Assessing Value-based Health Care Delivery for Hemodialysis

Rationale, aims and objectives Disparities in haemodialysis outcomes among centres have been well-documented. Besides, attempts to assess haemodialysis results have been based on non-comprehensive methodologies. This study aimed to develop a comprehensive methodology for assessing haemodialysis centres, based on the value of health care. The value of health care is defined as the patient benefit from a specific medical intervention per monetary unit invested (Value = Patient Benefit/Cost). This study assessed the value of health care and ranked different haemodialysis centres. Method A nephrology quality management group identified the criteria for the assess- ment. An expert group composed of stakeholders (patients, clinicians and managers) agreed on the weighting of each variable, considering values and preferences. Multi-criteria methodology was used to analyse the data. Four criteria and their weights were identified: evidence-based clinical performance measures = 43 points; yearly mortality = 27 points; patient satisfaction = 13 points; and health-related quality of life = 17 points (100-point scale). Evidence-based clinical performance measures included five sub-criteria, with respective weights, including: dialysis adequacy; haemoglobin concentration; mineral and bone disorders; type of vascular access; and hospitalization rate. The patient benefit was determined from co-morbidity–adjusted results and corresponding weights. The cost of each centre was calculated as the average amount expended per patient per year. Results The study was conducted in five centres (1–5). After adjusting for co-morbidity, value of health care was calculated, and the centres were ranked. A multi-way sensitivity analysis that considered different weights (10–60% changes) and costs (changes of 10% in direct and 30% in allocated costs) showed that the methodology was robust. The rankings: 4-5-3-2-1 and 4-3-5-2-1 were observed in 62.21% and 21.55%, respectively, of simula- tions, when weights were varied by 60%. Conclusions Value assessments may integrate divergent stakeholder perceptions, create a context for improvement and aid in policy-making decisions

Taphonomic and spatial analyses from the Early Pleistocene site of Venta Micena 4 (Orce, Guadix-Baza Basin, southern Spain)

Venta Micena is an area containing several palaeontological sites marking the beginning of the Calabrian stage (Early Pleistocene). The richness of the fossil accumulation including species of Asian, African and European origin, makes Venta Micena a key site for the the palaeoecological and palaeoenvironmental study of southern Europe during the Early Pleistocene. Thus, research has been focused on Venta Micena 3, which was originally interpreted as a single palaeosurface associated with a marshy context, in which most of the fauna was accumulated by Pachycrocuta brevirostris. Recent excavations have unearthed a new site, Venta Micena 4, located in the same stratigraphic unit (Unit C) and in close proximity to Venta Micena 3. Here we show the first analyses regarding the taphonomic and spatial nature of this new site, defining two stratigraphic boundaries corresponding to two different depositional events. Furthermore, the taphonomic analyses of fossil remains seem to indicate a different accumulative agent than Pachycrocuta, thus adding more complexity to the palaeobiological interpretation of the Venta Micena area. These results contribute to the discussion of traditional interpretations made from Venta Micena 3. © 2021, The Author(s)

Palynology and chronology of hyaena coprolites from the Piñar karstic Caves Las Ventanas and Carihuela, southern Spain

This paper presents pollen analyses and radiocarbon dating on Crocuta coprolites from Las Ventanas (LV) and Carihuela (Car) Caves in southern Spain (Granada), with the aim of reconstructing the environmental conditions of these hominin sites. The LV coprolites are radiocarbon dated from c. 37,890 to 6980 cal yr BP, and the Car coprolites from c. 31,063 to 7861 cal yr BP. Overall, the palaeoecological scenario inferred from both coprolite series display similar patterns, with Pinus, Poaceae, and Artemisia as dominant during the full Pleistocene, and an important contribution of Quercus in the most recently dated coprolite samples. While the palynology is consistent with results of former investigations on the past environments in the region as obtained from other deposits (peat bogs, cave infills), the Late Glacial and Holocene chronology of several coprolites in both sites is in conflict with the generally accepted timing of extinction of Crocuta in western Europe. A discussion on the taphonomical processes and potential sources of carbon contamination of the radiocarbon samples is provided. The correlation between pollen from coprolites and from sedimentary records, and the paucity of the fossil bone record suggests nevertheless, that a late survival of Crocuta in southern Spain should not be categorically discarded

Effectiveness and safety of first-generation protease inhibitors in clinical practice: Hepatitis C virus patients with advanced fibrosis

