Coordinación para el abordaje de la viruela del mono con perspectiva de diversidad afectiva y sexual / Coordination for an affective and sexual diversity approach to monkeypox

En mayo de 2022 se detectaron las primeras cadenas de transmisión de la viruela del mono fuera de los países endémicos. Este brote presenta características clínicas y epidemiológicas diferentes de las observadas en los brotes anteriores, con un mayor impacto en el grupo de hombres que tienen sexo con hombres. El abordaje de brotes epidémicos que conlleva intervenciones sobre comunidades o poblaciones en riesgo de estigmatización resulta un desafío. La independencia y la capacidad profesional de las sociedades científicas permiten adoptar iniciativas para dar respuestas rápidas a este tipo de desafíos. Mediante el trabajo colaborativo y la iniciativa profesional se elaboró un documento orientado a evitar la estigmatización a la vez que se promovían la prevención y el control de la enfermedad. Para su divulgación se emplearon distintos canales y se contó con los agentes de interés. El trabajo en equipo, dentro de las estructuras de participación de una sociedad científica, permite impulsar acciones rápidas basadas en recomendaciones técnicas. (AU)

In May 2022, the first monkeypox transmission chains were detected outside endemic countries. This outbreak presents clinical and epidemiological characteristics different from those observed in previous outbreaks, with a greater impact among the group of men who have sex with other men. The approach of epidemic outbreaks that requires interventions on communities or populations at risk of stigmatization is a major public health challenge. The independence and professional capacity of scientific societies allow to be take initiatives to provide rapid responses to this type of challenges. Through collaborative work and professional initiative, a document was issued aimed at avoiding stigmatization while promoting the prevention and control measures. For its dissemination, different channels were used counting with key partners. Teamwork, within the participation structures of a scientific society, allows to promote rapid public health actions based on technical recommendations. (AU)

[Coordination for an affective and sexual diversity approach to monkeypox]. / Coordinación para el abordaje de la viruela del mono con perspectiva de diversidad afectiva y sexual.

In May 2022, the first monkeypox transmission chains were detected outside endemic countries. This outbreak presents clinical and epidemiological characteristics different from those observed in previous outbreaks, with a greater impact among the group of men who have sex with other men. The approach of epidemic outbreaks that requires interventions on communities or populations at risk of stigmatization is a major public health challenge. The independence and professional capacity of scientific societies allow to be take initiatives to provide rapid responses to this type of challenges. Through collaborative work and professional initiative, a document was issued aimed at avoiding stigmatization while promoting the prevention and control measures. For its dissemination, different channels were used counting with key partners. Teamwork, within the participation structures of a scientific society, allows to promote rapid public health actions based on technical recommendations.

Reviewing Disease Activity Indices in Spondyloarthritis From the Sex Perspective: A Systematic Review and Metaanalysis.

OBJECTIVE: To determine whether the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) and the Ankylosing Spondylitis Disease Activity Score (ASDAS) exhibited differences between women and men. METHODS: We systematically searched MEDLINE, Embase, Web of Science, and other sources in English or Spanish from January 1, 1995, to July 31, 2020, to assess the differences according to sex in BASDAI and ASDAS. We performed a comparative analysis by sex using t test and mean difference by sex metaanalyses for BASDAI and ASDAS, as well as a random-effects model using the inverse-variance method. RESULTS: Forty-one studies included BASDAI (6785 women, 12,929 men) and 16 of them included ASDAS (2046 women, 4403 men). Disease activity detected using BASDAI was significantly higher in women than in men (mean 4.9 vs 4.2, P = 0.02), whereas ASDAS did not detect differences between sexes (mean 2.8 women vs 2.8 men). In the metaanalyses, BASDAI detected significant differences between women and men (mean difference = 0.55 [95% CI 0.46-0.65], P < 0.00001), but ASDAS did not identify significant mean difference between sexes (0.04, 95% CI -0.05 to 0.12], P = 0.38). CONCLUSION: The 2 most widely used indices of disease activity in spondyloarthritis (SpA) discriminate differently according to sex by their different evaluations of peripheral disease. The different components and weights in BASDAI and ASDAS influence their values. BASDAI may be affected by fatigue, and in predominantly peripheral manifestations such as enthesitis, ASDAS may not be sensitive enough to detect activity. This may represent a sex bias unfavorable to women, because peripheral SpA is more common in women than in men.

