Gut microbiome as a key monitoring indicator for reintroductions of captive animals.

Reintroduction programs seek to restore degraded populations and reverse biodiversity loss. To examine the hypothesis that gut symbionts could be used as an indicator of reintroduction success, we performed intensive metagenomic monitoring over 10 years to characterize the ecological succession and adaptive evolution of the gut symbionts of captive giant pandas reintroduced to the wild. We collected 63 fecal samples from 3 reintroduced individuals and 22 from 9 wild individuals and used 96 publicly available samples from another 3 captive individuals. By microbial composition analysis, we identified 3 community clusters of the gut microbiome (here termed enterotypes) with interenterotype succession that was closely related to the reintroduction process. Each of the 3 enterotypes was identified based on significant variation in the levels of 1 of 3 genera: Clostridium, Pseudomonas, and Escherichia. The enterotype of captive pandas was Escherichia. This enterotype was gradually replaced by the Clostridium enterotype during the wild-training process, which in turn was replaced by the Pseudomonas enterotype that resembled the enterotype of wild pandas, an indicator of conversion to wildness and a successful reintroduction. We also isolated 1 strain of Pseudomonas protegens from the wild enterotype, a previously reported free-living microbe, and found that its within-host evolution contributed to host dietary adaptation in the wild. Monitoring gut microbial structure provides a novel, noninvasive tool that can be used as an indicator of successful reintroduction of a captive individual to the wild.

Microbiomas intestinales como indicadores clave de monitoreo para la reintroducción de animales cautivos Resumen Los programas de reintroducción buscan restaurar las poblaciones degradadas y revertir la pérdida de la biodiversidad. Realizamos un monitoreo metagenómico intensivo durante más de diez años para caracterizar la sucesión ecológica y la evolución adaptativa de los simbiontes intestinales de pandas reintroducidos en la naturaleza y así comprobar la hipótesis de que estos simbiontes pueden usarse como indicadores de una reintroducción exitosa. Recolectamos 63 muestras fecales de tres individuos reintroducidos y 22 de nueve individuos silvestres y usamos 96 muestras disponibles al público de otros tres individuos cautivos. Mediante el análisis de la composición microbiana identificamos tres grupos comunitarios del microbioma intestinal (denominados como enterotipos) con una sucesión entre enterotipos relacionada cercanamente al proceso de reintroducción. Identificamos cada uno de los tres enterotipos con base en la variación significativa en los niveles de uno de los tres géneros: Clostridium, Pseudomonas, y Escherichia. El enterotipo de los pandas cautivos fue Escherichia. A este enterotipo lo reemplazó gradualmente el enterotipo de Clostridium durante el proceso de adaptación a la naturaleza, y a su vez fue reemplazado por el enterotipo de Pseudomonas similar al de los pandas silvestres, un indicador de la conversión a la vida silvestre y de una reintroducción exitosa. También aislamos una cepa de Pseudomonas protegens del enterotipo silvestre, un microbio reportado previamente como de vida libre, y descubrimos que su evolución dentro del hospedero contribuyó a que este se adaptara a la naturaleza de la dieta. El monitoreo de la estructura microbiana intestinal proporciona una herramienta novedosa y no invasiva que puede usarse como indicador del éxito de la reintroducción de un individuo cautivo a la naturaleza.

Indicators to monitor the status of the tree of life.

Following the failure to fully achieve any of the 20 Aichi biodiversity targets, the future of biodiversity rests in the balance. The Convention on Biological Diversity's Kunming-Montreal Global Biodiversity Framework (GBF) presents the opportunity to preserve nature's contributions to people (NCPs) for current and future generations by conserving biodiversity and averting extinctions. There is a need to safeguard the tree of life-the unique and shared evolutionary history of life on Earth-to maintain the benefits it bestows into the future. Two indicators have been adopted within the GBF to monitor progress toward safeguarding the tree of life: the phylogenetic diversity (PD) indicator and the evolutionarily distinct and globally endangered (EDGE) index. We applied both to the world's mammals, birds, and cycads to show their utility at the global and national scale. The PD indicator can be used to monitor the overall conservation status of large parts of the evolutionary tree of life, a measure of biodiversity's capacity to maintain NCPs for future generations. The EDGE index is used to monitor the performance of efforts to conserve the most distinctive species. The risk to PD of birds, cycads, and mammals increased, and mammals exhibited the greatest relative increase in threatened PD over time. These trends appeared robust to the choice of extinction risk weighting. EDGE species had predominantly worsening extinction risk. A greater proportion of EDGE mammals (12%) had increased extinction risk compared with threatened mammals in general (7%). By strengthening commitments to safeguarding the tree of life, biodiversity loss can be reduced and thus nature's capacity to provide benefits to humanity now and in the future can be preserved.

