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The present study sought to describe the use of generic drugs and single-tablet regimen (STR) de-simplification for the treatment of human immunodeficiency virus (HIV) infection among 41 hospitals from the cohort of the Spanish HIV/AIDS Research Network (CoRIS). In June 2018, we collected information on when generic antiretroviral drugs (ARVs) were introduced in the different hospitals, how the decisions to use them were made, and how the information was provided to the patients. Most of the nine available generic ARVs in Spain by June 2018 had been introduced in at least 85% of the participating hospitals, except for zidovudine (AZT)/lamivudine (3TC) and AZT. The time difference between the effective marketing date of each generic ARV and its first dispensing date in the hospitals was much shorter for the more recently approved generic ARV since the year 2017. However, only up to 20% of the hospitals de-simplified efavirenz (EFV)/tenofovir disoproxil (TDF)/emtricitabine (FTC), dolutegravir (DTG)/abacavir (ABC)/3TC, and rilpivirine (RPV)/TDF/FTC (to generic EFV+TDF/FTC, DTG+generic ABC/3TC, and RPV+generic TDF/FTC, respectively), whereas the generic STR EFV/TDF/FTC was introduced in 87.8% of the centers. The median times between the date of effective marketing of generic TDF/FTC and the date of de-simplification of EFV/TDF/FTC and RPV/TDF/FTC were 723 [interquartile range (IQR): 369-1,119] and 234 (IQR: 142-264) days, respectively; this time was 155 (IQR: 28-287) days for de-simplification of DTG/ABC/3TC. In conclusion, despite the widespread use of generic ARVs, STRs de-simplification was only undertaken in20% of the hospitals. There was wide variability in the timing of the introduction of each generic ARV after they were available in the market.

Objectives This study reports on the performance of a leadless ventricular pacemaker with automated, enhanced accelerometer-based algorithms that provide atrioventricular (AV) synchronous ...

Waterborne polyurethanes (WBPUs) with relatively high biobased content (up to 43.7%) were synthesized, aiming at their use as coatings for metals and woods. The study was performed on self-standing films obtained from anionic polyurethane water dispersions (PUDs). The initially targeted PUD was prepared from castor oil (CO), while tartaric acid (TA), a byproduct of wine production, was utilized as the internal anionic emulsifier. Although the films were cohesive and transparent, they were fragile, and thus blending the CO-TA PUD with other WBPUs was the chosen strategy to obtain films with improved handling characteristics. Two different WBPUs based on polycaprolactone diol (PCL), a biodegradable macrodiol, were prepared with dimethylolpropionic acid (DMPA) and tartaric acid (TA) as synthetic and biobased internal emulsifiers, respectively. The use of blends with PCL-TA and PCL-DMPA allowed for tailoring the moduli of the samples and also varying their transparency and haze. The characterization of the neat and hybrid films was performed by colorimetry, FTIR-ATR, XRD, DMA, TGA, solubility and swelling in toluene, and water contact angle. In general, the addition of PCL-based films increases haze; reduces the storage modulus, G’, which at room temperature can vary in the range of 100 to 350 MPa; and reduces thermal degradation at high temperatures. The results are related to the high gel content of the CO-TA film (93.5 wt.%), which contributes to the cohesion of the blend films and to the crystallization of the PCL segments in the samples. The highest crystallinity values corresponded to the neat PCL-based films (32.3% and 26.9%, for PCL-DMPA and PCL-TA, respectively). The strategy of mixing dispersions is simpler than preparing a new synthesis for each new requirement and opens possibilities for new alternatives in the future.

INTRODUCTION: MARVEL 2 assessed the efficacy of mechanical atrial sensing by a ventricular leadless pacemaker, enabling a VDD pacing mode. The behavior of the enhanced MARVEL 2 algorithm during variable atrio-ventricular conduction (AVC) and/or arrhythmias has not been characterized and is the focus of this study. METHODS: Of the 75 patients enrolled in the MARVEL 2 study, 73 had a rhythm assessment and were included in the analysis. The enhanced MARVEL 2 algorithm included a mode-switching algorithm that automatically switches between VDD and ventricular only antibradycardia pacing (VVI)-40 depending upon AVC status. RESULTS: Forty-two patients (58%) had persistent third degree AV block (AVB), 18 (25%) had 1:1 AVC, 5 (7%) had variable AVC status, and 8 (11%) had atrial arrhythmias. Among the 42 patients with persistent third degree AVB, the median ventricular pacing (VP) percentage was 99.9% compared to 0.2% among those with 1:1 AVC. As AVC status changed, the algorithm switched to VDD when the ventricular rate dropped less than 40 bpm. During atrial fibrillation (AF) with ventricular response greater than 40 bpm, VVI-40 mode was maintained. No pauses longer than 1500 ms were observed. Frequent ventricular premature beats reduced the percentage of AV synchrony. During AF, the atrial signal was of low amplitude and there was infrequent sensing. CONCLUSION: The mode switching algorithm reduced VP in patients with 1:1 AVC and appropriately switched to VDD during AV block. No pacing safety issues were observed during arrhythmias. ispartof: JOURNAL OF CARDIOVASCULAR ELECTROPHYSIOLOGY vol:32 issue:7 pages:1947-1957 ispartof: location:United States status: published

