VarPPUD: Variant post prioritization developed for undiagnosed genetic disorders.

Rare and ultra-rare genetic conditions are estimated to impact nearly 1 in 17 people worldwide, yet accurately pinpointing the diagnostic variants underlying each of these conditions remains a formidable challenge. Because comprehensive, in vivo functional assessment of all possible genetic variants is infeasible, clinicians instead consider in silico variant pathogenicity predictions to distinguish plausibly disease-causing from benign variants across the genome. However, in the most difficult undiagnosed cases, such as those accepted to the Undiagnosed Diseases Network (UDN), existing pathogenicity predictions cannot reliably discern true etiological variant(s) from other deleterious candidate variants that were prioritized through N-of-1 efforts. Pinpointing the disease-causing variant from a pool of plausible candidates remains a largely manual effort requiring extensive clinical workups, functional and experimental assays, and eventual identification of genotype- and phenotype-matched individuals. Here, we introduce VarPPUD, a tool trained on prioritized variants from UDN cases, that leverages gene-, amino acid-, and nucleotide-level features to discern pathogenic variants from other deleterious variants that are unlikely to be confirmed as disease relevant. VarPPUD achieves a cross-validated accuracy of 79.3% and precision of 77.5% on a held-out subset of uniquely challenging UDN cases, respectively representing an average 18.6% and 23.4% improvement over nine traditional pathogenicity prediction approaches on this task. We validate VarPPUD's ability to discriminate likely from unlikely pathogenic variants on synthetic, GAN-generated candidate variants as well. Finally, we show how VarPPUD can be probed to evaluate each input feature's importance and contribution toward prediction-an essential step toward understanding the distinct characteristics of newly-uncovered disease-causing variants.

Local Health Service Response to COVID-19 in Mexico: Notes From an Exploratory Qualitative Study.

BACKGROUND: The main goal of a health system is to maintain or improve people's health. The COVID-19 pandemic showed the fragility of health systems worldwide. In Mexico, the pandemic affected the performance of the health system, along with the presence of contextual conditions such as its segmentation and high prevalence of chronic diseases. AIMS: To analyze from an approach to the functions of the health system, the service delivery, human resources, financing, and stewardship/governance in the local health services of five states of Mexico, from the perspective of the staff working in health centers. METHODS: This is an exploratory qualitative study conducted from November 2020 to August 2021, involving 124 health professionals from 39 health facilities (18 rural and 21 urban). The technique used was the semi-structured interview. Interview guides were developed according to core topics. Subsequently, the thematic analysis method was used. RESULTS: The lack of financial resources delayed prevention efforts and made it difficult for health centers to adapt to the crisis. Inequity was found in the distributive efficiency of staff between rural and urban areas and levels of care. In addition, there was evidence of capacity for coordination, capacity sharing, and joint participation between health institutions, civil authorities, and the population to face the emergency. CONCLUSIONS: We identified relevant public health actions that showed the capacity of local health services to organize a response to the pandemic at the level of the actors responsible for these services.

Video Consultations and Safety App Targeting Pregnant Women Exposed to Intimate Partner Violence in Denmark and Spain: Nested Cohort Intervention Study (STOP Study).

