[Determinants of the use of different healthcare levels in the General System of Social Security in Health in Colombia and the Unified Health System in Brazil].

OBJECTIVE: To compare the use of different healthcare levels, and its determinants, in two different health systems, the General System of Social Security in Health (GSSSH) and the Unified Health System (UHS) in municipalities in Colombia and Brazil. METHODS: A cross-sectional study was carried out, based on a population survey in two municipalities in Colombia (n=2163) and two in Brazil (n=2155). Outcome variables consisted of the use of primary care services, outpatient secondary care services, and emergency care in the previous 3 months. Explanatory variables were need and predisposing and enabling factors. Bivariate and multivariate logistic regression analyses were performed by healthcare level and country. RESULTS: The determinants of use differed by healthcare level and country: having a chronic disease was associated with a greater use of primary and outpatient secondary care in Colombia, and was also associated with the use of emergency care in Brazil. In Colombia, persons enrolled in the contributory scheme more frequently used the services of the GSSSH than persons enrolled with subsidized contributions in primary and outpatient secondary care and more than persons without insurance in any healthcare level. In Brazil, the low-income population and those without private insurance more frequently used the UHS at any level. In both countries, the use of primary care was increased when persons knew the healthcare center to which they were assigned and if they had a regular source of care. Knowledge of the referral hospital increased the use of outpatient secondary care and emergency care. CONCLUSIONS: In both countries, the influence of the determinants of use differed according to the level of care used, emphasizing the need to analyze healthcare use by disaggregating it by level of care

Mortes evitáveis em vítimas com traumatismos

OBJETIVO: Descrever métodos e estimativas de mortalidade proporcional por mortes evitáveis e tipos de não conformidades do atendimento relacionadas a esses eventos. MÉTODOS: Revisão sistemática de publicações sobre mortes evitáveis em vítimas com traumatismos entre 2000 e 2009. Foi realizada pesquisa nas bases de dados Lilacs, SciELO e Medline utilizando-se a estratégia de busca com as palavras-chave "trauma", "avoidable", "preventable", "interventions" e "complications", e os descritores em ciências da saúde "death", "cause of death" e "hospitals". RESULTADOS: Identificaram-se 29 artigos publicados no período, com predomínio de estudos retrospectivos (96,5%). Os métodos mais comumente utilizados para definir a evitabilidade do óbito foram painel de especialistas ou pontuação de índices de gravidade, tendo sido empregadas as seguintes categorias: evitável, potencialmente evitável e não evitável. A média da mortalidade proporcional por mortes evitáveis dos estudos foi de 10,7% (dp 11,5%). As não conformidades mais comumente relatadas nas publicações foram sistema inadequado de atendimento ao traumatizado e erro na avaliação e tratamento. CONCLUSÕES: Observaram-se falhas na uniformização dos termos empregados para categorizar as mortes e as não conformidadades encontradas. Portanto, sugere-se a padronização da taxonomia da classificação das mortes e dos tipos de não conformidades observadas

Formin Homology 2 Domain Containing 3 (FHOD3) Is a Genetic Basis for Hypertrophic Cardiomyopathy

