Modeling the COVID-19 Travel Choices in Colombia and India: A Hybrid Multiple Discrete-Continuous Nested Extreme Value Approach.

The COVID-19 pandemic has affected many daily activities, primarily as a result of the perceived contagion risk and government restrictions to mitigate the spread of the virus. To this end, drastic changes in the trip choices for commuting to work have been reported and studied, mostly through descriptive analysis. On the other hand, modeling-based research that can simultaneously understand both changes in mode choice and its frequency at an individual level has not been much used in existing studies. As such, this study aims to understand the changes in mode-choice preference and the frequency of trips, comparing pre-COVID with during-COVID scenarios, in two different countries of the Global South: Colombia and India. A hybrid multiple discrete-continuous nested extreme value model was implemented using the data obtained from online surveys in Colombia and India during the early COVID-19 period of March and April 2020. This study found that, in both countries, utility related to active modes (more used) and public transportation (less used) changed during the pandemic. In addition, this study highlights potential risks in likely unsustainable futures where there may be increased use of private vehicles such as cars and motorcycles, in both countries. It was also identified that perceptions toward government responses had a significant impact on the choices in Colombia, though this was not the case in India. These results may help decision makers focus on public policies to encourage sustainable transportation by avoiding the detrimental long-term behavioral changes resulting from the COVID-19 pandemic.

Raising Capacity to Address Mental Health Concerns in Costa Rica.

Background A family medicine team based out of Mayo Clinic, Rochester assembled in 2019 to provide home visits and direct care to underserved populations of patients in La Cruz, Costa Rica. In addition to the provision of direct patient care, our team was interested in conducting a community needs-based assessment to identify an area for provider education efforts and the local providers on a chronic health issue using local feedback and physician data. Suicide awareness and prevention were identified as a priority based on rising suicide rates as well as limited psychiatry services in the area, with some major providences having ~0.60 psychiatrists available per 100,000 people. Our group provided a half-day educational course on mental health topics related to suicide awareness for local health workers. The primary objective of this study was to evaluate any lasting changes in practice, confidence, and knowledge among local health workers attributable to our training and add to the limited research on this topic. Methods Two groups of participants (81) from local hospitals were recruited via local providers and divided into two morning and afternoon groups on a single day. Each group comprised primary care providers, nurses, social workers, and finance officers. Both were given the same educational presentation that could be broadly applied to each various role. Our team provided lectures on mental health, as well as how to improve personal resilience. Locally medically trained translators were used. Pre and post-lecture surveys gathered demographic data, experience with these mental health issues, and confidence in addressing mental health concerns. Pre and post-lecture surveys, including open-ended as well as Likert scale and multiple-choice questions, were handed out at the beginning and end of each lecture to all participants. A four to six months follow-up survey was delivered by email using SurveyMonkey to evaluate retention and impact of educational materials. Results The initial two groups of participants (n = 81) were aged 23-60 years (mean: 43), and 67% (39) were female. Work experience ranged from 0 to 37 years (mean: 14) with 64% (37) doing direct patient care. Preliminary lecture content data from participants (n = 44) demonstrated an overall increase in correct responses by +15.4% from the pre-test (percent correct, 38.1%) to post-test (53.5%, p < 0.01). Individuals (n = 55) with past exposure to suicide were much more likely to report asking patients about suicide than those with no prior exposure (56.3% vs. 8.3%; p < 0.01). At the six-month follow-up with participants (n = 11), when asked about their confidence in learning objectives from the lecture given prior, the rates of low confidence decreased as well as the level of high confidence improved but was not statistically significant. The rate of low confidence of respondents' confidence in asking about mental health concerns decreased from 35.2% to 0% (p < 0.01). Conclusions Our group was able to successfully deliver lectures to a mixed audience of health workers in a region self-identified as struggling with mental health issues in Costa Rica. The surveys suggested learning occurred. A trend suggestive that the educational content improved the participants' confidence and knowledge components over time was noted. Future service trips may be able to build on this initial experience to improve on ways to raise capacity while delivering direct care to regions in need.

Overview of conditions seen on a Canadian Memorial Chiropractic College outreach to the Dominican Republic.

OBJECTIVE: This study aims to gather information on conditions seen, treatments rendered, and referrals made during a Canadian Memorial Chiropractic College outreach to the Dominican Republic serving those in need. METHODS: Data was extracted from templated patient files retrospectively. RESULTS: Spinal, extremity and other/whole body chief complaints accounted for 71.79%, 24.64% and 3.57% respectively in patients ranging in age from 1.5 to 106 years whose data was collected. Mechanical pain accounted for 95.07% of all cervical, 96.81% of thoracic and 91.27% of lumbar spine diagnoses. Various non-mechanical conditions were also encountered.Manual therapy was performed in 96.10% of cases. Twenty referrals were made to urgent care, six to a World Spine Care clinic and 46 for further investigation, including local medical doctors or surgery. CONCLUSION: This study reports empirical data collected from an 11-day outreach to the Dominican Republic that provided otherwise unattainable chiropractic care for musculoskeletal complaints.

