Restructuring of Welfare States: quantitative and qualitative changes: the case of Spain / Reestructuración de los Estados del Bienestar: cambios cuantitativos y cualitativos: el caso de España

This paper examines a possible paradigm shift from protective welfare states to investment welfare states, using Spain as a case study. Methodologically, a historical-institutionalist approach to paradigm change was adopted, and three dimensions of analysis were studied: problems to be solved, objectives to be achieved and policies to be used. The main findings indicated there has been a quantitative change in Spain that recommodifies living conditions, and a qualitative reorientation is underway that individualizes risks and social protection.

En este trabajo se examina el posible cambio de paradigma desde el Estado del Bienestar Protector hacia un Estado del Bienestar Inversor, tomando a España como estudio de caso. Metodológicamente se adopta un enfoque histórico-institucionalista sobre el cambio de paradigmas, y se aplican tres dimensiones de análisis: problemas a resolver, objetivos a conseguir y políticas a emplear. El principal resultado es que en España se ha producido un cambio cuantitativo que remercantiliza las condiciones de vida, y está en marcha una reorientación cualitativa que individualiza los riesgos y la protección social.

Anticoagulantes orales directos y un cambio en el paradigma del monitoreo de la anticoagulación / New direct oral anticoagulants, a paradigm shift in haemostasis assays / Anticoagulantes orais diretos e uma mudança no paradigma da monitorização da anticoagulação

Los nuevos anticoagulantes orales directos (DOACs) son agentes sintéticos dirigidos en forma específica contra el factor Xa o contra la trombina. Por su farmacocinética predecible y escasa variabilidad interindividual no es necesario el monitoreo de anticoagulación. Esto es un cambio en el paradigma del tratamiento anticoagulante. Sin embargo, los DOACs alteran las pruebas de hemostasia y es importante saber cómo interpretarlas en caso de hemorragia, episodio trombótico o ante una cirugía de urgencia. Las pruebas clásicas de coagulación solo sirven para orientar sobre el efecto anticoagulante de los DOACs. Se debe conocer, para cada agente, cuál de las pruebas es útil, el reactivo que se utilizó y el tiempo transcurrido desde la ingesta del medicamento. Las pruebas específicas miden la concentración del DOAC. Son más sensibles, pero no han sido investigadas en relación a eventos clínicos y poseen una gran variación interindividual. Se concluye que hasta ahora no se cuenta con pruebas validadas para definir si se debe ajustar la dosis de los DOACs, aún en pacientes con alto riesgo hemorrágico. Nuevos estudios clínicos que utilizan diferentes pruebas de hemostasia serán de utilidad para ayudar a interpretar el efecto de los DOACs. Hasta que esto suceda, se tendrá que convivir con este nuevo paradigma, la ausencia del monitoreo.

New oral direct anticoagulants (DOACs) are synthetic agents targeting either thrombin or factor Xa. Their predictable pharmacokinetics and scarce variability eliminate the need for regular coagulation monitoring. This is a paradigm shift in anticoagulation treatment. However, DOACs interfere with coagulation assays and it is very important to recognize them in a bleeding or thrombotic event or in an urgent surgery. Commonly used screening coagulation tests are of limited utility and different test reagents, what kind of test to perform for each anticoagulant and the time of drug intake must be considered. Specific assays can accurately quantify drug levels, but they are not yet related to clinical events and there is great inter-individual variability. As a conclusion,there are no laboratory assays developed to support dose adjustment based on these test results. New clinical trials with laboratory measurement will help solve this. Until then, this new paradigm of no laboratory testing in routine clinical practice will have to be accepted.

