[«Missing time¼: Experiences of demand management doctors in Chilean primary health care]. / «Falta tiempo¼: experiencias de médicos gestores de la demanda en la atención primaria de salud chilena.

OBJECTIVE: Characterize the current situation of the demand manager physician (DMP) in primary health care (PHC), from the perceptions of those who fulfill this role, their medical peers and the directors of the family health centers (CESFAMs). DESIGN: Qualitative cross-sectional study with a grounded theory approach. SITE: Four CESFAMs from the South East Metropolitan Health Service in Santiago, Chile. PARTICIPANTS: Demand manager physician, general practitioners and directors of CESFAM. METHOD: A semi-structured interview and discussion group were used as data collection technique. Open, axial, and selective coding was carried out with the support of the NVivo12 software. RESULTS: In practice, DMP performs more functions than those defined for the position by the Ministry of Health, generating the feeling of lack of time to carry out their work, what represents their main barrier at work and reflects the absence of institutional support they receive from their employees. Among these invisible functions are: providing feedback to the medical team, leading clinical meetings, and generating reference protocols. For the good performance of the DMP it is necessary to have technical skills and be recognized by their peers. It was estimated that the family doctor is the most suitable professional for the position. The work of the DMP is limited by institutional factors such as waiting lists, lack of specialists, and poor coordination between levels of care. CONCLUSIONS: Standardizing the functions of the DMP is a necessary element for its consolidation and achieving the objectives of maintaining continuity of care in the population.

The facilitative effect of gestures on the neural processing of semantic complexity in a continuous narrative.

Gestures are elemental components of social communication and aid comprehension of verbal messages; however, little is known about the potential role of gestures in facilitating processing of semantic complexity in an ecologically valid setting. The goal of this study was to investigate whether cognitive load, as indexed by semantic complexity, is modulated by the presentation of gestures accompanying speech. Twenty healthy participants watched 16 video clips of a short narrative while instructed to carefully listen to and watch the narrator while functional magnetic resonance imaging (fMRI) data were acquired. The videos contained passages with and without various co-speech gestures, as well as passages where the semantic complexity was either low or high, as measured by the metric of idea density. Increasing semantic complexity led to reduced activation within the default mode network (DMN); whereas, presents of gestures decreased activation in language-related regions (left middle temporal gyrus and left inferior frontal gyrus) and increased activation in high-level visual and multimodal regions of occipitotemporal cortex. Most interestingly, an interaction between semantic complexity and gestures was observed in a language-related area in left anterior temporal cortex; specifically, increasing gestures led to a greater drop in activation with high vs. Low semantic complexity. These results provide evidence that the facilitation of gestures on semantic processing, particularly for complex narratives, is reflected in the neural substrates of language processing.

The Processing of Semantic Complexity and Cospeech Gestures in Schizophrenia: A Naturalistic, Multimodal fMRI Study.

Schizophrenia is marked by aberrant processing of complex speech and gesture, which may contribute functionally to its impaired social communication. To date, extant neuroscientific studies of schizophrenia have largely investigated dysfunctional speech and gesture in isolation, and no prior research has examined how the two communicative channels may interact in more natural contexts. Here, we tested if patients with schizophrenia show aberrant neural processing of semantically complex story segments, and if speech-associated gestures (co-speech gestures) might modulate this effect. In a functional MRI study, we presented to 34 participants (16 patients and 18 matched-controls) an ecologically-valid retelling of a continuous story, performed via speech and spontaneous gestures. We split the entire story into ten-word segments, and measured the semantic complexity for each segment with idea density, a linguistic measure that is commonly used clinically to evaluate aberrant language dysfunction at the semantic level. Per segment, the presence of numbers of gestures varied (n = 0, 1, +2). Our results suggest that, in comparison to controls, patients showed reduced activation for more complex segments in the bilateral middle frontal and inferior parietal regions. Importantly, this neural aberrance was normalized in segments presented with gestures. Thus, for the first time with a naturalistic multimodal stimulation paradigm, we show that gestures reduced group differences when processing a natural story, probably by facilitating the processing of semantically complex segments of the story in schizophrenia.

Age-related effects on the neural processing of semantic complexity in a continuous narrative: Modulation by gestures already present in young to middle-aged adults.

The processing of semantically complex speech is a demanding task which can be facilitated by speech-associated arm and hand gestures. However, the role of age concerning the perception of semantic complexity and the influence of gestures in this context remains unclear. The goal of this study was to investigate if age-related differences are already present in early adulthood during the processing of semantic complexity and gestures. To this end, we analyzed fMRI images of a sample of 38 young and middle-aged participants (age-range: 19-55). They had the task to listen and to watch a narrative. The narrative contained segments varying in the degree of semantic complexity, and they were spontaneously accompanied by gestures. The semantic complexity of the story was measured by the idea density. Consistent with previous findings in young adults, we observed increased activation for passages with lower compared to higher complexity in bilateral temporal areas and the precuneus. BOLD signal in the left frontal and left parietal regions correlated during the perception of complex passages with increasing age. This correlation was reduced for passages presented with gestures. Median-split based post-hoc comparisons confirmed that group differences between younger (19-23 years) and older adults within the early adult lifespan (24-55 years) were significantly reduced in passages with gestures. Our results suggest that older adults within early adulthood adapt to the requirements of highly complex passages activating additional regions when no gesture information is available. Gestures might play a facilitative role with increasing age, especially when speech is complex.

