Luces y sombras del impuesto digital.

Aproximándonos al final del plazo para acordar una solución multilateral a la tributación directa de los negocios altamente digitalizados, que debía tomarse antes de fin de 2020, resulta intelectualmente estimulante contemplar cómo el Marco Inclusivo de BEPS ha roto tabúes hasta ahora incuestionables, como la supremacía de los precios de transferencia o la inatacable bilateralidad de las relaciones fiscales internacionales. Al mismo tiempo, han quedado en evidencia las tremendas limitaciones políticas y administrativas que complican el acuerdo. EE. UU. se retiró en junio de las negociaciones, lo que hace virtualmente imposible la ratificación por el Marco Inclusivo en octubre de 2020 y por el G20 en noviembre, como estaba previsto. Sin embargo, la OCDE ha seguido madurando la propuesta, por lo que no cabe excluir que en un futuro vuelva a la mesa de negociación. Por eso, en este artículo examinamos la sostenibilidad de los dos pilares que ha propuesto la OCDE: el nuevo derecho de gravamen para los países del mercado donde intervengan los gigantes digitales con presencia económica significativa, pero sin establecimiento permanente, y el nuevo impuesto multilateral antielusión denominado GloBE.2020-2

Luces y sombras del impuesto digital

As we approach the deadline for a multilateral solution to the corporate taxation of highly digitalized business –it was supposed to be approved by the end of 2020– it is intellectually stimulating to realize how the BEPS Inclusive Framework has broken longstanding unquestionable taboos, such as the supremacy of transfer pricing or the bilateral nature of international tax relationships. At the same time, we have realized how strong political and administrative constraints ended up blocking the deal. In June 2020, the US withdrew from the discussions, making the consensus ratification by the BEPS Inclusive Framework in October 2020 and the G-20 in November virtually impossible. Regardless, the OECD has continued to pursue technical work, leaving the door open for a future deal. Therefore, in this article we examine the sustainability of the two pillars proposed by the OECD: the new taxing right for market jurisdictions where digital giants operate with a significant economic presence but without a permanent establishment, and the new multilateral anti-BEPS tax, the GloBE.Este trabajo ha obtenido el 1.er Premio «Estudios Financieros» 2020 en la modalidad de Tributación. Aproximándonos al final del plazo para acordar una solución multilateral a la tributación directa de los negocios altamente digitalizados, que debía tomarse antes de fin de 2020, resulta intelectualmente estimulante contemplar cómo el Marco Inclusivo de BEPS ha roto tabúes hasta ahora incuestionables, como la supremacía de los precios de transferencia o la inatacable bilateralidad de las relaciones fiscales internacionales. Al mismo tiempo, han quedado en evidencia las tremendas limitaciones políticas y administrativas que complican el acuerdo. EE. UU. se retiró en junio de las negociaciones, lo que hace virtualmente imposible la ratificación por el Marco Inclusivo en octubre de 2020 y por el G20 en noviembre, como estaba previsto. Sin embargo, la OCDE ha seguido madurando la propuesta, por lo que no cabe excluir que en un futuro vuelva a la mesa de negociación. Por eso, en este artículo examinamos la sostenibilidad de los dos pilares que ha propuesto la OCDE: el nuevo derecho de gravamen para los países del mercado donde intervengan los gigantes digitales con presencia económica significativa, pero sin establecimiento permanente, y el nuevo impuesto multilateral antielusión denominado GloBE

Effectiveness of a strategy that uses educational games to implement clinical practice guidelines among Spanish residents of family and community medicine (e-EDUCAGUIA project):A clinical trial by clusters

