[Work commitment of middle-line managers in health-care: Manageable organizational factors]. / Compromiso laboral de los directivos intermedios en sanidad: factores organizativos gestionables.

Middle-line managers are a key element in the management of health-care organizations. Reinforcing their commitment to their job could contribute to improving the health outcomes of the population they serve. OBJECTIVE: Analyzing the work commitment of middle-line managers to the health-care organizations they work for, as well as their profile and perception of the main manageable organizational factors involved. METHODOLOGY: Descriptive multicenter study based on a questionnaire about work commitment and 20 associated manageable factors, analyzing 60 variables (scale 1-10). The theoretical framework on which it was based was adapted from the model of demands and resources, along with 2organizational commitment questionnaires. It was distributed among the professionals of 23 non-profit health-care organizations belonging to the Health and Social Care Consortium of Catalonia, in the period 2015-2019. RESULTS: A number of 2,060 surveys were obtained; 60% were answered by women; 69% declared an antiquity of more than 10 years. Cronbach's alpha coefficient was 0.974. The overall indicator of work commitment received 7.94 points. Overall, job resources received higher scores than demands (7.39 versus 6.69 points). The 3highest-scoring manageable organizational factors were demand, equality policies with 8.27 points, and 2resources: professional autonomy (7.81 points) and job stability (7.79 points). The 3lowest scoring factors were 3demands: Remuneration (5.52 points), time and personnel resources (5.74 points) and social benefits (6.10 points). Seventy-one percent of middle-line managers' work commitment to their institution was explained by 4manageable factors: Trust and coherence, professional autonomy, institutional image, and training and development. CONCLUSIONS: The middle-line managers showed a high level of work commitment to their institutions. The main predictor of this commitment was the perception of trust in the institution and coherence in the management of the centers.

Barriers and opportunities for the treatment of mild-to-moderate depression with a watchful waiting approach.

OBJECTIVE: The aim of this study is to explore barriers and opportunities in non-pharmacological treatment of depression in primary care (PC) from the perspective of family physicians (FPs). METHODS: Qualitative analysis was used to explore a sample of 36 FPs treating patients with depressive symptoms. Criteria to maximize variability were followed. Participants were identified by key informants. Six group interviews were developed following a semi-structured thematic script. All interviews were transcribed, analyzed and triangulated. Information was saturated. Principals of reflexivity and circularity were implemented. RESULTS: The results obtained followed 3 main theoretical axes: the FP, the patient, the healthcare system, and the interaction between them. Barriers included poor alignment with clinical practice guidelines, inadequate FP training, patients' preferences and structural challenges in PC. Among opportunities were good FP clinical interview skills, the beneficial bond of trust between patients and FPs and improved communication with mental healthcare services. CONCLUSION: Based on FPs' perceptions, non-pharmacological treatment of depression in PC is particularly limited by lack of structured training; patients' preferences and treatment expectations; structural challenges in PC; and insufficient support from specialized mental health professionals. PRACTICE IMPLICATIONS: Resources for education, structural support in PC and modified back up from mental healthcare services are needed.

Reasons for medication non-initiation: A qualitative exploration of the patients' perspective.

BACKGROUND: Non-initiation occurs when the doctor prescribes a new pharmacological treatment to a patient who does not fill the prescription. Non-initiation prevalence estimates range between 6% and 28% in Primary Care (PC) and it is associated with poorer clinical outcomes, more sick-leave days and higher costs. To date, the reasons for non-initiation have not been explored using a qualitative framework. OBJECTIVE: The aim of the present study was to identify reasons for medication non-initiation among PC patients with distinct treatment profiles (acute, chronic symptomatic and asymptomatic, and mental disorders). METHODS: An exploratory, explanatory qualitative study based on Grounded Theory. We conducted individual semi-structured interviews with 30 PC patients. A constant comparative method of analysis was performed. RESULTS: The results were similar for all therapeutic groups. The decision to initiate treatment is multifactorial. Users make a risk-benefit assessment which is influenced by their beliefs about the pathology and the medication, their emotional reaction, health literacy and cultural factors. The patients' context and relationship with the health system influence decision-making. CONCLUSIONS: The decision to initiate a treatment is strongly influenced by factors that health professionals can discuss with patients. Health professionals should explore patients' beliefs about benefits and risks to help them make informed decisions and promote shared decision-making. General practitioners should ensure that patients understand the benefits and risks of disease and treatment, while explaining alternative treatments, encouraging patients to ask questions and supporting their treatment decisions.

