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IntroductionThere is an urgent need to reduce the burden of non-communicable diseases (NCDs), particularly in low-and middle-income countries, where the greatest burden lies. Yet, there is little research concerning the specific issues involved in scaling up NCD interventions targeting low-resource settings. We propose to examine this gap in up to 27 collaborative projects, which were funded by the Global Alliance for Chronic Diseases (GACD) 2019 Scale Up Call, reflecting a total funding investment of approximately US$50 million. These projects represent diverse countries, contexts and adopt varied approaches and study designs to scale-up complex, evidence-based interventions to improve hypertension and diabetes outcomes. A systematic inquiry of these projects will provide necessary scientific insights into the enablers and challenges in the scale up of complex NCD interventions.Methods and analysisWe will apply systems thinking (a holistic approach to analyse the inter-relationship between constituent parts of scaleup interventions and the context in which the interventions are implemented) and adopt a longitudinal mixed-methods study design to explore the planning and early implementation phases of scale up projects. Data will be gathered at three time periods, namely, at planning (TP), initiation of implementation (T0) and 1-year postinitiation (T1). We will extract project-related data from secondary documents at TPand conduct multistakeholder qualitative interviews to gather data at T0and T1.We will undertake descriptive statistical analysis of TPdata and analyse T0and T1data using inductive thematic coding. The data extraction tool and interview guides were developed based on a literature review of scale-up frameworks.Ethics and disseminationThe current protocol was approved by the Monash University Human Research Ethics Committee (HREC number 23482). Informed consent will be obtained from all participants. The study findings will be disseminated through peer-reviewed publications and more broadly through the GACD network.

Los videojuegos como productos culturales, encierran toda una potencialidad en clave de significados y otorgan posibilidades de manifestar posiciones enunciativas divergentes por parte de colectividades no hegem��nicas. El objetivo de este ensayo es analizar la relaci��n que existe entre el consumo cultural de videojuegos y la construcci��n de subjetividades en los jugadores hispanoamericanos. Se trata de una investigaci��n documental a partir de la b��squeda de publicaciones cient��ficas, a fin de seleccionar los art��culos con mayores ��ndices de impacto, que abordaron la tem��tica en cuesti��n. Se observ�� que prevalecen los g��neros de videojuegos de acci��n y aventura, de disparos en primera y tercera persona con narrativas m��tico-heroicas para que los usuarios trasciendan en una situaci��n ��pica en el marco resistencia - poder entre jugadores norteamericanos angloparlantes y latinoamericanos hispanohablantes generando din��micas de exclusi��n migratoria en el espacio virtual. Se concluye, que las subjetividades de los video-jugadores se construyen mediante las interrelaciones que se producen entre los sujetos y la din��mica en la que se desarrolla el juego, incorporando a su constructo tanto valores como sentimientos y significados.

Objetivo.Identificar y sistematizar la evidencia empírica disponible sobre factores e intervenciones que inciden en las condiciones y medio ambiente de trabajo para incrementar la atracción, captación y retención de recursos humanos en salud en el primer nivel de atención de áreas rurales, remotas o desatendidas.Métodos.Revisión rápida de revisiones, seleccionadas según criterios de pertinencia, elegibilidad e inclusión con búsquedas en bases de datos electrónicas, de literatura gris y manual. Se empleó el AMSTAR I para evaluar la calidad de revisiones sistemáticas y un análisis temático para síntesis de resultados.Resultados.Se incluyeron 16 revisiones, una de las cuales contenía a su vez 14 revisiones. Del total, 20 revisiones analizaron factores y 9 evaluaron efectividad de intervenciones. La evidencia sobre factores es abundante, pero de limitada calidad. Los factores individuales, familiares y la “exposición rural previa” se asociaron a mayor captación; factores organizacionales y del contexto externo fueron gravitantes en la retención. El trabajo en red y el apoyo profesional incidieron en la captación y retención. La evidencia sobre efectividad de intervenciones fue limitada, en cantidad y calidad. El tipo de intervención más frecuentemente empleada fueron los incentivos.Conclusiones.La evidencia sobre factores que se relacionan positivamente con la captación y retención de trabajadores en el primer nivel de atención de áreas rurales, remotas o desatendidas es suficiente y debería ser tenida en cuenta al diseñar intervenciones. La evidencia de calidad sobre la efectividad de intervenciones es escasa. Se requieren más estudios controlados con rigurosidad metodológica, particularmente en las Américas.

El trabajo de investigación tuvo como objetivo general determinar la incidencia que tiene el uso de la herramienta Web 2.0, Mangus Classroom, para el fortalecimiento de la competencia Resolución de Problemas Tipo PAEV (Problemas Aritméticos con Enunciado Verbal) en Estudiantes de Básica Primaria de Barranquilla. Su orientación metodológica fue de tipo longitudinal, cuasi-experimental, explicativo y con una modalidad de campo. La muestra estuvo representada por Estudiantes de dos (2) cursos de Cuarto Grado de la Institución Educativa Distrital La Milagrosa, Fe y Alegría, seleccionados a través de un muestreo por conveniencia. Se empleó para la recolección de datos una Prueba Tipo Pre-Test / Post-Test. Se obtuvo, como resultado, que el Grupo Experimental A (4º01), en los problemas de tipo PAEV, mostró competencias satisfactorias, mientras el Grupo Control mantuvo sus niveles con relación al Pretest, por lo que el uso de la herramienta Web 2.0 Mangus Classroom es considerada, significativamente, como una estrategia didáctica. The general objective of the research work was to determine the incidence of the use of the Web 2.0 tool, Mangus Classroom, for the strengthening of the competence Resolution of PAEV Problems (Arithmetic Problems with Verbal Statement) in Elementary Students of Barranquilla. Its methodological orientation was longitudinal, quasi-experimental, explanatory and with a field modality. The sample was represented by Students of two (2) Fourth Grade courses of the La Milagrosa, Fe y Alegría District Educational Institution, selected through convenience sampling. A Test Type Pre-Test / Post-Test Test was used for data collection. It was obtained, as a result, that Experimental Group A (4º01), in the PAEV type problems, showed satisfactory competencies, while the Control Group maintained its levels in relation to the Pretest, so the use of the Web 2.0 Mangus Classroom tool is considered, significantly, as a didactic strategy.

