Three essays on Convergence and Health Economics

Health is one of the mainstays for the economic development and the welfare state of any society. Therefore, it comes as no surprise that the main international organizations, such as United Nations, World Bank or International Monetary Fund, have highlighted its importance by granting numerous projects worldwide and by creating international institutions dedicated exclusively to the field of health. This is the case of the WorldHealth Organization (WHO), which was constituted in 1948. We can additionally emphasize the importance of health by taking into account the United Nations Millennium Declaration, the most ambitious project of this organization so far, signed in September 2000 by 189 member countries, in which they undertook to pursue eightMillennium Development Goals (MDGs) of the United Nations. These MDGs were replaced in 2016 by the Sustainable Development Goals (SDGs).Although all the objectives set out in the MDGs have a direct or indirect relationship with health, there are three of them dedicated exclusively to it: MDG4- Reduce child mortality, MDG5- Improve maternal health and MDG6- Combat Human Immunodeficiency Virus (HIV) / Acquire Immunodeficiency Syndrome (AIDS), malaria and other diseases. Currently, these objectives have been included in objective 3 of the SDGs, denominated "Health and well-being", whose targets for 2030 include: To end the preventable deaths of newborns and children under 5 years of age, making all countries try to reduce neonatal mortality to at least as low as 12 per 1,000 live birthsand the mortality of children under 5 years old at least as low as 25 per 1,000 live births. End to the epidemics of AIDS, tuberculosis, malaria and neglected tropical diseases. As well as fighting hepatitis, waterborne diseases and other communicable diseases.The interest that the field of health arouse in the economy has attracted a large number of researchers. Following the same interest, it seems relevant to analyze how and to what degree have the objectives established by the United Nations in the MDGs been achieved. Specifically, we analyze the evolution of the HIV / AIDS epidemic andthe degree of reduction of the infant mortality rate (IMR), from the time series approach.The reason for the study of these two objectives is to determine the evolution of these variables over time and to verify if the obtained achievements have been equally reached by all the countries, or if, on the contrary, the progress has been unequal both between countries and within them. So that if these objectives have not been met, we can study the causes and possible explanations of this result, in order to shed some light on the decision making that helps these objectives can be achieved by 2030.In order to be able to compare the analysis results of the different series, we have used the same methodology throughout the three chapters that make up the thesis: convergence analysis. The justification in the choice of the convergence analysis to carry out our research focuses on the fact that any policy aimed at either reducing infantmortality or ending the HIV / AIDS epidemic implies these variable should move go closer to their respective reference rates. Therefore, if all countries have reached the rates established in the MDGs /SDGs, this result could be interpreted as existence demonstration of convergence between countries. On the contrary, if only a part of the countries had been able to reach the reference rates in terms of infant mortality and prevalence of HIV / AIDS, then we could interpret the result as proof of the existence of a divergent behavior between countries. This fact would open the gate to the presence of different convergence clubs.In this context, we consider recent advances in the field of convergence analysis, which are extremely useful to study whether the objectives proposed have been achieved and to identify those countries that have not managed to complete them. In this way, we are in a position to determine the forces that influence the creation of theseconvergence clubs by investigating the potentially explanatory variables previously collected in the literature.This represents a radical change with respect to the type of data used mostly in the field of health economics, in which the use of time series data is strangely scarce.Against this, this thesis provides a different approach in the evaluation of health, from the perspective of time series and analysis of convergence, using macroeconomic data at national and international level, and through the application of novel econometric techniques not used until now in this type of studies.Against this framework, this thesis tries to answer the following questions: Chapter 1: The recent evolution of the HIV / AIDS rates in Sub-Saharan Africa: Do differences still persist?