The social return on investment of a new approach to heart failure in the Spanish National Health System

AIMS: We aim to agree on a set of proposals to improve the current management of heart failure (HF) within the Spanish National Health System (SNHS) and apply the social return on investment (SROI) method to measure the social impact that these proposals would generate. METHODS AND RESULTS: A multidisciplinary working team of 16 experts was set up, with representation from the main stakeholders regarding HF: medical specialists (cardiologists, internal medicine physicians, general practitioners, and geriatric physicians), nursing professionals, health management professionals, patients, and informal caregivers. This team established a set of proposals to improve the management of HF according to the main areas of HF care: emergency and hospitalization, primary care, cardiology, and internal medicine. A forecast-type SROI method, with a 1-year time frame, was applied to measure the social impact resulting from the implementation of these proposals. The required investment and social return were estimated and summarized into a ratio indicating how much social return could be generated for each euro invested. Intangible returns were included and quantified through financial proxies. The approach to improve the management of HF consisted of 28 proposals, including the implementation of a case management nurse network, standardization of operational protocols, psychological support, availability of echocardiography machines at emergency departments, stationary units and primary care, early specialist visits after hospital discharge, and cardiac rehabilitation units, among others. These proposals would benefit not only patients and their informal caregivers but also the SNHS. Regarding patients, proposals would increase their autonomy in everyday activities, decrease anxiety, increase psychological and physical well-being, improve pharmacological adherence and self-care, enhance understanding of the disease, delay disease progression, expedite medical assessment, and prevent the decrease in work productivity associated with HF management. Regarding informal caregivers, proposals would increase their quality of life; improve their social, economic, and emotional well-being; and reduce their care burden. The SNHS would benefit from shorter stays of HF patients at intensive care units and reduction of hospitalizations and admissions to emergency departments. The investment needed to implement these proposals would amount to euro548m and yield a social return of euro1932m, that is, euro3.52 for each euro invested. CONCLUSIONS: The current management of HF could be improved by a set of proposals that resulted in an overall positive social return, varying between areas of analysis. This may guide the allocation of healthcare resources and improve the quality of life of patients with HF

Nursing students? knowledge and attitudes regarding medical marijuana: A descriptive cross-sectional study

Marijuana use for medical purposes dates back to ancient times. Despite its high therapeutic potential, its adverse effects have raised important legal restrictions. However, this situation in Spain may soon undergo significant changes, without anyone so far having studied the knowledge and/or the level of acceptance of medical marijuana by future healthcare professionals. The aim of the present study was to determine nursing students' knowledge of and attitudes towards medical marijuana. A cross-sectional design was used. A total of 578 nursing students from the University of Santiago de Compostela (Spain), >/=18 years old and of both sexes, were invited to complete the Spanish version of the questionnaire "Medical Marijuana" between January and May 2019. A total of 364 students decided to participate in the study. More than 75% of the students agreed with the legalization of medical marijuana, although their knowledge and confidence levels regarding efficacy, safety and drug interactions of medical marijuana were low. Nursing students showed a clear lack of knowledge about medical marijuana and thus, in light of possible regulatory changes, it would be necessary to strengthen the training of nurses with respect to medical marijuana in order to make responsible use of it

Anti-tumour necrosis factor discontinuation in inflammatory bowel disease patients in remission: study protocol of a prospective, multicentre, randomized clinical trial

Background: Patients with inflammatory bowel disease who achieve remission with anti-tumour necrosis factor (anti-TNF) drugs may have treatment withdrawn due to safety concerns and cost considerations, but there is a lack of prospective, controlled data investigating this strategy. The primary study aim is to compare the rates of clinical remission at 1?year in patients who discontinue anti-TNF treatment versus those who continue treatment. Methods: This is an ongoing, prospective, double-blind, multicentre, randomized, placebo-controlled study in patients with Crohn?s disease or ulcerative colitis who have achieved clinical remission for ?6?months with an anti-TNF treatment and an immunosuppressant. Patients are being randomized 1:1 to discontinue anti-TNF therapy or continue therapy. Randomization stratifies patients by the type of inflammatory bowel disease and drug (infliximab versus adalimumab) at study inclusion. The primary endpoint of the study is sustained clinical remission at 1?year. Other endpoints include endoscopic and radiological activity, patient-reported outcomes (quality of life, work productivity), safety and predictive factors for relapse. The required sample size is 194 patients. In addition to the main analysis (discontinuation versus continuation), subanalyses will include stratification by type of inflammatory bowel disease, phenotype and previous treatment. Biological samples will be obtained to identify factors predictive of relapse after treatment withdrawal. Results: Enrolment began in 2016, and the study is expected to end in 2020. Conclusions: This study will contribute prospective, controlled data on outcomes and predictors of relapse in patients with inflammatory bowel disease after withdrawal of anti-TNF agents following achievement of clinical remission. Clinical trial reference number: EudraCT 2015-001410-1

