Economic evaluation of a multimorbidity patient centered care model implemented in the Chilean public health system.

Multimorbidity and patient-centered care approaches are growing challenges for health systems and patients. The cost of multimorbidity patients and the transition to a new care strategy is still sightly explored. In Chile, more than 70% of the adult population suffer from multimorbidity, opening an opportunity to implement a Multimorbidity patient-centered care model. The objective of this study was to perform an economic evaluation of the model from the public health system perspective.The methodology used a cost-consequence evaluation comparing seven exposed with seven unexposed primary care centers, and their reference hospitals. It followed three steps. First, we performed a Time-Driven Activity-Based Costing with routinely collected data routinely collected. Second, we run a comparative analysis through a propensity score matching and an estimation of the attributable costs to health services utilization at primary, secondary and tertiary care and health outcomes. Third, we estimated implementation and transaction costs.Results showed savings in aggregate costs of the total population (-0.12 (0.03) p < 0.01) during the period under evaluation. Costs in primary care showed a significant increase, whereas tertiary care showed significant savings. Health outcomes were associated with higher survival in patients under the new care model (HR 0.70 (0.05) p < 0.01). Implementation and transaction costs increased as the number of pilot intervention centers increased, and they represented 0,07% of the total annual budget of the Servicio de Salud Metropolitano Sur Oriente. After three years of piloting, the implementation and transaction cost for the total period was USD 1,838,767 and 393,775, respectively.The study's findings confirm the purpose of the new model to place primary health care at the center of care for people with non-communicable chronic diseases. Thus, it is necessary to consider implementation and transaction costs to introduce a broad health system multimorbidity approach. The health system should assume some of them permanently to guarantee sustainability and facilitate scale-up.

Extension of Duplexed Single-Ended Distributed Temperature Sensing Calibration Algorithms and Their Application in Geothermal Systems.

Fiber-optic distributed temperature sensing (DTS) has been widely used since the end of the 20th century, with various industrial, Earth sciences, and research applications. To obtain precise thermal measurements, it is important to extend the currently available DTS calibration methods, considering that environmental and deployment factors can strongly impact these measurements. In this work, a laboratory experiment was performed to assess a currently available duplexed single-ended DTS calibration algorithm and to extend it in case no temperature information is available at the end of the cables, which is extremely important in geothermal applications. The extended calibration algorithms were tested in different boreholes located in the Atacama Desert and in the Central Andes Mountains to estimate the geothermal gradient in these regions. The best algorithm found achieved a root mean square error of 0.31 ± 0.07 °C at the far end of a ~1.1-km cable, which is much smaller than that obtained using the manufacturer algorithm (2.17 ± 0.35 °C). Moreover, temperature differences between single- and double-ended measurements were less than 0.3 °C at the far end of the cable, which results in differences of ~0.5 °C km-1 when determining the geothermal gradient. This improvement in the geothermal gradient is relevant, as it can reduce the drilling depth by at least 700 m in the study area. Future work should investigate new extensions of the algorithms for other DTS configurations and determining the flow rate of the Central Andes Mountains artesian well using the geothermal profile provided by the DTS measurements and the available data of the borehole.

Obeticholic Acid and Fibrates in Primary Biliary Cholangitis: Comparative Effects in a Multicentric Observational Study.

