Derivaciones en los centros de salud de Andalucía según el sexo de profesionales y pacientes: un análisis de género.

BACKGROUND It has been identified differences of medical care practice in primary care related to physician's sex. Simultaneously, there are gender inequalities in the assignment of health resources. Both aspects give rise to an increasing growing interest in the management and provision of health services. OBJECTIVES To examine the differences in the referral practice made by female and male primary care physicians working in health centers in Andalusia, to consider whether there are disparities in referrals received by men and women, and to examine the interaction between patient's sex and physician's sex. METHODS Observational, cross-sectional, and multicenter study. POPULATION 4 health districts in Andalucía and their physicians. SAMPLE 382 physicians. MEASUREMENTS referral rate per visit (RV), referral rate per patient quota (RQ), patient's sex, physician: sex, age, postgraduate family medicine specialty, size of the patient quota by sex, mean number of patients/day by sex, mean age of the patient quota by sex, and proportion of men in the quota. Health center: urban / rural, size of the team, enrolled population, and postgraduate family medicine specialty's accreditation. SOURCES databases of health districts. PERIOD OF STUDY 2010. ANALYSIS Bivariate and multivariate multilevel analysis of the referral rate per visit with mixed Poisson model. RESULTS In 2010 382 physicians made 129,161 referrals to specialized care. The RQ was 23.47 and the RV was 4.92. The RQ in women and men was 27.23 and 19.78 for women physicians, being 27.37 and 19.51 for male physicians. The RV in women and men was 4.92 and 5.48 for women physicians, being 4.54 and 4.93 for male physicians. CONCLUSION There are no differences in referral according to physician's sex. However, there are signs that might indicate the existence of gender inequality, and women patient received less referrals. There are no physician-patient's sex interaction.

Identification of factors associated with diagnostic error in primary care.

BACKGROUND Missed, delayed or incorrect diagnoses are considered to be diagnostic errors. The aim of this paper is to describe the methodology of a study to analyse cognitive aspects of the process by which primary care (PC) physicians diagnose dyspnoea. It examines the possible links between the use of heuristics, suboptimal cognitive acts and diagnostic errors, using Reason's taxonomy of human error (slips, lapses, mistakes and violations). The influence of situational factors (professional experience, perceived overwork and fatigue) is also analysed. METHODS Cohort study of new episodes of dyspnoea in patients receiving care from family physicians and residents at PC centres in Granada (Spain). With an initial expected diagnostic error rate of 20%, and a sampling error of 3%, 384 episodes of dyspnoea are calculated to be required. In addition to filling out the electronic medical record of the patients attended, each physician fills out 2 specially designed questionnaires about the diagnostic process performed in each case of dyspnoea. The first questionnaire includes questions on the physician's initial diagnostic impression, the 3 most likely diagnoses (in order of likelihood), and the diagnosis reached after the initial medical history and physical examination. It also includes items on the physicians' perceived overwork and fatigue during patient care. The second questionnaire records the confirmed diagnosis once it is reached. The complete diagnostic process is peer-reviewed to identify and classify the diagnostic errors. The possible use of heuristics of representativeness, availability, and anchoring and adjustment in each diagnostic process is also analysed. Each audit is reviewed with the physician responsible for the diagnostic process. Finally, logistic regression models are used to determine if there are differences in the diagnostic error variables based on the heuristics identified. DISCUSSION This work sets out a new approach to studying the diagnostic decision-making process in PC, taking advantage of new technologies which allow immediate recording of the decision-making process.

Guía de buenas prácticas para mejorar la facturación por la asistencia sanitaria a ciudadanos de la UE en el SSPA

Esta guía ha sido elaborada y editada como parte de las actividades del proyecto de investigación “Como mejorar la recuperación de costes derivados de la asistencia sanitaria a ciudadanos de la Unión Europea en la Comunidad Autónoma de Andalucía”. Inés García-Sánchez, editora

Influencia de un programa de actividad física en niños y adolescentes obesos con apnea del sueño; protocolo de estudio.