Objective Most patients with mild COVID-19 had to stay at home trying to implement an optimal quarantine. The aim of this study was to describe the COVID-19 cases during the first wave of the pandemic in Spain, how they managed the disease at home, focusing on differences by age, as well as differences in knowledge, attitudes and preventive practices, compared with the uninfected population. Design An online survey was used to conduct a cross-sectional study of individuals who were 14 years or older living in Spain during the COVID-19 lockdown. The main variable was a COVID-19 case. Logistic regression models for COVID-19 cases were obtained using a backward stepwise procedure to assess the association between social variables, disease knowledge, attitudes, prevention practices and emotional impact. Results 3398 people completed the survey. Participants' mean age was 49.6 (SD=14.3). COVID-19 was significantly more prevalent among married people (5.3%) and those currently doing an on-site work (8.7%). Most of the COVID-19 cases stayed at home (84.0%) during the episode. There were significant age-based differences with regard to self-isolation conditions at home during the disease. COVID-19 cases showed better attitudes, practices and knowledge about disease symptoms and transmission than the uninfected population. COVID-19 cases also felt more depressed (adjusted OR: 3.46, 95% CI 1.45 to 8.26) and had better preventive behaviour than the uninfected population, such as always wearing a mask outside the home (adjusted OR 1.58, 95% CI 1.06 to 2.30). Conclusion COVID-19 cases found it difficult to comply with recommended home self-isolation conditions, with differences by age group. COVID-19 had an important impact on care dependency in non-hospitalised patients, who were mostly dependent on their families for care. It is necessary to reinforce social and health services and to be ready to meet the care needs of populations during the different waves or in future epidemics. This work was supported by Instituto de Salud Carlos III through the National Tropical Diseases Research Network (RD16CIII/003/001RICET). The funders had no role in study design or in the collection, analysis and interpretation of data, or the decision to submit the article for publication.

The results reported by different studies on telemonitoring in patients with chronic obstructive pulmonary disease (COPD) have been contradictory, without showing clear benefits to date. The objective of this study was to ascertain whether an early discharge and home hospitalization telehealth program for patients with COPD exacerbation is as effective as and more efficient than a traditional early discharge and home hospitalization program. A prospective experimental non-inferiority study, randomized into two groups (telemedicine/control) was conducted. The telemedicine group underwent monitoring and was required to transmit data on vital constants and ECGs twice per day, with a subsequent telephone call and 2 home visits by healthcare staff (intermediate and at discharge). The control group received daily visits. The main variable was time until first exacerbation. The secondary variables were: number of exacerbations; use of healthcare resources; satisfaction; quality of life; anxiety-depression; and therapeutic adherence, measured at one and 6 months of hospital discharge. A total of 116 patients were randomized (58 to each group) without significant differences in baseline characteristics or time until first exacerbation, i.e. median 48 days (pp. 25-75:23-120) in the control group, and 47 days (pp. 25-75:19-102) in the intervention group; p = 0.52). A significant decrease in the number of visits was observed in the intervention versus the control group, 3.8 ± 1 vs 5.1 ± 2(p = 0.001), without significant differences in the number of exacerbations. In conclusion follow-up via a telemedicine program in early discharge after hospitalization is as effective as conventional home follow up, being the cost of either strategy not significantly different. This study was awarded a Health Research Fund (Fondo de Investigaciones Sanitarias/FIS) grant, dossier No. PI12/01161 of the Carlos III Institute of Health and the Ministry of Sciences, Innovation and Universities. Sí

BACKGROUND: The MARVEL (Micra Atrial TRacking Using a Ventricular AccELerometer) 2 study assessed the efficacy of atrioventricular (AV) synchronous pacing with a Micra leadless pacemaker. Average atrioventricular synchrony (AVS) was 89.2%. Previously, low amplitude of the Micra-sensed atrial signal (A4) was observed to be a factor of low AVS. OBJECTIVE: The purpose of this study was to identify predictors of A4 amplitude and high AVS. METHODS: We analyzed 64 patients enrolled in MARVEL 2 who had visible P waves on electrocardiogram for assessing A4 amplitude and 40 patients with third-degree AV block for assessing AVS at rest. High AVS was defined as >90% correct atrial-triggered ventricular pacing. The association between clinical factors and echocardiographic parameters with A4 amplitude was investigated using a multivariable model with lasso variable selection. Variables associated with A4 amplitude together with premature ventricular contraction burden, sinus rate, and sinus rate variability (standard deviation of successive differences of P-P intervals [SDSD]) were assessed for association with AVS. RESULTS: In univariate analysis, low A4 amplitude was inversely related to atrial function assessed by E/A ratio and e'/a' ratio, and was directly related to atrial contraction excursion (ACE) and atrial strain (Ɛa) on echocardiography (all P ≤.05). The multivariable lasso regression model found coronary artery bypass graft history, E/A ratio, ACE, and Ɛa were associated with low A4 amplitude. E/A ratio and SDSD were multivariable predictors of high AVS, with >90% probability if E/A

