Análisis de los sistemas de salud como sistemas políticos / Analysis of health systems as political systems

La literatura técnica suele presentar los Sistemas de Salud (SS) como conjuntos de recursos médicos destinados a atender enfermedades. Un análisis más amplio del tema permite caracterizar los SS como la expresión de sistemas políticos que surgen y cambian en contextos históricos diferentes, al impulso de las condiciones e intereses predominantes. Los sistemas políticos son los mismos sistemas sociales cuando los valoramos desde la perspectiva de las relaciones de poder que se establecen entre sus integrantes. Desde esta perspectiva los SS, sus agentes, discursos y dispositivos, se revelan como componentes de sistemas políticos que determinan, bajo las apariencias el tipo de gestión que se aplica a la comprensión y cuidado de la salud, y configuran "modelos de respuesta social". Este documento, describe los SS como sistemas políticos, con base en las características de la respuesta social preponderante. Se describen cinco tipologías que pueden coexistir tanto de forma sinérgica como contradictoria reflejando las condiciones e intereses predominantes en el grupo: sistemas populares, de beneficencia, de seguridad social, estatales, y privados. Al final se propone que el análisis de los aspectos formales y técnicos es por sí mismo insuficiente para explicar e intervenir la dinámica de los SS.

Technical literature usually presents Health Systems (HS) as sets of medical resources aimed at treating diseases. A broader analysis of the subject allows us to characterize HS as the expression of political systems, which arise and change in different historical contexts, driven by prevailing conditions and interests. Political systems are the same social systems when we value them from the perspective of the power relations established among their members. From this perspective, HS, their agents, discourses, and devices, are revealed as components of political systems that determine, under appearances, the type of management that people applied to understand and care for their health, and configure "models of social response." In this document, the analysis of HS is based on the characteristics of the prevailing social response. We describe five typologies that can coexist, both synergistically and contradictory, reflecting the prevailing conditions and interests in the group: popular, charity, social security, state, and private systems. In the end, it is proposed that the analysis of the formal and technical aspects is by itself insufficient to explain HS and intervene in their dynamics

Epidemiología de la interrelación cáncer colorrectal y diabetes mellitus tipo 2. Revisión sistemática / Epidemiology of the interrelationship between colorectal cancer and diabetes mellitus type 2. Systematic review / Epidemiologia da inter-relação câncer colorretal e Diabetes Mellitus tipo 2 - Revisão sistemática

Resumen Objetivos: Describir el estado del arte sobre estudios epidemiológicos que evalúen asociaciones de riesgo entre el cáncer colorrectal y la diabetes tipo 2, y las políticas de salud pública internacionales y colombianas encaminadas a reducir tales patologías. Metodología: Revisión sistemática cualitativa sobre estudios epidemiológicos que evalúen asociaciones de riesgo entre el cáncer colorrectal y la diabetes tipo 2, publicados en idioma español e inglés en PubMed®, United States National Library of Medicine (u.s nlm®), Embase®, Literatura Latinoamericana y del Caribe en Ciencias de la Salud (Lilacs®) y Scientific Electronic Library Online (SciELO®), antes del 30 de junio de 2019. Adicionalmente, se describen las políticas internacionales y nacionales para el control de la diabetes y el cáncer colorrectal. Resultados: De 251 estudios evaluados para elegibilidad, se incluyeron 32 investigaciones originales tipo casos y controles, cohorte prospectivo y retrospectivo, retrospectivos con enfoque de casos y controles, retrospectivos con enfoque casos-cohorte, al mostrar asociaciones de riesgo de padecer cáncer de colon o recto en individuos diabéticos tipo 2. Existen cinco normatividades internacionales para el control de diabetes y cáncer, y dos normatividades colombianas de control de ambas patologías. Conclusiones: La evidencia epidemiológica a nivel mundial señala que individuos con diabetes tipo 2 poseen mayor riesgo de padecer cáncer de colón o recto, en comparación con los no diabéticos, en una forma dependiente de la etnicidad y el sexo. Las políticas de salud pública internacionales y colombianas no han logrado reducir significativamente la carga de ambas patologías, ni los factores de riesgo comunes entre ambas condiciones, y tampoco reconocen los nexos epidemiológicos y biológicos entre la diabetes tipo 2 y el cáncer colorrectal.

Abstract Objective: Describe the state of the art on epidemiological studies that assess risk associations between colorectal cancer and type 2 diabetes, and Colombian and international public health policies to reduce these pathologies. Methodology: Qualitative systematic review on epidemiological studies that assess risk associations between colorectal cancer and type 2 diabetes, published in Spanish and English in PubMed®, United States National Library of Medicine (U.S NLM®), Embase®, Literatura Latinoamericana y del Caribe en Ciencias de la Salud (Lilacs®) and Scientific Electronic Library Online (SciELO®), before 30 June 2019. Furthermore, we describe the international and national policies for the control of diabetes and colorectal cancer. Results: Of 251 studies assessed for eligibility, we included 32 original case-control studies, prospective and retrospective cohort studies, retrospective studies with a case-control approach and retrospective studies with a case-cohort approach as they showed risk associations for colon or rectal cancer in type 2 diabetic individuals. There are five international regulations for the control of diabetes and cancer, and two Colombian regulations for the control of both pathologies. Conclusions: The global epidemiological evidence indicates that individuals with type 2 diabetes have an increased risk of cancer of the colon or rectum, compared with non-diabetics, dependent on ethnicity and sex. International and Colombian public health policies have not been able to significantly reduce the burden of both pathologies, nor the common risk factors between both conditions, nor recognize the epidemiological and biological links between type 2 diabetes and colorectal cancer.

