Evaluation of the effectiveness and safety of single-operator cholangiopancreatoscopy with the SpyGlass™ system.

BACKGROUND AND STUDY AIMS: The single-operator cholangiopancreatoscopy (SOCP) with the SpyGlass™ system is a endoscopy technique whose use has grown exponentially in recent years. The aims of this study were to evaluate the efficacy and safety of SOCP with SpyGlass™ and determine the factors related to the onset of adverse events (AEs). PATIENTS AND METHODS: Retrospective study at a single tertiary institution with inclusion of all consecutive patients undergoing SOCP with SpyGlass™ from February-2009 to December-2021. No exclusion criteria were considered. A descriptive statistical analysis was performed. The factors associated with the existence of AE were analyzed using Chi-square and Student's t-test. RESULTS: A total of 95 cases were included. The most common indications were biliary strictures (BS) evaluation (66.3%) or treatment of difficult common bile duct stones (27.4%). Technical and clinical success was attained in 98.9%. Single-session stone clearance was obtained in 84%. The AE rate was 7.4%. To detect malignancy in BS, optical diagnosis presents a sensitivity and specificity of 100% and 91.2%, respectively; while histology results were 36.4% and 100% respectively. A previous endoscopic sphincterotomy was associated with a lower rate of AEs (2.4% vs 41.7%; p<0.001). CONCLUSIONS: SOCP with SpyGlass™ is a safe and effective technique to diagnose and treat pancreatobiliary pathology. The presence of sphincterotomy performed prior to the procedure could improve the technique's safety.

Quality of Colonoscopy Is Associated With Adenoma Detection and Postcolonoscopy Colorectal Cancer Prevention in Lynch Syndrome.

BACKGROUND & AIMS: Colonoscopy reduces colorectal cancer (CRC) incidence and mortality in Lynch syndrome (LS) carriers. However, a high incidence of postcolonoscopy CRC (PCCRC) has been reported. Colonoscopy is highly dependent on endoscopist skill and is subject to quality variability. We aimed to evaluate the impact of key colonoscopy quality indicators on adenoma detection and prevention of PCCRC in LS. METHODS: We conducted a multicenter study focused on LS carriers without previous CRC undergoing colonoscopy surveillance (n = 893). Incident colorectal neoplasia during surveillance and quality indicators of all colonoscopies were analyzed. We performed an emulated target trial comparing the results from the first and second surveillance colonoscopies to assess the effect of colonoscopy quality indicators on adenoma detection and PCCRC incidence. Risk analyses were conducted using a multivariable logistic regression model. RESULTS: The 10-year cumulative incidence of adenoma and PCCRC was 60.6% (95% CI, 55.5%-65.2%) and 7.9% (95% CI, 5.2%-10.6%), respectively. Adequate bowel preparation (odds ratio [OR], 2.07; 95% CI, 1.06-4.3), complete colonoscopies (20% vs 0%; P = .01), and pan-chromoendoscopy use (OR, 2.14; 95% CI, 1.15-3.95) were associated with significant improvement in adenoma detection. PCCRC risk was significantly lower when colonoscopies were performed during a time interval of less than every 3 years (OR, 0.35; 95% CI, 0.14-0.97). We observed a consistent but not significant reduction in PCCRC risk for a previous complete examination (OR, 0.16; 95% CI, 0.03-1.28), adequate bowel preparation (OR, 0.64; 95% CI, 0.17-3.24), or previous use of high-definition colonoscopy (OR, 0.37; 95% CI, 0.02-2.33). CONCLUSIONS: Complete colonoscopies with adequate bowel preparation and chromoendoscopy use are associated with improved adenoma detection, while surveillance intervals of less than 3 years are associated with a reduction of PCCRC incidence. In LS, high-quality colonoscopy surveillance is of utmost importance for CRC prevention.

[Primary health care expenditure in the Americas: measuring what mattersGasto en atención primaria en salud en las Américas: medir lo que importa]. / Gasto em atenção primária à saúde nas Américas: medir o que importa.

This special report compares the measurement of primary health care (PHC) expenditure proposed by the Organization for Economic Cooperation and Development (OECD) and by the World Health Organization (WHO), according to the global framework for reporting health expenditures (SHA 2011) in three countries in the Region of the Americas. There are conceptual differences: 1) operationalization as basic care, by OECD, versus first contact, by WHO; 2) a wider range of goods and services in the WHO definition (including medicines, administration, and collective preventive services); and 3) consideration only of services in outpatient providers by OECD. PHC expenditures as a percentage of current healthcare spending in 2017 for WHO and OECD: Mexico (43.6% vs. 15.1%); Dominican Republic (41.1% vs. 5.75%), and Costa Rica (31.4% vs. 5.7%). The broad WHO definition of PHC as first contact facilitates inclusion of services that reflect the way countries provide care to their populations. Even so, WHO could improve its category descriptions for the purposes of international comparison. Restricting PHC to outpatient providers (as the OECD does) greatly limits measurement and excludes interventions intrinsic to the concept of PHC, such as collective preventive services. As a transitional step, we recommend that countries should monitor PHC funding and should explain what they include in their definition. SHA 2011 makes it possible to identify and compare these differences.

