Costing Interventions for Developing an Essential Package of Health Services: Application of a Rapid Method and Results From Pakistan.

BACKGROUND: The Federal Ministry of National Health Services, Regulations and Coordination (MNHSR&C) in Pakistan has committed to progress towards universal health coverage (UHC) by 2030 by providing an Essential Package of Health Services (EPHS). Starting in 2019, the Disease Control Priorities 3rd edition (DCP3) evidence framework was used to guide the development of Pakistan's EPHS. In this paper, we describe the methods and results of a rapid costing approach used to inform the EPHS design process. METHODS: A total of 167 unit costs were calculated through a context-specific, normative, ingredients-based, and bottom-up economic costing approach. Costs were constructed by determining resource use from descriptions provided by MNHSR&C and validated by technical experts. Price data from publicly available sources were used. Deterministic univariate sensitivity analyses were carried out. RESULTS: Unit costs ranged from 2019 US$ 0.27 to 2019 US$ 1478. Interventions in the cancer package of services had the highest average cost (2019 US$ 837) while interventions in the environmental package of services had the lowest (2019 US$ 0.68). Cost drivers varied by platform; the two largest drivers were drug regimens and surgery-related costs. Sensitivity analyses suggest our results are not sensitive to changes in staff salary but are sensitive to changes in medicine pricing. CONCLUSION: We estimated a large number of context-specific unit costs, over a six-month period, demonstrating a rapid costing method suitable for EPHS design.

Effects of cannabis legalisation on patterns of cannabis consumption among adolescents in Ontario, Canada (2001-2019).

INTRODUCTION: Cannabis legalisation was enacted on 17 October 2018 in Canada. Accordingly, the effects of cannabis legalisation on patterns of cannabis consumption were examined among adolescents, including on cannabis initiation, any cannabis use, daily cannabis use and cannabis dependence. METHODS: Data from a biennial population-based, cross-sectional survey of students in Ontario were pooled in a pre-post design (2001-2019; N = 89,238). Participants provided self-reports of cannabis initiation, any cannabis use, daily cannabis use and cannabis dependence. Long-term trends in these patterns of cannabis consumption over two decades of observation were characterised to provide a broader context of usage. The effects of cannabis legalisation on patterns of cannabis consumption were quantified using logistic regression analyses. RESULTS: Long-term trends over the two decades of observation indicated that cannabis initiation decreased and then increased (p = 0.0220), any cannabis use decreased and daily cannabis use decreased (p < 0.0001 and p = 0.0001, respectively) and cannabis dependence remained unchanged (p = 0.1187). However, in comparisons between the pre-cannabis legalisation period (2001-2017) and the post-cannabis legalisation period (2019), cannabis legalisation was not associated with cannabis initiation (odds ratio; 95% confidence interval 1.00; 0.79-1.27), but it was associated with an increased likelihood of any cannabis use (1.31; 1.12-1.53), daily cannabis use (1.40; 1.09-1.80) and cannabis dependence (1.98; 1.29-3.04). DISCUSSION AND CONCLUSIONS: Cannabis legalisation was not associated with cannabis initiation, but it was associated with an increased likelihood of any cannabis use, daily cannabis use and cannabis dependence.

Tratamiento de la enfermedad de Pompe / Treatment of Pompe Disease

Introducción: La enfermedad de Pompe es un trastorno de origen genético causado por la deficiencia de la enzima alfa-glucosidasa ácida, que se caracteriza por el acumulo anormal de glucógeno en los músculos y otros tejidos, generando una debilidad muscular progresiva, la cual debe ser diagnosticada y tratada de forma oportuna, ya que de esto dependerá el pronóstico, la sobrevida y la funcionalidad de los pacientes con esta condición. Contenidos: El abordaje multidisciplinario incluye tanto una adecuada valoración y soporte nutricional como el inicio del tratamiento modificador de enfermedad a través de la terapia de reemplazo enzimático, que a su vez dependerá de la forma de presentación, la variante genética, el perfil inicial del paciente, las condiciones especiales que puedan existir y las metas propias para cada paciente. Para garantizar un manejo adecuado, se deben realizar estudios de seguimiento con parámetros objetivos, evaluar posibles eventos secundarios e instaurar su manejo en caso de presentarlos. Conclusiones: El pronóstico de esta enfermedad dependerá del inicio oportuno del tratamiento, la implementación de pautas nutricionales adecuadas y el establecimiento del seguimiento de los parámetros clínicos y paraclínicos para cada uno de los pacientes.

Introduction: Pompe disease is a disorder of genetic origin caused by the deficiency of the acid alpha-glucosidase enzyme, which is characterized by the abnormal accumulation of glycogen in the muscles and other tissues, generating progressive muscle weakness, which must be diagnosed and treated in a timely manner, since the prognosis, survival, and functionality of patients with this condition will depend on this. Contents: The multidisciplinary approach includes both an adequate evaluation and nutritional support as well as the initiation of disease-modifying treatment through enzyme replacement therapy, which in turn will depend on the form of presentation, the genetic variant, the initial profile of the patient, the special conditions that may exist and the specific goals for each patient. To guarantee adequate management, follow-up studies must be carried out with objective parameters, evaluate possible secondary events and establish their management in case of presenting them. Conclusions: The prognosis of this disease will depend on the timely initiation of treatment, the implementation of adequate nutritional guidelines and the establishment of monitoring of clinical and paraclinical parameters for each of the patients.

