Overcoming multimorbidity: Chrodis Integrated Multimorbidity Care Model pilot implementation

Background

Multimorbidity (MM) has become one of the greatest challenges for patients and healthcare providers, calling for the development of care models that offer holistic, patient-centered care plans. Our objective was to assess the applicability and effectiveness of the Chrodis Integrated Multimorbidity Care Model (IMCM) to improve care for patients with MM in the Public Health System of Aragón, a region in northeastern Spain where MM affects 80% of people over 65 years of age.

Methods

We developed and implemented a set of actions (”change package”) to target three main improvement areas (i.e., care fragmentation, training of professionals and community care) covering all five dimensions of the model. We used key process and outcome indicators to evaluate each action, including healthcare service use (hospitalizations, emergency room visits), delivery of care (care plans, case managers), improvement in MM management skills of professionals (online training course), and patient self-perceived quality of care (ad-hoc questionnaire).

Results

291 patients of over 65 years of age with MM were recruited. At the end of the implementation every patient had a designated case manager and an individualized care plan, and 96.7% had their social situation assessed. During the 1-year pilot intervention, patients averaged 0.69 hospitalizations and 1.24 visits to the emergency room; 87.5% reported a self-perceived improvement of received care. 348 community resources were mapped and made available online in an official website. 89% of professionals who were offered to participate in the training programme agreed, reporting 8.3/10 satisfaction with the course, and improved their MM management skills from 7.36 to 9.18/10.

Conclusions

The IMCM is applicable in the context of the Spanish Public Health System and is effective in improving quality of care for patients and professionals alike.

Key messages

Reinforcing the mechanisms that integrate community, primary and hospital care is still necessary if we intend to reduce the negative health outcomes associated to care fragmentation in multimorbidity. The sustainability of the model requires the continued collaboration of key stakeholders and the awareness that multimorbidity is an issue that exceeds purely economic and structural barriers.

Incidence of testicular cancer and occupation among Swedish men gainfully employed in 1970

PURPOSE

To estimate occupation-specific risk of seminomas and nonseminoma subtypes of testicular cancer among Swedish men gainfully employed in 1970 over the period 1971-1989.

METHODS

Age-period standardized incidence ratios were computed in a dataset linking cancer diagnoses from the Swedish national cancer register to occupational and demographical data obtained in the census in 1970. Log-linear Poisson models were fitted, allowing for geographical area and town size. Taking occupational sector as a proxy for socioeconomic status, occupational risks were recalculated using intra-sector analyses, where the reference group comprised other occupations in the same sector only. Risk estimators per occupation were also computed for men reporting the same occupation in 1960 and 1970, a more specifically exposed group.

RESULTS

Seminomas and nonseminomas showed a substantial geographical variation. The association between germ-cell testicular tumors and high socioeconomic groups was found mainly for nonseminomas. Positive associations with particular occupations were more evident for seminomas, for which railway stationmasters, metal annealers and temperers, precision toolmakers, watchmakers, construction smiths, and typographers and lithographers exhibited a risk excess. Concrete and construction worker was the only occupation consistently associated with nonseminomas.

CONCLUSIONS

Among the many occupations studied, our results corroborate the previously reported increased risk among metal workers, specifically related with seminomatous tumors in this study. Our results confirm the geographical and socioeconomical differences in the incidence of testicular tumors. These factors should be accounted for in occupational studies. The different pattern of occupations related with seminomas and nonseminomas support the need to study these tumors separately.

Telomere biology of trypanosomatids: more questions than answers

Trypanosomatids are severe pathogens in developing countries, where they affect both humans and domestic animals. Factors intrinsic to the host, the toxicity or subcurative effects of the available antiparasite medication and the low perspective of potential vaccines favor research on novel candidates for drug target. Telomeres are essential for the survival of most eukaryotes. In trypanosomatids, events such as antigenic variation and/or gene conversion and duplication occur at telomeric positions, possibly facilitating genome rearrangement. Understanding the role that telomere maintenance might play in the cell life span of trypanosomatids has important implications for therapeutics of parasitic diseases.

Non-Hodgkin's lymphomas and occupation in Sweden

OBJECTIVES

To investigate whether there is a risk excess of non-Hodgkin's lymphoma among Swedish workers associated with particular occupations.