En este informe especial se compara la medición del gasto en atención primaria en salud (APS) propuesta por la Organización para la Cooperación y el Desarrollo Económico (OCDE) y la Organización Mundial de la Salud (OMS) según el marco mundial para reportar gastos en salud (SHA 2011) en tres países de la región de las Américas. Hay divergencias conceptuales: 1) la operacionalización como atención básica, por OCDE, o primer contacto, por OMS; 2) la mayor amplitud de bienes y servicios en la definición de OMS (incluye medicamentos, administración y servicios preventivos colectivos); 3) la consideración únicamente de servicios en proveedores ambulatorios en OCDE. Los gastos en APS como el porcentaje del gasto corriente en salud (GCS) en 2017 para OMS y OCDE, serían: México (43,6% vs 15.1%); República Dominicana (41,1 vs 5,75%) y Costa Rica (31,4% vs 5,7%). La definición amplia de APS como primer contacto de OMS facilita la inclusión de servicios que reflejan la forma en que los países ofrecen atención a su población. Aun así, la OMS podría mejorar las descripciones de las categorías incluidas para fines de comparación internacional. Restringir la APS a proveedores ambulatorios como hace OCDE limita mucho la medición y excluye intervenciones intrínsecas al concepto de APS, como servicios colectivos de prevención. Como paso transitorio se recomienda a los países que monitoreen el financiamiento de la APS, explicitando qué incluyen en su definición. El SHA 2011 permite identificar y comparar estas diferencias.

Primary health care expenditure in the Americas: measuring what matters.

This special report compares the measurement of primary health care (PHC) expenditure proposed by the Organization for Economic Cooperation and Development (OECD) and by the World Health Organization (WHO), according to the global framework for reporting health expenditures (SHA 2011) in three countries in the Region of the Americas. There are conceptual differences: (1) operationalization as basic care, by OECD, versus first contact, by WHO; (2) a wider range of goods and services in the WHO definition (including medicines, administration, and collective preventive services); and (3) consideration only of services in outpatient providers by OECD. PHC expenditures as a percentage of current healthcare spending in 2017 for WHO and OECD: Mexico (43.6% vs. 15.1%); Dominican Republic (41.1% vs. 5.75%), and Costa Rica (31.4% vs. 5.7%). The broad WHO definition of PHC as first contact facilitates inclusion of services that reflect the way countries provide care to their populations. Even so, WHO could improve its category descriptions for the purposes of international comparison. Restricting PHC to outpatient providers (as the OECD does) greatly limits measurement and excludes interventions intrinsic to the concept of PHC, such as collective preventive services. As a transitional step, we recommend that countries should monitor PHC funding and should explain what they include in their definition. SHA 2011 makes it possible to identify and compare these differences.

En este informe especial se compara la medición del gasto en atención primaria en salud (APS) propuesta por la Organización para la Cooperación y el Desarrollo Económico (OCDE) y la Organización Mundial de la Salud (OMS) según el marco mundial para reportar gastos en salud (SHA 2011) en tres países de la región de las Américas. Hay divergencias conceptuales: 1) la operacionalización como atención básica, por OCDE, o primer contacto, por OMS; 2) la mayor amplitud de bienes y servicios en la definición de OMS (incluye medicamentos, administración y servicios preventivos colectivos); 3) la consideración únicamente de servicios en proveedores ambulatorios en OCDE. Los gastos en APS como el porcentaje del gasto corriente en salud (GCS) en 2017 para OMS y OCDE, serían: México (43,6% vs 15.1%); República Dominicana (41,1 vs 5,75%) y Costa Rica (31,4% vs 5,7%).La definición amplia de APS como primer contacto de OMS facilita la inclusión de servicios que reflejan la forma en que los países ofrecen atención a su población. Aun así, la OMS podría mejorar las descripciones de las categorías incluidas para fines de comparación internacional. Restringir la APS a proveedores ambulatorios como hace OCDE limita mucho la medición y excluye intervenciones intrínsecas al concepto de APS, como servicios colectivos de prevención. Como paso transitorio se recomienda a los países que monitoreen el financiamiento de la APS, explicitando qué incluyen en su definición. El SHA 2011 permite identificar y comparar estas diferencias.

Este informe especial apresenta uma comparação entre a medida do gasto em atenção primária à saúde (APS) conforme as propostas da Organização para a Cooperação e o Desenvolvimento Econômico (OCDE) e da Organização Mundial da Saúde (OMS), usando a metodologia mundialmente aceita para reportar gastos em saúde ­ o System of Health Accounts (SHA 2011) ­ em três países da Região das Américas. Observam-se divergências conceituais entre os métodos: 1) operacionalização do conceito como atenção básica pela OCDE ou primeiro contato pela OMS; 2) maior abrangência de bens e serviços de acordo com a definição da OMS (englobando medicamentos, administração e serviços de prevenção em âmbito coletivo) e 3) inclusão exclusivamente de serviços ambulatoriais de acordo com a OCDE. Os gastos em APS como percentual do gasto corrente em saúde (GCS) em 2017, de acordo com os métodos propostos pela OMS e pela OCDE, foram: 43,6% vs. 15,1% no México; 41,1 vs. 5,75% na República Dominicana; e 31,4% vs. 5,7% na Costa Rica. A definição ampla de APS como primeiro contato proposta pela OMS permite incluir os diferentes arranjos de atenção existentes nos países. No entanto, as categorias deveriam ser mais bem detalhadas para facilitar a comparação internacional. Por outro lado, a proposta da OECD restringe a APS aos prestadores de serviços ambulatoriais, o que limita muito a medição e exclui intervenções próprias do conceito de APS, como serviços de prevenção no âmbito coletivo. Numa etapa de transição, recomenda-se aos países monitorar o financiamento da APS, explicitando os itens incluídos na definição empregada. A metodologia SHA 2011 possibilita identificar e comparar essas diferenças.

[Primary health care expenditure in the Americas: measuring what mattersGasto em atenção primária à saúde nas Américas: calcular o que importa]. / Gasto en atención primaria en salud en las Américas: medir lo que importa.

