Abstract Background The COVID-19 pandemic triggered several changes in the organization of health services, such as the acceleration of the introduction of digital tools to improve cross-level clinical coordination and, therefore, the quality of care. The aim is to analyse changes in the experience, perception of cross-level clinical coordination and related factors of primary care (PC) and secondary care (SC) doctors in the Catalan health system between 2017 and 2022. Methods Comparison of two cross-sectional studies based on the online surveys COORDENA-CAT (2017) and COORDENA-TICs (2022) to PC and SC doctors. Sample 2017 n = 3308 (participation: 20.9%); 2022 n = 2277 (participation: 17.5%). Outcome variables: experience and perception of cross-level clinical coordination, and related factors, knowledge, and use of digital coordination mechanisms. Descriptive and multivariate analyses were performed to detect changes between years. Results Compared to 2017, there was a worse experience of clinical management coordination, particularly in cross-level care consistency and accessibility, and of the perception. Regarding related factors there was a worsening in some organizational factors (time available for coordination, institutional support), attitudinal factors (satisfaction with the job) and interactional factors (knowledge between doctors). The use of some coordination mechanisms such as electronic medical records and virtual consultations between PC and SC increased, while the use of virtual joint clinical sessions was limited. Conclusions Results show that after the pandemic there was a worsening in some items of the experience and in the perception of cross-level clinical coordination, despite the increased use of some digital coordination mechanisms. There is a need to explore in depth the factors associated with this worsening to identify and promote more effective strategies to improve cross-level clinical coordination in Catalonia. Key messages • Cross-level clinical coordination in Catalonia has worsened despite the increase in implementation and use of some digital coordination mechanisms. • It is necessary to explore in depth the factors related to this worsening to develop more effective strategies to improve cross-level clinical coordination.

Appendiceal tumors represent a large amalgam of different tumor lineages. The continuous evolution in their pathological classifications has led to some variable recommended attitudes over time. The aim of this study is to review the incidence, clinicopathological characteristics, therapeutic approach and oncological results in this type of tumor at our institution. This is a single-centre retrospective cohort study. Every pathologic report catalogued as an appendiceal specimen was reviewed for a time period of 5 years (2013–2017) at our institution. Demographic, clinical, pathological and oncologic follow-up data were recorded. A descriptive study of the sample was completed. A total of 1434 appendiceal specimens was analyzed. Appendiceal neoplasms incidence was 3.2%. Epithelial tumors were the predominant histological subtype, making up 68% of the cases. Low-grade appendiceal mucinous neoplasia and neuroendocrine tumors were the most frequent neoplasms with malignant potential, with 13 and 6 cases, respectively. In more than 80% of neoplasia cases, the definitive treatment was appendectomy. Mortality cases were related to tumors with a very poor prognosis and an advanced stage. All patients had adequate oncological follow-up. Although it is still quite rare, the incidence of appendiceal tumors is increasing with an epidemiological change in favor of mucinous neoplasms currently predominating. Therefore, it is necessary to know and use an updated anatomo-pathological classification in order to provide correct treatment in the first or second surgical stage, as well as the correct follow-up of patients.

We aimed to characterise cutaneous melanoma in the elderly and determine its association with poorer prognosis. We studied a prospective cohort of the melanoma population in Catalonia between 2012 and 2016. We compared young patient group (<75 years old) with elderly patient group (≥75 years old). We included 3009 patients (52.5% women) from 14 centres, with a mean age at diagnosis of 61.1 years. In the ≥75-year-old group there was a predominance of men (53.9% vs. 45.5%, P < 0.001), melanoma was more frequently located in the head and neck area (37.7% vs. 15.5%, P < 0.001) and lentigo maligna melanoma subtype was significantly more frequent (31.4% vs. 11.6%, P < 0.001), as were nodular melanoma and acral lentiginous melanoma (P < 0.001). In older people, Breslow index, the presence of ulceration and mitotic rate were higher than in younger people. Kaplan-Meier survival curves showed longer melanoma specific survival (MSS) and melanoma-free survival (MFS) in <75-year-old group compared to the elderly group. Cox regression models demonstrated reduced MSS in patients ≥75 years regardless of gender, location, IB, ulceration and lymph node status at diagnosis (HR 1.54, P = 0.013) whereas MFS was not independently associated with elderly when head and neck location was considered. Age appears to be an independent risk factor for MSS but not for MFS. Worse melanoma prognosis in elderly could be explained by factors unrelated to the tumour, such as age-related frailty and comorbidities that limit the access to systemic treatments and, eventually, age-related immune dysfunction.