Indicadores para monitorear el estado del árbol de la vida Resumen El futuro de la biodiversidad peligra tras no haberse logrado ninguno de los 20 Objetivos de Aichi. El Marco Global de Biodiversidad (GBF) de Kunming-Montreal del Convenio sobre la Diversidad Biológica (CDB) representa la oportunidad de preservar las contribuciones de la naturaleza a las personas (PNC) para las generaciones actuales y futuras mediante la conservación de la biodiversidad y la prevención de las extinciones. Es necesario salvaguardar el árbol de la vida -la historia evolutiva única y compartida de la vida en la Tierra- para mantener en el futuro los beneficios que aporta. En el GBF se han adoptado dos indicadores para supervisar los avances hacia el cuidado del árbol de la vida: el indicador de diversidad filogenética y el índice de especies evolutivamente distintas y globalmente amenazadas (EDGE). Aplicamos ambos a los mamíferos, las aves y las cícadas del mundo para demostrar su utilidad a escala mundial y nacional. El indicador de diversidad filogenética puede utilizarse para supervisar el estado de conservación general de grandes partes del árbol evolutivo de la vida, una medida de la capacidad de la biodiversidad para mantener los PNC para las generaciones futuras. El índice EDGE se utiliza para supervisar el rendimiento de los esfuerzos por conservar las especies más distintivas. El riesgo para la diversidad filogenética de aves, cícadas y mamíferos aumentó, y los mamíferos mostraron el mayor aumento relativo de la diversidad filogenética amenazada a lo largo del tiempo. Estas tendencias parecieron sólidas a la hora de elegir la valoración del riesgo de extinción. Las especies EDGE tuvieron un riesgo de extinción predominante cada vez peor. Una mayor proporción de mamíferos EDGE (12%) presentó un riesgo de extinción creciente en comparación con los mamíferos amenazados en general (7%). Si se refuerza el compromiso de salvaguardar el árbol de la vida, se puede reducir la pérdida de biodiversidad y preservar así la capacidad de la naturaleza para proporcionar beneficios a la humanidad ahora y en el futuro.

Selection of Quality Indicators for the Certification of Psoriasis Units: The CUDERMA Project Delphi Consensus Study. / Proyecto CUDERMA: Consenso Delphi de los indicadores de calidad para la certificación de las unidades de dermatología de atención en psoriasis.

Defining quality indicators is a key strategy for ensuring the quality and standardization of health care. The CUDERMA project, an initiative of the Spanish Academy of Dermatology and Venerology (AEDV), was undertaken to define quality indicators for the certification of specialized units in dermatology; the first 2 areas selected were psoriasis and dermato-oncology. The aim of this study was to reach a consensus on what should be assessed by the indicators used to certify psoriasis units. The structured process used to do this comprised a literature review to identify potential indicators, the selection of an initial set of indicators to be evaluated by a multidisciplinary group of experts and, finally, a Delphi consensus study. A panel of 39 dermatologists evaluated the selected indicators and classified them as either "essential" or "of excellence". Consensus was finally reached on 67 indicators, which will be standardized and used to develop the certification standard for psoriasis units.

Selection of Quality Indicators for the Certification of Dermato-Oncology Units: The CUDERMA Project Delphi Consensus Study. / Proyecto CUDERMA: Consenso Delphi de los indicadores de calidad para la certificación de las unidades de dermatología de atención en dermato-oncología.

Quality indicators are crucial for standardizing and guaranteeing the quality of health care practices. The Spanish Academy of Dermatology and Venereology (AEDV) launched the CUDERMA Project to define quality indicators for the certification of specialized units in dermatology; the first 2areas selected were psoriasis and dermato-oncology. The aim of this study was to achieve consensus on what should be evaluated by these indicators using a structured process comprising a literature review and selection of an initial list of indicators to be evaluated in a Delphi consensus study following review by a multidisciplinary group of experts. The selected indicators were evaluated by a panel of 28 dermatologists and classified as either «essential¼ or «of excellence¼. The panel agreed on 84 indicators, which will be standardized and used to develop the certification standard for dermato-oncology units.

Using decision science to evaluate global biodiversity indices.

Global biodiversity indices are used to measure environmental change and progress toward conservation goals, yet few indices have been evaluated comprehensively for their capacity to detect trends of interest, such as declines in threatened species or ecosystem function. Using a structured approach based on decision science, we qualitatively evaluated 9 indices commonly used to track biodiversity at global and regional scales against 5 criteria relating to objectives, design, behavior, incorporation of uncertainty, and constraints (e.g., costs and data availability). Evaluation was based on reference literature for indices available at the time of assessment. We identified 4 key gaps in indices assessed: pathways to achieving goals (means objectives) were not always clear or relevant to desired outcomes (fundamental objectives); index testing and understanding of expected behavior was often lacking; uncertainty was seldom acknowledged or accounted for; and costs of implementation were seldom considered. These gaps may render indices inadequate in certain decision-making contexts and are problematic for indices linked with biodiversity targets and sustainability goals. Ensuring that index objectives are clear and their design is underpinned by a model of relevant processes are crucial in addressing the gaps identified by our assessment. Uptake and productive use of indices will be improved if index performance is tested rigorously and assumptions and uncertainties are clearly communicated to end users. This will increase index accuracy and value in tracking biodiversity change and supporting national and global policy decisions, such as the post-2020 global biodiversity framework of the Convention on Biological Diversity.