This special report compares the measurement of primary health care (PHC) expenditure proposed by the Organization for Economic Cooperation and Development (OECD) and by the World Health Organization (WHO), according to the global framework for reporting health expenditures (SHA 2011) in three countries in the Region of the Americas. There are conceptual differences: 1) operationalization as basic care, by OECD, versus first contact, by WHO; 2) a wider range of goods and services in the WHO definition (including medicines, administration, and collective preventive services); and 3) consideration only of services in outpatient providers by OECD. PHC expenditures as a percentage of current healthcare spending in 2017 for WHO and OECD: Mexico (43.6% vs. 15.1%); Dominican Republic (41.1% vs. 5.75%), and Costa Rica (31.4% vs. 5.7%). The 30% target for current healthcare spending on PHC proposed by Compact 30-30-30 (Pan American Health Organization) would be surpassed by the WHO definition, but it would be far from achieved by the OECD definition. The broad WHO definition of PHC as first contact facilitates inclusion of services that reflect the way countries provide care to their populations. Even so, WHO could improve its category descriptions for the purposes of international comparison. Restricting PHC to outpatient providers (as the OECD does) greatly limits measurement and excludes interventions intrinsic to the concept of PHC, such as collective preventive services. As a transitional step, we recommend that countries should monitor PHC funding and should explain what they include in their definition. SHA 2011 makes it possible to identify and compare these differences.

Este informe especial apresenta uma comparação entre o cálculo do gasto em atenção primária à saúde (APS) conforme os métodos propostos pela Organização para a Cooperação e o Desenvolvimento Econômico (OCDE) e pela Organização Mundial da Saúde (OMS), segundo a metodologia System of Health Accounts (SHA 2011), em três países da Região das Américas. Observam-se divergências conceituais entre os métodos: 1) operacionalização do conceito como atenção básica pela OCDE ou primeiro contato pela OMS; 2) maior abrangência de bens e serviços de acordo com a definição da OMS (englobando medicamentos, administração e serviços de prevenção em âmbito coletivo) e 3) inclusão única de serviços ambulatoriais de acordo com a OCDE. Os gastos em APS como percentual do gasto corrente em saúde (GCS) em 2017, de acordo com os métodos propostos pela OMS e pela OCDE, foram: 43,6% vs. 15,1% no México; 41,1 vs. 5,75% na República Dominicana; e 31,4% vs. 5,7% na Costa Rica. Esses valores ultrapassam a meta de 30% do GCS em APS sugerida no Pacto 30.30.30 da Organização Pan-Americana da Saúde, com a definição proposta pela OMS, e essa meta estaria longe de ser alcançada com a definição proposta pela OCDE. A definição ampla de APS como primeiro contato que é proposta pela OMS permite incluir os diferentes serviços de atenção existentes nos países. No entanto, as categorias deveriam ser mais bem detalhadas para facilitar a comparação internacional. Por outro lado, a proposta da OECD restringe a APS aos prestadores de serviços ambulatoriais, o que limita muito o cálculo e exclui intervenções próprias do conceito de APS, como serviços de prevenção no âmbito coletivo. Numa etapa de transição, recomenda-se aos países monitorar o financiamento da APS, explicitando os itens incluídos na definição empregada. A metodologia SHA 2011 possibilita identificar e comparar essas diferenças.

Clinical and Pathological Characterization of Lynch-Like Syndrome.

BACKGROUND & AIMS: Lynch syndrome is characterized by DNA mismatch repair (MMR) deficiency. Some patients with suspected Lynch syndrome have DNA MMR deficiencies but no detectable mutations in genes that encode MMR proteins-this is called Lynch-like syndrome (LLS). There is no consensus on management of patients with LLS. We collected data from a large series of patients with LLS to identify clinical and pathology features. METHODS: We collected data from a nationwide-registry of patients with colorectal cancer (CRC) in Spain. We identified patients whose colorectal tumors had loss of MSH2, MSH6, PMS2, or MLH1 (based on immunohistochemistry), without the mutation encoding V600E in BRAF (detected by real-time PCR), and/or no methylation at MLH1 (determined by methylation-specific multiplex ligation-dependent probe amplification), and no pathogenic mutations in MMR genes, BRAF, or EPCAM (determined by DNA sequencing). These patients were considered to have LLS. We collected data on demographic, clinical, and pathology features and family history of neoplasms. The χ2 test was used to analyze the association between qualitative variables, followed by the Fisher exact test and the Student t test or the Mann-Whitney test for quantitative variables. RESULTS: We identified 160 patients with LLS; their mean age at diagnosis of CRC was 55 years and 66 patients were female (41%). The Amsterdam I and II criteria for Lynch syndrome were fulfilled by 11% of cases and the revised Bethesda guideline criteria by 65% of cases. Of the patients with LLS, 24% were identified in universal screening. There were no proportional differences in sex, indication for colonoscopy, immunohistochemistry, pathology findings, or personal history of CRC or other Lynch syndrome-related tumors between patients who met the Amsterdam and/or Bethesda criteria for Lynch syndrome and patients identified in universal screening for Lynch syndrome, without a family history of CRC. CONCLUSIONS: Patients with LLS have homogeneous clinical, demographic, and pathology characteristics, regardless of family history of CRC.

Endoscopic band ligation without resection in selected patients for small and superficial upper gastrointestinal tract lesions.

