Manual de procesos y procedimientos de atenciones de salud integrales ambulatorias de baja complejidad / Manual of processes and procedures for comprehensive low-complexity outpatient health care

El presente manual de procesos y procedimientos documenta la atención integral ambulatoria de baja complejidad como parte del proceso de atención en salud integral e integrada a la persona en el curso de vida con enfoque de atención primaria en salud, describe el sistema de operación de los establecimientos, mediante el enfoque por procesos, fomentando el desarrollo organizacional y el mejoramiento continuo para el cumplimiento de la misión institucional. Establece las bases para la ejecución de los procesos y procedimientos, unificando criterios de contenido que permita la sistematización de las actividades y la definición de la metodología para efectuarlas. En el contenido de cada procedimiento se detalla la normativa legal y los registros para desarrollar cada una de sus actividades.

This manual of processes and procedures documents low-complexity comprehensive outpatient care as part of the process of comprehensive and integrated health care for the person in the course of life with a primary health care approach, describes the operating system of the establishments , through the process approach, promoting organizational development and continuous improvement for the fulfillment of the institutional mission. It establishes the bases for the execution of processes and procedures, unifying content criteria that allow the systematization of activities and the definition of the methodology to carry them out. The content of each procedure details the legal regulations and the records to carry out each of its activities.

Assessment of community pharmacists’ communication and comfort levels when interacting with Deaf and hard of hearing patients

Background: Deaf and hard of hearing patients who use sign language face considerable communication barriers while accessing pharmacy services. Low comfort-levels between community pharmacists and Deaf and hard of hearing patients result in poor interactions and increase patient safety risks. Objective: 1) To examine the way community pharmacists interact with Deaf and hard of hearing patients in Malaysia, and their level of comfort in such interactions. 2) To examine how comfort-levels vary by the preferred communication methods, resources and employer support. Methods: This cross-sectional study was conducted among registered community pharmacists practicing in Malaysia. Questionnaire items included comfort-levels of community pharmacists when interacting with Deaf and hard of hearing patients, used and preferred communication methods, necessary resources, and perceived employer’s level of support. Based on the list of registered pharmacies, the questionnaire with a pre-paid return envelope was mailed out while pharmacies close to the university were approached in person. This questionnaire was distributed online using Google Form. Comparisons between comfort-levels and study parameters were analyzed using independent t-tests and ANOVA. Results: A total of 297 community pharmacists responded (response rate 29.2%). Higher comfort-levels were reported in those who had received between 1 to 5 prescriptions as compared to those who did not receive prescriptions from Deaf and hard of hearing patients (MD= -0.257, SD=0.104, p=0.042). More than 80% used written information and only 3.4% had used the services of a qualified sign language interpreter throughout their community pharmacist career. Significantly lower comfort-levels (p=0.0004) were reported in community pharmacists who perceived training in sign language as a necessity to interact with (AU)

Single Session Transcranial Magnetic Stimulation Ameliorates Hand Gesture Deficits in Schizophrenia.

Social interaction is impaired in schizophrenia, including the use of hand gestures, which is linked to poor social perception and outcome. Brain imaging suggests reduced neural activity in a left-lateralized frontoparietal network during gesture preparation; therefore, gesturing might be improved through facilitation of left hemispheric brain areas or via disruption of interhemispheric inhibition from the right homolog. This study tested whether repetitive transcranial magnetic stimulation (rTMS) protocols would improve gesture performance in schizophrenia. This randomized, placebo-controlled, double-blind, crossover trial applied 3 different protocols of rTMS separated by 48 h. Twenty right-handed schizophrenia patients and 20 matched healthy controls received facilitatory intermittent theta burst stimulation (iTBS) over the left inferior frontal gyrus (IFG), inhibitory continuous theta burst stimulation (cTBS) over right inferior parietal lobe (IPL), and placebo over left IPL in randomized order. Primary outcome was change in the test of upper limb apraxia (TULIA), rated from video recordings of hand gesture performance. Secondary outcome was change in manual dexterity using the coin rotation task. Participants improved on both tasks following rTMS compared with baseline. Only patients improved gesture performance following right IPL cTBS compared with placebo (P = .013). The results of the coin rotation parallel those of the TULIA, with improvements following right IPL cTBS in patients (P = .001). Single sessions of cTBS on the right IPL substantially improved both gesture performance accuracy and manual dexterity. The findings point toward an inhibition of interhemispheric rivalry as a potential mechanism of action.