Resumo Objetivo: Descrever o estado da arte relacionado aos estudos epidemiológicos que avaliam associações de risco entre o câncer colorretal e o diabetes tipo 2, e as políticas de saúde pública colombianas e internacionais encaminhadas à redução de tais patologias. Metodologia: Revisão sistemática qualitativa sobre estudos epidemiológicos que avaliem associações de risco entre o câncer colorretal e o diabetes tipo 2, publicados nos idiomas espanhol e inglês em PubMed®, United States National Library of Medicine (U.S NLM®), Embase®, Literatura Latinoamericana y del Caribe em Ciencias de la Salud (Lilacs®) e Scientific Electronic Library Online (SciELO®), antes de 30 de junho de 2019. Adicionalmente são descritas as políticas nacionais e internacionais para o controle do diabetes e o câncer colorretal. Resultados: Dos 251 estudos avaliados para elegibilidade foram incluídas 32 pesquisas originais tipo casos e controles, coorte prospectivo e retrospectivo, retrospectivos com foco de casos e controles, retrospectivos com foco casos-coorte, ao mostrar associações de risco de sofrer câncer de cólon ou reto em pacientes diabéticos tipo 2. Existem cinco regulamentos internacionais para o controle de diabetes e câncer e dois regulamentos colombianos de controle para ambas as patologias. Conclusões: A evidencia epidemiológica a nível mundial mostra que pacientes com diabetes tipo 2 possuem um risco maior de sofrer câncer de cólon ou reto, em comparação com os não-diabéticos, numa forma dependendo da etnia e do sexo. As políticas de saúde pública colombianas e internacionais ainda não conseguiram diminuir significativamente a carga de ambas as patologias, nem os fatores de risco comuns entre ambas as condições, além de não reconhecerem os nexos epidemiológicos e biológicos entre o diabetes tipo 2 e o câncer colorretal.

Normativas para la protección de mascotas: situación de Colombia, Chile, Uruguay y México / Normatives for the protection of pets in Latin America: situation of Colombia, Chile, Uruguay and México

RESUMEN Actualmente, la sociedad se ha enfocado en la tenencia de mascotas para adquirirlas por compañía desestimando el deber de atender sus necesidades y hacerse responsable de sus acciones, debido a esto, grupos sociales sensibles a esta problemática, promueven cambios culturales y han influenciado los gobiernos de países de América Latina con el fin de formular e implementar directrices para proteger a las mascotas. En el presente artículo se comparan aspectos esenciales de las normativas de protección de mascotas de cuatro países de América Latina, Colombia, Chile, Uruguay y México. Se realizó una revisión narrativa de la literatura publicada y de los sitios web de los entes gubernamentales responsables de la formulación y puesta en marcha de las normativas de los cuatro países, con el propósito de establecer una comparación entre su contenido y su desempeño. Mediante esta revisión se identificaron diferencias en cuanto a los objetivos de las directrices y el proceso de su formulación. Se describen, además, los actores que intervinieron en el proceso de formulación, estructura, objeto y los resultados más importantes reportados en cada país a partir de la implementación de estas normativas.

ABSTRACT Nowadays, society is focused on acquiring pets for the purpose of companionship, disregarding the duty of attending their needs and take responsibility for their actions. Consequently, social groups sensitive to this problem promote cultural changes and exert pressure on the governments of Latin American countries in order to formulate and implement guidelines to protect pets. This article compares essential aspects of pet protection regulations in four countries in Latin America, Colombia, Chile, Uruguay and Mexico. A narrative review of published literature and the websites of the government entities responsible for the formulation and implementation of the regulations in the four countries was carried out with the purpose of establishing a comparison between their content and their performance. Through this review, differences regarding the objectives of the guidelines and the process of their formulation were identified. The actors that intervened in the process of formulation, structure, object, and what is more important, results reported in each country since the implementation of these regulations are also described.

