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In Barcelona, the incompatible timetables of doctors of different levels emerged as a factor that hinders the organization of joint clinical case conferences and communication by telephone Table 5 , A2. Finally, the design of the mechanisms emerged as a determinant of their use. In the shared EMR, for example, the layout of the medical history makes it difficult to organize and quickly identify the information recorded by other professionals Table 5 , A3.

With regard to joint clinical case conferences, primary care doctors in Girona pointed out that when they are conducted virtually via videoconferencing, they are less productive because cases are not discussed in such detail and less knowledge is acquired of the skills and resources available in primary care Table 5 , A4. Moreover, sometimes the amount of time scheduled for the conferences is not enough, which prevents the discussion of all the clinical cases presented by the primary care doctors.

The factor of knowing each other influences both their level of participation in the conferences and their use of informal communication mechanisms to get support in the management of patients Table 5 , B2. According to secondary care doctors, lack of awareness of the criteria for referring patients by virtual means or via the rapid diagnostic pathway for cancer leads some primary care doctors to misuse these mechanisms Table 5 , B3.

Discussion Mechanisms that contribute most to clinical coordination are those based on mutual adjustment Our findings suggest that the main mechanisms contributing to clinical coordination across primary and outpatient secondary care are those based on mutual adjustment processes, which include the shared EMR, joint clinical case conferences between doctors, off-line virtual consultations and the use of telephone for communicating in urgent cases.

These mechanisms contribute to clinical coordination by enabling doctors from the two care levels to share information on patient care, as well as to establish direct, problem-solving communication, which translates into improved consistency of care, follow-up and accessibility across care levels.

In addition, joint clinical case conferences generate interaction between doctors, which encourages mutual knowledge and positive attitudes towards collaboration, thus promoting the use of other mechanisms. We expected to find differences in the type of care coordination mechanisms implemented in the networks since they are managed by different providers and represent different management models.

However, our findings suggest similar implementation of mechanisms in the three healthcare networks, with a comparable perceived contribution to clinical coordination. This result could be a consequence of the fact that all three healthcare networks form part of a national health system, and thus share many of the contextual factors that guide the implementation of coordination mechanisms: the same care model based on primary care, with a similar system of funding and incentives for professionals and organizations.

There is little research exploring the perceived benefits of shared EMRs across primary and secondary care under routine conditions [ 17 , 18 , 37 ]. The results of this study reveal that doctors perceive that the impact of the shared EMR goes beyond clinical information coordination, as it also has a significant effect on care consistency and patient follow-up across care levels.

Furthermore, it improves the functionality of additional coordination mechanisms based on asynchronous communication by helping secondary care doctors to obtain the information they need to respond to off-line virtual consultations, including those made via EMR and email. Interestingly, these benefits were identified both in networks where there is a single EMR for the two care levels and in networks where there are two different but interconnected EMRs.

There is little evidence available as yet on joint clinical case conferences between primary and secondary care doctors, with the exception of a few pilot studies [ 30 , 39 , 40 , 41 ], which consistently associate them with reductions in the number of face-to-face patient consultations and physical examinations carried out in secondary care.

Our study identifies additional paths by which this mechanism contributes to clinical coordination, such as creating the kind of professional interaction that promotes mutual knowledge and a better attitude towards collaboration and more communication outside the conferences. Although these conferences are not part of a formal training program, professionals highlight improvements in the training and response capacity of primary care doctors as a consequence of their participation in these conferences [ 10 , 31 ].

As a result, clinical case conferences emerge as a comprehensive mechanism that promotes clinical coordination across care levels through both mutual adjustment and standardization of professional skills. Off-line virtual consultations have been garnering more attention in healthcare studies, and have been shown to reduce face-to-face patient consultations in secondary care and waiting times for secondary care [ 42 , 43 , 44 ].

In this study, two types of virtual consultations were identified, those conducted via shared EMRs and those via e-mail. The first was perceived to be a formal mechanism to obtain feedback from specialists, and in some cases to enhance the traditional referral process. In contrast, virtual consultations through e-mail were perceived as an informal way to conduct specific curbside consultations. Accordingly, the use of virtual consultations through the EMR was related to different benefits in clinical coordination from those related to consultations via e-mail, including the prevention of inappropriate referrals and the assurance that patients have had all the required diagnostic testing before being referred.

