Pr��vention quaternaire: agir est-il toujours justifi�� en m��decine de famille [Quaternary prevention: is acting always justified in family medicine?].

Quaternary prevention aims to protect the patient or population against overmedicalisation. Quaternary prevention influences all the activities of family medicine by questioning the utility of primary prevention and early diagnosis, identifying the risks of creating new pathological entities and practicing a maximalist medicine. Family doctors can support quaternary prevention by focusing on their patients' priorities and the local resources of an efficient health system.

Stress ulcer prophylaxis in non-critically ill patients: a prospective evaluation of current practice in a general surgery department

Objective: There is little evidence regarding the benefit of stress ulcer prophylaxis (SUP) outside critical care setting. Over-prescription of SUP is not devoid of risks. This prospective study aimed to evaluate the use of proton pump inhibitors (PPIs) for SUP in a general surgery department.Methods: Data collection was performed prospectively during an 8-week period on patients hospitalized in a general surgery department (58 beds) by pharmacists. Patients with a PPI prescription for the treatment of ulcers, gastro-oesophageal reflux disease, oesophagitis or epigastric pain were excluded. Patients admitted twice during the study period were not re-included. The American Society of Health-System Pharmacists guidelines on SUP were used to assess the appropriateness of de novo PPI prescriptions.Results: Among 255 consecutive patients in the study, 138 (54%) received a prophylaxis with PPI, of which 86 (62%) were de novo PPI prescriptions. One-hundred twenty-nine patients (94%) received esomeprazole (according to the hospital drug policy). The most frequent dosage was 40 mg/day. Use of PPI for SUP was evaluated in 67 patients. Fifty-three patients (79%) had no risk factors for SUP. Twelve and 2 patients had one or two risk factors, respectively. At discharge, PPI prophylaxis was continued in 34% of patients with a de novo PPI prescription.Conclusion: This study highlights the overuse of PPIs in non-ICU patients and the inappropriate continuation of PPI prescriptions at discharge.Treatment

Patients ��g��s admis aux urgences suite �� une chute: que faire [Older people admitted to the emergency department after a fall: what to do?].

Falls in older people are frequent. Falls may lead to serious injuries and are associated with greater morbidity, mortality, and reduced overall functioning in the older population. Evidences exist regarding the beneficial effects of fall prevention programs. However, these interventions are rarely implemented in our health system. Older people admitted to the emergency department after a fall should get careful attention in order to initiate specific interventions to prevent new falls. This article provides a clinical assessment strategy to evaluate older persons after a fall and proposes an algorithm for discharge planning decision.

Medicaid Value Management Program SFY 2008 Report Executive Summary, 2007

In June, 2007, the Commonwealth Fund released a report entitled, ���Aiming Higher: Results from a State Scorecard on Health System Performance.��� The report ranked states��� health care performance based upon four areas: access, quality, potentially avoidable use of hospitals and costs of care, and healthy lives. Iowa was ranked second overall and was the only state to rank in the top 25 percent on each of the four measures.1 Coupling the HEDIS measures and CAHPS survey results with the Commonwealth report outcomes provides additional information for determining how the state performs with regard to the health care system, in general, and the Medicaid program specifically. For the past five years the results of eight outcome measures encompassing children and adults, and preventive, chronic and acute care have been reported by the University of Iowa Public Policy Center (PPC). The PPC is the independent evaluator for the Medicaid managed care programs and assists the state in an effort to understand the process of care within the Medicaid program. Seven of the eight measures are recommended by the Centers for Medicare and Medicaid, while the eighth, annual dental visit, is used in recognition of the challenges found in providing dental care to Medicaid���enrolled children and adults.

Penser la m��decine communautaire s'apprend avec les pairs. [The spirit of community medicine: students learning from students].

At the University of Lausanne third-year medical students are given the task of spending a month investigating a question of community medicine. In 2009, four students evaluated the legitimacy of health insurers intervening in the management of depression. They found that health insurers put pressure on public authorities during the development of legislation governing the health system and reimbursement for treatment. This fact emerged during the scientific investigation led jointly by the team in the course of the "module of immersion in community medicine." This paper presents each step of their study. The example chosen illustrates the learning objectives covered by the module.

Misleading tacrolimus concentration value in blood taken from a catheter used for tacrolimus administration.

