[Evaluation of contingency plans in the care of patients in intensive care units in the COVID-19 pandemic]. / Evaluación de los planes de contingencia en la atención a pacientes en Unidades de Cuidados Intensivos en la pandemia por COVID-19.

BACKGROUND: The expansion of intensive care areas has been one of the most significant measures in this forced adaptation to the evolution of the different phases of the COVID-19 pandemic. The objective is to evaluate the deployment of contingency plans in the care of patients admitted to intensive care units during the period from March 19 to April 20, 2020, in a public hospital, reference for 300,000 inhabitants belonging to the Galician Health Service. MATERIALS AND METHODS: Qualitative research from focus groups, with systematic sampling. Based on the adaptation to the health environment of the 10 measures recommended by Deloitte to face a pandemic, an evaluation was carried out by the quality unit of the Health Area. As outcome indicators, the number of COVID-19 patients, % of patients admitted to hospital, % patients admitted to intensive care units, as well as the number of deaths from COVID-19, were evaluated in seven health areas in the period March 19 to April 20, 2020. RESULTS: The qualitative evaluation identified 2 areas for improvement (communication and risk assessment) of the 10 recommended measures. The Health Area has the lowest relative (2.6%) and absolute (16) rate of deceased patients, as well as the lowest relative (7.9%) and absolute (24) rate of patients admitted to intensive services for COVID-19. The infection rate in professionals has been 4.4%. CONCLUSIONS: The simplicity and identification of areas for improvement added to the low consumption of resources are strengths of this proposal. This self-assessment can be helpful in identifying areas for improvement.

Evaluación de un modelo de dirección médica de hospital elegida por los profesionales / Assessment of a model of Health Manager elected by professional

Desde 1996 los directores médicos (DM) de los hospitales públicos de Andalucía se eligen mediante un proceso participativo. Objetivos: Conocer el perfil de los DM y evaluar este cambio organizativo a través de la opinión de los profesionales implicados. Material y métodos: El estudio se realizó entre abril de 1997 y enero de 2001, e incluyó todos los hospitales públicos. Para su realización se utilizó un cuestionario de 20 ítems (13 cerrados y 7 abiertos) para conocer el perfil de los DM y un estudio Delphi (dos rondas), que se aplicó a un grupo de 97 expertos (10 directivos, 24 gerentes, 23 DM y 40 médicos) seleccionados con arreglo a criterios explícitos (tiempo mínimo de permanencia y relación con la DM). Los datos se presentan como descripción de las variables, del grado de acuerdo/desacuerdo y de las diferencias en las respuestas entre categorías profesionales (ANOVA).Resultados: Perfil de DM: tasa de respuesta 69,5 por ciento (16/23). El DM es un varón de 45 años (media), especialista vía MIR, adjunto clínico y sin experiencia en gestión; refiere haber cubierto sus expectativas en estos años y que sus mayores dificultades se debieron a los propios médicos. Estudio Delphi: participación del 67,5 por ciento (directivos sólo 20 por ciento). No se identifican áreas de retroceso y la DM se valora en un plano positivo para accesibilidad y relación gestores/médicos; pero la confianza en el modelo es limitada y la DM tiene un papel poco definido y ambiguo. Las diferencias más significativas en la respuesta se establecen entre gerentes y DM. Comentario: El modelo parece suponer un cambio interesante más teórico que real en la manera de entender la relación entre médicos y gestores, ya que produce recelo entre ambos y escaso entusiasmo (AU)

Sources of influence on medical practice.

OBJECTIVES: To explore the opinion of general practitioners on the importance and legitimacy of sources of influence on medical practice. METHODS: General practitioners (n=723) assigned to Primary Care Teams (PCTs) in two Spanish regions were randomly selected to participate in this study. A self administered questionnaire was sent by mail and collected by hand. The dependent variable collected the opinion on different sources that exert influence on medical practice. Importance was measured with a 9 item scale while legitimacy was evaluated with 16 items measured with a 1 to 7 point Likert scale. RESULTS: The most important and legitimate sources of influence according to general practitioners were: training courses and scientific articles, designing self developed protocols and discussing with colleagues. The worst evaluated were: financial incentives and the role played by the pharmaceutical industry. CONCLUSIONS: The development of medical practice is determined by many factors, grouped around three big areas: organisational setting, professional system and social setting. The medical professional system is the one considered as being the most important and legitimate by general practitioners. Other strategies of influence, considered to be very important by the predominant management culture (financial incentives), are not considered to be so by general practitioners. These results, however, are not completely reliable as regards the real network of influences existing in medical practice, which reflect instead different "value systems".

[Qualitative techniques for public health research and the development of health care services: more than just another technique]. / Técnicas cualitativas para la investigación en salud pública y gestión de servicios de salud: algo más que otro tipo de técnicas.

