Integración de Atención Primaria en los programas de Cirugía Mayor Ambulatoria. Proyecto Kirubide / Integration of primary health care in outpatient surgery programs. Kirubide Project

Introducción: Kirubide busca mejorar la cooperación entre las asistencias hospitalaria y extrahospitalaria en procedimientos de Cirugía Mayor Ambulatoria (CMA), aprovechando herramientas como la historia clínica electrónica única y la consulta no presencial, a fin de proporcionar una asistencia de calidad centrada en las personas. Objetivos: Crear una ruta asistencial de CMA en la que una mayor colaboración con Atención Primaria (AP) en el arranque y continuidad del proceso permita simplificar la actividad preoperatoria y la programación quirúrgica, así como optimizar el seguimiento hasta el final del episodio clínico. Este objetivo se puede evaluar en términos de espera quirúrgica, satisfacción e inadecuaciones. Metodología: Población: pacientes con determinadas patologías susceptibles de CMA (hernia, tumor de partes blandas, quiste sacro). Despliegue progresivo hasta abarcar ocho de las Unidades de Atención Primaria de la Organización Sanitaria Integrada Ezkerraldea-Enkarterri-Cruces. Intervenciones: 1. Promover que Atención Primaria participe en la selección de pacientes, puesta en marcha del circuito preoperatorio, asistencia en el postoperatorio y seguimiento hasta el alta. 2. Coordinar las consultas de Cirugía y Preanestesia en un mismo día, acordando con el paciente la fecha de intervención. Acciones: constituir un grupo de trabajo, efectuar el despliegue progresivo del plan piloto programando sesiones informativas en los centros de salud, implementar la consulta no presencial AP-CMA, coordinar las consultas hospitalarias. Indicadores: demora en lista de espera quirúrgica, tiempo de espera preoperatorio total, satisfacción de pacientes y profesionales, suspensiones y cancelaciones, ingresos no planificados, pacientes incluidos sin indicación. Resultados: Ha participado el cuarenta por ciento de los médicos de AP del área de despliegue y desde septiembre de 2014 a agosto de 2016 han sido remitidos 150 pacientes e intervenidos 114. l promedio de días en lista de espera quirúrgica ha sido de 15,5 y desde la primera consulta con el médico de AP hasta la intervención, 43, con un grado de satisfacción por parte de pacientes y profesionales por encima del 90 %. Se han registrado seis ingresos no planificados (5,3 %) y una cancelación de la cirugía (0,9 %). En tres pacientes (2 %) se llevaron a cabo las pruebas y consultas preoperatorias sin indicación. Entre las dificultades surgidas se destacan: mayor carga de trabajo para AP, dudas en la selección de pacientes y dificultades para la coordinación de las consultas hospitalarias.Conclusiones: Pese a lo limitado en la expansión del programa Kirubide, los resultados en cuanto a tiempos de espera y satisfacción son alentadores, aportando beneficios tanto para el paciente (simplificación del circuito) como para los profesionales (integración) y la organización (aprovechamiento de recursos). Este diseño puede abrir camino a oportunidades de colaboración entre AP y otras especialidades quirúrgicas