This study was funded by the Fondo de Investigaciones Sanitarias FIS Grant Number PI11/0477 ISCIII.-REDISSEC Proyecto RD12/0001/0012 AND FEDER Funding.Background: Clinical practice guidelines (CPGs) have been developed with the aim of helping health professionals, patients, and caregivers make decisions about their health care, using the best available evidence. In many cases, incorporation of these recommendations into clinical practice also implies a need for changes in routine clinical practice. Using educational games as a strategy for implementing recommendations among health professionals has been demonstrated to be effective in some studies; however, evidence is still scarce. The primary objective of this study is to assess the effectiveness of a teaching strategy for the implementation of CPGs using educational games (e-learning EDUCAGUIA) to improve knowledge and skills related to clinical decision-making by residents in family medicine. The primary objective will be evaluated at 1 and 6months after the intervention. The secondary objectives are to identify barriers and facilitators for the use of guidelines by residents of family medicine and to describe the educational strategies used by Spanish teaching units of family and community medicine to encourage implementation of CPGs. Methods/design: We propose a multicenter clinical trial with randomized allocation by clusters of family and community medicine teaching units in Spain. The sample size will be 394 residents (197 in each group), with the teaching units as the randomization unit and the residents comprising the analysis unit. For the intervention, both groups will receive an initial 1-h session on clinical practice guideline use and the usual dissemination strategy by e-mail. The intervention group (e-learning EDUCAGUIA) strategy will consist of educational games with hypothetical clinical scenarios in a virtual environment. The primary outcome will be the score obtained by the residents on evaluation questionnaires for each clinical practice guideline. Other included variables will be the sociodemographic and training variables of the residents and the teaching unit characteristics. The statistical analysis will consist of a descriptive analysis of variables and a baseline comparison of both groups. For the primary outcome analysis, an average score comparison of hypothetical scenario questionnaires between the EDUCAGUIA intervention group and the control group will be performed at 1 and 6months post-intervention, using 95% confidence intervals. A linear multilevel regression will be used to adjust the model. Discussion: The identification of effective teaching strategies will facilitate the incorporation of available knowledge into clinical practice that could eventually improve patient outcomes. The inclusion of information technologies as teaching tools permits greater learning autonomy and allows deeper instructor participation in the monitoring and supervision of residents. The long-term impact of this strategy is unknown; however, because it is aimed at professionals undergoing training and it addresses prevalent health problems, a small effect can be of great relevance. Trial registration: ClinicalTrials.gov: NCT02210442.Publisher PDFPeer reviewe

Megaproyectos urbanos y productivos. Impactos socio-territoriales

El desarrollo de megaproyectos productivos trae consigo oportunidades para el crecimiento económico, la generación de empleos y el desarrollo regional. No obstante, en la actualidad, los grandes temas como la expansión urbana, el desarrollo industrial, las cementeras, la minería, el uso intensivo del agua y demás recursos naturales, preocupan a las comunidades por los impactos generados y porque en lo general, no consideran la racionalidad y responsabilidad ambiental y social hacia el entorno. En este contexto son diversos los estudios científicos que, en el marco de la política de económica imperante, intentan posicionarse como alternativas a proyectos económicos que confrontan los intereses particulares y comunitarios y que afectan la salud humana y ambiental. Megaproyectos urbanos y productivos. Impactos socio-territoriales, reúne veinticinco textos académicos sobre las afectaciones que éstos emprendimientos tienen para la sociedad y el entorno. Los temas expuestos recogen experiencias en el desarrollo urbano, industrial, turístico, portuario y aeroportuario, entre otros. Así mismo se retoman temas como la ética, la dialéctica, la política y la economía y su relación en el emprendimiento de megaproyectos. La búsqueda de esquemas productivos racionales y responsables con el entorno, que reivindiquen el derecho de las comunidades a un medio ambiente sano, a la preservación del territorio y sus recursos y de las formas de vida tradicionales, son los referentes para la realización del presente libro. Como elemento central se concibe el territorio como contenedor de identidad y vida, siendo preocupación y tema de estudio de la comunidad académica, las organizaciones de la sociedad civil y las redes de activistas organizados.UAEM, CONACyT, se

Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

Abstract Background Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres. Methods This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low–middle-income countries. Results In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of ‘single-use’ consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low–middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia. Conclusion This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high– and low–middle–income countries

Mortality from gastrointestinal congenital anomalies at 264 hospitals in 74 low-income, middle-income, and high-income countries: a multicentre, international, prospective cohort study

