Importancia de la consulta ambulatoria previa a la visita a las urgencias hospitalarias en pacientes mayores: impacto sobre resultados de hospitalización / Importance of outpatient medical consultation prior to going to the hospital emergency department in patients over 65 years of age: Impact on hospitalization results

Objetivo: Investigar los factores asociados a una consulta ambulatoria previa (CAP), al acudir a un servicio de urgencias hospitalario (SUH), en los pacientes mayores de 65 años y su impacto sobre los resultados. Emplazamiento: Cincuenta y dos SUH españoles.ParticipantesPacientes mayores de 65 años que consultan a un SUH. Medidas principales y metodología: Se utilizó una cohorte (n=24.645) de pacientes mayores e 65 años atendidos en 52 SUH durante una semana. Se consignaron 5 variables sociodemográficas, 6 funcionales y 3 de gravedad y se analizó su asociación cruda y ajustada con la existencia o no de una CAP a la consulta al SUH. La variable de resultado primaria fue la necesidad de ingreso y secundarias la realización de exploraciones complementarias y tiempo de estancia en el SUH. Se analizó si la CAP influenció en los resultados. Resultados: El 28,5% de los pacientes tenía una CAP previa a su visita al SUH. Vivir en residencia, NEWS2≥5, edad ≥80 años, dependencia funcional, comorbilidad grave, vivir solo, deterioro cognitivo, sexo masculino y depresión se asociaron de forma independiente con la CAP. La CAP se asoció a mayor necesidad de hospitalización y menor tiempo de estancia en el SUH, pero no se observó un menor consumo de recursos diagnósticos. Conclusiones: Los pacientes que acuden al SUH tras una CAP tienen más necesidad de hospitalización, sugiriendo que son debidamente derivados, y las urgencias menores son solucionadas de forma efectiva en la CAP. Su estancia en el SUH previa a la hospitalización es menor, por lo que la CAP facilitaría su resolución clínica.(AU)

Objective: Investigate factors associated with a previous outpatient medical consultation (POMC), to the health center or another physician, before attending a hospital emergency department (ED), in patients aged >65 and its impact on the hospitalization rate and variables related to ED stay. Site: Fifty-two Spanish EDs. Participants: Patients over 65 years consulting an ED. Main measurements and design: A cohort (n=24645) of patients aged >65 attended for one week in 52 ED. We recorded five sociodemographic variables, six functional, three episode-related severity and analyzed their crude and adjusted association with the existence of a POMC at ED consultation. The primary outcome variable was the need for admission and the secondary variables were complementary examinations and ED stay length. We analyzed whether the POMC influenced these outcomes. Results: 28.5% of the patients had performed a POMC prior to their visit to the ED. Living in a residence, NEWS-2 score ≥5, aged ≥80, dependency functions, severe comorbidity, living alone, cognitive impairment, male gender and depression were independently associated with a POMC. Also was associated with a greater need for hospitalization and shorter length of stay in the ED. No minor consumption of diagnostic resources in patients with POMC. Conclusion:Patients presenting to the ED following POMC are admitted more frequently, suggesting that they are appropriately referred and that minor emergencies are probably effectively resolved in the POMC. Their stay in the ED prior to hospitalization is shorter, so the POMC would facilitate clinical resolution in the ED.(AU)

[Importance of outpatient medical consultation prior to going to the hospital emergency department in patients over 65 years of age: Impact on hospitalization results]. / Importancia de la consulta ambulatoria previa a la visita a las urgencias hospitalarias en pacientes mayores: impacto sobre resultados de hospitalización.

OBJECTIVE: Investigate factors associated with a previous outpatient medical consultation (POMC), to the health center or another physician, before attending a hospital emergency department (ED), in patients aged >65 and its impact on the hospitalization rate and variables related to ED stay. SITE: Fifty-two Spanish EDs. PARTICIPANTS: Patients over 65 years consulting an ED. MAIN MEASUREMENTS AND DESIGN: A cohort (n=24645) of patients aged >65 attended for one week in 52 ED. We recorded five sociodemographic variables, six functional, three episode-related severity and analyzed their crude and adjusted association with the existence of a POMC at ED consultation. The primary outcome variable was the need for admission and the secondary variables were complementary examinations and ED stay length. We analyzed whether the POMC influenced these outcomes. RESULTS: 28.5% of the patients had performed a POMC prior to their visit to the ED. Living in a residence, NEWS-2 score ≥5, aged ≥80, dependency functions, severe comorbidity, living alone, cognitive impairment, male gender and depression were independently associated with a POMC. Also was associated with a greater need for hospitalization and shorter length of stay in the ED. No minor consumption of diagnostic resources in patients with POMC. CONCLUSION: Patients presenting to the ED following POMC are admitted more frequently, suggesting that they are appropriately referred and that minor emergencies are probably effectively resolved in the POMC. Their stay in the ED prior to hospitalization is shorter, so the POMC would facilitate clinical resolution in the ED.

Restricción del crecimiento intrauterino y enfermedades no transmisibles durante las edades pediátricas / Intrauterine Growth Restriction and Noncommunicable Diseases during Pediatric Ages

