Differential impacts of health systems and sociocultural environment on vulnerable populations during the COVID-19 pandemic: lessons from four Asia-Pacific countries.

BACKGROUND: This study aims to evaluate healthcare systems and pandemic responses in relation to marginalized and vulnerable groups, identify populations requiring urgent care, and assess the differential impacts on their health during the pandemic. METHODS: Data were collected by the Asia-Pacific Observatory on Health Systems and Policies (APO)-National University of Singapore and APO-International Health Policy Program consortium members: Korea, Indonesia, Philippines, and Singapore. Data were collected through a combination of semi-structured interviews, policy document reviews, and analysis of secondary data. RESULTS: Our findings reveal that the pandemic exacerbated existing health disparities, particularly affecting older adults, women, and children. Additionally, the study identified LGBTI individuals, healthcare workers, slum dwellers, and migrant workers as groups that faced particularly severe challenges during the pandemic. LGBTI individuals encountered heightened discrimination and limited access to health services tailored to their needs. Healthcare workers suffered from immense stress and risk due to prolonged exposure to the virus and critical working conditions. Slum dwellers struggled with healthcare access and social distancing due to high population density and inadequate sanitation. Migrant workers were particularly hard hit by high risks of virus transmission and stringent, often discriminatory, isolation measures that compounded their vulnerability. The study highlights the variation in the extent and nature of vulnerabilities, which were influenced by each country's specific social environment and healthcare infrastructure. It was observed that public health interventions often lacked the specificity required to effectively address the needs of all vulnerable groups, suggesting a gap in policy and implementation. CONCLUSIONS: The study underscores that vulnerabilities vary greatly depending on the social environment and context of each country, affecting the degree and types of vulnerable groups. It is critical that measures to ensure universal health coverage and equal accessibility to healthcare are specifically designed to address the needs of the most vulnerable. Despite commonalities among groups across different societies, these interventions must be adapted to reflect the unique characteristics of each group within their specific social contexts to effectively mitigate the impact of health disparities.

Polymerase Chain Reaction (PCR) is a Useful and Low-Cost Tool for Molecular Sexing Psittaciformes under Human Care: An Example of a Collaborative Approach in Mexico.

Sex determination in monomorphic birds is a precondition for captive breeding programs and management and conservation strategies for threatened species. Most species of the order Psittaciformes often present complications since these birds lack external sexual phenotypic traits, making it impossible to differentiate males and females. In the present study, we used molecular techniques to determine the sex of 31 individuals belonging to nine species of the order Psittaciformes kept under human care at the Akumal Monkey Sanctuary & Rescued Animals in Quintana Roo, Mexico. This is a useful and low-cost methodology based on the analysis of the conserved region of the CHD1 gene, which was amplified by PCR with two sets of primers: P8/P2 and 2550F/2718 R. All individuals were successfully sexed with the first set of primers, while only 28 out of 31 samples (90%) could be amplified with the second set. Out of the 31 individuals analyzed, fifteen are female, and seventeen are male. This information represents a handy tool for adequately managing birds under human care, resulting in their reproduction and eventual reintegration into their natural habitat.

Implementation of an Ecological Momentary Assessment (EMA) in Naturalistic Psychotherapy Settings: Qualitative Insights from Patients, Therapists, and Supervisors Perspectives.

Ecological momentary assessment (EMA) allows measuring intra-individual processes moment by moment, identifying and modeling, in a naturalistic way, individual levels and changes in different psychological processes. However, active EMA requires a high degree of adherence, as it implies a significant burden for patients. Moreover, there is still no consensus on standardized procedures for implementation. There have been few results in detecting desirable characteristics for the design and implementation of an EMA device. Studies that address these issues from the perspectives of participants in psychotherapeutic processes are needed. To analyze the perspectives of patients, therapists and supervisors on the implementation of an EMA device in a psychotherapeutic treatment for depression. The sample will include eight patients, eleven therapists and five supervisors, taken from a research project that implemented an EMA system for monitoring the dynamics of affectivity at the beginning of psychotherapies for depression. Semi-structured interviews specific to each group are being conducted and analyzed from a qualitative approach based on consensual qualitative research (CQR). Participants reported having a positive evaluation of the study's informational resources and implementation. Difficulties were expressed in responding in the morning hours and the importance of having a customized EMA that is tailored to the needs of the patients was expressed. Furthermore, patients and therapists agreed that the impact of the use of the monitoring system on treatment was neutral or positive. In contrast, patients considered the EMA to be positive for their daily life.

