Transitando hacia el ejercicio de autonomía y liderazgo:… «para el posicionamiento hay que luchar¼ / Moving towards the practice of autonomy and leadership:… «Positioning requires striving¼ / Transitar para o exercício de autonomia e liderança:… «Para o posicionamento, tem que lutar¼

Resumen Introducción: En Chile, las enfermeras/os tienen respaldo legal para gestionar el cuidado, esto facilita el desarrollo de competencias para ejercer autonomía y liderazgo. Actualmente persisten barreras para transitar hacia un reconocimiento real de la independencia profesional. Objetivo: Develar la experiencia vivida de enfermeras con cargos en niveles de jefatura respecto al propio desarrollo para lograr el liderazgo y autonomía profesional. Metodología: Estudio cualitativo, descriptivo-interpretativo, desde la trayectoria fenomenológica de Edmund Husserl. Muestreo selectivo de caso homogéneo de tres enfermeras que desempeñaban rol de jefatura en instituciones de salud, región Valparaíso, Chile. Participación consentida. Entrevista no estructurada. Análisis del discurso utilizando el modelo de liderazgo integral de Ken Wilber. Resultados: Categorías: Conciencia del líder «ser inquieta...intelectualmente¼. Construyendo competencias «el liderazgo se aprende¼. Transitando hacia el ejercicio de la autonomía y el liderazgo, "para el posicionamiento hay que luchar". El peso de las estructuras organizacionales «tu rol es parte de un hospital¼. Interpretación: El ejercicio del liderazgo y la autonomía se fundamenta en competencias actitudinales por sobre las cognitivas y técnicas. Existe mayor apoyo y reconocimiento a nivel institucional, que al interior del equipo de salud. Persisten limitaciones para lograr máxima expresión del liderazgo y autonomía, por persistencia de modelos institucionales hegemónicos, centrados en decisiones médicas y desconocimiento del rol integrado. Conclusión: El líder se mueve en un escenario dual, entre un menor reconocimiento del equipo y un creciente empoderamiento del rol autónomo y visibilidad a nivel directivo institucional.

Abstract Introduction: In Chile, nurses have legal support to manage care, a situation which facilitates the development of competencies to perform with autonomy and leadership; however, barriers still persist while moving towards a real acknowledgement of professional independency. Objective: To unveil the lived experience of nurses in executive roles regarding their own development towards leadership and professional autonomy. Methodology: This is a descriptive and interpretative qualitative study framed by the Edmund Husserl phenomenological approach. The sample by homogeneous case included three nurses in executive roles in health institutions in Valparaiso, Chile. The participation was by consent. An unstructured interview was used. For the discourse analysis, the Ken Wilber integral leadership model was followed. Results: Categories: Leadership awareness <being inquiring… intellectually>… Building Competencies <leadership is learned>. Moving towards the practice of autonomy and leadership, "positioning requires striving". Weight of the organizational structures <your role is part of a hospital>. Interpretation: A practice of leadership and autonomy is based on attitude competencies over the cognitive and technical ones. Nevertheless, there still persist limitations to achieve a maximal expression of leadership and autonomy due to hegemonic institutional models which focus on medical decisions and neglect the integrated roles. Conclusion: The leader moves in a dual setting between a lower acknowledgement from the team, and a higher empowerment of the autonomous role and the visibility at the institutional directive level.

