Una experiencia de grupo de reflexión para el manejo de entrevistas clínicas difíciles / A reflection group’s experience in handling hard clinical encounters

Fundamento. Se presenta la experiencia de un grupo de reflexión para valorar si la metodología llevada a cabo, ayuda a los profesionales sanitarios a entenderlos encuentros difíciles (ED), a mejorar su satisfacción profesional y la comunicación con el paciente. Material y método. Se siguió una metodología de reestructuración cognitiva con registro escrito para analizar, primero individualmente, los ED con los pacientes y comentarlos luego en el grupo de reflexión. Resultados. Los ED se referían principalmente a: solicitudes vividas como inapropiadas, cuestionamiento de competencia profesional, y cambio inesperado de médico. Las emociones surgidas, antes y después de “volver a pensar”, cambiaron de intensidad de forma significativa (p<0,001). Los pensamientos irracionales se agruparon en 9 tipos de distorsiones cognitivas, siendo las más frecuentes “razonamiento emocional” y “falacias de control”. Las pautas explicativas constructivas que surgieron después de “volver a pensar”, en su mayoría estaban relacionados con la necesidad de mejorar la comunicación. El grupo reconoció muchas aportaciones positivas. Ni las encuestas utilizadas para valorar el desgaste profesional (MBI), ni la encuesta diseñada para la evaluación, presentaron diferencias significativas, comparando al inicio y final del trabajo. Conclusiones. El empleo conjunto de una metodología cognitivo-conductual en el marco de un grupo de reflexión, se complementan mutuamente, y posibilitan el trabajo engrupo sin precisar un conductor profesional. La reflexión escrita y el trabajo con los pensamientos irracionales y “volver a pensar” con la perspectiva de comentarlo en el grupo, es una experiencia aplicable en el contexto de Atención Primaria y ayuda al manejo de los encuentros difíciles (AU)

Background. We present the experience of a reflection group to evaluate whether the methodology carried out helps health professionals to understand difficult encounters and improve their professional satisfaction and communication with the patient. Method. We followed a cognitive restructuring methodology with a written record in order to analyze difficult encounters with patients, first individually and then followed by comments in the reflection group. Results. Difficult encounters mainly involved: requests felt to be inappropriate, questioning of professional competence, and unexpected change of doctor. The emotions arising, before and after “rethinking”, changed in intensity in a significant way (p<0.001). Irrational thoughts were grouped in 9 types of cognitive distortions, with the most frequent being “emotional reasoning” and “control fallacies”. The majority of constructive explanatory patterns that emerged after “rethinking” were related to the need for improving communication. The group recognized many positive contributions. Neither the surveys used to evaluate occupational burnout, nor the survey designed for the evaluation showed significant differences, comparing the beginning and end of the work. Conclusions. The joint use of a cognitive-behavioral methodology in the framework of a reflection group is mutually complementary, and enables group work without the need for professional direction. Written reflection and work with irrational thoughts and “rethinking” with the perspective of group comment is an experience that is applicable in the context of Primary Care and helps in handling difficult encounters (AU)

[A reflection group's experience in handling difficult clinical encounters]. / Una experiencia de grupo de reflexión para el manejo de entrevistas clínicas difíciles.

BACKGROUND: We present the experience of a reflection group to evaluate whether the methodology carried out helps health professionals to understand difficult encounters and improve their professional satisfaction and communication with the patient. METHOD: We followed a cognitive restructuring methodology with a written record in order to analyze difficult encounters with patients, first individually and then followed by comments in the reflection group. RESULTS: Difficult encounters mainly involved: requests felt to be inappropriate, questioning of professional competence, and unexpected change of doctor. The emotions arising, before and after "rethinking", changed in intensity in a significant way (p<0.001). Irrational thoughts were grouped in 9 types of cognitive distortions, with the most frequent being "emotional reasoning" and "control fallacies". The majority of constructive explanatory patterns that emerged after "rethinking" were related to the need for improving communication. The group recognized many positive contributions. Neither the surveys used to evaluate occupational burnout, nor the survey designed for the evaluation showed significant differences, comparing the beginning and end of the work. CONCLUSIONS: The joint use of a cognitive-behavioral methodology in the framework of a reflection group is mutually complementary, and enables group work without the need for professional direction. Written reflection and work with irrational thoughts and "rethinking" with the perspective of group comment is an experience that is applicable in the context of Primary Care and helps in handling difficult encounters.