Introducción: En la aparición de las enfermedades crónicas durante las edades pediátricas y la adolescencia, la restricción del crecimiento intrauterino se considera un factor clave. Objetivo: Determinar la relación entre la restricción del crecimiento intrauterino y las enfermedades no trasmisibles durante las edades pediátricas. Métodos: Se realizó una revisión narrativa con búsqueda bibliográfica en Pubmed, SciELO, LILACS y Google académico en los últimos cinco años sobre el tema que se trata. Se examinaron artículos originales, de revisión y capítulos de libros. Se utilizaron las palabras clave: retardo del crecimiento fetal, factores de riesgo cardiometabólicoy atención integrada a las enfermedades prevalentes de la infancia. Se descartaron aquellos artículos no pertinentes o que tuvieran deficiencias metodológicas notables. Análisis y síntesis de la información: Se expusieron las definiciones de pequeño para la edad gestacional y restricción del crecimiento intrauterino, se mostró la clasificación más actualizada, se mencionaron las enfermedades que aparecen en la infancia en estos recién nacidos de riesgo y se señalaron sus mecanismos. Conclusiones: El antecedente de restricción del crecimiento intrauterino se relaciona con alteraciones del crecimiento pondoestatural, del neurodesarrollo; el síndrome metabólico; las afecciones cardiovasculares; las enfermedades endocrinas, hepáticas, respiratorias, del sistema inmunológico y renales, los trastornos auditivos y de la visión. Estas afecciones se presentan en etapas tempranas de la vida como la infancia y la adolescencia(AU)

Introduction: In the occurrence of chronic diseases during pediatric ages and adolescence, intrauterine growth restriction is considered a key factor. Objective: To determine the relationship between intrauterine growth restriction and noncommunicable diseases during pediatric ages. Methods: A narrative review was performed with a literature search in Pubmed, SciELO, LILACS and Google Scholar in the last five years on the topic under discussion. Original articles, review articles and book chapters were examined. The keywords used were: fetal growth retardation, cardiometabolic risk factors, integrated care for prevalent childhood diseases. Articles that were not relevant or had notable methodological deficiencies were discarded. Analysis and synthesis of the information: The definitions of small for gestational age and intrauterine growth restriction were exposed, the most updated classification was shown, the diseases that appear during infancy in these at-risk newborns were mentioned and their mechanisms were pointed out. Conclusions: The history of intrauterine growth restriction is related to alterations of pondoestatural growth, neurodevelopment, metabolic syndrome, cardiovascular conditions, endocrine, hepatic, respiratory, immune system, renal, hearing and vision disorders. These conditions surface in early stages of life such as infancy and adolescence(AU)

Actualización de la Guía Española de la EPOC (GesEPOC): comorbilidades, automanejo y cuidados paliativos / Spanish COPD Guideline (GesEPOC) Update: Comorbidities, Self-Management and Palliative Care

Los modelos de atención sanitaria actuales descritos en GesEPOC indican la mejor manera de hacer un diagnóstico correcto, la categorización de los pacientes, la adecuada selección de la estrategia terapéutica y el manejo y la prevención de las agudizaciones. Además, en la EPOC concurren diversos aspectos que resultan cruciales en una aproximación integrada de la atención sanitaria a estos pacientes. La evaluación de las comorbilidades en el paciente con EPOC representa un reto asistencial. Dentro de una valoración integral debe estudiarse la presencia de comorbilidades que tengan relación con la presentación clínica, con alguna técnica diagnóstica o con algunos tratamientos relacionados con la EPOC. Asimismo, son necesarias intervenciones en hábitos de vida saludables, la adhesión a tratamientos complejos, desarrollar capacidades para poder reconocer los signos y síntomas de la exacerbación, saber qué hacer para prevenirlos y tratarlos enmarcados en un plan de automanejo. Finalmente, los cuidados paliativos constituyen uno de los pilares en el tratamiento integral del paciente con EPOC, con los que se buscan prevenir o tratar los síntomas de una enfermedad, los efectos secundarios del tratamiento, y los problemas físicos, psicológicos y sociales de los pacientes y sus cuidadores. Por tanto, el objetivo principal de estos cuidados paliativos no es prolongar la esperanza de vida, sino mejorar su calidad. En este capítulo de GesEPOC 2021 se presenta una actualización sobre las comorbilidades más importantes, las estrategias de automanejo y los cuidados paliativos en la EPOC, y se incluye una recomendación sobre el uso de opiáceos para el tratamiento de la disnea refractaria en la EPOC. (AU)

The current health care models described in GesEPOC indicate the best way to make a correct diagnosis, the categorization of patients, the appropriate selection of the therapeutic strategy and the management and prevention of exacerbations. In addition, COPD involves several aspects that are crucial in an integrated approach to the health care of these patients. The evaluation of comorbidities in COPD patients represents a healthcare challenge. As part of a comprehensive assessment, the presence of comorbidities related to the clinical presentation, to some diagnostic technique or to some COPD-related treatments should be studied. Likewise, interventions on healthy lifestyle habits, adherence to complex treatments, developing skills to recognize the signs and symptoms of exacerbation, knowing what to do to prevent them and treat them within the framework of a self-management plan are also necessary. Finally, palliative care is one of the pillars in the comprehensive treatment of the COPD patient, seeking to prevent or treat the symptoms of a disease, the side effects of treatment, and the physical, psychological and social problems of patients and their caregivers. Therefore, the main objective of this palliative care is not to prolong life expectancy, but to improve its quality. This chapter of GesEPOC 2021 presents an update on the most important comorbidities, self-management strategies, and palliative care in COPD, and includes a recommendation on the use of opioids for the treatment of refractory dyspnea in COPD. (AU)

[Translated article] Spanish COPD Guideline (GesEPOC) Update: Comorbidities, Self-Management and Palliative Care / Actualización de la Guía Española de la EPOC (GesEPOC): comorbilidades, automanejo y cuidados paliativos

The current health care models described in GesEPOC indicate the best way to make a correct diagnosis, the categorization of patients, the appropriate selection of the therapeutic strategy and the management and prevention of exacerbations. In addition, COPD involves several aspects that are crucial in an integrated approach to the health care of these patients. The evaluation of comorbidities in COPD patients represents a healthcare challenge. As part of a comprehensive assessment, the presence of comorbidities related to the clinical presentation, to some diagnostic technique or to some COPD-related treatments should be studied. Likewise, interventions on healthy lifestyle habits, adherence to complex treatments, developing skills to recognize the signs and symptoms of exacerbation, knowing what to do to prevent them and treat them within the framework of a self-management plan are also necessary. Finally, palliative care is one of the pillars in the comprehensive treatment of the COPD patient, seeking to prevent or treat the symptoms of a disease, the side effects of treatment, and the physical, psychological and social problems of patients and their caregivers. Therefore, the main objective of this palliative care is not to prolong life expectancy, but to improve its quality. This chapter of GesEPOC 2021 presents an update on the most important comorbidities, self-management strategies, and palliative care in COPD, and includes a recommendation on the use of opioids for the treatment of refractory dyspnea in COPD. (AU)

