Improving primary health care through technological innovation.

As a result of policy changes and developments on the demand side, the importance of technology in primary health care will grow fast. An approach to the implementation of new technologies in primary health care is presented in this article. First we describe the main problems in Dutch primary health care. The second step is to identify new technologies which are becoming available. Subsequently, the interface between these problems and their possible technological resolution has to be found. The fact that a technological innovation appears to be a solution is not sufficient reason for introducing it. There are all kinds of reasons why an innovation that has proved useful in the hospital situation, for example, might be of doubtful use in primary health care. Accordingly, the next step is to assess whether a technological solution to a problem in primary health care is indeed an improvement. To acknowledge the particular situation of primary health care, a scheme has been developed that may be used to determine criteria of evaluation.     

Synaptic Plasticity in an In Vitro Slice Preparation of the Rat Nucleus Accumbens

Extra- and intracellular recordings in slices were used to examine what types of synaptic plasticity can be found in the core of the nucleus accumbens, and how these forms of plasticity may be modulated by dopamine. Stimulus electrodes were placed at the rostral border of the nucleus accumbens in order to excite primarily infralimbic and prelimbic afferents, as was confirmed by injections of the retrograde tracer fluoro-gold. In extracellular recordings, tetanization induced long-term potentiation (LTP) of the population spike in 20 out of 53 slices. The presynaptic compound action potential did not change following LTP induction. For the intracellularly recorded excitatory postsynaptic potential, three types of synaptic plasticity were noted: long-term potentiation (16 out of 54 cells), decremental potentiation (eight cells) and long-term depression (LTD; six cells). No correlation was found between the occurrence of potentiation or depression and various parameters of the tetanic depolarization (e.g. peak voltage, integral under the curve). The N -methyl- d -aspartate receptor antagonist d (–)-2-amino-5-phosphonopentanoic acid (50 μM; d -AP5) reduced, but did not completely prevent, the induction of LTP. The incidence of LTD was not markedly affected by d -AP5. No difference in LTP was found when comparing slices bathed in dopamine (10 μM) and controls. Likewise, slices treated with a mixture of the D1 receptor antagonist Sch 23390 (1 μM) and the D2 antagonist S (–)-sulpiride (1 μM) generated a similar amount of LTP as controls. In conclusion, both LTP and LTD can be induced in a key structure of the limbic-innervated basal ganglia. LTP in the nucleus accumbens strongly depends on N -methyl- d -aspartate receptor activity, but is not significantly affected by dopamine.     

Inputs from the olfactory bulb and olfactory cortex to the entorhinal cortex in the cat

Summary The spatial organization and laminar distribution of projections from the olfactory bulb and the anterior (PPCa) and posterior (PPCp) divisions of the prepiriform cortex to the entorhinal cortex were studied with anterograde (³H-leucine) and retrograde (WGA-HRP) tracing techniques. After ³H-leucine injections into the olfactory bulb transported labeling was seen over the lateral entorhinal area, except its most medial part, and over the rostral part of the medial entorhinal area. The labeling covers exclusively layer Ia. The lateral and medial entorhinal areas are also reached by fibers from the prepiriform cortex. The projection to the medial entorhinal area has not been described previously. Following injections of ³H-leucine into the PPCa transported labeling is present over the entire expanse of the entorhinal cortex and is located over layer Ib with the greatest density in its superficial part. Injections of ³H-leucine into the PPCp give rise to transported labeling over much of the entorhinal cortex. No labeling was found over the most medial parts of the medial subdivision (VMEA) of the lateral entorhinal area and the medial entorhinal area. Labeling occupies layer Ib, especially its middle part, and layers II and III. Both PPCa and PPCp appear to project most heavily to the dorsal (DLEA) and ventral (VLEA) subdivisions of the lateral entorhinal area. From the retrograde experiments it can be inferred that cells of layers II and III of the PPCa project predominantly to the DLEA, whereas those of the PPCp project predominantly to the VLEA. The MEA receives its heaviest projection from layer II of both PPCa and PPCp. In control experiments with ³H-leucine injections into the endopiriform nucleus it was found that this nucleus projects to the entire expanse of the entorhinal cortex. The fibers distribute to all layers with the exception of layer Ia.Abbreviations AI agranular insular cortex - AL lateral nucleus of the amygdala - BL basolateral nucleus of the amygdala - BM basomedial nucleus of the amygdala - C claustrum - CoA cortical nucleus of the amygdala - DLEA dorsal division of the lateral entorhinal cortex - END endopiriform nucleus - H hippocampus - I granular insular cortex - lot lateral olfactory tractus - MCL mitral cell layer of the olfactory bulb - MEA medial entorhinal area - OB olfactory bulb - PPCa anterior part of the prepiriform nucleus - PPCp posterior part of the prepiriform nucleus - VLEA ventral division of the lateral entorhinal cortex - VMEA ventromedial division of the lateral entorhinal cortex - 35 area 35 of the perirhinal cortex - 36 area 36 of the perirhinal cortex     

