Evaluation of health care systems and primary health care strategy

Objetivo: evaluar la calidad de los sistemas de salud y la estrategia de Atención Primaria de la Salud (APS) en distintas áreas geográficas del país. Método: estudio de corte transversal con abordaje metodológico triangular que involucró: a) encuestas a las personas que demandan la atención, b) entrevistas a referentes claves del equipo de salud y c) grupos focales con los equipos de salud. Los componentes de estructura, proceso y resultados de los sistemas de salud basados en APS se evaluaron por medio de indicadores específicos. Resultados: el análisis de la información muestra un déficit evidente de la integración del equipo profesional, principalmente en la actividad comunitaria y social, la carencia de normativas adecuadas y problemas de accesibilidad estructural para población discapacitada. Se destaca, además, el alto porcentaje de personal que desconoce los programas en ejecución dentro de la institución, así como la falta de un sistema de información adecuado sobre la población del área y de registros de los procesos de gestión en la mayoría de las unidades analizadas. Conclusión: a pesar de los esfuerzos para definir y ejecutar la estrategia de APS, los centros de salud continúan realizando sus actividades en base al modelo tradicional de atención exclusiva de la demanda.Objective: the aim of this project was to evaluate the quality of health care systems based on the strategy of Primary Health Care in different areas of the country. Method: cross-sectional study with a triangular approach, including a) a survey to the population demanding care, b) interviews to key referents of the health team, and c) health team focus groups. The components of structure, process and outcomes of the health system based on PHC were evaluated by specific indicators. Results: the analysis of the information shows an evident deficit of the integration of the professional team, mainly in the activities towards community, the lack of norms and lack of facilities for disable people. It must be noted also the high percentage of the health care team that does not know about current institutional health programs and the lack of an adequate information system for the area population and for the administrative process in most of the sites studied. Conclusion: in spite of the efforts to implement the PHC strategy, most of health centers evaluated are still providing care based on the traditional model oriented to the demands of care.Facultad de Ciencias Médica

Evaluation of health care systems and primary health care strategy

Objetivo: evaluar la calidad de los sistemas de salud y la estrategia de Atención Primaria de la Salud (APS) en distintas áreas geográficas del país. Método: estudio de corte transversal con abordaje metodológico triangular que involucró: a) encuestas a las personas que demandan la atención, b) entrevistas a referentes claves del equipo de salud y c) grupos focales con los equipos de salud. Los componentes de estructura, proceso y resultados de los sistemas de salud basados en APS se evaluaron por medio de indicadores específicos. Resultados: el análisis de la información muestra un déficit evidente de la integración del equipo profesional, principalmente en la actividad comunitaria y social, la carencia de normativas adecuadas y problemas de accesibilidad estructural para población discapacitada. Se destaca, además, el alto porcentaje de personal que desconoce los programas en ejecución dentro de la institución, así como la falta de un sistema de información adecuado sobre la población del área y de registros de los procesos de gestión en la mayoría de las unidades analizadas. Conclusión: a pesar de los esfuerzos para definir y ejecutar la estrategia de APS, los centros de salud continúan realizando sus actividades en base al modelo tradicional de atención exclusiva de la demanda.Objective: the aim of this project was to evaluate the quality of health care systems based on the strategy of Primary Health Care in different areas of the country. Method: cross-sectional study with a triangular approach, including a) a survey to the population demanding care, b) interviews to key referents of the health team, and c) health team focus groups. The components of structure, process and outcomes of the health system based on PHC were evaluated by specific indicators. Results: the analysis of the information shows an evident deficit of the integration of the professional team, mainly in the activities towards community, the lack of norms and lack of facilities for disable people. It must be noted also the high percentage of the health care team that does not know about current institutional health programs and the lack of an adequate information system for the area population and for the administrative process in most of the sites studied. Conclusion: in spite of the efforts to implement the PHC strategy, most of health centers evaluated are still providing care based on the traditional model oriented to the demands of care.Facultad de Ciencias Médica