La cultura de la seguridad del paciente: enfoques y metodologías para su medición / The patient safety culture: approaches and methodologies for measurement

Resumen Introducción: El concepto de cultura de la seguridad del paciente se desarrolla en las denominadas "organizaciones de alta confiabilidad", como estrategia para enfrentar la problemática de los eventos adversos. Objetivo: Revisar los enfoques que han predominado en cultura de la seguridad del paciente y describir algunas herramientas que se han utilizado para su medición. Metodología: Revisión narrativa enfocada en la conceptualización de cultura de la seguridad. Resultados: El término cultura de la seguridad es utilizado por la literatura con varios significados. La polisemia del término y en particular la confusión con la noción de "clima de seguridad", implica también confusiones en los métodos e interpretación de las mediciones. Se identifican dos enfoques conceptuales básicos en el estudio de la cultura de la seguridad: el antropológico y el funcionalista, siendo este último el predominante en el desarrollo de instrumentos utilizados para su medición; estos últimos, sin embargo, presentan constructos y propiedades métricas variables. Conclusión: El estudio de la seguridad del paciente, como categoría en desarrollo, debería utilizar los enfoques de medición disponibles con una mirada crítica, integrando técnicas de entrevista y estudios cualitativos, en especial de tipo etnográfico, que suministren información más integral y útil en la toma de decisiones encaminadas a mejorar la seguridad y confiabilidad de la atención médica.

Abstract: Introduction: The notion of Patient Safety Culture has been developed strongly linked to the concept of "High Reliability Organizations", as a strategy to face the problem of adverse events. Objective: To review the approaches that have prevailed in Patient Safety Culture and describe some tools that have been used for its measurement. Methodology: Narrative review focused on the conceptualization of safety culture. Results: Technical literature uses the term safety culture with several meanings. The multiple meanings of the term, and particularly the vagueness with the term "safety climate" also involve confusions in the methods and interpretations of measurements. Two main conceptual approaches to the study of the safety culture were identified: the anthropological and the functionalist approaches, the latter being predominant in the development of instruments used to measure Patient Safety Culture, however, their constructs and their metric properties are widely heterogeneous. Conclusion: The study of patient safety as developing category, one should use the available measurement approaches with a critical view, integrating information from other sources such as interviews and qualitative studies, including ethnographic approach, to provide more comprehensive and useful tools in the decision-making process aimed at improving the safety and reliability of medical care.

Plan Control del cáncer en Colombia 2012-2021. Un análisis formal / Cancer Control Plan in Colombia 2012-2021. A Formal Analysis / Plano Controle do cancro na Colômbia 2012-2021. Análise formal

Resumen En Colombia el cáncer es un problema de salud pública. Su incidencia y mortalidad afectan tanto a la población adulta como a la población pediátrica. Desde el año 2010 el país se viene preparando para afrontar este problema. El Instituto Nacional de Cancerología (INC) ha realizado investigaciones para caracterizar epidemiológicamente el cáncer, así como otros factores que inciden en su letalidad. Las leyes 1384 y 1388 de 2010 fijaron las bases para el control integral del cáncer y designaron al INC para asesorar al Ministerio de Salud y Protección Social en esta tarea. Se analizó el contenido del plan, con base en una guía elaborada por la Facultad de Salud Pública de la Universidad de Antioquia. Debido a la importancia del problema y la complejidad de la política, se concluye: solo con un sistema estricto de monitoreo, una evaluación permanente de las actividades del plan y la aplicación de correctivos oportunos, Colombia podría alcanzar las metas en el control del cáncer.

Abstract In Colombia, cancer is a public health problem. Its incidence and mortality affects both adult and pediatric population. Since 2010 the country has been preparing to address this problem. The National Cancer Institute (NCI) has conducted research to characterize epidemiologically cancer as well as other factors that influence their lethality. 1384 and 1388 laws of 2010 laid the foundation for comprehensive cancer control and designated the INC to advise the Ministry of Health and Social Protection in this task. We analyzed the contents of the plan, based on a guide developed by the School of Public Health at the University of Antioquia. Because of the importance of the problem and the complexity of the policy concludes: Only a strict monitoring system, continuous evaluation and timely corrective plan of activities, Colombia could reach targets in cancer control.

Resumo Na Colômbia, o câncer é um problema de saúde pública. A incidência e a mortalidade afectar ambos os adultos e a população pediátrica. Desde 2010 o país tem vindo a preparar para resolver este problema. O Instituto Nacional do Câncer (INC) realizou uma pesquisa para caracterizar epidemiologicamente câncer, bem como outros fatores que influenciam sua letalidade. 1384 e 1388 leis de 2010 lançou as bases para o controle integral de câncer eo INC nomeado para assessorar o Ministério da Saúde e Protecção Social nesta tarefa. o conteúdo do plano foi analisado, com base em um guia desenvolvido pela Escola de Saúde Pública da Universidade de Antioquia. Devido à importância do problema e da complexidade da política, ele conclui: Colômbia poderia atingir as metas para o controle do câncer se aplicado rigoroso sistema de monitorização, uma avaliação contínua das actividades do plano ea implementação de medidas corretivas adequadas.

Effects of a high-intensity interval training program versus a moderate-intensity continuous training program on maximal oxygen uptake and blood pressure in healthy adults: study protocol for a randomized controlled trial.