Cost-sensitive ordinal classification methods to predict SARS-CoV-2 pneumonia severity.

OBJECTIVE: To study the suitability of costsensitive ordinal artificial intelligence-machine learning (AIML) strategies in the prognosis of SARS-CoV-2 pneumonia severity. MATERIALS & METHODS: Observational, retrospective, longitudinal, cohort study in 4 hospitals in Spain. Information regarding demographic and clinical status was supplemented by socioeconomic data and air pollution exposures. We proposed AI-ML algorithms for ordinal classification via ordinal decomposition and for cost-sensitive learning via resampling techniques. For performance-based model selection, we defined a custom score including per-class sensitivities and asymmetric misprognosis costs. 260 distinct AI-ML models were evaluated via 10 repetitions of 5×5 nested cross-validation with hyperparameter tuning. Model selection was followed by the calibration of predicted probabilities. Final overall performance was compared against five well-established clinical severity scores and against a 'standard' (non-cost sensitive, non-ordinal) AI-ML baseline. In our best model, we also evaluated its explainability with respect to each of the input variables. RESULTS: The study enrolled n = 1548 patients: 712 experienced low, 238 medium, and 598 high clinical severity. d = 131 variables were collected, becoming d ' = 148 features after categorical encoding. Model selection resulted in our best-performing AI-ML pipeline having: a) no imputation of missing data, b) no feature selection (i.e. using the full set of d ' features), c) 'Ordered Partitions' ordinal decomposition, d) cost-based reimbalance, and e) a Histogram-based Gradient Boosting classifier. This best model (calibrated) obtained a median accuracy of 68.1% [67.3%, 68.8%] (95% confidence interval), a balanced accuracy of 57.0% [55.6%, 57.9%], and an overall area under the curve (AUC) 0.802 [0.795, 0.808]. In our dataset, it outperformed all five clinical severity scores and the 'standard' AI-ML baseline. DISCUSSION & CONCLUSION: We conducted an exhaustive exploration of AI-ML methods designed for both ordinal and cost-sensitive classification, motivated by a real-world application domain (clinical severity prognosis) in which these topics arise naturally. Our model with the best classification performance exploited successfully the ordering information of ground truth classes, coping with imbalance and asymmetric costs. However, these ordinal and cost-sensitive aspects are seldom explored in the literature.

Reducing biopharmaceutical manufacturing costs through continuous processing in a flexible J.POD® facility.

In this work, process models were developed to capture the impact of biomanufacturing costs on a commercial scale and emphasize the way in which facility design and operation must balance meeting product demand while minimizing production costs. Using a scenario-based modeling approach, several facility design strategies were evaluated, including a traditional large stainless-steel facility and a small footprint, portable-on-demand (POD)-based facility. Bioprocessing platforms were compared by estimating their total production costs across different facility types and specifically illustrating how continuous bioprocessing has gained in popularity as a novel and cost-effective approach to manufacture high-quality biopharmaceuticals. The analysis showed how fluctuations in market demand have a dramatic effect on manufacturing costs and plant utilization, with far-reaching implications on the total cost to patients.

Cognition Assessment Technologies on Deaf People.

In recent years there has been a growing interest in research about the different ways of processing and consolidating cognition in deaf people. It is known that hearing loss can lead to differences in some executive functions like control inhibitory or working memory. This literature review describes executive functions in deaf people and how they could be evaluated through technological devices complementing traditional assessments, like neuropsychological batteries. We identified biometric devices, digital and physical interfaces, and software from the literature, whose goal is to design or adapt technology to assess some cognition domains in several ways. The results of the review suggest the need to understand the cognitive phenomenon that significantly impacts the context of deaf people; moreover, it becomes relevant as a line of research in the Cognitive Science of Hearing. Using technologies to measure them and gain a better understanding of cognition in deaf people may provide possibilities for designing or adapting targeted educational or therapeutic strategies.

Longitudinal Validation of Right Ventricular Pressure Monitoring for the Assessment of Right Ventricular Systolic Dysfunction in a Large Animal Ischemic Model.

