Structural Reforms in Latin America Under Scrutiny

The future of structural reforms in Latin America is under discussion. The purpose of this document is to synthesize the facts and opinions that underlie this debate. The first section shows that although the reform process has not ground to a halt, it has been incomplete and uneven, both across countries and different areas of reform. The greatest progress has been made in reforming the trade and financial sectors. In terms of tax reform and privatization, the record has been mixed across countries. The most modest progress has been made in the area of labor code reform. The second section analyzes the status of public opinion of the reform process. Disillusionment with the reforms has been growing, particularly among the middle class. This disapproval, rather than reflecting concerns about the state of the economy or the degree of progress of the reforms, stems from the corruption that has tainted the privatization process in some countries. The third section reviews the effects of the reforms. Their impact on growth seems to have been positive, albeit temporary, but the effects on employment and income distribution have varied in different areas of reform and according to the particular context in each country. Specifically, the effectiveness of reforms has depended heavily on the quality of public institutions. The fourth section summarizes the main proposals to expand or reorient the reform agenda in the region. One set of proposals suggests broadening the Washington Consensus with more active policies aimed at addressing the need for greater economic stability, social integration and equitable income distribution. Another set of proposals, guided by a more encompassing view of the goals of development, emphasizes the interaction among civil society, the private sector, and the government. Finally, a more radical vision proposes a new national and international institutional architecture that would limit the role of markets and mitigate the effects of globalization.El futuro de las reformas estructurales en América Latina está en discusión. El objeto de este documento es resumir los hechos y las opiniones subyacentes de este debate. La primera parte muestra que si bien el proceso de reforma no se ha detenido del todo, sí ha sido incompleto y desigual, tanto entre países como entre las diversas áreas de reforma. Los mayores avances se han registrado en la reforma de los sectores del comercio internacional y las finanzas. En términos de reforma tributaria y privatización, los resultados de un país a otro son encontrados. Los avances más pequeños se han registrado en el área de la reforma del código laboral. En la segunda parte se analiza la situación de la opinión pública sobre el proceso de reforma. La desilusión con las reformas ha venido en aumento, especialmente entre la clase media. Más que reflejar inquietudes sobre el estado de la economía o el grado de avance de las reformas, esta crítica tiene que ver con la corrupción que ha empañado el proceso de privatización en algunos países. En la tercera sección se pasa revista a los efectos de las reformas. Sus repercusiones en el crecimiento parecen haber sido positivas, aunque pasajeras, pero sus efectos en el empleo y la distribución del ingreso han variado en diversas áreas de la reforma y según el contexto específico de cada país. En particular, la eficacia de las reformas ha dependido en gran medida de la calidad de las instituciones públicas. En la cuarta parte se presenta una síntesis de las principales propuestas para ampliar o reorientar el programa de reformas en la región. Un conjunto de propuestas sugiere ampliar el Consenso de Washington con políticas más activas, destinadas a acometer la necesidad de mayor estabilidad económica, integración social y una distribución equitativa del ingreso. Otro conjunto de propuestas, guiado por un punto de vista más amplio de los objetivos del desarrollo, hace hincapié en la interacción entre la sociedad civil, el sector privado y el gobierno. Por último, una visión más radical propone una nueva estructura nacional e internacional de las instituciones, a fin de limitar el papel de los mercados y atenuar los efectos de la globalización

Safety of hospital discharge before return of bowel function after elective colorectal surgery

Background: Ileus is common after colorectal surgery and is associated with an increased risk of postoperative complications. Identifying features of normal bowel recovery and the appropriateness for hospital discharge is challenging. This study explored the safety of hospital discharge before the return of bowel function.Methods: A prospective, multicentre cohort study was undertaken across an international collaborative network. Adult patients undergoing elective colorectal resection between January and April 2018 were included. The main outcome of interest was readmission to hospital within 30 days of surgery. The impact of discharge timing according to the return of bowel function was explored using multivariable regression analysis. Other outcomes were postoperative complications within 30 days of surgery, measured using the Clavien-Dindo classification system.Results: A total of 3288 patients were included in the analysis, of whom 301 (9.2 per cent) were discharged before the return of bowel function. The median duration of hospital stay for patients discharged before and after return of bowel function was 5 (i.q.r. 4-7) and 7 (6-8) days respectively (P < 0.001). There were no significant differences in rates of readmission between these groups (6.6 versus 8.0 per cent; P = 0.499), and this remained the case after multivariable adjustment for baseline differences (odds ratio 0.90, 95 per cent c.i. 0.55 to 1.46; P = 0.659). Rates of postoperative complications were also similar in those discharged before versus after return of bowel function (minor: 34.7 versus 39.5 per cent; major 3.3 versus 3.4 per cent; P = 0.110).Conclusion: Discharge before return of bowel function after elective colorectal surgery appears to be safe in appropriately selected patients