Evaluación de los sistemas de salud y estrategia de APS

Evaluar la calidad de los sistemas de salud y la estrategia de la atención primaria en distintas áreas geográficas del país. Método: estudio de corte transversal con abordaje metodológico triangular que involucró: a) encuestas a las personas que demandan la atención, b) entrevistas a referentes clave del equipo de salud y c) grupos focales con los equipos de salud.Los componentes de estructura, procesos y resultados de la atención basados en APS se evaluaron por medio de indicadores específicos. Resultados: el análisis de la información muestra un déficit evidente de la integración del equipo profesional, principalmente en la actividad comunitaria y social, la carencia de normativas adecuadas y barreras de accesibilidad estructural para población discapacitada. Se destaca además el alto porcentaje de personal que desconoce los programas en ejecución dentro de la institución, así como la falta de un sistema de información adecuado sobre la población del área y de registro de los procesos de gestión en la mayoría de las unidades analizadas. Conclusión: a pesar de los esfuerzos para definir y ejecutar la estrategia de ASPS, los centros de salud continúan realizando sus actividades en base al modelo tradicional de atención exclusiva de la demanda.Fil: Paganini, José M.. Universidad Nacional de la Plata. Facultad de Cs.médicas. Centro Interdisc.universitario Para la Salud; ArgentinaFil: Etchegoyen, Graciela Susana. Universidad Nacional de la Plata. Facultad de Cs.médicas. Centro Interdisc.universitario Para la Salud; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; ArgentinaFil: Bo, Ana. UNLP. Facultad de Ciencias Médicas. Cátedra de Salud y Medicina Comunitaria; ArgentinaFil: Rubio, Ana M.. Universidad Blas Pasca. Centro de Investigación y Desarrollo del Medio Ambiente; ArgentinaFil: Stival, Juan J.. Universidad Blas Pasca. Centro de Investigación y Desarrollo del Medio Ambiente; ArgentinaFil: Fredeimberg, Abel. Instituto Atenea; ArgentinaFil: Matkovic, Graciela. Hospital de Niños Sor María Ludovica. Instituto de Desarrollo e Investigaciones Pediátricas (IDIP). ; ArgentinaFil: Hipperdinger, Adriana Maria. Asociación Civil: Un Techo para mi Hermano; ArgentinaFil: Pérez Raventós, Alicia. Asociación Civil: Un Techo para mi Hermano; ArgentinaFil: González, Mónica. Asociación Civil: Un Techo para mi Hermano; ArgentinaFil: Zelayeta, Adrián. Universidad Nacional de la Plata. Facultad de Cs.médicas. Centro Interdisc.universitario Para la Salud; Argentin

Src is the connecting player between PKA activation and hyperpolarization through SLO3 regulation in mouse sperm

