Impact of a quality improvement intervention on nurses' management of same-day primary care flow.

AIM: To evaluate the impact of an interdisciplinary intervention designed to improve the capacity of nurses to manage walk-in patient demand for primary health care. BACKGROUND: Implementation of a programme to expand nursing practice is a complex process that requires the application of context-appropriate measures and adaptation when results do not meet expectations. METHODS: A longitudinal, uncontrolled intervention study with a 3-year follow-up, from 2009 to 2012, was carried out in Catalonia (northeast Spain). The intervention included three training periods focused on clinical and instrumentation topics. The capacity of nurses to manage walk-in patient demand was assessed by determining the number of cases resolved and of return visits for the same complaint within 72 hours. RESULTS: In total, 2751 patient care demands were evaluated. Resolved cases increased (χ(2)  = 54.624, df = 1, P < 0.001) and the number of return visits decreased (χ(2)  = 54.585, df = 1, P < 0.001) significantly from baseline to the end of the study period. CONCLUSIONS: Nurses' capacity to manage walk-in patient demand improved after an interdisciplinary intervention using a mutually agreed upon, locally adapted approach. IMPLICATIONS FOR NURSING MANAGEMENT: To improve outcomes, nurses in management positions should systematically consider the need for skills training, specific academic courses, leadership development and, as appropriate, legislative initiatives.

[Assessment of a chronic care program in Gerona (CRONIGICAT)]. / Evaluación de un programa de atención a la cronicidad en Girona (CRONIGICAT).

OBJECTIVE: To determine the utility and viability of a chronic care program. DESIGN: Cross-sectional descriptive study with qualitative and quantitative evaluation. SETTING AND PARTICIPANTS: 26 primary care teams (PCT) from the Catalan health service of Gerona. INTERVENTIONS: 20 projects within the program. Start 2011. MAIN OUTCOME MEASURES: The degree of development of the program, consensus indicators for chronic care, and the Instrument for the Assessment of Chronic Care Models (Instrumento de Evaluación de Modelos de Atención ante la Cronicidad [IEMAC]). RESULTS: Evaluation of the degree of development: 75% of projects were partially or fully implemented, with a high degree of development in 71% of the PCT. An increasing tendency was found in the consensus indicators for process (patients contacted 48 hours after hospital discharge, population attended in chronic care programs and with the highest risk stratification). There was a slight decrease in the consensus indicators for effectiveness (readmissions, mean length of hospital stay, avoidable hospital admissions, pharmaceutical expenditure, patients attended in the emergency department, and mortality). The dimensions receiving the highest scores on the IEMAC were those evaluating information systems and clinical decision support, while those receiving the lowest scores were community health and self-care. CONCLUSIONS: When assessing the utility of CRONIGICAT, we believe that progress has been made mainly in its implantation, which has acted as a catalyst for a self-directed shift to a better chronic care model and has identified areas for improvement. We believe that the CRONIGICAT is viable and sustainable, since its actions and projects are integrated within routine clinical practice.

Assessing the role of tandem repeats in shaping the genomic architecture of great apes.

BACKGROUND: Ancestral reconstructions of mammalian genomes have revealed that evolutionary breakpoint regions are clustered in regions that are more prone to break and reorganize. What is still unclear to evolutionary biologists is whether these regions are physically unstable due solely to sequence composition and/or genome organization, or do they represent genomic areas where the selection against breakpoints is minimal. METHODOLOGY AND PRINCIPAL FINDINGS: Here we present a comprehensive study of the distribution of tandem repeats in great apes. We analyzed the distribution of tandem repeats in relation to the localization of evolutionary breakpoint regions in the human, chimpanzee, orangutan and macaque genomes. We observed an accumulation of tandem repeats in the genomic regions implicated in chromosomal reorganizations. In the case of the human genome our analyses revealed that evolutionary breakpoint regions contained more base pairs implicated in tandem repeats compared to synteny blocks, being the AAAT motif the most frequently involved in evolutionary regions. We found that those AAAT repeats located in evolutionary regions were preferentially associated with Alu elements. SIGNIFICANCE: Our observations provide evidence for the role of tandem repeats in shaping mammalian genome architecture. We hypothesize that an accumulation of specific tandem repeats in evolutionary regions can promote genome instability by altering the state of the chromatin conformation or by promoting the insertion of transposable elements.

Polymorphic organization of constitutive heterochromatin in Equus asinus (2n = 62) chromosome 1.

