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Un vínculo claro entre la evaluación y la toma de decisión constituye un principio de buena práctica en evaluación de tecnologías sanitarias (ETESA) reconocido a nivel internacional. El objetivo del Foro de Políticas en Latino-América (LatamPF) 2019 de Health Technology Assessment International fue explorar los diferentes modelos que vinculan la ETESA y la toma de decisión y discutir su potencial aplicabilidad en Latino-América.
Este manuscrito está basado en un documento base y en el trabajo deliberativo realizado por los miembros (54 participantes, 12 países) que asistieron al LatamPF, a través de la metodología design thinking.
Los participantes coincidieron en que la relación inapropiada entre la ETESA y la toma de decisión atenta hoy contra la legitimidad de las decisiones, expone al proceso de ETESA a una excesiva influencia política y judicial, y condiciona que algunos actores se sientan relegados del proceso de evaluación y toma de decisión. Se identificaron los atributos del proceso de ETESA más prioritarios y factibles de ser mejorados en la región, y con el mayor potencial para generar un cambio positivo en los sistemas de salud. La mayor parte de estos están vinculados con la apropiada institucionalización de la ETESA, ampliar la participación de los diferentes actores y mejorar la transparencia de los procesos de ETESA.
El LatamPF ha identificado barreras y recomendado acciones para reforzar el vínculo entre ETESA y la decisión. A su vez, existe en estos momentos una ventana de oportunidad en la región, ya que el tema es visualizado como una prioridad por gran parte de los actores de la sociedad. Por ello, los diferentes actores de los sistemas sanitarios deberían ahora tomar esta oportunidad para avanzar en el fortalecimiento del vínculo entre ETESA y toma de decisión.
One of the good practice principles for health technology assessment (HTA) is having a clear link between the assessment and decision making. The objective of the 2019 Latin American Policy Forum (LatamPF) of Health Technology Assessment International was to explore different models of connection between HTA and decision making and to discuss the potential applicability of such models in Latin America.
This paper is based on a background document and the deliberations of the members of the LatamPF (fifty-four participants from twelve countries) where a design-thinking methodology was used.
The participants agreed that insufficient links between HTA and decision making undermine the legitimacy of decisions, expose the HTA process to excessive political and judicial influence, and promote the exclusion of some stakeholders from participating in the assessment process and decision making. High priority aspects of the HTA process that could feasibly be improved and which hold the greatest potential to generate positive changes in the health systems in the region were identified. The majority of these aspects were associated with the appropriate institutionalization of HTA, a greater degree of participation by different stakeholders, and improved transparency in the HTA process.
The LatamPF identified barriers and recommended actions to strengthen the link between HTA and decision making. Participants emphasized that there is now a window of opportunity in the region as many societal actors see this as a priority. For this reason, health system stakeholders must take this opportunity to increase efforts toward strengthening the link between HTA and decision making.
This article presents new evidence and analysis on age heaping—a proxy for numeracy and therefore for human capital—in New Spain during the Enlightenment. Human capital plays an important role in economic growth and welfare. It is also one of the dimensions of inequality. Our results are at odds with many of the usual assumptions on which most Mexicanist historiography is based. Age heaping levels of males and females and ethnic groups across locations in Central New Spain are estimated and compared through ad hoc indicators with other countries. We infer that a more empirical emphasis on the institutional legacy of the viceregal period and more attention to human capital since pre-Conquest times will benefit the progress of Hispanic American economic history.
Although it is known that certain emotion regulation processes produce a buffering effect on the relationship between life events and well-being, this issue has been poorly studied in the elderly population. Thus, the aim of the present study is to test and confirm a comprehensive model of the impact that past life events have on older adults’ psychological distress, exploring the possible mediating roles of emotion regulation processes. These include rumination, experiential avoidance, and personal growth.
In this cross-sectional study, 387 people over 60 years old residing in the community were assessed on life events, physical functioning, emotion regulation variables, psychological well-being, as well as symptoms of anxiety and depression.
The structural model tested achieved a satisfactory fit to the data, explaining 73% of the variance of older adults’ psychological distress. In addition, the main results suggest possible mediation effects of both the physical functioning and the emotional variables: rumination, experiential avoidance, and personal growth in the face of hardship.
These findings confirm the importance of emotion regulation processes in the final stages of life. They reveal the various adaptive and maladaptive mechanisms that underlie the relationship between life events and psychological distress. The findings suggest – both in the explanatory models of psychological well-being and in psychotherapeutic interventions – the importance of emotion regulation in the elderly population’s health.