Plasma membrane hyperpolarization is crucial for mammalian sperm to acquire acrosomal responsiveness during capacitation. Among signalling events leading to mammalian sperm capacitation, the immediate activation of protein kinase A plays a pivotal role, promoting the subsequent stimulation of protein tyrosine phosphorylation that associates with fertilizing capacity. We have previously shown that mice deficient on the tyr-kinase cSrc are infertile, and exhibit an improper cauda epididymis development. It is therefore not clear whether lack of sperm functionality is due to problems in epididymal maturation or to the absence of cSrc in sperm. To further address this problem, we investigated the kinetics of cSrc activation using anti phosphor Y416-cSrc antibodies that only recognize active cSrc. Our results provide evidence that cSrc is activated downstream of PKA and that inhibition of its activity blocks the capacitation-induced hyperpolarization of the sperm plasma membrane without blocking the increase in tyrosine phosphorylation that accompany capacitation. In addition, we show that cSrc inhibition also blocked the agonist-induced acrosome reaction and that this inhibition is overcome by pharmacological hyperpolarization. Considering that the capacitation-induced hyperpolarization is mediated by SLO3, we evaluated the action of cSrc inhibitors on heterologously expressed SLO3 channel. Our results indicate that, similarly to SLO1 K+ channels, cSrc blockers decreased significantly SLO3-mediated currents. Altogether these results are consistent with findings that hyperpolarization of the sperm plasma membrane is necessary and sufficient to prepare the sperm for the acrosome reaction and suggest that changes in sperm membrane potential are mediated by cSrc activation.Fil: Stival, Cintia Estefanía. Consejo Nacional de Investigaciones Científicas y Técnicas. Centro Científico Tecnológico Conicet - Rosario. Instituto de Biología Molecular y Celular de Rosario. Universidad Nacional de Rosario. Facultad de Ciencias Bioquímicas y Farmacéuticas. Instituto de Biología Molecular y Celular de Rosario; ArgentinaFil: la Spina, Florenza Antonella. Consejo Nacional de Investigaciones Científicas y Técnicas. Instituto de Biología y Medicina Experimental. Fundación de Instituto de Biología y Medicina Experimental. Instituto de Biología y Medicina Experimental; ArgentinaFil: Baró Graf, Carolina. Consejo Nacional de Investigaciones Científicas y Técnicas. Centro Científico Tecnológico Conicet - Rosario. Instituto de Biología Molecular y Celular de Rosario. Universidad Nacional de Rosario. Facultad de Ciencias Bioquímicas y Farmacéuticas. Instituto de Biología Molecular y Celular de Rosario; ArgentinaFil: Arcelay, Enid. University of Massachussets; Estados UnidosFil: Arranz, Silvia Eda. Consejo Nacional de Investigaciones Científicas y Técnicas. Instituto de Biología y Medicina Experimental. Fundación de Instituto de Biología y Medicina Experimental. Instituto de Biología y Medicina Experimental; ArgentinaFil: Ferreira, Juan J.. University of Washington. School of Medicine; Estados UnidosFil: Le Grand, Sibylle. University of Washington. School of Medicine; Estados UnidosFil: Dzikunu, Victor A.. University of Washington. School of Medicine; Estados UnidosFil: Santi, Celia M.. University of Washington. School of Medicine; Estados UnidosFil: Visconti, Pablo E.. University of Massachussets; Estados UnidosFil: Buffone, Mariano Gabriel. Consejo Nacional de Investigaciones Científicas y Técnicas. Instituto de Biología y Medicina Experimental. Fundación de Instituto de Biología y Medicina Experimental. Instituto de Biología y Medicina Experimental; ArgentinaFil: Krapf, Dario. Consejo Nacional de Investigaciones Científicas y Técnicas. Centro Científico Tecnológico Conicet - Rosario. Instituto de Biología Molecular y Celular de Rosario. Universidad Nacional de Rosario. Facultad de Ciencias Bioquímicas y Farmacéuticas. Instituto de Biología Molecular y Celular de Rosario; Argentin

Intracranial pressure monitoring in patients with acute brain injury in the intensive care unit (SYNAPSE-ICU): an international, prospective observational cohort study

