Consistencia mediante jerarquía

En esta contribución intentaré mostrar que el criterio lex superior derogat legi inferiori conduce a una consecuencia que, al menos en lo que conozco, no ha sido todavía advertida. Si las normas de la máxima jerarquía de un sistema jurídico, verbigracia, normas constitucionales constituyen un conjunto consistente, entonces necesariamente el sistema jurídico es consistente. Dicho de otra manera, lex superior preserva necesariamente la consistencia. Si las normas del nivel más alto son miembros de un conjunto consistente, los niveles inferiores de la jerarquía no podrían admitir normas contradictorias con las superiores. Más aún, habida cuenta que de una contradicción se sigue cualquier norma, en virtud del principio lógico ex falso quodlibet, de dos normas contradictorias que pertenecen a algún nivel inferior se derivan algunas normas en contradicción con normas del nivel superior; así normas contradictorias no podrían ser admitidas en los niveles inferiore

Cristina Lafont sobre la completitud de la razón pública

In this paper, an orthogonal aspect of Lafont (2020) is analysed: her rejection of the Rawlsian thesis of completeness of public reason. For that purpose, such doctrine is succinctly presented and the generated debate too. Lafont’s account is introduced: public reason is not sufficient in some hard cases, but this insufficiency does not mean that we should resort to the comprehensive conceptions, we should looking for some kind of policy of accommodation. In the paper, instead, it is argued in favour of the completeness of public reason and an objection to the Lafont’s account is introduced.En este trabajo se analiza un aspecto ortogonal de Lafont (2020): su rechazo de la tesis rawlsiana de la completitud de la razón pública. Con tal fin, se presenta sucintamente dicha doctrina y el debate que ha generado. Se introduce la posición de Lafont: la razón pública no es suficiente en algunos casos difíciles; aunque ello no significa que debamos acudir a las concepciones comprehensivas, debemos buscar algún tipo de acomodo institucional. Aquí, en cambio, se arguye a favor de la completitud de la razón pública y se presenta una objeción a la posición de Lafont

Consistencia mediante jerarquía

En esta contribución intentaré mostrar que el criterio lex superior derogat legi inferiori conduce a una consecuencia que, al menos en lo que conozco, no ha sido todavía advertida. Si las normas de la máxima jerarquía de un sistema jurídico, verbigracia, normas constitucionales constituyen un conjunto consistente, entonces necesariamente el sistema jurídico es consistente. Dicho de otra manera, lex superior preserva necesariamente la consistencia. Si las normas del nivel más alto son miembros de un conjunto consistente, los niveles inferiores de la jerarquía no podrían admitir normas contradictorias con las superiores. Más aún, habida cuenta que de una contradicción se sigue cualquier norma, en virtud del principio lógico ex falso quodlibet, de dos normas contradictorias que pertenecen a algún nivel inferior se derivan algunas normas en contradicción con normas del nivel superior; así normas contradictorias no podrían ser admitidas en los niveles inferioresIn this contribution, I shall intend to show that the criterion lex superior derogat legi inferiori has a consequence which, as far as I know, has not been noted yet: if the higherlevel norms in a legal system, i.e. constitutional norms, configure a consistent set, then necessarily the legal system is consistent. Lex superior preserves necessarily the consistency, as it were. If higher-level norms are members of a consistent set, then the lower-levels could admit no norm in contradiction with the higher-level norms. Moreover, given that from a contradiction follows anything, in virtue of the logical principle ex falso quodlibet, from two contradictory lower-level norms follow some norms in contradiction with norms of the higher-level, thus contradictory norms could never be admit in the lower-levels

Impacto en los resultados de salud cardiovascular de la implantación del contrato de Dirección Clínica en atención primaria de Tarragona