[Pheochromocytoma. A case report]. / Feocromocitoma. Informe de un caso.

We present the case of a 34 year-old male, who was diagnosed with a malign pheochromocytoma and who was treated with left laparascopic suprarenalectomy. This is a neoplasia of the chromoffin cells with a prevalence of two cases per million inhabitants, which generally causes the typical symptoms of episodic freeing of catecholamines. We describe the case's form of presentation, which began with successive episodes of intense abdominal pain on the left side. In the abdominal pelvic ultrasound and abdominal CT, a mass of 6.5 cm diameter was objectified, dependent on the left suprarenal gland. High levels of metanefrines and catecholamines were evident in the urine. A total left laparoscopic adrenalectomy was carried out. The pathological anatomy showed malign pheochromocytoma.

Feocromocitoma. Informe de un caso / Pheochromocytoma. A case report

Se presenta el caso de un varón de 34 años de edad, a quien se diagnosticó un feocromocitoma maligno y fue tratado con suprarrenalectomía izquierda lapararoscópica. Se trata de una neoplasia de las células cromafines con una prevalencia de dos casos por millón de habitantes, que, generalmente, causa los síntomas típicos de liberación episódica de catecolaminas. Se describe la forma de presentación del caso, que debuta con episodios sucesivos de dolorimiento abdominal intenso en flanco izdo. En la ecografía abdominopélvica y TAC abdominal, se objetiva una masa de 6,5 cms de diámetro, dependiente de la glándula suprarrenal izda. Se evidencian niveles elevados de metanefrinas ycatecolaminas en orina. Se realiza adrenalectomía total izquierda laparoscópica. La anatomía patológica evidencia feocromocitoma maligno(AU)

We present the case of a 34 year-old male, who was diagnosed with a malign pheochromocytoma and who was treated with left laparascopic suprarenalectomy. This is a neoplasia of the chromoff in cells with a prevalence of two cases per million inhabitants, which generally causes the typical symptoms of episodic freeing of catecholamines. We describe the case’s form of presentation, which began with successive episodes of intense abdominal pain on the left side. In the abdominal pelvic ultrasound and abdominal CT, a mass of 6.5 cm diameter was objectified, dependent on the left suprarenal gland. High levels of metanefrines and catecholamines were evident in the urine. A total left laparoscopic adrenalectomy was carried out. The pathological anatomy showed malign pheochromocytoma(AU)

Lipomatosis simétrica múltiple: a propósito de un caso / Multiple symmetric lipomatosis: a case report

Se presenta el caso de un varón de 46 años con lipomatosis simétrica múltiple (LSM), enfermedad poco frecuente y de etiología desconocida. La LSM se caracteriza por múltiples depósitos de tejido adiposo y se asocia con alcoholismo, trastornos metabólicos y neuropatía. Se describen las características clínico-morfológicas de las lesiones que presenta, los hallazgos exploratorios, TAC cervical, los resultados analíticos y de biopsia subcutánea. Se diagnostica al paciente de LSM tipo I, aplicándose el tratamiento de elección, la lipectomía que le permite obtener una importante mejoría de la enfermedad, tanto física como estéticamente

We present the case of a 46 year-old man with Multiple Symmetric Lipomatosis (MSL), an infrequent disease with an unknown aetiology. MSL is characterized by multiple masses of adipose tissue and it is usually associated with alcoholism, metabolic disorders and neuropathy. We describe the clinical-morphological characteristics of the lesions it presents, the exploratory findings, cervical CAT, the analytical results and the results of subcutaneous biopsy. MSL type I disease was diagnosed. The treatment of choice, the lipectomy, was performed, making it possible to obtain a substantial disease improvement, both physical and aesthetically

[Frequent users and difficult patients: how do they feel about their treatment by doctors?]. / Pacientes hiperfrecuentadores y difíciles: cómo se sienten tratados por sus médicos?