PURPOSE: A misleading blood tacrolimus concentration (BTC) value caused by the contamination of a central venous catheter previously used for tacrolimus administration is described. SUMMARY: A 59-year-old woman with severe chronic obstructive pulmonary disease successfully underwent double lung transplantation. In the intensive care unit, she received a continuous i.v. infusion of tacrolimus from days 1 to 5 after transplantation through the distal lumen of a polyurethane triple-lumen central venous catheter. The catheter lumen was flushed twice a day with 0.9% sodium chloride injection. The proximal lumen was used for blood sampling after being flushed; the first 10 mL of blood was discarded. BTCs determined in whole blood one, four, and five days after transplantation were within the therapeutic range of 5-15 ng/mL. On day five the patient was transferred to the thoracic surgery ward and was switched to oral tacrolimus 1.5 mg twice daily. The BTC on day 6 was unexpectedly high at 134.5 ng/mL. The patient's clinical status was normal, and no signs of tacrolimus toxicity were observed. On day 7, blood samples were drawn from a peripheral vein and simultaneously through the central venous catheter. Although the central venous catheter had not been exposed to tacrolimus during the preceding two days, it yielded blood with a BTC eight times higher than the BTC in blood from the peripheral vein (41.4 ng/mL versus 5.1 ng/mL). CONCLUSION: The collection of blood from a central venous catheter lumen that had been used for tacrolimus administration resulted in a BTC about eight times higher than what was measured in peripheral blood.

ICD-11 for quality and safety: overview of the who quality and safety topic advisory group.

This paper outlines the approach that the WHO's Family of International Classifications (WHO-FIC) network is undertaking to create ICD-11. We also outline the more focused work of the Quality and Safety Topic Advisory Group, whose activities include the following: (i) cataloguing existing ICD-9 and ICD-10 quality and safety indicators; (ii) reviewing ICD morbidity coding rules for main condition, diagnosis timing, numbers of diagnosis fields and diagnosis clustering; (iii) substantial restructuring of the health-care related injury concepts coded in the ICD-10 chapters 19/20, (iv) mapping of ICD-11 quality and safety concepts to the information model of the WHO's International Classification for Patient Safety and the AHRQ Common Formats; (v) the review of vertical chapter content in all chapters of the ICD-11 beta version and (vi) downstream field testing of ICD-11 prior to its official 2015 release. The transition from ICD-10 to ICD-11 promises to produce an enhanced classification that will have better potential to capture important concepts relevant to measuring health system safety and quality-an important use case for the classification.

Valoraci��n del patr��n sexualidad en las personas usuarias de los servicios sanitarios

Desde enfermer��a es necesario realizar una valoraci��n integral del usuario de los servicios sanitarios. La persona es un ser biopsicosocial y se hace necesario una visi��n en su integridad. La sexualidad forma parte de nuestra vida cotidiana y es un aspecto fundamental en la vida de todos nosotros. Sin embargo, parece ser excluida por los profesionales de enfermer��a, cuando el usuario entra dentro del sistema de salud. Independientemente de la patolog��a que sufra el sujeto de nuestros cuidados, la sexualidad est�� presente y forma parte de su vivencia personal y cotidiana. La influencia del sistema biom��dico hace que muchas veces la sexualidad sea tratada desde la patogenia, obviando la valoraci��n de una vivencia de una sexualidad saludable. La sexualidad es observada, en muchas ocasiones desde una perspectiva ��nicamente heterosexual, o ligada ��nicamente a la reproducci��n, negando con esta actitud la vivencia de una sexualidad a muchos de nuestros pacientes. Deber��amos ofrecer unos cuidados integrales y hol��sticos, pero tanto en la formaci��n enfermera como en la pr��ctica, en muchas ocasiones, excluimos el patr��n sexualidad, convirti��ndolo as�� en un tema tab��.A trav��s de un estudio cuantitativo, no experimental descriptivo y transversal se pretende conocer por qu�� las enfermeras y enfermeros no exploramos suficientemente el patr��n de sexualidad de los usuarios y cu��les son las causas que nos impiden hacerlo. El estudio se realizar�� a partir de un cuestionario, distribuido entre los enfermeros y enfermeras de los diferentes servicios sanitarios del parc de salut mar.

Intervenci�� educativa per a la millora de la detecci�� preco�� de la depressi�� major en adolescents

La depressi�� major ��s una patologia mental que afecta a persones de qualsevol edat, condici�� econ��mica, nivell educatiu, cultural i suposen un gran cost per l���individu, la fam��lia, el sistema sanitari i la comunitat en general. Es creu que una de cada cinc persones arribar�� a desenvolupar un trastorn depressiu al llarg de la seva vida i que al 2020 ser�� la segona causa de discapacitat i de p��rdua d���anys de vida saludables a escala mundial i la primera en pa��sos desenvolupats. L���objectiu d���aquest estudi quasi experimental ��s millorar la detecci�� preco�� de la simptomatologia depressiva en adolescents, descriure els factors de risc i atendre les necessitats d���aquests joves. Utilitzarem el Test de Beck Depression Inventory-2nd (BDI-II) i el Patient Health Questionnaire-Adolescent version (PHQ-9) per detectar l���estat de salut mental dels alumnes. No tenim la certesa de que la mostra sigui representativa, ja que escollim un grup intacte d���alumnes de 1r d��� ESO, del municipi de Cardedeu, amb una edat per norma general de 12 -13 anys i per tant, potser una amena��a per la nostra validaci�� ja que el factor entorn influeix directament en la situaci�� sociodemografica de la poblaci�� escollida, la situaci�� econ��mica i familiar.