BACKGROUND: Intimate partner violence (IPV) during pregnancy is a public health issue with wide-ranging consequences for both the mother and fetus, and interventions are needed. Therefore, the Stop Intimate Partner Violence in Pregnancy (STOP) cohort was established with the overall aim to identify pregnant women exposed to IPV through digital screening and offer women screening positive for IPV a digital supportive intervention. OBJECTIVE: The aim of this study was to (1) introduce the design and profile of the STOP cohort study, (2) assess the feasibility of implementing digital IPV screening among pregnant women, and (3) assess the feasibility of implementing a digital supportive intervention targeting pregnant women exposed to IPV. METHODS: Pregnant women attending antenatal care in the Region of Southern Denmark and in Andalucía, Spain were offered digital screening for IPV using validated scales (Abuse Assessment Screen and Women Abuse Screening Tool). Women who screened positive were eligible to receive a digital supportive intervention. The intervention consisted of 3-6 video consultations with an IPV counselor and a safety planning app. In Denmark, IPV counselors were antenatal care midwives trained by a psychologist specialized in IPV, whereas in Spain, the counselor was a psychologist. RESULTS: Data collection started in February 2021 and was completed in October 2022. Across Denmark and Spain, a total of 19,442 pregnant women were invited for IPV screening and 16,068 women (82.65%) completed the screening. More women in Spain screened positive for exposure to IPV (350/2055, 17.03%) than in Denmark (1195/14,013, 8.53%). Among the women who screened positive, only 31.39% (485/1545) were eligible to receive the intervention with only 104 (21.4%) of these women ultimately receiving it. CONCLUSIONS: Digital screening for IPV among pregnant women is feasible in an antenatal care context in Denmark and Spain; however, a digital supportive intervention during pregnancy appears to have limited feasibility as only a minor subgroup of women who screened positive for eligibility received the intervention. More research is needed on how to best support pregnant women exposed to IPV if universal IPV screening is to be implemented in antenatal care.

Calidad en la atención del servicio de odontología en población sin seguridad social / Quality of Dental Services in People with no Social Security

Resumen Objetivo: Evaluar la calidad de la atención odontológica en población sin seguridad social, en unidades de atención primaria. Material y métodos: Estudio observacional, descriptivo, exploratorio y transversal que evaluó la calidad de la atención a través de la estructura, los procesos y resultados, incluyó la revisión de 86 expedientes clínicos, siete consultorios, 168 usuarios y 43 odontólogos, los instrumentos utilizados fueron tres listas de cotejo y un cuestionario. Resultados: El índice total de la calidad fue de 69.73%, para las dimensiones de estructura, proceso y resultado fue de 72.9%, 54.61% y 81.6% respectivamente. Hay carencias de insumos, instrumental, déficit de unidades dentales y excedente de odontólogos, e incumplimiento técnico- normativo. Conclusiones: La evaluación integral de la calidad en la atención odontológica a través de medir la estructura, los procesos y resultados, permite identificar áreas de oportunidad y tomar decisiones basadas en evidencias científicas.

Abstract Objective: Assess the quality of dental care among population with no social security treated in primary care units. Material and methods: An observational, descriptive, exploratory, and cross-sectional study was conducted to assess, through structure, process and results. Also, 86 clinical records, seven (7) medical offices, 168 users and 43 dentists were reviewed. Three checklists and a questionnaire were the tools used. Results: The total quality index was that of 69.73, while for structure, process and the result was 72.9%, 54.61 and 81.6 respectively. There is a lack of supplies, instruments, dental units and surplus of dentists, as well as technical and regulatory non-compliance. Conclusions: Comprehensive evaluation of quality of dental care through measuring the structure, processes, and results, enables to identify areas of opportunity and scientific evidence-based decision making.

Local health systems resilience in managing the COVID-19 pandemic: lessons from Mexico.

The concept of resilience was applied to the public health field to investigate the way health systems are impacted by health crises, what conditions allow them to mitigate the blow and how they reorganize once the crisis is over. In 2020, the COVID-19 pandemic caused by the SARS-CoV-2 virus represented a global challenge demanding immediate response to an unprecedented health crisis. Various voices drew attention to the intensity of the crisis in countries with greater inequalities, where the pandemic converged with other social emergencies. We documented the experiences of health personnel who faced the pandemic at the primary care level while simultaneously maintaining the functioning of other areas of medical care. Our results derived from a qualitative study comprising 103 participants from five states of Mexico. We aimed to show through inferential analysis their perspective on what we call 'the resilience of local health systems'. We observed three stages of experience during the crisis: (a) Preparation (official guidelines received to organize care, training and planning of epidemiological surveillance); (b) Adaptation (performance of community-based prevention activities, infrastructure modifications, telehealth); and (c) Learning (participatory governance with city councils, business sector and organized population). The study suggests that the local health systems analysed benefited from the initiatives of health personnel that in some cases positively exceeded their duties. In terms of the resilience analysis, they were able to handle the impact of the crisis and cope with it. Their transformative capacity came from the strategies implemented to adapt health services by managing institutional resources. Their experience represents a lesson on the strengthening of the essential functions of health systems and shows a way to address successfully the increasingly complex health challenges of the present and future times.

