Atención Farmacéutica, Determinantes sociales de la Salud y Comunidad: nuevo paradigma / Pharmaceutical Care, Social Determinants of Health and Community: a new paradigm

Este trabajo analiza las limitaciones de la concep-tualización actual de la Atención Farmacéutica, revisando los distintos enfoques comunitarios centrados en los Determinantes Sociales de la Salud (DSS) y propone una evolución hacia la Atención Farmacéutica Comunitaria, definida como i) la participación activa de la farmacia en la asistencia a su comunidad a través del mapeo de, la coordinación y la derivación hacia otros recur-sos y profesionales de dentro y fuera del sistema sanitario, ii) el diagnóstico de salud de su barrio y iii) la catalización de procesos comunitarios, a fin de conseguir resultados que mejoren la calidad de vida del paciente y de su comunidad. De este modo, los autores proponen un nuevo paradigma de Farmacia Catalizadora de Salud Comunitaria. (AU)

This paper analyzes the limitations of the current conceptualization of Pharmaceutical Care, review-ing the different community approaches focused on the Social Determinants of Health (SDH) and proposes an evolution towards Community Phar-maceutical Care, defined as i) active participation of the pharmacy in assisting its community through mapping, coordination and referral to other resourc-es and professionals inside and outside the health system, ii) the health diagnosis of its neighborhood and iii) the catalysation of community processes in order to achieve results that improve the quality of life of the patient and its community. In this way, the authors propose a new paradigm of the Pharmacy as a catalyst for the Community Health. (AU)

Diagnóstico inicial de salud desde la farmacia comunitaria en el barrio de San Isidro de Granadilla de Abona (Tenerife) / Initial health diagnosis from the community pharmacy in the neighbourhood of San Isidro de Granadilla de Abona (Tenerife)

Introducción: Este diagnóstico comunitario de salud surge de la necesidad de un conocimiento compartido del territorio, sus recursos, sus retos, con el objetivo de desarrollar una acción comunitaria para la salud desde una farmacia.Métodos. Se ha realizado un inventario de recursos comunitarios categorizados en: territoriales, sanitarios, sociales, económicos, educativos, culturales y de ocio y asociativos; y 31 entrevistas semiestructuradas a 68 personas que integran instituciones, ONG o asociaciones vecinales.Resultados. Se presenta resumen de la guía de recursos, que tienden a concentrarse en torno a la avenida Santa Cruz. Los resultados iniciales del diagnóstico comunitario presentados muestran un barrio donde las desigualdades en salud tienen un peso importante, con problemas estructurales en relación con distintos determinantes de la salud.Discusión. El proceso ha generado relaciones de colaboración en materia de promoción de la salud en el territorio. El Ayuntamiento de Granadilla de Abona ha mostrado su voluntad de extender la iniciativa al resto del municipio. Es necesario mejorar la participación en salud de los y las pacientes en espacios de construcción compartida e incluir técnicas como el análisis del discurso y análisis de contenido. (AU)

Diagnóstico inicial de salud desde la farmacia comunitaria en el barrio de San Isidro de Granadilla de Abona (Tenerife) / Health mapping and diagnosis from the community pharmacy. Initial results of an experiment in San Isidro

Introducción: Este diagnóstico comunitario de salud surge de la necesidad de un conocimiento compartido del territorio, sus recursos, sus retos, con el objetivo de desarrollar una acción comunitaria para la salud desde una farmacia. Métodos: Se ha realizado un inventario de recursos comunitarios categorizados en: territoriales, sanitarios, sociales, económicos, educativos, culturales y de ocio y asociativos; y 31 entrevistas semiestructuradas a 68 personas que integran instituciones, ONG o asociaciones vecinales. Resultados: Se presenta resumen de la guía de recursos, que tienden a concentrarse en torno a la avenida Santa Cruz. Los resultados iniciales del diagnóstico comunitario presentados muestran un barrio donde las desigualdades en salud tienen un peso importante, con problemas estructurales en relación con distintos determinantes de la salud. Discusión: El proceso ha generado relaciones de colaboración en materia de promoción de la salud en el territorio. El Ayuntamiento de Granadilla de Abona ha mostrado su voluntad de extender la iniciativa al resto del municipio. Es necesario mejorar la participación en salud de los y las pacientes en espacios de construcción compartida e incluir técnicas como el análisis del discurso y análisis de contenido. (AU)