OBJECTIF: Cette étude vise à recueillir des données sur les conditions observées, les traitements administrés et les renvois effectués pendant la mission d'un établissement d'enseignement de la chiropratique en République dominicaine, au service des personnes dans le besoin. MÉTHODOLOGIE: Les données ont été extraites de dossiers de patients. RÉSULTATS: Les principaux symptômes des patients étaient des douleurs à la colonne vertébrale, aux extrémités et à toutes les parties du corps; elles étaient apparues respectivement chez 71,79 %, 24,64 % et 3,57 % des patients âgés de 1,5 à 106 ans. La douleur mécanique comptait pour 95,07 % de tous les symptômes cervicaux, 96,81 % des douleurs thoraciques et 91,27 % des douleurs lombaires. Divers troubles non mécaniques étaient aussi observés.Des thérapies manuelles ont été pratiquées dans 96,1 % des cas. Vingt patients ont été orientés vers des établissements de soins d'urgence; 6 vers une clinique World Spine Care et 46 vers des médecins de la région pour subir d'autres examens, ou une intervention chirurgicale. CONCLUSION: Cette étude rend compte des données empiriques recueillies au cours d'une mission de 11 jours en République dominicaine au cours de laquelle des soins chiropratiques ont été offerts à des patients qui autrement n'auraient pas pu en bénéficier.

Perspectivas curriculares y didácticas de las salidas de campo en las licenciaturas en Ciencias Sociales del Caribe Colombiano / Curricular and didactic perspectives of field trips in bachelor's degrees in Social Sciences of the Colombian Caribbean / Perspectivas curriculares e didáticas das viagens de campo em ciências sociais no Caribe colombiano

RESUMEN Se presentan los resultados de una investigación cualitativa a nivel de maestría orientada a identificar las perspectivas didácticas y curriculares de las salidas de campo inmersas en las Licenciaturas en Ciencias Sociales en el Caribe Colombiano (Universidad de Córdoba, Universidad de Cartagena y Universidad del Atlántico) que conlleven a un conocimiento de la realidad del acto educativo en relación con la formación del nuevo maestro, teniendo en cuenta los requerimientos y necesidades del contexto. El estudio implementó como técnica de recolección de la información las entrevistas semiestructuradas a docentes, estudiantes y directivos de las Instituciones de Educación Superior y la revisión documental de lineamientos curriculares y disposiciones normativas para los programas de formación de docentes en Colombia. En este sentido, se identificaron siete perspectivas didácticas y curriculares: academicista, sistémica, formativa, integradora, transversal, desarrolladora y transformadora. Las cuales surgieron a partir de las apreciaciones de las voces de los docentes, directivos y estudiantes de las tres universidades participantes.

ABSTRACT This article presents a reflection from a qualitative research at the master's level, focused on characterizing the didactic and curricular perspectives of field trips in training programs in Social Sciences in the Colombian Caribbean (University of Córdoba, University of Cartagena and Universidad del Atlántico), in order to re-signify the foundations of the training process of the new Bachelor of Social Sciences, taking into account the requirements and needs °f the context. The study implemented as a data collection technique, semi-structured interviews with teachers, students and directors of the participating educational institutions and the documentary review of curricular guidelines and normative provisions for teacher training programs in Colombia. In this sense seven didactic and curricular perspectives were identified (7): academic, systemic, formative, integrating, transversal, developing and transforming, which arose from the appreciations of the voices of the teachers, managers and students of the three participating universities.

RESUMO Apresentam-se os resultados de uma pesquisa qualitativa em nível de mestrado com o objetivo de identificar as perspectivas didáticas e curriculares das viagens de campo imersas nos cursos de Bacharelado em Ciências Sociais no Caribe colombiano (Universidade de Córdoba, Universidade de Cartagena e Universidade do Atlântico) que levam ao conhecimento da realidade do ato educativo em relação à formação do novo professor; levando em consideração as exigências e necessidades do contexto. O estudo implementou entrevistas semiestruturadas com professores, alunos e diretores de instituições de ensino superior, e a revisão documental das diretrizes curriculares e disposições normativas para programas de formação de professores na Colômbia como uma técnica de coleta de informações. Nesse sentido, foram identificadas sete perspectivas didáticas e curriculares: acadêmica, sistêmica, formativa, integrativa, transversal, desenvolvedora e transformadora. Que surgiram a partir da apreciação das vozes de professores, gestores e alunos das três universidades participantes.

Quality outcomes for pediatric colorectal surgery treated during short-term international medical service trips at a dedicated site in Honduras.