Barriers and facilitators to successful management of type 2 diabetes mellitus in Latin America and the Caribbean: A systematic review.

BACKGROUND: Given that most evidence-based recommendations for managing type 2 diabetes mellitus (T2DM) are generated in high-income settings, significant challenges for their implementation exist in Latin America and the Caribbean region (LAC), where the rates of T2DM and related mortality are increasing. The aim of this study is to identify the facilitators and barriers to successful management of T2DM in LAC, from the perspectives of patients, their families or caregivers, healthcare professionals, and/or other stakeholders. METHODS: We conducted a systematic review in MEDLINE, Web of Science, SciELO, and LILACS. We included studies of disease management, prevention of complications and risk factor management. We qualitatively synthesized the verbatim text referring to barriers and/or facilitators of diabetes management according to the Theoretical Domain Framework and described their relative frequencies. FINDINGS: We included 60 studies from 1,595 records identified. 54 studies (90%) identified factors related to the environmental context and resources, highlighting the importance of questions related to health care access or lack of resources in the health system, and the environmental context and living conditions of the patients. Issues related to "social influences" (40 studies) and "social/professional role and identity" (37 studies) were also frequently addressed, indicating the negative impact of lack of support from family and friends and clinicians' paternalistic attitude. 25 studies identified patients beliefs as important barriers, identifying issues such as a lack of patients' trust in the effectiveness of the medication and/or the doctor's advice, or preferences for alternative therapies. CONCLUSIONS: Successful diabetes management in LAC is highly dependent on factors that are beyond the control of the individual patients. Successful disease control will require emphasis on public policies to reinforce health care access and resources, the promotion of a patient-centred care approach, and health promoting infrastructures at environmental level.

Sesgos de género en el esfuerzo terapéutico: de la investigación a la atención sanitaria / Gender bias in therapeutic effort: from research to health care

Existen dimensiones relevantes desde una perspectiva de género relaciona-das con el esfuerzo terapéutico. Se pretende ilustrar y traer a debate posibles sesgos de género relacionados con los medicamentos, mediante el análisis del consumo en las mujeres, la prescripción de fármacos biológicos según sexo, la potencial desigualdad de género en las reacciones adversas a los medicamentos y la investigación con ensayos clínicos, así como las decisiones de las instituciones internacionales en la comercialización de medicamentos. mSe observa una mayor tendencia a prescribir analgésicos, con independencia del dolor, y fármacos para síntomas depresivos de baja intensidad en mujeres que en hombres. Lo contrario sucede en la prescripción de estatinas y dosis adecuadas, y con la mayor probabilidad de prescripción de antifactor de necrosis tumoral en hombres que en mujeres con espondilitis anquilosante, pese a la similar carga de la enfermedad. Las reacciones adversas a los medicamentos se observan con más frecuencia en mujeres que en hombres, donde determinantes como el peso corporal están influyendo poco en la dosificación. En la actualidad se considera escasamente en la prescripción que las mujeres presentan diferencias en la actividad de las enzimas del citocromo CYPP450, que puede afectar a la velocidad del metabolismo hepático. Incluso hay efectos inmunológicos, genéticos y epigenéticos (por la herencia y la dosificación desigual de los genes ubicados en los cromosomas X e Y) que pueden influir en estas diferencias por sexo. Por último, mediante los casos de ensayos clínicos de la terapia hormonal, un fármaco para el deseo sexual inhibido de las mujeres y un anticonceptivo para hombres, se muestran sesgos y estereotipos de género que influyen en una potencial generación de desigualdades, especialmente en las reacciones adversas a los medicamentos en perjuicio de las mujeres. Concluyendo, los profesionales sanitarios atribuyen con frecuencia a la emocionalidad de las mujeres lo que son síntomas físicos, influyendo en la mayor prescripción de fármacos sintomáticos en ellas. Debe analizarse si la misma razón influye en la menor prescripción de fármacos terapéuticos en mujeres que en hombres. Existen determinantes biológicos a considerar por su influencia en una mayor toxicidad farmacológica en las mujeres. Los ensayos clínicos deben mejorar atendiendo a las recomendaciones de género de la Food and Drug Administration