Los modelos de atención sanitaria actuales descritos en GesEPOC indican la mejor manera de hacer un diagnóstico correcto, la categorización de los pacientes, la adecuada selección de la estrategia terapéutica y el manejo y la prevención de las agudizaciones. Además, en la EPOC concurren diversos aspectos que resultan cruciales en una aproximación integrada de la atención sanitaria a estos pacientes. La evaluación de las comorbilidades en el paciente con EPOC representa un reto asistencial. Dentro de una valoración integral debe estudiarse la presencia de comorbilidades que tengan relación con la presentación clínica, con alguna técnica diagnóstica o con algunos tratamientos relacionados con la EPOC. Asimismo, son necesarias intervenciones en hábitos de vida saludables, la adhesión a tratamientos complejos, desarrollar capacidades para poder reconocer los signos y síntomas de la exacerbación, saber qué hacer para prevenirlos y tratarlos enmarcados en un plan de automanejo. Finalmente, los cuidados paliativos constituyen uno de los pilares en el tratamiento integral del paciente con EPOC, con los que se buscan prevenir o tratar los síntomas de una enfermedad, los efectos secundarios del tratamiento, y los problemas físicos, psicológicos y sociales de los pacientes y sus cuidadores. Por tanto, el objetivo principal de estos cuidados paliativos no es prolongar la esperanza de vida, sino mejorar su calidad. En este capítulo de GesEPOC 2021 se presenta una actualización sobre las comorbilidades más importantes, las estrategias de automanejo y los cuidados paliativos en la EPOC, y se incluye una recomendación sobre el uso de opiáceos para el tratamiento de la disnea refractaria en la EPOC. (AU)

Spanish COPD Guideline (GesEPOC) Update: Comorbidities, Self-Management and Palliative Care. / Actualización de la Guía Española de la EPOC (GesEPOC): comorbilidades, automanejo y cuidados paliativos.

The current health care models described in GesEPOC indicate the best way to make a correct diagnosis, the categorization of patients, the appropriate selection of the therapeutic strategy and the management and prevention of exacerbations. In addition, COPD involves several aspects that are crucial in an integrated approach to the health care of these patients. The evaluation of comorbidities in COPD patients represents a healthcare challenge. As part of a comprehensive assessment, the presence of comorbidities related to the clinical presentation, to some diagnostic technique or to some COPD-related treatments should be studied. Likewise, interventions on healthy lifestyle habits, adherence to complex treatments, developing skills to recognize the signs and symptoms of exacerbation, knowing what to do to prevent them and treat them within the framework of a self-management plan are also necessary. Finally, palliative care is one of the pillars in the comprehensive treatment of the COPD patient, seeking to prevent or treat the symptoms of a disease, the side effects of treatment, and the physical, psychological and social problems of patients and their caregivers. Therefore, the main objective of this palliative care is not to prolong life expectancy, but to improve its quality. This chapter of GesEPOC 2021 presents an update on the most important comorbidities, self-management strategies, and palliative care in COPD, and includes a recommendation on the use of opioids for the treatment of refractory dyspnea in COPD.

Assessing a care programme for complex and advanced chronic patients: Use of resources and costs.

INTRODUCTION: The Public Health System of the Balearic Islands (IB-Salut) implemented between 2016 and 2019 the Chronic Patient Care Plan to properly manage complex chronicity and provide quality care attention. The goal of this study is assessing the use of healthcare services and their associated costs before and after the implementation of the programme. METHODS: Descriptive analyses of resources destined to complex and advanced chronic patients (CCP and ACP). RESULTS: After entering the programme: the frequency of CCP admissions to acute hospitals reduced by 6.9%, the frequency of CCP visits to emergency departments reduced by 8.4%, while the frequency of ACP admitted to intermediate care hospitals increased. Both the frequencies of ACP admitted to acute hospitals and emergency visits decreased to 16.7% and to 27.3%, respectively. Total cost before and after the implementation of the programme was €60,884,241 and €46,889,693, respectively. Taking into account the 1011 admissions avoided, the result is a negative incremental cost-effectiveness ratio (€-396.57) per acute hospital admission that was avoided. CONCLUSION: The Chronic Patient Care Plan might be interpreted as a cost-effective intervention. This first assessment would benefit from further research including control groups.

Breastfeeding and diseases prevalent in the first two years of a child's life: a cross-sectional study / Lactancia materna y enfermedades prevalentes en los dos primeros años de vida del niño: un estudio transversal / Amamentação e as doenças prevalentes nos primeiros dois anos de vida da criança: estudo transversal

ABSTRACT Objectives: to assess the association between breastfeeding and diseases prevalent in the first two years of a child's life. Methods: a retrospective cross-sectional study that analyzed electronic medical records of 401 children. Data on birth, growth, breastfeeding and medical care in the first two years of life were collected. In the analysis, Poisson regression with robust variance was used. Results: 27.9% of children were exclusively breastfed until six months, and, at 24 months, 93.3% had already had some prevalent childhood disease. In the crude analysis, 5-minute Apgar association, length, weight at 12 months, exclusive and non-exclusive breastfeeding time had association. In the adjusted analysis, only the variable breastfeeding at six months maintained the association with prevalent childhood diseases. Conclusions: children who were not breastfed, exclusively or not, up to six months of age, had a higher prevalence of diseases compared to breastfed children.

