Teleconsultation Between Patients and Health Care Professionals in the Catalan Primary Care Service: Message Annotation Analysis in a Retrospective Cross-Sectional Study

BACKGROUND

Over the last decade, telemedicine services have been introduced in the public health care systems of several industrialized countries. In Catalonia, the use of eConsulta, an asynchronous teleconsultation service between primary care professionals and citizens in the public health care system, has already reached 1 million cases. Before the COVID-19 pandemic, the use of eConsulta was growing at a monthly rate of 7%, and the growth has been exponential from March 15, 2020 to the present day. Despite its widespread usage, there is little qualitative evidence describing how this tool is used.

OBJECTIVE

The aim of this study was to annotate a random sample of teleconsultations from eConsulta, and to evaluate the level of agreement between health care professionals with respect to the annotation.

METHODS

Twenty general practitioners retrospectively annotated a random sample of 5382 cases managed by eConsulta according to three aspects: the type of interaction according to 6 author-proposed categories, whether the practitioners believed a face-to-face visit was avoided, and whether they believed the patient would have requested a face-to-face visit had eConsulta not been available. A total of 1217 cases were classified three times by three different professionals to assess the degree of consensus among them.

RESULTS

The general practitioners considered that 79.60% (4284/5382) of the teleconsultations resulted in avoiding a face-to-face visit, and considered that 64.96% (3496/5382) of the time, the patient would have made a face-to-face visit in the absence of a service like eConsulta. The most frequent uses were for management of test results (26.77%, 1433/5354), management of repeat prescriptions (24.30%, 1301/5354), and medical enquiries (14.23%, 762/5354). The degree of agreement among professionals as to the annotations was mixed, with the highest consensus demonstrated for the question "Has the online consultation avoided a face-to-face visit?" (3/3 professionals agreed 67.95% of the time, 827/1217), and the lowest consensus for the type of use of the teleconsultation (3/3 professionals agreed 57.60% of the time, 701/1217).

CONCLUSIONS

This study shows the ability of eConsulta to reduce the number of face-to-face visits for 55% (79% × 65%) to 79% of cases. In comparison to previous research, these results are slightly more pessimistic, although the rates are still high and in line with administrative data proxies, showing that 84% of patients using teleconsultations do not make an in-person appointment in the following 3 months. With respect to the type of consultation performed, our results are similar to the existing literature, thus providing robust support for eConsulta's usage. The mixed degree of consensus among professionals implies that results derived from artificial intelligence tools such as message classification algorithms should be interpreted in light of these shortcomings.

General Practitioners' Perceptions of Whether Teleconsultations Reduce the Number of Face-to-face Visits in the Catalan Public Primary Care System: Retrospective Cross-Sectional Study

BACKGROUND

eConsulta is a teleconsultation service involving general practitioners (GPs) and patients. It is part of the information system belonging to Catalonia's primary care service. It has been in operation since the end of 2015 in conjunction with face-to-face consultations with Primary Care Teams as one of the services offered in the patient's Personal Health Folder.

OBJECTIVE

This study aimed to assess the ability of using eConsulta to reduce the number of face-to-face visits to Primary Care Teams.

METHODS

Using 13 categories proposed by the researchers, 18 GPs from the Central Catalonia Health Region retrospectively classified 2268 cases managed with eConsulta and indicated whether, in their opinion, the teleconsultations reduced the number of face-to-face visits.

RESULTS

There was broad consensus among the GPs that eConsulta has the potential to resolve patient queries for every type of consultation. eConsulta avoided the need for a face-to-face visit in 87.9% of cases. In addition, the GPs reported that the ease of access increased the demand for health care support in 27.7% of cases; otherwise, the patient would not have initiated the queries. Therefore, based on the equation (88% x [1-28%]), eConsulta could replace 63%-88% of conventional appointments. The most frequent uses of the teleconsultation service were for management of test results (35.2%), medical enquiries (16.0%), and the management of repeat prescriptions (12.2%). On average, the teleconsultations consisted of a mean 1.57 messages (SD 0.54 messages); 45.9% (1040/2268) of the teleconsultations consisted of 1 message, and the majority of the remaining teleconsultations consisted of 2-5 interactions. The patient initiated 60.0% (1361/2268) of the teleconsultations.