There are relevant dimensions from a gender perspective related to the-rapeutic effort. To illustrate and discuss possible gender bias related to medicines, through the consumption analysis in women, the prescription of biological drugs according to sex, the potential gender inequality in adverse drug reactions, and research with clinical trials, as well as the decisions of international institutions in the marketing of medicinal products.There is greater tendency to prescribe pain relievers, regardless of pain, and drugs for low intensity depressive symptoms in women than in men. The opposite occurs in the prescription of statins and adequate doses, and with the greater probability of prescribing anti-tumor necrosis factor in men than in women with ankylosing spondylitis, despite a similar disease burden. Adverse drug reactions are observed more frequently in women than in men, where determinants such as body weight are having little influence on the dosage. It is currently scarcely considered in the prescrip-tion that women have differences in the activity of cytochrome CYPP450 enzymes, which can affect the liver's metabolism rate. There are even immunological, genetic and epigenetic effects (due to heredity and une-ven gene dosing located in the X and Y chromosomes) that can influence these differences by sex. Finally, through cases of hormonal therapy clini-cal trials, a drug for women's inhibited sexual desire and a contraceptive for men, gender bias and stereotypes are shown to influence a potential generation of inequalities, especially in adverse drug reactions to the de-triment of women. In conclusion, health professionals frequently attribute physical symptoms to women's emotionality, influencing their greater prescription of sympto-matic drugs. Whether the same reason influences the lower prescription of therapeutic drugs in women than in men should be analyzed. There are biological determinants to consider due to their influence on a greater pharmacological toxicity in women. Clinical trials should improve accor-ding to the gender recommendations by the Food and Drugs Administration

Gender bias in therapeutic effort: from research to health care.

There are relevant dimensions from a gender perspective related to  therapeutic effort. To illustrate and discuss possible gender bias related  to medicines, through the consumption analysis in women, the  prescription of biological drugs according to sex, the potential gender  inequality in adverse drug reactions, and research with clinical trials, as  well as the decisions of international institutions in the marketing of  medicinal products. There is greater tendency to prescribe pain  relievers, regardless of pain, and drugs for low intensity depressive  symptoms in women than in men. The opposite occurs in the  prescription of statins and adequate doses, and with the greater  probability of prescribing anti-tumor necrosis factor in men than in  women with ankylosing spondylitis, despite a similar disease burden.  Adverse drug reactions are observed more frequently in women than in  men, where determinants such as body weight are having little influence on the dosage. It is currently scarcely considered in the prescription that women have differences in the activity of cytochrome CYPP450 enzymes, which can affect the liver's metabolism rate. There  are even immunological, genetic and epigenetic effects (due to heredity  and uneven gene dosing located in the X and Y chromosomes) that can  influence these differences by sex. Finally, through cases of hormonal  therapy clinical trials, a drug for women's inhibited sexual desire and a  contraceptive for men, gender bias and stereotypes are shown to  influence a potential generation of inequalities, especially in adverse  drug reactions to the detriment of women. In conclusion, health  professionals frequently attribute physical symptoms to women's  emotionality, influencing their greater prescription of symptomatic drugs. Whether the same reason influences the lower prescription of  therapeutic drugs in women than in men should be analyzed. There are  biological determinants to consider due to their influence on a greater pharmacological toxicity in women. Clinical trials should improve  according to the gender recommendations by the Food and Drugs  Administration.