Summary Background Congenital anomalies are the fifth leading cause of mortality in children younger than 5 years globally. Many gastrointestinal congenital anomalies are fatal without timely access to neonatal surgical care, but few studies have been done on these conditions in low-income and middle-income countries (LMICs). We compared outcomes of the seven most common gastrointestinal congenital anomalies in low-income, middle-income, and high-income countries globally, and identified factors associated with mortality. Methods We did a multicentre, international prospective cohort study of patients younger than 16 years, presenting to hospital for the first time with oesophageal atresia, congenital diaphragmatic hernia, intestinal atresia, gastroschisis, exomphalos, anorectal malformation, and Hirschsprung’s disease. Recruitment was of consecutive patients for a minimum of 1 month between October, 2018, and April, 2019. We collected data on patient demographics, clinical status, interventions, and outcomes using the REDCap platform. Patients were followed up for 30 days after primary intervention, or 30 days after admission if they did not receive an intervention. The primary outcome was all-cause, in-hospital mortality for all conditions combined and each condition individually, stratified by country income status. We did a complete case analysis. Findings We included 3849 patients with 3975 study conditions (560 with oesophageal atresia, 448 with congenital diaphragmatic hernia, 681 with intestinal atresia, 453 with gastroschisis, 325 with exomphalos, 991 with anorectal malformation, and 517 with Hirschsprung’s disease) from 264 hospitals (89 in high-income countries, 166 in middleincome countries, and nine in low-income countries) in 74 countries. Of the 3849 patients, 2231 (58·0%) were male. Median gestational age at birth was 38 weeks (IQR 36–39) and median bodyweight at presentation was 2·8 kg (2·3–3·3). Mortality among all patients was 37 (39·8%) of 93 in low-income countries, 583 (20·4%) of 2860 in middle-income countries, and 50 (5·6%) of 896 in high-income countries (p<0·0001 between all country income groups). Gastroschisis had the greatest difference in mortality between country income strata (nine [90·0%] of ten in lowincome countries, 97 [31·9%] of 304 in middle-income countries, and two [1·4%] of 139 in high-income countries; p≤0·0001 between all country income groups). Factors significantly associated with higher mortality for all patients combined included country income status (low-income vs high-income countries, risk ratio 2·78 [95% CI 1·88–4·11], p<0·0001; middle-income vs high-income countries, 2·11 [1·59–2·79], p<0·0001), sepsis at presentation (1·20 [1·04–1·40], p=0·016), higher American Society of Anesthesiologists (ASA) score at primary intervention (ASA 4–5 vs ASA 1–2, 1·82 [1·40–2·35], p<0·0001; ASA 3 vs ASA 1–2, 1·58, [1·30–1·92], p<0·0001]), surgical safety checklist not used (1·39 [1·02–1·90], p=0·035), and ventilation or parenteral nutrition unavailable when needed (ventilation 1·96, [1·41–2·71], p=0·0001; parenteral nutrition 1·35, [1·05–1·74], p=0·018). Administration of parenteral nutrition (0·61, [0·47–0·79], p=0·0002) and use of a peripherally inserted central catheter (0·65 [0·50–0·86], p=0·0024) or percutaneous central line (0·69 [0·48–1·00], p=0·049) were associated with lower mortality. Interpretation Unacceptable differences in mortality exist for gastrointestinal congenital anomalies between lowincome, middle-income, and high-income countries. Improving access to quality neonatal surgical care in LMICs will be vital to achieve Sustainable Development Goal 3.2 of ending preventable deaths in neonates and children younger than 5 years by 2030

Manual para administrar, organizar, dirigir y operar una PyME en México

Seminario: la importancia de las micro, pequeñas y medianas empresas (MiPyMES) en el desarrollo económico de Méxic

Cardiac arrest as a manifestation of unknown Type V glycogenosis: a case report

Few cases have been reported to date, in which a massive rhabdomyolysis causes a cardiac arrest in a male adult suffering from undiagnosed McArdle disease. Veno-arterial extracorporeal membrane oxygenation and cytokine adsorption filter (CytoSorb®) were required to reach a complete and successful recovery.Cardiac arrestCytoSorb®ECMOExercise intoleranceMyoglobinuriaMyophosphorylase deficiencyRenal failureRhabdomyolysi

Stent liberador de rapamicina en el tratamiento de lesiones coronarias con alto riesgo de reestenosis: seguimiento clínico a 6 meses de los primeros 100 pacientes