Right ventricular (RV) dysfunction is a major cause of morbidity and mortality in intensive care and cardiac surgery. Early detection of RV dysfunction may be facilitated by continuous monitoring of RV waveform obtained from a pulmonary artery catheter. The objective is to evaluate the extent to which RV pressure monitoring can detect changes in RV systolic performance assess by RV end-systolic elastance (Ees) following the development of an acute RV ischemic in a porcine model. HYPOTHESIS: RV pressure monitoring can detect changes in RV systolic performance assess by RV Ees following the development of an acute RV ischemic model. METHODS AND MODELS: Acute ischemic RV dysfunction was induced by progressive embolization of microsphere in the right coronary artery to mimic RV dysfunction clinically experienced during cardiopulmonary bypass separation caused by air microemboli. RV hemodynamic performance was assessed using RV pressure waveform-derived parameters and RV Ees obtained using a conductance catheter during inferior vena cava occlusions. RESULTS: Acute ischemia resulted in a significant reduction in RV Ees from 0.26 mm Hg/mL (interquartile range, 0.16-0.32 mm Hg/mL) to 0.14 mm Hg/mL (0.11-0.19 mm Hg/mL; p < 0.010), cardiac output from 6.3 L/min (5.7-7 L/min) to 4.5 (3.9-5.2 L/min; p = 0.007), mean systemic arterial pressure from 72 mm Hg (66-74 mm Hg) to 51 mm Hg (46-56 mm Hg; p < 0.001), and mixed venous oxygen saturation from 65% (57-72%) to 41% (35-45%; p < 0.001). Linear mixed-effect model analysis was used to assess the relationship between Ees and RV pressure-derived parameters. The reduction in RV Ees best correlated with a reduction in RV maximum first derivative of pressure during isovolumetric contraction (dP/dtmax) and single-beat RV Ees. Adjusting RV dP/dtmax for heart rate resulted in an improved surrogate of RV Ees. INTERPRETATION AND CONCLUSIONS: Stepwise decreases in RV Ees during acute ischemic RV dysfunction were accurately tracked by RV dP/dtmax derived from the RV pressure waveform.

Determining the environmental and economic implications of lupin cultivation in wheat-based organic rotation systems in Galicia, Spain.

Crop rotation represents a potentially sustainable strategy to address environmental problems of intensive agricultural practices, such as soil degradation, biodiversity reduction, and greenhouse gas emissions. This manuscript assesses the environmental and economic implications of introducing lupin cultivation into winter wheat-based rotation systems under an organic regime in Galicia, Spain. Life Cycle Assessment methodology was used to determine the environmental impacts of three rotation systems over a six-year period: lupin → wheat → rapeseed (OA1), lupin → potato → wheat (OA2), and lupin → wheat → rapeseed ‖ maize (OA3). For a robust assessment, three functional units were applied: land management (ha), economic indicator (gross margin in euros) and protein content (1 kg of protein-corrected grain). Moreover, the environmental profiles were compared with rotation systems without lupin crop in a conventional regime. In terms of Global Warming, impacts of about 2214, 3119 and 766 kg CO2eq·ha-1 were obtained for OA1, OA2 and OA3, respectively. Moreover, OA1 is the best rotation in terms of land and protein. Meanwhile, OA2 rotation is the best choice in the economic function, as it obtained the highest level of gross margin (5708 €·ha-1). Furthermore, with the exception of acidification, organic systems are less impactful than conventional systems. Ammonia emissions from the use of manure are the reason for these higher impacts. Organic rotations OA1 and OA2 have about 6 % or 15 % less gross margin than their conventional counterparts, respectively, however, an increase of 28 % was obtained for rotation OA3. This study helps decision-makers to implement environmentally and economically viable strategies.

Introducing lupin in autochthonous wheat rotation systems in Galicia (NW Spain): An environmental and economic assessment.

