Summary
Aims: To assess the evolution of type 2 diabetes mellitus (T2DM) quality indicators in primary care centers (PCC) as part of the Group for the Study of Diabetes in Primary Care (GEDAPS) ...Continuous Quality Improvement (GCQI) programme in Catalonia.
Methods: Sequential cross‐sectional studies were performed during 1993–2007. Process and outcome indicators in random samples of patients from each centre were collected. The results of each evaluation were returned to each centre to encourage the implementation of correcting interventions. Sixty‐four different educational activities were performed during the study period with the participation of 2041 professionals.
Results: Clinical records of 23,501 patients were evaluated. A significant improvement was observed in the determination of some annual process indicators: HbA1c (51.7% vs. 88.9%); total cholesterol (75.9% vs. 90.9%); albuminuria screening (33.9% vs. 59.4%) and foot examination (48.9% vs. 64.2%). The intermediate outcome indicators also showed significant improvements: glycemic control HbA1c ≤ 7% (< 57 mmol/mol); (41.5% vs. 64.2%); total cholesterol ≤ 200 mg/dl (5.17 mmol/l); (25.5% vs. 65.6%); blood pressure ≤ 140/90 mmHg; (45.4% vs. 66.1%). In addition, a significant improvement in some final outcome indicators such as prevalence of foot ulcers (7.6% vs. 2.6%); amputations (1.9% vs. 0.6%) and retinopathy (18.8% vs. 8.6%) was observed.
Conclusions: Although those changes should not be strictly attributed to the GCQI programme, significant improvements in some process indicators, parameters of control and complications were observed in a network of primary care centres in Catalonia.
To compare the percentage of tobacco consumers obtained by checking Primary care clinical notes (PCCN) with the percentage obtained by a telephone poll of the same people. To compare the record of ...tobacco counselling in the PCCN with that discovered by polling.
Crossover and descriptive study.
Two urban health districts.
Random sample of 450 with PCCN and between 15 and 75 years-old.
A telephone questionnaire with data on tobacco consumption and smokers' perceptions of anti-tobacco counselling. Data obtained from checking the PCCN were: age, gender, basic care unit, number of attendances, pathologies and related risk factors, tobacco consumption and counselling. Tobacco consumption did not figure in 51% of the PCCN. Out of the 108 smokers identified by telephone polling, only 61 had this fact in their PCCN. 55 of these smokers said they had been counselled, which was only recorded on 11 occasions in the PCCN. The probability of receiving counselling increased when patient was over 45, when there were pathologies or related risk factors, with frequency of attendance and with each daily cigarette smoked.
The PCCN substantially under-record tobacco consumption and, especially, counselling. The smokers who receive most counselling are those have already, most probably, smoked for a long time.
A qualitative technique for determining microalbuminuria (Micro-Bumintest) was compared with nephelometry testing in 129 DMNID outpatients with the purpose of validating the method in our medium. The ...sensitivity, specificity, and predictive values of the Micro-Bumintest are calculated with respect to 40, 20, and 17 micrograms/ml, which are figures that indicate a risk of early mortality and/or nephropathy. The sensitivity rates are 100, 85, and 69.2%, and the specificity 91.5, 96.3, and 97%, respectively. Our results were compared as well with those of other authors. The correlation between the Micro-Bumintest and nephelometry was 0.59 (p less than 0.005). The intra- and inter-observer variability is minimal. The conclusion that was drawn is that the Micro-Bumintest is reliable for concentrations greater than 40 micrograms/ml, losing some sensitivity in lower concentrations when applied in the control of primary care patients with DMNID.
Factors affecting catch-up growth after liver transplantation López-Espinosa, Jesús Alberto; Yeste-Fernández, Diego; Iglesias-Berengue, Juan ...
Journal of pediatric endocrinology & metabolism : JPEM,
08/2004, Letnik:
17, Številka:
8
Journal Article
Recenzirano
The reported incidence of catch-up growth following orthotopic liver transplantation (OLT) ranges widely, from 0% to 97%.
We undertook bivariate analysis of multiple factors that might affect ...post-OLT growth in children undergoing OLT, and described the results with different parameters used to determine catch-up growth.
Eighty patients met the inclusion criteria.
Catch-up growth occurred in 14% during the first 6 months, 15% at 1 year, 39% at 2 years, 16% between 3 and 6 years, and 16% after 6 years post-OLT. The earlier catch-up growth was shown in metabolic diagnosis, patients over 10 years old and those without steroids at 1 year post-OLT.