Funding Acknowledgements Medtronic, Inc. Background/Introduction Accelerometer (ACC)-based AV synchronous pacing by tracking atrial activity is feasible using a leadless ventricular pacemaker. Patients may experience variable AV conduction (AVC) and/or atrial arrhythmias during the lifetime of their device. ACC-based AV synchronous pacing should facilitate AVC and pace appropriately in those two common rhythms. Purpose To characterize the behavior of ACC-based AV synchronous pacing algorithms during paroxysmal AV block (AVB) and atrial arrhythmias. Methods The MARVEL2 (Micra Atrial tRacking using a Ventricular accELerometer) was a 5-hour acute study to assess the efficacy of atrial tracking with a temporarily downloaded algorithm into a Micra leadless pacemaker. Patients with a history of AVB were eligible for inclusion. The MARVEL2 algorithm included a mode-switching algorithm that switched between VDD and VVI-40 depending upon AVC status. The AVC algorithm requires 2 ventricular paces (VP) at 40 bpm out of 4 pacing cycles to switch to VDD. Results Overall, 75 patients (age 77.5 ± 11.8 years, 40% female, median time from Micra implant 9.7 months) from 12 centers worldwide were enrolled. During study procedures, 40 patients (53%) had normal sinus rhythm with complete AVB, 18 (24%) had 1:1 AVC, 5 (7%) had varying AVC status, 8 (11%) had atrial arrhythmias, and 2 other rhythms. Two patients with complete AVB had the AVC mode switch feature disabled due to an idioventricular rate >40 bpm. Among the 40 subjects with a predominant 3rd degree AVB and normal sinus function the median %VP was 99.9% compared to 0.2% among those with 1:1 AVC (Figure). In the patients with 1:1 AVC, there were 64 opportunities to AVC mode switch with 48 switching to VDI-40. In the other 16 cases (2 patients) the mode remained VDD due to sinus bradycardia varying between 40-45 bpm. High %VP was observed in 2 patients with 1:1 AVC and sinus bradycardia 300 ms (N = 2). Among patients with varying AVC, the algorithm appropriately switched to VDD when the ventricular rate was paced at 40 bpm. During infrequent AVB or AF with ventricular response >40 bpm, VVI-40 mode was maintained. In patients with AF, the ACC signal was of low amplitude and there was infrequent sensing, resulting in VP at the lower rate (50 bpm). In the one patient with atrial flutter, the ACC was intermittently detected, resulting in VP at 67 bpm (IQR 66-67 bpm). Conclusion(s) The mode switching algorithm in the MARVEL2 reduced %VP in patients with 1:1 AVC and appropriately switched to VDD during complete AVB. If greater AV synchrony or rate support is required, disabling the AVC algorithm may be appropriate for low grade AVB or idioventricular rhythms. In the presence of atrial arrhythmias, the algorithm paced near the lower rate. Abstract Figure. Distribution of VP% by heart rhythm

This study reports on the performance of a leadless ventricular pacemaker with automated, enhanced accelerometer-based algorithms that provide atrioventricular (AV) synchronous pacing.Despite many advantages, leadless pacemakers are currently only capable of single-chamber ventricular pacing.The prospective MARVEL 2 (Micra Atrial tRacking using a Ventricular accELerometer 2) study assessed the performance of an automated, enhanced accelerometer-based algorithm downloaded to the Micra leadless pacemaker for up to 5 h in patients with AV block. The primary efficacy objective was to demonstrate the superiority of the algorithm to provide AV synchronous (VDD) pacing versus VVI-50 pacing in patients with sinus rhythm and complete AV block. The primary safety objective was to demonstrate that the algorithm did not result in pauses or heart rates of100 beats/min.Overall, 75 patients from 12 centers were enrolled; an accelerometer-based algorithm was downloaded to their leadless pacemakers. Among the 40 patients with sinus rhythm and complete AV block included in the primary efficacy objective analysis, the proportion of patients with ≥70% AV synchrony at rest was significantly greater with VDD pacing than with VVI pacing (95% vs. 0%; p 0.001). The mean percentage of AV synchrony increased from 26.8% (median: 26.9%) during VVI pacing to 89.2% (median: 94.3%) during VDD pacing. There were no pauses or episodes of oversensing-induced tachycardia reported during VDD pacing in all 75 patients.Accelerometer-based atrial sensing with an automated, enhanced algorithm significantly improved AV synchrony in patients with sinus rhythm and AV block who were implanted with a leadless ventricular pacemaker. (Micra Atrial Tracking Using a Ventricular Accelerometer 2 [MARVEL 2]; NCT03752151).

Summary Melanoma in individuals with oculocutaneous albinism has been reported in the literature to be rare compared with the more common occurrence of squamous cell carcinoma and basal cell carcinoma. We present a singular case of amelanotic naevoid melanoma arising from a small congenital naevus in a 16-month old albino boy, the youngest reported to date.

