Hacia un modelo de atención en salud para el siglo XXI: breve historia del modelo de atención integrada en Chile / Towards a Health Care Model for the 21st Century: a brief history of the integrated care model in Chile

El desarrollo y organización del sistema sanitario en Chile tuvo importantes cambios durante la segunda mitad del siglo pasado, los que permitieron al país mejorar sustantivamente algunos índices de salud poblacional. Por otra parte, tanto el cambio de paradigma biomédico que surgió en el mundo durante las últimas décadas del siglo XX y que se orientaba hacia un modelo biopsicosocial de salud, como la aparición del concepto de Atención Primaria de Salud (APS) como una estrategia de intervención social, se sumaron al cambio en el perfil epidemiológico y demográfico del país y a las expectativas de la población, para alzarse todos ellos como factores catalizadores de un nuevo cambio en la forma de organizar la atención de salud en Chile. Esto generó un espacio para el desarrollo y fortalecimiento del nivel primario de atención de salud y de la medicina ambulatoria, lo que impulsó también la aparición de una nueva generación de especialistas que fueran capaces de dar solución a la gran mayoría de los problemas de las personas y de las comunidades, los médicos especialistas en Medicina Familiar y Comunitaria. Esta nueva forma de organización sanitaria, actualmente vigente en Chile, y que se enmarca dentro del Modelo de Atención Integral de Salud iniciado a comienzos del siglo XXI, está basado en un sistema de salud sustentado en el modelo biopsicosocial y en la APS; y su eje primordial son las personas, las familias y las comunidades.

The development and organization of the health system in Chile underwent important changes during the second half of the last century that allowed the country to substantially improve some population health indices. On the other hand, both the change in the biomedical paradigm that emerged in the world during the last decades of the 20th century and which was oriented towards a biopsychosocial model of health, as well as the appearance of the concept of Primary Health Care as a social intervention strategy, they added to the change in the epidemiological and demographic profile of the country and the expectations of the population, all of them rising as catalysts for a new change in the way of organizing health care in Chile. This created a space for the development and strengthening of the primary level of health care and outpatient medicine, which also promoted the emergence of a new generation of specialists who were capable of solving the vast majority of people's problems. and from the communities, specialists in Family and Community Medicine. This new form of health organization, currently in force in Chile, and which is part of the Comprehensive Health Care Model initiated at the beginning of the 21st century, is based on a health system based on the biopsychosocial model and PHC; and its main axis are people, families and communities.

The Psychopharmacological Revolution in the USSR: Schizophrenia Treatment and the Thaw in Soviet Psychiatry, 1954-64.

Twentieth-century psychiatry was transformed in the 1950s and 1960s by the introduction of powerful psychopharmaceuticals, particularly Chlorpromazine (Thorazine). This paper examines the reception of Chlorpromazine in the Soviet Union and its effect on the Soviet practice of psychiatry. The drug, known in the USSR by the name Aminazine, was first used in Moscow in 1954 and was officially approved in 1955. I argue that Soviet psychiatrists initially embraced it because Aminazine enabled them to successfully challenge the Stalin-era dogma in their field (Ivan Pavlov's 'theory of higher nervous activity'). Unlike in the West, however, the new psychopharmaceuticals did not lead to deinstitutionalisation. I argue that the new drugs did not disrupt the existing Soviet system because, unlike the system in the West, the Soviets were already dedicated, at least in theory, to a model which paired psychiatric hospitals with community-based 'neuropsychiatric dispensaries.' Chlorpromazine gave this system a new lease on life, encouraging Soviet psychiatrists to more rapidly move patients from in-patient treatment to 'supporting' treatment in the community.

[The history of the decree on the Department of ambulatory care and community medicine]. / La Policlinique médicale universitaire de Lausanne : aperçu historiquede son cadre législatif et politique.

In 1957 the Grand Council of Vaud adopted a decree aiming to clarify the administrative situation of the Department of ambulatory care and community medicine created in 1887 under the name of central dispensary. The new decree confirms the special status of the Department of ambulatory care and community medicine, which becomes a public-law institution. This article reviews the context and the stakes of this legal evolution.