BACKGROUND: The genetic cause of hypertrophic cardiomyopathy remains unexplained in a substantial proportion of cases. Formin homology 2 domain containing 3 (FHOD3) may have a role in the pathogenesis of cardiac hypertrophy but has not been implicated in hypertrophic cardiomyopathy. OBJECTIVES: This study sought to investigate the relation between FHOD3 mutations and the development of hypertrophic cardiomyopathy. METHODS: FHOD3 was sequenced by massive parallel sequencing in 3,189 hypertrophic cardiomyopathy unrelated probands and 2,777 patients with no evidence of cardiomyopathy (disease control subjects). The authors evaluated protein-altering candidate variants in FHOD3 for cosegregation, clinical characteristics, and outcomes. RESULTS: The authors identified 94 candidate variants in 132 probands. The variants' frequencies were significantly higher in patients with hypertrophic cardiomyopathy (74 of 3,189 [2.32%]) than in disease control subjects (18 of 2,777 [0.65%]; p < 0.001) or in the gnomAD database (1,049 of 138,606 [0.76%]; p < 0.001). FHOD3 mutations cosegregated with hypertrophic cardiomyopathy in 17 families, with a combined logarithm of the odds score of 7.92, indicative of very strong segregation. One-half of the disease-causing variants were clustered in a small conserved coiled-coil domain (amino acids 622 to 655); odds ratio for hypertrophic cardiomyopathy was 21.8 versus disease control subjects (95% confidence interval: 1.3 to 37.9; p < 0.001) and 14.1 against gnomAD (95% confidence interval: 6.9 to 28.7; p < 0.001). Hypertrophic cardiomyopathy patients carrying (likely) pathogenic mutations in FHOD3 (n = 70) were diagnosed after age 30 years (mean 46.1 ± 18.7 years), and two-thirds (66%) were males. Of the patients, 82% had asymmetric septal hypertrophy (mean 18.8 ± 5 mm); left ventricular ejection fraction <50% was present in 14% and hypertrabeculation in 16%. Events were rare before age 30 years, with an annual cardiovascular death incidence of 1% during follow-up. CONCLUSIONS: FHOD3 is a novel disease gene in hypertrophic cardiomyopathy, accounting for approximately 1% to 2% of cases. The phenotype and the rate of cardiovascular events are similar to those reported in unselected cohorts. The FHOD3 gene should be routinely included in hypertrophic cardiomyopathy genetic testing panels

Cooperative management and its effects on shade tree diversity, soil properties and ecosystem services of coffee plantations in western El Salvador

We compared how management approaches affected shade tree diversity, soil properties, and provisioning and carbon sequestration ecosystem services in three shade coffee cooperatives. Collectively managed cooperatives utilized less diverse shade, and pruned coffee and shade trees more intensively, than individual farms. Soil properties showed significant differences among the cooperatives, with the following properties contributing to differentiation: N, pH, P, K, and Ca. Higher tree richness was associated with higher soil pH, CEC, Ca, and Mg, and lower K. Higher tree densities were associated with lower N, K, and organic matter. Although we found differences in the incidence of provisioning services (e.g., fruit), all plantations generated products other than coffee. No differences were observed between C-stocks. The history and institutional arrangements of cooperatives can influence management approaches, which affect ecosystem properties and services. Our study corroborates that interdisciplinary investigations are essential to understand the socio-ecological context of tropical shade coffee landscapes

Percepciones de continuidad de la atención por parte de los usuarios de los sistemas de salud en Colombia y Brasil: M Luisa Vázquez