Introduction: Kirubide is trying to improve the cooperation between hospital and non-hospital care in Cirugia Mayor Ambulatoria/Major Outpatient Surgery (CMA is the Spanish abbreviation) procedures by using tools such as the unique electronic health record and remote consultations for the purpose of providing quality care focused on patients. Objectives: Create a medical care route in CMA where a greater collaboration with Primary Care (PC) at the beginning and subsequently during the process allows simplifying the pre-operation procedure and the surgery schedule as well as optimising the follow-up process to the end of the clinical event. This objective can be evaluated in terms of the time waited until surgery, satisfaction and shortcomings. Methodology: Population: patients with specific pathologies requiring CMA (hernia, soft tissue tumour, sacral cyst). Progressive deployment until covering eight of the Primary Care Units of the Organización Sanitaria Integrada (Comprehensive Care Organisation) Ezkerraldea-Enkarterri-Cruces. Interventions: 1. Promote that Primary Care participate in the selection of patients, initiating the pre-operation circuit, post-operation care and monitoring until discharge. 2. Coordinate the Surgery and Pre-anaesthesia appointments to occur on the same day and scheduling the surgery date with the patient. Actions: create a Working Group, carry out a progressive deployment of the pilot plan by scheduling informative training sessions at Medical Centres, implement remote consultations PC-CMA, coordinate the hospital appointments. Indicators: delay in the surgery waiting list, total pre-operation waiting time, patient and hospital staff satisfaction, suspensions and cancellations, unscheduled admissions, patients included that have been improperly referred by the primary care doctor. Results: Forty percent of the PC Doctors from the deployment area have participated. Between 2014 September to 2016 August, 150 patients have been referred and 114 have undergone surgery. 15.5 days was the average number of days on the waiting list and 43 days elapsed between the first appointment with the PC Physician and the surgery, with a patient and medical staff degree of satisfaction above 90 %. Six patients (5.3 %) were admitted that were not scheduled and one surgery was cancelled (0.9 %). Three patients (2 %) were subjected to tests and attended pre-operation appointments that had not been properly referred by the primary care doctor. The following difficulties encountered are worth mentioning: increased workload for PC, doubts in the selection of patients and difficulties coordinating hospital appointments.Conclusions: In spite of the limited deployment of the Kirubide programme, the results in terms of waiting times and satisfaction are encouraging, providing benefits for patients (simplifying the circuit), medical professionals (integration) and the organisation (maximising the use of resources). This design can lead the way to collaboration between PC and other surgical specialities

Chronic liver disease and cirrhosis mortality and social deprivation: a spatial analysis in small areas of Madrid region.

OBJECTIVES: To study census-tract distribution of chronic liver disease and cirrhosis mortality in the Madrid Region and its association with socio-economic deprivation. METHODS: Cross-sectional, ecological (3906 census-tract) study, using mortality data for 1996-2003 and a deprivation index drawn up on the basis of 2001 census data. Standardised mortality ratios were calculated taking Spanish rates for 2001 as reference. Smoothed census-tract relative risks were computed using the Besag-York-Mollie model. Relative risks (RRs) of dying and their 95% credibility intervals (95% CIs) were calculated according to quartiles of the deprivation index (with the fourth quartile -Q- of the indicator being the most unfavourable situation). Maps were plotted depicting the distribution of the posterior probability of RR > 1. RESULTS: Census tracts with a high risk of mortality were detected, mostly located in the centre and on the eastern, south-eastern and south-western fringes of the city of Madrid. Mortality increased with deprivation. RRs of mortality according to quartíles of the deprivation index were: Q2 = 1.5 (CI: 1.3-1.6), Q3 = 1.9 (CI:1.7-2.2) and Q4 = 2.5 (CI:2.2-2.8) for men; and Q2 = 1.3 (CI:1.1-1.5), Q3 = 1.5 (CI:1.3-1.7) and Q4 = 1.6 (CI:1.3-1.8) for women. CONCLUSIONS: This small-area study enabled census tracts with excess mortality eligible for a special public health intervention to be identified, and their association with socio-economic deprivation to be confirmed.

Chronic liver disease and cirrhosis mortality and social deprivation: a spatial analysis in small areas of Madrid region / Mortalidad por cirrosis y otras hepatopatías crónicas y privación social: un análisis espacial por áreas pequeñas de la Comunidad de Madrid

Objectives: To study census-tract distribution of chronic liver disease and cirrhosis mortality in the Madrid Region and its association with socio-economic deprivation. Methods: Cross-sectional, ecological (3906 censustract) study, using mortality data for 1996-2003 and a deprivation index drawn up on the basis of 2001 census data. Standardised mortality ratios were calculated taking Spanish rates for 2001 as reference. Smoothed censustract relative risks were computed using the Besag-York-Mollie model. Relative risks (RRs) of dying and their 95% credibility intervals (95% CIs) were calculated according to quartiles of the deprivation index (with the fourth quartile -Q- of the indicator being the most unfavourable situation). Maps were plotted depicting the distribution of the posterior probability of RR > 1. Results: Census tracts with a high risk of mortality were detected, mostly located in the centre and on the eastern, south-eastern and south-western fringes of the city of Madrid. Mortality increased with deprivation. RRs of mortality according to quartíles of the deprivation index were: Q2 = 1.5 (CI: 1.3-1.6), Q3 = 1.9 (CI:1.7-2.2) and Q4 = 2.5 (CI:2.2-2.8) for men; and Q2 = 1.3 (CI:1.1-1.5), Q3 = 1.5 (CI:1.3-1.7) and Q4 = 1.6 (CI:1.3-1.8) forwomen. Conclusions: This small-area study enabled census tracts with excess mortality eligible for a special public health intervention to be identified, and their association with socio-economic deprivation to be confirmed (AU)

