“Scotomes” or “blind spots” in the medical field that limit its role in adolescent sexual and reproductive health (ASRH) : ideas about how to eliminate them

ABSTRACT: This article reviews the medical field’s role in adolescent sexual and reproductive health (ASRH) from the historical perspectives of two influential medical specialties: adolescent and young adult medicine and pediatric and adolescent gynecology. The article identifies aspects that act as blind spots, limiting the medical field’s capacity to respond to the challenges of ASRH. The article reviews the theoretical contributions of the critical social sciences, highlighting some of Latin America’s collective health movements and feminist theories, as well as the hegemonic medical institutional discourses and practices that perpetuate health inequities in relation to patients’ sexualities, subjectivities and identities. Finally, this paper presents a new concept: that of “sexual citizenship,” a useful concept that integrates these theoretical and methodological contributions into a relational analysis that includes sexualities, subjectivities and identities. The incorporation of these theoretical developments into medical training programs would generate a radical change in the role of the medical field that has been challenged by the new conceptual and ethical framework of the UN system, as confirmed at the conferences in Cairo (1994) and Beijing (1995). These conferences urged states to offer policies that guarantee sexual and reproductive rights (SRR)

“Scotomas” of the medical field that limit its role in sexual and reproductive health of adolescents. Ideas to overcome them

ABSTRACT: This paper reviews the role of the medical field in adolescent sexual and reproductive health (ASRH). A brief historical account of the emergence of two specialties -Adolescent and Young Adult Medicine and Youth and Adolescent Gynecology- shows a predominance of the medical views and practices that act as “scotomas” limiting the role on ASRH promotion. It offers a conceptual framework built from critical social sciences, standing out the innovative contributions made by the Latin American collective health and feminism movements to overcome such “scotomas” by offering a better comprehension of key points involved in ASRH. Among them: the social and gender determination on health, the hegemonic medical institutional discourses and practices that perpetuate health inequities in relation to sexualities, subjectivities and identities of patients. The concept of “sexual citizenship” is presented as a useful analytical and methodological tool to integrate all these key points. Their incorporation into medical training programs would produce a deep turn in medicine granting the fulfillment of goals set out in the international conferences of Cairo and Beijing that urged governments to carry out actions to attend adolescent’s needs and demands by granting their sexual and reproductive rights (SRR), thus providing the enhanced role that medicine must play in ASRH.RESUMEN: Este artículo revisa el papel del campo médico en la salud sexual y reproductiva (SSR) de los adolescentes; a partir de una perspectiva histórica de la configuración de dos especializaciones médicas para intervenirla –la Medicina de Adolescentes y la Ginecología Infanto-Juvenilidentifica aspectos que actúan como “escotomas” limitantes de su capacidad resolutiva en la problemática de la SSR. Rescata aportes teóricos de corrientes crítico-sociales, resaltando algunos del movimiento latinoamericano de salud colectiva y de las teorías feministas, fundamentales para superarlos tales como la determinación social y del género en la salud y enfoques y prácticas médicas institucionalizados en Latinoamérica, que yacen detrás de políticas que perpetúan las inequidades en salud en este campo de la SSR. Por último, revela un novedoso concepto: el de “ciudadanía sexual” útil para integrar dichos aportes teóricos y metodológicos en un análisis relacional con sexualidades, subjetividades e identidades. La incorporación de estos desarrollos teóricos en programas de formación médica daría un profundo giro al papel del campo médico interpelado por el nuevo marco conceptual y ético del sistema de Naciones Unidas, acordado en las conferencias de El Cairo (1994) y Beijing (1995), instando a los estados a ofrecer políticas con garantías de los derechos sexuales y reproductivos (DSR)

Análisis sociopolítico de los derechos sexuales y reproductivos (DSR) de adolescentes en la formación médica. Una etnografía institucional (EI) del proceso de renovación curricular del programa del pregrado médico en la Universidad de Antioquia : 1997-2013

RESUMEN: La investigación “Análisis sociopolítico de los Derechos Sexuales y Reproductivos (DSR) de adolescentes en la formación médica. Una Etnografía Institucional (EI) del proceso de renovación curricular del programa del pregrado médico en la Universidad de Antioquia, 1997-2013” surge del interés de la autora en comprender y aportar al desarrollo de los DSR de adolescentes en Colombia, desde la formación de pregrado y como profesora de la Universidad de Antioquia. El enfoque para este estudio procura la articulación de contextos, aristas y categorías que se imbrican dentro y fuera de la institución médica configurada por siglos en este país. La investigación contempló el análisis de la regulación social de las prácticas discursivas médicas que predominaron perpetuando la medicalización de los DSR de adolescentes en el marco del proceso de renovación curricular del programa de formación médica de la Facultad de Medicina de la Universidad de Antioquia, en el período delimitado, en cuanto institución emblemática de la función de formación médica en ámbitos local, nacional e internacional. Dicho período de análisis se llevó a cabo a la luz de dos contextos de marcada agitación sociopolítica que rodean el proceso de cambio curricular: el contexto de reformas educativas en la región de América Latina y el contexto de un acalorado debate por las conquistas en materia de DSR que vienen ocurriendo en el plano internacional y nacional