CONCLUSIONS

Based on the GPs' perceptions, eConsulta could replace 63%-88% of conventional appointments. Therefore, asynchronous teleconsultations between practitioners and patients in primary care could avoid interactions that have limited added clinical value.

Teleconsultations between Patients and Healthcare Professionals in Primary Care in Catalonia: The Evaluation of Text Classification Algorithms Using Supervised Machine Learning

Background: The primary care service in Catalonia has operated an asynchronous teleconsulting service between GPs and patients since 2015 (eConsulta), which has generated some 500,000 messages. New developments in big data analysis tools, particularly those involving natural language, can be used to accurately and systematically evaluate the impact of the service. Objective: The study was intended to assess the predictive potential of eConsulta messages through different combinations of vector representation of text and machine learning algorithms and to evaluate their performance. Methodology: Twenty machine learning algorithms (based on five types of algorithms and four text representation techniques) were trained using a sample of 3559 messages (169,102 words) corresponding to 2268 teleconsultations (1.57 messages per teleconsultation) in order to predict the three variables of interest (avoiding the need for a face-to-face visit, increased demand and type of use of the teleconsultation). The performance of the various combinations was measured in terms of precision, sensitivity, F-value and the ROC curve. Results: The best-trained algorithms are generally effective, proving themselves to be more robust when approximating the two binary variables "avoiding the need of a face-to-face visit" and "increased demand" (precision = 0.98 and 0.97, respectively) rather than the variable "type of query" (precision = 0.48). Conclusion: To the best of our knowledge, this study is the first to investigate a machine learning strategy for text classification using primary care teleconsultation datasets. The study illustrates the possible capacities of text analysis using artificial intelligence. The development of a robust text classification tool could be feasible by validating it with more data, making it potentially more useful for decision support for health professionals.

Potentiation of the humoral immune response elicited by a commercial vaccine against bovine respiratory disease by Enterococcus faecalis CECT7121

Vaccination against pathogens involved in bovine respiratory disease (BRD) is a useful tool to reduce the risk of this disease however, it has been observed that the commercially available vaccines only partially prevent the infections caused by Pasteurella multocida and Mannheimia haemolytica. Therefore, it is recommended to search for new adjuvant strategies to minimise the economic impact of this respiratory syndrome. A possibility to improve the conventional vaccine response is to modulate the immune system with probiotics, since there is accumulating evidence that certain immunomodulatory strains administered around the time of vaccination can potentiate the immune response. Considering veterinary vaccines are frequently tested in murine models, we have developed an immunisation schedule in BALB/c mice that allows us to study the immune response elicited by BRD vaccine. In order to evaluate a potential strategy to enhance vaccine efficacy, the adjuvant effect of Enterococcus faecalis CECT7121 on the murine specific humoral immune response elicited by a commercial vaccine against BRD was studied. Results indicate that the intragastric administration of E. faecalis CECT7121 was able to induce an increase in the specific antibody titres against the bacterial components of the BRD vaccines (P. multocida and M. haemolytica). The quality of the humoral immune response, in terms of antibody avidity, was also improved. Regarding the cellular immune response, although the BRD vaccination induced a low specific secretion of cytokines in the spleen cell culture supernatants, E. faecalis CECT7121-treated mice showed higher interferon-γ production than immunised control mice. Our results allowed us to conclude that the administration of E. faecalis CECT7121 could be employed as an adjuvant strategy to potentiate humoral immune responses.