Regarding the debate on the existence of two current focuses on health science research (qualitative and quantitative), the paper states the need for complementing the techniques which contribute to a better knowledge of populations and communities, and the need for offering effective solutions to different problems. The article analyses the usefulness of qualitative methods, describes the techniques and procedures more frequently used to guarantee the validity and reliability of research findings and ends bringing up the need for using qualitative and quantitative approaches. This way of working together or learning from each other will enrich research and interventions on public heath and health management fields. Qualitative methods are useful for sound understanding of a given issue that is being investigated or evaluated taking into account the point of view of the participants under research. Key techniques, listed from the most structured to the less structured are among others: structured interview, Delphi, nominal group, case study, semistructured interview, focal group, brainstorming, discussion group, in depth interview, life story and participant observation.

Transient protection of human T-cells from human immunodeficiency virus type 1 infection by transduction with adeno-associated viral vectors which express RNA decoys.

RNA decoys are oligonucleotides corresponding to the TAR and RRE sequences of HIV which inhibit the HIV-encoded regulatory proteins Tat and Rev, respectively. Adeno-associated viral vectors encoding RNA decoys stably transduced into the human T-cell line CEM-SS expressed transactivating region (TAR) and Rev-responsive element (RRE) RNA decoys from tRNA polIII promoters at high levels, without any apparent deleterious effects on cell growth or expression of CD4. DNA blot analysis indicated that RNA decoy-encoding vectors were not rearranged and were integrated into the genomic DNA of selected cell lines. Vector DNA with the appropriate TAR and RRE sequences was isolated from transduced cell lines after prolonged growth in culture, further confirming that the vector DNA was present in a stable form through multiple cell cycles. Cell lines expressing TAR and RRE decoys transiently inhibited HIV gene expression and replication by 70-99% as determined by measurement of intracellular and extracellular HIV p24 production. Adeno-associated vectors encoding RNA decoys may be useful for gene therapy of HIV infection.

High-efficiency retroviral vector mediated gene transfer into human peripheral blood CD4+ T lymphocytes.

Genetic modification of peripheral blood T lymphocytes has been proposed as a therapeutic strategy for treating congenital disorders, cancer and viral diseases. Central to all T lymphocyte-based gene therapy strategies is the ability to efficiently and stably deliver genes into primary T lymphocytes. In this study, we sought to increase the gene transfer efficiency in CD4+ peripheral blood T lymphocytes using procedures which could be utilized in clinical applications. In order to quantity the gene transfer efficiency in primary CD4+ T cells, a high-titer retroviral vector which efficiently expresses a truncated version of the human low-affinity nerve growth factor receptor (delta LNGFR) was constructed. Transduced cells were then accurately enumerated with immunofluorescence staining and fluorescence activated cell sorting (FACS) analysis and rapidly isolated at high purity for further analysis. Using this system, a supernatant-based gene transfer procedure was developed which routinely yields gene transfer efficiencies of 25-40% into a wide repertoire of both freshly obtained and cryopreserved peripheral blood CD4+ T lymphocytes.

Inhibition of HIV-1 in CEM cells by a potent TAR decoy.

TAR decoys are short RNA oligonucleotides, corresponding to the HIV TAR sequence, which inhibit HIV expression and replication by blocking the binding of the HIV regulatory protein Tat to the authentic TAR region. In previous studies, TAR decoys expressed from a tRNA polIII promoter were moderately effective at inhibiting HIV in isolated human T cell lines and less effective at inhibiting HIV in peripheral blood CD4+ T cells. In this study, a series of modifications was introduced into the tRNA expression cassette in order to improve their effectiveness. These modifications included the addition of sequences which are predicted to have stem-loop secondary structures and addition of a wild-type tRNA processing site. TAR decoy RNA expressed in CEM cells from modified tRNA-based expression cassettes yielded five- to 20-fold more TAR transcripts than unmodified tRNA-based expression cassettes. HIV replication, as measured by a flow cytometric method to quantify intracellular viral p24 expression, was significantly reduced in polyclonal populations of CEM cells expressing a modified tRNA-TAR transcript that contains a wild-type tRNA processing site and stem-loops 5' and 3' to the TAR sequence. Similar modifications to the tRNA expression cassette also increased the intracellular concentration of a random test oligonucleotide, indicating that this improved expression system may also be useful for antisense and ribozyme based gene inhibition strategies.

Hickman catheter tip displacement.

In a series of 60 consecutive patients in whom Hickman catheters were placed for treatment of malignancy, four properly positioned catheter tips migrated secondarily from the superior vena cava to the ipsilateral jugular vein 2, 4, 21, and 25 days after placement. Three of the four patients had begun to have catheter dysfunction when the displacement was diagnosed. No satisfactory explanation for this rarely reported complication was evident in three of the cases. Maneuvers such as coughing, Valsalva's maneuver, and forceful heparin flushing produced no motion in three normally directed catheter tips in other patients observed under fluoroscopy. The phenomenon may be more common than previously reported. Evaluation of any new Hickman catheter dysfunction should include a chest x-ray film to ascertain the position of the catheter.