One possible explanation is related to the particular nature of asynchronous communication, which limits the possibility of engaging in the meaningful discussion that is required to promote the learning process. Finally, among the mechanisms based on process standardization, only referral protocols and agreements emerged as mechanisms that contribute to clinical coordination by facilitating access to secondary care after referral, albeit in a marginal way.

Agreements were generally established during the joint conferences, which supports the case for introducing this type of mechanism alongside mechanisms based on direct communication to increase their adaptation and uptake [ 24 ]. One possible explanation is the limited uptake of these mechanisms by doctors; however, we cannot rule out the possibility that doctors tend to conceptualise clinical coordination in terms of direct interaction among professionals, but not in terms of distribution of tasks.

Factors influencing the use of coordination mechanisms The main barrier reported in the use of coordination mechanisms is insufficient time during consultations for example, the recording and uptake of information in the EMR and outside consultations for example, participating in joint conferences or responding to virtual consultations. This factor, frequently reported in the literature [ 10 , 17 , 31 , 46 ], might be even more relevant in the current context of the economic crisis, which has been associated by professionals with an increase in their work overload [ 35 , 47 ].

Moreover, it should be noted that some of the mechanisms identified involve additional work for primary care doctors, since they retain patients that were previously referred to secondary care doctors [ 48 ]. In keeping with previous research [ 10 , 17 , 22 ], the study results highlight the importance of carefully designing mechanisms to properly respond to the clinical coordination needs of doctors and enhance their usability.

The granularity of these data made it possible to control for confounding and test for residual systematic bias. Our data are highly relevant for ongoing global vaccination strategies and future and current third-dose and booster campaigns. In conclusion, by leveraging the potential of multiple data sources in parallel, our study confirmed that a heterologous vaccination schedule of ChAdOx1 and BNTb2 was safe and provided better protection against COVID than a homologous ChAdOx1 vaccination schedule in real-world settings experiencing the Delta variant.

More research on other mixed-vaccine schedules with different prime-boost intervals are needed. Methods Study design and data sources We performed a cohort study based on linked routinely collected data available to the Public Health Secretariat of Catalonia. Vaccine exposure was obtained from the Catalan Shared Clinical Records, a database with vaccine data covering the entire Catalan health system and all its vaccination centres.

Participants, cohorts and follow-up For our primary analysis, we included all individuals aged 19—59 years old who received a first dose of the ChAdOx1 vaccine and a second dose of ChAdOx1 homologous vaccination or BNTb2 heterologous vaccination. We followed participants from the day they received their second dose of either vaccine until an outcome, death, third dose of the vaccine, or the end of data availability 5 December Each participant receiving heterologous vaccination was matched to one person receiving homologous vaccination using exact matching by age, sex, general practice centre and date of second dose.

In a sensitivity analysis, we changed the matching ratio to and to increase sample size. We measured the number of tests over time regardless of results as an additional outcome to account for diagnostic effort. Safety outcomes included venous thromboembolism, venous thromboembolism with thrombocytopenia and myopericarditis within 21 days after the second vaccine dose, based on ChAdOx1 21 and BNTb2 23 safety reports.

Supplementary Table S2 includes the ICDCM codes international classification of diseases, 10th revision, clinical modification used to ascertain when these events occurred. We analysed the occurrence of a negative control outcome—low back pain—to identify potential unmeasured confounding. Negative control outcomes are health events not causally associated with the exposure of interest, here vaccination. Additional covariates Covariates used for confounding assessment included socio-demographics and clinical features assessed at the time of inclusion day of the second vaccination , as recorded in primary-care electronic health records and linked administrative data: age in years , sex, area of residence, rurality and socio-economic status, number of RT-PCR tests or LFT performed, pre-existing comorbidities and long-term medicine use.

We assessed socio-economic status using a validated deprivation index based on census data MEDEA deprivation index 26 , As a sensitivity analysis, we generated additional study populations and repeated all analyses after matching with and ratios. We assessed confounding due to known variables by measuring covariate imbalance as the standardised mean difference SMD of all covariates listed above. Separately, we used propensity score matching as part of a post-hoc analysis requested by one of the manuscript reviewers.