Retinopathy of prematurity (ROP) is a largely avoidable cause of blindness in children worldwide, requiring high-quality neonatal care, early detection and treatment. In middle-income countries throughout Latin America, Eastern Europe and South Asia, there has been a rise in ROP blindness due to a combination of increased survival of preterm infants, resource-scarce medical environments and lack of policies, training and human resources. However, Argentina is an example of country where rates of ROP blindness have declined and ROP programmes have been successfully and effectively embedded within the health and legal system. The purpose of this study is to describe the activities and stakeholders, including Ministry of Health (MoH) and UNICEF, involved in the process, from recognition of an epidemic of ROP blindness to the development of national guidelines, policies and legislation for control. Using a retrospective mixed methods case study design, data on rates of severe ROP was collected from 13 neonatal intensive care units from 1999 to 2012, and on the proportion of children blind from ROP in nine blind schools in seven provinces. Legislative document review, focus group discussions and key informant interviews were conducted with neonatologists, ophthalmologists, neonatal nurses, parents, MoH officials, clinical societies, legislators and UNICEF officials in seven provinces. Results are presented combining the stages heuristic policy framework and Shiffman including: agenda setting, policy formulation, implementation and evaluation. By 2012, ROP had declined as a cause of blindness in children in schools for the blind as had rates of severe ROP needing treatment in the NICUs visited. Multiple factors played a role in reducing blindness from ROP in Argentina and successfully coordinating its control including national advocacy, leadership, legislation and international collaboration. Lessons learned in Argentina can potentially be scaled to other LMICs in Latin America and beyond with further context-specific research.

OBJECTIVE: To review and analyze the regulatory framework of clinical trial registration, use of existing tools (publicly accessible national/international registration databases), and users' perspectives to identify possible barriers to registration compliance by sponsors and researchers in Argentina. METHODS: Internationally registered trials recruiting patients in Argentina were found through clincialtrials.gov and the International Clinical Trial Registration Platform (ICTRP) and compared with publically available clinical trials registered through the National Administration of Drugs, Foods, and Medical Devices (ANMAT). A questionnaire addressing hypothesized attitudinal, knowledge-related, idiomatic, technical, economic, and regulatory barriers that could discourage or impede registration of clinical trials was developed, and semi-structured, in-depth interviews were conducted with a purposively selected sample of researchers (investigators, sponsors, and monitors) in Argentina. RESULTS: A response rate of 74.3% (n = 29) was achieved, and 27 interviews were ultimately used for analysis. Results suggested that the high proportion of foreign-sponsored or multinational trials (64.8% of all protocols approved by ANMAT from 1994-2006) may contribute to a communication gap between locally based investigators and foreign-based administrative officials. A lack of knowledge about available international registration tools and limited awareness of the importance of registration were also identified as limiting factors for local investigators and sponsors. CONCLUSIONS: To increase compliance and promote clinical trial registration in Argentina, national health authorities, sponsors, and local investigators could take the following steps: implement a grassroots educational campaign to improve clinical trial regulation, support local investigator-sponsor-initiated clinical trials, and/or encourage local and regional scientific journal compliance with standards from the International Committee of Medical Journal Editors (ICMJE) and/or the World Association of Medical Editors (WAME)OBJETIVO: Examinar y analizar el marco normativo del registro de ensayos clínicos, el uso de los instrumentos existentes (bases de datos de registro nacionales o internacionales de acceso público), y las perspectivas de los investigadores para determinar posibles obstáculos al cumplimiento del registro por los patrocinadores y los investigadores en la Argentina. MÉTODOS: Se realizó una búsqueda en el sitio web clinicaltrials.gov y en la Plataforma Internacional de Registro de Ensayos Clínicos (ICTRP) de los ensayos clínicos registrados en el ámbito internacional que reclutan pacientes en la Argentina y los resultados se compararon con los ensayos clínicos incluidos en el registro de acceso público de la Administración Nacional de Medicamentos, Alimentos y Tecnología Médica (ANMAT). Se elaboró un cuestionario que abordaba los hipotéticos obstáculos relacionados con la actitud hacia el registro y el conocimiento de este, así como obstáculos idiomáticos, técnicos y económicos que podrían desalentar o dificultar el registro de los ensayos clínicos, y se llevaron a cabo entrevistas semiestructuradas exhaustivas en una muestra de investigadores seleccionada para este fin (investigadores clínicos, patrocinadores y monitores) en la Argentina. RESULTADOS: Se obtuvo una tasa de respuesta de 74,3% (n = 29) y finalmente se analizaron 27 entrevistas. Los resultados sugieren que la proporción elevada de ensayos clínicos con patrocinadores extranjeros o los ensayos multinacionales (64,8% de los protocolos aprobados por la ANMAT entre 1994 y el 2006) pueden contribuir a una deficiencia de comunicación entre los investigadores locales y los funcionarios administrativos ubicados en el extranjero. También se identificaron como factores limitantes para los investigadores y los patrocinadores locales la falta de conocimiento de los recursos internacionales disponibles para el registro y el escaso reconocimiento de la importancia del registro. CONCLUSIONES: Para aumentar el cumplimiento y promover el registro de los ensayos clínicos en la Argentina, las autoridades sanitarias nacionales, los patrocinadores y los investigadores locales podrían adoptar las siguientes medidas: ejecutar una campaña educativa para mejorar la reglamentación de los ensayos clínicos, apoyar los ensayos clínicos iniciados por investigadores o patrocinadores locales, y promover el cumplimiento de las normas del Comité Internacional de Editores de Revistas Médicas (ICMJE) o la Asociación Mundial de Editores Médicos (WAME) por parte de las revistas científicas locales y regionales

