Compasión en salud: Una mirada a su pasado, presente y futuro

La compasión es valorada dentro de los elementos centrales de la atención en salud, existiendo en los últimos años un aumento progresivo del interés en su investigación, al menos en parte, por la percepción de que ha disminuido en los sistemas de salud. Desde hace siglos se ha encontrado en forma universal en diferentes culturas y disciplinas, pero presentando variaciones según las diferentes culturas en cuanto a su comprensión y expresión, siendo su abordaje desde el punto de vista científico relativamente reciente en la historia. Se distinguiría de conceptos similares como empatía, altruismo y lástima. Evolutivamente habría surgido en el marco de las conductas de cuidado y crianza de los mamíferos, y neurobiológicamente se relacionaría con cambios a nivel de activación autonómica, neurotransmisores, estructuras corticales y subcorticales, de forma similar a otras emociones prosociales. Ha sido asociada a múltiples beneficios en salud física, mental y para la atención en salud. Se han diseñado múltiples instrumentos para evaluarla e intervenciones en relación a ella, requiriéndose de mayores estudios para poder generalizarse. Se han descrito también barreras para la compasión y que podría fatigarse, encontrándose esto último actualmente en discusión. A futuro existirían desafíos para su desarrollo en conjunto con la tecnología, los cambios políticos, sociológicos, asistenciales y docentes, existiendo orientaciones sobre cómo superarlos para avanzar hacia sistemas de salud más compasivos.

Compassion is valued within the central elements of health care, existing in recent years a progressive increase in interest in its research, at least in part by the perception that it has decreased in health systems. For centuries it has been found universally in different cultures and disciplines but presenting variations according to different cultures in terms of its understanding and expression, and being its approach from scientific point of view relatively recent in history. It could be distinguished from similar concepts such as empathy, altruism and pity. Evolutionarily, it would have arisen within the framework of care and breeding behaviors of mammals, and neurobiologically it would be related to changes at autonomic activation levels, neurotransmitters, cortical and subcortical structures, similar to other prosocial emotions. It has been associated with multiple benefits in physical and mental health, and in health care. Multiple instruments have been designed to evaluate it and interventions in relation to it, which would require further studies to be able to be generalized. Barriers to compassion have also been described, and that it could be fatigued, the latter being currently under discussion. In the future there would be challenges for its development in conjunction with technology, political, sociological, clinical and educational changes, existing orientations on how to overcome them to move towards more compassionate health systems.

Si Quiero Sanar, Debería Perdonar: Una Revisión Sobre el Perdón y la Salud / If I Want to Heal, I Should Forgive: A Review of Forgiveness and Health

Resumen La Organización Mundial de la Salud (OMS) entiende salud no solo como la ausencia de enfermedad, sino que también considera el bienestar personal. El perdón es un concepto relacionado con el bienestar y se conceptualiza generalmente como la reducción de los pensamientos, sentimientos y conductas negativas, así como el aumento de las positivas, en torno a la persona particular involucrada o a la situación de transgresión. A nivel biológico, se ha vinculado con marcadores de menor estrés fisiológico, con áreas cerebrales relacionadas con la teoría de la mente, la empatía, la regulación emocional, y con neurotransmisores como la oxitocina y monoaminas. Se asocia además a mejores resultados en salud mental y física, principalmente a nivel cardiovascular. Existen numerosas intervenciones en perdón que han mostrado efectividad, siendo los modelos teóricos con más evidencia el modelo de Enright y el modelo REACH. Dado los potenciales beneficios y escasos riesgos, el estudio y abordaje del perdón en la práctica clínica se convierte en una posibilidad que los clínicos deberían considerar para eventualmente disminuir el malestar y aumentar el bienestar de los pacientes.

The World Health Organization (WHO) understands health not only as the absence of disease, but also considers personal well-being. Forgiveness is a concept related to well-being and is generally conceptualized as the reduction of negative thoughts, feelings and behaviors, as well as the increase of positive ones, around the particular person involved or the situation of transgression. At the biological level, it has been linked to markers of lower physiological stress, with brain areas related to the theory of mind, empathy, emotional regulation, and neurotransmitters such as oxytocin and monoamines. It is also associated with better results in mental and physical health, mainly at the cardiovascular level. There are numerous interventions in forgiveness that have shown effectiveness, being the theoretical models with more evidence the Enright model and the REACH model. Given the potential benefits and few risks, the study and approach of forgiveness in clinical practice becomes a possibility that clinicians should consider to eventually reduce discomfort and increase the well-being of patients.

