Featuring BRCA1 and BRCA2 germline mutational landscape from Asturias (North Spain).

The singular BRCA1/2 mutational landscape of Asturias is updated 10 years after the first study. We analyzed BRCA1 and BRCA2 pathogenic variants in 1653 index cases. In total, 238 families were identified to carry a pathogenic variant, 163 families in BRCA1 and 75 families in BRCA2. This yielded a prevalence rate of 14.4%. Seven recurrent variants were found accounting for 55% of the cases. Among them, three are widely distributed (BRCA1 c.211A>G, c.470_471del and c.3331_3334del) and four had been reported as novel in Asturias: two in BRCA1 (c.1674del and c.2901_2902dup) and two in BRCA2 (c.2095C>T and c.4040_4035delinsC). A common haplotype was established for all recurrent variants indicating a shared ancestral origin. Three splicing analyses are shown: BRCA1:c.5152+3A>C and BRCA1:c.5333-3T>G that lead to skipping of exon 18, and 22 respectively, and BRCA1:c.5278-1G>T giving rise to two transcripts, one lacking exon 21 (p.Ille1760Glyfs*60) and one lacking the first 8 nucleotides of exon 21 (p.Phe1761Asnfs*14), supporting pathogenicity for these variants.

Initiation of lipid-lowering therapy as primary prevention of cardiovascular disease in the elderly.

AIMS: This study aimed to analyse the initiation adherence phase to lipid-lowering therapy for primary prevention of cardiovascular disease in a Spanish population aged 70 years or older. The secondary objective was to identify the determinants of initiation and early discontinuation. METHODS: This was an observational study conducted in the CArdiovascular Risk factors for HEalth Service research (CARhES) cohort. People aged 70 and older with a first prescription of a lipid-lowering drug and without a previous major adverse cardiovascular event (MACE) were selected (2018-2021). Data on sociodemographics, clinical conditions, drugs and use of health services were collected from clinical and administrative electronic databases. The study population was classified into: non-initiation, early discontinuation (i.e., discontinuation after the first dispensing) and initiation with more than one dispensing. Their characteristics were compared. Determinants of initiation and early discontinuation were explored. RESULTS: Among the 15 019 people studied, 80.2% initiated the medication, 11.2% showed an early discontinuation and 8.6% were non-initiators. An older age or conditions such as dementia, diabetes or depression reduced the likelihood of initiation, while obesity and a high pharmacological burden increased it. People over 90 years of age or those prescribed a statin in combination were more likely to have an early discontinuation. CONCLUSIONS: Non-initiation and early discontinuation are common among older people prescribed lipid-lowering drugs as primary prevention of cardiovascular disease for the first time. The presence of chronic pathologies other than cardiovascular ones should be considered when assessing whether or not to prescribe these drugs in the elderly.

Gender inequalities in secondary prevention of cardiovascular disease: a scoping review.

BACKGROUND: Despite significant progress in cardiovascular disease (CVD) management, it remains a public health priority and a global challenge. Within the disease process, health care after a cardiovascular event (secondary prevention) is essential to prevent recurrences. Nonetheless, evidence has suggested the existence of gender disparities in CVD management, leaving women in a vulnerable situation. The objective of this study is to identify all available evidence on the existence of gender differences in health care attention after a major adverse cardiovascular event. METHODS: A scoping review following the structure of PRISMA-ScR was conducted. To define the inclusion criteria, we used Joanna Briggs Institute (JBI) population, concept, context framework for scoping reviews. A systematic search was performed in MEDLINE (PubMed), EMBASE and Cochrane. The methods of this review are registered in the International Platform of Registered Systematic Review and Meta-Analysis Protocols (INPLASY) (INPLASY202350084). RESULTS: The initial search retrieved 3,322 studies. 26 articles were identified manually. After the reviewing process, 93 articles were finally included. The main intervention studied was the pharmacological treatment received (n = 61, 66%), distantly followed by guideline-recommended care (n = 26, 28%) and cardiac rehabilitation (CR) referral (n = 16)". Literature described gender differences in care and management of secondary prevention of CVD. Women were less frequently treated with guideline-recommended medications and seem more likely to be non-adherent. When analysing guideline recommendations, women were more likely to make dietary changes, however, men were more likely to increase physical activity. Studies also showed that women had lower rates of risk factor testing and cholesterol goals attainment. Female sex was associated with lower rates of cardiac rehabilitation referral and participation. CONCLUSIONS: This review allowed us to compile knowledge on the existence of gender inequalities on the secondary prevention of CVD. Additional research is required to delve into various factors influencing therapeutic disparities, referral and non-participation in CR programs, among other aspects, in order to improve existing knowledge about the management and treatment of CVD in men and women. This approach is crucial to ensure the most equitable and effective attention to this issue.