On offer to Ontario consumers three years after legalization: A profile of cannabis products, cannabinoid content, plant type, and prices.

Introduction: Cannabis was legalized in Canada in October 2018, regulating the production, distribution, sale, and possession of dried cannabis and cannabis oils. Additional products were legalized 1 year later, including edibles, concentrates, and topicals, with new lines of commercial products coming to market. Ontario is the most populous province in Canada and has the largest cannabis market with the highest number of in-person retail stores and the most cannabis products available online. This study aims to create a profile of products available to consumers three years after legalization by summarizing types of products, THC and CBD potency, plant type, and prices of product sub-categories. Methods: We extracted data from the website of the Ontario Cannabis Store (OCS)-the public agency overseeing the only online store and sole wholesaler to all authorized in-person stores-in the first quarter of 2022 (January 19-March 23). We used descriptive analyses to summarize the data. A total of 1,771 available products were mapped by route of administration into inhalation (smoking, vaping, and concentrates), ingestible (edibles, beverages, oils, and capsules) and topical. Results: Most inhalation products included ≥20%/g THC (dried flower: 94%; cartridges: 96%; resin: 100%) while ingestible products had similar proportions of THC and CBD content. Indica-dominant products tend to be more prominent in inhalation products while sativa-dominant products tend to be more prominent in ingestible products. The average sale price of cannabis was 9.30 $/g for dried flower, 5.79 $/0.1g for cartridges, 54.82 $/g for resin, 3.21 $/unit for soft chews, 1.37 $/ml for drops, 1.52 $/unit for capsules, and 39.94 $/product for topicals. Discussion: In summary, a wide variety of cannabis products were available to Ontarians for different routes of administration and provides numerous indica-dominant, sativa-dominant, and hybrid/blend options. The current market for inhalation products however is geared towards the commercialization of high-THC products.

Cannabis legalization and cannabis use, daily cannabis use and cannabis-related problems among adults in Ontario, Canada (2001-2019).

BACKGROUND: In the context of cannabis legalization in Canada, we examined the effects on cannabis patterns of consumption, including cannabis use, daily cannabis use and cannabis-related problems. In addition, we examined differential effects of cannabis legalization by age and sex. METHODS: A pre-post design was operationalized by combining 19 iterations of the Centre for Addiction and Mental Health (CAMH) Monitor Surveys (N = 52,260; 2001-2019): repeated, population-based, cross-sectional surveys of adults in Ontario. Participants provided self-reports of cannabis use (past 12 months), daily cannabis use (past 12 months) and cannabis-related problems though telephone interviews. The effects of cannabis legalization on cannabis patterns of consumption were examined using logistic regression analyses, with testing of two-way interactions to determine differential effects by age and sex. RESULTS: Cannabis use prevalence increased from 11 % to 26 % (p < 0.0001), daily cannabis use prevalence increased from 1 % to 6 % (p < 0.0001) and cannabis-related problems prevalence increased from 6 % to 14 % (p < 0.0001) between 2001 and 2019. Cannabis legalization was associated with an increased likelihood of cannabis use (OR, 95 % CI: 1.62, 1.40-1.86), daily cannabis use (1.59, 1.21-2.07) and cannabis-related problems (1.53, 1.20-1.95). For cannabis-related problems, a significant two-way interaction was observed between cannabis legalization and age (p = 0.0001), suggesting differential effects among adults ≥55 years. CONCLUSIONS: Cannabis legalization was associated with an increased likelihood of cannabis use, daily cannabis use and cannabis-related problems. Given increases in these cannabis patterns of consumption, broader dissemination and uptake of targeted prevention tools is indicated.

Costs and Cost-Effectiveness of Biomedical, Non-Surgical HIV Prevention Interventions: A Systematic Literature Review.

BACKGROUND: Considerable evidence on the costs and cost-effectiveness of biomedical, non-surgical interventions to prevent human immunodeficiency virus (HIV) transmission has been generated over the last decade. This study aims to synthesize findings and identify remaining knowledge gaps to suggest future research priorities. METHODS: A systematic literature review was carried out in August 2020 using the MEDLINE, Embase, Global Health and EconLit databases to retrieve economic evaluations and costing studies of oral pre-exposure prophylaxis (PrEP), injectable long-acting PrEP, vaginal microbicide rings and gels, HIV vaccines and broadly neutralizing antibodies. Studies reporting costs from the provider or societal perspective were included in the analysis. Those reporting on behavioural methods of prevention, condoms and surgical approaches (voluntary medical male circumcision) were excluded. The quality of reporting of the included studies was assessed using published checklists. RESULTS: We identified 3007 citations, of which 87 studies were retained. Most were set in low- and middle-income countries (LMICs; n = 53) and focused on the costs and/or cost-effectiveness of oral PrEP regimens (n = 70). Model-based economic evaluations were the most frequent study design; only two trial-based cost-effectiveness analyses and nine costing studies were found. Less than half of the studies provided practical details on how the intervention would be delivered by the health system, and only three of these, all in LMICs, explicitly focused on service integration and its implication for delivery costs. 'Real-world' programme delivery mechanisms and costs of intervention delivery were rarely considered. PrEP technologies were generally found to be cost-effective only when targeting high-risk subpopulations. Single-dose HIV vaccines are expected to be cost-effective for all groups despite substantial uncertainty around pricing. CONCLUSIONS: A lack of primary, detailed and updated cost data, including above-service level costs, from a variety of settings makes it difficult to evaluate the cost-effectiveness of specific delivery modes at scale, or to evaluate strategies for services integration. Closing this evidence gap around real-world implementation is vital, not least because the strategies targeting high-risk groups that are recommended by PrEP models may incur substantially higher costs and be of limited practical feasibility in some settings.