ObjetivoLos objetivos del presente estudio son: a) determinar la mejora en la salud cardiovascular de una población tras la implantación del contrato de Dirección Clínica en los profesionales de los Equipos de Atención Primaria de Tarragona-Reus y Terres de l’Ebre (provincia de Tarragona), y b) identificar los factores predictivos que determinan una mejor salud cardiovascular tras la implantación del contrato de Dirección Clínica. La implantación del contrato de Dirección Clínica (basada en el liderazgo profesional, feedback de la información asistencial, control de los indicadores de riesgo cardiovascular basados en la evidencia científica concretadas en guías de práctica clínica) mejorará los resultados de salud cardiovascular de la población de referencia.DiseñoSe trata de un estudio antes-después y multicéntrico.EmplazamientoAtención primaria de salud.ParticipantesParticipan 30 centros de salud (totalidad de los centros de salud del ámbito de atención primaria del Institut Català de la Salut).Mediciones principalesCaracterísticas del centro. Variables de proceso: indicadores de buena práctica asistencial, cálculo del riesgo cardiovascular, aplicación de la guía de práctica clínica (hipertensión arterial, diabetes, dislipemia, tabaquismo y factores de riesgo cardiovascular), estándares de calidad de la prescripción farmacológica. Variables de resultados: cifras de riesgo cardiovascular, número de visitas en atención continuada, urgencias hospitalarias e ingresos por angina, infarto agudo de miocardio y accidente cerebrovascular, y cribados poblacionales de factores de riesgo.DiscusiónEste estudio es útil, ya que la dirección clinica pretende ser un motor para que los profesionales lideren la gestión asistencial y, mediante el control de indicadores y la «retroalimentación» de estos resultados a los profesionales, se mejore la calidad asistencial. Con este trabajo se pretende demostrar que una estrategia de gestión puede mejorar la salud cardiovascular de la población. La originalidad de este proyecto se basa en el desarrollo de una nueva herramienta de evaluación basada en una novedosa estrategia de gestión para medir resultados en salud cardiovascular.ObjectiveThe objectives of this study are: 1) to determine the improvement in the cardiovascular health of the population after the introduction of the clinical governance contract for primary care team professionals in Tarragona-Reus and the Terres de l’Ebre area (Tarragona province, Spain); 2) to identify the factors predictive of better cardiovascular health after the introduction of the clinical governance contract. The introduction of the clinical governance contract, which is based on professional leadership, feed-back of care information, and monitoring of indicators of cardiovascular risk based on scientific evidence and concretised in clinical practice guidelines, will improve the cardiovascular health results of the reference population. Improvements in indicators of procedure and result are specified in “Material and methods.”DesignThis is a before-and-after, multicentre study.SettingPrimary health care.ParticipantsTirty health centres (all the primary care Centres in the area).Main measurementsCharacteristics of the centre. Variables in procedures: indicators of good care practice, calculation of cardiovascular risk, application of clinical practice guidelines (hypertension, diabetes, lipaemia, tobacco and cardiovascular risk) and quality standards for drug prescription. Result variables: cardiovascular risk figures, number of ongoing care visits, hospital emergencies and admissions for angina, heart attack or stroke, and risk factor screenings of the population.DiscussionThis study is useful, in that clinical governance aims to be a dynamic device to bring professionals into the leadership of health care management and, through monitoring indicators and feeding the findings back to the professionals, to improve health care quality. The study aims to show that management strategy can improve the populatiońs cardiovascular health. The originality of the study lies in the development of a new tool of evaluation based on a novel management strategy for measuring cardiovascular health findings

Cellular Immunity to Predict the Risk of Cytomegalovirus Infection in Kidney Transplantation: A Prospective, Interventional, Multicenter Clinical Trial