Crop diversification, as a sustainable land management practice, is a potential strategy to face soil degradation, climate change and food security, being the incorporation of legumes in cereal rotation systems, a strategy that improves soil nutrient levels. In a context of sustainable agriculture, this manuscript aims to evaluate the effect of lupin cultivation from an environmental and economic perspective in Galician winter wheat-based rotation systems. The life cycle analysis (LCA) methodology was applied for three rotation systems over a six-year period: lupin + wheat + oilseed rape (RA1), lupin + potato + wheat (RA2), and lupin + wheat + oilseed rape + maize (RA3). The general approach of this study was to collect primary data associated with the rotation crops to quantify their environmental impacts and economic benefits and to identify their advantages or disadvantages. Comparing and contrasting the environmental profiles based on three functional units: hectare land (ha), financial indicator (gross margin, €) and yield production (kg of wheat grain) allows a robust evaluation of each crop rotation system. Relating to rotations without lupin, the results indicate that for the impact categories evaluated, the introduction of lupin proved to be favourable with notable reductions of 64% and 30% in the environmental categories of Global Warming and Marine Eutrophication, respectively. Moreover, favourable economic consequences were evident in rotations RA1 and RA2 with a 19% and 51% increase in financial indicators, respectively, but with a marginal reduction of 2% in gross margin in RA3. This study motivates stakeholders to understand the environmental impacts of diversification strategies in agricultural systems and serves as a baseline to address the assessment of the social aspects of these systems for a complete sustainability perspective.

Subsoil-potassium depletion accounts for the nutrient budget in high-potassium agricultural soils.

Continuous potassium (K) removal without replenishment is progressively mining Argentinean soils. Our goals were to evaluate the sensitivity of soil-K to K budgets, quantify soil-K changes over time along the soil profile, and identify soil variables that regulate soil-K depletion. Four on-farm trials under two crop rotations including maize, wheat and soybean were evaluated. Three treatments were compared: (1) control (no fertilizer applied); (2) application of nitrogen, phosphorus, and sulfur fertilizers -NPS-; and (3) pristine condition. After nine years, crops removed from 258 to 556 kg K ha-1. Only two sites showed a decline in the exchangeable-K levels at 0-20 cm but unrelated to K budget. Topsoil exchangeable-K levels under agriculture resulted 48% lower than their pristine conditions, although still above response levels. Both soil exchangeable-K and slowly-exchangeable K vertical distribution patterns (0-100 cm) displayed substantial depletion relative to pristine conditions, mainly concentrated at subsoil (20-100 cm), with 55-83% for exchangeable-K, and 74-95% for slowly-exchangeable-K. Higher pristine levels of exchangeable-K and slowly-exchangeable-K and lower clay and silt contents resulted in higher soil-K depletion. Soil K management guidelines should consider both topsoil and subsoil nutrient status and variables related to soil K buffer capacity.

Life cycle assessment of autochthonous varieties of wheat and artisanal bread production in Galicia, Spain.

For millennia, bread and wheat have been one of the most important sources of nutrients in many civilizations. Today, mechanization and evolution in agriculture and food processing have intensified yields and modified the biological and nutritional aspects of multiple crops and foods. The Galician bread is a reference value of food heritage in Spain, which is made from common wheat grain and is a mixture of indigenous Galician wheat and conventional Spanish wheat. In the pursuit of product excellence, it is interesting to identify the environmental profile as support criteria in decision-making, not only to analyse product environmental sustainability, but also as a marketing element to improve consumer awareness. The paper has a twofold perspective to analyse the environmental burdens of wheat cultivation and the bread sector, using life cycle assessment approach: 1) the comparison of the different types of agricultural systems, i.e. the cultivation of Galician wheat following a strategy of monoculture and crop rotation, certified Galician seed production and its comparison with conventional wheat cultivation and 2) the environmental profile of Galician bread. The functional units chosen were 1 kg of wheat grain transported to the milling facility and 1 kg of Galician bread. The results show that wheat cultivation presents the main environmental impacts of bread production, mainly due to the use of agrochemicals and field emissions. The best cultivation scenario corresponds to a crop rotation system, since chemical fertilisation is not applied. In comparative terms with many staple foods produced in Europe, Galician bread has a low environmental impact. The overall environmental results of bread production draw attention to the dependence of bread and flour manufacturers on the agricultural sector, highlighting the need to share responsibilities across the supply chain. In addition, this study contributes to the stakeholder debate on environmental impacts related to food heritage.

Biological variation data for lipid cardiovascular risk assessment biomarkers. A systematic review applying the biological variation data critical appraisal checklist (BIVAC).

