Nuevo modelo de autogestión profesional en atención primaria / New model of professional self-management in primary care

Objetivo. Analizar las ventajas de un modelo organizativo en atención primaria basado en mayor autonomía de gestión de profesionales respecto al modelo habitual (equipo dirigido por director médico). Mejorar la calidad asistencial y la satisfacción de pacientes y profesionales. Material y métodos. En febrero de 2009 un grupo de 6 médicos de familia y 4 administrativos se organizaron autónomamente para atender a 10.281 usuarios de 32.318 asignados al Centro de Atención Primaria (CAP) Les Corts de Barcelona. Entre marzo y diciembre de 2010 se incorporaron 7 enfermeras, 3 médicos y 2 administrativos más, atendiendo a 16.368 usuarios de 34.423 del centro. El modelo ha priorizado la autogestión de la demanda, autocobertura de profesionales, desburocratización de la consulta, mayor eficiencia y participación en investigación y docencia. Resultados. Resultados asistenciales: 1) Etapa piloto (diciembre/2008 a diciembre/2009): incremento de población atendida, disminución de visitas presenciales, importante aumento de atención no presencial, reducción muy significativa de demora de visita; reducción destacable de productos intermedios; menor utilización de novedades terapéuticas y mayor de medicamentos genéricos. 2) Etapa de consolidación (a diciembre de 2010, respecto a resto de profesionales del CAP): menos visitas presenciales y porcentaje muy superior de no presenciales atendiendo a más población asignada; menor gasto en productos intermedios. Otros resultados: mejora de la satisfacción profesional (cuestionario QVP-35) y participación activa en docencia e investigación. Conclusiones. El modelo ha innovado, mejorando la atención al usuario, dotando la consulta de mayor profesionalidad y aumentando la satisfacción de profesionales. Ha demostrado mayor eficiencia y los resultados obtenidos muestran superioridad al modelo habitual en indicadores de salud (AU)

Objective. To analyse the benefits of a new organisational model in Primary Care based on the empowerment of professional management compared to standard model (team led by medical director). To improve the quality of care, and patient and professional satisfaction. Material and methods. In February 2009 six family physician (FP) and four administrative staff met to create a self-management group to care for the 10,281 population assigned to them. The total catchment population of the Primary Care (PC) centre was 32,318. Additionally, between March and December 2010 three FP, seven nurses and two administrative staff, were included in the self-management group making the total population served by the self-management group of 16,368, compared to 15,950 patients seen using the standard model. The model gave priority to self-demand management, professional self-coverage, to reduce clinic bureaucracy, greater efficiency and participation in research and teaching. Results. 1) Milestone in Pilot Phase (December-2008 to December-2009): increase in attended population, reduction in clinic visits, significant reduction in delay to be visited by a doctor; significant reduction of complementary tests (x-rays, laboratory tests); increase in use of generic drugs and reduction of expensive and new drugs without added value, and active participation in teaching and clinical trials. 2) Consolidation Phase (December-2010, compared to other professionals working in a standard model in the same centre): self-management group reported a lower percentage of clinic visits and a higher percentage of visits resolved through telephoning the clinic. Furthermore, the self-management group achieved better financial results than the control group (additional medical tests, pharmacy budget). The self-management group had improved job satisfaction compared to control group (measured by Professional Questionnaire QoL-35). Conclusions. The new model has increased professional satisfaction and may improve results in some health indicators (accessibility, efficiency, pharmacy budget) compared with the usual clinical practice (AU)

[New model of professional self-management in primary care]. / Nuevo modelo de autogestión profesional en atención primaria.

OBJECTIVE: To analyse the benefits of a new organisational model in Primary Care based on the empowerment of professional management compared to standard model (team led by medical director). To improve the quality of care, and patient and professional satisfaction. MATERIAL AND METHODS: In February 2009 six family physician (FP) and four administrative staff met to create a self-management group to care for the 10,281 population assigned to them. The total catchment population of the Primary Care (PC) centre was 32,318. Additionally, between March and December 2010 three FP, seven nurses and two administrative staff, were included in the self-management group making the total population served by the self-management group of 16,368, compared to 15,950 patients seen using the standard model. The model gave priority to self-demand management, professional self-coverage, to reduce clinic bureaucracy, greater efficiency and participation in research and teaching. RESULTS: 1) Milestone in Pilot Phase (December-2008 to December-2009): increase in attended population, reduction in clinic visits, significant reduction in delay to be visited by a doctor; significant reduction of complementary tests (x-rays, laboratory tests); increase in use of generic drugs and reduction of expensive and new drugs without added value, and active participation in teaching and clinical trials. 2) Consolidation Phase (December-2010, compared to other professionals working in a standard model in the same centre): self-management group reported a lower percentage of clinic visits and a higher percentage of visits resolved through telephoning the clinic. Furthermore, the self-management group achieved better financial results than the control group (additional medical tests, pharmacy budget). The self-management group had improved job satisfaction compared to control group (measured by Professional Questionnaire QoL-35). CONCLUSIONS: The new model has increased professional satisfaction and may improve results in some health indicators (accessibility, efficiency, pharmacy budget) compared with the usual clinical practice.