BACKGROUND: Participation in aerobic exercise generates increased cardiorespiratory fitness, which results in a protective factor for cardiovascular disease and all-cause mortality. High-intensity interval training might cause higher increases in cardiorespiratory fitness in comparison with moderate-intensity continuous training; nevertheless, current evidence is not conclusive. To our knowledge, this is the first study to test the effect of high-intensity interval training with total load duration of 7.5 min per session. METHODS: A randomized controlled trial will be performed on two groups of healthy, sedentary male volunteers (n = 44). The study protocol will include 24 exercise sessions, three times a week, including aerobic training on a treadmill and strength training exercises. The intervention group will perform 15 bouts of 30 s, each at an intensity between 90 % and 95 % of maximal heart rate. The control group will complete 40 min of continuous exercise, ranging between 65 % and 75 % of maximal heart rate. The primary outcome measure to be evaluated will be maximal oxygen uptake (VO2max), and systolic and diastolic blood pressure will be evaluated as secondary outcome measures. Waist circumference, body mass index, and body composition will also be evaluated. DISCUSSION: Epidemiological evidence shows the link between VO2max and its association with chronic conditions that trigger CVD. Therefore, finding ways to improve VO2max and reduce blood pressure it is of vital importance to public health. TRIAL REGISTRATION: NCT02288403 . Registered on 4 November 2014.

Análisis de las relaciones sociales durante el embarazo en mujeres con y sin morbilidad materna extrema. Medellín, 2011-2012 / Social Network Analysis of Women during Pregnancy with and without Extreme Maternal Morbidity. Medellin, 2011-2012 / Análise das relações sociais durante a gravidez em mulheres com e sem morbidade materna extrema. Medellin, 2011-2012

Introducción: los vínculos que establecemos se configuran en redes sociales. El análisis de estas redes nos permite comprender su influencia en la salud materna, asunto poco estudiado. Objetivo: caracterizar las redes sociales de gestantes con y sin diagnóstico de morbilidad materna extrema. Metodología: se realizó un análisis de las redes de seiscientas mujeres: 150 maternas diagnosticadas con morbilidad materna extrema y 450 gestantes sanas, configurándose así un estudio de casos y controles. Las maternas estuvieron hospitalizadas en hospitales de Medellín durante el 2011 y el 2012, donde respondieron una encuesta de caracterización de las relaciones sociales durante el embarazo. Resultados: las maternas reportaron relaciones extensas, densas y cercanas y se mostraron satisfechas con el soporte social recibido. La morbilidad materna extrema se asoció con la exposición a alguna forma de agresión, contar con un mayor número de contactos y mayor satisfacción con la red. Este último puede ser un sesgo del diseño utilizado.

Introduction: The boundaries that we establish configure social networks. Analyze these networks allow us to understand their influence in maternal health. Objective: to characterize social networks of pregnant women with and without extreme maternal morbidity. Methodology: a case-control study through a social network analysis of six hundred pregnant women: 150 with extreme maternal morbidities diagnosis and 450 who went to maternal services for different reasons. Women were hospitalized between 2011 and 2012 and they responded a social network characterization survey. Findings: in general, women reported satisfactory, strong and long relationships. For cases, antecedents of aggression, a wider social network and more satisfaction were statistically associated. This could be a bias due the type of the study. It's necessary a deeply knowledge of this relation.

Introdução: as ligações são configurados estabelecer redes sociais. A análise dessas redes nos permite compreender sua influência na saúde materna, um assunto pouco estudado. Objetivo: Caracterizar as redes sociais de mulheres grávidas com e sem diagnóstico de morbidade materna extremo. Metodologia: 150 materna diagnosticado com morbidade materna extrema e 450 mulheres grávidas saudáveis, constituindo, assim, um estudo de casos e controles: uma análise das redes de seiscentas mulheres ocorreu. Materna foram internadas em hospitais em Medellín em 2011 e 2012, onde eles responderam a um inquérito caracterização das relações sociais durante a gravidez. Resultados: maternos relataram relações grandes, densos e íntimos e expressaram satisfação com o suporte social recebido. morbidade materna extrema associada à exposição a qualquer forma de agressão, ter mais contato e maior satisfação com a rede; este último, pode ser utilizado um desenho de polarização.

Análisis de sostenibilidad de la política de control de malaria del municipio de El Bagre, Colombia / Sustainability Analysis of the Malaria Control Policy in the Municipality of El Bagre, Colombia / Análise de sustentabilidade da política de controle de malária do município de El Bagre, Colombia

El objetivo de esta investigación fue analizar la sostenibilidad de la política de control de malaria en el municipio de El Bagre durante el año 2011. Se llevó a cabo un estudio de diseño mixto de modelo dominante CUAL-cuan, de carácter exploratorio. Se hicieron catorce entrevistas y una revisión documental, para identificar procesos sociales y ecológicos involucrados con la malaria, y también para describir y analizar la política de control de esta enfermedad. Se encontró que la minería, las migraciones, las prácticas y creencias culturales, el conflicto armado y las variaciones climáticas se relacionaban con la dinámica de la enfermedad y, asimismo, que la estructura de la política de control da cuenta de escasa capacidad de los actores para adaptar las acciones de control a estos procesos socioecológicos de la región. La política de control mostró ser efectiva aunque, bajo los supuestos del modelo, es escasamente sostenible.