BACKGROUND AND AIM: The aim of this study was to evaluate the efficacy of endoscopic band ligation (EBL) in carefully selected patients who would benefit from this method of resection. METHODS: Patients with early upper gastrointestinal and small (< 15 mm) lesions treated with EBL (Duette® Multi-Band Mucosectomy) were prospectively recruited and retrospectively analyzed between 2010 and 2015. All cases were discussed in a multidisciplinary cancer committee and it was concluded that, owing to patient conditions, surgery was not possible and that not conducting histology would not change the clinical management. A first endoscopic control with biopsies was planned at 4-8 weeks. If there was no persistence of the lesion, new controls were programmed at 6 and 12 months. RESULTS: The group (n = 12) included 5 esophagus lesions (adenosquamous carcinoma, n = 1; carcinoma squamous, n = 2; adenocarcinoma, n = 2); 4 gastric lesions (high grade dysplasia, n = 1; adenocarcinoma, n = 2; neuroendocrine tumor [NET], n = 1), and 3 duodenal lesions (NETs) (n = 3). The mean tumor diameter was 9.6 ± 2.8 mm (range 4-15). Only one minor adverse event was described. At first follow-up (4-8 weeks), there was 91.6% and 75% of endoscopic and histological remission, respectively. At 6-month follow-up there was 70% of both endoscopic remission and negative biopsies. And at 12 months, there was 100% and 75% of endoscopic and histological remission, respectively. Persisting lesions were T1 cancers. The median follow-up was 30.6 months. CONCLUSION: EBL without resection is an easy and safe technique that should be considered in patients with multiple morbidities and small superficial UGI lesions.

Effect of ursodeoxycholic acid treatment on the altered progesterone and bile acid homeostasis in the mother-placenta-foetus trio during cholestasis of pregnancy.

AIM: Intrahepatic cholestasis of pregnancy (ICP) is characterized by pruritus and elevated bile acid concentrations in maternal serum. This is accompanied by an enhanced risk of intra-uterine and perinatal complications. High concentrations of sulphated progesterone metabolites (PMS) have been suggested to be involved in the multifactorial aetiopathogenesis of ICP. The aim of this study was to investigate further the mechanism accounting for the beneficial effect of oral administration of ursodeoxycholic acid (UDCA), which is the standard treatment, regarding bile acid and PMS homeostasis in the mother-placenta-foetus trio. METHOD: Using HPLC-MS/MS bile acids and PMS were determined in maternal and foetal serum and placenta. The expression of ABC proteins in placenta was determined by real time quantitative PCR (RT-QPCR) and immunofluorescence. RESULTS: In ICP, markedly increased concentrations of bile acids (tauroconjugates > glycoconjugates >> unconjugated), progesterone and PMS in placenta and maternal serum were accompanied by enhanced concentrations in foetal serum of bile acids, but not of PMS. UDCA treatment reduced bile acid accumulation in the mother-placenta-foetus trio, but had no significant effect on progesterone and PMS concentrations. ABCG2 mRNA abundance was increased in placentas from ICP patients vs. controls and remained stable following UDCA treatment, despite an apparent further increase in ABCG2. CONCLUSION: UDCA administration partially reduces ICP-induced bile acid accumulation in mothers and foetuses despite the lack of effect on concentrations of progesterone and PMS in maternal serum. Up-regulation of placental ABCG2 may play an important role in protecting the foetus from high concentrations of bile acids and PMS during ICP.

Optical diagnosis in still images of colorectal polyps: comparison between expert endoscopists and PolyDeep, a Computer-Aided Diagnosis system.

Background: PolyDeep is a computer-aided detection and classification (CADe/x) system trained to detect and classify polyps. During colonoscopy, CADe/x systems help endoscopists to predict the histology of colonic lesions. Objective: To compare the diagnostic performance of PolyDeep and expert endoscopists for the optical diagnosis of colorectal polyps on still images. Methods: PolyDeep Image Classification (PIC) is an in vitro diagnostic test study. The PIC database contains NBI images of 491 colorectal polyps with histological diagnosis. We evaluated the diagnostic performance of PolyDeep and four expert endoscopists for neoplasia (adenoma, sessile serrated lesion, traditional serrated adenoma) and adenoma characterization and compared them with the McNemar test. Receiver operating characteristic curves were constructed to assess the overall discriminatory ability, comparing the area under the curve of endoscopists and PolyDeep with the chi- square homogeneity areas test. Results: The diagnostic performance of the endoscopists and PolyDeep in the characterization of neoplasia is similar in terms of sensitivity (PolyDeep: 89.05%; E1: 91.23%, p=0.5; E2: 96.11%, p<0.001; E3: 86.65%, p=0.3; E4: 91.26% p=0.3) and specificity (PolyDeep: 35.53%; E1: 33.80%, p=0.8; E2: 34.72%, p=1; E3: 39.24%, p=0.8; E4: 46.84%, p=0.2). The overall discriminative ability also showed no statistically significant differences (PolyDeep: 0.623; E1: 0.625, p=0.8; E2: 0.654, p=0.2; E3: 0.629, p=0.9; E4: 0.690, p=0.09). In the optical diagnosis of adenomatous polyps, we found that PolyDeep had a significantly higher sensitivity and a significantly lower specificity. The overall discriminative ability of adenomatous lesions by expert endoscopists is significantly higher than PolyDeep (PolyDeep: 0.582; E1: 0.685, p < 0.001; E2: 0.677, p < 0.0001; E3: 0.658, p < 0.01; E4: 0.694, p < 0.0001). Conclusion: PolyDeep and endoscopists have similar diagnostic performance in the optical diagnosis of neoplastic lesions. However, endoscopists have a better global discriminatory ability than PolyDeep in the optical diagnosis of adenomatous polyps.

Pathogenicity Levels of Colombian Strains of Candida auris and Brazilian Strains of Candida haemulonii Species Complex in Both Murine and Galleria mellonella Experimental Models.