Folate deficiency modifies the risk of CIN3+ associated with DNA methylation levels: a nested case-control study from the ASCUS-COL trial.

PURPOSE: To our knowledge, there are very few studies evaluating if the levels of folate modify the risk of cervical intraepithelial neoplasia grade 2 and higher (CIN2+ and CIN3+) associated with the levels of HPV genome methylation, two cofactors related to single carbon metabolism and independently associated with cervical cancer in previous studies. We conducted a case-control study nested in a three-arm randomized clinical pragmatic trial (ASCUS-COL trial) to evaluate the risk of CIN3+ associated with methylation levels according to serum folate concentrations. METHODS: Cases (n = 155) were women with histologically confirmed CIN2+ (113 CIN2, 38 CIN3, and 4 SCC) and controls were age and follow-up time at diagnosis-matched women with histologically confirmed ≤ CIN1 (n = 155), selected from the 1122 hrHPV + women of this trial. The concentrations of serum folate were determined by the radioimmunoassay SimulTRAC-SNB-VitaminB12/Folate-RIAKit and the methylation levels by the S5 classifier. Stepwise logistic regression models were used to estimate the association between folate or methylation levels and CIN2+ or CIN3+. The joint effect of folate levels and methylation on the risk of CIN3+ was estimated using combinations of categorical stratifications. RESULTS: Folate levels were significantly lower in women with CIN3+ than in other diagnostic groups (p = 0.019). The risk of CIN3+ was eight times higher (OR 8.9, 95% CI 3.4-24.9) in women with folate deficiency and high methylation levels than in women with normal folate and high methylation levels (OR 1.4, 95% CI 0.4-4.6). CONCLUSION: High methylation and deficient folate independently increased the risk of CIN3+ while deficient folate combined with high methylation was associated with a substantially elevated risk of CIN3+.

Exploring sex variations in the incidence of cardiovascular events: a counterfactual decomposition analysis.

BACKGROUND: Some cardiovascular risk factors (CVRFs) that occur differently in men and women can be addressed to reduce the risk of suffering a major adverse cardiovascular event (MACE). Furthermore, the development of MACE is highly influenced by social determinants of health. Counterfactual decomposition analysis is a new methodology that has the potential to be used to disentangle the role of different factors in health inequalities. This study aimed to assess sex differences in the incidence of MACE and to estimate how much of the difference could be attributed to the prevalence of diabetes, hypertension, hypercholesterolaemia and socioeconomic status (SES). METHODS: Descriptive and counterfactual analyses were conducted in a population of 278 515 people with CVRFs. The contribution of the causal factors was estimated by comparing the observed risk ratio with the causal factor distribution that would have been observed if men had been set to have the same factor distribution as women. The study period was between 2018 and 2021. RESULTS: The most prevalent CVRF was hypercholesterolaemia, which was similar in both sexes, while diabetes was more prevalent in men. The incidence of MACE was higher in men than in women. The main causal mediating factors that contributed to the sex differences were diabetes and SES, the latter with an offsetting effect. CONCLUSIONS: This result suggests that to reduce the MACE gap between sexes, diabetes prevention programmes targeting men and more gender-equal salary policies should be implemented.