Enteroliths in Crohn's disease: a case report.

Bowel wall inflammation in Crohn's disease can be the cause of strictures along the small and large bowel. Frequently there is an accompanying prestenotic bowel dilation. This creates stasis of bowel fluids, which can eventually lead to the formation of enteroliths. These are hard dense masses inside the bowel that may be responsible for (sub)obstruction, ulceration and even perforation. The latter is caused by mechanical stress on an already weak and inflamed bowel wall. We present a rare case of a Crohn's disease patient in her early thirties who was seen at the emergency department with acute abdominal pain. Radiographs and CT examination showed the appearance of enterolithiasis. Furthermore, we provide diagnostic and therapeutic options.

Vaccination of fiber-modified adenovirus-transfected dendritic cells to express HER-2/neu stimulates efficient HER-2/neu-specific humoral and CTL responses and reduces breast carcinogenesis in transgenic mice.

HER-2/neu transgene-modified dendritic cell (DC)-based vaccines are potent at eliciting HER-2/neu-specific antitumor immunity. In this study, we constructed a recombinant adenovirus (RGD)AdVneu with fiber gene modified by RGD insertion into the viral knob's H1 loop. We transfected DCs with (RGD)AdVneu, and assessed/compared HER-2/neu-specific humoral and cytotoxic T lymphocyte (CTL) responses and antitumor immunity derived from the original AdVneu-transfected DCs (DCneu1) and (RGD)AdVneu-transfected DCs (DCneu2). We demonstrated that DCneu2 displayed increased HER-2/neu expression by 8.3-fold compared to DCneu1. We also demonstrated that DCneu2 vaccination induced stronger HER-2/neu-specific humoral and CTL immune responses than DCneu1 vaccination. DCneu2 vaccination protected all the mice from HER-2/neu-expressing Tg1-1 tumor cell challenge in wild-type FVB/NJ mice, compared to a partial protection in DCneu1-immunized mice. In addition, DCneu2 vaccination also significantly delayed tumor growth than DCneu1 immunization (P<0.05) in Tg FVBneuN mice. Three immunizations of DCneu2 starting at the mouse age of 2 months also significantly delayed breast cancer development in Tg mice compared to DCneu2 vaccine (P<0.05). Importantly, DCneu2 vaccine reduced breast carcinogenesis by 9% in Tg mice with self HER-2/neu tolerance. Therefore, vaccination of fiber-modified adenovirus-transfected DCs to enhance expression of tumor antigens such as HER-2/neu is likely representative of a new direction in DC-based vaccine of breast cancer.

Engineered CD8+ cytotoxic T cells with fiber-modified adenovirus-mediated TNF-alpha gene transfection counteract immunosuppressive interleukin-10-secreting lung metastasis and solid tumors.

T-cell suppression derived from tumor-secreted immunosuppressive interleukin (IL)-10 becomes a major barrier to CD8+ T-cell immunotherapy of tumors. Tumor necrosis factor-alpha (TNF-alpha) is a multifunctional cytokine capable of activating T and dendritic cells (DCs) and counteracting IL-10-mediated DC inhibition and regulatory T-cell-mediated immune suppression. In this study, we constructed a recombinant adenovirus (MF)AdVTNF with fiber-gene modified by RGD insertion into the viral knob's H1 loop and a melanoma cell line B16(OVA/IL-10) engineered to express ovalbumin (OVA) and to secrete IL-10 (2.2 ng/ml/10(6) cells/24 h). We transfected OVA-specific CD8+ T cells with (MF)AdVTNF, and found a fivefold increase in transgene human TNF-alpha secretion (4.3 ng/ml/10(6) cells/24 h) by the engineered CD8+ T(TNF) cells transfected with (MF)AdVTNF, compared to that (0.8 ng/ml/10(6) cells/24 h) by CD8+ T cells transfected with the original AdVTNF without viral fiber modification. The engineered CD8+ T(TNF) cells exhibited enhanced cytotoxicity and elongated survival in vivo after adoptive transfer. TNF-alpha derived from both the donor CD8+ T cells and the host cells plays an important role in donor CD8+ T-cell survival in vivo after adoptive transfer. We also demonstrated that the transfected B16(OVA/IL-10) tumor cells secreting IL-10 are more resistant to in vivo CD8+ T-cell therapy than the original B16(OVA) tumor cells without IL-10 expression. Interestingly, the engineered CD8+ T(TNF) cells secreting transgene-coded TNF-alpha, but not the control CD8+ T(control) cells without any transgene expression eradicated IL-10-secreting 12-day lung micrometastasis in all 10/10 mice and IL-10-secreting solid tumors ( approximately 5 mm in diameter) in 6/10 mice. Transfer of the engineered CD8+ T(TNF) cells further induced both donor- and host-derived memory CD8+ T cells, leading to a stronger long-term antitumor immunity against the IL-10-secreting B16(OVA/IL-10) tumor cell challenges. Therefore, CD8+ T cells engineered to secrete TNF-alpha may be useful when designing strategies for adoptive T-cell therapy of solid tumors.