Introduction: This community health diagnosis arises from the need for a shared knowledge of the region, its resources and challenges. The aim is to develop community health action from a Pharmacy. Methods. An inventory of community resources has been made, categorized as: territorial, health, social, economic, educational, cultural and leisure and associative; and 31 semi-structured interviews with 68 people comprising institutions, NGOs or community associations. Results. A summary of the community resources, which tend to be concentrated around Avenida Santa Cruz, is presented. The initial results of the community diagnosis presented reveals a neighbourhood where health inequalities play an important role with structural problems in relation to different health determinants. Discussion. The process has generated collaborative relationships in the area of health promotion in the territory. The City Council of Granadilla de Abona has shown its willingness to extend the initiative to the rest of the municipality. It is necessary to improve the participation of patients in health within spaces of shared construction and to include techniques such as discourse analysis and content analysis. (AU)

Urinary and hair concentrations of trace metals in pregnant women from Northeastern British Columbia, Canada: a pilot study.

BACKGROUND: Northeastern British Columbia (Canada) is an area of intense natural gas exploitation by hydraulic fracturing. Hydraulic fracturing can release contaminants, including trace metals, many of which are known developmental toxicants. To date, there is limited data on human exposure to contaminants in this region. OBJECTIVE: We aimed to examine trace metals in urine and hair samples from 29 Indigenous and non-Indigenous pregnant women from two communities (Chetwynd and Dawson Creek) in Northeastern British Columbia. METHODS: We recruited 29 pregnant women who provided spot urine samples over five consecutive days and one hair sample. We measured 19 trace metals in pooled urine samples from each participant and in the first 2 cm of hair closest to the scalp. We compared urinary and hair concentrations to those measured in women from the general population using data from the Canadian Health Measure Survey (CHMS), or reference values found in the literature for trace metals not measured in the CHMS. RESULTS: Median urinary (0.49 µg/L) and hair (0.16 µg/g) concentrations of manganese were higher in our participants than in the CHMS (<0.05 µg/L in urine) or reference population (0.067 µg/g in hair). In hair, median values for barium (4.48 µg/g), aluminum (4.37 µg/g) and strontium (4.47 µg/g) were respectively 16, 3, and 6 times higher compared with median values in a reference population. Concentrations of barium and strontium in hair were higher in self-identified Indigenous participants (5.9 and 5.46 µg/g, respectively) compared to non-Indigenous participants (3.88 and 2.60 µg/g) (p-values = 0.02 and 0.03). CONCLUSION: Our results suggest higher gestational exposure to certain trace metals in our study population compared to reference populations.

A new anti-mesothelin antibody targets selectively the membrane-associated form.

Mesothelin is a glycosylphosphatidylinositol (GPI)-anchored membrane protein that shows promise as a target for antibody-directed cancer therapy. High levels of soluble forms of the antigen represent a barrier to directing therapy to cellular targets. The ability to develop antibodies that can selectively discriminate between membrane-bound and soluble conformations of a specific protein, and thus target only the membrane-associated antigen, is a substantive issue. We show that use of a tolerance protocol provides a route to such discrimination. Mice were tolerized with soluble mesothelin and a second round of immunizations was performed using mesothelin transfected P815 cells. RNA extracted from splenocytes was used in phage display to obtain mesothelin-specific antigen-binding fragments (Fabs) that were subsequently screened by flow cytometry and ELISA. This approach generated 147 different Fabs in 34 VH-CDR3 families. Utilizing competition assays with soluble protein and mesothelin-containing serum obtained from metastatic cancer patients, 10 of these 34 VH-CDR3 families were found to bind exclusively to the membrane-associated form of mesothelin. Epitope mapping performed for the 1H7 clone showed that it does not recognize GPI anchor. VH-CDR3 sequence analysis of all Fabs showed significant differences between Fabs selective for the membrane-associated form of the antigen and those that recognize both membrane bound and soluble forms. This work demonstrates the potential to generate an antibody specific to the membrane-bound form of mesothelin. 1H7 offers potential for therapeutic application against mesothelin-bearing tumors, which would be largely unaffected by the presence of the soluble antigen.