Disentangling Medicinal and Recreational cannabis Use Among People Living with HIV: An Ecological Momentary Assessment Study.

This study examined the feasibility of using ecological momentary assessment (EMA) to disentangle medicinal cannabis use (MCU) from recreational cannabis use (RCU) among people living HIV (PLWH). Over a 14-day period, PLWH (N = 29) who engaged in both MCU and RCU completed a smartphone-based survey before and after every cannabis use event assessing general motivation for cannabis use (MCU-only, RCU-only, or mixed MCU/RCU), cannabis use behavior, and several antecedents and outcomes of cannabis use. A total of 739 pre-cannabis surveys were completed; 590 (80%) of the prompted post-cannabis surveys were completed. Motives for cannabis use were reported as MCU-only on 24%, RCU-only on 30%, and mixed MCU/RCU on 46% of pre-cannabis surveys. Mixed effects models examined within-person differences across MCU-only, RCU-only, and mixed MCU/RCU events. Results showed that relative to RCU-only events, MCU-only events were more likely to involve symptom management and drug substitution motives, physical and sleep-related symptoms, solitary cannabis use, and use of cannabis oils and sprays; MCU-only events were less likely to involve relaxation, happiness, and wellness motives, cannabis flower use, and positive cannabis consequences. Differences between mixed MCU/RCU and RCU-only events were similar, except that mixed MCU/RCU events were additionally associated with stress reduction motives and symptoms of anxiety and depression. Findings support the feasibility of partially disentangling MCU and RCU behavior among PLWH who engage in concurrent MCU and RCU. This study highlights the need for more EMA studies isolating MCU from RCU to inform ongoing changes to cannabis policies.

Healthcare practitioner perceptions on barriers impacting cannabis prescribing practices.

BACKGROUND: Canadians seeking medical cannabis (MC) may encounter difficulties in finding a healthcare provider (HCP) who authorizes their access to it. Barriers that HCPs face in authorizing MC are unclear. The objectives of this study were to evaluate HCP opinions, knowledge, comfort, and practice in MC prescribing and counseling on recreational cannabis use, and whether the COVID-19 pandemic affected MC prescribing practices. METHODS: Eligible participants included HCPs (e.g., attending physicians, nurses, pharmacists) in Canada. A questionnaire evaluating their knowledge, comfort, and practice in medical and recreational cannabis was designed based on instruments developed in previous studies. Between April 13th-December 13th 2021, ninety-one healthcare associations were asked to distribute the survey to their members, and an advertisement was placed in the online Canadian Medical Association Journal. Descriptive statistics were used to analyze the results. RESULTS: Twenty-four organizations agreed to disseminate the survey and 70 individuals completed it. Of respondents, 71% were attending physicians or medical residents, while the remainder were nurses, pharmacists or other HCPs. Almost none (6%) received training in MC in professional school but 60% did receive other training (e.g., workshops, conferences). Over half (57%) received more questions regarding MC since recreational cannabis was legalized, and 82% reported having patients who use MC. However, 56% felt uncomfortable or ambivalent regarding their knowledge of MC, and 27% were unfamiliar with the requirements for obtaining MC in Canada. The most common symptoms for recommending MC were pain and nausea, whereas the most common conditions for recommending it were cancer and intractable pain. The strongest barrier to authorizing MC was uncertainty in safe and effective dosage and routes of administration. The strongest barrier to recommending or authorizing MC was the lack of research evidence demonstrating its safety and efficacy. During the pandemic, many respondents reported that a greater number of their patients used cannabis to relieve anxiety and depression. CONCLUSIONS: Our results suggest that HCPs across Canada who responded to our survey are unfamiliar with topics related to MC. The strongest barriers appear to be lack of clinical research, and uncertainty in safe and effective MC administration. Increasing research, training, and knowledge may help HCPs feel more equipped to make informed treatment/prescribing decisions, which may help to improve access to MC.

Prevention of violence against women and girls: A cost-effectiveness study across 6 low- and middle-income countries.