Gastric emptying of solids in cirrhotic and peritoneal dialysis patients: influence of peritoneal volume load.

INTRODUCTION: A delay in gastric emptying rate has been reported in peritoneal dialysis patients, often normalizing after evacuation of the dialysate. To evaluate the effect of the intraperitoneal volume, we compared this finding with a cirrhotic model in which gastric emptying was studied before and after a large-volume paracentesis. METHODS AND DESIGN: We used the 13C-octanoic acid breath test to measure gastric half-emptying time (T1/2) for solids in patients with alcoholic cirrhosis, non-diabetic peritoneal dialysis patients, and a control population (asymptomatic volunteers). Cirrhotic patients underwent the test on two consecutive mornings before and after an evacuating paracentesis. Peritoneal dialysis patients were studied twice on consecutive days: once with the dialysate present intra-abdominally ("full"), and once with an emptied abdomen ("empty"). Biochemical analysis was carried out on blood samples before the first test. All cirrhotics underwent a 13C-aminopyrine breath test to assess residual liver function. RESULTS: Gastric emptying in cirrhotics showed no difference before or after paracentesis (median T1/2 108.0 min v. 117.9 min), but it was delayed significantly versus normal in both tests. There was no correlation with biochemical parameters, Child-Pugh score, or 13C-aminopyrine breath test results. Gastric half-emptying times of "full" peritoneal dialysis patients (median T1/2 103.1 min) were significantly higher than those of "empty" peritoneal dialysis patients (median T1/2 68.9 min) and asymptomatic volunteers (median T1/2 60.1 min). "Empty" peritoneal dialysis patients showed no gastroparesis. CONCLUSION: In alcoholic cirrhotic patients with ascites, gastric emptying of solids is delayed, independently of the volume of ascites. In peritoneal dialysis patients, gastric emptying was delayed when "full" and normalized after drainage of the dialysate.

Distinctive activated cellular subsets in colon from patients with Crohn's disease and ulcerative colitis.

BACKGROUND: Activated lymphocytes are considered to play a pathogenic role in Crohn's disease (CD) and ulcerative colitis (UC), although only a limited fraction of the gut-residing lymphocytes in these diseases may be pathogenetically involved, due to active recruitment from the peripheral circulation. Our aim was to characterize in situ preactivated lymphocytes in inflammatory bowel disease mucosa by expansion with interleukin-2. METHODS: Flow cytometry was performed on T cells expanded from the colon of patients with CD (7), UC (16), and controls (20), with special reference to T-cell activation markers and adhesion molecules. RESULTS: In CD a decrease in alpha4beta7 integrin expression was associated with an increase in alphaEbeta7. In UC a similar increase in alphaEbeta7 was observed. Moreover, L-selectin and CD30 were overexpressed on T helper cells in UC versus CD. CONCLUSION: These findings indicate different immunopathogenic pathways for CD and UC.

Ambiguity as the route to shame.

In patients who have been exposed to extreme conditions, shame is connected with a dilemma of identity: it is indicative of the patient's conflict over his alienation, his adaptation to and familiarization with the conditions offered by an unacceptable frame. Bleger's (1967) theoretical model, with the concepts of the symbiotic link, ambiguity and the ambiguous position (which precedes the classical Kleinian positions), dynamically combines the problem of the frame or context with that of the capacity of discrimination between the ego and its objects. Ambiguity is characterized by the adaptability, malleability, permeability and non-conflictuality which it confers on the personality. Shame appears as an alarm signal concerning ambiguity, connected with the ego's need to maintain its internal conflictuality, its capacity for integration and its sense of continuity. Experiences of dependence and passivity, or ones which touch upon the dilemma between true and false, private and public, ethics and aesthetics, etc., may give rise to feelings of shame. In this paper it is suggested that a common denominator for the many different factors of shame may be found in the dynamics of ambiguity.