Effectiveness of watchful waiting versus antidepressants for patients diagnosed of mild to moderate depression in primary care: A 12-month pragmatic clinical trial (INFAP study).

BACKGROUND: Although mild to moderate major depressive disorder (MDD) is one of the main reasons for consulting a general practitioner (GP), there is still no international consensus on the most appropriate therapeutic approach. METHODS: The aim of this study is to evaluate the clinical effectiveness of watchful waiting (WW) compared with the use of antidepressants (ADs) for the treatment of mild to moderate depressive symptoms in 263 primary care (PC) usual-practice patients in a 12-month pragmatic non-randomised controlled trial. Both longitudinal and per-protocol analyses were performed, through a multilevel longitudinal analysis and a sensitivity analysis. RESULTS: We observed a statistically significant time x treatment interaction in the severity of depression (Patient Health Questionnaire, PHQ-9) and disability (World Health Organization Disability Assessment Schedule, WHODAS) in favour of the AD group at 6 months but not at 12 months. The effect size of this difference was small. No statistically significant differences were observed between groups in severity of anxiety (Beck Anxiety Inventory, BAI) or health-related quality-of-life (EuroQol-5D, EQ-5D). Sensitivity analysis and per-protocol analysis showed no differences between the two groups in any of the evaluated scales. CONCLUSIONS: Superiority of either treatment (WW and AD) was not demonstrated in patients treated for depression in PC after one year of follow-up.

[Good care for patients who die in intensive care units in Spain. A study based on international care quality indicators]. / El buen cuidado de pacientes que fallecen en unidades de cuidados intensivos en España. Un estudio basado en indicadores internacionales de calidad asistencial.

BACKGROUND: Good care for patients who die in intensive care should be pursued in the same way that excellence is sought in other clinical aspects. OBJECTIVE: To assess the quality of clinical care given to patients who die in intensive care units (ICU) in Spain. Methodos. A retrospective observational cohort study of patients who died in the ICU based on a Spanish sample. Inclusion criteria were patients older than 18 years who died in ICU after a minimum stay of 24 hours. Consecutive admissions without exclusions were analyzed. Excellence criteria in intensive care were assessed by quality indicators and measures, related to end-of-life care, developed by the Robert Wood Johnson Foundation Critical Care Workgroup. RESULTS: Two hundred and eighty-two patients from 15 Spanish ICU were included. A median of 13% was observed in the achievement of the indicators. Almost all clinical records assessed both the patients' decision making capacity (96%) and their communication with families (98%), while a plan of care goals was achieved in only 50% of them. Only two ICU had open visiting policies. Distress assessment (48%) was better than that of pain assessment (28%). The absence of protocol for the withdrawal of life-sustaining treatments was observed in thirteen ICU. The indicators of emotional and spiritual support were achieved in less than 10%. CONCLUSIONS: The quality of end-of-life care in the participating ICU needs to be improved. The study identifies shortcomings and indicates existing resources in clinical practice from which a gradual improvement plan, adapted to the situation in each hospital, can be designed. The analysis, inexpensive in its implementation, offers an opportunity for improvement, a goal recommended by most professional societies of intensive care medicine. Key words. End-of-life care. Intensive care. Critical care. Palliative care. Quality improvement.

Evaluación de una intervención educativa grupal en el control de pacientes con riesgo cardiovascular / Evaluation of an educational group intervention in the control of patients with cardiovascular risk

Objetivo: Comparar una intervención educativa grupal frente a una atención individual para mejorar variables clínicas y de gestión, en pacientes con riesgo cardiovascular (RCV) atendidos en Atención Primaria (AP).MétodoEstudio experimental controlado aleatorizado realizado en 7 centros de AP de Barcelona. Se seleccionaron 2.127 pacientes incluidos en el protocolo de patologías crónicas de los centros. El grupo intervención (GI) durante un año recibió atención educativa en cuatro talleres grupales conducidos por sus enfermeras referentes. Las variables medidas en el GI y el grupo control (GC) al inicio del estudio y tres meses tras la intervención fueron clínicas y de gestión (número visitas, gasto farmacéutico, dedicación/tiempo enfermería). Se analizaron los resultados pre-post-intervención y entre GI y GC.ResultadosEl GI inicial (n=672) al final del seguimiento perdió 144 pacientes que no cumplieron la totalidad de sesiones. El GC no sufrió pérdidas (n=824). Al final del seguimiento no hubo diferencias significativas en las variables clínicas. El número de visitas y el gasto farmacéutico se incrementó en el GI. Sin embargo, la dedicación anual enfermera/paciente/año fue de 39,59 minutos en el GI y de 60 minutos en el GC.ConclusionesEl control grupal en AP de pacientes con RCV ahorra tiempo al colectivo de enfermería respecto al control individual, sin perjuicio del grado de control del paciente. A pesar de ello, son necesarios más estudios para definir mejor que tipo de paciente es más susceptible de abordar el control de su enfermedad cardiovascular mediante talleres grupales y si esta reducción repercute en el consumo de otros recursos asistenciales(AU)