BACKGROUND: Violence against women and girls (VAWG) is a human rights violation with social, economic, and health consequences for survivors, perpetrators, and society. Robust evidence on economic, social, and health impact, plus the cost of delivery of VAWG prevention, is critical to making the case for investment, particularly in low- and middle-income countries (LMICs) where health sector resources are highly constrained. We report on the costs and health impact of VAWG prevention in 6 countries. METHODS AND FINDINGS: We conducted a trial-based cost-effectiveness analysis of VAWG prevention interventions using primary data from 5 randomised controlled trials (RCTs) in sub-Saharan Africa and 1 in South Asia. We evaluated 2 school-based interventions aimed at adolescents (11 to 14 years old) and 2 workshop-based (small group or one to one) interventions, 1 community-based intervention, and 1 combined small group and community-based programme all aimed at adult men and women (18+ years old). All interventions were delivered between 2015 and 2018 and were compared to a do-nothing scenario, except for one of the school-based interventions (government-mandated programme) and for the combined intervention (access to financial services in small groups). We computed the health burden from VAWG with disability-adjusted life year (DALY). We estimated per capita DALYs averted using statistical models that reflect each trial's design and any baseline imbalances. We report cost-effectiveness as cost per DALY averted and characterise uncertainty in the estimates with probabilistic sensitivity analysis (PSA) and cost-effectiveness acceptability curves (CEACs), which show the probability of cost-effectiveness at different thresholds. We report a subgroup analysis of the small group component of the combined intervention and no other subgroup analysis. We also report an impact inventory to illustrate interventions' socioeconomic impact beyond health. We use a 3% discount rate for investment costs and a 1-year time horizon, assuming no effects post the intervention period. From a health sector perspective, the cost per DALY averted varies between US$222 (2018), for an established gender attitudes and harmful social norms change community-based intervention in Ghana, to US$17,548 (2018) for a livelihoods intervention in South Africa. Taking a societal perspective and including wider economic impact improves the cost-effectiveness of some interventions but reduces others. For example, interventions with positive economic impacts, often those with explicit economic goals, offset implementation costs and achieve more favourable cost-effectiveness ratios. Results are robust to sensitivity analyses. Our DALYs include a subset of the health consequences of VAWG exposure; we assume no mortality impact from any of the health consequences included in the DALYs calculations. In both cases, we may be underestimating overall health impact. We also do not report on participants' health costs. CONCLUSIONS: We demonstrate that investment in established community-based VAWG prevention interventions can improve population health in LMICs, even within highly constrained health budgets. However, several VAWG prevention interventions require further modification to achieve affordability and cost-effectiveness at scale. Broadening the range of social, health, and economic outcomes captured in future cost-effectiveness assessments remains critical to justifying the investment urgently required to prevent VAWG globally.

Are vaporizers a lower-risk alternative to smoking cannabis?

Cannabis use is associated with various adverse physical and mental health outcomes as well as increased risk of motor vehicle collision. Many organizations and the "Lower-Risk Cannabis Use Guidelines" have recommended to use cannabis vaporizers instead of smoking to reduce the associated health risk. This commentary draws attention to the present evidence regarding harm reduction potential of cannabis vaping. Cannabis vaporizer use can reduce the emission of carbon monoxide, chronic respiratory symptoms, and exposure to several toxins while producing similar subjective effects and blood THC concentration compared with smoking cannabis, holding potential for harm reduction among habitual cannabis smokers. However, new cannabis users, regardless of method of administration of cannabis, may experience intense subjective effects and cognitive impairment with increased susceptibility to dependence. Hence, policy makers should consider limiting access to cannabis among young people and adopting strategies to reduce impaired driving under influence of cannabis. Future research should focus on impact of switching from cannabis smoking to dried herb vaping using cannabis vaporizers among chronic cannabis smokers, and long-term outcomes of medical cannabis vaping, and further explore association of vaping-associated lung injury with THC-containing e-liquids.

RéSUMé: L'usage du cannabis est associé à une panoplie de résultats de santé physique et mentale indésirables et à un risque accru de collision entre véhicules automobiles. De nombreux organismes, ainsi que les « Recommandations canadiennes pour l'usage du cannabis à moindre risque ¼, recommandent d'utiliser un vaporisateur au lieu de fumer le cannabis afin d'en réduire les risques pour la santé. Notre commentaire attire l'attention sur les preuves actuelles concernant le potentiel de réduction des méfaits du vapotage du cannabis. L'utilisation d'un vaporisateur de cannabis peut réduire l'émission de monoxyde de carbone, les symptômes respiratoires chroniques et l'exposition à plusieurs toxines tout en produisant des effets subjectifs et une concentration de THC dans le sang semblables à ceux du cannabis fumé, ce qui pourrait réduire les méfaits chez les fumeurs réguliers de cannabis. Par contre, les nouveaux consommateurs de cannabis, peu importe la méthode d'administration du cannabis choisie, peuvent éprouver des effets subjectifs intenses et une détérioration cognitive, ainsi qu'une susceptibilité accrue à la dépendance. Les responsables des politiques devraient donc songer à limiter l'accès des jeunes au cannabis et adopter des stratégies pour réduire la conduite avec facultés affaiblies par cette drogue. Des études futures devraient porter sur les conséquences, pour les fumeurs réguliers de cannabis, de vapoter l'herbe séchée à l'aide d'un vaporisateur au lieu de fumer le cannabis, et sur les effets à long terme du vapotage du cannabis médical, et explorer plus avant l'association entre les lésions pulmonaires associées au vapotage et les liquides à vapoter contenant du THC.