RESUMEN Objetivos: evaluar la asociación entre lactancia materna y enfermedades prevalentes en los dos primeros años de vida del niño. Métodos: estudio transversal retrospectivo que analizó las historias clínicas electrónicas de 401 niños. Se recogieron datos sobre nacimiento, crecimiento, lactancia y atención médica en los dos primeros años de vida. En el análisis se utilizó la regresión de Poisson con varianza robusta. Resultados: el 27,9% de los niños fueron amamantados exclusivamente hasta los seis meses de edad y, a los 24 meses, el 93,3% ya había tenido alguna enfermedad infantil prevalente. En el análisis crudo presentaron asociación de Apgar al minuto 5, longitud, peso a los 12 meses, tiempo de lactancia materna exclusiva y no exclusiva. En el análisis ajustado, sólo la variable lactancia materna a los seis meses mantuvo la asociación con las enfermedades prevalentes de la infancia. Conclusiones: los niños que no fueron amamantados, exclusivamente o no, hasta los seis meses de edad, presentaron mayor prevalencia de enfermedades en comparación con los niños amamantados.

RESUMO Objetivos: avaliar a associação do aleitamento materno e as doenças prevalentes nos primeiros dois anos de vida da criança. Métodos: estudo transversal retrospectivo, que analisou prontuários eletrônicos de 401 crianças. Foram coletados dados sobre nascimento, crescimento, aleitamento materno e atendimentos médicos nos dois primeiros anos de vida. Na análise, utilizou-se Regressão de Poisson com variância robusta. Resultados: receberam aleitamento exclusivo até os seis meses 27,9% das crianças, e, aos 24 meses de vida, 93,3% já haviam tido alguma doença prevalente da infância. Na análise bruta, apresentaram associação Apgar no 5º minuto, comprimento, peso aos 12 meses, tempo de aleitamento exclusivo e não exclusivo. Na análise ajustada, apenas a variável aleitamento materno aos seis meses manteve a associação com as doenças prevalentes da infância. Conclusões: as crianças que não foram amamentadas, exclusivamente ou não, até os seis meses, apresentaram maior prevalência de doenças em relação às amamentadas.

Factores de riesgo de enfermedades prevalentes de la infancia en hogares de atención integral

RESUMEN Introducción: La Organización Mundial de la Salud manifiesta que las enfermedades prevalentes de la infancia en el 2016 causaron una mortalidad de 5 millones en menores de 5 años, a causa de neumonía y enfermedad diarreica aguda. Objetivo: Examinar los factores de riesgo modificables de enfermedades prevalentes de la infancia en los hogares comunitarios tradicionales del bienestar en Cúcuta, Colombia. Métodos: Se realizó un estudio observacional, descriptivo, transversal en el 2018, en 23 hogares del Instituto Colombiano del Bienestar Familiar en Cúcuta; la información se recolectó a partir del instrumento de identificación de factores de riesgo de enfermedades prevalentes de la infancia previo prueba inicial. Resultados: Se atendieron 276 menores, 56,8 % niños. Se identificaron factores de riesgo modificables en los hogares, en 22,0 % de estos, los infantes deben mejorar el lavado de manos; con un porcentaje similar, se demostró que se debe insistir en la limpieza del material didáctico, juguetes, ventiladores y cortinas; en 17,3 % se observaron condiciones regulares en cuanto a la infraestructura; además, 20,0 % de los menores compartían alimentos, se presentó asistencia de infantes con enfermedades en curso y ausencia de protocolos de atención a seguir en tales casos, entre otros. Conclusiones: Los factores de riesgo pueden ser intervenidos a través de la estrategia de atención integrada a las enfermedades prevalentes de la infancia desde sus componentes clínico, comunitario y organización local para su prevención, con el interés y comprensión de la responsabilidad compartida para la atención de esta problemática en salud.

ABSTRACT Introduction: The World Health Organization states that prevalent childhood diseases in 2016 caused a mortality of 5 million in children under 5 years old, due to pneumonia and acute diarrheal disease. Objective: Examine modifiable risk factors for prevalent childhood diseases in traditional community welfare homes in Cucuta, Colombia. Methods: An observational, descriptive, cross-sectional study was conducted in 2018 in 23 households of the Colombian Institute of Family Welfare in Cúcuta; the information was collected from the instrument to identify risk factors for prevalent childhood diseases after initial testing. Results: 276 children were attended, 56.8% of them were boys. Modifiable risk factors were identified in homes; in 22,0% of these, children should improve hand washing; with a similar percentage, it was shown that the cleaning of teaching materials, toys, fans and curtains should be insisted upon; in 17.3% regular infrastructure conditions were observed. In addition, 20,0% of the children shared food, there were children with ongoing diseases and absence of care protocols to follow in such cases, among others. Conclusions: The risk factors can be intervened through the strategy of integrated care for prevalent childhood diseases from its clinical, community and local organization components for its prevention, with the interest and understanding of the shared responsibility for the care of this health problem.

Barriers and facilitators to the diagnosis and treatment of depression in primary care in Colombia: Perspectives of providers, healthcare administrators, patients and community representatives.

INTRODUCTION: Depression represents a major disease burden in Colombia. To better understand opportunities to improve access to mental healthcare in Colombia, a research team at Javeriana University conducted formative qualitative research to explore stakeholders' experiences with the integration of mental healthcare into the primary care system. METHODS: The research team conducted 16 focus groups and 4 in-depth interviews with patients, providers, health administrators and representatives of community organisations at five primary care clinics in Colombia, and used thematic analysis to study the data. RESULTS: Themes were organised into barriers and facilitators at the level of patients, providers, organisations and facilities. Barriers to the treatment of depression included stigma, lack of mental health literacy at the patient and provider level, weak links between care levels, and continued need for mental health prioritization at the national level. Facilitators to the management of depression in primary care included patient support systems, strong patient-provider relationships, the targeting of depression interventions and national depression guidelines. DISCUSSION: This study elucidates the barriers to depression care in Colombia, and highlights action items for further integrating depression care into the primary care setting.