Impact of the universal health insurance benefits on cervical cancer mortality in Colombia.

BACKGROUND: Cervical cancer patients in Colombia have a lower likelihood of survival compared to breast cancer patients. In 1993, Colombia enrolled citizens in one of two health insurance regimes (contributory-private insurance and subsidized- public insurance) with fewer benefits in the subsidized regime. In 2008, the Constitutional Court required the Colombian government to unify services of both regimes by 2012. This study evaluated the impact of this insurance change on cervical cancer mortality before and after 2012. METHODS: We accessed 24,491 cervical cancer mortality records for 2006-2020 from the vital statistics of Colombia's National Administrative Department of Statistics (DANE). We calculated crude mortality rates by health insurance type and departments (geopolitical division). Changes by department were analyzed by rate differences between 2006 and 2012 and 2013-2020, for each health insurance type. We analyzed trends using join-point regressions by health insurance and the two time-periods. RESULTS: The contributory regime (private insurance) exhibited a significant decline in cervical cancer mortality from 2006 to 2012, characterized by a noteworthy average annual percentage change (AAPC) of -3.27% (P = 0.02; 95% CI [-5.81, -0.65]), followed by a marginal non-significant increase from 2013 to 2020 (AAPC 0.08%; P = 0.92; 95% CI [-1.63, 1.82]). In the subsidized regime (public insurance), there is a non-significant decrease in mortality between 2006 and 2012 (AAPC - 0.29%; P = 0.76; 95% CI [-2.17, 1.62]), followed by a significant increase from 2013 to 2020 (AAPC of 2.28%; P < 0.001; 95% CI [1.21, 3.36]). Examining departments from 2013 to 2020 versus 2006 to 2012, the subsidized regime showed fewer cervical cancer-related deaths in 5 out of 32 departments, while 6 departments had higher mortality. In 21 departments, mortality rates remained similar between both regimes. CONCLUSION: Improvement of health benefits of the subsidized regime did not show a positive impact on cervical cancer mortality in women enrolled in this health insurance scheme, possibly due to unresolved administrative and socioeconomic barriers that hinder access to quality cancer screening and treatment.

[Evaluation of virtual consultation by primary care professionals: quality dimensions and opportunities for improvement]. / Evaluación de la interconsulta virtual por los profesionales de atención primaria: dimensiones de la calidad y oportunidades de mejora.

OBJECTIVE: To know the opinion of Aragon primary care physicians about virtual consultation and its impact on the different healthcare quality domains. DESIGN: Cross-sectional study through a self-developed survey. Data collection was enabled from April 14th to May 31st, 2023. SITE: Physicians with healthcare duties in primary care in Aragon. PARTICIPANTS: Specialist physicians and resident interns in Family and Community Medicine. MEANSUREMENTS: Job characteristics, Likert variables assessing virtual consultation as a tool and its impact on healthcare quality domains, identification of advantages and disadvantages, and free answer questions proposing improvement strategies. RESULTS: 202 responses. 90.1% of participants consider virtual consultation useful, while 67.8% believe that it improves the quality of referrals. The main advantages identified are its contribution to professional enrichment and the integral visión of the patient, and the improvement of communication between the primary and secondary levels of care; the main drawback is the role of Primary Care as an intermediary in patient information. Efficiency and equity were the most highly rated quality domains, with safety being the least valued. CONCLUSIONS: Virtual consultation can promote communication and coordination of care, and enhance the primary care resolution capacity. Its success relies on training and time for its use, as well as on reaching a consensus on protocols and to homogenize resource distribution. Nevertheless, there are still opportunities for improvement, mainly in the realm of safety.

Delivering health interventions to women, children, and adolescents in conflict settings: what have we learned from ten country case studies?