- Have the MDGs / SDGs been met in terms of prevalence of HIV / AIDS in sub-Saharan Africa?- Are the differences in the evolution of HIV / AIDS maintained between sub-Saharan countries?- If the differences with regard to the expansion of HIV / AIDS in the countries of the African continent remain, what are the forces that lead to this result?- Are the explanatory variables collected in the literature as determinants of HIV / AIDS relevant in our analysis? Chapter 2: Do international child mortality rates converge?- Are the MDGs / SDGs met homogeneously in terms of reducing child mortality?- Which countries have problems to achieve the MDGs / SDGs with respect to the objective established for the IMR?- What are the socioeconomic determinants that limit a country in the attempt to reduce its IMR? Chapter 3: Convergence in infant mortality rates: The Spanish case - Does convergence in the IMR exist between Spanish regions?- Has the great economic recession influenced the regional differences of IMR in Spain?- What have been the determining factors in the evolution of the IMR in Spain?With the purpose of answer these questions, the Thesis compiles three scientific articles structured into chapters, which can be considered independently, although they are related to each other, prioritizing in this way the publication format.Each of the chapters consists of two clearly differentiated parts. The first one is the convergence analysis, which includes the possibility of finding convergence clubs in the case of rejecting full convergence. The second one corresponds to the study of the explanatory factors that have led to the formation of these clubs in the case of having them.The first chapter analyses the prevalence and incidence rates of HIV / AIDS in the countries of sub-Saharan Africa. Although the HIV epidemic is a global issue, the sub- Saharan region is the most affected region, with 25.6 million people living with HIV in 2016 and concentrating almost two-thirds of new infections. Countries in this region also face resource scarcity and depend on foreign aid to fight against HIV/AIDS. Accordingly, we find sufficient reason to geographically concentrate our research in the African continent.In this chapter, after a preliminary study of the recent evolution of HIV prevalence and incidence rates, we proceed to test the null hypothesis of convergence for the entire sample, with the aim of verifying the existence of a unique pattern of behavior in the evolution of the analyzed rates. If we can reject the convergence hypothesis, andtherefore the MDGs / SDGs have not been reached in the sub-Saharan region, we try to determine the presence of groups of countries with similar profiles trends in prevalence or incidence rates, or “convergence clubs”. Once the presence of these clubs is determined, we analyze their characteristics and explain the factors that make these different behaviors coexist.The second chapter studies the reduction of international infant mortality rates (IMRs), which coincides with the fourth objective of the MDGs / SDGs. The IMR is considered one of the best global indicators to assess the welfare and health of a society, and this is the reason why this work has focused its attention on this MDG / SDGobjective. Despite the great achievements made in reducing the IMR around the world, we cannot forget that around 15,000 children died every day in 2016 before reaching their fifth birthday, and more than five million children continue to die each year nowadays.The procedure followed in this chapter is similar to the previous one. First, we evaluated the existence of a single pattern of behavior for the two samples used (Infant mortality rate of children under one year of age and infant mortality rate for children under five years of age). If we reject this hypothesis, we should analyze the existencedifferent groups of convergence between countries. In the second phase of the study, we proceed to determine the forces that lead to the creation of these clubs.To conclude, the third chapter of this Thesis explores the long-term evolution of infant mortality rates in the case of Spain. The justification in the choice of this essay comes from the need to compare the results obtained in the previous chapter, at the international level, in a context where different national health systems do not interferein the results.The application of the convergence analysis methodology, which acts as the backbone of this Thesis, allows us to exploit in greater depth the possible existence of stochastic convergence between the IMR of the Spanish regions. This offers us the opportunity to study the determinants that lead to obtaining the results in the previous analysis, as has been done in the preceding chapters.<br /

