Determining the legality of newly described CITES-listed species in the horticulture trade of tropical pitcher plants (Nepenthes).

Due diligence is a fundamental component of ensuring a sustainable and legal wildlife trade that is also supportive of the livelihoods and businesses that depend on the trade. This is particularly true with species listed on the Convention on International Trade in Endangered Species (CITES) that are considered threatened or may become threatened by trade. Undertaking due diligence exercises requires access to information on which to base such decisions; however, the extent to which information is available is unclear. We used the trade in tropical pitcher plants (Nepenthes) for horticultural purposes as a case study to determine the extent to which information is available. A systematic survey of online trade was conducted for species described from 1996 to 2016. For the species found in trade, these were cross-referenced with the CITES trade database, and inquiries were made to the relevant CITES Management Authorities and National Focal Points Access and Benefit Sharing (ABS). Of 83 newly described species, 61% were offered for sale online in 2018. Despite all Nepenthes species being listed on CITES, only 23% (n = 19) of the species being sold online were reported in trade on the CITES Trade Database, and only 3 were from the countries of origin. Thirty-two of these species had no international trade recorded according to the database. Management authorities of CITES for the countries of origin confirmed trade had been permitted for 5 of 32 species. Lack of CITES records may be explained by trade under "Nepenthes spp." or as exempt parts and derivatives. However, permits to collect and commercialize are likely to be required as part of the Nagoya Protocol on ABS from the Convention on Biological Diversity. The ABS National Focal Points were contacted to determine whether collection or commercialization permits had been issued for the remaining species. Only 2 of 7 focal points replied, and both stated no permits had been issued. Lack of traceability information or response related to the issuance of collection and commercialization permits is concerning and hinders the due diligence of businesses and consumers wanting to ensure their trade is legal, sustainable, and ethical.

Definición de la legalidad de especies recién catalogadas en CITES en la horticultura comercial de plantas de jarra tropicales (Nepenthes) Resumen La diligencia debida es un componente fundamental para garantizar un comercio de vida silvestre legal y sostenible que también apoye los medios de subsistencia y las empresas que dependen del comercio. Esto es especialmente cierto en el caso de las especies incluidas en la Convención sobre el Comercio Internacional de Especies Amenazadas de Fauna y Flora Silvestres (CITES) que se consideran amenazadas o pueden verse amenazadas por el comercio. La realización de ejercicios de diligencia debida requiere acceso a información con la cual fundamentar tales decisiones; sin embargo, no está claro hasta qué punto se dispone de información. Usamos como estudio de caso el comercio de plantas de jarra tropicales (Nepenthes) con fines hortícolas para determinar cuánta información hay disponible. Realizamos un estudio sistemático del comercio en línea de las especies descritas entre 1996 y 2016. Para las especies encontradas en el comercio, hicimos referencias cruzadas con la base de datos de comercio CITES y consultamos a las Autoridades Administrativas CITES pertinentes y a los Puntos Focales Nacionales de Acceso y Distribución de Beneficios. De las 83 especies con descripción reciente, el 61% se pusieron a la venta en línea en 2018. A pesar de que todas las especies de Nepenthes están catalogadas en CITES, sólo el 23% (n = 19) de las especies que se vendían en línea figuraban en la base de datos sobre comercio CITES, y sólo tres procedían de los países de origen. Treinta y dos de estas especies no tenían comercio internacional registrado según la base de datos. Las autoridades de gestión de CITES de los países de origen confirmaron que se permitió el comercio de 5 de las 32 especies. La falta de registros CITES puede explicarse por el comercio de «Nepenthes spp¼ o como partes y derivados exentos. Sin embargo, es probable que se exijan permisos de recolección y comercialización en el marco del Protocolo de Nagoya sobre Acceso y Participación en los Beneficios (APB) del Convenio sobre la Diversidad Biológica. Contactamos a los Puntos Focales Nacionales de APB para determinar si se habían expedido permisos de recolección o comercialización para las especies restantes. Sólo dos de los siete puntos focales respondieron y ambos afirmaron que no se había expedido ningún permiso. La falta de información de rastreo o de respuesta en relación con la expedición de permisos de recolección y comercialización es preocupante y obstaculiza la diligencia debida de las empresas y los consumidores que desean asegurarse de que su comercio es legal, sostenible y ético.

Legal and economic perspectives on fair and equitable benefit sharing in the Nagoya Protocol.

Adopted in 2010 as a supplementary agreement to the 1992 Convention on Biological Diversity, the Nagoya Protocol (NP) mandates the fair and equitable sharing of benefits arising from the use of genetic resources provided by Indigenous peoples. Member states must newly enact or amend domestic laws to align with the NP. Consequently, many countries are currently implementing legislative, administrative, and policy measures to ensure fair benefit sharing from the use of Indigenous genetic resources. We examined the inclusion of intellectual property (IP) protection in the sharing of benefits from research and development that utilizes Indigenous genetic resources. The NP does not specify guidelines for IP-related benefit sharing, leaving each member state to establish its own rules. We used an economics-based approach to explore the optimal scope and duration of IP protection for maximizing stakeholder interests, including those of Indigenous peoples, at the national level. The optimal duration of IP protection was when the marginal social cost and benefit of IP protection were equal. When this point occurred varied depending on various factors, such as the type of genetic resources in the country, existence of alternatives, number of users, and competing actors. The optimal scope of IP protection was when the social benefit of investment in fundamental research equaled the social benefit of application development. Likewise, this point of implementation also varied based on various factors, such as the type, uniqueness, potential for further discovery, and diversity of providers in the country.