INTRODUCTION: Obeticholic acid (OCA) and fibrates therapy results in biochemical improvement in placebo-controlled trials in patients with primary biliary cholangitis and insufficient response to ursodeoxycholic acid. There is scarce information outside of clinical trials. Therefore, we have assessed the effectiveness and adverse events of these treatments. METHODS: Data from patients included in the ColHai registry treated with OCA, fibrates, or both were recorded during a year, as well as adverse events and treatment discontinuation. RESULTS: Eighty-six patients were treated with OCA, 250 with fibrates (81% bezafibrate; 19% fenofibrate), and 15 with OCA plus fibrates. OCA group had baseline significantly higher alkaline phosphatase (ALP) (P = 0.01) and lower platelets (P = 0.03) than fibrates. Both treatments significantly decreased ALP, gamma-glutamyl transferase (GGT), and transaminases and improved Globe score. Albumin and immunoglobulin type M improved in the fibrates group. ALP decrease was higher under fibrates, whereas alanine aminotransferase decline was higher under OCA. Although baseline transaminases and GGT were higher in patients with OCA plus fibrates, significant ALP, GGT, alanine aminotransferase, and Globe score improvement were observed during triple therapy. Adverse events were reported in 14.7% of patients (21.3% OCA; 17.6% fenofibrate; 10.7% bezafibrate), mainly pruritus (10.1% with OCA). Discontinuation was more frequent in fenofibrate treatment mainly because of intolerance or adverse events. DISCUSSION: Second-line therapy with OCA or fibrates improves hepatic biochemistry and the GLOBE score in primary biliary cholangitis patients with suboptimal response to ursodeoxycholic acid. Simultaneous treatment with OCA and fibrates improved ALP as well.

A New Current-Shaping Technique Based on a Feedback Injection Mechanism to Reduce VCO Phase Noise.

Inductor-capacitor voltage controlled oscillators (LC-VCOs) are the most common type of oscillator used in sensors systems, such as transceivers for wireless sensor networks (WSNs), VCO-based reading circuits, VCO-based radar sensors, etc. This work presents a technique to reduce the LC-VCOs phase noise using a new current-shaping method based on a feedback injection mechanism with only two additional transistors. This technique consists of keeping the negative resistance seen from LC tank constant throughout the oscillation cycle, achieving a significant phase noise reduction with a very low area increase. To test this method an LC-VCO was designed, fabricated and measured on a wafer using 90 nm CMOS technology with 1.2 V supply voltage. The oscillator outputs were buffered using source followers to provide additional isolation from load variations and to boost the output power. The tank was tuned to 1.8 GHz, comprising two 1.15 nH with 1.5 turns inductors with a quality factor (Q) of 14, a 3.27 pF metal-oxide-metal capacitor, and two varactors. The measured phase noise was -112 dBc/Hz at 1 MHz offset. Including the pads, the chip area is 750 × 850 µm2.

Results in liver transplantation using grafts from donors after controlled circulatory death: A single-center experience comparing donor grafts harvested after controlled circulatory death to those harvested after brain death.

BACKGROUND: In recent years, interest in donation after cardiac death (DCD) has increased. Although DCD liver transplantation (LT) has demonstrated satisfactory long-term outcomes, different studies have shown poorer patient and graft survival after DCD than after donation after brain death (DBD). This study aimed to evaluate the results of LT using controlled DCD (cDCD) donors, specifically the incidence of primary non-function and ischemic cholangiopathy (IC), and to compare these results with those of LT using DBD in the same time period. METHODS: Between June 2012 and July 2018, we performed 66 transplants using cDCD and 258 with DBD grafts. RESULTS: The incidence of IC was similar in both groups (2% in DBD, 1.5% in DCD; P = .999). No significant differences were found for overall graft and patient survival rates between the groups at 1 and 2 years post-transplantation. CONCLUSIONS: This study provided evidence that cDCD donors exhibit excellent graft and patient survival outcomes. When the warm ischemia time is <30 minutes and cold ischemia time is <6 hours, the graft and patient survival rates and the incidence of IC in DCD are similar to those in DBD, even when using donors without age restrictions.

Impact of Transcatheter Device Closure of Atrial Septal Defect on Atrial Arrhythmias Propensity in Young Adults.