Uso de las Ciencias de la Decisión para Evaluar los Índices Globales de Biodiversidad Resumen Los índices globales de biodiversidad se usan para medir el cambio ambiental y el avance hacia los objetivos de conservación, aunque pocos han sido evaluados completamente en cuanto a su capacidad para detectar las tendencias de interés como las declinaciones de especies amenazadas o la función del ecosistema. Evaluamos cualitativamente nueve índices de uso común para dar seguimiento a la biodiversidad a escala global y regional contra cinco criterios relacionados con los objetivos, diseño, comportamiento, incorporación de la incertidumbre y restricciones (p. ej.: costos y disponibilidad de datos) mediante una estrategia estructurada basada en las ciencias de la decisión. La evaluación se basó en la literatura de referencia para los índices disponibles al momento del análisis. Identificamos cuatro vacíos importantes en los índices estudiados: las vías para lograr los objetivos (objetivos medios) no fueron siempre claras o relevantes para los resultados deseados (objetivos fundamentales); el análisis del índice y el entendimiento del comportamiento esperado casi siempre fueron escasos; pocas veces se consideró o explicó la incertidumbre; y casi nunca se consideraron los costos de la implementación. Estos vacíos pueden hacer que los índices sean inadecuados en ciertos contextos de toma de decisiones y son problemáticos para los índices vinculados a los objetivos de biodiversidad y las metas de sustentabilidad. Es de suma importancia asegurarse que los objetivos del índice sean claros y que su diseño esté respaldado por un modelo de procesos relevantes para tratar con los vacíos identificados en nuestro estudio. La aceptación y el uso productivo de los índices mejorarán si el desempeño del índice es evaluado rigurosamente y las suposiciones e incertidumbres se les comunican claramente a los usuarios finales. Lo anterior aumentará la precisión y valor del índice en el seguimiento de los cambios de la biodiversidad y en el apoyo a las decisiones políticas nacionales y mundiales, como el marco de trabajo para la biodiversidad post-2020 establecido por la Convención sobre la Diversidad Biológica.

The species awareness index as a conservation culturomics metric for public biodiversity awareness.

Although threats to global biodiversity are well known, slowing current rates of biodiversity loss remains a challenge. The Aichi targets set out 20 goals on which the international community should act to alleviate biodiversity decline, 1 of which (Target 1) aims to raise public awareness of the importance of biodiversity. Although conventional indicators for Target 1 are of low spatial and temporal coverage, conservation culturomics metrics show how biodiversity awareness can be quantified at the global scale. Following methods used for the Living Planet Index, we devised a species awareness index (SAI) to measure change in species awareness based on Wikipedia views. We calculated this index at the page level for 41,197 species listed by the International Union for Conservation of Nature (IUCN) across 10 Wikipedia languages and >2 billion views from 1 July 2015 to 30 March 2020. Bootstrapped indices for the page-level SAI showed that overall awareness of biodiversity increased marginally over time, although there were differences among taxonomic classes and languages. Among taxonomic classes, overall awareness increased fastest for reptiles and slowest for amphibians. Among languages, overall species awareness increased fastest for Japanese and slowest for Chinese and German users. Although awareness of species as a whole increased and was significantly higher for traded species, from January 2016 through January 2020, change in awareness appeared not to be strongly related to whether the species is traded or is a pollinator. As a data source for public biodiversity awareness, the SAI could be integrated into the Conservation International Biodiversity Engagement Indicator.

El Índice de Sensibilización de Especie como Medida de Culturomia de la Conservación para la Sensibilización Pública por la Biodiversidad Resumen Aunque las amenazas a la biodiversidad mundial son bien conocidas, reducir las tasas actuales de pérdida de la biodiversidad todavía es un desafío. Los objetivos de Aichi establecieron 20 metas para las cuales debe actuar la comunidad internacional para aliviar la declinación de la biodiversidad. Una de estas metas (Objetivo 1) busca sensibilizar al público sobre la importancia de la biodiversidad. Aunque los indicadores convencionales del Objetivo 1 tienen una baja cobertura espacial y temporal, las medidas de culturomia para la conservación muestran cómo la sensibilización por la biodiversidad puede cuantificarse a escala global. Seguimos los métodos utilizados para el Índice del Planeta Viviente para diseñar un índice de sensibilización de especie (ISE) para medir el cambio en la sensibilización por una especie con base en las vistas en Wikipedia. Calculamos este índice a nivel de página para 41,197 especies incluidas en las listas de la Unión Internacional para la Conservación de la Naturaleza (UICN) en diez diferentes idiomas en Wikipedia y más de 2 mil millones de vistas entre el 1 de julio de 2015 y el 30 de marzo de 2020. Los índices de arranque para el ISE a nivel de página mostraron que la sensibilización general por la biodiversidad incrementó ligeramente con el tiempo, aunque hubo diferencia entre las clasificaciones taxonómicas y los idiomas. Entre las clasificaciones taxonómicas, la sensibilización general incrementó más rápido para los reptiles y más lento para los anfibios. Entre los idiomas, la sensibilización general por especie incrementó más rápido para los usuarios del japonés y más lento para los usuarios del chino y el alemán. Aunque la sensibilización por las especies en su totalidad incrementó y fue significativamente más alta para las especies comercializadas, entre enero de 2016 y enero de 2020 el cambio en la sensibilización pareció no estar relacionado fuertemente con si la especie es un polinizador o es comercializada. Como fuente de información para la sensibilización pública por la biodiversidad, el ISE podría ser integrado dentro del Indicador de Participación Internacional para la Conservación de la Biodiversidad.

A framework to measure the wildness of managed large vertebrate populations.

As landscapes continue to fall under human influence through habitat loss and fragmentation, fencing is increasingly being used to mitigate anthropogenic threats and enhance the commercial value of wildlife. Subsequent intensification of management potentially erodes wildness by disembodying populations from landscape-level processes, thereby disconnecting species from natural selection. Tools are needed to measure the degree to which populations of large vertebrate species in formally protected and privately owned wildlife areas are self-sustaining and free to adapt. We devised a framework to measure such wildness based on 6 attributes relating to the evolutionary and ecological dynamics of vertebrates (space, disease and parasite resistance, exposure to predation, exposure to limitations and fluctuations of food and water supply, and reproduction). For each attribute, we set empirical, species-specific thresholds between 5 wildness states based on quantifiable management interventions. We analysed data from 205 private wildlife properties with management objectives spanning ecotourism to consumptive utilization to test the framework on 6 herbivore species representing a range of conservation statuses and commercial values. Wildness scores among species differed significantly, and the proportion of populations identified as wild ranged from 12% to 84%, which indicates the tool detected site-scale differences both among populations of different species and populations of the same species under different management regimes. By quantifying wildness, this framework provides practitioners with standardized measurement units that link biodiversity with the sustainable use of wildlife. Applications include informing species management plans at local scales; standardizing the inclusion of managed populations in red-list assessments; and providing a platform for certification and regulation of wildlife-based economies. Applying this framework may help embed wildness as a normative value in policy and mitigate the shifting baseline of what it means to truly conserve a species.