BACKGROUND: Biological variation (BV) data can be used to set analytical performance specifications (APS) for lipid assays. Poor performance will impact upon the efficacy of international guidelines for cardiovascular risk assessment (CVR) and relevant clinical decision limits. This systematic review applies the Biological Variation Data Critical Appraisal Checklist (BIVAC) to published studies of BV of CVR biomarkers enabling metanalysis of the data. METHODS: Studies of BV of total cholesterol, HDL-cholesterol, LDL-cholesterol, triglycerides and apolipoproteins A1 and B, retrieved using a systematic literature search, were evaluated and graded using the BIVAC. Meta-analysis of CVI and CVG estimates were performed utilizing weightings based upon BIVAC grades and the width of the data confidence intervals. RESULTS: Applying the BIVAC, ten publications were graded as D, 43 as C, 5 as B and 1 as A (fully compliant). A total of 196 CVI and 87 CVG estimates were available for the different lipid measurands. The meta-analysis-derived BV data estimates were generally concordant with those in the online 2014 BV database. CONCLUSIONS: Application of BIVAC identifies BV data suitable for many important applications including setting APS. Additionally, this review identifies a need for new BIVAC compliant studies to deliver BV reference data in different subpopulations.

Socioeconomic factors and parity of access to robotic surgery in a county health system.

Equal access to novel surgical technologies remains a policy concern as hospitals adopt robotic surgery with increasing prevalence. This study sought to determine whether socioeconomic factors influence access to robotic surgery. All laparoscopic and robotic fundoplications and paraesophageal hernia repairs performed by a surgical group over 6 years at a county and two neighboring private hospitals were identified. Robotic use by hospital setting, age, gender, reported ethnicity, estimated income, insurance payer, and diagnosis were examined. Of 418 patients identified, 180 (43%) presented to the county hospital, where subjects were younger (51.1 versus 56.2 years, p < 0.001) with lower estimated income ($50,289 versus $62,959, p < 0.001). In the county setting, there was no difference in reported ethnicity (p = 0.169), estimated income (p = 0.081), or insurance payer (p = 0.535) between groups treated laparoscopically versus robotically. There was no difference in the treatment groups by estimated income in the private hospital setting (p = 0.308). Overall higher estimated income and insurance payer were associated with a higher chance of undergoing robotic procedures (p < 0.001). Presence of a paraesophageal hernia was associated with increased chance of undergoing robotic therapy in all comparisons (p < 0.001). No disparity in access to robotic surgery offered in the county hospital was observed based on age, gender, reported ethnicity, estimated income, or insurance payer. Patients with higher income and private insurers were more likely to present to the private hospital setting where robotics is utilized more often. The presence of a paraesophageal hernia was a significant factor in determining robotic therapy in both settings.

A large-scale behavior change intervention to prevent Nipah transmission in Bangladesh: components and costs.

BACKGROUND: Nipah virus infection (NiV) is a bat-borne zoonosis transmitted to humans through consumption of NiV-contaminated raw date palm sap in Bangladesh. The objective of this analysis was to measure the cost of an NiV prevention intervention and estimate the cost of scaling it up to districts where spillover had been identified. METHODS: We implemented a behavior change communication intervention in two districts, testing different approaches to reduce the risk of NiV transmission using community mobilization, interpersonal communication, posters and TV public service announcements on local television during the 2012-2014 sap harvesting seasons. In one district, we implemented a "no raw sap" approach recommending to stop drinking raw date palm sap. In another district, we implemented an "only safe sap" approach, recommending to stop drinking raw date palm sap but offering the option of drinking safe sap. This is sap covered with a barrier, locally called bana, to interrupt bats' access during collection. We conducted surveys among randomly selected respondents two months after the intervention to measure the proportion of people reached. We used an activity-based costing method to calculate the cost of the intervention. RESULTS: The implementation cost of the "no raw sap" intervention was $30,000 and the "only safe sap" intervention was $55,000. The highest cost was conducting meetings and interpersonal communication efforts. The lowest cost was broadcasting the public service announcements on local TV channels. To scale up a similar intervention in 30 districts where NiV spillover has occurred, would cost between $2.6 and $3.5 million for one season. Placing the posters would cost $96,000 and only broadcasting the public service announcement through local channels in 30 districts would cost $26,000. CONCLUSIONS: Broadcasting a TV public service announcement is a potential low cost option to advance NiV prevention. It could be supplemented with posters and targeted interpersonal communication, in districts with a high risk of NiV spillover.