Atrial septal defect (ASD) is a condition that requires early intervention because of the consequences over the right-side heart. Chronic atrial stretching promotes atrial conduction delay and the imbalance of the conduction homogeneity, which lead to the propensity to atrial arrhythmias (AA). We aim to evaluate the impact of transcatheter closure of ASD on atrial vulnerability markers leading to late AA in young adults. We conducted a prospective, longitudinal study in one hundred patients (mean age 25.2 ± 5.4 years) who underwent transcatheter closure of ASD at Cardiocentro Pediátrico William Soler. P-wave maximum (Pmax) and P-wave dispersion (Pd) were analyzed from 12-lead electrocardiogram. Left-side and right-side intraatrial and interatrial electromechanical delay (EMD) were measured with tissue Doppler imaging. Both electrocardiographic and echocardiographic analyses were performed during the study period. Compared to baseline, there was a significant reduction in P max (p ≤ 0.001) and Pd (p ≤ 0.001) after 3 months of procedure. All atrial electromechanical coupling parameters significantly reduced at 6 months of ASD closure and tend to remain at lower values till the last evaluation. Over 9.2 ± 1.6 years of follow-up, 15 subjects (15%) developed AA, of which intraatrial reentrant tachycardia (66.6%) became the main rhythm disturbance. Intra-right atrial EMD ≥ 16 ms (HR 4.08, 95% CI 1.15-14.56; p = 0.03) and Pd 45 ms (HR 1.66, 95% CI 1.06-2.59; p = 0.02) were identified as predictors of late AA. Transcatheter device closure of ASD in young adults promotes a significant reduction of electrocardiographic and echocardiographic markers of AA vulnerability, which persist during the long-term follow-up. Nevertheless, Pd and interatrial EMD were identified as independent risk factors of AA.

Challenges in determining soil moisture and evaporation fluxes using distributed temperature sensing methods.

To protect fragile groundwater-dependent environments of arid zones, it is important to monitor soil moisture and groundwater evaporation. Hence, it is important to assess new methods to quantify these environmental variables. In this work, we propose a new method to determine groundwater evaporation rates by combining the actively heated fiber-optic (AHFO) method with vadose zone modeling, assuming that the evaporation front remains at the soil surface. In our study, the AHFO method yielded estimates of the soil moisture (θ) profile with a spatial resolution of ~6.5 mm and with an error of 0.026 m3 m-3. The numerical model resulted in a slightly different θ profile than that measured, where the largest differences occurred at the soil surface. Sensitivity and uncertainty analyses highlighted that a better precision is required when determining the soil hydraulic parameters. To improve the proposed method, the soil heat-vapor-water dynamics should be included and the assumption that the evaporation front remains at the soil surface must be relaxed. Additionally, if the AHFO calibration curve is enhanced, the errors of the estimated θ profile can be reduced and thus, successful estimation of the evaporation rates for a wider range of soil textures can be achieved. The spatial scales measured are an important advantage of the proposed method that should be further explored to improve the analysis presented here.

Influence of donor liver CYP3A4*20 loss-of-function genotype on tacrolimus pharmacokinetics in transplanted patients.

OBJECTIVE: Cytochrome P450 3A4 (CYP3A4) metabolizes about half of all drugs on the market; however, the impact of CYP3A4 loss-of-function variants on drug exposures remains poorly characterized. Here, we report the effect of the CYP3A4*20 frameshift allele in two Spanish liver transplant patients treated with tacrolimus. PATIENTS AND METHODS: A series of 90 transplanted patients (with DNA available for 89 of the recipients and 76 of the liver donors) treated with tacrolimus were included in the study. The genotypes of liver donors and of the recipients for CYP3A4*20 (rs67666821), CYP3A4*22 (rs35599367) and CYP3A5*3 (rs776746) were compared with weight-adjusted tacrolimus dose (D), tacrolimus trough concentration (C0), and dose-adjusted tacrolimus trough concentrations (C0/D) using the Mann-Whitney U-nonparametric test. RESULTS: The CYP3A4*20 allele was detected in two of the liver donors. This genotype yielded at all times higher C0/D (2.6-fold, average) than intermediate CYP3A metabolizers (CYP3A4*1/*1 and CYP3A5*3/*3) (P=0.045, 90 days after transplantation). CYP3A4*22 carriers showed a 1.9-fold average increase in C0/D (P=0.047, 0.025, and 0.053; at days 7, 14, and 30 after transplantation, respectively) compared with intermediate metabolizers. In terms of recipients' genotype, CYP3A5*1 had reduced (P=0.025) and CYP3A4*22 increased C0/D (P=0.056) 7 days after transplantation. The incidence of biopsy-proven acute rejection was 0, 12, and 20% for livers with poor, intermediate, and extensive CYP3A-metabolizing capacity, respectively (P=0.0995). CONCLUSION: This first description of CYP3A4*20 null genotype in liver-transplanted patients, supports the relevance of CYP3A genotyping in tacrolimus therapy.