The burden of hospital malnutrition in Spain: methods and development of the PREDyCES�� study

It is well known that hospital malnutrition is a highly prevalent condition associated to increase morbidity and mortality as well as related healthcare costs. Although previous studies have already measured the prevalence and/or costs of hospital nutrition in our country, their local focus (at regional or even hospital level) make that the true prevalence and economic impact of hospital malnutrition for the National Health System remain unknown in Spain. The PREDyCES�� (Prevalence of hospital malnutrition and associated costs in Spain) study was aimed to assess the prevalence of hospital malnutrition in Spain and to estimate related costs. Some aspects made this study unique: a) It was the first study in a representative sample of hospitals of Spain; b) different measures to assess hospital malnutrition (NRS2002, MNA as well as anthropometric and biochemical markers) where used both at admission and discharge and, c) the economic consequences of malnutrition where estimated using the perspective of the Spanish National Health System.

Stress ulcer prophylaxis in non-critically ill patients: a prospective evaluation of the practice in a surgical ward

Introduction The benefit of stress ulcer prophylaxis (SUP) in noncriticallyill patients has not been proved. Over-prescription of SUP isnot devoided of risks (i.e. drug-drug interactions, adverse events).This prospective study aimed to evaluate the use of proton pumpinhibitors (PPIs) for SUP in a visceral surgery ward.Materials & Methods Data collection was performed prospectivelyduring a 8-week period on patients hospitalized in a visceral surgeryward (58 beds). Patients with a PPI prescription for the treatment ofulcers, gastroesophageal reflux disease, esophagitis or epigastralgiawere excluded as well as patients hospitalized twice during the studyperiod. The American Society of Health-System Pharmacists guidelineson SUP were used to assess the appropriateness of de novo PPIprescriptions.Results Among 255 patients in the study, 138 (54.1%) received aprophylaxis with PPI, of which 86 (62.3%) were de novo PPI prescriptions.93.5% of patients received esomeprazole (according to thehospital drug formulary) mainly orally at 40 mg qd. 79.1% of patientshad no risk factors for SUP. 17.9% and 3.0% had one and two riskfactors, respectively. 95% of the patients with PPI were not hospitalizedin the intensive care unit (ICU) before their stay in the visceralsurgery ward. At discharge, PPI therapy was continued in 34.2% ofpatients with a de novo PPI prescription.Discussion & Conclusion This study highlights the over-utilizationof PPIs in non-ICU patients and the inappropriate continuation of PPIprescriptions at discharge. The PPI dosage prescribed for prophylaxiswas probably too high compared with the data of the literature.Treatment recommendations for SUP are needed to restrict PPIuse for justified indications.

Abordaje en las heridas de dif��cil cicatrizaci��n

Los conocimientos sobre la cicatrizaci��n han evolucionado de forma importante en las ��ltimas dos d��cadas. Gracias a ello, actualmente es posible predecir la secuencia probable de acontecimientos que tendr��n lugar a lo largo de la cicatrizaci��n y pronosticar el tiempo aproximado que tardar�� una herida, pero a menudo, durante la pr��ctica cl��nica, y a pesar del mayor conocimiento y desarrollo de intervenciones, muchos profesionales de enfermer��a se enfrentan a diario ante heridas de dif��cil cicatrizaci��n, es decir, la cicatrizaci��n se prolonga en el tiempo o no se llega a alcanzar. Estos esfuerzos pueden provocar al profesional un aumento del estr��s psicosocial y ansiedad, convirti��ndose en una carga financiera importante para el sistema de salud, ya de por s��, tan necesitado en los tiempos actuales. Estas heridas complejas siguen siendo en la actualidad un problema prevalente y de especial atenci��n en salud, que afecta a pacientes en todos los niveles asistenciales y de todas las clases sociales. Requieren un compromiso de todos los profesionales de salud respecto a la prevenci��n y atenci��n de las mismas hasta el punto final de la cicatrizaci��n, por lo que los profesionales sanitarios, deben potenciar avances y conocimientos que permitan un cambio radical en la atenci��n de estas lesiones.