[Virtual consultations in Traumatology and Orthopaedic Surgery]. / Consultas virtuales en Traumatología y Cirugía Ortopédica.

OBJECTIVE: The objective of this study is to analyse the current system of virtual consultations between the levels of Primary and Specialised Care in the field of Traumatology and Orthopaedic Surgery (TOS) in our healthcare area. MATERIAL AND METHOD: A retrospective observational study was carried out on 90 consecutive patients who had a non-face-to-face consultation between 3 January 2017 and 10 February 2017 and subsequently a face-to-face consultation. All the patients belonged to the same healthcare area attached to the Nuestra Señora de Candelaria University Hospital. The data on the diagnostic orientation, medical history provided and complementary tests were evaluated by 2 observers, one with training in Family and Community Medicine and the other with specialised training in TOS, and compared with those obtained in the final face-to-face assessment. RESULTS: The results showed a low inter-judge agreement regarding the diagnostic orientation, anamnesis, exploration and complementary tests provided in the virtual consultation request. It was considered that only 59% for one observer (Family and Community Medicine) and 47.7% for the other (specialised care) had sufficient information for decision-making. Furthermore, 35.2% required more than one face-to-face assessment consultation until diagnosis and in 45.5% it was necessary to request new complementary tests. In 30.7%, there was no concordance in the suggested and final diagnosis. In 51.9%, no therapeutic action other than that carried out by Primary Care was carried out and 34.1% of the patients were referred to the Rehabilitation department. CONCLUSIONS: The current model of virtual consultations in TOS does not seem adequate to respond to this new healthcare model. The number of unnecessary referrals is very high despite the previous virtual assessment by a specialist in TOS. The Family and Community Medicine specialist should have more diagnostic resources and coordination between Primary and Specialised Care is necessary to determine, in the area of TOS, the type of consultations and conditions for which this system should be implemented to obtain adequate coordination and improve communication between both levels of care.

[Evaluation of the collaboration between Primary and Hospital Care in order to improve inappropriate prescription]. / Evaluación de la colaboración entre atención primaria y hospitalaria para mejorar la polimedicación inapropiada.

INTRODUCTION AND OBJECTIVES: To evaluate the implementation of a collaborative experience between Primary (PC) and Hospital Care (HC) aimed at reducing potentially inappropriate prescribing (PIP) in patients with polypharmacy. MATERIALS AND METHODS: Collaborative experience including a controlled before-after intervention study, carried out in the Donostialdea Integrated Health Organization (IHO), with Bilbao Basurto IHO as control group, Osakidetza, Basque Health Service. Participant were 227 PC physicians and physicians from 7 hospital services, and patients with 5 or more drugs meeting at least one PIP criteria. The intervention consisted of communication and knowledge between professionals, PC-HC consensus, training, identification of patients at risk, medication review, evaluation and feed-back. The collaboration process (agreements, consensus documents, training activities) and the change in the prevalence of PIP in polymedicated patients (using computerised health records) were evaluated. RESULTS: A total of 21 PIP criteria and 6 recommendation documents were agreed. An analysis was performed on 15,570 PIP from OSI Donostialdea and 24,866 from the control group. The prevalence of PIP in polymedicated patients was reduced by -4.53% (95% CI: -4.71 to -4.36, P< .0001) in comparison with the control group. The before-after differences were statistically significant across the 7 services. CONCLUSIONS: PC-HC collaboration is feasible and, along with other intervention components, reduces inappropriate polypharmacy in the context of a recently integrated healthcare organisation. The collaboration process is complex and requires continuous monitoring, policy involvement, leadership that encourages health professional participation, and intensive use of information systems.

Aplicación de prácticas clave: lactancia materna, alimentación complementaria, micronutrientes, desarrollo mental y social de niños menores de 5 años / Application of key practices: breastfeeding, complementary feeding, micronutrients, mental and social development of children under 5 years of age

Objetivo: evaluar la aplicación de la estrategia AIEPI en la promoción de la lactancia materna exclusiva, alimentación complementaria, uso de micronutrientes y prevención de alteraciones en el desarrollo mental y social de los niños menores de 5 años. Materiales y métodos: estudio cuantitativo descriptivo-correlacional; se utilizó una muestra de 323 padres de familia y/o cuidadores. Resultados: la lactancia materna exclusiva se proporcionó en un 52% y en la alimentación complementaria los alimentos de elección fueron los cereales 77,1%, tubérculos 71,8%, frutas 40% y verduras 43%. Administran cantidades suficientes de micronutrientes 82,4%. El 92,6% brindan caricias y un 83,9% usan el juego como forma de estímulo para sus hijos. Hubo correlación entre la edad del cuidador y la lactancia materna exclusiva (p valor 0,019), de igual forma se correlaciono la edad del cuidador (mayores de 23 años) y la inclusión de la alimentación complementaria como cereales (p valor 0,000) /NOTA: "p" quiere decir muchas. Conclusión: se evidencia que las prácticas relacionadas con el componente uno de la estrategia AIEPI relacionada a la lactancia materna, alimentación complementaria, micronutrientes, desarrollo mental y social de niños menores de 5 años, son aplicadas en un sector de Cartagena; sin embargo, existes resultados que constituyen porcentajes significativos en el aumento del riesgo de aparición de enfermedades como la diarrea e infección respiratoria aguda..Au