This research shows a protocol to assess the computational complexity of querying relational and non-relational (NoSQL (not only Structured Query Language)) standardized electronic health record (EHR) medical information database systems (DBMS). It uses a set of three doubling-sized databases, i.e. databases storing 5000, 10,000 and 20,000 realistic standardized EHR extracts, in three different database management systems (DBMS): relational MySQL object-relational mapping (ORM), document-based NoSQL MongoDB, and native extensible markup language (XML) NoSQL eXist. The average response times to six complexity-increasing queries were computed, and the results showed a linear behavior in the NoSQL cases. In the NoSQL field, MongoDB presents a much flatter linear slope than eXist. NoSQL systems may also be more appropriate to maintain standardized medical information systems due to the special nature of the updating policies of medical information, which should not affect the consistency and efficiency of the data stored in NoSQL databases. One limitation of this protocol is the lack of direct results of improved relational systems such as archetype relational mapping (ARM) with the same data. However, the interpolation of doubling-size database results to those presented in the literature and other published results suggests that NoSQL systems might be more appropriate in many specific scenarios and problems to be solved. For example, NoSQL may be appropriate for document-based tasks such as EHR extracts used in clinical practice, or edition and visualization, or situations where the aim is not only to query medical information, but also to restore the EHR in exactly its original form. This work was supported by Instituto de Salud Carlos III [grant numbers PI15/00321, PI15/00003, PI1500831, PI15CIII/00010 and RD16CIII]. Sí

The reaction between 4,4′-diiodoazobenzene (0) with excess trimethylsilylacetylene or dec-1-yne in the presence of catalytic amounts of PdCl2(PPh3)2 and CuI, Sonogashira coupling conditions, gave rise to the formation of 4,4′-bis(trimethylsilylethynyl)azobenzene (1) and 4,4′-bis(dec-1-ynyl)azobenzene (2), in good yield, in addition to icosa-9,11-diyne (3) as byproduct in the last case. The analogous reactions from 0 and the alkynyl-cobalt complexes Co2(CO)4(μ-L-L)(μ2-η2-SiMe3C2)](C≡CH) (L-L = dppm, dmpm) afforded 12–14. Complexes 4–7 and 15 have been obtained by direct reaction between Co2(CO)8 and the organic ligands 1–3. In order to increase the stabilization of Co–Co bonds, diphenylphosphinomethane-substituted alkyne-carbonyl complexes 8–11 were prepared by substitution reaction of carbonyl ligands in the presence of Me3NO at the Co2(CO)6 units from 4–7. All products were characterized by analytical and spectroscopic data (IR, 1H, 13C, and 31P NMR, and MS). Crystals of 9 suitable for single-crystal X-ray diffraction were grown, and the molecular structure of this compound is discussed. In this paper we report a comparative electrochemical study of these complexes by means of cyclic and square-wave voltammetry techniques, the trans–cis photoisomerization study of azobenzene compounds, and the thermotropic liquid-crystalline behavior., Support for this work is acknowledged from the Comunidad de Madrid (FOTOCARBON-CM S2013/MIT-2841), Spain. Thanks to Joaquın Barbera ́ ́Gracia (Universidad de Zaragoza, Spain) for technical and scientific support.

Prólogo también en inglés. La Plataforma de Innovación en Telemedicina y e-Salud (PITES) constituye un marco de actuación en red para la investigación y la innovación en soluciones, servicios y herramientas basadas en Tecnología de la Información y la Comunicación (TIC) dirigidos al soporte de los nuevos modelos de asistencia. Formalmente, PITES es una agrupación de nodos de innovación tecnológica con base en unidades clínicas para la implementación de entornos de aplicaciones, herramientas, e infraestructuras TIC, seguras, accesibles, e interoperables conforme a estándares abiertos tal que permiten implementar soluciones de telemedicina móvil personal y de e-salud para el soporte de nuevos modelos asistenciales dirigidos a la condición crónica, fragilidad y dependencia, acele¬rando la transferencia del conocimiento a la práctica clínica. Esta publicación presenta seis artículos cuyo objetivo es presentar algunos de los resultados más relevantes alcanzados en los respectivos subproyectos que se han llevado a cabo en el marco de PITES-ISA. Chapter 1. Reformulating the database persistence of the pites interoperability platform. Chapter 2. Implementation of an early detection service for COPD exacerbations: experimental evaluation for an early discharge, hospital-at-home programme. Chapter 3. Servicio Aragonés de Salud: Results of the “PITES ISA T-CUIDAENCASA: Platform of Innovation in home ehealth services” project. Chapter 4. PITeS ISA in Andalusia: Clinical Decision Support System for the prescription of genetic testing in the gynecological cancer risk and screening the risk of thromboembolism during hospitalization. Chapter 5. PITES-ISA in Catalonia: Innovation in Integrated Care Services for Chronic Patients. Chapter 6. Development of a Telemedicine System for Rheumatology Patient

Summary Background Capillary malformation–arteriovenous malformation (CM-AVM) syndrome is associated with multifocal small CMs and a high risk for high-flow lesions. It is an autosomal dominant disorder, caused by RASA1 gene mutations. Recently, two novel clinical features have been identified: numerous small pale halos with central punctate red spots, and naevus anemicus. Objectives To identify the prevalence of the new clinical manifestations in our patients with CM-AVM. The secondary objective was to investigate the presence of other skin lesions. Methods We retrospectively searched the picture database of our department for cases with a clinical diagnosis of CM-AVM, based on the identification of multiple cutaneous CMs and a negative history of epistaxis. We prospectively conducted a clinical and dermoscopic skin examination in all of these patients. Results Seven patients with multiple CMs were found, and only in one case was a cutaneous AVM present. Five patients had red punctate spots surrounded by pale halos on the upper limbs. Two adult patients also showed multiple telangiectasias on the neck and upper trunk. Naevus anemicus was not detected in any patient. A partial or total absence of vellous hair on the surface of CMs was observed in all patients. Conclusions Red punctate spots with pale halos or small telangiectasias are frequent findings in CM-AVM syndrome. Hypotrichosis on the CMs suggests that RASA1 gene mutations could be involved in the hair follicle proliferation and cell cycle.