INTRODUCTION: Short-term international medical service trips (MSTs) provide specialized care in resource-constrained countries. There are limited data on immediate and long-term reported outcomes following specialty MST. We hypothesized that dedicated collaborative MST team and host institution produce outcomes and results comparable to those of high-income settings. Our primary aim was to analyze the long-term surgical and functional outcomes of our specialty-specific MSTs following five years of annual MST in Honduras. METHODS: We performed a single-institution retrospective analysis of 56 children who underwent colorectal and pelvic reconstructive operations between 2014 and 2018. Demographics, diagnosis, comorbidities, type of repair, long-term complications, and functional bowel and bladder results were recorded. RESULTS: We included a total of 56 children, 47 with ARM and 9 with HD, with a median age of 43.5 months (17-355) at the time of surgery. 25% (22) of the patients were lost to follow-up. Fecal continence was achieved by 23 (60%) patients <5 years who reported toilet training (n = 39) and by 5 (45%) patients >5 years (n = 11). Complications included constipation in 18 (42.9%) children with ARM and in 1 (12.5%) with HD. Eleven (19.6%) patients required revisional surgery for skin level anal stricture. Seventy-five percent of the patients with pediatric colorectal disorders attending the MST were compliant with continued long-term follow-up. CONCLUSION: We were able to demonstrate that with organized, dedicated site and surgeon, results achieved can be comparable to those in the high-income countries (HICs). We conclude that this type of specialized care is feasible and beneficial for affected pediatric colorectal patients in resource-limited settings, when a strong partnership with a system of preoperative assessments and peri- and postoperative care can be established. LEVEL OF EVIDENCE: Level IV (retrospective cohort study).

Influências estrangeiras e concretizações nos intentos de regionalização da rede hospitalar em Portugal (1946-1974) / Foreign influence and achievements in the regionalization of Portugal's hospital network (1946-1974) / Influencias extranjeras y concretizaciones en los intentos de regionalización de la red hospitalaria en Portugal (1946-1974)

O presente artigo aborda os propósitos de regionalização da rede hospitalar portuguesa durante o regime ditatorial do Estado Novo (1933-1974), lançados no após Segunda Guerra Mundial. Almejando um sistema hospitalar coordenado com base regional, o governo português limitou-se a comparticipar a construção e a remodelação de edifícios, relegando as múltiplas tarefas envolvidas no funcionamento hospitalar para instituições particulares, o que dificultou o desenvolvimento e o acesso a cuidados de saúde a uma parte significativa da população. Com base na análise de viagens de estudo realizadas por administradores hospitalares e engenheiros sanitários nas décadas de 1940 e 1950, sobretudo a países europeus como Itália, França e Inglaterra, pondera-se acerca da importância dos contatos com redes internacionais de especialistas e da influência exercida pelos exemplos estrangeiros sobre as medidas de organização da assistência hospitalar em Portugal estabelecidas nos anos seguintes. (AU)

This article analyzes the regionalization of Portugal's hospital network during the "New State" dictatorial regime (1933-1974), launched after the second world war. In an attempt to create a regionally-based hospital system, the Portuguese government limited itself to subsidizing the construction and refurbishment of buildings, relegating the multiple tasks involved in hospital management to private organizations, hampering access to health care for a significant part of the population. Through the analysis of study trips made by hospital administrators and sanitary engineers in the 1940s and 1950s, mainly to European countries such as Italy, France and England, this article reflects on the importance of contacts with international networks of experts and influence of foreign experiences on the approach to the organization of hospital care in Portugal adopted in subsequent years. (AU)

El presente artículo aborda los principios de regionalización de la red hospitalaria portuguesa durante el régimen dictatorial del Estado Novo (1933-1974), lanzados después de la Segunda Guerra Mundial. El gobierno portugués, que anhelaba un sistema hospitalario coordinado con base regional, se limitó a coparticipar la construcción y remodelación de edificios, relegando a instituciones particulares las múltiples tareas envueltas en el funcionamiento hospitalario, lo que dificultó el desarrollo y el acceso a cuidados de salud para una parte significativa de la población. Por medio del análisis de viajes de estudio realizados por administradores hospitalarios e ingenieros sanitarios durante las décadas de 1940 y 1950, principalmente a países europeos como Italia, Francia e Inglaterra, se pondera sobre la importancia de los contactos con redes internacionales de especialistas y de la influencia ejercida por los ejemplos extranjeros sobre las medidas de organización de la asistencia hospitalaria en Portugal, establecidas en los años siguientes. (AU)

USMCA 2.0: a few improvements but far from a 'healthy' trade treaty.

The USMCA (NAFTA 2.0), although signed over a year ago, went through several months of renegotiation of certain of its new rules that the Democrat-controlled US Congress wanted altered or strengthened. In December a 'Protocol of Amendment' was agreed upon and signed by the three Parties (the USA, Mexico, and Canada). A number of tough, new measures governing pharmaceuticals were revised or deleted, making it potentially easier for generic competition and lower drug costs in all three countries. Rules on protection of labour rights were also strengthened, lowering the threshold at which a complaint of unfair labour practices could be initiated. Procedures for investigating such a complaint or resolving a formal dispute were also improved. Similar procedural improvements were made on measures affecting environmental protection. These Protocol agreements are more health-positive than health-negative, and in the case of pharmaceuticals are of significant impact. Overall, however, these amendments are simply a political fine-tuning of the agreement. Concerns raised in our earlier health impact assessment of the USMCA, notably how the agreement's regulatory reforms reduce public health policy flexibilities, remain. The agreement continues to subordinate known or potential health costs of many of its measures to dubious claims of aggregate economic gains. Moreover, these gains, if materialized, are likely to accrue to those atop the income/wealth hierarchies in all three nations.

Association between Transport Risk Index of Physiologic Stability in Extremely Premature Infants and Mortality or Neurodevelopmental Impairment at 18 to 24 Months.