Objective: To compare an educational group intervention with individual care to improve clinical and management variables among patients with cardiovascular risk (CVR) in community health care (PC).MethodsA randomised controlled experimental study was developed in 7 PC centres of Barcelona (Spain). A total of 2,127 patients included in the chronic diseases protocol of the centres were selected. The intervention group (IG) attended four educative workshops led by their nurses during one year. Clinical and management variables (number of visits, pharmaceutical expenditure, nurse time consumption) were measured at baseline and 3 months after the intervention in the IG and in the control group (CG). Pre-post-intervention and IG vs. CG differences were analysed.ResultsAmong the 672 patients belonging to the IG, 144 were lost due to failing to attend the workshops. CG (n=824) had no withdrawals. At the end of follow-up there were no significant differences between their clinical variables. The number of visits and pharmaceutical expenditure increased in the IG. However, the annual dedication of nurses per patient per year was 39.59minutes in the IG and 60minutes in the CG.ConclusionsNurse group control of patients with CVR in PC saves nurse-time compared with the usual individual visits. However, further studies are needed to better define what type of patient that is more susceptible to follow cardiovascular control through group workshops and whether this time-saving is related to the use of other health resources(AU)

[Evaluation of an educational group intervention in the control of patients with cardiovascular risk]. / Evaluación de una intervención educativa grupal en el control de pacientes con riesgo cardiovascular.

OBJECTIVE: To compare an educational group intervention with individual care to improve clinical and management variables among patients with cardiovascular risk (CVR) in community health care (PC). METHODS: A randomised controlled experimental study was developed in 7 PC centres of Barcelona (Spain). A total of 2,127 patients included in the chronic diseases protocol of the centres were selected. The intervention group (IG) attended four educative workshops led by their nurses during one year. Clinical and management variables (number of visits, pharmaceutical expenditure, nurse time consumption) were measured at baseline and 3 months after the intervention in the IG and in the control group (CG). Pre-post-intervention and IG vs. CG differences were analysed. RESULTS: Among the 672 patients belonging to the IG, 144 were lost due to failing to attend the workshops. CG (n=824) had no withdrawals. At the end of follow-up there were no significant differences between their clinical variables. The number of visits and pharmaceutical expenditure increased in the IG. However, the annual dedication of nurses per patient per year was 39.59 minutes in the IG and 60 minutes in the CG. CONCLUSIONS: Nurse group control of patients with CVR in PC saves nurse-time compared with the usual individual visits. However, further studies are needed to better define what type of patient that is more susceptible to follow cardiovascular control through group workshops and whether this time-saving is related to the use of other health resources.

Afasia de instauración aguda como forma de presentación inicial de una enfermedad de Creutzfeldt-Jakob / Acute-onset aphasia as the presenting symptoms in a case of Creutzfeldt-Jakob disease

No disponible

La historia de la voz / No disponible

La voz humana fue definida por Platón como un impacto del aire que llega por los oídos al alma. La voz es el sustrato en el que se apoya el método de comunicación habitual del ser humano, con el que se transmite la cultura, con el que se expresan los sentimientos y las emociones. Por su cotidianidad muchas veces pasa desapercibida su extraordinaria importancia, sin embargo por su carácter específico y exclusivamente humano ha sido estudiado desde los inicios de nuestra civilización. Se revisan las aportaciones de los estudiosos en las principales épocas, sobre todo a partir del siglo XVI con los estudios de disección anatómica sobre laringes de carácter humano. Una época de extraordinaria importancia fue el siglo XVII donde los trabajos de Dodart y Perrault supusieron la base para que en el siglo siguiente Ferrein iniciara la fisiología experimental de la laringe. Mención especial merece Johanes Müller cuyos experimentos permitirán establecer las teorías de la fonación vigentes hoy día (AU)