It is difficult to determine an acceptable definition of catch-up growth. We suggest that Zvel score > or =0 is the best parameter to evaluate catch-up growth, since the results are more normally distributed. Patients with prednisone withdrawal later than 1 year post-OLT and those with diagnosis of hepatitis and cirrhosis showed the slowest catch-up growth.
: Background: The diagnosis and treatment of diarrhea in liver transplant recipients often pose a challenge owing to the variety of infectious and non‐infectious causes. However, diagnosis is ...principally focused on ruling out an infectious etiology. Tacrolimus, an immunosuppressive agent generally used after liver transplantation, is absorbed mainly from the duodenum through the upper jejunum. It can be assumed that metabolism of the drug will be influenced by diarrhea.
Methods: Four liver transplant recipients who developed an episode of acute gastroenteritis. Infectious etiology was confirmed; trough tacrolimus levels were measured before, during and after gastroenteritis.
Results: All patients presented a two‐ to three‐fold increase in blood tacrolimus levels after the onset of gastroenteritis.
Conclusions: Until the role played by the intestine in the metabolism of tacrolimus is fully understood, it is prudent to recommend early dose reduction of tacrolimus and careful monitoring of trough levels during diarrheal disorders of any nature in pediatric liver‐transplanted patients.
Hematologic abnormalities as adverse effects related to immunosuppressive drugs in liver-transplanted children are rarely reported. We have observed anemia, neutropenia, and thrombocytopenia in our ...pediatric liver-transplant population. The aim of this study was to exclude all suspected etiologies to define the association of immunosuppressants with these abnormalities.
Patients under 18 years old who still attend periodic controls at liver-transplant outpatient clinics were considered. Seventy patients met the inclusion criteria, 36 girls and 34 boys. Mean patient age was 5.6 years (range: 7 months to 17 years) and mean follow-up 6 years (range: 1–10 years). Medical records were reviewed beginning 1 month posttransplant. Treatment exposures, irradiation, blood product administration, and all laboratory studies were reviewed. When a hematologic abnormality was detected, we recorded the management for its resolution, the clinical response to therapy and the length of treatment.
Twenty-five of the 70 children suffered 26 abnormal hematologic episodes (anemia 14, neutropenia 2, thrombocytopenia 3, simultaneous anemia and neutropenia 5, and pancytopenia 2). Eleven episodes (42%) had unclear etiologies and the process of elimination suggested an association with the immunosuppressant. Switching immunosuppressant was required in four patients and dose reduction in seven.
Hematologic abnormalities in liver-transplanted children are common. The etiology is readily attributable to several causes. When the immunosuppressant appears to be a possible cause, the first step is dose reduction. If the hematologic abnormality persists despite dose reduction, a trial switch may be required.
Pediatric solid-organ transplant recipients are at high risk for various infectious diseases. Many children are not fully vaccinated before transplantation. To reduce the risk of morbidity and ...mortality from vaccine-preventable disease, physicians treating pediatric solid-organ transplant recipients should monitor the immunization status of these patients. Consensus on the most appropriate immunization schedule for solid-organ transplant recipients is lacking. Therefore, we provide a review of the currently available data on immunization safety and efficacy and describe strategies to avoid vaccine-preventable diseases in pediatric solid-organ transplant recipients.
Biliary atresia (BA) is the most common indication for liver transplantation in children. Approximately 7-10% of these patients have the associated polysplenia syndrome (PS). The prognosis of ...patients with BA and PS has been reported to be poorer than that in patients with BA without PS. All patients who underwent liver transplantation for BA and who still attend periodic controls at the outpatient clinic were considered. A retrospective study of outcome and growth in children with BA was made, and compared with a subgroup of patients with BA and PS. There were no significant differences on complications, liver and renal function tests, lipids and growth data. We concluded that BA and PS do not preclude successful liver transplantation.
Biliary atresia is the most common indication for liver transplantation in the pediatric age group. The Kasai portoenterostomy has become established as the primary treatment for biliary atresia. If ...portoenterostomy fails, death before 2 years of age is likely without liver transplantation. The most common multiple malformation syndrome associated with biliary atresia is polysplenia syndrome, which forms a constellation of defects of body symmetry, splenic development and vascular anomalies, including situs inversus, polysplenia and others. The situs inversus was formerly considered an absolute contraindication for liver transplantation. Recently however, several case reports have been published suggesting that neither situs inversus nor this particular subset of vascular abnormalities should be considered contraindications to liver transplantation. We present one case of liver transplantation performed in patient with biliary atresia, situs inversus and polysplenia. This is the first report described in Spain for a liver transplant in a child with biliary atresia plus situs inversus.
PDF