La seguridad del paciente es un problema grave de salud pública en todo el mundo. El análisis causal con un enfoque sistemático y participativo es una herramienta útil para mejorar la seguridad. OBJETIVOS: Aplicar un análisis causa raíz (ACR) y proponer acciones para corregir estas causas y/o minimizar el riesgo de ocurrencia de eventos similares. MÉTODOS: Análisis Causa Raíz de un evento centinela ocurrido en Unidad de Cuidados Intensivos Neonatales del Hospital Penna de Bahía Blanca, Argentina, en las siguientes etapas: 1) Identificación y selección del evento; 2) Recopilación de la información y descripción del evento; 3) Construcción del mapa de los hechos; 4) Análisis de los factores contribuyentes y estudio de las barreras (físicas, administrativas, organizacionales) que pueden prevenir daños, 5) Desarrollo de soluciones y plan de acción. RESULTADOS: Se seleccionó un brote intra-hospitalario por Staphylococcus aureus meticilino resistente, calificado como catastrófico (muerte de un neonato y de frecuencia ocasional). Con el análisis causal se identificaron los factores humanos proximales y las fallas latentes del sistema relacionadas con aspectos de la organización, la gestión de la información, el manejo del contexto y la cultura corporativa. Como principales barreras de contención se reconocieron la adecuada comunicación entre los profesionales de la salud y la sistematización de los procesos relacionados con la adherencia del personal a las normas de bioseguridad. Luego se diseñó un plan de acción destinado a fortalecer estas barreras. CONCLUSIONES: El ACR es un método factible de implementar para el equipo de salud. Su uso permitiría mejorar la seguridad de los pacientes a través de la identificación y corrección de las fallas latentes del sistema.

BACKGROUND: Cut points for defining obesity have been derived from mortality data among Whites from Europe and the United States and their accuracy to screen for high risk of coronary heart disease (CHD) in other ethnic groups has been questioned. OBJECTIVE: To compare the accuracy and to define ethnic and gender-specific optimal cut points for body mass index (BMI), waist circumference (WC) and waist-to-hip ratio (WHR) when they are used in screening for high risk of CHD in the Latin-American and the US populations. METHODS: We estimated the accuracy and optimal cut points for BMI, WC and WHR to screen for CHD risk in Latin Americans (n=18 976), non-Hispanic Whites (Whites; n=8956), non-Hispanic Blacks (Blacks; n=5205) and Hispanics (n=5803). High risk of CHD was defined as a 10-year risk > or =20% (Framingham equation). The area under the receiver operator characteristic curve (AUC) and the misclassification-cost term were used to assess accuracy and to identify optimal cut points. RESULTS: WHR had the highest AUC in all ethnic groups (from 0.75 to 0.82) and BMI had the lowest (from 0.50 to 0.59). Optimal cut point for BMI was similar across ethnic/gender groups (27 kg/m(2)). In women, cut points for WC (94 cm) and WHR (0.91) were consistent by ethnicity. In men, cut points for WC and WHR varied significantly with ethnicity: from 91 cm in Latin Americans to 102 cm in Whites, and from 0.94 in Latin Americans to 0.99 in Hispanics, respectively. CONCLUSION: WHR is the most accurate anthropometric indicator to screen for high risk of CHD, whereas BMI is almost uninformative. The same BMI cut point should be used in all men and women. Unique cut points for WC and WHR should be used in all women, but ethnic-specific cut points seem warranted among men.