Objetivos: Estudiar la distribución por secciones censales de la mortalidad por cirrosis y hepatopatías crónicas de la Comunidad de Madrid y su asociación con la privación socioeconómica. Métodos: Estudio transversal y ecológico (3.906 secciones censales) utilizando los datos del registro de mortalidad de 1996-2003 y un índice de privación construido a partir de los datos del Censo de 2001. Se calcularon razones de mortalidad estandarizadas tomando como referencia las tasas de España del 2001. Los riesgos relativos suavizados de las secciones censales se calcularon siguiendo el modelo Besag-York-Molife. Se han estimado los riesgos relativos (RR) de morir, y su intervalo de credibilidad al 95% (ICI), según los cuartiles del índice de privación (siendo el cuarto cuartil -Q4- del indicador la situación más desfavorable). Se realizaron mapas representando la distribución de la probabilidad posterior de RR > 1. Resultados: Se han detectado secciones censales con alto riesgo de mortalidad localizadas en su mayoría en el centro y la periferia este, sureste y suroeste de la ciudad de Madrid. La mortalidad se incrementa con la privación social: El RR de mortalidad según cuartiles del índice de privación fue: Q2 = 1,5 (CI: 1,3-1,6); Q3 = 1,9 (CI: 1,7-2,2); Q4 = 2,5 (CI: 2,2-2,8), para los hombres; y Q2 = 1,3 (CI: 1,1-1,5); Q3 = 1,5 (CI: 1,3-1,7); Q4 = 1,6 (CI: 1,3-1,8), para las mujeres. Conclusiones: El estudio de áreas pequeñas ha permitido identificar secciones censales con sobremortalidad subsidiarias de una intervención especial de salud pública, así como confirmar su asociación con la privación socioeconómica (AU)

Census tract socioeconomic and physical environment and cardiovascular mortality in the Region of Madrid (Spain).

BACKGROUND: Features of the area might contribute to differences in cardiovascular mortality. The census tract distribution of ischaemic heart disease (IHD) and cerebrovascular disease mortality in the Region of Madrid and its association with deprivation and environmental variables were examined in this study. METHODS: Cross-sectional, ecological study covering 3906 census tracts (median of around 1000 inhabitants), using mortality data (population aged <75 years) for 1996-2003, as well as socioeconomic deprivation and other environmental indicators (subjective perceptions of pollution, background noise, lack of green spaces and delinquency) drawn from the 2001 census. Standardised mortality ratios were calculated. Smoothed census tract relative risks were calculated using the Besag-York-Mollié model. Relative risks (RRs) of dying and their 95% credibility intervals (95% CI) were calculated according to the indicators considered (with the fourth quartile, Q, being the most unfavourable situation). Maps were plotted depicting the distribution of the posterior probability of RR>1. RESULTS: Census tracts with excess mortality were mostly located in the city of Madrid. Mortality increased with deprivation: RRs of IHD and stroke mortality in Q4 with respect to Q1 were 1.42 (95% CI 1.31 to 1.54) and 1.66 (95% CI 1.45 to 1.88) for men, and 1.54 (95% CI 1.33 to 1.79) and 1.52 (95% CI 1.29 to 1.76) for women respectively. Associations with deprivation decreased only slightly when perceived lack of green spaces and delinquency were included in the model. In men, subjective perceptions of areas remained associated with cardiovascular mortality after adjustment for deprivation. CONCLUSION: Deprivation and subjective perceptions of physical environmental characteristics are ecologically associated with cardiovascular disease mortality.