Recent studies show an alarming increase in the rate of overweight / obesity among the infant - juvenile population. Obesity in childhood is associated with a significant number of complications, such as sleep apnea syndrome, insulin resistance and type 2 diabetes, hypertension, cardiovascular disease and some cancers. It is estimated that the prevalence of sleep apnea in children is 2-3% in the general population, while in obese adolescents, varies between 13% and 66%, according to various studies. It is associated with impairment of neurocognitive function, behavior, cardiovascular system, metabolic disorders and growth. Sleep apnea is a serious public health problem that increases when children and adolescents are overweight or obese. We hypothesize that aerobic endurance exercise can be an effective treatment for obesity and apnea at the same time. The aim of this study was to determine the influence of physical activity in children and adolescents with overweight / obesity in sleep apnea. An observational, descriptive, prospective, longitudinal study will be carried out in children with sleep apnea and obesity. The universe will be made up of 60 children and adolescents aged between 10 and 18 years, attending the endocrinology service for suffering of obesity in the Hospital Clinico San Cecilio of Granada during the period September 2012-September 2013. The smple will consist of children and adolescents that meet these characteristics and to hom their arents/tutors have authorized through the informed consent. Sleep apnea in children wil be measured by polysomnography and sleep quality questionnaire. There will also be a nutritional assessment by a food frequency questionnaire and an anthropometric assessment. Among the expected results are the lower overweight and obesity in children through the physical activity program. To reduce apnea and to improve sleep quality

HLA and non-HLA genes in Behçet's disease: a multicentric study in the Spanish population.

INTRODUCTION According to genome wide association (GWA) studies as well as candidate gene approaches, Behçet's disease (BD) is associated with human leukocyte antigen (HLA)-A and HLA-B gene regions. The HLA-B51 has been consistently associated with the disease, but the role of other HLA class I molecules remains controversial. Recently, variants in non-HLA genes have also been associated with BD. The aims of this study were to further investigate the influence of the HLA region in BD and to explore the relationship with non-HLA genes recently described to be associated in other populations. METHODS This study included 304 BD patients and 313 ethnically matched controls. HLA-A and HLA-B low resolution typing was carried out by PCR-SSOP Luminex. Eleven tag single nucleotide polymorphisms (SNPs) located outside of the HLA-region, previously described associated with the disease in GWA studies and having a minor allele frequency in Caucasians greater than 0.15 were genotyped using TaqMan assays. Phenotypic and genotypic frequencies were estimated by direct counting and distributions were compared using the χ(2) test. RESULTS In addition to HLA-B*51, HLA-B*57 was found as a risk factor in BD, whereas, B*35 was found to be protective. Other HLA-A and B specificities were suggestive of association with the disease as risk (A*02 and A*24) or protective factors (A*03 and B*58). Regarding the non-HLA genes, the three SNPs located in IL23R and one of the SNPs in IL10 were found to be significantly associated with susceptibility to BD in our population. CONCLUSION Different HLA specificities are associated with Behçet's disease in addition to B*51. Other non-HLA genes, such as IL23R and IL-10, play a role in the susceptibility to the disease.

Efecto del phlebodium decumanum y de la coenzima q10 sobre el rendimiento deportivo en jugadores profesionales de voleibol

INTRODUCTION: Physical training programmes are based on provoking transitory states of fatigue in order to induce super compensation by the biological systems involved in the activity, in order to improve the athlete's medium-long term performance. The administration of nutritional supplements with antioxidant and immunomodulatory properties, such as Phlebodium decumanum and coenzyme Q10, can be a very advantageous means of achieving recovery from the inflammation and tissue damage caused by the stress of prolonged, intense exercise. METHODOLOGY: An experimental, longitudinal, double- blind experiment was conducted, with three randomised groups obtained from a sample of 30 male volleyball players (aged 22-32 years) at the University of Granada, with a high level of training (17 hours a week during the 6 months preceding the study). The effects were then evaluated of a month-long physical training programme, common to all the study groups, associated with the simultaneous administration of the following nutritional supplements: Phlebodium decumanum (4 capsules of 400 mg/capsule, daily), Experimental Group 1; Phlebodium decumanum (same dose andchedule as Group 1) plus coenzyme Q10 (4 capsules of 30 mg/ capsule, daily), Experimental Group 2; a placebo substance, Control Group. The following dependent blood variables were examined to assess the effects of the intervention on the basal immune and endocrine-metabolic profile: cortisol and interleukin-6, both related to the axis of exercise-induced stress; and lactic acid and ammonium, related essentially to the anaerobic metabolism of energy. RESULTS: All the study groups presented favourable adaptive changes with respect to the endocrine-metabolic and immune profile, as reflected by a significant decrease in the post-test concentrations of cortisol, interleukin 6, lactic acid and ammonium, compared to the values recorded before the physical activity with/without nutritional supplement, per protocol. The groups that achieved the most favourable profile were those which had received nutritional supplementation, rather than the placebo, and among the former, those which had received the double- strength supplement with Phlebodium decumanum plus coenzyme Q10. CONCLUSIONS: The intake of Phlebodium decumanum plus coenzyme Q10 for 4 weeks produced protective effects on the endocrine-metabolic and immune profile, which we attribute to the immunomodulatory and antioxidant properties of these substances, which are highly beneficial not only in terms of delaying fatigue and improving athletic performance, but also in reducing the risk of injuries associated with high intensity exercise.