OBJECTIVES: To examine the association between mortality or neurodevelopmental impairment at 18-24 months of corrected age and the Transport Risk Index of Physiologic Stability (TRIPS) score on admission to the neonatal intensive care unit (NICU) in extremely premature infants. STUDY DESIGN: Retrospective cohort study of extremely premature infants (inborn and outborn) born at 22-28 weeks of gestational age and admitted to NICUs in the Canadian Neonatal Network between April 2009 and September 2011. TRIPS scores and clinical data were collected from the Canadian Neonatal Network database. Follow-up data at 18-24 months of corrected age were retrieved from the Canadian Neonatal Follow-Up Network database. Neurodevelopment was assessed using the Bayley Scales of Infant and Toddler Development, Edition III. The primary outcome was death or significant neurodevelopmental impairment at 18-24 months of corrected age. The secondary outcomes were individual components of the Bayley Scales of Infant and Toddler Development, Edition III assessment. RESULTS: A total of 1686 eligible infants were included. A TRIPS score of ≥20 on admission to the NICU was significantly associated with mortality (aOR 2.71 [95% CI, 2.02-3.62]) and mortality or significant neurodevelopmental impairment (aOR 1.91 [95% CI, 1.52-2.41]) at 18-24 months of corrected age across all gestational age groups of extremely premature infants. CONCLUSION: The TRIPS score on admission to the NICU can be used as an adjunctive, objective tool for counselling the parents of extremely premature infants early after their admission to the NICU.

Analyzing the impact of trade and investment agreements on pharmaceutical policy: provisions, pathways and potential impacts.

BACKGROUND: Trade and investment agreements negotiated after the World Trade Organization's Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS) have included increasingly elevated protection of intellectual property rights along with an expanding array of rules impacting many aspects of pharmaceutical policy. Despite the large body of literature on intellectual property and access to affordable medicines, the ways in which other provisions in trade agreements can affect pharmaceutical policy and, in turn, access to medicines have been little studied. There is a need for an analytical framework covering the full range of provisions, pathways, and potential impacts, on which to base future health and human rights impact assessment and research. A framework exploring the ways in which trade and investment agreements may affect pharmaceutical policy was developed, based on an analysis of four recently negotiated regional trade agreements. First a set of core pharmaceutical policy objectives based on international consensus was identified. A systematic comparative analysis of the publicly available legal texts of the four agreements was undertaken, and the potential impacts of the provisions in these agreements on the core pharmaceutical policy objectives were traced through an analysis of possible pathways. RESULTS: An analytical framework is presented, linking ten types of provisions in the four trade agreements to potential impacts on four core pharmaceutical policy objectives (access and affordability; safety, efficacy, and quality; rational use of medicines; and local production capacity and health security) via various pathways. CONCLUSIONS: The analytical framework highlights provisions in trade and investment agreements that need to be examined, pathways that should be explored, and potential impacts that should be taken into consideration with respect to pharmaceutical policy. This may serve as a useful checklist or template for health and human rights impact assessments and research on the implications of trade agreements for pharmaceuticals.

Sexual Dimorphism and Foraging Trips of the Laysan Albatross (Phoebastria immutabilis) on Guadalupe Island.

Sexual dimorphism in the Laysan albatross (Phoebastria immutabilis) on Guadalupe Island was evaluated during the breeding seasons of 2015-2018 by measuring and comparing 10 morphological attributes: cranial length, bill length, nostril length, cranial width, bill height, bill width, tarsus length, closed wing length, opened wing length, and wingspan length in reproductive adults (n = 135). Males were larger than females across all traits (Student's t-test, p < 0.05, p < 0.05). We created a logistic model using stepwise regression to predict sex based on morphological variables. This model indicated four significant morphological predictor variables (z < 0.05) and was able to successfully predict the sex of P. immutabilis individuals in more than 90% of the cases. Based on these predictor variables, a web app was developed to determine the sex of the Laysan albatross in the field, providing a non-invasive method for rapid data collection that reduces costs and handling times while improving conservation efforts. We tracked Laysan albatross (n = 36) during breeding seasons and found no significant differences between females and males for either trip length (GLMM, F = 0.017, DF = 1, 1, p = 0.917 > 0.05) or maximum trip distance (GLMM, F = 0.374, DF = 1, 1, p = 0.651 > 0.05). Our results suggest that both sexes show a strong preference to travel to highly productive coastal waters northeast of the breeding colony that are influenced by the California Current. The present research will serve to establish a baseline to protect this species on Guadalupe Island and highlights the importance of understanding sexual dimorphism in at-risk seabird species.

USMCA (NAFTA 2.0): tightening the constraints on the right to regulate for public health.