METHODS

The base population was made up of Swedish men (1,779,646) and women (1,101,669) who were gainfully employed at the time of the 1970 census, had also been present in the 1960 census and were still alive and older than 24 years as of 1 January, 1971. They were followed up for 19 years until the end of 1989. Age-period standardised incidence ratios were computed in a dataset linking cancer diagnoses from the Swedish national cancer register to occupational and demographic data obtained in the census of 1970. Log-linear Poisson models were fitted, allowing for geographical area. Risk estimators per occupation were also computed for workers reporting the same occupation in 1960 and 1970, a more specifically exposed group.

RESULTS

There were 7,610 non-Hodgkin's lymphomas reported in the study cohort, 5,391 cases in men and 2,219 in women. A relative risk of over 1.20 and statistically significant was observed in men among accountants and auditors, secretaries and typists, auctionists, non-specified rail and road transport workers, telecommunications traffic officers, telegraph and radio operators, photographic-laboratory workers and other production and related work. The risk excess was confirmed in men with the same occupation in both censuses. In women, only three occupations achieved statistical significance: metal platers and coaters, truck and conveyor operators and store and warehouse workers.

CONCLUSIONS

The risk excess observed in telecommunication and transport workers could be explained by electromagnetic radiation exposure. We did not find a risk excess in agricultural occupations, that has been largely documented by other study groups.

Telomerase in kinetoplastid parasitic protozoa

We have identified telomerase activity in extracts of three evolutionarily diverse kinetoplastid species: Trypanosoma brucei, Leishmania major, and Leishmania tarentolae. Telomerase activity was initially detected in extracts from insect form cells of all three kinetoplastid species by using a modification of the one-tube telomere repeat amplification protocol [Kim, N., et al. (1994) Science 266, 2011-2015], although better results were subsequently achieved with the two-tube telomere repeat amplification protocol [Autexier, C., Pruzan, R., Funk, W. & Greider, C. (1996) EMBO J. 15, 5928-5935]. The activity in T. brucei extracts was sufficiently robust to enable its detection in a direct assay of telomerase; enzyme processivity was found to be relatively low. The in vitro properties of telomerase suggest a possible templating domain sequence for the telomerase RNA of T. brucei. Telomerase activity is likely to contribute to telomere maintenance in these parasitic organisms and provides a new target for chemotherapeutic intervention.

Electrophoretic karyotypes and genome sizing of the pathogenic fungus Paracoccidioides brasiliensis

Here we present the karyotype analysis and genome sizing of Paracoccidioides brasiliensis, a pathogen refractory to conventional genetic analysis. We have established pulsed-field gel electrophoresis (PFGE) conditions to resolve the high-molecular-weight chromosomal bands of two clinical isolates of P. brasiliensis. Both isolates showed four megabase-sized bands, ranging from 2.0 to 10.0 Mbp. Significant differences in chromosome sizes and in the chromosomal location of genes for the gp43 antigen and chitin synthase were found. Different technical approaches were employed to estimate the DNA content and to define the ploidy of P. brasiliensis. An estimated genome size in the range of 45.7 to 60.9 Mbp was provided by the analysis of data generated by measuring the amplitude of fluorescence intensity of DAPI (4',6-diamidino-2-phenylindole)-stained nuclei (by confocal microscopy). The nuclear genome size estimated by confocal microscopy is twice that estimated by the average sum of the molecular weight of chromosome-sized DNA molecules by PFGE, suggesting that each separated P. brasiliensis chromosomal band is diploid.

Characterization of an interspersed repetitive DNA element in the genome of Trypanosoma cruzi

We report the molecular characterization of a middle repetitive DNA sequence, named C6, isolated from the Trypanosoma cruzi genome. C6 appears to be a composite repeated element since 3 subregions may be defined within it on the basis of sequence similarities with other T. cruzi genomic sequences. Sequences homologous to C6 are interspersed in the genome and can be mapped out on most chromosomal bands of different T. cruzi. strains. The copy number of the C6 element is about 1000 per haploid genome. Given the species specificity and different genomic distribution of C6 homologous sequences among the T. cruzi strains the C6 element could be a useful probe for diagnosis and typing of parasites. C6 is a polymorphic marker with potential as a tool for physical mapping of the T. cruzi genome.

The Trypanosoma cruzi genome project: nuclear karyotype and gene mapping of clone CL Brener

By using improved pulsed field gel electrophoresis conditions, the molecular karyotype of the reference clone CL Brener selected for Trypanosoma cruzi genome project was established. A total of 20 uniform chromosomal bands ranging in size from 0.45 to 3.5 Megabase pairs (Mbp) were resolved in a single run. The weighted sum of the chromosomal bands was approximately 87 Mbp. Chromoblots were hybridized with 39 different homologous probes, 13 of which identified single chromosomes. Several markers showed linkage and four different linkage groups were identified, each comprising two markers. Densitometric analysis suggests that most of the chromosomal bands contain two or more chromosomes representing either homologous chromosomes and/or heterologous chromosomes with similar sizes.