Objective: to evaluate the application of the IMCI strategy, in the promotion of exclusive breastfeeding, complementary feeding, use of micronutrients and prevention of alterations in the mental and social development of children under 5 years of age. Materials and methods: descriptive-correlational quantitative study, a sample of 323 parents and / or caregivers was used. Results: exclusive breastfeeding was provided in 52% and in complementary feeding the foods of choice were cereals 77.1%, tubers 71.8%, fruits 40% and vegetables 43%. They administer enough micronutrients 82.4%.92.6% provide caresses and 83.9% use the game as a form of encouragement for their children. There was a correlation between the age of the caregiver and exclusive breastfeeding (p value 0.019), in the same way the age of the caregiver (over 23 years) and the inclusion of complementary feeding such as cereals (p value 0.000) were correlated. Conclusion: it is evidenced that the practices related to component one of the IMCI strategy related to breastfeeding, complementary feeding, micronutrients, mental and social development of children under 5 years of age, are applied in a sector of Cartagena; however, there are results that constitute significant percentages in the increased risk of the appearance of diseases such as diarrhea and acute respiratory infection..Au

La práctica pedagógica en la atención integrada de las enfermedades prevalentes de la infancia desde la perspectiva de Basil Bernstein / Pedagogical practice in the integrated management of prevalent childhood illness from the perspective of Basil Bernstein / A prática pedagógica na atenção integrada das doenças prevalentes da infância da perspectiva de Basil Bernstein

Resumen La estrategia "Atención integrada de las enfermedades prevalentes de la infancia" (aiepi) es reconocida por las entidades de salud internacionales y nacionales como una estrategia que impacta la salud de la población infantil y que sus componentes clínico y comunitario desarrollan la educación para la salud. Objetivo: Comprender cómo se desarrolla la práctica pedagógica en la consulta médica atendida bajo la estrategia aiepi, en una institución de primer nivel de atención durante el año 2015. Metodología: Investigación cualitativa, con una perspectiva hermenéutica. Para la comprensión de la construcción social de la práctica pedagógica se tuvo una orientación etnográfica y el sistema de reglas (jerarquía, secuencia y criterio) propuesto por Bernstein. Las técnicas etnográficas utilizadas fueron entrevista cualitativa, observación participante y entrevista grupal. Se entrevistó a once cuidadores y tres médicas. Resultados: Para las médicas, muchas de las enfermedades son "autolimitadas", se resuelven solas. El propósito de la educación es convencer a los cuidadores de que la información suministrada por las médicas es verdadera. Los temas en educación son determinados por las médicas y centrados en la enfermedad. Para los cuidadores, la médica es referente de conocimiento. Las médicas reconocen que hay saber popular que se estudia y se acepta por el conocimiento científico; sin embargo, solo el conocimiento científico es válido. Conclusión: En la atención de aiepi, la práctica pedagógica es visible, porque se centra en el desempeño del cuidador y en la cantidad de texto que él aprende mediante la repetición, y las médicas ejercen poder sobre los cuidadores, al poseer el conocimiento hegemónico (válido y verdadero) que refuerza el modelo biomédico en la práctica pedagógica.

Abstract The strategy "Integrated Management of Childhood Illness"(IMCI) is recognized by international and national health bodies as a strategy that affects the health of the child population and whose clinical and community components develop health education. Objective: To understand how pedagogical practice develops in medical consultation attended under the IMCI strategy, in a first level care institution in 2015. Methodology: Qualitative research, with a hermeneutic perspective. To understand the social construction of pedagogic practice an ethnographic stance and the system of rules (hierarchy, sequence and criterion) proposed by Bernstein were adopted. The ethnographic techniques used were qualitative interview, participant observation and group interview. Eleven caregivers and three doctors were interviewed. Results: For the doctors, many of the diseases are "self-limiting", i.e. they resolve on their own. The purpose of education is to convince the caregivers that the information provided by the doctors is true. The education topics are determined by the doctors and focused on the disease. For the caregivers, the doctor is a reference of knowledge. The doctors recognize that there is popular knowledge that is studied and accepted by scientific knowledge; however, only scientific knowledge is valid. Conclusion: Pedagogical practice is visible in IMCI care because it focuses on the performance of the caregiver and the amount of text that he learns through repetition, and the doctors exert power over caregivers, as they possess hegemonic (valid and true) knowledge that reinforces the biomedical model in pedagogical practice..

Resumo A estratégia "Atenção integrada das doenças prevalecentes da infância" (AIEPI), é reconhecida pelas entidades de saúde nacionais e internacionais como uma estratégia que impacta a saúde da população infantil e que seus componentes clínicos e comunitários desenvolvem a educação para a saúde. Objetivo: Compreender como se desenvolve a prática pedagógica na consulta médica atendida sob a estratégia AIEPI, numa instituição de primeira linha de atenção durante o ano de 2015. Metodologia: Pesquisa qualitativa com uma perspectiva hermenêutica. Para a compreensão da construção social da prática pedagógica se teve uma orientação etnográfica e o sistema de regras (hierarquia, sequência e critério) proposto por Bernstein. As técnicas etnográficas usadas foram: entrevista qualitativa, observação participante e entrevista grupal. Foram entrevistados 11 cuidadores e 3 médicas. Resultados: De acordo com as médicas, muitas das doenças são "autolimitadas", se curam sozinhas. O objetivo da educação é convencer os cuidadores de que a informação fornecida pelas médicas é verídica. Os temas relacionados à educação são determinados pelas médicas e focados nas doenças. Para os cuidadores, a médica é um referencial de conhecimento. As médicas reconhecem que existe um conhecimento popular que é estudado e aceito pelo conhecimento científico; porém, só o conhecimento científico é válido. Conclusão: No que se refere à atenção de AIEPI, a prática pedagógica é visível, porque está centralizada no desempenho do cuidador e na quantidade de informação escrita que ele aprende através da repetição e as médicas influenciam os cuidadores já que possuem o conhecimento hegemônico (válido e verídico) que reforça o modelo biomédico na prática pedagógica.