Direct-acting antivirals are effective and safe in HCV/HIV-coinfected liver transplant recipients who experience recurrence of hepatitis C: A prospective nationwide cohort study.

Direct-acting antivirals have proved to be highly efficacious and safe in monoinfected liver transplant (LT) recipients who experience recurrence of hepatitis C virus (HCV) infection. However, there is a lack of data on effectiveness and tolerability of these regimens in HCV/HIV-coinfected patients who experience recurrence of HCV infection after LT. In this prospective, multicenter cohort study, the outcomes of 47 HCV/HIV-coinfected LT patients who received DAA therapy (with or without ribavirin [RBV]) were compared with those of a matched cohort of 148 HCV-monoinfected LT recipients who received similar treatment. Baseline characteristics were similar in both groups. HCV/HIV-coinfected patients had a median (IQR) CD4 T-cell count of 366 (256-467) cells/µL. HIV-RNA was <50 copies/mL in 96% of patients. The DAA regimens administered were SOF + LDV ± RBV (34%), SOF + SMV ± RBV (31%), SOF + DCV ± RBV (27%), SMV + DCV ± RBV (5%), and 3D (3%), with no differences between the groups. Treatment was well tolerated in both groups. Rates of SVR (negative serum HCV-RNA at 12 weeks after the end of treatment) were high and similar for coinfected and monoinfected patients (95% and 94%, respectively; P = .239). Albeit not significant, a trend toward lower SVR rates among patients with advanced fibrosis (P = .093) and genotype 4 (P = .088) was observed. In conclusion, interferon-free regimens with DAAs for post-LT recurrence of HCV infection in HIV-infected individuals were highly effective and well tolerated, with results comparable to those of HCV-monoinfected patients.

Cardiovascular morbidity and mortality after liver transplantation: The protective role of mycophenolate mofetil.

Cardiovascular (CV) diseases are recognized longterm causes of death after liver transplantation (LT). The objective of this multicenter study was to analyze the prevalence and the evolution of CV risk factors and CV morbidity and mortality in 1819 LT recipients along 5 years after LT. The influence of baseline variables on survival, morbidity, and mortality was studied. There was a continuous and significant increase of the prevalence of all the CV risk factors (except smoking) after LT. CV diseases were the fourth cause of mortality in the 5 years after LT, causing 12% of deaths during the follow-up. Most CV events (39%) occurred in the first year after LT. Preexisting CV risk factors such as age, pre-LT CV events, diabetes, metabolic syndrome, and hyperuricemia, and mycophenolate-free immunosuppressive therapy, increased post-LT CV morbidity and mortality. The development of new-onset CV risk factors after LT, such as dyslipidemia and obesity, independently affected late CV morbidity and mortality. Tacrolimus and steroids increased the risk of posttransplant diabetes, whereas cyclosporine increased the risk of arterial hypertension, dyslipidemia, and metabolic syndrome. In conclusion, CV complications and CV mortality are frequent in LT recipients. Preexisting CV risk factors, immunosuppressive drugs, but also the early new onset of obesity and dyslipidemia after LT play an important role on late CV complications. A strict metabolic control in the immediate post-LT period is advisable for improving CV risk of LT recipients. Liver Transplantation 23 498-509 2017 AASLD.