Clinical and sociodemographic characterization of pregnant women hospitalized with COVID-19.

INTRODUCTION: In pregnant women, a higher risk for developing viral respiratory infections is identified. OBJECTIVE: To analyze sociodemographic characteristics, evolution, clinical manifestations, and complications of pregnant women hospitalized with COVID-19. METHODS: Study conducted at 11 public hospitals; sociodemographic variables, comorbidities, signs and symptoms, laboratory and imaging findings, pregnancy characteristics, treatment and pregnancy outcome were included for analysis. RESULTS: Age ranged between 15 and 40 years; 85.1% were at third trimester of pregnancy, 11.9% at second and 3% at first; 27% had any comorbidity such as obesity, hypertension or asthma; 89.5% had fever, 73.1% cough, 44.8% dyspnea, 43.3% headache and 35.8% myalgia. Diagnoses were mild disease (55.2%), mild pneumonia (26.9%), severe pneumonia (10.4%), severe pneumonia with acute respiratory distress syndrome (4.5%), and severe pneumonia with septic shock (3%); 76.2% had noninvasive oxygen support, and 9%, mechanical ventilation. Pregnancy was interrupted in 53.8%; 95.5% were discharged due to improvement of their condition and 4.5% died. CONCLUSIONS: Age range and symptoms are consistent with those previously reported. Evidence was found of an increase in cesarean section without a clear indication in women with COVID-19.

INTRODUCCIÓN: En las mujeres embarazadas se identifica mayor riesgo de desarrollar infecciones respiratorias virales. OBJETIVO: Analizar características sociodemográficas, evolución, manifestaciones clínicas y complicaciones en mujeres embarazadas con COVID-19 que fueron hospitalizadas. MÉTODOS: Estudio en 11 hospitales públicos; se incluyeron variables sociodemográficas, comorbilidades, síntomas y signos, hallazgos de laboratorio y gabinete, características del embarazo, tratamiento y desenlace de la gestación. RESULTADOS: La edad osciló entre 15 y 40 años; 85.1 % cursaba el tercer trimestre del embarazo, 11.9 % el segundo y 3 % el primero; 27 % presentó alguna comorbilidad como obesidad, hipertensión o asma; 89.5 % presentó fiebre, 73.1 % tos, 44.8 % disnea, 43.3 % cefalea y 35.8 % mialgias. Los diagnósticos fueron enfermedad leve (55.2 %), neumonía leve (26.9 %), neumonía severa (10.4 %), neumonía severa con síndrome de distrés respiratorio agudo (4.5 %) y neumonía severa con choque séptico (3 %); 76.2 % recibió soporte de oxígeno no invasivo y 9 %, ventilación mecánica. Se interrumpió el embarazo en 53.8 %; 95.5 % egresó por mejoría y 4.5 % falleció. CONCLUSIONES: El rango de edad y los síntomas coinciden con los señalados en la literatura especializada. En mujeres con COVID-19 se evidenció el incremento de la operación cesárea sin una indicación clara.

An overview on the promotion on patient-centered care and shared decision-making in Mexico.

Mexico is a mid-income North American country. It strives to materialize the right to health in accordance with its laws. But the health system faces various problems: fragmentation, segmentation, limited funding, insufficient coverage, and low quality of health care. Mexico's population is aging, which has led to an increasing prevalence of chronic conditions. To overcome this issue, the goals have shifted towards free universal health coverage under equality, effectivity, and quality criteria focused on primary health care. Consequently, the health system has moved towards Patient-Centered Care (PCC), and an opportunity to promote Shared Decision-Making (SDM) during the clinical encounter to enhance patient and family involvement in their own health care. PCC and SDM are relatively new ideas in Mexico. The research agenda has focused on initiatives attempting to bring these concepts to clinical practice. This paper seeks to describe the local headway and the state of the art of PCC- and SDM-related strategies in the Mexican health system.