The objective of this research was to analyze the sustainability of the malaria control policy in the municipality of El Bagre, during 2011. We performed a mixed-design study with a dominant model QUAL^quan, of exploratory character. We carried out fourteen interviews and a review of the documentation to identify social and ecological processes involved with malaria, and also to describe and analyze the control policy for this illness. We found that mining, migrations, cultural practices and beliefs, the armed conflict and climate variations are related with the dynamic of the illness. Likewise, we found that the structure of the control policy accounts for the limited capacity of the actors to adapt the control actions to the socio-ecological processes of the region. The control policy showed to be effective, although, under the assumptions of the model, it is barely sustainable.

O objetivo desta pesquisa foi analisar a sustentabilidade da política de controle de malária no município de El Bagre durante o ano 2011. Efetuou-se estudo de desenho misto de modelo dominante QUAL-quan, de caráter exploratorio. Foram feitas quatorze entrevistas e uma revisao documental, para identificar processos sociais e ecológicos envolvidos na malária, mesmo para descrever e analisar a política de controle desta doenca. Encontrou-se que a mineracao, migra-coes, práticas e crencas culturais, o conflito armado e as variacoes climáticas relacionavam-se com a dinámica da doenca e, do mesmo modo, que a estrutura da política de controle mostra escassa capacidade dos atores para adaptar as acoes de controle a esses processos socioecológicos da regiao. A política de controle mostrou ser efetiva embora, sob os supostos do modelo, escassamente sustentável.

Colombia: ¿qué ha pasado con su reforma de salud? / Colombia: what has happened with its health reform?

La reforma de salud adoptada en Colombia en 1993 fue promovida por diferentes agencias como el modelo a seguir en materia de política sanitaria. Siguiendo los lineamientos del Consenso de Washington y del Banco Mundial, el Gobierno de Colombia, con el apoyo de élites políticas y económicas nacionales reorganizó la gestión de los servicios de salud con base en principios del mercado, desmontó el sistema estatal, incrementó las finanzas del sector, asignó la administración del sistema al sector privado, segmentó la prestación de los servicios y promovió la interacción de los actores en un esquema de competencia de baja regulación. Después de 20 años de implantación, el modelo colombiano evidencia serias fallas y es objeto de controversia. El Estado se debilitó como ente rector de la salud; los grupos privados que administran los recursos se configuraron como fuertes núcleos de poder económico y político, y aumentaron las vulneraciones al derecho a la salud. Adicionalmente, la corrupción y el sobrecosto de los servicios han puesto en crisis la sostenibilidad del sistema, y la red estatal se encuentra en peligro de cierre. Pese a su desprestigio en el ámbito interno, varios agentes dentro y fuera del país propenden por mantener el modelo con base en reformas coyunturales.

The health reform adopted in Colombia in 1993 was promoted by different agencies as the model to follow in matters of health policy. Following the guidelines of the Washington Consensus and the World Bank, the Government of Colombia, with the support of national political and economic elites, reorganized the management of health services based on market principles, dismantled the state system, increased finances of the sector, assigned the management of the system to the private sector, segmented the provision of services, and promoted interaction of actors in a competitive scheme of low regulation. After 20 years of implementation, the Colombian model shows serious flaws and is an object of controversy. The Government has weakened as the governing entity for health; private groups that manage the resources were established as strong centers of economic and political power; and violations of the right to health increased. Additionally, corruption and service cost overruns have put a strain on the sustainability of the system, and the state network is in danger of closing. Despite its loss of prestige at the internal level, various actors within and outside the country tend to keep the model based on contextual reforms.

[Variation in NK cell number and function in individuals with recurrent or severe infections]. / Variaciones en el número y función de los linfocitos asesinos naturales durante infecciones recurrentes o graves.

INTRODUCTION: The information about defects affecting natural killer cell (NK) development and activity in patients with an abnormal increase of recurrent infections is scarce. OBJECTIVE: To perform a systematic analysis of NK abnormalities in patients with recurrent infections. MATERIALS AND METHODS: Our study enrolled twenty patients with severe or recurrent viral infections. Natural killer cell subsets, surface receptors expression and cytotoxicity were analyzed. Results were compared with those from age- and sex-matched healthy controls. RESULTS: Transient alterations were observed in the percentages and absolute numbers of NK cells in patients with infection active episodes. We also described five patients with stable disturbances in the distribution of NK cell subpopulations. These defects are mainly due to a decrease in the CD56 dim CD16 bright cells in peripheral blood. In addition, NK cell function abnormalities were observed in some patients, however, those were always transient and mainly associated to active disease. CONCLUSIONS: These findings demonstrate transient alterations in the percentages and absolute numbers of NK cells in patients with recurrent or severe infection. Also, stable disturbances in CD56 dim CD16 bright NK cells are observed in these patients. Nevertheless, these parameters must be thoroughly studied to determine the mechanisms that entail these immune abnormalities and investigate how they alter the immune response.