Existen dimensiones relevantes desde una perspectiva de género  relacionadas con el esfuerzo terapéutico. Se pretende ilustrar y traer a  debate posibles sesgos de género relacionados con los medicamentos,  mediante el análisis del consumo en las mujeres, la prescripción de  fármacos biológicos según sexo, la potencial desigualdad de género en  las reacciones adversas a los medicamentos y la investigación con  ensayos clínicos, así como las decisiones de las instituciones  internacionales en la comercialización de medicamentos. Se observa una mayor tendencia a prescribir analgésicos, con independencia del dolor, y fármacos para síntomas depresivos de baja intensidad en mujeres que  en hombres. Lo contrario sucede en la prescripción de estatinas y dosis  adecuadas, y con la mayor probabilidad de prescripción de antifactor de  necrosis tumoral en hombres que en mujeres con espondilitis anquilosante, pese a la similar carga de la enfermedad. Las  reacciones adversas a los medicamentos se observan con más  frecuencia en mujeres que en hombres, donde determinantes como el  peso corporal están influyendo poco en la dosificación. En la actualidad  se considera escasamente en la prescripción que las mujeres presentan  diferencias en la actividad de las enzimas del citocromo CYPP450, que  puede afectar a la velocidad del metabolismo hepático. Incluso hay  efectos inmunológicos, genéticos y epigenéticos (por la herencia y la  dosificación desigual de los genes ubicados en los cromosomas X e Y)  que pueden influir en estas diferencias por sexo. Por último, mediante  los casos de ensayos clínicos de la terapia hormonal, un fármaco para el deseo sexual inhibido de las mujeres y un anticonceptivo para hombres, se muestran sesgos y estereotipos de género que influyen en una  potencial generación de desigualdades, especialmente en las reacciones  adversas a los medicamentos en perjuicio de las mujeres. Concluyendo,  los profesionales sanitarios atribuyen con frecuencia a la emocionalidad  de las mujeres lo que son síntomas físicos, influyendo en la mayor  prescripción de fármacos sintomáticos en ellas. Debe analizarse si la  misma razón influye en la menor prescripción de fármacos terapéuticos en mujeres que en hombres. Existen determinantes biológicos a considerar por su influencia en una mayor toxicidad farmacológica en las mujeres. Los ensayos clínicos deben mejorar atendiendo a las  recomendaciones de género de la Food and Drug Administration.

Perspectiva de género en epidemiología clínica. Aprendiendo con el caso de las espondiloartritis / Gender perspective in clinical epidemiology. Learning from spondyloarthritis

OBJETIVO: Ilustrar con una enfermedad crónica como la espondiloartritis algunos retos y contribuciones de género más frecuentes en investigación y atención sanitaria. MÉTODO: Utilizando dos de los principales sesgos de género en investigación y atención sanitaria identificados (la descontextualización de las enfermedades, especialmente en las mujeres, y la definición del problema y la producción de conocimiento en salud de las mujeres), se utilizó para su análisis un estudio transversal con 96 hombres y 54 mujeres con espondiloartritis de la Unidad de Reumatología del Hospital General Universitario de Alicante, cuyas fuentes de información fueron entrevistas semiestructuradas a los/las pacientes y su historia clínica. RESULTADOS: Se muestra que la perspectiva de género puede contribuir a contextualizar las diferencias por sexo de las alteraciones funcionales y otros indicadores sociosanitarios, a poner de manifiesto desigualdades en las repercusiones socioeconómicas entre pacientes de ambos sexos, a reconceptualizar las enfermedades, especialmente de las mujeres, precisando el perfil de diagnóstico diferencial según sexo, y a aportar conocimiento sobre retos metodológicos relacionados con las pruebas diagnósticas. CONCLUSIONES: Alcanzar la excelencia científica y profesional en la atención sanitaria es una cuestión también de género. Analizar desde la perspectiva de género la historia de las enfermedades, cómo se establecieron sus criterios diagnósticos y los puntos de corte de normalidad y anormalidad, en especial de las enfermedades identificadas de hombres, como la espondiloartritis, es una prioridad para reconceptualizar la medicina, así como aportar información sobre cómo interaccionan las normas y los valores de género del contexto con las vidas de quienes padecen estas enfermedades

OBJECTIVE: To illustrate some gender challenges and contributions which are more frequent in research and health care through a chronic disease such as spondyloarthritis. METHOD: Using two of the main identified gender biases in research and health care (de-contextualization of diseases, especially in women, and problem definition and knowledge production in women's health), a cross-sectional study was used with 96 men and 54 women with spondyloarthritis of the Rheumatology Department of the Alicante University General Hospital, whose sources of information were semi-structured patient interviews and clinical records. RESULTS: We show how the gender perspective can contribute to contextualise the differences by sex of functional alterations and other social and health indicators, and highlight inequalities in the socioeconomic repercussions between patients of both sexes. It can contribute towards re-conceptualizing diseases, especially of women, specifying the profile of differential diagnosis according to sex, and provide knowledge about methodological challenges related to diagnostic tests. CONCLUSIONS: Achieving scientific and professional excellence in health care is also a gender issue. Analysing from a gender perspective the history of the diseases, how their diagnosis criteria were established and the normality and abnormality cut-off points, especially identified diseases of men, such as spondyloarthritis, is a priority to re-conceptualize medicine; as well as providing information on how the gender norms and values of the context interact with the lives of those who suffer these diseases

Contextualizing Evidence for Action on Diabetes in Low-Resource Settings-Project CEAD Part I: A Mixed-Methods Study Protocol.