Candida auris and Candida haemulonii complex (C. haemulonii, C. haemulonii var. vulnera and C. duobushaemulonii) are phylogenetically related species that share some physiological features and habits. In the present study, we compared the virulence of these yeast species using two different experimental models: (i) Galleria mellonella larvae to evaluate the survival rate, fungal burden, histopathology and phagocytosis index and (ii) BALB/c mice to evaluate the survival. In addition, the fungal capacity to form biofilm over an inert surface was analyzed. Our results showed that in both experimental models, the animal survival rate was lower when infected with C. auris strains than the C. haemulonii species complex. The hemocytes of G. mellonella showed a significantly reduced ability to phagocytize the most virulent strains forming the C. haemulonii species complex. Interestingly, for C. auris, it was impossible to measure the phagocytosis index due to a general lysis of the hemocytes. Moreover, it was observed a greater capability of biofilm formation by C. auris compared to C. haemulonii species complex. In conclusion, we observed that C. auris and C. haemulonii complex have different levels of pathogenicity in the experimental models employed in the present study.

Risk of Cancer in Family Members of Patients with Lynch-Like Syndrome.

Lynch syndrome (LS) is a common cause of hereditary colorectal cancer (CRC). Some CRC patients develop mismatch repair deficiency without germline pathogenic mutation, known as Lynch-like syndrome (LLS). We compared the risk of CRC in first-degree relatives (FDRs) in LLS and LS patients. LLS was diagnosed when tumors showed immunohistochemical loss of MSH2, MSH6, and PMS2; or loss of MLH1 with BRAF wild type; and/or no MLH1 methylation and absence of pathogenic mutation in these genes. CRC and other LS-related neoplasms were followed in patients diagnosed with LS and LLS and among their FDRs. Standardized incidence ratios (SIRs) were calculated for CRC and other neoplasms associated with LS among FDRs of LS and LLS patients. In total, 205 LS (1205 FDRs) and 131 LLS families (698 FDRs) had complete pedigrees. FDRs of patients with LLS had a high incidence of CRC (SIR, 2.08; 95% confidence interval (CI), 1.56-2.71), which was significantly lower than that in FDRs of patients with LS (SIR, 4.25; 95% CI, 3.67-4.90; p < 0.001). The risk of developing other neoplasms associated with LS also increased among FDR of LLS patients (SIR, 2.04; 95% CI, 1.44-2.80) but was lower than that among FDR of patients with LS (SIR, 5.01, 95% CI, 4.26-5.84; p < 0.001). FDRs with LLS have an increased risk of developing CRC as well as LS-related neoplasms, although this risk is lower than that of families with LS. Thus, their management should take into account this increased risk.

Cognitive load in academic clinical simulation activities. Cross-sectional study / Carga cognitiva en actividades académicas de simulación clínica. Estudio de corte transversal

Abstract Introduction: Cognitive load determines working memory ability to store and retain information in long-term memory, thus conditioning learning. Objective: To compare cognitive loads among different simulation activities, including anesthesia and surgery simulation workshops in medical students. Methods: Cross-sectional analytical observational study. Two cognitive load measurement scales (Paas and NASA-TLX) were given to the students after each simulation workshop. Comparisons were made based on the scores derived from the scales. Results: Relevant differences were found in terms of the mental effort assessed by means of the Paas scale, as relates to student rotation order in the airway management workshop, with a greater effort being found in the group that rotated initially in surgery (6.19 vs. 5.53; p = 0.029). The workshop with the highest associated rate of frustration was the airway management workshop. Higher scores were obtained for this workshop in all the items of the NASA-TLX scale, reflecting a higher cognitive load when compared to the others. Conclusions: It was not possible to determine whether higher scores in some of the activities were associated with the inherent difficulty of airway management or the specific workshop design. Consequently, further studies are required to distinguish between those components in order to improve the way learning activities are designed.

Resumen Introducción: La carga cognitiva determina la capacidad que tendrá la memoria de trabajo para almacenar y grabar información en la memoria a largo plazo, lo cual condiciona el aprendizaje. Objetivo: Comparar la carga cognitiva entre las distintas actividades de simulación, incluyendo talleres de simulación de anestesiología y cirugía en estudiantes de medicina. Métodos: Estudio observacional analítico tipo corte transversal. Se aplicaron dos escalas de medición de la carga cognitiva (Paas y NASA-TLX) a los estudiantes después de cada taller de simulación. Se realizaron comparaciones de los puntajes obtenidos mediante las escalas. Resultados: Se encontraron diferencias relevantes en cuanto al esfuerzo mental evaluado por la escala de Paas, en relación con el orden de rotación de los estudiantes en el taller de manejo de vía aérea; se encontró mayor esfuerzo en el grupo que rotó primero por cirugía (6,19 vs. 5,53; p = 0,029). El taller con mayores índices de frustración fue el de manejo de vía aérea. Este taller mostró los mayores puntajes en todos los ítems en la escala NASA-TLX, lo que indica una mayor carga cognitiva respecto a los demás. Conclusión: No fue posible diferenciar si los puntajes altos en algunas de las actividades se debieron a la dificultad natural del manejo de vía aérea, o al diseño específico del taller. Por lo que se requieren nuevos estudios que diferencien estos componentes para mejorar el diseño de actividades de aprendizaje.