C'est en 1957 que le Grand Conseil vaudois adopte un décret visant à clarifier la situation administrative de la Policlinique médicale universitaire, créée en 1887 sous le nom de dispensaire central. Le nouveau décret entérine le statut particulier de la Policlinique qui devient un établissement de droit public. Cet article revient sur le contexte et les enjeux de cette évolution juridique.

Dramatic Changes in Health Care Professions in the Past 40 Years.

During the forty-year life of the Journal of Ambulatory Care Management, revolutionary transformations have occurred in the roles of existing health professions, as has the emergence of new categories of health professionals. This paper specifies the reasons for these dramatic changes, the new types of health care professions that have emerged, changes in existing professions, and suggestions of future directions. Many of these changes will be impacted by what occurs in Washington, DC in the debate over the Accountable Care Act.

The Medical Battery in The United States (1870-1920): Electrotherapy at Home and in the Clinic.

This paper focuses on the history of a portable shock-producing electrotherapeutic device known as the medical battery (1870-1920), which provided both direct and alternating current and was thought to cure a wide variety of ailments. The product occupied a unique space at the nexus of medicine, consumerism and quackery: it was simultaneously considered a legitimate device by medical professionals who practiced electrotherapeutics, yet identical versions were sold directly to consumers, often via newspaper advertisements and with cure-all marketing language. Indeed, as I show in this paper, the line between what was considered a medical device and a consumer product was often blurred. Even though medical textbooks and journals never mentioned (much less promoted) the home use of electricity, every reputable electrotherapy instrument manufacturer sold a "family battery" for patients to use on themselves at home. While a handful of physicians spoke out against the use of electricity by the laity-as they felt it undermined the image of electrotherapy as a skilled medical procedure-existing evidence suggests that many physicians were likely recommending the home use of medical electricity to their patients. Taken together, this paper shows how the professional ideals of electrotherapeutics were not always aligned with physicians' actual practices.

TEVAR for ruptured descending thoracic aortic aneurysm: case report / TEVAR para aneurisma roto da aorta torácica descendente: relato de caso

Abstract A ruptured descending thoracic aortic aneurysm (rDTAA) is a life-threatening condition associated with high morbidity and mortality. Endovascular treatment for rDTAA promotes effective aneurysm exclusion with a minimally invasive approach. The authors report a case of a 76-year-old man with hemodynamically unstable 9-cm-diameter rDTAA treated with emergency thoracic endovascular aortic repair (TEVAR).

Resumo O aneurisma roto de aorta torácica descendente constitui uma situação ameaçadora associada a alta morbidade e mortalidade. O tratamento endovascular desse tipo de aneurisma promove exclusão eficaz com uma terapêutica minimamente invasiva. Os autores relatam o caso de um paciente do sexo masculino, 76 anos, hemodinamicamente instável, com aneurisma roto de aorta torácica descendente de 9 cm de diâmetro, tratado em caráter emergencial por cirurgia endovascular.

Simulación médica en punción aspiración con aguja fina utilizando maniquíes. Experiencia docente universitaria / Medical simulation training in fine needle aspiration cytology using phantoms. University teaching experience