Mastocitosis cutánea de distribución unilateral en un niño / Unilateral cutaneous mastocytosis in a boy

Las mastocitosis son un grupo de trastorno caracterizados por la acumulación de mastocitos en varios órganos, el más frecuentemente afectado es la piel, pero pueden afectarse otros órganos. Hay formas cutáneas y formas sistémicas. Las mastocitosis sistémicas son más frecuentes en adultos y adolescentes. Las mastocitosis cutáneas pueden presentar lesiones cutáneas y síntomas sistémicos consecuencia de la degranulación de mastocitos. Presentamos el caso de un niño con mastocitosis cutánea de comienzo tardío y distribución segmentaria, con ausencia de síntomas sistémicos (AU)

Mastocytosis is a disorder characterized by mast cell proliferation and accumulation within various organs, most commonly the skin, (although is possible to find it in other localizations). There are cutaneous and systemic forms, this one appears more often in adults and adolescent. Cutaneous mastocytosis may present cutaneous lesions and systemic symptoms due to release mast cell-derived mediators. We present a case of a cutaneous mastocytosis with a late beginning and asymmetrical localization without systemic symptoms (AU)

Supervivencia del cáncer de mama invasivo en estadio I según el método diagnóstico / Survival in stage I invasive breast cancer according to diagnostic method

Objetivos: Valoración de la utilidad de los programas de cribado en la disminución de la mortalidad por cáncer de mama en estadio I. Material y métodos: Estudio retrospectivo de 314 mujeres con cáncer de mama en estadio I separadas según el método de detección (lesiones diagnosticadas por palpación frente a lesiones diagnosticadas por mamografía). Estudio estadístico comparando la edad, el tamaño tumoral, la anatomía patológica, el grado de diferenciación, el tratamiento, la recurrencia y la supervivencia. Resultados: No encontramos diferencias estadísticamente significativas entre ambos grupos en ninguno de los factores analizados, excepto en la supervivencia, que fue mejor en el grupo de lesiones palpables (54,904 frente a 53,170 meses para las lesiones palpables).Discusión: El principal factor pronóstico es el tamaño tumoral al diagnóstico, independientemente del método diagnóstico (AU)

The Applied Nutrition Project of eastern Kenya--an initiative for reducing hunger and malnutrition.

Sustainable development is the only kind of development possible for help in the third world. Due to various historical, political, geographic and climatic conditions the divergence between those countries providing and those receiving help is so vast that donations of labor and/or money is simply not enough. Rather, communities have to be taught to support and develop themselves during the receipt of aid and especially after the help pulls out. It is our goal in this article to summarize one such "sustainable development" project. As volunteers for AMREF (African Medical and Research Foundation), we worked with the remarkable Makueni Applied Nutrition Project in eastern Kenya in the summer of 2001. Our job was to visit the various locations in this semi-arid and arid environment and to write a report on the situation of the diverse parts of the project. The Applied Nutrition Project (ANP) started in 1984 and serves as an excellent example of the significant help that can be provided to needy areas of the world with a multifaceted approach.

[Tuberculosis outbreak at a public school]. / Brote epidémico de tuberculosis en un colegio público.

BACKGROUND: At school there are special circumstances of living together and a particular susceptibility, which favour the emergence of tuberculosis microepidemics. We report here the microepidemic occurred at a school among 9-year old children. METHODS: After ruling out a possible familiar source in a child with pulmonary tuberculosis, we detected a case with high bacillar shedding in a female teacher and conducted a tuberculin search among children and teachers, initially outlining the theoretical groups at risk. Tuberculin positive children underwent chest-X-ray and when abnormalities were found, children were derived to the pediatrician for chemotherapy. All converters received secondary chemoprophylaxis and all non-respondents primary chemoprophylaxis. RESULTS: The classroom where the teacher spent most of het time had a higher rate of converters (70%) than other classroom, where the index teacher spent only a partial time (40%; RR: 1.75; CI: 1.06-2.88) or the collective of teachers (45.4%; RR: 1.45; CI: 0.94-2.23). Three additional cases of secondary disease were detected, all of them children. The initial compliance with chemoprophylaxis was greater among (for) children (97.0%) than among teachers (41.6%). Among children there was one case of tuberculin conversion compared with three cases among teachers. No additional cases were detected; also, an abnormal rate of reactors outside the initially studied groups was also not detected. CONCLUSIONS: Our results somehow agree with those reported from other school outbreaks. To note the anergy and lack of symptoms in the index case and the suggestion to delineate the degree of spending hours together to identify groups with a higher theoretical risk of being infected. Thus, an unnecessary expense of resources and a social alarm would be avoided.

[Occupational asthma]. / Asma profesional.