Perspectivas legales y económicas del reparto justo y equitativo de beneficios en el Protocolo de Nagoya Resumen Adoptado en 2010 como un acuerdo complementario del Convenio sobre la Diversidad Biológica de 1992, el Protocolo de Nagoya establece el reparto justo y equitativo de los beneficios derivados del uso de los recursos genéticos proporcionados por los pueblos indígenas. Los Estados miembros deben promulgar o modificar su legislación nacional para adaptarla al Protocolo de Nagoya. En consecuencia, muchos países están aplicando actualmente medidas legislativas, administrativas y políticas para garantizar una participación justa en los beneficios derivados del uso de los recursos genéticos indígenas. Examinamos la inclusión de la protección de la propiedad intelectual (PI) en la participación en los beneficios derivados de la investigación y el desarrollo que utilizan recursos genéticos indígenas. El Protocolo de Nagoya no especifica directrices para la participación en los beneficios relacionados con la PI, dejando que cada Estado miembro establezca sus propias normas. Usamos un enfoque económico para estudiar el alcance y la duración óptimos de la protección de la propiedad intelectual con el fin de maximizar los intereses de los actores, incluidos los de los pueblos indígenas, a escala nacional. La duración óptima de la protección de la PI ocurría cuando el costo social marginal y el beneficio de la protección de la PI eran iguales. El momento en que se produce este punto varía en función de diversos factores, como el tipo de recursos genéticos del país, la existencia de alternativas, el número de usuarios y los actores que compiten entre sí. El alcance óptimo de la protección de la PI ocurría cuando el beneficio social de la inversión en investigación fundamental igualaba al beneficio social del desarrollo de aplicaciones. Asimismo, este punto de aplicación también varió en función de diversos factores, como el tipo, la singularidad, el potencial de nuevos descubrimientos y la diversidad de proveedores en el país.

Evidence-based protocol for diagnosis and treatment of hepatorenal syndrome is independently associated with lower mortality.

BACKGROUND: Hepatorenal syndrome (HRS) is the deadliest complication of cirrhosis. The purpose of this study is to analyze if the use of a protocol for HRS is associated with higher survival in these patients. METHODS: An evidence-based protocol for the diagnosis and treatment of HRS was instituted in 2013. Data from medical records from 2010 to 2016 were obtained by searching the hospital database for patients who received terlipressin, in the three years before and after the institution of the protocol. Data were reviewed to confirm the diagnosis of HRS and multiple variables were collected. Liver-specific scores were calculated and a stepwise Cox regression approach was used for univariate and multivariate analysis. RESULTS: The study included 46 patients, 20 from the pre-protocol period and 26 from the post-protocol period. Respectively, mortality at 30 days, 90 days and 365 days was 75%, 75% and 90% for the pre-protocol period, and 61%, 69% and 80% for the post-protocol period. In the multivariate analysis, an aspartate aminotransferase (AST) of <40U/L, the pre-protocol period and higher Child-Turcotte-Pugh scores were associated with higher 30-day and 90-day mortality. The total mean dose of terlipressin and human albumin used per patient was reduced from 27mg to 22mg and from 236g to 144g, respectively, after the institution of the protocol. This was not associated with higher mortality. CONCLUSION: The use of an evidence-based protocol for the treatment of HRS translated into a higher survival. The authors suggest that the use of evidence-based protocols for the diagnosis and treatment of HRS could reduce cost and mortality in tertiary hospitals.

Impact of COVID-19 prevention measures on health service quality, perceived value and user satisfaction. A structural equation modelling (SEM) approach.

OBJECTIVE: To explain using a structural equation model to patient satisfaction by analysing confidence in preventive measures against COVID-19 as an antecedent of this satisfaction and the effect that these measures have on the antecedents of service quality and perceived value. DESIGN: An observational cross-sectional study. SITE: Online survey was sent via social networks for recruiting citizens resident in Spain. PARTICIPANTS: The final sample consisted of 149 women and 122 men. The mean age of the participants was 36.73 years, all of whom were health service users. INTERVENTIONS: No interventions were conducted in the study. MAIN MEASUREMENTS: The study variables for the development of the structural equation model were: confidence in COVID-19 safety protocol, perceived value, quality and user satisfaction. RESULTS: The results showed a direct and positive effect of confidence in COVID-19 safety protocol on the quality of services provided, perceived value and user satisfaction. CONCLUSIONS: The study is expected to be of interest to those in charge of designing protective measures against the spread of diseases, health centre managers and marketing professionals interested in the improvement user satisfaction, affected as a result of the current pandemic.

How to prepare a research proposal in the health sciences? / ¿Cómo elaborar un proyecto de investigación en ciencias de la salud?