Complications of laparoscopic gynecologic surgery.

BACKGROUND AND OBJECTIVES To analyze the frequency of complications during laparoscopic gynecologic surgery and identify associated risk factors. METHODS A descriptive observational study was performed between January 2000 and December 2012 and included all gynecologic laparoscopies performed at our center. Variables were recorded for patient characteristics, indication for surgery, length of hospital stay (in days), major and minor complications, and conversions to laparotomy. To identify risk factors and variables associated with complications, crude and adjusted odds ratios were calculated with unconditional logistic regression. RESULTS Of all 2888 laparoscopies included, most were procedures of moderate difficulty (adnexal surgery) (54.2%). The overall frequency of major complications was 1.93%, and that of minor complications was 4.29%. The level of technical difficulty and existence of prior abdominal surgery were associated with a higher risk of major complications and conversions to laparotomy. CONCLUSION Laparoscopic gynecologic surgery is associated with a low frequency of complications but is a procedure that is not without risk. Greater technical difficulty and prior surgery were factors associated with a higher frequency of complications.

Expression profiling of rectal tumors defines response to neoadjuvant treatment related genes.

To date, no effective method exists that predicts the response to preoperative chemoradiation (CRT) in locally advanced rectal cancer (LARC). Nevertheless, identification of patients who have a higher likelihood of responding to preoperative CRT could be crucial in decreasing treatment morbidity and avoiding expensive and time-consuming treatments. The aim of this study was to identify signatures or molecular markers related to response to pre-operative CRT in LARC. We analyzed the gene expression profiles of 26 pre-treatment biopsies of LARC (10 responders and 16 non-responders) without metastasis using Human WG CodeLink microarray platform. Two hundred and fifty seven genes were differentially over-expressed in the responder patient subgroup. Ingenuity Pathway Analysis revealed a significant ratio of differentially expressed genes related to cancer, cellular growth and proliferation pathways, and c-Myc network. We demonstrated that high Gng4, c-Myc, Pola1, and Rrm1 mRNA expression levels was a significant prognostic factor for response to treatment in LARC patients (p<0.05). Using this gene set, we were able to establish a new model for predicting the response to CRT in rectal cancer with a sensitivity of 60% and 100% specificity. Our results reflect the value of gene expression profiling to gain insight about the molecular pathways involved in the response to treatment of LARC patients. These findings could be clinically relevant and support the use of mRNA levels when aiming to identify patients who respond to CRT therapy.

Pattern of use of radiotherapy for lung cancer: a descriptive study.

BACKGROUND Lung cancer remains one of the most prevalent forms of cancer. Radiotherapy, with or without other therapeutic modalities, is an effective treatment. Our objective was to report on the use of radiotherapy for lung cancer, its variability in our region, and to compare our results with the previous study done in 2004 (VARA-I) in our region and with other published data. METHODS We reviewed the clinical records and radiotherapy treatment sheets of all patients undergoing radiotherapy for lung cancer during 2007 in the 12 public hospitals in Andalusia, an autonomous region of Spain. Data were gathered on hospital, patient type and histological type, radiotherapy treatment characteristics, and tumor stage. RESULTS 610 patients underwent initial radiotherapy. 37% of cases had stage III squamous cell lung cancer and were treated with radical therapy. 81% of patients with non-small and small cell lung cancer were treated with concomitant chemo-radiotherapy and the administered total dose was ≥60 Gy and ≥45 Gy respectively. The most common regimen for patients treated with palliative intent (44.6%) was 30 Gy. The total irradiation rate was 19.6% with significant differences among provinces (range, 8.5-25.6%; p<0.001). These differences were significantly correlated with the geographical distribution of radiation oncologists (r=0.78; p=0.02). Our results were similar to other published data and previous study VARA-I. CONCLUSIONS Our results shows no differences according to the other published data and data gathered in the study VARA-I. There is still wide variability in the application of radiotherapy for lung cancer in our setting that significantly correlates with the geographical distribution of radiation oncologists.

Initial complications and factors related to prehospital mortality in acute myocardial infarction with ST segment elevation.