Entrenamiento en habilidades básicas de gestión de grupos para la mejora de la competencia transversal de hablar en público: protocolo para alumnos de posgrado de Psicología

El presente proyecto se enmarca en la mejora educativa de dos grandes bloques: 1)La mejora de competencias transversales indispensables en la carrera académica de cualquier alumno universitario. En este proyecto en concreto, se abordará la tarea de hablar en público, que ostenta un papel central en el desempeño de los alumnos en la práctica totalidad de asignaturas y en la potenciación de sus destrezas básicas a ofrecer en su futuro profesional. 2)La mejora educativa de alumnos del Master Oficial en Psicología General Sanitaria, como parte aplicada de su formación. Atendiendo al primer bloque, son múltiples las situaciones en las que los alumnos han de enfrentarse a un público y exponer o defender un trabajo, opinión etc… Ante esta situación, tradicionalmente se ha dado mayor peso a cuestiones de contenido (lo que se expone) y no tanto a cuestiones de forma (cómo se hace). La demanda de servicios que presten atención y ayuda en este ámbito va en aumento. Desde un punto de vista comunitario cada vez son más las asociaciones, fundaciones, escuelas que se dirigen a potenciar esta destreza (p. ej. ToastMaster). En el mismo sentido, desde un contexto clínico, se observa la misma tendencia de demanda de ayuda, en este caso profesional, para hacer frente a este tipo de situaciones, fundamentalmente por parte de alumnos universitarios. La ansiedad a exponer es un fenómeno ampliamente estudiado y relacionados con síndromes clínicos, como por ejemplo la Fobia Social. La carrera universitaria exige a sus alumnos tareas, ejercicios, exámenes… que requieren la puesta en práctica de esta competencia. Además, no es un fenómeno exclusivo de ninguna disciplina concreta, por lo que esta competencia es transversal a diferentes asignaturas y ramas del conocimiento. Un enfoque comunitario (desde la universidad) y focalizado (para universitarios) supondría atender a la competencia transversal de hablar en público de una manera formal y sistematizada, centrándose en el aprendizaje de la forma (cómo se hace) y de aquellos factores que pudieran interferir (ansiedad, timidez…). El segundo bloque que define este proyecto va dirigido a la mejora educativa de los alumnos del Máster Oficial en Psicología General Sanitaria. Parte de su formación práctica supone la confección, planificación y ejecución de planes de psicoeducativos de salud. Todos los miembros de este proyecto guardamos relación, de una u otra manera con la Clínica Universitaria de Psicología de la UCM (CUP-UCM), centro de prácticas del itinerario del citado master. Esto supone una excepcional oportunidad de añadir a su plan formativo de rotación por la CUP-UCM, el diseño y ejecución de estos talleres, siempre bajo estrecha supervisión y acompañamiento de miembros del proyecto

Estudio de los efectos de las lesiones del labrum acetabular en la cadera en un modelo experimental lagomorfo adulto

Objetivo: El cartílago labral es una estructura cartilaginosa que recubre el acetábulo de la cadera. Su lesión es controvertida en cuanto a sus implicaciones debido a que no se conoce bien si es una causa de degeneración articular o sólo un cambio degenerativo más. Hemos diseñado un modelo animal en conejo para estudiar esta lesión. Material y metodología: Se utilizaron tres grupos de 13 animales a los que se lesionó una cadera dejando la otra como control y se les mantuvo estabulados al primer grupo 12 semanas, al segundo 18 y al tercero 30. Posteriormente se les realizó un estudio radiológico, otro por resonancia magnética y, tras su sacrificio, un estudio histológico. Resultados: No encontramos relación en nuestro modelo entre la lesión labral y los cambios degenerativos posteriores en los plazos citados. Tampoco encontramos daños labrales sin cicatrizar en el momento del sacrificio. Conclusión: En el modelo animal lagomorfo, la lesión labral no produce cambios degenerativos artrósicos y el cartílago labral podría presentar cierta capacidad de regeneración

La química da mucho juego...¿jugamos?