Knowing how to properly prepare a research proposal is a real challenge - and being able to prepare an excellent research proposal is increasingly a requirement to compete for funding with assurances of success. With this in mind, we aim to share with the reader our experience (in many cases, unsuccessful) as applicants on the most important aspects of preparing a research proposal and securing its approval and funding. This article aims not only to list theoretical recommendations but also to share some personal and eminently practical suggestions on the following elements of a research proposal: the title, the abstract, the introduction, the objectives, the methodology, the work plan or schedule, the proposal's consistency and coherence, its viability, its applicability, the importance of the principal investigator and the research team, the proposal's limitations and alternatives, its budget, its references, and, finally, the research proposal's form or wording. In summary, a research proposal is a carefully written plan that includes all the scientific, ethical and logistical aspects of the study to be conducted. Writing a good research proposal requires considerable effort and a great deal of time, but it's worth it.

Challenges of independent clinical research. / Retos y desafíos de la investigación clínica independiente.

Pharmaceutical companies fund most clinical trials on drugs. However, there are clinical issues that might not be a priority from a commercial point of view, but that should certainly be addressed, given their importance for patients and society in general. Independent clinical research represents a fundamental pillar here and its basic element is investigator-initiated studies/trials. In these studies, it is the researcher who conceives the idea, develops the project and also acts as the sponsor. Most researchers are familiar with participating as collaborators in studies sponsored by pharmaceutical companies. In these studies, the company is in charge of all the scientific, legal and financial aspects, leaving the responsibility of the researcher mainly limited to the inclusion of patients and compliance with the protocol. On the contrary, the start-up and development of an independent research study requires considerable resources - of knowledge, money and time - and careful planning on the part of the researcher. In this manuscript, we will review the main characteristics of the studies initiated by the researcher and their fundamental differences with those sponsored by the pharmaceutical industry. We will also outline what its strengths and limitations are. Finally, we will propose some solutions to the main challenges they pose. Our ultimate goal is to stimulate potential researchers to undertake the challenge of conducting an independent clinical research project.

Vessel/perfusion density in two optical coherence tomographic angiography protocols: Interchangeable?

INTRODUCTION: Different optical coherence tomography angiography (OCTA) scanning protocols evaluate the macula. OBJECTIVE: To compare the determination coefficients (R2) between vessel and perfusion densities of two OCTA scanning protocols in order to determine if their metrics could be interchanged. METHOD: Cross-sectional, prospective, comparative, observational, study between two OCTA scanning protocols (Angioplex, Zeiss) in healthy subjects. The R2 between central, inner, and full densities (3 x 3 mm protocol) and between central, inner, outer and full densities (6 x 6 mm protocol) was identified, both for vessel and perfusion densities. RESULTS: Seventy-eight eyes were evaluated; subjects' median age was 23 years. There were high R2 between inner and full densities with the 3 x 3 mm protocol (0.96), between outer and full densities with the 6 x 6 mm protocol (0.96), and between central vessel and perfusion densities (≥ 0.96); R2 between central vessel and perfusion densities of different protocols was ≤ 0.71. CONCLUSIONS: Vessel and perfusion densities have high determination coefficients within a scanning protocol, but not between protocols, given that each one preferentially measures different macular areas. Metrics from different protocols should not be interchanged for follow up.

INTRODUCCIÓN: Distintos protocolos de angiotomografía de coherencia óptica evalúan la mácula. OBJETIVO: R2 entre las densidades vascular y de perfusión de dos protocolos de angiotomografía de coherencia óptica, para determinar si sus mediciones podían intercambiarse. MÉTODO: Estudio observacional, comparativo, prospectivo, transversal entre dos protocolos de angiotomografía de coherencia óptica (AngioPlex, Zeiss) en sujetos sanos. Se identificó la R2 entre las densidades vascular y de perfusión central, interna y completa (protocolo de 3 x 3 mm), y central, interna, externa y completa (protocolo de 6 x 6 mm). RESULTADOS: 78 ojos, mediana de edad 23 años. Hubo R2 altas entre las densidades interna y completa del protocolo de 3 x 3 mm (0.96), externa y completa del de 6 x 6 mm (0.96), y centrales vasculares y de perfusión (≥ 0.96); la R2 entre las densidades centrales vascular y de perfusión de distintos protocolos fue ≤ 0.71. CONCLUSIONES: Las densidades vasculares y de perfusión tienen R2 alta dentro de un protocolo, pero no entre protocolos, porque estos miden preferentemente zonas distintas, lo cual limita intercambiar mediciones.

Protocol For Patients With Suspected Acute Porphyria. / Protocolo de actuación en pacientes con sospecha de porfiria aguda.

Porphyrias are a group of congenital errors in porphyrin metabolism and in the heme biosynthetic pathway. Accumulation of porphyrin precursors (delta-aminolaevulinic acid and porphobilinogen) is responsible for the neurovisceral crises of acute porphyria, which, when expressed clinically, start with intense abdominal pain. During crises, the urinary elimination of porphobilinogen and delta-aminolaevulinic acid is always very high. Excessive porphobilinogen concentration in urine is easily identified using the simple Hoesch test. A negative test rules out a current porphyric crisis. The clinical protocol for patients with acute abdominal pain of unknown origin in whom a positive Hoesch test leads to the suspicion of acute porphyria is based on the following aspects: initial clinical assessment in the emergency department, suppression of potential triggers, specific treatment for the crisis with hemin and/or glucose overload and symptomatic treatment.