Larval fish collected from sound-scattering layers in an offshore tropical area

The composition of the larval fish assemblage in the sound-scattering layer of the continental shelf waters off the coast of south-eastern Brazil (12 and 22° S), a research project that is part of the Brazilian programme Avaliação do Potencial Sustentável de Recursos Vivos na Zona Econômica Exclusiva (REVIZEE), is described. Samples were collected during daylight hours and at dusk at five oceanographic stations in the winter of 1999 using an Isaacs-Kidd Midwater Trawl (IKMT). The oceanographic stations were chosen based on the detection of plankton layers by acoustic observation. A total of 2192 larval fish were identified, comprising 52 families and 62 species. Maurolicus stehmanni (Sternoptychidae) was the most abundant species found within the study area, comprising 18·5% of all identified larvae, followed by Psilotris celsus (Gobiidae) at 10·9%.

Probiotic activity of Enterococcus faecalis CECT7121: effects on mucosal immunity and intestinal epithelial cells

AIMS

To analyse the effect of Enterococcus faecalis CECT7121 on intestinal epithelial cells (IECs) and its effects on the mucosal immune response.

METHODS AND RESULTS

Enterococcus faecalis CECT7121 showed a high adhesion capacity to completely and heterogeneously differentiated human intestinal epithelial cell line (Caco-2 cells). In addition, the contact of this bacterium with Caco-2 cells did not induce inflammatory chemokines (IL-8 and CCL-20). The presence of IgA(+) and IL-6(+) cells in the small intestine, as well as the production of inflammatory cytokines (TNFα, IL-6 and IL-12) in the gut, was determined after intragastric inoculation of Ent. faecalis CECT7121 in BALB/c mice. The administration of Ent. faecalis CECT7121 increased the number of IgA(+) cells in the intestinal lamina propria without modifying the percentage of IL-6(+) cells. No differences were observed in the cytokines measured in the intestinal extracts between probiotic-treated and control mice.

CONCLUSIONS

Enterococcus faecalis CECT7121 stimulates local mucosal immunity and adheres to IECs without inducing inflammatory signals.

SIGNIFICANCE AND IMPACT OF THE STUDY

Our results indicate that, apart from its already reported systemic immune activity, Ent. faecalis CECT7121 has a modulatory effect at a local level.

Neutrophil proteomic analysis reveals the participation of antioxidant enzymes, motility and ribosomal proteins in the prevention of ischemic effects by preconditioning

Intestinal ischemia and reperfusion injury are widely used models, which result into tissue injury and multiple organ failure also observed after trauma and surgery. Ischemic preconditioning (IPC) preceding ischemia and reperfusion (IR) was shown to attenuate this injury and has a potential therapeutic application; however the exact underlying mechanism is not clear. Neutrophils play an important role in the mechanism of injuries caused by ischemia and reperfusion while IPC led to a decrease in neutrophil stimulation and activation. The effect of preconditioning on the neutrophil proteome is unclear. Proteomic analysis has been ratified as an appropriate tool for studying complex systems. In order to evaluate the effect of IPC preceding 45min of ischemia on the proteome of neutrophils we used Wistar rats divided in four experimental groups: Control, sham laparotomy, intestinal ischemia reperfusion and ischemic preconditioning. After neutrophil separation, proteins were extracted, trypsin digested and the resulting peptides were iTRAQ labeled followed by HILIC fractionation and nLC-MS/MS analysis. After database searches, normalization and statistical analysis our proteomic analysis resulted in the identification of 2437 protein groups that were assigned to five different clusters based on the relative abundance profiles among the experimental groups. The clustering followed by statistical analysis led to the identification of significantly up and downregulated proteins in IR and IPC. Cluster based KEGG pathways analysis revealed up- regulation of actin cytoskeleton, metabolism, Fc gamma R mediated phagocytosis, chemokine signaling, focal adhesion and leukocyte transendothelial migration whereas downregulation in ribosome, spliceosome, RNA transport, protein processing in endoplasmic reticulum and proteasome, after intestinal ischemic preconditioning. Furthermore, enzyme prediction analysis revealed the regulation of some important antioxidant enzymes and having their role in reactive oxygen species production. To our knowledge, this work describes the most comprehensive and detailed quantitative proteomic study of the neutrophil showing the beneficial role of ischemic preconditioning and its effects on the neutrophil proteome. This data will be helpful to understand the effect of underlying protective mechanisms modulating the role of PMNs after IPC and provide a trustworthy basis for future studies.