Refractory angina presents a major clinical challenge for everyday medical practice. Despite the widespread use of statins and improvements in revascularization techniques, a substantial proportion of patients with preserved left ventricular function and no life-threatening arrhythmias remain symptomatic, with severe debilitating angina. Because the rate of major cardiac events in this population is relatively low, the major aim of therapy should be not only to prolong survival but also to improve quality of life. The cornerstone of therapy for all these patients should be the aggressive modification of risk factors using evidence-based treatment, with the aim of stabilizing the disease process and improving overall survival. No opportunity for revascularization should be overlooked. Complementary approaches should be implemented to raise the angina threshold by either reducing oxygen demand or improving hemodynamics to increase myocardial oxygen supply. This review provides an update on therapeutic techniques and goals, and reinforces the need for a multidisciplinary approach to the management of patients with refractory angina.

La angina refractaria constituye un importante reto clinico para la medicina actual. A pesar del amplio uso de las estatinas y del perfeccionamiento de las tecnicas de revascularizacion, una parte importante de los pacientes con una funcion ventricular izquierda preservada y sin arritmias con peligro para la vida continuan presentando sintomas, con una angina grave debilitante. Dado que las tasas de eventos cardiacos mayores en esa poblacion son relativamente bajas, las metas principales del tratamiento deben ser no solo la prolongacion de la supervivencia, sino tambien la mejora de la calidad de vida. La modificacion energica de los factores de riesgo mediante tratamientos basados en la evidencia, con objeto de estabilizar el proceso de la enfermedad y mejorar la supervivencia, debe constituir el tratamiento de base en todos estos pacientes. No deben pasarse por alto las posibilidades de revascularizacion. Deben aplicarse estrategias complementarias para elevar el umbral anginoso, ya sea mediante la reduccion de la demanda de oxigeno, ya mediante la mejora de la hemodinamica para aumentar el aporte de oxigeno miocardico. En esta revision se presenta una actualizacion sobre las estrategias y las metas terapeuticas y se resalta la necesidad de un enfoque multidisciplinario del tratamiento de los pacientes con angina refractaria.

The authors have designed and developed a telemedicine-based service for the follow-up and monitoring of patients on oral anticoagulant therapy (OAT) that consists of two phases; the first involving self-testing and the second involving guided self-management. To evaluate the first phase of the protocol, a project was conducted with 108 patients, with a mean age of 72.7 years and a mean treatment time at the start of the study of 55.2 months, divided into two groups: telemedicine and control (conventional procedure). The degree of anticoagulation control was similar in the two groups: individual in-range international normalized ratios (59.2% vs 61.1%; p = 0.55) and individual time within target range (65.7% vs 66.4%; p = 0.85) showed no significant differences. The incidence of adverse events--death (5.5% vs 5.5%; p = 1.0), major hemorrhagic complications (0% vs 1.8%; p = 1.0), minor hemorrhagic complications (7.4% vs 3.7%; p = 0.67), and thromboembolism (1.8% vs 3.7%; p = 1.0)--was also similar, with no significant differences. Acceptability of the change, measured in terms of quality of life (SF-12 and Sawicki questionnaires) and anxiety (state-trait anxiety inventory questionnaire) at the beginning and end of the study period was higher in the telemedicine group, with statistically significant improvements in mental component summary (3.6 vs -6.2; p = 0.02), dissatisfaction (-0.8 vs 0.2; p = 0.001), stress (-0.3 vs 0.05; p = 0.03), limitations (-0.2 vs 0.3; p = 0.005), social problems (-0.1 vs 0.3; p = 0.03), and state anxiety (-2.5 vs 2.3; p = 0.04). Parameters related to costs, such as the mean number per patient of office visits due to OAT (1.7 vs 13.8; p < 0.001) and other office visits (10.1 vs 11.5; p = 0.028), were also more favorable in the telemedicine group, as were additional parameters that enabled an exhaustive evaluation of the service. The positive results obtained indicate that the second phase of the trial can be initiated.