OBJECTIVE Hospital mortality in myocardial infarction ST-elevation myocardial infarction has decreased in recent years, in contrast to prehospital mortality. Our objective was to determine initial complications and factors related to prehospital mortality in patients with acute myocardial infarction with ST segment elevation (STEMI). METHODS Observational study based on a prospective continuous register of patients of any age attended by out-of-hospital emergency teams in Andalusia between January 2006 and June 2009. This includes patients with acute coronary syndrome-like symptoms whose initial ECG showed ST elevation or presumably new left bundle branch block (LBBB). Epidemiological, prehospital data and final diagnostic were recorded. The study included all patients with STEMI on the register, without age restrictions. Forward stepwise logistic regression analysis was performed to control for confounders. RESULTS A total of 2528 patients were included, 24% were women. Mean age 63.4±13.4 years; 16.7% presented atypical clinical symptoms. Initial complications: ventricular fibrillation (VF) 8.4%, severe bradycardia 5.8%, third-degree atrial-ventricular (AV) block 2.4% and hypotension 13.5%. Fifty-two (2.1%) patients died before reaching hospital. Factors associated with prehospital mortality were female sex (OR 2.36, CI 1.28 to 4.33), atypical clinical picture (OR 2.31, CI 1.21 to 4.41), hypotension (OR 4.95, CI 2.60 to 9.20), LBBB (OR 4.29, CI 1.71 to 10.74), extensive infarction (ST elevation in ≥5 leads) (OR 2.53, CI 1.28 to 5.01) and VF (OR 2.82, CI 1.38 to 5.78). CONCLUSIONS A significant proportion of patients with STEMI present early complications in the prehospital setting, and some die before reaching hospital. Prehospital mortality was associated with female sex and atypical presentation, as pre-existing conditions, and hypotension, extensive infarction, LBBB and VF on emergency team attendance.

Conocimientos y actitudes de los profesionales sanitarios en el proceso de declaración de las voluntades vitales anticipadas.

Objective: To identify the underlying interests of the Living Will Declaration (LWD) process and to determine the consensus, using a questionnaire, of the knowledge and attitudes of health professionals. Design: A study was performed in two phases using a Delphi technique with a Rand method. 1. Dimensions proposed: generation of ideas and their subsequent prioritizing; 2. Proposal andprioritizing of items grouped into blocks of Knowledge and Attitudes, developed between August 2012 and January 2013.Setting: The work was carried out by initial telephone contact with panellists, and then later by the panellists belonged to the Andalusia Public Health System.Participants: The criteria for selecting the eight components of the panel were knowledge andexperience in the field of the freedom of the patient in Andalusia. Results: The Knowledge identified included: 1 A) Legal and general aspects; 2 A) A conceptual definition; 3 A) Standardised LWD documents: 4 A) Practical experience; 5 A) Procedure and registering of the LWDs. The second block included Attitudes: 1 B) Attitudes of the professional in the application of LWDs in clinical practice, and 2 B) Attitudes of the professional in «complex» ethical scenarios The 7 panellists who finally took part proposed 165 items. After applying the prioritizing criteria, scores, and scenario selection, 58 (35.2%) items were identified as suitable scenarios. Conclusions: The proposed questionnaire included wide parcels of concepts and contents that, once validated, will help to measure the training interventions carried out on health professionals in order to improve knowledge and attitudes on the subject of LWDs.

Evaluation of quality improvement for cesarean sections caesarean section programmes through mixed methods.

BACKGROUND The rate of avoidable caesarean sections (CS) could be reduced through multifaceted strategies focusing on the involvement of health professionals and compliance with clinical practice guidelines (CPGs). Quality improvements for CS (QICS) programmes (QICS) based on this approach, have been implemented in Canada and Spain. OBJECTIVES Their objectives are as follows: 1) Toto identify clusters in each setting with similar results in terms of cost-consequences, 2) Toto investigate whether demographic, clinical or context characteristics can distinguish these clusters, and 3) Toto explore the implementation of QICS in the 2 regions, in order to identify factors that have been facilitators in changing practices and reducing the use of obstetric intervention, as well as the challenges faced by hospitals in implementing the recommendations. METHODS Descriptive study with a quantitative and qualitative approach. 1) Cluster analysis at patient level with data from 16 hospitals in Quebec (Canada) (n = 105,348) and 15 hospitals in Andalusia (Spain) (n = 64,760). The outcome measures are CS and costs. For the cost, we will consider the intervention, delivery and complications in mother and baby, from the hospital perspective. Cluster analysis will be used to identify participants with similar patterns of CS and costs based, and t tests will be used to evaluate if the clusters differed in terms of characteristics: Hospital level (academic status of hospital, level of care, supply and demand factors), patient level (mother age, parity, gestational age, previous CS, previous pathology, presentation of the baby, baby birth weight). 2) Analysis of in-depth interviews with obstetricians and midwives in hospitals where the QICS were implemented, to explore the differences in delivery-related practices, and the importance of the different constructs for positive or negative adherence to CPGs. Dimensions: political/management level, hospital level, health professionals, mothers and their birth partner. DISCUSSION This work sets out a new approach for programme evaluation, using different techniques to make it possible to take into account the specific context where the programmes were implemented.