Introducción. En 2010, se lanzó la iniciativa Maternidad Segura y Centrada en la Familia con el propósito de transformar las grandes maternidades públicas en espacios donde se implementaran prácticas seguras y se garantizaran los derechos de mujeres, recién nacidos y sus familias, lo que propuso un cambio de paradigma en la atención perinatal. El artículo reporta los hallazgos acerca de la cultura organizacional como insumo para la implementación de la iniciativa. Población y métodos. Se seleccionó una muestra no probabilística de 29 hospitales públicos de la provincia de Buenos Aires adheridos a la iniciativa. Durante 2011 y 2012, se aplicó una encuesta autoadministrada anónima a los integrantes de los servicios de Neonatología y Obstetricia, en la que se recogió información sobre tres dimensiones de la cultura organizational: clima organizational, prácticas seguras y facilitación para el cambio. Resultados. Se recolectaron 1828 encuestas; el 51% expresó la necesidad de mejorar la comunicación mediante más reuniones y el 60% evaluó positivamente algunos aspectos del liderazgo. La sobrecarga de trabajo fue reconocida como la principal causa de conflictos por el 60%. Aproximadamente, 25% expresó acuerdo y compromiso con la transformación de las maternidades en dirección a la iniciativa. La adhesión a las prácticas resultó dispar según cuáles fueran, aunque la mitad de los encuestados reportó que había razones legítimas para el cambio. Conclusiones. El diagnóstico de la cultura organizacional demostró que falta consolidar el compromiso con la iniciativa Maternidad Segura y Centrada en la Familia y que la evaluación del liderazgo no es integral. La sobrecarga de trabajo y las fallas de comunicación son las más importantes fuentes de conflicto. Fil: Ramos, Silvina. Centro de Estudio de Estado y Sociedad; Argentina Fil: Romero, Mariana. Centro de Estudio de Estado y Sociedad; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; Argentina Fil: Ortiz, Zulma. Organización de Las Naciones Unidas. Unicef; Argentina Fil: Brizuela, Vanessa. Centro de Estudio de Estado y Sociedad; Argentina

In 2010, the Safe and Family-Centered Maternity Hospitals initiative was launched in order to transform large public maternity centers into settings where safe practices are implemented and the rights of women, newborn infants and families are warranted. As a result, the paradigm of perinatal care was modified. This article reports on the findings of organizational culture as a component for the implementation of the initiative.The sample was selected in a non-probabilistic way and was made up of 29 public hospitals located in the province of Buenos Aires that participated in the initiative. During 2011 and 2012, an anonymous, self-administered survey was completed by members of the Department of Neonatology and the Department of Obstetrics. The survey collected information on three dimensions of the organizational culture: organizational environment, safe practices, and facilitation of change.A total of 1828 surveys were collected; 51% of survey respondents stated that there is a need to improve communication by having more meetings, while 60% made a positive assessment of various aspects of leadership. Work overload was described as the main cause of conflicts by 60%. Approximately 25% agreed and showed commitment with the initiative of transforming maternity centers. Adherence to practices was dissimilar depending on the practice, but half of survey respondents reported that there were genuine reasons for change.The assessment of the organizational culture showed that commitment to the Safe and Family-Centered Maternity Hospitals initiative is yet to be consolidated, and the evaluation of leadership is not comprehensive. Work overload and communication failures are the main reasons for conflict.Introducción. En 2010, se lanzó la iniciativa Maternidad Segura y Centrada en la Familia con el propósito de transformar las grandes maternidades públicas en espacios donde se implementaran prácticas seguras y se garantizaran los derechos de mujeres, recién nacidos y sus familias, lo que propuso un cambio de paradigma en la atención perinatal. El artículo reporta los hallazgos acerca de la cultura organizacional como insumo para la implementación de la iniciativa. Población y métodos.Se seleccionó una muestra no probabilística de 29 hospitales públicos de la provincia de Buenos Aires adheridos a la iniciativa. Durante 2011 y 2012, se aplicó una encuesta autoadministrada anónima a los integrantes de los servicios de Neonatología y Obstetricia, en la que se recogió información sobre tres dimensiones de la cultura organizacional: clima organizacional, prácticas seguras y facilitación para el cambio. Resultados. Se recolectaron 1828 encuestas; el 51% expresó la necesidad de mejorar la comunicación mediante más reuniones y el 60% evaluó positivamente algunos aspectos del liderazgo. La sobrecarga de trabajo fue reconocida como la principal causa de conflictos por el 60%. Aproximadamente, 25% expresó acuerdo y compromiso con la transformación de las maternidades en dirección a la iniciativa. La adhesión a las prácticas resultó dispar según cuáles fueran, aunque la mitad de los encuestados reportó que había razones legítimas para el cambio. Conclusiones. El diagnóstico de la cultura organizacional demostró que falta consolidar el compromiso con la iniciativa Maternidad Segura y Centrada en la Familia y que la evaluación del liderazgo no es integral. La sobrecarga de trabajo y las fallas de comunicación son las más importantes fuentes de conflicto.

En las últimas décadas la vigilancia de la salud pública extendió su objeto de estudio hacia el desarrollo de estrategias que mejoren la seguridad del paciente a través de la notificación de los errores en medicina. El objetivo fue analizar las investigaciones publicadas en la Argentina acerca de sistemas diseñados para la vigilancia de los errores en el proceso de atención de los pacientes. Se realizaron búsquedas electrónicas y una búsqueda manual de literatura. Se revisaron 4656 resúmenes, 150 de MEDLINE, 145 de LILACS (Literatura Latinoamericana y del Caribe en Ciencias de la Salud) y 4361 de búsqueda manual. De ellos 52 estudios fueron incluidos y 8 calificados como relevantes para la vigilancia del error. Los hallazgos mostraron que el enfoque del error en medicina y en particular su notificación es escasa y no está sistematizada. Una explicación probable sería el temor de los profesionales por la potencial demanda. La sistematización de la literatura científica es necesaria para acceder de manera eficiente al estado del conocimiento sobre el tema y la definición de prioridades en investigación.In the last decades, public health surveillance extended its scope of study to new fields, such as medical errors, in order to improve patient safety. This study was aimed to review all the evidence produced in Argentina about the surveillance of medical errors. An exhaustive literature search was performed. A total of 4656 abstracts were assessed (150 MEDLINE, 145 LILACS, and 4361 hand searched abstracts). Of them, 52 were analysed and 8 were considered relevant for health care error surveillance. Different approaches were used to study medical errors. Some of them have focused on patient safety and others on medical malpractice. There is still a need to improve the surveillance of this type of event. Mainly, the quality reports of study design and surveillance attributes were unclear. A critical appraisal and synthesis of all relevant studies on health care errors may help to understand not only the state of the art, but also to define research priorities.