Armed conflict disproportionately affects the morbidity, mortality, and wellbeing of women, newborns, children, and adolescents. Our study presents insights from a collection of ten country case studies aiming to assess the provision of sexual, reproductive, maternal, newborn, child, and adolescent health and nutrition interventions in ten conflict-affected settings in Afghanistan, Colombia, Democratic Republic of the Congo, Mali, Nigeria, Pakistan, Somalia, South Sudan, Syria, and Yemen. We found that despite large variations in contexts and decision making processes, antenatal care, basic emergency obstetric and newborn care, comprehensive emergency obstetric and newborn care, immunisation, treatment of common childhood illnesses, infant and young child feeding, and malnutrition treatment and screening were prioritised in these ten conflict settings. Many lifesaving women's and children's health (WCH) services, including the majority of reproductive, newborn, and adolescent health services, are not reported as being delivered in the ten conflict settings, and interventions to address stillbirths are absent. International donors remain the primary drivers of influencing the what, where, and how of implementing WCH interventions. Interpretation of WCH outcomes in conflict settings are particularly context-dependent given the myriad of complex factors that constitute conflict and their interactions. Moreover, the comprehensiveness and quality of data remain limited in conflict settings. The dynamic nature of modern conflict and the expanding role of non-state armed groups in large geographic areas pose new challenges to delivering WCH services. However, the humanitarian system is creative and pluralistic and has developed some novel solutions to bring lifesaving WCH services closer to populations using new modes of delivery. These solutions, when rigorously evaluated, can represent concrete response to current implementation challenges to modern armed conflicts.

Desigualdades de género en la utilización de servicios sanitarios, España 2006-2017.

Objetivo. Identificar la existencia de desigualdades de género en utilización de atención primaria (AP), urgencias y consulta de enfermería. Material y métodos. Estudio transversal, con encuestas nacionales y europeas de salud (2006-2017) de población española de 16 o más años (n=98 929 personas). Se estudió la evolución en el tiempo y la influencia de los determinantes de género mediante regresiones logísticas en la utilización de servicios sanitarios. Resultados. La utilización de los tres servicios asistenciales fue mayor en mujeres. Personas pensionistas, aquellas dedi-cadas a labores del hogar, con estudios bajos y clase social manual, tuvieron mayor riesgo de utilización de AP. Urgencias: a mayor edad menor riesgo de utilización. Enfermería: aque-llas dedicadas a las labores del hogar tenían mayor riesgo de utilización. Conclusiones. Son necesarios estudios que analicen las desigualdades de género en contextos como la utilización de servicios sanitarios, así como nuevas estrategias de gestión para conseguir la equidad asistencial.

Health-related quality of life of women after HPV testing as triage strategy for an abnormal Pap smear: a nested randomized pragmatic trial in a middle-income country.

BACKGROUND: Information obtained in studies on the impact of human papilloma virus (HPV) testing on health-related quality of life is contradictory. OBJECTIVE: To assess the impact on health-related quality of life of the HPV test, colposcopy, and cytology as triage strategies after a cytology with atypical squamous cells of undetermined significance (ASCUS) in Medellín, Colombia. METHODS: We carried out a nested analysis on the randomized pragmatic trial (ASCUS-COL). Women with ASCUS were assigned randomly to one of the 3 arms (Pap smear, colposcopy, HPV). Participants completed a questionnaire at baseline, two weeks after receiving the results of the triage tests and one year after the second questionnaire. We used the SF-36 to assess health-related quality of life. RESULTS: The sum score of the physical health component (PHC) and mental health component (MHC) increased significantly over time for the whole sample and there were no statistically significant differences between arms of PHC = survey 1: mean 52.4 (SD 8.21) vs. survey 3: mean 54.4 (SD 8.16) p < 0.0001 and of MHC = survey 1: mean 44.9 (SD 11.72) vs. survey 3: mean 48.1 (SD 11.20) p < 0.0001. A lower MHC occurred in women with lesser schooling, belonging to the public health care regimen, higher number of live births, and separated. A lower PHC was associated with the cytology arm, higher age, lesser schooling, and belonging to the subsidized regime. The risk of having depression went from 42% in the first survey to 26% in the third. CONCLUSION: The triage strategies affected health-related quality of life in the same manner. ClinicalTrials.gov Identifier: NCT02067468.