Cultura Escolar en el Bajo Cauca Antioqueño: de lo Mecánico a lo Complejo / School Culture in Bajo Cauca Antioqueño: from the Mechanical to the Complex / Cultura Escolar no Bajo Cauca Antioqueño: da Mecânica ao Complexo

Resumen Introducción: Las miradas sobre cultura escolar propuestas en este ejercicio investigativo son resultado del trabajo en red realizado en el Centro de Pensamiento Pedagógico (CPP), en el cual, se promueve la reflexión en torno al quehacer educativo desde diversos ámbitos académicos, en el marco de los contextos educativos de Antioquia. Bajo este marco de referencia, el Objetivo de este artículo hace acento en comprender la cultura escolar de la subregión del bajo Cauca-antioqueño, territorio enmarcado en medio del conflicto armado. Materiales y métodos: la investigación se realizó desde un diseño cualitativo y está suscrita en un paradigma hermenéutico (interpretativo); específicamente, se orienta por el enfoque biográfico-narrativo. Participaron veinte maestros con los cuales se llevaron a cabo grupos de discusión y relatos de experiencia como técnica de recolección de información. Los datos se analizaron a partir del análisis narrativo haciendo uso de la matriz de interpretación narrativa propuestas por los investigadores. Los Resultados dan cuenta de que la cultura escolar en el Bajo Cauca antioqueño es compleja, cambiante y diferente a la de otras subregiones del departamento debido a las realidades propias del territorio. Conclusión: la cultura escolar en esta subregión antioqueña está matizada y se configura por tres aspectos significativos que son "El quehacer del maestro" "Las grietas de la pedagogía de la memoria" y "La fusión de cosmogonías paisas y costeñas, la presencia del río Cauca y la escuela como territorio de resiliencia".

Abstract Introduction: The views on school culture proposed in this investigative exercise are the result of the networking carried out in the Pedagogical Thought Center (CPP), in which reflection on educational work is promoted from various academic fields, within the framework of the educational contexts of Antioquia. Under this frame of reference, the Objective of this article emphasizes understanding the school culture of the lower Cauca-Antioqueño subregion, a territory framed in the middle of the armed conflict. Materials and methods: The research was carried out from a qualitative design and is subscribed to a hermeneutical (interpretive) paradigm; specifically, it is guided by the biographical-narrative approach. Twenty teachers participated with whom discussion groups and experience reports were carried out as an information gathering technique. The data were analyzed from the narrative analysis using the narrative interpretation matrix proposed by the researchers. The Results show that the school culture in Lower Cauca Antioquia is complex, changing and different from that of other subregions of the department due to the realities of the territory. It is Concluded that the school culture in this Antioquia subregion is nuanced and is configured by three significant aspects are "The work of the teacher" "The cracks of the pedagogy of memory" and "The fusion of cosmogonies of the country and the coast, the presence of the river Cauca and the school as a territory of resilience"

Resumo Introdução: As visões sobre cultura escolar propostas neste exercício investigativo resultam do trabalho em rede realizado no Centro de Pensamento Pedagógico (CPP), no qual é promovida a reflexão sobre o trabalho educativo a partir de várias áreas académicas, no âmbito dos contextos educativos de. Antioquia. Sob esse quadro de referência, o Objetivo deste artigo enfatiza a compreensão da cultura escolar da sub-região do baixo Cauca-Antioqueño, território enquadrado no meio do conflito armado. Materiais e métodos: a investigação foi desenvolvida a partir de um desenho qualitativo e está inscrita num paradigma hermenêutico (interpretativo); especificamente, é orientado pela abordagem biográfico-narrativa. Participaram 20 professores com os quais foram realizados grupos de discussão e relatos de experiência como técnica de coleta de informações. Os dados foram analisados a partir da análise narrativa por meio da matriz de interpretação narrativa proposta pelos pesquisadores. Os Resultados mostram que a cultura escolar no Baixo Cauca Antioquia é complexa, mutante e diferente das demais sub-regiões do departamento devido às realidades do território. Conclusão que a cultura escolar desta sub-região de Antioquia é matizada e configurada por três aspectos significativos: "O trabalho do professor" "As fissuras da pedagogia da memória" e "A fusão das cosmogonias do país e do litoral, a presença do rio Cauca e da escola como território de resiliência"

Divertículo de Meckel en asociación a onfalocele y tetralogía de Fallot: reporte de caso y revisión de la literatura / Meckel's diverticulum in association with omphalocele and tetralogy of Fallot: Case report and literature review

El onfalocele o exónfalos se definen como un defecto congénito de la pared abdominal, que consiste en la herniación de las vísceras abdominales a través del anillo umbilical. Esta entidad rara vez se asocia a la comunicación del divertículo de Meckel con el saco del onfalocele. Teniendo en cuenta la escasa prevalencia de dicha entidad, compartimos el reporte de caso de un paciente recién nacido, con diagnóstico de onfalocele menor, en quien se sospechaba ruptura del saco, sin embargo, de manera intraoperatoria se encontró que la aparente ruptura del saco, correspondía a la comunicación con un divertículo de Meckel. El caso además se asoció con hallazgos ecocardiográficos de tetralogía de Fallot

Omphalocele or exomphalos are defined as a congenital defect of the abdominal wall, which consists of the herniation of the abdominal viscera through the umbilical ring. This entity is rarely associated with the communication of Meckel's diverticulum with the omphalocele sac. Considering the low prevalence of this entity, we report the case of a newborn with a diagnosis of minor omphalocele, in whom rupture of the sac was suspected; however, intraoperatively it was found that the apparent rupture of the sac corresponded to a communication with a Meckel's diverticulum. The case was also associated with echocardiographic findings of tetralogy of Fallot

Prevalence and Correlates of Medicinal Cannabis Use Among Adolescents.