Anatomical evidence for direct connections between the shell and core subregions of the rat nucleus accumbens

The nucleus accumbens is thought to subserve different aspects of adaptive and emotional behaviors. The anatomical substrates for such actions are multiple, parallel ventral striatopallidal output circuits originating in the nucleus accumbens shell and core subregions. Several indirect ways of interaction between the two subregions and their associated circuitry have been proposed, in particular through striato-pallido-thalamic and dopaminergic pathways. In this study, using anterograde neuroanatomical tracing with Phaseolus vulgaris-leucoagglutinin and biotinylated dextran amine as well as single-cell juxtacellular filling with neurobiotin, we investigated the intra-accumbens distribution of local axon collaterals for the identification of possible direct connections between the shell and core subregions. Our results show widespread intra-accumbens projection patterns, including reciprocal projections between specific parts of the shell and core. However, fibers originating in the core reach more distant areas of the shell, including the rostral pole (i.e. the calbindin-poor part of the shell anterior to the core) and striatal parts of the olfactory tubercle, than those arising in the shell and projecting to the core. The latter projections are more restricted to the border region between the shell and core. The density of the fiber labeling within both the shell and core was very similar. Moreover, specific intrinsic projections within shell and core were identified, including a relatively strong projection from the rostral pole to the rostral shell, reciprocal projections between the rostral and caudal shell, as well as projections within the core that have a caudal-to-rostral predominance. The results of the juxtacellular filling experiments show that medium-sized spiny projection neurons and medium-sized aspiny neurons (most likely fast-spiking) contribute to these intra-accumbens projections. While such neurons are GABAergic, the intrastriatal projection patterns indicate the existence of lateral inhibitory interactions within, as well as between, shell and core subregions of the nucleus accumbens.     

Organization of the thalamostriatal projections in the rat, with special emphasis on the ventral striatum

The organization of the thalamic projections to the ventral striatum in the rat was studied by placing injections of the retrograde tracer cholera toxin subunit B in the ventral striatum and small deposits of the anterograde tracer Phaseolus vulgaris-leucoagglutinin (PHA-L) in individual midline and intralaminar thalamic nuclei. In order to provide a complete map of the midline and intralaminar thalamostriatal projections, PHA-L injections were also made in those parts of the intralaminar nuclei that project to the dorsal striatum. The relationship of thalamic afferent fibres with the compartmental organization of the ventral striatum was assessed by combining PHA-L tracing and enkephalin immunohistochemistry. The various midline and intralaminar thalamic nuclei project to longitudinally oriented striatal sectors. The paraventricular thalamic nucleus sends most of its fibres to medial parts of the nucleus accumbens and the olfactory tubercle, whereas smaller contingents of fibres terminate in the lateral part of the nucleus accumbens and the most ventral, medial, and caudal parts of the caudate-putamen complex. The projections of the parataenial nucleus are directed towards central and ventral parts of the nucleus accumbens and intermediate mediolateral parts of the olfactory tubercle. The intermediodorsal nucleus projects to lateral parts of the nucleus accumbens and the olfactory tubercle and to ventral parts of the caudate-putamen. The projection of the rhomboid nucleus is restricted to the rostrolateral extreme of the striatum. A diffuse projection to the ventral striatum arises from neurons ventral and caudal to the nucleus reuniens rather than from cells inside the nucleus. Fibres from the central medial nucleus terminate centrally and dorsolaterally in the rostral part of the nucleus accumbens and medially in the caudate-putamen. Successively more lateral positions in the caudate-putamen are occupied by fibres from the paracentral and central lateral nuclei, respectively. The lateral part of the parafascicular nucleus projects to the most lateral part of the caudate-putamen, whereas projections from the medial part of this nucleus terminate in the medial part of the caudate-putamen and in the dorsolateral part of the nucleus accumbens. Furthermore, a rostral to caudal gradient in a midline or intralaminar nucleus corresponds to a dorsal to ventral and rostral to caudal gradient in the striatum. In the ventral striatum, thalamic afferent fibres in the "shell" region of the nucleus accumbens avoid areas of high cell density and weak enkephalin immunoreactivity.(ABSTRACT TRUNCATED AT 400 WORDS)     