The human voice was defined by Plato as an impact of air which passes through the ears to reach the soul. The voice is the substrate used for the human being’s normal method of communication. It is used to transmit culture, express feelings and emotions. As it is such an everyday phenomenon, its extraordinary importance often goes unnoticed. However, its specific, exclusively human character means that it has been studied since the very beginnings of our civilization.The contributions made by thinkers and specialists of different eras are reviewed, particularly from the 16th century on wards once the anatomical dissection of human larynx had begun.The 17th century was extremely important, because this was when the work of Dodart and Perrault provided the basis on which Ferien, in the following century, would build his experimental physiology of the larynx.Special mention must be made of Johanes Müller, whose experiments allow us to establish the theories of phonation that are still valid today (AU)

Vibrato de la voz cantada. Caracterización acústica y bases fisiológicas / No disponible

El vibrato es uno de los ornamentos más comunes del canto clásicooccidental y de la música destinada a aquellos instrumentos que puedenproducirlo. El vibrato vocal corresponde físicamente a una modulaciónperiódica sinusoidal de frecuencia fundamental de la fonación.El vibrato hace que la voz suene agradable, viva, excitante, cálida, menosmecánica que aquella que se consigue al emitir un tono plano. Da naturalidady expresividad al sonido vocal. La mayoría de los cantantes loconsideran un elemento deseable pero no todos son capaces de desarrollarlo.Parece que la aparición del vibrato depende de un nivel técnicodeterminado. Se revisan las consideraciones históricas, las propiedadesfísicas, acústicas y aerodinámicas del vibrato. Se establecenhipótesis en lo referente a su origen y se plantean estrategias dirigidas afacilitar su desarrollo y aprendizaje(AU)

Vibrato is one of the most frequent ornamentations of western classicalsong, and of certain types of instrumental music. Physically speaking,vocal vibrato is a periodic sinusoidal modulation of the fundamentalfrequency of phonation.Vibrato makes the voice sound pleasant, lively, exciting, warm and lessmechanical than when a flat pitch is used. It makes the voice soundnatural and expressive. Most singers regard it as desirable, but not allare capable of developing it. It would seem that vibrato can only bedeveloped at a certain technical level. Historical considerations arereviewed, and the physical, acoustic and aerodynamic properties ofvibrato are discussed. Hypotheses are advanced regarding its origin,and strategies are described which facilitate its acquisition anddevelopment(AU)

Discapacidad vocal / No disponible

En el momento actual disponemos de herramientas precisas para diagnosticary valorar los trastornos de la voz. Esto nos permite desarrollarun plan de tratamiento dirigido a cada problema concreto. No obstante,es preciso establecer además del diagnóstico, la severidad de esa disfoníay en que medida influye este trastorno en la vida del paciente.Se revisan los conceptos de deficiencia, discapacidad y minusvalía enrelación con los trastornos de la voz y de acuerdo con herramientascontrastadas y validadas para establecer el grado de afectación de lavoz en cada trastorno concreto.Se revisan las escalas del GRABS, el índice de severidad de la disfonía(SDI) y el índice de disfunción vocal. El empleo de dichas herramientasasí como de la utilización de la terminología aprobada recientementepor la OMS en la clasificación internacional del funcionamiento de ladiscapacidad y de la salud permitirán establecer grados de severidad dela disfonía y planificar tratamientos integrales más eficaces(AU)

At present, tools of great precision are available for the diagnosis andassessment of voice disorders. This makes it possible to design a tailoredtreatment plan for every individual problem. However, in addition to thediagnosis, it is necessary to establish the severity of dysphonia and theextent to which it affects the patient’s life.The concepts of vocal deficiency, disability and handicap are reviewed,with reference to the tools that have been compared and validated toestablish the degree to which the voice is affected in each particulardisorder.The GRABS scales, the dysphonia severity index (DSI) and the index ofvocal dysfunction are reviewed.The use of these tools, and the terminology approved recently by theWHO in the international classification of disability and health, enableus to establish degrees of severity for dysphonia and plan more effectiveall-round treatment for these disorders(AU)

Implicación de los profesionales en la gestión de recursos / Involvement of health care professionals in resource management

Objetivo: Demostrar el desfase entre los tiempos preestablecidos y los reales en la realización del electrocardiograma; cuantificar económicamente una actividad de enfermería; obtener más productividad y más valor añadido con los mismos recursos asignados. Diseño: Es un estudio de gestión de costos, basado en métodos de mejora continua, que utiliza técnicas de autoevaluación y reingienería de procesos. Estas técnicas permiten una mejor y más equitativa redistribución de los recursos asignados, una mayor participación de los profesionales implicados porque priman ideas y responsabilidades individuales, lo que redunda en una mayor satisfacción del profesional. Emplazamiento: Área Básica de Llefià (Badalona). Metodología y resultados: Se escogió una muestra al azar del 50,2 por ciento de los electrocardiogramas realizados en el año 1997. Se observaron unas diferencias entre los tiempos preestablecidos y los reales de 1,48 minutos por ECG, debido a anomalías de organización, gestión e infraestructura. Se halló una diferencia en el costo de 38,51 pesetas por electrocardiograma (ECG) debido al desfase de los tiempos. Se han buscado posibles soluciones que eliminan o palian las anomalías (AU)

Insulin receptors and insulin-like growth factor I receptors in embryos from gastrula until organogenesis.