Phenotype and genotype in 52 patients with Rubinstein-Taybi syndrome caused by EP300 mutations.

Rubinstein-Taybi syndrome (RSTS) is a developmental disorder characterized by a typical face and distal limbs abnormalities, intellectual disability, and a vast number of other features. Two genes are known to cause RSTS, CREBBP in 60% and EP300 in 8-10% of clinically diagnosed cases. Both paralogs act in chromatin remodeling and encode for transcriptional co-activators interacting with >400 proteins. Up to now 26 individuals with an EP300 mutation have been published. Here, we describe the phenotype and genotype of 42 unpublished RSTS patients carrying EP300 mutations and intragenic deletions and offer an update on another 10 patients. We compare the data to 308 individuals with CREBBP mutations. We demonstrate that EP300 mutations cause a phenotype that typically resembles the classical RSTS phenotype due to CREBBP mutations to a great extent, although most facial signs are less marked with the exception of a low-hanging columella. The limb anomalies are more similar to those in CREBBP mutated individuals except for angulation of thumbs and halluces which is very uncommon in EP300 mutated individuals. The intellectual disability is variable but typically less marked whereas the microcephaly is more common. All types of mutations occur but truncating mutations and small rearrangements are most common (86%). Missense mutations in the HAT domain are associated with a classical RSTS phenotype but otherwise no genotype-phenotype correlation is detected. Pre-eclampsia occurs in 12/52 mothers of EP300 mutated individuals versus in 2/59 mothers of CREBBP mutated individuals, making pregnancy with an EP300 mutated fetus the strongest known predictor for pre-eclampsia. © 2016 Wiley Periodicals, Inc.

Pegylated interferon plus ribavirin in HIV-infected patients with recurrent hepatitis C after liver transplantation: a prospective cohort study.

BACKGROUND & AIMS: The aim of this study was to evaluate the results of treatment with pegylated interferon and ribavirin for the recurrence of hepatitis C after liver transplantation in HCV/HIV-coinfected patients. METHODS: This was a prospective, multicentre cohort study, including 78 HCV/HIV-coinfected liver transplant patients who received treatment for recurrent hepatitis C. For comparison, we included 176 matched HCV-monoinfected patients who underwent liver transplantation during the same period of time at the same centres and were treated for recurrent hepatitis C. RESULTS: Antiviral therapy was discontinued prematurely in 56% and 39% (p = 0.016), mainly because of toxicity (22% and 11%, respectively; p=0.034). Sustained virological response (SVR) was achieved in 21% of the coinfected patients and in 36% of monoinfected patients (p = 0.013). For genotype 1, SVR rates were 10% and 33% (p = 0.002), respectively; no significant differences were observed for the other genotypes. A multivariate analysis based on the whole series identified HIV-coinfection as an independent predictor of lack of SVR (OR, 0.17; 95% CI, 0.06-0.42). Other predictors of SVR were donor age, pretreatment HCV viral load, HCV genotype, and early virological response. SVR was associated with a significant improvement in survival: 5-year survival after antiviral treatment was 79% for HCV/HIV-coinfected patients with SVR vs. 43% for those without (p = 0.02) and 92% vs. 60% in HCV-monoinfected patients (p < 0.001), respectively. CONCLUSIONS: The response to pegylated interferon and ribavirin was poorer in HCV/HIV-coinfected liver recipients, particularly those with genotype 1. However, when SVR was achieved, survival of coinfected patients increased significantly.

Niche-habitat mechanisms and biotic interactions explain the coexistence and abundance of congeneric sandgrouse species.