To evaluate the level of agreement between specialists in osteoporosis regarding the management of patients with high-risk fractures in Spain. A two-round Delphi study was performed using an online survey. In round 1, panel members rated their level of agreement with assessments on a 9-point Likert scale. Item selection was based on acceptance by ≥ 66.6% of panel experts and the agreement of the scientific committee. In round 2, the same panelists evaluated non-consensus items in round 1. A total of 80 panelists participated in round 1; of these, 78 completed the round 2 survey. In round 1, 122 items from 4 dimensions (definition of fracture risk: 11 items, prevention and diagnosis: 38 items, choice of treatment: 24 items, and treatment-associated quality of life: 49 items) were evaluated. The consensus was reached for 90 items (73.8%). Panelists agreed that categorizing high risk, very high risk, or imminent risk determines secondary prevention actions (97.5%). Experts agreed that treatment with bone-forming drugs should be considered in case of a very high risk of fracture, and a sequential change to antiresorptive drugs should be made after 1-2 years (97.5%). Panelists also recommended corrective action plans for non-adherent patients to improve adherence (97.5%). A total of 131 items were finally accepted after round 2. This Delphi study provides expert-based recommendations on clinical decision-making for managing patients with osteoporosis at high risk of fracture.

BackgroundThe efficacy of routine admission of high-risk patients to a critical care unit after surgery is not clear. The aim of our study was to investigate the association between critical care admission after scheduled colorectal surgery and postoperative complications, 30-day mortality, and length of stay in hospital. MethodsA pre-defined secondary substudy of POWER study was performed. POWER study was a prospective multicenter observational study of patients undergoing elective primary colorectal surgery during a single period of two months of recruitment between September and December 2017. ResultsA total of 2084 patients from 80 Spanish hospitals were included, of which 722 (34.6%) were admitted to critical care unit (CCU) after elective surgery. After adjusting for confounding factors in the multivariate analysis, postoperative CCU admission was independently associated with a higher incidence of moderate-to-severe postoperative complications (adjusted OR 1.951, 95% CI 1.570, 2.425; p < 0.001). Regarding secondary outcomes, postoperative critical care admission was independently associated with higher 30-day mortality (adjusted OR 6.736; 95% CI 2.507, 18.101; p < 0.001) and independently associated with an increased hospital length of stay (adjusted OR 1.143, 95% CI 1.112, 1.175; p < 0.001). ConclusionsDirect admission to CCU after scheduled colorectal surgery was not associated with a reduction in moderate-to-severe postoperative complications.

To analyze the impact of perioperative characteristics on the risk of recurrence in patients with uterine leiomyosarcomas. A sub-analysis of the SARComa of the UTerus (SARCUT) study, which is a multicentric cross-sectional pan-European study that included 390 patients diagnosed with leiomyosarcoma, between 2001 and 2007. Perioperative factors related to risk of recurrence and survival were analyzed. The 5-year and 10-year disease-free survivals (DFS) were 46% and 55%, respectively. Overall survival at 5 and 10 years was 34% and 47%, respectively. The most important factors related to global recurrence were the incomplete cytoreduction (hazard ratio [HR] 2.87; 95% confidence interval [CI] 1.91-4.31); performing bilateral adnexectomy (HR 2.71; 95% CI 1.23-5.93); tumor persistence after any treatment (HR 2.38; 95% CI 1.39-4.06); and adjuvant chemotherapy administration (HR 2.55; 95% CI 1.82-3.58) or adjuvant radiotherapy (HR 2.26; 95% CI 1.53-3.32). The major factors significantly associated with pelvic relapse were tumor persistence after any treatment (HR 3.63; 95% CI 1.83-7.20) and adjuvant radiotherapy (HR 2.74; 95% CI 1.44-5.20). Incomplete cytoreduction was the most important factor associated with distant relapse (HR 1.91; 95% CI 1.22-2.97). The most important factors related to overall survival were tumor persistence after any treatment (HR 4.59; 95% CI 2.51-8.40), incomplete cytoreduction (HR 3.68; 95% CI 2.44-5.56), tumor margin involvement (HR 2.41; 95% CI 1.64-3.55) and adjuvant chemotherapy (HR 1.91; 95% CI 1.31-2.78). Complete cytoreduction is the main prognosis factor impacting the DFS and overall survival of patients with uterine leiomyosarcoma. Adjuvant chemotherapy administration was associated with decreased rates of DFS and overall survival. The adjuvant radiotherapy was associated with a higher risk of global recurrence.

The genetic mechanisms associated with splenic marginal zone lymphoma (SMZL) transformation are not well defined. We studied 41 patients with SMZL that eventually underwent large B-cell lymphoma transformation. Tumor material was obtained either only at diagnosis (9 patients), at diagnosis and transformation (18 patients), and only at transformation (14 patients). Samples were categorized in 2 groups: (1) at diagnosis (SMZL, n= 27 samples), and (2) at transformation (SMZL-T, n= 32 samples). Using copy number arrays and a next-generation sequencing custom panel, we identified that the main genomic alterations in SMZL-T involved TNFAIP3, KMT2D, TP53, ARID1A, KLF2, 1q gains, and losses of 9p21.3 (CDKN2A/B) and 7q31-q32. Compared with SMZL, SMZL-T had higher genomic complexity, and higher incidence of TNFAIP3 and TP53 alterations, 9p21.3 (CDKN2A/B) losses, and 6p gains. SMZL and SMZL-T clones arose by divergent evolution from a common altered precursor cell that acquired different genetic alterations in virtually all evaluable cases (92%, 12 of 13 cases). Using whole-genome sequencing of diagnostic and transformation samples in 1 patient, we observed that the SMZL-T sample carried more genomic aberrations than the diagnostic sample, identified a translocation t(14;19)(q32;q13) present in both samples, and detected a focal B2M deletion due to chromothripsis acquired at transformation. Survival analysis showed that KLF2 mutations, complex karyotype, and International Prognostic Index score at transformation were predictive of a shorter survival from transformation (P= .001; P= .042; and P= .007; respectively). In summary, SMZL-T are characterized by higher genomic complexity than SMZL, and characteristic genomic alterations that could represent key players in the transformation event.