Caracterización clínica y sociodemográfica de mujeres embarazadas con COVID-19 hospitalizadas / Clinical and sociodemographic characterization of pregnant women hospitalized with COVID-19

Resumen Introducción: En las mujeres embarazadas se identifica mayor riesgo de desarrollar infecciones respiratorias virales. Objetivo: Analizar características sociodemográficas, evolución, manifestaciones clínicas y complicaciones en mujeres embarazadas con COVID-19 que fueron hospitalizadas. Métodos: Estudio en 11 hospitales públicos; se incluyeron variables sociodemográficas, comorbilidades, síntomas y signos, hallazgos de laboratorio y gabinete, características del embarazo, tratamiento y desenlace de la gestación. Resultados: La edad osciló entre 15 y 40 años; 85.1 % cursaba el tercer trimestre del embarazo, 11.9 % el segundo y 3 % el primero; 27 % presentó alguna comorbilidad como obesidad, hipertensión o asma; 89.5 % presentó fiebre, 73.1 % tos, 44.8 % disnea, 43.3 % cefalea y 35.8 % mialgias. Los diagnósticos fueron enfermedad leve (55.2 %), neumonía leve (26.9 %), neumonía severa (10.4 %), neumonía severa con síndrome de distrés respiratorio agudo (4.5 %) y neumonía severa con choque séptico (3 %); 76.2 % recibió soporte de oxígeno no invasivo y 9 %, ventilación mecánica. Se interrumpió el embarazo en 53.8 %; 95.5 % egresó por mejoría y 4.5 % falleció. Conclusiones: El rango de edad y los síntomas coinciden con los señalados en la literatura especializada. En mujeres con COVID-19 se evidenció el incremento de la operación cesárea sin una indicación clara.

Abstract Introduction: In pregnant women, a higher risk for developing viral respiratory infections is identified. Objective: To analyze sociodemographic characteristics, evolution, clinical manifestations, and complications of pregnant women hospitalized with COVID-19. Methods: Study conducted at 11 public hospitals; sociodemographic variables, comorbidities, signs and symptoms, laboratory and imaging findings, pregnancy characteristics, treatment and pregnancy outcome were included for analysis. Results: Age ranged between 15 and 40 years; 85.1% were at third trimester of pregnancy, 11.9% at second and 3% at first; 27% had any comorbidity such as obesity, hypertension or asthma; 89.5% had fever, 73.1% cough, 44.8% dyspnea, 43.3% headache and 35.8% myalgia. Diagnoses were mild disease (55.2%), mild pneumonia (26.9%), severe pneumonia (10.4%), severe pneumonia with acute respiratory distress syndrome (4.5%), and severe pneumonia with septic shock (3%); 76.2% had noninvasive oxygen support, and 9%, mechanical ventilation. Pregnancy was interrupted in 53.8%; 95.5% were discharged due to improvement of their condition and 4.5% died. Conclusions: Age range and symptoms are consistent with those previously reported. Evidence was found of an increase in cesarean section without a clear indication in women with COVID-19.

[Adverse events and essential actions for patient safety]. / Eventos adversos y acciones esenciales para la seguridad del paciente.