Trypanosoma cruzi genome project: biological characteristics and molecular typing of clone CL Brener

Clone CL Brener is the reference organism used in the Trypanosoma cruzi Genome Project. CL Brener was obtained by cloning procedures from bloodstream trypomastigotes isolated from mice infected with the CL strain. The doubling time of CL Brener epimastigotes cultured at 28 degrees C in liver infusion-tryptose (LIT) medium is 58 +/- 13 h. Differentiation to metacyclic forms is induced by incubation of epimastigotes in LIT-20% Grace's medium. Metacyclics give very low parasitemia in mice, contrary to what is observed for blood forms which promote 100% mortality of the animals with inocula of 5 x 10(3) parasites. CL Brener blood forms are highly susceptible to nifurtimox, benznidazole and ketoconazole. Allopurinol is inefficient in the treatment of mice experimental infection. The clone infects mammalian cultured cells and performs the complete intracellular cycle at 33 and 37 degrees C. The molecular typing of CL Brener has been done by isoenzymatic profiles; sequencing of a 24S alpha ribosomal RNA gene domain and by schizodeme, randomly amplified polymorphic DNA and DNA fingerprinting analyses. For each typing approach the patterns obtained do not change after prolonged parasite subcultivation in LIT medium (up to 100 generations). The stability of the molecular karyotype of the clone was also confirmed.

Cloning and characterization of a gene encoding a novel immunodominant antigen of Trypanosoma cruzi

A Trypanosoma cruzi genomic expression library was screened with a pool of sera obtained from chronic chagasic patients. The recombinant antigen (Tc40) isolated from this library reacted with a large number of serum samples of chronic chagasic patients, suggesting that the presence of anti-Tc40 antibodies may be specifically associated to Chagas' disease. The full-length sequence of the Tc40 gene was determined after isolation of genomic and cDNA clones. The Tc40 cDNA includes a large open reading frame (2745 bp-long) that encodes a polypeptide of 100 kDa without any homology with previously described T. cruzi sequences. In contrast with other T. cruzi antigens whose immunodominant B-cell epitopes are composed by amino acid repetitive motifs, Tc40 does not show any amino acid repetition. Antibodies against the Tc40 recombinant protein reacted with three native polypeptides of 100, 41 and 38 kDa which are tightly associated with membranes or cytoskeleton and expressed in all developmental stages of the parasite life cycle. A transcript of 3.9-kb was detected in Northern blot analysis which is large enough to encode a 100 kDa polypeptide. Tc40 genes were mapped on a chromosomal band of 1.1 Mbp and in a few copies per haploid genome in the G strain.

Cloning, characterization, and epitope expression of the major diagnostic antigen of Paracoccidioides brasiliensis

The 43,000-Da glycoprotein (gp43) of Paracoccidioides brasiliensis is an immunodominant antigen for antibody-dependent and immune cellular responses in patients with paracoccidioidomycosis. In order to identify the peptide epitopes involved in the immunological reactivities of the gp43 and to obtain highly specific recombinant molecules for diagnosis of the infection, genomic and cDNA clones representing the entire coding region of the antigen were sequenced. The gp43 open reading frame was found in a 1,329-base pair fragment with 2 exons interrupted by an intron of 78 nucleotides. The gene is present in very few copies per genome, as indicated by Southern blotting and chromosomal megarestriction analysis. A single transcript of 1.5 kilobase pairs was verified in the yeast phase. The gene encodes a polypeptide of 416 amino acids (Mr 45,947) with a leader peptide of 35 residues; the mature protein has a single N-glycosylation site. The deduced amino acid sequence showed similarities of 56-58% with exo-1,3- beta-D-glucanases from Saccharomyces cerevisiae and Candida albicans. However, the gp43 is devoid of hydrolase activity and does not cross-react immunologically with the fungal glucanases. Internal and COOH-terminal gene fragments of the gp43 were expressed as recombinant fusion proteins, which reacted with antibodies elicited against the native antigen.