Consensus on basic conduct during the hospital admission of patients with acute heart failure. / Consenso de actuación básica durante el ingreso hospitalario por insuficiencia cardiaca aguda.

Acute heart failure (AHF) is a highly prevalent clinical entity in individuals older than 45years in Spain. AHF is associated with significant morbidity and mortality and is the leading cause of hospitalisation for individuals older than 65years in Spain, a quarter of whom die within 1year of the hospitalisation. In recent years, there has been an upwards trend in hospitalisations for AHF, which increased 76.7% from 2003 to 2013. Readmissions at 30days for AHF have also increased (from 17.6% to 22.1%), at a relative mean rate of 1.36% per year, with the consequent increase in the use of resources and the economic burden for the healthcare system. The aim of this document (developed by the Heart Failure and Atrial Fibrillation Group of the Spanish Society of Internal Medicine) is to guide specialists on the most important aspects of treatment and follow-up for patients with AHF during hospitalisation and the subsequent follow-up. The main recommendations listed in this document are as follows: (1)At admission, perform a comprehensive assessment, considering the patient's standard treatment and comorbidities, given that these determine the disease prognosis to a considerable measure. (2)During the first few hours of hospital care, decongestive treatment is a priority, and a staged diuretic therapeutic approach based on the patient's response is recommended. (3)To manage patients in the stable phase, consider starting and/or adjusting evidence-based drug treatment (e.g., sacubitril/valsartan or angiotensin-converting enzyme inhibitors/angiotensinII receptor blockers, beta blockers and aldosterone antagonists). (4)At hospital discharge, use a checklist to optimise the patient's management and identify the most efficient options for maintaining continuity of care after discharge.

Microtargeting for conservation.

Widespread human action and behavior change is needed to achieve many conservation goals. Doing so at the requisite scale and pace will require the efficient delivery of outreach campaigns. Conservation gains will be greatest when efforts are directed toward places of high conservation value (or need) and tailored to critical actors. Recent strategic conservation planning has relied primarily on spatial assessments of biophysical attributes, largely ignoring the human dimensions. Elsewhere, marketers, political campaigns, and others use microtargeting-predictive analytics of big data-to identify people most likely to respond positively to particular messages or interventions. Conservationists have not yet widely capitalized on these techniques. To investigate the effectiveness of microtargeting to improve conservation, we developed a propensity model to predict restoration behavior among 203,645 private landowners in a 5,200,000 ha study area in the Chesapeake Bay Watershed (U.S.A.). To isolate the additional value microtargeting may offer beyond geospatial prioritization, we analyzed a new high-resolution land-cover data set and cadastral data to identify private owners of riparian areas needing restoration. Subsequently, we developed and evaluated a restoration propensity model based on a database of landowners who had conducted restoration in the past and those who had not (n = 4978). Model validation in a parallel database (n = 4989) showed owners with the highest scorers for propensity to conduct restoration (i.e., top decile) were over twice as likely as average landowners to have conducted restoration (135%). These results demonstrate that microtargeting techniques can dramatically increase the efficiency and efficacy of conservation programs, above and beyond the advances offered by biophysical prioritizations alone, as well as facilitate more robust research of many social-ecological systems.

Micro-focalización para la Conservación Resumen Se necesitan acciones humanas diseminadas y un cambio en el comportamiento para lograr muchos objetivos de conservación. Que se logre esto a la escala y al ritmo requerido requerirá de la entrega eficiente de las campañas de participación. Las ganancias de la conservación serán mayores cuando los esfuerzos estén dirigidos hacia sitios con un alto valor (o necesidad) de conservación y estén personalizados para los actores más importantes. La reciente planeación estratégica de la conservación ha dependido principalmente de las evaluaciones espaciales de los atributos biofísicos, ignorando generalmente las dimensiones humanas. En otros ámbitos, los mercadólogos, las campañas políticas, así como otros, usan la micro-focalización - el análisis predictivo de datos masivos - para identificar a las personas con mayor probabilidad de responder positivamente a mensajes o intervenciones particulares. Los conservacionistas todavía no han capitalizado extensamente estas técnicas. Desarrollamos un modelo de tendencia para predecir el comportamiento de restauración entre 203,645 terratenientes privados en un área de estudio de 5,200,000 ha en la cuenca de la Bahía de Chesapeake (E.U.A.) y así investigar la eficiencia de la micro-focalización en el aumento de la conservación. Para aislar el valor adicional que puede ofrecer la micro-focalización más allá de la priorización geoespacial, analizamos un nuevo conjunto de alta resolución de datos sobre la cobertura del suelo y datos catastrales para identificar a los terratenientes privados de áreas ribereñas que necesitan restauración. Después de esto, desarrollamos y evaluamos el modelo de tendencia a la restauración basado en una base de datos de terratenientes que han realizado restauraciones en el pasado y aquellos que no (n = 4,978). La validación del modelo en una base de datos paralela (n = 4,989) mostró que los terratenientes con los puntajes más altos para la tendencia a la restauración (es decir, el decil superior) tenían el doble de probabilidad de haber realizado acciones de conservación que el terrateniente promedio (135%). Estos resultados muestran que las técnicas de micro-focalización pueden incrementar dramáticamente la eficiencia y la eficacia de los programas de conservación, más allá de los avances ofrecidos sólo por las priorizaciones biofísicas, así como facilitar la investigación más sólida sobre muchos sistemas socio-ecológicos.

