilitation units, rehabilitation intensity and access to prompt community rehabilitation in the community.

Hospital care services for digestive diseases in Italy: the first quantitative assessment.

The scarcity of human and structural resources for specialized gastroenterology care is a problem in many Western countries. Data regarding the resources for Italian Gastroenterology, so far lacking, have been thus searched and evaluated. Based on an agreement protocol between the Italian Association of Hospital Gastroenterologists and Endoscopists (AIGO) and the Ministry of Health, national data regarding all Institutions providing gastroenterological care were analysed. Hospital beds in Gastroenterology units are presented by region, regimen of stay and per million inhabitants as of January 2011. Association of Hospital Gastroenterologists and Endoscopists also performed a survey of gastroenterology units in all Italian regions regarding number of ordinary/day hospital beds and the number of staff gastroenterologists. The Ministry data showed a total of 174 Gastronterology Units in Italy, a total of 2062 hospital beds for the discipline, for a proportion of 34.2 beds per million inhabitants. The Association of Hospital Gastroenterologists and Endoscopists survey showed a total of 1425 gastroenterologists in Italy. These data should represent a key reference for appropriate planning of specialized care for digestive diseases.

Diabetic foot units in Spain: knowing the facts using a questionnaire.

OBJECTIVE: To ascertain the number of diabetic foot units (DFUs) in Spain, the specialists working in them, and the population covered by them. MATERIAL AND METHODS: The Spanish Group on the Diabetic Foot (SGDF) prepared and agreed a questionnaire based on the recommendations of the 2011 International Consensus on the Diabetic Foot (ICDF). From October to December 2012, the questionnaire was sent to members of three scientific societies formed by professionals involved in the care of patients with diabetes mellitus. Population coverage of the responding centers and DFUs was estimated using the 2012 population census. RESULTS: Seventy five questionnaires were received, 64 of them from general hospitals, which accounted for 13% of the general hospitals of the National Health System. It was calculated that they provided coverage to 43% of the population. Thirty four centers answered that they had a DFU. Specialized diabetic foot care was only provided to 25% of the population. The number of different professionals working at diabetic foot units was 6.3±2.7. Classification of DFUs based on their complexity was as follows: 5 basic units (14.7%), 20 intermediate units (58.8%), and 9 excellence units (26.5%). CONCLUSIONS: The number of DFUs reported in this study in Spain is low, and allow for foot care of only one out of every four patients with diabetes. Spanish health system needs to improve diabetic foot care by creating new DFUs and improving the existing ones.

Stroke units and stroke care services in Korea.

Organized stroke care systems improve stroke outcomes, but require resources and quality-improvement programs. This study was aimed at understanding the current status of stroke care services and stroke units in Korea. An on-line survey to investigate stroke services was conducted using a structured questionnaire for physicians who were in charge of stroke services or neurology departments of Korean hospitals that had neurology resident training programs. Of the 86 neurology training hospitals in Korea, 67 (78·0%) participated in this study. Brain computed tomography and computed tomography angiography were available 24 h a day and seven days a week (24/7) in all hospitals. More than 95% of hospitals offered transcranial Doppler, carotid duplex sonography, echocardiography, and conventional catheter angiography. Intravenous thrombolysis and hemicraniectomy for ischemic brain edema were provided 24/7 in all hospitals, and 50 hospitals (74·6%) were capable of intra-arterial thrombolysis. Stent or angioplasty was more frequently performed than endarterectomy. Performance measures were monitored in 57 hospitals (85·1%). Twenty-nine (43·3%) hospitals had stroke units. Stroke units were more common as the number of beds in the hospital increased (P = 0·001). When compared with hospitals without stroke units, stroke coordinators, use of general management protocol and education program for stroke team were more frequently available in the hospitals with stroke units. Most neurology training hospitals in Korea offered competent acute stroke care services. However, stroke units have not been widely implemented. Encouragement and support at the government or national stroke society level would promote the implementation of stroke units with little additional effort.