¿Quién no ha jugado alguna vez? ¿Qué juegos conocemos? ¿Podemos motivar a los alumnos a través del juego?. Desde nuestra experiencia durante el curso 2016-2017 y utilizando adaptaciones de dos juegos tradicionales de mesa podemos observar que los alumnos participan y aprenden jugando y que el profesor puede utilizar el juego para evaluar las competencias y habilidades de los participantes. Con el juego los docentes dejamos de ser el centro de la clase o del laboratorio y pasamos a ser meros conductores del proceso de aprendizaje además de facilitar el trabajo en pequeños grupos. Los juegos utilizados son una adaptación de juegos de mesa que utilizan preguntas relacionadas con la Química. Se ha desarrollado material didáctico en forma de cartulinas con cuatro tipos de preguntas adaptadas a diferentes asignaturas de diferentes grados y que se pueden utilizar tanto en el laboratorio de prácticas como en el aula. Los juegos se han utilizado en asignaturas de los grados de Química, Biología e Ingeniería Química en tutorías, seminarios o en el laboratorio o bien al final del mismo o durante los periodos en los que los alumnos tienen “tiempos muertos” dado el desarrollo de las prácticas

Immunogenicity, transplacental transfer of pertussis antibodies and safety following pertussis immunization during pregnancy: Evidence from a randomized, placebo-controlled trial.

Background: Pertussis immunization during pregnancy is recommended in many countries. Data from large randomized controlled trials are needed to assess the immunogenicity, reactogenicity and safety of this approach. Methods: This phase IV, observer-blind, randomized, placebo-controlled, multicenter trial assessed immunogenicity, transplacental transfer of maternal pertussis antibodies, reactogenicity and safety of a reduced-antigen-content diphtheria-tetanus-three-component acellular pertussis vaccine (Tdap) during pregnancy. Women received Tdap or placebo at 27–36 weeks’ gestation with crossover 72-hourpostpartum immunization. Immune responses were assessed before the pregnancy dose and 1 month after, and from the umbilical cord at delivery. Superiority (primary objective) was reached if the lower limits of the 95% confidence intervals (CIs) of the pertussis geometric mean concentration (GMC) ratios (Tdap/control) in cord blood were 1.5. Solicited and unsolicited adverse events (AEs) and pregnancy-/ neonate-related AEs of interest were recorded. Results: 687 pregnant women were vaccinated (Tdap: N = 341 control: N = 346). Superiority of the pertussis immune response (maternally transferred pertussis antibodies in cord blood) was demonstrated by the GMC ratios (Tdap/control): 16.1 (95% CI: 13.5–19.2) for anti-filamentous hemagglutinin, 20.7 (15.9–26.9) for anti-pertactin and 8.5 (7.0–10.2) for anti-pertussis toxoid. Rates of pregnancy-/ neonate-related AEs of interest, solicited general and unsolicited AEs were similar between groups. None of the serious AEs reported throughout the study were considered related to maternal Tdap vaccination. Conclusions: Tdap vaccination during pregnancy resulted in high levels of pertussis antibodies in cord blood, was well tolerated and had an acceptable safety profile. This supports the recommendation of Tdap vaccination during pregnancy to prevent early-infant pertussis disease.post-print502 K

A Novel Circulating MicroRNA for the Detection of Acute Myocarditis.