Gasto en atención primaria en salud en las Américas: medir lo que importa / Primary health care expenditure in the Americas: measuring what matters / Gasto em atenção primária à saúde nas Américas: calcular o que importa

RESUMEN En este informe especial se compara la medición del gasto en atención primaria en salud (APS) propuesta por la Organización para la Cooperación y el Desarrollo Económico (OCDE) y la Organización Mundial de la Salud (OMS) según el marco mundial para reportar gastos en salud (SHA 2011) en tres países de la región de las Américas. Hay divergencias conceptuales: 1) la operacionalización como atención básica, por OCDE, o primer contacto, por OMS; 2) la mayor amplitud de bienes y servicios en la definición de OMS (incluye medicamentos, administración y servicios preventivos colectivos); 3) la consideración únicamente de servicios en proveedores ambulatorios en OCDE. Los gastos en APS como el porcentaje del gasto corriente en salud (GCS) en 2017 para OMS y OCDE, serían: México (43,6% vs 15.1%); República Dominicana (41,1 vs 5,75%) y Costa Rica (31,4% vs 5,7%); superarían la meta del 30% del GCS en APS que propone el Pacto 30-30-30 de la Organización Panamericana de la Salud, con la definición de la OMS y estarían muy lejos de alcanzarla con la de la OCDE. La definición amplia de APS como primer contacto de OMS facilita la inclusión de servicios que reflejan la forma en que los países ofrecen atención a su población. Aun así, la OMS podría mejorar las descripciones de las categorías incluidas para fines de comparación internacional. Restringir la APS a proveedores ambulatorios como hace OCDE limita mucho la medición y excluye intervenciones intrínsecas al concepto de APS, como servicios colectivos de prevención. Como paso transitorio se recomienda a los países que monitoreen el financiamiento de la APS, explicitando qué incluyen en su definición. El SHA 2011 permite identificar y comparar estas diferencias.

ABSTRACT This special report compares the measurement of primary health care (PHC) expenditure proposed by the Organization for Economic Cooperation and Development (OECD) and by the World Health Organization (WHO), according to the global framework for reporting health expenditures (SHA 2011) in three countries in the Region of the Americas. There are conceptual differences: 1) operationalization as basic care, by OECD, versus first contact, by WHO; 2) a wider range of goods and services in the WHO definition (including medicines, administration, and collective preventive services); and 3) consideration only of services in outpatient providers by OECD. PHC expenditures as a percentage of current healthcare spending in 2017 for WHO and OECD: Mexico (43.6% vs. 15.1%); Dominican Republic (41.1% vs. 5.75%), and Costa Rica (31.4% vs. 5.7%). The 30% target for current healthcare spending on PHC proposed by Compact 30-30-30 (Pan American Health Organization) would be surpassed by the WHO definition, but it would be far from achieved by the OECD definition. The broad WHO definition of PHC as first contact facilitates inclusion of services that reflect the way countries provide care to their populations. Even so, WHO could improve its category descriptions for the purposes of international comparison. Restricting PHC to outpatient providers (as the OECD does) greatly limits measurement and excludes interventions intrinsic to the concept of PHC, such as collective preventive services. As a transitional step, we recommend that countries should monitor PHC funding and should explain what they include in their definition. SHA 2011 makes it possible to identify and compare these differences.

RESUMO Este informe especial apresenta uma comparação entre o cálculo do gasto em atenção primária à saúde (APS) conforme os métodos propostos pela Organização para a Cooperação e o Desenvolvimento Econômico (OCDE) e pela Organização Mundial da Saúde (OMS), segundo a metodologia System of Health Accounts (SHA 2011), em três países da Região das Américas. Observam-se divergências conceituais entre os métodos: 1) operacionalização do conceito como atenção básica pela OCDE ou primeiro contato pela OMS; 2) maior abrangência de bens e serviços de acordo com a definição da OMS (englobando medicamentos, administração e serviços de prevenção em âmbito coletivo) e 3) inclusão única de serviços ambulatoriais de acordo com a OCDE. Os gastos em APS como percentual do gasto corrente em saúde (GCS) em 2017, de acordo com os métodos propostos pela OMS e pela OCDE, foram: 43,6% vs. 15,1% no México; 41,1 vs. 5,75% na República Dominicana; e 31,4% vs. 5,7% na Costa Rica. Esses valores ultrapassam a meta de 30% do GCS em APS sugerida no Pacto 30.30.30 da Organização Pan-Americana da Saúde, com a definição proposta pela OMS, e essa meta estaria longe de ser alcançada com a definição proposta pela OCDE. A definição ampla de APS como primeiro contato que é proposta pela OMS permite incluir os diferentes serviços de atenção existentes nos países. No entanto, as categorias deveriam ser mais bem detalhadas para facilitar a comparação internacional. Por outro lado, a proposta da OECD restringe a APS aos prestadores de serviços ambulatoriais, o que limita muito o cálculo e exclui intervenções próprias do conceito de APS, como serviços de prevenção no âmbito coletivo. Numa etapa de transição, recomenda-se aos países monitorar o financiamento da APS, explicitando os itens incluídos na definição empregada. A metodologia SHA 2011 possibilita identificar e comparar essas diferenças.

Primary health care expenditure in the Americas: measuring what matters / Gasto en atención primaria en salud en las Américas: medir lo que importa / Gasto em atenção primária à saúde nas Américas: medir o que importa

ABSTRACT This special report compares the measurement of primary health care (PHC) expenditure proposed by the Organization for Economic Cooperation and Development (OECD) and by the World Health Organization (WHO), according to the global framework for reporting health expenditures (SHA 2011) in three countries in the Region of the Americas. There are conceptual differences: (1) operationalization as basic care, by OECD, versus first contact, by WHO; (2) a wider range of goods and services in the WHO definition (including medicines, administration, and collective preventive services); and (3) consideration only of services in outpatient providers by OECD. PHC expenditures as a percentage of current healthcare spending in 2017 for WHO and OECD: Mexico (43.6% vs. 15.1%); Dominican Republic (41.1% vs. 5.75%), and Costa Rica (31.4% vs. 5.7%). The broad WHO definition of PHC as first contact facilitates inclusion of services that reflect the way countries provide care to their populations. Even so, WHO could improve its category descriptions for the purposes of international comparison. Restricting PHC to outpatient providers (as the OECD does) greatly limits measurement and excludes interventions intrinsic to the concept of PHC, such as collective preventive services. As a transitional step, we recommend that countries should monitor PHC funding and should explain what they include in their definition. SHA 2011 makes it possible to identify and compare these differences.