Ascertaining which niche processes allow coexistence between closely related species is of special interest in ecology. We quantified variations in the environmental niches and densities of two congeneric species, the pin-tailed and the black-bellied sandgrouse (Pterocles alchata and Pterocles orientalis) in allopatry and sympatry under similar abiotic, habitat and dispersal contexts to understand their coexistence. Using principal component analysis, we defined environmental gradients (niche dimensions) including abiotic, habitat and anthropogenic variables, and calculated niche breadth, position and overlap of both species in sympatry and allopatry. Additionally, sandgrouse density was modelled as a function of the niche dimensions and the density of the other species. We found evidence that each species occupies distinct environmental niches in sympatry and in allopatry. The black-bellied sandgrouse exploits a broader range of environmental conditions (wider niche breadth) while the pin-tailed sandgrouse reaches high densities where conditions seem to match its optimum. In sympatry, both species shift their niches to intermediate positions, indicating the importance of abiotic factors in setting coexistence areas. Environmental conditions determine regional densities of pin-tailed sandgrouse whereas biotic interactions explain the density of the black-bellied sandgrouse in areas with abiotic conditions similarly conducive for both species. Highly suitable areas for the pin-tailed sandgrouse fall beyond the upper thermal limit of the black-bellied sandgrouse, leading to niche segregation and low densities for the latter. Finally, local niche shift and expansion plus possible heterospecific aggregation allow the pin-tailed sandgrouse to thrive in a priori less favourable environments. This work provides insight into how different mechanisms allow species coexistence and how species densities vary in sympatry compared to allopatry as a result of environmental filtering and biotic interactions.

Alteration of the ankle brachial index, follow-up of patients at risk of peripheral arterial disease, a descriptive longitudinal study.

Background The objective of this study was to detect peripheral arterial disease (PAD) by measuring the ankle-brachial index (ABI) in patients attending medical offices in primary health care who presented a moderate or high risk on the risk scale of Framingham. Design longitudinal descriptive. Setting urban health center. Materials and methods Patients at risk of peripheral arterial disease of the lower limbs: diabetes mellitus (DM), cardiovascular disease (CVD), high cardiovascular risk (HCR) (SCORE>5%), and/or compatible symptoms. Consecutive sampling, n=136 (expected prevalence 8%, alpha 0.05, precision 0.95, projected losses 20%). Dependent variable: ankle-brachial index (ABI). Independent variables: hypertension (HBP), age, sex, CVD, DM, glycosylated hemoglobin (HbA1C), hyperlipidemia (HLP), LDL cholesterol (LDL), smoking, body mass index (BMI), pulses, treatment. Multivariate analysis: linear regression. Confidence level 95%. Results From a sample of 136 patients, 90 were male (66.2%) and 46 were female (33.8%), with a mean age of 72.2 years (in 2021), and a standard deviation (SD) of 7. The prevalence of abnormal ABI (ABI <0.9) was 11%, with a mean ABI of 0.7 (SD 0.18). The bivariate analysis showed a significant relationship between abnormal ABI and pulse palpation (p<0.0001). Excluding patients with ABI ≥ 1.4, in the multivariate analysis (coefficient of determination 0.977), the B coefficients and their 95% confidence intervals (CI) are as follows: age B=0.006, 95% CI (0.002-0.010) (p=0.003); diabetes B=0.289, 95% CI (0.1-0.479) (p=0.003); pulse palpation B= -0.199, 95% CI (-0.289- -0.11) (p<0.0001). Conclusions Doctor consultations in primary care are a favorable context for making an early diagnosis of PAD, by measuring the ABI. The performance of the ABI should be included as part of the annual examination for chronic patients who regularly attend consultations, particularly those with moderate or high cardiovascular risk. In this way, preventive measures could be intensified to prevent future cardiovascular complications in these patients. The predictors of ABI are age, diabetes, and palpation of pulses.

The International Association for the Study of Lung Cancer Staging Project for Lung Cancer: Proposals for the Revision of the M Descriptors in the Forthcoming Ninth Edition of the TNM Classification for Lung Cancer.