The maternal brain undergoes adaptations to sensitive caregiving that are critical for infant well-being. We investigated structural alterations associated with neglectful caregiving and their effects on mother–child interactive behavior. High-resolution 3D volumetric images were obtained on 25 neglectful (NM) and 23 non-neglectful control (CM) mothers. Using voxel-based morphometry, we compared differences in gray and white matter (GM and WM, respectively) volume. Mothers completed an empathy scale and participated with their children in a play task (Emotional Availability Scale, EA). Neglectful mothers showed smaller GM volume in the right insula, anterior/middle cingulate (ACC/MCC), and right inferior frontal gyrus and less WM volume in bilateral frontal regions than did CM. A greater GM volume was observed in the right fusiform and cerebellum in NM than in CM. Regression analyses showed a negative effect of greater fusiform GM volume and a positive effect of greater right frontal WM volume on EA. Mediation analyses showed the role of emotional empathy in the positive effect of the insula and right inferior frontal gyrus and in the negative effect of the cerebellum on EA. Neglectful mothering involves alterations in emotional empathy-related areas and in frontal areas associated with poor mother–child interactive bonding, indicating how critical these areas are for sensitive caregiving.
This paper deals with the evolution of wages in the construction offices of Segovia, one of the most important Castilian and Spanish manufacturing towns, between 1571 and 1807. Part two deals with the nominal wages earned by the building officials and labourers of the city and part three presents the Segovian prices index between 1571 and 1807. Finally, part four analyses the evolution of the real wages earned in the construction offices of the town. Segovian real wages evolved in line with the local economy; after peaking in the first quarter of the 17th century, they experienced a continuous decline, so in 1807 the real wages of Segovian building officials and labourers were 50 per cent of those of the first quarter of the 17th century.
In the intensive care setting, delirium is a common occurrence; however, the impact of the level of alertness has never been evaluated. Therefore, this study aimed to assess the delirium characteristics in the drowsy, as well as the alert and calm patient.
In this prospective cohort study, 225 intensive care patients with Richmond Agitation and Sedation Scale (RASS) scores of −1 — drowsy and 0 — alert and calm were evaluated with the Delirium Rating Scale-Revised-1998 (DRS-R-98) and the Diagnostic and Statistical Manual 4th edition text revision (DSM-IV-TR)-determined diagnosis of delirium.
In total, 85 drowsy and 140 alert and calm patients were included. Crucial items for the correct identification of delirium were sleep–wake cycle disturbances, language abnormalities, thought process alterations, psychomotor retardation, disorientation, inattention, short- and long-term memory, as well as visuo-spatial impairment, and the temporal onset. Conversely, perceptual disturbances, delusions, affective lability, psychomotor agitation, or fluctuations were items, which identified delirium less correctly. Further, the severities of inattentiveness and visuo-spatial impairment were indicative of delirium in both alert- or calmness and drowsiness.
Significance of results
The impairment in the cognitive domain, psychomotor retardation, and sleep–wake cycle disturbances correctly identified delirium irrespective of the level alertness. Further, inattentiveness and — to a lesser degree — visuo-spatial impairment could represent a specific marker for delirium in the intensive care setting meriting further evaluation.
Little is known about changes in brain functioning after first-episode psychosis (FEP). Such knowledge is important for predicting the course of disease and adapting interventions. Functional magnetic resonance imaging has become a promising tool for exploring brain function at the time of symptom onset and at follow-up.
A systematic review of longitudinal fMRI studies with FEP patients according to PRISMA guidelines. Resting-state and task-activated studies were considered together.
Eleven studies were included. These reported on a total of 236 FEP patients were evaluated by two fMRI scans and clinical assessments. Five studies found hypoactivation at baseline in prefrontal cortex areas, two studies found hypoactivation in the amygdala and hippocampus, and three others found hypoactivation in the basal ganglia. Other hypoactivated areas were the anterior cingulate cortex, thalamus and posterior cingulate cortex. Ten out of eleven studies reported (partial) normalization by increased activation after antipsychotic treatment. A minority of studies observed hyperactivation at baseline.
This review of longitudinal FEP samples studies reveals a pattern of predominantly hypoactivation in several brain areas at baseline that may normalize to a certain extent after treatment. The results should be interpreted with caution given the small number of studies and their methodological and clinical heterogeneity.