Un Marco de Trabajo para Medir el Estado Salvaje de Poblaciones de Vertebrados Mayores bajo Manejo Resumen Conforme los paisajes siguen cayendo bajo la influencia del humano por causa de la pérdida del hábitat y la fragmentación, cada vez se usa más el encercado para mitigar las amenazas antropogénicas o incrementar el valor comercial de la fauna. La intensificación subsecuente del manejo tiene el potencial para erosionar el estado salvaje al desincorporar a las poblaciones de los procesos a nivel de paisaje, desconectando así a las especies del proceso de selección natural. Por lo tanto, se necesitan herramientas para medir el grado al cual las poblaciones de especies de vertebrados mayores dentro de áreas de fauna protegidas y privadas son autosostenibles y libres de adaptarse. Diseñamos un marco de trabajo para medir dicho estado salvaje con base en seis atributos relacionados con las dinámicas evolutivas y ecológicas de los vertebrados (espacio, resistencia a las enfermedades y a los parásitos, exposición a la depredación, exposición a las limitaciones y fluctuaciones en las reservas de agua y alimentos, y reproducción). Para cada atributo, establecimos umbrales empíricos y específicos por especie entre cinco estados salvajes basados en las intervenciones de manejo cuantificables. Usamos datos de 205 propiedades privadas de fauna con objetivos de manejo que abarcan desde el ecoturismo hasta el uso para consumo para probar el marco de trabajo en seis especies de herbívoros con una gama de estados de conservación y valores comerciales. Los puntajes de estado salvaje entre las especies difirieron significativamente y la proporción de poblaciones identificadas como salvajes osciló del 12% al 84%, lo que indica que la herramienta detectó diferencias a escala de sitio entre las poblaciones de diferentes especies y las poblaciones de la misma especie bajo diferentes regímenes de manejo. Si cuantificamos el estado salvaje, este marco de trabajo les proporciona a los practicantes las unidades de medida estandarizadas que vinculan a la biodiversidad con el uso sostenible de la fauna. Las aplicaciones de este marco de trabajo incluyen informar a los planes de manejo de las especies a escalas locales; estandarizar la inclusión de las poblaciones manejadas en las evaluaciones de listas rojas; y proporcionar una plataforma para la certificación y regulación de las economías basadas en la fauna. La aplicación de este marco de trabajo puede ayudar a insertar a la fauna como un valor normativo dentro de la política y a mitigar la línea base cambiante de lo que significa conservar verdaderamente a una especie.

Estimating the footprint of pollution on coral reefs with models of species turnover.

Ecological communities typically change along gradients of human impact, although it is difficult to estimate the footprint of impacts for diffuse threats such as pollution. We developed a joint model (i.e., one that includes multiple species and their interactions with each other and environmental covariates) of benthic habitats on lagoonal coral reefs and used it to infer change in benthic composition along a gradient of distance from logging operations. The model estimated both changes in abundances of benthic groups and their compositional turnover, a type of beta diversity. We used the model to predict the footprint of turbidity impacts from past and recent logging. Benthic communities far from logging were dominated by branching corals, whereas communities close to logging had higher cover of dead coral, massive corals, and soft sediment. Recent impacts were predicted to be small relative to the extensive impacts of past logging because recent logging has occurred far from lagoonal reefs. Our model can be used more generally to estimate the footprint of human impacts on ecosystems and evaluate the benefits of conservation actions for ecosystems.

Development of quality indicators to evaluate antibiotic treatment of patients with community-acquired pneumonia in Indonesia.

OBJECTIVE: To develop an instrument for evaluating the quality of antibiotic management of patients with community-acquired pneumonia (CAP) applicable in a middle-income developing country. METHOD: A previous study and Indonesian guidelines were reviewed to derive potential quality of care indicators (QIs). An expert panel performed a two-round Delphi consensus procedure on the QI's relevance to patient recovery, reduction of antimicrobial resistance and cost containment. Applicability in practice, including reliability, feasibility and opportunity for improvement, was determined in a data set of 128 patients hospitalised with CAP in Semarang, Indonesia. RESULTS: Fifteen QIs were selected by the consensus procedure. Five QIs did not pass feasibility criteria, because of inappropriate documentation, inefficient laboratory services or patient factors. Three QIs provided minor opportunity for improvement. Two QIs contradicted each other; one of these was considered not valid and excluded. A final set of six QIs was defined for use in the Indonesian setting. CONCLUSION: Using the Delphi method, we defined a list of QIs for assessing the quality of care, in particular antibiotic treatment, for CAP in Indonesia. For further improvement, a modified Delphi method that includes discussion, a sound medical documentation system, improvement of microbiology laboratory services, and multi-center applicability tests are needed to develop a valid and applicable QI list for the Indonesian setting.

Using community-level metrics to monitor the effects of marine protected areas on biodiversity.