Propensity scores were estimated using logistic regression including all available confounders, and cohorts matched using propensity score values with a maximum caliper width of 0. We plotted time-to-event Kaplan—Meier estimates according to vaccine exposure homologous vs heterologous.

Absolute risk reduction ARR was estimated as the difference in cumulative incidence of Covid amongst those receiving homologous—heterologous vaccination. Visual inspection of Schoenfeld residuals against the transformed time was used to evaluate the proportionality of hazards. All analyses were conducted using R version 4. Ethical considerations and information governance All data were obtained from linked administrative sources after pseudonymisation in accordance with articles 6.

Reporting summary Further information on research design is available in the Nature Research Reporting Summary linked to this article. Aggregated data are provided for inspection as Supplementary Data 1 - 3 , and R code used for analyses as Supplementary Code 1. Voysey, M.

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Unidad de Salud Internacional Metropolitana Nord. Sonia Vega, especialista en enfermedades infecciosas. Meritxell Vidal, coordinadora de comadronas. Pilar Villalobos, pediatra. Judith Villar, especialista en enfermedades infecciosas. Parc de Salut Mar. Circuito de cribado en mujeres embarazadas. Un aspecto fundamental que se desprende de este documento y del funcionamiento del Programa es la multidisciplinariedad.

Fuente: Neglected Tropical Diseases. World Health Organization. En el electrocardiograma ECG se pueden detectar alteraciones del ritmo, bloqueos auriculoventriculares, complejos QRS con voltaje bajo y ondas T negativas. En el ecocardiograma se observan dilataciones cavitarias, aneurismas apicales e hipocinesia o acinesia fragmentaria de predominio posteroinferior- intramural por fibrosis. Su valor predictivo positivo depende del grado de parasitemia. Se pueden realizar estudios complementarios con fibrogastroscopia.

Alergia a los imidazoles. Tabla 1. El embarazo no debe complicarse especialmente. Se recomienda seguir el mismo esquema de cribado que el de las gestantes figura 2 y 3. Mujer embarazada: 1. Los objetivos principales de la VE son: 1. Formar y dar apoyo a los profesionales en contacto con los pacientes y el personal de laboratorio. Las funciones que deben realizar son: 1. Cribado de la embarazada de riesgo. Tasa de cobertura del Programa 2.

Chagas disease. Lancet ;— Chagas disease in Latin America: an epidemiological update based on estimates. Wkly Epidemiol Rec ;— PDF accessed November 7, Chagas disease: a Latin American health problem becoming a world health problem.

Acta Trop ;— Chagas disease in European countries: the challenge of a surveillance system. Euro Surveill ; Prevalence of Chagas disease in Latin-American migrants living in Europe: a systematic review and meta- analysis. Health policies to control Chagas disease transmission in European countries.

Prevalence and vertical transmission of Trypanosoma cruzi infection among pregnant Latin American women attending 2 maternity clinics in Barcelona, Spain. Clin Infect Dis ;— Congenital transmission of Chagas disease: a clinical approach.

Expert Rev Anti Infect Ther ;— Prevalence of Chagas disease in pregnant women and congenital transmission of Trypanosoma cruzi in Brazil: a systematic review and meta-analysis. Trop Med Int Health ;— Prevalence of Chagas disease in pregnant women and incidence of congenital transmission in Santa Cruz de la Sierra, Bolivia. Am J Trop Med Hyg ;— Maternal fetal transmission of Trypanosoma cruzi: a problem of public health little studied in Mexico.

Exp Parasitol ;— Etiological treatment of young women infected with Trypanosoma cruzi, and prevention of congenital transmission. Rev Soc Bras Med Trop ;—7. Economic evaluation of Chagas disease screening of pregnant Latin American women and of their infants in a non endemic area. Acta Trop ;—7. Clinical and epidemiological aspects of Chagas disease. Lancet Infect Dis ;— Acute chagas disease: new global challenges for an old neglected disease.

Neurologic manifestations of Chagas disease. Curr Neurol NeurosciRep ;— Trypanosoma cruzi discrete typing units in Chagas disease patients from endemic and non-endemic regions of Argentina. Parasitology ;— Indeterminate form of Chagas disease. MemInst Oswaldo Cruz ;94 Suppl —6. Chagas disease cardiomyopathy: immunopathology and genetics.