In the karyotype of Equus asinus (domestic donkey, 2n = 62), non-centromeric heterochromatic bands have been described in subcentromeric and telomeric positions. In particular, chromosome 1 is characterised by heterochromatic bands in the proximal region of the long arm and in the short arm; it has been shown that these regions are polymorphic in size. Here we investigated the variation in the intensity and distribution of fluorescence signals observed on donkey chromosome 1 after in situ hybridization with two DNA probes containing fragments from the two major equine satellite DNA families. Our results show that, in Equus asinus chromosome 1, the amount and distribution of large clusters of satellite DNA can define at least nine polymorphic variants of the constitutive heterochromatin that cannot be detected by C-banding alone.

Selection against Robertsonian fusions involving housekeeping genes in the house mouse: integrating data from gene expression arrays and chromosome evolution.

Monobrachial homology resulting from Robertsonian (Rb) fusions is thought to contribute to chromosomal speciation through underdominance. Given the karyotypic diversity characterizing wild house mouse populations [Mus musculus domesticus, (MMU)], variation that results almost exclusively from Rb fusions (diploid numbers range from 22 to 40) and possibly whole arm reciprocal translocations (WARTs), this organism represents an excellent model for testing hypotheses of chromosomal evolution. Previous studies of chromosome size and recombination rates have failed to explain the bias for certain chromosomes to be involved more frequently than others in these rearrangements. Here, we show that the pericentromeric region of one such chromosome, MMU19, which is infrequently encountered as a fusion partner in wild populations, is significantly enriched for housekeeping genes when compared to other chromosomes in the genome. These data suggest that there is selection against breakpoints in the pericentromeric region and provide new insights into factors that constrain chromosomal reorganizations in house mice. Given the anticipated increase in vertebrate whole genome sequences, the examination of gene content and expression profiles of the pericentromeric regions of other mammalian lineages characterized by Rb fusions (i.e., other rodents, bats, and bovids, among others) is both achievable and crucial to developing broadly applicable models of chromosome evolution.

Chromosome territory positioning of conserved homologous chromosomes in different primate species.

Interphase chromosomes form distinct spatial domains called chromosome territories (CTs). The position of CTs is known not to be at random and is related to chromosome size and gene density. To elucidate how CTs are arranged in primate proliferating fibroblasts and whether the radial position of CTs has been conserved during primate evolution, several specific CTs corresponding to conserved chromosomes since the Simiiformes (human 6, 12, 13, and 17 homologous CTs) have been studied in 3D preserved interphase nuclei from proliferant cells of two New World monkey species (Lagothrix lagothricha, Saimiri sciureus) and in human by three-dimensional fluorescent in situ hybridization (3D-FISH). Our results indicate that both gene-density and chromosome size influence chromosome territory arrangement in the nucleus. This influence is greater for chromosome-size than for gene-density in the three species studied. A comparison of the radial position of a given CT and its homolog in the species analyzed suggests similar CT distributions for homologous chromosomes. Our statistical analysis using the logit model shows that such homologous positionings cannot, however, be considered identical.

Conservation of aphidicolin-induced fragile sites in Papionini (Primates) species and humans.

Fragile sites are considered structural features of mammalian chromosomes and a commonly repeated hypothesis is that they are evolutionarily conserved. We tested this hypothesis by establishing the subchromosomal homology of regions harbouring fragile sites in the chromosomes of humans, Macaca fascicularis (MFA) and Mandrillus sphinx (MSP). We delineated the interspecific homology of chromosome bands expressing aphidicolin-induced fragile sites of homologues to human chromosomes 1, 3, 5, 7, 18 and X by the comparative FISH of human BAC and YAC clones. Notably, two YAC clones known to span human chromosome regions containing fragile sites were shown to also span fragile sites in macaques and mandrills. The present comparative BAC/YAC mapping data represent, up to now, the most precise evidence of fragile site conservation during primate evolution.

Eurasian otters, Lutra lutra, have a dominant mtDNA haplotype from the Iberian Peninsula to Scandinavia.

The Eurasian otter, Lutra lutra, has a Palaearctic distribution and has suffered a severe decline throughout Europe during the last century. Previous studies in this and other mustelids have shown reduced levels of variability in mitochondrial DNA, although otter phylogeographic studies were restricted to central-western Europe. In this work we have sequenced 361 bp of the mtDNA control region in 73 individuals from eight countries and added our results to eight sequences available from GenBank and the literature. The range of distribution has been expanded in relation to previous works north towards Scandinavia, east to Russia and Belarus, and south to the Iberian Peninsula. We found a single dominant haplotype in 91.78% of the samples, and six more haplotypes deviating a maximum of two mutations from the dominant haplotype restricted to a single country. Variability was extremely low in western Europe but higher in eastern countries. This, together with the lack of phylogeographical structuring, supports the postglacial recolonization of Europe from a single refugium. The Eurasian otter mtDNA control region has a 220-bp variable minisatellite in Domain III that we sequenced in 29 otters. We found a total of 19 minisatellite haplotypes, but they showed no phylogenetic information.