The diagnosis of acute myocarditis typically requires either endomyocardial biopsy (which is invasive) or cardiovascular magnetic resonance imaging (which is not universally available). Additional approaches to diagnosis are desirable. We sought to identify a novel microRNA for the diagnosis of acute myocarditis. To identify a microRNA specific for myocarditis, we performed microRNA microarray analyses and quantitative polymerase-chain-reaction (qPCR) assays in sorted CD4+ T cells and type 17 helper T (Th17) cells after inducing experimental autoimmune myocarditis or myocardial infarction in mice. We also performed qPCR in samples from coxsackievirus-induced myocarditis in mice. We then identified the human homologue for this microRNA and compared its expression in plasma obtained from patients with acute myocarditis with the expression in various controls. We confirmed that Th17 cells, which are characterized by the production of interleukin-17, are a characteristic feature of myocardial injury in the acute phase of myocarditis. The microRNA mmu-miR-721 was synthesized by Th17 cells and was present in the plasma of mice with acute autoimmune or viral myocarditis but not in those with acute myocardial infarction. The human homologue, designated hsa-miR-Chr8:96, was identified in four independent cohorts of patients with myocarditis. The area under the receiver-operating-characteristic curve for this novel microRNA for distinguishing patients with acute myocarditis from those with myocardial infarction was 0.927 (95% confidence interval, 0.879 to 0.975). The microRNA retained its diagnostic value in models after adjustment for age, sex, ejection fraction, and serum troponin level. After identifying a novel microRNA in mice and humans with myocarditis, we found that the human homologue (hsa-miR-Chr8:96) could be used to distinguish patients with myocarditis from those with myocardial infarction. (Funded by the Spanish Ministry of Science and Innovation and others.).Supported by a grant (PI19/00545, to Dr. Martín) from the Ministry of Science and Innovation through the Carlos III Institute of Health–Fondo de Investigación Sanitaria; by a grant from the Biomedical Research Networking Center on Cardiovascular Diseases (to Drs. Martín, Sánchez-Madrid, and Ibáñez); by grants (S2017/BMD-3671-INFLAMUNE-CM, to Drs. Martín and Sánchez-Madrid; and S2017/BMD-3867-RENIM-CM, to Dr. Ibáñez) from Comunidad de Madrid; by a grant (20152330 31, to Drs. Martín, Sánchez-Madrid, and Alfonso) from Fundació La Marató de TV3; by grants (ERC-2011-AdG 294340-GENTRIS, to Dr. Sánchez-Madrid; and ERC-2018-CoG 819775-MATRIX, to Dr. Ibáñez) from the European Research Council; by grants (SAF2017-82886R, to Dr. Sánchez-Madrid; RETOS2019-107332RB-I00, to Dr. Ibáñez; and SAF2017-90604-REDT-NurCaMeIn and RTI2018-095928-BI00, to Dr. Ricote) from the Ministry of Science and Innovation; by Fondo Europeo de Desarrollo Regional (FEDER); and by a 2016 Leonardo Grant for Researchers and Cultural Creators from the BBVA Foundation to Dr. Martín. The National Center for Cardiovascular Research (CNIC) is supported by the Carlos III Institute of Health, the Ministry of Science and Innovation, the Pro CNIC Foundation, and by a Severo Ochoa Center of Excellence grant (SEV-2015-0505). Mr. Blanco-Domínguez is supported by a grant (FPU16/02780) from the Formación de Profesorado Universitario program of the Spanish Ministry of Education, Culture, and Sports. Ms. Linillos-Pradillo is supported by a fellowship (PEJD-2016/BMD-2789) from Fondo de Garantía de Empleo Juvenil de Comunidad de Madrid. Dr. Relaño is supported by a grant (BES-2015-072625) from Contratos Predoctorales Severo Ochoa para la Formación de Doctores of the Ministry of Economy and Competitiveness. Dr. Alonso-Herranz is supported by a fellowship from La Caixa–CNIC. Dr. Caforio is supported by Budget Integrato per la Ricerca dei Dipartimenti BIRD-2019 from Università di Padova. Dr. Das is supported by grants (UG3 TR002878 and R35 HL150807) from the National Institutes of Health and the American Heart Association through its Strategically Focused Research Networks.S

Role of age and comorbidities in mortality of patients with infective endocarditis