The Need to Develop Standard Measures of Patient Adherence for Big Data: Viewpoint.

Despite half a century of dedicated studies, medication adherence remains far from perfect, with many patients not taking their medications as prescribed. The magnitude of this problem is rising, jeopardizing the effectiveness of evidence-based therapies. An important reason for this is the unprecedented demographic change at the beginning of the 21st century. Aging leads to multimorbidity and complex therapeutic regimens that create a fertile ground for nonadherence. As this scenario is a global problem, it needs a worldwide answer. Could this answer be provided, given the new opportunities created by the digitization of health care? Daily, health-related information is being collected in electronic health records, pharmacy dispensing databases, health insurance systems, and national health system records. These big data repositories offer a unique chance to study adherence both retrospectively and prospectively at the population level, as well as its related factors. In order to make full use of this opportunity, there is a need to develop standardized measures of adherence, which can be applied globally to big data and will inform scientific research, clinical practice, and public health. These standardized measures may also enable a better understanding of the relationship between adherence and clinical outcomes, and allow for fair benchmarking of the effectiveness and cost-effectiveness of adherence-targeting interventions. Unfortunately, despite this obvious need, such standards are still lacking. Therefore, the aim of this paper is to call for a consensus on global standards for measuring adherence with big data. More specifically, sound standards of formatting and analyzing big data are needed in order to assess, uniformly present, and compare patterns of medication adherence across studies. Wide use of these standards may improve adherence and make health care systems more effective and sustainable.

Association between violence during pregnancy and preterm birth and low birth weight in Colombia: Analysis of the demographic and health survey.

To explore the association between low birth weight and preterm birth with violence during pregnancy, we conducted a cross-sectional study by using the 2010 Colombian Demographic and Health Survey. We conducted bivariate analyses, binomial logistic regression, and stratified models by age, and 14,520 women were included. There was no association between violence and low birth weight. Nonetheless, an association with preterm birth in women aged over 35 was observed (OR 1.98, 95%CI 1.23, 3.17). Prenatal care appeared to be a protective factor for both outcomes. This research unexpectedly showed that supplementation with folic acid and iron was associated with preterm birth.

Health Beliefs Associated with the Follow-Up of Pap Smear Abnormalities Among Low-Income Women in Medellín, Colombia.

The purpose of the study was to explore variables of the health belief model in relation to the follow-up of abnormal Pap smear among low-income women in Medellín, Colombia. Eight focus groups (62 women) were conducted according to age groups (25-45 and 46-69 years). The data were analyzed using content analysis. The participants perceived themselves as vulnerable, recognized the severity of the disease in terms of both its emotional and physical consequences, perceived the benefits of the follow-up, and mentioned cues to action, such as social support and the support of health entities. Perceived self-efficacy was compromised by health system barriers and by personal barriers, such as placing the needs of their children ahead of their own, fear, neglect, and the pain caused by the diagnostic and therapeutic procedures. Health education activities aimed at increasing the follow-up of abnormal Pap smears should consider psychological factors.

Evaluation of Entertainment Education Strategies to Promote Cervical Cancer Screening and Knowledge in Colombian Women.

Cervical cancer is considered to be a major health problem for women in developing countries, but it is also problematic for more developed countries as global migration increases and health behaviors move from the countries of origin to new places of residence. We designed and produced a testimonial video and a fotonovela (printed short story) to educate women about cervical cancer and screening. The development of the materials included formative research, production, pretesting, dissemination, and evaluation. The evaluation included 100 women that completed a pretest and a posttest at eight health clinics in Medellin. The pretest and posttest were analyzed using McNemar's test for categorical variables and paired t test for continuous variables. Women in the study had a high initial Stage of Change as defined by the Transtheoretical Model and a high baseline knowledge of HPV and cervical cancer, with the caveat of specific knowledge deficiencies especially for HPV. While not statistically significant, postintervention Transtheoretical Model status in both interventions changed towards higher stages, specifically, from Precontemplation to Contemplation and Preparation. Women who participated in the study liked the educational materials and their knowledge increased, especially for HPV. However, the perception of risk did not change.