Inyección Intraarticular Única de Ácido Hialurónico en la Artrosis de Rodilla: Estudio Multicéntrico Prospectivo Abierto (ART-ONE 75) mediante Comparación Post-Hoc con Placebo.

INTRODUCCIÓN: La viscosuplementación del líquido sinovial mediante la inyección intraarticular (IA) de ácido hialurónico (AH) es un tratamiento sintomático ampliamente utilizado en la artrosis de rodilla (AR). Además de los productos diseñados para realizar inyecciones múltiples (normalmente de 3 a 5 inyecciones, en intervalos de 1 semana), se presta especial atención a los productos de una única inyección, ya que ofrecen ventajas específicas, como son un menor número de visitas al médico y de intervenciones invasivas con sus riesgos asociados. Sin embargo, aún existen dudas sobre la eficacia de estas inyecciones únicas, en comparación con los regímenes de inyecciones múltiples. MÉTODOS: Se realizó un estudio multicéntrico, abierto, prospectivo, post-mercado (ART-ONE 75) con el producto de inyección única ARTHRUM 2,5% (3 ml, 75 mg AH), en 214 pacientes que sufrían de AR. Los pacientes fueron seguidos en D30, D60, D120 y D180 (días). El perfil promedio de los pacientes en el momento de la inclusión fue de 62,9 años, 56% mujeres, grados I-III de Kellgren-Lawrence (46% KL III), IMC de 27,2 kg/m2 y 4 años desde el diagnóstico de AR. Se realizó una comparación post-hoc con una inyección IA única de placebo (326 pacientes, agrupados de 3 estudios ECA), que proporcionaron un perfil de paciente similar. RESULTADOS: el criterio principal fue la variación desde el inicio de la puntuación de la escala WOMAC A (dolor, escala 0-100) en D60, que se redujo en 28,9 (17,4) para la población por intención de tratar (ITT, por sus siglas en inglés) (199 pacientes), 28,0 (17,8) para la población por protocolo (PP) en la inclusión (175 pacientes), y en 27,7 (16,8) para la población PP al finalizar (143 pacientes).Los criterios secundarios y accesorios incluyeron WOMAC A en otras ocasiones, WOMAC B (rigidez), WOMAC C (función), calidad de vida y discapacidad en cada momento de seguimiento. Todos los índices mejoraron significativamente y continuaron mejorando al final del estudio. La evaluación terapéutica en D180 mostró que más del 75% de los pacientes se encontraban satisfechos con la reducción del dolor, la mejora de la movilidad, y la reducción de analgésicos y AINE. El porcentaje de pacientes definidos como respondedores de OMERACT-OARSI fue superior al 86%, a partir de D60 y en adelante. La tolerancia general fue buena, sin que ocurriera ningún evento adverso grave. El resultado de la comparación post-hoc para la escala WOMAC A mostró un tamaño del efecto [IC 95%] desde TE = 0,33 [0,15; 0,51] en D60 a TE = 0,65 [0,45; 0,85] en D180 (p <0,001), frente a la inyección de placebo (solución salina), lo cual es un resultado clínicamente relevante a favor de ARTHRUM 2,5%. CONCLUSIÓN: El presente estudio confirma la eficacia clínica de una única inyección IA de 3 ml de solución de AH conteniendo 75 mg de AH nativo de alto PM (> 2 MDa).

Uroterapia y mindfulness en el tratamiento de niños con disfunción vesical e intestinal: protocolo para un ensayo clínico.

OBJETIVO: Presentar un protocolo para ensayo clínico controlado y aleatorizado que estudie los resultados de la asociación entre técnicas de uroterapia estándar y mindfulness en la adhesión al programa y reducción de síntomas de disfunción vesical e intestinal en escolares. MÉTODO: Presentación descriptiva del protocolo. RESULTADOS: El grupo de control deberá recibir orientaciones de medidas comportamentales gradualmente en visitas semanales, durante cuatro semanas. Tales medidas deberán contemplar: control de la ingesta de agua, intervalo de evacuación, ingestión de potenciales irritantes de la vejiga, y entrenamiento muscular del fondo pélvico. El grupo experimental deberá ser sometido al mismo protocolo, además de las técnicas de atención plena (mindfulness), previamente al inicio de cada consulta de uroterapia. CONCLUSIÓN: Se espera estimular la aplicación de este protocolo en diferentes escenarios y así evaluar la contribución de la práctica de atención plena en la adhesión al tratamiento y en la reducción de síntomas.