Everolimus-Eluting Stents or Bypass Surgery for Left Main Coronary Artery Disease

BACKGROUND Patients with obstructive left main coronary artery disease are usually treated with coronary-artery bypass grafting (CABG). Randomized trials have suggested that drug-eluting stents may be an acceptable alternative to CABG in selected patients with left main coronary disease.METHODS We randomly assigned 1905 eligible patients with left main coronary artery disease of low or intermediate anatomical complexity to undergo either percutaneous coronary intervention (PCI) with fluoropolymer-based cobalt-chromium everolimus-eluting stents (PCI group, 948 patients) or CABG (CABG group, 957 patients). Anatomic complexity was assessed at the sites and defined by a Synergy between Percutaneous Coronary Intervention with Taxus and Cardiac Surgery (SYNTAX) score of 32 or lower (the SYNTAX score reflects a comprehensive angiographic assessment of the coronary vasculature, with 0 as the lowest score and higher scores [ no upper limit] indicating more complex coronary anatomy). The primary end point was the rate of a composite of death from any cause, stroke, or myocardial infarction at 3 years, and the trial was powered for noninferiority testing of the primary end point (noninferiority margin, 4.2 percentage points). Major secondary end points included the rate of a composite of death from any cause, stroke, or myocardial infarction at 30 days and the rate of a composite of death, stroke, myocardial infarction, or ischemia-driven revascularization at 3 years. Event rates were based on Kaplan-Meier estimates in time-to-first-event analyses.RESULTS At 3 years, a primary end-point event had occurred in 15.4% of the patients in the PCI group and in 14.7% of the patients in the CABG group (difference, 0.7 percentage points; upper 97.5% confidence limit, 4.0 percentage points; P = 0.02 for noninferiority; hazard ratio, 1.00; 95% confidence interval, 0.79 to 1.26; P = 0.98 for superiority). The secondary end-point event of death, stroke, or myocardial infarction at 30 days occurred in 4.9% of the patients in the PCI group and in 7.9% in the CABG group (P< 0.001 for noninferiority, P = 0.008 for superiority). The secondary end-point event of death, stroke, myocardial infarction, or ischemia-driven revascularization at 3 years occurred in 23.1% of the patients in the PCI group and in 19.1% in the CABG group (P = 0.01 for noninferiority, P = 0.10 for superiority).CONCLUSIONS In patients with left main coronary artery disease and low or intermediate SYNTAX scores by site assessment, PCI with everolimus-eluting stents was noninferior to CABG with respect to the rate of the composite end point of death, stroke, or myocardial infarction at 3 years. (Funded by Abbott Vascular; EXCEL ClinicalTrials.gov number, NCT01205776.

On the Role of NMR Spectroscopy for Characterization of Antimicrobial Peptides

Antimicrobial peptides (AMPs) provide a primordial source of immunity, conferring upon eukaryotic cells resistance against bacteria, protozoa, and viruses. Despite a few examples of anionic peptides, AMPs are usually relatively short positively charged polypeptides, consisting of a dozen to about a hundred amino acids, and exhibiting amphipathic character. Despite significant differences in their primary and secondary structures, all AMPs discovered to date share the ability to interact with cellular membranes, thereby affecting bilayer stability, disrupting membrane organization, and/or forming well-defined pores. AMPs selectively target infectious agents without being susceptible to any of the common pathways by which these acquire resistance, thereby making AMPs prime candidates to provide therapeutic alternatives to conventional drugs. However, the mechanisms of AMP actions are still a matter of intense debate. The structure-function paradigm suggests that a better understanding of how AMPs elicit their biological functions could result from atomic resolution studies of peptide-lipid interactions. In contrast, more strict thermodynamic views preclude any roles for three-dimensional structures. Indeed, the design of selective AMPs based soley on structural parameters has been challenging. In this chapter, we will focus on selected AMPs for which studies on the corresponding AMP-lipid interactions have helped reach an understanding of how AMP effects are mediated. We will emphasize the roles of both liquid- and solid-state NMR spectroscopy for elucidating the mechanisms of action of AMPs