BACKGROUND: To determine the opinions and expectations of difficult, frequent user, patients about their relationship with their GP. MATERIAL AND METHODS: Qualitative design. Discussion groups. Invitation to a meeting at the Chantrea Health Centre (Pamplona). The participants were frequent users of the health centre in the year 2003, who had been defined as "difficult"--according to previously defined criteria--by each of the 12 doctors of the health centre. Excluded were patients with mental retardation, severe hearing problems, severe mental illness, difficulties in mobility and travelling, and over 70 years of age. Groups were formed from amongst the 112 preselected patients. Four groups were designed: "older" persons (GMA) of 46 to 70 years (14); "women" (GMU) of 31 to 45 years (14); "men" (GHO) of 31 to 45 years (13) and "youths" (GJO) of 16 to 30 years (12). The patients were invited by letter and by a subsequent telephone confirmation to a meeting, the content of which was not specified. Sessions of 2 hours duration were held with each of the groups formed. Audio recording, with prior authorization, and verbatim transcription of sessions. Discussion and content analysis by the research group resulting in lines of consensus. RESULTS: The three groups of older patients were formed with a total of 16 participants. The group of youths was not formed since the figure for attendance did not reach the number of 3 or more after three appointments. CONCLUSIONS: From the perspective of the patient it is very important that there should be efficient communication with the doctor. Awareness of a state of frequent use was not detected in those attending. They feel themselves to be chronic patients who need frequent attention. Satisfaction at the treatment received was observed as well as an understanding attitude towards the organisational limitations of the health centre. They did not give verbal expression to the existence of conflictive relations with their GPs.

Pacientes hiperfrecuentadores y difíciles: ¿cómo se sienten tratados por sus médicos? / Frequent users and difficult patients: How do they feel about their treatment by doctors?

Fundamento. Conocer las opiniones y expectativas de los pacientes hiperfrecuentadores difíciles sobre la relación con sus médicos de familia.Material y métodos. Diseño cualitativo. Grupos de discusión. Emplazamiento en el Centro de Salud Chantrea (Pamplona). Los participantes fueron pacientes hiperfrecuentadores que acudieron al centro de salud en el año 2003 y que habían sido preseleccionados como “difíciles” –según criterios previamente definidos– por cada uno de los 12 médicos del centro de salud. Se excluyeron los pacientes con: retraso mental, problemas severos de audición, enfermedad mental grave, dificultades de movilidad y desplazamiento y mayores de 70 años.Se formaron grupos de entre los 112 pacientes preseleccionados. Se diseñaron 4 grupos: personas “mayores” (GMA) de 46 a 70 años (14); “mujeres” (GMU) de 31 a 45 años (14); “hombres” (GHO) de 31 a 45 años (13) y “jóvenes” (GJO) de 16 a 30 años (12), citando mediante una carta y posterior confirmación telefónica a los pacientes para una reunión, sin especificar el contenido de la misma.Se desarrollaron sesiones de 2 horas de duración en cada uno de los grupos formados. Grabación de audio, previa autorización y transcripción literal. Discusión y análisis de contenido por parte del grupo investigador provocando líneas de consenso.Resultados. Se realizaron los tres grupos de pacientes de mayor edad con un total de 16 participantes. No se formó el grupo de jóvenes, por no acudir en un número de 3 o más tras 3 citas. Conclusiones. Según la perspectiva del paciente, es muy relevante una comunicación eficaz con el médico. No se detecta estado de conciencia de hiperfrecuentación por parte de los asistentes. Se sienten pacientes crónicos que precisan atención frecuente. Se observa satisfacción ante el trato recibido y actitud comprensiva ante las limitaciones organizativas del centro de salud. No verbalizan la existencia de relaciones conflictivas con sus médicos de familia

Background. To determine the opinions and expectations of difficult, frequent user, patients about their relationship with their GP. ;;Material and methods. Qualitative design. Discussion groups. Invitation to a meeting at the Chantrea Health Centre (Pamplona). ;;The participants were frequent users of the health centre in the year 2003, who had been defined as “difficult” – according to previously defined criteria – by each of the 12 doctors of the health centre. Excluded were patients with mental retardation, severe hearing problems, severe mental illness, difficulties in mobility and travelling, and over 70 years of age. ;;Groups were formed from amongst the 112 preselected patients. Four groups were designed: “older” persons (GMA) of 46 to 70 years (14); “women” (GMU) of 31 to 45 years (14); “men” (GHO) of 31 to 45 years (13) and “youths” (GJO) of 16 to 30 years (12). The patients were invited by letter and by a subsequent telephone confirmation to a meeting, the content of which was not specified. ;;Sessions of 2 hours duration were held with each of the groups formed. Audio recording, with prior authorisation, and verbatim transcription of sessions. Discussion and content analysis by the research group resulting in lines of consensus. ;;Results. The three groups of older patients were formed with a total of 16 participants. The group of youths was not formed since the figure for attendance did not reach the number of 3 or more after three appointments. ;;Conclusions. From the perspective of the patient it is very important that there should be efficient communication with the doctor. Awareness of a state of frequent use was not detected in those attending. They feel themselves to be chronic patients who need frequent attention. Satisfaction at the treatment received was observed as well as an understanding attitude towards the organisational limitations of the health centre. They did not give verbal expression to the existence of conflictive relations with their GPs