[Characteristics of hospital care and its relationship to severe maternal morbidity in Medellín, Colombia]. / Características de la atención hospitalaria y su relación con la morbilidad materna extrema en Medellín, Colombia.

OBJECTIVE: The objective of this study was to determine whether there is an association between severe maternal mortality (SMM) and the characteristics of access to and use of obstetric services by the participating women. METHODS: A study of cases and controls was conducted in a group of 600 women who were attended during pregnancy or the puerperium between 2011 and 2012 by obstetric services located in Medellín, Colombia. The study considered cases (n = 150) in obstetric patients who met the criteria for SMM established by the surveillance system being used in Medellín at the time of their admission. The controls (n = 450) were randomly selected in the same institutions where the patients were being treated. The information was obtained through an in-person interview, review of the patient's clinical history, and rating of the medical care provided by surveillance program personnel. The analysis was based on the model Road Map for Preventing Maternal Death developed jointly by Pan American Health Organization/World Health Organization, Centers for Disease Control, United Nations Population Fund for Latin America and the Caribbean, and Mothercare UK. RESULTS: The proportion of unplanned pregnancies in the women studied was 57.6%, while the proportion of delay in the decision to seek care was 32.0%. Two variables were found to be associated with SMM: ethnicity (OR = 1.79) and delays due to deficiencies in the quality of care provided (OR = 8.54). CONCLUSIONS: The findings suggest that improving the effectiveness and quality of family planning, prenatal check-up, and hospital obstetric care programs could help to reduce avoidable cases of SMM.

Variaciones en el número y función de los linfocitos asesinos naturales durante infecciones recurrentes o graves / Variation in NK cell number and function in individuals with recurrent or severe infections

Introducción. Existen pocos datos sobre los defectos que afectan el desarrollo y función de los linfocitos asesinos naturales ( natural killers, NK) en pacientes con un incremento anormal en la recurrencia de infecciones. Objetivo. Realizar una evaluación sistemática de las diferentes subpoblaciones y la función de estas células en pacientes con infecciones recurrentes. Materiales y métodos. Se incluyeron 20 pacientes con infecciones graves o recurrentes y se analizaron las subpoblaciones y la respuesta citotóxica de los linfocitos NK en sangre periférica. Los resultados de los pacientes se compararon con controles sanos pareados por edad y sexo. Resultados. Los pacientes con episodios infecciosos activos presentaron anormalidades transitorias en el porcentaje o el número absoluto de linfocitos NK. Se caracterizaron, además, cinco pacientes con alteraciones persistentes en la distribución de las subpoblaciones de linfocitos NK. Estas alteraciones se debieron principalmente a la disminución de células CD56 dim CD16 bright . Se evidenciaron, también, defectos en la función de los linfocitos NK en algunos de nuestros pacientes; sin embargo, estas alteraciones fueron transitorias y se asociaron principalmente a la fase activa de la enfermedad. Conclusiones. Nuestros resultados evidencian defectos transitorios en el número y función de los linfocitos NK en pacientes con infecciones recurrentes o graves, además de alteraciones persistentes en los LNK CD56 dim CD16 bright en algunos individuos. Es necesario profundizar en los mecanismos que conllevan al desarrollo de estos defectos inmunes y estudiar cómo estas alteraciones influyen en la respuesta inmune.

Introduction: The information about defects affecting natural killer cell (NK) development and activity in patients with an abnormal increase of recurrent infections is scarce. Objective: To perform a systematic analysis of NK abnormalities in patients with recurrent infections. Materials and methods: Our study enrolled twenty patients with severe or recurrent viral infections. Natural killer cell subsets, surface receptors expression and cytotoxicity were analyzed. Results were compared with those from age- and sex-matched healthy controls. Results: Transient alterations were observed in the percentages and absolute numbers of NK cells in patients with infection active episodes. We also described five patients with stable disturbances in the distribution of NK cell subpopulations. These defects are mainly due to a decrease in the CD56 dim CD16 bright cells in peripheral blood. In addition, NK cell function abnormalities were observed in some patients, however, those were always transient and mainly associated to active disease. Conclusions: These findings demonstrate transient alterations in the percentages and absolute numbers of NK cells in patients with recurrent or severe infection. Also, stable disturbances in CD56 dim CD16 bright NK cells are observed in these patients. Nevertheless, these parameters must be thoroughly studied to determine the mechanisms that entail these immune abnormalities and investigate how they alter the immune response.