INTRODUCTION: The adverse events (AE) in hospitalized patients occur with increasing frequency due to the increase in complexity of medical care, which implies a greater risk of committing a human error inherent to the care, constituting a serious threat to the safety of the patient. MATERIAL AND METHODS: Cross-sectional study, including patients older than 16years, with hospital stay longer than 24h and discharge from the general surgery service, patients treated in emergency observation units or other hospital services were not considered. AE were identified, classified by cause according to the essential actions for patient safety (EAPS), and compliance with the EAPS was verified. RESULTS: 352 clinical records were reviewed, 61 (17%) were positive on screening. Of the positives, 66% resulted in AE (47 cases). The prevalence of AE was 13%. The AE were: 40% related to procedures; 39% with infections; 17% with medication; 4% with patient identification. The EAPS with the best rating was EAPS5 and the lowest rating was EAPS4. The night shifts with the greatest opportunity area, only with 40% and 44% correct procedures. CONCLUSIONS: The study shows that the two methodologies used, one to identify AE and the other to establish its causes and classification according to the EAPS, demonstrated usefulness and synergy for patient safety, when detecting AE, as well as determining their causes and evaluate compliance with the EAPS.

Towards reproducible metabarcoding data: Lessons from an international cross-laboratory experiment.

Advances in high-throughput sequencing (HTS) are revolutionizing monitoring in marine environments by enabling rapid, accurate and holistic detection of species within complex biological samples. Research institutions worldwide increasingly employ HTS methods for biodiversity assessments. However, variance in laboratory procedures, analytical workflows and bioinformatic pipelines impede the transferability and comparability of results across research groups. An international experiment was conducted to assess the consistency of metabarcoding results derived from identical samples and primer sets using varying laboratory procedures. Homogenized biofouling samples collected from four coastal locations (Australia, Canada, New Zealand and the USA) were distributed to 12 independent laboratories. Participants were asked to follow one of two HTS library preparation workflows. While DNA extraction, primers and bioinformatic analyses were purposefully standardized to allow comparison, many other technical variables were allowed to vary among laboratories (amplification protocols, type of instrument used, etc.). Despite substantial variation observed in raw results, the primary signal in the data was consistent, with the samples grouping strongly by geographical origin for all data sets. Simple post hoc data clean-up by removing low-quality samples gave the best improvement in sample classification for nuclear 18S rRNA gene data, with an overall 92.81% correct group attribution. For mitochondrial COI gene data, the best classification result (95.58%) was achieved after correction for contamination errors. The identified critical methodological factors that introduced the greatest variability (preservation buffer, sample defrosting, template concentration, DNA polymerase, PCR enhancer) should be of great assistance in standardizing future biodiversity studies using metabarcoding.

ATLAS2030 Pediatric Gait Exoskeleton: Changes on Range of Motion, Strength and Spasticity in Children With Cerebral Palsy. A Case Series Study.

Background: Cerebral Palsy (CP), the most common motor disability in childhood, affects individual's motor skills, movement and posture. This results in limited activity and a low social participation. The ATLAS2030 exoskeleton is a pediatric device that enables gait rehabilitation for children with neurological or neuromuscular pathologies with gait pathology. Purpose: To study changes in relation to range of motion (ROM), strength and spasticity in children with CP after using the ATLAS2030 gait exoskeleton. Methods and Participants: Three children (mean age 8.0 ± 2.0), two girls and one boy, two of them with GMFCS IV and one with GMFCS III, received robot-assisted gait training (RAGT) with ATLAS2030 for one month. Results: The average time of exoskeleton use was 54.7 ± 10.4 min in all sessions, and all participants were able to perform all exercises. The strength of all muscle groups was increased after the 10 sessions for the participants assessed and the limited ROM in the sagittal plane (hip and knee extension and ankle dorsiflexion) decreased after the use of the exoskeleton compared to the initial state. Spasticity was reduced at the end of the sessions after the use of the exoskeleton compared to their initial state. Conclusion: The ROM, spasticity and strength were improved after RAGT with ATLAS2030 exoskeleton in these children with CP. However, further studies with larger samples should be carried out to confirm our findings.

Gait-assisted exoskeletons for children with cerebral palsy or spinal muscular atrophy: A systematic review.