BIOLOGICAL SIGNIFICANCE

Preconditioning is a relevant strategy to overcome clinical implications from ischemia and reperfusion. Such implications have the neutrophil as a major player. Although many publications describe specific biochemical and physiological roles of the neutrophil in such conditions, there is no report of a proteomic study providing a broader view of this scenario. Here we describe a group of proteins significantly regulated by ischemia and reperfusion being such regulation prevented by preconditioning. Such finding may provide relevant information for a deeper understanding of the mechanisms involved, as well as serve as basis for future biomarker or drug target assays.

Anticancer peptides and proteins: a panoramic view

Despite progress in understanding carcinogenesis, cancer is still a major cause of morbidity and mortality worldwide. Treatment is complicated by the resistance to chemotherapeutics acquired by tumors, ability to repair damaged DNA, alteration of the interaction between drug and its target, and defects in the machinery that leads to apoptosis. The development of novel therapies based on biologically active peptides, especially antimicrobial peptides (AMPs), and proteins has emerged as a new strategy to defeat cancer.

Dielectric behavior of epoxy/BaTiO₃ composites using nanostructured ceramic fibers obtained by electrospinning

Composite materials made of epoxy resin and barium titanate (BT) electrospun nanostructured fibers were prepared. BT fibers were synthesized from a sol based on barium acetate, titanium isopropoxide, and poly(vinyl pyrrolidone). The fibers were heat-treated at different temperatures and characterized by X-ray diffraction, scanning electron microscopy (SEM), and Raman spectroscopy. Mats of BT fibers heat-treated at 800 °C were embedded in epoxy resin into suitable molds. The composites were characterized by SEM, and dielectric measurements were performed by means of dielectric spectroscopy. The dielectric permittivity and dielectric modulus of epoxy resin/BT-fiber composites were measured for two types of samples: with the electrodes parallel and perpendicular to the BT fiber layers. Interestingly, composite samples with electrodes perpendicular to the fiber layers and a BT content as low as 2 vol % led to dielectric permittivities three times higher than that of pure epoxy resin.

Assessment of modeled mercury dry deposition over the Great Lakes region

Three sets of model predicted values for speciated mercury concentrations and dry deposition fluxes over the Great Lakes region were assessed using field measurements and model intercomparisons. The model predicted values were produced by the Community Multiscale Air Quality Modeling System for the year 2002 (CMAQ2002) and for the year 2005 (CMAQ2005) and by the Global/Regional Atmospheric Heavy Metals Model for the year 2005 (GRAHM2005). Median values of the surface layer ambient concentration of gaseous elemental mercury (GEM) from all three models were generally within 30% of measurements. However, all three models overpredicted surface-layer concentrations of gaseous oxidized mercury (GOM) and particulate bound mercury (PBM) by a factor of 2-10 at the majority of the 15 monitoring locations. For dry deposition of GOM plus PBM, CMAQ2005 showed a clear gradient with the highest deposition in Pennsylvania and its surrounding areas while GRAHM2005 showed no such gradient in this region; however, GRAHM2005 had more hot spots than those of CMAQ2005. Predicted dry deposition of GOM plus PBM from these models should be treated as upper-end estimates over some land surfaces in this region based on the tendencies of all the models to overpredict GOM and PBM concentrations when compared to field measurements. Model predicted GEM dry deposition was found to be as important as GOM plus PBM dry deposition as a contributor to total dry deposition. Predicted total annual mercury dry deposition were mostly lower than 5 μg m(-2) to the surface of the Great lakes, between 5 and 15 μg m(-2) to the land surface north of the US/Canada border, and between 5 and 40 μg m(-2) to the land surface south of the US/Canada border. Predicted dry deposition from different models differed from each other by as much as a factor of 2 at regional scales and by a greater extent at local scales.