The evaluation in real-life settings of services for the follow-up and control of hypertensive patients is a complex intervention, which still needs analysis of the roles, tasks, and resources involved in the basic items: patient, healthcare professional, and the interaction between the two. To evaluate the impact of patient-general practitioner (GP) short-messages-based interaction, isolated from other items, on the degree of hypertension control in the follow-up of medium-to-low-risk patients in primary care, a randomized controlled trial has been performed: 38 GPs enrolled 285 hypertensive patients who recorded the results of self-blood-pressure (BP) monitoring, heart rate, and body weight, and completed an optional questionnaire in an identical manner over a six-month period. The telemedicine group (TmG) sent the data to a telemedicine-based system that enabled patient-GP interaction; the control group (CG) recorded the data on paper and could only deliver it to their GP personally in the routine visits. In the TmG, the results were better, but not significantly so, for: 1) degree of hypertension control, in terms of the percentage of uncontrolled hypertensives at the final visit (TmG versus CG: 31.7% versus 35.6%; p = 0.47); 2) reduction in hypertension during follow-up, comparing measurements (performed by a professional) at the initial and final visits of systolic BP (15.5 versus 11.9; p = 0.13) and diastolic BP (9.6 versus 4.4; p = 0.40); and 3) adherence to the protocol within compliance levels of interest in a real-life follow-up service: Gt50% (84.8% versus 73.3%) and Gt25% (92.4.8% versus 75.4%) (p = 0.053). Other factors such as average values of self-measured systolic BP, diastolic BP and heart rate, acceptability of the protocol, and median number of consultations and hospital admissions were similar in both groups. Outcomes show that, taken alone, the patient-GP short-messages-based interaction has very little impact on the degree of hypertension control in patients with this profile. In complex interventions, to discriminate the impact of each of its components in isolation will enable us to design an efficient follow-up service, little demanding in terms of healthcare professional dedication, and optimized in other basic aspects.

A new mark-up programming language is introduced in order to facilitate and improve the visualization of ISO/EN 13606 dual model-based normalized medical information. This is the first time that visualization of normalized medical information is addressed and the programming language is intended to be used by medical non-IT professionals.

A platform built around three information entities (patient, health-care/spl I.bar/agent, and central/spl I.bar/station) was designed to enable patients with chronic heart disease (in stable condition; emergency situations were excluded deliberately) to complete specifically defined protocols for out-of-hospital follow-up and monitoring. The patients belonged to one of four specific risk groups: arterial hypertension, malignant arrhythmias, heart failure, and postinfarction rehabilitation. They were provided with portable recording equipment and a cellular phone that supported data transmission [electrocardiogram (ECG)] and wireless application protocol (WAP) (remaining parameters and ad hoc questionnaires). The central station was an automatized platform, with no human operator. The information received was organized chronologically in patient folders. The health-care/spl I.bar/agents had continuous and secure access to the patient folders, through tools based on the world wide web and WAP, and to short messages sent by their patients. A pilot project was conducted with 89 patients (mean length of participation: 50.1 days). A total of 2168 ECGs (mean duration transmission=2 min/30 s; network errors < 0.1%) and 4011 short messages (none lost, in 95% of cases 30 s

We recorded the activity over one year of users of two identical teleradiology systems installed at different primary care centres. In one centre, which generated 3711 cases, the process was conducted according to the decisions made by the general practitioner (GP); in the second, which generated 3786 cases, the radiologist at the referral hospital controlled the process. In a one-year study, the number of studies created, transmitted and interpreted per day was similar in the two scenarios (14.3 vs 14.6, respectively); however, there were considerable differences in the number of images (2.2 vs 1.8, respectively) and folder volume (19.2 vs 14.3 Mbyte, respectively) per study. Also, there were differences in the time taken to create the patient folders (4 min 35 s vs 2 min 55 s, respectively) and the time taken for the radiologist to diagnose a case (3 min 32 s vs 2 min 47 s, respectively), which may be important at high workloads. The radiologist-driven scenario included 64 rejected requests (1.6% of cases) and 280 studies in which additional images were required (7.4% of cases). Whenever it is possible to choose, the radiologist-driven scenario for teleradiology appears to be preferable. A prerequisite for successful teleradiology is the availability of appropriate bandwidth and operational protocols.

Angiogenesis is widely accepted to play a central role in tumor growth and spreading. Therefore, anti-angiogenic agents appear as promising tools in cancer therapy, and great efforts have been devoted to their identification in recent years. Despite fast progress in this area, a quantitative and objective system for rapid anti-angiogenic testing is not currently available. In this work, we describe a new platform for the large-scale screening of agents with potential anti-angiogenic activity. This involved the miniaturization of an in vitro two-dimensional assay model of vascular morphogenesis to run in a high-density format (384- or 1536-well microplates) and the development of a specific digital image-analysis system for the automated and quantitative evaluation of biological activity. To test the efficacy and reproducibility of the platform, we used a wide variety of well-characterized angiogenesis inhibitors, including antibodies against components of the extracellular matrix, peptides, and chemicals. The system proved to be a reproducible, polyvalent, and powerful tool for massive screening of agents with potential application in cancer therapy. Ongoing developmental work, directed toward optimizing this system for use with a fully automated high-throughput screening platform, should accelerate research into the mechanisms of tumor angiogenesis and the development of drugs that target the essential tumor vasculature.