Introducción. La punción aspiración con aguja fina (PAAF) es un procedimiento diagnóstico mínimamente invasivo y extremadamente útil para tipificar lesiones. La limitación de medios en las prácticas de anatomía patológica ha dificultado su enseñanza. Describimos la incorporación de maniquíes diseñados para realizar PAAF en nuestro centro. Material y métodos. Los maniquíes consisten en 2 simuladores de tareas, artesanales y a tamaño natural, de las regiones facial/cervical (modelo de utilidad U201500372) y de torso, respectivamente, revestidos por silicona, simulando piel, con áreas tumorales. Permiten realizar PAAF (palpación, punción, aspiración, obtención de material y extensión sobre portaobjetos) y son reutilizables. La práctica se realizó durante 3 cursos académicos (2013-2016) y consistió en realizar PAAF de manera individualizada sobre contexto clínico, con ulterior correlación citológica. Resultados. Un total de 178 estudiantes de medicina de la Universidad de Murcia de tercer curso realizaron la práctica (28 grupos: 105 mujeres, 73 hombres). La tasa de acierto (punción, aspiración de material y extensión en portaobjetos) fue del 97,2% con la primera punción. Además, 13 estudiantes procedentes de otras 10 universidades (nacionales e internacionales) llevaron a cabo la práctica, refiriendo la no existencia en sus centros de procedencia. Fue considerada como de gran valor sobre encuesta anónima. Discusión. Las prácticas de PAAF son fácilmente implementables y potencialmente incorporables a los formatos evaluativos tipo examen clínico objetivo estructurado (ECOE). No existe una adecuada estandarización en las prácticas de diferentes centros universitarios. Las prácticas de PAAF mejoran la formación del estudiante y proporciona un mayor conocimiento y una mejor consideración de nuestra especialidad (AU)

Background. Fine needle aspiration cytology (FNAC) is a minimally invasive and extremely useful procedure. The characteristics of the practice of pathology, together with limited equipment, make teaching this technique difficult. We therefore have introduced phantoms designed to perform FNAC as part of the medical education programme in our hospital. Material and methods. Phantoms are two life-sized hand-made reproductions of an adult head & neck (utility model ES1140059) and a trunk, respectively, coated with silicone simulating skin and with inserted tumor areas. They allow the whole FNAC process (palpation, puncture, aspiration, placement of material on slide and smear preparation) to be performed and, furthermore, are reusable. During 3 academic years (2013-2016) FNAC samples have been obtained in this way by each student individually, in a clinical context and with subsequent cytological correlation. Results. A total of 178 third year medical students from the University of Murcia, Spain, took part in the FNAC training programme (28 groups: 105 women, 73 men). The success rate in the first attempt (puncture, aspiration of material, placing and extending the obtained material on slides) was 97.2%. Furthermore, 13 students from 10 other universities (national and international) also took part, not having such a programme in their medical schools. In an anonymous survey the consensus was that it was valuable practical training. Discussion. Training in FNAC techniques is easy to include in the undergraduate curriculum and also in the Objective Structured Clinical Examination (OSCE) evaluation format. There is no proper standardization in training among different universities. FNAC simulation provides students with greater knowledge and appreciation of our specialty (AU)

The history and evolution of outpatient parenteral antibiotic therapy (OPAT).

Outpatient parenteral antibiotic therapy (OPAT) is now a widely accepted and safe therapeutic option for carefully selected patients. Benefits include cost savings and improved patient satisfaction; risks include failure to adhere to care, unexpected changes in the underlying infection, and adverse drug and intravenous access events. We report on our 40-year experience with OPAT in a single healthcare system in the USA and highlight OPAT developments in several countries. We compared data on patients treated in our programme over two time periods: Period 1 from 1978 to 1990; and Period 2, calendar year 2014. In Period 2 paediatric patients were excluded. Between Periods 1 and 2, changes included an almost three-fold increase in the number of patients treated per year (80 vs. 229), treatment of more patients with severe orthopaedic-related infections (20% vs. 38%), a marked increase in the use of peripherally inserted central catheters to administer antibiotics (20% vs. 98%), a shorter duration of inpatient stay and a longer duration of OPAT (13 days vs. 24 days). Other changes in Period 2 included treatment of 20% of patients without antecedent hospitalisation, and use of carbapenems rather than cephalosporins as the most frequently administered agents. OPAT was safe, with rehospitalisation rates of 6% and 1% in Periods 1 and 2, respectively. We recommend increased access to structured OPAT teams and the development of standard definitions and criteria for important outcome measures (e.g. clinical 'cure' and unplanned hospital re-admissions). These steps are critical for patient safety and financial stewardship of resources.