Mediat Inflamm ; Predictors of mortality in chronic Chagas disease: a systematic review of observational studies. Circulation ;—8. Clin Cardiol ;—9. Rev Esp Cardiol ;— Clinical profile of Trypanosoma cruzi infection in a non-endemic setting: immigration and Chagas disease in Barcelona Spain. Acta Trop ;—5. Characterization of digestive involvement in patients with chronic T. Gastroenterol Hepatol ;— Immunosuppression and Chagas disease: a management challenge.

Rev Soc Bras Med Trop ;— Chagas disease in the immunosuppressed host. Curr Opin Infect Dis ;— 7. Quantification of Trypanosoma cruzi parasitaemia by direct micromethod. Bol ChilParasitol ;—5. Braz J Med Biol Res ;—3. Chagas disease: increased parasitemia during pregnancy detected by hemoculture. Am J Trop Med Hyg ;— Parasit Vectors ; Use of a simplified polymerase chain reaction procedure to detect Trypanosoma cruzi in blood samples from chronic chagasic patients in a rural endemic area.

Am J Trop Med Hyg ;—7. Development of a real-time PCR assay for Trypanosoma cruzi detection in blood samples. Predictive role of polymerase chain reaction in the early diagnosis of congenital Trypanosoma cruzi infection. How to improve the early diagnosis of Trypanosoma cruzi infection: relationship between validated conventional diagnosis and quantitative DNA amplification in congenitally infected children.

Detection of Trypanosoma cruzi in blood specimens of chronic chagasic patients by polymerase chain reaction amplification of kinetoplast minicircle DNA: comparison with serology and xenodiagnosis. J Clin Microbiol ;—6. BMC Infect Dis ; Enferm Infecc Microbiol Clin ;— Diagnosis of Chagas disease: what has been achieved? What remains to be done with regard to diagnosis and follow up studies?

MemInst Oswaldo Cruz ; Suppl— Evaluation of in-house ELISA using Trypanosoma cruzi lysate and recombinant antigens for diagnosis of Chagas disease and discrimination of its clinical forms. Enferm Infecc Microbiol Clin ;—8. Enferm Infecc Microbiol Clin ;—5. J Clin Microbiol ;— Control of Chagas disease. Sociedad Espanola de Infectologia Pediatrica. Sociedad de Enfermedades Infecciosas y Microbiologia Clinica.

Sociedad Espanola de Ginecologia y. Chagas disease: control and elimination Report by the Secretariat. J Antimicrob Chemother ;—9. Tabla 1. El embarazo no debe complicarse especialmente. Se recomienda seguir el mismo esquema de cribado que el de las gestantes figura 2 y 3. Mujer embarazada: 1. Los objetivos principales de la VE son: 1. Formar y dar apoyo a los profesionales en contacto con los pacientes y el personal de laboratorio.

Las funciones que deben realizar son: 1. Cribado de la embarazada de riesgo. Tasa de cobertura del Programa 2. Chagas disease. Lancet ;— Chagas disease in Latin America: an epidemiological update based on estimates. Wkly Epidemiol Rec ;— PDF accessed November 7, Chagas disease: a Latin American health problem becoming a world health problem. Acta Trop ;— Chagas disease in European countries: the challenge of a surveillance system. Euro Surveill ; Prevalence of Chagas disease in Latin-American migrants living in Europe: a systematic review and meta- analysis.

Health policies to control Chagas disease transmission in European countries. Prevalence and vertical transmission of Trypanosoma cruzi infection among pregnant Latin American women attending 2 maternity clinics in Barcelona, Spain. Clin Infect Dis ;— Congenital transmission of Chagas disease: a clinical approach. Expert Rev Anti Infect Ther ;— Prevalence of Chagas disease in pregnant women and congenital transmission of Trypanosoma cruzi in Brazil: a systematic review and meta-analysis.