Effect of apamin on the responses to VIP, ATP and NANC neurone stimulation in the rat and cat gastric fundus.

1. The influence of apamin on non-adrenergic non-cholinergic (NANC) relaxation and on the effect of the putative transmitters VIP and ATP was examined in the rat and cat gastric fundus. 2. In longitudinal muscle strips of the rat gastric fundus, ATP induced a biphasic effect, relaxation followed by contraction. The relaxant effect of ATP was blocked by apamin, whereas the relaxations induced by VIP and NANC neurone stimulation were not influenced by apamin. 3. In circular and longitudinal muscle strips of the cat gastric fundus, ATP only induced relaxation at high concentrations. The ATP-induced relaxation was increased in the presence of apamin, whereas the VIP-induced and NANC relaxations were not influenced. 4. It is concluded that the relaxant effect of ATP might be related to activation of apamin-sensitive Ca(2+)-dependent K(+)-channels in the rat gastric fundus. In the cat gastric fundus, apamin did not antagonize the relaxant effect of ATP so that it cannot be used to investigate an ATP involvement in inhibitory NANC neurotransmission in this tissue. No evidence for a presynaptic inhibitory action of apamin on VIP-ergic NANC neurones was obtained.

Relaxant effect of capsaicin in the rat gastric fundus.

The effect of capsaicin was studied in precontracted longitudinal muscle strips of the rat gastric fundus. Capsaicin induced a relaxation in the concentration range 10(-7)-10(-6) M. The relaxation induced by 10(-6) M capsaicin was completely prevented by extrinsic denervation of the stomach. The adrenoceptor antagonists phentolamine and propranolol did not influence the effect of capsaicin while hexamethonium potentiated it; this potentiation was not observed with another nicotinic receptor antagonist trimethaphan. Tetrodotoxin did not have a consistent effect as it reduced the capsaicin-induced relaxation in some but not all tissues. The peptidase trypsin consistently reduced the action of capsaicin but vasoactive intestinal polypeptide (VIP) antiserum, desensitization to calcitonin gene-related peptide (CGRP), and CGRP antiserum had no influence. The neuropeptide involved in the relaxant effect of capsaicin in the rat gastric fundus has thus still to be determined.

Relaxant effect of rat PHI, PHI-Gly and PHV(1-42) in the rat gastric fundus.

It was previously shown that porcine PHI is 30 times less potent than VIP in relaxing the rat gastric fundus; the relaxant potency of rat PHI and its 2 C-terminally extended forms PHI-Gly and PHV(1-42) in the rat gastric fundus was compared here with that of VIP, porcine PHI and PHM. The rank order of potency in relaxing the precontracted fundus tissues was VIP greater than rat PHI greater than PHM greater than PHV greater than PHI-Gly greater than porcine PHI, rat PHI being only 2 times less potent than VIP. In the presence of antioxidants, the potency and efficacy of porcine PHI increased, but the peptide was still the least potent of the series tested. The results illustrate the importance of using species-related peptides and are compatible with a cotransmitter role of rat PHI in nonadrenergic noncholinergic neurotransmission of the rat gastric fundus.

[Mirizzi syndrome]. / Het syndroom van Mirizzi.

Obstruction of the common hepatic duct due to pressure from an impacted stone in the cystic duct or in the gallbladder infundibulum is known as Mirizzi's syndrome. The obstruction is due to direct impression of the stone on the common hepatic duct or to the concomitant inflammatory infiltrate. The diagnostic features are illustrated by 6 recently observed cases. Clinical features, sonography and CT scan do not always contribute to a correct diagnosis. Endoscopic retrograde cholangiography usually provides the diagnosis but confusion with gallbladder carcinoma, metastatic malignancies at the porta hepatis and even cholangiocarcinoma is possible. The therapy of the Mirizzi syndrome is essentially surgical. In obstructive jaundice preoperative direct cholangiography is always warranted even with a history suggestive of cholelithiasis. Especially in case of associated cholangitis non-surgical biliary drainage procedures are a valuable temporary treatment facilitating surgery. If, however, in a probably malignant obstruction of the common hepatic duct biliary stenting is considered as the only treatment, careful exclusion of Mirizzi's syndrome is required.