La especialidad de Medicina de Urgencias y Emergencias en Europa: estamos quedándonos solos / Specialization in emergency medicine in Europe: Spain is in danger of being left behind

No disponible

La evolución personal a lo largo del ejercicio profesional / Professional development over the course of a physician's career

No disponible

Evolución de la actividad asistencial de una plantilla estable de médicos adjuntos de urgencias a lo largo del tiempo / Differences in practice among physicians staffing an emergency department in relation to years of experience

Objetivos: Conocer la evolución de diferentes aspectos asistenciales en un grupo de urgenciólogos con grados de experiencia diversa y comprobar si su experiencia modifica alguna actitud asistencial. Método: Estudio retrospectivo observacional con seguimiento longitudinal que analiza la actividad anual de los urgenciólogos de un hospital universitario entre 2005 y 2012 en términos de actividad asistencial (meses trabajados, pacientes atendidos, y distribución según su grado de prioridad en el triaje), manejo de los pacientes (interconsultas a otros especialistas hospitalarios, ingresos, ambulancias solicitadas), exploraciones realizadas (radiología simple, analítica, ecografía, tomografía computarizada) y tiempo asistencial (tiempo de estancia de los pacientes dados de alta), y se relacionó esta actividad anual con la experiencia del urgenciólogo mediante regresión lineal. Los resultados significativos se ajustaron por las características de los urgenciólogos. Resultados: Se analizaron 50 urgenciólogos y 291 periodos anuales. Su experiencia osciló entre 1 y 22 años (media 9,5; DE: 5,8) y su actividad mensual entre 47 y 157 pacientes atendidos (media: 86; DE: 19). La experiencia del urgenciólogo se relacionó de forma inversa e independiente con el promedio total de pacientes mensuales atendidos y la proporción de estos con prioridad de triaje 1-2, y de forma directa e independiente con el tiempo de estancia en urgencias en los pacientes dados de alta y las solicitudes de radiología simple, si bien todas estas relaciones fueron tenues (R2 siempre inferiores a 0,010). Estas relaciones mantuvieron la significación estadística tras el ajuste realizado con modelos de complejidad creciente, que incluyeron las variables del urgenciólogo edad, sexo, especialidad y formación previa como médico interno residente (MIR) en el propio hospital. Conclusiones: Existen cambios discretos pero significativos en la actividad asistencial de los urgenciólogos en función de la experiencia acumulada (AU)

Objectives: To determine differences in certain variables reflecting clinical practice in a group of emergency physicians with varying levels of experience and to explore whether differences are associated with experience. Methods: Retrospective observational study of differences in variables reflecting emergency physicians’ practice between 2005 and 2012. We studied work variables (months worked, patients treated, caseload distribution according to triage levels), patient management variables (consultation with other specialists, admissions, ambulance requests), diagnostic procedures ordered (simple radiographs, laboratory tests, ultrasound or computed tomography imaging), and time patients discharged home spent in the department (arrival to discharge). We explored relationships between these variables and the emergency physician’s experience using linear regression analysis, followed by the construction of multivariable models to adjust for physician characteristics. Results: Data for 50 emergency medicine physicians, in 291 years of work, were analyzed. The specialists’ experience ranged from 1 to 22 years (mean [SD], 9.5 [5.8] years). They attended between 47 and 158 patients monthly (mean, 86 [19] patients). The physicians’ experience was inversely and independently related to the mean number of patients attended monthly and the percentage of patients assigned a triage level of 1 or 2. Experience was directly and independently related to discharged patients’ time spent in the emergency department and number of simple radiographs ordered. All associations were small (R2<0.010), however. Those variables continued to show statistically significant associations after increasingly complex modeling to adjust for the following physician variables: physician, age, sex, specialty, residency training in the same hospital). Conclusions: The practice of emergency physicians with more accumulated experience shows slight but significant differences from the practice of less experienced physicians (AU)

Freud's free clinics: a tale of two continents.

Two important schools of thought began in the nineteenth century in Central Europe: Marxism and psychoanalysis. They had much common but there were significant differences. The Marxist influence on early psychoanalysts played out in one way in Europe and another way in the United States. Freud and his Austro-Marxist colleagues were committed to human welfare and social justice. They established a network of clinics that offered psychoanalysis to patients of limited means. The free clinics movement did not cross the Atlantic. There was a cohort of Marxists in the United States who belonged to the United States Communist Party. They were not publicly socially committed, but this paper will try to show that their Marxism influenced their psychoanalytic theory, practice, and politics.