[Multiple symmetric lipomatosis: a case report]. / Lipomatosis simétrica múltiple: a propósito de un caso.

We present the case of a 46 year-old man with Multiple Symmetric Lipomatosis (MSL), an infrequent disease with an unknown aetiology. MSL is characterized by multiple masses of adipose tissue and it is usually associated with alcoholism, metabolic disorders and neuropathy. We describe the clinical-morphological characteristics of the lesions it presents, the exploratory findings, cervical CAT, the analytical results and the results of subcutaneous biopsy. MSL type I disease was diagnosed. The treatment of choice, the lipectomy, was performed, making it possible to obtain a substantial disease improvement, both physical and aesthetically.

First observation of intersex cyprinids in the Po River (Italy).

Barbel (Barbus plebejus, Cyprinidae) were captured in the Po River, upstream and downstream from the confluence of the Lambro River, a polluted tributary of the major Italian watercourse. The gonads of the two groups of barbel have been histologically examined, and only the downstream specimens showed histo-morphological alterations that can be related to the Lambro tributary as a source to the main river of endocrine disrupting chemicals, possibly with estrogenic effects. In fact, 50% of the barbel captured (8 of 16 fish) in the downstream reach showed intersex gonads.

Parasitic diatoms inside antarctic sponges.

Antarctic sponges may host large populations of planktonic and benthic diatoms. After settling on the sponge, these diatoms enter its body through pinacocytes (1) and form, there, large mono- or pauci-specific assemblages. Yet the total amount of carbohydrates in the invaded sponge tissue is inversely correlated with that of chlorophyll-a. We suggest, therefore, that endobiont diatoms utilize the products of the metabolism of their host as an energy source. This is the first evidence indicating that an endobiotic autotrophic organism may parasitize its animal host. Moreover, this unusual symbiotic behavior could be a successful strategy that allows the diatom to survive in darkness.

Concentrations of PCBs, DDTs, and TCDD equivalents in cyprinids of the Middle Po River, Italy.

The concentrations of non-ortho-, mono-ortho-, di-ortho-substituted polychlorinated biphenyls (PCBs) and DDTs (pp'-DDT and pp'-DDE) were measured in fish and bed sediments of the Po River. Three species of cyprinids, nase (Chondrostoma söetta), chub (Leuciscus cephalus), and barbel (Barbus plebejus), were captured in the major Italian river, upstream and downstream from the confluence of the Lambro River. The two carnivorous species, chub and barbel, were found to be the most contaminated, showing muscle tissue concentrations up to eightfold higher than the corresponding upstream fish. DDT concentrations were parallel to PCB changes although at lower values. Despite the increased contamination caused by the input from the Lambro tributary, when fish PCB loads are converted to 2,3,7, 8-tetrachlorodibenzo-p-dioxin (TCDD) equivalents using piscine toxic equivalency factors (TEFs), no specific hazard can be associated to the limited toxic potentials of PCBs. Although these results seem to minimise the risk for the fish community of the Po River, the presence of other organochlorines and halogenated hydrocarbons is very probable in the downstream area, and a more exhaustive hazard assessment, based on further studies, should be undertaken.

An "in vitro" approach to water pollution monitoring.