Resumo Introdução: No Chile, as enfermeiras/os têm apoio legal para gerenciar o cuidado, isto facilita o desenvolvimento de competências para exercer autonomia e liderança. Atualmente, persistem barreiras para transitar em direção a um reconhecimento real da independência profissional. Objetivo: Desvendar a experiência vivida de enfermeiras com cargos em níveis de chefia ao respeito do próprio desenvolvimento, para atingir a liderança e autonomia profissional. Metodologia: Estudo qualitativo, descritivo-interpretativo, desde a trajetória fenomenológica de Edmund Husserl. Amostragem seletiva de caso homogéneo de três enfermeiras que desempenhavam papel de chefia em instituições de saúde, região Valparaíso, Chile. Participação consentida. Entrevista não estruturada. Análise de discurso, utilizou-se o modelo de liderança integral de Ken Wilber. Resultados: Categorias: Consciência do líder «ser irrequieta...intelectualmente¼. Ir construindo competências «a liderança se aprende¼. Transitar em direção ao exercício da autonomia e a liderança, "para o posicionamento tem que lutar". O peso das estruturas organizacionais «seu rolo é parte de um hospital¼. Interpretação: O Exercício da liderança e a autonomia fundamenta-se em competências atitudinais, sobre as cognitivas e técnicas. Existe maior apoio e reconhecimento a nível institucional, que no interior da equipe de saúde. Persistem limitações para atingir a máxima expressão de liderança e autonomia, por persistência de modelos institucionais hegemónicos, centrados em decisões médicas e desconhecimento do rolo integrado. Conclusão: O líder movimenta-se em um cenário dual, entre um menor reconhecimento da equipe e um empoderamento crescente do rolo autónomo e visibilidade a nível diretivo institucional.

Adalimumab or infliximab as monotherapy, or in combination with an immunomodulator, in the treatment of Crohn's disease.

BACKGROUND: The comparative efficacy of adalimumab (ADA) and infliximab (IFX) in Crohn's disease, and the benefit of initial combotherapy with an immunomodulator, are debated. AIM: To assess the best anti-TNF treatment regimens in Crohn's disease. METHODS: We included 906 biologic-naïve Crohn's disease patients [median age, 31 years (24-41)] and performed a retrospective analysis of 1284 therapeutic exposures to ADA (n = 521) or IFX (n = 763) between 2006 and 2015. An immunomodulator was associated during the first 4-6 months (initial combotherapy) during 706 therapeutic exposures (55%). Median duration of anti-TNF therapy was 39 months (IQR 17-67). Primary outcomes were 6-month and 2-year response rates and drug survival. Logistic regression with propensity scoring and Cox proportional hazard analysis determined variables associated with outcomes. RESULTS: The response rates at 6 months and 2 years were 64% and 44% on ADA mono, 86% and 70% on ADA combo, 72% and 45% on IFX mono, and 84% and 68% on IFX combotherapy, respectively. Differences between ADA and IFX were not significant, whereas combotherapy was superior to monotherapy (P < 0.001). Drug survival was longer with combotherapy vs. monotherapy [adjusted hazard ratio 2.17 (1.72-2.70)] and not significantly different between ADA and IFX. During subsequent anti-TNF exposures, IFX combotherapy fared better than other groups regarding response rates, drug survival, disease activity, hospitalisations and abdominal surgery. CONCLUSION: In this retrospective analysis of a large tertiary centre cohort of Crohn's disease patients, ADA and IFX had similar efficacy as first line treatment, while initial combotherapy with an immunomodulator improved all outcome measures.

[Gut microbiota: Description, role and pathophysiologic implications]. / Le microbiote intestinal : description, rôle et implication physiopathologique.

The human gut contains 10(14) bacteria and many other micro-organisms such as Archaea, viruses and fungi. Studying the gut microbiota showed how this entity participates to gut physiology and beyond this to human health, as a real "hidden organ". In this review, we aimed to bring information about gut microbiota, its structure, its roles and its implication in human pathology. After bacterial colonization in infant, intestinal microbial composition is unique for each individual although more than 95% can be assigned to four major phyla. The use of culture independent methods and more recently the development of high throughput sequencing allowed to depict precisely gut microbiota structure and diversity as well as its alteration in diseases. Gut microbiota is implicated in the maturation of the host immune system and in many fundamental metabolic pathways including sugars and proteins fermentation and metabolism of bile acids and xenobiotics. Imbalance of gut microbial populations or dysbiosis has important functional consequences and is implicated in many digestive diseases (inflammatory bowel diseases, colorectal cancer, etc.) but also in obesity and autism. These observations have led to a surge of studies exploring therapeutics which aims to restore gut microbiota equilibrium such as probiotics or fecal microbiota transplantation. But recent research also investigates biological activity of microbial products which could lead to interesting therapeutics leads.