RESUMEN En este informe especial se compara la medición del gasto en atención primaria en salud (APS) propuesta por la Organización para la Cooperación y el Desarrollo Económico (OCDE) y la Organización Mundial de la Salud (OMS) según el marco mundial para reportar gastos en salud (SHA 2011) en tres países de la región de las Américas. Hay divergencias conceptuales: 1) la operacionalización como atención básica, por OCDE, o primer contacto, por OMS; 2) la mayor amplitud de bienes y servicios en la definición de OMS (incluye medicamentos, administración y servicios preventivos colectivos); 3) la consideración únicamente de servicios en proveedores ambulatorios en OCDE. Los gastos en APS como el porcentaje del gasto corriente en salud (GCS) en 2017 para OMS y OCDE, serían: México (43,6% vs 15.1%); República Dominicana (41,1 vs 5,75%) y Costa Rica (31,4% vs 5,7%).La definición amplia de APS como primer contacto de OMS facilita la inclusión de servicios que reflejan la forma en que los países ofrecen atención a su población. Aun así, la OMS podría mejorar las descripciones de las categorías incluidas para fines de comparación internacional. Restringir la APS a proveedores ambulatorios como hace OCDE limita mucho la medición y excluye intervenciones intrínsecas al concepto de APS, como servicios colectivos de prevención. Como paso transitorio se recomienda a los países que monitoreen el financiamiento de la APS, explicitando qué incluyen en su definición. El SHA 2011 permite identificar y comparar estas diferencias.

RESUMO Este informe especial apresenta uma comparação entre a medida do gasto em atenção primária à saúde (APS) conforme as propostas da Organização para a Cooperação e o Desenvolvimento Econômico (OCDE) e da Organização Mundial da Saúde (OMS), usando a metodologia mundialmente aceita para reportar gastos em saúde - o System of Health Accounts (SHA 2011) - em três países da Região das Américas. Observam-se divergências conceituais entre os métodos: 1) operacionalização do conceito como atenção básica pela OCDE ou primeiro contato pela OMS; 2) maior abrangência de bens e serviços de acordo com a definição da OMS (englobando medicamentos, administração e serviços de prevenção em âmbito coletivo) e 3) inclusão exclusivamente de serviços ambulatoriais de acordo com a OCDE. Os gastos em APS como percentual do gasto corrente em saúde (GCS) em 2017, de acordo com os métodos propostos pela OMS e pela OCDE, foram: 43,6% vs. 15,1% no México; 41,1 vs. 5,75% na República Dominicana; e 31,4% vs. 5,7% na Costa Rica. A definição ampla de APS como primeiro contato proposta pela OMS permite incluir os diferentes arranjos de atenção existentes nos países. No entanto, as categorias deveriam ser mais bem detalhadas para facilitar a comparação internacional. Por outro lado, a proposta da OECD restringe a APS aos prestadores de serviços ambulatoriais, o que limita muito a medição e exclui intervenções próprias do conceito de APS, como serviços de prevenção no âmbito coletivo. Numa etapa de transição, recomenda-se aos países monitorar o financiamento da APS, explicitando os itens incluídos na definição empregada. A metodologia SHA 2011 possibilita identificar e comparar essas diferenças.

Gasto em atenção primária à saúde nas Américas: medir o que importa / Primary health care expenditure in the Americas: measuring what matters / Gasto en atención primaria en salud en las Américas: medir lo que importa

RESUMO Este informe especial apresenta uma comparação entre a medida do gasto em atenção primária à saúde (APS) conforme as propostas da Organização para a Cooperação e o Desenvolvimento Econômico (OCDE) e da Organização Mundial da Saúde (OMS), usando a metodologia mundialmente aceita para reportar gastos em saúde - o System of Health Accounts (SHA 2011) - em três países da Região das Américas. Observam-se divergências conceituais entre os métodos: 1) operacionalização do conceito como atenção básica pela OCDE ou primeiro contato pela OMS; 2) maior abrangência de bens e serviços de acordo com a definição da OMS (englobando medicamentos, administração e serviços de prevenção em âmbito coletivo) e 3) inclusão exclusivamente de serviços ambulatoriais de acordo com a OCDE. Os gastos em APS como percentual do gasto corrente em saúde (GCS) em 2017, de acordo com os métodos propostos pela OMS e pela OCDE, foram: 43,6% vs. 15,1% no México; 41,1 vs. 5,75% na República Dominicana; e 31,4% vs. 5,7% na Costa Rica. A definição ampla de APS como primeiro contato proposta pela OMS permite incluir os diferentes arranjos de atenção existentes nos países. No entanto, as categorias deveriam ser mais bem detalhadas para facilitar a comparação internacional. Por outro lado, a proposta da OECD restringe a APS aos prestadores de serviços ambulatoriais, o que limita muito a medição e exclui intervenções próprias do conceito de APS, como serviços de prevenção no âmbito coletivo. Numa etapa de transição, recomenda-se aos países monitorar o financiamento da APS, explicitando os itens incluídos na definição empregada. A metodologia SHA 2011 possibilita identificar e comparar essas diferenças.