OBJECTIVE: Description of three cases of work-related asthma. DESIGN: Retrospective clinical observations. SETTING: Primary care clinics in the centre of the metropolitan health area of Madrid. PATIENTS: A 19-year old male who worked in the manufacture of Psyllium and reported one month's evolution of an irritative cough on getting up in the morning. A 33-year-old male who worked as a car mechanic and reported episodes of respiratory difficulty while at work. A 17-year-old male employed by a bread manufacturer who attended because of a catarrhal condition accompanied by respiratory difficulty. MEASUREMENTS AND MAIN RESULTS: The maximum expiratory flow monitor (MEFM) was used to measure maximum expiratory flow (MEF) in two patients. The third was temporarily separated from his work environment. The monitoring of the MEF showed a slow fall of 25% in the patient who worked with Psyllium and a rapid fall of 36% in the mechanic, which coincided with the symptoms. The patient with asthma probably caused by flour evolved favourably while off work and deteriorated again on returning to work. The allergological study showed sensitivity to Psyllium, Isocyanate and flour, respectively. The three patients stayed asymptomatic on being separated from the catalysing substances. CONCLUSIONS: The early diagnosis of work-related asthma requires a high level of diagnostic awareness. It is extremely important to separate the patient from the catalysing agent. The MEFM is a very useful instrument of diagnosis for the primary care doctor.

[Bowen's disease. A report of 9 cases]. / Enfermedad de Bowen. Presentación de nueve casos.

OBJECTIVE: To revise clinical histological, therapeutic and evolutive specifications of Bowen's disease. To emphasise the importance of an early diagnosis and to promote treatment with topical 5-fluorouracil by the family doctor. DESIGN: Descriptive and transversal study. SETTING: Outpatient and dermatology departments in a hospital in the metropolitan area of Madrid. PATIENTS AND OTHER PARTICIPANTS: Nine patients (5 male and 4 female), aged over 50, with slightly pigmented skin and diagnosed to have Bowen's disease. TREATMENT: In five patients. Topical 5-fluorouracil (Efudix) was applied once a day for 20-30 days. Surgery was performed on three patients and one underwent radiotherapy. MEASUREMENTS AND MAIN RESULTS: The clinical histories of the patients were used. In each case a histological study of the papule that had confirmed diagnosis was carried out. Treatment was effective in all patients and no recidivation was observed during the one year follow up. CONCLUSIONS: An early diagnosis and treatment of Bowen's disease is important for preventing its progression to invasive epidermoid carcinoma and later dissemination. The use of topical 5-fluorouracil is an efficient measure that can be prescribed by the family doctor.

Five-year follow-up evaluation of the noncemented press-fit titanium hip-joint endoprosthesis.

A series of 260 noncemented total hip arthroplasties with a titanium alloy stem and fixation by the Zweymüller press-fit and an Endler polyethylene threaded cup was reviewed in detail. The minimum follow-up period was 48 months and the maximum 72 months, with an average of 60 months. A scale from zero to five points was applied to evaluate pain, mobility, and motion for a total possible accumulation of 15 points. The global results of the different etiologic groups (arthrosis, femoral head necrosis, rheumatoid arthritis, and subcapital hip fractures) have been very good and good (12-15 points) in 67.5% of the cases and fairly good and bad in 32.3%. These results have been better in femoral head necrosis than in arthrosis or rheumatoid arthritis, but not as good in subcapital hip fractures. The age groups below 60 had better results than the above 60 groups. The Singh index higher than 3 was correlated with better-than-average results. The polyethylene cup migrated horizontally (more than 4 mm) in 7.6% of the cases and vertically (more than 5 mm) in 10%. The non-evolutionary cortical remodelation of the femur does not influence the results. Prosthetic stem sinking less than 4 mm has been found in 62% of the cases, from 4 to 9 mm in 21%, and greater than 9 mm in 6%. No alterations with clinical consequences attributable to stress-shielding have been detected.

[Evaluation of compliance with appointments and the control of blood pressure in a group of hypertensive patients]. / Evaluación del cumplimiento de la citación y del control de la tensión arterial en un grupo de hipertensos.

The social and public health relevance of hypertension (HT) is well know. In the present study, 308 hypertensive patients were evaluated in two six month periods. An organized variation was carried out, consisting of the suppression of the scheduled visit with subsequent attention of the patient by visit on demand. The evaluated variables were the degree of compliance with the appointment and the control of the blood pressure levels in the two periods, depending on sex, age, and degree of hypertension. Better results were achieved during the first period (with scheduled visit), both regarding compliance and control. Therefore, it seems preferable to keep scheduled visits for the HT protocols.