«Falta tiempo»: experiencias de médicos gestores de la demanda en la atención primaria de salud chilena / «Missing time»: Experiences of demand management doctors in Chilean primary health care

Objetivo: Caracterizar la situación actual del médico gestor de la demanda (MGD) en la atención primaria de salud (APS), desde las percepciones de aquellos que cumplen ese rol, sus pares médicos y los directivos de los centros de salud familiar (CESFAM). Diseño: Estudio transversal cualitativo con enfoque de teoría fundamentada. Emplazamiento: Cuatro CESFAM del Servicio de Salud Metropolitano Sur Oriente en Santiago, Chile. Participantes: Médico gestor de la demanda, médicos generales y directores de CESFAM. Método: Se utilizó la entrevista semiestructurada y el grupo de discusión como técnica de recolección de datos. Se realizó codificación abierta, axial y selectiva con el apoyo del software NVivo v.12. Resultados: El MGD realiza en la práctica más funciones que las definidas para el cargo por el Ministerio de Salud, generando una sensación de falta de tiempo para realizar su labor, lo que representa su principal barrera en el trabajo y refleja la falta de apoyo institucional que reciben de sus jefaturas. Entre estas funciones invisibles están: retroalimentar al equipo médico, liderar reuniones clínicas y generar protocolos de referencia. Para el buen desempeño del MGD es necesario contar con competencias técnicas y ser reconocido por sus pares. Se estimó que el médico de familia es el profesional más apto para el cargo. La labor del MGD está limitada por factores institucionales como las listas de espera, la falta de especialistas y la baja coordinación entre niveles asistenciales. Conclusiones: Estandarizar las funciones del MGD es un elemento necesario para su consolidación y lograr cumplir los objetivos de mantener la continuidad del cuidado en la población.(AU)

Objective: Characterize the current situation of the demand manager physician (DMP) in primary health care (PHC), from the perceptions of those who fulfill this role, their medical peers and the directors of the family health centers (CESFAMs). Design: Qualitative cross-sectional study with a grounded theory approach. Site: Four CESFAMs from the South East Metropolitan Health Service in Santiago, Chile. Participants: Demand manager physician, general practitioners and directors of CESFAM. Method: A semi-structured interview and discussion group were used as data collection technique. Open, axial, and selective coding was carried out with the support of the NVivo12 software. Results: In practice, DMP performs more functions than those defined for the position by the Ministry of Health, generating the feeling of lack of time to carry out their work, what represents their main barrier at work and reflects the absence of institutional support they receive from their employees. Among these invisible functions are: providing feedback to the medical team, leading clinical meetings, and generating reference protocols. For the good performance of the DMP it is necessary to have technical skills and be recognized by their peers. It was estimated that the family doctor is the most suitable professional for the position. The work of the DMP is limited by institutional factors such as waiting lists, lack of specialists, and poor coordination between levels of care. Conclusions: Standardizing the functions of the DMP is a necessary element for its consolidation and achieving the objectives of maintaining continuity of care in the population.(AU)

Prevalencia de síndrome metabólico en pacientes psoriáticos chilenos / Prevalence of metabolic syndrome in Chilean patients with psoriasis

Introducción: Existe poca información de la asociación entre Psoriasis y síndrome metabólico (SM) en Chile. Objetivos: Determinar la prevalencia de SM en psoriáticos chilenos. Material y métodos: Se realizó un estudio caso-control, con 487 pacientes (238 psoriáticos y 239 controles). En ambos grupos se analizó la prevalencia de SM además del exceso de peso, hipertensión arterial, diabetes mellitus 2, hipertrigliceridemia y niveles de HDL bajo. Resultados: Los psoriáticos presentaron mayor probabilidad de padecer SM versus los controles (35,29% vs 23,29%) OR 1,8 (1,20-2,66) p<0,05. Se asoció también con circunferencia abdominal aumentada (57,14% vs 36,94) OR 2,6 (1,79 - 3,78), exceso de peso (85,99% vs 63,45%) OR 2,46 (1,62 ­ 3,73) p<0,05 y diabetes mellitus 2 (13,45% vs 4,42%) OR 3,85 (1,79 - 8,26) p<0,05. Conclusiones: Se encontró una mayor prevalencia de SM, exceso de peso, circunferencia abdominal aumentada y diabetes mellitus 2 en el grupo psoriático en comparación al grupo control.

Background: There is a paucity of information about Psoriasis and metabolic syndrome (MS) association in Chile. Aim: To determine the MS prevalence in Chilean psoriatic patients. Material and Methods: A case-control study was conducted which included 487 patients (238 psoriatic patients and 239 controls). In both groups, MS prevalence, overweight, hypertension, diabetes mellitus type 2, hypertriglyceridemia and low HDL were analyzed. Results: Psoriatic patients were more likely to present MS than controls (35.29% vs 23.29%) OR 1.8 (1.20 to 2.66) p <0.05. In addition, it was associated with increased abdominal circumference (57.14% vs 36.94) OR 2.6 (1.79 to 3.78), overweight (85.99% vs 63.45%) OR 2.46 (1.62 to 3.73) p <0.05 and diabetes mellitus type 2 (13.45% vs. 4.42%) OR 3.85 (1.79 to 8.26) p <0.05. Conclusions: There is a higher prevalence of MS, overweight, increased abdominal circumference and type 2 diabetes mellitus in the psoriatic group compared with the control group.