[A first step towards safer sedation and analgesia: A systematic evaluation of outcomes and level of sedation and analgesia in the mechanically ventilated critically ill patient]. / Un primer paso hacia una analgosedación más segura: evaluación sistemática de objetivos y grado de analgesia y sedación en el paciente crítico con ventilación mecánica.

INTRODUCTION: Safe analgesia and sedation strategies are necessary in order to avoid under or over sedation, as well as improving the comfort and safety of critical care patients. OBJECTIVES: To compare and contrast a multidisciplinary protocol of systematic evaluation and management of analgesia and sedation in a group of critical care patients on mechanical ventilation with the usual procedures. MATERIALS AND METHODS: A cohort study with contemporary series was conducted in a tertiary care medical-surgical ICU February to November during 2013 and 2014. The inclusion criteria were mechanical ventilation ≥ 24h and use of sedation by continuous infusion. Sedation was monitored using the Richmond agitation-sedation scale or bispectral index, and analgesia were measured using the numeric rating scale, or behavioural indicators of pain scale. The study variables included; mechanical ventilation time, weaning time, ventilation support time, artificial airway time, continuous sedative infusion time, daily dose and frequency of analgesic and sedative drug use, hospital stay, and ICU and hospital mortality, Richmond agitation-sedation scale, bispectral index, numeric rating scale, and behavioural indicators of pain scale measurements. Kruskal Wallis and Chi2, and a significance of p<.05 were used. RESULTS: The study included 153 admissions, 75 pre-intervention and 78 post-intervention, with a mean age of 55.7±13 years old, and 67% men. Both groups showed similarities in age, reason for admission, and APACHE. There were non-significant decreases in mechanical ventilation time 4 (1.4-9.2) and 3.2 (1.4-8.1) days, respectively; p= 0.7, continuous sedative infusion time 6 (3-11) and 5 (3-11) days; p= 0.9, length of hospital stay 29 (18-52); 25 (14-41) days; p= 0.1, ICU mortality (8 vs. 5%; p= 0.4), and hospital mortality (10.6 vs. 9.4%: p= 0.8). Daily doses of midazolam and remifentanil decreased 347 (227-479) mg/day; 261 (159-358) mg/day; p= 0.02 and 2175 (1427-3285) mcg/day; 1500 (715-2740) mcg/day; p= 0.02, respectively. There were increases in the use of remifentanil (32% vs. 51%; p= 0.01), dexmedetomidine (0 vs.6%; p= 0.02), dexketoprofen (60 vs. 76%; p= 0.03), and haloperidol (15 vs.28%; p= 0.04). The use of morphine decreased (71 vs. 54%; p= 0.03). There was an increase in the number of measurements and Richmond agitation-sedation scale scores 6 (3-17); 21 (9-39); p< 0.0001, behavioural indicators of pain scale 6 (3-18); 19(8-33); p< 0.001 and numeric rating scale 4 (2-6); 8 (6-17); p< 0.0001. CONCLUSIONS: The implementation of a multidisciplinary protocol of systematic evaluation of analgesia and sedation management achieved an improvement in monitoring and adequacy of dose to patient needs, leading to improved outcomes.

Implementation of a management protocol for massive bleeding reduces mortality in non-trauma patients: Results from a single centre audit.

OBJECTIVE: To audit the impact upon mortality of a massive bleeding management protocol (MBP) implemented in our center since 2007. DESIGN: A retrospective, single-center study was carried out. Patients transfused after MBP implementation (2007-2012, Group 2) were compared with a historical cohort (2005-2006, Group 1). BACKGROUND: Massive bleeding is associated to high mortality rates. Available MBPs are designed for trauma patients, whereas specific recommendations in the medical/surgical settings are scarce. PATIENTS: After excluding patients who died shortly (<6h) after MBP activation (n=20), a total of 304 were included in the data analysis (68% males, 87% surgical). INTERVENTIONS: Our MBP featured goal-directed transfusion with early use of adjuvant hemostatic medications. VARIABLES OF INTEREST: Primary endpoints were 24-h and 30-day mortality. Fresh frozen plasma-to-red blood cells (FFP:RBC) and platelet-to-RBC (PLT:RBC) transfusion ratios, time to first FFP unit and the proactive MBP triggering rate were secondary endpoints. RESULTS: After MBP implementation (Group 2; n=222), RBC use remained stable, whereas FFP and hemostatic agents increased, when compared with Group 1 (n=82). Increased FFP:RBC ratio (p=0.053) and earlier administration of FFP (p=0.001) were also observed, especially with proactive MBP triggering. Group 2 patients presented lower rates of 24-h (0.5% vs. 7.3%; p=0.002) and 30-day mortality (15.9% vs. 30.2%; p=0.018) - the greatest reduction corresponding to non-surgical patients. Logistic regression showed an independent protective effect of MBP implementation upon 30-day mortality (OR=0.3; 95% CI 0.15-0.61). CONCLUSIONS: These data suggest that the implementation of a goal-directed MBP for prompt and aggressive management of non-trauma, massive bleeding patients is associated to reduced 24-h and 30-day mortality rates.

Surgical protocol for confirmed or suspected cases of Ebola and other highly transmissible diseases.