Prescripción prudente y deprescripción de fármacos como herramientas para la prevención cuaternaria / Prudent prescribing and deprescribing drugs as tools for quaternary prevention / Prescrição prudente e desprescrição de fármacos como ferramentas para a prevenção quaternária / Prudent prescribing and deprescribing drugs as tools for quaternary prevention

Las consecuencias de una medicación inadecuada son diversas y con gran repercusión a nivel clínico: desde efectos adversos e interacciones medicamentosas a fracturas por caídas y aumento de morbi-mortalidad. Para evitar o mejorar dichas consecuencias, así como para abordar sus causas y con la seguridad del paciente en mente, nace la deprescripción para conseguir una prescripción más segura, más prudente y más humana. La atención primaria se sitúa en un lugar privilegiado para hacer frente a este reto que debería formar parte de cualquier estrategia de prevención cuaternaria.

As consequências de uma medicação inadequada são diversas e com grande repercussão clínica: desde efeitos adversos e interações medicamentosas até fraturas por quedas e aumento da morbidade e mortalidade. Para se evitar ou amenizar essas consequências, bem como abordar as suas causas, levando-se em conta a segurança dos pacientes, surge a desprescrição para se obter uma prescrição mais segura, mais prudente e mais humana. A atenção primária está em uma posição privilegiada para enfrentar o desafio da desprescrição e esta deveria fazer parte de qualquer estratégia de prevenção quaternária.

The consequences of inappropriate medication are diverse and have great clinical impact: from adverse effects and medication interactions to fractures from falls and increased morbidity and mortality. To avoid or ameliorate such consequences, as well as to address its causes, bearing in mind patients' safety, deprescription has emerged as a safer, more prudent and humane practice. Primary care is in a privileged position to address this challenge of deprescription and it should be part of any strategy of quaternary prevention.

TFIIH-dependent MMP-1 overexpression in trichothiodystrophy leads to extracellular matrix alterations in patient skin.

Mutations in the XPD subunit of the DNA repair/transcription factor TFIIH result in distinct clinical entities, including the cancer-prone xeroderma pigmentosum (XP) and the multisystem disorder trichothiodystrophy (TTD), which share only cutaneous photosensitivity. Gene-expression profiles of primary dermal fibroblasts revealed overexpression of matrix metalloproteinase 1 (MMP-1), the gene encoding the metalloproteinase that degrades the interstitial collagens of the extracellular matrix (ECM), in TTD patients mutated in XPD compared with their healthy parents. The defect is observed in TTD and not in XP and is specific for fibroblasts, which are the main producers of dermal ECM. MMP-1 transcriptional up-regulation in TTD is caused by an erroneous signaling mediated by retinoic acid receptors on the MMP-1 promoter and leads to hypersecretion of active MMP-1 enzyme and degradation of collagen type I in the ECM of cell/tissue systems and TTD patient skin. In agreement with the well-known role of ECM in eliciting signaling events controlling cell behavior and tissue homeostasis, ECM alterations in TTD were shown to impact on the migration and wound-healing properties of patient dermal fibroblasts. The presence of a specific inhibitor of MMP activity was sufficient to restore normal cell migration, thus providing a potential approach for therapeutic strategies. This study highlights the relevance of ECM anomalies in TTD pathogenesis and in the phenotypic differences between TTD and XP.

Lipoarabinomannan mannose caps do not affect mycobacterial virulence or the induction of protective immunity in experimental animal models of infection and have minimal impact on in vitro inflammatory responses.