Can?n literatio para incentivar la sensibilidad po?tica comunicativa de los estudiantes del grado primero del centro educativo Germ?n Pardo Sede La Paz

109 P?ginasMediante el proceso de recolecci?n y observaci?n del canon formativo po?tico realizado en el grado primero de la instituci?n educativa Germ?n Pardo Garc?a sede La Paz del departamento del Tolima, se determin? una ausencia significativa del g?nero po?tico dentro del canon de ense?anza que all? se lleva a cabo. Por tal motivo se plante? la necesidad de incluir la poes?a en el canon formativo e implementarlo mediante estrategias pedag?gicas. Para tal fin se llev? a cabo una serie de actividades, como primera medida se inici? un rastreo bibliogr?fico del g?nero po?tico, que tuvo como objetivo seleccionar el canon formativo para el grado primero. Para esto, se aplicaron las categor?as de valor est?tica, pertinencia y relaci?n con el contexto, obteniendo como resultado una antolog?a po?tica de la cual se desprend?an los poemas pertinentes para abordar una propuesta pedag?gica encaminada a mostrarles a los ni?os la importancia de la poes?a, orientada a desarrollar el canon formativo propuesto en el grado ya mencionado. Se hace necesario resaltar que para llegar a este punto, previamente se realizaron entrevistas a los padres de familia, docentes y cuerpo estudiantil, se analizaron los puntos de vista que ten?an acerca de las obras literarias all? trabajadas, de igual forma se hizo un bosquejo que permiti? identificar las necesidades de la poblaci?n estudiantil. En este orden de ideas, la investigaci?n busc? la respuesta a la necesidad de implementar el g?nero po?tico y estrategias metodol?gicas con los estudiantes de la instituci?n educativa Germ?n Pardo Garc?a sede La Paz. El trabajo que se presenta a continuaci?n da cuenta de todas las fases y resultados adquiridos en el proceso.ABSTRACT. Through the process of collection and observation of training poetic canon made in the first degree of the school headquarters Germain Garcia Pardo La Paz department of Tolima, we found a significant lack of poetic genre in the canon of teaching that takes place there . For this reason it was considered necessary to include in the canon of poetry and implement training through teaching strategies. To this end, carried out a series of activities as a first step began tracking bibliographic poetic genre, which had as its objective the training fee for the first degree. For this, we applied the categories of aesthetic value, relevance and relationship to the context, resulting in a poetry anthology which fell off the poems relevant to a pedagogical approach designed to show children the importance of poetry, oriented to develop the training fee proposed in the aforementioned degree. It is necessary to note that to reach this point, previously conducted interviews with parents, teachers and student body, we analyzed the views they had about literary worked there, just as it did a sketch identified the needs of the student population. In this vein, the study sought the answer to the need to implement the poetic genre and methodological strategies with students of the school headquarters Germain Garcia Pardo La Paz. The work presented here accounts for all phases and outcomes achieved in the process.ADVERTENCIA El programa de Licenciatura en Educaci?n B?sica con ?nfasis en Lengua Castellana de la Universidad del Tolima, el director del trabajo y el jurado calificador, no son responsables de los conceptos ni de las ideas expuestas por las autoras del presente trabajo. Art?culo 16, Acuerdo 032 de 1976 y Art?culo 29, Acuerdo 064 de 1991, Consejo Acad?mico de la Universidad del Tolima.INTRODUCCI?N 16 1. PROBLEMA 17 1.1 PLANTEAMIENTO DEL PROBLEMA 17 1.2 FORMULACI?N DEL PROBLEMA 18 2. JUSTIFICACI?N 19 3. OBJETIVOS 20 3.1 OBJETIVO GENERAL 20 3.2 OBJETIVOS ESPEC?FICOS 20 4. MARCO TE?RICO 21 4.1 MARCO LEGAL 21 4.2 MARCO PEDAG?GICO 22 4.3 MARCO EPISTEMOL?GICO 26 4.3.1 Poes?a 27 4.3.2 Canon literario 27 4.3.3 Investigaci?n formativa 28 5. DISE?O METODOL?GICO 30 5.1 RASTREO BIBLIOGR?FICO 30 5.2 APLICACI?N DE LA CATEGOR?AS DE VALORACI?N 31 5.2.1 Valoraci?n est?tica 31 5.2.2 Valoraci?n de pertinencia 31 5.2.3 Relaci?n con el contexto 31 5.4 RESE?A CR?TICA 32 5.5 DISE?O DE LA PROPUESTA 32 5.6 APLICACI?N DE LA PROPUESTA 32 6. PONENCIA 33 7. ANTOLOG?A PO?TICA 39 8. RESE?A CR?TICA 51 9. PROPUESTA PEDAG?GICA 56 10. AN?LISIS E INTERPRETACI?N DE RESULTADOS 73 10.1 AN?LISIS COMPARATIVO 97 11. CONCLUSIONES 102 12. RECOMENDACIONES 103 13. REFERENCIAS 104 14. ANEXOS 10