BACKGROUND: In late 2018 the United States, Canada, and Mexico signed a new trade agreement (most commonly referred to by its US-centric acronym, the United States-Mexico-Canada Agreement, or USMCA) to replace the 1994 North American Free Trade Agreement (NAFTA). The new agreement is the first major trade treaty negotiated under the shadow of the Trump Administration's unilateral imposition of tariffs to pressure other countries to accept provisions more favourable to protectionist US economic interests. Although not yet ratified, the agreement is widely seen as indicative of how the US will engage in future international trade negotiations. METHODS: Drawing from methods used in earlier health impact assessments of the Trans-Pacific Partnership agreement, we undertook a detailed analysis of USMCA chapters that have direct or indirect implications for health. We began with an initial reading of the entire agreement, followed by multiple line-by-line readings of key chapters. Secondary sources and inter-rater (comparative) analyses by the four authors were used to ensure rigour in our assessments. RESULTS: The USMCA expands intellectual property rights and regulatory constraints that will lead to increased drug costs, particularly in Canada and Mexico. It opens up markets in both Canada and Mexico for US food exports without reducing the subsidies the US provides to its own producers, and introduces a number of new regulatory reforms that weaken public health oversight of food safety. It reduces regulatory policy space through new provisions on 'technical barriers to trade' and requirements for greater regulatory coherence and harmonization across the three countries. It puts some limitations on contentious investor-state dispute provisions between the US and Mexico, provisions often used to challenge or chill health and environmental measures, and eliminates them completely in disputes between the US and Canada; but it allows for new 'legacy claims' for 3 years after the agreement enters into force. Its labour and environmental chapters contain a few improvements but overall do little to ensure either workers' rights or environmental protection. CONCLUSION: Rather than enhancing public health protection the USMCA places new, extended, and enforceable obligations on public regulators that increase the power (voice) of corporate (investor) interests during the development of new regulations. It is not a health-enhancing template for future trade agreements that governments should emulate.

Incidentes relacionados con resbalos, tropiezos y caídas en una fábrica pulverizadora de leche en el municipio de Valledupar, Cesar / Incidents related to slips, trips and falls in a Milkpulverizer factory in the municipality of Valledupar, Cesar

Introducción: Los incidentes relacionados con resbalos, tropiezos y caídas requieren un enfoque de prevención integral y constante para un desempeño sostenible a largo plazo, enfocado hacia la identificación, evaluación y control, para generar una mejora continua. Objetivo: Determinar las causas de incidentesrelacionados con resbalos, tropiezos y caídas en una fábrica pulverizadora de leche en Valledupar, Cesar. Materiales y métodos: Estudio descriptivo transversal; se utilizaron como instrumentos, la matriz de riesgos de la Guía Técnica Colombiana 45/2012 y lista de chequeo Anexo1 de Instrucción Técnica Gu-18.007,06/2016. Resultados: Los mayores reportes estuvieron relacionados con desnivel, hueco, rejillas, tapas de registro en piso, escaleras, objeto prominente en rutas peatonales, sustancias derramadas y rampa/Plataforma. El área con mayor número de hallazgos asociados fue condensación con 19%, con 34% Riesgos Altos y 39% Riesgos Medios. Los agentes causales: Suelo arrojó: riesgo Alto 87.4% y riesgo medio 10.3%; Escaleras: riesgo Alto 85.7%, riesgo bajo 14.3%; Rampas/plataformas: riesgo Alto 60% y riesgo medio 33.3% y para Limpieza y señalización: riesgo Alto 52% yriesgomedio48%.Siendo598RiesgosAltos,145RiesgosMediosy28Riesgos Bajos evaluados en la lista de chequeo del Anexo1 de la Guía Técnica Gu-18.007,06/2016. Para valoración y priorización según Guía Técnica Colombiana 45/2012 fue de 16 Riesgos Muy Altos, 116 Riesgos Altos, 122 Riesgos Medios y 57 Riesgos Bajos. Conclusiones: Se concluye que las principales causas de resbalos, tropiezos y caídas están relacionada con Suelo, Escalera, Limpieza y señalización.

Introduction: The incidents related to slips, trips and falls require acomprehensive and constant preventionapproach for long-term sustainable performance, with an effortfocusedonidentifying,evaluatingandcontrollingthemtogenerateasignificant improvement. Objective: Determine the causes of incidents related to slips, trips and falls in a milk pulverizer factory in Valledupar, Cesar. Design: Descriptive type and cross section. Methodology: Instruments: Risk matrix of the Colombian TechnicalGuide45/2012andChecklistAnnex1ofTechnicalInstructionGu-18.007, 06 / 2016. Results: The biggest reports were related to unevenness, gaps, grids, floor registration caps, stairs, prominent object in pedestrian routes, spilled substances and ramp / Platform. The area with the highest number of associated findings was 19% condensation, with 34% High Risksand 39% Average Risks.The causal agents: Soil showed: High risk 87.4% and medium risk 10.3%, Stairs: High risk85.7%,lowrisk14.3%,Ramps/platforms:Highrisk60%andmediumrisk33.3% and for Cleaning and signaling: High risk 52% and medium risk 48%. For a total of 598 High Risks, 145 Medium Risks and 28 Low Risks evaluated in the checklist of Annex 1 of Technical Guide Gu-18.007,06 / 2016. For valuation and prioritization according to the Colombian Technical Guide 45/2012, it was 16 Very High Risks, 116 High Risks, 122 Medium Risks and 57 Low Risks. Conclusions:Conclusions: It is concluded that the main cause of slips, trips and falls is related to Soil, Ladder, Cleaning andsignaling

Addressing Noncommunicable Disease on Short-Term Medical Trips: A Longitudinal Study of Hypertension Treatment in Santo Domingo.