INTRODUCTION: This study analyzed all metastatic categories of the current TNM classification of NSCLC to propose modifications of the M component in the next edition (ninth) of the classification. METHODS: A database of 124,581 patients diagnosed between 2011 and 2019 was established; of these, 14,937 with NSCLC in stages IVA to IVB were available for this analysis. Overall survival was calculated using the Kaplan-Meier method, and prognosis was assessed using multivariable-adjusted Cox proportional hazards regression. RESULTS: The eighth edition M categories revealed good discrimination in the ninth edition data set. Assessments revealed that an increasing number of metastatic lesions were associated with decreasing prognosis; because this seems to be a continuum and adjustment for confounders was not possible, no specific lesion number was deemed appropriate for stage classification. Among tumors involving multiple metastases, decreasing prognosis was found with an increasing number of organ systems involved. Multiple assessments, including after adjustment for potential confounders, revealed that M1c patients who had metastases to a single extrathoracic organ system were prognostically distinct from M1c patients who had involvement of multiple extrathoracic organ systems. CONCLUSIONS: These data validate the eighth edition M1a and M1b categories, which are recommended to be maintained. We propose the M1c category be divided into M1c1 (involvement of a single extrathoracic organ system) and M1c2 (involvement of multiple extrathoracic organ systems).

GEMA-Na and MELD 3.0 severity scores to address sex disparities for accessing liver transplantation: a nationwide retrospective cohort study.

Background: The Gender-Equity Model for liver Allocation corrected by serum sodium (GEMA-Na) and the Model for End-stage Liver Disease 3.0 (MELD 3.0) could amend sex disparities for accessing liver transplantation (LT). We aimed to assess these inequities in Spain and to compare the performance of GEMA-Na and MELD 3.0. Methods: Nationwide cohort study including adult patients listed for a first elective LT (January 2016-December 2021). The primary outcome was mortality or delisting for sickness within the first 90 days. Independent predictors of the primary outcome were evaluated using multivariate Cox's regression with adjusted relative risks (RR) and 95% confidence intervals (95% CI). The discrimination of GEMA-Na and MELD 3.0was assessed using Harrell c-statistics (Hc). Findings: The study included 6071 patients (4697 men and 1374 women). Mortality or delisting for clinical deterioration occurred in 286 patients at 90 days (4.7%). Women had reduced access to LT (83.7% vs. 85.9%; p = 0.037) and increased risk of mortality or delisting for sickness at 90 days (adjusted RR = 1.57 [95% CI 1.09-2.28]; p = 0.017). Female sex remained as an independent risk factor when using MELD or MELD-Na but lost its significance in the presence of GEMA-Na or MELD 3.0. Among patients included for reasons other than tumours (n = 3606; 59.4%), GEMA-Na had Hc = 0.753 (95% CI 0.715-0.792), which was higher than MELD 3.0 (Hc = 0.726 [95% CI 0.686-0.767; p = 0.001), showing both models adequate calibration. Interpretation: GEMA-Na and MELD 3.0 might correct sex disparities for accessing LT, but GEMA-Na provides more accurate predictions of waiting list outcomes and could be considered the standard of care for waiting list prioritization. Funding: Instituto de Salud Carlos III, Agencia Estatal de Investigación (Spain), and European Union.

Simazine transport in undisturbed soils from a vineyard at the Casablanca valley, Chile.