AIM: To evaluates the effectiveness and safety of the first generation, NS3/4A protease inhibitors (PIs) in clinical practice against chronic C virus, especially in patients with advanced fibrosis. METHODS: Prospective study and non-experimental analysis of a multicentre cohort of 38 Spanish hospitals that includes patients with chronic hepatitis C genotype 1, treatment-nai¨ve (TN) or treatment-experienced (TE), who underwent triple therapy with the first generation NS3/4A protease inhibitors, boceprevir (BOC) and telaprevir (TVR), in combination with pegylated interferon and ribavirin. The patients were treatment in routine practice settings. Data on the study population and on adverse clinical and virologic effects were compiled during the treatment period and during follow up. RESULTS: One thousand and fifty seven patients were included, 405 (38%) were treated with BOC and 652 (62%) with TVR. Of this total, 30% (n = 319) were TN and the remaining were TE: 28% (n = 298) relapsers, 12% (n = 123) partial responders (PR), 25% (n = 260) null-responders (NR) and for 5% (n = 57) with prior response unknown. The rate of sustained virologic response (SVR) by intention-to-treatment (ITT) was greater in those treated with TVR (65%) than in those treated with BOC (52%) (P < 0.0001), whereas by modified intention-to-treatment (mITT) no were found significant differences. By degree of fibrosis, 56% of patients were F4 and the highest SVR rates were recorded in the non-F4 patients, both TN and TE. In the analysis by groups, the TN patients treated with TVR by ITT showed a higher SVR (P = 0.005). However, by mITT there were no significant differences between BOC and TVR. In the multivariate analysis by mITT, the significant SVR factors were relapsers, IL28B CC and non-F4; the type of treatment (BOC or TVR) was not significant. The lowest SVR values were presented by the F4-NR patients, treated with BOC (46%) or with TVR (45%). 28% of the patients interrupted the treatment, mainly by non-viral response (51%): this outcome was more frequent in the TE than in the TN patients (57% vs 40%, P = 0.01). With respect to severe haematological disorders, neutropaenia was more likely to affect the patients treated with BOC (33% vs 20%, P = 0.0001), and thrombocytopaenia and anaemia, the F4 patients (P = 0.000, P = 0.025, respectively). CONCLUSION: In a real clinical practice setting with a high proportion of patients with advanced fibrosis, effectiveness of first-generation PIs was high except for NR patients, with similar SVR rates being achieved by BOC and TVR

RICORS2040 : The need for collaborative research in chronic kidney disease

Chronic kidney disease (CKD) is a silent and poorly known killer. The current concept of CKD is relatively young and uptake by the public, physicians and health authorities is not widespread. Physicians still confuse CKD with chronic kidney insufficiency or failure. For the wider public and health authorities, CKD evokes kidney replacement therapy (KRT). In Spain, the prevalence of KRT is 0.13%. Thus health authorities may consider CKD a non-issue: very few persons eventually need KRT and, for those in whom kidneys fail, the problem is 'solved' by dialysis or kidney transplantation. However, KRT is the tip of the iceberg in the burden of CKD. The main burden of CKD is accelerated ageing and premature death. The cut-off points for kidney function and kidney damage indexes that define CKD also mark an increased risk for all-cause premature death. CKD is the most prevalent risk factor for lethal coronavirus disease 2019 (COVID-19) and the factor that most increases the risk of death in COVID-19, after old age. Men and women undergoing KRT still have an annual mortality that is 10- to 100-fold higher than similar-age peers, and life expectancy is shortened by ~40 years for young persons on dialysis and by 15 years for young persons with a functioning kidney graft. CKD is expected to become the fifth greatest global cause of death by 2040 and the second greatest cause of death in Spain before the end of the century, a time when one in four Spaniards will have CKD. However, by 2022, CKD will become the only top-15 global predicted cause of death that is not supported by a dedicated well-funded Centres for Biomedical Research (CIBER) network structure in Spain. Realizing the underestimation of the CKD burden of disease by health authorities, the Decade of the Kidney initiative for 2020-2030 was launched by the American Association of Kidney Patients and the European Kidney Health Alliance. Leading Spanish kidney researchers grouped in the kidney collaborative research network Red de Investigación Renal have now applied for the Redes de Investigación Cooperativa Orientadas a Resultados en Salud (RICORS) call for collaborative research in Spain with the support of the Spanish Society of Nephrology, Federación Nacional de Asociaciones para la Lucha Contra las Enfermedades del Riñón and ONT: RICORS2040 aims to prevent the dire predictions for the global 2040 burden of CKD from becoming true