Os novos anticoagulantes orais diretos (DOACs) são agentes sintéticos dirigidos em forma específica contra o fator Xa ou contra a trombina. Devido a sua farmacocinética previsível e escassa variabilidade interindividual não é necessária a monitoração de anticoagulação. Essa é uma mudança no paradigma do tratamento anticoagulante. Entretanto, os DOACs alteram as provas de hemostasia e é importante saber de que maneira interpretá-las em caso de hemorragia, episódio trombótico ou diante de uma cirurgia de urgência. Os testes clássicos de coagulação apenas servem para orientar a respeito do efeito anticoagulante dos DOACs. É necessário conhecer, para cada agente, qual dos testes é útil, o reagente que foi utilizado e o tempo decorrido desde a ingestão do medicamento. Os testes específicos medem a concentração do DOAC. São mais sensíveis, mas não foram pesquisados em relação a eventos clínicos e possuem grande variação interindividual. A conclusão é que até o momento não se conta com provas validadas para definir se deve ser ajustada a dosagem dos DOACs, mesmo em pacientes com alto risco hemorrágico. Novos estudos clínicos utilizando diferentes testes de hemostasia serão de utilidade para ajudar-nos a interpretar o efeito dos DOACs. Até que isto aconteça, será preciso conviver com este novo paradigma, a ausência da monitorização.

Occupational Health: Meeting the Challenges of the Next 20 Years

BACKGROUND: The industrial revolution that took place in the United Kingdom (UK) between 1760 and 1830 led to profound social change. Occupational medicine was concerned with the diagnosis, treatment, and prevention of occupational diseases, that is, diseases directly caused by exposure to workplace hazards. A similar pattern of development has occurred globally. METHODS: A review of relevant literature. RESULTS: The international conceptualization and development of occupational health occurred during the 20th century. A new paradigm for occupational health has emerged that extends the classical focus on what might be termed "health risk management" that is, the focus on workplace hazards and risk to health to include the medical aspects of sickness absence and rehabilitation, the support and management of chronic noncommunicable diseases, and workplace health promotion. CONCLUSION: The future strategic direction for occupational health will be informed by a needs analysis and a consideration of where it should be positioned within future healthcare provision. What are the occupational health workforce implications of the vision for occupational health provision? New challenges and new ways of working will necessitate a review of the competence and capacity of the occupational health workforce, with implications for future workforce planning.

Ocio transformacional y contrahegemónico: "disoñando" un mundo sustentable / Ocio transformacional e contra hegemônico: "desenhando-sonhando" um mundo sustentável / Resignified and counter-hegemonic leisure: "dreamdesigning" a sustainable world / Loisir transformationnel et contre-hégémonique: ''disoñando'' un monde durable

El objetivo de este texto es situar la temática del ocio en la actualidad, vinculándola con la necesidad de un profundo cambio paradigmático, epistemológico-político-educativo, que logre hacer frente a algunas de las alarmantes realidades sociales y ecológicas del presente. Se realiza un recorrido en el cual se vinculan la transformación y "evolución" social con una nueva educación, basada en el aprendizaje transformacional, donde el ocio se abre como un potencial aporte para este salto evolutivo que se requiere. Diseñamos máquinas, tecnologías, mapas, planos, ciudades, mundos. Ahora se plantea el soñar y diseñar juntos, esto será disoñar, como una estrategia esencial para revitalizar nuestras sociedades y atrevernos a soñar con otros mundos posibles. Desde aquí se postula que, potencialmente, la relación entre el ocio resignificado y el aprendizaje transformacional, nos puede ayudar a atrevernos a disoñar nuevas utopías hacia donde producir la transformación social. En este sentido, paradojalmente, el ocio puede contribuir, y de hecho lo hace, a mantener el status quo y el orden social vigente, reforzando estereotipos y valores excluyentes, consumistas y alienantes. Pero, a su vez, puede abrir posibilidades para la construcción de sociedades más humanas, justas, inclusivas, participativas y solidarias. Tales consideraciones revelan que, en nuestras sociedades, el ocio es un fenómeno dinámico, complejo y lleno de conflictos, tensiones, ambigüedades y potencialidades...