Burnout: una revisión de intervenciones basadas en la evidencia en salud mental / Burnout: a review of evidence-based interventions in mental health

El burnout es un síndrome de origen multifactorial que surge como una respuesta a un estrés prolongado en el ámbito laboral, tiene 3 dimensiones, el agotamiento emocional, la despersonalización y la sensación de insatisfacción. Su prevalencia oscila entre un 4% y 30,5% en los trabajadores, para llegar a un 50% en trabajadores en salud mental. Existen diversas estrategias para el manejo del burnout, sin embargo no está claro cuáles serían las más eficaces. El objetivo de este artículo es revisar las estrategias para el manejo del burnout, para ello se realizó un revisión narrativa que incluye el término de burnout entre los años 2012 y 2017 en buscadores PubMed. Se encontraron siete estudios entre revisiones narrativas, sistemáticas y metaanálisis, en los cuales se describen estrategias individuales e institucionales; una investigación considera además las estrategias grupales. Se describe que para el adecuado abordaje del burnout se deben considerar no solo la responsabilidad del individuo, sino también la de las organizaciones de salud, tanto en su génesis como en su manejo. Existen estrategias para abordar este problema de forma efectiva. Falta mayor precisión respecto al tipo de intervenciones, en qué combinación y en qué tiempos lograrían mayor efectividad, dado lo multifactorial de su origen y lo multidimensional de su problemática. Se requieren futuras investigaciones e intervenciones que permitan evaluar estas estrategias para el manejo de burnout en los distintos niveles de intervención.

Resiliencia en población Infanto-Juvenil: Una aproximación a las intervenciones basadas en la evidencia / Resilience in Child Population: An Approach to Evidence-Based Interventions

La resiliencia corresponde a la habilidad de superar la adversidad, recuperarse de una experiencia negativa o evitar un desarrollo adverso. Existen intervenciones que han demostrado utilidad en la promoción de la resiliencia en población infanto-juvenil, el conocerlas, es relevante para el uso adecuado de recursos. El objetivo de este artículo es revisar las intervenciones que han demostrado ser eficaces en fomentar la resiliencia en niños y adolescentes y compararlas con aquellas de nuestra realidad local. Métodos: Se realizó una revisión narrativa de la evidencia publicada los últimos 5 años de intervenciones en resiliencia dirigidas a la población de niños y adolescentes, tanto a nivel internacional como nacional. Resultados: Se encontraron 14 intervenciones basadas en la evidencia a nivel internacional y 4 programas a nivel nacional. Discusión: Existen iniciativas nacionales coherentes con la evidencia internacional en promoción de resiliencia en niños y adolescentes, aunque hay escasez de estudios que avalen la efectividad de dichos programas.Palabras claves: Resiliencia, Intervenciones, Revisión, Niño, Adolescente.

Resilience corresponds to the ability to overcome adversity, recover from a negative experience or prevent an altered development. There are interventions that have proven useful in promoting resilience in population of children and adolescents, being relevant to the proper use of resources to know them. The objective of this study is to review the interventions that have been proven effective and compare them with those performed in Chile. Methods: A narrative review was made with the evidence published during the last 5 years related to resilience interventions directed to children and adolescents, at international and national level. Results: 14 international evidence based interventions and 4 national programs were found. Discussion: The national programs are coherent with the international evidence related to resilience promotion in children and adolescents, although there is a lack of studies that support the effectiveness of these programs in resilience related variables.Key words: Resilience, Interventions, Review, Child, Adolescent.

Exocytosis of Endothelial Lysosome-Related Organelles Hair-Triggers a Patchy Loss of Glycocalyx at the Onset of Sepsis.

Sepsis is a systemic inflammatory syndrome induced by bacterial infection that can lead to multiorgan failure. Endothelial surface glycocalyx (ESG) decorating the inner wall of blood vessels is a regulator of multiple vascular functions. Here, we tested a hypothesis that patchy degradation of ESG occurs early in sepsis and is a result of exocytosis of lysosome-related organelles. Time-lapse video microscopy revealed that exocytosis of Weibel-Palade bodies and secretory lysosomes occurred a few minutes after application of lipopolysaccharides to endothelial cells. Two therapeutic maneuvers, a nitric oxide intermediate, NG-hydroxy-l-arginine, and culture media conditioned by endothelial progenitor cells reduced the motility of lysosome-related organelles. Confocal and stochastic optical reconstruction microscopy confirmed the patchy loss of ESG simultaneously with the exocytosis of lysosome-related organelles and Weibel-Palade bodies in cultured endothelial cells and mouse aorta. The loss of ESG was blunted by pretreatment with NG-hydroxy-l-arginine or culture media conditioned by endothelial progenitor cells. Moreover, these treatments resulted in a significant reduction in deaths of septic mice. Our data support the hypothesis assigning to stress-induced exocytosis of these organelles the role of a hair-trigger for local degradation of ESG that initiates leukocyte infiltration, increase in vascular permeability, and partially accounts for the later rates of morbidity and mortality.