Introducción y objetivos. Los stents con rapamicina han demostrado reducir drásticamente la reestenosis en lesiones con un riesgo reestenótico entre ligero y moderado. No existen estudios amplios que evalúen su comportamiento en contextos lesionales de alto riesgo. Nos planteamos conocer el posible impacto de su empleo en este tipo de lesiones. Pacientes y método. Se incluyó a pacientes consecutivos con indicación de angioplastia con alguna lesión que reuniera al menos una de las siguientes características: a) reestenosis intra-stent; b) difusa (> 20 mm); c) vaso pequeño (= 2,5 mm), y d) oclusión total. Resultados. Entre junio y diciembre de 2002 se incluyó a 100 pacientes (61 ± 11 años; un 84% varones; un 21% diabéticos) que tenían 154 lesiones tratadas (un 34% difusas, un 36% en un vaso pequeño, un 20% reestenosis intra-stent y un 20% oclusiones). Se implantaron 1,6 ± 0,7 stents/paciente, con un diámetro de 2,74 ± 0,26 mm, una longitud de 21 ± 8,5 mm y una longitud total stent/paciente de 33 ± 16 mm. Se obtuvo un éxito inmediato en el 98%. Se produjeron 2 infartos sin onda Q (2%) tras el procedimiento. No hubo ningún caso de trombosis agudas ni subagudas. Durante el seguimiento de 8,5 ± 2 meses (rango, 6-12 meses) se produjeron 2 trombosis tardías (2%), a los 3 y 7 meses, una de las cuales ocasionó un infarto. Se efectuó revascularización de la lesión tratada en 3 casos (3%), 2 de los cuales correspondieron a las trombosis tardías. Conclusiones. La utilización de stents con rapamicina en lesiones de alto riesgo para reestenosis fue segura y la necesidad de nueva revascularización en el seguimiento fue notablemente baja

First record of Babesia sp. in Antarctic penguins

This is the first reported case of Babesia sp. in Antarctic penguins, specifically a population of Chinstrap penguins (Pygoscelis antarctica) in the Vapour Col penguin rookery in Deception Island, South Shetlands, Antarctica. We collected peripheral blood from 50 adult and 30 chick Chinstrap penguins. Examination of the samples by microscopy showed intraerythrocytic forms morphologically similar to other avian Babesia species in12 Chinstrap penguinadults and sevenchicks. The estimated parasitaemias ranged from 0.25 × 10−2%to 0.75 × 10−2%. Despite the low number of parasites found inblood smears, semi-nested PCR assays yielded a 274 bp fragment in 12 of the 19 positive blood samples found by microscopy. Sequencing revealed that the fragment was 97% similar to Babesia sp. 18S rRNA from Australian Little Penguins (Eudyptula minor) confirming presence of the parasite. Parasite prevalence estimated by microscopy in adults and chicks was higher (24% vs. 23.3%, respectively) than found by semi-nested PCR (16% vs. 13.3% respectively).Although sampled penguins were apparently healthy,the effect of Babesia infection in these penguins is unknown. The identification of Babesia sp. inAntarctic penguins is an important finding. Ixodes uriae, as the only tick species present in the Antarctic Peninsula, is the key to understanding the natural history of this parasite. Future work should address the transmission dynamics and pathogenicity of Babesia sp. in Chinstrap penguin as well as in other penguin species, such as Gentoo penguin (Pygoscelis papua) and Adélie penguin (Pygoscelis adeliae), present within the tick distribution range in the Antarctic Peninsula.Fil: Montero, Estrella. Instituto de Salud Carlos III; EspañaFil: González, Luis Miguel. Instituto de Salud Carlos III; EspañaFil: Chaparro, Alberto. Instituto de Salud Carlos III; EspañaFil: Benzal, Jesus. Consejo Superior de Investigaciones Científicas. Estación Experimental de Zonas Aridas; EspañaFil: Bertellotti, Néstor Marcelo. Consejo Nacional de Investigaciones Científicas y Técnicas. Centro Científico Tecnológico Conicet - Centro Nacional Patagónico; ArgentinaFil: Masero, Jose A.. Universidad de Extremadura; EspañaFil: Colominas Ciuró, Roger. Museo Nacional de Ciencias Naturales; EspañaFil: Vidal Burgos, Virginia. Museo Nacional de Ciencias Naturales; EspañaFil: Barbosa, Andres. Museo Nacional de Ciencias Naturales; Españ