H�bitos alimentarios de tres especies de raya (Rajiformes: Urotrygonidae) en el Pac�fico central mexicano

Se realiz� el an�lisis del contenido estomacal y de las interacciones tr�ficas de tres especies de raya (Urobatis halleri, Urotrygon munda y Urotrygon rogersi) capturadas en la plataforma continental del Pac�fico central mexicano durante los dos periodos hidroclim�ticos (T1 y T2) que caracterizan la variabilidad ambiental en la zona. Las tres especies de raya presentaron un estrecho intervalo de distribuci�n batim�trica, y su m�xima abundancia se present� a los 20 m en ambos periodos de estudio. En general, las dietas estuvieron compuestas principalmente de microcrust�ceos bent�nicos (camarones car�deos) y en menor proporci�n de peces, poliquetos y moluscos. Las categor�as de presas de mayor abundancia en las dietas fueron los car�deos de las familias Processidae y Ogyriididae, y peneidos, y en segundo t�rmino las larvas de braquiuros y estomat�podos. La estrategia alimentaria exhibida por las tres especies fue generalista. Las dietas mostraron valores altos de superposici�n durante el periodo T1 tanto en el an�lisis de intra como de interespecies, mientras que durante el periodo T2 la superposici�n de las dietas fue menor. No se evidenciaron cambios ontog�nicos en las dietas, y el sexo tampoco represent� un factor de diferencias tr�ficas. Se considera que las ligeras diferencias en las dietas son debidas a los cambios estacionales en las asociaciones de macroinvertebrados de fondos blandos de la zona somera, y que las relaciones como competencia y depredaci�n no son los factores m�s determinantes en la din�mica de las tres especies de raya analizadas

Interacciones tr�ficas de las seis especies de peces m�s abundantes en la pesquer�a artesanal en dos bah�as del Pac�fico Central Mexicano

Se analizaron los componentes tr�ficos de las seis especies de peces m�s importantes en la captura de la pesquer�a artesanal en las Bah�a de Navidad y Chamela, ubicadas en la costa de Jalisco, M�xico. Las especies estudiadas fueron Microlepidotus brevipinnis, Caranx caballus, Haemulon flaviguttatum, Lutjanus guttatus, Lutjanus argentiventris y Mulloidichthys dentatus. Se consideraron dos periodos de estudio de acuerdo a las pautas hidroclim�ticas y los patrones de producci�n biol�gica en la zona: periodo de influencia de la Contracorriente Norecuatorial (T1), y periodo de influencia de la Corriente de California (T2). En Bah�a de Navidad se identificaron 78 presas en total para las seis especies. En el periodo comprendido entre julio y diciembre (T1) se identificaron 64 presas y 45 de enero a junio (T2). En Bah�a de Chamela se identificaron 93 presas, encontrando 74 presas en el periodo T1 y 60 presas para el periodo T2. El mayor n�mero de presas se encontr� en M. dentatus con 34 presas en el periodo T1 de Bah�a de Chamela y el menor n�mero fue en H. flaviguttatum en T1 de Bah�a de Navidad con solo 7 presas. Los crust�ceos fueron las presas de mayor presencia en la dieta, seguidos por peces, moluscos, poliquetos y equinodermos, en ambos periodos y sitios de muestreo. Las seis especies analizadas se consideran como especialistas, dados los bajos valores del �ndice de amplitud de nicho en ambos periodos y sitios de muestreo