Características de la atención hospitalaria y su relación con la morbilidad materna extrema en Medellín, Colombia / Characteristics of hospital care and its relationship to severe maternal morbidity in Medellín, Colombia

OBJETIVO: El objetivo de este estudio es establecer si la morbilidad materna extrema (MME) se asocia con algunas características del acceso y la utilización de los servicios obstétricos de las gestantes participantes. MÉTODOS: Se realizó un estudio de casos y controles con 600 pacientes en embarazo, en parto o el puerperio atendidas entre 2011 y 2012 en servicios de obstetricia de Medellín (Colombia). Se consideraron casos (n = 150) las pacientes obstétricas que durante el ingreso cumplían los criterios de MME establecidos por el sistema de vigilancia que se aplica en la ciudad. Los controles (n = 450) se obtuvieron aleatoriamente de las mismas instituciones que los casos. La información se recabó mediante entrevista personalizada, revisión de la historia clínica y calificación del cuidado médico, realizada por el personal del programa de vigilancia. El análisis se realizó sobre la base del modelo Camino para la supervivencia a la muerte materna de la OPS/OMS, CDC, FNUAP-LAC y Mother Care. RESULTADOS: El porcentaje de embarazo no planificado en las mujeres estudiadas fue 57,6% y el retraso en la decisión de buscar atención, 32,0%. La etnia (OR = 1,8; IC95%: 1,0-2,9) y el retraso por deficiencias en la calidad de la atención prestada (OR = 8,3; IC95%: 5,0-13,7) fueron las variables que se encontraron asociadas con la MME. CONCLUSIONES: Los hallazgos sugieren que mejorar la efectividad y calidad de los programas de planificación familiar, control prenatal y atención obstétrica hospitalaria pudiera contribuir a reducir los casos evitables de MME.

OBJECTIVE: The objective of this study was to determine whether there is an association between severe maternal mortality (SMM) and the characteristics of access to and use of obstetric services by the participating women. METHODS: A study of cases and controls was conducted in a group of 600 women who were attended during pregnancy or the puerperium between 2011 and 2012 by obstetric services located in Medellín, Colombia. The study considered cases (n = 150) in obstetric patients who met the criteria for SMM established by the surveillance system being used in Medellín at the time of their admission. The controls (n = 450) were randomly selected in the same institutions where the patients were being treated. The information was obtained through an in-person interview, review of the patient’s clinical history, and rating of the medical care provided by surveillance program personnel. The analysis was based on the model Road Map for Preventing Maternal Death developed jointly by Pan American Health Organization/World Health Organization, Centers for Disease Control, United Nations Population Fund for Latin America and the Caribbean, and Mothercare UK. RESULTS: The proportion of unplanned pregnancies in the women studied was 57.6%, while the proportion of delay in the decision to seek care was 32.0%. Two variables were found to be associated with SMM: ethnicity (OR = 1.79) and delays due to deficiencies in the quality of care provided (OR = 8.54). CONCLUSIONS: The findings suggest that improving the effectiveness and quality of family planning, prenatal check-up, and hospital obstetric care programs could help to reduce avoidable cases of SMM.

[Colombia: what has happened with its health reform?]. / Colombia: ¿qué ha pasado con su reforma de salud?

The health reform adopted in Colombia in 1993 was promoted by different agencies as the model to follow in matters of health policy. Following the guidelines of the Washington Consensus and the World Bank, the Government of Colombia, with the support of national political and economic elites, reorganized the management of health services based on market principles, dismantled the state system, increased finances of the sector, assigned the management of the system to the private sector, segmented the provision of services, and promoted interaction of actors in a competitive scheme of low regulation. After 20 years of implementation, the Colombian model shows serious flaws and is an object of controversy. The Government has weakened as the governing entity for health; private groups that manage the resources were established as strong centers of economic and political power; and violations of the right to health increased. Additionally, corruption and service cost overruns have put a strain on the sustainability of the system, and the state network is in danger of closing. Despite its loss of prestige at the internal level, various actors within and outside the country tend to keep the model based on contextual reforms.

[Paradigms in the analysis of public health policies: limitations and challenges]. / Paradigmas en el análisis de políticas públicas de salud: limitaciones y desafíos.

Research on health policies is considered essential to ensure the effectiveness and efficiency of public policies. Analyses of public health policies have various objectives, including helping to solve the problems for which the policy was originated. That objective faces two large obstacles: (1) the ambiguity and heterogeneity of the models applied for the analysis of public policies, conditions that hinder the selection of analytical methods and the assessment of the scope of the objective; and (2) the traditional methodological approaches that limit the capacity of analyses to help solve the problems detected. This paper reviews the epistemology of the predominant models of public health policy analysis in order to assess their scope and limitations. It concludes that the development of new conceptual approaches could improve the quality of research on public policies and their ability to favorably impact decisions.

Paradigmas en el análisis de políticas públicas de salud: limitaciones y desafíos / Paradigms in the analysis of public health policies: limitations and challenges

La investigación en políticas de salud se considera esencial para asegurar la efectividad y eficiencia de las políticas públicas. Los análisis de políticas públicas de salud (APPS) obedecen a diferentes propósitos; entre ellos, contribuir a resolver aquellos problemas que originaron la política. Tal propósito enfrenta dos grandes obstáculos: 1) la polisemia y heterogeneidad de los modelos aplicados al análisis de políticas públicas, condiciones que dificultan la selección de los métodos de análisis y la valoración de sus alcances; y 2) los enfoques metodológicos tradicionales que limitan la capacidad de los análisis para contribuir a resolver los problemas detectados. En este ensayo se revisan los fundamentos epistemológicos de los modelos predominantes en APPS con el fin de valorar sus alcances y limitaciones. Se concluye que el desarrollo de nuevas perspectivas conceptuales podría mejorar la calidad de la investigación en políticas públicas y su capacidad para incidir favorablemente en las decisiones.