Simazine is a soil-active herbicide that has been applied worldwide in agricultural soils, being the second most commonly detected herbicide in groundwater and surface waters. Although its use has been restricted in many countries of Europe, it is still applied in many locations around the world in orchards, vineyards and forestry. Therefore, it is important to study its fate and transport in the environment. This paper investigates simazine transport in undisturbed bare soils from a vineyard at the Casablanca valley, Chile. In the study site, shallow groundwater tables (<1.0 m depth) and high simazine levels (>15 µg L(-1)) in the groundwater were observed and thus, there is potential for simazine to be transported further away through the saturated zone. The soils from the study site were characterized and the hydrodynamic transport parameters were determined. Column leaching experiments showed that the two-site chemical non-equilibrium model correctly represented simazine transport. It was found that 36.3% of the adsorption sites achieve instantaneous equilibrium and that the first-order kinetic rate of the non-equilibrium sites was 6.2 × 10(-3) h(-1). Hydrus 2D was used to predict the transport of simazine in the study site under natural field conditions. Simulation results showed that simazine concentrations at depths shallower than 2.1 m are above the maximum contaminant level of 4 µg L(-1) (defined by the U.S. Environmental Protection Agency). The timing of herbicide application was found to be important on simazine leaching and the main processes involved in simazine transport were degradation and adsorption, which accounted for 95.78 and 4.19% of the simulated mass of pesticide, respectively. A qualitative agreement in the timing and magnitude of simazine concentration was obtained between the simulations and the field data. Therefore, the model utilized in this investigation can be used to predict simazine transport and is a valuable tool to assess agricultural practices to minimize environmental impacts of simazine.

Evaluating the contribution of satellite-derived evapotranspiration in the calibration of numerical groundwater models in remote zones using the EEFlux tool.

Assessment of groundwater resources is crucial for developing water management practices for its sustainable exploitation, both for current and future needs. Numerical models are useful tools for such purpose. However, the lack of continuous monitoring networks, mainly due to difficult access to some remote locations, poses a challenge in developing and calibrating groundwater models. Remote sensing offers an alternative for acquiring information on hydrological and climatic variables at multiple spatiotemporal scales that has the potential to strengthen groundwater modeling. The aim of this study is to develop a methodology that uses remote sensing products to support model calibration. With this aim, we used the Parameter Estimation software (PEST) to calibrate a hydrogeological model of an unexploited basin located in the arid Chilean Altiplano using observed groundwater levels and evapotranspiration (ET) derived from the Earth Engine Evapotranspiration Flux (EEFlux) tool as observations. Our results show that the best model calibration is achieved using both EEFlux-ET and heads as observations to calibrate the hydraulic properties (normalized root mean square error = 4.1 %). We analyzed the effect of EEFlux-ET on the calibration of these properties and found a direct effect on specific yield parameters, which regulate the fluctuations of the water table over time. Incorporating EEFlux-ET estimates in the calibration resulted in lower values of specific yield across the aquifer. Therefore, incorporating remotely sensed ET as observations in the calibration of the groundwater model contributes to a better simulation of the spatiotemporal head variations in the basin.

Evaluation of a Transitional Care Strategy Implemented in Adults With High-Risk and Multimorbidity in Chile.

OBJECTIVES: Fragmentation of continuity of care impacts the health system's efficiency and increases inequity. It severely affects high-risk patients with multimorbidity, requiring coordinated care to avoid preventable complications. The Centro de Innovación en Salud ANCORA UC, together with the Servicio de Salud Metropolitano Sur Oriente, and the National Health Fund, implemented a transitional care strategy for high-risk adults with multimorbidity at 3 hospitals in the southeast of Santiago. The study aimed to evaluate the impact on length of hospital stay, consultations with primary care physicians and contacts after discharge, and also to describe the implementation process of the transition nurse activities. METHODS: A cohort study was performed between 2017 and 2019, with 137 hospitalizations from exposed patients and 167 hospitalizations from unexposed patients. The results of the study showed a significant decrease in the length of hospital stays and an increase in consultations with physicians. RESULTS: The results of the implementation process showed that the transition nurse followed-up in a mean of 24 hospitalizations monthly, and 91% of the discharged patients were contacted via the telephone within 7 days. The implementation process showed that the transition nurse's tasks merged with the daily clinical activities in which training on case management, transition care, and continuous support were key aspects of success. CONCLUSION: We conclude that transitional care intervention has a strong potential in addressing fragmentation of care and is feasible to install and sustain over time in the Chilean context. Finally, this study provides a detailed description of the intervention strategy contributing to its spread and scale-up.