[Development of communicative abilities in infants with Down syndrome after systematized training in gestural communication]. / Desarrollo de habilidades comunicativas en lactantes con síndrome de Down posterior a capacitaciones sistematizadas en comunicación gestual.

INTRODUCTION: Gestural communication, understood as the use of non-verbal gestures before the word appears, is a strength in children with Down syndrome (DS). OBJECTIVE: To describe com munication development behaviors in children with DS, before and after gestural communication training, based on the "Signs, words and games" workshops of the Baby Signs® program. SUBJECTS AND METHOD: Prospective study of children with DS between 18 and 22 months of cognitive age, who were trained in gestural communication according to the "Baby Signs®" methodology, evaluating communication skills through the MacArthur inventory adapted for children with DS (Communica tive Development Inventories, CDI-DS), analyzing the scores before and three months after the in tervention. The evaluated items were: Early comprehension, First sentences comprehension, Starting to speak, Vocabulary list, and Decontextualized language use (part 1) and total, early and late gestures (part 2). RESULTS: 21 children completed the workshops, with an average chronological age of 27.5 months and 19.8 months of cognitive age. 29% of the participants increased their scores in sentence comprehension, 62% in vocabulary production with gestures, 33% improved in vocabulary compre hension, 57% lost early gestures, and 43% increased late gestures production. CONCLUSIONS: Gestural communication training favors the communication skills development in a group of children with DS, mainly in the initial understanding and gesture production. There is important inter-individual variability, therefore is necessary to consider child to child recommendations.

Differential roles of gestures on spatial language in neurotypical elderly adults and individuals with focal brain injury.

Gestures might serve communicative functions by supplementing spoken expressions or restorative functions by facilitating speech production. Also, speakers with speech deficits use gestures to compensate for their speech impairments. In this study, we examined gesture use in speakers with and without speech impairments and how spoken spatial expressions changed when gestures were restrained. Six patients with speech problems and with left frontal and/or temporal lesions and 20 neurotypical controls described motion events in 3 different conditions (spontaneous gesture, only speech, and only gesture). In addition to the group analyses, we ran case analyses. Results showed that patients used more gestures compared to controls. Gestures served both communicative and restorative functions for patients whereas controls only used gestures for communicative purposes. Case analyses revealed that there were differential patterns among patients. Overall, gesture production is multifunctional and gestures serve different functions for different populations as well as within a population.

Desarrollo de habilidades comunicativas en lactantes con síndrome de Down posterior a capacitaciones sistematizadas en comunicación gestual / Development of communicative abilities in infants with Down syndrome after systematized training in gestural communication

INTRODUCCIÓN: La comunicación gestual, entendida como el uso de gestos no verbales antes de la aparición de la palabra, es una fortaleza en niños con síndrome de Down (SD). OBJETIVO: Describir conductas de desarrollo comunicativo en niños con SD, previo y posterior a capacitaciones en comunicación gestual, basadas en talleres de "Señas, palabras y juegos" del programa Baby Signs®. SUJETOS Y MÉTODO: Estudio prospectivo de niños con SD entre 18 y 22 meses de edad cognitiva, a los cuales se les realizó capacitaciones en comunicación gestual según la metodología Baby Signs, evaluando habilidades comunicativas a través del inventario McArthur adaptado para niños con SD (Inventario de desarrollo comunicativo, CDI-SD), analizando los puntajes antes y 3 meses después de la intervención. Los ítems evaluados corresponden a: Comprensión temprana, Comprensión de las primeras frases, Comenzando a hablar, Lista de vocabulario y Uso descontextualizado del lenguaje (parte 1) y a Gestos totales, tempranos y tardíos (parte 2). RESULTADOS: 21 niños completaron los talleres, con una media de edad cronológica de 27,5 meses y 19,8 meses de edad cognitiva. El 29% de los participantes aumentaron sus puntajes en comprensión de frases, el 62% en producción de vocabulario con gestos, el 33% mejora la comprensión de vocabulario, el 57% perdió los gestos tempranos y el 43% aumentó la producción de gestos tardíos. CONCLUSIONES: Las capacitaciones en comunicación gestual favorecen el desarrollo de habilidades comunicativas en un grupo de niños con SD, principalmente en la com prensión inicial y producción de gestos. Existe importante variabilidad interindividual, por lo que es necesario considerar las recomendaciones niño a niño.