A global reference for caesarean section rates (C-Model): a multicountry cross-sectional study.

OBJECTIVE: To generate a global reference for caesarean section (CS) rates at health facilities. DESIGN: Cross-sectional study. SETTING: Health facilities from 43 countries. POPULATION/SAMPLE: Thirty eight thousand three hundred and twenty-four women giving birth from 22 countries for model building and 10,045,875 women giving birth from 43 countries for model testing. METHODS: We hypothesised that mathematical models could determine the relationship between clinical-obstetric characteristics and CS. These models generated probabilities of CS that could be compared with the observed CS rates. We devised a three-step approach to generate the global benchmark of CS rates at health facilities: creation of a multi-country reference population, building mathematical models, and testing these models. MAIN OUTCOME MEASURES: Area under the ROC curves, diagnostic odds ratio, expected CS rate, observed CS rate. RESULTS: According to the different versions of the model, areas under the ROC curves suggested a good discriminatory capacity of C-Model, with summary estimates ranging from 0.832 to 0.844. The C-Model was able to generate expected CS rates adjusted for the case-mix of the obstetric population. We have also prepared an e-calculator to facilitate use of C-Model (www.who.int/reproductivehealth/publications/maternal_perinatal_health/c-model/en/). CONCLUSIONS: This article describes the development of a global reference for CS rates. Based on maternal characteristics, this tool was able to generate an individualised expected CS rate for health facilities or groups of health facilities. With C-Model, obstetric teams, health system managers, health facilities, health insurance companies, and governments can produce a customised reference CS rate for assessing use (and overuse) of CS. TWEETABLE ABSTRACT: The C-Model provides a customized benchmark for caesarean section rates in health facilities and systems.

PP138. Human fetal malformations associated with the use of angiotensin II receptor antagonist.

INTRODUCTION: antagonists of angiotensin II receptor (AAR) are commonly used for the treatment of chronic hypertension in the general population. Some of these pharmacological agents are losartan, candesartan, valsartan and tasosartan. Despite the good response achieved with these drugs in the control of hypertension, all medications that act directly on the renin-angiotensin system should be contraindicated during pregnancy. These drugs have been associated with fetal and neonatal injury, including hypotension, neonatal skull hypoplasia, anuria, reversible or irreversible renal failure and death.Here we report a case of fetal malformations and death associated with the use of losartan. OBJECTIVES: describing the association of fetal malformations and the use of losartan during first and second trimester of pregnancy. METHODS: this is a case report involving a 37-year-old pregnant woman at 26 gestational weeks. This patient had history of chronic hypertension for more than five years that was being regularly treated with Losartan 50mg/day. After her first consultation losartan was promptly discontinued and substituted for methyldopa. However, scan evaluation demonstrated severe oligohydramnios associated with altered fetal biophysical profile and altered Doppler fluxometry (absent diastolic flow at umbilical arteries). Therefore, a cesarean-section was performed after corticoid administration for fetal lung maturation. At first moment some characteristic alterations as fetal limb contractures and craniofacial deformation were detected at the 1007g new-born. This baby went to death 36h after delivery due to severe lung hypoplasia. RESULTS: the autopsy examination revealed renal tubular dysgenesis associated with changes secondary to nephropathy, probably induced by drug (Fig. 1). Associated findings were underdevelopment of bones of the skull with large fontanelles, thymus atrophy and signs of perinatal hypoxia. CONCLUSION: the difficulty of attending basic health assistance was attributed to be associated with this case, as this patient did not have opportunity and sufficient information about the necessity of changing her medication during pregnancy. Apart from this situation, this case report brings good information about the association between antagonists of angiotensin II receptor and human fetal malformations.

Preoperative therapeutic programme for elderly patients scheduled for elective abdominal oncological surgery: a randomized controlled pilot study.