Imperio vs. multitud : el problema de la biopolítica y la formación

Esta obra recoge y actualiza el debate contemporáneo de la biopolítica a partir de Imperio de Michael Hardt y Antoni Negri. Se presentan diversas contribuciones que articulan, desde una mirada crítica, el despliegue de la biopolítica respecto de la formación. La multitud constituye uno de los horizontes que atraviesa el debate dado. Se caracteriza cómo la reciente concepción de la biopolítica se ancla en la tradición filosífica que se desprende desde Ockham y Scoto, hasta llegar a la discusión contemporánea sobre la individuación, y cómo el despliegue de las variantes de la biopolítica va posibilitando la configuración de subjetividad(es) en el imperio. En estos escenarios deviene la producción no sólo de mercancías materiales, sino, también, de bienes inmateriales. Las sociedades producen subjetividades que el imperio quiere dominar, por lo que cobra relevancia, entonces, el tema de la resistencia y la pregunta por un proyecto de formación que posibilite el despliegue de la persona

Global variation in postoperative mortality and complications after cancer surgery: a multicentre, prospective cohort study in 82 countries

© 2021 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY-NC-ND 4.0 licenseBackground: 80% of individuals with cancer will require a surgical procedure, yet little comparative data exist on early outcomes in low-income and middle-income countries (LMICs). We compared postoperative outcomes in breast, colorectal, and gastric cancer surgery in hospitals worldwide, focusing on the effect of disease stage and complications on postoperative mortality. Methods: This was a multicentre, international prospective cohort study of consecutive adult patients undergoing surgery for primary breast, colorectal, or gastric cancer requiring a skin incision done under general or neuraxial anaesthesia. The primary outcome was death or major complication within 30 days of surgery. Multilevel logistic regression determined relationships within three-level nested models of patients within hospitals and countries. Hospital-level infrastructure effects were explored with three-way mediation analyses. This study was registered with ClinicalTrials.gov, NCT03471494. Findings: Between April 1, 2018, and Jan 31, 2019, we enrolled 15 958 patients from 428 hospitals in 82 countries (high income 9106 patients, 31 countries; upper-middle income 2721 patients, 23 countries; or lower-middle income 4131 patients, 28 countries). Patients in LMICs presented with more advanced disease compared with patients in high-income countries. 30-day mortality was higher for gastric cancer in low-income or lower-middle-income countries (adjusted odds ratio 3·72, 95% CI 1·70–8·16) and for colorectal cancer in low-income or lower-middle-income countries (4·59, 2·39–8·80) and upper-middle-income countries (2·06, 1·11–3·83). No difference in 30-day mortality was seen in breast cancer. The proportion of patients who died after a major complication was greatest in low-income or lower-middle-income countries (6·15, 3·26–11·59) and upper-middle-income countries (3·89, 2·08–7·29). Postoperative death after complications was partly explained by patient factors (60%) and partly by hospital or country (40%). The absence of consistently available postoperative care facilities was associated with seven to 10 more deaths per 100 major complications in LMICs. Cancer stage alone explained little of the early variation in mortality or postoperative complications. Interpretation: Higher levels of mortality after cancer surgery in LMICs was not fully explained by later presentation of disease. The capacity to rescue patients from surgical complications is a tangible opportunity for meaningful intervention. Early death after cancer surgery might be reduced by policies focusing on strengthening perioperative care systems to detect and intervene in common complications. Funding: National Institute for Health Research Global Health Research Unit

Effects of hospital facilities on patient outcomes after cancer surgery: an international, prospective, observational study

© 2022 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 licenseBackground: Early death after cancer surgery is higher in low-income and middle-income countries (LMICs) compared with in high-income countries, yet the impact of facility characteristics on early postoperative outcomes is unknown. The aim of this study was to examine the association between hospital infrastructure, resource availability, and processes on early outcomes after cancer surgery worldwide. Methods: A multimethods analysis was performed as part of the GlobalSurg 3 study—a multicentre, international, prospective cohort study of patients who had surgery for breast, colorectal, or gastric cancer. The primary outcomes were 30-day mortality and 30-day major complication rates. Potentially beneficial hospital facilities were identified by variable selection to select those associated with 30-day mortality. Adjusted outcomes were determined using generalised estimating equations to account for patient characteristics and country-income group, with population stratification by hospital. Findings: Between April 1, 2018, and April 23, 2019, facility-level data were collected for 9685 patients across 238 hospitals in 66 countries (91 hospitals in 20 high-income countries; 57 hospitals in 19 upper-middle-income countries; and 90 hospitals in 27 low-income to lower-middle-income countries). The availability of five hospital facilities was inversely associated with mortality: ultrasound, CT scanner, critical care unit, opioid analgesia, and oncologist. After adjustment for case-mix and country income group, hospitals with three or fewer of these facilities (62 hospitals, 1294 patients) had higher mortality compared with those with four or five (adjusted odds ratio [OR] 3·85 [95% CI 2·58–5·75]; p<0·0001), with excess mortality predominantly explained by a limited capacity to rescue following the development of major complications (63·0% vs 82·7%; OR 0·35 [0·23–0·53]; p<0·0001). Across LMICs, improvements in hospital facilities would prevent one to three deaths for every 100 patients undergoing surgery for cancer. Interpretation: Hospitals with higher levels of infrastructure and resources have better outcomes after cancer surgery, independent of country income. Without urgent strengthening of hospital infrastructure and resources, the reductions in cancer-associated mortality associated with improved access will not be realised. Funding: National Institute for Health and Care Research