Marine protected areas (MPAs) are used to protect species, communities, and their associated habitats, among other goals. Measuring MPA efficacy can be challenging, however, particularly when considering responses at the community level. We gathered 36 abundance and 14 biomass data sets on fish assemblages and used meta-analysis to evaluate the ability of 22 distinct community diversity metrics to detect differences in community structure between MPAs and nearby control sites. We also considered the effects of 6 covariates-MPA size and age, MPA size and age interaction, latitude, total species richness, and level of protection-on each metric. Some common metrics, such as species richness and Shannon diversity, did not differ consistently between MPA and control sites, whereas other metrics, such as total abundance and biomass, were consistently different across studies. Metric responses derived from the biomass data sets were more consistent than those based on the abundance data sets, suggesting that community-level biomass differs more predictably than abundance between MPA and control sites. Covariate analyses indicated that level of protection, latitude, MPA size, and the interaction between MPA size and age affect metric performance. These results highlight a handful of metrics, several of which are little known, that could be used to meet the increasing demand for community-level indicators of MPA effectiveness.

Selection of multiple umbrella species for functional and taxonomic diversity to represent urban biodiversity.

Surrogates, such as umbrella species, are commonly used to reduce the complexity of quantifying biodiversity for conservation purposes. The presence of umbrella species is often indicative of high taxonomic diversity; however, functional diversity is now recognized as an important metric for biodiversity and thus should be considered when choosing umbrella species. We identified umbrella species associated with high taxonomic and functional biodiversity in urban areas in Switzerland. We analyzed 39,752 individuals of 574 animal species from 96 study plots and 1397 presences of 262 plant species from 58 plots. Thirty-one biodiversity measures of 7 taxonomic groups (plants, spiders, bees, ground beetles, lady bugs, weevils and birds) were included in within- and across-taxa analyses. Sixteen measures were taxonomical (species richness and species diversity), whereas 15 were functional (species traits including mobility, resource use, and reproduction). We used indicator value analysis to identify umbrella species associated with single or multiple biodiversity measures. Many umbrella species were indicators of high biodiversity within their own taxonomic group (from 33.3% in weevils to 93.8% in birds), to a lesser extent they were indicators across taxa. Principal component analysis revealed that umbrella species for multiple measures of biodiversity represented different aspects of biodiversity, especially with respect to measures of taxonomic and functional diversity. Thus, even umbrella species for multiple measures of biodiversity were complementary in the biodiversity aspects they represented. Thus, the choice of umbrella species based solely on taxonomic diversity is questionable and may not represent biodiversity comprehensively. Our results suggest that, depending on conservation priorities, managers should choose multiple and complementary umbrella species to assess the state of biodiversity.

Determining decision thresholds and evaluating indicators when conservation status is measured as a continuum.

Categorization of the status of populations, species, and ecosystems underpins most conservation activities. Status is often based on how a system's current indicator value (e.g., change in abundance) relates to some threshold of conservation concern. Receiver operating characteristic (ROC) curves can be used to quantify the statistical reliability of indicators of conservation status and evaluate trade-offs between correct (true positive) and incorrect (false positive) classifications across a range of decision thresholds. However, ROC curves assume a discrete, binary relationship between an indicator and the conservation status it is meant to track, which is a simplification of the more realistic continuum of conservation status, and may limit the applicability of ROC curves in conservation science. We describe a modified ROC curve that treats conservation status as a continuum rather than a discrete state. We explored the influence of this continuum and typical sources of variation in abundance that can lead to classification errors (i.e., random variation and measurement error) on the true and false positive rates corresponding to varying decision thresholds and the reliability of change in abundance as an indicator of conservation status, respectively. We applied our modified ROC approach to an indicator of endangerment in Pacific salmon (Oncorhynchus nerka) (i.e., percent decline in geometric mean abundance) and an indicator of marine ecosystem structure and function (i.e., detritivore biomass). Failure to treat conservation status as a continuum when choosing thresholds for indicators resulted in the misidentification of trade-offs between true and false positive rates and the overestimation of an indicator's reliability. We argue for treating conservation status as a continuum when ROC curves are used to evaluate decision thresholds in indicators for the assessment of conservation status.

[Synthetic indicator of compliance with standards for Quality Units of health centers and multicenter prospective pilot study]. / Indicador sintético de cumplimiento de estándares para Unidades de Calidad de centros sanitarios y estudio de pilotaje prospectivo multicéntrico.

BACKGROUND AND OBJECTIVE: In Spain, Quality Units play a key and unique role in advising healthcare centers on the methodology of healthcare quality. The objectives of the study were to develop computer algorithms to obtain a synthetic indicator of standard compliance for Quality Units and to pilot its functioning in these units. MATERIALS AND METHODS: The Excel program was used to establish evaluation algorithms, and quantitatively interrelate and weight various categories of standards, as a computer evaluation tool, to build a continuous improvement cycle system, and offer a global synthetic indicator of compliance. The tool was tested in a prospective multicenter pilot study, in which coordinators of Quality Units from different health centers and care settings participated, to evaluate the usefulness of the tool and compliance with the standards, in addition to analyzing the content validity of each standard. RESULTS: The formulas for the structured computer algorithms were developed, consecutively, in a «PLAN-DO-CHECK-ACT¼ improvement cycle for the 9 categories of standards, resulting in a single synthetic indicator of compliance. Twenty-one Quality Units participated in the piloting. The overall average compliance rate for the synthetic indicator was 55.63% with differences between centers (P=.002) and between categories (P<.0001), but not by autonomous communities (P=.86) or by areas (P=.97). Content validity was ensured through the variable of «understanding¼ of the standards (P<.001), and through their «justification¼ with documentary evidence (P<.001). CONCLUSIONS: The computer tool with the synthetic indicator have allowed for the evaluation of standard compliance in Quality Units of healthcare centers.