O objetivo deste texto é discutir a temática do lazer, vinculando-a com a necessidade de gerar uma mudança paradigmática, epistemológica, política e educativa que permita fazer frente às alarmantes problemáticas sociais da atualidade. Busca-se relacionar a transformação e "evolução" social com uma educação baseada na aprendizagem transformacional, na qual o lazer representa um potencial aporte para o salto evolutivo que essas problemáticas requerem. Planejamos máquinas, tecnologias, cidades e mundos. É necessário planejar e sonhar ao mesmo tempo, isto é, "desenhar-sonhar", enquanto uma estratégia essencial para revitalizar nossas sociedades e poder sonhar com outros mundos possíveis. Aqui se abre uma relação entre o lazer ressignificado e a aprendizagem transformacional, impulsionando novas utopias comprometidas com a transformação social. Neste sentido, paradoxalmente, o lazer pode contribuir, e de fato o faz, com a manutenção do status quo e da ordem social vigente, reforçando estereótipos e valores excludentes, consumistas e alienantes. Mas, também pode abrir possibilidades para a construção de sociedades mais humanas, justas, inclusivas, participativas e solidárias. Estas considerações revelam que, em nossas sociedades, o lazer é um fenômeno dinâmico, complexo e cheio de conflitos, tensões, ambiguidades e potencialidades...

The objective of this paper is to place the issue of leisure in the present, linking it to the need for a profound paradigmatic, epistemological-political-educational change, which manages to cope with some of the alarming social and ecological realities of the moment. It is a review linking social transformation and "evolution" with a new education, based on transformational learning, in which leisure appears as a potential contributor for this required evolutionary leap. We design machines, technology, maps, plans, cities, worlds. Now arises the idea of dreaming and designing together, a "dreamdesigning", as an essential strategy to revitalize our society and allow us to dare and dream other possible worlds. From this starting point, it is postulated that the relationship between resignified leisure and transformational learning can, potentially, help us to dare and dreamdesign utopias from which we can produce social transformation. Paradoxically, leisure can contribute to preserve and, in fact it does, the status quo and the current social order, the stereotypes and the exclusionary, alienating and consumerist values. From another perspective, leisure can open the possibility for more humane, just, inclusive, participative and solidary societies. These considerations show that leisure, in our societies, is a dynamic, complex phenomenon, full of conflicts, tensions, ambiguities and potentialities...

Le but de cet article est de placer le thème de loisir d'aujourd'hui. Loisir est analysé dans son rapport avec la nécessité de promouvoir un profond changement de paradigme, épistémologique, politique et éducatif, qui parvient à résoudre certains des problèmes sociaux et écologiques alarmants d'aujourd'hui. Il entreprend un voyage dans lequel reliant la transformation sociale et de l'évolution avec une nouvelle éducation basée sur l'apprentissage transformationnel, où le loisir est ouvert comme une contribution potentielle à ce saut évolutif qui est nécessaire. Maintenant se pose le rêve et le design, comme une stratégie essentielle pour revitaliser notre société et rêver d'autres mondes. En ce sens, paradoxalement, les loisir peuvent contribuer, pour maintenir le statu quo et l'ordre social, de renforcer les stéréotypes et les valeurs consuméristes et aliénantes. Mais, à son tour, peut ouvrir des possibilités pour la construction de sociétés plus humain, juste, inclusive, participative et solidaire. Ces considérations montrent que, dans nos sociétés le loisir est complexe, est dynamique, et pleine de conflits, des tensions, des ambiguïtés et des potentialités...

Construcción de significados de experiencia del cuerpo en personas con situación de discapacidad física adquirida / Construction of meaning on body experience with people in situation of acquired physical disability

En el contexto de los nuevos desarrollos teóricos y metodológicos en Terapia Ocupacional, surgen perspectivas cualitativas de investigación y una compresión social de la disciplina, desde esta perspectiva, nos hemos interrogado con respecto a la significación del cuerpo y la discapacidad. El estudio profundiza en el tema presentado, desde una óptica de los fundamentos y su expresión en la práctica de la Terapia Ocupacional (T.O.). En el análisis, observamos cómo se enuncian ideas que aluden a la unión entre lo objetivo y subjetivo, entendiendo lo objetivo como aspectos naturales, fisiológicos,anatómicos, y lo subjetivo como las ideas de unión mente-cuerpo, historia de vida y contexto sociocultural. Se propone una mirada del cuerpo como hecho subjetivo, sociohistórico, asumiendo que no tiene un punto de partida en una materialidad abstracta, separada del sujeto mismo. Al respecto, se plantea el siguiente objetivo de investigación: Explorar qué significados de experiencia de cuerpo construyen laspersonas en situación de discapacidad física adquirida. El método de investigación utilizado son Relatos de Vida para construir narraciones relacionadas a la experiencia subjetiva de cuerpo. En cuanto a las técnicas, se aplicaron entrevistas en profundidad, y el análisis y producción de datos se apoyó en la Teoría fundamentada. La muestra la constituyó un grupo de personas adultas con el diagnóstico de discapacidad física adquirida. Los principales resultados se relacionan con los puntos de inflexión que identificamos en los relatos de vida, y que a su vez son fundamentales en la construcción y significación de la experiencia de cuerpo.