Modernitzaci�� tecnol��gica, canvi organitzatiu i serveis als usuaris en el sistema de salut de Catalunya. Informe de recerca (volum III)

Aquest estudi va analitzar la interacci�� del canvi organitzatiu, els valors culturals i el canvi tecnol��gic en el sistema sanitari catal��. L'estudi se subdivideix en cinc parts diferents. La primera ��s una an��lisi de contingut de webs relacionats amb la salut a Catalunya. La segona ��s un estudi dels usos d'Internet en q��estions relacionades amb la salut entre la poblaci�� en general, les associacions de pacients i els professionals de la salut, i es basa en un sondeig per Internet adaptat a cada un d'aquests grups. La tercera part ��s un estudi de treball de camp dels programes experimentals duts a terme pel Govern catal�� en diverses ��rees i hospitals locals per a integrar electr��nicament la hist��ria cl��nica dels pacients. La quarta ��s un estudi de les implicacions organitzatives de la introducci�� de sistemes d'informaci�� en la gesti�� d'hospitals i centres d'assist��ncia prim��ria a l'Institut Catal�� de Salut, el principal prove��dor de salut p��blica a Catalunya, i es basa en un sondeig per Internet i entrevistes en profunditat. La cinquena part ��s un estudi de cas dels efectes organitzatius i socials de la introducci�� de les tecnologies de la informaci�� i la comunicaci�� en un dels principals hospitals de Catalunya, l'Hospital Cl��nic de Barcelona. L'estudi es va dur a terme entre el maig del 2005 i el juliol del 2007.

Modernizaci��n tecnol��gica, cambio organizativo y servicio a los usuarios en el sistema de salud de Catalunya. Informe de investigaci��n (documento de s��ntesis)

Aquest estudi va analitzar la interacci�� del canvi organitzatiu, els valors culturals i el canvi tecnol��gic en el sistema sanitari catal��. L'estudi se subdivideix en cinc parts diferents. La primera ��s una an��lisi de contingut de webs relacionats amb la salut a Catalunya. La segona ��s un estudi dels usos d'Internet en q��estions relacionades amb la salut entre la poblaci�� en general, les associacions de pacients i els professionals de la salut, i es basa en un sondeig per Internet adaptat a cada un d'aquests grups. La tercera part ��s un estudi de treball de camp dels programes experimentals duts a terme pel Govern catal�� en diverses ��rees i hospitals locals per a integrar electr��nicament la hist��ria cl��nica dels pacients. La quarta ��s un estudi de les implicacions organitzatives de la introducci�� de sistemes d'informaci�� en la gesti�� d'hospitals i centres d'assist��ncia prim��ria a l'Institut Catal�� de Salut, el principal prove��dor de salut p��blica a Catalunya, i es basa en un sondeig per Internet i entrevistes en profunditat. La cinquena part ��s un estudi de cas dels efectes organitzatius i socials de la introducci�� de les tecnologies de la informaci�� i la comunicaci�� en un dels principals hospitals de Catalunya, l'Hospital Cl��nic de Barcelona. L'estudi es va dur a terme entre el maig del 2005 i el juliol del 2007.

Modernitzaci�� tecnol��gica, canvi organitzatiu i serveis als usuaris en el sistema de salut de Catalunya. Informe de recerca (volum I)

Aquest estudi va analitzar la interacci�� del canvi organitzatiu, els valors culturals i el canvi tecnol��gic en el sistema sanitari catal��. L'estudi se subdivideix en cinc parts diferents. La primera ��s una an��lisi de contingut de webs relacionats amb la salut a Catalunya. La segona ��s un estudi dels usos d'Internet en q��estions relacionades amb la salut entre la poblaci�� en general, les associacions de pacients i els professionals de la salut, i es basa en un sondeig per Internet adaptat a cada un d'aquests grups. La tercera part ��s un estudi de treball de camp dels programes experimentals duts a terme pel Govern catal�� en diverses ��rees i hospitals locals per a integrar electr��nicament la hist��ria cl��nica dels pacients. La quarta ��s un estudi de les implicacions organitzatives de la introducci�� de sistemes d'informaci�� en la gesti�� d'hospitals i centres d'assist��ncia prim��ria a l'Institut Catal�� de Salut, el principal prove��dor de salut p��blica a Catalunya, i es basa en un sondeig per Internet i entrevistes en profunditat. La cinquena part ��s un estudi de cas dels efectes organitzatius i socials de la introducci�� de les tecnologies de la informaci�� i la comunicaci�� en un dels principals hospitals de Catalunya, l'Hospital Cl��nic de Barcelona. L'estudi es va dur a terme entre el maig del 2005 i el juliol del 2007.