Opioidergic orofacial antinociception induced by electroacupuncture at acupoint St36

The participation of opioids in the antinociceptive effect of electroacupuncture was evaluated in terms of nociception produced by thermal stimuli applied to the face of male Wistar rats, weighing 180-230 g. Electrical stimulation (bipolar and asymmetric square wave with 0.5 mA intensity for 20 min) of acupoint St36, located in the anterior tibial muscle 10 mm distal to the knee joint, induced antinociception in the present model, which was maintained for 150 min. Acupoint LI4, located in the junction of the first and second metacarpal bones, did not achieve antinociception at any frequency studied (5 Hz: 1.7 +/- 0.1; 30 Hz: 1.8 +/- 0.1; 100 Hz: 1.7 +/- 0.1 vs 1.4 +/- 0.2). The antinociception obtained by stimulation of acupoint St36 was only achieved when high frequency 100 Hz (3.0 +/- 0.2 vs 1.0 +/- 0.1) was used, and not with 5 or 30 Hz (1.2 +/- 0.2 and 0.7 +/- 0.1 vs 1.0 +/- 0.1). The antinociceptive effect of acupuncture occurred by opioid pathway activation, since naloxone (1 and 2 mg/kg, subcutaneously) antagonized it (1.8 +/- 0.2 and 1.7 +/- 0.2 vs 3.0 +/- 0.1).

Partial characterization of enterocin MR99 from a corn silage isolate of Enterococcus faecalis

AIMS

To assess the inhibitory activity on Gram-positive and Gram-negative bacteria of several species of enterococci recovered from a natural corn silage.

METHODS AND RESULTS

The inhibitory activity of strains of Enterococcus faecalis (58), Enterococcus faecium (35), Enterococcus gallinarum (3) and Enterococcus casseliflavus (4) were studied employing indicator strains from various sources (clinical, food and ATCC). Enterococcus faecalis MR99, the only strain with inhibitory activity, inhibited other enterococci, Listeria spp., Staphylococcus aureus, Clostridium spp., Bacillus spp., Escherichia coli, Shigella sonnei and Shigella flexneri. The bacterium contained only one conjugative pheromone-responsive plasmid. The partially chromatography-purified MR99 enterocin (PPE) had a molecular weight of approx. 5000 Da and a pI of 6.2, was sensitive to proteolytic enzymes and could be extracted in benzene and butanol. It appeared stable to adjustment of pH 4.0, 5.0, 6.0, 7.0 and 8.0 and was resistant to heat. Inactivation was at 15 min at 121 degrees C. Enterocin MR99 was bactericidal on strains of Listeria monocytogenes, Staph. aureus, and bovine mastitis agents, it was bacteriostatic on E. coli. Although enterocins MR99 and AS48 have inhibitory activity on Gram-negative bacilli, PCR studies demonstrated a lack of relationship between them.

CONCLUSIONS

The active component had a protein nature, was resistant to heat and presented a wide inhibitory spectrum.

SIGNIFICANCE AND IMPACT OF THE STUDY

The biological properties of Ent. faecalis MR99 suggest that this strain merits further investigations so it can be applied in human and veterinary health programmes.