The demonstration of growth factor receptors in very young embryos is limited by the difficulty in obtaining sufficient tissue to yield adequate membrane preparations. We have developed an in situ binding technique that allowed quantitation of [125I]insulin and [125I]insulin-like growth factor-I (IGF-I) binding to individual chick embryos. Specific binding per embryo increased from the youngest stage studied (Hamburger and Hamilton (HH) stages 3-4, gastrulating embryo of approximately 18-20 h) until the third day of development. At all ages, the binding of [125I]IGF-I was several fold higher than the binding of [125I]insulin. Autophosphorylation of the beta-subunit of the receptors was stimulated by insulin and IGF-I in a stage- and dose-dependent manner. The two peptides did not have an additive effect. The present studies further support our previous data showing the early developmental appearance of insulin and IGF-I receptors, which very likely are essential for normal embryo development. In addition, this in situ method for demonstration of receptors can be applied to other types of receptors present in isolated organs and young embryos.

Insulin receptors and insulin-like growth factor I receptors are functional during organogenesis of the lens.

Insulin and insulin-like growth factor I (IGF-I) stimulate overall growth and development of the chick embryo in early organogenesis. Turning to individual organs, to clarify the cellular effects of these peptides and the activity of the receptors involved, we had demonstrated with developing lens that insulin and IGF-I increase the accumulation of delta-crystallin mRNA, a marker for lens differentiation, in part by stimulation of transcription. In this study we expand our previous work on lens receptors to an earlier time in organogenesis, day 4, which marks the beginning of differentiation of the lens epithelial cells into elongated fibers. Insulin receptors are demonstrable by affinity cross-linking in epithelial cells at day 6, and specific binding of [125I]insulin and [125I]IGF-I is detectable in day 4 lenses. Insulin and IGF-I stimulation of substrate phosphorylation in the presence of solubilized receptors occurs only with high concentrations (10-100 nM) of either peptide in day 4 lenses, while a clear response with low concentrations (1 nM) is elicited by day 6 of development. Low concentrations of both insulin and IGF-I (0.1-1 nM) increase the incorporation of [3H]leucine and [3H]uridine in day 6 lens cells, suggesting that each peptide acts through its own receptor. These results confirm and extend the finding of insulin and IGF-I receptors in the developing chicken lens, and demonstrate their functional activity. This embryonic model should be valuable for further analysis of the action of insulin and IGF-I in growth and differentiation processes during early development.

Development of receptors for insulin and insulin-like growth factor-I in head and brain of chick embryos: autoradiographic localization.

In whole brain of chick embryos insulin receptors are highest at the end of embryonic development, while insulin-like growth factor-I (IGF-I) receptors dominate in the early stages. These studies provided evidence for developmental regulation of both types of receptors, but they did not provide information on possible differences between brain regions at each developmental stage or within one region at different embryonic ages. We have now localized the specific binding of [125I]insulin and [125I]IGF-I in sections of head and brain using autoradiography and computer-assisted densitometric analysis. Embryos have been studied from the latter part of organogenesis (days 6 and 12) through late development (day 18, i.e. 3 days before hatching), and the binding patterns have been compared with those in the adult brain. At all ages the binding of both ligands was to discrete anatomical regions. Interestingly, while in late embryos and adult brain the patterns of [125I]insulin and [125I] IGF-I binding were quite distinct, in young embryos both ligands showed very similar localization of binding. In young embryos the retina and lateral wall of the growing encephalic vesicles had the highest binding of both [125I]insulin and [125I]IGF-I. In older embryos, as in the adult brain, insulin binding was high in the paleostriatum augmentatum and molecular layer of the cerebellum, while IGF-I binding was prominent in the hippocampus and neostriatum. The mapping of receptors in a vertebrate embryo model from early prenatal development until adulthood predicts great overlap in any possible function of insulin and IGF-I in brain development, while it anticipates differential localized actions of the peptides in the mature brain.