Aspectos metabólicos y nutricionales en el paciente quirúrgico

Cada día se presta una mayor atención a los aspectos nutricionales en el ejercicio clínico de la cirugía. La malnutrición se considera como uno de los factores que influyen sobre la mortalidad y morbilidad en el paciente quirúrgico, representando para éste un riesgo adicional debido a la incompetencia inmunológica y a los trastornos en la curación de las heridas o las anastomosis. El paciente operado se encuentra sujeto a una situación de ayuno, más o menos prolongado, y a un estado de agresión traumática. Metabólicamente existe un hipercatabolismo, cuyo origen se debe a la disminución del ingreso, aumento de las necesidades, disminución del aprovechamiento y aumento de las pérdidas nutritivas. Es esencial que el cirujano conozca adecuadamente los cambios metabólicos y endocrinos fundamentales asociados con la cirugía, y que esté bien informado sobre los métodos disponibles para suprimir o mejorar los problemas derivados de dichas alteraciones. La corrección o la prevención de una malnutrición global en el enfermo quirúrgico exige generalmente el empleo de formas de nutrición artificial. En estos casos, el aporte necesario de principios inmediatos, únicamente se consigue de una forma fiable utilizando sustratos nutritivos especiales que se administran a través de una sonda o de un catéter venoso central (nutrición parenteral total). La nutrición por vía digestiva (nutrición enteral) o por una vía venosa periférica está justificada sólo en casos excepcionales. Finalmente, los pacientes que reciben nutrición artificial requieren una vigilancia cuidadosa, con especial atención al estado metabólico y al balance de líquidos y electrólitos. Es necesario establecer un protocolo y seguirlo para tener la seguridad de que se alcanzan las metas nutricionales con el menor número posible de complicaciones

Sexual dimorphism in the vertebral wedging of the human lumbar vertebrae and its importance as a comparative framework for understanding the wedging pattern of Neanderthals

Lumbar lordosis is a key element of the upright posture, being interpreted as a consequence of bipedal locomotion. There is consensus that the generic modern human pattern of metameric vertebral body wedging is sexually dimorphic in modern humans. However, recently published studies have compared this pattern with other hominins, such as Neanderthals. These tried to establish whether the (male) Neanderthal lumbar vertebrae express a pattern that falls within or outside the range of modern human males. In the present study, data collected by 3D landmarks of the lumbar vertebrae of modern humans from different geographic regions and Neanderthals (Ntotal = 505 individual vertebrae) are used to clarify this problem, observing a similarity of the generic human pattern but with some interspecific differences in the pattern in the upper and lower lumbar vertebrae. Thus, the vertebral bodies L1-L3 of Neanderthals are more ventrally-wedged than in male modern humans, whilst the L4-L5 vertebral bodies of Neanderthal show a more progressive increase of dorsal wedging than in modern human males. The obtained results support modularity of the lumbar spine with different patterns in its upper and lower parts, and add that human geographic variability must be taken into account when carrying out comparisons of Neanderthals and modern humans. Our findings make clear the need to investigate this matter in more detail including complementary methods. Finally, key issues concerning the choice of measurement are discussed and recommendations made about how much inference can be made about complex systems such as the lumbar spine based on single linear measurements.The “Juan de la Cierva Formación” program (FJCI-2017-32157), from the Spanish Ministry of Science, Innovation, and Universities, funds DGM. The Virtual Morphology Lab (MNCN-CSIC) was funded by the projects CGL2012-37279 and, from the Ministry of Economy, Industry and Competitiveness (Spain). The Laboratorio de Poblaciones del Pasado (LAPP) has been supported by Projects HAR2016‐78036‐P, HAR2016‐74846‐P, HAR2017‐82755‐P, and HAR2017‐83004‐P (Spanish Government) and a grant (Ref. 38360) from the Leakey Foundation