BACKGROUND: Noncommunicable diseases (NCDs) are the leading cause of mortality worldwide and pose complex challenges in developing nations. Short-term medical trips, which often operate independently of government and pharmaceutical companies, are in a unique position to address NCDs in developing nations. In 2010, the Dominican Aid Society of Virginia shifted the focus of their semiannual clinic to addressing NCDs in Paraíso, Santo Domingo. OBJECTIVE: This study analyzes the longitudinal impact of a short-term medical trip on the control of hypertension in their patient population. METHODS: Returning patients were identified through a review of medical records from 2014 and 2016. A sample of patients who only visited in either 2014 or 2016 were matched on sex and age and served as an internal comparison group. A generalized linear mixed model was applied to assess changes in blood pressure, the proportion of patients receiving blood pressure treatment, and the intensity of blood pressure treatment within and between returning and new patients over the study period. FINDINGS: There was a significant decrease in diastolic blood pressure within returning patients. Change in systolic blood pressure was significantly different between returning and new patients, with improvement in returning patients. There was a significant increase in the proportion of new patients receiving blood pressure treatment and a higher intensity of blood pressure treatment over time. The change in the proportion of patients receiving blood pressure treatment in the new patient group was significantly higher than that of the returning patient group. CONCLUSIONS: Short-term medical trips with a recurrent presence in a community may improve control of hypertension and other NCDs in developing nations. Further research into the impact that short-term medical trips may have on NCDs is needed.

O Palco Regulatório das Patentes Farmacêuticas: Licença Compulsória como Ferramenta Regulatória apoiada em PD&I / The Regulatory Stage of pharmaceutical patents: Compulsory Licensing as a RD&I-based Regulatory Tool / El escenario regulatorio de las patentes farmacéuticas: la licencia obligatoria como herramienta regulatoria apoyada en I + D + i

O direito à saúde garantido por intermédio do acesso a medicamentos estratégicos passou por um teste decisivo no início da década de 2000, quando os Estados Unidos e a União Europeia se posicionaram em frontal colisão com países em desenvolvimento, em especial África do Sul e Brasil, sobre a extensão do instituto jurídico da licença compulsória prevista no Acordo TRIPS. O presente artigo insere a licença compulsória e o investimento público em PD&I farmacêutico como instrumentos de estratégias regulatórias que contracenam no palco sociológico do direito ao configurarem mais do que reações pontuais a deficiências de mercado de fármacos ou de crises de saúde pública. Tais medidas de licença compulsória e investimento em PD&I farmacêutico representam atores de um palco regulatório que se descortina como um todo coerente voltado à administração do direito à saúde mediante uso da ameaça de licença compulsória para bloqueio de aumento arbitrário de preços de medicamentos e uso do investimento em PD&I para reforço da medida regulatória de quebra de patentes de medicamentos. A proposta defendida neste artigo é a de que o quadro regulatório da defesa da saúde pública foi melhor esboçado quando a licença compulsória deixou de representar a solução definitiva para se apresentar como a ultima ratio de modelagem regulatória após o reforço da condição de produção local de medicamentos via investimentos públicos em PD&I.

Access to strategic medicines as a guarantee of the right to health was submitted to a decisive test in the first half of 2000s, when the US and Europe positioned themselves in frontal collision with several developing nations, particularly South Africa and Brazil, on the topic of extension of the legal construct of compulsory license inaugurated by the TRIPS Agreement. This paper puts side-by-side the legal construct of compulsory license and RD&I investment in the pharmaceutical sector as regulatory tools prone to interact in the law sociological stage, as they present themselves as acts of an encompassing regulatory scheme. The regulatory stage makes use of off-stage characteristics of the socioeconomic environment to set up those tools in different ways. Compulsory license has been used as a threat that blocks arbitrary price increase of drugs, while RD&I investment has been applied to counteract the big pharma expectations of state inability to produce drugs following specific threats to break patented pharmaceutical inventions. This paper addresses the role of RD&I investments towards drug development to modulate the efficacy of compulsory licenses.

El derecho a la salud garantizado a través del acceso a la medicación estratégica se sometió a una prueba de fuego en la década de 2000, cuando Estados Unidos y Europa se han posicionado en colisión frontal con ciertos países en desarrollo, particularmente África del Sur y Brasil, alrededor de la extensión del instituto jurídico de las licencias obligatorias previsto en el Acuerdo TRIPS. Este artículo inserta la licencia obligatoria y la inversión en I + D + i como instrumentos farmacéuticos estratégicos de regulación que contraseñan en el escenario sociológico jurídico configurando más do que una respuesta puntual a las deficiencias del mercado de las drogas o las crisis de salud pública. Tales medidas de licencias obligatorias y de inversión en I + D + i farmacéutica representan actores de una etapa de regulación que se desarrollan como un todo coherente centrado en la administración del derecho a la salud a través del uso de amenazas de licencias obligatorias para bloquear el aumento arbitrario de precios de los medicamentos y el uso de la inversión en I + D + i para fortalecer la regulación de las patentes de medicamentos. La propuesta presentada en este artículo es que el marco regulador de la protección de la salud pública se ha definido mejor cuando la licencia obligatoria ya no representa la solución definitiva sino la última ratio en la estrategia de regulación basada en inversiones en I + D + i