Organization and expression of the gene encoding an immunodominant repetitive antigen associated to the cytoskeleton of Trypanosoma cruzi

We have studied the genomic organization and expression of the gene encoding a high molecular mass (300 kDa) repetitive antigen associated with the cytoskeleton of Trypanosoma cruzi. Protease digestion of the native protein, restriction analysis of genomic DNA and sequencing of genomic and cDNA clones indicated that most of the protein is built up by tandemly arranged, nearly identical repeats of 68 amino acids. The gene size was estimated to be approx. 9.4 kb based on the sizes of the transcript and the native protein. The nucleotide sequence conservation among the repeats indicates that selective sequence homogenization, presumably through gene conversion, maintained the amino-acid sequence conservation. Two duplicated allelic forms of this gene were mapped in fragments of about 20 kb. In some strains an additional allele was located in a fragment of 9.4 kb. Our results suggest that this repetitive antigen is a structural protein which could be involved in the attachment of the flagellum to the cell body.

Cloning and characterization of a gene for the stage-specific 82-kDa surface antigen of metacyclic trypomastigotes of Trypanosoma cruzi

We have cloned and sequenced a cDNA clone coding for a metacyclic trypomastigote-specific surface glycoprotein with a molecular mass of 82 kDa (MTS-gp82). By immunoblotting and immunoprecipitation, antibodies against the recombinant protein recognized an 82-kDa protein of metacyclic trypomastigotes, without any detectable reaction towards amastigotes, epimastigotes or tissue culture-derived trypomastigotes. The insert of the MTS-gp82 cDNA clone strongly hybridized with a single 2.2-kb metacyclic trypomastigote mRNA, suggesting that the steady-state levels of mRNAs for MTS-gp82 are developmentally regulated. MTS-gp82 is encoded by a multigene family whose members are distributed in several chromosomes. Sequence analysis revealed 40-56% identity at amino acid level between MTS-gp82 and members of Trypanosoma cruzi gp85/sialidase family (TSA-1, Tt34c1, SA85-1.1). MTS-gp82 showed several amino acid motifs that are characteristic of gp85/sialidase family, such as the Asp box (SxDxGxTW), the subterminal (VTVxNVFLYNR) motif and the putative GPI-anchor sequence. On the basis of its structural features, the MTS-gp82 gene could be included in the T. cruzi gp85/sialidase family, but constituting a distinct group which is preferentially expressed in metacyclic trypomastigotes.

[The isolation and evaluation of Aspergillus fumigatus antigens]

Antigens from three strains of Aspergillus fumigatus (354, 356, and JIG) and an antiserum against the mixing of these antigens have been produced, and evaluated immunochemically. The antigens were obtained through a modified Coleman & Kaufman technique (culture filtrate concentrated by acetone). Analysis by the immunodiffusion test (ID) against homologous serum has yielded 100% sensitivity (with the studied sera). Concerning heterologous sera we found reactivity with a serum of a patient of candidiasis and another with histoplasmosis. The same result was obtained with a reference antigen in immunodiffusion, showing similar standards of response. Titration of the antiserum by ID and counterimmunoelectrophoresis showed a title of 1:32, and by complement fixation (micro-technique) a title of 1:128. Using immunoelectrophoresis (IEF), the produced antiserum yielded 8 lines of precipitation (5 in the anodic pole and 3 in the cathodic one). In SDS-PAGE at 12.5% the antigen has presented a rather complex electrophoretic profile (26 proteic subunits with a molecular weight ranging from 18 a > 100 kDa). Immunogenicity of the antigen was observed in all fractions of SDS-PAGE when the immunoblotting against the antiserum was carried out.

The sensitivity, specificity and efficiency values of some serological tests used in the diagnosis of paracoccidioidomycosis

This work reports on the results of double immunodiffusion (ID), counterimmunoelectrophoresis (CIE), complement fixation (CF) and indirect immunofluorescence (IIF) techniques in the serodiagnosis of paracoccidioidomycosis. The study was undertaken on four groups of individuals: 46 patients with untreated paracoccidioidomycosis, 22 patients with other deep mycoses, 30 with other infectious diseases (tuberculosis and cutaneous leishmaniasis) and 47 blood donors as negative controls. Data were obtained using Paracoccidioides brasiliensis antigens, i.e., a yeast culture filtrate for ID, CIE and CF, and a yeast cell suspension for IIF. The sensitivity, specificity and efficiency values were measured according to GALEN & GAMBINO. The gel precipitation tests (ID and CIE) showed the greatest sensitivity (91.3 and 95.6%, respectively), maximum specificity (100%) and the highest efficiency values when compared to the CF and IIF tests.