Trypanosoma cruzi is the causative agent of Chagas disease, a vector-borne disease. The parasite molecules involved in vector interaction have been little investigated. Metallopeptidases and gp63 molecules have been implicated in parasite adhesion of several trypanosomatids to the insect midgut. Although gp63 homologues are highly expanded in the T. cruzi genome, and are implicated in parasite–mammalian host interaction, its role in the insect vector has never been explored. Here, we showed that divalent metal chelators or anti-Tcgp63-I antibodies impaired T. cruzi adhesion to Rhodnius prolixus midgut. Parasites isolated after insect colonization presented a drastic enhancement in the expression of Tcgp63-I. These data highlight, for the first time, that Tcgp63-I and Zn-dependent enzymes contribute to the interaction of T. cruzi with the insect vector.
Our purpose was to determine the effectiveness and harms of vaccination in patients with any sexual history to prevent the prevalence of papillomavirus infection. A search strategy was conducted in the MEDLINE, CENTRAL, EMBASE and LILACS databases. Searches were also conducted in other databases and unpublished literature. The risk of bias was evaluated with the Cochrane Collaboration's tool. Analysis of fixed effects was conducted. The primary outcome was the infection by any and each human papillomavirus (HPV) genotype, serious adverse effects and short-term adverse effects. The measure of the effect was the risk difference (RD) with a 95% confidence interval (CI). The planned interventions were bivalent vaccine/tetravalent/nonavalent vs. placebo/no intervention/other vaccines. We included 29 studies described in 35 publications. Bivalent HPV vaccine offers protection against HPV16 (RD −0.05, 95% CI −0.098 to −0.0032), HPV18 (RD −0.03, 95% CI −0.062 to −0.0004) and HPV16/18 genotypes (RD of −0.1, 95% CI −0.16 to −0.04). On the other side, tetravalent HPV vaccine offered protection against HPV6 (RD of −0.0500, 95% CI −0.0963 to −0.0230), HPV11 (RD −0.0198, 95% CI −0.0310 to −0.0085). Also, against HPV16 (RD of −0.0608, 95% CI −0.1126 to −0.0091) and HPV18 (RD of −0.0200, 95% CI −0.0408 to −0.0123). There was a reduction in the prevalence of HPV16, 18 and 16/18 genotypes when applying the bivalent vaccine, with no increase in adverse effects. Regarding the tetravalent vaccine, we found a reduction in the prevalence of HPV6, 11, 16 and 18 genotypes, with no increase in adverse effects.
The recent development of value frameworks to inform healthcare resource allocation responds to a demand to make the decision-making process more inclusive and explicit. The objectives of the 2018 Latin American (LAtam) Health Technology Assessment International (HTAi) Policy Forum were to explore the current international experiences and to discuss the potential application of value frameworks in Latin America.
A background paper, presentations, and group discussions of Policy Forum members (43 participants, 12 LAtam countries represented) at the 2018 HTAi Policy Forum meeting informed this paper.
Participants agreed that HTA and decision making based on more comprehensive and inclusive value frameworks could improve health system effectiveness, efficiency, sustainability, and equity; promote transparency in the decision process; sustain a more comprehensive assessment of technologies; and facilitate stakeholder participation as well as accountability of decisions. Criteria that were identified as essential to be included in a value framework for LAtam were burden of illness and severity of the disease, effectiveness and safety of the technology, quality of the evidence, cost-effectiveness, and budget impact. Potential challenges identified for the application of value frameworks in LAtam, included scarcity of human resources and delays in the assessment process.
Forum participants agreed that the next steps should be to identify appropriate processes and methodologies, adapted to the context of each country, regarding the application of value frameworks to improve the link between HTA and decision making.
Pure metallic nanofoams in the form of interconnected networks have shown strong potentials over the past few years in areas such as catalysts, batteries and plasmonics. However, they are often fragile and difficult to integrate in engineering applications. In order to better understand their deformation mechanisms, a multiscale approach is required to simulate the mechanical behavior of the nanofoams, although these materials will operate at the macroscale, they will still be maintaining an atomistic ordering. Hence, in this work we combine molecular dynamics (MD) and finite element analysis (FEA) to study the mechanical behavior of copper (Cu) nanofoams. Molecular dynamics simulations were performed to study the yield surface of a representative cell structure. The nanofoam structure has been generated by spinodal decomposition of binary alloy using an atomistic approach. Then, the information obtained from the molecular dynamics simulations in the form of yield function is transferred to the finite element model to study the macroscopic behavior of the Cu nanofoams. The simulated mechanical behavior of Cu nanofoams is in good agreement of the real experiment results.
El reciente desarrollo de marcos de valor responde a una demanda por hacer más explícito e inclusivo el proceso de toma de decisiones sobre asignación de recursos sanitarios. El objetivo del Foro de Políticas en Latino América 2018 de Health Technology Assessment International fue explorar las experiencias internacionales y discutir la potencial aplicación de marcos de valor en la región.