Hospital survival upon discharge of ill-neonates transported by ground or air ambulance to a tertiary center / Sobrevida hospitalar após a alta de neonatos doentes transportados por ambulância terrestre ou aérea para um centro terciário

Abstract Objective: To evaluate the differences in hospital survival between modes of transport to a tertiary center in Colombia for critically ill neonates. Methods: Observational study of seriously ill neonates transported via air or ground, who required medical care at a center providing highly complex services. Data on sociodemographic, clinical, the Transport Risk Index of Physiologic Stability (TRIPS), and mode of transport were collected. Patients were described, followed by a bivariate analysis with condition (live or dead) at time of discharge as the dependent variable. A multiple Poisson regression with robust variance model was used to adjust associations. Results: A total of 176 neonates were transported by ambulance (10.22% by air) over six months. The transport distances were longer by air (median: 237.5 km) than by ground (median: 11.3 km). Mortality was higher among neonates transported by air (33.33%) than by ground (7.79%). No differences in survival were found between the two groups when adjusted by the multiple model. An interaction between mode of transport and distance was observed. Live hospital discharge was found to be associated with clinical severity upon admittance, birth weight, hemorrhaging during the third trimester, and serum potassium levels when admitted. Conclusions: Mode of transport was not associated with the outcome. In Colombia, access to medical services through air transport is a good option for neonates in critical condition. Further studies would determine the optimum distance (time of transportation) to obtain good clinical outcomes according type of ambulance.

Resumo Objetivo: Avaliar as diferenças na sobrevida hospitalar entre os modos de transporte para um centro terciário na Colômbia para neonatos gravemente doentes. Métodos: Estudo observacional de neonatos gravemente doentes transportados por ar ou terra que precisam de cuidados médicos em um centro que oferece serviços altamente complexos. Foram coletados dados sociodemográficos, clínicos, sobre o Índice de Risco da Estabilidade Fisiológica no Transporte (TRIPS) e o meio de transporte. Os pacientes foram descritos e submetidos a uma análise bivariada e a variável dependente foi a condição (vivo ou morto) no momento da alta. Uma regressão múltipla de Poisson com modelo de variância robusta foi usada para ajustar as associações. Resultados: Foram transportados 176 neonatos por ambulância (10,22% pelo ar) ao longo de seis meses. As distâncias foram maiores pelo ar (mediana: 237,5 km) do que por terra (mediana: 11,3 km). A mortalidade foi mais alta entre neonatos transportados pelo ar (33,33%) do que por terra (7,79%). Não foram encontradas diferenças na sobrevida entre os dois grupos após o ajuste com o modelo múltiplo. Foi observada uma interação entre o meio de transporte e a distância. A alta hospitalar com vida foi associada à gravidade clínica na internação, ao peso ao nascer, à hemorragia durante o terceiro trimestre e aos níveis de potássio sérico na internação. Conclusões: O meio de transporte não foi associado ao resultado. Na Colômbia, o acesso a serviços médicos por transporte aéreo é uma boa opção para neonatos em condições críticas. Estudos adicionais determinariam a distância ideal (tempo de transporte) para obter bons resultados clínicos de acordo com o tipo de ambulância.

Motivations, barriers and ethical understandings of healthcare student volunteers on a medical service trip: a mixed methods study.

BACKGROUND: The motivation to volunteer on a medical service trip (MST) may involve more than a simple desire for philanthropy. Some volunteers may be motivated by an intrinsic interest in volunteering in which the context of the volunteer activity is less important. Others may volunteer because the context of their volunteering is more important than their intrinsic interest in volunteering. Furthermore, MSTs may pose a variety of ethical problems that volunteers should consider prior to engaging in a trip. This study evaluated the motivations and barriers for graduate health care students volunteering for an MST to either the Dominican Republic or Mississippi. Volunteers' understanding of some of the ethical issues associated with MSTs was also assessed. METHODS: Thirty-five graduate health professions students who volunteered on an MST were asked to complete an online survey. Students' motivations and barriers for volunteering were assessed using a 5-point Likert scale and Fisher's exact test. Ethical understanding of issues in volunteering was assessed using thematic analysis. RESULTS: Students' motivations for volunteering appeared to be related to the medical context of their service more than an inherent desire for volunteer work. Significant differences were seen in motivations and barriers for some student groups, especially those whose volunteer work had less opportunity for clinical service. Thematic analysis revealed two major themes and suggested that students had an empirical understanding that volunteer work could have both positive and negative effects. CONCLUSIONS: An understanding of students' motivations for volunteering on an MST may allow faculty to design trips with activities that effectively address student motivations. Although students had a basic understanding of some of the ethical issues involved, they had not considered the impact of a service group on the in-country partners they work with.

Hospital survival upon discharge of ill-neonates transported by ground or air ambulance to a tertiary center.