[Utilization of aminoacids in the study of the growth of Paracoccidioides brasiliensis. Influence on dimorphism]

Fifteen Paracoccidioides brasiliensis strains, in the mycelial (M) and yeast like (Y), were cultivated in minimal medium (MM) and subcultivated to be adapted to the same medium supplemented with a pool of amino acid in solution (MMS). Each of the amino acids were studied separately of the solution to provide the auxological study. The prototrophism was demonstrated by nine strains in both M and Y forms, and the auxotrophism by the remaining strains. The heterologous results has not allowed us to draw an auxological characterization of the P. brasiliensis. As far as we could observe none of the amino acid studied in this piece of research can be considered of absolute importance for to the growth and the morphogenesis maintainance of the fungus. Morphological alterations were only verified in the prototroph strains, which suggest that there could have been adaptative metabolism activity due to the absence of organic nitrogen compounds in the minimal medium (MM).

Coagglutination test (COA) for Cryptococcus neoformans circulating antigen detection in cerebral spinal fluid (CSF)

We tested 82 CSF of 24 renal transplanted patients (RT) with cerebral cryptococcosis, 8 CSF of asymptomatic RT patients, 43 CSF of proven cryptococcosis cases (positive control) and 35 CSF of patients with other diseases (histoplasmosis, paracoccidioidomycosis and bacterial infections) as negative control. The RT CSF were cultured in Sabouraud agar slant added with sunflower seeds and both control and RT CSF were qualitatively examined by cryptococcosis latex test (Crypto-LA test). The COA test was developed both qualitatively and quantitatively. The highest titre encountered was 1:2048. No false reactions appeared among the controls. The diagnostic value demonstrated by Galen and Gambino's method was: sensitivity--92.1%; specificity--92.6% and efficiency--92.3%. Besides that, the COA proved to be quick, exact and cheap, but it depends on CSF and sera pre-treatment, in order to avoid autoagglutination and increase its sensibility.

Relationship between mitotic instability and accumulation of B chromosomes in males and females of Locusta migratoria

Mitotic instability of B chromosomes has been studied in males and females from two Spanish populations of Locusta migratoria. This instability is a common feature in embryos, adult somatic tissues such as gastric caeca, and ovariole wall cells and male and female germ lines. While B chromosomes accumulate in the male germ line independently of the existence or absence of intraindividual variation in the number of B chromosomes in gastric caeca cells, they do not accumulate in the female germ line despite meiotic instability. The relationship between the mitotic instability of the B chromosomes in germ lines and their mode of transmission is discussed.Key words: Locusta migratoria, B chromosomes, mitotic instability, accumulation.

Cytological basis of the B chromosome accumulation mechanism in the grasshopper Heteracris littoralis (Ramb)

An accumulation mechanism of the standard B chromosome of the grasshopper Heteracris littoralis has been studied in a natural population located in El Saler (Valencia) by two different methods: (i) the karyological analysis of the offspring from wild females and (ii) cytological observations of male and female meiosis. The transmission rate of the accessory through females obtained from crosses (0.61) was slightly lower than that obtained from direct meiotic observations of secondary oocytes (0.71). The B chromosome is transmitted at a rate of about 0.5 through 1B males, the value expected from mendelian segregation. The implications of these findings are discussed and the parasitic nature of the B is proposed.

B chromosomes of the grasshopper Heteracris littoralis: meiotic behaviour and endophenotypic effects in both sexes

A main type of a large supernumerary B chromosome has been found in several natural populations of the grasshopper Heteracris littoralis. A study on the geographical distribution of the polymorphism and the meiotic behavior of Bs in both sexes has been carried out with special reference to their effect on two endophenotypic parameters: recombination level and macrospermatid production. Male B bivalents are characterized by a high level of pairing and a strict proximal localization of chiasmata. In the females the B chromosome always divides reductionally at anaphase I indicating the possible existence of an accumulation mechanism based on meiotic drive. There is no effect of Bs on either mean chiasma frequency or between-cell variance in either of the sexes. However, in males a positive correlation between the number of Bs and production of abnormal spermatids (macrospermatids) was found.Key words: B chromosomes, chiasma frequency, female meiosis.

Female meiosis during oocyte maturation in Eyprepocnemis plorans (Orthoptera: Acrididae)

The progression of meiosis from metaphase I to telophase II was followed in oocytes of Eyprepocnemis plorans that were dissected from mature females and maintained in saline solution. The durations of the various meiotic stages were assessed at three different temperatures.Key words: grasshoppers, meiosis, oocytes.