Textbook outcome in gastric surgery, what implications does it have on survival?

INTRODUCTION: The textbook outcome (TO) is a multidimensional measure to assess the quality of healthcare practice. This is reflected as the "ideal" surgical result, attending to a series of indicators or established reference points that are adapted depending on the surgical disease that we want to analyze. There are few references and series published about TO, all of them very recent. OBJECTIVE: We present a series of gastric surgery from the TO perspective and we analyze its impact on survival. METHOD: Retrospective observational study of all gastric neoplasms operated on in our center. PERIOD: January 2015-December 2020. The criteria for TO were: margins R0, >15 lymph nodes in the histological study, no Clavien-Dindo complications > IIIa, hospital stay < 21 days, no mortality or readmission in the 30 postoperative days. A comparative analysis was performed between the TO group versus the non-TO group. RESULTS: 91 patients were operated on. We reached the TO in 34.1% of the patients. The variable >15 lymph nodes was the one that most affected to achieve a TO. When performing the survival analysis, we obtained that the group in which the TO was obtained had a greater survival (p < 0.008). CONCLUSION: In our series, obtaining the TO has an impact on survival which 34,1% of degree of compliance.

Indicators of quality use of medicines in South-East Asian countries: a systematic review.

OBJECTIVES: To identify indicators of quality use of medicines used in South-East Asian region. METHODS: A systematic review was conducted searching MEDLINE, Embase and The International Network for Rational Use of Drugs (INRUD) and The World Health Organization (WHO) website. Original studies or reports carried out in the South-East Asian region, explicitly using indicators to measure quality use of medicines, and published between January 2000 and July 2011 were included. RESULTS: A total of 17 studies conducted in 7 of 11 countries in South-East Asia were included. WHO indicators focusing on general medication use in health facilities were most widely used (10 studies). Twelve studies used non-WHO indicators for measuring quality use of medicines in clinical areas (geriatrics and obstetrics) or specific diseases, such as diarrhoea and pneumonia. In five studies, WHO indicators were used along with non-WHO indicators. There was little information available about validity, reliability and feasibility of the non-WHO indicators. The majority of indicators measured process rather than structure or outcome. There were very few indicators addressing non-communicable diseases. CONCLUSIONS: A limited number of studies have been published explicitly using indicators of quality use of medicines across South-East Asia. Importantly, existing indicators need to be complemented with valid, reliable and feasible indicators related to non-communicable diseases, particularly those with a high financial burden to meet the current medical challenges in the region.

[Process of medical nutrition therapy]. / Proceso de tratamiento médico nutricional.

Introduction: Medical nutrition therapy is a very useful tool in maintaining and recovering the health of patients with disease-related malnutrition, although its implementation can be complex and is not without risks. Quality processes are understood as sets of activities that are related or interact to transform input elements into results. From the SENPE Management Work Group we present the process of medical nutrition therapy (PMNT), which aims to facilitate the management of clinical nutrition of a multidisciplinary nutrition support team in a hospital setting. This paper describes the seven sub-processes PMNT is comprised of, in addition to a previous nutritional screening sub-process. Each sub-process is divided into a first section with a technical sheet detailing its general aspects, while a second section proposes key objectives, quality indicators, and standards for their evaluation. .

Introducción: El tratamiento médico nutricional es de gran utilidad en el mantenimiento y recuperación de la salud de los pacientes con desnutrición relacionada con la enfermedad, aunque su implementación puede ser compleja y no está exenta de riesgos. Se entiende por proceso aquel conjunto de actividades que están mutuamente relacionadas o que interactúan para transformar elementos de entrada en resultados. Desde el Grupo de Trabajo de Gestión de la SENPE presentamos el Proceso de Tratamiento Médico Nutricional (PTMN), que tiene por objetivo facilitar la gestión de la nutrición clínica, pensando en un equipo de soporte nutricional multidisciplinar de atención al paciente hospitalizado. En este documento se describen los siete subprocesos que constituyen el PTMN, además de un subproceso previo de cribado nutricional. Cada subproceso se divide en una primera sección con una ficha técnica en la que se detallan sus aspectos generales, mientras que en la segunda sección se proponen objetivos clave, indicadores de calidad y estándares para su evaluación.

[Recommendations on the use of telemedicine as applied to nutritional pathology]. / Recomendaciones sobre el uso de la telemedicina aplicada a la patología nutricional.

Introduction: Introduction: telemedicine can improve the standards of clinical care and use of resources. The COVID-19 pandemic has required its implementation in routine practice. For this reason, a group of endocrinologists from Valencia, Murcia and the Balearic Islands created a committee for its development. Objectives: to establish recommendations in order to improve the quality of consultation in nutritional disorders, and to create indicators for its management. Methodology: the Delphi methodology was followed with the participation of 13 professionals in order to reach the widest consensus. A 16-item questionnaire was distributed within 3 rounds: in the first round, the degree of consensus was established; in the second round, the participants responded to the posed questions after having access to the first-round results. Agreement was considered if ≥ 75 % participants reached consensus, while strong agreement was considered if consensus was reached by ≥ 90 %. In addition, quality indicators were established. In a third round, these indicators were developed. Results: after 3 rounds and a revision 5 recommendations with strong agreement were established based on organizational aspects. Regarding administrative aspects, 6 recommendations with strong agreement were established while 4 recommendations reached the level of agreement. Eight quality indicators were selected and developed. Conclusions: this document compiles a list of recommendations about needs and requirements to be taken into account for a quality telematic consultation in patients with nutritional disorders. In addition, health care quality indicators have been created and developed.