Mannose-capped lipoarabinomannan (ManLAM) is considered an important virulence factor of Mycobacterium tuberculosis. However, while mannose caps have been reported to be responsible for various immunosuppressive activities of ManLAM observed in vitro, there is conflicting evidence about their contribution to mycobacterial virulence in vivo. Therefore, we used Mycobacterium bovis BCG and M. tuberculosis mutants that lack the mannose cap of LAM to assess the role of ManLAM in the interaction of mycobacteria with the host cells, to evaluate vaccine-induced protection and to determine its importance in M. tuberculosis virulence. Deletion of the mannose cap did not affect BCG survival and replication in macrophages, although the capless mutant induced a somewhat higher production of TNF. In dendritic cells, the capless mutant was able to induce the upregulation of co-stimulatory molecules and the only difference we detected was the secretion of slightly higher amounts of IL-10 as compared to the wild type strain. In mice, capless BCG survived equally well and induced an immune response similar to the parental strain. Furthermore, the efficacy of vaccination against a M. tuberculosis challenge in low-dose aerosol infection models in mice and guinea pigs was not affected by the absence of the mannose caps in the BCG. Finally, the lack of the mannose cap in M. tuberculosis did not affect its virulence in mice nor its interaction with macrophages in vitro. Thus, these results do not support a major role for the mannose caps of LAM in determining mycobacterial virulence and immunogenicity in vivo in experimental animal models of infection, possibly because of redundancy of function.

En relación con el número extraordinario monográfico sobre insulina aspártica / As regards the Special Issue on insulin aspart

No disponible

Ancianos frágiles polimedicados: ¿es la deprescripción de medicamentos la salida? / Polypharmacy in frail elderly patients: is deprescribing the answer?

La deprescripción es el proceso de desmontaje de la prescripción de medicamentos por medio de su revisión, que concluye con la modificación de dosis, sustitución o eliminación de unos fármacos y adición de otros. Su desarrollo pretende resolver tensiones y contradicciones entre 2 pares de interrogantes: 1) ¿es la expectativa de vida menor que el tiempo que tarda el medicamento en obtener beneficios?, y 2) ¿ son congruentes las metas de la atención sanitaria con los objetivos de la prescripción-deprescripción? La validez de la deprescripción está fundamentada en argumentos científicos y éticos. Desconocemos la utilidad y seguridad de muchos medicamentos que siguen los ancianos frágiles o enfermos terminales; otros producen efectos adversos molestos o graves. Por tanto, en determinadas ocasiones su retirada pudiera estar justificada, siendo de una manera sustancial seguro hacerlo(AU)

Deprescribing is the process of reconstructing multiple medication use by review and analysis and which concludes with dose modification, replacement or elimination of some drugs or adding others. Its development is intended to resolve tensions and contradictions between two sets of questions: 1/is life expectancy shorter than the time the drug takes to obtain a benefit?, and 2/are the goals of prescribingdeprescribing consistent with those of care? The validity of the rationale on deprescribing is based on scientific and ethical reasons. The usefulness and safety of many drugs that frail elderly or terminally ill takes is unknown, and other drugs may cause troublesome or severe side effects. Thus, in some cases their removal could be justified, being substantially safe doing so(AU)

[Polypharmacy in frail elderly patients: is deprescribing the answer?]. / Ancianos frágiles polimedicados: ¿es la deprescripción de medicamentos la salida?

Deprescribing is the process of reconstructing multiple medication use by review and analysis and which concludes with dose modification, replacement or elimination of some drugs or adding others. Its development is intended to resolve tensions and contradictions between two sets of questions: 1/is life expectancy shorter than the time the drug takes to obtain a benefit?, and 2/are the goals of prescribing-deprescribing consistent with those of care? The validity of the rationale on deprescribing is based on scientific and ethical reasons. The usefulness and safety of many drugs that frail elderly or terminally ill takes is unknown, and other drugs may cause troublesome or severe side effects. Thus, in some cases their removal could be justified, being substantially safe doing so.