INTRODUCTION: Gestural communication, understood as the use of non-verbal gestures before the word appears, is a strength in children with Down syndrome (DS). OBJECTIVE: To describe com munication development behaviors in children with DS, before and after gestural communication training, based on the "Signs, words and games" workshops of the Baby Signs® program. SUBJECTS AND METHOD: Prospective study of children with DS between 18 and 22 months of cognitive age, who were trained in gestural communication according to the "Baby Signs®" methodology, evaluating communication skills through the MacArthur inventory adapted for children with DS (Communica tive Development Inventories, CDI-DS), analyzing the scores before and three months after the in tervention. The evaluated items were: Early comprehension, First sentences comprehension, Starting to speak, Vocabulary list, and Decontextualized language use (part 1) and total, early and late gestures (part 2). RESULTS: 21 children completed the workshops, with an average chronological age of 27.5 months and 19.8 months of cognitive age. 29% of the participants increased their scores in sentence comprehension, 62% in vocabulary production with gestures, 33% improved in vocabulary compre hension, 57% lost early gestures, and 43% increased late gestures production. CONCLUSIONS: Gestural communication training favors the communication skills development in a group of children with DS, mainly in the initial understanding and gesture production. There is important inter-individual variability, therefore is necessary to consider child to child recommendations.

Exploring infant signing to enhance responsive parenting: Findings from the INSIGHT study.

Responsive parenting is a promising framework for obesity prevention, yet attempts to date have largely relied on parents accurately interpreting their child's cues. Infant signing or "baby sign language" could enhance these interventions by improving bidirectional parent-child communication during the preverbal and emerging language years. In a clinical trial testing, a responsive parenting intervention designed for obesity prevention, we pilot tested a brief intervention at age 40 weeks with a subset of participating dyads that taught the signing gesture of "all done" to improve parental recognition of satiety. In addition, we surveyed all participating mothers at child age 18 months on the use of infant signing gestures in the prior year. Two hundred twenty-eight mothers completed the survey including 72 responsive parenting group mothers that received the signing instructions. A majority of mothers, 63.6%, reported teaching their infant signs in the prior year, and 61.4% of infants were using signs to communicate at 18 months (median signs = 2). The signs for "more" and "all done" were used by over half of study participants and were the most common signs used. Other signs related to eating or drinking were commonly used. Signing intervention group infants were more likely to use the sign for "all done" than controls (63.9% vs. 45.5%; P = 0.01), but there was no difference between groups with regard to the use of the sign for "more" (56.9% vs. 51.3%; P = 0.43). Signing is commonly used by parents of young children and holds potential to improve parental responsiveness and obesity prevention efforts.

High-level language processing regions are not engaged in action observation or imitation.

A set of left frontal, temporal, and parietal brain regions respond robustly during language comprehension and production (e.g., Fedorenko E, Hsieh PJ, Nieto-Castañón A, Whitfield-Gabrieli S, Kanwisher N. J Neurophysiol 104: 1177-1194, 2010; Menenti L, Gierhan SM, Segaert K, Hagoort P. Psychol Sci 22: 1173-1182, 2011). These regions have been further shown to be selective for language relative to other cognitive processes, including arithmetic, aspects of executive function, and music perception (e.g., Fedorenko E, Behr MK, Kanwisher N. Proc Natl Acad Sci USA 108: 16428-16433, 2011; Monti MM, Osherson DN. Brain Res 1428: 33-42, 2012). However, one claim about overlap between language and nonlinguistic cognition remains prominent. In particular, some have argued that language processing shares computational demands with action observation and/or execution (e.g., Rizzolatti G, Arbib MA. Trends Neurosci 21: 188-194, 1998; Koechlin E, Jubault T. Neuron 50: 963-974, 2006; Tettamanti M, Weniger D. Cortex 42: 491-494, 2006). However, the evidence for these claims is indirect, based on observing activation for language and action tasks within the same broad anatomical areas (e.g., on the lateral surface of the left frontal lobe). To test whether language indeed shares machinery with action observation/execution, we examined the responses of language brain regions, defined functionally in each individual participant (Fedorenko E, Hsieh PJ, Nieto-Castañón A, Whitfield-Gabrieli S, Kanwisher N. J Neurophysiol 104: 1177-1194, 2010) to action observation ( experiments 1, 2, and 3a) and action imitation ( experiment 3b). With the exception of the language region in the angular gyrus, all language regions, including those in the inferior frontal gyrus (within "Broca's area"), showed little or no response during action observation/imitation. These results add to the growing body of literature suggesting that high-level language regions are highly selective for language processing (see Fedorenko E, Varley R. Ann NY Acad Sci 1369: 132-153, 2016 for a review). NEW & NOTEWORTHY Many have argued for overlap in the machinery used to interpret language and others' actions, either because action observation was a precursor to linguistic communication or because both require interpreting hierarchically-structured stimuli. However, existing evidence is indirect, relying on group analyses or reverse inference. We examined responses to action observation in language regions defined functionally in individual participants and found no response. Thus language comprehension and action observation recruit distinct circuits in the modern brain.