Introducción: Introducción: la telemedicina puede mejorar la calidad asistencial y el uso de recursos. La pandemia de COVID-19 ha hecho necesaria su implementación en la práctica habitual. Por ello, un grupo de endocrinólogos de la Comunidad Valenciana, Murcia y Baleares creó un comité para su desarrollo. Objetivos: establecer unas recomendaciones para mejorar la calidad de la consulta de patología nutricional y diseñar unos indicadores para su gestión. Metodología: se siguió la metodología Delphi con participación de 13 profesionales con el fin de alcanzar el mayor consenso. Para ello se circuló un cuestionario de 16 puntos en 3 rondas: en la primera se estableció el grado de consenso; en la segunda, los participantes tuvieron acceso a los resultados de la primera y respondieron a las cuestiones planteadas. Se consideró que había acuerdo si el consenso era ≥ 75 % de los participantes, y que existía acuerdo fuerte si este era ≥ 90 %. Además, se estableció la temática de los indicadores de calidad. En la tercera se desarrollaron dichos indicadores. Resultados: tras 3 rondas y una reunión de revisión se establecieron los sobre aspectos organizativos 5 recomendaciones con acuerdo fuerte; sobre los aspectos administrativos, 6 recomendaciones con acuerdo fuerte y 4 con acuerdo. Se seleccionaron 8 indicadores de calidad que se desarrollaron en formato de fichas. Conclusiones: este documento recopila una serie de recomendaciones sobre cuestiones, necesidades y requisitos a tener en cuenta para una consulta telemática de calidad al paciente con patología nutricional. Así mismo, se han desarrollado unos indicadores para mejorar la calidad asistencial.

Is docetaxel-free interval a predictive factor for castration-resistant prostate cancer?

OBJECTIVE: Prostate cancer (PCa) is the second most common solid tumor in men and the fifth leading cause of cancer-related death. In advanced stage, palliative treatments are used instead of curative therapies. Therefore, finding predictive indicators seems crucial. Patients with castration-resistant prostate cancer (CRPC) that received Dx chemotherapy have been retrospectively reviewed. The aim of this study was to investigate whether docetaxel (Dx)-free interval could have a predictive value for PCa and influence other sequential therapies. MATERIAL AND METHODS: This clinical trial study was performed on 104 patients at Medeniyet University Oncology Clinic in 2018-2020. All CRPC patients had metastases, received Dx as first-line treatment and underwent androgen receptor axis targeted (ARAT) therapy after disease progression. We analyzed patients' progression time after Dx therapy and the effects on sequential treatment. RESULTS: After Dx therapy, all patients received ARAT (abiraterone (ABI) n: 49 (47.1%) and enzalutamide (ENZ) n: 54 (51.9%)) as a second-line treatment, except for one patient who received cabazitaxel. There was a statistically significant relationship between the Dx-free interval and duration of response to ARAT (p<0.001). The response time of ARAT treatment was <10.5 months in all patients whose Dx-free interval period was <9 months. CONCLUSIONS: Our findings support the theory that Dx-free interval can be a predictive factor for CRPC. CRPC disease can be classified as Dx-sensitive disease or Dx-resistance disease, based on the Dx-free interval. Decision on subsequent treatments could be made considering this information.

Abdominal obesity and myocardial infarction risk - We demonstrate the anthropometric and mathematical reasons that justify the association bias of the waist-to-hip ratio.

INTRODUCTION: Antecedentes: el índice cintura-cadera (ICC) se utiliza ampliamente para evaluar la asociación de la obesidad abdominal con el infarto de miocardio (IM). Objetivo: nuestro propósito era determinar si el riesgo asociado a la ICC produce sesgo. Métodos: estudio de casos y controles en 252 varones. Usamos la estratificación como criterio para eliminar los efectos del sesgo. Creamos una covariable basal (ICC0,95-0,99) para una nueva muestra emparejada en el estrato de valores entre 0,95 y 0,99. Este estrato coincide con el área común de solapamiento de la distribución de puntos, donde todos los sujetos tienen un índice de propensión similar. Consideramos otra covariable (ICCS) condicionada en ICC < 1 y una circunferencia de cintura (CC) donde la asignación de riesgo fuera espúrea. Hipotetizamos que restando CC del valor de la cadera se calculaba otra variable aritmética (DCC) que podría ser esencial para evidenciar el efecto de confusion que genera el ICC. Resultados: IMC: ABC: 0,694, IC 95 % (0,628-0,760); OR: 3,8. CC: ABC: 0,743, IC 95 % (0,681-0,805); OR: 5,7. ICC: ABC: 0,798, IC 95 % (0,740-0,855); OR: 8,6. Índice cintura-talla (ICT): ABC: 0,782, IC 95 % (0,724-0,840); OR: 8,5. DCC: ABC: 0,204, IC 95 % (0,146-0,261); OR: 0,36. Prevalencia en los casos: ICC ≥ 0,95 (84,1 % vs. 38 %; OR: 8,6); ICC < 1 (36,3 % vs. 85,7 %; OR: 2,3); ICC ≥ 1 (63,4 % vs. 14,2 %; OR: 4,4); CC ≥ 94,4 (71,4 % vs. 30,1 %; OR: 5,7); DCC ≥ 2,2 (27,7 % vs. 75,3 %; OR: 7,9); ICCs (50 % vs. 25 %; OR: 2). Conclusiones: el ICC produce un sesgo de asociación en los casos de IM. Ello puede extrapolarse a otras poblaciones de estudio. El sesgo se explica por un error de concepto matemático que sobreestima el efecto protector de la cadera con respecto a la CC y la altura. El riesgo asociado al ICC por encima del de la CC o el ICT presenta inconsistencia antropométrica y sesgo, llegando a ser epidemiológicamente falso.