OBJECTIVE: To evaluate the differences in hospital survival between modes of transport to a tertiary center in Colombia for critically ill neonates. METHODS: Observational study of seriously ill neonates transported via air or ground, who required medical care at a center providing highly complex services. Data on sociodemographic, clinical, the Transport Risk Index of Physiologic Stability (TRIPS), and mode of transport were collected. Patients were described, followed by a bivariate analysis with condition (live or dead) at time of discharge as the dependent variable. A multiple Poisson regression with robust variance model was used to adjust associations. RESULTS: A total of 176 neonates were transported by ambulance (10.22% by air) over six months. The transport distances were longer by air (median: 237.5km) than by ground (median: 11.3km). Mortality was higher among neonates transported by air (33.33%) than by ground (7.79%). No differences in survival were found between the two groups when adjusted by the multiple model. An interaction between mode of transport and distance was observed. Live hospital discharge was found to be associated with clinical severity upon admittance, birth weight, hemorrhaging during the third trimester, and serum potassium levels when admitted. CONCLUSIONS: Mode of transport was not associated with the outcome. In Colombia, access to medical services through air transport is a good option for neonates in critical condition. Further studies would determine the optimum distance (time of transportation) to obtain good clinical outcomes according type of ambulance.

Clinical guidelines for Western clinicians engaged in primary care medical service trips in Latin America and the Caribbean: an integrative literature review.

OBJECTIVE: Participation in primary care-focused medical service trips (MSTs) by North American providers is increasingly common, with many of these being conducted in Latin America. The literature has yet to comprehensively explore the nature of MST practice, including the use of evidence-based clinical guidelines. This integrative review presents an analysis of guidelines employed in MSTs in Latin America. METHODS: MEDLINE and LILACs were searched using the terms 'medical brigades', 'Latin America', 'primary health care' and related terms. The search was limited to articles published between 2000 and 2015 in any language. Qualitative or quantitative articles were subsequently included if they described management protocols in the context of patient care on an MST occurring in Latin America. Additional publications were identified by searching the citations of articles reviewed in full. Themes were extracted to an Excel file, and objective instruments were used to evaluate article quality (Mixed Methods Assessment Tool) and the quality of guidelines (Appraisal of Guidelines for Research & Evaluation II). RESULTS: Of 391 abstracts screened, eight met inclusion criteria. All described MSTs operating in rural settings in Central America. Five were qualitative descriptive, including two travel reports, an ethics thesis paper, and a description of a dermatologic MST. Four described subjective clinician experiences while describing non-evidence-based treatment suggestions or practices. Only one described evidence-supported primary care interventions. Three studies were quantitative descriptive, including two epidemiological articles, one of which used case definitions for select diagnoses. One described the application of American Family Physician guidelines to the description of UTI prevalence on a MST. Article scores in MMAT quality domains were variable, and only one article achieved a positive overall AGREE II score for guideline quality. CONCLUSIONS: Existing literature demonstrates minimal development or use of clinical guidelines on MSTs in Latin America. Future work must focus on the development, implementation, and evaluation of culturally sensitive, evidence-based guidelines for the management of patients receiving care from MSTs.

Utilidad de un índice de estabilidad fisiológica basado en TRIPS (Transport Risk Index of Physiologic Stability) para la evaluación de neonatos trasladados a un hospital de concentración / Utility of a physiologic stability index based on Transport Risk Index of Physiologic Stability (TRIPS) for the evaluation of infants transferred to a specialized hospital

Introducción: La mortalidad neonatal es una de las prioridades de la salud pública, por lo que se debe revisar cómo la inestabilidad fisiológica del recién nacido después de un traslado contribuye al incremento de la mortalidad neonatal. El objetivo de este trabajo fue determinar si el índice de estabilidad fisiológica (TRIPS) en los recién nacidos trasladados a la Unidad de Cuidados Intensivos Neonatales de un hospital de segundo nivel sirve como factor predictivo de mortalidad neonatal temprana. Métodos: Se valoró el índice de estabilidad fisiológica de la escala de TRIPS para predecir la muerte neonatal en los primeros 7 días del ingreso de los pacientes. Resultados: Se encontró que la mortalidad neonatal a los 7 días del ingreso está relacionada con la puntuación de la calificación TRIPS. La puntuación de los sobrevivientes y las defunciones presentaron una diferencia significativa (p = 0.009). Para una puntuación de 16 se determinó una sensibilidad del 62% y una especificidad de 84%, con un área bajo la curva de 0.757. Conclusiones: La ponderación del índice de estabilidad fisiológica de TRIPS es un buen predictor de la mortalidad neonatal. Es importante establecer medidas para mejorar la estabilidad fisiológica de los recién nacidos antes, durante y después del traslado, con la finalidad de disminuir la mortalidad neonatal.

Background: Neonatal mortality is a public health priority. We review the physiological instability of the newborn after a transfer, which contributes to increased neonatal mortality. The objective of this work was to determine whether the Transport Risk Index of Physiologic Stability (TRIPS) in newborns transferred to the Neonatal Intensive Care Unit of a secondary hospital serves as a predictor of early neonatal mortality. Methods: We use the TRIPS to predict neonatal death in the first 7 days after patients' admission. Results: Neonatal mortality at 7 days after admission is related to the TRIPS rating. The score of the survivors and neonatal deaths show a significant difference (p: 0.009). For a score of 16, a sensitivity of 62% and a specificity of 84%; area under the curve of 0.757 was determined. Conclusions: Physiological index weighting using TRIPS is a good predictor of neonatal mortality. It is important to establish measures to improve physiological stability of the newborn before, during and after the transfer in order to reduce neonatal mortality.