Visual attention and action: How cueing, direct mapping, and social interactions drive orienting.

Despite considerable interest in both action perception and social attention over the last 2 decades, there has been surprisingly little investigation concerning how the manual actions of other humans orient visual attention. The present review draws together studies that have measured the orienting of attention, following observation of another's goal-directed action. Our review proposes that, in line with the literature on eye gaze, action is a particularly strong orienting cue for the visual system. However, we additionally suggest that action may orient visual attention using mechanisms, which gaze direction does not (i.e., neural direct mapping and corepresentation). Finally, we review the implications of these gaze-independent mechanisms for the study of attention to action. We suggest that our understanding of attention to action may benefit from being studied in the context of joint action paradigms, where the role of higher level action goals and social factors can be investigated.

Restoring the voids of voices by signs and gestures, in dentistry: A cross-sectional study.

AIMS: To help dentists to communicate with the hearing impaired patients, reach an accurate diagnosis and explain the treatment plan by learning some signs and gestures used in the nonverbal communication (NVC) and by devising some new signs and gestures related to dentistry which shall be easy to learn and understand both by the hearing impaired patients and the dentists. SETTINGS AND DESIGN: The study was carried out on 100 hearing impaired students in the age group of 10-14 years in two special schools for hearing impaired children located in two different states of India, where different spoken languages and different sign languages are used. One dentist (expert dentist) was trained in the NVC and the other dentist (non expert dentist) had no knowledge of this type of communication, communicated the same sets of statements related to dentistry, to the hearing impaired children. One1 translator was assigned to judge their interactions. Students were asked to tell the interpreter at the end of each signed interaction what they understood from the statement conveyed to them by both the dentists. STATISTICAL ANALYSIS USED: All data collected were subjected to statistical analysis using Chi-square test and odds ratio test. RESULTS: In the special school of 1st state, the nonexpert dentist conveyed only 36.3% of the information correctly to the students, whereas the expert dentist conveyed 83% of the information correctly. In the special school of 2nd state, the nonexpert dentist conveyed only 37.5% of the information correctly to the students, whereas the expert dentist conveyed 80.3% of the information correctly. CONCLUSIONS: Dentists should be made aware of the NVC and signs and gestures related to dentistry should be taught to the hearing impaired students as well as the dental students.

How Much Information Do People With Aphasia Convey via Gesture?

PURPOSE: People with aphasia (PWA) face significant challenges in verbally expressing their communicative intentions. Different types of gestures are produced spontaneously by PWA, and a potentially compensatory function of these gestures has been discussed. The current study aimed to investigate how much information PWA communicate through 3 types of gesture and the communicative effectiveness of such gestures. METHOD: Listeners without language impairment rated the information content of short video clips taken from PWA in conversation. Listeners were asked to rate communication within a speech-only condition and a gesture + speech condition. RESULTS: The results revealed that the participants' interpretations of the communicative intentions expressed in the clips of PWA were significantly more accurate in the gesture + speech condition for all tested gesture types. CONCLUSION: It was concluded that all 3 gesture types under investigation contributed to the expression of semantic meaning communicated by PWA. Gestures are an important communicative means for PWA and should be regarded as such by their interlocutors. Gestures have been shown to enhance listeners' interpretation of PWA's overall communication.

Exploring Expressive Communication Skills in a Cross-Sectional Sample of Children and Young Adults With Angelman Syndrome.