Challenges remain for policy adoption and implementation to tackle the unprecedented and relentless increase in obesity, diabetes and other non-communicable diseases (NCDs), especially in low- and middle-income countries. The aim of this mixed-methods study is to analyse the contextual relevance and applicability to low-resource settings of a sample of evidence-based healthy public policies, using local knowledge, perceptions and pertinent epidemiological data. Firstly, we will identify and prioritise policies that have the potential to reduce the burden of diabetes in low-resource settings with a scoping review and modified Delphi method. In parallel, we will undertake two cross-sectional population surveys on diabetes risk and morbidity in two low-resource settings in Ecuador. Patients, community members, health workers and policy makers will analyse the contextual relevance and applicability of the policy actions and discuss their potential for the reduction in inequities in diabetes risk and morbidity in their population. This study tackles one of the greatest challenges in global health today: how to drive the implementation of population-wide preventative measures to fight NCDs in low resource settings. The findings will demonstrate how local knowledge, perceptions and pertinent epidemiological data can be used to analyse the contextual relevance and applicability of potential policy actions.

[Gender perspective in clinical epidemiology. Learning from spondyloarthritis]. / Perspectiva de género en epidemiología clínica. Aprendiendo con el caso de las espondiloartritis.

OBJECTIVE: To illustrate some gender challenges and contributions which are more frequent in research and health care through a chronic disease such as spondyloarthritis. METHOD: Using two of the main identified gender biases in research and health care (de-contextualization of diseases, especially in women, and problem definition and knowledge production in women's health), a cross-sectional study was used with 96 men and 54 women with spondyloarthritis of the Rheumatology Department of the Alicante University General Hospital, whose sources of information were semi-structured patient interviews and clinical records. RESULTS: We show how the gender perspective can contribute to contextualise the differences by sex of functional alterations and other social and health indicators, and highlight inequalities in the socioeconomic repercussions between patients of both sexes. It can contribute towards re-conceptualizing diseases, especially of women, specifying the profile of differential diagnosis according to sex, and provide knowledge about methodological challenges related to diagnostic tests. CONCLUSIONS: Achieving scientific and professional excellence in health care is also a gender issue. Analysing from a gender perspective the history of the diseases, how their diagnosis criteria were established and the normality and abnormality cut-off points, especially identified diseases of men, such as spondyloarthritis, is a priority to re-conceptualize medicine; as well as providing information on how the gender norms and values of the context interact with the lives of those who suffer these diseases.

Challenges to conquer from the gender perspective in medicine: The case of spondyloarthritis.

BACKGROUND: Diagnostic delay is well-known in spondyloarthritis and studies have demonstrated a longer deferral in women. The aim of this study was to explore whether diagnostic delay of spondyloarthritis depends on clinical manifestations expressed by patients according to sex or whether it is related to a doctor's misdiagnosis bias. METHODS: A cross-sectional study of 96 men and 54 women with spondyloarthritis was performed at Alicante University General Hospital in Spain using a semistructured interview and clinical records. Comparative sex analysis were done via Student's T and Mann-Whitney U tests for parametric and nonparametric continuous variables, chi-square and Fisher's exact tests for unpaired categorical variables, and McNemar's test for paired ones. FINDINGS: The median diagnostic delay in women 7.5 (11.5) years is higher than men 4 (11) years, with a difference close to statistical significance (p = 0.053). A total of 30.2% of men received a first correct diagnosis of spondyloarthritis versus 11.1% of women (p = 0.016), indicating that men have higher probability of not having a misdiagnosis of spondyloarthritis (odds ratio = 3.5; 1.3-9). Eleven different health services referred male patients to the rheumatology clinic but only six in the case of female. No sex differences were detected in patients' manifestations of back pain at onset. However, medical records registered differences (women 44.4%, men 82.1%; p < 0.001). There were differences between patients (women 57.7%, men 35.2%; p = 0.008) and medical records in peripheral signs/symptoms at onset (women 55.6%, men 17.9%; p < 0.001). CONCLUSION: The few differences of self-reported manifestations between both sexes with spondyloarthritis as compared with their clinical records (more axial pain in men and more peripheral pain in women) suggests that the professionals' annotations reflect what they expect according to Literature, which could explain the higher misdiagnosis and diagnostic delay in women with spondyloarthritis.