[Health-care utilization in elderly (Spain 2006-2012): Influence of health status and social class]. / Utilización de servicios sanitarios en ancianos (España 2006-2012): influencia del nivel de salud y de la clase social.

OBJECTIVE: to explore health-care utilization (primary and specialized health-care, hospitalizations, day hospital and emergency services) and overuse in elderly in Spain, considering the influence of health status, sex, social class and its temporal trend. DESIGN: cross sectional study in two phases. SETTING: Spain. PARTICIPANTS: people surveyed in the National Health Surveys 2006 and 2011-12. MAIN MEASUREMENTS: Health status was measured using self-rated and diagnosed health (number and diagnoses). Social class was obtained from the last occupation of the main supporter (manual and non-manual workers). Logistic regression analyses were conducted adjusting by sex, age, health status, social class and year, obtaining its predictive capacity. RESULTS: the percentage of elderly population with health-care utilization decreased during the period analyzed. Women who belonged to the manual workers category presented the highest prevalence of low health (low self-rated health in 2006: 70.6%). Low health status was associated with a higher utilization of health-care services. Self-rated health was a better predictor of health-care utilization and overuse than diagnosed health, getting the highest predictive capacity for specialized health-care (C = 0.676). Old people from low social class used with higher frequency primary health-care and emergency services. On the other hand, specialized health-care and day hospital were more used by high social classes. CONCLUSIONS: inequalities in health and health-care utilization have been observed in elderly according social class. It is necessary to consider self-rated health as a health-care utilization predictor and to review our health-care services accessibility and equity.

[Differences in the use of health services in the Spanish adult populations].

Objective: To explore the use of health services in the Spanish population, according health insurance. Methods: A cross-sectional study using data from the Spanish National Health Survey 2011-2012 was conducted. 21 007 people were included. Among individuals with health coverage, three groups were differentiated: people with public, private and mixed insurance. Univariate and bivariate analyses were developed to know health services and bivariate analyses were developed to know health services use differences by health insurance. Results: 83.5 % of the population reported only a public coverage, 2.5 % has only private insurance and 14 % was enrolled in both forms. Individuals with public coverage visited with higher frequency the general physician (81.9 %), while those with only private insurance visited a specialist in the highest proportion (65.6 %). Individuals with only public health coverage presented the longest waiting times, for both programmed hospitalization and medical attention. In general terms, people with double coverage showed the greatest participation in preventive activities. Conclusions: Public coverage is the most important coverage of the Spanish population. Different use of health resources were observed according to health insurance.

Virtual Consultation in Dermatology: Access Inequalities According to Socioeconomic Characteristics and the Place of Residence.

Virtual consultation has been implemented as a tool to improve the cooperation and coordination between primary care and other specialties. However, in its use in dermatology, inequities have been described. The aim of this study was to identify individual and geographical factors affecting the likelihood of accessing this resource. We conducted a cross-sectional study. The study population was individuals living in Aragón, a region in the north-east of Spain, who were users of the Aragon Health Service in 2021. To explore the differences in individual and area characteristics, between patients with virtual and non-virtual dermatology consultation, we performed bivariate analyses. To analyse the use of virtual consultation in dermatology, a multilevel methodology stratified by sex was developed. We analysed 39,174 dermatology visits, with 16,910 being virtual (43.17%). The rates of virtual consultation were higher in urban areas and the most affluent areas, for older persons, chronic complex patients and people with more advantageous socioeconomic positions. The best multilevel model conducted showed inequalities by socioeconomic position and area of residence. There are individual and area inequalities in the use of teledermatology. As this tool should improve equity of access, teledermatology interventions must address and adapt to the needs of the local patient population.