PURPOSE: Prior studies of medicinal cannabis use (MCU) have focused primarily on adults. This study examined the prevalence and correlates of self-reported MCU among adolescents. METHODS: Secondary school students (grades 9-12; N = 3,221) completed a cross-sectional survey in classrooms across Ontario, Canada, in 2016-2017. Participants reported on cannabis use behavior, cannabis dependence, other drugs use, and general health and sleep. Participants reporting cannabis use in the past year were grouped based on whether they reported MCU or not (i.e., recreational cannabis use only [RCU-only]). RESULTS: An estimated 6.89% (95% confidence interval 5.48%-8.63%) of students reported MCU, representing one quarter of the students reporting current cannabis use. Relative to the RCU-only group, the MCU group reported using cannabis more frequently, were more likely to report vaping and eating cannabis, had greater risk for cannabis dependence, perceived cannabis as less harmful, were more likely to report tobacco use, recreational use of other drugs, and medicinal use of sedatives or tranquilizers, and were less likely to report good health and sleeping for seven or more hours per night. Frequency of cannabis use accounted for differences between MCU and RCU-only groups in cannabis dependence risk, recreational use of other drugs, and perceiving cannabis as harmful, but it did not account for the other differences. CONCLUSIONS: A sizable portion of secondary school students report MCU, which appears to be associated with more frequent cannabis use and certain substance use and health-related correlates. Research is needed to further characterize motives for self-reported MCU among adolescents.

Prevalência de tejido mamario denso en una población de Bucaramanga, Colombia / Prevalence of breast dense in a population in Bucaramanga, Colombia

Resumen Objetivo: Establecer la prevalencia de mujeres mayores de 50 años con mamas densas estudiadas por mamografía en el área de Bucaramanga. Métodos: Se realizó un estudio descriptivo retrospectivo durante el periodo comprendido entre enero de 2014 y agosto de 2015, en el que se revisaron 10.110 mamografías de pacientes mayores de 50 años. Posteriormente, se hizo una revisión de la literatura en las principales bases de datos. Resultados: De las 10.110 mamografías realizadas, 4.448 fueron encontradas como positivas para mama densa. De estas, el 39,69% correspondió a tejido mamario heterogéneamente denso y el 4,29%, a tejido mamario extremadamente denso, para un total de 43,9% de los casos estudiados. Conclusión: La densidad mamaria es un factor de riesgo independiente de cáncer de mama, considerado de mediana importancia frente a otros factores. A medida que incrementa la densidad mamaria, se genera la superposición del tejido mamario radio-opaco que puede ocultar y llegar a retardar el diagnóstico de un cáncer subyacente. Dada la alta prevalencia de tejido mamario denso encontrado en la población estudiada, se sugiere complementar el tamizaje con otros métodos de imágenes.

Abstract Objective: To establish the prevalence of dense breast tissue in a group of women aged over 50 years, who were studied with mammography in the city of Bucaramanga (Colombia). Methods: A retrospective descriptive study was conducted from January 2014 to August 2015; 10.110 mammograms of patients aged over 50 years were reviewed. Subsequently, a review of the literature in the main databases was made. Results: From 10.110 mammograms that were performed, 4.448 were found to be positive for dense breast tissue. 39,69% had heterogeneously dense breast tissue, and 4,29% extremely dense breast tissue, for a total result of 43,9% patients with positive dense breast tissue. Conclusion: Breast density is an independent risk factor for breast cancer, being of medium importance compared with other factors. As the breast density increases, the overlap of the radiopaque breast tissue that can hide and delay the diagnosis of an underlying cancer is generated. The high prevalence of dense breast tissue that we found in this population suggests the need of complementing screening with other imaging methods.

The Structure and Parameterization of the Breast Cancer Transition Model Among Chinese Women.

OBJECTIVES: Markov model simulation based on the natural history of disease is commonly employed for the comparative research of health interventions. The present study aims to simulate the natural progression of breast cancer and parameterize the initial and transition probabilities of multiple states of breast cancer development among Chinese women. METHODS: The age-specific incidence, mortality, and clinical stage distribution of breast cancer; and relapse rate of each clinical stage were collected from China's cancer registry yearbooks and clinical epidemiological studies to simulate the process from full health to breast cancer to death among Chinese women aged 30 to 80 through a Markov cohort study. The validity analysis was conducted to evaluate the accuracy of the model estimation. RESULTS: A Markov transition model with 7 states (no breast cancer, clinical stages 0-IV breast cancer, and death) was constructed for Chinese women. The age-specific incidence, mortality, and clinical stage distribution of breast cancer estimated by the initial and transition probabilities among different Markov states were highly consistent with the registered data and observed studies. CONCLUSION: A breast cancer transition model for Chinese women has been established with validity. It could be a point of reference for further economic evaluations and breast cancer screening policy formulation.