Debido a los sesgos que afectan a la publicación de ensayos clínicos y sus resultados, los estudios cuyos resultados son positivos son más fáciles de encontrar que los que tienen resultados sin significación estadística y a ello se debe que los primeros estén sobrerrepresentados. Para contrarrestar este tipo de sesgo se ha propuesto ingresar en un registro toda investigación, desde sus comienzos. No obstante, estos registros se encuentran en distintas fases de evolución, especialmente en países en desarrollo, de tal manera que la Red Cochrane Iberoamericana, parte de la Colaboración Cochrane, ha establecido el Registro Latinoamericano de Ensayos Clínicos en Curso (LATINREC, por Latin American Clinical Trial Registry) con la idea de facilitar el registro de los datos contenidos en el protocolo de todo ensayo clínico que se esté llevando a cabo en un momento dado y poner esa información a la disposición del público. El LATINREC, que viene a respaldar los objetivos de la Organización Mundial de la Salud (OMS), representa un intento por reducir la duplicación de trabajo y el financiamiento poco equitativo de la investigación sobre enfermedades rezagadas al olvido; por evitar que se efectúen investigaciones sobre asuntos de poca cuantía o que se midan resultados poco útiles; y por fomentar las prácticas éticas y la transparencia. Se han detectado algunos obstáculos mayores que hasta ahora han impedido crear un registro único y común de ensayos clínicos. Con el fin de franquearlos, LATINREC será un registro gratuito que permitirá hacer búsquedas y que se ceñirá a la Plataforma Internacional de Registro de Ensayos Clínicos (ICTRP) de la OMS. Además, LATINREC permitirá que los investigadores ingresen en el registro cualquier modificación del protocolo, así como los resultados preliminares. LATINREC ofrecerá grandes ventajas para los consumidores, el gobierno, los profesionales de la salud pública y la industria farmacéutica al incrementar la accesibilidad de la información y la participación en los ensayos clínicos. La disponibilidad de información objetiva acerca de todo ensayo clínico que se inicie ayudará a garantizar que todos tengan libre acceso a los conocimientos generados.

OBJETIVO: Caracterizar los servicios de genética médica de Argentina, con el propósito de contribuir a la organización de una red que coordine la actividad asistencial, disminuya la inequidad en el acceso y promueva el desarrollo integral de la genética médica en el país. MÉTODOS: Se realizó un padrón (abril-agosto de 2004) de los servicios de genética médica de Argentina, por medio de una encuesta sobre recursos humanos, procedimientos diagnósticos, utilización de servicios y financiamiento. El criterio de inclusión fue que los servicios realizaran asesoramiento genético o pruebas diagnósticas citogenéticas, de biología molecular o bioquímicas para la detección de defectos congénitos o enfermedades genéticas. No se consideraron los centros dedicados exclusivamente a la investigación. RESULTADOS: Cumplieron el criterio de inclusión 134 servicios. De ellos, 84 eran servicios privados y los demás 50 eran servicios públicos en universidades y hospitales. Trabajaban en los servicios públicos un total de 67 médicos con formación en genética y 133 profesionales de laboratorio. La mayor parte de los servicios realizaban diagnóstico clínico y citogenético, con un menor desarrollo del diagnóstico molecular, bioquímico y prenatal. La región Centro tuvo más de 70% de los servicios y de los recursos humanos. En 10 de 23 provincias no se identificaron servicios de gestión pública, los cuales se concentran más bien en las grandes ciudades. CONCLUSIONES: Los servicios existentes muestran una notable heterogeneidad en su distribución geográfica y amplia variabilidad en cuanto a los procedimientos de diagnóstico ofrecidos. La distribución desigual de los servicios es un problema de organización que requiere la aplicación de políticas que garanticen las prestaciones mínimas para la población de todas las regiones del país, así como el acceso a procedimientos diagnósticos de mayor complejidad.OBJECTIVE: To describe the medical genetics services in Argentina, in order to help organize a network to coordinate those services, decrease inequity in access to them, and promote the comprehensive development of medical genetics in the country. METHODS: In April-August 2004 a survey was conducted of centers providing medical genetics services in Argentina, looking at their human resources, diagnostic procedures, the services that patients use, and funding. The survey covered service centers that conduct genetic assessment, cytogenetic diagnostic testing, molecular biology testing, and biochemical testing to detect birth defects or genetic disorders. Centers that were devoted exclusively to research were not surveyed. RESULTS: A total of 134 centers fulfilled the selection criteria for the survey; 84 of them were private services, and the other 50 were publicly managed services, at universities and hospitals. The 50 public facilities had a total of 67 physicians who had studied clinical genetics, plus 133 non-medical laboratory professionals. A majority of the 50 centers performed clinical and cytogenetic diagnoses, with a smaller number performing molecular, biochemical, and prenatal diagnoses. More than 70% of the centers and human resources were located in an area that includes the city of Buenos Aires, the province of Buenos Aires, and the nearby north-central provinces of Córdoba and Santa Fe. The 50 public centers were found mainly in large cities; 10 of the country's 23 provinces had no public services. CONCLUSIONS: There is a great geographic disparity in the availability of resources as well as wide variability in the diagnostic procedures that are provided in the different service centers. The unequal distribution of the facilities is an organizational problem that will require the application of policies to guarantee minimum services for people in all regions of the country, as well as access to more complex diagnostic procedures.

