Oracion funeral panegyrica en las honras que el dia 14 de diciembre de 1734 hizo la Congregacion de S. Phelipe Neri de la ciudad de Alcalá, á ... doña Josepha de Borja y Centellas Ponce de Leon ...

Sign.: [parágrafo]-3[parágrafo]4,A-E4,F2Port. con orla tip

Effectiveness of an intervention for improving drug prescription in primary care patients with multimorbidity and polypharmacy:Study protocol of a cluster randomized clinical trial (Multi-PAP project)

This study was funded by the Fondo de Investigaciones Sanitarias ISCIII (Grant Numbers PI15/00276, PI15/00572, PI15/00996), REDISSEC (Project Numbers RD12/0001/0012, RD16/0001/0005), and the European Regional Development Fund ("A way to build Europe").Background: Multimorbidity is associated with negative effects both on people's health and on healthcare systems. A key problem linked to multimorbidity is polypharmacy, which in turn is associated with increased risk of partly preventable adverse effects, including mortality. The Ariadne principles describe a model of care based on a thorough assessment of diseases, treatments (and potential interactions), clinical status, context and preferences of patients with multimorbidity, with the aim of prioritizing and sharing realistic treatment goals that guide an individualized management. The aim of this study is to evaluate the effectiveness of a complex intervention that implements the Ariadne principles in a population of young-old patients with multimorbidity and polypharmacy. The intervention seeks to improve the appropriateness of prescribing in primary care (PC), as measured by the medication appropriateness index (MAI) score at 6 and 12months, as compared with usual care. Methods/Design: Design:pragmatic cluster randomized clinical trial. Unit of randomization: family physician (FP). Unit of analysis: patient. Scope: PC health centres in three autonomous communities: Aragon, Madrid, and Andalusia (Spain). Population: patients aged 65-74years with multimorbidity (≥3 chronic diseases) and polypharmacy (≥5 drugs prescribed in ≥3months). Sample size: n=400 (200 per study arm). Intervention: complex intervention based on the implementation of the Ariadne principles with two components: (1) FP training and (2) FP-patient interview. Outcomes: MAI score, health services use, quality of life (Euroqol 5D-5L), pharmacotherapy and adherence to treatment (Morisky-Green, Haynes-Sackett), and clinical and socio-demographic variables. Statistical analysis: primary outcome is the difference in MAI score between T0 and T1 and corresponding 95% confidence interval. Adjustment for confounding factors will be performed by multilevel analysis. All analyses will be carried out in accordance with the intention-to-treat principle. Discussion: It is essential to provide evidence concerning interventions on PC patients with polypharmacy and multimorbidity, conducted in the context of routine clinical practice, and involving young-old patients with significant potential for preventing negative health outcomes. Trial registration: Clinicaltrials.gov, NCT02866799Publisher PDFPeer reviewe

Solving Task Scheduling Problems in Dew Computing via Deep Reinforcement Learning

Due to mobile and IoT devices’ ubiquity and their ever-growing processing potential, Dew computing environments have been emerging topics for researchers. These environments allow resource-constrained devices to contribute computing power to others in a local network. One major challenge in these environments is task scheduling: that is, how to distribute jobs across devices available in the network. In this paper, we propose to distribute jobs in Dew environments using artificial intelligence (AI). Specifically, we show that an AI agent, known as Proximal Policy Optimization (PPO), can learn to distribute jobs in a simulated Dew environment better than existing methods—even when tested over job sequences that are five times longer than the sequences used during the training. We found that using our technique, we can gain up to 77% in performance compared with using human-designed heuristics

New Heuristics for Scheduling and Distributing Jobs under Hybrid Dew Computing Environments

Mobile grid computing has been a popular topic for researchers due to mobile and IoT devices’ ubiquity and their evergrowing processing potential. While many scheduling algorithms for harnessing these resources exist in the literature for standard grid computing scenarios, surprisingly, there is little insight into this matter in the context of hybrid-powered computing resources, typically found in Dew and Edge computing environments. This paper proposes new algorithms aware of devices’ power source for scheduling tasks in hybrid environments, i.e., where the battery- and non-battery-powered devices cooperate. We simulated hybrid Dew/Edge environments by extending DewSim, a simulator that models battery-driven devices’ battery behavior using battery traces profiled from real mobile devices. We compared the throughput and job completion achieved by algorithms proposed in this paper using as a baseline a previously developed algorithm that considers computing resources but only from battery-dependent devices called Enhanced Simple Energy-Aware Schedule (E-SEAS). The obtained results in the simulation reveal that our proposed algorithms can obtain up to a 90% increment in overall throughput and around 95% of completed jobs in hybrid environments compared to E-SEAS. Finally, we show that incorporating these characteristics gives more awareness of the type of resources present and can enable the algorithms to manage resources more efficiently in more hybrid environments than other algorithms found in the literature

Migraciones sur-sur : Paradojas globales y promesas locales

Durante la primera década del siglo XX el 90% de los migrantes provenía de Europa y se dirigía a cinco países: EEUU, Argentina, Canadá, Brasil y Australia. Hoy esa misma proporción de migrantes proviene de tres continentes: Asia, África y Latinoamérica y se dirige a cuatro grandes regiones: Europa, Norteamérica, Asia Pacífico y El Golfo Pérsico. Las migraciones se han mundializado no tanto por la magnitud de los flujos, que sigue estando por debajo del 5% de la población mundial, sino por el reducido número de países que hoy permanece al margen de las redes migratorias. Estas realidades crecientes crean las condiciones para que los potenciales migrantes en países empobrecidos y en proceso de empobrecimiento quieran migrar. A esto precisamente apuntó Joaquín Arango cuando definió nuestra época como el tiempo de la inmovilidad involuntaria

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