Research on health policies is considered essential to ensure the effectiveness and efficiency of public policies. Analyses of public health policies have various objectives, including helping to solve the problems for which the policy was originated. That objective faces two large obstacles: (1) the ambiguity and heterogeneity of the models applied for the analysis of public policies, conditions that hinder the selection of analytical methods and the assessment of the scope of the objective; and (2) the traditional methodological approaches that limit the capacity of analyses to help solve the problems detected. This paper reviews the epistemology of the predominant models of public health policy analysis in order to assess their scope and limitations. It concludes that the development of new conceptual approaches could improve the quality of research on public policies and their ability to favorably impact decisions.

Histoplasmosis en pacientes con sida: Un estudio de cohorte en Medellín, Colombia / Histoplasmosis in AIDS patients: A cohort study in Medellín, Colombia

Introducción: la histoplasmosis es una micosis endémica en nuestro país y una complicación relativamente frecuente de los pacientes con sida. El objetivo del estudio era identificar las características clínicas, epidemiológicas y los factores de riesgo asociados a la mortalidad en pacientes con sida coinfectados con histoplasmosis. Materiales y métodos: se realizó un estudio de cohorte retrospectivo en el Hospital Universitario San Vicente de Paúl, en Medellín, con 1177 pacientes con VIH atendidos en un programa especializado de sida. Se identificaron los pacientes con histoplasmosis confirmada por aislamiento del hongo, o identificaci&oacut compatibles con Histoplasma capsulatum, mediante microscopía. Se analizaron variables demográficas, clínicas, de laboratorio, comorbilidad, tratamiento recibido y mortalidad. Resultados: La histoplasmosis afectó a 44 de 709 pacientes con sida (6,2%). Entre éstos, el 95,4% tuvo fiebre, el 54,5% enfermedad diseminada e;n de levaduras intracelulares y el 61,3% compromiso pulmonar. El cultivo fue positivo en el 89,3% y la histopatología en el 93,3%. Se encontró tuberculosis concomitante en el 15,9% y neumocistosis en el 11,4%. La mortalidad fue del 22,7%. El riesgo de morir fue mayor en pacientes con formas diseminadas (todas las muertes ocurrieron en sujetos con este tipo de compromiso), disnea (RR 13; IC95% 1,8-93,8), hipotensión (RR 4,5; IC95% 1,6-13,1), deshidrogenasa láctica (DHL) >2 veces (RR 5,2; IC95% 1,2-22,5), y fue menor en quienes recibieron Anfotericina B (RR 0,3; IC95% 0,1-0,8). Discusión: en la región, la histoplasmosis es frecuente en pacientes con sida, y el rendimiento diagnóstico de las técnicas de rutina para H. capsulatum es alto, por lo que deben solicitarse en cualquier caso compatible. Demostrar la comorbilidad sida-histoplasmosis no descarta otras infecciones oportunistas. Los pacientes con formas diseminadas, disnea, hipotensión y DHL alta tienen mayor riesgo de muerte. El tratamiento con anfotericina B se asoció con una mayor sobrevida.

Introduction: histoplasmosis is an endemic mycosis in Colombia and a relatively common complication in HIV patients. The aim of this study was to identify clinical and epidemiological characteristics and mortality risk factors in patients infected with histoplasmosis and HIV. Materials and methods: a retrospective cohort study was carried out at Hospital Universitario San Vicente de Paúl in Medellín with 1177 HIVpositive patients. Patients with histoplasmosis were confirmed by isolation of Histoplasma capsulatum from culture or by identification of intracellular yeasts through microscopy. Data collected from patients included demographic and clinical variables, laboratory values, treatment, and survival. Results: histoplasmosis affected 44/709 patients with AIDS (6.2%). Out of those, 95.4% had fever, 54.5% disseminated illness, and 61.3% pulmonary disease. Culture was positive in 89.3%, and histopathology in 93.3%. Concomitant tuberculosis and Pneumocystis jirovecii infection were diagnosed in 15.9% and 11.4%, respectively. General mortality was 22.7%. Mortality was higher in patients with disseminated forms (all 10 deaths occurred in this fashion), dyspnea (RR 13; 95% CI 1.8-93.8), hypotension (RR 4.5; 95% CI 1.6-13.1), lactate dehydrogenase >2 times the upper limit of the normal range (RR 5.2; 95% CI 1.2-22.5), and it was lower among patients treated with amphotericine B (RR 0.3; 95% CI 0.1-0.8). Discusion: histoplasmosis is frequent in AIDS patients in the region. As the diagnosis yield of routine techniques to identify H. capsulatum is high, they must be required in any compatible setting. Many patients with AIDS-histoplasmosis co-infection acquire other opportunistic infections. Patients with disseminated forms, dyspnea, hypotension, and high levels of DHL have a higher mortality risk. Exposure to amphotericine B is associated with longer survival.