Fitness costs associated with the acquisition of antibiotic resistance.

Acquisition of antibiotic resistance is a relevant problem for human health. The selection and spread of antibiotic-resistant organisms not only compromise the treatment of infectious diseases, but also the implementation of different therapeutic procedures as organ transplantation, advanced surgery or chemotherapy, all of which require proficient methods for avoiding infections. It has been generally accepted that the acquisition of antibiotic resistance will produce a general metabolic burden: in the absence of selection, the resistant organisms would be outcompeted by the susceptible ones. If that was always true, discontinuation of antibiotic use would render the disappearance of resistant microorganisms. However, several studies have shown that, once resistance emerges, the recovery of a fully susceptible population even in the absence of antibiotics is not easy. In the present study, we review updated information on the effect of the acquisition of antibiotic resistance in bacterial physiology as well as on the mechanisms that allow the compensation of the fitness costs associated with the acquisition of resistance.

Throughput Optimization of Continuous Biopharmaceutical Manufacturing Facilities.

In order to operate profitably under different product demand scenarios, biopharmaceutical companies must design their facilities with mass output flexibility in mind. Traditional biologics manufacturing technologies pose operational challenges in this regard due to their high costs and slow equipment turnaround times, restricting the types of products and mass quantities that can be processed. Modern plant design, however, has facilitated the development of lean and efficient bioprocessing facilities through footprint reduction and adoption of disposable and continuous manufacturing technologies. These development efforts have proven to be crucial in seeking to drastically reduce the high costs typically associated with the manufacturing of recombinant proteins. In this work, mathematical modeling is used to optimize annual production schedules for a single-product commercial facility operating with a continuous upstream and discrete batch downstream platform. Utilizing cell culture duration and volumetric productivity as process variables in the model, and annual plant throughput as the optimization objective, 3-D surface plots are created to understand the effect of process and facility design on expected mass output. The model shows that once a plant has been fully debottlenecked it is capable of processing well over a metric ton of product per year. Moreover, the analysis helped to uncover a major limiting constraint on plant performance, the stability of the neutralized viral inactivated pool, which may indicate that this should be a focus of attention during future process development efforts.LAY ABSTRACT: Biopharmaceutical process modeling can be used to design and optimize manufacturing facilities and help companies achieve a predetermined set of goals. One way to perform optimization is by making the most efficient use of process equipment in order to minimize the expenditure of capital, labor and plant resources. To that end, this paper introduces a novel mathematical algorithm used to determine the most optimal equipment scheduling configuration that maximizes the mass output for a facility producing a single product. The paper also illustrates how different scheduling arrangements can have a profound impact on the availability of plant resources, and identifies limiting constraints on the plant design. In addition, simulation data is presented using visualization techniques that aid in the interpretation of the scientific concepts discussed.

Análisis de 7 años de la queja en gineco-obstetricia por la Comisión Estatal de Arbitraje Médico en Oaxaca, México / 7-year analysis of the complaint in gynecology-obstetrics by the State Commission of Medical Arbitration in Oaxaca, Mexico

ANTECEDENTES: Se realizó la revisión de 7 años del Sistema de Quejas Médicas en la Comisión Estatal de Arbitraje Médico del Estado de Oaxaca, México, entidad autónoma y calificada para dirimir el proceso de inconformidad durante el fenómeno de la atención médica. Se analizaron todas las quejas, formas de resolución y en especial se identifico la queja en gineco-obstetricia. OBJETIVO: Caracterizar la inconformidad en la queja del usuario en la especialidad de gineco-obstetricia. MÉTODO: Investigación documental, descriptiva, transversal, retrospectiva y sin implicaciones éticas, efectuada mediante el análisis de bases de datos del SAQMEDO de enero de 2008 a abril de 2015. Se seleccionaron todos los expedientes de quejas médicas de la especialidad, entre todas las presentadas. RESULTADOS: El Instituto Mexicano del Seguro Social fue la entidad más frecuente en quejas médicas seguida por la medicina privada. Por octavo año consecutivo la ginecología y obstetricia prevalece como líder en quejas de los usuarios, sumando en el actual análisis 100 de 438 quejas. El origen de las quejas resulta de la deficiencia en la otorgación del servicio institucional y privado que contabilizó el 69% de los casos. CONCLUSIONES: La falta en el proceso de la evaluación del desempeño ha sido fundamental en la repetición de la queja en gineco-obstetricia. A lo largo de 8 años se ha repetido el modelo vicioso, sin que las instituciones hagan algo a cambio. De continuar ignorando el problema de manera local conseguiremos que éste ciclo se perpetúe.