BACKGROUND: Cerebral Palsy (CP) and Spinal Muscular Atrophy (SMA) are common causes of motor disability in childhood. Gait exoskeletons are currently being used as part of rehabilitation for children with walking difficulties. OBJECTIVE: To assess the safety and efficacy and describe the main characteristics of the clinical articles using robot-assisted gait training (RAGT) with exoskeleton for children with CP or SMA. METHODS: A computer search was conducted in five bibliographic databases regarding clinical studies published in the last ten years. In order to be included in this review for further analysis, the studies had to meet the following criteria: (1) assess efficacy or safety of interventions; (2) population had to be children with CP or SMA aged between 3 and 14; (3) exoskeleton must be bilateral and assist lower limbs during walking. RESULTS: Twenty-one articles were selected, of which only five were clinical trials. 108 participants met the inclusion criteria for this study, all with a diagnosis of CP. The evidence level of the selected papers was commonly low. CONCLUSIONS: RAGT therapy seems to be safe for children with CP. However, further investigation is needed to confirm the results related to efficacy. There is no evidence of RAGT therapy for SMA children.

Feasibility of a multifaceted educational strategy for strengthening rural primary health care.

OBJECTIVE:: To evaluate the feasibility and acceptability of a comprehensive educational strategy designed to improve care quality in rural areas of Mexico. MATERIALS AND METHODS:: A demonstration study was performed in 18 public rural health centers in Mexico, including an educational intervention that consists of the following steps: Development of the strategy; Selection and training of instructors (specialist physicians from the referral hospital and multidisciplinary field teams); Implementation of the strategy among health care teams for six priority causes of visit, through workshops, individual tutorials, and round-table case-review sessions. Feasibility and acceptability were evaluated using checklists, direct observation, questionnaires and in-depth interviews with key players. RESULTS:: Despite some organizational barriers, the strategy was perceived as worthy by the participants because of the personalized tutorials and the improved integration of health teams within their usual professional practice. CONCLUSION:: The educational strategy proved to be acceptable; its feasibility for usual care conditions will depend on the improvement of organizational processes at rural facilities.

Feasibility of a multifaceted educational strategy for strengthening rural primary health care / Factibilidad de una estrategia educativa multifacética para fortalecer la atención primaria rural

Abstract: Objective: To evaluate the feasibility and acceptability of a comprehensive educational strategy designed to improve care quality in rural areas of Mexico. Materials and methods: A demonstration study was performed in 18 public rural health centers in Mexico, including an educational intervention that consists of the following steps: Development of the strategy; Selection and training of instructors (specialist physicians from the referral hospital and multidisciplinary field teams); Implementation of the strategy among health care teams for six priority causes of visit, through workshops, individual tutorials, and round-table case-review sessions. Feasibility and acceptability were evaluated using checklists, direct observation, questionnaires and in-depth interviews with key players. Results: Despite some organizational barriers, the strategy was perceived as worthy by the participants because of the personalized tutorials and the improved integration of health teams within their usual professional practice. Conclusion: The educational strategy proved to be acceptable; its feasibility for usual care conditions will depend on the improvement of organizational processes at rural facilities.

Resumen: Objetivo: Evaluar la factibilidad y aceptabilidad de una estrategia educativa multifacética de mejora de calidad de atención en áreas rurales de México. Material y métodos: Se realizó un estudio de demostración con una intervención educativa a equipos de salud en 18 centros de salud rurales en México, que incluyó desarrollo de la estrategia; selección y capacitación de instructores (especialistas del hospital de referencia y equipos asesores multidisciplinarios); implementación de la estrategia educativa para seis motivos prioritarios de atención, mediante talleres, asesorías individualizadas y sesiones de revisión de casos. Se evaluaron factibilidad y aceptabilidad mediante listas de cotejo, observación directa, cuestionarios y entrevistas a profundidad con actores clave. Resultados: A pesar de algunas barreras organizacionales, la estrategia fue percibida como valiosa por los participantes, por la asesoría personalizada y la integración de los equipos de salud en su práctica profesional. Conclusión: La estrategia educativa es aceptable para áreas rurales; su factibilidad en la operación usual dependerá de mejoras organizacionales de los servicios.

[Challenges in the implementation of clinical practice guidelines in major public health institutions in Mexico: A multiple case study]. / Desafíos en la implantación de guías de práctica clínica en instituciones públicas de México: estudio de casos múltiple.