Outbreaks of viral haemorrhagic fevers such as Ebola can lead to imported cases in Europe and America. The eventuality of surgery in the setting of Ebola Virus Disease (EVD) is low, but the Spanish Association of Surgeons elaborated a surgical protocol for EVD. INDICATION: Elective surgical procedures are not indicated. Emergency cases can be considered in: persons under investigation, possible cases and early confirmed cases. In some conditions usually treated by surgery a medical treatment can be tested. HOSPITALS AND TEAMS: All cases must be treated in high technology hospitals. These hospitals must be equipped with adequate means for healthcare provider's protection. All members of the healthcare team should practice thorough simulation prior to caring for a possible Ebola patient. SURGICAL PROTOCOL: This protocol is based on international guidelines on use of Personal Protective Equipment, protocols of other scientific societies, and specific recommendations for the operating room environment.

Effect of risk aversion on prioritizing conservation projects.

Conservation outcomes are uncertain. Agencies making decisions about what threat mitigation actions to take to save which species frequently face the dilemma of whether to invest in actions with high probability of success and guaranteed benefits or to choose projects with a greater risk of failure that might provide higher benefits if they succeed. The answer to this dilemma lies in the decision maker's aversion to risk--their unwillingness to accept uncertain outcomes. Little guidance exists on how risk preferences affect conservation investment priorities. Using a prioritization approach based on cost effectiveness, we compared 2 approaches: a conservative probability threshold approach that excludes investment in projects with a risk of management failure greater than a fixed level, and a variance-discounting heuristic used in economics that explicitly accounts for risk tolerance and the probabilities of management success and failure. We applied both approaches to prioritizing projects for 700 of New Zealand's threatened species across 8303 management actions. Both decision makers' risk tolerance and our choice of approach to dealing with risk preferences drove the prioritization solution (i.e., the species selected for management). Use of a probability threshold minimized uncertainty, but more expensive projects were selected than with variance discounting, which maximized expected benefits by selecting the management of species with higher extinction risk and higher conservation value. Explicitly incorporating risk preferences within the decision making process reduced the number of species expected to be safe from extinction because lower risk tolerance resulted in more species being excluded from management, but the approach allowed decision makers to choose a level of acceptable risk that fit with their ability to accommodate failure. We argue for transparency in risk tolerance and recommend that decision makers accept risk in an adaptive management framework to maximize benefits and avoid potential extinctions due to inefficient allocation of limited resources.

Clinical protocol for the topical use of a cream with nanoparticles and vitamin E to prevent radiodermatitis in patients with breast cancer]. / Aplicación tópica de crema con nanopartículas con vitamina E para prevenir radiodermatitis en cáncer de mama: protocolo de ensayo clínico.

Objetivo: Poco se conoce sobre la eficacia de productos para la prevención de radiodermatitis, que afecta al 90­95% de las mujeres con cáncer de mama. El uso de antioxidantes es promisorio, sin embargo, poco estudiado. Los autores desarrollaron un protocolo de ensayo clínico para evaluar el efecto potencial de la aplicación de crema con nanopartículas con vitamina E para prevenir radiodermatitis aguda en mujeres con cáncer de mama. Método: El protocolo sugiere que 108 mujeres adultas con cáncer de mama, que estén recibiendo radioterapia, sean incluidas en este ensayo clínico, controlado, aleatorizado y triple ciego, en un hospital oncológico. Se prevé la distribución de pacientes en tres grupos de 36 personas: el grupo A recibirá una crema con nanopartículas lipídicas con vitamina E, el grupo B obtendrá una crema sin nanopartículas ni vitamina E, y el grupo C usará una crema con nanopartículas sin vitamina E. Los resultados primarios evaluarán la incidencia, el grado y el tiempo de surgimiento de la radiodermatitis. Los resultados secundarios se centrarán en la calidad de vida, los síntomas y la temperatura local. Las pacientes serán evaluadas tres veces por semana, desde el inicio de la radioterapia hasta dos semanas después de la última sesión. El presente proyecto fue aprobado por el comité de ética en investigación de las instituciones involucradas.Objective: Little is known about the efficacy of products that aim to prevent radiodermatitis, which affects between 90­95% of women with breast cancer. The use of antioxidants is promising, however, there is a lack of evidence on their effectiveness. Here, the authors present a clinical trial protocol to evaluate the potential effects of applying a nanoparticle cream with vitamin E to prevent radiodermatitis in patients with breast cancer. Method: The protocol recommends that 108 women with breast cancer, who are receiving radiotherapy, be included in a triple-blinded, randomised, controlled study in an oncology hospital. Patients will be divided in three groups of 36 people each: group A will receive a cream with lipid nanoparticles and vitamin E, group B will obtain a cream without nanoparticles or vitamin E, and group C will receive a cream with nanoparticles without vitamin E. The primary endpoints will evaluate the incidence, degree and time of onset of radiodermatitis. The secondary endpoints will focus on quality of life, symptoms and local temperature. Patients will be assessed three times a week, from the start of their radiotherapy treatment to two weeks after the last session. This protocol was approved by the research ethics committee of the institutions involved.

[Improving the nutritional care of oncology patients - Validation of a multidisciplinary protocol in the Spanish clinical setting]. / Mejorando la atención nutricional del paciente oncológico: validación de un protocolo multidisciplinar en el entorno clínico español.