Prácticas pa ra la prevención de accidentes en el hogar en cuidadores de niños de 1 a 5 años en un barrio de Cartagena (Colombia) / Practices for the prevention of accidents in the home in caregivers of children from 1 to 5 years in a district of Cartagena (Colombia)

Introducción: los accidentes en la población infantil constituyen una importante causa de morbilidad y mortalidad convirtiéndose hoy día en un problema de salud pública mundial, principalmente la población más afectada son los niños en etapa preescolar, por la vulnerabilidad y dependencia del cuidador. Objetivos: describir las prácticas para la prevención de accidentes en el hogar en cuidadores de niños de 1 a 5 años en un barrio de Cartagena (Colombia). Materiales y métodos: estudio cuantitativo descriptivo transversal. Constituido por 354 cuidadores de niños menores de 5 años, se utilizó la técnica de observación y la aplicación del instrumento con base a la práctica N° 15 de AIEPI (Atención Integrada a las Enfermedades Prevalentes de la Infancia). Resultados: socio demográficamente los cuidadores fueron principalmente de género femenino (87%), con 20 ­ 29 años de edad (44,9%), madres de los niños (61,3%), conviven en unión libre (54,2%), son bachilleres (50,3%), de estrato uno (91,8%), amas de casa (62,7%), con hijos (93,8%), residen en casas (54,5%). Los niños de 1 a 5 años fueron mayoritariamente de género masculino (51,7%), y han presentado accidentes (75,1%), sobre todo, caídas (61,9%). El nivel de riesgo de accidentes en el hogar fue bajo (85%), y las prácticas de prevención suelen ser regulares (55,1%). Conclusión: los niños enfrentan relativamente bajo riesgo de accidente en el hogar, sin embargo, las prácticas para prevenirlos resultan ser regulares..(AU)

Introduction: accidents in children are an important cause of morbidity and mortality,becoming today a global public health problem, mainly the most affected population are children in preschool, for the vulnerability and dependence of the caregiver. Objectives:to describe the practices for the prevention of accidents at home in caregivers of children from 1 to 5 years of age, in a neighborhood of Cartagena (Colombia). Materials and methods: quantitative, descriptive and cross-sectional study. Consisting of 354 caregivers of children under 5 years of age, the technique of observation and the application of the instrument was used based on practice No. 15 of IMCI (Integrated Management of Childhood Illness). Results: demographic partner caregivers were mainly female (87%), with 20 - 29 years of age (44.9%), mothers of children (61.3%), live together in a free union (54.2%), are high school graduates (50.3%), of stratum one (91.8%), housewives (62.7%), with children (93.8%), reside in houses (54.5%). Children from 1 to 5 years old were male (51.7%), and had accidents (75.1%), especially falls (61.9%). The level of accident risk in the home was low (85%), and prevention practices are usually regular (55.1%). Conclusion: children face relatively low risk of accident in the home, however, practices to prevent them turn out to be regular..(AU)

[Hospital-at-home Integrated Care Programme tailored to older patients with disabling acute processes: identification of prognostic factors]. / Hospitalización Domiciliaria Integral para la atención a pacientes mayores con procesos agudos discapacitantes: factores predictivos de éxito terapéutico.

INTRODUCTION: Several authors have demonstrated the efficacy of different hospital-at-home strategies in older patients. The identification of prognostic factors is key for improving the targeting process of candidates. METHODS: We performed an analysis of a cohort of older patients attended due to disabling health crises (medical, orthopaedics, or stroke) by a hospital-at-home scheme developed in an integrated care institution over a 5-year period. Main outcomes were: health crisis resolution (discharge to Primary Care); functional resolution (relative functional gain ≥35%), and their combined variable. A logistic regression analysis was performed, including clinical variables from Comprehensive Geriatric Assessment at admission to detect factors related to favourable outcomes. RESULTS: A total of 484 patients were included. The main characteristics were: age 84.4 (6.7), female gender 69%, baseline Barthel score 74.2 (22.6), family-private caregiver/nursing home 82%/18%, referral from hospital wards/emergency department-community in 55%/45%. The main results (for selected processes medical/orthopaedics/stroke) were: health crisis resolution 71.7/87.5/77.6%; functional resolution 72.1/84.9/73.5%; favourable crisis resolution (health crisis resolution with functional resolution) 67.1/81.6/67.3%. Favourable crisis resolution was associated with [OR (95%CI)]: orthopaedic as main diagnosis [2.00 (1.22-3.29)], Barthel score at admission higher than 40 points [2.00 (1.18-3.38)], and the absence of pressure ulcers at admission [2.80 (1.68-4.65)]. CONCLUSIONS: Patients presenting with an orthopaedic diagnosis, not having severe disability at admission, and not having pressure ulcers at admission could obtain better results on favourable crisis resolution. Suffering cognitive impairment or delirium, or being institutionalised, was not found related with less favourable results.

[Complexity and prevalence of geriatric syndromes in patients treated in intermediate care units in Catalonia: A multicentre study of XARESS project]. / Complejidad y prevalencia de síndromes geriátricos de los pacientes atendidos en unidades sociosanitarias en Catalunya. Estudio multicéntrico del proyecto XARESS.

BACKGROUND: Descriptive study is presented on the complexity and prevalence of geriatric syndromes (GS) in Intermediate Care Units in Catalonia. METHODS: A retrospective study was conducted on 6471 stays completed during the year 2014 in the participating centres of the XARESS network. Data was obtained by extracting the information routinely collected on the CMBD-RSS registry (Minimum Basic Dataset for the Intermediate Care Resources). The prevalence and associations between geriatric síndromes (resource group) RG category, length of stay, and destination at discharge is described. Results were stratified by type of unit (convalescence or long stay). RESULTS: Participants presented a median of 3 GS at admission in long stay units, and 2 GS at admission in convalescence units. The number of GS varied with RG category, although in all RG categories, there were patients without complexity (no SG), and patients with extreme complexity (up to 9 GS). Patients with geriatric syndromes had a longer mean length of stay and greater dependence than patients without syndromes, although with great variability across GS. However, the presence of geriatric syndromes had no impact on the destination at discharge. CONCLUSIONS: The population cared for in intermediate care units have high complexity and a high prevalence of geriatric syndromes at admission. The CMBD-RSS registry allows the characterisation of complexity of the population admitted to the Catalan convalescence and long term intermediate care units.