OBJECTIVE: To identify, prioritize and relate barriers and facilitators in the implementation of Clinical Practice Guidelines (GPC, in Spanish). MATERIALS AND METHODS: We used qualitative methods to study and compare the introduction of GPC across the domains of the consolidated research implementation framework in hospitals of the three main public institutions in a state of Mexico. Authorities and hospital staff were interviewed using a semi-structured questionnaire. RESULTS: The main barriers to implementation are the absence of standards, training, resources and incentives. The most important implementation facilitators are the characteristics of the GPC, which are perceived as properly designed and with simple language as well as with capacity to improve the work environment. CONCLUSION: The barriers to implementation must be solved to achieve the goal of standardizing the healthcare process across the sector; the positive perception of the GPC should promote the continuous actualization of the evidence and a sectoral view from their development stage to ensure adoption in the heterogeneous environments that characterize health institutions.

Desafíos en la implantación de guías de práctica clínica en instituciones públicas de México: estudio de casos múltiple / Challenges in the implementation of clinical practice guidelines in major public health institutions in Mexico: A multiple case study

Objetivo. Identificar, jerarquizar y relacionar barreras y facilitadores en la implantación de las Guías de Práctica Clínica (GPC). Material y métodos. Estudio cualitativo que compara la implantación de GPC a través de los dominios del marco consolidado para la investigación de implementación en hospitales de las tres principales instituciones públicas de una entidad. Se entrevistaron a funcionarios estatales y personal hospitalario. Resultados. Las principales barreras son ausencia de lineamientos, de capacitación, de recursos e incentivos. Los facilitadores se relacionan con las características de las GPC, percibidas con diseño adecuado, lenguaje sencillo y ventajas para mejorar el ambiente laboral. Conclusión. Las barreras deberán resolverse para alcanzar el objetivo de homologar el proceso en todo el sector; además, la buena percepción de las GPC deberá promover investigaciones para promover la actualización continua de las evidencias y una visión sectorial desde su elaboración para su implantación en los heterogéneos contexto que caracterizan a las instituciones de salud.

Objective. To identify, prioritize and relate barriers and facilitators in the implementation of Clinical Practice Guidelines (GPC, in Spanish). Materials and methods. We used qualitative methods to study and compare the introduction of GPC across the domains of the consolidated research implementation framework in hospitals of the three main public institutions in a state of Mexico. Authorities and hospital staff were interviewed using a semi-structured questionnaire. Results. The main barriers to implementation are the absence of standards, training, resources and incentives. The most important implementation facilitators are the characteristics of the GPC, which are perceived as properly designed and with simple language as well as with capacity to improve the work environment. Conclusion. The barriers to implementation must be solved to achieve the goal of standardizing the healthcare process across the sector; the positive perception of the GPC should promote the continuous actualization of the evidence and a sectoral view from their development stage to ensure adoption in the heterogeneous environments that characterize health institutions.

First report of Trichinella pseudospiralis in a red fox in mainland Britain.

Active surveillance of red foxes for Trichinella has been undertaken in mainland Britain since 1999. Post-mortems are carried out, followed by a magnetic stirrer method for sample digestion based on European Commission (EC) Regulation 216/2014 (which amends 2075/2005). Initially samples are tested in batches of 20 foxes and in December 2013, for the first time under the surveillance programme, a batch tested positive for Trichinella at the Animal and Plant Health Agency, York. Further individual tests identified one infected fox, from the Bristol area. The larvae were identified as Trichinella pseudospiralis. This is the first report of T. pseudospiralis in Great Britain and suggests the possibility of a cycle of infection existing in wildlife.

Evaluation of 'best practice' (SCOPS) guidelines for nematode control on commercial sheep farms in England and Wales.