Background: Improving cytomegalovirus (CMV) immune-risk stratification in kidney transplantation is highly needed to establish guided preventive strategies. Methods: This prospective, interventional, multicenter clinical trial assessed the value of monitoring pretransplant CMV-specific cell-mediated immunity (CMI) using an interferon-γrelease assay to predict CMV infection in kidney transplantation. One hundred sixty donor/recipient CMV-seropositive (D+/R+) patients, stratified by their baseline CMV (immediate-early protein 1)-specific CMI risk, were randomized to receive either preemptive or 3-month antiviral prophylaxis. Also, 15-day posttransplant CMI risk stratification and CMI specific to the 65 kDa phosphoprotein (pp65) CMV antigen were investigated. Immunosuppression consisted of basiliximab, tacrolimus, mycophenolate mofetil, and corticosteroids in 80% of patients, whereas 20% received thymoglobulin induction therapy. Results: Patients at high risk for CMV based on pretransplant CMI developed significantly higher CMV infection rates than those deemed to be at low risk with both preemptive (73.3% vs 44.4%; odds ratio [OR], 3.44 [95% confidence interval {CI}, 1.30-9.08]) and prophylaxis (33.3% vs 4.1%; OR, 11.75 [95% CI, 2.31-59.71]) approaches. The predictive capacity for CMV-specific CMI was only found in basiliximab-treated patients for both preemptive and prophylaxis therapy. Fifteen-day CMI risk stratification better predicted CMV infection (81.3% vs 9.1%; OR, 43.33 [95% CI, 7.89-237.96]). Conclusions: Pretransplant CMV-specific CMI identifies D+/R+ kidney recipients at high risk of developing CMV infection if not receiving T-cell-depleting antibodies. Monitoring CMV-specific CMI soon after transplantation further defines the CMV infection prediction risk. Monitoring CMV-specific CMI may guide decision making regarding the type of CMV preventive strategy in kidney transplantation. Clinical Trials Registration: NCT02550639

High intrapatient variability of tacrolimus exposure associated with poorer outcomes in liver transplantation

Liver transplantation; Tacrolimus; Liver diseasesTrasplante de hígado; Tacrolimús; Enfermedades del hígadoTrasplantament hepàtic; Tacrolimús; Malalties del fetgeTacrolimus (TAC) is a dose-dependent immunosuppressor with considerable intrapatient variability (IPV) in its pharmacokinetics. The aim of this work is to ascertain the association between TAC IPV at 6 months after liver transplantation (LT) and patient outcome. This single-center cohort study retrospectively analyzed adult patients who underwent transplantation from 2015 to 2019 who survived the first 6 months with a functioning graft. The primary end point was the patient’s probability of death and the secondary outcome was the loss of renal function between month 6 and the last follow-up. TAC IPV was estimated by calculating the coefficient of variation (CV) of the dose-corrected concentration (C0/D) between the third and sixth months post-LT. Of the 140 patients who underwent LT included in the study, the low-variability group (C0/D CV < 27%) comprised 105 patients and the high-variability group (C0/D CV ≥ 27%) 35 patients. One-, 3-, and 5-year patient survival rates were 100%, 82%, and 72% in the high-variability group versus 100%, 97%, and 93% in the low-variability group, respectively (p = 0.005). Moreover, significant impaired renal function was observed in the high-variability group at 1 year (69 ± 16 ml/min/1.73 m2 vs. 78 ± 16 ml/min/1.73 m2, p = 0.004) and at 2 years post-LT (69 ± 17 ml/min/1.73 m2 vs. 77 ± 15 ml/min/1.73 m2, p = 0.03). High C0/D CV 3–6 months remained independently associated with worse survival (hazard ratio = 3.57, 95% CI = 1.32–9.67, p = 0.012) and loss of renal function (odds ratio = 3.47, 95% CI = 1.30–9.20, p = 0.01). Therefore, high IPV between the third and sixth months appears to be an early and independent predictor of patients with poorer liver transplant outcomes.Isabel Campos-Varela’s research activity is funded by grant PI19/00330 from Instituto de Salud Carlos III. CIBERehd is supported by Instituto de Salud Carlos III. The work was independent of all funding