This paper focuses on determining the raw milk collection routes with heterogeneous fleet aiming to minimize the average operational emissions of carbon dioxide. The problem is a particular case of the Vehicle Routing Problem (VRP) which considers the variation of emissions in terms of load and distance. Two types of the problem are studied, one in which the routes of the available fleet are optimized, and another which determines the configuration of the fleet and its routes. For solving the problems, an exact method based on a Branch and Bound formulation and a multi-start heuristic based on the Iterated Local Search (ILS) are implemented. Randomly generated instances were implemented inspired by the conditions of the Ubaté-Chiquinquirá dairy region in central Colombia, considered one of the five largest milk producers with the highest daily productivity. The instances have a combination of different factors which are: the location of the processing plant, the farms in clusters, and the number of farms. The analysis reveals that in terms of route design, an environmental approach can produce an increase in the distance traveled by vehicles (up to 60%) while reducing the overall emissions, and also the importance of replacing part of the large and polluting vehicles with smaller vehicles with lower emissions. The results may facilitate decision-making, provide insights for shifting to sustainable approaches in routing problems, and suggest future works.

BackgroundThe challenging rigorous management of hypercholesterolemia promotes referral to specialized units. This study explored the need, based on referral rate and cardiovascular (CV) risk factor control in patients evaluated for familial hypercholesterolemia (FH), for a lipid unit (LU).MethodsOver a four-year period, 340 referrals to our unit were analyzed to establish the lipid disorder referral rate. Moreover, 118 patients referred for potential FH during the period 2010–2018 (52.4 ± 13.9 years, 47.5% male, Caucasian, 26.3% obese, 33.1% smokers and 51.7% with some glycaemic alteration) were investigated. The Dutch Lipid Clinic Network (DLCN) score, type and dose of lipid-lowering drugs, lipid profile including lipoprotein (a) (Lp(a)) and the presence of plaques with carotid ultrasound (CU) were recorded.ResultsLipids represented 6.2% of referrals (38 patient-years) requiring a 2–3 h weekly monographic outpatient consultation. The potential FH sample displayed a DLCN score ≥ 6 in 78% and modifiable CV risk factors in 51%. Only 22% achieved tight disease control despite intensive treatment. The statin-ezetimibe combination treatment group achieved better goals (73.0% vs. 45.5%, P = 0.003), and the rosuvastatin group had a higher proportion of prediabetes (60.9% vs. 39.1%, P = 0.037). Neither CU plaque presence nor Lp(a) > 50 mg/dL was linked with established CV disease patients, but higher Lp(a) concentrations were detected between them (102.5 (26.3–145.8) vs. 25.0 (13.0–52.0) mg/dL, P = 0.012).ConclusionsThe referral rate, degree of control, and proportion of modifiable CV risk factors in FH patients demonstrate the need for LU in our area as well as optimize control and treatment.

Abstract Objective Analyze the results of the self-adhesive polyester mesh placement in the prevention of the postoperative evisceration and incisional hernia after median abdominal incision during an emergency digestive surgery. Material and methods A prospective observational study was done in those patients who underwent a midline abdominal incision and a self-adhesive polyester mesh was placed in onlay position, for an emergency digestive surgery between December 2020 and December 2022. Analysis was done by means of demographics, body mass index (BMI), blood tests, ASA, P-Possum score, etiology, surgical contamination, abdominal incision closure, postoperative records (≥ 90 days) categorized with Clavien-Dindo (CD) classification and 1 year of follow-up. Results Sixty patients were included, mean age 62.86, (57.6% men), 52% were ASA III, BMI&amp;gt;30 12%. Most frequent etiologies were complicated small bowel obstruction (17) and complicated acute sigmoid diverticulitis (12). Postoperative records showed a 26,6% of morbidity, 93.7% were D I- II (minor) and 6.3% CD IIIb. Neither wound evisceration nor incisional hernia was observed during the follow-up. A significative relationship (p&amp;lt;0.05) was observed between BMI, preoperative C-reactive protein and ASA classification with postoperative complications, same relationship was observed between surgical contamination but without statistical significance. Conclusions In this series, a preventive self-adhesive polyester mesh placement after abdominal midline incision during emergency digestive surgery, showed an acceptable rate of postoperative complications with a low rate of local morbidity and a good results during the follow-up