OBJETIVO: Caracterizar los servicios de genetica medica de Argentina, con el proposito de contribuir a la organizacion de una red que coordine la actividad asistencial, disminuya la inequidad en el acceso y promueva el desarrollo integral de la genetica medica en el pais. METODOS: Se realizo un padron (abril-agosto de 2004) de los servicios de genetica medica de Argentina, por medio de una encuesta sobre recursos humanos, procedimientos diagnosticos, utilizacion de servicios y financiamiento. El criterio de inclusion fue que los servicios realizaran asesoramiento genetico o pruebas diagnosticas citogeneticas, de biologia molecular o bioquimicas para la deteccion de defectos congenitos o enfermedades geneticas. No se consideraron los centros dedicados exclusivamente a la investigacion. RESULTADOS: Cumplieron el criterio de inclusion 134 servicios. De ellos, 84 eran servicios privados y los demas 50 eran servicios publicos en universidades y hospitales. Trabajaban en los servicios publicos un total de 67 medicos con formacion en genetica y 133 profesionales de laboratorio. La mayor parte de los servicios realizaban diagnostico clinico y citogenetico, con un menor desarrollo del diagnostico molecular, bioquimico y prenatal. La region Centro tuvo mas de 70% de los servicios y de los recursos humanos. En 10 de 23 provincias no se identificaron servicios de gestion publica, los cuales se concentran mas bien en las grandes ciudades. CONCLUSIONES: Los servicios existentes muestran una notable heterogeneidad en su distribucion geografica y amplia variabilidad en cuanto a los procedimientos de diagnostico ofrecidos. La distribucion desigual de los servicios es un problema de organizacion que requiere la aplicacion de politicas que garanticen las prestaciones minimas para la poblacion de todas las regiones del pais, asi como el acceso a procedimientos diagnosticos de mayor complejidad.

Las enfermedades cardiovasculares (ECV) constituyen la primera causa de mortalidad y morbilidad a nivel nacional. Varios factores de riesgo (FR) se han reconocido como responsables del aumento de ECV y reflejan cambios en los hábitos alimentarios, de actividad física y en el consumo del tabaco. Las enfermedades cardiovasculares son la primera causa de mortalidad en Olavarría. Con el objeto de establecer la línea de base de prevalencia de los FR de ECV, se desarrolló un relevamiento a partir de la aplicación de un modelo de encuesta estandarizado y validado. Se diseñó una muestra representativa de la población. Los resultados muestran las siguientes prevalencias de los factores de riesgo de ECV en la población adulta (18-65 años): tabaquismo 34%, sedentarismo 32%, hipertensión 25%, sobrepeso 24%, colesterol elevado 13% y diabetes 5%. Muchos factores estuvieron asociados, lo cual significa que se comparten dos o más FR al mismo tiempo. La metodología empleada hace posible no sólo establecer la línea de base poblacional para medir el impacto de programas preventivos y futuras intervenciones destinadas a reducir los FRECV, sino, más aún, hacer comparaciones con otras poblaciones que empleen el mismo esquema propuesto.

Objective To summarize controlled trials examining the effect of calcium on bone density and fractures in postmenopausal women. Data source We searched MEDLINE and EMBASE up to 1998 and the Cochrane Controlled Register up to 2000, and we examined citations of relevant articles and proceedings of international meetings. We contacted osteoporosis investigators to identify additional studies, and primary authors for unpublished data. Study selection We included 15 trials (1806 patients) that randomized postmenopausal women to calcium supplementation or usual calcium intake in the diet and reported bone mineral density of the total body, vertebral spine, hip, or forearm, or recorded the number of fractures, and followed patients for at least 1 yr. Data extraction For each trial, three independent reviewers assessed the methodological quality and extracted data. Data synthesis We found calcium to be more effective than placebo in reducing rates of bone loss after two or more years of treatment. The pooled difference in percentage change from baseline was 2.05% [95% confidence interval (CI) 0.24-3.86] for total body bone density, 1.66% (95% CI 0.92-2.39) for the lumbar spine, 1.64% (95% CI 0.70-2.57) for the hip, and 1.91% (95% CI 0.33-3.50) for the distal radius. The relative risk (RR) of fractures of the vertebrae was 0.77, with a wide CI (95% CI 0.54-1.09); the RR for nonvertebral fractures was 0.86 (95% CI 0.43-1.72). Conclusions Calcium supplementation alone has a small positive effect on bone density. The data show a trend toward reduction in vertebral fractures, but do not meaningfully address the possible effect of calcium on reducing the incidence of nonvertebral fractures.