Revisión de botiquines domésticos de personas incluidas en ayuda domiciliaria / No disponible

Objetivo: Educar en el conocimiento responsable y en el uso racional de los medicamentos por parte de las personas beneficiarias de los programas sociales de ayuda a domicilio (SAD). Método: Entrevista personal en visita domiciliaria a los usuarios del SAD, haciendo constar en documento escrito los medicamentos revisados, si se conocen o no, si se retiran o no y las distintas incidencias registradas. Intentando educar, integrar y derivar si fuese el caso. Resultados: Cada paciente toma una media de 6,4 medicamentos. Se derivan al médico una media del 27,3% de los casos. Se derivan a los servicios sociales un 25,5% de los casos. Se retiran el 23,9% de todos los medicamentos revisados con grandes diferencias entre distintos grupos terapéuticos. Se desconoce 31,6% de todos los medicamentos revisados; grandes diferencias entre grupos los más desconocidos R. (aparato respiratorio) con un 56,5% de desconocimiento, J. (terapia antiinfecciosa) con un 67% y S. (órganos de los sentidos) con un 75% (AU)

Objective: Educate in the responsible knowledge and in the rational use of the medicines concerning the persons who benefit from the social programs of home assistant. Method: Personal home interviews of SAD users, reporting on certified documents the medicine used, if they are known or not, if they move back or not. Any medical incidents will also be reported, for a better education, integration, or derivation, if needed. Results: Each patient takes an average of 6,4 medicines. An average of 27,3% of the cases is derived to the doctor. 25,5% of: the cases are derived to the social services. They withdraw 23,9 % of all the medicines checked are withdrawn by the social services, with big differences between known therapeutic groups. 31,6% of all the checked medicines remain unknown; with also big differences between these groups. The most important are groups R. (respiratory apparatus) with 56,5% of ignorance, J. (antiinfectious therapy) with 67% and S. (organs of the senses) with 75% (AU)

Tentando entender a gestäo do conhecimento / Trying to understand knowledge management

Faz uma revisäo do tema gestäo do conhecimento e suas interrelaçöes com outras disciplinas. Avalia algumas de suas definiçöes. Apresenta exemplos do uso desta nova concepçäo em algumas organizaçöes e uma experiência de implementaçäo de uma unidade de inteligência competitiva no Brasil. Afirma que näo importa se denominamos o conhecimento existente dentro da organizaçäo como propriedade intelectual, capital intelectual ou base de conhecimento mas que certamente é este um dos mais valiosos ativos de uma empresa. Vê como fundamental a capacidade de gerenciar, distribuir e criar conhecimento com eficiência/eficácia para que uma organizaçäo se coloque em posiçäo de vantagem competitiva em relaçäo a outras.

Impericia médica en Puerto Rico: 1990-1996 / medical negligence in Puerto Rico: 1990-1996

The purpose of this communication is to present the statistical information of the medical and hospital professional liability situation in Puerto Rico from 1990 to 1996. The Medical Institutional liability is a topic of great relevancy and importance to the people of Puerto Rico and the leaders responsible for establishing policies for the health care services. The Reports on Medical and Hospital Professional Liability from 1991 to the 1996 produced by the Examining Physicians Board were reviewed. The liability claims from 1991 to the 1996 totaled 4054. During the seven years analyzed, 3506 cases were closed against physicians and institutions, a payment was issued in 1272 cases (36.3 percent), for a total compensation of $56,268,053. The risk of a legal claim is greater for the group of Plastic Surgeons and Emergency Medicine. The probability of a plaintiff receiving a compensation payment in a case of medical malpractice is approximately 36 percent, usually receiving a third of the total of the award as suggested by the medical literature. A thoughtful analysis of the current medical liability situation and defensive medicine should be done with the purpose of protecting the fiduciary function of the physicians with respect to the health of their patients, this is the function that guarantees a physician-patient relationship that is healthy, righteous and empathic

Algunos factores psicosociales en la dinámica familiar en un sector del médico de la familia / Some phychosocial factors in the family dynamics in a sector of the family physician

Se estudiaron algunos factores psicosociales en 100 familias de un consultorio perteneciente al Policlínico "Armando García Aspurú", en el cual, para facilitar la puntuación y la validación estadística de los aspectos de la dinámica familiar fue preciso modificar la historia clínica. Entre los principales hallazgos figuran que la comunicación extrafamiliar y la no verbal resultaron significativas con respecto a la legítima comunicación de la progenie. Se concluye que la mejor comunicación se logró en las familias con estructura nuclear; asimismo, la calidad afectiva (funciones afectivas) resultó inferior en las parejas en comparación con la de otros parientes. Se recomienda la incorporación de los conceptos de dinámica familiar en los cursos de psogrado para médicos de la familia (AU)