Parasitic diseases are a major constraint to optimum livestock production and are the major cause of economic loss in UK sheep flocks, with farmers remaining dependant on anthelmintics for control. In the UK, research and evidence based, "best practice" guidelines for sustainable control of parasites in sheep (SCOPS) were first produced in 2004 and have been regularly updated since. This study was designed to evaluate the effect of these best practice guidelines for worm control on lamb production and infection levels, compared with more traditional management. Sixteen farms were selected based on a 2 cube factorial design with 3 factors known to affect worm epidemiology: control regimen; farm type; and climatic region. A formalised plan for worm control using 7 potential resistance-delaying practices was prepared for each of the 8 best practice (SCOPS) farms, in conjunction with the farms veterinarians. The 8 farms in the traditional management group (CONTROL farms) were selected based on ongoing evidence of them using worm control strategies deemed to be "higher-risk". A cohort of 40-50 study lambs at each farm was monitored from birth to finishing, allowing evaluation of lamb productivity, worm infection levels and for comparison of numbers of anthelmintic treatments. Birth and mid-season weights were used to calculate daily live-weight gain. Birth and finish dates were used to calculate time to finish and finish weights were also compared. Faecal egg counts, larval culture and species differentiation were undertaken throughout the year to assess the impact of the control strategies on worm burdens. There was no significant difference in results for any of the 3 production responses when comparing predicted means accounting for the differences in birth weight. In fact SCOPS farms had, on average, a higher daily weight gain and finish weight than CONTROL farms when comparing observed means. Statistical analysis of infection levels clearly showed no significant effect according to farm type (p=0.71) or treatment (p=0.81). In contrast the effect of region (p=0.08), although not significant, had a much larger effect size (standardised mean difference) with lower parasite burdens based on faecal egg counts on Northern farms compared to Southern farms. For both ewes and lambs, significantly fewer treatments were carried out on the SCOPS farms. The data collected from this study suggests that farms implementing SCOPS principles use less anthelmintic than other farms, without loss of animal performance or increased worm burden.

Ecdysis behaviors and circadian rhythm of ecdysis in the stick insect, Carausius morosus.

Successful ecdysis in insects depends on proper timing and sequential activation of an elaborate series of motor programs driven by a relatively conserved network of neuropeptides. The behaviors must be activated at the appropriate times to ensure successful loosening and shedding of the old cuticle, and can be influenced by environmental cues in the form of immediate sensory feedback and by circadian rhythms. We assessed the behaviors, components of the neural network and the circadian basis of ecdysis in the stick insect, Carausius morosus. C. morosus showed many of the characteristic pre-ecdysis and ecdysis behaviors previously described in crickets and locusts. Ecdysis was described in three phases, namely the (i) preparatory or pre-ecdysis phase, (ii) the ecdysial phase, and (iii) the post-ecdysis or exuvial phase. The frequencies of push-ups and sways during the preparatory phase were quantified as well as durations of all the phases. The regulation of ecdysis appeared to act via elevation of cGMP, as described in many other insects, although eclosion hormone-like immunoreactivity was not noted using a lepidopteran antiserum. Finally, C. morosus showed a circadian rhythm to the onset of ecdysis, with ecdysis occurring just prior to or at lights on. Ecdysis could be induced precociously with mechanical stimulation.

Quantification and analysis of ecdysis in the hornworm, Manduca sexta, using machine vision-based tracking.

We have developed a machine vision-based method for automatically tracking deformations in the body wall to monitor ecdysis behaviors in the hornworm, Manduca sexta. The method utilizes naturally occurring features on the animal's body (spiracles) and is highly accurate (>95 % success in tracking). Moreover, it is robust to unanticipated changes in the animal's position and in lighting, and in the event tracking of specific features is lost, tracking can be reestablished within a few cycles without input from the user. We have paired our tracking technique with electromyography and have also compared our in vivo results to fictive motor patterns recorded from isolated nerve cords. We found no major difference in the cycle periods of contractions during naturally occurring ecdysis compared to ecdysis initiated prematurely through injection of the peptide ecdysis-triggering hormone, and we confirmed that the ecdysis period in vivo is statistically similar to that of the fictive motor pattern.