Total mercury concentrations in lakes and fish of western Maryland, USA

The purpose of this study was to quantify total mercury concentrations in three species of fish in three lakes of western Maryland: Piney Creek reservoir, Deep Creek Lake, and Lake Habeeb. We measured total mercury concentrations in water from each lake and muscle tissue from 119 fish collected in fall 2000: 15 largemouth bass (Micropterus salmoides), 15 yellow perch (Perca flavescens), and 15 bluegill (Lepomis macrochirus) from the Piney Creek reservoir; 15 largemouth bass, 15 yellow perch, and 14 bluegill from Deep Creek Lake; and 15 largemouth bass and 15 bluegill from Lake Habeeb. Average total mercury concentrations (+/- SD) in surface waters were 0.96 +/- 0.03 ng L(-1) for the Piney Creek reservoir, 0.56 +/- 0.07 ng L(-1) for Deep Creek Lake, and 0.40 +/- 0.05 ng L(-1) for Lake Habeeb. These water quality differences were sometimes reflected in the total mercury concentration in fish muscle tissue. Total mercury concentrations in bluegill (0.05 +/- 0.02 microg g(-1)) and largemouth bass (0.10 +/- 0.03 microg g(-1)) from Lake Habeeb were significantly (p < 0.001) lower than the total mercury concentrations in bluegill and largemouth bass from the Piney Creek reservoir (bluegill: 0.13 +/- 0.04 microg g(-1) and largemouth bass: 0.37 +/- 0.18 microg g(-1)) and Deep Creek Lake (bluegill: 0.11 +/- 0.04 microg g(-1) and largemouth bass: 0.30 +/- 0.09 microg g(-1)). Yellow perch from the Piney Creek reservoir had significantly higher total mercury concentrations than yellow perch from Deep Creek Lake (0.20 +/- 0.08 microg g(-1) versus 0.13 +/- 0.04 microg g(-1)). In contrast, total mercury concentrations in largemouth bass from the Piney Creek reservoir and Deep Creek Lake were not significantly different. With the exception of largemouth bass from Lake Habeeb and yellow perch from Deep Creek Lake, there were relatively strong (r(2) > 0.39-0.79) log-log relationships between the size (weight and length) of the fish and total mercury concentrations in muscle tissue. The largest largemouth bass (> 800 g and > 38 cm) from both Deep Creek Lake and the Piney Creek reservoir had total mercury concentrations that exceeded the consumption advisory of 0.5 microg g(-1) that is used by many states and Canada. In contrast, total mercury concentrations in largemouth bass from Lake Habeeb did not exceed this consumption advisory. Our results suggest that fish consumption advisories are needed for largemouth bass in the Piney Creek reservoir and Deep Creek Lake.

Cyclosporin inhibits hyperalgesia and edema in arthritic rats: role of the central nervous system

Since arthritis induced by Mycobacterium products (adjuvant) in rats is considered to be immunologically driven, the objective of the present study was to determine if the immunosuppressor drug cyclosporin could affect hindpaw edema and joint hyperalgesia simultaneously. Female Holtzman rats (140-170 g) presented hyperalgesia and edema on the 8th and 12th day following adjuvant injection. Daily systemic (oral or intramuscular) administration of cyclosporin (0.5-5.0 mg kg (-1) day (-1)) or dexamethasone (0.01-0.1 mg kg (-1) day (-1)) for 15 days starting on day zero dose-dependently inhibited the hindpaw edema and hyperalgesia in arthritic rats. However, hyperalgesia but not edema could be detected two days after cyclosporin withdrawal. We concluded that a) the continuous presence of cyclosporin is essential to reduce the development of joint hyperalgesia and that b) different mechanisms underlie the appearance of hyperalgesia and edema in this model. The intracerebroventricular (i.c.v.) administration of 5-50-fold smaller doses of cyclosporin (1.5-150 micrograms/day) or dexamethasone (15 micrograms/day) also reduced the arthritic hindpaw edema and hyperalgesia. Peripheral blood from animals injected with effective systemic cyclosporin doses showed detectable levels of the drug, whereas peripheral blood from those injected with i.c.v. cyclosporin did not, as measured by specific RIA. Our results indicate that cyclosporin administered by the central route is as effective as by the systemic route to reduce joint hyperalgesia and hindpaw edema in arthritic rats. The antiarthritic effect induced by low doses of cyclosporin in the central nervous system (CNS) could be explored to avoid it often associated systemic side effects during chronic therapy. However, the mechanism(s) involved in the antiarthritic response to cyclosporin in the CNS remain to be elucidated.

Cutaneous Nocardia asteroides infection of nontraumatic origin

This paper reports a case of cutaneous infection of nontraumatic origin caused by Nocardia asteroides in a hospitalized patient with chronic obstructive pulmonary disease. Diagnosis was established by direct and histological examination, cultures from exudate and biopsy specimen. We discuss the classification of clinical forms of Nocardia infections affecting the skin.

Curvularia lunata peritonitis complicating peritoneal dialysis

A case of peritonitis due to Curvularia lunata during continuous ambulatory peritoneal dialysis is reported. Diagnosis was established by culture of dialysis effluent and peritoneal exudate, and was also confirmed through histological examination.