La Zona de Galicia – Ossa-Morena: una nueva zona del Macizo Ibérico

Trabajo presentado en el IX Congreso Geológico de España, celebrado en Huelva (España), del 12 al 14 de septiembre de 2016[EN] Correlation of a group of allochthonous terranes (referred to as basal, ophiolitic and upper units) exposed in the NW and SW of the Iberian Massif, is used to propose a new geotectonic zone in the southern branch of the Variscan Orogen: the Galicia - Ossa-Morena Zone. Recent advances in SW Iberia identify most of the former Ossa-Morena Zone as another allochthonous complex of the Iberian Massif, the Ossa-Morena Complex, equivalent to the Cabo Ortegal, Órdenes, Malpica-Tui, Bragança and Morais complexes described in NW Iberia. The new geotectonic zone and its counterparts along the rest of the Variscan Orogen constitute an Internal Variscan Zone with ophiolites and units affected by high-P metamorphism. The Galicia - Ossa-Morena Zone includes a Variscan suture and pieces of continental crust bearing the imprint of Ediacaran-Cambrian events related to the activity of peri-Gondwanan magmatic arcs (Cadomian orogenesis). In the Iberian Massif, the general structure of this geotectonic zone represents a duplication of the Gondwanan platform, the outboard sections being juxtaposed on top of domains located closer to the mainland before amalgamation.[ES] La correlación de un grupo de terrenos alóctonos (denominados unidades basales, ofiolíticas y superiores), representados en el NW y SW del Macizo Ibérico, es utilizada para proponer una nueva zona geotectónica en el sector meridional del Orógeno Varisco: la Zona de Galicia – Ossa-Morena. Algunos avances recientes en el SW de Iberia han permitido reconocer que la mayor parte de la anterior Zona de Ossa-Morena representa en realidad otro complejo alóctono del Macizo Ibérico, el Complejo de Ossa-Morena, equivalente a los complejos de Cabo Ortegal, Órdenes, Malpica-Tui, Bragança y Morais, descritos en el NW de Iberia. La nueva zona geotectónica y sus equivalentes a lo largo del Orógeno Varisco constituyen una Zona Varisca Interna con ofiolitas y unidades afectadas por metamorfismo de alta-P. La Zona de Galicia – Ossa-Morena incluye una sutura Varisca y secciones de corteza continental afectadas por eventos Ediacarenses-Cámbricos, relacionados con la actividad de arcos magmáticos peri-Gondwánicos (Orogenia Cadomiense). En el Macizo Ibérico, la estructuración general de esta zona geotectónica representa una duplicación de la plataforma de Gondwana, con los dominios más externos superpuestos en la actualidad sobre otros dominios situados más cerca del continente emergido antes del ensamblado.Financial support has been provided by the Spanish project CGL2012-34618 (Ministerio de Economía y Competitividad).Peer reviewe

Calcifediol treatment and COVID-19-related outcomes

Context: COVID-19 is a major health problem because of saturation of intensive care units (ICU) and mortality. Vitamin D has emerged as a potential treatment able to reduce the disease severity. Objective: This work aims to elucidate the effect of 25(OH)D3 (calcifediol) treatment on COVID-19-related outcomes. Methods: This observational cohort study was conducted from March to May 2020, among patients admitted to COVID-19 wards of Hospital del Mar, Barcelona, Spain. A total of 930 patients with COVID-19 were included; 92 were excluded because of previous calcifediol intake. Of the remaining 838, a total of 447 received calcifediol (532 μg on day 1 plus 266 μg on days 3, 7, 15, and 30), whereas 391 were not treated at the time of hospital admission (intention-to-treat). Of the latter, 53 patients were treated later during ICU admission and were allocated in the treated group in a second analysis. In healthy individuals, calcifediol is about 3.2-fold more potent on a weight basis than cholecalciferol. Main outcome measures were ICU admission and mortality. Results: ICU assistance was required by 102 (12.2%) participants. Out of 447 patients treated with calcifediol at admission, 20 (4.5%) required the ICU, compared to 82 (21%) out of 391 nontreated (P < .001). Logistic regression of calcifediol treatment on ICU admission, adjusted by age, sex, linearized 25-hydroxyvitamin D levels at baseline, and comorbidities showed that treated patients had a reduced risk of requiring the ICU (odds ratio [OR] 0.13; 95% CI 0.07-0.23). Overall mortality was 10%. In the intention-to-treat analysis, 21 (4.7%) out of 447 patients treated with calcifediol at admission died compared to 62 patients (15.9%) out of 391 nontreated (P = .001). Adjusted results showed a reduced mortality risk with an OR of 0.21 (95% CI, 0.10-0.43). In the second analysis, the obtained OR was 0.52 (95% CI, 0.27-0.99). Conclusion: In patients hospitalized with COVID-19, calcifediol treatment significantly reduced ICU admission and mortality