Heterogeneity in the Dorsal Subiculum of the Rat. Distinct Neuronal Zones Project to Different Cortical and Subcortical Targets

The aim of the present study was to relate the distribution of efferents of the dorsal subiculum to their origin along the proximodistal axis of the subiculum. The distribution of subicular projections was studied in detail by means of the sensitive anterograde tracer Phaseolus vulgaris-leucoagglutinin (PHA-L), and the precise origin of these projections analysed with retrogradely transported fluorescent tracers, using double- and triple-labelling protocols. Injections of PHA-L in the proximal part of the dorsal subiculum, i.e. that part which borders field CA1, result in labelling of the infralimbic, entorhinal and perirhinal cortices, the nucleus accumbens and the lateral septal region, the interanteromedial nucleus of the thalamus, the core of the nucleus gelatinosus, and the mammillary nuclei, in particular in the rostral parts of the medial nucleus. In contrast, injections in the distal part of the dorsal subiculum, i.e. that part which borders the presubiculum, give rise to labelling in the retrosplenial and postrhinal cortices, the presubiculum, the anterior thalamic complex, the shell of the nucleus gelatinosus, and the mammillary nuclei, preferentially in the caudal part of the medial nucleus. The results of injections of different retrograde tracers, simultaneously placed in two or three targets of the subicular efferents, confirm the results of the anterograde tracing experiments. Moreover, they clearly demonstrate that the population of subicular neurons which, for example, projects to the nucleus accumbens and the interanteromedial nucleus of the thalamus is almost completely segregated from the population that projects to the retrosplenial cortex and the anterior complex of the thalamus. Thus within the dorsal subiculum, populations of neurons can be differentiated so that each population projects to a unique set of target structures. These cell populations are differentially positioned along the proximo-distal axis. In view of additional evidence indicating that some of the major afferents to the subiculum are organized along the same axis, we suggest that the heterogeneity of the dorsal subiculum along the proximo-distal axis reflects a general organizational characteristic of this hippocampal field.     

Het identificeren van benzodiazepinen en het aantonen van ontledings-produkten met behulp van een en hetzelfde DLC-systeem

Samenvatting Een systeem voor dunnelaagchromatografie wordt beschreven met behulp waarvan twaalf verschillende benzodiazepinen kunnen worden geïdentificeerd en waarmee tevens eventuele ontledingsprodukten kunnen worden aangetoond. Er wordt gebruik gemaakt vanhptlc Silica Gel 60 F₂₅₄ plaatjes en als loopvloeistof wordt tolueen-methanol (96 + 6) gebruikt.De vlekjes kunnen direct onderuv-licht worden waargenomen; ze kunnen nader worden geïdentificeerd na bespuiten met zwavelzuur en/of het reagens van Bratton Marshall. Van enkele benzodiazepinen kan de identiteit echter pas worden vastgesteld nadat ze zijn gehydrolyseerd.     

The strength of primary care in Europe: an international comparative study

Background

A suitable definition of primary care to capture the variety of prevailing international organisation and service-delivery models is lacking.

Aim

Evaluation of strength of primary care in Europe.

Design and setting

International comparative cross-sectional study performed in 2009–2010, involving 27 EU member states, plus Iceland, Norway, Switzerland, and Turkey.

Method

Outcome measures covered three dimensions of primary care structure: primary care governance, economic conditions of primary care, and primary care workforce development; and four dimensions of primary care service-delivery process: accessibility, comprehensiveness, continuity, and coordination of primary care. The primary care dimensions were operationalised by a total of 77 indicators for which data were collected in 31 countries. Data sources included national and international literature, governmental publications, statistical databases, and experts’ consultations.

Results

Countries with relatively strong primary care are Belgium, Denmark, Estonia, Finland, Lithuania, the Netherlands, Portugal, Slovenia, Spain, and the UK. Countries either have many primary care policies and regulations in place, combined with good financial coverage and resources, and adequate primary care workforce conditions, or have consistently only few of these primary care structures in place. There is no correlation between the access, continuity, coordination, and comprehensiveness of primary care of countries.

Conclusion

Variation is shown in the strength of primary care across Europe, indicating a discrepancy in the responsibility given to primary care in national and international policy initiatives and the needed investments in primary care to solve, for example, future shortages of workforce. Countries are consistent in their primary care focus on all important structure dimensions. Countries need to improve their primary care information infrastructure to facilitate primary care performance management.