Background: The indications for intracranial pressure (ICP) monitoring in patients with acute brain injury and the effects of ICP on patients’ outcomes are uncertain. The aims of this study were to describe current ICP monitoring practises for patients with acute brain injury at centres around the world and to assess variations in indications for ICP monitoring and interventions, and their association with long-term patient outcomes. Methods: We did a prospective, observational cohort study at 146 intensive care units (ICUs) in 42 countries. We assessed for eligibility all patients aged 18 years or older who were admitted to the ICU with either acute brain injury due to primary haemorrhagic stroke (including intracranial haemorrhage or subarachnoid haemorrhage) or traumatic brain injury. We included patients with altered levels of consciousness at ICU admission or within the first 48 h after the brain injury, as defined by the Glasgow Coma Scale (GCS) eye response score of 1 (no eye opening) and a GCS motor response score of at least 5 (not obeying commands). Patients not admitted to the ICU or with other forms of acute brain injury were excluded from the study. Between-centre differences in use of ICP monitoring were quantified by using the median odds ratio (MOR). We used the therapy intensity level (TIL) to quantify practice variations in ICP interventions. Primary endpoints were 6 month mortality and 6 month Glasgow Outcome Scale Extended (GOSE) score. A propensity score method with inverse probability of treatment weighting was used to estimate the association between use of ICP monitoring and these 6 month outcomes, independently of measured baseline covariates. This study is registered with ClinicalTrial.gov, NCT03257904. Findings: Between March 15, 2018, and April 30, 2019, 4776 patients were assessed for eligibility and 2395 patients were included in the study, including 1287 (54%) with traumatic brain injury, 587 (25%) with intracranial haemorrhage, and 521 (22%) with subarachnoid haemorrhage. The median age of patients was 55 years (IQR 39–69) and 1567 (65%) patients were male. Considerable variability was recorded in the use of ICP monitoring across centres (MOR 4·5, 95% CI 3·8–4·9 between two randomly selected centres for patients with similar covariates). 6 month mortality was lower in patients who had ICP monitoring (441/1318 [34%]) than in those who were not monitored (517/1049 [49%]; p<0·0001). ICP monitoring was associated with significantly lower 6 month mortality in patients with at least one unreactive pupil (hazard ratio [HR] 0·35, 95% CI 0·26–0·47; p<0·0001), and better neurological outcome at 6 months (odds ratio 0·38, 95% CI 0·26–0·56; p=0·0025). Median TIL was higher in patients with ICP monitoring (9 [IQR 7–12]) than in those who were not monitored (5 [3–8]; p<0·0001) and an increment of one point in TIL was associated with a reduction in mortality (HR 0·94, 95% CI 0·91–0·98; p=0·0011). Interpretation: The use of ICP monitoring and ICP management varies greatly across centres and countries. The use of ICP monitoring might be associated with a more intensive therapeutic approach and with lower 6-month mortality in more severe cases. Intracranial hypertension treatment guided by monitoring might be considered in severe cases due to the potential associated improvement in long-term clinical results. Funding: University of Milano-Bicocca and the European Society of Intensive Care Medicine

Intracranial pressure monitoring in patients with acute brain injury in the intensive care unit (SYNAPSE-ICU): an international, prospective observational cohort study