OBJECTIVE: Investigation of the feasibility and preliminary effect of a short-term intensive preoperative exercise programme for elderly patients scheduled for elective abdominal oncological surgery. DESIGN: Single-blind randomized controlled pilot study. SETTING: Ordinary hospital in the Netherlands. SUBJECTS: Forty-two elderly patients (>60 years). INTERVENTIONS: Patients were randomly assigned to receive a short-term intensive therapeutic exercise programme to improve muscle strength, aerobic capacity, and functional activities, given in the outpatient department (intervention group; n =22), or home-based exercise advice (control group; n=20). MAIN MEASURES: Parameters of feasibility, preoperative functional capacity and postoperative course. RESULTS: The intensive training programme was feasible, with a high compliance and no adverse events. Respiratory muscle endurance increased in the preoperative period from 259 +/- 273 to 404 +/- 349 J in the intervention group and differed significantly from that in the control group (350 +/- 299 to 305 +/- 323 J; P<0.01). Timed-Up-and-Go, chair rise time, LASA Physical Activity Questionnaire, Physical Work Capacity and Quality of Life (EORTC-C30) did not reveal significant differences between the two groups. There was no significant difference in postoperative complications and length of hospital stay between the two groups. CONCLUSION: The intensive therapeutic exercise programme was feasible and improved the respiratory function of patients due to undergo elective abdominal surgery compared with home-based exercise advice.

Preoperative chemotherapy-sensitized radiation therapy for cervical metastases in head and neck cancer.

OBJECTIVE: To determine the efficacy of concurrent preoperative cisplatin chemotherapy and radiotherapy (CT/RT) for patients with advanced head and neck cancer and cervical metastatic disease. DESIGN: Retrospective analysis. SETTING: University hospitals. PATIENTS: Eighty-eight patients with operable stage III and IV squamous cell carcinoma of the head and neck and palpable cervical lymphogenous metastases received preoperative concurrent CT/RT followed by planned neck dissection. INTERVENTIONS: All patients undergoing CT/RT received concomitant continuous infusions of cisplatin (20 mg/m2) on days 1 to 4 and 22 to 25 of CT/RT. Thirty-nine patients underwent single-fraction (1.8-Gy) radiotherapy to 45.0 Gy, and 49 patients received 10 single-fraction (1.8-Gy) treatments, which were hyperfractionated (1.2-Gy twice a day) to 46.8 Gy. MAIN OUTCOME MEASURES: The 71 patients for whom complete post-CT/RT data were available were evaluated for clinical response in addition to survival. Histologic complete response (HCR) was confirmed from planned neck dissection specimens (n = 48) after clinical complete response (CCR) from initial CT/RT. Kaplan-Meier statistical analysis for disease-specific survival and overall survival was performed on all 88 patients who received CT/RT. RESULTS: A CCR and an HCR were noted in 78% (18/23) and 59% (10/17) of patients with N1 lesions, respectively, and in 60% (29/48) and 45% (14/31) of patients with N2-3 lesions, respectively. The percentage of patients with CCR who also had HCR was 67% (10/15) for patients with N1 lesions and 54% (14/26) for patients with N2-3 lesions. With a median follow-up of 18.5 months, the Kaplan-Meier disease-specific survival rate at 54 months (n = 88) was 70% (21/30) for patients with N1 lesions, 60% (24/40) for patients with N2 lesions, and 39% (7/18) for patients with N3 lesions. The overall survival and disease-specific survival rates at 5 years for all nodal groups combined were 36% (32/88) and 59% (52/88), respectively. CONCLUSIONS: A CCR to CT/RT was achieved in nearly two thirds of patients with head and neck cervical lymphogenous metastases, independent of nodal tumor load. Most patients (59% [24/41]) with CCR were pathologically tumor free before neck dissection.

Recurrence patterns with concurrent platinum-based chemotherapy and accelerated hyperfractionated radiotherapy in stage III and IV head and neck cancer patients.