Sentidos de las prácticas discursivas en la formación de maestros en clave de educación para la paz y construcción de ciudadanía / Meaning of discursive practices in the training of teachers for peace and citizenship construction / Sentidos das práticas discursivas na formação de educadores na chave da educação pela paz e a construção da cidadania

Resumen Introducción: esta reflexión investigativa surge en el marco de la situación que vivía Colombia con miras a consolidar el acuerdo de paz, por lo cual, se hacía necesario centrar la mirada en la formación de maestros, ya que estos son actores sociales, éticos y políticos que con su trabajo pedagógico le aportan a la construcción de una cultura de paz. En este sentido, el objetivo estuvo orientado a develar las prácticas discursivas en torno a la educación para la paz y construcción de ciudadanía que circulan y se apropian en la formación de maestros en ocho facultades de educación y dos normales superiores en el departamento de Antioquia. Los materiales y métodos: la investigación es cualitativa con enfoque fenomenológico y documental, las técnicas utilizadas: entrevista, grupo focal y análisis documental; los instrumentos: guía de entrevista, guía de grupo focal y ficha para el análisis de documentos institucionales. El análisis se hizo con la información que arrojaba cada instrumento y posteriormente se trianguló en una matriz de cuatro cuadrantes del sentido propuesta por los investigadores. Los resultados: los sentidos de las prácticas discursivas se plantearon desde cuatro perspectivas, que son subjetiva, objetiva, intersubjetiva e inter objetiva. Se Concluye que los sentidos de las prácticas discursivas se sitúan desde lo subjetivo en el propio saber, sentir y vivencia. Lo objetivo en las experiencias, protocolos y estrategias. Lo intersubjetivo en la interrelación y cultura discursiva y la inter objetiva se refiere a la institucionalización y aplicación explicita de las políticas educativas.

Abstract Introduction: This research reflection arises within the framework of the situation that Colombia was living in order to consolidate the peace agreement, so it was necessary to focus on the training of teachers, since these are social, ethical and political actors who, with their pedagogical work, contribute to the construction of a culture of peace. Objective: Unveil the discursive practices around education for peace and citizenship construction that circulate and are appropriated in the training of teachers in eight Faculties of Education and two Normal Schools in the department of Antioquia. Materials and methods: The research is qualitative with a phenomenological and documentary approach. The techniques used are: interview, focus group and documentary analysis; the instruments: interview guide, focus group guide and card for the analysis of institutional documents. The analysis was made with the information provided by each instrument and subsequently triangulated into a matrix of four meaning quadrants proposed by the researchers. Results: The meanings of the discursive practices were raised from four perspectives, namely subjective, objective, inter-subjective and inter-objective. Conclusions: The meanings of the discursive practices are placed from the subjective in one's own knowledge, feeling and experience; from the objective in experiences, protocols and strategies; from the inter-subjective in the interrelation and discursive culture; and from the inter-objective in the institutionalization and explicit application of educational policies.

Resumo Introdução: esta reflexão de pesquisa emerge no marco da situação que vivia Colômbia a fim de consolidar o acordo da paz, é por isso que, se fiz necessário centrar o olhar na formação de educadores, pois estes são atores sociais, éticos e políticos que com seu trabalho pedagógico aportam à construção uma cultura de paz. Neste sentido, o objetivo esteve orientado para revelar as práticas discursivas em torno à educação para a paz e construção de cidadania que circulam e se apropriam na formação de educadores em oito faculdades de educação e dois normais superiores no departamento de Antioquia. Os materiais e métodos: a pesquisa é qualitativa com a abordagem fenomenológico e documental, as técnicas utilizadas: entrevista, grupo focal e análise documental; os instrumentos: guia de entrevista, guia de grupo focal e o ficho para a análise de documentos institucionais. A análise se realizou com a informação que emitia cada instrumento e posteriormente se triangulou em uma matriz de quatro quadrantes do sentido proposto pelos pesquisadores. Os resultados: os sentidos das práticas discursivas se plantearam desde quatro perspectivas, que são subjetiva, objetiva, intersubjetiva e interobjetiva. Se Conclui que os sentidos das práticas discursivas estão situados desde o subjetivo no próprio saber, sentir e vivência. O objetivo nas experiências, protocolos e estratégias. O intersubjetivo na inter-relação e cultura discursiva e a interobjetiva se refere à institucionalização e aplicação explícita das políticas educativas.

Cannabis legalization in the provinces and territories: missing opportunities to effectively educate youth?

Cannabis is now legal in Canada, yet important questions remain regarding how the provinces and territories are approaching cannabis education and messaging aimed at youth. Although widespread education and awareness campaigns are long considered cornerstones of substance use and related harm prevention, there is limited evidence to support the effectiveness of such campaigns. We continue to see examples of cannabis-related messaging that focus on risk and harm and often adopt a narrow view of the ways in which young people may use cannabis. This traditional risk-based messaging does not resonate with how many youth experience cannabis use. We have further observed that most provinces and territories have yet to fully reveal concrete details regarding what they are and have been planning in terms of youth engagement in the development and delivery of educational initiatives. As Canadian youth desire reliable, evidence-based educational material on cannabis, and can be credible key partners in the development of such materials, we hope that all levels of government will see the value of promoting balanced cannabis discussions and co-designing resources with youth.