A key to improved ion core confinement in the JET tokamak: ion stiffness mitigation due to combined plasma rotation and low magnetic shear.

New transport experiments on JET indicate that ion stiffness mitigation in the core of a rotating plasma, as described by Mantica et al. [Phys. Rev. Lett. 102, 175002 (2009)] results from the combined effect of high rotational shear and low magnetic shear. The observations have important implications for the understanding of improved ion core confinement in advanced tokamak scenarios. Simulations using quasilinear fluid and gyrofluid models show features of stiffness mitigation, while nonlinear gyrokinetic simulations do not. The JET experiments indicate that advanced tokamak scenarios in future devices will require sufficient rotational shear and the capability of q profile manipulation.

Influence of magnetic field ripple on the intrinsic rotation of tokamak plasmas.

Using the unique capability of JET to monotonically change the amplitude of the magnetic field ripple, without modifying other relevant equilibrium conditions, the effect of the ripple on the angular rotation frequency of the plasma column was investigated under the conditions of no external momentum input. The ripple amplitude was varied from 0.08% to 1.5% in Ohmic and ion-cyclotron radio-frequency (ICRF) heated plasmas. In both cases the ripple causes counterrotation, indicating a strong torque due to nonambipolar transport of thermal ions and in the case of ICRF also fast ions.

Evidence in action--guidelines directing workload.

OBJECTIVE: To approximate the workload of blood pressure (BP) measurements and lifestyle counselling in primary healthcare when the related guidelines are followed. To evaluate the impact of facilitated guideline implementation with respect to workloads. DESIGN: Modelling study after cross-sectional audit process. SETTING: Thirty-one municipal health stations. Intervention Intrinsic facilitation in implementation of hypertension guideline. MAIN OUTCOME MEASURES: Number and level (normal <140/85 mmHg, slightly 140-160/85-95 mmHg or markedly elevated >160/95 mmHg) of BP measurements at nurses' appointments, approximation of time allocated for measurements and lifestyle counselling before and 1 year after the intervention. RESULTS: A total of 3119 BP measurements were recorded during the audit week in 2002. BP level measurements were "normal" in 1214 (38.9%), slightly elevated in 1371 (44.0%) and markedly elevated in 534 (17.1%). According to the modelling, 12% of a nurse's workday consisted of BP recordings and counselling. After intervention, the corresponding figures were 2330 measurements (828 (35.5%) normal, 990 (42.5%) slightly and 512 (22.0%) markedly elevated) corresponding to 6.3% of the workday. CONCLUSIONS: Through facilitation programmes, it is possible to change working practices according to the related guidelines, agree on the division of tasks and empower patients to engage with their own treatment. These changes can lead to considerable decreases in the workload of health centre personnel with consequent redistribution of personnel resources to patients in true need for services.

Experimental study of the ion critical-gradient length and stiffness level and the impact of rotation in the JET tokamak.

Experiments were carried out in the JET tokamak to determine the critical ion temperature inverse gradient length (R/LTi=R|nablaTi|/Ti) for the onset of ion temperature gradient modes and the stiffness of Ti profiles with respect to deviations from the critical value. Threshold and stiffness have been compared with linear and nonlinear predictions of the gyrokinetic code GS2. Plasmas with higher values of toroidal rotation show a significant increase in R/LTi, which is found to be mainly due to a decrease of the stiffness level. This finding has implications on the extrapolation to future machines of present day results on the role of rotation on confinement.

Evidence of inward toroidal momentum convection in the JET tokamak.

Experiments have been carried out on the Joint European Torus tokamak to determine the diffusive and convective momentum transport. Torque, injected by neutral beams, was modulated to create a periodic perturbation in the toroidal rotation velocity. Novel transport analysis shows the magnitude and profile shape of the momentum diffusivity are similar to those of the ion heat diffusivity. A significant inward momentum pinch, up to 20 m/s, has been found. Both results are consistent with gyrokinetic simulations. This evidence is complemented in plasmas with internal transport barriers.

Observation of zero current density in the core of jet discharges with lower hybrid heating and current drive.

Simultaneous current ramping and application of lower hybrid heating and current drive (LHCD) have produced a region with zero current density within measurement errors in the core ( r/a< or =0.2) of JET tokamak optimized shear discharges. The reduction of core current density is consistent with a simple physical explanation and numerical simulations of radial current diffusion including the effects of LHCD. However, the core current density is clamped at zero, indicating the existence of a physical mechanism which prevents it from becoming negative.