BACKGROUND: Stage III and IV squamous cell cancers of the head and neck are often unresectable at presentation and are associated with poor disease-free and overall survival rates. A phase II study using concurrent cisplatin and radiotherapy in advanced head and neck cancer indicated impressive local-regional control and survival with organ preservation. METHODS: A multicentered phase II study was undertaken consisting of 1.8 Gy fraction radiotherapy for 2 weeks followed by 1.2 Gy BID hyperfractionation to 46.8 Gy. Continuous infusion cisplatin 20 mg/m2 was given on days 1 through 4 and 22 through 25. Biopsy of the primary tumor was done at this point, and patients with clinical and pathologic complete response continued with hyperfractionated radiotherapy to 75.6 Gy plus simultaneous carboplatin 25 mg/m2 BID for 12 consecutive days. Residual disease at 46.8 Gy required curative surgery. RESULTS: Seventy-four patients entered the study, and 73 completed their treatment. Twenty were stage III and 54 were stage IV. Fifty patients had involved regional lymph nodes. Treatment was well tolerated with only one grade IV hematologic toxicity. At 46.8 Gy, biopsy revealed a complete response in 75% of the primary sites and 47% of the nodes. Only 12 patients required resection of the primary lesion. At 4 years (median follow-up is 26 months), 29 patients have recurred. CONCLUSIONS: Accelerated hyperfractionated radiotherapy with concurrent chemotherapy in stage III and IV head and neck cancer yields excellent local-regional control with organ preservation. This protocol is intensive, and some patients have distant failures.

Preoperative cisplatin and accelerated hyperfractionated radiation induces high tumor response and control rates in patients with advanced head and neck cancer.

BACKGROUND: Preoperative therapy with concurrent cisplatin infusion and accelerated hyperfractionated radiation has the potential to eradicate pools of resistant cells with high-growth fraction that accumulate during standard radiation therapy. Based on preliminary data showing a high complete response rate (necessary for organ preservation) in patients with advanced squamous cell cancer of the head and neck (stages III and IV), we conducted a multi-institutional study using accelerated hyperfractionated radiation to maximize local and regional tumor control without adding toxicity. PATIENTS AND METHODS: Preoperative radiation was given in 1.8 Gy fractions for 2 weeks followed by 1.2 Gy BID hyperfractionation to 46.7 Gy. Continuous infusion of cisplatin 20 mg/m2 was given on days 1 through 4 and 22 through 25. Patients were initially assessed with panendoscopy and were subsequently reassessed with biopsy of primary site (+/- nodes). Patients with negative primary site biopsy received additional hyperfractionated radiation to 76 Gy with simultaneous carboplatin 25 mg/m2 BID for 12 consecutive days. Patients with residual disease after 47 Gy had resection of primary site and node dissection. Of 69 patients treated, 56 were T3 and T4, and 46 were N1, N2, and N3; 17 patients (25%) were stage III and 50 (72%) were stage IV; in 2 patients (3%) the stage was unknown. RESULTS: Treatment was well tolerated with no grade IV toxicities, but there were 13 patients with grade III toxicities (mucositis, dysphagia, or hematological toxicity). Biopsy specimens were taken from 84% of the patients, and 81% of the primary sites showed pathologic complete response and 49% of the lymph nodes showed a pathologic complete response. Thirty-four patients underwent curative surgery. Eleven required resection of the primary and 23 required neck dissection only. At 2 years (median followup 12 months), 44 of 69 patients (64%) have no evidence of disease, 9 are dead of disease, 9 are dead of other causes, and 6 are alive with disease. Surgical toxicities were minimal and primarily limited to fibrosis in 12 patients, edema in 8 patients, tracheoesophageal fistula in 1 patient, and delayed wound healing in 1 patient. Late toxicities included xerostomia in 22 patients, dysphagia in 17, and speech impairment in 9. CONCLUSIONS: Preoperative concurrent radiotherapy and chemotherapy provides a high level of organ preservation and local and regional control because of the high complete response rate at the primary site. A planned neck dissection with minimal morbidity ensures local/regional control, as well as providing definitive staging information. A randomized evaluation is suggested for this program.