Recommendations on non-Pharmacological Treatment in Chronic Obstructive Pulmonary Disease From the Spanish COPD Guidelines (GesEPOC 2017). / Recomendaciones sobre tratamiento no farmacológico en la enfermedad pulmonar obstructiva crónica de la Guía española de la EPOC (GesEPOC 2017).

Non-pharmacological treatment is essential in patients with chronic obstructive pulmonary disease (COPD), but this treatment is sometimes not given the importance it deserves. Patients diagnosed with COPD should benefit from comprehensive care services. These services comprise a protocolized set of actions aimed at covering the health needs of the patient, taking into account their environment and circumstances. Pulmonary rehabilitation is one of the essential components of non-pharmacological treatment in comprehensive COPD care services. In the Spanish COPD Guidelines (GesEPOC) 2017, we provided a systematic report of the scientific evidence for pulmonary rehabilitation programs in acute and stable phase disease. Another important issue in the non-pharmacological treatment of COPD is physical activity, and the most essential considerations regarding prescription are described in the GesEPOC guidelines, along with a review of the most effective strategies to ensure adherence. GesEPOC 2017 aims to underline the importance of non-pharmacological treatment as a co-adjuvant to pharmacological treatment.

Prácticas clave y conocimientos maternos de la -Estrategia AIEPI en el Ambiente Comunitario / Key practices and maternal knowledge regarding the IMCI strategy in a community setting / Práticas-chave e conhecimentos maternos da Estratégia AIEPI no Ambiente Comunitário

Resumen La estrategia de Atención Integral a Enfermedades Prevalentes de la Infancia (AIEPI) busca disminuir la enfermedad y la mortalidad en menores de 5 años, por medio de la implementación de acciones orientadas a una atención idónea, tanto en el ámbito asistencial como en el hogar y en la comunidad. El objetivo fue identificar y clasificar los reportes que se han publicado con respecto a la aplicación de las prácticas clave, y a los conocimientos maternos y de cuidadores de la estrategia AIEPI en el mundo. Se recopilaron publicaciones nacionales e internacionales, escritas en inglés y español, que estuvieran registradas en las bases de datos o fuentes de información Scielo, Bireme, Pubmed, Google académico y tesis académicas. La mayoría de los artículos presentan niveles de evidencia VII y VIII, ya que son estudios de casos y controles y descriptivos. Los estudios relacionados con conocimientos maternos evidencian las falencias que presentan los padres y/o cuidadores de los menores de 5 años, con relación a las acciones y estrategias que deben ejercer frente al manejo apropiado de las enfermedades prevalentes. Con respecto a las prácticas clave, los estudios que hicieron parte de la presente revisión de la literatura coinciden en demostrar su efectividad, en cuanto al mejoramiento de las condiciones de salud y bienestar de los menores de 5 años que son objeto de su aplicación. Los estudios concuerdan en la importancia de adelantar procesos educativos que fortalezcan el conocimiento y la aplicación de las prácticas clave, y de la estrategia en general, tanto en las comunidades como en los profesionales de la salud.

Abstract The Integrated Management of Childhood Illness (IMCI) strategy aims to reduce disease and mortality among children under five years of age through the implementation of actions aimed at providing adequate care at the medical, home and community levels. The objective was to identify and classify the reports that have been published regarding the application of key practices and the knowledge that mothers and caregivers have regarding the IMCI strategy in the world. To this end, national and international publications were collected which were written in English or Spanish and registered in databases or information sources such as Scielo, Bireme, Pubmed, Google Scholar and academic theses. The evidence levels of most papers were VII and VIII because they were case, controls and descriptive studies. The studies on maternal knowledge showed the shortcomings of parents and/or caregivers of children under five years of age concerning the actions and strategies that should be applied to appropriately manage prevalent diseases. Regarding key practices, the studies considered in this literature review are consistent in demonstrating their effectiveness in improving the health and welfare conditions among children under five years of age, on whom they are applied. The studies also agree on the importance of advancing educational processes which strengthen the knowledge and application of the key practices as well as the strategy in general, for both communities and healthcare professionals.

Resumo A estratégia de Assistência Integral a Doenças Prevalentes da Infância (AIEPI) visa diminuir doenças e a mortalidade em menores de 5 anos, por meio da implantação de ações destinadas a um atendimento idôneo, tanto no plano assistencial quanto no lar e na comunidade. O propósito foi identificar e classificar os relatórios que têm sido publicados sobre a aplicação das práticas-chave, e sobre os conhecimentos maternos e de protetores da estratégia AIEPI no mundo. Foram coletadas publicações nacionais e internacionais, escritas em inglês e espanhol, que estivessem registradas nas bases de dados ou fontes de informação Scielo, Bireme, Pubmed, Google acadêmico e teses acadêmicas. A maioria dos artigos apresentam níveis de evidência VII e VIII, pois são estudos de casos e controles e descritivos. Os estudos relacionados com conhecimentos maternos evidenciam as falhas que apresentam os pais e/ou pessoas encarregadas do cuidado dos menores de 5 anos, com relação às ações e estratégias que devem exercer diante do controle apropriado das doenças prevalentes. Com relação às práticas-chave, os estudos que fizeram parte desta revisão da literatura coincidem em demonstrar a sua efetividade, quanto à melhora das condições de saúde e bem-estar dos menores de 5 anos que são objeto da sua aplicação. Os estudos concordam na importância de se desenvolver processos educativos que fortaleçam o conhecimento e a aplicação das práticas-chave, e da estratégia em geral, tanto nas comunidades quanto nos profissionais da saúde.