International regimes as knowledge syndicates? Energy and trends of global governance

El poder de l'Estat i la sobirania tradicional s'està deteriorant de manera constant, sobretot en termes de la provisió de certs béns públics fonamentals. Els Estats, en particular, són incapaços de manejar el coneixement i la informació que és essencial per mantenir la competitivitat i la sostenibilitat en una economia interdependent. Estructures fiables de la governança mundial i la cooperació internacional estan lluny de ser establertes. Energia com a problema a les agendes p dels governs, les empreses privades i la societat civil és un exemple manifest d'aquesta dinàmica.. L'actual sistema de governança mundial d'energia implica accions polítiques disperses per actors divers. L'Agència Internacional de l'Energia té un paper destacat, però està debilitat per la seva composició limitada i basada en el coneixement- epistèmic en lloc del material o executiu. Aquest treball sosté que ni la mida ni nombre de membres disponibles estan dificultant la governabilitat mundial d'energia. Més aviat, l'energia és una sèrie de béns públics que es troben als llimbs, on els estats no poden pagar la seva disposició, així com els diversos interessos impedir l'establiment d'una autoritat internacional. Després de la introducció de la teoria del règim internacional i el concepte de coneixement basats en les comunitats epistèmiques, l'article revisa l'estat actual de la governabilitat de l'energia mundia. A continuació es presenta una comparació d'aquesta estructura amb els règims de govern nacional i regional, d'una banda, i amb règims globals ambientals i de salut, de l'altra

A Typology of agents and subjects of regional cooperation: the experience of the Mediterranean Arch

El document és el resultat d'una investigació més àmplia sobre la construcció de l'Arc Mediterrani. El seu objectiu és posar en relleu el notable grau de desenvolupament de la cooperació regional en la matèria, a través d'una anàlisi detallada de les diferents figures institucionalitzades de cooperació territorial existents (o haver existit) a la zona. L'anàlisi s'ha dut a terme des d'un punt de vista temàtic, basat en els objectius prioritaris d'aquestes institucions. En concret, les xifres estudiades es limiten a les institucions formals o les associacions de col · laboració de caràcter específic, com ara euroregions o les agrupacions europees d'interès econòmic, entès com les figures de major institucionalització dels espais transnacionals a nivell europeu. En canvi, hem deixat de banda altres figures, com Interreg (finançat pel FEDER), ja que no són entitats correctament. Encara que de vegades els acords de cooperació establerts per als projectes d'Interreg han donat lloc a algunes de les entitats estudiades aquí.

Els Actors de l’Euroregió Pirineus-Mediterrània. Xarxes, percepcions i expectatives

Segons la nostra hipòtesi, la viabilitat de l’Euroregió Pirineus Mediterrània (EPM) dependrà sobretot de la seva capacitat de mobilitzar, d’implicar i de connectar els actors públics i privats dels diferents nivells territorials als quals s’adreça aquesta iniciativa. Per tant, el grau de coneixement i el posicionament dels diferents actors respecte al projecte resulten essencials a l’hora de definir una estratègia de cooperació d’aquestes característiques. L’objectiu d’aquest document és explicar els resultats de l’enquesta duta a terme amb un miler d’actors públics i privats de l’EPM. Aquesta tenia per objectiu obtenir dades relatives a aspectes clau del context en el que s’insereix el projecte, així com informació rellevant per definir estratègies d’actuació que poden ajudar a desenvolupar les capacitats organitzatives i comunicatives necessàries per gestionar una organització complexa com aquesta. L’estudi empíric es va estructurar al voltant de tres línies d’anàlisi: 1r) el present de l’Euroregió; 2n) El posicionament respecte l’EPM i 3r) El futur de l’EPM