PURPOSE: This study explores data on expressive communication skills of 300 individuals aged 0.0-21.11 years with Angelman syndrome (AS). These data provide a composite portrait of communication skills in a large sample of children and young adults with this rare disorder, specifying new detailed information about expressive communication. METHOD: The database associated with the Communication Matrix assessment (Rowland, 2004, 2011; Rowland & Fried-Oken, 2010) was mined for data regarding individuals with AS. We extracted data on the reasons for communicating, level of communication achieved, and use of various expressive communication modes to convey 24 specific messages. The performance of children and young adults in 5 age groups in the cross-sectional sample were contrasted. RESULTS: Results confirmed earlier studies showing that few individuals with AS use natural speech. However, in addition to using presymbolic modes, many children used alternative symbolic modes such as picture symbols, object symbols, and manual signs. Assessment scores increased slightly with age, F(4, 295) = 2.416, p = .049. CONCLUSIONS: Aggregating data on a large sample of individuals with AS provides a reference point for practitioners and family members and a basis for future investigations.

Motor and verbal perspective taking in children with Autism Spectrum Disorder: Changes in social interaction with people and tools.

BACKGROUND: Children with Autism Spectrum Disorder (ASD) have difficulty communicating with others nonverbally, via mechanisms such as hand gestures, eye contact and facial expression. Individuals with ASD also have marked deficits in planning future actions (Hughes, 1996), which might contribute to impairments in non-verbal communication. Perspective taking is typically assessed using verbal scenarios whereby the participant imagines how an actor would interact in a social situation (e.g., Sally Anne task; Baron-Cohen, Leslie, & Frith, 1985). METHOD: The current project evaluated motor perspective taking in five children with ASD (8-11 years old) as they participated in a narrative intervention program over the course of about 16 weeks. The goal of the motor perspective-taking task was to facilitate the action of an experimenter either hammering with a tool or putting it away. RESULTS: Initially, children with ASD facilitated the experimenter's action less than neurotypical control children. As the narrative intervention progressed, children with ASD exhibited increased motor facilitation that paralleled their increased use of mental state and causal language, indicating a link between verbal and motor perspective taking. CONCLUSIONS: Motoric perspective taking provides an additional way to assess understanding and communication in children with ASD and may be a valuable tool for both early assessment and diagnosis of children with ASD.

Final Priority--Training of Interpreters for Individuals Who Are Deaf or Hard of Hearing and Individuals Who Are Deaf-Blind Program. Final priority.

Rehabilitative Services announces a final priority under the Training of Interpreters for Individuals Who Are Deaf or Hard of Hearing and Individuals Who Are Deaf-Blind program. The Assistant Secretary may use this priority for competitions in fiscal year 2016 and later years. We take this action to provide training and technical assistance to better prepare novice interpreters to become highly qualified nationally certified sign language interpreters.

Manual anchoring biases in slant estimation affect matches even for near surfaces.

People verbally overestimate hill slant by ~15°-25°, whereas manual estimates (e.g., palm board measures) are thought to be more accurate. The relative accuracy of palm boards has contributed to the widely cited theoretical claim that they tap into an accurate, but unconscious, motor representation of locomotor space. Recently, it was shown that a bias that stems from anchoring the hand at horizontal prior to the estimate can quantitatively account for the difference between manual and verbal estimates of hill slant. The present work extends this observation to manual estimates of near-surface slant, to test whether the bias derives from manual or visual uncertainty. As with far surfaces, strong manual anchoring effects were obtained for a large range of near-surface slants, including 45°. Moreover, correlations between participants' manual and verbal estimates further support the conclusion that both measures are based on the same visual representation.

Teaching Adults With Intellectual Disability Manual Signs Through Their Support Staff: A Key Word Signing Program.

PURPOSE: The goal of this study was to evaluate a key word signing (KWS) program in which adults with mild to severe intellectual disability (ID) were taught manual signs through their support staff. Our hypothesis was that spontaneous manual sign production of participants would increase significantly after 12 months of implementation of the KWS program. METHOD: A KWS immersion program was implemented in a facility for adults with ID. First, 8 support workers received 8 hr of training. These KWS ambassadors then taught 2 manual signs per week to their colleagues, who modeled the use of the signs throughout the day in natural interactions with their clients. KWS use in 15 adults with ID and 15 of their support staff was evaluated before the start of the program and at a 12-month follow-up using a narrative task and during spontaneous conversation. RESULTS: Manual sign production of support workers and adults with ID had increased significantly 12 months after the start of the program. The adults with ID were able to express significantly more communicative functions in their narrative language after the intervention and when using KWS. CONCLUSION: The KWS program was successful and can be applied in similar clinical settings.