[Purpose]: The aim of this study was to analyse the characteristics of patients with IE in three groups of age and to assess the ability of age and the Charlson Comorbidity Index (CCI) to predict mortality. [Methods]: Prospective cohort study of all patients with IE included in the GAMES Spanish database between 2008 and 2015.Patients were stratified into three age groups:<65 years,65 to 80 years,and ≥ 80 years.The area under the receiver-operating characteristic (AUROC) curve was calculated to quantify the diagnostic accuracy of the CCI to predict mortality risk. [Results]: A total of 3120 patients with IE (1327 < 65 years;1291 65-80 years;502 ≥ 80 years) were enrolled.Fever and heart failure were the most common presentations of IE, with no differences among age groups.Patients ≥80 years who underwent surgery were significantly lower compared with other age groups (14.3%,65 years; 20.5%,65-79 years; 31.3%,≥80 years). In-hospital mortality was lower in the <65-year group (20.3%,<65 years;30.1%,65-79 years;34.7%,≥80 years;p < 0.001) as well as 1-year mortality (3.2%, <65 years; 5.5%, 65-80 years;7.6%,≥80 years; p = 0.003).Independent predictors of mortality were age ≥ 80 years (hazard ratio [HR]:2.78;95% confidence interval [CI]:2.32–3.34), CCI ≥ 3 (HR:1.62; 95% CI:1.39–1.88),and non-performed surgery (HR:1.64;95% CI:11.16–1.58).When the three age groups were compared,the AUROC curve for CCI was significantly larger for patients aged <65 years(p < 0.001) for both in-hospital and 1-year mortality. [Conclusion]: There were no differences in the clinical presentation of IE between the groups. Age ≥ 80 years, high comorbidity (measured by CCI),and non-performance of surgery were independent predictors of mortality in patients with IE.CCI could help to identify those patients with IE and surgical indication who present a lower risk of in-hospital and 1-year mortality after surgery, especially in the <65-year group

COVID-19 vaccine failure

COVID-19 affects the population unequally with a higher impact on aged and immunosuppressed people. Hence, we assessed the effect of SARS-CoV-2 vaccination in immune compromised patients (older adults and oncohematologic patients), compared with healthy counterparts. While the acquired humoral and cellular memory did not predict subsequent infection 18 months after full immunization, spectral and computational cytometry revealed several subsets within the CD8+ T-cells, B-cells, NK cells, monocytes and CD45RA+ CCR7- Tγδ cells differentially expressed in further infected and non-infected individuals not just following immunization, but also prior to that. Of note, up to 7 subsets were found within the CD45RA+ CCR7- Tγδ population with some of them being expanded and other decreased in subsequently infected individuals. Moreover, some of these subsets also predicted COVID-induced hospitalization in oncohematologic patients. Therefore, we hereby have identified several cellular subsets that, even before vaccination, strongly related to COVID-19 vulnerability as opposed to the acquisition of cellular and/or humoral memory following vaccination with SARS-CoV2 mRNA vaccines.This study has been funded through Programa Estratégico Instituto de Biología y Genética Molecular (IBGM Junta de Castilla y León. Ref. CCVC8485), Junta de Castilla y León (Proyectos COVID 07.04.467B04.74011.0) and the European Commission – NextGenerationEU (Regulation EU 2020/2094), through CSIC's Global Health Platform (PTI Salud Global; SGL21-03-026 and SGL2021-03-038)N

Evolving trends in the management of acute appendicitis during COVID-19 waves. The ACIE appy II study

Background: In 2020, ACIE Appy study showed that COVID-19 pandemic heavily affected the management of patients with acute appendicitis (AA) worldwide, with an increased rate of non-operative management (NOM) strategies and a trend toward open surgery due to concern of virus transmission by laparoscopy and controversial recommendations on this issue. The aim of this study was to survey again the same group of surgeons to assess if any difference in management attitudes of AA had occurred in the later stages of the outbreak. Methods: From August 15 to September 30, 2021, an online questionnaire was sent to all 709 participants of the ACIE Appy study. The questionnaire included questions on personal protective equipment (PPE), local policies and screening for SARS-CoV-2 infection, NOM, surgical approach and disease presentations in 2021. The results were compared with the results from the previous study. Results: A total of 476 answers were collected (response rate 67.1%). Screening policies were significatively improved with most patients screened regardless of symptoms (89.5% vs. 37.4%) with PCR and antigenic test as the preferred test (74.1% vs. 26.3%). More patients tested positive before surgery and commercial systems were the preferred ones to filter smoke plumes during laparoscopy. Laparoscopic appendicectomy was the first option in the treatment of AA, with a declined use of NOM. Conclusion: Management of AA has improved in the last waves of pandemic. Increased evidence regarding SARS-COV-2 infection along with a timely healthcare systems response has been translated into tailored attitudes and a better care for patients with AA worldwide