Background Methotrexate (MTX) is a disease modifying antirheumatic drug (DMARD) used as a first line agent for treating rheumatoid arthritis (RA). Pharmacologically, it is classified as an antimetabolite due to its antagonistic effect on folic acid metabolism. Many patients treated with MTX experience mucosal, gastrointestinal, hepatic or haematologic side effects. Supplementation with folic or folinic acid during treatment with MTX may ameliorate these side effects. Objectives To identify trials of supplementation with folic acid or folinic acid during MTX therapy for rheumatoid arthritis and to assess the benefits and harms of folic acid and folinic acid (a) in reducing the mucosal, gastrointestinal (GI), hepatic and haematologic side effects of MTX, and (b) whether or not folic or folinic acid supplementation has any effect on MTX benefit. Search methods We originally performed MEDLINE searches, from January 1966 to June 1999. During the update of this review, we searched additional databases and used a sensitive search strategy designed to retrieve all trials on folic acid or folinic acid for rheumatoid arthritis from 1999 up to 2 March 2012. Selection criteria We selected all double-blind, randomised, placebo-controlled clinical trials (RCTs) in which adult patients with rheumatoid arthritis were treated with MTX (at a dose equal to or less than 25 mg/week) concurrently with folate supplementation. In this update of the review we only included trials using 'low dose' folic or folinic acid (a starting dose of ≤ 7 mg weekly). Data collection and analysis Data were extracted from the trials, and the trials were independently assessed for risk of bias using a predetermined set of criteria. Main results Six trials with 624 patients were eligible for inclusion. Most studies had low or unclear risk of bias for key domains. The quality of the evidence was rated as 'moderate' for each outcome as assessed by GRADE, with the exception of haematologic side effects which were rated as 'low'. There was no significant heterogeneity between trials, including where folic acid and folinic acid studies were pooled. For patients supplemented with any form of exogenous folate (either folic or folinic acid) whilst on MTX therapy for rheumatoid arthritis, a 26% relative (9% absolute) risk reduction was seen for the incidence of GI side effects such as nausea, vomiting or abdominal pain (RR 0.74, 95% CI 0.59 to 0.92; P = 0.008). Folic and folinic acid also appear to be protective against abnormal serum transaminase elevation caused by MTX, with a 76.9% relative (16% absolute) risk reduction (RR 0.23, 95% CI 0.15 to 0.34; P < 0.00001), as well as reducing patient withdrawal from MTX for any reason (60.8% relative (15.2% absolute) risk reduction, RR 0.39, 95% CI 0.28 to 0.53; P < 0.00001). We analysed the effect of folic or folinic acid on the incidence of stomatitis / mouth sores, and whilst showing a trend towards reduction in risk, the results were not statistically significant (RR 0.72, 95% CI 0.49 to 1.06) It was not possible to draw meaningful conclusions on the effect of folic or folinic acid on haematologic side effects of methotrexate due to small numbers of events and poor reporting of this outcome in included trials. It does not appear that supplementation with either folic or folinic acid has a statistically significant effect on the efficacy of MTX in treating RA (as measured by RA disease activity parameters such as tender and swollen joint counts, or physician's global assessment scores). Authors' conclusions The results support a protective effect of supplementation with either folic or folinic acid for patients with rheumatoid arthritis during treatment with MTX. There was a clincally important significant reduction shown in the incidence of GI side effects, hepatic dysfunction (asmeasured by elevated serum transaminase levels) as well as a clincally important significant reduction in discontinuation of MTX treatment for any reason. A trend towards a reduction in stomatitis was demonstrated however this did not reach statistical significance. This updated review with its focus on lower doses of folic acid and folinic acid and updated assessment of risk of bias aimed to give a more precise and more clinically relevant estimate of the benefit of folate supplementation for patients with rheumatoid arthritis receiving methotrexate.

Limited knowledge on the prevalence and distribution of risk factors impairs the planning and implementation of cardiovascular prevention programs in the Latin American and Caribbean (LAC) region. For the last two decades cardiovascular diseases have been the main cause of death in Latin America and the Caribbean (LAC). [1] Cardiovascular mortality rates continue to increase in most LAC countries, and in those countries where rates have declined the blunting of the trend has been considerably lower than in the United Sates (US). [2]. Data on the distribution of cardiovascular risk factors in LAC region are limited, and the few studies available show significant variation in the levels of prevalence. For instance, the CARMELA study, [3] conducted in seven major urban cities from LAC, reported markedly different hypertension levels. For instance, hypertension prevalence in Santiago (Chile), Buenos Aires (Argentina), and Barquisimeto (Venezuela), ranged from 24% to 29%, whereas in Quito (Ecuador), Bogotá (Colombia), Mexico City (Mexico), and Lima (Peru) varied from 9% to 13%. Yet, diabetes prevalence in these cities was similar to world’s estimates, around 7%. [3] Differences in rural-urban residence, socioeconomic development, and internal migration patterns could partly explain the contrasting profiles of cardiovascular risk factors, but knowledge on this regard is also very limited. This scarcity of data on the distribution of risk factors and, in turn, on their impact on incidence and mortality hampers efforts to curtail the growing epidemic of cardiovascular disease in LAC. In fact, national and regional health policies have been customarily based on estimates of the burden of risk factors and disease that rely heavily on demographic profiles. [4]. Here we report the distribution of cardiovascular risk factors using data from population-based studies from eight LAC countries. We also compare the distribution of cardiovascular risk factors in LAC and the US, as a way to illustrate the current stage of LAC in the process of the epidemiological transition. Insight into the specific differences in the distribution of risk factors in the LAC and US populations is important to foresee future trends in cardiovascular morbidity and mortality in the region. UCR::Vicerrectoría de Investigación::Unidades de Investigación::Ciencias Sociales::Centro Centroamericano de Población (CCP)