Gender health care inequalities in health crisis: when uncertainty can lead to inequality.

BACKGROUND: In health crisis, inequalities in access to and use of health care services become more evident. The objective of this study is to analyse the existence and evolution of gender inequalities in access to and use of healthcare services in the context of the COVID-19 health crisis. METHODS: Retrospective cohort study using data from all individuals with a confirmed COVID-19 infection from March 2020 to March 2022 in Aragón (Spain) (390,099 cases). Health care access and use was analysed by gender for the different pandemic waves. Univariate and multivariate analyses were conducted to evaluate the effect of sex in health care. Blinder-Oaxaca decomposition methods were performed to explain gender gaps observed. RESULTS: The health care received throughout the COVID-19 pandemic differed between men and women. Women were admitted to hospital and intensive care units less frequently than men and their stays were shorter. Differences observed between men and women narrowed throughout the pandemic, but persisted even after adjusting for age, socioeconomic status, morbidity burden or the patient's place of residence. Differences in sociodemographic characteristics and morbidity burden could explain partially the gender inequalities found, mainly in the later phases of the pandemic, but not in the earlier waves. CONCLUSIONS: There were gender inequalities in access to and use of health services during the COVID-19 pandemic. Inequalities were greater in the first waves of the pandemic, but did not disappear. Analysis of health crises must take into account an intersectional gender perspective to ensure equitable health care.

Impacts of attacks to female health care workers in three territories of Colombia.

BACKGROUND: This study explores the impacts of attacks perpetrated in the context of armed conflict, to female health workers in three Colombian territories. METHODS: We conducted a document review of the reports and databases of the Colombian Truth Commission, 17 in-depth semi-structured interviews with experts on the national and regional armed conflict and the medical mission, and 26 female health workers who were victims of attacks. RESULTS: Experts and female health workers reported attacks to health activities, facilities, equipment, and personnel, including attacks to traditional doctors belonging to indigenous communities. The most frequent attacks were threats and retention of health personnel; theft of supplies and medicines; damage and use of infrastructure and means of transport for purposes other than health care; and hinderance of health service provision. The attacks occurred in a framework of structural violence that intersects with poverty, racism, and gender bias. The impacts of these attacks include gender-based violence, significant disruption of the lives of health workers, and physical, emotional, psychological, social, and economic effects on the victims and their families. The government response to protect victims and populations has been absent or insufficient. CONCLUSIONS: Attacks to health care were reported in all the studied territories obstructing adequate health care. Impacts of these attacks affect negatively the professional and personal life of the workers and are aggravated by structural violence and absent or little institutional response.

Field Emission from Carbon Nanotubes on Titanium Nitride-Coated Planar and 3D-Printed Substrates.

Carbon nanotubes (CNTs) are well known for their outstanding field emission (FE) performance, facilitated by their unique combination of electrical, mechanical, and thermal properties. However, if the substrate of choice is a poor conductor, the electron supply towards the CNTs can be limited, restricting the FE current. Furthermore, ineffective heat dissipation can lead to emitter-substrate bond degradation, shortening the field emitters' lifetime. Herein, temperature-stable titanium nitride (TiN) was deposited by plasma-enhanced atomic layer deposition (PEALD) on different substrate types prior to the CNT growth. A turn-on field reduction of up to 59% was found for the emitters that were generated on TiN-coated bulk substrates instead of on pristine ones. This observation was attributed exclusively to the TiN layer as no significant change in the emitter morphology could be identified. The fabrication route and, consequently, improved FE properties were transferred from bulk substrates to free-standing, electrically insulating nanomembranes. Moreover, 3D-printed, polymeric microstructures were overcoated by atomic layer deposition (ALD) employing its high conformality. The results of our approach by combining ALD with CNT growth could assist the future fabrication of highly efficient field emitters on 3D scaffold structures regardless of the substrate material.