INTRODUCCIÓN: Background: the waist-to-hip ratio (WHR) is widely used to evaluate the association of abdominal obesity with myocardial infarction (MI). Objective: our aim was to determine whether WHR-associated risk provides a bias. Methods: a case-control study in 252 men. Stratification was used as an approach for removing bias effects. We created a baseline covariate (WHR0.95-0.99) from a new matched sample in the stratum between 0.95 and 0.99. This stratum coincides with the overlap area of the distribution, where all subjects have a similar propensity score. We considered other covariate (WHRS), conditioned on WHR < 1 and waist circumference (WC) being assigned a spurious risk. We hypothesized that subtracting hip circumference from WC (WHD) can be essential to observe the confounding effect provided by WHR. Results: BMI: AUC: 0.694, 95 % CI (0.628-0.760); OR: 3.8. WC: AUC: 0.743, 95 % CI (0.681-0.805); OR: 5.7. WHR: AUC: 0.798, 95 % CI (0.740-0.855); OR: 8.6. Waist-height ratio (WHtR): AUC: 0.782, 95 % CI (0.724-0.840); OR: 8.5. WHD: AUC: 0.204, 95 % CI (0.146-0.261); OR: 0.36. Prevalence in cases: WHR ≥ 0.95 (84.1 % vs. 38 %; OR: 8.6); WHR < 1 (36.3 % vs. 85.7 %; OR: 2.3); WHR ≥ 1 (63.4 % vs. 14.2 %; OR: 4.4); WC ≥ 94.4 (71.4 % vs. 30.1 %; OR: 5.7); WHD ≥ 2.2 (27.7 % vs. 75.3 %; OR: 7.9); WHRs (50 % vs. 25 %; OR: 2). Conclusions: WHR provides an association bias in MI cases. This can be extrapolated to other study populations. The bias is explained by a mathematical misconception where the protective effect of HC is overestimated concerning WC and height. The risk associated with WHR as higher than that associated with WC and WHtR entails anthropometric inconsistency and bias, to the extent of becoming epidemiologically false.

Mortality in patients treated for COVID-19 in the emergency department of a tertiary care hospital during the first phase of the pandemic: Derivation of a risk model for emergency departments. / Análisis de mortalidad de los pacientes atendidos por COVID-19 en el servicio de urgencias de un hospital de tercer nivel en la fase incial de la pandemia. Derivación de un modelo de riesgo para urgencias.

OBJECTIVES: To develop a risk model to predict 30-day mortality after emergency department treatment for COVID-19. MATERIAL AND METHODS: Observational retrospective cohort study including 2511 patients with COVID-19 who came to our emergency department between March 1 and April 30, 2020. We analyzed variables with Kaplan Meier survival and Cox regression analyses. RESULTS: All-cause mortality was 8% at 30 days. Independent variables associated with higher risk of mortality were age over 50 years, a Barthel index score less than 90, altered mental status, the ratio of arterial oxygen saturation to the fraction of inspired oxygen (SaO2/FIO2), abnormal lung sounds, platelet concentration less than 100 000/mm3, a C-reactive protein concentration of 5 mg/dL or higher, and a glomerular filtration rate less than 45 mL/min. Each independent predictor was assigned 1 point in the score except age, which was assigned 2 points. Risk was distributed in 3 levels: low risk (score of 4 points or less), intermediate risk (5 to 6 points), and high risk (7 points or above). Thirty-day risk of mortality was 1.7% for patients who scored in the low-risk category, 28.2% for patients with an intermediate risk score, and 67.3% for those with a high risk score. CONCLUSION: This mortality risk stratification tool for patients with COVID-19 could be useful for managing the course of disease and assigning health care resources in the emergency department.

OBJETIVO: Derivar un modelo de riesgo para estimar la probabilidad de mortalidad a los 30 días de la visita a urgencias de pacientes con COVID-19. METODO: Estudio observacional de cohortes retrospectivo de 2.511 pacientes con COVID-19 atendidos en el servicio de urgencias hospitalario (SUH) del 1 de marzo al 30 de abril de 2020. Se realizó análisis de supervivencia mediante Kaplan Meier y regresión de Cox. RESULTADOS: La mortalidad por cualquier causa a los 30 días fue de un 8%. Los factores asociados de forma independiente a mayor mortalidad fueron: edad 50 años, índice de Barthel 90 puntos, alteración del nivel de consciencia, índice de SaO2/FIO2 400, auscultación respiratoria anómala, cifra de plaquetas 100.000/mm3, PCR 5 mg/dL y filtrado glomerular 45 mL/min. A estos factores se les asignó una puntuación de 1, excepto a la edad, que se le asignó un valor de 2 puntos. Se dividió el modelo de riesgo en 3 categorías: riesgo bajo (menor o igual a 4 puntos), riesgo intermedio (5-6 puntos) y riesgo alto (igual o superior a 7 puntos). Para los pacientes clasificados como de bajo riesgo la probabilidad de mortalidad a los 30 días fue del 1,7%, en los casos de riesgo intermedio fue del 28,2% y para los de alto riesgo fue del 67,3%. CONCLUSIONES: Disponer de una herramienta para estratificar el riesgo de mortalidad de los pacientes con COVID-19 que consultan a un SUH podría ser de utilidad para la gestión de los recursos sanitarios disponibles.