Pollutants of River Lambro, a tributary River Po, were monitored by their potential to induce 1A1 isoform of cytochrome P450 in the FaO hepatoma cell line. Extracts of water samples taken during different months over about one year were fractionated by reverse phase HPLC technique. Six fractions of decreasing polarity were collected, concentrated, freeze-dried and suspended in DMSO for the treatment of the cells. Aliquots of such suspensions were dissolved in the growth medium and left for 48 h in contact with FaO cells, that were maintained in 24-well plates. Cellular monolayers were also exposed to a mixture of the six fractions, to evaluate the effects of all the pollutants mixed together in the original water sample. The CYP1A1-dependent ethoxyresorufin-O-deethylase (EROD) activity was fluorimetrically detected as a measure of inducing potential, and total protein content was evaluated as cytotoxicity end-point. The results showed significant increases of EROD activity over the controls in nearly all the fractions with marked reduction of viability only in two of the mixed samples. The effects of the mixtures were not simply additive, thus suggesting both synergistic and antagonistic interactions. The potential utility of this simple and fast bioassay in environmental risk/hazard assessment is clearly apparent.

Mitochondrial alteration caused by cnidarian toxins: a preliminary study.

Cnidarians contain different toxins causing cytotoxic and cytolytic effects probably due to cell membrane alterations. Mitochondria were used here as an experimental model system to characterize the action of cnidarian toxins. Toxin from the sea anemone Anemonia sulcata affects the function of rat liver mitochondria. Effects are dose- and time-dependent and they disappear when Ca2+ is absent. This toxin could therefore have a phospholipase-like action, as reported for other cnidarians. Mitochondrial alterations by cnidarian toxins could therefore be a particular case of a general mechanism of toxicity directed towards biological membranes.

Bioconcentration of polychlorinated biphenyls (PCBs) in rainbow trout caged in the River Po.

Two groups of rainbow trout were caged in the River Po upstream and downstream of the confluence with the River Lambro, a relatively small tributary which drains the most industrialized and urbanized area of the entire basin. Fish were analyzed for PCB concentration at the start of the experiment and after 7, 15, and 30 days of exposure. The results demonstrate that the emission of the River Lambro represents an important point source of PCBs to the River Po and that part of the transported load is readily bioavailable, since caging virtually excluded trophic transfers. On the basis of PCB levels measured in downstream trout, the steady-state concentration and the congener pattern were predicted by means of a computer program. These projections were compared with published data obtained with native fish caught downstream from the River Lambro.

Multiple genotoxicity biomarkers in fish exposed in situ to polluted river water.

Specimens of rainbow trout (Oncorhynchus mykiss) were either kept in an aquarium under laboratory conditions or caged in the River Po (Northern Italy), upstream or downstream the confluence with the River Lambro, a small yet heavily polluted tributary. Genotoxicity biomarkers, evaluating the internal dose or early biological effects, were monitored after 7, 15 and 30 days of in situ exposure. With the exception of a slight increase of aminopyrine-N-demethylase and uridine-5'-diphospho-glucuronosyl-transferase, no significant effect was produced in fish kept upstream the River Lambro, as compared to control fish kept in the aquarium. In contrast, the responsibility of this tributary in carrying sublethal doses of both genotoxic agents and enzyme inducers into the main river was proved by the significant occurrence of early biological alterations in fish caged downstream. In fact, (a) bile extracts contained frameshift mutagens requiring metabolic activation, with a prevalence of liposoluble components after a short exposure, followed by a time-related increase of conjugated components, in minor part with glucuronic acid; (b) the monooxygenases aminopyrine-N-demethylase, uridine-5'-diphospho-glucuronosyl-transferase and, with sharp differences, arylhydrocarbon hydroxylase and 7-ethoxyresorufin-O-deethylase were enhanced in liver microsomal fractions; (c) the liver cytosolic fractions had an enhanced ability to convert 3-amino-1-methyl-5H-pyrido(4,3)indole into mutagenic metabolites in S. typhimurium; (d) cytogenetic damage was demonstrated by an increased frequency of micronuclei in peripheral blood erythrocytes.

[Mixed-function oxidase induction as a test for the biological monitoring of water: limitations and prospects]. / Induzione delle ossigenasi a funzione mista come strumento di monitoraggio biologico delle acque: limiti e prospettive.