In the context of new theoretical and methodological developments in Occupational Therapy, emerge new qualitative perspectives of research and a social understanding of the discipline, for this reason we have questioned regarding the signification of body and disability. The following study depths in the mentioned topic from the point of view of basis (paradigms, approachesand models) and its expression in Occupational Therapy (OT) practice. In this analysis, we observe how some ideas are alluded in the union between the objective and subjective, defined objective as natural, physiological, anatomical aspects, among others, and the subjective as the ideas of the mind-body union, history of live, social-cultural context, among others. The present study aims to propose a view of the body as a subjective fact, sociohistorical, assuming thatit does not have a starting point in an abstract substance, separated from the subject himself. Regarding to this, it is posed the following research objective: To explore which meanings of body experience build people suffering from acquired physical disability. The research method used was The Life Stories to build narratives related to the subjective experience of the body, In regard to the techniques, they were applied in-depth interviews, and data analysis and production was supported by the grounded theory. The sample comprised a group of adults diagnosedwith acquired physical disability.The main results are related to the turning points that we identified in the life stories, which at the same time are fundamental in the construction and significance of body experience.

Megatrends and Perspectives of Emerging Medical Services

In the era of u-health, the megatrends of new medical services are the use of information and communication technologies to provide health care information and services to stakeholders including medisumers. They pursue improved quality of health care, increased access to information and process, cost-saving, industry development related to u-Health, and enforcement of competitiveness. The goals of activating u-Health are to improve laws and regulations, to provide incentives, to increase government support and establish a monitoring system, and to encourage financial investment for institutes related to health service market for an effective health system. Characteristics of megatrends in the era of u-health are represented as 5 c's: content, community, commerce, connectivity, and care. It contains the development of 'contents' for u-health, share and exchange information in the 'u-community', promote 'commercial u-health care models', 'connectivity' for standardization, activating 'care for network governance' by developing services, and build a value- and IT-based and patient-centered purchasing system, which will bring a paradigm shift in medical services.

Philosophical background of Evidence-based medicine / 의사학

Through the whole history of medicine, there runs a long struggle between two principal tendencies-empiricism and rationalism. The empirical trend lays its emphasis on "experience" for the cure of the sick. The rationalistic trend lays its main emphasis on "mechanism" for the causes of diseases. The term "evidence-based medicine (EBM) ", defined as "the conscious, explicit and judicious use of the best current evidence in making decisions about the individual patients", was introduced about ten years ago. The proponents has been described EBM as a "paradigm shift" that will change medical practice in the years ahead. But there has been considerable debate about the value of EBM. The modern medicine, following philosophy of modern science such as the 'realism controlled by empiricism', has developed biomedical model. But the EBM wrapped with clinical epidemiology and statistics, represents response of empiricism to the rationalism (realism). The roots of EBM extend back at least as far as the Paris clinical school, and the work of Pierre Louis in Paris in the early 19th century. Is EBM a paradigm shift? To answer this question, We have to specify the alternative with which we are comparing EBM. The alternative to EBM is the basic science approach: studying the pathophysiolological mechanism of the body. But EBM is so clearly intertwined with and complementary to the basic science that it would make little sense to see EBM as a paradigm shift away from basic science. In a sense, evidence-based medicine shows only methodological contribution aimed at improving the gathering and sorting of the best information published by biomedical scientists and clinical epidemiologists for use in clinical practice. Although EBM and the traditional medicine embody different approaches, this does not mean that they are competitors. In fact, the two approach need each; neither can stand alone for the development of clinical practice.