ABSTRACT This special report compares the measurement of primary health care (PHC) expenditure proposed by the Organization for Economic Cooperation and Development (OECD) and by the World Health Organization (WHO), according to the global framework for reporting health expenditures (SHA 2011) in three countries in the Region of the Americas. There are conceptual differences: 1) operationalization as basic care, by OECD, versus first contact, by WHO; 2) a wider range of goods and services in the WHO definition (including medicines, administration, and collective preventive services); and 3) consideration only of services in outpatient providers by OECD. PHC expenditures as a percentage of current healthcare spending in 2017 for WHO and OECD: Mexico (43.6% vs. 15.1%); Dominican Republic (41.1% vs. 5.75%), and Costa Rica (31.4% vs. 5.7%). The broad WHO definition of PHC as first contact facilitates inclusion of services that reflect the way countries provide care to their populations. Even so, WHO could improve its category descriptions for the purposes of international comparison. Restricting PHC to outpatient providers (as the OECD does) greatly limits measurement and excludes interventions intrinsic to the concept of PHC, such as collective preventive services. As a transitional step, we recommend that countries should monitor PHC funding and should explain what they include in their definition. SHA 2011 makes it possible to identify and compare these differences.

RESUMEN En este informe especial se compara la medición del gasto en atención primaria en salud (APS) propuesta por la Organización para la Cooperación y el Desarrollo Económico (OCDE) y la Organización Mundial de la Salud (OMS) según el marco mundial para reportar gastos en salud (SHA 2011) en tres países de la región de las Américas. Hay divergencias conceptuales: 1) la operacionalización como atención básica, por OCDE, o primer contacto, por OMS; 2) la mayor amplitud de bienes y servicios en la definición de OMS (incluye medicamentos, administración y servicios preventivos colectivos); 3) la consideración únicamente de servicios en proveedores ambulatorios en OCDE. Los gastos en APS como el porcentaje del gasto corriente en salud (GCS) en 2017 para OMS y OCDE, serían: México (43,6% vs 15.1%); República Dominicana (41,1 vs 5,75%) y Costa Rica (31,4% vs 5,7%). La definición amplia de APS como primer contacto de OMS facilita la inclusión de servicios que reflejan la forma en que los países ofrecen atención a su población. Aun así, la OMS podría mejorar las descripciones de las categorías incluidas para fines de comparación internacional. Restringir la APS a proveedores ambulatorios como hace OCDE limita mucho la medición y excluye intervenciones intrínsecas al concepto de APS, como servicios colectivos de prevención. Como paso transitorio se recomienda a los países que monitoreen el financiamiento de la APS, explicitando qué incluyen en su definición. El SHA 2011 permite identificar y comparar estas diferencias.

Primary health care expenditure in the Americas: measuring what matters

[ABSTRACT]. This special report compares the measurement of primary health care (PHC) expenditure proposed by the Organization for Economic Cooperation and Development (OECD) and by the World Health Organization (WHO), according to the global framework for reporting health expenditures (SHA 2011) in three countries in the Region of the Americas. There are conceptual differences: (1) operationalization as basic care, by OECD, versus first contact, by WHO; (2) a wider range of goods and services in the WHO definition (including medicines, administration, and collective preventive services); and (3) consideration only of services in outpatient providers by OECD. PHC expenditures as a percentage of current healthcare spending in 2017 for WHO and OECD: Mexico (43.6% vs. 15.1%); Dominican Republic (41.1% vs. 5.75%), and Costa Rica (31.4% vs. 5.7%). The broad WHO definition of PHC as first contact facilitates inclusion of services that reflect the way countries provide care to their populations. Even so, WHO could improve its category descriptions for the purposes of international comparison. Restricting PHC to outpatient providers (as the OECD does) greatly limits measurement and excludes interventions intrinsic to the concept of PHC, such as collective preventive services. As a transitional step, we recommend that countries should monitor PHC funding and should explain what they include in their definition. SHA 2011 makes it possible to identify and compare these differences.

Gasto em atenção primária à saúde nas Américas: medir o que importa

[RESUMO]. Este informe especial apresenta uma comparação entre a medida do gasto em atenção primária à saúde (APS) conforme as propostas da Organização para a Cooperação e o Desenvolvimento Econômico (OCDE) e da Organização Mundial da Saúde (OMS), usando a metodologia mundialmente aceita para reportar gastos em saúde – o System of Health Accounts (SHA 2011) – em três países da Região das Américas. Observam- -se divergências conceituais entre os métodos: 1) operacionalização do conceito como atenção básica pela OCDE ou primeiro contato pela OMS; 2) maior abrangência de bens e serviços de acordo com a definição da OMS (englobando medicamentos, administração e serviços de prevenção em âmbito coletivo) e 3) inclusão exclusivamente de serviços ambulatoriais de acordo com a OCDE. Os gastos em APS como percentual do gasto corrente em saúde (GCS) em 2017, de acordo com os métodos propostos pela OMS e pela OCDE, foram: 43,6% vs. 15,1% no México; 41,1 vs. 5,75% na República Dominicana; e 31,4% vs. 5,7% na Costa Rica. A definição ampla de APS como primeiro contato proposta pela OMS permite incluir os diferentes arranjos de atenção existentes nos países. No entanto, as categorias deveriam ser mais bem detalhadas para facilitar a comparação internacional. Por outro lado, a proposta da OECD restringe a APS aos prestadores de serviços ambulatoriais, o que limita muito a medição e exclui intervenções próprias do conceito de APS, como serviços de prevenção no âmbito coletivo. Numa etapa de transição, recomenda-se aos países monitorar o financiamento da APS, explicitando os itens incluídos na definição empregada. A metodologia SHA 2011 possibilita identificar e comparar essas diferenças.