[75 years safeguarding health of warriors of Saints-Petersburg (Leningrad) garrison].

The article is devoted to the anniversary of Consultation-and-diagnostic outpatient hospital of 442nd District military clinical hospital in Saint-Petersburg. This outpatient hospital was founded in on the 20th March 1938. Work of garrison outpatient hospital was especially difficult during the Great Patriotic War. Employees of this hospital heroically fulfilled their duties in conditions of severe blocade winter 1941-1942. The outpatient hospital was nominally garrison, in fact this hospital operated units of Leningrad front-line. In 1993 the garrison outpatient hospital was renamed as 104th Consultation-and-diagnostic. The main branch of activity is health maintenance of participants in the rectification of the consequences of the accident at the Chernobyl Atomic Electric Power Station and veterans (case follow up) belonging to special risk subunits. Nowadays there are 30 treatment-and-diagnostic departments including staff military physician board.

The expansion of HIV-1 in colonial Leopoldville, 1950s: driven by STDs or STD control?

OBJECTIVES: To understand the factors that drove the exponential spread of HIV-1 in Léopoldville (Kinshasa) in the 1950s. METHODS: A review of colonial and post-colonial health service reports, medical publications, and demographic and social science research in Léopoldville. RESULTS: Sex work appeared early in the history of Léopoldville, driven by a strong gender imbalance. Throughout the colonial era, sex work was of a low-risk type, with 'free women' having a few regular clients. This sufficed for the persistence of HIV-1, but probably not for the dramatic expansion that occurred in the 1950s. During that decade, genital ulcerative diseases were uncommon and their effect on HIV-1 transmission must have been modest. Circumstantial evidence indicates that this expansion may have been related to parenteral transmission of HIV-1 in the city's sexually transmitted disease clinic, where up to 500 injections were administered daily using syringes and needles that were merely rinsed between patients. Most intravenous injections were given to treat syphilis in patients who never had any clinical evidence of this disease but only had a positive non-treponemal serology, often because of prior yaws infection. An outbreak of 'inoculation hepatitis' was reported among these patients in 1951-1952. It is only after the Congo's independence (1960) that, in a context of pauperisation, a pattern of sex work appeared in Léopoldville wherein women had sex with more than 1000 clients each year, allowing the sexual amplification of the virus. CONCLUSIONS: It is plausible that the exponential amplification of HIV-1 in Léopoldville occurred mostly parenterally in the 1950s and sexually in the 1960s.

[The establishment of the hospital-system in the Byzantine Empire]. / A kórházi rendszer kialakulása a Bizánci Birodalomban.

Byzantine hospitals developed out of Christian institutions for the poor and homeless. Philanthropy provided the initial impulse to create hospices (xenons) and to expand these institutions into specialized medical centers (iatreons or nosokomeions). However the Byzantine nosocomeions resemble more closely modern hospitals than they do any of the institutions of Greek-Roman antiquity or any of the houses of charity in the Latin West during the Middle Ages. Since the 4th century the Byzantine hospitals have stressed the central position of the nosocomeion in Byzantine society at the intersection of state, ecclesiastical and professional interest. In the great cities and in the capital, more than hundred hospitals worked in the East-Roman Empire. The Byzantine hospital rules guaranted patients private beds, required physicians to wash their hands after each examination and arranged the physical plant to keep all the sick warm. The Byzantine hospitals had separate sections (in modern terms: surgery-trauma surgery, internal medicine, ophthalmology, etc.) and at the beginning of the sixth century a separate institution for women. From the sixth century at least, bathing facilities normally adjoined Byzantine nosocomeia. By the twelfth century Byzantine hospitals also set aside a room or perhaps a separate building to treat outpatients. In addition to the main dormitories the surgery, baths and outpatient clinic, the large parts of hospitals also had separate rooms (or adjoining buildings) for library, for lecture hall, for administrative functions and record keeping for storage and for other services.