Este manuscrito está basado en un documento base y en las presentaciones y discusiones mantenidas por los miembros del Foro (43 participantes, 12 países) durante el Foro del 2018.
Los participantes coincidieron en que un proceso de evaluación y toma de decisión basado en marcos de valor más inclusivos y abarcativos podría mejorar la efectividad, eficiencia, sustentabilidad y equidad; promover la transparencia y una evaluación más completa de las tecnologías, mejorar la rendición de cuentas de las decisiones y la participación de actores. Se identificaron como criterios esenciales para ser incluidos en marcos de valor en la región a la carga de enfermedad y severidad de la condición, la efectividad y seguridad de la tecnología, la calidad de la evidencia, la costo-efectividad e impacto presupuestario. Los potenciales desafíos para su implementación identificados incluyeron la escasez de recursos humanos y las demoras en el proceso de evaluación que se podrían producir.
Los participantes remarcaron que los próximos pasos deberían ser identificar procesos y metodologías apropiadas, adaptadas al contexto de cada país, para facilitar la aplicación de marcos de valor y mejorar el vínculo entre la evaluación y la toma de decisiones.
The importance of the proper identification of delirium, with its high incidence and adversities in the intensive care setting, has been widely recognized. One common screening instrument is the Intensive Care Delirium Screening Checklist (ICDSC); however, the symptom profile and key features of delirium dependent on the level of sedation have not yet been evaluated.
In this prospective cohort study, the ICDSC was evaluated versus the Diagnostic and Statistical Manual, 4th edition, text revision, diagnosis of delirium set as standard with respect to the symptom profile, and correct identification of delirium. The aim of this study was to identify key features of delirium in the intensive care setting dependent on the Richmond Agitation and Sedation Scale levels of sedation: drowsiness versus alert and calmness.
The 88 delirious patients of 225 were older, had more severe disease, and prolonged hospitalization. Irrespective of the level of sedation, delirium was correctly classified by items related to inattention, disorientation, psychomotor alterations, inappropriate speech or mood, and symptom fluctuation. In the drowsy patients, inattention reached substantial sensitivity and specificity, whereas psychomotor alterations and sleep-wake cycle disturbances were sensitive lacked specificity. The positive prediction was substantial across items, whereas the negative prediction was only moderate. In the alert and calm patient, the sensitivities were substantial for psychomotor alterations, sleep-wake cycle disturbances, and symptom fluctuations; however, these fluctuations were not specific. The positive prediction was moderate and the negative prediction substantial. Between the nondelirious drowsy and alert, the symptom profile was similar; however, drowsiness was associated with alterations in consciousness.
Significance of results
In the clinical routine, irrespective of the level of sedation, delirium was characterized by the ICDSC items for inattention, disorientation, psychomotor alterations, inappropriate speech or mood and symptom fluctuation. Further, drowsiness caused altered levels of consciousness.
The aim of this study was to identify good practice principles for health technology assessment (HTA) that are the most relevant and of highest priority for application in Latin America and to identify potential barriers to their implementation in the region.
HTA good practice principles proposed at the international level were identified and then explored during a deliberative process in a forum of assessors, funders, and product manufacturers.
Forty-two representatives from ten Latin American countries participated. Good practice principles proposed at the international level were considered valid and potentially relevant to Latin America. Five principles were identified as priority and with the greatest potential to be strengthened at this time: transparency in the production of HTA, involvement of relevant stakeholders in the HTA process, mechanisms to appeal decisions, clear priority-setting processes in HTA, and a clear link between HTA and decision making. The main challenge identified was to find a balance between the application of these principles and the available resources in a way that would not detract from the production of reports and adaptation to the needs of decision makers.
The main recommendation was to progress gradually in strengthening HTA and its link to decision making by developing appropriate processes for each country, without trying to impose, in the short-term, standards taken from examples at the international level without adequate adaptation of these to local contexts.
Although the rumen fluke, Calicophoron daubneyi is now very common and widespread throughout Western Europe, reports of clinical cases are still rare. This study explores the epidemiological background to a severe rumen fluke outbreak in 6-month-old heifers on a dairy farm in Ireland. Sequence analysis of the cytochrome oxidase subunit 1 (Cox1) gene of the rumen fluke metacercariae on pasture failed to identify predominant, possibly pathogenic subtypes. However, estimates of metacercarial load indicated that the animals were exposed to a daily dose of about 5334 C. daubneyi metacercariae for a period of 3 weeks resulting in the build-up of very large numbers of immature worms in the small intestine. It is hypothesized that specific environmental conditions may favour this parasite over its competitor, the liver fluke, Fasciola hepatica, possibly by allowing it to emerge earlier. The possibility that C. daubneyi may be better adapted to the Irish climate than F. hepatica together with the fact that selective treatment against F. hepatica effectively frees the niche for C. daubneyi, may result in the gradual replacement of F. hepatica by C. daubneyi.