Se expone que el lenguaje infantil se debe valorar por diversas razones: primera porque el habla es uno de los indicadores del desarrollo integral del niño, segunda para detectar las dificultades en este proceso y tercera para determinar los niños en riesgo. Al no contar en Cuba con propias referencias acerca del desarrollo del lenguaje infantil, se realizó una investigación nacional descriptiva y transversal, que se aplicó a niños sanos de 6 meses a 5 años de edad, en 8 provincias del país. Para este trabajo se analizó el grupo de niños menores de 18 meses. Se halló que más del 50 % de los niños cubanos emiten sonidos bisílabos a los 7 meses, utilizan a los 8 meses jerga, comprenden órdenes sencillas alrededor de los 9 meses y conocen partes del cuerpo a los 12 meses. Existe cierto adelanto en las conductas de lenguaje de los niños cubanos en comparación con lo establecido en las escalas de desarrollo que se utilizan en Cuba.We suggest that child speech must be assessed for diferent reasons: first, because of speech is one of the indicators of child´s integral development, second, to detect difficulties in this process, and third, to determine children in risk. As there aren´t available references about child speech development in our country, we carried out a nation-wide descriptive and crossover research, applied to health children aged 6 months and 5 years in 8 provinces of the country. In the case of this paper, we proceed to analyze a group of children under 18 months. We found that more than 50 % of Cuban children emit two-sylabed sounds to months, they use a gibberish to 8 months, understand single orders around 9 months, and know parts of the body to 12 months. There is some advance in speech behaviour of Cuban children compared to that stablished in development scales used in Cuba.

This paper presents a service for the anonymisation of electronic health care record (EHR) extracts for secondary use based on the ISO/EN 13606 norm. The sending of clinical data for secondary use, in accordance with current legislation, must be carried out using anonymised data. The ISO/EN 13606 standard has characteristics which favour the development of an anonymisation service, thanks to a design that separates clinical information from demographic information and allows a semantic interoperability to be achieved in the exchange of information. The developed system, based on ISO/EN 13606, consists of two modules: demographic server and an anonymising module. El demographic server is able to work independently, while the anonymising module must always work with an associated demographic server. The anonymisation is the process through which it is no longer possible to establish the link between the data and the subject to whom it refers. The demographic server is responsible for the permanent storage of the demographic entities. The anonymising module is responsible for eliminating everything linked to the demographic data of a given extract. The anonymisation process consists of four phases: storage of the demographic information included in the extract, substitution of identifiers, elimination of the demographic information of the extract and final validation. The anonymising system has been integrated into Telemedicine projects with favourable results. The sending of anonymised data for a secondary use allows the generation of large clinical databases from which knowledge can be deduced using data-mining techniques.

28 real homes of elderly have been monitored during three weeks by a platform based on the BUSing protocol that consists of 5 sensors of presence and 5 sensors of action.

BACKGROUND: In order to ensure proper management of primary care (PC) services, the efficiency of the health professionals tasked with such services must be known. Patients with heart failure (HF) are characterized by advanced age, high co-morbidity and high resource utilization. OBJECTIVE: To ascertain PC resource utilization by HF patients and variability in the management of such patients by GPs. METHODS: Descriptive, cross-sectional study targeting a population attended by 129 GPs over the course of 1 year. All patients with diagnosis of HF in their clinical histories were included, classified using the Adjusted Clinical Group system and then grouped into six resource utilization bands (RUBs). Resource utilization and Efficiency Index were both calculated. RESULTS: One hundred per cent of patients with HF were ranked in RUBs 3, 4 and 5. The highest GP visit rate was 20 and the lowest in excess of 10 visits per year. Prescription drug costs for these patients ranged from €885 to €1422 per patient per year. Health professional efficiency varied notably, even after adjustment for co-morbidity (Efficiency Index Variation Ratio of 28.27 for visits and 404.29 for prescription drug cost). CONCLUSIONS: Patients with HF register a high utilization of resources, and there is great variability in the management of such patients by health professionals, which cannot be accounted for by the degree of case complexity. Funding: This study was partially supported by a CENIT Programme (MICINN-CDTI) [CEN-2007-1010 “Digital personal environment for health and well-being – AmiVital” project]; by a grant from the Ministry of Health and Consumer Affairs [FIS PI08-0435]. The funders had no role in the study design, data collection and data analysis, decision to publish or drafting of the manuscript. Sí

Objective: The objective of this paper is to introduce a new language called ccML, designed to provide convenient pragmatic information to applications using the ISO/EN13606 reference model (RM), such as electronic health record (EHR) extracts editors. EHR extracts are presently built using the syntactic and semantic information provided in the RM and constrained by archetypes. The ccML extra information enables the automation of the medico-legal context information edition, which is over 70% of the total in an extract, without modifying the RM information. Materials and methods: ccML is defined using a W3C XML schema file. Valid ccML files complement the RM with additional pragmatics information. The ccML language grammar is defined using formal language theory as a single-type tree grammar. The new language is tested using an EHR extracts editor application as proof-of-concept system. Results: Seven ccML PVCodes (predefined value codes) are introduced in this grammar to cope with different realistic EHR edition situations. These seven PVCodes have different interpretation strategies, from direct look up in the ccML file itself, to more complex searches in archetypes or system precomputation. Discussion: The possibility to declare generic types in ccML gives rise to ambiguity during interpretation. The criterion used to overcome ambiguity is that specificity should prevail over generality. The opposite would make the individual specific element declarations useless. Conclusion: A new mark-up language ccML is introduced that opens up the possibility of providing applications using the ISO/EN13606 RM with the necessary pragmatics information to be practical and realistic. This research has been partially supported by projects PI09/90110 ‘Plataforma de innovación en nuevos servicios de telemedicina y eSalud para pacientes crónicos y dependientes (Innovation platform for new telemedicine and e-health services for chronic and dependent patients)—PITES’ and PI08/1148 ‘Representación de información clínica en cáncer de mama mediante arquetipos (Modeling clinical information in breast cancer through archetypes)—CAMAMA’ from Fondo de Investigación Sanitaria (FIS) Plan Nacional de I+D+i, and by project CEN-20091043 ‘Tecnologías disruptivas para la rehabilitación del futuro (Disruptive technologies for Rehabilitation in the Future)—REHABILITA’ from Plan Nacional de Investigación Científica Desarrollo e Innovación Tecnológica—CENIT-E. Sí