Current, high-quality data are needed to evaluate the health impact of the epidemic of obesity in Latin America. The Latin American Consortium of Studies of Obesity (LASO) has been established, with the objectives of (i) Accurately estimating the prevalence of obesity and its distribution by sociodemographic characteristics; (ii) Identifying ethnic, socioeconomic and behavioural determinants of obesity; (iii) Estimating the association between various anthropometric indicators or obesity and major cardiovascular risk factors and (iv) Quantifying the validity of standard definitions of the various indexes of obesity in Latin American population. To achieve these objectives, LASO makes use of individual data from existing studies. To date, the LASO consortium includes data from 11 studies from eight countries (Argentina, Chile, Colombia, Costa Rica, Dominican Republic, Peru, Puerto Rico and Venezuela), including a total of 32 462 subjects. This article describes the overall organization of LASO, the individual studies involved and the overall strategy for data analysis. LASO will foster the development of collaborative obesity research among Latin American investigators. More important, results from LASO will be instrumental to inform health policies aiming to curtail the epidemic of obesity in the region. Wellcome Trust Research Training Fellowship/[GR074833MA]//Perú National Center for Research Resources/[G12RR03051]/NCRR/Estados Unidos National Institutes of Health/[G12RR03051]/NIH/Estados Unidos National Center for Research Resources/[P20RR011126]/NCRR/Estados Unidos National Institutes of Health/[P20RR011126]/NIH/Estados Unidos UCR::Vicerrectoría de Investigación::Unidades de Investigación::Ciencias Sociales::Centro Centroamericano de Población (CCP)

Objective To evaluate the quality of clinical practice guidelines (CPGs) and consensus statements (CS) for the treatment of rheumatoid arthritis with tumor necrosis factor α (TNFα) antagonists. Methods We searched for CPGs and CS on the use of infliximab, etanercept, and/or adalimumab for the treatment of rheumatoid arthritis, published through October 10, 2006. Sources included electronic databases (Medline, EMBase, BIOSIS, etc.), guideline registries, and pertinent Web sites. Review of 4,915 citations revealed 16 CPGs and 20 CS. Two independent reviewers evaluated development methods of selected studies using the 23-item Appraisal of Guidelines for Research and Evaluation (AGREE) instrument and compared recommendations between guidelines. Results Of the 16 guidelines, only 5 (31%) were based on a systematic review of relevant research evidence. Only 4 (25%) of the guidelines fulfilled ≥60% of the AGREE criteria. AGREE scores were lower for guidelines from rheumatology societies than government agencies when reporting scope and purposes (P = 0.03), stakeholder involvement (P = 0.03), and clarity and presentation (P = 0.01). Guidelines scored higher than CS in most domains. Overall, guideline recommendations were consistent with respect to the use of biologic agents after failure of disease-modifying antirheumatic drugs, but differed or did not provide specific guidance on tests for screening. Conclusion Guidelines for introducing TNFα antagonists in rheumatoid arthritis often fail to meet expected methodologic criteria and therefore vary significantly in quality and with respect to some recommendations for patient assessment and management.

BACKGROUND: Since 1990 non communicable diseases and injuries account for the majority of death and disability-adjusted life years in Latin America. We analyzed the relationship between the global burden of disease and Randomized Clinical Trials (RCTs) conducted in Latin America that were published in the five leading medical journals. METHODOLOGY/PRINCIPAL FINDINGS: We included all RCTS in humans, exclusively conducted in Latin American countries, and published in any of the following journals: Annals of Internal Medicine, British Medical Journal, Journal of the American Medical Association, Lancet, and New England Journal of Medicine. We described the trials and reported the number of RCTs according to the main categories of the global burden of disease. Sixty-six RCTs were identified. Communicable diseases accounted for 38 (57%) reports. Maternal, perinatal, and nutritional conditions accounted for 19 (29%) trials. Non-communicable diseases represent 48% of the global burden of disease but only 14% of reported trials. No trial addressed injuries despite its 18% contribution to the burden of disease in 2000. CONCLUSIONS/SIGNIFICANCE: A poor correlation between the burden of disease and RCTs publications was found. Non communicable diseases and injuries account for up to two thirds of the burden of disease in Latin America but these topics are seldom addressed in published RCTs in the selected sample of journals. Funding bodies of health research and editors should be aware of the increasing burden of non communicable diseases and injuries occurring in Latin America to ensure that this growing epidemic is not neglected in the research agenda and not affected by publication bias.

Objective To evaluate the quality of reviews about etanercept (ETN) and infliximab (IFX), two biologic treatments for rheumatoid arthritis (RA). Study Design A comprehensive, systematic review, including searches of MEDLINE, EMBASE, and other electronic databases and hand-searches for published and unpublished literature. Two raters independently examined each article and identified systematic reviews as those including either a description of: (1) sources for identification and data retrieval; or (2) search strategy. They applied the quality of reporting of meta-analyses (QUOROM) instrument to systematic reviews. Results Of 3,620 total citations, 281 were identified as reviews. Of these, 26 (9%) qualified as systematic rather than narrative. Overall, few reviews described selection of sources, critical appraisal, or quantitative summary or synthesis. Systematic reviews most often failed to explain validity assessment. Several articles did not disclose authors' participation in industry-funded clinical trials. Most reviews published in high impact factor and rheumatology journals did not meet many quality standards. Significant associations existed between review type (narrative vs. systematic) and reported funding (P = 0.05), conflicts of interest (P = 0.005), and country of publication (P Conclusion More than 90% of the published reviews were narrative and did not report methods and conflicts of interest in sufficient detail, raising concerns about selection and reporting bias.