Post-Asymptotic giant branch (post-ABG) sources with high-velocity spectral features of H2O maser emission detected toward their circumstellar envelopes (CSEs) are known as Water Fountain (WF) nebulae. These are low- or intermediate-mass Galactic stellar sources that are undergoing the late stages of an intense mass-loss process. The velocity and the spatial distribution of the H2O maser spectral features can provide information about the kinematics of the molecular gas component of their CSEs. Hence, observational studies toward WF nebulae could help to better understand the formation of the asymmetric structures (hundred to thousand AUs) commonly seen toward Planetary nebulae (PNe). Here we present preliminary results of observations done toward the WF IRAS 15445-5449 using the Australia Telescope Compact Array (ATCA) and the Very Large Telescope (SINFONI/VLT). Assuming that the pumping of the H2O maser transitions is a consequence of shocks between different velocity winds, the spatial distribution of the emission shed light on the scales of the regions affected by the propagation of the shock-fronts.
Temporal variations over short and medium time scales play an important role in fish assemblage dynamics, but have been poorly investigated in tropical estuaries. This study evaluates the hypothesis that fishes co-occurring on a tidal mudflat have different patterns of temporal segregation at short- and medium-term scales that optimize resource use and habitat partitioning. A total of 6222 individuals and 66 fish species were caught during different hours covering the entire 24 h cycle, tidal regimes and the wet and dry seasons. Biomass and species richness, and to a lesser extent CPUE and evenness, showed statistically significant interactions across short- and medium-term scales. Biomass was higher during the dry season and its oscillation along tidal cycles revealed distinct patterns over the photoperiod in each season. A similar complex pattern was also observed for species richness, which showed distinct temporal patterns between high and low tides over the photoperiod in each season. Overall, shorter-term variations on fish assemblage attributes were correlated mainly with photoperiod and, to a lesser extent, tidal regime. Medium-term variations in fish abundance and species richness, in contrast, could result from seasonality in recruitment patterns and higher availability of allochthonous food resources during the wet period.
Fasciola hepatica has both zoonotic importance and high economic impact in livestock worldwide. After ingestion by the definitive host, the Newly Excysted Juveniles (NEJ) penetrate the intestine before reaching the peritoneal cavity. The role of some NEJ-derived proteins in invasion has been documented, but the role of NEJ glycans or lectin-binding receptors during initial infection in the gut is still unknown. To address these questions, the migration of NEJ through rat intestine was recorded at 30 min intervals up to 150 min by two ex vivo methods. Firstly, jejunal sheets were challenged with NEJ incubated with biotinylated lectins. Secondly, untreated NEJ were incubated with distal jejunum pre-treated with lectins. Both Concanavalin A (ConA) and Galanthus nivalis (GNL), which recognize mannose-type N-glycans, significantly inhibited NEJ migration across the jejunum. Most of the lectins bound to the tegument and oral sucker of the NEJ, but only ConA and GNL maintained this interaction over 150 min. None of the lectins examined significantly reduced NEJ migration when pre-incubated with jejunal sheets, suggesting that host glycans might not be essential for initial binding/recognition of the gut by NEJ. Agents capable of blocking mannose-type N-glycans on the NEJ tegument may have potential for disrupting infection.
Attachment is an innate programming whereby a child seeks for security. There is scientific and empirical evidence that insecure attachment is usual in eating disorder patients .
To highlight the relevance of attachment between child and caregivers, as well as its significance in therapeutic approach.
A 17-year-old girl hospitalized after attending to emergency department due to fainting. BMI: 12.89. She reports restrictive behavior since age 11 that her mother regards as “child issues”. Divorced parents, she grew up with her mother, diagnosed of hypochondria, who mentions not understanding why she is not the one who is hospitalized.
During hospitalization, she turned 18-years-old. Guardianship of her younger siblings was removed to her mother. She had a secure relationship with her 24-year-old sister, so she decided to move in with her. Later on, she had a positive progress, maintaining the gained weight and mood stability, although cognitive distortions persist.
Among developmental and maintaining factors of eating disorders, impaired attachment is becoming increasingly interesting. Even though the main goal of treatment is weight restoration, exploring attachment patterns can facilitate to achieve that aim. This clinical case emphasizes the importance of attachment in eating disorders among child and young adults.
Disclosure of interest
The authors have not supplied their declaration of competing interest.