Sex and Gender Interactions in the Lives of Patients with Spondyloarthritis in Spain: A Quantitative-qualitative Study.

OBJECTIVE: To illustrate the experiences and contextual support perceived by men and women with spondyloarthritis (SpA) in relation to their demanding productive and reproductive roles. METHODS: A quantitative-qualitative study of 96 men and 54 women with SpA was conducted at the Alicante University General Hospital, in a Spanish Mediterranean city, from March 2013 to February 2014. Descriptive and qualitative content analyses compared working lives and family/partner relationships of male and female patients. RESULTS: Working life: both women (55.6%) and men (51.04%) were similarly affected, but women had worse disease activity (5.4 vs 4.0, p = 0.01) and less antitumor necrosis factor-α therapy (56.7% vs 77.6%, p < 0.05). Different patterns were found by gender: women mostly practiced presenteeism whereas men practiced absenteeism, women took antiinflammatories prior to work and men after work, employers suggested more frequently the beneficial actions for men, and some women withdrew permanently from the labor market. Family/partner relationships: women were more affected (57.4%) than men (41.7%), with worse results for diagnostic delay (11.2 vs 6.4 yrs, p = 0.02), disease activity (5.8 vs 3.6, p < 0.001), and physical function (5.2 vs 3.8, p = 0.02). Gender role conflicts emerged, with women developing strategies to face compulsory housework whereas men avoided them; women regretted neglecting their children and men not sharing leisure activities with them. CONCLUSION: Our study highlights the vital complexity in which patients with SpA are immersed, especially for women in a country where a mix of new and traditional gender roles coexist. Awareness of its existence is crucial when professionals strive to provide healthcare focused on their well-being in addition to medical therapy.

Understanding How the Diagnostic Delay of Spondyloarthritis Differs Between Women and Men: A Systematic Review and Metaanalysis.

OBJECTIVE: To identify empirical evidence of diagnostic delay in spondyloarthritis (SpA), determine whether sex-related differences persist, and conduct an analysis from that perspective of the possible causes, including the influence of quality research, in this group of inflammatory rheumatic diseases. METHODS: A systematic review was done of delay in diagnosis of SpA in MEDLINE and EMBASE and other sources. Study quality was determined in line with the Strengthening The Reporting of OBservational studies in Epidemiology (STROBE) statement. A metaanalysis of 13 papers reporting sex-disaggregated data was performed to evaluate sex-related differences in diagnostic delay. The global effect of diagnostic delay by sex was calculated using means difference (D) through a fixed effects model. RESULTS: The review included 23,883 patients (32.3% women) from 42 papers. No significant differences between the sexes were detected for symptoms at disease onset or during evolution. However, the mean for delay in diagnosis of SpA showed sex-related differences, being 8.8 years (7.4-10.1) for women and 6.5 (5.6-7.4) for men (p = 0.01). Only 40% of papers had high quality. A metaanalysis included 12,073 participants (31.2% women). The mean global effect was D = 0.6 years (0.31-0.89), indicating that men were diagnosed 0.6 year (7 months) before women. CONCLUSION: Delay in diagnosis of SpA persists, and is longer in women than in men. There are no significant sex-related differences in symptoms that could explain sex-related differences in diagnostic delay. Methodological and possible publication bias could result in sex-biased medical practice.

Carta respuesta a Aspectos a señalar de la formación en salud pública / Outstanding features of training in public health-Response

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Ampliando la profesionalización de la salud pública: la formación especializada multiprofesional / Broadening the professionalization of public health: multiprofessional specialized training

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