Regional differences in acute stroke admission and thrombolysis rates in the German federal state of Hesse.

BACKGROUND: Using data from the mandatory quality assurance program for stroke care in Hesse, we analyze regional differences in thrombolysis rates and infer some ways in which care can be improved. METHODS: We identified 7707 patients with acute ischemic stroke who were admitted to hospital within 3 hours of symptom onset in 2007 and 2008, and we determined the local thrombolysis rate district by district. In order to exclude the possibility that the observed local differences in thrombolysis rates might be accounted for, in large part, by off-label thrombolysis procedures, we further narrowed down the subgroup of patients who underwent thrombolysis to the 1108 patients admitted within 2 hours of symptom onset. We also analyzed the local thrombolysis rates for patients who were primarily referred to stroke units. RESULTS: The overall thrombolysis rate among patients admitted within 3 hours of symptom onset was 19%, varying locally from 6% to 35%. Among patients admitted within 2 hours of symptom onset, the local thrombolysis rate ranged from 13% to 85%. Even in patients primarily referred to stroke units, the local thrombolysis rate ranged from 8% to 44% in the 3-hour group and from 16% to 62% in the 2-hour group. CONCLUSION: Local thrombolysis rates vary unexpectedly widely across the state of Hesse. The care of patients with acute stroke after they reach the hospital urgently needs critical reappraisal and improvement.

Provision of acute stroke care and associated factors in a multiethnic population: prospective study with the South London Stroke Register.

OBJECTIVES: To investigate time trends in receipt of effective acute stroke care and to determine the factors associated with provision of care. DESIGN: Population based stroke register. SETTING: South London. PARTICIPANTS: 3800 patients with first ever ischaemic stroke or primary intracerebral haemorrhage registered between January 1995 and December 2009. MAIN OUTCOME MEASURES: Acute care interventions, admission to hospital, care on a stroke unit, acute drugs, and inequalities in access to care. RESULTS: Between 2007 and 2009, 5% (33/620) of patients were still not admitted to a hospital after an acute stroke, particularly those with milder strokes, and 21% (124/584) of patients admitted to hospital were not admitted to a stroke unit. Rates of admission to stroke units and brain imaging, between 1995 and 2009, and for thrombolysis, between 2005 and 2009, increased significantly (P<0.001). Black patients compared with white patients had a significantly increased odds of admission to a stroke unit (odds ratio 1.76, 95% confidence interval 1.35 to 2.29, P<0.001) and of receipt of occupational therapy or physiotherapy (1.90, 1.21 to 2.97, P=0.01), independent of age or stroke severity. Patients with motor or swallowing deficits were also more likely to be admitted to a stroke unit (1.52, 1.12 to 2.06, P=0.001 and 1.32, 1.02 to 1.72, P<0.001, respectively). Length of stay in hospital decreased significantly between 1995 and 2009 (P<0.001). The odds of brain imaging were lowest in patients aged 75 or more years (P=0.004) and those of lower socioeconomic status (P<0.001). The likelihood of those with a functional deficit receiving rehabilitation increased significantly over time (P<0.001). Patients aged 75 or more were more likely to receive occupational therapy or physiotherapy (P=0.002). CONCLUSION: Although the receipt of effective acute stroke care improved between 1995 and 2009, inequalities in its provision were significant, and implementation of evidence based care was not optimal.

Utility and sufficiency of psychiatric inpatient units in general hospitals: a cross-sectional study in Tokyo.

In order to investigate the utility and sufficiency of psychiatric beds in general hospitals (GHP beds), a cross-sectional study was performed in general hospitals all over Tokyo. Reasons for admission were acute-phase treatment (43%), medical comorbidity (15%), electroconvulsive therapy (13%), differential diagnosis (12%), and others (17%). The number of patients who could not be admitted to GHP beds despite appropriate reasons for admission was estimated to be greater than that of inpatients without indispensable reasons for admission to GHP beds on the day of the survey. GHP beds played the expected roles, and were in short supply.