Background: The indications for intracranial pressure (ICP) monitoring in patients with acute brain injury and the effects of ICP on patients’ outcomes are uncertain. The aims of this study were to describe current ICP monitoring practises for patients with acute brain injury at centres around the world and to assess variations in indications for ICP monitoring and interventions, and their association with long-term patient outcomes. Methods: We did a prospective, observational cohort study at 146 intensive care units (ICUs) in 42 countries. We assessed for eligibility all patients aged 18 years or older who were admitted to the ICU with either acute brain injury due to primary haemorrhagic stroke (including intracranial haemorrhage or subarachnoid haemorrhage) or traumatic brain injury. We included patients with altered levels of consciousness at ICU admission or within the first 48 h after the brain injury, as defined by the Glasgow Coma Scale (GCS) eye response score of 1 (no eye opening) and a GCS motor response score of at least 5 (not obeying commands). Patients not admitted to the ICU or with other forms of acute brain injury were excluded from the study. Between-centre differences in use of ICP monitoring were quantified by using the median odds ratio (MOR). We used the therapy intensity level (TIL) to quantify practice variations in ICP interventions. Primary endpoints were 6 month mortality and 6 month Glasgow Outcome Scale Extended (GOSE) score. A propensity score method with inverse probability of treatment weighting was used to estimate the association between use of ICP monitoring and these 6 month outcomes, independently of measured baseline covariates. This study is registered with ClinicalTrial.gov, NCT03257904. Findings: Between March 15, 2018, and April 30, 2019, 4776 patients were assessed for eligibility and 2395 patients were included in the study, including 1287 (54%) with traumatic brain injury, 587 (25%) with intracranial haemorrhage, and 521 (22%) with subarachnoid haemorrhage. The median age of patients was 55 years (IQR 39–69) and 1567 (65%) patients were male. Considerable variability was recorded in the use of ICP monitoring across centres (MOR 4·5, 95% CI 3·8–4·9 between two randomly selected centres for patients with similar covariates). 6 month mortality was lower in patients who had ICP monitoring (441/1318 [34%]) than in those who were not monitored (517/1049 [49%]; p<0·0001). ICP monitoring was associated with significantly lower 6 month mortality in patients with at least one unreactive pupil (hazard ratio [HR] 0·35, 95% CI 0·26–0·47; p<0·0001), and better neurological outcome at 6 months (odds ratio 0·38, 95% CI 0·26–0·56; p=0·0025). Median TIL was higher in patients with ICP monitoring (9 [IQR 7–12]) than in those who were not monitored (5 [3–8]; p<0·0001) and an increment of one point in TIL was associated with a reduction in mortality (HR 0·94, 95% CI 0·91–0·98; p=0·0011). Interpretation: The use of ICP monitoring and ICP management varies greatly across centres and countries. The use of ICP monitoring might be associated with a more intensive therapeutic approach and with lower 6-month mortality in more severe cases. Intracranial hypertension treatment guided by monitoring might be considered in severe cases due to the potential associated improvement in long-term clinical results. Funding: University of Milano-Bicocca and the European Society of Intensive Care Medicine

Treatments for intracranial hypertension in acute brain-injured patients: grading, timing, and association with outcome. Data from the SYNAPSE-ICU study

Purpose: Uncertainties remain about the safety and efficacy of therapies for managing intracranial hypertension in acute brain injured (ABI) patients. This study aims to describe the therapeutical approaches used in ABI, with/without intracranial pressure (ICP) monitoring, among different pathologies and across different countries, and their association with six months mortality and neurological outcome. Methods: A preplanned subanalysis of the SYNAPSE-ICU study, a multicentre, prospective, international, observational cohort study, describing the ICP treatment, graded according to Therapy Intensity Level (TIL) scale, in patients with ABI during the first week of intensive care unit (ICU) admission. Results: 2320 patients were included in the analysis. The median age was 55 (I-III quartiles = 39-69) years, and 800 (34.5%) were female. During the first week from ICU admission, no-basic TIL was used in 382 (16.5%) patients, mild-moderate in 1643 (70.8%), and extreme in 295 cases (eTIL, 12.7%). Patients who received eTIL were younger (median age 49 (I-III quartiles = 35-62) vs 56 (40-69) years, p < 0.001), with less cardiovascular pre-injury comorbidities (859 (44%) vs 90 (31.4%), p < 0.001), with more episodes of neuroworsening (160 (56.1%) vs 653 (33.3%), p < 0.001), and were more frequently monitored with an ICP device (221 (74.9%) vs 1037 (51.2%), p < 0.001). Considerable variability in the frequency of use and type of eTIL adopted was observed between centres and countries. At six months, patients who received no-basic TIL had an increased risk of mortality (Hazard ratio, HR = 1.612, 95% Confidence Interval, CI = 1.243-2.091, p < 0.001) compared to patients who received eTIL. No difference was observed when comparing mild-moderate TIL with eTIL (HR = 1.017, 95% CI = 0.823-1.257, p = 0.873). No significant association between the use of TIL and neurological outcome was observed. Conclusions: During the first week of ICU admission, therapies to control high ICP are frequently used, especially mild-moderate TIL. In selected patients, the use of aggressive strategies can have a beneficial effect on six months mortality but not on neurological outcome