Trop Med Int Health ;— Prevalence of Chagas disease in pregnant women and incidence of congenital transmission in Santa Cruz de la Sierra, Bolivia. Am J Trop Med Hyg ;— Maternal fetal transmission of Trypanosoma cruzi: a problem of public health little studied in Mexico. Exp Parasitol ;— Etiological treatment of young women infected with Trypanosoma cruzi, and prevention of congenital transmission. Rev Soc Bras Med Trop ;—7. Economic evaluation of Chagas disease screening of pregnant Latin American women and of their infants in a non endemic area.

Acta Trop ;—7. Clinical and epidemiological aspects of Chagas disease. Lancet Infect Dis ;— Acute chagas disease: new global challenges for an old neglected disease. Neurologic manifestations of Chagas disease. Curr Neurol NeurosciRep ;— Trypanosoma cruzi discrete typing units in Chagas disease patients from endemic and non-endemic regions of Argentina.

Parasitology ;— Indeterminate form of Chagas disease. MemInst Oswaldo Cruz ;94 Suppl —6. Chagas disease cardiomyopathy: immunopathology and genetics. Mediat Inflamm ; Predictors of mortality in chronic Chagas disease: a systematic review of observational studies. Circulation ;—8. Clin Cardiol ;—9. Rev Esp Cardiol ;— Clinical profile of Trypanosoma cruzi infection in a non-endemic setting: immigration and Chagas disease in Barcelona Spain.

Acta Trop ;—5. Characterization of digestive involvement in patients with chronic T. Gastroenterol Hepatol ;— Immunosuppression and Chagas disease: a management challenge. Rev Soc Bras Med Trop ;— Chagas disease in the immunosuppressed host. Curr Opin Infect Dis ;— 7. Quantification of Trypanosoma cruzi parasitaemia by direct micromethod.

Bol ChilParasitol ;—5. Braz J Med Biol Res ;—3. Chagas disease: increased parasitemia during pregnancy detected by hemoculture. Am J Trop Med Hyg ;— Parasit Vectors ; Use of a simplified polymerase chain reaction procedure to detect Trypanosoma cruzi in blood samples from chronic chagasic patients in a rural endemic area. Am J Trop Med Hyg ;—7. Development of a real-time PCR assay for Trypanosoma cruzi detection in blood samples.

Predictive role of polymerase chain reaction in the early diagnosis of congenital Trypanosoma cruzi infection. How to improve the early diagnosis of Trypanosoma cruzi infection: relationship between validated conventional diagnosis and quantitative DNA amplification in congenitally infected children. Detection of Trypanosoma cruzi in blood specimens of chronic chagasic patients by polymerase chain reaction amplification of kinetoplast minicircle DNA: comparison with serology and xenodiagnosis.

J Clin Microbiol ;—6. BMC Infect Dis ; Enferm Infecc Microbiol Clin ;— Diagnosis of Chagas disease: what has been achieved? What remains to be done with regard to diagnosis and follow up studies? MemInst Oswaldo Cruz ; Suppl— Evaluation of in-house ELISA using Trypanosoma cruzi lysate and recombinant antigens for diagnosis of Chagas disease and discrimination of its clinical forms.

Enferm Infecc Microbiol Clin ;—8. Enferm Infecc Microbiol Clin ;—5. J Clin Microbiol ;— Control of Chagas disease. Sociedad Espanola de Infectologia Pediatrica. Sociedad de Enfermedades Infecciosas y Microbiologia Clinica. Sociedad Espanola de Ginecologia y. Chagas disease: control and elimination Report by the Secretariat.

J Antimicrob Chemother ;—9. Am J Trop Med Hyg ;—9. Impact of aetiological treatment on conventional and multiplex serology in chronic Chagas disease. Long-term cardiac outcomes of treating chronic Chagas disease with benznidazole versus no treatment: a nonrandomized trial. Ann Intern Med ;— A, Rosas F, et al. N Engl J Med ;— JAMA ; Congenital Chagas disease: recommendations for diagnosis, treatment and control of newborns, siblings and pregnant women. Buenos Aires Argentina : Pediatric Chagas disease in Europe: 45 cases from Spain and Switzerland.

Pediatr Infect Dis J ;— Tolerance and safety of nifurtimox in patients with chronic chagas disease. Clin Infect Dis ;e69— Seroprevalence of Trypanosoma cruzi infection in at-risk blood donors in Catalonia Spain. Transfusion ;—8.