Introduction: Introduction: malnutrition is a very frequent problem in oncology patients and may have serious repercussions. Adequate nutritional management is cost-effective in terms of health and survival in this population, but it requires multidisciplinary coordination, specific training, and continuous follow-up. Objective: to validate the applicability and efficacy of a multidisciplinary nutritional support protocol in oncology patients. Methods: a multidisciplinary nutritional protocol was developed for oncology patients, with guidelines for screening and assessment of malnutrition, treatment, re-evaluation, and management of side effects, as well as guidance on supplementation and eating patterns. The protocol would be implemented in various clinical centers, collecting data through a structured questionnaire, registering variables before and after implementation. Results: the protocol and its impact were implemented and evaluated in 39 centers. An improvement in nutritional care was observed, evidenced by an earlier initiation of nutritional assessment and an increase in the number of patients receiving adequate care following the protocol implementation. Problems related to inadequate malnutrition coding in the centers, limited resources, and the need for greater interdepartmental collaboration were identified. Conclusions: the conduct of this study provides insights into how the implementation of a multidisciplinary nutritional support protocol can improve the nutritional care received by patients and informs about the main obstacles to adequate implementation.

Introducción: Introducción: la desnutrición es un problema muy frecuente en el paciente oncológico y puede tener graves repercusiones. Un manejo nutricional adecuado es coste-efectivo en términos de salud y supervivencia en esta población, pero requiere de coordinación multidisciplinar, formación específica y seguimiento continuo. Objetivo: validar la aplicabilidad y eficacia de un protocolo multidisciplinar de soporte nutricional en pacientes oncológicos. Métodos: se desarrolló un protocolo nutricional multidisciplinar para pacientes oncológicos, con pautas para el cribado y valoración de la desnutrición, el tratamiento, la reevaluación y la gestión de los efectos secundarios, además de orientaciones sobre suplementación y patrones de alimentación. Se implementaría el protocolo en diversos centros clínicos, recogiendo datos a través de un cuestionario estructurado, registrando variables antes y después de la implementación. Resultados: se implementó y se valoraron el protocolo y su impacto en 39 centros. Se observó una mejoría en la atención nutricional, evidenciada por un inicio más precoz de la valoración nutricional y un aumento en el número de pacientes que recibían atención adecuada tras la implementación del protocolo. Se identificaron problemas relacionados con una inadecuada codificación de la desnutrición en los centros, recursos limitados y la necesidad de mayor colaboración interdepartamental. Conclusiones: la realización de este estudio ofrece información de cómo la implementación de un protocolo multidisciplinar de soporte nutricional puede contribuir a mejorar la atención nutricional que reciben los pacientes e informa de cuáles son los principales obstáculos para una implementación adecuada.

Basic action protocol for the outpatient management of chronic heart failure of the Spanish Society of Internal Medicine.

Chronic heart failure (CHF) represents a challenge for the healthy system due to its high prevalence, high burden of morbidity and mortality, and high consumption of health resources. To address this problem, it is necessary to develop efficient management strategies that include both hospital care and outpatient care. The primary objective is to stabilize the patient and prevent decompensation, with the consequent improvement in quality of life, reduction in hospital admissions and emergency department care, and, consequently, reduction in healthcare costs. In this context, the heart failure and atrial fibrilation working group of the Spanish Society of Internal Medicine has developed a protocol for the management of outpatient CHF, that addresses, from the perspective of Internal medicine, all the problems suffered by the patient with CHF. This protocol aims to optimize pharmacological treatment, control cardiovascular risk factors and various comorbidities, educate the patient and their environment about the disease, promote adherence to treatment and stablish follow-up adapted to their condition.

DPYD genotyping and 5-fluoropyrimidine toxicity: An overview of systematic reviews protocol. / [Artículo traducido] Genotipado del gen DPYD y toxicidad de las 5-fluoropirimidinas: protocolo de un resumen de revisiones sistemáticas.

INTRODUCTION: The increased risk of severe and life-threatening toxicity in patients with dihydropyridine dehydrogenase deficiency, under treatment with fluoropyrimidines, has been widely studied. An up-to-date overview of systematic reviews summarizing existing literature can add value by highlighting most relevant information and supports decision-making regarding treatment in dihydropyridine dehydrogenase deficient patients. The main objective of this overview is to identify published systematic reviews on the association between germline variations in the DPYD gene and fluoropyrimidine toxicity. METHODS AND ANALYSIS: This protocol was developed following the Preferred Reported Items for Systematic Review and Meta-analysis Protocols (PRISMA-P) checklist, and the overview of systematic reviews will be reported in accordance with the PRISMA statement. PubMed, Embase, Scopus and the Cochrane Library will be searched from inception to 2023. Systematic reviews irrespective of study designs that analyze the association between germline variations in the DPYD and fluoropyrimidine toxicity will be considered. Methodological quality will be assessed using AMSTAR2 checklist (Measurement Tool to Assess Systematic Reviews 2). Two independent investigators will perform the study selection, quality assessment and data collection. Discrepancies will be solved by a third investigator.