Association of Cannabis With Long-Term Clinical Symptoms in Anxiety and Mood Disorders: A Systematic Review of Prospective Studies.

OBJECTIVE: To systematically review studies examining the longitudinal associations between cannabis use and symptomatic outcomes among individuals with an anxiety or mood disorder at baseline. DATA SOURCES: A search of the literature up to May 2017 was conducted using several databases. Search terms related to the exposure (ie, cannabis) and outcome (ie, symptoms) variables of interest. There were no search restrictions. STUDY SELECTION: In total, 10,191 citations were screened. Key inclusion criteria related to (1) cohort-based longitudinal study design using adults who met criteria for a mood or anxiety disorder at baseline, (2) an independent variable focusing on at least baseline cannabis use, and (3) a dependent variable focusing on the symptomatic course and/or outcomes in anxiety and mood disorders (AMD). DATA EXTRACTION: We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Methodological characteristics and key findings were extracted from each study, and quality assessments were conducted for each study. RESULTS: Twelve studies (with a total of 11,959 individuals) met inclusion criteria related to posttraumatic stress disorder (n = 4), panic disorder (n = 1), bipolar disorder (n = 5), and depressive disorder (n = 2). Across 11 studies, "recent" cannabis use (ie, any/greater frequency of use during the last 6 months) was associated with higher symptomatic levels over time relative to comparison groups (ie, no/lesser frequency of use). Ten of these studies further suggested that cannabis use was associated with less symptomatic improvement from treatment (eg, medication, psychotherapy for AMD). CONCLUSIONS: Recent cannabis use was associated with negative long-term symptomatic and treatment outcomes across AMD. The findings should be interpreted with caution, considering the observational designs across studies and the biases associated with the samples (eg, inpatients) and sources of cannabis consumed (ie, unregulated sources). Nonetheless, clinicians can use the insight gained to inform their own and their patients' knowledge concerning potential risks of cannabis with regard to symptoms of AMD.

Childhood Adversities and Physical and Mental Health Outcomes in Adults Living with HIV: Findings from the Ontario HIV Treatment Network Cohort Study.

We sought to estimate the prevalence of childhood adversity and examine its relationship with health outcomes among people living with HIV. Study participants included 1409 adults living with HIV and receiving care in Toronto, Canada. Data on childhood adversity, health behaviors, HIV outcome measures, depression, and health-related quality of life (HRQOL) were collected through face-to-face interviews and medical records. Statistical analyses included multivariable linear and logistic regression modeling. The prevalence of any childhood adversity was 71% (individual types ranged from 11% to 44%) and higher prevalence was associated with younger age, Indigenous or African/Caribbean/Black ethnicity, lower socioeconomic status, and higher rates of cigarette smoking and nonmedicinal drug use. Greater number of childhood adversities was associated with greater odds of depression and decreasing mental HRQOL. HIV care providers need to screen for childhood adversities and address childhood trauma within the context of HIV care.

Cost and Cost-Effectiveness of a Demand Creation Intervention to Increase Uptake of Voluntary Medical Male Circumcision in Tanzania: Spending More to Spend Less.

BACKGROUND: Although voluntary medical male circumcision (VMMC) reduces the risk of HIV acquisition, demand for services is lower among men in most at-risk age groups (ages 20-34 years). A randomized controlled trial was conducted to assess the effectiveness of locally-tailored demand creation activities (including mass media, community mobilization, and targeted service delivery) in increasing uptake of campaign-delivered VMMC among men aged 20-34 years. We conducted an economic evaluation to understand the intervention's cost and cost-effectiveness. SETTING: Tanzania (Njombe and Tabora regions). METHODS: Cost data were collected on surgery, demand creation activities, and monitoring and supervision related to VMMC implementation across clusters in both trial arms, as well as start-up activities for the intervention arms. The Decision Makers' Program Planning Tool was used to estimate the number of HIV infections averted and related cost savings, given the total VMMCs per cluster. Disability-adjusted life years were calculated and used to estimate incremental cost-effectiveness ratios. RESULTS: Client load was higher in the intervention arms than in the control arms: 4394 vs. 2901 in Tabora and 1797 vs. 1025 in Njombe, respectively. Despite additional costs of tailored demand creation, demand increased more than proportionally: mean costs per VMMC in the intervention arms were $62 in Tabora and $130 in Njombe, and in the control arms $70 and $191, respectively. More infections were averted in the intervention arm than in the control arm in Tabora (123 vs. 67, respectively) and in Njombe (164 vs. 102, respectively). The intervention dominated the control because it was both less costly and more effective. Cost savings were observed in both regions stemming from the antiretroviral treatment costs averted as a result of the VMMCs performed. CONCLUSIONS: Spending more to address local preferences as a way to increase uptake of VMMC can be cost-saving.