The induction in fish liver of some enzyme activities, and typically of microsomal mixed-function oxidases (MFO), provides the earliest biological warning signal of exposure to pollutants. Our studies provided evidence that the basal levels of cytochrome P-450 and specific MFO activities, such as arylhydrocarbon hydroxylase (AHH) and ethoxyresorufin deethylase (EROD), were strongly influenced by the diet in freshwater fish (Oncorhynchus mykiss). The response of fish liver to a known enzyme inducer, i.e., beta-naphthoflavone, was also affected by the diet, which therefore should be carefully controlled in laboratory studies. Under field conditions MFO activities were significantly enhanced in the liver of O. mykiss kept in polluted river water as well as in the liver of the seawater fish Diplodus annularis collected from a polluted harbour area, as compared to specimens of the same species collected from an unpolluted reference area.

Nitrite biotransformation by mitochondria from the earthworm Eisenia foetida (Savigny).

1. Nitrite oxidase and cytochrome-c oxidase activity catalysed by cytochrome-aa3 were assayed in earthworms and rats. 2. Cytochrome-aa3 and intact mitochondria from the two species were anaerobically incubated in the presence of nitrite; the occurrence of mitochondria-induced nitrite biotransformations was evaluated by monitoring nitrite recovery in incubation medium. Possible nitric oxide production was also tested. 3. The ratio nitrite oxidase/cytochrome-c oxidase activity was much higher in earthworms than in rats. 4. Under anaerobic conditions and in the presence of respiratory substrates, earthworm mitochondria produced a time-dependent loss of nitrite in the incubation medium. On the contrary, rat mitochondria are unable to decrease environmental nitrite concentration. 5. Results support the notion that metabolic properties of earthworm mitochondria can be considered as an adaptation to chronic nitrite exposure, this toxicant being typically present in natural habitats of these worms.

Enhanced liver metabolism of mutagens and carcinogens in fish living in polluted seawater.

Specimens of the seawater fish annular seabream (Diplodus annularis) were caught from a polluted harbor area and from a clean reference area. Seawater concentrates and fish-muscle extracts were not mutagenic in the Salmonella reversion test. Liver preparations of fish from the 2 sources were comparatively assayed for microsomal mixed-function oxidases and cytosolic biochemical parameters, as well as for the ability of S12 fractions to activate promutagens or to detoxify direct-acting mutagens. A shift of the cytochrome P-450 peak from 450.3 to 448.5 was accompanied by a 4.5-fold increase in arylhydrocarbon hydroxylase activity in fish living in the polluted environment. At the same time, glucose 6-phosphate dehydrogenase and 6-phosphogluconate dehydrogenase were doubled in the cytosol of the same animals, while reduced glutathione (GSH) peroxidase and GSH S-transferase were slightly yet significantly depressed. No significant difference was recorded for other biochemical parameters, including GSH, oxidized glutathione (GSSG) reductase, NADH- and NADPH-dependent diaphorases, and DT diaphorase. In parallel, fish exposed to polluted seawater exhibited a significant and marked enhancement of the metabolic activation of the pyrolysis product Trp-P-2 and of benzo[a]pyrene-trans-7,8-diol, and at the same time were less efficient in detoxifying the antitumor compound ICR 191. Liver S12 fractions from both sources efficiently decreased the direct mutagenicity of sodium dichromate, and failed to activate benzo[a]pyrene and aflatoxin B1 to mutagenic metabolites. These results provide evidence that both biochemical parameters and the overall capacity of fish liver to activate or detoxify certain mutagens can be assumed to be sensitive indicators of exposure to mixed organic pollutants in the marine environment.

Reduction of hexavalent chromium by the earthworm Eisenia foetida (Savigny).

Several metabolic systems in Eisenia foetida competent to achieve an intracellular Cr(VI) reduction are described. Evidence that earthworms act as effective scavengers of hexavalent chromium from the environment is also provided. Results suggest that E. foetida may play an important role during occasional Cr(VI) pollution of soils.

Xenobiotic metabolizing enzymes in rainbow trout exposed to river water.

1. Juvenile rainbow trout were exposed to river water in a flow-through system. After 15 days of exposure, hepatic biotransformation activities and related parameters were measured and compared to those of the control group organisms that were maintained in tap water under identical experimental conditions. 2. Liver somatic index (LSI), microsomal protein and cytochrome P-450 contents, benzo[a]pyrene hydroxylase (AHH), ethoxyresorufin-O-deethylase (EROD) and UDP glucuronyl transferase activities were not significantly affected. 3. Aminopyrine-N-demethylase (APD) activity showed a slight yet significant increase in exposed trout.