Antecedentes La continuidad de la atención (CC) es el grado en que el paciente experimenta la atención con el tiempo como coherente y vinculada. Se identifican tres tipos de CC: relacional, informativo y gerencial. El objetivo es determinar el grado de continuidad de la atención entre la atención primaria (PC) y la atención secundaria (SC) e identificar los factores asociados en Brasil y Colombia, países con diferentes sistemas de salud. Métodos Estudio transversal mediante una encuesta de población en Brasil (Pernambuco, n = 465) y Colombia (Bogotá, n = 609) en 2011. Se analizaron los usuarios de los servicios de salud de los sistemas de salud pública de cada país. Variables de resultado: índices sintéticos en CC relacional, informativo y gerencial. Variables explicativas: características sociodemográficas y salud. Se realizaron análisis descriptivos y modelos de regresión logística multivariante. Resultados El CC relacional fue mayor en Brasil que en Colombia tanto para los médicos de PC (82.2 y 72.9%, respectivamente) como para los médicos de SC (82.4 y 70.1%, respectivamente), pero la percepción de una buena transferencia de información (CC informativo) es menor (56.3 y 67.6%, respectivamente). No se encontraron diferencias en la percepción de consistencia de la atención (CC gerencial) (alrededor del 70%). Entre los factores asociados con CC, se destacan los siguientes: en Brasil, la edad (ancianos) y el área (Caruaru, ciudad remota) se asociaron con cualquier tipo de CC. En ambos países, la mala salud autoevaluada se asoció con niveles más bajos de CC relacional y en Colombia, también, con el control clínico CC. Además, en Colombia, Conclusiones El nivel de continuidad relacional y gerencial percibida es alto, y de continuidad informativa, baja. Los factores asociados con la percepción de la continuidad de la atención difieren según el país y el tipo de continuidad de la atención. Mensajes clave Es el primer intento de evaluar los tres tipos de continuidad de la atención en áreas de Colombia y Brasil. La comprensión de los factores asociados con la continuidad de la atención revelará qué aspectos del sistema de salud pública podrían mejorarse.Background Continuity of care (CC) is the degree to which the patient experiences care over time as coherent and linked. Three types of CC are identified: relational, informational and managerial. The aim is to determine the degree of continuity of care between primary (PC) and secondary care (SC) and to identify the associated factors in Brazil and Colombia, countries with different health systems. Methods Cross-sectional study by means of a population survey in Brazil (Pernambuco, n = 465) and Colombia (Bogota, n = 609) in 2011. Users of health services of public health systems of each country were analyzed. Outcome variables: synthetic indexes on relational, informational and managerial CC. Explanatory variables: sociodemographic characteristics and health. Descriptive analysis and multivariate logistic regression models were performed. Results Relational CC was higher in Brazil than in Colombia both for PC physicians (82.2 and 72.9%, respectively) and for SC physicians (82.4 and 70.1%, respectively), but the perception of a good information transfer (informational CC) is lower (56.3 and 67.6%, respectively). No differences in the perception of consistency of care (managerial CC) were found (around 70%). Among the associated factors with CC, the following stand out: in Brazil, age (elderly) and area (Caruaru, remote town) was associated with any type of CC. In both countries, poor self-rated health was associated with lower levels of relational CC and in Colombia, also, with clinical management CC. In addition, in Colombia, having at least one chronic disease was associated with higher levels of any type of CC and sex (female) with a continuous relationship with PC physicians and informational CC. Conclusions The level of perceived relational and managerial continuity is high, and of informational continuity, low. Factors associated with the perception of continuity of care differ by countries and type of continuity of care. Key messages It is the first attempt to evaluate the three types of continuity of care in areas of Colombia and Brazil The understanding of the factors associated with the continuity of care will reveal which aspects of the public health system could be improve

Validación de la versión brasileña y colombiana de la escala CCAENA (continuidad de la atención en todos los niveles de atención): Irene Garcia-Subirats

Introducción El cuestionario de continuidad de la atención en todos los niveles de atención (CCAENA en español) evalúa los tres tipos de continuidad de la atención (relacional, informativa, gerencial) en todos los niveles de atención desde la perspectiva del paciente. Había sido validado para el contexto sanitario español. Objetivo: evaluar las propiedades psicométricas de la versión abreviada de la escala CCAENA en el contexto colombiano y brasileño. Métodos Estudio transversal mediante encuesta de población en municipios de Colombia (n = 2,163) y Brasil (n = 2,167). Los datos se recopilaron en 2011 mediante un cuestionario que incluía 14 ítems de la escala CCAENA adaptados a ambos contextos (y traducidos). Se evaluaron la validez de constructo (análisis factorial exploratorio), la consistencia interna (alfa de Cronbach) y la multidimensionalidad (coeficientes de correlación de Spearman). Resultados Al igual que en la versión original, el análisis factorial mostró que los ítems se agruparon en tres factores: la continuidad entre los niveles de atención y la relación entre el proveedor de atención primaria y el proveedor de atención secundaria. El alfa de Cronbach indicó una buena consistencia interna (Colombia: 0.87, 0.91, 0.87; Brasil: 0.86, 0.89, 0.86). Los coeficientes de correlación sugieren que los tres factores pueden interpretarse como escalas separadas (<0.70). Conclusión La validez y la confiabilidad de la versión abreviada de CCAENA son adecuadas en ambos países, manteniendo una alta equivalencia con la versión original, por lo tanto, es una herramienta útil para evaluar la continuidad de la atención en estos contextos. Mensajes clave Este estudio demuestra buenas propiedades psicométricas (validez y confiabilidad) de la versión abreviada de la escala CCAENA adaptada al contexto colombiano y brasileño. Esta herramienta será útil para proveedores e investigaciones para evaluar los tres tipos de continuidad de la atención en todos los niveles de atención desde la perspectiva del paciente en Colombia y Brasil. The Author 2014. Publicado por Oxford University Press en nombre de la Asociación Europea de Salud Pública. Todos los derechos reservados.Introduction The questionnaire of continuity of care across care levels (CCAENA in Spanish) assesses the three types of continuity of care (relational, informational, managerial) across care levels from the patient’s perspective. It had been validated for the Spanish health care context. Objective: To evaluate the psychometric properties of shortened version of the CCAENA scale in the Colombian and Brazilian context. Methods Cross-sectional study by means of a population survey in municipalities of Colombia (n = 2,163) and Brazil (n = 2,167). Data were collected in 2011 using a questionnaire that included 14 items of the CCAENA scale adapted to both contexts (and translated). Construct validity (exploratory factor analysis), internal consistency (Cronbach’s alpha) and multidimensionality (Spearman correlation coefficients) were assessed. Results As in the original version, the factor analysis showed that the items grouped into three factors: continuity across care levels and patient-primary care provider and -secondary care provider relationship. Cronbach’s alpha indicated good internal consistency (Colombia: 0.87, 0.91, 0.87; Brazil: 0.86, 0.89, 0.86). The correlation coefficients suggest that the three factors can be interpreted as separated scales (<0.70). Conclusion Validity and reliability of the shortened version of CCAENA are adequate in both countries – maintaining high equivalence with the original version – thus, is a useful tool to assess continuity of care in these contexts. Key messages This study demonstrates good psychometric properties - validity and reliability- of the shortened version of CCAENA scale adapted to the Colombian and Brazilian context. This tool will be useful for providers and researches to assess the three types of continuity of care across care levels from the patient’s perspective in Colombia and Brazil. The Author 2014. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved

Efectividad de las estrategias de integración asistencial en los sistemas de salud de América Latina: estudio EQUITY-LA II: Ingrid Vargas Lorenzo

Introducción Aunque la fragmentación en la provisión de atención médica se considera un obstáculo importante para una atención efectiva, la evidencia sobre las mejores prácticas en la coordinación de la atención en América Latina es escasa. El objetivo del proyecto Equity-LA financiado por el 7PM es evaluar la efectividad de diferentes estrategias de integración de la atención para mejorar la coordinación entre los niveles de atención y la calidad de la atención relacionada en seis sistemas de atención médica: Argentina, Brasil, Chile, Colombia, México y Uruguay. Métodos y análisis: Un estudio cuasi experimental controlado antes y después que toma un enfoque de investigación de acción participativa. En cada país, se seleccionaron dos redes sanitarias comparables (intervención y control). El estudio consta de cuatro fases: 1) Estudio de línea de base para establecer el desempeño de la red en la coordinación y continuidad de la atención, utilizando a) métodos cualitativos: entrevistas semiestructuradas y grupos focales de administradores de salud, profesionales y usuarios; yb) métodos cuantitativos: dos encuestas por cuestionario con muestras de 173 médicos de atención primaria y secundaria y 392 usuarios con afecciones crónicas por red; tamaño de muestra calculado para detectar una diferencia de proporción de 15% y 10%, antes y después de la intervención (? = 0.05; ? = 0.2 en una prueba de dos lados); 2) Selección participativa ascendente, diseño e implementación de estrategias de atención compartida, un proceso dirigido por el comité directivo local; 3) Evaluación de la efectividad de las intervenciones que aplican el mismo diseño que en el estudio de línea de base y los factores asociados; 4) Análisis comparativo entre países. Resultados y relevancia El proyecto generará evidencia para informar la formulación de políticas sobre las mejores prácticas de integración entre la atención primaria y secundaria en diferentes tipos de sistemas de salud en América Latina, con especial referencia a las enfermedades crónicas, y sobre el efecto de los nuevos enfoques organizacionales en la calidad de la atención, en diferentes contextos de asistencia sanitaria también relevantes para los sistemas sanitarios europeos. Mensajes clave Existe poca evidencia sobre las mejores prácticas en coordinación de la atención en América Latina Los resultados sobre la coordinación de la atención pueden depender del factor contextual y del proceso. The Author 2015. Publicado por Oxford University Press en nombre de la Asociación Europea de Salud Pública. Todos los derechos reservados.Introduction Although fragmentation in the provision of health care is considered an important obstacle to effective care, evidence on best practices in care coordination in Latin America is scant. The aim of the FP7 funded Equity-LA project is to evaluate the effectiveness of different care integration strategies in improving coordination across care levels and related care quality in six healthcare systems: Argentina, Brazil, Chile, Colombia, México and Uruguay. Methods and analysis: A controlled before and after quasi-experimental study taking a participatory action research approach. In each country, two comparable healthcare networks (intervention and control) were selected. The study consists of four phases: 1) Base-line study to establish network performance in care coordination and continuity, using a) qualitative methods - semi-structured interviews and focus groups of health managers, professionals and users; and b) quantitative methods - two questionnaire surveys with samples of 173 primary and secondary care physicians and 392 users with chronic conditions per network; sample size calculated to detect a proportion difference of 15% and 10%, before and after intervention (? = 0.05; ? = 0.2 in a two-sided test); 2) Bottom-up participatory selection, design and implementation of shared care strategies, a process led by the local steering committee; 3) Evaluation of the effectiveness of interventions applying the same design as in the base-line study and associated factors; 4) Cross-country comparative analysis. Results and relevance The project will generate evidence to inform policy making on best practices of integration between primary and secondary care in different types of health systems in Latin America, with particular reference to chronic diseases, and on the effect of new organisational approaches on quality of care, in different health care contexts also relevant for European healthcare systems. Key messages There is scant evidence on best practices in care coordination in Latin America Results on care coordination might depend on contextual and process factor The Author 2015. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved

Global diffusive fluxes of methane in marine sediments

Anaerobic oxidation of methane provides a globally important, yet poorly constrained barrier for the vast amounts of methane produced in the subseafloor. Here we provide a global map and budget of the methane flux and degradation in diffusion-controlled marine sediments in relation to the depth of the methane oxidation barrier. Our new budget suggests that 45-61 Tg of methane are oxidized with sulfate annually, with approximately 80% of this oxidation occurring in continental shelf sediments (<200 m water depth). Using anaerobic oxidation as a nearly quantitative sink for methane in steady-state diffusive sediments, we calculate that ∼3-4% of the global organic carbon flux to the seafloor is converted to methane. We further report a global imbalance of diffusive methane and sulfate fluxes into the sulfate-methane transition with no clear trend with respect to the corresponding depth of the methane oxidation barrier. The observed global mean net flux ratio between sulfate and methane of 1.4:1 indicates that, on average, the methane flux to the sulfate-methane transition accounts for only ∼70% of the sulfate consumption in the sulfate-methane transition zone of marine sediments

Mutations in TRIM63 cause an autosomal-recessive form of hypertrophic cardiomyopathy

Objective: Up to 50% of patients with hypertrophic cardiomyopathy (HCM) show no disease-causing variants in genetic studies. TRIM63 has been suggested as a candidate gene for the development of cardiomyopathies, although evidence for a causative role in HCM is limited. We sought to investigate the relationship between rare variants in TRIM63 and the development of HCM. / Methods: TRIM63 was sequenced by next generation sequencing in 4867 index cases with a clinical diagnosis of HCM and in 3628 probands with other cardiomyopathies. Additionally, 3136 index cases with familial cardiovascular diseases other than cardiomyopathy (mainly channelopathies and aortic diseases) were used as controls. / Results: Sixteen index cases with rare homozygous or compound heterozygous variants in TRIM63 (15 HCM and one restrictive cardiomyopathy) were included. No homozygous or compound heterozygous were identified in the control population. Familial evaluation showed that only homozygous and compound heterozygous had signs of disease, whereas all heterozygous family members were healthy. The mean age at diagnosis was 35 years (range 15–69). Fifty per cent of patients had concentric left ventricular hypertrophy (LVH) and 45% were asymptomatic at the moment of the first examination. Significant degrees of late gadolinium enhancement were detected in 80% of affected individuals, and 20% of patients had left ventricular (LV) systolic dysfunction. Fifty per cent had non-sustained ventricular tachycardia. Twenty per cent of patients suffered an adverse cerebrovascular event (20%). / Conclusion: TRIM63 appears to be an uncommon cause of HCM inherited in an autosomal-recessive manner and associated with concentric LVH and a high rate of LV dysfunction