■ PURPOSE: Efficient ways are needed to implement the secondary prevention (SP) of coronary heart disease. Because few studies have investigated Web-based SP programs, our aim was to determine the usefulness of a new Web-based telemonitoring system, connecting patients provided with self-measurement devices and care managers via mobile phone text messages, as a tool for SP. ■ METHODS: A single-blind, randomized controlled, clinical trial of 203 acute coronary syndrome (ACS) survivors, was conducted at a hospital in Madrid, Spain. All patients received lifestyle counseling and usual-care treatment. Patients in the telemonitoring group (TMG) sent, through mobile phones, weight, heart rate, and blood pressure (BP) weekly, and capillary plasma lipid profile and glucose monthly. A cardiologist accessed these data through a Web interface and sent recommendations via short message service. Main outcome measures were BP, body mass index (BMI), smoking status, low-density lipoprotein-cholesterol (LDL-c), and glycated hemoglobin A 1c (HbA 1c ). ■ RESULTS: At 12-month followup, TMG patients were more likely (RR � 1.4; 95% CI � 1.1-1.7) to experience improvement in cardiovascular risk factors profile than control patients (69.6% vs 50.5%, P � .010). More TMG patients achieved treatment goals for BP (62.1% vs 42.9%, P � .012) and HbA1c (86.4% vs 54.2%, P � .018), with no differences in smoking cessation or LDL-c. Body mass index was significantly lower in TMG (� 0.77 kg/m 2 vs � 0.29 kg/m 2 , P � .005). ■ CONCLUSIONS: A telemonitoring program, via mobile phone messages, appears to be useful for improving the risk profile in ACS survivors and can be an effective tool for secondary prevention, especially for overweight patients.

INTRODUCTION: Healthcare management is oriented toward single diseases, yet multimorbidity is nevertheless the rule and there is a tendency for certain diseases to occur in clusters. This study sought to identify comorbidity patterns in patients with chronic diseases, by reference to number of comorbidities, age and sex, in a population receiving medical care from 129 general practitioners in Spain, in 2007. METHODS: A cross-sectional study was conducted in a health-area setting of the Madrid Autonomous Region (Comunidad Autónoma), covering a population of 198,670 individuals aged over 14 years. Multiple correspondences were analyzed to identify the clustering patterns of the conditions targeted. RESULTS: Forty-two percent (95% confidence interval [CI]: 41.8-42.2) of the registered population had at least one chronic condition. In all, 24.5% (95% CI: 24.3-24.6) of the population presented with multimorbidity. In the correspondence analysis, 98.3% of the total information was accounted for by three dimensions. The following four, age- and sex-related comorbidity patterns were identified: pattern B, showing a high comorbidity rate; pattern C, showing a low comorbidity rate; and two patterns, A and D, showing intermediate comorbidity rates. CONCLUSIONS: Four comorbidity patterns could be identified which grouped diseases as follows: one showing diseases with a high comorbidity burden; one showing diseases with a low comorbidity burden; and two showing diseases with an intermediate comorbidity burden. This study was partially supported by the CENIT Program (MICINN-CDTI) [CEN-2007-1010 ‘‘Digital personal environment for health and wellbeing – AmiVital’’ project], a grant from the Ministry of Health & Consumer Affairs [FIS PI08-0435], and the MOBIS Program of the Spanish Vodafone Foundation . The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Sí

Tesis (Ingeniero en Gestión Informática) Alcance del proyecto: Desarrollar un Plan de Fidelización que se ajuste a /as necesidades de la empresa MASISA, esto le permitirá tener conocimiento claro de los gustos y necesidades de sus clientes finales, para así poder ofrecerles un mejor servicio y producto.

Biomarkers are biological parameters that can be objectively measured and quantified as indicators of normal biologic processes, pathogenic processes, or responses to a therapeutic intervention. Typically thought of as disease process screening, diagnosing, or monitoring tools, biomarkers may also be used to determine disease susceptibility and eligibility for specific therapies. Cardiac biomarkers are protein components of cell structures that are released into circulation when myocardial injury occurs. They play a pivotal role in the diagnosis, risk stratification, and treatment of patients with chest pain and suspected acute coronary syndrome and those with acute exacerbations of heart failure. Cardiac markers are central to the new definition of acute myocardial infarction put forward by the American College of Cardiology and the European Society of Cardiology. Active investigation has brought forward an increasingly large number of novel candidate markers but few have withstood the test of time and become integrated into contemporary clinical care because of their readily apparent diagnostic, prognostic, or therapeutic utility.