BACKGROUND: It has been made a complete analysis of 7 years in the State Commission of Medical Arbitration in Oaxaca, one of the southern states in México. This Commission is the legal entity to judge the process of malpractice. The study was aim to identify the obstetrics and gynecology complains. OBJECTIVE: Characterize the medical complain in the obstetrics and gynecology specialty. METHOD: It was conducted a documentary research, descriptive, transversal, retrospective and without ethical implications, through analysis of databases of the State Commission of Medical Arbitration of Oaxaca, corresponding to 2008 -2015 activity report; we selected records were medical complaints in the specialty of gynecology-obstetrics. RESULTS: The Mexican Institute of Social Security Services became the most demanded medical provider closely followed by the private practice. Obstetrics and gynecology was the most demanded medical specialty for 8th uninterrupted years. From 438 claims 100 accounted to this specialty. The failure to give or perform the service was the origin of the complains. CONCLUSION: Absence of risk assessment and supervision of competence in the performance of the medical process were the most forthcoming issues when malpractice were continue to identified. Eight in a row years of failure to amended these vicious process speaks for itself. Lots of hard work are to be consider as a reliability strategy.

Bridging the gap between research and practice in a clinical and training network: Aigle's program.

The aim of this article is to share our experience at the Aiglé Foundation in fostering research that can conducted by (or in collaboration with) clinicians within a specific type of naturalistic setting-one that not only provides psychological services but also trains psychotherapists. After presenting the structure of Aiglé and the implementation of its scientific-practitioner philosophy, we describe some of the research that has been conducted with our network of clinicians and the benefits of connecting clinical practice and academic work. We then discuss some of the obstacles that we have encountered in conducting such studies, as well as a number of strategies that we adopted in attempting to address these challenges. We end this article by briefly describing the current state of our practice-research network, and by offering some recommendations to facilitate the conduct of research by and for clinicians.

Do federal and state audits increase compliance with a grant program to improve municipal infrastructure (AUDIT study): study protocol for a randomized controlled trial.

BACKGROUND: Poor governance and accountability compromise young democracies' efforts to provide public services critical for human development, including water, sanitation, health, and education. Evidence shows that accountability agencies like superior audit institutions can reduce corruption and waste in federal grant programs financing service infrastructure. However, little is know about their effect on compliance with grant reporting and resource allocation requirements, or about the causal mechanisms. This study protocol for an exploratory randomized controlled trial tests the hypothesis that federal and state audits increase compliance with a federal grant program to improve municipal service infrastructure serving marginalized households. METHODS/DESIGN: The AUDIT study is a block randomized, controlled, three-arm parallel group exploratory trial. A convenience sample of 5 municipalities in each of 17 states in Mexico (n=85) were block randomized to be audited by federal auditors (n=17), by state auditors (n=17), and a control condition outside the annual program of audits (n=51) in a 1:1:3 ratio. Replicable and verifiable randomization was performed using publicly available lottery numbers. Audited municipalities were included in the national program of audits and received standard audits on their use of federal public service infrastructure grants. Municipalities receiving moderate levels of grant transfers were recruited, as these were outside the auditing sampling frame--and hence audit program--or had negligible probabilities of ever being audited. The primary outcome measures capture compliance with the grant program and markers for the causal mechanisms, including deterrence and information effects. Secondary outcome measure include differences in audit reports across federal and state auditors, and measures like career concerns, political promotions, and political clientelism capturing synergistic effects with municipal accountability systems. The survey firm and research assistants assessing outcomes were blind to treatment status. DISCUSSION: This study will improve our understanding of local accountability systems for public service delivery in the 17 states under study, and may have downstream policy implications. The study design also demonstrates the use of verifiable and replicable randomization, and of sequentially partitioned hypotheses to reduce the Type I error rate in multiple hypothesis tests. TRIAL REGISTRATION: Controlled-trials.com Identifier ISRCTN22381841: Date registered 02/11/2012.